Experiencia en el uso de colgajos locales para cobertura del pulgar / Local flaps utility for thumb coverage: our experience

Introducción y Objetivo. El pulgar asume el 40-50% de la funcionalidad de la mano, por lo que es fundamental su reconstrucción estable y funcional. Además de las opciones que nos ofrece la microcirugía, debemos manejar de manera eficaz los colgajos locales para cobertura del pulgar, ya que nos pueden aportar soluciones adecuadas a difíciles problemas reconstructivos, si se emplean correctamente. El objetivo de este trabajo es presentar nuestra sistemática en la reconstrucción con colgajos locales de defectos de pequeño y moderado tamaño del pulgar. Para ello, utilizamos el concepto de unidades estético-funcionales del pulgar y describimos los colgajos que consideramos como primera línea reconstructiva en cada tipo de defecto. Material y Método. Realizamos una revisión retrospectiva, descriptiva, de una serie de 56 casos de pérdidas de sustancia del pulgar con exposición ósea, tendinosa o ambas, susceptibles de cobertura con colgajos locales. Recogemos la edad, mano lesionada, tipo de accidente y mecanismo lesional, subunidad digital afectada y geometría de la lesión. Describimos la técnica reconstructiva indicada en cada caso. Resultados. De los 56 pacientes, el 95% (53 casos) correspondieron a defectos en subunidad distal del pulgar (distal a articulación interfalángica (IF)) que comprometían pulpejo y placa ungueal; 2 de ellos asociados a lesión en subunidad proximal volar y 8 a subunidad proximal dorsal. El otro 5% (3 casos) correspondieron a subunidad dorsal proximal exclusivamente. Para su cobertura, contabilizamos 17 colgajos basados en arteria dorso-cubital tipo Brunelli modificado (30%), 3 Brunelli clásicos (5%), 12 colgajos basados en primera arteria intermetacarpiana dorsal tipo Foucher (22%), 9 Elliot (16%), 4 Elliot asociados a colgajo eponiquial (7%), 6 colgajos heterodigitales de Littler (12%), 3 basados en arteria dorso-radial tipo Moschella (5%) y 2 colgajos heterodigitales tipo Buchler (3%). Conclusiones. Aplicando el concepto reconstructivo de unidades estético funcionales del pulgar, para defectos volares, nuestra primera línea reconstructiva son los colgajos de avance volar o los heterodigitales, por sus características mecánicas y posibilidad de neurotización. En algunos casos, asociamos el colgajo eponiquial de Backach que aporta una mejoría estética considerable. En defectos de predominio dorsal, nuestra preferencia son los colgajos dorso-cubitales o dorso-radiales, o bien al colgajo de primera arteria intermetacarpiana dorsal en defectos mayores. Estos colgajos no aportan apenas sensibilidad, pero presentan características similares a la piel dorsal en grosor y elasticidad (AU)

Background and Objective. The thumb represents 40-50%of hand function making its stability and functional reconstruction essential. Despite the development in microsurgery, the correct use of local flaps for thumb coverage can provide us appropriate solutions to difficult reconstructive problems. The aim of this paper is to present our systematic reconstruction treatment of small and moderate thumb defects using local flaps.We use the concept of functional aesthetic units of the thumb describing the flaps to be consider as first reconstructive line in each type of defect. Methods. We present a descriptive, retrospective review of 56 cases of loss of thumb substance that presented exposure of the bone, tendon or both, which could benefit from coverage by local flaps. We include age, injured hand, type of accident and injury mechanism, digital subunit affected and geometry of the lesion. We describe reconstructive technique indicated in each case. Results. 95% of the cases (53 cases) corresponded to defects in the thumb distal subunit (distal to the interphalangeal joint (IJ)) compromising the pulp and the nail plate; including 2 of them associated with proximal palmar subunit injury and 8 associated with a proximal dorsal subunit injury. The other 5% (3 cases) corresponded to the proximal dorsal subunit exclusively. We performed 17 dorsal ulnar artery modified Brunelli flaps (30%); 3 Brunelli classic (5%); 12 first dorsal metacarpal artery flap (Foucher's flap) (22%); 9 Elliot's flap (16%); 4 Elliot's flaps associated with eponychial flap (7%); 6 Littler's heterodigital flaps (12%); 3 dorsoradial collateral artery flap (Moschella's flap) (5%); and 2 Buchler's heterodigital flaps (3%). Conclusions. In application of the functional aesthetic units of the thumb reconstructive concepts for volar defects, our first reconstructive line are the palmar flaps or the heterodigital flaps due to their mechanical characteristics and the possibility of neurotization. In some cases, we would consider the Backach eponychial flap, which provides a considerable aesthetic improvement. On the other hand, in defects of dorsal preponderance, our preference are the dorsal ulnar and radial flaps and the first metacarpal artery flap for major defects cases. These types of flaps only contribute minimally for the sensitivity, but present similar characteristics with the dorsal skin in terms of thickness and elasticity (AU)

