Reconstrucción en amputaciones distales de dedos en niños con injerto compuesto y vendaje semioclusivo / Reconstruction of distal finger amputations in children with composite autograft and semi-oclusive dressing

La reconstrucción de una amputación distal de dedo en un niño es un desafío. Los procedimientos propuestos son muchos, y los resultados no han sido buenos. La reconstrucción con reposición del segmento a modo de injerto compuesto, o con técnicas microquirúrgicas, parece ofrecer la mejor de las posibilidades, pues se conservan estructuras irremplazables, como el lecho ungueal y el hiponiquio, lo que permite que los niños mantengan un pulpejo anatómico y con función normal. Presentamos una serie de tres pacientes pediátricos tratados con una nueva técnica, que combina la reposición del segmento, como un injerto compuesto, y el uso de curación semioclusiva (composite autograft and semi-oclussive dressing, CASOD, en inglés). Hemos observado buenos resultados.

The reconstruction of finger tip amputation in children is challenging. There are many procedures described to treat this injury, none of which present optimal results. Repositioning of the amputated segment as an autograft or with microsurgical techniques seems to offer the best outcome. It enables the preservation of otherwise irreplaceable structures, such as the nail bed and the hyponychium, thus enabling children to mantain an anatomically and functionally normal finger pad. We present a series of three pediatric patients treated with tha new technique, which combines composite autograft and semi-oclusive dressing (CASOD). The results observed so far have been promising.

Indicadores de valor pronóstico de amputación en pacientes hospitalizados con pie diabético / Indicators of amputation´s prognostic value in hospitalized patients with diabetic foot

Introducción: La diabetes mellitus es la causa más importante de amputaciones no traumáticas en el mundo. El pronóstico de riesgo de amputación resulta vital para el tratamiento óptimo de los pacientes hospitalizados con pie diabético. Objetivo: Caracterizar las variables con valor pronóstico de amputación en pacientes hospitalizados con diagnóstico de pie diabético. Método: Se realizó un estudio analítico longitudinal prospectivo en el período desde diciembre de 2015 hasta diciembre de 2017, con una muestra constituida por 77 pacientes. Las variables recogidas fueron edad, sexo, resultados hemoquímicos al ingreso, co-morbilidad, control glucémico y amputaciones realizadas, estos dos últimos durante la estadía hospitalaria. Se hizo inclusión de las variables con asociación significativa en un análisis univariado (p < 0,05) en un modelo de regresión logística múltiple para evaluar su asociación independiente. Se determinaron los valores predictivos positivos, negativos, y el grado de sensibilidad y especificidad. Resultados: Los indicadores pronósticos resultantes del análisis de las variables fueron el índice leuco-hematocrito (p = 0,045), el nivel de albúmina en sangre (p = 0,004), la glicemia a mitad del ingreso (p = 0,045) y la glicemia al ingreso (p = 0,039). El índice leuco-hematocrito, menor de 6 al ingreso, se relacionó con una especificidad de 92 por ciento; la albúmina, menor de 29,9 g/L, presentó un valor predictivo positivo de 71 por ciento; la glicemia al ingreso, mayor de 21,5 mmol/L, mostró una sensibilidad de 75 por ciento; y la glicemia a mitad del ingreso, mayor de 12,9 mmol/L, manifestó una sensibilidad de 71 por ciento. Conclusiones: La evolución a la amputación de los pacientes ingresados por pie diabético se relaciona con el estado inflamatorio crónico, el estado nutricional y el control glucémico(AU)

