[Use of muscle free flaps in lower limbs reconstruction in children]. / Utilisation de lambeaux libres dans la reconstruction des membres inférieurs chez l'enfant.

A series of 12 muscle free flaps was performed from 2000 to 2005 in 11 children 3 to 15 years of age (mean: 10.6): seven serratus anterior, four latissimus dorsi and one rectus abdominis. The defects (acute or as a result of sequelae) were always located in lower limbs: seven in feet, three in the lower third of the leg and one in the knee. None of the children was re-operated within 72 hours. Total necrosis due to venous thrombosis occurred at Day 5 in one case. After mean follow-up of 2.5 years (minimum: 1 year), the flaps show good integration. Functional or esthetic sequelae are considered acceptable by the health-care team as well as the children's parents. No repercussions on growth have been observed. Our series confirms the results of previous studies, indicating that free flaps should be part of the therapeutic arsenal in pediatric surgery.

[Pectus excavatum: what treatment in plastic surgery? About 10 cases]. / Le thorax en entonnoir: quelle prise en charge en chirurgie plastique? A propos de 10 cas.

SUBJECT: Several controversial issues concern pectus excavatum (funnel chest), the most common chest wall deformity. The pathogenesis of this deformity is uncertain, and there is no agreement as to its psychological, cardiac and pulmonary effects. An even more debatable point is the choice of surgical treatment among the more or less radical proposals made by different teams. No consensus exists concerning the indications for surgery, the technique to be used, or the suitable age of the patient. MATERIALS AND METHODS: This retrospective study concerns 10 patients with funnel chest who underwent reconstruction surgery in our unit between 1989 and 2002. Nine patients received a silicone chest implant made to measure, and one a single breast implant. Each patient was interviewed and examined to obtain information and provide a basis for evaluation. The effects of possible associated abnormalities were evidenced by complementary cardiopulmonary examinations, and the severity of funnel chest was evaluated according to the Haller pectus index. RESULTS: The mean period after surgery was 5 years. The effects of funnel chest deformity were essentially psychological, relating to aesthetic disgrace. Although two-thirds of the deformities were considered severe, cardiopulmonary repercussions were minor. All 10 patients were satisfied with the repair performed, and this judgment was independent of surgical assessment. Acute complications concerned 5 seromas and one minimal scar separation. DISCUSSION: The indications for surgery and the means of surgical treatment for funnel chest are considered after comparison of our results with those in the literature and a survey of the different existing possibilities for treatment (implant, chondrosternoplasty, fat transplant).

[Use of a vascularized fibula for spinal reconstruction in neurofibromatosis]. / Intérêt d'un péroné vascularisé pour la reconstruction du rachis dans le cadre d'une neurofibromatose de type 1.

We report a case of reconstruction of a dysplasic thoracic spine with vascularized fibula in Recklinghausen's disease. We present the case of a thirteen-year-old lady with neurofibromatosis type 1 who developed a dystrophic thoracic kyphoscoliosis. A T9 compression due to a severe scaloping of the thoracic spine caused an important deformation and a medullar compression (with dorsal pain, right sciatica and a pyramidal syndrome). The surgery consisted in medullar liberation by a T9-T10 corporectomy and an osteosynthesis with arthrodesis T3-L3. A free vascularized fibula bone graft, with an end-to-end anastomosis on a thoracic pedicle, was realized to fill the T8-T11 spinal defect. All the symptoms decreased after surgery and the patient could walk normally few months later. At one-year follow-up the radiographs showed a stable montage and a solid bony fusion. Analysing the literature, vascularized bone graft can be recommended to fill the bony spinal defect due to surgery in cases of tumor, infection, trauma or severe scoliosis. Compared to non-vascularized grafts, which are exposed to resorption, fatigue fracture and then instability, the vascularized fibula grafts provide a rapid fusion, a biomechanically stable and long-standing support with low risks of infection.

[Surgical technique and advantages of the free temporal fascia flap for covering loss of substance of the dorsum of the foot and around the ankle: report of 12 cases]. / Particularités de la couverture des pertes de substance au niveau de la cheville et de la face dorsale du pied : intérêt du lambeau de fascia superficialis temporalis et précision technique du protocole opératoire: a propos de 12 cas.

