Surgical treatment of secondary lymphedema of the upper limb by stepped microsurgical lymphaticovenous anastomoses.

OBJECTIVE: The incidence of lymphedema following treatment for breast cancer ranges between 10 and 50% after complete axillary dissection and gives rise to severe functional discomfort in patients. Results of lymphaticovenous anastomoses (LVA) in surgical treatment of lymphedema appear to be favorable. However, the available literature on this topic is scarce, often with short follow-up times. The aim of this study is to analyze the results of LVA on 31 patients and to review the existing literature. PATIENTS AND METHODS: This study comprised 31 female patients presenting lymphedema of the upper limb following treatment for breast cancer for which surgical treatment was given by microsurgery consisting of three stepped LVA performed in an outpatient setting. RESULTS: The post-LVA arm circumference was measured at three levels (wrist, forearm, and arm) in 31 female patients. Mean follow-up time was 12.8 months. Reduction in the circumference was 22.5, 21.32, and 30.2%, respectively, in the wrist, forearm, and arm. Functional improvement was observed in the majority (84%) of patients ranging from moderate to substantial. Only 2 patients had no result. The only patients to experience recurrence were those with a high level of lymphedema. CONCLUSION: The review of the current literature and the present study revealed modest results in terms of decreased excess volume, although a major improvement in function points to LVA as a useful technique in this indication. Progress in imaging techniques has enhanced the results achieved with this procedure, although further studies on recurrence rates are needed with a follow-up greater than 1 year.

Hook nail deformity.

Hook-nail deformity is frequently seen after a fingertip amputation, whether or not flap reconstruction has been done. It is more frequent if the bony support is missing. The deformity results in esthetic and functional impairment which can lead to complete finger amputation. Correction is surgical, but is difficult and surgical series are small. Soft-tissue flap augmentation is simple, but does not add a bony support. Bone augmentation using local flaps is limited by the small size of the distal phalanx remnant. Toe transfer is more logical but, as it is a highly demanding technique, only a few cases have been published. The present study sought to review all the published techniques and their results, to help the reader choose the one best suited to their patient.

Complex abdominal wall reconstruction after oncologic resection in a sequalae of giant omphalocele: A case report.

INTRODUCTION: Trauma injuries and oncologic resection are common aetiologies of complex abdominal wall defect. Reconstruction of abdominal wall is an everlasting question for general, paediatric and reconstructive surgeons. The plethora of techniques, bioprosthetic and engineered tissues offer countless possibilities. PRESENTATION OF CASE: The patient was a 28 years old woman, with past history of untreated giant liver omphalocele, admitted for a suspicious hepatic tumefaction without specific clinical signs. The thoraco abdominopelvic CT scan revealed lung metastasis and a bilobed left hepatic tumour. Pre-operative cytologic findings of mild differentiated hepatocellular carcinoma differed from the post-operative findings of hepatoblastoma. The full-thickness abdominal wall defect after a radical resection was reconstructed with a combined acellular dermal matrix, NPWT and skin graft solution. A total epithelization was obtained after 8 weeks follow-up. DISCUSSION: Hepatoblastoma in adult is rare, with no consensus. A radical resection in context of giant untreated omphalocele is an unusual challenge for the surgical team. The pre-operative evaluation, the defect classification and the general conditions of the patient are paramount steps for an appropriate reconstruction. Primary or delayed reconstruction with myocutaneous flap as gold standard, depends on the oncologic management and anticipated post-operative complications. Acellular dermal matrix used for a bridged fascial repair directly on viscera and covered by NPWT, favourited a healthy granulation tissue. The full-thickness defect was then reconstructed with an ADM, NPWT and skin graft instead of an association with the myocutaneous flap. The patient follow-up was emphasized in the hepatoblastoma, but the complications of this reconstruction strategy are unknown. A total epithelization was obtained, the abdominal bulge or hernia is the first complication under surveillance. CONCLUSION: Delayed reconstruction after an oncologic large abdominal wall resection has the advantage to manage post-operative complications and prepare alternative solutions. Acellular dermal matrix was not first designed for skin tissue regeneration, some authors as us experimented the conclusion that this matrix could be used for permanent abdominal wall reconstruction.

Posttraumatic pseudoaneurysm of a superficial branch of the ulnar artery: A case report.

