Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19.

Background: Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19. Methods: We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes. Results: Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002). Conclusions: In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.

REVERSE SURAL FLAP FOR LOWER LIMB RECONSTRUCTION.

Introduction: Reconstruction of distal wounds in lower extremities can be challenging due to the lack of tissue to perform local flaps. Fasciocutaneous and muscular flaps are some options for coverage, such as the reverse-flow fasciocutaneous sural flap. Objective: To present an 18-month experience on ankle, calcaneus, and foot reconstruction using the reverse-flow sural flap, performed by the Complex Wounds Group of the Plastic Surgery Department of the University of São Paulo Medical School. Methods: An observational, retrospective and descriptive study was performed through data survey on medical records of all patients treated between November 2018 and June 2020. Results: Nine reverse-flow fasciocutaneous sural flaps were performed. All patients were men. The mean age was 38 years old. Five patients had acute wounds for traffic collision, one electrical trauma and three chronic post-traumatic injuries. The ankle was the most common injury site (6), followed by foot (2) and calcaneus (1). Four patients had complications, three of which were partial necrosis and one distal epitheliosis. No case of total necrosis was recorded. The average hospital stay was 30.1 days. Conclusion: The reverse-flow fasciocutaneous sural flap proved to be a viable, reproducible, and reliable option for distal lower limb reconstruction. Level of Evidence IV, Case Series.

Introdução: Reconstrução de lesões distais de extremidades inferiores podem ser desafiadoras devido à limitação de tecido para retalhos locais. Retalhos fasciocutâneos e musculares são opções, como o retalho fasciocutâneo sural reverso. Objetivo: Apresentar a experiência de 18 meses do Grupo de Feridas Complexas do Serviço de Cirurgia Plástica da Faculdade de Medicina da Universidade de São Paulo no uso do retalho sural reverso para reconstruções de defeitos em tornozelo, calcâneo e pé. Métodos: Estudo observacional, retrospectivo e descritivo, com dados de prontuário de todos os casos operados no serviço entre novembro de 2018 e junho de 2020. Resultados: Foram realizados nove retalhos fasciocutâneos sural reverso. Todos os pacientes eram do sexo masculino, com idade média de 38 anos. Cinco foram vítimas de acidente automobilístico, um de trauma elétrico e três apresentavam sequelas pós-traumáticas. Seis lesões localizadas em tornozelo, dois em pé e um em calcâneo. Quatro pacientes apresentaram complicações, sendo três necroses parciais e uma epiteliólise distal. Não houve perda total de retalho. O tempo médio de hospitalização foi de 30,1 dias. Conclusão: O retalho fasciocutâneo sural reverso mostrou-se uma opção viável, reprodutível e segura para reconstrução de lesões complexas em terço distal de perna e pé. Nível de Evidência IV, Série de Casos.

Different litter compositions influence broiler chicken locomotion.

Background: Bedding material must absorb moisture, reduce impacts, and allow chicken to express their natural behavior reducing the occurrence of injuries in the footpad and joints, and improving carcass quality and performance. Aims: This study evaluated different bedding materials with different levels of inclusion of dried grass (Zoysia japonica) on the development of lesions in the locomotor system of broiler chickens. Methods: One thousand eight-day-old male chicks of the Cobb 500® were distributed in a completely randomized design with a 3 × 2 factorial scheme: three levels of grass inclusion and two bedding materials (100% wood shavings; 100% rice husks; 25% grass and 75% wood shavings; 25% grass and 75% rice husks; 50% grass and 50% wood shavings; 50% grass and 50% rice husks). The birds at 21, 28, 35, and 42 days of age were evaluated for pododermatitis. Ten birds from each repetition were identified and evaluated weekly from 21 to 42 days for Gait score, latency to lie and leg angle (valgus and varus). At 43 days of age, 60 birds of each treatment were slaughtered and evaluated for femoral degeneration and tibial dyschondroplasia. Results: Different litter compositions did not affect the incidence of lameness, tibial dyschondroplasia and spondylolisthesis. Pododermatitis scores increased after 28 days when including 50% of grass. Conclusion: Age contributes more to the development of locomotion injuries than does bedding material. It is recommended to use inclusions of dried grass only as bedding for young broilers.

