Randomized comparative study of negative pressure wound therapy versus compression dressing on split-thickness skin grafts of the lower limbs in an elderly population.

INTRODUCTION: Failure to adequately secure the skin graft to the lower limbs recipient bed can result in loss of the graft. Our objective was to compare the healing of split-thickness skin grafts three weeks postoperatively, using either negative pressure wound therapy (NPWT) or conventional compression bandaging. METHODS: In this multicenter randomized controlled study, patients with tissue loss ranging from 50 cm2 to 600 cm2 on the lower limbs and treated with split-thickness skin grafts were included in three French hospitals. A digital photographic evaluation was performed at 3 weeks. RESULTS: During 9 years, 70 patients were included in the study and allocated to a treatment group. The grafted area was similar in both groups. Loss of graft was significantly reduced in the NPWT group with 14.6 cm2 compared to 29 cm2 in the control group (p = 0.0003). The hospital stay was also significantly reduced in the NPWT group, at 4 days versus 6.5 days in the control group (p = 0.0284). In the NPWT group, 60% reported pain compared to 22.9% in the control group (p = 0.0048). CONCLUSIONS: The use of NPWT dressings improves skin graft take by reducing necrosis, improving the graft's adherence to the recipient site, and reducing hospital length-of-stay.

Bone consolidation under septic condition and hardware retention: about 69 patients.

INTRODUCTION: Management of infection on internal fixation hardware is particularly complex. The main aim of the present study was to assess bone consolidation rates under septic conditions in patients treated for bone and joint infection (BJI) with hardware retention. Secondary objectives were to determine a time limit beyond which it is unreasonable to retain hardware, and to assess risk factors for non-consolidation and functional results. The study hypothesis was that bone consolidation is possible under septic conditions without hardware exchange. MATERIAL AND METHOD: A single-center retrospective observational study was conducted on 69 patients for the period January 1, 2009 to December 31, 2019. We included all patients aged over 15 years with infection after internal fixation or fusion whose files had been discussed in the multidisciplinary team meeting during the study period. Bone healing was screened for on X-ray or CT. Study data comprised type of fracture, smoking status, time to treatment for open fracture, initial surgery time, type of hardware, interval between fixation and revision, and type of irrigation. Functional results were assessed at follow-up: walking, pain, return to work and SF12 and QuickDASH scores. RESULTS: The bone healing rate was 73.5% (50/68 patients) at a mean 24 weeks (range, 6-68 weeks). Time to revision did not significantly impact consolidation: 60% for 2 weeks (6/10 cases), 80% for 2-10 weeks (35/40 cases), and 64% for >10 weeks (9/14 cases) (p = 0.28). Smoking, longer initial surgery time and Gustilo type IIIb or IIIc were significant risks factors for non-consolidation. DISCUSSION: Bone consolidation under septic conditions with hardware retention adhering to an established medical and surgical protocol was reliable and straightforward, without extra morbidity. These findings are encouraging, and in line with the literature. We were unable to determine a time limit beyond which hardware prevented healing. LEVEL OF EVIDENCE: IV; descriptive epidemiological study.

[RECOMA study: Evaluation of quality of life and satisfaction after immediate or delayed breast reconstruction]. / Étude RECOMA : évaluation de la qualité de vie et de la satisfaction après reconstruction mammaire immédiate ou différée.

OBJECTIVE: Breast reconstruction after mastectomy, whether immediate or delayed, is an integral part of the overall management of breast cancer. However, up to 40 % of reconstructed patients are not satisfied with the aesthetic result. The primary objective of the study was to evaluate satisfaction and quality of life according to the reconstruction techniques used in our center. The secondary objectives were to identify the parameters that could influence satisfaction and quality of life after surgery, to list the main complications, and the number of operations required to consider the reconstruction process as completed. METHOD: A retrospective monocentric study, RECOMA, was carried out at the CHRU Minjoz in Besançon. All patients who underwent immediate or delayed breast reconstruction between 2010 and 2021 were contacted by post or e-mail and asked to complete the standardized BREAST-Q postoperative module. RESULTS: Of 508 patients contacted, 149 were included. Reconstructed patients reported satisfaction, but also "average" quality of physical and psychological sexual life. Only the surgeon's assessment was rated as "good". There was no significant difference in satisfaction and quality of life depending on the reconstruction method chosen. On the other hand, patients who underwent nipple areolar complex (NAC) reconstruction had a significantly higher psychic quality of life score (P=0.02). In addition, a significant decrease in physical satisfaction was observed over time(P=0.049). An average of 2.4 operations was required to consider breast reconstruction complete. CONCLUSION: In our opinion, breast reconstruction is an essential procedure to be considered as soon as the indication for mastectomy is given, but it is a process that requires the patient to be prepared for a result that may be weaker than expected, may require several operations, and may be complicated.

