The use of the medial femoral condyle free flap is a versatile option for the treatment of upper extremity non unions and reconstructive procedures associated with bone loss or osteonecrosis. The benefit of this type of flap is the viability of the bone which favors primary ossification and increases bone density. Vascularized free bone flaps are especially useful for the treatment of recalcitrant nonunions, or nonunions that have failed three or more treatments to obtain consolidation. We present a case series of three patients treated with medial femoral condyle free flap for reconstruction of the upper extremity of different etiologies at the level of the distal humerus, distal radius and distal phalanx of the thumb.
Negative pressure wound therapy (NPWT) is widely used in skin defects, active infection, and surgical reconstruction; lately, it is being used after skin graft to improve the adhesion on the receptor area. During the last decade, another indication has been identified: the use of NPTW to avoid complications after free flaps such as venous congestion and the risk of necrosis. NPWT can be used in the initial complication of a free flap, and the venous congestions can be treated with this technique, with very good outcomes. NPWT can be established as a part of a postoperative protocol in microsurgical procedures to avoid major complications.
This is a 39-year-old male, fell from a bike, left wrist with trans-styloid perilunate fracture dislocation that underwent open reduction internal fixation, 20 months after surgery the patient developed avascular necrosis of the lunate, final wrist fusion was performed secondary to the arthritic changes on the wrist. Anatomic dissection was performed and vascularity of the lunate was identified, its origin is from the volar palmar arch, when dislocated palmarly and more than 90 degrees the vessel is still intact. More than 512 patients with perilunate dislocation and perilunate fracture dislocation are included we identified in the literature transient avascular necrosis of the lunate in nine and seventeen of pure avascular necrosis of the lunate. Concluding that avascular necrosis of the lunate after perilunate dislocation or perilunate fracture dislocation is an infrequent finding especially when the volar ligaments are intact.
Resumen El presente artículo tuvo tres objetivos fundamentales: 1. analizar los principales factores que inciden en la presencia de Burnout en docentes; 2. determinar los síntomas que lo evidencian; 3. establecer bajo qué estatuto (1278 o 2277) los docentes son más susceptibles a padecer el síndrome. Los datos fueron obtenidos mediante un cuestionario (n=54), el cual fue convalido y calculada su fiabilidad a través de la prueba Alfa de Cronbach (Escala General ; Factores de Riesgo y Síntomas de Burnout). Los análisis de correlación se realizaron con la prueba no paramétrica Chi cuadrado; para hallar diferencias entre las variables se usó la U de Mann Whitney. Los resultados del análisis evidenciaron que los principales problemas relacionados con síntomas de Burnout en docentes fueron: trabajar horas extras, falta de espacios de comunicación con los jefes, salario inadecuado para satisfacer sus necesidades y falta de apoyo de los jefes frente a dificultades con padres de familia. Finalmente, se concluyó que los docentes regulados con el estatuto 1278 son más susceptibles al síndrome en razón de presentar unas condiciones laborales menos adecuadas que los regulados por el estatuto 2277.
Background: The Pulvertaft weave was described more than 50 years ago and is still used in tendon transfers. The aim of this study was to evaluate the strength of a modified core suture Pulvertaft weave technique and compare it to the original Pulvertaft weave traditionally used in tendon transfer surgery. Methods: 12 extensor pollicis longus tendons and extensor indices proprius tendons were harvested from fresh frozen cadavers. Six Pulvertaft weaves were performed using FiberWire 4.0 and six core suture tendon weave were performed using FiberLoop 4.0. Biomechanical analysis was performed and stifness, first failure load and ultimate failure load were measured for both set of repairs. Results: The stiffness of the core suture tendon repair (9.5 N/mm) was greater than that of the Pulvertaft repair (2.5 N/mm) The first failure load of the core suture tendon repairs (68.9 N) was greater than the Pulvertaft repairs (19.2 N) and the ultimate failure load of the core suture tendon repairs (101.8 N) was greater than the Pulvertaft repairs (21.9 N). All of these differences were statistically significant. Conclusions: The core suture Pulvertaft weave is a modification to the Pulvertaft weave used in tendon transfers. The results of this cadaveric study suggest it is 5 times stronger than the traditional Pulvertaft repair, potentially allowing it to be used with early active motion protocols after tendon transfers.
Venous congestion is the most critical complication following microsurgical finger replantation and can present within the first postoperative days or even in the immediate postoperative period. 1 Several treatment options for this complication have been described, including leech therapy, 2 active bleeding of the fingertip or nail bed, 3 and systemic anticoagulation with a high risk of anemia and blood transfusion requirements. 4 Recently, negative pressure wound therapy (NPWT) has been identified as a novel method to treat venous congestion in free flaps. 5 These favorable results have allowed for exploration of the use of NPWT in venous congestion following finger replantation. We report three cases of finger replantation that developed venous congestion and were treated with NPWT as a salvage procedure.
MATERIALS AND METHODSThis is a case series of three patients who underwent digit replantation. The postoperative course was complicated by venous congestion. NPWT was applied after the diagnosis of venous congestion since venous reconstruction was very challenging due to the amputation zone. All patients followed the same anticoagulation protocol previously described. 5 Settings and duration of NPWT of all three digits were recorded.
RESULTSThe first patient is a 33-year-old woman with an amputation of the index finger at the level of the distal interphalangeal joint secondary to a table saw injury. Microsurgical anastomosis of one artery and one vein was performed 33 hours after her admission. Venous congestion and probable arterial insufficiency were identified 44 hours after the finger reimplantation and NPWT was initiated. Five days after continuous NPWT the finger was no longer congested and viable.The second patient is a 46-year-old man with an amputation of the left thumb at interphalangeal joint secondary to a table saw injury. Microsurgical anastomosis of one artery and one vein was performed after 8 hours of cold ischemia. Venous congestion was identified 96 hours later, and NPWT was applied. Three days after continuous NPWT, the thumb was less congested and was viable.The third patient is a 28-year-old man with an avulsion amputation of the right ring finger at mid-third of the proximal phalanx. Microsurgical anastomosis of one artery and two veins was performed after 2 hours of cold ischemia. Fracture of the head of the middle phalanx with avulsion of the flexor digitorium profundus and complete laceration of the extensor mechanism was the initial injury. The radial and ulnar nerves were sutured, and the
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