Modified Colson flap with subcutaneous liposuction for one-stage donor site removal: A case series.

OBJECTIVES: The aim of this study was to evaluate the functional and cosmetic results of an innovative procedure for modified Colson flap-graft consisting of immediate defatting of the flap by a liposuction cannula. METHODS: A cross-sectional study was performed among patients with deep hand burns requiring a modified Colson flap between 2018 and 2021. Outcomes included functional and cosmetic assessment of the hand through a quality-of-life questionnaire, a sensitivity scale and a scar assessment scale. RESULTS: During this period, 7 patients were operated on using our technique. One patient was lost to follow-up; 7 patients with a median age of 44 years were included, with a total of 10 burned hands. The burns were thermal in 5 out of 7 cases and the coverage concerned the whole hand in 50% of the cases. The flaps all received cannula defatting. The median time to flap weaning was 23 days (20 to 30 days). The median follow-up was 16 months. One case required remote flap weaning. The median POSAS (Patient and Observer Scar Assessment Scale) per patient was 4 and 2 per observer. The median BMRCSS (British Medical Research Council Sensory Scale) was 122. One case had recovered S2 sensitivity, the other cases had S3 or S4 sensitivity. CONCLUSION: Immediate defatting is one of the factors in tegumental quality allowing rapid functional recovery of the hand. The cannula defatting technique does not appear to require additional defatting time. The use of the liposuction cannula allows a one-step, homogeneous, and easier defatting, with a lower risk of devascularization.

Induced membrane technique with sequential internal fixation: use of a reinforced spacer for reconstruction of infected bone defects.

PURPOSE: To evaluate a novel sequential internal fixation strategy using a reinforced spacer for infected bone defect reconstruction by the induced membrane technique (IMT). METHODS: A retrospective case study was performed among patients treated for infected bone defects by applying this strategy. Following radical debridement, temporary stabilization was provided by a massive cement spacer combined with minimal intramedullary fixation during step 1. Definitive internal fixation was performed together with bone grafting at step 2. RESULTS: Eight patients with a mean age of 58 years were reviewed. The mean bone defect length was 8.8 cm. The spacer armature mostly consisted of elastic nails and Steinmann pins. Iterative debridement was required in one case after step 1. The mean interval between steps was 12 weeks. Definitive internal fixation was performed by intramedullary nailing (n = 4) or plating (n = 4). At a mean follow-up of 21 months, bone union was achieved in seven cases without additional bone grafting or infection recurrence. CONCLUSIONS: Sequential internal fixation using a reinforced cement spacer seems to be a valuable option for avoiding external fixation between IMT steps and limiting the recurrence of infection.

Management of acute radiation syndrome.

Acute radiation syndrome encompasses a spectrum of pathological manifestations resulting from exposure to high doses of ionizing radiation. This syndrome typically progresses through three stages with a prodromal phase, a latency phase and a critical phase. Each of them varies in intensity and duration depending on the absorbed dose of radiation. Predominantly affecting the bone marrow, skin, and gastrointestinal tract, its clinical implications are profound and multiorgan failure must be considered. Radiation doses below 2 Gray generally result in insignificant clinical consequences, while exposures surpassing 12 Gray exceeds current therapeutic capacities. Survival outcomes for patients within this therapeutic range depend on their ability to withstand radiation-induced aplasia, compounded by an increased risk of bleeding and infection due to skin, gastrointestinal, and potentially combined radiation injuries. Assessing the degree of radiation exposure plays a pivotal role in tailoring patient management strategies and is based on a combination of clinical, biological, and physical parameters. Treatment approaches primarily include intensive hematologic support to manage symptomatic manifestations and etiologic treatment is now based on the administration of growth factors. The role of hematopoietic stem cell transplant (HSCT) will be carefully considered on an individual basis, especially for patients who do not respond following 3 weeks of cytokine therapy. This review highlights the pathophysiological mechanisms, assessment modalities, and therapeutic interventions crucial for managing acute radiation syndrome aiming to optimize patient outcomes and guide clinical practice.