Interest of acellular dermal matrices in immediate breast reconstruction: Comparison of quality of life and complications with and without matrix.

INTRODUCTION: Since 2001, acellular dermal matrices have been increasingly used in immediate breast reconstruction (IBR) because they allow for the placement of the ideal-sized definitive implant in one step. They are used in both retropectoral and prepectoral prosthetic breast reconstructions. The aim of this study was to evaluate the impact of dermal matrices on the quality of life and on complications. MATERIALS AND METHODS: Two surveys were used to evaluate the quality of life: the BREAST-Q V2.0© and the QuickDASH. The surveys were sent to all patients who had an immediate prosthetic breast reconstruction at a University Hospital Center from 2010 to 2020. A case-control study was performed for comparison of responses between the "Matrix+" and "Matrix-" groups. RESULTS: Seventeen IBR with matrix (23.6%) and 55 IBR without matrix (76.4%) were analyzed. Patients in the "Matrix+" group had a better quality of life in terms of sexual well-being (p = 0.038) and a significantly lower QuickDASH (p < 0.01). They had better breast satisfaction (p = 0.016) and better implant satisfaction (p < 0.01). The likelihood of encountering major complications later in time was more important in the group with matrix (p = 0.04). CONCLUSION: We found a satisfactory quality of life with scores of sexual well-being and satisfaction with the breast and the implants, and a better satisfaction with care thanks to the use of the matrices. However, due to a higher number of major late complications and a lack of follow-up, we believe that immediate prosthetic breast reconstruction with matrix should be discussed according to the comorbidities, medical treatments, and the vitality of the skin flaps of each patient.

Outcomes of Autologous Fat Graft Injection(s) in Treating Sequelae of Digital Trauma: A Case Series.

Background: Sequelae of digital trauma, such as painful scars adherent to tendons and bones, pain of neural origin, cold intolerance, skin and pulp atrophy, occur frequently. Autologous fat graft injections is an interesting option to treat these sequelae. The aim of this study is to describe the outcomes of autologous fat graft injections to treat sequelae of digital trauma. Methods: This retrospective study included all adult patients with digital trauma who underwent an autologous fat grafting procedure at our hospital between 2015 and 2019. The procedure was done at least 6 months after the initial trauma. Outcomes were assessed at least 9 months after the injection and included 2-point epicritic discrimination by Weber test (2-PD) and pulp circumference of the affected finger compared with the contralateral finger, a satisfaction questionnaire concerning the improvement of symptoms, aesthetic aspects and pain related to the operation, evaluation of pain by visual analogue scale, quality of life by SF-36 score and quick disabilities of the arm, shoulder and hand questionnaire (QuickDASH) score. We also assessed whether the patients had reintegrated a previously excluded finger. Results: The study included 14 patients. All patients received one session except for one patient who received two sessions. The average 2-PD of the injured finger was 7 mm compared to 3.57 mm for the contralateral finger. There was no difference in pulp circumference between the treated and contralateral fingers. The mean satisfaction score for symptom improvement and aesthetic improvement was 3.36/5, and the mean score for procedure-related pain was 2.36/5. The mean VAS of the patients was 2.91/10, the mean SF-36 was 60.42/100 and the mean QuickDASH was 40.09/100. Five of the nine patients who had a previously excluded finger were able to reintegrate it. Conclusions: Autologous fat transfer seems to offer some benefit in patients with adherent scars and pulp atrophy. It has little effect on neuropathic pain. Level of Evidence: Level IV (Therapeutic).

The impact of COVID-19 on hand surgery: A French retrospective comparative study in COVID-19 and non-COVID-19 hand trauma centers.

