Platelet rich plasma and plasma rich in growth factors for split-thickness skin graft donor site treatment in the burn patient setting: A randomized clinical trial.

INTRODUCTION: Management of donor site morbidity in the setting of split thickness skin graft (STSG) is of crucial importance with no superior wound dressing described to date and the growing need of decreasing epithelializing time. The purpose of the study was to compare the standard of care using a hydrocolloid dressing to platelet rich plasma (PRP) and plasma rich in growth factors (PRGF) in order to determine its therapeutic potential in this setting. METHODS: A randomized clinical trial was conducted in which each patient served as its own control. PRGF was obtained by means of freeze-thaw out of the PRP from the subject of the study. Patients from the study had three donor sites and each donor site received either to PRP, PRGF or the standard of care, hydrocolloid. The main variable was time to epithelialization, and secondary variables subject to study were pain, quality of the scar, complications and cost. RESULTS: 20 patients were recruited with a total number of 60 donor sites to study. On the 8th post-operative day 55% and 45% of the sites treated with PRP and PRGF, respectively, complete epithelialization was observed as compared to 20% of the sites treated with hydrocolloid, statistical significance was achieved between the latter two (p = 0.036). The areas treated with PRP and PRGF received inferior values on the visual analog scale on post-op day 5 and 8 compared to hydrocolloid. Values on wound healing metrics were lower in the PRP when compared to hydrocolloid. No adverse effects were recorded. CONCLUSION: Donor site of STSG treated with PRP in the setting of the burn patient decreased time to epithelialization. In our study a better pain control and in scar quality was observed in both, the PRP and PRGF group.

Autologous Patellar Tendon Reconstruction after Total Knee Arthroplasty Infection with Skin Loss: Anatomical Study and Case Report.

Disruption of patellar tendon after total knee arthroplasty (TKA) is a devastating complication. If associated with infection or soft tissue defect, knee arthrodesis is usually indicated. The purpose of this study is to analyze, by means of an anatomical study, the feasibility of our novel technique for reconstruction of extensor apparatus after TKA infections with skin defects, combining gracilis (G) and semitendinosus (ST) tendon autografts and chimeric medial gastrocnemius-sural artery perforator (SAP) flap. In addition, to report on the use of this reconstruction, we described an illustrative clinical case. Ten fresh cadaver lower limbs were dissected. The width of the gastrocnemius, number of medial SAP, length of hamstrings tendons, and distance from the lower pole of the patella to anterior tibial tuberosity (ATT) were measured. A mean of 1.37 perforator branches (range 1-3) was found. In all cases, the tendon length for gracilis and ST, and the width in the middle third of gastrocnemius related to the patella-ATT distance were enough to make the reconstruction. We performed this technique in a 78-year-old man with an infected TKA with skin defect. After 1 year and two-stage procedure, the patient achieved full active knee extension and was able to ambulate without aids. Extensor apparatus reconstruction combining tendon autografts and chimeric medial gastrocnemius-SAP flap is an available technique and may be considered as an alternative to arthrodesis in extensor mechanism ruptures after infection in TKA.

Malformación arteriovenosa de la vena de Galeno. Serie de casos / Vein of Galen aneurysmal malformation. A case series

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Secondary Leiomyosarcoma of the Lower Limb Following Uterine Smooth Muscle Tumor of Uncertain Malignant Potential.

INTRODUCTION: This report presents uterine smooth muscle tumors of uncertain malignant potential course with an unpredictable clinical behavior and late metastases. Metastases have been described to the humerus, lung, and peritoneum. CASE PRESENTATION: Hereby we present the case of a 71-year-old woman with a past surgical history of hysterectomy and bilateral adnexectomy due to a smooth muscle tumor of unknown malignant potential, who was evaluated 6 years later after the appearance of a mass in the proximal third of the right lower limb. The mass was diagnosed as a G1 epithelioid leiomyosarcoma and was surgically removed with immediate reconstruction with a tendinous transfer to the tibialis posterior muscle to maintain foot dorsiflexion. CONCLUSION: Patients diagnosed with smooth uterine muscle tumors of uncertain malignant potential should be closely followed up given the possibility of recurrence and late metastases, bearing in mind uncommon locations as well, such as the lower limb.

