Coverage of cutaneous substance loss in the leg: Techniques and indications.

Cutaneous substance loss in the leg is frequent; more often than not, it is trauma-related. It calls for complex management and necessitates the application of all current reconstruction techniques, particularly microsurgery. As regards treatment, the available therapeutic arsenal is highly diversified, ranging from a simple free flap skin graft to local and locoregional flaps. During reconstruction, the surgeon is subjected to several constraints insofar as the objectives of the operation are esthetic as well as functional. Ideally, the fineness of the skin covering the anterior side of the leg will have been scrupulously respected. Reconstruction is aimed at producing a stable and reliable cutaneous envelope while limiting the morbidity of the donor site. The development of free perforator flaps corresponds to these two criteria by producing a fine flap adapted to the cutaneous thickness of the leg and limiting any functional and esthetic sequelae at the donor site.

Aesthetic functional reconstruction of the mutilated hand: Indications and selection of reconstructive techniques.

Advances in microsurgery together with improvements in reconstructive surgical techniques over recent decades have enlarged the scope of available techniques for mutilated hand reconstruction, shifting the reconstructive paradigm from restoring hand function to providing the best functional and aesthetic results with minimal donor-site morbidity. Successful reconstruction of a mutilated hand should no longer be measured only by the degree of improvement of hand function but also by a more aesthetic hand appearance as well as by improved psychological well-being. In this article, the authors present their concept of aesthetic functional reconstruction of the mutilated hand with a focus on the indications and selection of reconstructive techniques. They emphasize that in order to select the most appropriate technique, providing the best functional and aesthetic outcomes with minimal donor-site morbidity for each individual patient, it is imperative for the reconstructive hand surgeon to possess perfect mastery of all available surgical techniques, thorough understanding of functional and aesthetic requirements and accurate appreciation of multidimensional reconstruction of a given defect of the hand. They have concluded that in precisely indicated cases, successful replantation of an amputated hand or digits remains the best reconstructive procedure designed to obtain a more functional and more normal-appearing hand, whereas, toe-to-hand transplantation, in cases of failed or impossible digit replantation, provides better results than any other digit reconstruction techniques aimed at achieving functioning digits with good appearance. Although skin graft and various distant pedicled flaps and free flaps may be valid options for coverage of some soft tissue defects of the hand, reverse flow forearm flaps, especially those based on the secondary arteries of the forearm, are often the best-suited reconstructive options for like-with-like hand reconstruction. They can provide the best matching of color, texture, soft-tissue volume, donor-recipient tissue interface and fulfill all the aesthetic and functional reconstruction requirements of moderate-sized or even large soft tissue defects of the hand, with acceptable donor site morbidity.

[Secondary digit reconstruction of mutilated hand]. / La chirurgie secondaire après amputation digitale traumatique.

Traumatic digit amputation generates functional, aesthetic and psychological disabilities. Such post-traumatic consequences call for a rigorous therapeutic approach, aiming at an early secondary surgical procedure - which is ideally to be performed before the patients psychologically recover from their initial trauma. The therapeutic principle consists in improving the global function of the hand, basically aiming at re-creating a quality pollici-digital pinch, ideally thin, stable, sensitive, strong, mobile enough, but also, when possible, at improving the aesthetic aspect of the hand. The therapeutic arsenal includes not only surgical processes using local ressources in order to improve the allocation of the remaining digital capital such as phalangisation, elongating techniques, proximal amputation, digital translocation and redistribution but also remote processes - such as osteoplastic and toe-to-hand transfer techniques. The authors expose their approach and indications of secondary digit reconstruction procedures in mutilated hand. They conclude that a thorough knowledge and mastery of the vast available therapeutic arsenal, a fine and profound analysis of the benefits and downsides of each available surgical technique, a comprehensive acknowledgement of the patient's personal information such as age, gender, profession, dominant hand, status of the mutilated hand, physical and psychological health as well as patient's desire are all necessary in order to define the best therapeutic strategy for each particular case.

[Treatment of necrosis of Achilles tendon without tendon reconstruction: About four cases]. / Traitement des nécroses du tendon d'Achille sans reconstruction tendineuse : à propos de quatre cas.

INTRODUCTION: Management of the combined loss of Achilles tendon and skin is difficult. However, these are not exceptional situations after Achilles tendon surgery. Data from the literature are extensive and there is currently no consensus on the technique of tendon reconstruction. CASE REPORTS: We report four cases of purulent necrosis of the Achilles tendon complicating longitudinal incision or suturing of a tendon rupture. After debridement of necrotic tissue, the defect was covered either by a fasciocutaneous perforating flap or a thin skin graft without reconstruction of the underlying tendon. DISCUSSION AND CONCLUSION: The functional results are very satisfactory with good joint mobilities and a resumption of walking without lameness for all patients. Fibrosis can reconstitute a true neo-tendon confirmed on MRI. The advantages are many compared to other methods: a single operating time is necessary, the postoperative management is simple and it avoids certain technical difficulties related to tendon reconstruction. A larger series would be needed to support these results.

[Traumatic hand injuries in children]. / La main traumatique de l'enfant.

Hand injuries in children are frequent in pediatric emergencies. Epidemiology of hand injuries in children depends on age and social context. The management of these injuries requires experienced pediatrics in order to obtain a functional hand to preserve the potential growth and to reduce the risk of cosmetic sequelae. We will describe the specificities of hand trauma in children and their therapeutic principles.