[Double use of sural fascio-cutaneous flap with distal pedicle to cover loss of substance of ankle or heel]. / Double utilisation du lambeau fascio-cutané sural à pédicule distal pour couvrir une perte de substance cutanée de la cheville et du talon.

The authors report on a case of a distally based fascio-cutaneous flap from the sural region which has been used twice to cover two different cutaneous sites of an ankle. A 50 years old patient underwent a polytrauma including an open fracture of the ankle. The wound at the anterior aspect of the ankle did not heal and the cover by a distally based fascio-cutaneous sural flap was decided and realized successfully. Three weeks later, owing to the development of an ulcer of the heel, it was decided to cover this skin ulceration with the same distally based flap. This second procedure needed a complementary dissection at the bottom of the flap. Twenty days later, the remaining flap was put back and the uncovered donor site was skin-grafted. The two sites covered by the flap healed, without any further complications. They only benefited in the following months of plastic revision to improve their shapes. In the discussion the authors remind the anatomic basis of this distally based flap, described by Donsky and Fogdestam in 1983. They also discuss the other possibilities to cover these two lesions on the same ankle, using others flaps particularly the lateral supra malleolar flap described by Masquelet, the medial plantar island skin flap described by Harrison and Morgan, the lateral calcaneal skin flap described by Grabb and Argenta and the neuro-vascular island skin flap proposed by Masquelet et al. This clinical case emphasizes on the great interest of the distally based sural flap in the cover of the skin defect of the ankle. The flap is easy to raise and offers a great available skin surface, which can be used, as demonstrated by this original case, in two different sites of the ankle.

[Macroscopic, histologic and ultrastructural study of 89 prostheses of anterior cruciate ligament excised because of prosthesis failure]. / Etude macroscopique, histologique et ultrastructurale de 89 prothèses du ligament croisé antérieur explantées pour échec.

PURPOSE OF THE STUDY: This study concerns the etiology of failed synthetic anterior cruciate ligament (ACL) prostheses, and attempts to identify the primary mechanisms that lead to their premature rupture. MATERIAL AND METHODS: A total of 89 failed and surgically excised ACL prostheses were retrieved from young and active patients (27 +/- 7 years) at various orthopaedic centres in France. Their average duration of implantation was 34 +/- 24 months. They were examined macroscopically, histologically and by scanning electron microscopy (SEM) to determine the model, the manufacturer, the surgical technique used at implantation, the extent of healing, the site of rupture, as well as the morphology of the damage fibers. RESULTS: Seventy two of these explants represented 6 different models. While all 6 were fabricated from polyester fibres, each had a different textile construction, and each were associated with a unique healing and mechanical response in vivo. SEM observations confirmed that abrasion of the textile fibres were a phenomenon common to all models, and were the primary cause of prosthesis failure. Such wear zones were particularly prevalent at the exit of the tibial tunnel and around the femoral condyle. Collagenic infiltration into the synthetic ACL was poorly organized and unpredictable. It did not increase with the duration of implantation. In fact in certain models, it appeared to have caused deterioration and fraying of the textile structure rather than serving as a reinforcing matrix around the prosthesis. DISCUSSION: A synthetic ACL prosthesis is to be preferred for patients who do not have tissue available for autologous ligamentoplasty. Yet none of the synthetic devices examined in the present study were capable of stabilizing the knee over the long term. Among the factors that influenced their failure we found that the three most common mechanisms were flat abrasion against an osseous surface, flexural and rotational fatigue of the fibres, and loss of integrity of the textile structure due to unpredictable tissue infiltration during healing. CONCLUSION: The results of the present study show that none of the current models succeed in replacing the natural ACL. Future improvements may be achieved by developing surgical procedures for implantation combined with a prosthesis made from fibres and textile structures which are more abrasion resistant and promote predictable and controlled tissue infiltration.