Management of Hand Burn With Pedicled Converted Anterolateral Thigh Free Flap.

The upper limb is involved in burns in a high percentage of cases and its reconstruction is extremely important, given the functional impact of this anatomical region. Among the reconstruction choices for severe and large structural defects, the pedicled anterolateral thigh flap is an available option. This case study discusses the utilization of the pedicled anterolateral thigh flap for reconstruction of a complex full-thickness hand burn, when adequate arterial perforators were not available. Complex hand burns can often present challenges for reconstructive coverage, because of the complex anatomy of the upper extremity and the need to preserve as much function as possible. The use the anterolateral thigh free flap is one option that can be utilized for coverage of these large hand defects, in the face of poor local tissue advancement options. The finding of inadequate or lack of perforator vessels necessitates intraoperative changes in the surgical approach. In these cases, different alternatives exist depending on the dimensions and characteristics of the required coverage, the dissection of a pedicled flap being one of them. The pedicled anterolateral thigh flap represents an alternative for the coverage of large hand defects in the absence of valid perforators during free-flap dissection.

Endonasal Infiltrative Anesthesia for Nasal Fracture Reduction.

This study investigated the use of endonasal infiltrative anesthesia for the management of pain associated with nasal bone fracture reduction. Fifty-two patients with nasal bone fractures were distributed in 2 groups. In the first group, topical endonasal anesthesia and external transcutaneous infiltrative anesthesia were employed. In the second group, endonasal infiltrative anesthesia was also added. Visual analog scale pain scores related to the different steps of the procedure were registered. The addition of endonasal infiltrative anesthesia was associated with a significant decrease (p < .05) in pain during reduction maneuvers (6.71 vs. 4.83) and nasal packing (5.18 vs. 3.46). Addition of endonasal infiltrative anesthesia is an effective method of pain reduction during nasal bone fracture treatment.

Bronquiolitis obliterante en paciente con poliquistosis hepatorrenal en lista para trasplante / Bronchiolitis obliterans in a transplant-waitlisted patient with hepatorenal polycystic disease

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Masseter-to-Facial Nerve Transfer for Reanimation of a Patient With Long-Term Facial Paralysis.

Facial paralysis is a condition caused by a wide variety of etiologies, including neurologic, congenital, infectious, neoplastic, systemic, and iatrogenic causes. A patient suffering from long-term facial paralysis, with minimal innervation detected through electroneurography, who was successfully reanimated by performing a masseter-to-facial nerve transfer, was presented in this study. Facial paralysis had been caused after resection of an acquired middle ear cholesteatoma more than 5 years before.

Reconstrucción escrotal: cobertura mediante colgajo muscular de gracilis pediculado frente a injerto de piel parcial / Scrotal reconstruction with pedicled gracilis muscle flap versus split thickness skin graft

