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Trapianto di lembo neurocutaneo vascolarizzato in caso di distrofia simpatica riflessa

27 maggio, 2019

Injerto de colgajo neurocutáneo_CRPS_01_20190527

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Patient, 8 years old, suffers a partial amputation of the left thumb in accident. She attends the clinic of Piñal y Asociados 12 weeks after the trauma with a diagnosis of reflex sympathetic dystrophy or Sudeck’s atrophy.

Injerto de colgajo neurocutáneo_CRPS_02_EN_20190527

The problem

Before being treated by the Spanish surgeon and his surgical unit, an attempt is made for reconstruction and revascularization by venous graft. The procedure is not successful and doesn’t respond to the damage suffered by one of the nerves of the affected area, sectioned in its proximal end and stuck to the existing scar.

Nerve sectioned in its proximal end
One of the nerves of the thumb is sectioned in its proximal end and adhered to the existing scar.
Hyperextension of the metacarpophalangeal joint
The combination of images above allows to observe the hyperextension of the metacarpophalangeal joint and the contracture at the commissure between thumb and forefinger. In turn, an increase in hair due to inflammatory reaction is appreciated.

In turn, the patient presents the picture of a diagnosis of reflex sympathetic dystrophy with a high level of pain and increase in hair due to the inflammatory reaction, together with a hyperextension of the metacarpophalangeal joint and a contracture of the first commissure between the thumb and the index. This clinical situation has a decisive impact on the functional capabilities of the affected hand.

The goals

The microsurgical procedure designed by Dr Piñal has as its main objective the functional recovery of the patient’s limb, minimizing the aesthetic impact on the recipient and donor areas of the autologous transplant.

The plan

Dr Piñal applies his technique of autologous transplantation of vascularized neurocutaneous tibial flap -taken from the big toe of the patient’s left foot- indicated in cases of severe nerval damage. The flap presents venous, arterial and nerve segments that are reconnected locally through microsurgery, as well as skin and fat that act as a coverage and new gliding plane and contribute to repair tissue damage caused by the original trauma.

Vascularized tibial flap
Dr Piñal takes a vascularized tibial flap to repair the damaged area. In the image, green trace for the nerve, red for the digital artery (digital a.), blue for the vein and yellow for fat.
Local reconnection by microsurgery
The flap is reconnected locally by microsurgery, eliminating pain and restoring function in the affected area.

The results

The new procedure offers satisfactory results, with a full functional and neurovascular recovery and minimal aesthetic impact on the limb and the donor area (the scar on the forearm corresponds to the failed initial surgery).

Injerto de colgajo neurocutáneo_CRPS_07_20190527

Postoperative result of the procedure.

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