Introduction: Diabetes mellitus is the most important cause of non-traumatic amputations in the world. The prognosis of amputation risk is vital for the optimal treatment of patients hospitalized with diabetic foot disease. Objective: Characterize variables with amputation´s prognostic value in hospitalized patients diagnosed with diabetic foot disease. Method: A prospective longitudinal analytical study was conducted in the period from December 2015 to December 2017, with a sample consisting of 77 patients. The variables collected were age, sex, hemochemical results upon admission, co-morbidity, glycaemic control and amputations performed, the latter two during the hospital stay. Variables with significant association were included in a one-variety analysis (p < 0.05) in a multiple logistic regression model to evaluate their independent association. Positive, negative predictive values, and the degree of sensitivity and specificity were determined. Results: The prognosis indicators resulting from the analysis of the variables were the leuko-hematocrit index (p = 0.045), the level of albumin in blood (p = 0.004), the glycaemia at the mid-time of the stay (p = 0.045) and the glycaemia at the admission time (p = 0.039). The leuko-hematocrit index, in less than 6 patients at admission time, was related to a specificity of 92 percent; albumin, in less than 29.9 g/L, had a positive predictive value of 71 percent; glycaemia at admission time, higher than 21.5 mmol/L, showed a sensitivity of 75 percent;and glycaemia at mid-time of the stay, higher than 12.9 mmol/L, showed a sensitivity of 71 percent. Conclusions: The evolution to amputation of patients admitted due to diabetic foot is related to chronic inflammatory state, nutritional state and glycaemic control(AU)

Amputación traumática de miembros inferiores / Traumatic Amputation of Lower Limbs

RESUMEN La amputación traumática completa se define como la separación total de un segmento del miembro del resto del cuerpo. El segmento cercenado algunas veces se puede reconectar, siempre que ambas partes de la extremidad hayan sido correctamente tratadas y se cumplan determinadas condiciones. Se presentan dos casos de amputación traumática de ambos miembros inferiores: el primero, una paciente femenina de 49 años de edad, debido a un accidente de trabajo y, el segundo, un paciente masculino de 39 años, víctima de un accidente en las vías férreas. Se expone la sintomatología presentada por ambos pacientes, su tratamiento quirúrgico y evolución(AU)

ABSTRACT Complete traumatic amputation is defined as the total separation of a limb segment from the rest of the body. The severed segment can sometimes be reconnected, provided that both parts of the limb have been correctly treated and certain conditions are met. Two cases of traumatic amputation of both lower limbs are presented: the first, a female patient of 49 years of age, due to an accident at work; and the second, a male patient of 39 years, victim of a railroad accident. The symptoms presented by both patients, their surgical treatment and evolution are exposed(AU)

Versatility of the medial gastrocnemius muscle flap in reconstructing lower limb soft tissue lesions / Versatilidade do uso do retalho do músculo gastrocnêmio medial na reconstrução de lesões de partes moles de membros inferiores

Introduction: Covering complex lower limb wounds is a major challenge. The medial gastrocnemius muscle flap is usually indicated for reconstruction of loss of substance of the knee and proximal third of the leg. The objective of this study was to evaluate the results using gastrocnemius muscle flaps in lower limb wounds. Methods: A total of 28 patients with loss of substance in the lower limbs were treated with medial gastrocnemius muscle flaps. Data were obtained from clinical records of patients who underwent surgery from 2003 to 2012. Results: In 28 patients who underwent surgery, the age range was 4 to 57 years, with a mean of 30.6 years. The etiology of the lesions was a motorcycle accident in 16 cases (57.1%), being run over in 8 cases (28.6%), car crash in 2 cases (7.2%), meningococcemia in 1 case (3.6%), and snake bite in 1 case (3.6%). After an average follow-up of 15 months (range: 6 to 26 months), all patients had stable coverage. The mean number of preoperative debridements was 2.4 (range: 1 to 8). In 22 patients, the flaps were made without the release of the muscle origin and in 6 patients the muscle flaps were separated from their origin in the femur. Conclusions: Transfer of a gastrocnemius muscle flap is a simple and safe procedure in the treatment of lower limb injuries. The application of the medial gastrocnemius muscle flap was demonstrated in different situations, with satisfactory results and easy reproducibility.