PGE-1 in replantation and free tissue transfer: early preliminary experience.

Experimental and clinical trials demonstrate the vascular, anti-ischemic and tissue protective effects of PGE1, which has been used for many years in different macrovascular diseases. However, few reports have addressed its potential use in microvascular surgery. The authors share their early experience with PGE1 in replantations and free tissue transfers. Considering its established benefits and minimal adverse reactions, PGE1 might be included as a first-line medication in the antithrombotic pharmacologic treatment in replantation and free flap surgery. However, the overall clinical efficacy and safety of PGE1 in microvascular surgery remains to be determined in larger, prospective clinical trials.

Fibrohistiocitoma maligno (sarcoma pleomórfico indiferenciado de alto grado) sobre tofo gotoso / Malignant fibrous histiocytoma (undifferentiated high grade pleomorphic sarcoma) arising in a gouty tophus

La gota es una enfermedad por alteración del metabolismodel ácido úrico que puede producir graves lesiones articulares.Presentamos un caso clínico correspondiente a unvarón de 76 años con episodios de gota aguda desde hace 30años y presencia de tofos gotosos en manos y pies. Debidoal crecimiento rápido del tofo situado en la región dorsal dela articulación metacarpofalángica del 2.º y 3.er dedo de lamano izquierda, se hicieron estudios de imagen, observándoseuna imagen radiológica compatible con enfermedad dedepósito. Se procede a resecar la lesión, siendo necesaria laamputación del 2.º dedo por afectación de sus tendones. Enel examen de la pieza, se observaron dos zonas diferenciadas,una amarillenta y granular que microscópicamentecorrespondía a un típico tofo gotoso y otra zona blanquecinay carnosa que correspondía a una proliferación fusocelularmaligna de alto grado que inmunohistoquímicamentesólo expresaba CD68 y lisozima. Con estos hallazgos sehizo el diagnóstico de fibrohistiocitoma maligno sobre tofogotoso. El paciente fue reintervenido, encontrándose tumorresidual, remitiéndose al servicio de Oncología donde fuetratado con radioterapia y quimioterapia adyuvante. A los 5meses fue reintervenido por una recidiva en el antebrazoizquierdo, encontrándose actualmente libre de enfermedad

Gout is a uric acid metabolism disorder that is able toproduce severe joint injuries. We describe a case of a 76year old man with a history of acute gout attacks during 30years and tophaceous deposits in hands and feet. After aquick growth of a tophus located in his left hand dorsal 2ndand 3rd metacarpophalangical joint, radiological studieswere done. An image compatible with destructive uric aciddeposit illness was shown. Resection was made, findingtendons affected which made necessary 2nd finger amputation.Surgical specimen showed two differentiated areas: ayellowish and granular corresponding to the typical tophaceousdeposit and other fleshy and white corresponding to ahigh grade malignant fusocellular proliferation. Immunohistochemicalstudies showed only positivity for CD68 andlysozime in tumoral cells. The diagnosis of malignantfibrous histiocytoma associated to gouty tophus was made.Residual tumor was found after reintervention, and thepatient was sent to the Oncology Service for adjuvant radioand chemotherapy. Five months later, the patient was reoperatedfor recurrence of the tumor in the left arm, staying freeof disease at these moments

Combined latissimus dorsi-thoracodorsal artery perforator free flap: the "razor flap".

Elevation of the skin island overlying the latissimus dorsi muscle, dissecting the dominant perforating vessel, permits independent positioning of the skin island in relation to the muscle. This combination of the thoracodorsal artery perforator (TAP) and the latissimus dorsi (LD) muscle flap expands the surface of the flap without increasing donor morbidity.