The two-stage free flap strategy: An alternative to reconstruct major oncological surgical defects with noble organ exposure.

BACKGROUND: To minimize the risk of viscera exposure for parietal or calverial reconstruction after tumor removal, we used the two-stage free flap strategy. The flap was transferred a few days before tumor resection and left in a standby position until the second stage. PATIENTS AND METHOD: We conducted a retrospective monocentric study. All patients who underwent reconstruction with the two-stage free flap strategy after tumor resection since 2000 were included. RESULTS: We performed 14 two-stage flaps (8 for calvaria, 3 for abdomen, and 3 for thorax) on 12 patients. The average skin paddle surface was 318 cm2. The mean operative time was 274min for the first stage and 172min for the second stage. The average time between the two stages was 8.8 days (2 to 24 days). One flap necrosis, one venous thrombosis, and one hematoma were observed after the first stage. Partial skin paddle necrosis (2 flaps) and infections (3 flaps) occurred after the second stage. The mean follow-up was 20 months (6 to 61 months), and two patients had tumor recurrence. CONCLUSIONS: The two-stage free flap strategy is another option for major oncological reconstructions, to be safe and reliable some rules must be followed. The flap must contain a large skin paddle to ensure flap autonomization and to allow for complete tight plication of the flap between the two stages, which limits germ colonization. A short delay between the two stages (<12 days) decreases the risk of infection. The presence of a plastic surgeon during the second stage decreases the risk of pedicle trauma.

Arm reconstruction.

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

[Mycetoma of the foot: a case report]. / Mycétome actino-mycosique du pied, à propos d'un cas.

Mycetoma is a chronic inflammatory cutaneous and subcutaneous pathology caused by either a fongic (eumycetoma) or bacterial (actinomycetoma) infection, which lead to a granulomatous tumefaction with multiple sinuses. When localized in the foot this infection is named "Madura foot". This infection is endemic to tropical and subtropical regions and rarely occurs in western countries. A historical case in Europe of a foot mycetoma evolving since 20 years without any treatment is presented. A histopathologic diagnosis of actinomycetoma has been done in 1987. The patient presented a severe Staphylococcus aureus chronic osteitis leading to a trans-tibial amputation. This case allows to present this infection which, even if rarely presented in France, can be meet especially among a migrant's population.

[Superficial ulnar artery while harvesting a radial forearm flap]. / Artère ulnaire superficielle, découverte fortuite lors du prélèvement d'un lambeau antébrachial radial.

Forearm vascular anatomical variations are common and may have complications during flaps harvesting. This article describes the presence of an ulnar superficial artery, revealed while harvesting a radial forearm flap. The prevalence of this anatomical variation is between 0.7 and 9.4%. It may have important consequences while covering loss of substance with a radial forearm flap. Unknown, there is a risk of vascular injury which may lead to distal ischemia of the upper limb. Preoperative diagnosis can anticipate this risk and harvest a fascio-cutaneous flap centered on a perforator of this artery.

[The persistent sciatic artery aneurysm. A rare and painful buttock mass]. / Anévrisme de l'artère sciatique persistante. Une cause rare de masse fessière douloureuse.

The persistent sciatic artery is a rare cause of painful buttock mass with L5-S1 radicular signs. A 56-year-old man presents a right painful buttock mass with L5-S1 radicular symptoms for 3 years. The surgical exploration found a pulsatile vascular mass like a persistent sciatic artery aneurysm. This vascular pathology is a misunderstood embryogenesis anomaly. The treatment aims to avoid serious complications. This pathology must be known from plastic surgeon.

[Botulinum toxin type A contribution in the treatment of Raynaud's phenomenon due to systemic sclerosis]. / Intérêt de la toxine botulinique de type A dans le traitement des syndromes de Raynaud sévères secondaires à la sclérodermie systémique.

