Introduction

This article presents an analysis of the importance of encouraging interinstitutional work and multidisciplinary approaches, in order to provide better care and obtain the best results for the patient. It is demonstrated through the presentation of a case of limb salvage, in the work of López Hernández, Daniel and collaborators in 2014, who addressed this issue as a way to improve medical care, promoting the development of institutions and improving the quality of service. The importance of making agreements from a legal point of view is mentioned in order to establish the scope of the collaboration and its purpose, whether it is for academic, research or patient care purposes. Nowadays, in different states of the republic, collaborations have been established between high specialty hospitals and the Mexican Institute of Social Security (IMSS), as is the case of Campeche, with the objective of establishing the basis for collaboration and coordination between both institutions for the medical attention of patients who require specialized services and who cannot be attended by the IMSS in the state. In various states of the Mexican Republic, collaborations have been established between high-specialty hospitals and the Mexican Institute of Social Security (IMSS), as is the case in Campeche, with the objective of establishing the basis for collaboration and coordination between both institutions for the medical attention of patients who require specialized services and cannot be treated by the IMSS in the state. Esther Gonzalez Requena’s thesis addresses this issue from a teamwork perspective since studies conducted by universities and hospitals have shown that patients benefited from being treated by a team of health professionals. Examples of implementation can be seen in intensive care units and surgical areas. It is important to mention that collaboration, with the purpose of providing the best patient care, focuses not only on human resources but also on material resources. It should be noted that some conditions will require more specific supplies and equipment, and medical personnel with higher qualifications to perform treatment. In the case of highenergy accidents, which according to INEGI 2018 worldwide statistics have recorded between 20 and 50 million accidents and 1.3 million deaths due to this cause, they can lead to disability. We must remember that any accident caused at a speed greater than 40 km/h can cause high-energy injuries involving soft tissue loss, associated neurovascular compromise, and high-comminute fracture patterns. It is important to keep in mind that long bone fractures are often accompanied by vascular injuries, especially when they are high-energy, representing a risk and a public health problem, since they generate long-term disabilities, high incidence of mortality, and recurrence of amputations, due to the loss of soft tissues, bone exposure, and contamination. In order to avoid amputation, different techniques have been developed, which aim to reconstruct the affected area. In this clinical case, the use of a free peroneal flap was chosen, as it has characteristics that make it suitable for lesions larger than 6 cm for the treatment of bone defects. It is also used in patients where the vascular bed is poor or where there are signs of osteomyelitis. This type of flap favours safe revascularization, as long as the procedure is performed by an experienced surgeon.

Clinical case

This is a 24-year-old female patient, with no significant medical history, who suffered a motorcycle accident at an unknown speed, with contusion in the right hemibody.

Figure 1: Radiographs of the right pelvic limb; A and B- AP radiographs of the right hip with postoperative changes due to multiple femoral fractures reduction, level of the diaphysis with osteosynthesis material (oss to femur with Centro medullary nail); C and D- AP and lateral radiographs of the right leg with postoperative changes due to multifragmented tibial plateau fracture with osteosynthesis material (oss to tibial plateau with two plates); E and F- Radiograph of the right knee with decreased intra-articular space due to tibia fracture with tibial condyle involvement and changes described in figures A, B, C, and D.

She presents a right femoral shaft fracture, and an exposed fracture of the right tibial plateau, which is surgically intervened with oss to femur with Centro medullary nail and loss to tibial plateau with two plates (Figure 1). Later on, she presents wound infection, which is the reason why surgical cleaning is performed. Subsequently, she presents a cutaneous defect in the anterolateral aspect of the knee with a diameter of 18 cm and 4 cm in its major axes. She is referred to the National Institute of Rehabilitation (INR), where interinstitutional support between the INR and the Central Military Hospital is provided, providing highly qualified personnel for the treatment consisting of surgical cleaning, culture collection, and placement of VAC system in the first surgical act (Figure 2). In a second surgical act, surgical cleaning is performed, right tibial oss removal (Figure 3), and primary harvest of the left vascular fibula (Figure 4). In a third surgical act, oss is placed on the tibial plateau with an anatomical plate for the proximal tibia and reconstruction of the pelvic limb using the microvascular free peroneal flap in a second surgical time (Figure 5).

Figure 2: Radiographs of the right pelvic limb; A- AP and lateral radiographs of the right foot with images of multifragmented fracture of the tibial epiphysis and diaphysis in the proximal third, with an image suggestive of drainage or VAC system; B AP and lateral radiographs of the left leg showing postoperative changes for the harvest of vascularized peroneal grafts.

Figure 3: Removal of tibial oss, with extraction of the proximal the use of walking aids. On physical examination directed to the tibial epiphysis, where a large cutaneous defect with exposure of right pelvic limb, surgical scars are found, eutrophic, hyperchromic, osteosynthesis material and loss of the extensor system is observed.

Figure 4: Primary harvest of the left fibula; A and B show a portion of the fibular diaphysis, which will be used for the free peroneal flap with the peroneal artery and vein; C and D show the dissection performed for the primary harvest of the fibula.