Thumb reconstruction for aesthetic reasons using an exteriorised microvascular pedicle.

Thumb reconstruction following amputation is usually performed in order to restore function. Nevertheless, the reconstruction should be cosmetically acceptable in order to be fully functional, and, in some cases, reconstructive surgery may be justified for purely aesthetic reasons. The most satisfying aesthetic results in adults are obtained with microsurgical partial great-toe transfer. The technique that we use for thumb reconstruction is illustrated by two case reports: that of a 26-year-old female patient and that of a 35-year-old male patient. Both patients had a distal thumb amputation with destroyed nail apparatus, and both sought thumb reconstruction for cosmetic reasons. Aesthetic reconstruction was performed in both cases with a partial ipsilateral great-toe transfer, composed of nail apparatus, underlying bone and custom-made pulp tissue. The vascular anastomosis was done at the snuff-box, through a small incision, with an exteriorised pedicle. The result was satisfactory in both cases, with minimal donor-site sequelae. Partial toe transfer has proven to be a reliable technique for thumb reconstruction. It is an evolving technique. Many modifications have been introduced to optimise the aesthetic result and to reduce donor-site morbidity. Our technique allows us to restore thumb length, replace the missing nail and reconstruct the pulp, with acceptable sequelae at the donor toe. The exteriorised-pedicle technique prevents pedicle compression and twisting and reduces scarring and stiffness. It does, however, require delicate postoperative care and a second procedure for pedicle division.

[Inquiry into the incidence of nosocomial infections and evaluation of the transmission of methicillin-resistant Staphylococcus aureus in an orthopedic surgical unit]. / Enquête d'incidence des infections nosocomiales et évaluation du portage de Staphylococcus aureus résistant à la méticilline dans un service de chirurgie orthopédique.

Nosocomial infections are an important cause of morbidity and mortality. Methicillin resistant Staphylococcus aureus (MRSA) is often the severe causal agent in this kind of infections. In order to evaluate risk factors for nosocomial infections and nasal MRSA carriage, an incidence study was carried out on patients hospitalized in an orthopaedic surgery department in Boucicaut Hospital (Paris). This study was carried out over a five month period. Data of all the patients who stayed more than two days in the unit were collected in medical and nursing records. Nasal swab specimens were taken at the admission of each patient included in order to screen nasal MRSA carriers. Statistical analysis were performed using Epi Info software version 6.0. A total of 451 patients were included in the study. Nosocomial infections incidence rate was 11.5%. Risk factor significantly associated with nosocomial infection was high wound containation classes III and IV (Altemeier). Incidence rate of MRSA carriage was 3.1%. A previous hospitalization in a general hospital 6 months before an admission at Boucicaut Hospital was the only risk factor identified. According to this, these patients, when they are admitted, are proposed to be preventely isolated awaiting their microbiological results.

Thumb reconstruction by pollicization of an index finger stump combined with a wrap-around flap from the big toe.

A finger stump pollicization combined with a thin wrap-around procedure from the big toe for reconstruction of the thumb is described. This technique permits excellent functional and cosmetic restoration, providing length to the new thumb as well as widening the first web. There is joint motion in the reconstructed thumb. Sensibility of the transferred pulp is good and allows fine pinch without pulp shrinkage. This method is indicated in cases of multidigit amputations, for thumb loss near the carpometacarpal joint.

Thenar flap rehabilitated: a review of 20 cases.

The thenar flap is a satisfactory reconstruction technique for the treatment of extensive loss of the distal phalanx of the index and middle fingers. As we observed in this series of 20 patients, this flap is reliable and provides tissue that closely matches the missing finger pulp. Flap sensibility is good (average Weber of 6.5 mm). Transferring a distally based flap prevents proximal interphalangeal joint contracture and allows the surgeon to better reconstruct the outlines of the distal phalanx, thereby reducing the risk of a clawed nail. Finally, we did not observe major postoperative complications at the donor site.