INTRODUCTION: In 2020, the pandemic divided France into two zones: COVID-19 and non-COVID-19. The main objective of our study was to compare the variability of surgical and emergency consultation activity amongst two hand trauma centers, between the pandemic period and outside the pandemic period. The secondary objective was to identify at-risk patients in order to develop preventative strategies in hand trauma. METHODS: This bi-centric retrospective study considered the epidemiology of admissions to trauma centers during the first French lockdown. The data were compared to the same period in 2019 (control group). Two thousand and fifty-five patients underwent consultations for hand or wrist trauma. RESULTS: The first French lockdown was associated with a 35% decrease in hand and wrist injuries in the COVID-19 zone versus 24% in the non-COVID-19 zone, compared to the same period in 2019 (p<0.0001, 95% CI: 6.5-15.6). Comparing 2019 and 2020, the incidence of wounds significantly increased in the COVID-19 zone (58% vs. 78%, p<0.0001) and significantly decreased in the non-COVID-19 zone (55% vs. 50%, p<0.0001). Complex wounds (16% vs. 35%, p<0.0001 and 15% vs. 17%, p<0.0001) and open fractures (8% vs. 14%, p=0.019 and 4.5% vs. 5.3%, p<0.0001) significantly increased in both zones during the pandemic. The rate of male, non-manual workers injured in domestic accidents (76% vs. 36%, p<0.0001) was significantly increased in all areas. CONCLUSION: Hand and wrist trauma was less frequent but more severe during the pandemic compared to the same period in 2019. By encouraging the public to be aware of the risks and the means to avoid trauma, such as better information and compliance with safety instructions, we could minimize these risks. This data can be useful in planning preventative strategies for future lockdowns. LEVEL OF EVIDENCE: III; case-control study.

Has the COVID lockdown altered the incidence and management of fragility fractures in older adults? Case-control study at a French University Hospital.

INTRODUCTION: In France, a national lockdown related to the COVID-19 pandemic was imposed from March 17 to May 11, 2020, drastically changing our professional and organizational practices. We were interested on the impact of the lockdown on fragility fractures in older adults (65 years and older). The primary objective of this study was to evaluate the incidence of peripheral and pelvic fragility fractures during the lockdown. The secondary objectives were to carry out an epidemiological analysis of the fractures, treatments and hospitalization data. HYPOTHESIS: The main hypothesis was that the number of peripheral and pelvic fragility fractures was lower during the lockdown in 2020 than in the same (non-lockdown) period in 2019. MATERIALS AND METHODS: We retrospectively collected epidemiological (age, sex), clinical (type of fracture, treatment) and hospitalization data from patients 65 years and older who came to the emergency room because of a peripheral and/or pelvic fracture between March 17 and May 11 of the years 2019 and 2020. RESULTS: We included 192 patients in 2019 and 157 patients in 2020. The mean age and sex ratio were not statistically different. The number of peripheral and/or pelvic fragility fractures decreased by 16%. The share of patients treated surgically was similar in both years (46% in 2019; 51% in 2020 (p=0.47)). The number of proximal femur fractures dropped by 21%. The mean time to surgery for these fractures was shorter in 2020 (p=0.02) although the mean length of hospital stay was unchanged (p=0.72) The mortality rate of patients hospitalized for fragility fractures did not increase significantly (p=0.51). DISCUSSION: We observed a reduction in the number of peripheral and pelvic fragility fractures in patients 65 years and older during the lockdown. To ensure that we met our goals of optimal care for proximal femur fractures, a general reorganization of the operating room was necessary. The continued availability of fully functional technical facilities despite this health crisis was crucial to being able to treat these fractures and to prevent increased mortality. LEVEL OF EVIDENCE: III, case-control study.

Abdominoplasty and lower body lift surgery improves the quality of life after massive weight loss: a prospective multicenter study.