Introdução: A cobertura de feridas complexas de membros inferiores é um grande desafio. O retalho muscular do gastrocnêmio medial é comumente indicado para reconstrução de perdas de substância do joelho e terço proximal da perna. O objetivo desse trabalho é avaliar os resultados da utilização do retalho muscular do gastrocnêmio nos casos de ferida em membros inferiores. Métodos: Um total de 28 pacientes com perda de substância de membros inferiores foi tratado com retalho muscular do gastrocnêmio medial. Os dados foram obtidos em registros clínicos dos pacientes operados no período de 2003 a 2012. Resultados: Vinte e oito pacientes foram operados, com idades variando de 4 a 57 anos, e média de 30,6 anos. A etiologia das lesões foi acidente por motocicleta em 16 casos (57,1%), atropelamentos em oito casos (28,6%), acidente automobilístico em dois casos (7,2%), meningococcemia em um caso (3,6%) e acidente ofídico em um caso (3,6%). Depois de um seguimento médio de 15 meses (variação de 6 a 26 meses), todos pacientes mostraram cobertura estável. O número médio de desbridamentos pré-operatórios foi 2,4 (variação de 1 a 8). Em 22 pacientes, os retalhos foram confeccionados sem a liberação da origem muscular e em seis pacientes os retalhos musculares foram separados de sua origem no fêmur. Conclusões: A transferência do retalho muscular do gastrocnêmio é um procedimento simples e seguro no tratamento de lesões de membros inferiores. Foi demonstrada a aplicação do retalho muscular do gastrocnêmio medial em diferentes situações, com resultados satisfatórios e fácil reprodução.

Reconstrucción en un tiempo del pabellón auricular en amputación parcial traumática con preservación del pedículo inferior: revisión de la literatura y presentación de dos casos / One-stage auricular replantation in traumatic partial ear amputation with inferior pedicle preservation: review of the literature and presentation of two cases

La amputación parcial traumática del pabellón auricular con preservación del pedículo inferior corresponde a una patología infrecuente. Su reconstrucción incluye el uso de diversas técnicas quirúrgicas. Presentamos dos casos de reimplante inmediato, sin uso de microcirugía, con resultados favorables y sin necesidad de reintervenciones, junto a una revisión de la literatura. La revisión bibliográfica realizada apoya el uso de esta técnica, basándose en la preservación del puente cutáneo bajo el tragus que incluye una rama de la arteria temporal superficial y que sería responsable de la irrigación del reimplante.

Partial auricle amputation with preservation of the inferior pedicle is an unusual pathology. The reconstruction in these cases includes many surgical techniques. We present two cases of immediate replantation, without the use of microsurgery, with favorable outcomes and without need of new interventions. The revision of the literature supports this technique based in the preservation of the cutaneus bridge under the tragus that includes a branch of the superficial temporal artery that is responsible of the perfusion of the reimplant.

Second toe-to-hand transplantation.: A surgical option for hand amputations / Trasplante del segundo dedo del pie a la mano.: Una opción quirúrgica para las amputaciones en la mano

Background: The toe to hand transplantation is a method of reconstruction on the unique or multiple amputations of the fingers. It can be used the whole toe or with certain modifications as a wrap-around flap from the big toe or fingertip. It is a widely accepted option for the thumb. Methods: It is a series of patients with amputation of one or more fingers of the hand were operated with second toe to hand transplantation. The survival was evaluated and the sensory recovery by 2-point discrimination. Results: We practiced 12 transplants, 8 thumb, and 4 in other fingers. Ten were adults and two children. All transplants survived. Two patients required tenolysis flexor. The sensibility was recovered with good 2-point discrimination of 8 mm. Discussion: In the more proximal finger amputations, a second toe is the most appropriate, with lower morbidity of the donor site. The rates of success are between 95 to 100%. We had a success rate of 100%. The resulting defect is in the foot is minimum when the second toe was used. The decision to use one of these techniques depends on the decision and transplant surgeon training. We always used the second toe for transfers to the hand, considering that it will be thinner than the original thumb; our patients had no complaint about the appearance. Conclusion: Toe-to-hand transplantation is a good technique, providing a very good aesthetic appearance and allowing the recovery of sensitivity. The defect that is created in the foot does not produce significant aesthetic and functional alterations.