[Experimental cervicoplasty: correction of the cervicomental angle by postero-superior suspension of the hyoid bone. A study of 20 anatomical dissections]. / Cervicoplastie expérimentale: correction de l'angle cervico-mentonnier par la suspension postéro-supérieure de l'os hyoïde. Etude sur vingt pièces de dissection anatomique.

The elegance of the cervical region is due to a certain balance between concave and convex surfaces, and is based on the presence of a well-defined cervicomental angle, generally between 90 degrees to 110 degrees. An excessively wide-open cervicomental angle makes the cervical profile inelegant. Numerous surgical techniques can improve this angle. There is however a certain limit to this correction: an excessively caudal and anterior hyoid bone. In this case the last proposal is a modification of the hyoid bone position in order to replace it in a backward and upper location. To achieve this goal we studied postero-superior suspension of the hyoid bone by plication of the tendon of the digastric muscle in 20 anatomic dissection. Each an dissection was controlled by x-ray of the profile of the cervical region before and after application of this technique. Cephalometric measures were performed and statistically analysed using the "Paired t-test" on Statview II. Analysis of the results after the plication of the tendon of the digastric muscle, demonstrated an average closing of the cervicomental angle of 25.6 degrees with an average ascent of the hyoid bone of 13.27 millimeters and an average posterior transposition of 3.75 millimeters. This experimental cervicoplasty appears to be feasible. A precise surgical technique has been developed with an easy approach to the digastric tendon during standart faced lift procedures. The effect of the compression generated on the pharyngo-oesophageal complex by posterior transposition of the hyoid bone is unknown. This problem is now under investigation.

[Reconstruction of digital pulp by pulp tissue transfer of the toe. Apropos of 15 cases]. / Reconstruction de la pulpe des doigts par transfert d'hémipulpe de gros orteil. A propos de 15 cas.

PURPOSE OF THE STUDY: The authors report their experience of digital pulp reconstruction by free toe pulp transfer. Fifteen patients were treated with the lateral great toe hemipulp. MATERIAL AND METHODS: 15 cases of post-traumatic finger tip reconstruction were reviewed including 9 thumbs, 5 index, 2 medius, and one ring finger. There were 6 emergency cases and 9 secondary reconstructions (7 after inconvenient spontaneous healing and 2 after groin flap coverage). RESULTS: We noted 2 partial necrosis, and 4 patients suffered from cold intolerance. The flap sensibility, according to the American Society for Hand Surgery criteria, was excellent in 1 case good in 6 cases, fair in 7 cases and bad in 1 case. The value of the mean two point discrimination test was 10 mm, the mean moving two points discrimination test equalled 9 mm. We had 1 excellent functional result, 6 good, 6 fair and 2 bad. The subjective evaluation found 12 patients satisfied and 3 disappointed. DISCUSSION: A wide range of procedures from spontaneous healing to thenar flap, neuro vascular flap or toe pulp transfer can be proposed to treat digital pulp loss. In the case of moderate thumb pulp avulsion and homodigital volar flap can be proposed; if microsurgery is contra-indicated, an hetero-digital flap from the index can be performed. When the other fingers are concerned, a homodigital flap can be proposed for moderate defects. For more important trauma, the thenar flap is convenient to cover the index and the medius pulp. Ring and little fingers can be treated by a reverse digital artery flap or by a cross finger flap. When a toe pulp transfer is indicated we recommend the lateral great toe hemipulp for the thumb and a second or third toe pulp transfer for the other fingers when digital vascular anastomosis are possible. The great toe hemipulp transfer represented a good indication for complete digital pulp loss reconstruction where the thumb is concerned. Performing this reconstruction during the acute phase may improve the management of those trauma by reducing the time needed for cicatrisation and the length of work inability.

[Phlegmon of the digital and digital-carpal synovial sheaths]. / Phlegmon des gaines digitales et digito-carpiennes.

