Necrotizing soft-tissue infection of the upper limb: A single-center study of 24 cases.

OBJECTIVES: Necrotizing soft-tissue infection and necrotizing fasciitis of the upper limb are infrequent. Studies are rare, and often include other anatomical regions. The specificities and particularities of this pathology are not well known. The aim of this study was to report diagnosis and treatment aspects. METHODS: A retrospective study was conducted over 10 years on every patient treated for necrotizing fasciitis of the upper limb with clinical, bacteriological and histological confirmation. One hundred ninety-eight items were extracted for each patient concerning clinical, biological, radiological and therapeutic data. RESULTS: During 10 years, 24 patients were diagnosed with necrotizing fasciitis of the upper limb: 18 males, 6 females; mean age, 59.9 years; mean body mass index, 25. Local erythema, pain and fever were the most frequent symptoms. Skin necrosis was present in fewer than 40% of patients. Sixteen cases (66.6%) had prior skin lesions and/or an entry point on the limb. Ten had non-steroidal anti-inflammatory drug prescription before acute symptom onset (42%), requiring intensive care unit admission. Treatment comprised surgical resection, resuscitative measures, antibiotic therapy and reconstructive surgery. Seven patients (30.4%) had 1 session of cutaneous excision, and the others had more than 2. Microbiological analysis found mono-microbial beta-hemolytic group A streptococci (BHGAS) infection in 14 patients (58.4%). Antibiotics were prescribed in 91% of cases before surgery, and in 100% after. The most frequently prescribed substance was clindamycin (18 patients, 75%). Ten patients (42%) stayed in the intensive care unit during treatment. Seventeen patients (70.8%) had thin skin graft reconstruction, including 50% with dermal substitute. Five patients (20.8%) had partial upper limb amputation. Two patients (8.3%) died in the 30 days following diagnosis. CONCLUSIONS: The death rate in necrotizing fasciitis of the upper limb was rather low but the amputation rate was higher than in other locations. This study shows the specific clinical, biological and treatment features of this rare but serious pathology of the upper limb.

The distal dorsal intermetacarpal ligament: characterization of an overlooked structure-an anatomical study of 25 hands.

PURPOSE: Exhaustive literature is available on the metacarpophalangeal joints of the long fingers, but the dorsal ligamentous structure overlaying the interosseous muscles and joining the metacarpal heads of the long fingers remains to be fully characterized. Previously, our surgical hand team observed a non-classically reported structure connecting the metacarpal heads of the long fingers, in the dorsal part of the intermetacarpal spaces. Therefore, the aim of this anatomical study was to characterize this ligamentous structure in terms of size, insertions, and anatomical position. METHODS: Twenty-five hands were dissected for a total of 75 long finger intermetacarpal spaces. A ligamentous structure was exposed after cellular tissue excision and dorsal superficial fascia opening. The length and thickness were measured and anatomical position and insertions were studied. Histological analysis was performed on five specimens and ultrasound analysis in one healthy subject. RESULTS: All 25 dissections revealed a dorsal ligamentous structure, hereafter named distal dorsal intermetacarpal ligament, which was inserted in the lateral tubercle of each adjacent long finger metacarpal head. This distal dorsal intermetacarpal ligament surrounded interosseous tendons. It was more proximal compared to oblique and transversal interosseous muscle fibers. Histological analysis confirmed the ligamentous nature of the structure. Ultrasound analysis showed that this structure was well identified under the dorsal aspect of the hand. CONCLUSION: All dissections revealed a tense ligamentous structure between each metacarpal head of the long fingers. This was a constant structure meeting the definition of a ligament. The distal dorsal intermetacarpal ligament seems to stabilize the metacarpal heads at the second and fourth spaces by limiting hyperabduction.

Adipose tissue-derived stromal vascular fraction for treating hands of patients with systemic sclerosis: a multicentre randomized trial Autologous AD-SVF versus placebo in systemic sclerosis.