Reverse sural flap for lower limb reconstruction / Retalho sural reverso na reconstrução de membros inferiores

ABSTRACT Introduction: Reconstruction of distal wounds in lower extremities can be challenging due to the lack of tissue to perform local flaps. Fasciocutaneous and muscular flaps are some options for coverage, such as the reverse-flow fasciocutaneous sural flap. Objective: To present an 18-month experience on ankle, calcaneus, and foot reconstruction using the reverse-flow sural flap, performed by the Complex Wounds Group of the Plastic Surgery Department of the University of São Paulo Medical School. Methods: An observational, retrospective and descriptive study was performed through data survey on medical records of all patients treated between November 2018 and June 2020. Results: Nine reverse-flow fasciocutaneous sural flaps were performed. All patients were men. The mean age was 38 years old. Five patients had acute wounds for traffic collision, one electrical trauma and three chronic post-traumatic injuries. The ankle was the most common injury site (6), followed by foot (2) and calcaneus (1). Four patients had complications, three of which were partial necrosis and one distal epitheliosis. No case of total necrosis was recorded. The average hospital stay was 30.1 days. Conclusion: The reverse-flow fasciocutaneous sural flap proved to be a viable, reproducible, and reliable option for distal lower limb reconstruction. Level of Evidence IV, Case Series.

RESUMO Introdução: Reconstrução de lesões distais de extremidades inferiores podem ser desafiadoras devido à limitação de tecido para retalhos locais. Retalhos fasciocutâneos e musculares são opções, como o retalho fasciocutâneo sural reverso. Objetivo: Apresentar a experiência de 18 meses do Grupo de Feridas Complexas do Serviço de Cirurgia Plástica da Faculdade de Medicina da Universidade de São Paulo no uso do retalho sural reverso para reconstruções de defeitos em tornozelo, calcâneo e pé. Métodos: Estudo observacional, retrospectivo e descritivo, com dados de prontuário de todos os casos operados no serviço entre novembro de 2018 e junho de 2020. Resultados: Foram realizados nove retalhos fasciocutâneos sural reverso. Todos os pacientes eram do sexo masculino, com idade média de 38 anos. Cinco foram vítimas de acidente automobilístico, um de trauma elétrico e três apresentavam sequelas pós-traumáticas. Seis lesões localizadas em tornozelo, dois em pé e um em calcâneo. Quatro pacientes apresentaram complicações, sendo três necroses parciais e uma epiteliólise distal. Não houve perda total de retalho. O tempo médio de hospitalização foi de 30,1 dias. Conclusão: O retalho fasciocutâneo sural reverso mostrou-se uma opção viável, reprodutível e segura para reconstrução de lesões complexas em terço distal de perna e pé. Nível de Evidência IV, Série de Casos.

Lower extremity nerve injuries and their management at a referral center in Mexico City.

OBJETIVO: Describir el manejo de las lesiones nerviosas de extremidad inferior atendidas en un centro de referencia en cirugía plástica y reconstructiva en la Ciudad de México. MÉTODO: Estudio descriptivo, transversal y retrospectivo, en el que se evaluaron los expedientes clínicos de pacientes atendidos por lesiones nerviosas de extremidad inferior entre 2010 y 2018. RESULTADOS: Se incluyeron 21 pacientes, 14 hombres (66.6%) y 7 mujeres (33.3%), con una edad promedio de 30.00 ± 8.89 años. Las lesiones en la extremidad derecha fueron más prevalentes (52.3%). El mecanismo de lesión más común fue por herida por proyectil de arma de fuego (28.5%) o por accidente automovilístico (13.6%). Los nervios más afectados fueron el ciático (38.0%) y el peroneo (38.0%), seguidos por el tibial (9.5%), el peroneo y el tibial simultáneamente (9.5%) y el femoral (4.7%). Las medidas de tratamiento más empleadas fueron las transferencias nerviosas (7 casos, 33.3%) y la aplicación de injertos nerviosos para el manejo de brechas (7 casos, 33.3%). CONCLUSIONES: La reparación de las estructuras nerviosas de la extremidad inferior ha recibido poca atención. Sin embargo, nuestro estudio muestra que es posible aplicar diversas estrategias reconstructivas microquirúrgicas, buscando mejorar los desenlaces funcionales de los pacientes. OBJECTIVE: To describe the management of lower extremity nerve injuries at a plastic and reconstructive surgery referral center in Mexico City. METHOD: A descriptive, transversal and retrospective study was performed, evaluating clinical records of patients with lower extremity nerve injuries managed in our center between 2010 and 2018. RESULTS: Twenty-one patients were included, 14 males (66.6%) and 7 females (33.3%); mean age was 30.00 ± 8.89 years. Right-sided injuries were more prevalent (52.3%). The most common etiologies were gunshot injuries (28.5%) and motor vehicle accidents (13.6%). The most frequently affected nerves were the sciatic (38.0%) and the peroneal nerves (38.0%), followed by the tibial (9.5%), simultaneous tibial and peroneal nerve injury (9.5%) and the femoral nerve (4.7%). Nerve transfers (7 cases, 33.3%) and autologous nerve grafts (7 cases, 33.3%) were the preferred surgical techniques for injury management. CONCLUSIONS: Repair of lower extremity nerve injuries has not been popularized, however our study shows that several microsurgical reconstructive strategies are available in order to improve functional outcomes.

