Necrotizing soft-tissue infection of the upper limb: A single-center study of 24 cases.

OBJECTIVES: Necrotizing soft-tissue infection and necrotizing fasciitis of the upper limb are infrequent. Studies are rare, and often include other anatomical regions. The specificities and particularities of this pathology are not well known. The aim of this study was to report diagnosis and treatment aspects. METHODS: A retrospective study was conducted over 10 years on every patient treated for necrotizing fasciitis of the upper limb with clinical, bacteriological and histological confirmation. One hundred ninety-eight items were extracted for each patient concerning clinical, biological, radiological and therapeutic data. RESULTS: During 10 years, 24 patients were diagnosed with necrotizing fasciitis of the upper limb: 18 males, 6 females; mean age, 59.9 years; mean body mass index, 25. Local erythema, pain and fever were the most frequent symptoms. Skin necrosis was present in fewer than 40% of patients. Sixteen cases (66.6%) had prior skin lesions and/or an entry point on the limb. Ten had non-steroidal anti-inflammatory drug prescription before acute symptom onset (42%), requiring intensive care unit admission. Treatment comprised surgical resection, resuscitative measures, antibiotic therapy and reconstructive surgery. Seven patients (30.4%) had 1 session of cutaneous excision, and the others had more than 2. Microbiological analysis found mono-microbial beta-hemolytic group A streptococci (BHGAS) infection in 14 patients (58.4%). Antibiotics were prescribed in 91% of cases before surgery, and in 100% after. The most frequently prescribed substance was clindamycin (18 patients, 75%). Ten patients (42%) stayed in the intensive care unit during treatment. Seventeen patients (70.8%) had thin skin graft reconstruction, including 50% with dermal substitute. Five patients (20.8%) had partial upper limb amputation. Two patients (8.3%) died in the 30 days following diagnosis. CONCLUSIONS: The death rate in necrotizing fasciitis of the upper limb was rather low but the amputation rate was higher than in other locations. This study shows the specific clinical, biological and treatment features of this rare but serious pathology of the upper limb.

The accessory vascularization of the tensor fasciae latae muscle: towards a new classification?

PURPOSE: The tensor fasciae latae (TFL) muscle is supplied by the lateral femoral circumflex artery (LCFA), arising from the deep femoral artery. However, it has been noted that there is also a consistent vascular anastomotic network. The aim of this study was to describe the accessory vascularization of the TFL muscle through a descriptive anatomical study, in order to hypothesize the feasibility of harvesting a TFL flap in the event of an injury to the main pedicle. In addition, we illustrate this hypothesis with a successful clinical case of Scarpa freconstruction following ligature of the deep femoral artery. METHODS: The description of the accessory vascularization was obtained by injecting dye into seven lateral femoral circumflex arteries (LCFA), six superficial circumflex iliac arteries (SCIA), and three inferior gluteal arteries (IGA). RESULTS: The TFL muscle was vascularized primarily by the LCFA. A vascular anastomotic network with the SCIA and the IGA was observed. After selective injection to the SCIAs and IGAs, the subsequent injection to the LCFA showed a diffusion of the TFL skin paddle with a perforasome overlapping between the different vascular territories. CONCLUSION: The ascending branch of the lateral femoral circumflex plays a dominant role in the vascularization of the TFL muscle. As a result of a periarticular anastomotic network of the hip, this artery establishes several connections with the proximal arteries. Consequently, in cases where blood flow through the LCFA is interrupted, it should be equally possible to harvest the TFL flap through its accessory vascularization.

Gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia: Long-term results of endoscopic treatment.

Background and study aims This longitudinal prospective study evaluated the long-term outcome of endoscopic treatment of gastrointestinal bleeding in hereditary hemorrhagic telangiectases (HHT), its safety and outcome predictors. Patients and methods Consecutive patients with HHT and either anemia disproportionate to epistaxis or overt gastrointestinal bleeding received endoscopic treatment of gastrointestinal telangiectases with argon plasma coagulation (APC). Hemoglobin levels and transfusion requirements were evaluated before and after treatment. Treatment effectiveness was classified as: 1) complete: hemoglobin level during the follow-up ≥9 g/dL; 2) complete with recurrence: hemoglobin ≥9 g/dL for at least 12 months with subsequent drop to <9 g/dL; or 3) absent: no improvement of hemoglobin level. Adverse events (AEs) were classified as mild, moderate, severe or fatal. Correlations were searched between treatment outcome and demographic/genetic characteristics, number, size and site of telangiectases, and hepatic arterio-venous malformations grade. Results Forty-seven patients with HHT were enrolled. At median follow-up of 134 months (range 20-243 months), 41 of 47 patients showed treatment response (complete or with recurrence) after one (14/47) or more (27/47) endoscopic treatments. Median hemoglobin levels were 7.0 g/dL and 11.9 g/dL at baseline and at the end of follow-up, respectively. Transfusion requirement decreased from 22.8 to 7.3 red cell unit/year. A higher baseline number of telangiectases was associated with a lower chance of response ( P =0.008). Only one severe AE (0.4%, jejunal perforation) was recorded. Conclusions Endoscopic treatment of gastrointestinal teleangiectases for gastrointestinal bleeding in patients with HHT is effective in the long term and safe.