OBJECTIVE: To assess the superiority of adipose tissue-derived stromal vascular fraction (AD-SVF) injection into the fingers vs placebo in reducing hand disability in systemic sclerosis (SSc) patients. METHODS: We performed a double-blind, multicentre, phase II trial from October 2015 to January 2018 in France. SSc patients with a Cochin Hand Function Scale (CHFS) ≥20/90 were randomized 1:1 to receive injection of AD-SVF or placebo. AD-SVF was obtained using the automated processing Celution 800/CRS system. The placebo was lactated Ringer's solution. The primary efficacy end point was the change of the CHFS score from baseline to 3 months. Secondary efficacy endpoints included the CHFS score at 6 months, hand function, vasculopathy, hand pain, skin fibrosis, sensitivity of the finger pulps, Scleroderma Health Assessment Questionnaire, patients and physician satisfaction, and safety. RESULTS: Forty patients were randomized. The AD-SVF and placebo groups were comparable for age, sex ratio, disease duration, skin fibrosis of the hands and main cause of hand disability. After 3 months' follow-up, hand function significantly improved in both groups with no between-group difference of CHFS (mean change of -9.2 [12.2] in the AD-SVF group vs -7.6 [13.2] in the placebo group). At 6 months, hand function improved in both groups. CONCLUSION: This study showed an improvement of hand function in both groups over time, with no superiority of the AD-SVF. Considering the limits of this trial, studies on a larger population of patients with homogeneous phenotype and hand handicap should be encouraged to accurately assess the benefit of AD-SVF therapy. TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02558543. Registered on September 24, 2015.

Ambulatory hand emergency: 2 years-experience in an public university hospital center.

Hand emergencies represent the most frequent traumatic injuries and outpatient surgery is still improving. It will achieve 70% of total surgeries by 2022. Our hand trauma center has been able to set up an emergency day surgery department in a university hospital center. With this article, we would like to report the ambula- tory care management and practice for hand emer- gencies in our university hospital center over 2 years. 892 patients suffering from hand traumas and managed in our day surgery department, were retro-spectively reviewed between January 2016 and December 2017. Patients' demographic data, anesthe- tic data, trauma's circumstances, medical care and surgical outcomes have been disclosed. A descriptive analysis and a statistical assessment was realized. Cut injury was the most recorded case, followed by impactions. Tendon injuries were the most frequent (32%), followed by fractures (26%), and exposed joints (18%). 13% of injuries were nil findings. Average patient care delay was 1.16 days. Mean of hospitalization was 7.5 hours. 16/892 patients needing intravenous antibiotics required hospitalization. 41 complications including 27 secondary surgeries were reported. Hospital facilities are forced to reassess their entire procedures to achieve efficiency and improvement for healthcare. Progress in outpatient surgery permits emergency management in hand surgery, improving patient cares both medically and economically.

Segmental aponeurectomy with Z-Plasty as a treatment option in Dupuytren's disease: A retrospective cohort study.

BACKGROUND: Aponeurectomy remains the reference standard treatment for digit tethering by palmar fascial cords in Dupuytren's disease but is associated with a substantial complication rate. An alternative technique decreases metacarpophalangeal joint (MCPJ) flexion contracture by combining palmar segmental aponeurectomy with Z-plasty skin closure. The primary objective of this study was to assess range of motion of the operated ray after the procedure. The secondary objectives were to assess the complication rate and to determine the recurrence rate after at least 1 year. HYPOTHESIS: Palmar segmental aponeurectomy with Z-plasty closure may provide the advantages of aponeurectomy while decreasing the surgical risk and recurrence rate. MATERIAL AND METHODS: A retrospective study was conducted in 16 patients with predominant MCPJ flexion contracture due to a well-defined palmar fascial cord. Anaesthesia was loco-regional. The Z-plasty design involved a longitudinal incision along the palmar cord with an oblique incision at each end at a 60° angle to the longitudinal incision. The length of the aponeurectomy was about 1.5cm, to allow full MCPJ extension. RESULTS: In all, the 16 patients-13 males and 3 females-had 17 segmental palmar aponeurectomy procedures with Z-plasty closure. Mean operative time was 18minutes. Before surgery, mean loss of extension was 47° at the MCP joint and 15° at the corresponding proximal interphalangeal joint (PIPJ). Immediately after surgery, a 97% improvement in MCPJ extension was noted, leaving a mean extension deficit of 1.25°. Mean follow-up was 18.9 months. No complications occurred. Two patients experienced a recurrence. DISCUSSION: Segmental palmar aponeurectomy as described by Moermans in 1991 improves extension similarly to extensive aponeurectomy but has a lower complication rate. Z-plasty provides good exposure of the pedicles and takes advantage of the greater pliability of the skin on either side of the cord to lengthen the skin by 75%, thereby limiting the risk of the complications seen with needle aponeurotomy. Segmental palmar aponeurectomy with Z-plasty has a role in the management of Dupuytren's disease with flexion contracture predominantly involving the MCPJ.