AIMS: Raynaud's phenomenon is a vasospastic disorder of the extremities that can lead, in the hands, to pain, disability, ischemic ulcers and digital chronic ischemia. Medical and surgical current treatments are not fully effective while causing side effects. Recent studies have emphasized the value of botulinum toxin type A (BTX A) in the management of primary Raynaud's phenomenon. The originality of Raynaud's syndrome secondary to systemic sclerosis is to combine both arterial vasospasm and sclerosis of the arterial wall, what is supposed to reduce BTX A effects. The purpose of this work is to evaluate BTX A efficiency in patients with Raynaud's phenomenon secondary to systemic sclerosis. PATIENTS AND METHOD: We performed a prospective study for 12 months. Patients with severe Raynaud's phenomenon due to systemic sclerosis were injected with BTX A in the two hands. Evolution of ischemic ulcers, QuickDASH Score, O2 partial pressure, pain were measured before and 30 days after injection. RESULTS: We treated 18 patients. Thirty days after injection, we noticed a complete healing of ulcers, QuickDASH Score was improved from 39.4 to 20, as the O2 partial pressure from 16 to 42 mmHg and the pain from VNS from 6/10 to 2/10. CONCLUSION: BTX A appears to improve significantly Raynaud's phenomenon symptomatology in patients with systemic sclerosis despite the component of arterial sclerosis.

[Management of upper obstetrical brachial plexus palsy. Long-term results of non-operative treatment in 22 children]. / Traitement conservateur des paralysies obstétricales hautes du plexus brachial. Résultats à long terme chez 22 enfants.

INTRODUCTION: Treatment of obstetrical brachial plexus palsy (OBPP) is always debated, especially for upper plexus palsy. Some authors perform early surgical treatment in case of absence of biceps contraction at the age of 3 months. Others prefer to wait until the age of 6 months before considering a surgical procedure when no suspicion of root avulsion is found. We think that a conservative approach with intensive rehabilitation program can obtain good functional outcome for patients who will recover biceps function spontaneously between 3 and 6 months, and that it is not necessary to perform surgery at 3 months. To argue our choice, we have compared the long-term outcome of two groups of children with upper OBPP conservatively treated regarding the age of biceps recovery (before or after 3 months). PATIENTS AND METHODS: Twenty-two patients with non operated upper roots birth palsy, followed in Timone's Hospital of Marseille by a multidisciplinary team, have recovered a biceps contraction between 1 and 8 months and were retrospectively included in this study. All children underwent an intensive rehabilitation program since birth, performed by a specialized physiotherapist. Patients were reviewed, and their shoulder function was assessed using Mallet score. The score was analysed regarding the age of biceps recovery. RESULTS: The mean follow up was 8.2 years. Nine children recovered a biceps contraction at 3 months of age or before; the mean global Mallet score was 4.11. Thirteen children recovered a biceps contraction after 3 months of age (between 3 and 8 months); the mean global Mallet score was 3.92. The difference was not statistically significant. CONCLUSION: This study shows that global shoulder function is comparable for two groups. The children who did not recover a biceps contraction at 3 months of age had a global shoulder function as good as the one who recovered biceps function earlier. We think our intensive rehabilitation program allowed us to avoid a useless early surgery. Surgical plexus treatment was indicated for children who did not have biceps contraction after 6 months of age.

Illusory movements prevent cortical disruption caused by immobilization.

Enforced limb disuse strongly disrupts the cortical networks that are involved in sensorimotor activities. This disruption causes a cortical reorganization that may be functionally maladaptive. In this study, we used functional magnetic resonance imaging (fMRI) to investigate whether it is possible to prevent this reorganization by compensating for the lack of actual kinesthetic perception with illusory movements induced by "neuromimetic" proprio-tactile feedback that is artificially delivered during immobilization. Sixteen healthy volunteers were equipped for five days with full-hand ortheses that prevented them from performing finger and hand movements but allowed for kinesthetic and tactile sensations. Eight participants received a twice-daily proprio-tactile treatment consisting of the perception of kinesthetic sensations resembling those felt during actual movements generated by miniature vibrators set in the ortheses at the finger and wrist levels. Eight untreated participants received no stimulation. The effects of hand immobilization and treatment were assessed by fMRI during a calibrated voluntary hand movement task and hand tactile stimulation before cast placement and immediately after cast removal. We found that the sensorimotor network was preserved in subjects who underwent this treatment during hand immobilization, while the sensorimotor network of untreated subjects was significantly altered. These findings suggest that sensory feedback and associated movement perception may counteract disuse-induced cortical plastic changes through recruitment of a large part of the cortical network used for actual performed movement. The possibility of guiding cortical plasticity with proprioceptive augmented feedback is potentially relevant for rehabilitation efforts.

