Caso Clínico: Cirugía Reconstructiva de Tobillo / Case Report: Reconstructive Ankle Surgery

INTRODUCCIÓN: La diabetes mellitus es un importante problema de salud pública, según la Organización Mundial de la Salud, 422 millones de adultos en todo el mundo en 2014. En 2012 provocó 1.5 millones de muertes a nivel mundial; es la primera causa de amputación no traumática en miembros inferiores y las infecciones del pie ocurren con alta frecuencia en pacientes mal controlados. Este caso muestra la reconstrucción de defectos de partes blandas en el tercio inferior pierna, talón, maléolos y pie a través de la descripción del colgajo sural reverso. En este estudio se discuten las ventajas y desventajas de la utilización de esta técnica. CASO CLÍNICO: Paciente de sexo femenino 56 años de edad con antecedentes de Diabetes Mellitus tipo 2 mal controlada, que sufrió una fractura de tobillo izquierdo tratada con osteosíntesis; durante el postoperatorio acudió a emergencia, por presentar dolor de gran intensidad en tobillo izquierdo, fiebre, dehiscencia de herida quirúrgica, acompañada de secreción serosa. EVOLUCIÓN: La paciente luego de varias limpiezas quirúrgicas y cambios de terapia de cierre asistido por presión negativa, se consigue controlar la infección, con persistencia del defecto de cobertura ósea y del material de osteosíntesis. Se presentaron complicaciones adicionales como la rigidez articular, atrofia muscular; se decidió realizar reconstrucción del tercio distal del pie usando colgajo fasciocutáneo sural de flujo reverso, que evolucionó satisfactoriamente, consiguiendo cubrir el defecto con tejido biológico. CONCLUSIÓN: El colgajo sural de flujo reverso, es una técnica reproducible, que permite cubrir defectos de cobertura en tercio distal de pierna y tobillo; acortar los tiempos de hospitalización, especialmente cuando hay exposición ósea o de material de osteosíntesis.

BACKGROUND: Diabetes mellitus is a major public health problem, according to the World Health Organization, 422 million adults worldwide in 2014. In 2012, it caused 1.5 million deaths worldwide. Diabetes is the leading cause of non-traumatic amputation in lower limbs and foot infections occur with high frequency in poorly controlled patients. This case shows the reconstruction of soft tissue defects in the lower third leg, heel, malleoli and foot through the description of the reverse sural flap. In this study the advantages and disadvantages of the use of this technique are discussed. CASE REPORT: A 56-year-old female patient with a poorly controlled history of Diabetes Mellitus type 2, who suffered a fracture of the left ankle treated with osteosynthesis, and who during the postoperative period attended emergency orthopedics and traumatology, due to severe pain in the left ankle, fever, dehiscence of surgical wound, accompanied by serous secretion. EVOLUTION: The patient, after several surgical cleanings and changes in closure therapy assisted by negative pressure, manages to control the infection, with persistence of the bone coverage defect and the osteosynthesis material. There were additional complications such as joint stiffness, muscle atrophy; it was decided to reconstruct the distal third of the foot using a reverse flow sural fasciocutaneous flap, which evolved satisfactorily, managing to cover the defect with biological tissue. CONCLUSIONS: The sural flap of reverse flow is a reproducible technique that allows to cover coverage defects in the distal third of the leg and ankle; shorten hospitalization times, especially when there is bone exposure or osteosynthesis material.

Descripción anatómica de la irrigación del colgajo sural a pedículo distal en piezas cadavéricas / Anatomical description of the blood supply of the distally based sural flap in eight lower limbs

Background: The distally based sural fasciomyocutaneous flap is widely used in the coverage of deep soft tissue defects on the distal third of lower limbs. Aim: To perform a morphometric description of the perforating arteries that supplies the flap. Material and Methods: We used eight lower limbs from amputations performed above the knee. The limbs were injected through the popliteal artery with red colored latex. After the injection, the limbs were dissected to obtain a distally based sural fasciomyocutaneous flap. Once the fasciomyocutaneous island was obtained, the flap was elevated dissecting its pedicle. Once the whole flap was dissected, a morphometric registry of the lateral and medial perforating arteries was performed. The pivot point for the flap was set 5 cm above the upper border of the lateral malleolus. The distance between the upper border of the lateral malleolus and the emergence of each perforating artery was measured. Results: The sural nerve was identified in all eight dissections. A perineural plexus was the source of the blood supply of the flap, in three of the eight dissections. In two dissections, three sural arteries were identified (medial, median and lateral). The lateral sural artery was identified in two dissections and the medial and lateral arteries in one. Three to six perforating arteries were identified in the medial part of the pedicle and four to five perforating arteries in the lateral part of the pedicle. Conclusions: The distribution of the sural artery along the flap's pedicle is very variable. The most common distribution in these dissections was in the form of a perineural plexus. Considering the distance from the lateral malleolus to the emergence of the perforating arteries, the pivot point of the flap, should be set approximately at 5.5 centimeters above the lateral malleolus.