[Marjolin ulcers after cultured epidermal autograft in severely burned patients: a rare case series and literature review]. / Marjolin ulcers after cultured epidermal autograft in severely burned patients: a rare case series and literature review.

The advent of tissue engineering and the clinical applications with cultured epidermal autograft (CEA) have improved the prognosis of severely burned patients. Marjolin ulcers (MUs) are a well-known complication of burns. These malignant neoplasm transformations of burn scars are usually squamous cell carcinomas with a higher incidence of regional metastases. Radical surgery remains the treatment of choice. To identify cases of malignant transformation occurring at sites of CEA in a cohort of 68 massively burned patients. A retrospective single-centre study was performed from April 2017 to June 2019 at the Military Hospital of Clamart (France). A total of 34 patients treated between 1991 and 2013 (including one post-mortem) were included. Four cases of squamous cell carcinoma occurred in areas previously covered by CEA. The data from clinical and histopathological examination as well as treatment modalities are presented. One patient died as a result of the evolution of his squamous cell carcinoma, and two others required salvage amputation due to locoregional recurrence. The prevalence of these CEA-MUs is estimated at between 5.9% and 11.7% and the person-time incidence rate of CEA-related MUs is about 5.9 per 1,000 persons-years. In our study, the average time to malignant transformation seems considerably shortened (32-35 years for "classic burn MU" versus 15.7 years for CEA-MU). This first documented case series of CEA-MUs demonstrates the need to inform caregivers and educate patients. Further studies are needed to specify the true incidence of CEA-graft site malignancy.

Emerging therapy for improving wound repair of severe radiation burns using local bone marrow-derived stem cell administrations.

The therapeutic management of severe radiation burns remains a challenging issue today. Conventional surgical treatment including excision, skin autograft, or flap often fails to prevent unpredictable and uncontrolled extension of the radiation-induced necrotic process. In a recent very severe accidental radiation burn, we demonstrated the efficiency of a new therapeutic approach combining surgery and local cellular therapy using autologous mesenchymal stem cells (MSC), and we confirmed the crucial place of the dose assessment in this medical management. The patient presented a very significant radiation lesion located on the arm, which was first treated by several surgical procedures: iterative excisions, skin graft, latissimus muscle dorsi flap, and forearm radial flap. This conventional surgical therapy was unfortunately inefficient, leading to the use of an innovative cell therapy strategy. Autologous MSC were obtained from three bone marrow collections and were expanded according to a clinical-grade protocol using platelet-derived growth factors. A total of five local MSC administrations were performed in combination with skin autograft. After iterative local MSC administrations, the clinical evolution was favorable and no recurrence of radiation inflammatory waves occurred during the patient's 8-month follow-up. The benefit of this local cell therapy could be linked to the "drug cell" activity of MSC by modulating the radiation inflammatory processes, as suggested by the decrease in the C-reactive protein level observed after each MSC administration. The success of this combined treatment leads to new prospects in the medical management of severe radiation burns and more widely in the improvement of wound repair.

Autologous Bone Marrow Mesenchymal Stem Cells Improve the Quality and Stability of Vascularized Flap Surgery of Irradiated Skin in Pigs.

