Necrotizing fasciitis: A highly fatal infection.

BACKGROUNDS: Necrotizing fasciitis is a severe bacterial infection characterized by involvement of all skin's layers, including the superficial fascia. Diagnosis and treatment must be as quick as possible. Once suspected, extensive surgical debridement is required. METHODS: All necrotizing fasciitis, managed in our hospital in Dijon, during the period from January 2011 to May 2021, were retrospectively analyzed. Demographics characteristics of patients, biological parameters, and type of bacteria were collected. Statistical analysis was performed on the cost of hospitalization, as well as on the death rate between type I and II NF and the speed of management. Student's t-test and Chi2 test were performed with a significant level P<0.05. FINDINGS: A total of 65 patients were included over the period. The mean age was 68.8 years. The average length of stay was 32.4 days, with an average cost of 79,305 €. The main locations were the lower limbs (57%) and the perineum (35%). Cost of hospitalization did not differ between type I and II (P=0.21), unlike mortality rate (P=0.003). Furthermore, the mortality rate according to the speed of management did not vary in our series (P=0.45). CONCLUSION: Necrotizing fasciitis is quickly fatal if left untreated. Early diagnosis, combined with surgical debridement and probabilistic antibiotic therapy are required. Our study shows the impact of necrotizing fasciitis in terms of cost to society and the importance of prevention of certain risk factors. A global management of the patient is necessary to increase the survival rate.

Observational study of a series of basal cell carcinomas: Evaluation of location as a risk factor for recurrence.

Basal cell carcinoma (BCC) is locally aggressive and its prognosis depends on the risk of recurrence. The initial location of the tumor is a key criterion for calculating the risk of recurrence. The aim of this study was to evaluate the sites that appear to be most at risk of recurrence of BCC. All cases of BCC analyzed at the anatomopathology laboratory of the University Hospital of Montpellier for 1 year were retrospectively included. In case of recurrence on the same site, only carcinomas that had previously been completely removed were analyzed. Among 803 BCC, 37 (4.6%) were confirmed as recurrent, including 34 (92%) on the head. The locations statistically at higher risk of recurrence were the temporal and frontal/temporal areas (32.4%), the medial canthus and lower eyelid area (18.9%), the ala and tip of the nose (16.2%), and the ears (8.1%). The frontal/temporal regions appear to be an area of major interest in this series. A high risk of recurrence was confirmed in the periorificial locations for the ear, the nose, and periorbital area, but not for the perioral area. In addition, the entire nose did not appear to be at risk, only the tip and the ala.

The infragluteal fold: An appraisal by MRI combined with an anatomic study.

PURPOSE: The gluteal region is a key element of beauty balance and sexual appearance. However, there is no clear anatomical description of the infragluteal fold, nor any classification exists allowing standardizing treatment of this area in case of jeopardisation. The purpose of this study was to perform an anatomical description of the infragluteal fold (IGF) matching radiological and anatomical findings in describing specifically raise of the fibrous component at the bone level. METHODS: Six volunteers (three males and three females) underwent an MRI scan (Siemens Aera® 1.5 T) of the pelvic region. T1 Vibe Morpho T2, Sag Space 3D, and Millimetric slices were performed in order to obtain a more detailed selection of the gluteal landmark. Trabecular connective tissue of the region was analyzed using Horos® ROI (region of interest) segmentation function. Four fresh cadavers (two males, two females, accounting for 8 hemipelvis) were dissected in order to compare the radiological findings. RESULTS: The infragluteal fold is a connectival fibrous band extending from the ramus of the ischium (but not involving the ischial tuberosity, for a length of 21 mm ± 2 and 21 mm ± 3), the apex of the sacrum (for a length of 13 ± 2 and 11 mm ± 2), and the coccyx (for a length of 19 mm ± 2 and 20 mm ± 2, all measures referring to volunteers and cadavers, respectively) reaching superficially the dermis of the medial one-third of the cutaneous fold. No significant difference was found between volunteer and cadaver group in MRI measurement of bony origins, or between MRI and cadaveric dissection measurements. CONCLUSION: Knowledge of this structure will define novel surgical techniques in infragluteal fold restoration.