Antecedentes: El trasplante de un dedo del pie a la mano es un método de reconstrucción en las amputaciones únicas o múltiples de los dedos. Se puede usar el dedo en su totalidad o con ciertas modificaciones como una envoltura de piel y uña, o de la punta del dedo. Es una opción ampliamente aceptada para el pulgar. Métodos: Es una serie de pacientes con amputación de uno o más dedos de la mano, intervenidos con un trasplante del segundo dedo del pie a la mano. Se evaluó la supervivencia del trasplante y la recuperación sensitiva con la discriminación de 2 puntos. Resultados: Se realizaron 12 trasplantes, 8 para el pulgar, y cuatro en otros dedos de la mano. Diez fueron adultos y 2 niños. Todos los trasplantes sobrevivieron. Dos pacientes requirieron tenolisis del flexor. La sensibilidad recuperada fue buena con discriminación de 2 puntos de 8 mm. Discusión: En las amputaciones más proximales de los dedos, un segundo dedo del pie es el más adecuado, con menor morbilidad de la zona donante. La tasa de éxito está entre el 95 a 100%. Nosotros tuvimos un 100%. El defecto resultante en el pie es mínimo cuando se usa el segundo dedo. La decisión de utilizar una de las técnicas de trasplante depende de la decisión y formación del cirujano. Conclusión: Es una buena técnica que brinda una apariencia estética muy buena y permite la recuperación de la sensibilidad. El defecto resultante en el pie no produce alteraciones funcionales ni estéticas significativas.

Trauma complexo da mão parte II: lesão óssea, amputação e reimplante, perda de substância dos dedos, lesão da polpa digital e lesão ungueal / Complex trauma of the hand, part II: bone injury, amputation and replantation, loss of fi nger substance, digital pulp injury and nail injury

O trauma da mão representa uma das lesões que com maior frequência pode deixar sequelas funcionais importantes. A idade mais afetada é a economicamente ativa. Valorizamos o conhecimento adequado do primeiro atendimento e do manejo das lesões mais frequentes na mão traumatizada. Nesta segunda parte, serão abordados os fundamentos e conceitos considerados como essenciais na lesão óssea, amputações e reimplantes, perda de substância na mão, lesão da polpa digital e do complexo ungueal. Procuramos orientar a conduta dos médicos nas diversas situações clínico-cirúrgicas para diminuir o grau de complicações e sequelas (AU)

Hand trauma is one of the injuries that can most often leave important functional sequelae. The most affected age group is economically active people. We appreciate proper knowledge of the initial treatment and management of the most common injuries in the traumatized hand. In this second part we address the fundamentals and concepts considered essential in bone injury, amputation and replantation, loss of substance in the hand, and injuries of digital pulp and ungual complex. We aim to guide the conduct of physicians in different clinical and surgical situations to reduce the degree of complications and sequelae (AU)

Reconstruction of an Amputated Glans Penis With a Buccal Mucosal Graft: Case Report of a Novel Technique

Penile amputation is a rare catastrophe and a serious complication of circumcision. Reconstruction of the glans penis may be indicated following amputation. Our report discusses a novel technique for reconfiguration of an amputated glans penis 1 year after a complicated circumcision. A 2-year-old male infant presented to us with glans penis amputation that had occurred during circumcision 1 year previously. The parents complained of severe meatal stenosis with disfigurement of the penis. Penis length was 3 cm. Complete penile degloving was performed. The distal part of the remaining penis was prepared by removing fibrous tissue. A buccal mucosal graft was applied to the distal part of the penis associated with meatotomy. The use of a buccal mucosal graft is a successful and simple procedure with acceptable cosmetic and functional results for late reconfiguration of the glans penis after amputation when penile size is suitable.

Re-implantation of a degloving amputation of distal index finger caused by fireworks: a case report and literature review / Re-implantación de una amputación por desguantamiento de un dedo índice distal causada por fuegos artificiales: Reporte de caso y revisión de la literatura

Amputations associated with fireworks are customarily treated by stump revision resulting in permanent disability. In this case report, we present an eight-year old boy who suffered an amputation of his right distal index finger at the level of the epiphyseal disk with degloving injury of the amputated finger caused by fireworks. Successful re-implantation was achieved. Two-year follow-up revealed fair cosmesis and acceptable functional and aesthetic recovery though the free distal phalanx had been absorbed completely. Re-implantation of a degloving amputation finger caused by fireworks is possible and can provide good distal soft tissue coverage and recovery ofsensory and motor functions.