Anatomical study of the perforator flap based on the acromial branch of the thoraco-acromial artery (abTAA flap): a cadaveric study.

PURPOSE: The aim of this anatomical study was to describe a local perforator flap, for covering shoulder defects, by determining the features of the acromial branch of the thoraco-acromial artery (abTAA), and the supplied cutaneous area. METHODS: Thirteen fresh cadaveric thoraxes were dissected bilaterally. A precise and reproducible protocol was performed. For each abTAA flap cadaveric dissection, the following parameters were measured after arterial injection: distances between the origin of the perforator artery on the abTAA and the sternum, the acromion, the clavicle, diameter of the perforator artery of the abTAA, length of the perforator pedicle course through major pectoralis muscle, and rotation arc. We also calculated the surface of the injected skin paddle. These measurements were related to morphometric parameters evaluated through the distance between sternum and acromion. RESULTS: The mean distances measured from the origin of the perforator artery on the abTAA were 14.25 cm to the sternum, 3.45 cm to the acromion, 5.65 cm to the clavicle. The mean diameter of the abTAA was 1.20 mm ± 0.2. The arc of rotation was 180°, and the length of the perforator pedicle could be extended to 7.46 cm ± 1.15. We observed an colored elliptical cutaneous paddle with a longer radius 18 cm and a small radius 15 cm. CONCLUSIONS: Our results suggest that this type of flap could be useful in clinical practice for reconstruction and covering of the acromial area with a thin cutaneous flap with low sequelae on the donor site.

Dorsal Dupuytren's disease: a systematic review of published cases and treatment options.

Dorsal lesions in Dupuytren's disease are rare and data concerning their epidemiology and management are sparse. We conducted a systematic review to summarize reported cases of dorsal Dupuytren's disease. Pubmed, Cochrane, and Embase databases were searched from 1893 to 2018, and 17 articles were selected (525 patients). The male to female ratio was 3.8:1. The dorsal disease was bilateral in 225 patients (50%). The index was the most commonly affected finger (48 patients). The proximal interphalangeal joint was the most commonly affected (484 cases). The most frequently reported lesions were knuckle pads (503 patients), dorsal nodules between interphalangeal joints (14 patients), boutonnière deformities (12 patients), and swan-neck deformities (2 patients). Nearly half of the included patients were treated surgically. Postoperative functional result depended on the treated lesion. Most of the included studies had a low level of evidence. Higher-quality studies are necessary to confirm our findings.

The flip-flap puzzle flap: Another recycling option.

Post-traumatic soft tissue defects sometimes require sequential flap coverage to achieve complete healing. In the era of propeller flaps, which were developed to reduce donor site morbidity, Feng et al. introduced the concept of the free-style puzzle flap, in which a previously harvested flap becomes its own donor site by recycling the perforator. However, when a perforator cannot be found with a Doppler device, we suggest performing a new type of flap, the flip-flap puzzle flap, which combines two concepts: the free-style puzzle flap and the flip-flap flap described by Voche et al. in the 1990s. We present the cases of three patients who achieved complete healing through this procedure.

Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: an updating review.