Fluorescent indocyanine green angiography: Preliminary results in microsurgery monitoring.

INTRODUCTION: Pedicled flaps and free-tissue transfer flaps are used routinely to reconstruct hard and soft tissue defects in head and neck, limb, hand, thoracic and abdominopelvic reconstructive surgery. But failure remains a constant concern, particularly in free-tissue transfers. Usually failure is due to blood supply compromise. Indocyanine green (ICG), a fluorescent dye is a suitable tracer for vessel perfusion. The objective of this study is to evaluate the fluorescent indocyanine green angiography (FA ICG) in free flaps procedures. MATERIEL AND METHODS: Patients who had microsurgical flap reconstruction were included during the study period in a single center. The FA ICG was used at specific times. Intra-veinous injections of 0.1mg/kg of INFRACYANINE® (concentration 2.5mg/mL) were done intraoperatively. The Fluobeam® device programmed on sensitivity and mapping to interpret the data, was used. These different injections allowed to checked skin paddle perforators vessels, osseous perforators vessels, arterial and venous patency after anastomosis and the cutaneous, muscular and osseous perfusion. RESULTS: A total of 12 patients enrolled were 10 males and 1 female. Their mean age was 54.5 years (range 25-75 years). Of the 12 flaps, 8 were free flaps with 4 fibular flaps (3 for mandibular reconstruction and one for femur reconstruction); 2 radial forearm flaps for maxillary reconstruction; one latissimus free flap for tibia skin coverage and one retroauricular fasciocutaneous free flap for thumb skin coverage. We got to modify specific steps during surgery with 8 patients by using the FA ICG to anticipate potential complications: modifying the draw of the skin paddle, recut of this paddle, modifying the osteotomies, re-doing the anastomosis or modifying the position of the pivot point. DISCUSSION: Evaluation of microvascular flap perfusion is still based on subjective clinical features. Clinical monitoring is observer-dependent and does not allow information sharing, test reproducibility, and consistent postoperative follow-up. The successful of salvage rate is linked to the delay between the onset of ischemia and its clinical assessment. FA ICG could be a reliable method for monitoring free-tissue transfers. This technique is objective, non invasive and facilitate a complex reconstructive procedure to augment is liability. This technique may be used such a pedagogical tool for young practitioners in their first microsurgery procedures.

Interest of studying the saliva metabolome, transcriptome and microbiome in screening for pancreatic cancer.

INTRODUCTION: Pancreatic cancer is a public health problem because its mortality rate is close to its incidence rate. If it were possible to detect this cancer before the onset of symptoms, 5-year survival could reach 75%. Numerous studies have attempted to accelerate the diagnosis to improve survival. Saliva presents interesting characteristics as a fluid for screening and diagnosis. Its many components provide a promising source of constitutive biomarkers with a specific signature of the disease. The aim of this work was to determine the interest of studying the metabolome, the transcriptome and the microbiome of saliva in screening for pancreatic cancer. MATERIALS AND METHODS: A review of the literature was conducted using the PubMed search engine. The last search was conducted in July 2017. RESULTS: Nine references, all original studies, published between 2010 and 2017 were included. DISCUSSION: Different combinations of metabolites, RNA and bacteria were found. Analysis of the saliva transcriptome and metabolome seems to be the most promising avenue. CONCLUSION: The identification of an early salivary signature of pancreatic cancer is still in its infancy and the results obtained here must be confirmed in larger prospective multicentre studies.

Traumatic atlanto-axial rotatory subluxation after surgical correction of prominent ears: Case report and review of the literature.

Corrective surgery of prominent ears may be justified for social or aesthetic reasons during childhood or adulthood. Post-operative complications occur in approximately 0 to 8.4% of cases. This case describes a rare atlanto-axoid rotatory subluxation after bilateral surgical correction of prominent ears under general anesthesia. Orthopedic treatment was done after two months of medical roaming outside of our center. The one-year post-operative clinic consultation and radiological exam were normal. Only the psychological impact of the episode remained. Traumatic atlanto-axial rotatory subluxation is a rare complication but should be considered after post-operative torticollis in order to aid with diagnosis and allow doctors to implement the appropriate course of treatment.