Introducción y Objetivo: La región escrotal presenta unas características especiales que otorgan una adecuada protección y termorregulación testicular. La etiología de su defecto puede ser múltiple, siendo la causa más frecuente la gangrena de Fournier. Hasta el momento actual se han descrito múltiples opciones reconstructivas, no obstante no se ha llegado a encontrar un método ideal. El objetivo de este estudio es evaluar los efectos de la reconstrucción escrotal mediante colgajo de músculo gracilis o injerto de piel parcial sobre la función hormonal testicular y la satisfacción del paciente. Material y Método: Desde enero de 2006 hasta marzo de 2016, 19 pacientes fueron sometidos a reconstrucción de defecto escrotal en nuestra unidad mediante cobertura con injerto de piel parcial o colgajo de gracilis pediculado. En todos los casos el defecto fue secundario a gangrena de Fournier. Estudiamos las características de los pacientes y medimos su función hormonal testicular, así como su satisfacción tras la reconstrucción al cabo de 5 ±3.6 años de postoperatorio. Resultados: De los 19 pacientes intervenidos, incluimos 11 en el estudio: 5 con reconstrucción mediante colgajo muscular de gracilis pediculado con injerto de piel parcial y 6 mediante injerto de piel parcial. No apreciamos diferencias entre los grupos respecto a los valores de función hormonal testicular. No obstante, observamos diferencias a favor de la reconstrucción mediante colgajo de gracilis pediculado respecto a satisfacción (93 frente a 60 puntos), sensación de protección (98 frente a 68 puntos), influencia en la actividad sexual (20% frente a 80%) y sensibilidad táctil grosera del área reconstruida (80% frente a 0%). Conclusiones: La reconstrucción de defecto escrotal mediante colgajo de gracilis. en nuestra muestra, ofreció un mejor resultado estético y una mayor satisfacción del paciente que la reconstrucción mediante injertos de piel parcial. Además, no observamos diferencias notables entre las dos técnicas reconstructivas respecto a la función hormonal testicular de los pacientes

Background and Objective: The scrotal area presents special characteristics that allow the protection and thermal regulation of testicles. The etiology of scrotum defect can be multiple, being the most frequent cause Fournier's gangrene. Multiple reconstructive options have been described, nevertheless it has not yet been reached an ideal method. This study was designed to evaluate the effects of scrotal reconstruction, using gracilis muscle flap or skin graft, on testicular hormonal function and patient satisfaction. Methods: From January 2006 to March 2016, 19 patients underwent a reconstruction of scrotum defect in our unit through covering by skin graft or pedicled gracilis flap. In all cases the defect was due to Fournier's gangrene. The characteristics of the patients were studied and testicle hormonal function as well as satisfaction after the reconstruction were assessed, with a mean follow-up of 5 ± 3.6 years. Results: From 19 operated patients, 11 were included in the survey: 5 patients were reconstructed through pedicled gracilis muscle flap with skin graft and 6 by means of split thickness skin graft. There were no differences between the groups with regard to the values of testicular hormonal function. Nevertheless, differences were observed in favor of the reconstruction by pedicled gracilis flap regarding to satisfaction (93 versus 60 points), feelings of protection (98 versus 68 points), effects on sexual activity (20% versus 80%) and tactile rude sensibility of the area reconstructed (80% versus 0%). Conclusions: Reconstruction of scrotum defect through pedicled gracilis flap turned out to be in our sample a better aesthetic result and a higher satisfaction of the patient that the reconstruction by means of skin grafts. However, no differences were found regarding testicular hormonal function

Tratamiento quirúrgico del paciente gran quemado: casuística de siete años en el Hospital Universitario y Politécnico la Fe de Valencia, España / Tratamento cirúrgico do paciente grande queimado: casuística de sete anos do Hospital Universitario y Politécnico la Fe de Valência, Espanha / Surgical treatment of the major burn: seven years experience in the University and Polytechnic La Fe Hospital of Valencia, Spain

Objetivo: Caracterizar los casos atendidos en el Hospital Universitario y Politécnico la Fe de Valencia, España, en el transcurso de 7 años de uso de un protocolo quirúrgico para pacientes con quemaduras de más del 50% de superfície corporal quemada (SCQ). Métodos: Se ha realizado un análisis descriptivo de los pacientes con quemaduras mayores al 50% de SCQ, tratados entre enero de 2011 y enero de 2017, en la Unidad de Quemados del Hospital La Fe (Valencia, España). Todos los pacientes fueron tratados de acuerdo al protocolo quirúrgico establecido en nuestra unidad para el paciente gran quemado. Resultados: Se trataron 35 pacientes, 25 varones y 10 mujeres, con edad media de 51,3±16,2 años. La llama fue el agente lesional más frecuente. La SC media afecta por quemadura fue 66,9±13,5%. La tasa de mortalidad (TM) neta fue del 55%, siendo el shock por quemadura la causa de muerte predominante en las primeras 48h y la sepsis tras las 48h. Conclusiones: El paciente gran quemado supone un reto terapéutico donde un enfoque multidisciplinar es determinante para su adecuada evolución. En nuestra serie, la estandarización del tratamiento quirúrgico mediante un protocolo ha permitido un adecuado manejo de los pacientes con una TM inferior a la estimada y comparable a la informada en la literatura.