[Use of Extensor digitorum brevis flap in routine reconstructive surgery of lower limbs. Report of more than 50 cases]. / Utilisation du lambeau Extensor digitorum brevis en pratique courante de la chirurgie reconstructrice des membres inférieurs. Une expérience de plus de 50 cas.

The authors report their experience about more than 50 patients with soft tissue defects in the area of the lower leg, of the ankle and of the dorsal aspect of the foot and toes, managed with the Extensor digitorum brevis flap. We have most often performed it with a proximal pedicle. Healing was obtained for all case. Infections of malleola have been treated thank to the better delivery of antibiotics. The donor site shows often delayed healing, but in one case, the harvestment area has presented a complete necrosis, which healed with immobilisation of the ankle with external fixator and dressings. At last, we insist on the fast learning of the procedure and the aim to use it in humanitary mission.

[Flaps in lower limb reconstruction: a 10-year retrospective review of 157 pedicled flaps]. / Cent cinquante-sept lambeaux pédiculés utilisés dans la reconstruction des membres inférieurs : étude rétrospective sur dix ans.

BACKGROUND: The aim of this study was to review and present our experience with pedicled flap reconstruction of lower limb defects with particular reference to choice of flap, complications and pre-existing health disorders. METHODS: A retrospective review of lower limb reconstructions by pedicled flaps was carried out by the plastic and reconstructive surgery unit at Marseille's hospitals from January 1st, 1997 to December 31st, 2007. This study evaluated patients satisfaction and complications rate. RESULTS: During 10 years, 152 patients had 157 local flap reconstructions of lower limb defects. General patients satisfaction was 94% with 80% good or very good results and 20% of medium results. There were 16 immediate complications with three total necrosis, four partial necrosis, six hematoma, and three infections. There were nine late complications including wound dehiscence and graft instability. There were 11 functional sequels and 40 aesthetic sequels secondary to flaps. CONCLUSIONS: The current study presented our experience with locoregional flap reconstruction of lower limb defects. Lower limb reconstruction used a lot of locoregional flaps which had their own advantages and disadvantages. Their indication depended on the fiability and quality of the donor site.

[Skin diversity: histological study of 140 skin residues, adapted to plastic surgery]. / La diversité de la peau : étude histologique de 140 résidus cutanés, adaptée à la chirurgie plastique.

UNLABELLED: We present in this original article a histological study of surgical skin residues. AIM OF THE STUDY: This study was realized in order to show, in objective way, skin diversity according to sex, age and area, and to illustrate some current surgical practices of our speciality. PATIENTS AND METHOD: Two years along, 141 patients was selected, 69 Men and 72 women. Fifty-four biopsies were realized on the upper extremity, 34 on the trunk and 53 on legs and arms. The histological study was based on two steps; the first one was a classic quantitative study, with measurement of each cutaneous layer, and objective evaluation of elastic density in superficial dermis. The second one was a descriptive histological analysis of each cutaneous area. RESULTS: The results coming from the quantitative analysis, allowed us to establish a classification of all the areas, according to each parameter. These results are globally compliant to the literature. The results of the descriptive analysis, lead us to conclude that it exists a lot of different skins with regional specificities. Then the crossover of the two analyses allowed us to define good practices tricks, in order to choose the best reconstruction technique for each area. CONCLUSION: This study is just a rough draft of a dynamic skin cartography adapted to our surgery. But it allowed us to confirm our basic premise: it doesn't exist only one skin but many skins.

Restoration of the first dorsal interosseous muscle.

Motor dysfunction of the 1st dorsal interosseous (DIO) muscle is typically observed in low and high ulnar nerve palsy. This causes weak thumb-index pinch, which can be disabling for the patient. Various reconstructive techniques have been described; however, the choice often depends on the surgeon's experience, the presence of associated neurovascular and musculotendinous injuries, as well as the requirements of the palliative surgery schedule. Nerve transfers can be proposed when patients present early in the course of the disease. Tendon transfers are often a last resort when late presentation occurs. Tendon transfers must follow general principles: the insertion is made on the 1st DIO terminal tendon; the tension must be adjusted in a neutral position to avoid excessive tension, and immobilization is maintained for 4 weeks. Although many transfers are possible, the extensor pollicis brevis transfer is our preferred option. This donor does not require additional tendon grafting, has a direct line of pull close to that of the 1st DIO and is not often used for other reconstructive purposes.