BACKGROUND: This study was conducted to assess the impact of abdominoplasty and lower body lift surgery following massive weight loss on both the general quality of life and the sexual life of patients. METHODS: We performed a multicenter prospective study on the quality of life after massive weight loss using three scoring questionnaires: The Short Form 36 questionnaire, the Female Sexual Function Index questionnaire, and the Moorehead-Ardelt Quality of Life Questionnaire. Seventy-two patients who underwent lower body lift and 57 patients who underwent abdominoplasty in three centers with pre and post-operative evaluation were included. RESULTS: The mean age of the patients was 43.2 ± 13.2 years. All categories of the SF36 questionnaire were statistically significant at 6 months, and all categories except health change were significantly improved at 12 months post-operative. Overall, the Moorehead-Ardelt questionnaire showed a higher quality of life in general (1.78 ± 0.92 and 1.64 ± 1.03, at 6 and 12 months respectively) and in all domains (self-esteem, physical activity, social relationships, work performance, and sexual activity). Interestingly, global sexual activity improved at 6 months but not at 12 months. Some domains of sexual life improved at 6 months (desire, arousal, lubrication, satisfaction), but only the desire stayed improved at 12 months. CONCLUSION: Abdominoplasty and lower body lift improve the quality of life of patients after massive weight loss as well as the sexual quality of life. This should be an additional valid reason for promoting reconstructive surgery for massive weight loss patients.

Should the artery be trimmed before anastomosis in every finger replantation/revascularization case? Prospective, single-center, multidisciplinary study over 46 months.

INTRODUCTION: Despite optimal arterial anastomosis, some finger replantations fail. Our objective was to evaluate how the mechanism of injury (MOI) affects the artery's microscopic appearance and the success of anastomosis. We hypothesized that the MOI influences arterial histology and microsurgical success. METHODS: This single-center prospective study enrolled patients who had an acute traumatic arterial injury of the hand and/or wrist. The proximal and distal ends of the artery were trimmed before anastomosis in every case. The arterial margins were analyzed in anatomical pathology. Clinical follow-up along with an ultrasound arterial patency check was carried out at 1 month postoperative. RESULTS: Between 2018 and 2022, 104 patients were enrolled with a follow-up of 12 months. Macroscopically, 42% of the arterial margins were dilapidated. Histological analysis found damage in 74% of surgical specimens: blast (100%)>laceration by mechanical or power tool (92%; 82%)>amputation by mechanical or power tool (80%; 67%)>laceration by glass (50%)>crush injury (33%). The arterial margins were more likely to be normal based on the histological analysis when the MOI was laceration by glass (p<.05; OR=3.72) and the patient was 65 years or older (p<.01). Risk factors for anastomosis failure were an amputation by power tool (p<.01, OR 8.19) and shorter length of arterial resection (p<.02). The clinical failure rate was 7.8% and the patency failure rate was 10.4%. DISCUSSION: Histological arterial lesions correlate with the MOI. Trimming >2mm from the proximal and distal arterial ends is recommended for all MOI before arterial end-to-end anastomosis. For blast injuries or amputation, we recommend trimming>4mm and using a vein bypass graft. This study's findings could lead to a change in surgical practices. LEVEL OF EVIDENCE: II; well-conducted non-randomized comparative study; recommendation grade B: scientific presumption.

Intra- and Inter-rater Reliability of Postoperative Radiographic Analysis of Reverse Shoulder Arthroplasty in 49 Shoulders After Proximal Humerus Fracture.

Introduction: The lateralization shoulder angle (LSA), the distalization shoulder angle (DSA) and the new "pentagon" concept are tools used in scheduled shoulder surgery to evaluate the positioning of reverse shoulder arthroplasty (RSA) implants. There is no information on the intra- and inter-rater reliability of these tools in the context of RSA for a proximal humerus fracture. The first hypothesis was the high reliability of the intra- and inter-rater analysis of the LSA and DSA angles. The second hypothesis was the reproductibility of the pentagon based on LSA and DSA analysis. Methods: Forty-nine patients were evaluated retrospectively with a minimum of 2 years radiological follow-up after RSA surgery. Tuberosity healing was evaluated using an AP radiograph of the shoulder and their location analyzed within the said "pentagon" defined by the LSA/DSA angles and the maximum lengthening recommended. Results: The intra-rater analysis found strong to an almost perfect agreement for the LSA and DSA. The agreement was moderate to strong for the pentagon. The inter-rater analysis found a fair agreement for the LSA and moderate agreement for the DSA and pentagon. Conclusion: The LSA/DSA is used in patients undergoing RSA for glenohumeral OA. In this context, the tuberosities were intact and certain complications inherent to RSA for humeral fracture were not present. The population studied here (RSA after fracture) creates an interpretation bias due to the difficulty in analyzing tuberosity position. Level of Evidence: 4, retrospective study.

