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.

Uso de doble colgajo diep para reconstrucción de extremidad inferior / Double diep flap for lower extremities reconstruction

Introduction: A soft tissue defect considering the extent, location, depth and involved structures can be a complex task, leading to search for unusual reconstructive alternatives. Case report: Puerperal woman, 21 years, previously healthy, admitted for septic shock and skin necrosis of both extremities secondary to purpura fulminans. Escharectomy was performed and the final defect was 27 percent of total body surface, corresponding to necrotic areas of both superior and lower extremities. Is remarkable the presence of musculocutaneous perforating vessels thrombosis and segmental muscular necrosis in legs and interosseous muscles necrosis in hands. In upper extremity coverage was performed with dermoepidermal grafts. To cover peroneal malleolus and feet dorsum, whereas there were no regional or local alternatives, we realize a double DIEP flap. Flap elevation of bilateral DIEP flap was performed simultaneously for two surgical teams. The patient had no complications and was discharged with complete soft tissue coverage.

Introducción: Un defecto de cobertura extenso de extremidades inferiores (EEII), considerando ubicación, profundidad y estructuras involucradas es de una alta complejidad y puede llevar a buscar alternativas reconstructivas poco habituales. Caso Clínico: Paciente de 21 años, puérpera, ingresa por shock séptico y necrosis cutánea extensa de extremidades secundario a un purpura fulminans. Se realiza escarectomía y el defecto resultante es de 27 por ciento de superficie corporal, correspondiendo a zonas necróticas en ambas extremidades, superiores e inferiores. Destaca la presencia de trombosis de vasos perforantes musculocutáneos, necrosis muscular segmentaria en piernas y de musculatura interósea en manos. En extremidades superiores se realizó cobertura con injertos dermoepidérmicos. Para la exposición de ambos maléolos peroneos y dorso de pies, considerando que no existen alternativas locales ni regionales, se decide realizar un colgajo DIEP bilateral; se eleva en un tiempo, con dos equipos quirúrgicos simultáneos. La anastomosis microquirúrgica se realizó a los vasos tibiales de cada extremidad. La evolución postoperatoria fue favorable. La paciente es dada de alta en buenas condiciones generales, extubada, con cobertura cutánea completa.

Colgajos en reconstrucción de la región calcánea lateral / Flaps in reconstruction of the lateral calcaneal region: case series and treatment algorithm for soft-tissue complications of the lateral approach for calcaneal fractures

Introduction: Calcaneal fractures are the most frequent tarsal bone fracture. A high complication rate has been reported for the L-shaped lateral calcaneus surgical approach. Coverage of the resulting defect can be challenging. The aim of this article is to report a case series and propose a new treatment algorithm. Materials and Methods: Between January 2011 and December 2013 ninety-five patients underwent a close calcaneus fracture surgery by lateral approach. Ten patients suffered from surgical wound complications. Defects were classified as small (< 2 cm), medium (2-5 cm) or big size (> 5 cm). Results: Small size defects were covered with local fasciocutaneous advancement and rotation flaps. Medium size defect were covered either with a distally based sural neurocutaneous flap or propeller flap based on peroneal artery perforators. A free flap was used in the big size defect presented. Mean follow-up was 16 month (range 5-41 month). Stable coverage was achieved in all cases and no revision surgery was needed. Conclusions: Soft-tissue complications associated to lateral approach for calcaneal fractures needs an ordered approach. The algorithm presented including propeller perforator flaps proved to be safe and useful.

Introducción: Las fracturas de calcáneo son las fracturas más frecuentes de los huesos del tarso. Diversos estudios han mostrado alta tasa de complicaciones del abordaje que requieren cobertura. El objetivo principal es presentar un nuevo algoritmo de tratamiento para estos defectos de cobertura. Material y Métodos: Entre el 2011 y el 2013 se operaron 95 pacientes con fractura cerrada de calcáneo. Diez pacientes presentaron defectos de cobertura de la herida operatoria. Los defectos se clasificaron en pequeños (< 2 cm), medianos (2-5 cm) y grandes (> 5 cm). Resultados: Se realizaron 11 colgajos en 10 pacientes. Seis pacientes presentaron un defecto pequeño y fueron tratados mediante colgajos locales; cuatro casos de defectos medianos se resolvieron mediante tres colgajos perforantes de arteria peronea de tipo propeller y un colgajo sural. Todos los defectos de la zona dadora, tanto en el colgajo sural como en los colgajos propeller, fueron cerrados de manera primaria sin requerir injertos. Hubo un defecto grande que fue necesario cubrir con un colgajo libre. El período de seguimiento promedio fue 16 meses, con un rango de 5 a 41 meses. En todos los casos se proporcionó una cobertura estable que no requirió revisiones. Conclusiones: Es necesario un enfrentamiento ordenado y protocolizado para resolver estos defectos. En nuestro trabajo, proponemos un algoritmo simple basándonos en el ancho del defecto, incorporando como alternativa el colgajo perforante pediculado tipo propeller para defectos medianos, con el cual se logran coberturas estables y planas, con cierre primario de la zona dadora.

Colgajo sural de flujo reverso, a propósito de un caso / Sural artery perforator flap of reverse flow, apropos of a case

La reconstrucción del pie y pierna representa un desafío para el cirujano. Se presenta el caso clínico de un paciente de 32 años con una úlcera maleolar externa en el tobillo izquierdo que se trató con un colgajo sural de flujo reverso. Describimos el tratamiento realizado, detallando la técnica quirúrgica. Posteriormente comentamos algunos conceptos relevantes que encontramos al realizar una revisión de la literatura. Se comentan las indicaciones, detalles de la técnica quirúrgica y las complicaciones de esta cirugía.

The reconstruction of the foot and leg are a challenge for surgeons. We present a clinical case of a 32 years patient with an external malleolar ulcer in his left ankle. We treated it with a distally based sural flap. In this article we describe the treatment done, detailing the surgical technique. Thereafter, we describe some relevant concepts founded in the literature. We describe the indications, details of the surgical technique and complications of this surgery.