El colgajo sural fasciomiocutáneo es ampliamente utilizado en la reparación de defectos profundos de tejidos blandos del miembro inferior distal. Este estudio describe su base anatómica mediante la morfometría de las arterias perforantes en una muestra de nuestra población chilena. Material y Método: Se utilizaron 8 miembros inferiores de amputaciones supracondileas. Previa repleción con látex coloreado vía poplítea, se procedió a disecar los miembros inferiores para así obtener un colgajo fasciomiocutáneo sural de pedículo distal. Una vez obtenida la isla, se procedió a elevar el colgajo y disecar su pedículo. Luego se realizó la mor-fometría de las arterias perforantes tanto por lateral como por medial al pedículo, desde el punto pívot definido a 5 cm cefálico al maléolo lateral, hasta la base de la isla fasciomiocutánea. Se describió la distribución de la irrigación y se realizó registro fotográfico de los hallazgos. Resultados: El paquete vasculonervioso sural con un nervio fue identificado en todas las disecciones. La morfología arterial predominante fue la distribución como plexo perineural. Se reconocen tres arterias surales (lateral, mediana y medial). Fueron identificadas 3 a 6 perforantes hacia medial y 4 a 5 hacia lateral del pedículo. Conclusiones: La distribución de la arteria sural es variable y en la mayoría de los casos se presenta como plexo perineural. Dados los hallazgos de las perforantes, consideramos que el punto de giro del colgajo se encuentra aproximadamente a 5,5 cm del maleolo lateral, lo cual coincide con el punto ideal para la viabilidad del colgajo informado en otras series.

Retalho sural reverso para reconstrução distal daperna, tornozelo, calcanhar e do pé / The distally based sural artery flap for reconstruction of lower leg, ankle, heel

Introdução: A reconstrução de defeitos de partes moles no terço inferior da perna, tornozelo,calcanhar e pé é um desafio à cirurgia plástica reconstrutora. O retalho sural reverso é uma boaopção para esses casos. Apresenta o maior arco de rotação e não artérias importantes, sendoutilizado como uma alternativa à microcirurgia nessas situações. A técnica é relativamentesimples e o dano na área doadora é mínimo. Objetivo: Estudar casos de realização do retalhosural reverso na reconstrução do terço inferior da perna, tornozelo, calcanhar e do pé. Método:Quinze pacientes com defeitos de partes moles no terço inferior da perna, tornozelo, calcanhare pé foram estudados no período de 2004 a 2007. Todos foram submetidos a retalho suralreverso em dois tempos, sem tunelização, para evitar congestão venosa. Resultados: Desses15 pacientes, 11 eram homens e 4 mulheres, 10 tinham lesões pós-traumáticas e 5 eram diabéticos.A idade variou de 18 a 75 anos. Todas as lesões ocorreram no terço inferior da perna,tornozelo, calcanhar e foram submetidas ao retalho sural reverso em 2 tempos. Todos os casosapresentaram boa evolução. Houve congestão venosa em apenas um caso, que respondeu bem amedidas posturais. Conclusão: O retalho sural reverso é uma alternativa para a reconstrução doterço inferior da perna, tornozelo, calcanhar e do pé. É versátil, reproduzível, seguro, de curtaduração e proporciona uma alternativa à microcirurgia nesses casos relatados, com excelenteevolução conforme descrito, estando de acordo com os dados da literatura.

Background: Soft tissue defects on the lower third of the leg, ankle, heel and foot remainsa challenge for reconstructive plastic surgery. The distally based sural flap is an option in thereconstruction of these areas because of the largest arc of rotation and does not sacrifice anymajor artery. Objective: To study the distally based sural flap in patients with soft lesions inthe lower third of the leg, ankle, heel and foot. Method: We report 15 patients with lesions inthe on the lower third of the leg, ankle, heel and foot, submitted to distally based sural flap ina two-step surgery approach, without a tunnel to reduce venous congestion. Results: Fifteenpatients were studied, 11 men and 4 female, 10 after trauma. Five patients had diabetes andthe ages varied from 18 to 75 years. All the soft defects occurred in the lower third of the leg,ankle, heel and foot were submitted to distally based sural flap in two-step surgery approach.All defects were successfully covered without major complications. Venous congestion wasreported in only one case, completely reversed with the elevation of the limb. Conclusion:The distally based sural flap is an alternative to the reconstruction of the lower third of theleg, ankle, heel and foot defects. It is a versatile, reliable procedure, and surgical techniqueis safe, short of duration and provides an excellent option to microsurgical reconstruction intheses presented cases. The success rate in this study is comparable to literature.

Distally based sural artery flap: a workhorse to cover the soft tissue defects of lower 1/3 Tibia and Foot

To present our experience of soft tissue cover of lower one third of tibia and foot, treated by an Orthopaedic Surgeon without any special training and reliability of this flap. Eleven patients, ten males and one female, with soft tissue defect of lower one third tibia and foot requiring soft tissue cover were treated from March 1999 to February 2004. The flap was outlined at the posterior aspect of junction of upper and middle 1/3 leg. The pivot point of the pedicle was at least 5cm i.e., 3 fingers" breadth above the lateral mallelous to allow anastomosis with the peroneal artery. Skin incision was started along the line in which the fascial pedicle would be taken. The subdermal layer was dissected to expose the sural nerve, accompanying superficial sural vessels and short saphenous vein. The subcutaneous fascial pedicle was elevated, with a width of 2cm to include the nerve and these vessels. At the proximal margin of the flap, the nerve and the vessels were ligated and severed. The skin island was elevated with the deep fascia. The donor site defect was closed directly when the flap was less than 3cm wide. A larger donor site defect along with the pedicle was covered with a split thickness skin graft. All flaps except one survived. Most flaps showed slight venous congestion which cleared in a few days. There was no loss of split skin graft. Distally based Sural artery flap remains the choice for reconstruction of soft tissue defects of lower 1/3 tibia and foot. The dissection is easy, quicker and can be done by an Orthopaedic surgeon without any special training