Medial Thighplasty Improves Patient's Quality of Life After Massive Weight Loss: a Prospective Multicentric Study.

BACKGROUND: The aim of this study was to assess the impact of medial thighplasty following massive weight loss on the quality of life of patients and on their sexual life. METHODS: We performed a multicentric, prospective study on the quality of life after massive weight loss using the Short-Form 36 questionnaire, the Female Sexual Function Index questionnaire, and the Moorehead-Ardelt Quality of life questionnaire. Forty-nine patients who underwent medial thighplasty were included in three centers and evaluation was made pre- and post-operatively. RESULTS: The mean age of the patients was 44 ± 12.5 years. The average pre-medial thighplasty body mass index was 27 ± 3.8 kg/m2. All the categories of the SF36 questionnaire scored higher after surgery apart from "health change" but only the "role limitations due to emotional problems" category was significantly improved (p = 0.0081). Similarly, the Moorehead-Ardelt questionnaire showed a positive impact of the surgery on the quality of life in general (mean total score 1.04 ± 1.37) and on self-esteem, physical activity, social relationships, and work performance. Interestingly, sexual activity was not improved by the surgery and this result is in line with the FSFI, which showed no effect of medial thighplasty on sexual life. CONCLUSIONS: Medial thighplasty improves the quality of life of patients after massive weight loss but does not seem to modify the sexual quality of life. These results clearly indicate that this surgery should be widely offered to patients seeking reconstruction of massive weight sequelae.

Epidemiology of upper limb chronic exertional compartment syndrome (CECS) in the French Motorcycle Federation racers: Results of a national questionnaire-based study.

Upper limb chronic exertional compartment syndrome (CECS) has been described in amateur and professional motorcycle racers, but there is no published data about its prevalence. The purpose of this study was to define the awareness, prevention and prevalence of this syndrome in licensed motorcycle racers in competition in France. Secondary purposes were to determine the functional impact of CECS and post-treatment outcomes. The 20,641 licensed racers in competition of the French Motorcycle Federation were sent a self-assessment questionnaire about upper limb pain and CECS physical examination findings, functional impact and treatment outcomes. The satisfaction level was assessed after each type of treatment. Acceptability rate was 6.35% with 1311 racers responding. CECS was unknown by 29% of racers. Prevention methods were unknown by 10% of racers. Less than 50% of racers modified their bikes. The prevalence of upper limb CECS in competitive racers was 9%: 8.7% forearm, 0.2% thenar, 0.1% hypothenar and 0.4% first dorsal interosseus compartments. The prevalence was 16% in international level racers, 11% in national level racers and 7.3% in regional level racers. A quarter of racers were satisfied or very satisfied with the outcomes of conservative therapy and rehabilitation. Only 67 racers underwent surgical treatment for their upper limb CECS: 31 by open fasciotomy, 23 by minimally invasive fasciotomy and 13 by endoscopy-assisted compartment release. In these 67 racers, the mean visual analog score for pain improved significantly (p < 0.001 95% CI [3.1-4.5]) with 81% satisfied or very satisfied with surgery outcomes. This epidemiologic self-assessment questionnaire for upper limb CECS is a new concept. This study screened for CECS and offer information regarding evaluation, treatment, and management.

Extensor digitorum brevis muscle flap for lower extremity coverage in a context of posttraumatic sepsis.