Objetivo: Caracterizar os casos atendidos no Hospital Universitário y Politécnico la Fe de Valencia, Espanha, no transcurso de sete anos de uso de um protocolo cirúrgico para pacientes com queimaduras de superfície corporal queimada (SCQ) superior a 50%. Método: foi realizada análises descritiva dos casos de pacientes com SCQ superior a 50%, tratados entre janeiro de e janeiro de 2017, na Unidade de Queimados do Hospital La Fe (Valência, Espanha). Todos os pacientes foram tratados de acordo com o protocolo cirúrgico estabelecido na unidade para o paciente grande queimado. Resultados: Foram tratados 35 pacientes, 25 homens e 10 mulheres, com idade média de 51,3±16,2 anos. A chama foi o agente causador mais frequente. A SCQ media foi de 66,9±13,5%. A taxa de mortalidade (TM) foi de 55%, sendo o choque por queimadura a causa de morte predominante nas primeiras 48h e a sepses após 48h. Conclusões: O paciente grande queimado representa um desafio terapêutico no qual o foco multidisciplinar é determinante para sua adequada evolução. Nos casos estudados, a padronização do tratamento cirúrgico por meio de um protocolo permitiu um adequado manejo dos pacientes com una TM inferior à estimada e comparável à informada na literatura.

Objective: To characterize the cases treated at the University and Polytechnic la Fe Hospital in Valencia, Spain, over the course of 7 years with the use of a surgical protocol for patients with burns greater than 50% of total body surface area (TBSA). Methods: From January 2011 to January 2017, 35 patients with burns greater than 50% TBSA were treated in our Burn Unit. All patients were treated according to our major burn surgical protocol. Results: A total of 35 patients were treated, 25 men and 10 women, with a mean age of 51.3±16.2 years. Flame burn was the most common etiology. The mean TBSA affected was 66.9±13.5%. The mortality rate was 55%, with burn shock being the main cause of death in the first 48 hours. Conclusion: Patients with burns greater than 50% TBSA suppose a therapeutic challenge where a multidisciplinary approach is essential for its adequate evolution. In our series, the treatment standardization with a protocol has allowed an adequate management of the patients with a mortality rate similar to the literature report and lower than our estimated rate.

Síndrome GAPO, a propósito de un caso / GAPO syndrome: case report

El síndrome GAPO es una rara enfermedad autosómica recesiva caracterizada por retraso en el crecimiento, alopecia, pseudoanodoncia y atrofia óptica. Se han descrito mutaciones en el gen ANTXR1 como origen etiológico. Presenta afectación de múltiples aparatos, por lo que requiere un manejo multidisciplinar para lograr su adecuado tratamiento.

GAPO syndrome is a rare autosomal recessive disease characterized by growth retardation, alopecia, pseudoanodontia and optic atrophy. Gene alterations in the ANTXR1 gene have been reported to be causative of this disorder. Abnormalities of diverse organs and systems have been described. A multidisciplinary management to achieve an adequate treatment is required.

Recomendaciones de rehabilitación en el paciente quemado: revisión de literatura / Recomendações de reabilitação para paciente queimado: revisão da literatura / Rehabilitation recommendations in the burn patient: literature review

