Reconstruction of soft tissue defects of the distal third of the arm using a muscle-sparing latissimus dorsi musculocutaneous flap.

Use of a latissimus dorsi (LD) flap has been widely described for upper limb reconstruction. However, donor site sequelae have led to the development of muscle-sparing techniques for the LD flap. We present the technical principles of a muscle-sparing LD flap and its use as a pedicled flap to reconstruct the distal third of the arm.

[Phalloplasty: Microsurgical options and management algorithm]. / Phalloplastie : options microchirurgicales et algorithme décisionnel.

The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. This options are discussed and a therapeutic algorithm is presented. The main techniques used are the pedicled anterolateral thigh perforator flap and free muscle sparing latissimus dorsi flap. Principal criteria are listed, the choice of patient and the local anatomical conditions are the most important. Antebrachial flap stay the first choice. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Urethral reconstruction will be done by a narrow free forearm flap or by a delayed thin skin graft or buccal mucosa graft. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.

Is there any place for spontaneous healing in deep palmar burn of the child?

Child palm burns arise by contact and are often deep. The singular difficulty of such a disease comes from the necessity of the child growth and from the potential occurrence of constricted scars. In order to avoid sequelae, the actual gold standard is to practice an early excision of the burn, followed by a skin graft. The aim of this study is to evaluate the results of spontaneous healing combined with rehabilitation versus early skin grafting and rehabilitation concerning the apparition of sequelae. We performed a retrospective study in two burn centers and one rehabilitation hospital between 1995 and 2010. Eighty-seven hands have been included in two groups: one group for spontaneous healing and the other group for excision and skin grafting. Every child benefited from a specific rehabilitation protocol. The two main evaluation criteria were the duration of permanent splint wearing and the number of reconstructive surgery for each child. The median follow-up duration is about four years. The two groups were comparable. For the early skin grafting group, the splint wearing duration was 1/3 longer than for the spontaneous healing group. Concerning the reconstructive surgery, half of the grafted hands needed at least one procedure versus 1/5 of spontaneous healing hands. Our results show the interest of spontaneous healing in palmar burn in child, this observation requires a specific and intense rehabilitation protocol.

[Acute renal insufficiency revealing an IgA nephropathy]. / Insuffisance rénale aiguë révélatrice d'une néphropathie à IgA. Rôle déclenchant d'une intoxication à l'oxyde de carbone.

The authors report a case of non-reversing acute renal failure following a carbon monoxide poisoning in a 28-year-old woman with a previous history of pyelonephritis. The renal biopsy reveals an IgA nephropathy with interstitial and tubular changes. The mechanism of this exceptional complication is discussed.

[Treatment of persistent cardiac failure by ultrafiltration]. / Traitement de l'insuffisance cardiaque réfractaire par ultrafiltration.

Ultrafiltration, a method of extra renal filtering, which accomplishes an iso-osmotic removal of water an sodium from the plasma, was used in twelve patients. It is reserved for terminal persistent heart failures. In one case, it preceded a heart transplant. Simple to carry out, this technique is well tolerated when the pulmonary pressure is elevated, respecting an ultrafiltration output inferior or equal to 500 ml/h. Immediate improvement of the patients is spectacular. A new treatment failure may impose long-term ultrafiltration sessions. Failure of the medical treatment, impossibility of heart transplant, must be an indication for ultrafiltration which improves the comfort, and most likely the life expectancy of patients with persistent heart failure.

[Value of prolonged epidural analgesia in thoracic surgery]. / Intérêt de l'analgésie péridurale prolongée en chirurgie thoracique.

The use of high thoracic epidurals for post-thoracotomy pain relief in 156 patients is reviewed. Analgesia was maintained with a continuous infusion of a local anaesthetic, bupivacaïne 0.5% 40 ml, mixed with a narcotic, fentanyl 10 ml (perfusion rate between 3 and 7 ml/h). There was successful analgesia in 92%, with efficient ventilation, effective cough, no respiratory distress and only 8 cases of fibroaspiration. Only two significant respiratory complications occurred, due to incorrect management of the peridural route: the analgesic mixture was too concentrated and was injected by bolus instead of by continuous infusion. Other complications occurred, 8 cases of nausea or pruritus, 4 hallucinations, 10 cases of urinary retention lasting more than 24 h, 14 superior limb palsies and 22 Horner's oculopapillary syndrome. All of these complications were minor, easy to manage, and resolved after stopping peridural infusion. In conclusion, peridural analgesia is highly effective and improves the atmosphere in post-thoracotomy wards.

[Severe hypophosphoremia in a toxic shock syndrome]. / Hypophosphorémie sévère au cours d'un syndrome de choc toxique.