[Recurrent nevus: Case-report about a pagetoid form occurring from a congenital nevus in infancy]. / Une forme pagétoïde de pseudomélanome d'Ackerman secondaire à un naevus congénital dans l'enfance : à propos d'un cas.

INTRODUCTION: Recurrent nevus (RN) is a cutaneous benign tumour with similarities with malignant lesions. Typically, it occurs after a partial resection of commun-acquired nevus. Its incidence varies from 0.3 to 27% according to the studies. We present here a pediatric case of a pagetoid form of a recurrent nevus occurring from a congenital nevus. CASE REPORT: A congenital nevus was removed from a 9-month-old girl. Pathologists concluded to a commun-acquired nevus of complete exeresis. Two other cutaneous lesions appeared and we decided to realise a total removal. Analysis showed a recurrent nevus with some atypical histological features. No recurrence has occurred during the three post-operative of follow-up. DISCUSSION: It is an interesting case because of the occurrence of a RN after the removal of a congenital nevus in a child. Furthermore, it displayed some atypical histological features. Practicians, such as surgeons, dermatologists or pathologists, have to be aware of the risk of misdiagnosis with this lesion, which presents some similarities with SSM melanoma. It would be interesting to determinate some markers to statuate about its benign feature. There is no management recommendation about this lesion but it seems to be necessary to remove it to eliminate a malignant tumour.

Carcinoma cuniculatum of the lip: A case report.

Carcinoma cuniculatum, a very well differentiated sub-type of epidermoid carcinoma, is a rare invasive tumor with a low risk of metastasis. It principally affects the lower limbs, notably the soles of the feet. Facial involvement is exceptional. A case of a patient with carcinoma cuniculatum of the lower lip is presented and diagnostic difficulties of head locations of this tumor, as well as their management are discussed.

Duration of treatment with bisphosphonates at the time of osteonecrosis of the jaw onset in patients with rheumatoid arthritis. Review.

INTRODUCTION: Rheumatoid arthritis (RA) is a frequent and co-morbid condition. One of the main complications is induced osteoporosis. Treatments related to this complication significantly modify oral and implant management. Affected patients represent a population at intermediate risk of osteonecrosis of the jaw (ONJ). The objective was to search the literature for durations of treatment with bisphosphonates at the time of ONJ occurrence in patients with RA in order to obtain an average duration. MATERIALS AND METHODS: A bibliographic search in the PubMed/Medline database was carried out using the following equation "(osteonecrosis and jaw) and rheumatoid arthritis" with no time limitation. The primary study endpoint was the duration of treatment with bisphosphonates (BP) at the time of ONJ onset in patients with RA. RESULTS: Twelve articles accounting for 50 patients were included. Patients had had a median of 46.8 months of treatment with BP before ONJ occurred. Mean, minimum and maximum treatment times were 48.68, 6 and 120 months, respectively. The standard deviation was 27.77 months. DISCUSSION: The median treatment duration in our cohort of patients with RA was less than that reported for osteoporosis. We therefore, recommend that practitioners take additional precautions regarding oral surgery or implant procedures, particularly in patients with RA who have been treated with BP for more than 4 years.

Isolated unilateral temporalis muscle hypertrophy: First case in an 8-year-old boy and review.

INTRODUCTION: Isolated unilateral temporalis muscle hypertrophy (IUTMH) was first described in 1990 and few cases have been published since then. This disease occurs mainly in adults. There is no clear etiology of IUTMH, but bruxism is one of the risk factors. Only two cases have been described before the age of 20 years. To our knowledge, no cases have been described in persons younger than 15 years old. We report the first case of IUTMH in an 8-year-old and review the literature. MATERIAL AND METHODS: This section is separated into 3 parts: (1) search for and description of clinical cases of IUTMH in our department; (2) literature search to find similar cases; (3) data analysis of all cases found. RESULTS: Ten patients, including our case, were found over a period of 23 years: five females and five males with a mean age of 32.8 years. One patient was 15 years old. Time between onset and diagnosis was 16.7 months. Half of the patients reported pain and three had experienced bruxism. Most of the patients had non-surgical treatment. One patient evolved favorably with no treatment. One recurrence occurred 10 years later. DISCUSSION: IUTMH can occur in childhood in a high-stress environment. Diagnosis is based on the history and clinical and imaging findings. Biopsy helps to confirm the diagnosis, but electromyograms and neurological tests contribute little. Bruxism should be taken into account. The treatment with the least inconvenience must be given.