INTRODUCTION: Hand and Upper limb pseudoaneurysms are uncommon and misdiagnosed. The delayed diagnostic and treatment lead to severe vascular and nerve complications. Many mechanisms are involved like acute injury, chronic micro traumatism of the hand, with specific clinic and para clinic signs. PRESENTATION OF CASE: The patient was a 30-years old woman, right-handed, admitted at the emergencies for a penetrating hand injury at the junction of the middle third - distal third of the left forearm, palmar surface, with a good radial and ulnar pulse, without sensory or motor deficit. No vessels injuries observed per operatively. A post-operative worsened pain opposite to the scar with a purplish pulsatile swelling appeared after 20 days of complete wound healing. A needle puncture with a red blood contain, motivated an US Doppler revealing a pseudoaneurysm of a superficial artery of the ulnar artery, surgically resected, without complication. DISCUSSION: Two main mechanisms are involved in upper limb especially hand pseudoaneurysm: penetrating trauma and repeated micro traumatism. Superficial vessels are rarely damaged compare to deep subfascial vessels according to Laplace law. The diagnostic is clinical confirmed with the medical imaging. A pseudoaneurysm is suspected in front of a pulsatile painful tumefaction following a vessel path, with medical imaging in favor. A delayed misdiagnosis lead to a delayed care with severe complications as thrombosis, embolism and vessel. The therapeutic care is mainly surgical. CONCLUSION: This case reports a delayed diagnostic of posttraumatic pseudoaneurysm of a superficial branch of the ulnar artery, managed with a surgical resection.

Total Thumb Carpometacarpal Joint Arthroplasty: A Retrospective Functional Study of 28 MOOVIS Prostheses.

BACKGROUND: Trapeziometacarpal prostheses have been used for more than 50 years in the treatment of first carpometacarpal joint arthritis. Even though this technique is more expensive than trapeziectomy, it has many advantages such as faster convalescence with better patient comfort and improved strength and range of motion. The aim of this study was to report the early functional results of a patient cohort treated with a dual mobility thumb carpometacarpal joint prosthesis. METHODS: A retrospective study was performed to assess the functional results of 25 patients treated for trapeziometacarpal advanced osteoarthritis (Eaton and Littler stage III) with 28 MOOVIS prostheses. Preoperative and postoperative assessments included pain, range of motion, and pinch and grip strength. The average follow-up time was 27.5 months. RESULTS: The mean pain score measured by a visual analog scale was 8 preoperatively and 1 postoperatively. The mean preoperative Kapandji opposition score was 7 and counter-opposition score was 1; postoperative scores were 10 and 4, respectively. The grip strength improved after the surgery and the results were compared separately between dominant and nondominant sides. Final functional results were good: the mean Quick Disabilities of the Arm, Shoulder and Hand Questionnaire score was 12, and the mean Michigan Hand Outcomes score was 87%. CONCLUSIONS: Total joint arthroplasty with a dual mobility prosthesis appears to be a satisfactory solution in our series. The absence of prosthesis instability encourages us to recommend this technique for the treatment of advanced trapeziometacarpal osteoarthritis for people having an activity without too many manual constraints.

Adaptive Proximal Scaphoid Implant: Indications and Long-Term Results.

Objective This study aims to define the indications of APSI and to evaluate the long-term results. Patients and Methods This is a monocentric study including patients that underwent an arthroplasty of the scaphoid proximal pole using an APSI between 1994 and 2010. Patients were assessed using autoquestionnaires and measuring ranges of motion, key pinch, and grip strength. X-ray views of the wrist were done to control the mobility of the implant and the evolution of the carpal collapse, if present. Results There were 19 patients included with a mean follow-up of 11 years. The mean range of motion was 106 degrees (65% of contralateral side) in flexion-extension and 33 degrees (78% of contralateral side) in radialulnar deviation. The mean grip strength was 72% of the contralateral side. The mean Mayo wrist score was 69/100, the mean QuickDASH 26/100, and the mean patient-rated wrist evaluation (PRWE) 25/100. After 10 years, evolution to osteoarthritis was noted in 32% of the patients. This was associated with a decrease of the carpal height. More specifically, capito-lunate osteoarthritis was noted after 10 years and two out of three patients were concerned after 20 years of follow-up. No osteoarthritis was diagnosed at the radiolunate articulation. Conclusion APSI is a treatment option that enables patients with scaphoid nonunion advanced collapse (SNAC), scapholunate advanced collapse (SLAC) I or II to preserve the strength and mobility with good functional results. But this arthroplasty does not prevent natural evolution to a carpal collapse after a follow-up of 20 years which is clinically well tolerated.