Cutaneous radiation syndrome has severe long-term health consequences. Because it causes an unpredictable course of inflammatory waves, conventional surgical treatment is ineffective and often leads to a fibronecrotic process. Data about the long-term stability of healed wounds, with neither inflammation nor resumption of fibrosis, are lacking. In this study, we investigated the effect of injections of local autologous bone marrow-derived mesenchymal stromal cells (BM-MSCs), combined with plastic surgery for skin necrosis, in a large-animal model. Three months after irradiation overexposure to the rump, minipigs were divided into three groups: one group treated by simple excision of the necrotic tissue, the second by vascularized-flap surgery, and the third by vascularized-flap surgery and local autologous BM-MSC injections. Three additional injections of the BM-MSCs were performed weekly for 3 weeks. The quality of cutaneous wound healing was examined 1 year post-treatment. The necrotic tissue excision induced a pathologic scar characterized by myofibroblasts, excessive collagen-1 deposits, and inadequate vascular density. The vascularized-flap surgery alone was accompanied by inadequate production of extracellular matrix (ECM) proteins (decorin, fibronectin); the low col1/col3 ratio, associated with persistent inflammatory nodules, and the loss of vascularization both attested to continued immaturity of the ECM. BM-MSC therapy combined with vascularized-flap surgery provided mature wound healing characterized by a col1/col3 ratio and decorin and fibronectin expression that were all similar to that of nonirradiated skin, with no inflammation, and vascular stability. In this preclinical model, vascularized flap surgery successfully and lastingly remodeled irradiated skin only when combined with BM-MSC therapy. Stem Cells Translational Medicine 2018:569-582.

Long-term effectiveness of local BM-MSCs for skeletal muscle regeneration: a proof of concept obtained on a pig model of severe radiation burn.

BACKGROUND: Medical management of the severe musculocutaneous radiation syndrome involves surgical intervention with debridement of necrotic tissue. Even when skin excision is replaced by specific plastic surgery, treatment of the muscle radiation injury nonetheless remains difficult, for it involves a massive muscle defect in an unpredictable environment, subject to inflammatory waves weeks to months after irradiation, which delay healing and predispose the patient to the development of fibrous scar tissue. In this study, we investigated the long-term effect of local injections of bone marrow-derived mesenchymal stromal cells (BM-MSCs), combined with plastic surgery, to treat muscle necrosis in a large animal model. METHODS: Three months after irradiation to the rump, minipigs were treated by excision of necrotic muscle tissue, vascularized flap surgery, and four injections with or without local autologous BM-MSCs, performed weekly. The quality of the muscle wound healing was examined 1 year post-surgery. RESULTS: The skeletal muscle surgery without MSC treatment led to permanent deposition of collagen 1 and 3, decreased myofiber diameter, failed muscle fiber regeneration, a reduced number of capillaries, and the accumulation of high calcium and fat. In animals treated by surgery and MSC injections, these indicators were substantially better and demonstrated established regeneration. MSC therapy acts at several levels by stimulating growth factors such as VEGF, which is involved in angiogenesis and satellite cell pool maintenance, and creating a macrophage M1/M2 balance. CONCLUSION: Thus, cell therapy using BM-MSCs is an effective and safe way to improve recovery of irradiation-induced skeletal muscle damage without signs of long-term degeneration.

Simultaneous Reconstruction of Achilles Tendon and Soft-Tissue Defects with a Composite Anterolateral Thigh Free Flap with Vascularized Fascia Lata.

INTRODUCTION: Reconstruction to treat segmental loss of the Achilles tendon combined with soft-tissue defects can be challenging, particularly after the recurrent ruptures that may occur during intense physical activity. STEP 1 PREOPERATIVE PLANNING: Design flap and use Doppler ultrasound for perforator mapping. STEP 2 DEBRIDE WOUND AND PREPARE RECIPIENT VESSELS: Use a two-team approach, one for the affected side and one for the unaffected side. STEP 3 HARVEST THE COMPOSITE ALT FLAP: Take care to include one or two perforator vessels in the flap and to avoid vessel damage throughout the dissection. STEP 4 PERFORM VASCULAR ANASTOMOSIS: Use the posterior tibial vessel as the recipient site for the microvascular anastomosis. STEP 5 RECONSTRUCT THE ACHILLES TENDON: Suture the rolled up vascularized fascia lata sheet; then check for tension. STEP 6 POSTOPERATIVE CARE: Gradual, protected weight-bearing begins at twelve weeks. RESULTS & PREOP/POSTOP IMAGES: For recurrent tendon rupture, this single-step reconstruction saves both time and expense and it provides a functional tendon reconstruction (enabling normal daily activities) with limited donor-site morbidity and an acceptable cosmetic result without the need for a later debulking procedure. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.