Free flap for lower limb salvage in infectious purpura fulminans.

BACKGROUND: Infectious purpura fulminans is a disabling disease often leading to amputations. Free flaps preserve limb length, covering exposed areas. We examined the efficacy of free flaps for lower limb salvage in infectious purpura fulminans survivors by evaluating surgical management, walking ability and quality of life. METHODS: This single-center, observational, descriptive, retrospective study was conducted in from 2016 to 2019. Adult purpura fulminans survivors who received a free flap for lower limb salvage were included. Patient characteristics and data on surgical management and rehabilitation were collected. Quality of life (SF-36 questionnaire), limb function and walking ability were later evaluated post-surgically. RESULTS: The 6 patients included, mean age 38 years, had all required amputations. Nine free flaps were performed to cover important structures in 7 cases and for stump resurfacing in 2. All flaps were successful. Patients resumed walking at a mean of 204±108 days after the onset of purpura fulminans. Post-surgical evaluation was performed at a mean of 30±9.3 months. Five patients required secondary revision. All were independent for the activities of daily living. Mean physical component score was 37.6±9.4 and mental component score was 44.6±13.2 (minimum 0, maximum 100). CONCLUSIONS: Use of the free flap in patients with infectious purpura fulminans, after multidisciplinary reflection, is an appropriate procedure that preserves limb length. In spite of secondary complications, preservation of limb length enables patients to resume walking, with relatively good independence and quality of life.

[Plastic surgery and fighting: Our experience during Nagorno-Karabakh war in 2020]. / Chirurgie plastique et conflit armé : notre expérience lors du conflit au Haut-Karabakh en 2020.

INTRODUCTION: This work relates the experience of three French surgical missions in the care of the war wounded during the armed conflict in Nagorno Karabakh which took place from September 27 to November 10, 2020. MATERIALS AND METHODS: Three surgical missions were carried out in Armenia between October 2020 and January 2021. Surgeons intervened in different hospitals, at different times of the conflict and on various war wounds. RESULTS: The presence of a plastic surgeon proved to be essential in the care of war wounded, especially in delayed emergency and secondary care. The ortho-plastic treatment offered during these missions has proven to be effective in the reconstruction of limbs. These missions made it possible to introduce the induced membrane technique of Masquelet AC in Armenia. During our visit to the Yerevan burn center, we mentioned the very probable use of white phosphorus as an etiology in several of the cases analyzed. CONCLUSION: We relate the particular experience of civilian surgeons in the context of a modern armed conflict. The presence of a plastic surgeon proved to be indispensable in the care of war wounded and especially in their secondary reconstructions.

The interest of "ortho-plastic" collaboration in management of complex limb injury.

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.

Does arthroscopic assistance improve reduction in distal articular radius fracture? A retrospective comparative study using a blind CT assessment.

INTRODUCTION: The objective of this study was to compare the articular reduction in two groups of patients with a distal articular radius fracture who underwent surgery with versus without arthroscopic assistance. The initial hypothesis of this study is that arthroscopic assistance does not improve reduction in distal articular radius fractures. METHODS: The study was retrospective (1/04/2014-01/04/2017) and included 41 patients: 23 had arthroscopically assisted osteosynthesis, and 18 had not. All patients included had CT before and 3 months after surgery. All radiographic and CT measurements were retrospectively taken by an independent radiologist who did not know which operative technique was performed. Secondary judgement criteria were clinical analysis at 1-year follow-up and tourniquet time. We also reported all soft tissue injuries diagnosed and repaired and postoperative complications. RESULTS: At the third month, articular step was 0.91 ± 1.25 mm (arthroscopy) and 1.41 ± 1.68 mm (no arthroscopy), without statistical difference (p = 0.3756). No difference was found for articular gap between the two groups [arthroscopy (0.55 ± 1.04 mm), (no arthroscopy (0.82 ± 1.54 mm)] (p = 0.8574). Except for the tourniquet time, clinical results at 1-year follow-up were not different. One patient of each group had a scapholunate pinning, and 6 patients of the arthroscopy group had a TFCC 1B injury, which was repaired. CONCLUSION: This study did not demonstrate that arthroscopic assistance improves step and gap reduction of articular distal radius fracture, confirming initial hypothesis and recent literature data. LEVEL OF EVIDENCE: Retrospective, III.

[The Place of Groin, Colson and McGregor Flaps in the Acute Care of Deep Burns to the Hand Dorsum : A Series of 6 Cases In Lille's Burn Centre]. / Place Des Lambeaux Inguinaux Et Des Empochements Dans La Prise En Charge Aiguë Des Brûlures Profondes Du Dorsum De Main: Série De 6 Cas Au Centre De Traitement Des Brûlés De Lille.