Classification proposed of malignant intraosseous odontogenic tumors (MIOT).

Malignant intraosseous odontogenic tumors (MIOT) of the jaws are very rare. The diagnosis is difficult. Clinical, paraclinical and histological diagnostic criteria, strict are well established. But the International Union Against Cancer (UICC) does not provide TNM classification that will allow harmonization of the treatment. Indeed, despite their location, they cannot be classified as primary tumors of the oral cavity because of their localization in the bone marrow, making them systematically classified as T4. We propose a classification taking into account the clinical and radiological data.

[Custom-made implant for complex facial reconstruction: A case of total replacement of temporo-mandibular joint, zygomatic arch and malar bone]. / Reconstruction faciale complexe sur mesure : un cas de remplacement total de l'articulation temporo-mandibulaire, de l'arcade zygomatique et du zygoma.

INTRODUCTION: Total prosthetic replacement of the temporo-mandibular joint (TMJ) has become a common procedure, but it is usually limited to the TMJ itself. We report about one case of complex prosthetic joint reconstruction extending to the neighbouring bony structures. CASE: A 57-year-old patient, operated several times for a cranio-facial fibrous dysplasia, presented with a recurring TMJ ankylosis and a complexe latero-facial bone loss on the right side. We performed a reconstruction procedure including the TMJ, the zygomatic arch and the malar bone by mean of custom made composite prosthesis (chrome-cobalt-molybdenum-titanium and polyethylene). Five years postoperatively, mouth opening, nutrition, pain and oral hygiene were significantly improved. DISCUSSION: Nowadays technical possibilities allow for complex facial alloplastic reconstructions with good medium term results.

[Total temporomandibular joint prostheses]. / Prothèses totales des articulations temporomandibulaires.

The temporomandibular joint (TMJ) is probably the most complex human joint. As in all joints, its prosthetic replacement may be indicated in selected cases. Significant advances have been made in the design of TMJ prostheses during the last three decades and the indications have been clarified. The aim of our work was to make an update on the current total TMJ total joint replacement. Indications, contraindications, prosthetic components, advantages, disadvantages, reasons for failure or reoperation, virtual planning and surgical protocol have been exposed.

[Traumatic superior orbital fissure syndrome: Update]. / Syndrome de la fissure orbitaire supérieure post-traumatique : mise au point.

The traumatic superior orbital fissure syndrome is an uncommon complication of craniomaxillofacial trauma. The diagnosis is clinical and associates ophtalmoplegia (constantly at initial clinical examination), ptosis and anaesthesia of the forehead. Young men victim of road traffic accidents are most often affected. CT-scan usually shows facial and/or craniofacial fractures more or less spreading towards the superior orbital fissure. The absence of fracture seen at the X-rays does not eliminate the diagnosis. Initial management should be multidisciplinary (maxillofacial surgeons, ophthalmologists and neurosurgeons) and conducted early if possible. It combines high-dose corticosteroids and decompression surgery if necessary. Abstention may be indicated in cases of delayed diagnosis with spontaneous improvement. Symptoms improve early but follow-up should be extended over several months given the recovery time.

[Stevens-Johnson syndrome and toxic epidermal necrolysis (SJSTEN) related to insecticide: Second case in the literature and potential implications]. / Le syndrome de Stevens-Johnson-toxic epidermal necrolysis (SJSTEN) lié à un insecticide : second cas dans la littérature et implications potentielles.

