Reporte de un caso clínico: Reimplante de mano

BACKGROUND: The upper limb plays a vital role in our daily function; injuries to this vital structure can result in devastating consequences to functional, psychological and social well-being; especially traumatic amputations of the upper limb are challenging to manage and deciding which patients would benefit from limb salvage versus amputation is critical. CASE REPORTS: A 52-year-old male patient, who suffered a traumatic partial amputation in the distal third of his right forearm with an industrial machine, presenting an ulnar and radius fracture, with severe soft tissue injuries, who underwent a replantation surgery after 12 hours of ischemia. EVOLUTION: Patient presented good postsurgical outcome. 24 hours after surgery he presented normal Allen’s test results, adequate temperature, pink coloration, hypoesthesia and 2/5 muscle strength in the injured limb. He was discharged 7 days after surgery with follow-up and rehabilitation prescription. The percutaneous needles were removed 13 weeks after, with proper bone healing of the fracture. 5 months after surgery, he presented a DASH Score of 60.83. CONCLUSION: The replantation field has become very sophisticated in recent years; the decision to perform replantation of the amputated limb must be individualized to each patient, based on several established factors such as the characteristics of the injury, patient related factors, and the functional recovery capacity.

Development of Incidence and Surgical Treatment of Penile Cancer in Germany from 2006 to 2016: Potential Implications for Future Management

Background Penile cancer is a rare disease and surgical treatment often entails a significant impact on quality of life. The aim of this study was to analyze trends in surgical treatment patterns in Germany. Methods We analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2016. All penile cancer cases with penile surgery or lymph node dissection (LND) were included. We also analyzed the distribution of cases, extent of surgery, and length of hospital stay, stratified for annual caseload. The geographical distribution of centers for 2016 was presented. Results During the investigated timespan, tumor incidences increased from 748 to 971 (p = 0.001). We identified 11,353 penile surgery cases, increasing from 886 to 1196 (p < 0.001), and 5173 cases of LND, increasing from 332 to 590 (p < 0.001). Cases of partial amputation increased from 45.8 to 53.8% (p < 0.001), while total amputation remained stable at 11.2%. Caseload in high-volume hospitals increased from 9.0 to 18.8% for penile surgery (p < 0.001) and from 0 to 13.1% for LND (p < 0.001). The increase in LND caseload was caused by an increase in inguinal LND, from 297 to 505 (p < 0.001), with increasing sentinel LND, from 14.2 to 21.9% (p = 0.098). The assessment of geographical distribution of cases in Germany revealed extensive areas without sufficient coverage by experienced centers. Conclusions We saw consistent increases in penile surgery and LND, with a growing number of cases in high-volume hospitals, and, accordingly, an increase in tumor incidence. The increasing use of inguinal LND and organ-preserving surgery reflect the adaptation of current guidelines; however, geographical distribution of experienced centers could be improved.

Common late complications of longitudinal forefoot amputations in neuropathic foot treatment

Objective: To describe and quantify the complications arising in consecutive neuropathic patients undergoing partial longitudinal amputations of the foot. Method: A retrospective study was conducted with data collected from the medical records of patients monitored at the Insensitive Foot Clinic of the Foot and Ankle Group of our institution who underwent partial amputation of foot rays from 2000 to 2016. Results: A total of 28 patients met the inclusion criteria, with a total of 31 amputated/partially amputated feet. Of these, 18 (58.1%) feet were amputated/partially amputated due to diabetes, seven (22.6%) due to leprosy, two (6.5%) due to alcoholic neuropathy, two (6.5%) secondary to traumatic peripheral nerve injury, and two (6.5%) due to other causes. Fifth ray amputation was the most frequent type (n=12). The cause of amputation was the presence of an infected ulcer in 93.6% of the samples. At a mean follow-up time of 60 months, 13 (41.9%) feet required new amputations—five (38.5%) transtibial, five (38.5%) transmetatarsal, two (15.4%) of the toes, and one (7.7%) at Chopart's joint. Patients with diabetes had a 50.0% reamputation rate. Patients who initially underwent amputation of the fifth ray had a 58.3% reamputation rate. Conclusion: Partial longitudinal amputation of the foot in neuropathic patients exhibited a high reoperation rate, especially in patients with diabetes or in patients with initial amputation of the peripheral rays. Declaration of interest: The authors have no conflicts of interest.