Las amputaciones relacionadas con fuegos artificiales son tratadas habitualmente por revisión de muñón, lo que trae como resultado una discapacidad permanente. En este reporte de caso, presentamos a un niño de 8 años que sufrió una amputación de su dedo índice derecho distal a nivel del disco epifisario con lesión por desguantamiento del dedo amputado causada por fuegos artificiales. Se logró una re-implantación exitosa. Los dos años de seguimiento revelaron una corrección quirúrgica cosmética satisfactoria, así como una recuperación funcional y estética aceptable, aunque la falange distal libre había sido absorbida completamente. La re-implantación de un dedo amputado por desguantamiento causado por fuegos artificiales es posible y puede proporcionar buena cobertura de tejido suave distal y recuperación de las funciones sensoriales y motoras.

Auto-amputation of penis due to carcinoma: Still a threat in the era of modern medicine: Report of two cases.

Incidence of penile carcinoma is decreasing worldwide. Nevertheless, the incidence of penile cancer is still significant in various tropical countries, and it often presents in advanced stage. We report two unique cases of penile auto-amputation due to advanced cancer and review relevant literature. Both the patients presented with ulcerative lesion replacing penile base following automatic sloughing of the whole penis and voiding dysfunction. In addition, the first patient had metastatic inguinal lymph nodes. Supra-pubic urinary diversion was the initial management in both the patients. The first patient was treated with combined chemo-radiation, but he succumbed to death following two cycles of chemotherapy. The second patient was successfully treated with total penectomy and perineal urethrostomy. He recovered well but was lost to follow-up.

Trauma vascular na população pediátrica / Vascular trauma in the pediatric population

CONTEXTO: O trauma vascular na população pediátrica apresenta-se como um desafio único, frente à sua incidência relativamente baixa, mesmo em centros médicos de referência. Devido à fragilidade dos tecidos, ao reduzido tamanho dos vasos e à sua baixa incidência, manifesta-se com taxas significativas de morbidade e mortalidade. OBJETIVO: Descrever e analisar os casos de trauma vascular em pacientes pediátricos admitidos em hospital terciário. MÉTODOS: Por meio de estudo retrospectivo, analisaram-se os casos de trauma vascular em pacientes menores de 18 anos, admitidos de janeiro de 2000 a julho de 2010, levando-se em conta dados demográficos, mecanismos de lesão, traumas associados, tratamentos empregados e complicações. RESULTADOS: Foram estudados 242 pacientes com trauma vascular, sendo 37 (15,2%) pertencentes à população pediátrica. A média de idade foi de 12,5 anos, sendo 81% dos participantes da pesquisa do sexo masculino. Entre os mecanismos de lesão, o trauma penetrante foi o mais comum (57%), seguido do contuso (38%) e do iatrogênico (5%). Das técnicas cirúrgicas empregadas, o enxerto arterial com veia autóloga foi o procedimento mais comum (13 casos). Houve um caso de amputação primária (infrapatelar) e quatro amputações no período pós-operatório precoce (três transfemorais e uma transtársica). Dos 11 pacientes admitidos com lesão de artéria poplítea, a taxa de amputação transfemoral pós-operatória foi de 27,3%. Houve apenas um óbito devido a trauma iatrogênico em lactente hemofílico. CONCLUSÕES: O trauma vascular pediátrico envolve vários desafios técnicos, como o vasoespasmo e o calibre dos vasos. As altas taxas de amputações observadas em pacientes com lesões de artéria poplítea, apesar das tentativas de revascularização, reforçam a gravidade desse tipo de trauma.

