[Pre-iliac tumor mass syndrome: An atypical rheumatoid nodule]. / Syndrome de masse tumorale pré-iliaque : un nodule rhumatoïde atypique.

Rheumatoid arthritis (RA) is a polymorphous chronic inflammatory disease that is common in general population and is responsible for the occurrence of subcutaneous or visceral rheumatoid nodules. Their typical clinical presentations and localizations do not generally pose any diagnostic or therapeutic problem. We report here an atypical fistulized presentation of an unusual iliac rheumatoid nodule in a 65-year-old female patient. The evolution was favorable without recurrence at 6 months after complete surgical resection and appropriate antibiotherapy.

Methylmetacrylate (PMMA) cranioplasty technique: Technical interest of intraoperative modeling and review of the literature.

Reconstruction of bone loss in the cranial vault may be necessary for functional or aesthetic reasons following trauma, decompression craniectomy, or craniofacial malformations. Many techniques have been described in the literature, using various materials, each with its own advantages and drawbacks. Reconstruction with polymethylmetacrylate cement has the advantage of a durable result and relative ease of use. In this article we present our cement cranioplasty technique through 4 clinical cases of cranial vault reconstruction, by direct intraoperative modeling on the bone defect. This accessible, effective method, applicable to all sizes of defect, remains an attractive option in the arsenal of techniques available today.

[Current place of cultured epithelial autografts in the management of massive burns and future prospects: Literature review]. / Place actuelle des cultures d'épidermes autologues dans la prise en charge des brûlures étendues et perspective d'avenir : revue de littérature.

Cultured Epithelial Autografts (CEAs), developed at the end of the 1970s from in vitro culture amplification of keratinocytes, have led to a therapeutic revolution in the treatment of major burns. The areas of improvement of the cultures initially involved the manufacturing processes (culture media, support matrices, etc.) and then clinical applications (use of a largely expanded allogeneic or autologous dermal bed). These advances have enabled burn centers (BC) using CEAs to obtain very satisfactory percentages of graft integration and survival of major burns patients. However, since CEAs are not without major drawbacks (fragility, high rate of infection, high cost, unstable scars), these pitfalls have restricted their use worldwide. As of 2014, CEAs produced by Genyzme Tissue Repair are no longer available in Europe, which has considerably reduced an indispensable therapeutic arsenal for severe and extensive burns. To overcome these therapeutic limitations, current research is focusing on techniques combining surgery, tissue engineering and cell therapy. The advent of regenerative medicine, based on the use of stem cells, in particular mesenchymal stem cells (MSC), can contribute to an improvement in the management of these massively burned patients (optimization of the environmental medium, attenuation of the systemic inflammatory response and the immunosuppressive effects of the burn, acceleration of tissue regeneration, etc.). Cell therapy, therefore, offers alternatives to CEAs, which must imperatively retain their place in the therapeutic arsenal, namely an effective emergency coverage technique that can be improved.

Eyelid Chemical Burns: A Multidisciplinary And Challenging Approach.

During second- and third-degree eyelid sulfuric acid burns, many surgeons prefer to wait until primary wound separation occurs before grafting. However, this approach may miss the chance to recover the eyelids and can cause ectropion, resulting in delayed eyeball healing with exposure keratitis. We propose that early eyelid release and grafting makes a significant difference in long-term outcomes and improves eyeball healing. Here, we present the case of a woman who presented second- and third-degree burns of the eyelids secondary to physical domestic assault with acid, who had an early surgical management with a full-thickness skin graft. Ten days after surgery, we found that the graft had survived totally, and the donor site of the right arm had already healed. Eyelids were successfully grafted and the functions of both eyelids were well recovered, allowing complete cover of the eyeball. Two months after surgery, functional and cosmetic results were satisfying, with no postoperative lagophthalmos or difficulties with exposure-related problems. Case reports of eyelid chemical burns are very few. No specific and codified management of eyelid chemical burns was found in the literature search. This case report demonstrated that a multidisciplinary approach led by both ophthalmologists and plastic surgeons must be decided early (<6h) in order to achieve synergistic and coordinated management between the eye and the eyelid. There is a significant improvement in ocular healing with early excision and grafting of eyelids after sulfuric acid burn.

