[Thirty years of laser-assisted microvascular anastomosis (LAMA): what are the clinical perspectives?]. / Trente ans de microanastomoses vasculaires assistées par laser: des perspectives cliniques ?

INTRODUCTION: Since the first studies by Jain and Gorisch (1979), laser-assisted anastomoses have been steadily developed to a stage where clinical use is within reach. The laser-assisted vascular microanastomosis (LAMA) procedure is performed more quickly than conventional anastomosis, the surgically induced vessel damage is limited, and reduced bleeding after unclamping is observed. MATERIAL AND METHODS: A Medline literature search, for the January 1979 to February 2010 period, was performed to review articles focusing on the LAMA technique. RESULTS: The search yielded a total of 354 publications, of which 87 were relevant: 82 were animal series and five clinical studies. Microsurgical techniques and principal characteristics of LAMA in patients are the focus of the analysis. This study discusses the technological innovations and new orientations in laser welding. CONCLUSION: The first two clinical series using the 1.9-µm diode laser appear promising. Technical innovation will most likely lead to greater ease of use of the laser handpiece in the operating room.

[Historical review and future orientations of the conventional vascular microanastomoses]. / Revue historique et orientations futures aux microsutures vasculaires conventionnelles.

Microvascular surgery has become an important method for reconstructing surgical defects due to trauma, tumors or after burn. The most important factor for successful free flap transfer is a well-executed anastomosis. The time needed to perform the anastomosis and the failure rate are not negligible despite the high level of operator's experience. During the history, many alternatives were tried to help the microsurgeon and to reduce the complications. A Medline literature search was performed to find articles dealing with non-suture methods of microvascular anastomosis. Many historical books were also included. The non-suture techniques can be divided into four groups based on the used mechanism of sutures: double intubation including tubes and stents, intubation-eversion including simple rings, double eversion including staples and double rings, and wall adjustement with adhesives or laser. All these techniques were able to produce a faster and easier microvascular anastomosis. Nevertheless, disadvantages of the suturless techniques include toxicity, high cost, leakage or aneurysm formation. More refinement is needed before their widespread adoption. Thus, laser-assisted microvascular anastomosis using 1,9 µm diode laser appeared to be a safe and reliable help for the microsurgeon and may be further developed in the near future.

[Breast reconstruction with a free DIEP flap complicated by spontaneous rupture of internal mammary artery]. / Reconstruction mammaire en terrain irradié par lambeau libre DIEP compliqué d'une rupture spontanée de l'artère mammaire interne : à propos d'un cas.

Breast reconstruction with a free Deep Inferior Epigastric Perforator Flap (DIEP flap) is now well established and provides excellent aesthetic results. Nevertheless, preoperative radiotherapy can damage the recipient vascular axes. We report a case of a grave and undocumented spontaneous rupture of the internal mammary artery related to the use of irradiated arterial vessels.

[Microsurgical nail reconstruction with free short-pedicle vascularized nail flap: about 13 cases]. / Reconstruction de l'unité unguéale par transferts vascularisés à pédicule court. A propos de 13 transferts de l'appareil pulpo-unguéal.

This study was performed to review our 24-year experience in nail reconstruction with special attention to surgical technique, outcomes and cosmesis. A retrospective chart review of 13 toenail complexes transfers alone over a 24-year period was performed. The patients, nine men and four women, had an average age of 20 years (range, 2 to 38 years) at the time of surgery. Etiologies were trauma in 10 cases and tumor in three cases. The mean follow-up time was 13 years (range, 2 to 23 years). One nail flap necrosis occurred after surgery accounting for a complication rate of 8 %. Regarding nail cosmetic, the mean Foucher score was 15.4 points. Though nail reconstruction has been sometimes associated with complications and low cosmetic improvements, this study showed how microsurgery is able to reduce trauma issues.

[Flexor carpi radialis tendon rupture following percutaneous osteosynthesis of the scaphoid: a case report]. / Rupture du tendon du fléchisseur radial du carpe après ostéosynthèse percutanée d'une fracture de scaphoïde. A propos d'un cas.

We present a rare complication of percutaneous osteosynthesis of a scaphoid fracture. A 19-year-old professional handballer presented with a fracture of the scaphoid classified B2 according to the Herbert classification: the fracture was fixed with a percutaneous screw. The fracture was united by six weeks despite resumption of training eight days postoperatively. Subsequently, the patient presented with pain over the flexor carpi radialis (FCR) tendon together with reduction of wrist flexion strength suggested an FCR tendonitis. A CT scan with injection eliminated the diagnosis of non-union and showed protrusion of the distal end of the screw. After the failure of conservative treatment (corticosteroid injection), removal of the screw and synovectomy of the FCR were scheduled. During the procedure, attrition of the FCR tendon with scar tissue and metal inclusions in its fibres were observed. A visual examination of the screw's distal end showed a distortion of its hexagonal outline due to hammering, leading to metal projection likely to have caused the FCR tendon's attrition. We recommend the systematic burying of these canulated screws as well as changing any screw damaged during its insertion.