INTRODUCTION: The elbow joint is particularly exposed to soft tissue injuries associated with fractures and dislocations. Different coverage options within the past decades for recovering loss of soft tissue defects around the elbow region have been proposed based on anatomical research. Our aim was to make an updated focus on the anatomical basis of different techniques of coverage of loss of tissues around the elbow. MATERIALS AND METHODS: The main procedures of flaps were defined: local random, axial fasciocutaneous, local muscle pedicle, propeller and free microvascular flaps. A systematic literature review on anatomical basis on these different flaps options was conducted searching on PubMed databases and the selection process was undergone according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline. Inclusion criteria were: review and original articles, including anatomical basis of the procedures, in English and French languages. RESULTS: The final analysis included 37 relevant articles out of 1499 published references. 640 flaps were referenced, for covering 302 elbows. Local random flaps provide a good quality skin for small tissue defects in posterior elbow and periolecranon area, and depend on dermal and subdermal blood supply. Axial fasciocutaneous flaps have well-defined blood supplies and are designed as peninsular, island, or microvascular free flaps, as the radial forearm, lateral arm, ulnar artery, antecubital fasciocutaneous, and posterior interosseous flaps. Muscular flaps have advantages as strength, capacity to contrast local infection and to avoid empty spaces, and can be used as pedicle or as free transfers. Propeller flaps can be rotated up to 180° around an axis corresponding to the perforator vessel and do not require the sacrifice of a major artery or functional muscle. The concept of perforasome is evoked. Free microsurgical transfers can be proposed to cover any defect around the elbow. DISCUSSION AND CONCLUSION: The anatomical basis of the flap's harvesting and the possibilities of elbow coverage are discussed through the selected articles. The different indications according to the areas of soft tissues defects are considered.

Malignant transformation of mastocytoma developed on skin mastocytosis into cutaneous mast cell sarcoma.

Mastocytosis is a group of disorders characterized by abnormal mast cell proliferation, involving the skin in 80% of cases. Cutaneous mastocytosis, which appears in childhood in 60% of cases, usually has a benign course with a gradually regressive evolution before puberty. Mast cell sarcomas, part of the systemic forms of mastocytosis, are very rare tumors characterized by a destructive growth of highly atypical mast cells, with secondary spread, poor prognosis, and low survival rates. We report the first known case of primary cutaneous mast cell sarcoma due to the transformation of a benign solitary mastocytoma in an adult suffering from an unregressive localized cutaneous mastocytosis. Histologic characteristics of the tumor, mutation analysis, and c-Kit expression were compared with available data. Wide surgical excision of the tumor followed by adjuvant local radiotherapy were performed, and for the first time the use of imatinib was attempted, as neoplastic mast cells expressed the CD117 marker. However, they failed to control the progression of sarcoma. To date, no treatment is known to be effective for this disease, which is associated with short-term survival of the patients.

Synovium CD20 expression is a potential new predictor of bone erosion progression in very-early arthritis treated by sequential DMARDs monotherapy -- a pilot study from the VErA cohort.

OBJECTIVE: Because available biomarkers (rheumatoid factors [RF], anti-cyclic citrullinated autoantibodies [anti-CCP2], erythrocyte sedimentation rate at 1st hour [ESR]/C-reactive peptide [CRP] and bone erosions) are insufficient to predict rheumatoid arthritis (RA) structural damage, to determine whether synovium expression of greater or equal to 1 markers could constitute new prognostic factor(s). METHOD: The study was conducted on 18 prospectively enrolled disease-modifying anti-rheumatic drug (DMARD)- and glucocorticoid-naïve, VErA cohort patients with very-early arthritis (median duration: 4months). Recorded at baseline were: clinical and biological (serum ESR, CRP, RF-isotypes, anti-CCP2, osteoprotegerin, receptor activator of nuclear κB-ligand [RANK-L] and cartilage oligomeric matrix protein [COMP] levels) data; synovium expression (HLA-DR, CD163, CD3, CD20, VEGF, osteoprotegerin, RANK-L, Bcl2 and global inflammation index) for a metacarpophalangeal joint-synovium biopsy. Baseline and 3-year hand-and-foot X-rays were graded with the van der Heijde-modified-Sharp score; the judgment criterion was its progression during follow-up. Pearson's product moment correlation statistics were used to test for association between paired samples. RESULTS: A baseline, a significant relationship was found between erosive damage and markers of B-cell activation, notably the synovium CD20 expression (r=0.68; P=0.0001). Quantified by the modified-Sharp erosion score variation, the 3-year structural damage progression was significantly correlated with: serum levels of RF-IgG (r=0.75; P=0.0003), -IgM (r=0.69; P=0.001), anti-CCP2 (r=0.53; P=0.02) and RANK-L (r=0.61; P=0.007); synovium CD20 expression (r=0.70; P=0.001). CONCLUSION: This analysis of the prognostic value of a large panel of synovium markers in a limited sample of prospectively followed, well-documented patients suggested that both synovial CD20 and serum RANK-L levels might be new predictors of structural damage progression in very-early RA.

