Pelvic limb reconstruction failed by propeller flap resolved with microsurgery

Reconstruction of lower limb defects is a constant challenge for surgeons, the etiology of the defect can be very variable from diabetic ulcers, traffic accidents, fall from height, oncological resections and many others. Free flaps have always been an important option because it has great results in complex reconstructions in lower limbs, it is a microvascular technique, so it has a higher level of complexity. This technique is usually reserved for extensive perilesional wide defects. On the other hand, the propeller flap, which is considered less invasive and easier as it does not involve microvascular surgery. An 18-year-old patient who had a fracture of the right tibial pylon due to a 7-meter drop, who after orthopedic treatment had a defect with exposure of ostesynthesis material of 3 cm in circumference in the medial malleolus. This defect was first managed with a propeller flap complicated with necrosis at 48 hours which was treated with sub atmospheric pressure system for 5 days and later with an ultra-thin anterolateral flap of the pelvic limb. Complete pedicled propeller flap failure is very rare but, because necrosis develops distally, even partial necrosis can expose bone, tendons, or other tissue. Some surgeons consider that propeller flap placement is risky in this location, especially the distal third of the lower leg a prefer to use free flaps. Whenever any pelvic member reconstruction plan fails in the distal third, the best and safest is the use of microsurgery even with the failure of a previous micro vascular flap.

Heparin-induced bleeding treatment in microsurgery

Microsurgery is associated with prolonged surgical times with an increased risk of deep vein thrombosis, pulmonary embolism and myocardial infarction. The use of antithrombotic means is a commonly employed tactic to prevent vascular thrombosis after microvascular free flap surgery. Flap loss is a devastating complication of microsurgical procedures that leads to detrimental outcomes. A 32-year-old male patient has a ruptured calcaneal tendon. He underwent 5 surgical cleanings with multiple failed sequential attempts at wound closure. Traumatology department in its microsurgery division where it is proposed to perform neo-tendon with graft of palmaris longus of the right thoracic extemity and radial antebrachial microvascular flap. The neo tendon was performed in addition to the micro surgical coverage with the radial antebrachial flap.When having vascular control with micro-clamps, 6000 U of unfractionated heparin was initiated, approximately 20 minutes after the end of the microvascular anastomosis, there was incoercible bleeding, which is initially treated with spray fibrin. Continued bleeding after 3 hours, so it was decided to reverse the effect of heparin with transfusion of fresh frozen plasma, 10 mg of vitamin K and fibrinogen. The effect of heparin was reversed without having thrombotic complications of microvascular anastomoses. The flap was not reexplored since they showed no signs of vascular compromise. If anticoagulants have been used and an incoercible hemorrhage is found, the effect of heparin must be reversed. In the transfer of tissues with microsurgery, the recommended and safe anticoagulation are prophylactic doses and not therapeutic doses.

Microsurgery in complex trauma of pelvic limb in a pediatric patient: case report

Complex trauma is defined as the condition secondary to the exchange of kinetic energy of two or more tissues in one limb. This entity is a surgical emergency that can have many sequelae and can even result in limb loss. An 11-year-old female patient presents complex pelvic limb trauma secondary to contuse injury caused by a helicopter’s rotor blades.  Pelvic limb reconstruction was performed with iliac crest bone graft, the fracture was stabilized with an external fixator and the skin defect was covered with an anterolateral microvascular thigh flap (ALT). There was an adequate integration of the bone graft with adequate skin coverage thanks to the ALT thigh flap. The patient presented discreet limb shortening as consequence.  Currently, microsurgery is the only medical option that meets the objectives of limb reconstruction. Microsurgical techniques can be used in pediatric and adult patients. The success of any recovery from complex trauma is vigorous surgical cleaning, avoiding sequential and/or multiple washes.