Lower Limb Reconstruction - Fasciocutaneous Sural Flap.

Objective The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Methods A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Results Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from 6 to 75 years old. Most of the patients evolved with total healing of the flap ( n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered. Conclusion It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Cobertura de lesões em pé e terço inferior da perna com retalho fasciocutâneo reverso da panturrilha (Carriquiry) / Coverage of the lower third of the limb and foot injuries using reverse sural fasciocutaneous flap described by Carriquiry

Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.

Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.

Lower Limb Reconstruction - Fasciocutaneous Sural Flap / Reconstrução de membro inferior- retalho fasciocutâneo sural

Abstract Objective The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Methods A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Results Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from6 to 75 years old. Most of the patients evolved with total healing of the flap (n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered. Conclusion It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Resumo Objetivo Avaliar o uso do retalho fasciocutâneo sural de fluxo reverso na cobertura de lesões no terço distal dos membros inferiores. Métodos Foram analisados 24 casos, 20 de origem traumática, três por lesões esportivas e um por ressecção de lesão tumoral. Resultados Dos 24 prontuários avaliados, 16 eram homens e oito mulheres. A idade variou de seis a 75 anos. A maioria dos pacientes evoluiu com cicatrização total do retalho (21). Houve apenas um caso de necrose total do retalho em paciente diabético insulinodependente e hipertenso, evoluiu para posterior amputação do membro. Em dois casos, houve necrose parcial composterior cicatrização por segunda intenção, um desses pacientes era tabagista pesado. As complicações foram associadas às comorbidades e, ao contrário do evidenciado por outros estudos, não houve correlação com a curva de aprendizado. Também não houve correlação com o local ou o tamanho da lesão a ser coberta. Conclusão Tem-se como relevância clinica que a técnica de retalho fasciocutâneo sural de fluxo reverso usada obteve 87,5% de sucesso, é uma opção viável e eficaz no arsenal terapêutico das lesões complexas dos membros inferiores.

Incidence and causes of lower-limb amputations in the city of Ribeirão Preto from 1985 to 2008: evaluation of the medical records from 3274 cases / Incidência e causas de amputações dos membros inferiores em Ribeirão Preto de 1985 a 2008: avaliação de 3274 casos

ABSTRACT: Objective: It was to identify trends of traumatic and non-traumatic causes of lower limb amputations, as well as the role played by population aging, traffic violence increase, public health policy of diabetes control program and drivers anti-alcohol laws on these amputations. Method: Hospitalization data recorded in the discharge forms of 32 hospitals located in the region of Ribeirão Preto, Brazil, from 1985 to 2008 were analyzed. Result: A total of 3,274 lower-limb amputations were analyzed, of which 95.2% were related to non-traumatic causes, mainly infectious and ischemic complications of diabetes mellitus. Cancer (2.8%) and congenital (1.3%) causes were included in this group. Only 4.8% were related to traumatic causes. Traumatic amputation average rate was 1.5 amputations in 100,000 habitants with a slight tendency of increase in the last 5 years. Non-traumatic causes showed an average rate of 30.0 amputations for 100,000 habitants and remained relatively constant during the whole period. Non-traumatic were much more predominant in patients older than 60 years and traumatic amputations occurred more frequently in patients younger than 39 years. Conclusion: The overall rates of amputation and the rates of traumatic and non-traumatic amputations remained nearly constant during the study period. The impact of diabetes control policies and the introduction of traffic safety laws could not be identified on the amputation rates.

RESUMO: Objetivo: Identificar as tendências temporais de causas traumáticas e não traumáticas de amputações de membros inferiores, e os efeitos do envelhecimento da população, do aumento de violência no trânsito, da política de saúde pública do programa de controle de diabetes e das leis de controle do uso de álcool em motoristas sobre as taxas de amputações. Método: Foram analisados os dados das folhas de alta de pacientes submetidos a amputações de todos os 32 hospitais localizados na região de Ribeirão Preto, Brasil, de 1985 a 2008. Resultado: De 3.274 amputações de membros inferiores, 95,2% estavam relacionadas a causas não traumáticas, principalmente complicações do diabetes mellitus. Câncer (2,8%) e causas congênitas (1,3%) foram incluídos neste grupo. Apenas 4,8% estavam relacionados às causas traumáticas. A taxa média de amputação traumática foi de 1,5 amputações por 100.000 habitantes, com uma ligeira tendência de aumento nos últimos 5 anos. As causas não traumáticas mostraram uma taxa média de 30 amputações por 100.000 habitantes e mantiveram-se relativamente constantes durante todo o período. As causas não traumáticas foram predominantes em pacientes com mais de 60 anos, e as amputações traumáticas ocorreram mais frequentemente em pacientes com menos de 39 anos. Conclusão: A taxa total de amputações e as taxas de amputações traumáticas e não traumáticas permaneceram praticamente constantes durante o período de estudo. O impacto das políticas de controle do diabetes e da introdução de leis de repressão do uso de álcool no trânsito não pode ser identificado nas taxas de amputação.