[Treatment of hand ischemia with arterialization of the venous system of the hand: report of three cases]. / Traitement de la main en ischémie chronique par artérialisation du système veineux superficiel : à propos de trois cas.

INTRODUCTION: Hand ischemia is a rare phenomenom of various etiologies among which can be found Raynaud's phenomenon and autoimmune arteritis. The limitations of symptomatic medical treatment and the frequent plurisegmental and distal affection of arteries make the management of chronic hand ischemia difficult. The arterialization of the superficial venous system, which consists in redirecting the arterial flow to the fingertip through the dorsal venous system, could be an interesting alternative to the disappointing results of medical therapy and surgical sympathectomy. The authors present here the preliminary results of this technique. PATIENTS AND METHOD: We carried out a retrospective study analyzing the indications, the operative technique and results of three hands operated on two patients. An arteriography was carried out on each patient prior to perform the arterialization of the superficial venous system, in order to make sure that none of the patients was eligible for a technique of direct re-vascularization. RESULTS: Postoperatively, for each patient, the following points were evaluated: pain reduction, ulcer healing, and then we tried to obtain a more objective assessment by performing angio-MRI. CONCLUSION: This last resort technique in management of critical ischemia of the fingers led to an immediate and lasting improvement of symptoms in all the patients treated. This technique seems reliable and reproducible in selected cases aiming to re-vascularize hands that have reached the stage of critical ischemia. This treatment option should be known by hand surgeons, and distributed to internists who usually manage these patients.

Unusual rupture of the middle finger flexor digitorum superficialis tendon in a climber: Biomechanical analysis.

Sport climbing is increasingly popular and consultations by climbers in hand surgery departments are on the increase. The pathologies related to this sport concern essentially the pulley system, tendons being rarely affected. We report the case of a male climber who presented an atypical rupture of the flexor superficialis tendon in his left middle finger sustained when using an atypical climbing grip technique: the "hook grip". This consists in extension of the metacarpophalangeal joints and maximal flexion of the proximal interphalangeal joints with force exerted only on middle phalanx of the middle finger. A biomechanical analysis using finger musculoskeletal modeling was performed to compare the hook grip to other grips, and the patient's recovery performance was assessed. Adapted functional treatment with physiotherapy seems to have been a good option for the treatment of this atypical lesion since the patient recovered normal use of his finger in daily life. He recovered maximal force in climbing holds. The biomechanical analysis confirmed that the atypical "hook grip" was likely at the origin of the rupture, since flexor digitorum superficialis tendon force for this grip is greater than in other climbing grip techniques. The "hook grip" seems to be dangerous and should be used cautiously by climbers to prevent similar pathology. Additionally, the patient should henceforth be careful when climbing, since the biomechanical model showed that the remaining flexor digitorum profundus tendon was overused.

Revision of trapeziectomy failures in thumb base osteoarthritis: retrospective analysis of ten cases and review of the literature.

Controversy persists around trapeziectomy as standard of care in thumb base osteoarthritis. The difficulty of management of failure requires the utmost caution in choice of the initial technique. We here report a retrospective series of 10 revision procedures following trapeziectomy, supported by a review of literature. The main cause of revision was collapse of the thumb column resulting in arthrogenic contact of the first metacarpal with the scaphoid. At a mean 73.3 months' follow-up, 5 patients had to undergo additional surgery. Mean VAS pain score was 2.9; 5 patients were pain-free. Strength was more severely impaired than joint motion, resulting in disappointing functional results. The present outcomes are consistent with the literature, which mostly comprises heterogeneous series, making it impossible draw conclusions to guide practice. The most common option seems to be to perform a new ligament procedure, with or without tendon or pyrocarbon interposition, and was the one that provided the only good result in the present series. Other techniques (composite graft, non-autogenic interposition, scaphometacarpal prosthesis) seem promising, and deserve large-scale evaluation. Thus, the gold-standard status of trapeziectomy should be weighed against the observation of these multi-operated patients in situations of therapeutic impasse. Should indications for first-line trapeziectomy be restricted, especially in patients with a revision risk factor? LEVEL OF EVIDENCE: 4.