BACKGROUND: Vascular trauma in the pediatric population is a unique challenge, mainly due to its relatively low incidence, even in high complexity medical centers. Due to the fragility of the tissues, the small size of vessels and low incidence, it manifests with significant rates of morbidity and mortality. OBJECTIVE: To describe and analyze the cases of vascular trauma in pediatric patients admitted to a tertiary hospital. METHODS: Through retrospective study we analyzed the cases of vascular trauma in patients younger than 18 years, admitted from January 2000 to July 2010, taking into account demographic data, mechanisms of injury, associated injuries, treatment techniques and complications. RESULTS: During the studied period, 242 patients were admitted with vascular trauma, 37 (15.2%) belonging to the pediatric population. The average age was 12.5 years, and 81% of the research participants were male. Related to the mechanisms of injury, penetrating trauma was the most common (57%), followed by blunt (38%) and iatrogenic (5%). Among the surgical techniques employed, arterial bypass with autologous vein was the most common (13 cases). There was a case of primary major amputation (below the knee) and four amputations in the early postoperative period (three transfemoral and one transtarsic). For the 11 patients admitted with popliteal artery injury, the rate of postoperative transfemoral amputation was 27.3%. There was only one death due to an iatrogenic trauma in a hemophilic lactant. CONCLUSIONS: Vascular trauma in pediatric patients involves several technical challenges, such as vasospasm and vessel diameter. The high rates of amputation in patients with popliteal artery injuries, despite attempts of revascularization, reinforce the seriousness of this type of trauma.

Successful revascularization of near total amputation of the upper limb at the Sultan Qaboos hospital, Salalah

Severe crush injuries to the upper limb may require a formal amputation with devastating consequences to the patient. We report a patient with a near total amputation at the level of mid-forearm who underwent revascularization and salvage of his hand. The operative details of this case are described. It is the first time that such a patient has been treated successfully by plastic surgeons and orthopedic surgeons at the Sultan Qaboos Hospital, Salalah, Awareness of the possibility of salvage should be spread among health care personnel as well as the need for immediate attention by a multispeciality team. Literature related to the operative technique, contraindications and long term results is reviewed

Lesiones graves en las manos debido a artefactos pirotécnicos y/o explosivos / Serious injuries on the hands because of pyrotechnics and / or explosives

Las lesiones ocacionadas por artefactos pirotécnicos y/o explosivos son altamente incapacitantes, constituyendo un problema de salud pública. Se estudiaron 25 paciente, 96 por ciento del sexo masculino, el grupo etario mas afectado estuvo entre 16 y 25 años con 40 por ciento. 92 por ciento eran dextromanos: la mano izquierda se lesionó en un 72 por ciento. Las lesiones más frecuentes fueron las amputaciones parciales en el 19,23 por ciento y las heridas del espacio interdigital en 17,95 por ciento; el pulgar fue afectado en el 96 por ciento. La influencia del alcohol estuvo presente en el 80 por ciento, siendo estos procedencia ilegal en el 84 por ciento.

Amputação traumática da língua em cão. Relato de caso / Traumatic tongue amputation in dogs: A case report / Amputación traumática de lengua en perro relato de caso

Descreve-se um caso raro de amputação parcial da língua em cão. O animal foi atendido no Hospital Veterinário da Universidade Federal do Piauí, com amputação traumática da língua, devido à mordedura por outro cão, em uma briga. Foi feita a sutura simples do segmento remanescente. O animal se recuperou completamente, com boa qualidade de vida. Concluiu-se que o cão se adapta bem à perda parcial da língua.

A rare case of partial tongue amputation in a male dog is described. The animal was admitted in the Universidade Federal do Piauí Veterinary Hospital with traumatic tongue amputation due to a bite during a fight with another dog. A simple suture of reminiscent segment was made. The animal recovered completely, having good life quality. It was conclude that dogs can adapt well to partial tongue amputation.

Reimplante de dedo: indicações atuais / Finger reimplant: current indications

Introdução: o reimplante de dedos é uma opção no tratamento de amputações traumáticas. E tornou-se procedimento rotineiro, nos serviços onde existem profissionais com treinamento microcirúrgico.As indicações de reimplante de dedos, atualmente, estão baseadas na funcionalidade da mão. Objetivo: mostrar a modificação dos critérios para indicação de reimplante de dedos da mão. Métodos: estudo retrospectivo analisando pacientes com amputações digitais, que foram ou não reimplantados, durante os 26 anos do Serviço de Microcirurgia do Hospital Cristo Redentor em Porto Alegre. Resultados: observou-se que, inicialmente, o reimplante era aplicado a todos os segmentos amputados. Com o passar dos anos, essas indicações ficaram mais restritas, sendo contra-indicado nos pacientes com boa função remanescente, na mão traumatizada. Discussão: o principal objetivo do tratamento dos pacientes com amputações digitais é manter a funcionalidade da mão. Diversos fatores devem ser considerados para in- dicação de um reimplante digital.A reabilitação pós-operatória é fundamental para o sucesso do tratamento proposto ao segmento amputado. Conclusão: nas amputa- ções digitais, o principal critério para indicação de reimplante, além das indicações formais, deve ser a manutenção de uma boa função da mão.