Hemorragia digestiva en el Hospital Nacional Cayetano Heredia / Gastrointestinal bleeding in patients admitted to the Cayetano Heredia Public Hospital

Se realizó un estudio prospectivo, descriptivo, entre agosto de 1994 y mayo de 1995, en el Hospital Nacional Cayetano Heredia, con el objetivo de evaluar las características clínicas, demográficas, evolutivas y diagnóstico endoscópico de pacientes con hemorragia digestiva. Ingresaron 100 pacientes, 86 correspondieron a hemorragia digestiva alta y 14 a hemorragia baja. En el primer grupo la edad media fue de 45.24 años (rango de 10 a 93), con una relación masculino/femenino de 3.5 a 1. Se presentó melena y hematemesis en 56.9 por ciento y sólo melena en 26.7 por ciento. Un 46.5 por ciento de los pacientes acudieron con historia de días de sangrado (2.07 días), con un rango de 1 a 8 días. El antecedente de consumo de antiinflamatorios no esteroideos en las 48 horas previas a la hemorragia estuvo presente en 19:7 por ciento y un porcentaje similar había consumido bebidas alcohólicas en dichoperíodo. Un 36 por ciento tenía antecedente de hemorragia digestiva previa. Las causas más frecuentes de hemorragia digestiva alta fueron úlcera duodenal en 38.3 por ciento , lesiones agudas de mucosa gástrica (gastritis erosiva) en 20.9 por ciento, úlceragástrica en 11.6 por ciento, várices esofágicas en 5.8 por ciento, síndrome de Mallory Weiss en 4.6por ciento.adenocarcinoma gástrico 2.3 por ciento, gastropatía por prolapso 2.3 por ciento, esofagitis 2.3 por ciento, úlceraen esófago 1.1 por ciento, duodenitis 1.1 por ciento y malformación arteriovenosa 1.1 por ciento. No se precisó la causa de la hemorragia en 8 por ciento. La endoscopía permitió determinar la causa delsangrado en 91.7 por ciento y en 66 por ciento de los casos se realizó dentro de las primeras 24 horas del ingreso. En 20.9por ciento coexistieron dos o más lesiones potencialmente sangrantes.9.1por ciento resangraron durante la hospitalización y un 11.6 por ciento de los pacientes fue intervenido quirúrgicamente. Siete pacientes (8.13 por ciento)fueron sometidos a terapia endoscópica: ...

A prospective study was performed to evaluate the epidemiological characteristics, clinical outcome and to determine the cause of bleeding in patients admitted to the Cayetano Heredia National Hospital with the diagnosis of gastrointestinal bleeding. Between August 1994 and May 1995, 100 patients were admitted , 86 patients with upper gastrointestinal bleeding and 14 with lower gastrointestinal bleeding. The meanage for the former was 45.25 years and the male/female ratio was 3.5/1 . The main complaints were tarry stools and haematemesis in 56.9 per cent ,and 26.7per cent only with melena. A history of non steroidal antiinflamatory drugs intake within 48 hours before thebleeding episode was obtained in 19.7 per cent and alcohol ingestion was observed in 19.7 per cent. In 36 per cent of the patients a history of a previous episode of bleeding was obtained. The major causes of bleeding were duodenal ulcer in 38.3 per cent, acute lesions of the gastric mucosa in 20.9 per cent, gastric ulcer in 11.6 per cent and esophageal varices in 5.8 per cent, Mallory Weiss syndrome in 4.6 per cent gastric carcinoma in 2.3 per cent, prolapse gastropaty 2.3 per cent, esophagitis in 2.3 per cent, esophageal ulcer 1.1 per cent, duodenitis 1.1 per cent, arteriovenus malformations in 1.1 per cent. The etiology of the hemorrhage could not be established in 8 per cent of cases. The diagnostic rate of endoscopy was 91.7 per cent. In 66 per cent of the patients the endoscopy was carried out within the 24 hours of admission. 20.9 per cent of the patients had other potential bleeding lesions. 9.1 per cent of the patients had anew episode of bleeding during hospitalization and surgery was needed in 11.6 per cent. Injectotheraphy was done in 7 (8.13 per cent) patients (4 for variceal , 2 for duodenal and 1 for gastric bleeding ). The overall mortality was 3.4 per cent. Fourteen patients with lower gastrointestinal bleeding were evaluated. ...