Unawareness of HIV Infection Among Men Aged 15-59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015-2019.

BACKGROUND: Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries. METHODS: Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV. RESULTS: A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity. CONCLUSION: Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services.

Outcomes of ulnar shortening osteotomy using a new compression plate.

Ulnar impaction syndrome (UIS) is a frequent cause of ulnar-sided wrist pain. Several open and arthroscopic surgery techniques have been described. Ulnar shortening osteotomy (USO) is often the method of choice. It has the advantage of leveling the distal radioulnar joint extra-articularly while maintaining the integrity of the soft tissues that stabilize the joint. This retrospective study reports the short-term outcomes of 20 patients who underwent surgery between 2013 and 2015. USO was performed with a locked plate and a new compression device (Alians®, Newclip™, Haute Goulaine, France). Preoperative and postoperative ulnar variance were measured on wrist X-rays in neutral pronation-supination. Functional outcomes were evaluated with the QuickDASH score and the pain on VAS (visual analog scale). Postoperative range of motion and grip strength were compared to those of the contralateral wrist. The average follow-up was 16 months (4 to 28 months). Preoperative ulnar variance was positive with an average of 4mm (1-11mm). The average length of the final ulna shortening was 3.5mm (1.5-6mm); the mean time to union was 4 months (3-12 months). The average QuickDASH was 12 and pain had decreased 2.4mm on the VAS. The results achieved with this new compression plate designed specifically for USO are similar to those described in the literature. This kind of device has an easily reproducible technique and can reduce the operative time. LEVEL OF EVIDENCE: IV.

A case of pyoderma gangrenosum in hand surgery.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that can take many clinical forms. Its diagnosis is difficult and often delayed. We report the case of a 36-year-old man with PG complicating a chemical burn of the wrist. This mode of atypical onset delayed the diagnosis and the initiation of appropriate treatment. This was not sufficient since the patient's hand was amputated at his request because of unbearable pain, and failed treatment. Surgeons should be aware of this pathology in cases of rapidly progressing ulcers, especially if aggravated by repeated debridement.

Results of wrist hemiarthroplasty for comminuted distal radius fractures in independent elderly people: A retrospective study on eleven patients.

The comminuted distal radius fractures among elderly people are usually linked to osteoporosis, and repairing them in this context is a therapeutical challenge. Several teams have reported good results of radius resurfacing. The goal of our study was to evaluate the usability of the wrist in a new series of patients after surgery. We performed a monocentric retrospective study on the data of the medical files. All the included patients were older than 65 years and received a wrist hemiarthroplasty according to the criteria that have been established by the in charge medical team. Eleven patients have been included, their average age was 80.4 years old, and the average follow-up was 18.3 months. The average QuickDASH Score was 59 (27-95). The Visual Analogue Scale for pain was in average 3.8/10 and the average mobility was: flexion 36° (12-50), extension 27° (12-50), radial deviation 15° (12-15), ulnar deviation 26° (12-40), pronation-supination range of motion 164° (150-170). The average measured strength was 44% (16-72%) of the strength of the unaffected hand. Our results are rather modest, probably because of insufficient follow-up and very severe fractures. Furthermore, the implant that has been used does not take into account the distal radioulnar joint. Another bound of this treatment is the complexity of surgical revision in case of bad result. So far, hemiarthroplasty cannot be considered as the standard treatment for complex fractures of the distal radius.

Extensor digiti minimi muscular flap: From a clinical case to an anatomical study.

We present a case report of a failed posterior interosseous flap with distal pedicle rescued by an extensor digiti minimi (EDM) island pedicle flap supplied by the posterior interosseous artery (PIOA) in reverse flow to cover a soft tissue defect in the hand of a 25-year-old man. We subsequently performed an anatomical study on 5 cadaver limbs to determine the EDM muscle's vascularization: it was segmental, multiple and came from the PIOA. The rotation arc reached the dorsal side of the metacarpophalangeal (MCP) joints, as well as the distal part of the thumb. The indications selected are the same as those of the distal pedicle flap: defect on dorsal side of the hand and MCP joints, coverage of carpal tunnel, failure of posterior interosseous flap. This study describes a new flap and adds to our understanding of the EDM muscle's vascularization.