Pelvic Limb Amputation in a Giant Anteater (Myrmecophaga tridactyla) Traumatized by an Agricultural Harvester

Background: The giant anteater (Myrmecophaga tridactyla) returned to the category of vulnerable by the 2014 IUCN / SSC, due to the population reduction, less than 30%. The main reasons are: environmental degradation and fragmentation, being run over, burning, attacks by hunting dogs, illegal trade and diseases. It is very common to find these fractured patients and the treatment is mostly surgical. Amputation is indicated when there are extensive lacerations and when reconstructive surgery is not possible. The objective is to report a viable treatment option in fractured wild patients, contributing to the preservation of the species.Case: It was received at the Veterinary Hospital Dr. Halim Atique - UNIRP an young female giant anteater (M. tridactyla) weighing 5.75 kg, brought by the Environmental Forestry Police of the municipality of São José do Rio Preto - SP, found in the region of Olímpia at a gas station. The animal was traumatized by an agricultural harvester, with partial traumatic amputation in the left pelvic limb and tail. In the preoperative period, the patient was admitted to hospital under assisted care, analgesia and all the necessary support for stabilization. High amputation was performed, with hip disarticulation and treatment of the tail wound, which was initially opted for healing in the first intention, where sutures were used to approach the edges of the wound, but presented dehiscence and was treated as a second intention. There were almost 2 months of care with specific food, cleaning of the enclosures, medications and dressings. After 57 days of hospitalization, the patient was transferred to the Municipal Zoo of São José do Rio Preto - SP, where it was moved to a larger and ideal enclosure for the species, with other giant anteaters also rescued. Discussion: The rate of complex fractures in accidents with wild animals is high. Amputations are indicated for patients with extensive lacerations without possible reconstructions, the patient in the present study had partial amputation of the limb, and reconstruction was impossible. The amputation technique of choice was disarticulation of the hip, as it is important that the patient does not try to support the limb, to avoid further trauma. The adaptation of animals to amputation is satisfactory, however, it should be noted that these individuals must remain under observation in the postoperative period, must remain confined to small rooms to avoid complications such as hemorrhage, seroma, dehiscence and infection of the surgical wound. The multidisciplinary team specialized in the required areas must be trained for this type of service. Adaptation to the new hospital environment, adaptation without an amputated limb, different food from that found in nature, daily handling for dressings and the movement of people in the sector are precautions that we must have for the success of the treatment. The great challenge for the recovery of traumatized wild patients is capture stress, transport to the operating room, lack of adaptation to the hospital environment and use of protocols that are unsuitable for the species, factors that can compromise the success of the treatment. Amputation can be a viable treatment alternative for fractured giant anteaters, when bone reconstruction is not possible. The amputation was performed successfully, providing another opportunity for this patient and contributing to the preservation of the species.Keywords: fracture, amputation, Myrmecophaga tridactyla, giant anteater.

PENIS NECROSIS IN A DIABETIC PATIENT AND CHRONIC HEMODIALYSIS

Penis necrosis is a rare entity. Most often serious and it could have life-threatening prognosis because in the majority of cases its found in severe peripheral arterial disease it occurs mainly in chronic kidney failure patients with diabetes or diabetic patients. Penis has a very good blood supply Arterial obstruction secondary to arteriolic calcification can cause distal necrosis. the treatment is essentially surgical. We report a case of penis necrosis treated by partial amputation.

