RESUMO
The accumulation of ß2-microglobulin due to long-term hemodialysis is known as dialysis-related amyloidosis, a rare phenomenon that manifests as a subcutaneous mass. Subcutaneous ß2-microglobulin amyloidomas are predominantly located on the buttocks. Owing to the load-bearing properties of this location and proximity to the anus, amyloidomas on the buttocks may be prone to pressure ulcers and infection. This report presents two cases of long-term hemodialysis patients who required surgical treatment for infected ulcers caused by buttock amyloidomas. In the first case, treatment failed after the amyloidoma was excised and covered with a single-stage skin flap. In the second case, successful treatment was accomplished by reducing the volume of the amyloidoma, followed by a pause to allow for granulation growth and a two-stage skin graft. Amyloids of this nature are known to be cytotoxic; thus, a robust wound preparation technique should be used until the excision site is fully covered with granulation tissue before wound closure is initiated at the time of surgery. In addition, buttock amyloidomas often extend subcutaneously through the hip joint, and repeated infections may lead to more severe outcomes, such as hip joint infections. The number of dialysis-related amyloidosis patients has been increasing in recent years; thus, we report these case studies to improve patient outcomes in similar cases.
RESUMO
INTRODUCTION: The treatment of intractable toe ulcer with critical limb ischemia (CLI) is a challenge because of its poor blood flow and the wound. Here, a novel fixation technique for artificial dermis with negative pressure wound therapy (NPWT) was reported. METHOD: After the amputation of toe, artificial dermis made of collagen-gelatin sponge (CGS) was grafted onto the wound where human recombinant basic fibroblast growth factor (bFGF) was sprayed. The foot was put on adhesive iodine-impregnated drape, the artificial-dermis area was covered with a sponge dressing of which another end reached to the drape, and the vacuum port was applied on the dressing sponge sandwiched with two drapes and connected to an NPWT system. Since the shape of sponge-dressing was similar to that of elephant-trunk, the technique in this study was named an "Elephant-trunk" technique. RESULT: During NPWT period, no complications such as air leakage, skin erosion, ischemic around tissue were confirmed. The artificial dermis was engrafted completely at one week after surgery, and the wound was confirmed to close completely. CONCLUSION: This NPWT technique with bFGF and CGS accelerated the healing of wound treated conservatively with artificial dermis in CLI patients.
RESUMO
Replantation is an ideal method for treating fingertip amputation. However, in some cases, replantation is known to be a challenging issue. This report described a successful thumb tip reconstruction performed with bone and nail bed salvaged as spare parts, and a free posterior interosseous artery perforator (PIAP) flap. A 75-year-old man accidentally amputated his left thumb with an electric saw, and emergency replantation was started under brachial plexus block. However, the distal stump of digital artery was unable to be identified, forcing the initial plan to change to flap reconstruction. After vascular anastomosis, complex tissue containing nail bed and side nail fold was grafted on the adipofascial tissue of PIAP flap. Both PIAP flap and the complex tissue survived completely. At 12 months after surgery, only a slight deformity in the nail plate was observed. Spare parts surgery is a surgical procedure effectively salvaging and utilizing tissue that is going to be discarded in severe limb trauma. This idea can be applied to treatment for the finger amputation. In this case, replantation would be difficult in the thumb tip amputation, so spare parts surgery was performed with a PIAP flap. The innervated PIAP flap is reported, including the posterior antebrachial cutaneous nerve. In this case, the cutaneous nerve was able to be identified, neurorrhaphy was performed, and sufficient sensory recovery was obtained. Surgical procedure with PIAP flaps was found to be a useful method for immediate reconstruction with salvaged spare parts after fingertip replantation was considered to be difficult intraoperatively.