En cas de brûlure du 2ème ou du 3ème degré des paupières par acide sulfurique, de nombreux chirurgiens préfèrent attendre la séparation spontanée de l'escarre avant de greffer. Cette stratégie comporte le risque d'une cicatrisation défectueuse source d'ectropion, d'occlusion incomplète et de kératite. Nous conjecturons qu'une excision-greffe précoce améliore le pronostic à long terme de ce type de brûlure. Nous présentons le cas d'une femme victime d'une agression intra-familiale à l'acide sulfurique, souffrant de brûlure des 2ème et 3ème degrés des paupières traitée par excision-greffe de peau totale précoce. À J10, la greffe était totalement intégrée et le site donneur (bras droit) était cicatrisé. La fonction palpébrale était normale et l'occlusion oculaire complète. Ces bons résultats persistaient à 2 mois, sans lagophtalmie ni défaut d'occlusion, avec un aspect esthétique correct. Les rapports de brûlures chimiques des paupières sont peu fréquents et il nous n'avons pas trouvé de protocole dans la littérature. Ce cas clinique illustre la nécessité d'une analyse précoce (dans les 6h) par ophtalmologiste et plasticien afin de définir une stratégie coordonnée vis à vis du globe oculaire et de la paupière. L'excision-greffe précoce améliore la pronostic oculaire après brûlure par acide sulfurique.

Medical and surgical management of lower extremity war-related injuries. Experience of the French Military Health Service (FMHS).

Lower extremity war wounds are characterized by high-energy trauma occasioning loss of complex and pluritissular substances. The support pipeline put into place by the French defense health service (SSA) is designed to rapidly evacuate the injured person from the scene of injury to mainland France, following initial surgery in the framework of a sequential tactic known as "Damage Control Surgery". This strategy is aimed at stabilizing the traumatized individual and enabling his evacuation. Patients are subsequently treated in a restorative surgery unit in a Hôpital d'Instruction des Armées (HIA), a level 1 trauma center (HIA Percy, HIA Saint-Anne) Cooperation between the plastic and orthopedic surgery specialties is essential insofar as it allows for surgical optimization aimed at saving the limb while restoring function to the greatest possible extent. Notwithstanding painstaking application of this common strategy, septic pseudoarthrosis remains the principal and most feared complication, at times rendering impossible any therapeutic solution other than amputation. Whether prosthetic or non-prosthetic, the rehabilitation provided by doctor/physiotherapists is conducive to patients' social and professional reintegration. The nation's duty to assist its wounded veterans is carried out with determination by the French defense ministry. As concerns lower extremity war wounds, the authors detail the reconstruction doctrine based on the 6/7/8/9 rule, in accordance with which strategies for repair of soft tissue and reconstruction of the lost bone substance have been developed.

[The "racket-like" flap: Method to increase the reliability of the sural neuro-cutaneous flap]. / Le lambeau neurofasciocutané sural : fiabilisation par le prélèvement d'un lambeau en raquette.

We realized a retrospective study from 2003 to 2018 comparing two surgical techniques of neuro-fascio-cutaneous sural flap harvesting to improve their reliability: the "vascular pedicle tunneling" method and the "racket-like" flap method. There are 35 flaps in this series from lower distal limb reconstruction: 21 "racket-like" flaps and 14 "tunneling-pedicle" flaps. There were no partial or total necrosis case in the "racket-like" flaps group. Our technique reduces covering failure due to partial or total necrosis risk with a statistically significant impact. We propose to extend the "racket-like" technique to every fascio-cutaneous flap available.

[Atypical localization of a glomus tumor]. / Une tumeur glomique de localisation atypique.

Glomous tumors are rare and benign, generally affecting the fingers. Other localizations have nevertheless been described. We report the case of a patient who presented a supra-patellar glomous tumor provoking a pain-induced limp. Magnetic resonance imaging confirmed the diagnosis. The patient underwent complete surgical resection of the tumor followed by total resolution of the pain. Glomous tumors in an atypical localization may go unnoticed, with the risk of late or erroneous diagnosis. Symptoms are easily resolved with simple resection.

Type III open tibia fractures in low-resource setting. Part 2: soft-tissue coverage with simple, reliable and replicable pedicle flaps.

After limb salvage based on debridement and external fixation, Gustilo IIIB open tibia fractures must undergo soft-tissue repair within 7 days. In low-resource setting, the coverage is performed with pedicled flaps only, which can be used by any orthopedic surgeon after minimal training. The authors describe here the simplified use of 7 basic flap transfers that can deal with almost all soft tissue defects. The diffusion of these techniques in developing countries is crucial for limiting functional and trophic effects related to prolonged exposure of the fracture site.