The acute management of deep burns to the dorsum of the hand and fingers represents a challenge for the reconstructive surgeon. The exposure of osteo-tendinous structures often requires flap coverage, in a context where loco-regional or free flaps are not always feasible. The aims of reconstruction are to preserve a maximum of digital length, provide supple tissue, obtain protective sensitivity, and achieve a functional hand at 1 year. We report here on a series of 8 deep burns to the dorsum of the hand. Six hands were covered by Colson abdominal flap-graft and two by pedicled inguinal flap. Four out of 6 patients were reviewed in consultation, 1 patient was lost to follow-up, and 1 patient died. Clinical evaluation was performed by a surgeon other than the operator. Functional results are highly variable. Coverage time varies according to lesion depth and patient severity. Flap weaning took place at an average of 30 days. DASH scores ranged from 17.5 to 93/100, with average to poor total active motion (TAM) scores. The aesthetic result was satisfactory, with a Vancouver score of 4.5/13 on average, and an overall patient opinion of 3.75/10 on the POSAS scale. For deep burns to the dorsum of the hand and fingers, local flaps are rarely possible, and loco-regional flaps are not feasible in cases of associated upper limb damage. For medium to large surface areas, pedicled inguinal flaps and pocketing are two reliable techniques. Nevertheless, they require relative immobilization of the upper limb, which leads to stiffness. The question of digital pinning in the intrinsic or straight position remains unresolved, and does not appear to prevent secondary deformities. There is also a learning curve for these two flaps, even though they are reputed to be easy to lift. McGregor's flap or pocketing can be weighed against free flaps. However, the operating time is long, the surgical technique is complex, and vascular damage is common in the burn patient population. Although there have been enormous technical advances since their descriptions, the pedicled inguinal flap and pocketing remain alternatives to be considered in the acute management of deep burns to the dorsum of the hand. In this presentation, we propose a surgical management algorithm to situate these two techniques in the plastic surgeon's therapeutic armament.

Distal interphalangeal joint arthrodesis with the intramedullary Lync® implant: Prospective study of 22 cases.

Several techniques have been described for fusion of the distal interphalangeal joint. The intramedullary Lync® implant (Novastep™) may be superior to other options as it is available in straight or bent configurations, does not need to be removed and does not require fingertip incisions. The objective of our prospective study was to determine the effectiveness of finger distal interphalangeal (DIP) arthrodesis with Lync® implants. Between February 2016 and June 2017, we performed 22 cases of DIP arthrodesis with this implant. Pain was assessed with a visual analog scale, the joint range of motion was measured using a digital goniometer, the pulp to palm distance was measured using a ruler, and the QuickDASH Questionnaire was filled out. AP and lateral X-rays were used to look for secondary displacement at 3 weeks and joint fusion at 6 weeks, 3 months, 6 months and 12 months. The primary endpoint was clinical and radiological union defined as the presence of trabecular bone bridges across the arthrodesis site. The patients' mean age was 57.8 years ± 9.9 (36-73). The mean follow up was 10 months ± 4.9 (3-15). The pre-operative pain level was 6/10 ± 2.4 (0-10) and it was 1.3/10 ± 1.7 (0-6) at 3 months post-operative (P < 0.0001). The mean pre-operative DASH Score was 64/100 ± 16 (15.9-86.3) and it was 19/100 ± 14 (2.3-45.4) at 3 months post-operative (P < 0.0001). At the end of the study, 20 DIP joints were fused (91%); 18 joints had fused at the 3 month follow-up visit (82%). Three cases required reoperation. DIP arthrodesis with the Lync® implant resulted in DIP fusion in 91% of cases. When fusion was achieved, it provided pain relief and improved function. The Lync® implant is less bulky than other arthrodesis devices and does not need to be removed.

What happens to the posterior comminution in extra-articular fractures of the distal radius treated with volar locking plates?

Extra-articular fractures of the distal radius with posterior displacement are typically treated with volar locking plates. However, this fixation method does not address the posterior comminution, which seems to have no impact on the final result. The purpose of this study was to determine the fate of the posterior comminution. This was a retrospective study of 22 patients over 50 years old with a distal radius fracture. A preoperative computed tomography (CT) scan was performed to evaluate the comminution. All fractures were fixed with a volar locking plate. All patients underwent a bone density scan. Patients were reviewed at 6 months post-operative to determine their clinical, radiological and functional outcomes. The CT scan was performed again to determine the fate of the comminution. At 6 months post-operative, 82% of patients had an oval metaphyseal defect. The mean volume of this defect was 1.86 mL. The contents of this defect most closely resembled fat. There was no statistical link between the defect's volume and the various parameters studied. On the other hand, the defect's density was positively related to the functional outcome and negatively related to the patients' body mass index. Because of the compression experienced by the cancellous bone, a distal metaphyseal defect often persists after consolidation in dorsally displaced distal radius fractures. The posterior comminution is ultimately of little consequence.

Two cases of distal ulna giant cell tumors treated by extensive resection, prosthetic reconstruction and stabilization using the brachioradialis tendon.

Aggressive giant cell tumors are rare at the distal ulna. We report the results of two patients who were treated surgically using a distal ulna prosthesis stabilized by ligament reconstruction with the brachioradialis tendon. At the maximum follow-up of 18months, the two patients were satisfied. Joint range of motion and functional scores were improved. X-rays showed no recurrence or subluxation; however gradual impingement of the ulnar notch of radius by the prosthesis was visible. Our technique seems to be a viable alternative when compared with the treatments described in other published case reports.