The authors report a series of twelve patients with loss of substance of the dorsum of the foot or around the ankle who underwent coverage with a free temporal fascia flap. There were no failure of flaps and no vascular complication at the microanastomosis. There were three complications: partial burn of the flap with a lamp, failure of the split thickness skin graft and an area of scar alopecia at the donor site. With one year of follow up, there were no problems of cicatrisation and no patients had difficulty to the use of normal footwear. The different advantages of this flap led us to recommend it for the covering of wound in this area.

[Surgical treatment for giant congenital nevi: what are the psychosocial consequences for the child and family?]. / Prise en charge chirurgicale des naevi géants congénitaux : quel retentissement psychosocial sur l'enfant et son entourage ?

Giant congenital nevus is a rare pathology. The incidence of malignant transformation exists and his unsightly aspect requires a early surgical treatment. All techniques of plastic surgery must have to be used. The management of the skin capital is a real surgical challenge with complications which are difficult to bear psychologically and physically for these young children. Authors present psychosocial effects of this pathology then surgical practice through 105 cases analysed. The majority of the patients had axial disposition of the nevus (head and trunk) and tissue expansion was the most utilised technique. A questionnaire estimated the notion of other's looking, congenital deformity's acceptance, surgical story's transmission, family's opinion of the surgical treatment. More than the half of families feel that their child was cast-off because of deformity. A lot of family would forget the nevus and never photographed their child with nevus. Sometimes, children could not explain their scars. Despite many hospitalisations, all the children have normal schooling and extra-school activities. It's important to begin surgical plan very early so that child could integrate their scars in their corporal schema.

[Free-flap reconstruction in the elderly patient]. / La reconstruction par lambeau libre chez le sujet âgé

The objective of the study was to evaluate the safety and the efficacity of microsurgery in the elderly patient population. Between 2003 and 2005, 10 free-flaps were performed in 10 patients who were aged 70 years or older. One flap underwent reexploration, for an overall success rate of 100%. Medical complications in the postoperative period were further evaluated. Effects of American Society of Anesthesiologists (ASA) status, operation time, and age on complication rate were evaluated. Only ASA status was significant for the occurrence of postoperative medical complications; class 3 and 4 patients were at higher risk than class 1 and 2. Neither operation time nor age was predictive of postoperative complications. Microvascular free-tissue transfer is a safe and reliable option in the elderly population. The success rate of free-flaps is not different from that for other age groups. The rate of postoperative medical complications was 20%: most complications were in ASA class 3 and 4 patients.

[Effectiveness of Integra in the management of complete forearm degloving injury. A case report]. / Intérêt de l'Intégra dans la prise en charge d'un dégantage complet de l'avant-bras. A propos d'un cas.

A 43-year-old man suffered complete skin degloving of the right forearm in a work accident with a farm machine. Initial treatment using a total skin flap graft after fat removal failed because of nearly complete necrosis after ten days. Artificial dermis (Intégra) was then used to ensure skin cover and reduce adherence phenomena. Postoperative complications were minor, and a split-thickness graft performed after three weeks led to healing five weeks later. At one year of follow-up, scar quality was considered very good, with normal and symmetric mobility. This case suggests that Intégra could be a valid surgical alternative in the management of skin degloving injuries.

Cement burns: retrospective study of 18 cases and review of the literature.

SUBJECT: Cement is increasingly used in the construction industry, but the occurrence of cement burns is rarely reported. This retrospective study concerns patients treated for cement burns in our unit between 1997 and 2002. MATERIALS AND METHODS: Eighteen patients 18-64 years of age, treated previously in our unit for cement burns, were interviewed by telephone for evaluation. RESULTS: The mean time since treatment was 39 months. Burns were predominantly seen on the lower limbs, and a third occurred during an accident on the job. All deep burns were excised, and 16 patients received grafts. Mean hospital stay was 10 days, and mean sick leave 2 months. Our study indicated that all patients were poorly informed about cement-related risks. DISCUSSION: Surgical treatment of full-thickness cement burns at diagnosis enables rapid healing with a minimum of sequelae and reduces the high socioeconomic costs resulting from these lesions. CONCLUSION: This study indicates once again the need to improve preventive measures; which are very often inadequate because of lack of awareness of risks.

Dead-time free measurement of dipole-dipole interactions between electron spins.