Synovial sarcoma of the popliteal fossa

Soft tissue sarcomas are heterogeneous group of neoplasms making up to 1% of all malignant tumors in the adult population. The tumor generally appears on the extremities near large joints of middle-aged patients, especially in the popliteal fossa. Our patient presented in February 2014 due to a slowly enlarging, darker-colored swelling in the left popliteal fossa. Upon physical examination, a somewhat nodular, immobile, tender subcutaneous mass was observed. There was no locoregional lymphadenopathy. Patohistological findings showed a high-grade primary malignant mesenchymal tumor, biphasic synovial sarcoma type. The patient underwent surgery with wide surgical excision, followed by radiotherapy treatment. Magnetic resonance imagining follow up after one year revealed tumor recurrence. Neurovascular bundle involvement was detected, but without adjacent bone and muscular invasion and above-the-knee partial amputation of the left leg was performed. The intervention resulted in a remission of the neoplastic process and the patient was scheduled for regular check-ups. Broad surgical resection of the tumor with negative margins was the primary treatment in this case. Mutilating operations are necessary when anatomical structures around the tumor do not allow complete reintervention.

Digit Necrosis After Hand Surgery in Pregnancy: A Case Report

Digital blocks are routinely used for excision of lesions. We describe a unique presentation of digit necrosis after excisional biopsy with digital block and finger tourniquet in a pregnant patient with a history of ulcerative colitis. The patient had a history of a long-standing painful dorsal PIP joint mass and was scheduled for excision under local anaesthetic. On the day of the procedure, she disclosed that she was pregnant in the second trimester. After extensive discussion of risks and benefits between the patient and the surgeon, the decision was made to proceed with an excisional biopsy of the lesion because of its impact on her quality of life. Twelve hours after the procedure, she presented to the emergency department with blistering and severe pain to the digit. Doppler ultrasound showed flow through both digital arteries and the digit appeared viable. Over the coming days her pain continued to worsen and on post-operative day 3, she was admitted to hospital for attempted salvage of the digit using conservative methods. Her digit went on to demarcate at the level of the middle phalanx. Five weeks after her initial procedure, the patient underwent partial amputation of the small finger at the level of the DIP joint and 2-stage groin flap for soft tissue coverage. We discuss the effects of pregnancy and ulcerative colitis on thromboembolic events, and review the literature on digital blocks, digital tourniquet use and management of early digit necrosis. This case highlights the importance of delaying elective hand procedures in pregnant patients, especially if they have additional comorbidities such as pro-thrombotic diseases like inflammatory bowel disease.

Lower Limb Salvage Using Patent-Specific 3D-Printed Titanium Cage Following Severe Left Ankle Traumatic Partial Amputation: A Pediatric Case Report

Background Patients with large bony defects of the ankle who wish to avoid amputation have limited surgical intervention options for limb salvage. Each of these interventions are technically complex and present significant risk for complications. The use of a patient-specific 3D-printed titanium cage in conjunction with a tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is another management option. This case adds to the scarce published literature on this technique. Case presentation This report presents the case of a 16-year-old female who suffered a traumatic partial amputation of her left distal lower extremity following an all-terrain-vehicle accident that resulted in a 10.0 × 10.0 cm skin laceration and a 5-cm subsegmental bony loss of the distal tibia. She was successfully treated using a patient-specific 3D-printed titanium truss cage in conjunction with a TTC arthrodesis using a retrograde nail. Conclusions The decision to amputate or attempt limb salvage in a severely injured lower limb is still a topic of active debate. However, literature has shown that patients who undergo limb salvage surgery have better psychological health outcomes and equivalent functional outcomes as patients who have undergone amputation. Therefore, research on techniques that optimize and advance limb salvage surgery is needed. As the numerous potential benefits and limitations of patient-specific 3D-printed implants are assessed throughout the field of orthopedics, further research and cost-analysis will be required. Cases such as the one presented add to the limited existing literature of patient-specific 3D-printed implant for treatment of large distal lower extremity bony defects. Levels of Evidence Level V (Case Report)