Acute hamstring injury in football players: Association between anatomical location and extent of injury-A large single-center MRI report.

OBJECTIVES: To describe in detail the anatomic distribution of acute hamstring injuries in football players, and to assess the relationship between location and extent of edema and tears, all based on findings from MRI. DESIGN: Retrospective observational study. METHODS: We included 275 consecutive male football players who had sustained acute hamstring injuries and had positive findings on MRI. For each subject, lesions were recorded at specific locations of the hamstring muscles, which were divided into proximal or distal: free tendon, myotendinous junction, muscle belly, and myofascial junction locations. For each lesion, we assessed the largest cross-sectional area of edema and/or tears. We calculated the prevalence of injuries by location. The relationships between locations and extent of edema and tears were assessed using a one-sample t-test, with significance set at p<0.05. RESULTS: The long head of biceps femoris (LHBF) was most commonly affected (56.5%). Overall, injuries were most common in the myotendinous junction and in proximal locations. The proximal myotendinous junction was associated with a greater extent of edema in the LHBF and semitendinosus (ST) muscles (p<0.05). Proximal locations in the LHBF had larger edema than distal locations (p<0.05). Distal locations in the ST muscle had larger tears than proximal locations (p<0.05). CONCLUSIONS: The proximal myotendinous junction (LHBF and ST muscles) and proximal locations (LHBF muscle) are more commonly affected and are associated with a greater extent of edema in acute hamstring muscle injury. Distal locations (ST muscle), however, seem to be more commonly associated with larger tears.

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.

Algoritmo terapéutico para pacientes con fractura diafisaria de tibia / Therapeutic algorithm for patients who suffer from tibial diaphyseal fractures

Fundamento: la fractura de la diáfisis tibial constituye una enfermedad traumática muy frecuente. Sin embargo, no existe una conducta estandarizada para el tratamiento de estos enfermos, de allí la importancia de llegar a un consenso sobre los pasos a seguir en pacientes con esta afección. Objetivo: validar un algoritmo de tratamiento para pacientes con fracturas diafisaria de tibia. Métodos: para la validación del algoritmo, se empleó el método de Delphi, mediante la consulta a un grupo de expertos constituido por 16 especialistas en Ortopedia y Traumatología, pertenecientes a cinco instituciones médicas del país. Los profesionales consultados presentaron como promedio 18,5 años de experiencia profesional, un doctor en Ciencias Médicas, seis con categoría científica de Master, cinco especialistas de segundo grado, un profesor titular. Resultados: se calcularon los valores correspondientes a la matriz de frecuencias absolutas, matriz de frecuencias acumuladas, matriz de frecuencias relativas acumuladas y matriz indicativa de los puntos de corte. Conclusiones: el algoritmo propuesto por los autores resultó validado en cuanto a: diseño, aplicabilidad, pertinencia, reproductibilidad y sentido práctico.

Background: tibial diaphyseal fracture is a common traumatic condition. However, there is not a standardized consensus to treat patients with this condition. That is why, it is important to get to a consensus for treating patients with tibial diaphyseal fractures. Objective: to validate a therapeutic algorithm for the management of patients with tibial diaphyseal fractures. Methods: Delphi method was applied for the validation of the algorithm. A group of experts was consulted. This group was composed of 16 specialists in Orthopedics and Traumatology from five teaching hospitals in all the country. The consulted professionals have 18, 5 professional years of experience on average. One of them is a Doctor of Medical Sciences, one is a titular professor, six are Masters, and five are second degree specialists. Results: the values corresponding to different matrices (absolute-frequencies matrix, accumulated-frequencies matrix, indicative cutting-points matrix) were calculated. Conclusions: the proposed algorithm was validated regarding: design, applicability, pertinence, and practical sense.