Cutaneous vascularization of the proximal two-thirds of the dorsal aspect of the hand: descriptive anatomical study of a perforating arterial arch.

PURPOSE: Several reports have suggested that transverse arches between the radial and ulnar sides of dorsal hand skin supply the proximal part of the skin. The main objective of the study was to provide an anatomical and radiological description of a superficial vascular arch in the proximal third of the metacarpals of the long fingers. METHODS: We dissected 11 hands after injection with a mixture of lead and resin. A CT scan was performed before dissection. All vessels supplying the skin were individualized on the back of the hand and measured. RESULTS: A superficial perforating dorsal arch of the hand was present in all cases in this study. It was supplied by a dorsal radial perforating artery arising from the radial artery and by a dorsal ulnar perforating artery arising from the dorsal carpal arch. The distal recurrences of the intermetacarpal spaces communicated with this arch. This arch was the only source of vascularization of thess proximal third of the third space and presented a dominant ulnar side in the majority of cases. It presented numerous anatomical variations. The source vessels had mean diameters of 0.5 mm. There was an excellent radiological-anatomical correlation on CT scan. CONCLUSION: Given the constancy of this arch in the study, perforating flaps not yet described could be considered, having as pivot points the ulnar or radial origin of this arch.

European Reference Network for Rare Vascular Diseases (VASCERN): When and how to use intravenous bevacizumab in Hereditary Haemorrhagic Telangiectasia (HHT)?

Hereditary haemorrhagic telangiectasia (HHT) is a rare vascular multisystemic disease that leads to epistaxis, anaemia due to blood loss, and arteriovenous malformations (AVMs) in organs such as the lungs, liver and brain. HHT prevalence is estimated at 1/6000, i.e. around 85,000 European citizens, and is served by the European Reference Network for Rare Multisystemic Vascular Diseases (VASCERN). HHT treatments depend on clinical manifestations, and span multiple different medical, surgical and interventional disciplines. Separate to local treatments in the nose, in severe settings, intravenous bevacizumab has been proposed as treatment option, and the purpose of the current article is to assess the use of intravenous bevacizumab in patients with HHT in 2022 according to available data.

Risk Factors for Complications after J Medial Thighplasty following Massive Weight Loss: A Multivariate Analysis of 94 Consecutive Patients.

BACKGROUND: Bariatric surgery has increased the number of patients requiring medial thighplasty after massive weight loss. However, despite the various complications, the procedure improves quality of life. The authors report postoperative complications of vertical J-shaped medial thigh lift in a series of patients and identify preoperative risk factors. METHODS: For almost 5 years, the details of all J medial thighplasties performed by a single surgeon were recorded; detailed medical records were also available. Complications can be major (e.g., need for early surgical revision or readmission) or minor (delayed wound healing). RESULTS: During the study period, 94 patients were treated and only minor complications were recorded (42.5 percent). On multivariate analysis, older age (OR, 1.05; 95 percent CI, 1.01 to 1.10) and a body mass index greater than or equal to 30 kg/m2 (OR, 2.82; 95 percent CI, 1.10 to 7.22) were independent risk factors for postoperative complications. CONCLUSIONS: As with other postbariatric operations, medial thighplasty is associated with significant morbidity, but the risk thereof can be easily established and managed. Specific algorithms for determining the risk of postoperative complications based on age and body mass index are needed to guide preoperative discussions with patients and perform patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Ambulatory hand emergency: 2 years-experience in an public university hospital center.

Hand emergencies represent the most frequent traumatic injuries and outpatient surgery is still improving. It will achieve 70% of total surgeries by 2022. Our hand trauma center has been able to set up an emergency day surgery department in a university hospital center. With this article, we would like to report the ambula- tory care management and practice for hand emer- gencies in our university hospital center over 2 years. 892 patients suffering from hand traumas and managed in our day surgery department, were retro-spectively reviewed between January 2016 and December 2017. Patients' demographic data, anesthe- tic data, trauma's circumstances, medical care and surgical outcomes have been disclosed. A descriptive analysis and a statistical assessment was realized. Cut injury was the most recorded case, followed by impactions. Tendon injuries were the most frequent (32%), followed by fractures (26%), and exposed joints (18%). 13% of injuries were nil findings. Average patient care delay was 1.16 days. Mean of hospitalization was 7.5 hours. 16/892 patients needing intravenous antibiotics required hospitalization. 41 complications including 27 secondary surgeries were reported. Hospital facilities are forced to reassess their entire procedures to achieve efficiency and improvement for healthcare. Progress in outpatient surgery permits emergency management in hand surgery, improving patient cares both medically and economically.