Anatomical study and clinical relevance of the flexor superficialis synovial flap: an assessment of 31 hand dissections.

PURPOSE: The authors present an anatomical study of the flexor digitorum superficialis synovial flap and its clinical application for palmar soft tissue defects in hand trauma. METHODS: Green latex was injected into the brachial artery of thirty-one human upper limbs from corpses donated to science. Anatomical features of this pedicled flap were assessed: arterial vascularization, dimensions and covering surface. RESULTS: The anatomical support of this flap is the synovial tissue of the flexor tendons, and particularly the superficial layer of the synovial system, covering the flexor digitorum superficialis (FDS) tendons in the forearm. It is vascularized by four different arteries: a constant collateral branch of the ulnar artery, and three inconstant arterial supports: from collateral branches of the superficial palmar arch, from the radial artery, and from the vasa nervorum of the median nerve. The flap is harvested from proximal to distal on the ulnar pedicle to cover the palmar soft tissue defects of the hand. A clinical application of this synovial flap is presented via a case report for covering a palmar skin defect secondary to a hand injury. CONCLUSIONS: The synovial flap contains a constant ulnar pedicle and could be considered a useful alternative to cover palmar soft tissue defects.

Role of toll-like receptor 4 in the inflammation reaction surrounding silicone prosthesis.

The inflammation which occurs around the silicone prosthesis is a complex process that can provoke the failure of the device and compromise the health of the implanted patient. Toll-like receptors (TLRs), which are transmembrane proteins, are now known to act in the innate immune response and in endogenous inflammation. The aim of our study was to assess the role of TLR4 in the foreign body reaction to a silicone shell prosthesis. Disks of shell silicone prosthesis were implanted in the subcutaneous tissue of C57BL6-TLR4-/- and C57BL6-WT mice. At day 14, inflammatory cell infiltrate and vessel sections around the prosthesis were less numerous in TLR4-/- than in WT mice. A histomorphometric analysis showed that the capsule around the implant was 1.96-fold less thick in depleted TLR4 than in wild-type mice. In addition, vascular endothelial growth factor and transforming growth factor 1 were underexpressed in the surrounding tissue of the prosthesis in TLR4-/- mice. Our study suggests, from this foreign body response model against silicone in mice, that TLR4 plays a key role in the reaction process around silicone implants.

Early and long-standing rheumatoid arthritis: distinct molecular signatures identified by gene-expression profiling in synovia.

