An overview of the situation of hand surgery in Spain during the peak of COVID-19 pandemic.

Since the first cases were detected in China in December 2019, the COVID-19 pandemic has spread rapidly, collapsing many healthcare systems, and forcing them to adapt. Hand surgery has been indirectly affected by this scenario. This article aims to provide an overview on how Spanish hand surgeons have modified their daily practice. Based on a survey conducted nationwide, we observed a decrease in the number of emergency cases and cancellation of elective cases, shift to a more conservative treatment approach, use of personal protective equipment, and decrease in the number of outpatient visits and tests. Without definitive evidence at this point, knowing how we have dealt with the situation so far will help us adopt the needed measures to ensure both the patient's and surgeon's safety and manage available resources in future pandemics.

Aplicación de terapia de presión negativa en un caso de pioderma gangrenoso / Vacuum assisted negative pressure therapy in a clinical case of pyoderma gangrenosum

El pioderma gangrenoso es una enfermedad cutánea de etiología desconocida. Las lesiones comienzan típicamente como pústulas o nódulos de rápida evolución hacia úlceras profundas, mal determinadas y violáceas. El fenómeno de patergia está presente en un 20-50% de los casos, por lo que el desbridamiento de las lesiones conduce a un recrudecimiento del cuadro. Presentamos el caso de una paciente diagnosticada de pioderma gangrenoso en la cual, debido a la lenta evolución con inmunosupresores sistémicos y al importante dolor sufrido durante las curas, se decide la aplicación de terapia de presión negativa sobre las lesiones, obteniendo resultados favorables a corto-medio plazo (AU)

Pyoderma gangrenosum is a rare cutaneous disease of uncertain cause. Lesions usually start like pustulae or nodules that rapidly progress into shallow or deep ulcers, undermined. Pathergy occurs in 20% to 50% of the cases, that is why debriding lesions may only worsen them. We present a case of a woman with pioderma gangrenosum whose lesions evolution were slow despite systemic inmunosupression and whose dressing changes were very painful, so we decide to use vacuum assisted negative pressure therapy, obtaining favorable results in short to medium term (AU)

Colgajo de perforantes de la arteria colateral cubital inferior para defectos por quemadura eléctrica en fosa cubital / Inferior ulnar collateral perforators flap to cover defects on antecubital fossa after electrical burn

Las quemaduras eléctricas producen lesiones profundas, especialmente las debidas a la entrada y salida de la corriente y al arco voltaico, que pueden dejar expuestas estructuras nobles y afectar áreas de flexo-extensión, como la fosa antecubital. Los defectos resultantes pueden cubrirse mediante colgajos libres o pediculados de brazo y antebrazo. Entre las distintas opciones quirúrgicas, el colgajo medial del brazo evita la interrupción de los ejes vasculares mayores y la secuela en la zona donante es discreta. Sin embargo, su uso está poco extendido por considerarse un colgajo de difícil disección debido a la variabilidad anatómica de las arterias colaterales cubitales superior e inferior que lo irrigan. Presentamos la cobertura para un defecto secundario a quemadura eléctrica en la fosa antecubital mediante un colgajo medial del brazo basado en las ramas perforantes de la arteria colateral cubital inferior. Aunque confirmamos en este caso la variabilidad vascular, la disección resultó sencilla y el resultado estético y funcional fue excelente (AU)

Electrical burns result in deep injury to tissues, especially those lesions produced by entrance and exit of electric flow and voltaic arc, that expose structures such as tendons, nerves or vessels when it happens at the antecubital fossa. Defects produced by electrical burns can be covered using free flaps or local pedicled flaps from arm and forearm. Among different surgical procedures, medial arm flap is a useful one, as it avoids interruption of main vascular axis of the arm and donor site sequelae are minimal. Never the less, its use is not extended due to its difficult dissection, as because the pedicle of the flap has a highly variable anatomical vascularity (superior and inferior ulnar collateral artery). We present a defect produced by electrical burn and its coverage using a local flap based on perforator branches from inferior ulnar collateral artery. Although vascular variability was confirmed, dissection was easy and an aesthetical and functional outcome was achieved (AU)

Combined use of negative pressure wound therapy and Integra® to treat complex defects in lower extremities after burns.

Deep and extensive burns of lower extremities present a difficult challenge to healthcare professionals. After debridement, bones, tendons or joints are frequently exposed and cannot be covered by simple autografts. Moreover, in the case of major burns, damage to the surrounding areas of skin and the severity of the patient's overall condition, often count against using pedicled or microsurgical flaps. In dealing with such complex wounds, which are difficult to treat, several authors have recommended the combined use of Integra(®) and negative pressure wound therapy (NPWT). They emphasize that NPWT eliminates wound exudate, promotes neovascularisation and cell migration through the Integra(®) matrix while increasing its stability and adherence to the wound bed, as well as decreasing the time needed for its total integration. The case presented here is of a patient with major third-degree flame burns to the lower extremities. After debridement, the external and internal malleolus bilaterally became exposed as well as the partially debrided tendons (Achilles, extensor digitorum longus, long and short peroneus, anterior and posterior tibialis). After ruling out the use of local or microsurgical flaps due to the patient's poor general condition and the presence of burns debrided to the fascia over both lower extremities, we elected to manage the patient with a combined treatment using Integra(®) and NPWT. After three weeks of treatment, the surface layer of the Integra(®) matrix was replaced with autografts. Due to partial loss of the skin grafts, a second autograft was needed. At present the patient is completely healed; he can walk with full flexion-extension of both ankles.

Brûlures profondes et étendues des membres inférieurs du corp présentent un défi difficile pour les professionnels de la santé. Après débridement, les os, les tendons ou les articulations sont fréquemment exposés et ne peuvent pas être couverts par des simples autogreffes. En outre, dans le cas des grands brûlés, des dommages aux régions avoisinantes de la peau et de la gravité de l'état général du patient, contre-indiquent l'utilisation des lambeaux pédiculés ou de la microchirurgie. Dans le traitement de ces plaies complexes, qui sont difficiles à traiter, plusieurs auteurs ont recommandé l'utilisation combinée de l'Integra® et de la thérapie par pression négative (TPN). Ils soulignent que la TPN élimine les exsudats de la plaie, et favorise la néovascularisation et la migration des cellules à travers la matrice Integra®, tout en augmentant la stabilité et le collement du lit de la plaie et en réduisant le temps nécessaire à son intégration totale. Nous présentons le cas d'un patient avec des grandes brûlures au troisième degré causées par des flammes aux membres inférieurs. Après debridement, les malléoles externe et interne bilatérales sont devenues exposées ainsi que les tendons partiellement débridés (Achille, extenseur des orteils, long et court péronier latéral, muscles jambiers antérieurs et postérieurs). Après avoir exclu l'utilisation des lambeaux locaux ou de la microchirurgie en raison des brûlures débridées jusqu'à l'aponévrose sur les deux extrémités inférieures et le mauvais état général du patient, nous avons choisi de gérer le patient avec un traitement combiné de l'Integra® et de la TPN. Après trois semaines de traitement, la couche de surface de la matrice Integra® a été remplacée par des autogreffes. En raison de la perte partielle des greffes de peau, une deuxième autogreffe était nécessaire. Actuellement, le patient est complètement guéri; il peut marcher avec flexion et extension des deux chevilles.