Medial Thighplasty Improves Patient's Quality of Life After Massive Weight Loss: a Prospective Multicentric Study.

BACKGROUND: The aim of this study was to assess the impact of medial thighplasty following massive weight loss on the quality of life of patients and on their sexual life. METHODS: We performed a multicentric, prospective study on the quality of life after massive weight loss using the Short-Form 36 questionnaire, the Female Sexual Function Index questionnaire, and the Moorehead-Ardelt Quality of life questionnaire. Forty-nine patients who underwent medial thighplasty were included in three centers and evaluation was made pre- and post-operatively. RESULTS: The mean age of the patients was 44 ± 12.5 years. The average pre-medial thighplasty body mass index was 27 ± 3.8 kg/m2. All the categories of the SF36 questionnaire scored higher after surgery apart from "health change" but only the "role limitations due to emotional problems" category was significantly improved (p = 0.0081). Similarly, the Moorehead-Ardelt questionnaire showed a positive impact of the surgery on the quality of life in general (mean total score 1.04 ± 1.37) and on self-esteem, physical activity, social relationships, and work performance. Interestingly, sexual activity was not improved by the surgery and this result is in line with the FSFI, which showed no effect of medial thighplasty on sexual life. CONCLUSIONS: Medial thighplasty improves the quality of life of patients after massive weight loss but does not seem to modify the sexual quality of life. These results clearly indicate that this surgery should be widely offered to patients seeking reconstruction of massive weight sequelae.

Flap Venous Congestion and Salvage Techniques: A Systematic Literature Review.

Venous congestion is a frequent problem in flap surgery. Other than surgical revision, there are a multitude of procedures in the literature to tackle this problem, but their effectiveness is not clear. Through a systematic review, we aimed to identify and evaluate the different interventions available for managing flap venous congestion. METHODS: The MEDLINE, PubMed central, Embase, and Cochrane databases were searched. The study selection process was adapted from the PRISMA statement. All English and French original articles describing or comparing a method for managing flap venous congestion were included. For each article, a level of evidence was assigned, as defined by the Oxford Centre for Evidence-based Medicine. Lastly, we specifically analyzed the effectiveness of postoperative non-surgical methods. No formal analysis was performed. RESULTS: Through literature searches carried out in various databases, we identified 224 articles. Finally, 72 articles were included. The majority of these studies had a low-level evidence. A total of 17 different methods (7 pre- and intraoperative, and 10 postoperative) were found. Concerning non-surgical methods, the most represented were leeches, local subcutaneous injection of heparin with scarification, venocutaneous catheterization, negative pressure therapy, and hyperbaric oxygen therapy. CONCLUSIONS: Risks of venous congestion of flaps must always be present in a surgeon's mind, at every stage of flap surgery. Apart from studies on the use of leeches, which have a significant follow-up and large enough patient numbers to support their efficacy, the low-level evidence associated with studies of other methods of venous congestion management does not allow us to draw a scientifically valid conclusion about their effectiveness.

Lipo-Bodylift Reconstruction Following Massive Weight Loss: Our Experience with 100 Consecutive Cases.

BACKGROUND: We report our experience using the Lipo-Bodylift technique for circumferential lower trunk reconstruction following massive weight loss. METHODS: The procedure combines extensive circular liposuction with circular skin resection immediately under the dermis. We classify lower trunk deformities using three parameters: (1) excess skin (in the horizontal direction, or both horizontally and vertically); (2) the body mass index (BMI); and, (3) skin quality (hyperlaxity or a normal tone). All patients can be divided into four groups, of whom groups I and II are the best candidates for the Lipo-Bodylift procedure. We also describe our perioperative management and patient outcomes, with a focus on postoperative complications. RESULTS: Between January 2015 and January 2020, 100 patients underwent Lipo-Bodylift treatment. The median patient age was 41 years. The median preoperative BMI was 26.3 kg/m2. The median drainage duration and hospital stay were both 3 days. Of all patients, 30% experienced at least one complication, 2% of which were major. Of the minor complications, 27 patients evidenced wound dehiscence. Only (positive) smoking status was significantly associated with postoperative complications (p < 0.001). CONCLUSION: We developed the Lipo-Bodylift technique after analyzing changes in the skin and subcutaneous fat after massive weight loss. The technique completes the arsenal of body contouring techniques, appears to be less invasive than the undermining that is usually performed during circumferential reconstruction of the lower trunk, and is associated with a lower rate of major complications. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Dorsal Dupuytren's disease: a systematic review of published cases and treatment options.