INTRODUCTION: Rheumatoid arthritis (RA) is a heterogeneous disease and its underlying molecular mechanisms are still poorly understood. Because previous microarray studies have only focused on long-standing (LS) RA compared to osteoarthritis, we aimed to compare the molecular profiles of early and LS RA versus control synovia. METHODS: Synovial biopsies were obtained by arthroscopy from 15 patients (4 early untreated RA, 4 treated LS RA and 7 controls, who had traumatic or mechanical lesions). Extracted mRNAs were used for large-scale gene-expression profiling. The different gene-expression combinations identified by comparison of profiles of early, LS RA and healthy synovia were linked to the biological processes involved in each situation. RESULTS: Three combinations of 719, 116 and 52 transcripts discriminated, respectively, early from LS RA, and early or LS RA from healthy synovia. We identified several gene clusters and distinct molecular signatures specifically expressed during early or LS RA, thereby suggesting the involvement of different pathophysiological mechanisms during the course of RA. CONCLUSIONS: Early and LS RA have distinct molecular signatures with different biological processes participating at different times during the course of the disease. These results suggest that better knowledge of the main biological processes involved at a given RA stage might help to choose the most appropriate treatment.

The risk of pulmonary aspiration in patients after weight loss due to bariatric surgery.

BACKGROUND: We conducted a study including patients with gastric banding or gastroplasty who previously underwent plastic or functional surgery to assess the risk of pulmonary aspiration. METHODS: A retrospective case-control study was performed including all patients undergoing a plastic or functional surgery over a 5-yr period (2000-2005) at Rouen University Hospital. Two groups were defined: the postbariatric group included patients who previously had bariatric surgery (laparoscopic adjustable gastric banding or Mason's vertical gastroplasty) before undergoing the plastic surgery; all other patients were assigned to the control group. Data included all anesthetic management and were recorded in the hospital computer database. The incidence of pulmonary aspiration was the outcome variable. RESULTS: One hundred ninety-eight plastic and functional operations (66 cases and 132 controls) were performed. Pulmonary aspiration was significantly (P<0.006) higher in the postbariatric group (4 patients: 6%) than in the nonbariatric group (0 patient). For this complication, all patients had previously undergone gastric banding. One patient who did not receive prokinetic prophylaxis required intensive care for severe pulmonary alteration. CONCLUSION: The risk of perioperative pulmonary aspiration in a patient after weight loss due to gastric banding was considered significant.

Arterial anatomical basis of the dorsal digito-metacarpal flap for long fingers.

Several flaps have been described to treat severe soft tissue defects of the finger dorsal side. Many authors studied vascular organization of the hand on its dorsal side; most of them insisted on deep vascularization into the intermetacarpal spaces, which is formed by the dorsal metacarpal arteries. Those dorsal metacarpal arteries are the anatomical support of many flaps, which do not preserve the dorsal interosseous muscles fascias. Only few authors described dorsal vascular organization at the level of the proximal phalanx; however, using a rotation point of a flap distally to the metacarpal head with a donor site on the dorsal aspect of the hand could cover all distal soft tissue defect of long finger. In order to determine the technical limitations of dorsal digito-metacarpal flap procedures, we studied number and location of arterial anastomoses between the reticular subcutaneous dorsal network and the rest of the vascularization at this level, which was formed by the deeper dorsal metacarpal arteries, common palmar digital arteries and proper palmar digital arteries, and between the dorsal digital arteries. Twenty-four long fingers from embalmed cadavers were studied after a reverse flow injection of colored latex and dissected layer-by-layer preserving the digital-metacarpal arterial network. At the level of the hand, the dorsal metacarpal arteries of the third and fourth intermetacarpal spaces were inconstant. When present, two or three arteries anastomosed in star shape with the reticular network. No such arterial anastomosis was observed proximally to the level of the intertendinous connections (junctura tendinorum) that bridge the extensor digitorum communis tendons. When no dorsal metacarpal artery was present, some communicant arteries arose from the common palmar digital arteries. Moreover, all the nutrient branches were more numerous distally to the intertendinous connections (junctura tendinorum). At the level of the metacarpophalangeal joints, the hand cutaneous network was always anastomosed with the dorsal cutaneous network. At the level of fingers, the dorsal cutaneous network was always supplied by four branches arising from the proper digital artery. Our study supported the reliability of dorsal digitometacarpal flaps, supplied by numerous palmodorsal digital anastomoses and by a rich plexiforme network joining the hand skin supply and that of the dorsal finger skin. During the procedure, we recommend limiting the surgical dissection of the flap at the level of the middle phalanx.