Fijación externa en paciente con fractura abierta del pilón tibial: a propósito de un caso / External fixation in a patient with open tibial pylon fracture: a case report

FUNDAMENTO: las fracturas del pilón tibial son enfermedades traumáticas muy frecuentes debido a un mecanismo de compresión axial de la extremidad. OBJETIVO: mostrar un paciente con fractura del pilón tibial tratado mediante fijación externa triangular. CASO CLÍNICO: paciente de 52 años de edad, blanco, masculino con antecedentes de salud anterior, que sufrió caída de un caballo, luego comenzó con dolor, inflamación e impotencia funcional localizado a nivel distal de la pierna derecha, que le impedía la marcha y el apoyo de la extremidad. En el examen físico se observó deformidad en varo por encima del tobillo, así como herida medial de bordes irregulares de aproximadamente tres centímetros muy contaminada. La palpación reveló movilidad anormal y crepitación a nivel del foco de fractura. A la exploración neurovascular no se detectaron anormalidades. El paciente fue tratado mediante la colocación de aguja de Kirschner para la fractura del peroné y fijación externa en configuración triangular. CONCLUSIONES: la fijación externa constituye una modalidad efectiva en el tratamiento de pacientes con fracturas abiertas del pilón tibial.

BACKGROUND: tibial pylon fractures are traumatic diseases that appear very frequently due to a mechanism of axial compression of the extremity. OBJECTIVE: to present the case of a patient with tibial pylon fracture treated by means of triangular external fixation. CLINICAL CASE: a fifty-two-year-old, white, male patient with antecedents of being a healthy person who fell from a horse and then presented pain, inflammation, and functional impotence located at distal level in the right leg that impaired him from walking and leaning on his extremity. A varus deformity above the ankle and a very contaminated 3-odd cm medial wound of irregular margins, were found in the physical examination. Palpation showed an abnormal mobility and crepitation at the level of the fracture focus. No abnormalities were observed in the neurovascular examination. The patient was treated with the placement of Kirschner wires for the fibula fracture and with external fixation in triangular configuration. CONCLUSIONS: external fixation is an effective method in the treatment of patients with open tibial pylon fractures.

Reconstrução de dorso do pé com retalho supramaleolar lateral de fluxo reverso em menor de 4 anos de idade / Reconstruction of the dorsal foot with a retrograde flow lateral supramalleolar flap in a 4-year-old child

INTRODUÇÃO: Lesões em terço distal da perna podem deixar expostas áreas nobres, que devem ser recobertas. O retalho supramaleolar lateral faz parte de uma série de retalhos descritos na última década, é fasciocutâneo elevado no aspecto lateral da perna inferior, sendo empregado como um retalho pediculado com base distal. O objetivo do presente relato de caso é apresentar os resultados cirúrgicos e a eficácia do retalho supramaleolar lateral em lesões extensas no membro inferior com perdas de substâncias significativas em criança de 4 anos. RELATO DE CASO: Paciente A.K.E.S., sexo feminino, foi internada há 13 anos, vítima de atropelamento, com lesão extensa em dorso de pé esquerdo com exposição de áreas nobres de aproximadamente seis centímetros de diâmetro. Após desbridamento, no quinto dia foi realizada cobertura da lesão com retalho fasciocutâneo supramaleolar lateral. A paciente teve alta para acompanhamento ambulatorial, evoluindo sem intercorrência. Ela retornou ao serviço apenas 13 anos após com sobrepeso e reclamando do aumento de volume no dorso do pé. Foi realizada lipectomia do terço distal do retalho, evoluindo sem intercorrência. Um segundo procedimento do terço proximal foi programado para seis meses após. DISCUSSÃO: Lesões no terço distal da perna podem expor áreas nobres. Os retalhos supramaleolar lateral, sural e de perfurantes pediculados possuem aplicações semelhantes, mas apresentam peculiaridades técnicas individuais. Como vantagens no retalho supramaleolar lateral: não há necessidade de microanastomoses, é rápido para ser executado e simula a área receptora em várias características locais. CONCLUSÃO: É um retalho de maior facilidade de execução e reprodutível, podendo ser realizado em crianças menores de 5 anos. Tem sua aplicação como alternativa para lesões em terços inferiores da perna, tornozelo e pé.