A four-pulse version of the pulse double electron-electron resonance (DEER) experiment is presented, which is designed for the determination of interradical distances on a nanoscopic length-scale. With the new pulse sequence electron-electron couplings can be studied without dead-time artifacts, so that even broad distributions of electron-electron distances can be characterized. A version of the experiment that uses a pulse train in the detection period exhibits improved signal-to-noise ratio. Tests on two nitroxide biradicals with known length indicate that the accessible range of distances extends from about 1.5 to 8 nm. The four-pulse DEER spectra of an ionic spin probe in an ionomer exhibit features due to probe molecules situated both on the same and on different ion clusters. The former feature provides information on the cluster size and is inaccessible with previous methods.

EPR probes with well-defined, long distances between two or three unpaired electrons

The synthesis of rod- and star-shaped compounds carrying two or three spin labels as end groups is described. The unpaired electrons are 2.8-5.1 nm apart from each other. The shape-persistent scaffolds were obtained through Pd-Cu-catalyzed alkynyl-aryl coupling and Pd-Cu-catalyzed alkyne dimerization in the presence of oxygen using p-phenyleneethynylene as the basic shape-persistent building block. The spin label 1-oxyl-2,2,5,5-tetramethylpyrroline-3-carboxylic acid (4) was attached through esterification of the terminal phenolic OH groups of the scaffold.

Distally based sural fasciomuscular flap: anatomic study and application for filling leg or foot defects.

Since 1995, the authors have created 32 distally based superficial sural artery flaps based on the vascular axis of the sural nerve. The creation of the first 18 flaps permitted the authors to view perforators that issued from the gastrocnemius muscles to the vascular axis of the sural nerve. This led to the development of an anatomic study involving 25 cadaveric dissections to establish a relationship between the gastrocnemius muscles and the vascular axis of the sural nerve, with two to three constant and direct perforators from the gastrocnemius to the neurovascular axis. In this article, the technique for harvesting this new muscular flap is described. Between June of 1997 and March of 1998, three patients underwent flap operations. Two fasciomyocutaneous flaps and one fasciomuscular flap were created and were followed by uncomplicated postoperative courses in terms of flap viability and donor sites. In all cases, the flap created was designed to fill bone defects of the leg (one case) or of the foot (two cases). The results were considered to be excellent and stable over time, with follow-up periods ranging from 9 months to 18 months in duration.

A silver sulphadiazine-impregnated lipidocolloid wound dressing to treat second-degree burns.

OBJECTIVE: To evaluate the efficacy and tolerance of Urgotul SSD dressing (Laboratoires Urgo) in the treatment of second-degree burns. METHOD: This was a national multicentre phase III non-comparative open-label prospective study involving 10 burns units. The 41 subjects were non-immunosuppressed adults with second-degree thermal burn(s), which were clinically non-infected, less than 24 hours old, had a surface area less than 500 cm2 and warranted the local use of silver sulphadiazine. For four weeks, subjects were followed up weekly with a clinical assessment, bacteriological swabs and photographic recording. RESULTS: Of the 41 patients, 24 healed within a mean of 10.8 days and 13 had a skin graft on the study burn within a mean of 11.5 days. There were four premature study withdrawals. The total number of cumulative treatment days was 445, and 298 treatments were performed (including 257 dressing changes). Mean dressing wear time was 1.73 days. None of the subjects acquired a secondary infection. Researchers took 121 bacteriological samples, and wound colonisation with Staphylococcus aureus was found in only one patient. At follow-up nursing staff reported that dressing acceptability was good. CONCLUSION: Use of Urgotul SSD led to a good wound outcome--wounds healed or were grafted.

Solid tumors of the liver. Diagnostic and therapeutic problems.

The diagnostic and therapeutic problems involved in 29 cases of isolated hepatic tumors have been presented. In nine cases the hepatoma was discovered during emergency treatment for complications. Selective arteriography was the most accurate method of establishing the etiologic diagnosis. Suprahepatic phlebography indicated the possibilities for surgical treatment. These possibilities are not influenced by the volume of the tumor, but are closely dependent on damage to the suprahepatic vascular system. Effective surgery was performed in 22 cases, of which 14 were excisions.

[Dementia and extrapyramidal problems caused by long-term valproic acid]. / Démence et troubles extra-pyramidaux sous acide valproïque au long cours.

