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من البتر إلى التنقل: نقل رفرف العصبي في تقلص Dupuytren

25 يونيو, 2020

Estadio avanzado de enfermedad de Dupuytren_01_20200618

أدناه يمكنك قراءه ترجمه المترجم البشري باللغة الانجليزيه. لديك أيضا الوصول إلى الاسبانيه الاصليه عن طريق النقر علي العلم في الزاوية اليمني العليا. هذا الرابط يتيح لك الوصول إلى نسخه الترجمة اليه من جوجل في العربية

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The patient, a 70-year-old man, presents a picture of Dupuytren’s disease in the ring and little fingers of his left hand, which are contractured in flexion (Dupuytren’s contracture) causing a serious functional limitation.

Typical picture of Dupuytren's disease
In the images above, the patient’s preoperative state with the typical picture of advanced Dupuytren’s disease after failed surgery: the ring and little fingers closed towards the palm of the hand.

In the development of Dupuytren’s contracture, there is a thickening of the subcutaneous tissue of the palmar fascia that extends to the fingers, and ends up leading to the appearance of bands of fibrous tissue that act as cords or flanges, limiting finger extension.

Dupuytren’s disease is a hereditary pathology without prophylactic treatment, with a higher prevalence in northern Europe, especially in men over 60 years.

In this particular case, the patient underwent two previous surgeries before attending Dr Piñal’s clinic. These procedures generated a tissue deficit in the palm area and the palmar face of the ring and little fingers.

Neurocutaneous complex defect
View of the extension of the neurocutaneous defect after resection of the bands of fibrous tissue

The problem

The patient’s Dupuytren’s contracture is in such an advanced stage that the amputation of both fingers was considered, which Dr. Piñal finds very objectionable as there are other alternatives.

The goals

The fundamental aims of Dr Piñal and his surgical unit in this case are to eliminate the neurocutaneous defect and restore lost function, preserving the sensitivity of the affected area and minimizing the aesthetic impact on both the hand and the donor area of ​​the foot.

The plan

Microsurgical procedure
The superior general view allows to appreciate the complexity of the microsurgical procedure, with reconnections below one millimeter in diameter.

Dr Piñal designs a reconstructive microsurgery plan in a single procedure, which is based on the transfer to the hand of a vascularized free flap of the second toe (according to his own technique described in The Tibial Second Toe Vascularized Neurocutaneous Free Flap for Major Digital Nerve Defects, J Hand Surg 2007; 32A: 209–217. Copyright © 2007 by the American Society for Surgery of the Hand).

The flap is made up of a cutaneous island with skin and fat, accompanied by a segment of digital artery and nerve of the donor foot, and a subcutaneous vein to guarantee the irrigation of the transferred tissue.

After the fibrous bands and scar tissue have been removed, the defect is covered with the neurocutaneous flap: the digital artery of the toe is microsurgically connected to that of the hand, the nerves are also reconnected and, thus, both the enervation and blood flow are restored. The connections made in the proximal part of the palm and the fingertips are within a range of less than a millimeter in diameter (0.5-0.7 mm), which requires a great deal of experience and technical expertise from the surgeon.

Vascularized neurocutaneous free flap
In the center of the image, vascularized neurocutaneous free flap. The magnification shows the meager size of the points of the microsurgical suture of the digital artery.

 
The procedure lasts for 4,5 hours and the patient is discharged from hospital after three days.

The results

The intervention carried out by Dr. Piñal recovers a good part of the extension movement of the ring and little fingers, maintaining a sensitivity and appearance of the recipient and donor areas in satisfactory margins for the patient. It should be noted again that after two previous failed surgeries amputation of both fingers had been recommended.

Postoperative results
Postoperative results: extension movement of the ring and little fingers whose amputation had been recommended.

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