Complex upper arm reconstruction using an antero-lateral thigh free flap after an extravasation of Yttrium-90-ibritumomab Tiuxetan: A case report and literature review.

Yttrium-90-Ibritumomab Tiuxetan (Zevalin®) is used in the treatment of non- Hodgkin's lymphoma. Extravasation is an iatrogenic complication that is fortunately rare. However, the treatment of this complication is often complex due to the risk of extensive skin necrosis and unpredictable evolution of localized irradiation. This vesicant drug requires emergency management when extravasation occured. Radiations burns have specificities. Therefore, wound coverage involves specific plastic surgical techniques. Here, we report the case of a man presenting a chronic and extensive skin necrosis of upper arm treated with an antero-lateral thigh free flap. Moreover, we compare our experience of Zevalin® extravasation management to other past publications and propose recommendations to prevent this unacceptable complication.

Grafting both acute wound site and adjacent donor site with the same graft: an easy and safe procedure to improve healing and minimize pain in elderly and bedridden patients.

In harvesting skin to cover the defect caused by a burn, a second wound is created, the donor site wound. We propose an alternative method to manage the donor site: taking a split-thickness skin graft (STSG) from a donor site adjacent to the burn wound to be treated, and meshing at a 3:1 ratio to cover both sites at once. The main objective of this study is to evaluate the effectiveness of covering both burn wound and adjacent donor site with the same STSG in elderly and bedridden patients. We retrospectively reviewed the medical records of 6 patients over 60 years old or/and bedridden presenting with a small burn wound who underwent STSG of both burn wound and adjacent donor site between April 2016 and November 2016 in the Department of Plastic Surgery and Burn Treatment at Percy Military Hospital (France). Their data were compared with data of five patients who had undergone the usual STSG procedure during the same period. There was a statistically significant difference between patients who underwent adjacent STSG procedure and those who underwent usual STSG procedure in healing time (days) mean (SD) (7,33 ± 1,03 vs. 16,2 ± 0,83; p = 0,007) and Numeric Rating Scale pain mean (SD) at day 2 (0,33 ± 0,33 vs. 2,4 ± 1,35; p = 0,04). Grafting both acute burn wound and adjacent donor site with the same graft seems to be an easy method to improve healing and minimize pain in the STSG donor site in elderly and bedridden patients.

Lors du prélèvement de peau mince pour couvrir une plaie causée par une brûlure, une seconde plaie est créée, le site donneur. Voici une méthode alternative pour la gestion du site donneur: prélever une greffe de peau mince GPM à partir d'un site donneur adjacent à la brûlure, l'expandre avec un ratio de 3:1 pour couvrir les deux sites à la fois. Ici l'objectif principal est d'évaluer l'efficacité de la couverture simultanée d'une petite brûlure et du site donneur adjacent avec la même GPM chez les patients âgés et alités. Nous avons étudié rétrospectivement les dossiers de 6 patients traités par couverture simultanée de la brûlure et du site donneur adjacent avec la même GPM entre avril 2016 et novembre 2016 dans le Service de Chirurgie Plastique de l'hôpital militaire Percy (France). Les données ont été comparées à un groupe similaire de patients qui ont subi une procédure habituelle durant la même période. Il y avait une différence statistiquement significative entre les patients qui ont subi une procédure de GPM du site donneur adjacent et ceux qui ont subi une procédure habituelle sur la durée (jours) moyenne (écart-type, SD) de cicatrisation (7,33 ± 1,03 vs 16,2 ± 0,83; p = 0,007) et de la douleur sur l'échelle numérique au jour 2 (0,33 ± 0,33 vs 2,4 ± 1,35; p = 0,04). Greffer la plaie liée à la brûlure aiguë et le site donneur adjacent avec une même GPM semble être une méthode simple pour améliorer la guérison et minimiser la douleur du site donneur.

[Anterolateral thigh flap for distal lower leg reconstruction]. / Place du lambeau libre antérolatéral de cuisse dans la reconstruction des pertes de substance distales des membres inférieurs.