INTRODUCTION: Injuries in the distal third of the leg may expose noble areas that should be covered. The lateral supramalleolar flap is one of a series of flaps described in the last decade; it is an elevated fasciocutaneous flap in the lateral aspect of the lower leg, and is employed as a distally based pedicled flap. The purpose of this case report is to present the surgical results and the effectiveness of the lateral supramalleolar flap in extensive lower limb injuries with significant loss of substance in a 4-year-old child. CASE REPORT: Patient A. K. E. S., a girl, was admitted 13 years previously. She had been in an accident, and had extensive injuries on the dorsum of the left foot, with exposure of noble areas approximately 6 cm in diameter. After debridement, lesion coverage was performed on the fifth day by using a fasciocutaneous lateral supramalleolar flap. The patient was discharged for outpatient monitoring and progressed without complication. She only returned to the hospital 13 years later, overweight and complaining of swelling on the dorsal aspect of the foot. Lipectomy of the distal third of the flap was performed, with uncomplicated progress. A second procedure for the proximal third was scheduled six months later. DISCUSSION: Injuries in the distal third of the leg may expose noble areas. Lateral supramalleolar, sural, and pedicled perforating flaps have similar applications, but show individual technical peculiarities. The lateral supramalleolar flap has no need for microsurgery, is rapidly performed, and simulates the receiving area while considering several local characteristics. CONCLUSION: This flap is easily implemented and reproducible, and can be used in children younger than 5 years of age. It is an alternative for injuries in the lower third of the leg, the ankle, and the foot.

Alternativas para el tratamiento de las fracturas complejas de pilón tibial / Alternatives for the treatment of complex tibial pilon fractures

Las fracturas de pilón tibial representan una de las fracturas más graves, no sólo por la complejidad de su tratamiento, sino también por las importantes secuelas que pueden originar. Además de que un importante porcentaje de éstas son abiertas o con importante afectación de partes blandas, lo que dificulta aún más su tratamiento. Se revisaron 37 pacientes con fractura de pilón tibial tratados de forma quirúrgica, analizando los resultados con la escala de valoración funcional FREMAP y con los criterios radiográficos de Burwell-Charnley. Aunque no existe consenso en relación al tratamiento ideal, parece evidente que el tratamiento combinado con fijación externa e interna con placa ofrece los mejores resultados.

Tibial pilon fractures are one of the most severe types of fractures, not only due to the complexity of their treatment, but also due to the important sequelae they may cause. Moreover, an important percentage of them are open fractures or importantly involve the soft tissues, thus making treatment even more difficult. Thirty-seven patients with tibial pilon fractures treated surgically were included in this study. The results of the FREMAP functional assessment scale were analyzed together with Burwell-Charnley's radiographic criteria. Although there is no consensus on which is the best treatment, it is evident that combined treatment including external and internal fixation with a plate provides the best results.

Actinomicosis de una pierna: una localización infrecuente / Actinomycosis of the leg: an infrequent location

FUNDAMENTO: la actinomicosis es una enfermedad rara que después del advenimiento de los antibióticos se diagnóstica menos, puede asentar en cualquier sitio pero la localización primaria en una pierna es excepcional. OBJETIVO: presentar el caso de un paciente con actinomicosis de la piel de la pierna derecha, el cual constituye el primero reportado en el país. CASO CLÍNICO: paciente masculino de 32 años sin antecedentes patológicos de interés, el cual en un viaje al campo sufre de una lesión punzante en la pierna derecha. A los dos días de lo ocurrido, presentó lesión de 3 a 4 cm en dicha región, acompañado de fiebre de 38oC, acudió a un facultativo que le indicó antibiótico y antiinflamatorio y no mejoró. Concurrió al servicio de urgencia, ya con una lesión en peor estado por lo que se le realizó desbridamiento del absceso y antibiótico. Se le indicaron múltiples exámenes y sólo fueron positivos la velocidad de sedimentación globular, la proteína C reactiva y el cultivo, el cual fue positivo por primera intensión para estafilococo áureo y por segunda oportunidad se aisló el actinomyces israelii. Se realizó estudio histopatológico que confirmó el diagnóstico de actinomicosis. Se impuso tratamiento con penicilina G, 4 millones de UI cada 6 horas durante 4 semanas y tratamiento quirúrgico. Al mes se instauró terapéutica con amoxicilina (500 mg), 1 cápsula cada 6 horas durante seis meses. Después de esta terapéutica el paciente se encuentra asintomático. CONCLUSIONES: esta enfermedad debe considerarse en el diagnóstico diferencial de cualquier nódulo, induración o absceso en tejidos blandos. El diagnóstico definitivo requiere cultivo en un medio especial y la histopatología como complemento.

