Traumatismos Severos del Pie: Conclusiones

CONCLUSIONES

Se presenta una serie no seleccionada de catorce pacientes con traumatismos severos del pié, en los que la técnica microquirúrgica ofreció la mejor opción de reconstrucción al transportar en un solo tiempo operatorio y de manera segura los tejidos necesarios para la reparación adecuada desde los puntos de punto de vista estructurales y de cobertura. Los resultados observados fueron en la mayoría de casos excelentes, lográndose la deambulación y el uso normal de calzado, en el seguimiento a largo plazo los resultados son más alentadores aún; ya que muestran pacientes agradecidos que asisten a los controles programados para recibir evaluación e instrucción.

La microcirugía ofrece opciones de tratamiento aún en los casos más extremos, los resultados son seguros, y la morbilidad y costos son aceptables.

Cada caso debe ser valorado de manera integral y su plan de acción formulado individualmente, tal manejo nos aleja un poco de la práctica muy segura de la microcirugía pero nos acerca más a mejores resultados, no creo que todos los casos sean simplemente defectos de cobertura, tampoco creo que existan colgajos de batalla que sean la solución única a todos los defectos del pié.

No olvidamos que el uso de los colgajos libres también tiene potenciales desventajas como el tener que disponer de recursos y personal especializados, la mayor duración de los actos operatorios y la siempre existente posibilidad de pérdida total en caso de obstrucción vascular.

Hemos hallado en los colgajos libres un excelente método de reconstrucción de problemas traumáticos difíciles, con la factibilidad de ser aplicado consistentemente en nuestro medio.

Francisco Javier Villegas MD.
AA 8163, Tulúa Valle
E-mail:fvillegas@teletulua.Com.co

Agradecimientos:

El autor desea expresar sus agradecimientos a los médicosde los servicios de Ortopedía, Anestesia y Rehabilitación, así como a los terapistas del Hospital Tomás Uribe de Tulúa