Background: finger reimplant is an option in the treatment of traumatic amputations. It has become a routine procedure, when there are microsurgical trained professionals. The indications for fingers reimplant are currently based in the hand's fnctionality. Objective: to show the modification of criterions to indication finger reimplant. Methods: retrospective study analyzing digitally amputated patients, that were or weren't reimplanted during the 26 years of the Cristo Redentor Hospital's Microsurgical Service in Porto Alegre. Results: it has been observed that initially the reimplant was applied to all amputated segments. As the years have gone by, these indications are becoming more restricted. Nowadays, the reimplant is contraindicated for patients with good remaining function on the injured hand. Discussion: the main purpose on treating patients with digital amputations is to maintain the hand's fnctionality. Several factors should be considered when indicating a digital reimplant. The postoperative rehabilitation is fundamental to the success of the treatment proposed to the amputated segment. Cconclusion: in digital amputations the main criteria when indicating a reimplant, besides the formal conditions, should be keeping the good functionality of the hand.

Microsurgical free flap and replantation without antithrombotic agents.

Microsurgical reconstructions for free flap transfer, digits and limb replantation have been highly successful applications in the past decades. Antithrombotic prophylactic agents, such as low-molecular-weight dextran, aspirin and heparin have been routinely used for the prevention of microvascular thrombosis. Even though these agents are efficacious in microsurgery, some systemic morbidity is still reported. Forty cases of microsurgical reconstruction over the last five years are reported. They include 22 cases of free flap transfer and 18 cases of replantation (19 fingers, 2 toes and one hand). The surgery was performed by the same group of plastic surgeons and no antithrombotic agent was given intraoperatively or during the post operative period Results show one partial flap loss, two replantation losses due to severe crush injuries of the digits and one toe replantation failure in a two year old. The failure of toe replantation was due to surgical technique and poor post operative immobilization. The result shows that successful microsurgical reconstruction depends on many factors. One of the most important factors is microsurgical technique. Use of antithrombotic agents alone does not appear to play a significant role in the patency of microvascular structures.

Progeressive hair coil strangulation of penis

Strangulation of penis by hair strands is a well-known, but uncommon clinical entity. We report two cases occurring in circumcised boys causing progressive painless disfigurement of penis with strands of hair coiled around the penile shafts, strangulating the penis. Primary repair was done in one case and delayed primary repair was done in the other, both with satisfactory results

Microcirugía reconstructiva en trauma complejo de extremidades / Reconstructive microsurgery in complex trauma of the extremities

La microcirugía vascular es un campo relativamente nuevo en la cirugía y constituye uno de los avances técnicos más importantes de los últimos veinte años. Esto ha sido particularmente importante en la cirugía reconstructiva haciendo posible el trasplante de tejido libres y también el reimplante de extremidades amputadas. Se describe nuestra experiencia microquirúrgica en el tratamiento de graves lesiones de extremidades. Entre enero de 1994 y enero de 2000, un total de 55 pacientes fueron sometidos a procedimientos microquirúrgicos para reconstruir lesiones complejas de extremidades en el Hospital Clínico de la Universidad de Chile. Todos los pacientes fueron seguidos al menos 5 meses para evaluar resultados y complicaciones. Hubo una tasa de falla vascular global del 3 por ciento y un resultado estético y funcional satisfactorio de un 95 por ciento. Nuestros resultados demuestran que la transferencia libre de tejidos y particularmente los reimplantes, pueden ser considerados como una opción de tratamiento segura y viable en heridas complejas de extremidades o amputaciones