Among the side-effects attributed to valproic acid (VPA), the occurrence of Parkinsonian syndromes and cognitive impairment is very uncommonly reported. We describe five cases of reversible associated Parkinsonism. These cases were observed in epileptic patients, 57 to 74 years old, two women and three men. Extrapyramidal disorders appeared after various durations of treatment (from 6 months to 10 years). Dementia characterized by an insidious onset was associated in three cases and bradypsychia in one case. Brain pseudoatrophy was present in three patients. In all cases the signs and symptoms improved some weeks or months after discontinuation of VPA. In the literature some cases, usually in young adults or children, have been reported. In a prospective study, Armon et al. found various abnormal symptoms and signs related to motor and cognitive function impairment in patients with long-term VPA therapy. These side-effects may be related to a disturbance in the gabaergic pathways in the basal ganglia system. It is of interest to consider that delta 2-valproic acid, a metabolite of VPA, is especially accumulated in selected areas of the brain: the substantia nigra, superior and inferior colliculus, hippocampus and medulla.

[Intracranial hemorrhages associated with oral anticoagulant therapy. Analysis of 38 cases]. / Hémorragies intracrâniennes associées à un traitement anticoagulant oral. Analyse de 38 observations.

The major risk of oral anticoagulant therapy is haemorrhage potentially affecting all organs. Bleeding in the central nervous system is a rare but severe complication of anticoagulant therapy. This study aimed to analyse a series of intracranial haemorrhages. This series from the Regional Pharmacovigilance Center of Amiens included spontaneously reported and retrospectively collected cases from January 1999 to December 2000. During this period, 38 cases of intracranial bleeding possibly related to oral anticoagulant administration were reported; 19 women and 19 men, median age 69.5 (29 to 87) years. In 34% of the cases, patients died and in 18% neurologic sequelae were still present at the time of the evaluation. In 21 cases (62%), the INR (International Normalized Ratio) was higher than the therapeutic range recommended for the indication. Among the most frequent risk factors, hypertension and recent minor trauma are highlighted in this series. In 17 cases, oral anticoagulants were associated with potentially potentiating drugs. Mental status changes or headache were prominent early symptoms which had often been present for days. Our data confirm that anticoagulant-associated intracranial haemorrhages are not rare, can be severe, potentially fatal and are probably underestimated by physicians. The fact that more than 50% of patients in this series were overanticoagulated at the time of bleeding suggests that many cases of intracranial haemorrhage could be prevented by improved anticoagulation control. Epidemiological studies are needed in order to prospectively evaluate the incidence of this type of complication and its avoidance. The value of anticoagulation clinics can be discussed.

[Pharmacokinetics of azlocillin in the burn patient]. / Pharmacocinétique de l'azlocilline chez le brûlé.

Pharmacokinetic values of azlocillin were determined in burned patients during the exudation and repair periods. A single dose of 80 mg/kg was administered intravenously over 30 min. Pharmacokinetic constants were calculated using an open two-compartment model. During the exudation period the ultimate serum half-lives (t 1/2 beta) were 1.17 to 1.4 h, 1.73 to 1.78 h and 3.3 h respectively with creatinine clearances of 111-131, 60-94 and 14 ml/min/1.73 m2. Renal clearances varied from 30.9 to 128 ml/min/1.73 m2. During the repair period little change was observed in t 1/2 beta, but renal clearance increased from 36.6 to 116 ml/min/1.73 m2 in one patient. It is concluded that azlocillin behaves in burned patients as in patients with impaired renal function.

[Lyell syndrome after amoxicillin administration in a 2 year old child]. / Syndrome de Lyell consécutif à l'administration d'amoxicilline chez un enfant de 2 ans.

The authors report a toxic epidermal necrolysis (TEN) due to ampicillin (Agram) in a 2-year-old child. During the acute phase a septic syndrome occurred. The severity of the clinical and biological symptoms led to the administration of antibiotics, their systematic use remaining controversial. Recovery was favourable in a paediatric burn centre. Sequelae were minor. TEN, the physiopathological mechanism of which remaining still unknown, may carry a vital risk.

[Hemodynamic effects of bathing in severe burnt patients]. / Effets hémodynamiques du bain chez le patient gravement brûlé.