BIBLIOGRAFÍA

1-Francel T J.: Improving reemployment rates after limb salvage of acute severe tibial fractures by microvascular soft-tissue reconstruction. Plast Reconstr Surg 93:1028-1034,1994.
2-Godina, M.: Early microsurgical reconstruction of complex trauma of the extremities. Plast. Reconstr. Surg. 78: 285, 1986.
3- Nuzumlali E; G¨urb¨uz C; Kantarci U; Cepel S; Bayri O; Polatkan O: Moving car-tire injuries of the foot: reconstruction with microvascular free flaps. J Reconstr Microsurg, 12:297-302, 1996 .
4-Segers MJ; Wink D; Clevers GJ : Bicycle-spoke injuries: a prospective study. Injury, 28(4):267-9, 1997.
5-D’Souza LG; Hynes DE; McManus F; O’Brien TM; Stephens MM; Waide V: The bicycle spoke injury: an avoidable accident? Foot Ankle Int, 17(3):170-3 1996.
6-Boucree JB Jr; Gabriel RA; Lezine-Hanna JT: Gunshot wounds to the foot Orthop Clin North Am, 26(1):191-7 1995.
7-Washington ER; Lee WA; Ross WA Jr: Gunshot wounds to the extremities in children and adolescents. Orthop Clin North Am, 26(1):19-28 1995.
8-Cosgrove JM: Free radial forearm flap to the foot after a shotgun injury: the day I became a patient. Br J Plast Surg, 50:288-91, 1997.
9-Schoen NS; Gottlieb LJ; Zachary LS : Distribution of pedal burns by source and depth. J Foot Ankle Surg, 35(3):194-8, 1996 .
10-Anger DM; Ledbetter BR; Stasikelis PJ; Calhoun JH : Injuries of the foot related to the use of lawn mowers. J Bone Joint Surg Am, 77(5):719-25, 1995 .
11-Colen LB, Mathes SJ: “Foot.” In: Plastic Surgery, Principles and Practice. Chapter 38. MJ Jurkiewicz, TJ Krizek, SJ Mathes, S Ariyan. C V Mosby Company, Toronto 1990.
12-Hidalgo DA, Shaw WW: Reconstruction of foot injuries.
Clin Plast Surg 13:663-80, 1986.
13-Khouri, R. K., and Shaw, W. W: Reconstruction of the lower extremity with microvascular free flaps: A 10-year experience with 304 consecutive cases. J. Trauma 29: 1086, 1989.
14-Francel, T. J., Vander Kolk, C. A., Hoopes, J. E., et al.: Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: Timing of coverage and long-term functional results. Plast. Reconstr. Surg. 89: 478, 1992.
15-Milanov NO, Adamyan RT: Functional results of microsurgical reconstruction of plantar defects. Ann Plast Surg 32:52-56,1994.
16-Noever, G., Bruser, P., and Kohler, L.: Reconstruction of heel and sole defects by free flaps. Plast. Reconstr. Surg. 78: 345, 1986.
17-Nahai, F., and Mathes, S. J.: Aesthetic aspects of reconstructive microsurgery of the lower extremity. Clin. Plast. Surg. 8: 369, 1981.
18-Chen S, Wei F, Chen H, et al: Emergency free flap transfer for reconstruction of acute complex extremity wounds. Plast Reconstr Surg 89:882, 1992
19-N. Rajacic, M. K. H. Ebrahim, S. Grgurinovic, and B. Starovic: Foot reconstruction using vascularised fibula. Br J Plast Surg 46 :317-321,1993.
20-Harrison, D. H., Morgan, B. D. G.: The instep island flap to resurface plantar defects. Br. J. Plast. Surg. 34:315, 1981.
21-Morrison, W. A., Crabb, D. M., O’Brien, B. M., Jenkins, A. : The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast. Reconstr. Surg. 72:56, 1983.
22-Nohira, K., Shintomi, Y., Sugihara, T., Ohura, T.: Replacing losses in kind: Improved sensation following heel reconstruction using the free instep flap. J. Reconstr. Microsurg. 5:1, 1989.
23-Miyamoto, Y., Ikuta, Y., Shigeki, S., Yamura, M.: Current concepts of instep island flap. Ann. Plast. Surg. 19:97, 1987.
24-Lee HB; Tark KC; Rah DK; Shin KS : Pulp reconstruction of fingers with very small sensate medial plantar free flap.
Plast Reconstr Surg, 101(4):999-1005, 1998.
25-Ninkovi´c M; Wechselberger G; Schwabegger A; Anderl H : The instep free flap to resurface palmar defects of the hand. Plast Reconstr Surg, 97(7):1489-93, 1996.
26-Isik S; G¨uler MM; Selmanpako¨glu N: Salvage of foot amputation stumps of Chopart level by free medial plantar flap. Plast Reconstr Surg, 101:745-50, 1998
27-Shaw, W. W, Hidalgo, D. A.: Anatomic basis of plantar flap design: clinical applications. Plast Reconstr Surg, 78: 637. 1986.
28-Hidalgo, D. A, Shaw, W. W.: Anatomic basis of plantar flap design. Plast Reconstr Surg, 78: 627. 1986.
29-Moshammer HE; Hellbom BA; Schwarzl FX; Haas FM; Pierer GR: Reconstruction of a complex defect on the foot with an osteotendofasciocutaneous lateral arm free flap. Case report. Scand J Plast Reconstr Surg Hand Surg, 31(3):271-3 1997.