BACKGROUND: acticnomycosis is an uncommon disease which has diminished since the introduction of antibiotics. It can appear in any site of the body but the primary location in the leg is exceptional. OBJECTIVE: to present the case of a patient with actinomycosis of the skin of the right leg which constitutes the first case reported in the country. CLINICAL CASE: a thirty-two-year-old male patient without pathological antecedents of interest that suffered a stabbing injury in the right leg while camping. Two days later, the patient presented a 3-4cm lesion in the mentioned region, as well as a fever of 38oC. The patient went to the doctor who prescribed him an antibiotic and an anti-inflammatory but he did not get better. He went to the emergency service presenting the lesion in worse conditions. The patient underwent multiple exams and only the following were positive: erithrosedimentation rate, C reactive protein, and the culturing that was first positive for staphylococcus aureus and secondly actinomyces israelii was isolated. A histopathological study confirmed the diagnosis of actinomycosis. The patient had to undergo a treatment with penicillin-G, 4 million IU every 6h for four weeks, and surgery. A month later, a therapeutic treatment with amoxicillin (500 mg), a capsule every 6h for six months, was established. After the treatment, the patient is asymptomatic. CONCLUSIONS: this disease should be considered in the differential diagnosis of any nodule, induration or abscess in soft tissues. The definitive diagnosis requires a culturing in a special environment and histopathology as a complement.

Fasciocutaneous flaps for covering foot and ankle injuries / Retalhos fasciocutâneos para cobertura de lesões no pé e tornozelo

OBJECTIVE: to present some cases from our service and to confirm that sural and lateral supramalleolar flaps are good options for covering the soft tissues of the foot and ankle. METHODS: twenty-two flaps were constructed in 21 patients of ages ranging from 15 to 72 years. Male patients predominated (66.6%) and in 47.6% of the cases the injury resulted from accidents involving motorcycles. RESULTS: among the 22 flaps, 12 were sural and 10 were lateral supramalleolar; in one case, two flaps were used. In all the cases, the injuries were successfully covered and the patients recovered well. During the postoperative follow-up, the commonest complication was epidermolysis, occurring in eight cases (three in a sural flap and five in a supramalleolar flap), among which two cases progressed to distal necrosis of the flap (one sural and the other supramalleolar). One patient wanted the flap reviewed for esthetic reasons. CONCLUSIONS: sural and supramalleolar flaps are very reliable. They preserve the main trunk arteries, are quickly dissected, have low hospital cost, enable coverage of extensive areas, present esthetically acceptable damage to the donor area and do not impair motor function...

OBJETIVO: mostrar alguns casos do nosso serviço, além de confirmar como boas opções os retalhos sural e supramaleolar lateral na cobertura de partes moles do pé e tornozelo. MÉTODOS: foram feitos 22 retalhos em 21 pacientes, entre 15 e 72 anos. Houve predomínio do sexo masculino, com 66,6%, e em 47,6% as lesões foram decorrentes de acidentes que envolveram motocicletas . RESULTADOS: dos 22 retalhos, 12 foram do tipo sural e 10, supramaleolar lateral. Em um caso usaram-se os dois retalhos. Em todos os casos houve sucesso na cobertura das lesões, com boa recuperação dos pacientes. No seguimento pós-operatório a complicação mais comum foi a epidermólise, com oito casos, três no retalho sural e cinco no supramaleolar, dos quais dois progrediram para pequena necrose distal do retalho, um deles sural e o outro supramaleolar. Um paciente desejou rever o retalho por questão estética. CONCLUSÕES: os retalhos sural e supramaleolar são bastante confiáveis, preservam os troncos arteriais principais, são de rápida dissecção, têm baixo custo hospitalar, permitem cobertura de áreas extensas e apresentam dano estético aceitável na área doadora sem prejuízo funcional motor...

Fasciocutaneous flaps for covering foot and ankle injuries.

OBJECTIVE: to present some cases from our service and to confirm that sural and lateral supramalleolar flaps are good options for covering the soft tissues of the foot and ankle. METHODS: twenty-two flaps were constructed in 21 patients of ages ranging from 15 to 72 years. Male patients predominated (66.6%) and in 47.6% of the cases the injury resulted from accidents involving motorcycles. RESULTS: among the 22 flaps, 12 were sural and 10 were lateral supramalleolar; in one case, two flaps were used. In all the cases, the injuries were successfully covered and the patients recovered well. During the postoperative follow-up, the commonest complication was epidermolysis, occurring in eight cases (three in a sural flap and five in a supramalleolar flap), among which two cases progressed to distal necrosis of the flap (one sural and the other supramalleolar). One patient wanted the flap reviewed for esthetic reasons. CONCLUSIONS: sural and supramalleolar flaps are very reliable. They preserve the main trunk arteries, are quickly dissected, have low hospital cost, enable coverage of extensive areas, present esthetically acceptable damage to the donor area and do not impair motor function.