INTRODUCTION: Traumatic injuries to the distal quarter of the leg present a significant risk of skin necrosis and exposure of the underlying fracture site or the osteosynthesis material that often result in bone and joint infection. In the case of small or medium-sized bone exposure, local muscles may be one of the best options for lower extremity coverage. We describe our experience using the extensor digitorum brevis muscle flap in a context of posttraumatic bone and joint infection in fourteen patients. Our main objective was to assess the outcomes and the donor-site morbidity of the extensor digitorum brevis muscle flap. MATERIALS AND METHODS: A single-center retrospective study in a French reference center for bone and joint infection from 2014 to 2018 reviewed cases of traumatic injuries with skin complications and bone and joint infection that required an extensor digitorum brevis muscle flap coverage. Fourteen patients were evaluated for early and late complications, 11 men and three women with a mean age of 51.4±17.72 (19-71) years. Seven of these were open fractures and nine cases were pilon fractures. Donor-site morbidity was assessed in nine patients. RESULTS: Early flap complications included two cases (14.2%) of hematoma, one case (7.1%) of partial necrosis and four cases (28.5%) of donor-site dehiscence. Late complications caused by persistent infection were found in two patients (14.2%), with one case (7.1%) of chronic osteoarthritis and one case (7.1%) of septic pseudarthrosis. From a functional and cosmetic point of view, eight patients (89%) were satisfied, to very satisfied. CONCLUSION: Experience and a multidisciplinary approach are keys in providing an optimal treatment strategy for complex cases of bone and joint infection. The extensor digitorum brevis muscle is a reliable flap for small defects with underlying infection. Being made up of muscle tissue, this flap offers good resistance to infection and enables satisfactory distribution of antibiotics. LEVEL OF EVIDENCE: IV.

Induced membrane maintains its osteogenic properties even when the second stage of Masquelet's technique is performed later.

PURPOSE: Previous clinical studies have shown the effectiveness of bone repair using two-stage surgery called the induced membrane (IM) technique. The optimal wait before the second surgery is said to be 1 month. We have been successfully performing the IM technique while waiting an average of 6 months to carry out the second stage. We hypothesised that the IM maintains its beneficial capabilities, even at a later second stage, and that there is no relation between the speed of bone union and the wait between the first and second stage. We sought to explore the biological properties of 'older' IMs sampled to substantiate our clinical observations. METHODS: Thirty-four patients with a critical size defect were treated with the IM technique. In seven of these patients, pieces of the IM were collected 4.2-14.7 months after the first surgery. IM-derived cell phenotype and osteogenic potential were investigated using in vitro studies (n = 4) while IM nature and function were investigated by histology and immunohistochemistry (n = 3). RESULTS: The median wait before the second surgery was 5.8 months [range 1.2-14.7] and bone healing occurred at 7.6 months [range 2.5-49.9] for 26 patients. IMs aged 4.2-14.7 months contained mesenchymal stromal cells with in vitro osteogenic potential and corresponded to a multipotent tissue with osteogenic and chondrogenic capabilities contributing to osteogenesis over time. CONCLUSION: This preliminary study suggests the IM retains its powerful osteogenic properties over time and that waiting longer between the two surgeries does not delay bone union.

Correction to: Induced membrane maintains its osteogenic properties even when the second stage of Masquelet's technique is performed later.

The original version of this article unfortunately contained a mistake. The presentation and legends of Figs. 4 and 5 were incorrect. The corrected versions are given below. The original article has been corrected.

ALGINATE versus NPWT in the Preparation of Surgical Excisions for an STSG: ATEC Trial.

A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments. METHODS: This randomized, non-inferiority trial enrolled patients who underwent skin excision (>30 cm2), which was left open to heal by secondary intention. They received ALGINATE or NPWT by a centralized randomization. Follow-up was performed weekly until optimal granulation tissue was obtained. The primary outcome was time to obtain optimal granulation tissue for a split thickness skin graft take (non-inferiority margin: 4 days). Secondary outcomes were occurrence of adverse events (AEs) and impact of the treatments on the patient's daily life. RESULTS: ALGINATE and NPWT were applied to 47 and 48 patients, respectively. The mean time to optimal granulation was 19.98 days (95% CI, 17.7-22.3) with ALGINATE and 20.54 (95% CI, 17.6-23.5) with NPWT. Between group difference was -0.56 days (95% CI -4.22 to 3.10). The non-inferiority of ALGINATE versus NPWT was demonstrated. No AE related to the treatment occurred with ALGINATE versus 14 AEs with NPWT. There was no difference in the impact of the treatments on the patient's daily life. CONCLUSION: This trial demonstrates that ALGINATE has a similar healing efficacy to that of NPWT and that is markedly better with regard to patient safety.