Repeated water immersion is currently used in France in the treatment of severe burn injury. A prospective study was carried out to assess the haemodynamic effects of immersing such patients in a half sitting position in water, the temperature of which was kept at 35 degrees C. The burn exceeded 50% of body surface area (BSA), with at least 30% being third degree burns. The study was carried out during the first bath, three days after the injury. The patients were immersed up to the clavicles. They were sedated with 2 mg.h-1 of both flunitrazepam and phenoperidine, and were mechanically ventilated. The following haemodynamic parameters were monitored: heart rate, arterial blood pressure (the transducer being level with the arterial catheter), right atrial and pulmonary arterial pressures (the transducer being level with the right atrium, level which had been marked on the chest before immersion and placed two intercostal spaces higher after immersion because of the change in position of the heart). The cardiac output was measured using the thermodilution method. The patient's temperature was monitored with the thermistance of the Swan-Ganz catheter. Values were obtained before immersion, after 15 and 30 minutes of immersion, and 5 minutes after the end of the bath. Nine patients were included, 2 women and 7 men, aged between 24 and 45 years, weighing 73.7 kg on average. Burn size was 78% of BSA (range 64 to 95%). Water immersion was maintained for 34 +/- 3 min. The right atrial, mean pulmonary arterial, and wedge pressures, and the cardiac and systolic indices increased.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anatomical study of the nerve supply of the trapeziometacarpal joint. Fifteen dissections]. / Etude anatomique de l'innervation de l'articulation trapézo-métacarpienne. A propos de 15 dissections.

PURPOSE OF THE STUDY: When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation. MATERIAL AND METHODS: This anatomical study was performed by dissection under magnification (4.5-x350) of 15 upper limb cadaver specimens. The median nerve, its thenar and volar cutaneous branches and the terminal sensorial branches of the radial nerve were dissected. Articular branches to the TMCJ were carefully identified. Histological samples were taken to verify the neurological nature of the elements dissected. RESULTS: All TMCJs dissected exhibited radial and median nerve supply. Branches of the median nerve predominated in number and caliber. The volar cutaneous branch gave rise to articular branches in eleven dissections and the thenar branch gave rise to articular branches via a retrograde arciform trajectory between the short abductor and the opponens digiti pollicis in thirteen. For five dissections, the TMCJ branches arose directly from the median nerve within the carpal tunnel. At histological analysis the dissected elements were identified as nerves. DISCUSSION: There have been few anatomic studies concerning the nerve supply of the TMCJ. Unlike the findings reported by Cozzi in 1960, we did not find the dorsal sensorial branch of the radial nerve to play an exclusive or preponderant role in the innervation of the TMCJ. The median nerve supply to the TMCJ appeared to be more significant, particularly for the volar cutaneous and especially thenar branches. CONCLUSION: Total and definitive selective denervation of the TMCJ appears to be a most difficult procedure which would require a very wide access and extensive dissection, including the thenar branch which would raise the risk of significant complications.

Urgotul: a novel non-adherent lipidocolloid dressing.

Urgotul belongs to a new class of non-adherent dressings: the lipidocolloid dressings. It is composed of an open weave polyester mesh impregnated with hydrocolloid polymers dispersed within petrolatum. The first clinical trial data are presented. Efficacy and safety were evaluated in a multicentre non-comparative trial involving 92 patients treated to healing or up to 4 weeks. Adult outpatients with acute wounds (n = 34), leg ulcers (n = 24), other chronic wounds (n = 14) or with second-degree burns (n = 20) were included. Results showed 32.4% (n = 11) of the acute wounds, 12.5% (n = 3) of the leg ulcers and 14.3% (n = 2) of the other chronic wounds completely healed before 4 weeks. Surface areas decreased on average by 76.4%, 63.5% and 44.2% at study endpoint respectively. For burns, 19 patients healed (95%) within 5-19 days. A total of 771 dressing changes were performed during the course of the study. Dressing application was considered as easy or very easy in 90% or more of the changes and there was no difficulty in removing the dressing in about 95% of the cases. Safety was good with five reports of a transitory local adverse event, probably dressing-related, being observed, two patients (2.2%) prematurely stopped treatment because of moderate periwound erythema. Urgotul is a highly promising new dressing which is currently undergoing further comparative clinical evaluation.