30-Woods JM 4th; Shack RB; Hagan KF : Free temporoparietal fascia flap in reconstruction of the lower extremity. Ann Plast Surg, 34:501-6, 1995.
31-Chen HC; El-Gammal TA; Chen HH; Wei FC; Lin CH; Tang YB : Economy of donor site incisions: multiple free flaps of the subscapular family for extensive extremity wounds and bilateral foot defects. Ann Plast Surg, 41(1):28-35 1998.
32-Rautio J, Asko-Seljavaara S, Laasonen L, Harma M: Suitability of the scapular flap for reconstructions of the foot. Plast Reconstr Surg 85:922, 1990.
33-Kurokawa M; Muneuchi G; Hamagami H; Fujita H : Reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg, 101:1616-9, 1998.
34-Isenberg JS, Sherman R: The limited value of preoperative angiography in microsurgical reconstruction of the lower limb. J Reconstr Microsurg 12:303, 1996.
35-Valauri F: Discussion: The limited value of preoperative angiography in microsurgical reconstruction of the lower limb.
J Reconstr Microsurg 12:306 1996. 36-Morris AM, Buchan AC: The place of the cross-leg flap in reconstructive surgery of the lower leg and foot : A review of 165 cases. Br J Plast Surg 31:138, 1978.
37- Dawson RL: Complications in cross-leg flaps a review of 99 cases. Proc Roy Soc Med 65:626, 1972.
38-Gould JS; Shi SM : Free vascularized soft tissue flaps for coverage of the foot and ankle. Clin Orthop, :26-36, 1995.
39-Boeckx W; van den Hof B; van Holder C; Blondeel P: Changes in donor site selection in lower limb free flap reconstructions. Microsurgery, 17(7):380-5, 1996.
40-May, J. W., Jr., and Rohrich, R. J.: Foot reconstruction using free microvascular muscle flaps with skin grafts. Clin. Plast. Surg. 13: 681, 1986.
41-May, J. W., Jr., Halls, M. J., and Simon, S. R: Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: A clinical and gait analysis study. Plast. Reconstr. Surg. 75: 627, 1985.
42-Stevenson, T. R., and Mathes, S. J: Management of foot injuries with free-muscle flaps. Plast. Reconstr. Surg. 78: 665, 1986.
43-Bunkis, J., Walton, R. L., and Mathes, S. J: The rectus abdominis free flap for lower extremity reconstruction. Ann. Plast. Surg. 11: 373, 1983.
44-Zukowski M; Lord J; Ash K; Shouse B; Getz S; Robb G : The gracilis free flap revisited: a review of 25 cases of transfer to traumatic extremity wounds. Ann Plast Surg, 40(2):141-4 1998
45-Stevenson TR: Discussion.: The segmental rectus abdominis free flap for ankle and foot reconstruction. Plast Reconstr Surg 88: 829-830, 1991.
46-Jay A. Goldberg, Philip Trabulsy, William C. Lineaweaver, and Harry J. Buncke: Sensory reinnervation of muscle free flaps for foot reconstruction. J Reconstr Microsurg 10: 7-9,1994.
47-Rautio, J. : Resurfacing and sensory recovery of the sole. Clin. Plast. Surg. 18(3):615, 1991.
48-Potpari´c Z; Raja¨ci´c N :Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps. Br J Plast Surg, 50:176-81, 1997.
49-NoeverG, Bruser P, Kohler L: Reconstruction of the heel and sole defects by free flaps. Plast.Reconstr.Surg. 78: 345, 1986.
50 -Weinzweig N, Davies BW: Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases. Plast.Reconstr.Surg. 102:1999-2005, 1998.
51-Chicarilli Z N, Price GJ: Complete plantar foot coverage with free neurosensory radial forearm flap. Plast.Reconstr.Surg. 78:94, 1986.
52-Fernandez-Palacios J; De Armas Diaz F; Deniz Hernandez V; Rodriguez Aguirre M : Radial free flaps in plantar burns. Burns, 22(3):242-5 1996
53-Hidalgo D, Disa JJ. Cordeiro PG, Hu QY: A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor site selection and technique. Plast Rec Surg 102:722-34, 1998.
54-Kroll SS, Schusterman MA, Reece GP, Miller MJ; Evfans GR, Robb GL, Baldwin BJ: Choice of flap and incidence of free flap sucess.Plast Reconstr Surg 98:459-63, 1996.
55-Yaremchuck MJ, Brumback RJ, Manson PN, et al: Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg, 80:1, 1987.
56-Goldberk JA, Adkins P, Tsai TM: Microvascular reconstruction of the foot: Weight-bearing patterns, gait analysis, and long-term follow-up. Plast Reconstr Surg, 92:904, 1993
57-Perttunen J; Rautio J; Komi PV : Gait patterns after free flap reconstruction of the foot sole. Scand J Plast Reconstr Surg Hand Surg, 29(3):271-8 1995.