OBJETIVO: Realizar una revisión bibliográfica acerca de la rehabilitación en el paciente quemado, sintetizando las recomendaciones expuestas por los documentos de consenso internacionales y la bibliografía reciente. Además, exponemos la manera en que estas recomendaciones se han aplicado en la Unidad de Grandes Quemados del Hospital La Fe, en forma de un protocolo multidisciplinar de rehabilitación intensiva. MÉTODO: Se realizó una búsqueda bibliográfica de la literatura existente y los consensos internacionales centrados en el ámbito de la rehabilitación en el paciente quemado. Seguidamente, se relata la forma en que estas recomendaciones fueron implementadas en la Unidad de Grandes Quemados del Hospital La Fe de Valencia; en forma de un protocolo de rehabilitación intensivo y multidisciplinar. RESULTADOS: La bibliografía revisada refuerza los argumentos en favor del desarrollo y aplicación de protocolos de rehabilitación intensiva en las unidades de quemados para la mejora de los resultados funcionales de los pacientes. La experiencia en nuestra unidad en la cual se aplica un protocolo de este tipo coincide con los buenos resultados reportados. CONCLUSIONES: La aplicación precoz de una terapia rehabilitadora intensiva resulta clave a la hora de prevenir y tratar las posibles complicaciones funcionales y secuelas producidas por las quemaduras. Este tratamiento rehabilitador interdisciplinar se ha de centrar en la prevención de problemas a largo plazo, como las contracturas, la cicatrización anómala, deformidades, atrofia muscular, limitación de movilidad y otros problemas que merman la función física. Su utilización en cualquier unidad de quemados, permitirá optimizar los resultados funcionales de nuestros pacientes.(AU)

Objetivo: Realizar uma revisão da literatura científica sobre a reabilitação do paciente queimado, resumindo as recomendações estabelecidas por documentos de consenso internacional e na literatura recente. Além disso, apresentamos como essas recomendações foram implementadas na Unidade de Grandes Queimados do Hospital La Fe, na forma de um protocolo de reabilitação intensivo multidisciplinar. Método: Pesquisa bibliográfica da literatura e do consenso internacional existente centrado no campo da reabilitação no paciente queimado. Foi relatado como as recomendações internacionais foram implementadas para a prática dentro da unidade para atendimento ao grande queimado, no Hospital La Fe, no formato de um protocolo de reabilitação intensivo multidisciplinar. Resultados: A literatura existente reforça o desenvolvimento e implementação de protocolos de reabilitação intensiva em unidades de queimados para melhorar os resultados funcionais dos pacientes. A experiência em nossa unidade, em que esse tipo de protocolo é aplicado, corresponde aos bons resultados descritos na literatura. Conclusões: A aplicação antecipada de terapia de reabilitação intensiva é fundamental para a prevenção e tratamento de complicações e possíveis consequências funcionais causadas por queimaduras. Este tratamento interdisciplinar de reabilitação tem de se concentrar na prevenção de problemas de longo prazo, tais como contraturas, cicatrizes anormais, deformidades, atrofia muscular, dificuldade de locomoção e outros problemas que prejudicam a função física. Seu uso em qualquer unidade de queimados irá otimizar os resultados funcionais dos nossos pacientes.(AU)

ABSTRACT: OBJECTIVE: To perform a bibliographic review about rehabilitation of the burn patient, summarizing recommendations provided by international consensus documents and the most recent evidence. Moreover, we present the method in which this recommendations have been applied to the Great Burns Unit of the Hospital La Fe, in the format of a interdisciplinary intensive rehabilitation protocol. METHOD: A bibliographic search was performed among existent literature and international consensus documents focused on the field of burn patient rehabilitation. Following, the way in which this recommendations were applied at the Great Burns Unit of the Hospital La Fe of Valencia are presented in the shape of an intensive and multidisciplinar rehabilitation protocol. RESULTS: Reviewed bibliography supports the development and application of intensive rehabilitation protocols in burn units for the improvement of the functional results of their patients. The experience in our unit in which this sort of protocol is applied, matches the good results described in literature. CONCLUSIONS: Early intensive rehabilitation therapy is a key stone when it comes to prevention and treatment of functional complications. This interdisciplinary approach must focus in prevention of long term complications, such as contractures, abnormal scarring, deformities, muscular atrophy, mobility limitations and other issues which can decrease physical function. Its utilization in a Burn Unit, will help optimize functional results of their patients.(AU)