Dorsal lesions in Dupuytren's disease are rare and data concerning their epidemiology and management are sparse. We conducted a systematic review to summarize reported cases of dorsal Dupuytren's disease. Pubmed, Cochrane, and Embase databases were searched from 1893 to 2018, and 17 articles were selected (525 patients). The male to female ratio was 3.8:1. The dorsal disease was bilateral in 225 patients (50%). The index was the most commonly affected finger (48 patients). The proximal interphalangeal joint was the most commonly affected (484 cases). The most frequently reported lesions were knuckle pads (503 patients), dorsal nodules between interphalangeal joints (14 patients), boutonnière deformities (12 patients), and swan-neck deformities (2 patients). Nearly half of the included patients were treated surgically. Postoperative functional result depended on the treated lesion. Most of the included studies had a low level of evidence. Higher-quality studies are necessary to confirm our findings.

The flip-flap puzzle flap: Another recycling option.

Post-traumatic soft tissue defects sometimes require sequential flap coverage to achieve complete healing. In the era of propeller flaps, which were developed to reduce donor site morbidity, Feng et al. introduced the concept of the free-style puzzle flap, in which a previously harvested flap becomes its own donor site by recycling the perforator. However, when a perforator cannot be found with a Doppler device, we suggest performing a new type of flap, the flip-flap puzzle flap, which combines two concepts: the free-style puzzle flap and the flip-flap flap described by Voche et al. in the 1990s. We present the cases of three patients who achieved complete healing through this procedure.

Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: an updating review.

INTRODUCTION: The elbow joint is particularly exposed to soft tissue injuries associated with fractures and dislocations. Different coverage options within the past decades for recovering loss of soft tissue defects around the elbow region have been proposed based on anatomical research. Our aim was to make an updated focus on the anatomical basis of different techniques of coverage of loss of tissues around the elbow. MATERIALS AND METHODS: The main procedures of flaps were defined: local random, axial fasciocutaneous, local muscle pedicle, propeller and free microvascular flaps. A systematic literature review on anatomical basis on these different flaps options was conducted searching on PubMed databases and the selection process was undergone according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline. Inclusion criteria were: review and original articles, including anatomical basis of the procedures, in English and French languages. RESULTS: The final analysis included 37 relevant articles out of 1499 published references. 640 flaps were referenced, for covering 302 elbows. Local random flaps provide a good quality skin for small tissue defects in posterior elbow and periolecranon area, and depend on dermal and subdermal blood supply. Axial fasciocutaneous flaps have well-defined blood supplies and are designed as peninsular, island, or microvascular free flaps, as the radial forearm, lateral arm, ulnar artery, antecubital fasciocutaneous, and posterior interosseous flaps. Muscular flaps have advantages as strength, capacity to contrast local infection and to avoid empty spaces, and can be used as pedicle or as free transfers. Propeller flaps can be rotated up to 180° around an axis corresponding to the perforator vessel and do not require the sacrifice of a major artery or functional muscle. The concept of perforasome is evoked. Free microsurgical transfers can be proposed to cover any defect around the elbow. DISCUSSION AND CONCLUSION: The anatomical basis of the flap's harvesting and the possibilities of elbow coverage are discussed through the selected articles. The different indications according to the areas of soft tissues defects are considered.

Liver involvement in hereditary hemorrhagic telangiectasia.

Liver vascular malformations (VMs) in hereditary hemorrhagic telangiectasia (HHT) are typically diffuse and can evolve from small telangiectasias to large arteriovenous malformations, with various stages of severity. Doppler US is the ideal first-line investigation for the assessment of liver VMs in HHT due to its safety, tolerability, low costs, and accuracy for the detection of liver VMs. The caliber, course, and flow characteristics in the hepatic artery, portal vein, and hepatic vein as determined by Doppler US, together with parenchymal abnormalities, support the diagnosis of liver VMs in HHT and their severity staging. When Doppler US expertise is lacking or an assessment of HHT patients with symptoms/signs suggestive of complicated liver VMs is required, particularly if OLT is considered, multiphase CT or MRI is suitable to investigate symptomatic liver VMs. Liver biopsy is neither necessary for the diagnosis of hepatic VMs related to HHT nor should be considered in HHT patients with liver mass/es suggestive of focal nodular hyperplasia.