[Coverage of dorsal distal skin defects of the digits. Techniques and indications]. / Couverture des pertes de substance cutanée distales des doigts. Techniques et indications.

Distal dorsal skin defects of the digits could be considered as a surgical entity. The coverage of this area is challenging according to the following points: the proximity of the distal interphalangeal joint, the thinness of the extensor apparatus and the vicinity of the nail. Among the numerous flaps described, the homodigital turnover pedicled flaps appear the most effective option rather than cross-finger flaps.

[Outlook of composite tissues allotransplantation for limbs reconstructive surgery, especially hand surgery]. / Perspectives pour l'allotransplantation de tissus composites en chirurgie reconstructrice des membres, en particulier de la main.

The microsurgical composite tissues allotransplantation (CTA) is an emerging avenue in reconstructive surgery. Improvements in the immunosuppressive therapy and in the immunological induction of tolerance between host and donor allow for customized limb reconstruction, with limited graft alteration, and decreased exposure to immunosuppressive drugs. Several clinical cases with a potential use of CTA are described.

[Results of 46 digital replantations. With a minimal follow-up of one year]. / Résultats de 46 replantations digitales. A un an de recul minimum.

Forty six digital replantations were analysed with a minimum follow-up of one year. The mechanism of the injury and the level of the amputation were systematically analysed to asses the objective (mobility, sensitivity, prehension), and the subjective results (pain, vasomotor dysfunction, satisfaction). The replantations were typically in the long fingers in young men (index and middle fingers at the level of the middle phalanx) by work or industrial accident (complete section or digital crushing). Seventeen replantations (37%) were secondarily amputated. Arterial thrombosis was the main cause of amputation in 94% of the cases and had occurred in 50% of the cases by the forty eight postoperative hour. An early revascularization procedure was attempted in ten cases (21%). Among these ten revascularizations procedures, we noted eight failures (80%). During the first six postoperative weeks, the complications of the replantations were skeletal displacements, tendon ruptures and joint subluxations. After six weeks, the complications were joint stiffness (26%), sensory deficits (19.5%), severe cold intolerance (13%), vasomotor dysfunction (10%) with stiffness of the proximal interphalangeal joints in 60% of the cases. We noted other complications such as neuroma of distal stump, cutaneous retraction and deformation of the fingers. Finally, only nine digital replantations (19.5%) evolved favourably with complete restoration of sensorimotor function without any complication. The best results were obtained from amputations of the middle finger with the mechanism of section being a circular saw (40%).

[The anterior interosseous flap in wrist and hand surgery: a series of fifteen cases]. / Le lambeau interosseux antérieur dans la chirurgie du poignet et de la main: à propos de 15 cas.

INTRODUCTION: Fifteen anterior interosseous flaps were used to reconstruct wrist and hand defects in fifteen patients (thirteen men and two women) with a mean of 38 years (27-42 years). PATIENTS AND METHODS: Seven anterior interosseous osteoperiosteal flaps and eight anterior interosseous osteocutaneous flaps were used. Seven island flaps and eight free flaps based on the anterior interosseous artery were raised. The indications were scaphoid non-union (4 cases), first metacarpal non-union (2 cases), proximal phalanx non-union (1 case), Kienböck's disease (2 cases), osteocutaneous phalangeal defects (3 cases), osseous capitatum defect (1 case) and intracarpal arthrodesis (2 cases). RESULTS: Postoperatively, one fracture of the distal end of the radius was noted because of a large osteoperiosteal corticotomy. Osseous reconstruction was usually consolidated at three months. One failure was noticed (Kienböck's disease). No significant deformity was noticed in the donor site. CONCLUSION: The anterior interosseous flap seems to be a useful alternative to reconstruct small or moderate defects in wrist and hand surgery.

[The palmar nail syndrome. Case report]. / Le syndrome de l'ongle palmaire congénital. A propos d'un cas.

The congenital ectopic nail is very rare and usually present as an ectopic abnormal nail alongside the normal fingernail. Ridder described in 1992 the "congenital palmar nail syndrome" sharing a palmar ectopic nail, a loss of flexion and a small distal phalanx on x-ray. We report a case of a congenital palmar nail syndrome of both little fingers on a boy 13 years old.

Cryptosporidiosis leading to an unsuspected diagnosis of AIDS.