A case of toxic shock syndrome occurring during a menstrual period, and associated with severe hypophosphataemia, is reported. The patient was a 21-year old woman using tampons. On the fourth day, she developed encephalopathy with decreased consciousness and hyperventilation. Severe hypophosphataemia was noted. A phage-group-1 Staphylococcus aureus, producing TSST-1 and enterotoxin A, was isolated from vaginal, pharyngeal and skin sites. Pathogenesis and role of hypophosphataemia in toxic shock syndrome are emphasized.

[Peridural anesthesia in thoraco-abdominal surgery. Propofol-methohexital comparison for complementary anesthesia]. / Anesthésie péridurale en chirurgie thoraco-abdominale. Comparaison propofol-méthohexital pour narcose de complément.

Two groups of 20 patients scheduled for major abdominal surgery or thoracic surgery received analgesia by thoracic peridural route: 850 and 837 micrograms.kg-1 of bupivacaine, plus 4.30 and 4.20 micrograms.kg-1 of fentanyl. Anaesthesia was induced and maintained with either infusion of propofol 0.2% or infusion of methohexital 0.1% and patients were intubated and ventilated. The quality of induction was good in the two groups (3.48 mg.kg-1 in 4 min with propofol and 2.76 mg.kg-1 in 5 min with methohexital). But only 4 of propofol group needed vecuronium for intubation; they were 19 in the other group. Maintenance was extremely smooth with propofol (0.088 mg.kg-1.min-1) in 18 cases. In contrast, poor anaesthetic control was obtained with 14 methohexital patients and had to be abandoned. Hemodynamic data show fc, Pa and Ppa decreased with propofol but increased with methohexital in response to laryngoscopy and intubation. In this study, the onset of 5 sinusal bradycardias was noted with propofol. Two of them were severe 39 and 38 b.min-1 with major decrease of LVSWI to 32.45 and 24.47 g.mm-2. The role of hypovolemia (Bainbridge reflex) or vagomimetic effect of propofol is discussed. Nevertheless, this study shows that propofol given by infusion can better achieve adequate anaesthesia than methohexital.

[Severe visceral necrotizing angiitis with hereditary immune disorders: a case]. / Angéite nécrosante à formes viscérales graves avec troubles immunitaires héréditaires: un cas.

The authors report a new case of necrosing angeitis similar to those individualised by Churg and Strauss in 1951. After a persistent rhinitis, the patient developed serious asthma, left hemiplegia 8 months later (secondary to an intracerebral hemorrhage) polyneuritis and extensive necrosis of the small intestine. There was no renal or cardiac involvement. Anatomopathological examination of the small intestine revealed an arteriolitis with periarterial granuloma and severe inflammation. Complementary investigations revealed a hypereosinophilia, an inflammatory syndrome, a reduction in the hemolytic 50 complement and of the C4 fraction. Corticosteroid therapy associated with cyclophosphamide formed the basis of treatment. Plasmapheresis have been a useful aid. The follow-up is too short to assess the long term prognosis. A familial immune deficiency, disseminated lupus erythematosis in a sister, and rheumatoid purpura in one of the patient's children are interesting features of this text.

[Comparison of radiodensitometry and histomorphometry in normal and abnormal bone (author's transl)]. / Comparaison de la radiodensitométrie et de l'histomorphométrie dans l'étude de l'os normal et pathologique.

85 adults of both sexes, suffering from variety of bone disorders were studied by means of humeral radiodensitometry and histomorphometric analysis of iliac bone biopsies. Trabecular bone volume (TBV) was not related to cortical thickness. Bone mineral density was related to iliac TBV only in female subjects. The value of these measures is limited in osteoporosis because of measurement errors and skeletal inhomogeneity. In osteoporosis, variable histomorphometric features were observed. However, radiodensitometry proved a good measure of the state of mineralization in osteomalacia.

[Anatomy and physiology of the muscles and median frenum of the upper lip. Initial results of selective electromyography]. / Anatomie et physiologie des muscles et du frein médian de la lèvre supérieure. Premiers résultats de l'électromyographie sélective

Usually when reference is made to the Orbicularis oris muscle of the upper lip only the horizontal bands of muscle are mentioned. This muscle also comprises oblique fibres (Orbicularis externus) that are of very great importance in lip movements. The balance of the lip derives from the activity of the two types of muscle fibers. The lip can thus perform, at the same time, a movement of compression of the underlying structures and projection movements whereby these structures are freed. These different modes of action are well demonstrated by selective electromyography. There is also, in the middle of the upper lip, a medial cellulo-fibrous septum forming a prolongation of the septum and penetrating into the median interincisive suture and ending at the frenulum of the upper lip. This medial septum seems to play a very important physiological role in the growth of the premaxilla.