CONTEXT: Soft tissue defects of lower leg are still a challenge for the plastic surgeon. It should provide an effective and functional coverage with a minimal morbidity on the donor site. Free anterolateral thigh flap present in these areas many advantages over the pedicled local flaps and free muscle flaps used conventionally. We try to define its place through our experience with a bicentric retrospective study. MATERIALS AND METHODS: A retrospective analysis of all cases of reconstruction of the lower leg using the free ALT flap was performed in two centers of reconstructive surgery. The characteristics of the defect and reconstructions were collected. The rate of success and complication has been reported as well as long term aesthetic and functional outcomes. RESULTS: Forty-one patients were reconstructed between 2008 and 2013 for post-traumatic care in 58.5% of cases. The average size of the defect was 191.4cm2, their location was mainly on the foot and ankle (61%) and bone exposure was most frequently found (82.9%). Success rate was 92.8%. Functional results were judged as very good and good in 75.5% of cases and aesthetic results as very good and good for 63.6% of cases. Three "lost sight" 7.3% and 3 fails (7.3%) patients were not included in the result analysis. CONCLUSION: Showing functional results at least similar to other flaps, ALT flap demonstrated its reliability and its low morbidity on the donor site. Its versatility allows adaptation to the vast majority of defects of the lower leg.

Rate of intravenous thrombolysis for acute ischaemic stroke in the North-of-France region and evolution over time.

The proportion of patients with ischaemic stroke treated by intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) is an indicator of quality of stroke care. The objective of the study is to evaluate the rate of i.v. thrombolysis in the North-of-France region and its evolution over time. We determined the proportion of inhabitants treated by i.v. rt-PA in 2009-2010 (period A; 8 stroke units, no telemedicine) and 2012 (period B; population campaigns, 12 stroke units with telemedicine in 5). We used hospital registries from the 12 stroke units, and population-based data were collected in a subpopulation of 226,827 inhabitants (5.6% of the whole population). 1,563 inhabitants received i.v. rt-PA for stroke (period A: 835 in 24 months; period B: 728 in 12 months). Hospital and population data were similar. Annual rates of thrombolysis increased from 103 per million inhabitants [95% confidence interval (CI) 85-125] to 181 (95% CI 157-209; relative increase 76%, 95% CI 67-83%). This rate increased in 12 districts (significantly in 6), but the increase was greater in districts where new stroke units, telemedicine, or both were implemented. In conclusion, although the proportion of patients treated was already high in period A, there was still place for improvement. Implementation of new stroke units, extension of the telemedicine network and new population campaigns are necessary to improve the rate of thrombolysis in several areas, to ensure an equal access to treatment over the whole territory. The next step is now to determine whether this high rate of i.v. rt-PA delivery at the population level translates into clinical results.

Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers.

INTRODUCTION: The purpose of this study was to analyze the use of temporary external fixation within the perspective of a damage control orthopedics attitude in the management of battlefield extremity injuries. HYPOTHESIS: Damage control orthopaedics (DCO) is a valuable treatment option for easy and rapid limb fracture stabilization in an unfavorable surgical environment. METHODS: Sixteen French soldiers wounded on the battlefield between 2004 and 2009 and managed by damage control orthopedics were included in this retrospective series. All patients were males with a mean age of 30 years (20-53 years). Eighteen external fixators were applied on the theater of operations for multiple injuries (five cases), closed fractures of the pelvis or long bones (three cases) and open osteoarticular lesions (ten cases). RESULTS: After medical evacuation from original theater, conversion to internal fixation was possible in five cases. External fixation was maintained in thirteen cases due to the severity of the lesions or infectious complications. Bone union was achieved in all cases. The mean time for bone union was 2.8 months (2 to 3 months) in case of conversion to internal fixation, and 6.3 months (1.5 to 17 months) when external fixation was extended. To achieve bone union, three devices were removed after a three or four month period and converted to rigid internal fixation associated with bone grafting. No case of septic complication was observed after early conversion. The only case of post-conversion infection occurred after three months of external fixation. After a mean follow-up of 19 months (6 to 49 months) all patients recovered functional autonomy and thirteen could return to duty. CONCLUSION: When possible, early conversion from external to internal fixation improves bone union and functional recovery after war limb injuries in properly selected patients.

[Surgical strategy for neck burns and their sequelae]. / Stratégie chirurgicale des brûlures du cou et de leurs séquelles.

Burns of the neck are common and expose them to functional and aesthetic complications which are sometimes very serious. Care in the acute stage and treatment of sequelae contribute to a common goal of restoration: Maintain or recreate a chin-neck angle and get a quality skin as close as possible to the original skin, in terms of flexibility, texture, thickness and color. The wide variety of cases encountered requires knowing the armamentarium available to us today, and the anatomical basis and clinical underlying indications.

Cell therapy of burns.