We describe a 68-year-old woman with an episode of diarrhoea, malaise and weight loss, caused by infection with Cryptosporidium. The diagnosis was hampered because this patient had a low risk of HIV infection, a two-year history of Crohn's disease, and a simultaneous candidal infection. An infection with Cryptosporidium was demonstrated with electron microscopic examination, and subsequent tests revealed positive HIV serology. AIDS was probably contracted through her husband.

[Pisiforme-hamate coalition: a case report]. / Synostose symptomatique entre hamatum et pisiforme: à propos d'un cas.

The authors report a symptomatic case of pisiforme hamate coalition in a young woman. The resection of the synchondrosis allowed the complete resolution of the pain. The pisiforme hamate fusion is an exceptional deformity and it is confirmed by the revue of the Literature.

[The fasciocutaneous hypothenar flap: preliminary anatomical and clinical study]. / Le lambeau fasciocutané hypothénarien: étude anatomo-clinique préliminaire.

The authors have studied the vasculatization of the hypothenar area on 11 fresh hands. X ray done after injection and dissection under magnification confirm the possibility to take a fascio cutaneous flap vascularised by the ulnar digital artery of the fifth finger. Three patients who presented a loss of substance of the palmar site of the fifth finger received a fascio cutaneous hypothenar flap. The donor site was directly closed. This flap was proposed for the loss of substance of the palmar site of the fifth finger in competition with the others flaps.

[Failure of upper limb macro-implantations: surgery and outcome. 11 cases]. / Echec des macroréimplantations du membre supérieur: chirurgie et devenir. A propos de 11 cas.

The failure of macro-implantation of the upper limb must not be considered as the end of a therapeutic method, but instead as a step in the functional rehabilitation of the upper limb. From a group of 24 patients that have been operated with a macro-implantation of the upper limb, we have seen 11 patients for who the reimplantation had failed. We have studied the surgical procedure of those failures, the mid-term evolution (prosthesis and operations), and a long-term evolution with the functional future of those patients. A surgical procedure with latissimus dorsi flap was necessary in six cases, in one hand to maintain a sufficient length of the stump for prosthesis and the other hand to preserve the articulation of the elbow. Nine patients on 11 were able to be "apparated" by a myoelectric prosthesis for the amputation below the elbow (seven cases), by prosthesis for the amputation above the elbow (two cases). On a long period of time (average time 51 months) only four patients had a permanent use of their prosthesis (myoelectric type). For us, the functional rehabilitation of the upper limb need two important elements: first a good quality of the stump with a sufficient length, and second an important motivation from the patient to live with his "new hand".

[Acute digital ischemia: a microsurgical emergency]. / L'ischémie digitale aiguë: une urgence microchirurgicale.

The authors are reporting their experience about the treatment of the acute finger ischemia concerning 14 patients. Twelve men and two women were concerned. The average age was 39 years old (18 to 65 years old). The acute finger ischemia was caused by emboli released by an ulnar aneurysm in nine cases and consecutive to an atrial fibrillation in five cases. The angiography was realized each time systemically in the emergency context. The medical or surgical etiological treatment was associated each time an emboli was found on the digital arteries. A microsurgical dissection of the digital collateral arteries permitted to perform a thrombectomy. The transversal arteriotomies were closed after collateral arteries were washed. The most proximal emboli were accessible to an extraction with a Fogarty's probe up to the superficial palmar arcade. An anticoagulant treatment was conducted in the early postoperative period. Considering this aggressive treatment, no secondary amputation was necessary up to today. The average follow-up was five years. This method has no indication for the chronic digital ischemias (diabetes, Buerger's disease) and for infectious or auto-immune arteriopathy.

[Secondary reconstruction of stumps above the elbow. Five cases]. / Reconstruction secondaire des moignons d'amputation au-dessus du coude. A propos de cinq cas cliniques.

The authors report a serie of five patients with five stumps above the elbow who needed a secondary reconstruction to allow or facilitate a prosthesis. They used in the first case an expansion of the latissimus dorsi flap and of the axillary and prepectoral region in order to free the stump of the humerus sutured on the thorax. In the second case, a free parascapular flap covered an unstable scar of the clavicula after a scapulothoracic amputation. In the third case, the transfer of a free flap of fibula associated with a pedicled latissimus dorsi flap had allowed the elongation of the stump of the humerus. In the two last cases, a latissimus dorsi flap pedicled in one and free in the second one had allowed to preserved the length of the humerus for prosthesis. The technical choices are eclectic and different in every case. The purpose is to obtain an efficient trophicity and a thickness that can support the prosthesis and if possible a stump long enough to improve the adaptation of the prosthesis. The five operated patients were able to be apparated, reducing in this way their daily functional difficulties.