OBJETIVO: mostrar alguns casos do nosso serviço, além de confirmar como boas opções os retalhos sural e supramaleolar lateral na cobertura de partes moles do pé e tornozelo. MÉTODOS: foram feitos 22 retalhos em 21 pacientes, entre 15 e 72 anos. Houve predomínio do sexo masculino, com 66,6%, e em 47,6% as lesões foram decorrentes de acidentes que envolveram motocicletas. RESULTADOS: dos 22 retalhos, 12 foram do tipo sural e 10, supramaleolar lateral. Em um caso usaram-se os dois retalhos. Em todos os casos houve sucesso na cobertura das lesões, com boa recuperação dos pacientes. No seguimento pós-operatório a complicação mais comum foi a epidermólise, com oito casos, três no retalho sural e cinco no supramaleolar, dos quais dois progrediram para pequena necrose distal do retalho, um deles sural e o outro supramaleolar. Um paciente desejou rever o retalho por questão estética. CONCLUSÕES: os retalhos sural e supramaleolar são bastante confiáveis, preservam os troncos arteriais principais, são de rápida dissecção, têm baixo custo hospitalar, permitem cobertura de áreas extensas e apresentam dano estético aceitável na área doadora sem prejuízo funcional motor.

Tratamento da exposição óssea de membro inferior utilizando terapia por pressão negativa na fase aguda seguida de retalho livre na fase subaguda / Treatment of bone exposure of the lower limb using negative-pressure wound therapy in the acute phase followed by free flaps in the subacute phase

Fractures of the distal third of lhe leg, ankle, and foot frequently present with exposed boné, requiring specialized teams to accomplish skin coverage. These teams are often not readily available, which can prevent the standard treatment of extensive debridement, fracture fixation, and use of flaps, which is termed the "fix and flap" method. Methods: The author proposes a 2-stage treatment method for such cases: negative pressure is imposed during debridement and bone exposure by the orthopedic team, followed by the elective prepararion of free flaps for definitive coverage. Five patients were treated with a total of 6 free flaps, including I latissimus dorsi muscle and 5 of anterolateral thigh flaps. There was 1 total flap loss. Thus, the success rate was 83.34%. Results: The patients had good outcomes with limb salvage, preserved function, and no osteomyelitis. Conclusions: Negative-pressure wound therapy is an option for the emergency treatment of open fractures of the lower limb, allowing the survival of elective free flaps without resulting in impairment as a final outcome.

Trauma do terço distal da perna, do tornozelo e do pé cursam frequentemente com exposição óssea demandando equipes especializadas para realizar a cobertura cutânea definitiva. Muitas vezes, essas equipe não estão prontamente disponíveis, o que pode impedir o tratamento padrão que consiste em amplo desbridamento, fixação das fraturas e utilização de retalhos (fix and flap) Método: Neste trabalho, o autor propõe tratamento em duas etapas sendo a primeira a instituição de terapia por pressão negativa quando do desbridamento e exposição óssea pela equipe da ortopedia, seguida pela realização de retalhos livres para cobertura definitiva, de forma eletiva. Foram tratados 5 pacientes, com realização de 6 retalhos livres, sendo 1 do músculo grande dorsal e outro 5 da face ântero- lateral da coxa. Houve perda total de um retalho, com índice de sucesso de 83,34%. Resultado: Os pacientes apresentaram boa evolução, com salvamento do membro, função preservada e sem osteomielite. Conclusões: A terapia por pressão negativa é uma opção no tratamento de urgência das exposições ósseas do membro inferior permitindo a realização de retalhos livres de forma eletiva, sem prejuízo no resultado final para o paciente.

Trauma grave em membro inferior / Severe lower limb trauma

Traumatismos graves de membros inferiores, com grandes perdas cutâneas e comprometimento de estruturas vitais, são casos de difícil resolução. A combinação de vários fatores, como esforço realizado e capacidade de distinguir a gravidade das lesões, ou seja, diferenciar as lesões recuperáveis ou viáveis daquelas que inevitavelmente irão evoluir para amputação, tem importante papel. Para tanto, surgiram índices que buscam estratificar a gravidade da lesão e predizer a necessidade de amputação, como o índice MESS (do inglês, Mangled Extremity Severity Score). Neste artigo, é reportado um caso de trauma grave de membro inferior, com reconstrução baseada no índice MESS, com emprego de múltiplos retalhos musculares e boa evolução funcional.

Severe trauma to the lower limbs, with major skin loss and the compromise of vital structures, is often difficult to treat. A combination of several factors such as ability and effort made to distinguish lesion severity - that is, to differentiate recoverable traumas from those that will inevitably progress to amputation - plays an important role. Therefore, indices were developed to facilitate the stratification of injury severity and prediction of the need for amputation, such as the Mangled Extremity Severity Score (MESS). In this article, we report a case of severe trauma to the lower limb, where reconstruction was performed based on the MESS index with multiple muscle flaps, and a good functional outcome was achieved.