Severe burns remain a life-threatening local and general inflammatory condition often with serious sequelae, despite remarkable progress in their treatment over the past three decades. Cultured epidermal autografts, the first and still most up-to-date cell therapy for burns, plays a key role in that progress, but drawbacks to this need to be reduced by using cultured dermal-epidermal substitutes. This review focuses on what could be, in our view, the next major breakthrough in cell therapy of burns - use of mesenchymal stromal cells (MSCs). After summarizing current knowledge, including our own clinical experience with MSCs in the pioneering field of cell therapy of radiation-induced burns, we discuss the strong rationale supporting potential interest in MSCs in treatment of thermal burns, including limited but promising pre-clinical and clinical data in wound healing and acute inflammatory conditions other than burns. Practical options for future therapeutic applications of MSCs for burns treatment, are finally considered.

[The risk of iatrogenic burn must not be forgotten while struggling against nosocomial infection: rules and precautions in operating rooms]. / Prévention des infections nosocomiales et brûlures iatrogènes : rappel des règles et précautions à respecter au bloc opératoire.

Accidental burns in the operating room are hopefully rare events, but it could happen during any surgical procedure. To reduce the nosocomial infection, the use of alcohol-base products is recommended by all the recent guidelines. Yet these inflammables products represent a potential danger if they are not carefully employed, and the surgeon's responsibility can be involved. We therefore thought it would be interesting to show the benefit provided by such products in terms of wound infection and skin preparation. However, two recent cases of severe accidental burn illustrate the importance of precautions when using such products.

[Radiation burn "innovating therapeutic approach"]. / Brûlure par irradiation « approche thérapeutique innovante ¼.

Radiation burn is a determinist effect of localized irradiation. The lesion is in good correlation with absorbed dose. Radiation burn is different from thermal burn. The evolution is spatiotemporal unpredictable with successive inflammatory waves and recurrence of necrosis. The conventional surgical treatment is rarely efficient because each surgical operative act seems to stimulate the inflammatory waves and fibro-necrosis process. The lesion can escape to this conventional surgical treatment. The new therapeutic approach combines surgery and cellular therapy with local administration of autologous mesenchymal stem cells. From 5 years, cell therapy have been an adjuvant treatment of surgery. This association is a therapeutic innovation, it's now the recommendation for conservative surgery of this very serious radiation burn.

[Facial locoregional anesthetics: principles and precautions]. / Anesthésies locorégionales de la face : principes et précautions.

Facial locoregional anesthetics (ALR) with nervous blocks are simple and reliable to perform, need little technical resources with a very low iatrogenic risk. These blocks allow anesthesia without deforming wound banks using the same materials as usual local anesthetic procedures. Three principal nervous blocks, in a straight line along the vertical pupil axis, allow managing - even extensive - facial wounds. Few side effects may occur which can be easily prevented. It is a good alternative to local anesthetic for the treatment of extensive and deep areas which is performed with a lower number of injections and a high rate of success. These techniques are easy to learn and practise. These anesthetic techniques allow a nice treatment of different kinds of facial wounds from simple suture to flaps.

[Incidence and microbiology of infectious complications with the use of artificial skin Integra in burns]. / Incidence et microbiologie des complications infectieuses lors d'utilisation de la peau artificielle Integra chez le brûlé.

Integra dermal substitute is used as biomaterial after thermal injury. This artificial skin allows temporary coverage after burns excision, transformation of matrix in neo dermis and definitive engraftment. Infections are the most common complication of this technique. The objectives were to evaluate incidence of sepsis, to analyse microbiology and risk factors of developing Integra infections. Patients with acute burns and indications of Integra during five years were retrospectively enrolled. Demographic data, surgical procedures and microbiologic biopsies were collected. Fifty patients (40 + or - 15 years) were studied and 71 surgical procedures using Integra were performed. Burns were extended 45 + or - 21% total body surface area. Placement of Integra was made 15 + or - 11 days after burns and autografts 31 + or - 9 days after placement of Integra. Twenty-one patients had infected Integra (42% of population). A total of 23 Integra infected sites were observed (15 local and eight invasive). Diagnosis of infection was made after 13 + or - 5 days using quantitative cultures. Other sites of infection were respiratory tract (46 pneumonias) and others burned wounds (17 infections outside of Integra. Any risk factor was identified between burns who developed Integra infections and the others. Incidence of infected Integra was higher than in previous studies. Delayed application of Integra after burns could explain higher incidence of infection. Pseudomonas aeruginosa and Staphylococcus aureus were more frequently isolated than other pathogens. Standardized technique for wounds coverage with Integra is necessary to reduce incidence of infections and improve functional results in burns patients.