INTRODUCTION: Stevens-Johnson syndrome and toxic epidermal necrolysis (SJSTEN) is a rare acute drug reaction characterized by the brutal destruction of the superficial layer of the skin and mucosa. SJSTEN is favoured by some drugs (90 % of cases) and genetic factors. It occurs at any age in both sexes. The pathophysiology is not completely understood. To our knowledge, only one case linked to an insecticide has been described. We present the second case involving a combination of lambdacyhalothrin and thiamethoxam. OBSERVATION: A 34-year-old farmer was admitted in emergency for a severe allergic reaction occurring few days after the use of an insecticide to treat his field with no particular precaution. The disease progression was swift: deterioration of general condition, generalized itching, blisters, bubbles, hyperthermia, tachycardia, significant oral pain and oral lesions and dysphagia. Hands, feet were concerned and external genitalia was responsible for burning urination. Oral lesions have rapidly evolved from edema to infected lesions. The diagnosis of SJSTEN was confirmed by histopathology. After complete assessment and adequate treatment, the patient was discharged after 17 days of hospitalization. The etiological research concluded to a probable poisoning by lambdacyhalothrin and thiamethoxam. DISCUSSION: This is the second published case of a SJSTEN linked to an insecticide combining lambdacyhalothrin and thiamethoxam. Manufacturers, users, regulators and physicians should take these data into account.

Functional and radiographic evaluation of the treatment of traumatic bone loss of the hand using the Masquelet technique.

This study was a retrospective evaluation of 18 patients with traumatic bone loss affecting the fingers, hand and wrist who were treated using the induced-membrane technique. Sixteen men and two women, mean age 54years (27-74) presented a hand injury including bone loss. Sixteen patients were treated on an emergency basis and two following nonunion of their fractures. There were 13 cases of open fracture of the phalanx and 5 cases of metacarpal fractures. These patients were treated with debridement and the injuries were covered when necessary. To address the bone loss, the first step of the induced-membrane technique involved placing a cement spacer (polymethylmethacrylate [PMMA]) without antibiotics in the defect. During the second step, the cement spacer was removed and replaced by autologous cancellous bone graft. The graft was placed within the biological tube left empty after removal of the cement. For each patient, bone union was assessed with radiographs and/or CT scan. Failure was defined as nonunion at 1year. In 16 patients, the fractures had healed after 4months (1.5-12months) on average. Two failures were noted (one nonunion treated using a PIP prosthesis and one case of delayed union). Mobility of the fingers, evaluated using the Total Active Motion (TAM) was 145° (75°-270°). The Kapandji score reached 8 for the thumb. Grip strength reached 21kg/F and pinch strength was 5kg/F; these values were 50% of those in the healthy hand. The induced-membrane technique is simple and can be used to treat traumatic bone loss in an emergency, thus avoiding amputation and limb shortening, while preserving limb function. It provides immediate stability and allows early mobilization.

[Delayed endoscopic reconstruction of the anterior wall of the frontal sinus: Technical note]. / Reconstruction différée de la paroi antérieure du sinus frontal par voie endoscopique: note technique.

INTRODUCTION: Reconstruction of the anterior wall of the frontal sinus usually requires a coronal incision. This extended approach may lead to paresthesia, unsightly scars, bruises and cicatricial alopecia. These complications encouraged several authors to endoscopic management of this kind of fractures. We present a delayed technique of reconstruction of the anterior wall of the frontal sinus by means of endoscopic hydroxyapatite filling. TECHNICAL NOTE: Two incisions were performed behind the hair line. Subperiosteal dissection using a periosteal elevator was performed. A 30° angled endoscope was used to visualize the depression. The latter was filled by Hydroset® (Stryker, USA) as a bone substitute. DISCUSSION: In the absence of contra-indication, the reconstruction of the anterior wall of the frontal sinus by means of endoscopic hydroxyapatite filling has many advantages including uneventful outcome, reduction of the hospital stay and a fast learning curve.

[Pathomimia and plastic surgery, a case report]. / Pathomimie en chirurgie esthétique, à propos d'un cas.

Pathomimia is defined as a dummy pathology self-induced deliberately and is neither associated with mental confusion nor disturbance of consciousness. This article reports a case of pathomimia in plastic surgery. One of our patients had intentionally injected physiological saline solution into her breast implants in order to increase their volume. Implants removal was necessary because of severe local inflammatory signs. Psychiatric assessment revealed body dysmorphic disorder (BDD) developed on an hysterical personality, which explained the self-induced injuries. This nosologic entity must be promptly identified because it's diagnosis remains problematic and a multidisciplinary medical management is essential.