Contribution of arthroscopy to the treatment of intraarticular fracture of the distal radius: Retrospective study of 40 cases.

Our study aimed to compare the anatomical result after treatment of intraarticular distal radius fracture with locking volar plates with and without arthroscopy. This was a retrospective, single-center study of intraarticular fractures. A volar locked plate was used for fracture fixation in all patients. Twenty patients were operated on with fluoroscopy only ("plate" group) and 20 operated using arthroscopy assistance ("arthroscopy" group). All patients underwent a CT scan before surgery and at 3 months postoperative. The main outcome measure was the residual intraarticular step-off (measured in millimeters). Other studied outcomes were the residual gap between fragments and extra-articular reduction. The two groups were similar preoperatively in all aspects except the size of the gap between fragments. The residual step-off was significantly less in the arthroscopy group: 1.9mm (Q1 1.7; Q3 2.25) for plate versus 0.8mm (Q1 0.7; Q3 1.5) for arthroscopy (P=0.001). The change from the preoperative to the postoperative measurement was significantly greater in the arthroscopy group: 0.1 mm (Q1 -0.5; Q3 0.8) for plate and -1mm (Q1 -1.9; Q3 -0.6) for arthroscopy (P=0.0002). The residual gap was similar between both groups: 2.4mm (Q1 1.9; Q3 3.5) for plate vs. 2.3mm (Q1 1.1; Q3 2.8) for arthroscopy (P=0.37). The change in gap was not significantly different between the two groups: -0.9mm (Q1 -1.8; Q3 -0.1) for plate vs. -2.9mm (Q1 -4.4; Q3 -1.7) for arthroscopy (P=0.32). There was no difference in the extra-articular reduction. Damage was found to the scapholunate ligament in 30% and the TFCC in 30% of arthroscopy cases. Arthroscopy improves intraarticular reduction without altering extra-articular reduction in patients with intraarticular fractures of the distal radius, and it allows for assessment and treatment of any injuries discovered. We must now follow these patients over the long-term to assess the clinical benefit. LEVEL OF EVIDENCE: 3.

[Descriptive, radiographic, topographic and functional anatomy applied to distal radius fractures]. / Anatomie descriptive, radiographique, topographique et fonctionnelle appliquée aux fractures de l'extrémité distale du radius.

Extensive anatomical knowledge is needed in order to correctly treat distal radius fractures: normal and pathological osteology of the distal radius, distal radio-ulnar joint and radiocarpal joint-both on the descriptive and functional level-the neurovascular and muscular environments of the distal radius-which are essential to the surgical approaches-and the angles that need to be restored during the reduction. All of these concepts are broached in this article.

Intrabursal administration of protein kinase or proteinase inhibitors: effects on ovulation in the rat.

OBJECTIVE: To test the hypothesis that inhibition of protein kinase (PK) activity or proteolysis inhibits ovulation. DESIGN: Rats were injected intrabursally with protein kinase (H9 or staurosporin) or proteinase (alpha 2-macroglobulin) inhibitors and oocyte release was evaluated. SETTING: Clinical Research Laboratory, Center for Reproductive Medicine, University of Kentucky Medical Center. PARTICIPANTS: Immature rats stimulated with pregnant mare serum gonadotropin. INTERVENTIONS: Staurosporin (1 or 10 microM), H9 (1 mM), alpha 2-macroglobulin (835 microIU of activity); or vehicle was injected into the right ovarian bursa. The left ovarian bursa remained intact. Animals immediately received human chorionic gonadotropin (hCG). MAIN OUTCOME MEASURES: Analysis of oocyte release and ovarian morphology. RESULTS: Oocyte release from the inhibitor-treated side decreased for the H9 group (8.1 +/- 1.9 fewer oocytes released, P less than 0.001) and the 10 microM staurosporin group (5.5 +/- 0.6, P less than 0.001). No change in oocyte release was observed in the 1 microM staurosporin, alpha 2-macroglobulin, or vehicle injected groups. Histologic examination of vehicle treated ovaries demonstrated numerous developing corpora lutea (CL; 20.5 +/- 2.1 CL/ovary) and a lack of preovulatory follicles. In contrast, ovaries treated with PK inhibitors contained unruptured preovulatory follicles coincident with fewer forming CL (11.5 +/- 3.5 CL/ovary). CONCLUSIONS: Inhibition of PK activity in vivo suppresses ovulation, demonstrating that protein phosphorylation plays an important intermediary role in the ovulatory process.

Uncontrollable intraabdominal hemorrhage treated with packing and use of a MAST suit. A case report.

Uncontrollable hemorrhage can occur during any surgical procedure, and only an organized approach to its control will minimize morbidity and mortality. When routine hemostatic measures fail, extraordinary methods must be used. The use of intraabdominal packs with a MAST (medical antishock trousers) suit successfully controlled a life-threatening hemorrhage in one such patient.