The development of infection within the digital synovial sheaths of the middle fingers, or digital-carpal sheaths of the thumb and the little finger, represents a surgical emergency. Due more often to direct infection than to its spread, such phlegmons risk damage to the finger flexor apparatus, within hours in the first case and within days in the second. Diagnosis is made clinically. It is based on pain at the upper cul-de-sac of the sheath, distinct from that of the causal point. Progression consists of three stages according to presence and quantity of pus in the sheath, the appearance of the synovial membrane and tendon involvement. This diagnosis can be made only at surgery. Each stage requires specific treatment.

[Free transfer in the emergency treatment of complex injuries of the arm. Apropos of 18 cases]. / Apport des transferts libres en urgence dans le traitement des traumatismes complexes du membre supérieur. A propos de 18 cas.

In 18 cases the authors used a free tissue transfer during the first 24 hours of the treatment of a complex trauma of the upper limb involving osteoarticular and neurovascular loss combined with loss of skin cover. The various flaps include: lateral arm flap (8 cases), latissimus dorsi flap (4 cases), toe to hand transfer (4 cases), radial forearm flap (2 cases). The series includes 2 failures salvaged without further sequelae by means of a groin flap. With regard to complex one-stage reconstructions, particularly those requiring replacement of bone, the outcome is improved if the selected method permits early mobilisation and complete cover. Free transfers are to be compared with loco-regional flaps which are more reliable but suffer limitations such as a small cutaneous element and, frequently, involvement of the pedicle in the mechanism of the trauma. For the severe cases in this series, only free tissue transfers provided the adequate, immediate cover required to save the traumatised limb.

[Severe injuries of the elbow: emergency coverage and transient revascularization. Apropos of 13 cases over a 3-year period]. / Les traumatismes délabrants du coude: couverture en urgence et revascularisation transitoire. A propos de 13 cas sur 3 ans.

Large open elbow fractures with extensive soft-tissue loss must be treated as an emergency. Vessels and nerves are often alvulsed. One stage reconstruction is very challenging. Ischemia of the distal part of the upper extremity is limited by a synthetic arterial shunt (SAS). After debridement, the authors install the SAS, then the complex procedure can begin. The authors purpose a new four-stage classification and prognostic factors. Debridement concerns crushed, devitalised soft and osteo-articular tissues. If it appears possible to salvage the hand and forearm with necessity of complex reconstructions (vessels, nerves, osteosynthesis, soft tissues) SAS is used. SAS was used 3 times on the group of large avulsions with ischemia (5 cases); it was quickly installed between the humeral and a distal artery and allowed section of the best distal artery for revascularisation. Seven external fixation devices allowed intra operative and post operative management of the wound. The coverage of these large, complex wounds was performed by the latissimus dorsi transposition flap (2 muscular and 5 musculo-cutaneous flaps). It should be considered the flap of choice. Local flaps, which include local skin transposition, muscle transposition or vascular axis, would be contra indicated in a wide zone of injury (the base of these local flaps are damaged by high energy trauma) or when distal ischemia is present because of arterial axis sacrifice. The dorsal decubitus position, the specific dissection of neurovascular pedicle proximally as far as the axillary artery, the muscular and cutaneous design can be used to cover anterior, posterior, internal and external parts of the elbow. Restoration of elbow function uses an innervated latissimus dorsi muscle (3 cases). If only coverage is wanted, this flap has significant advantages over local flaps and free transfer procedures when the recipient vessels are within the area of injury. Between the donor site and the recipient site, the muscular part of the latissimus dorsi flap is placed in an arm counterincision. It ensures closure of the elbow joint. Early progressive range of movement exercises can be performed.

[Scalp reconstruction after avulsion: emergency microsurgery and secondary tissue expansion. Apropos of 3 cases caused by farming machines]. / Reconstruction du cuir chevelu après avulsion: microchirurgie en urgence et expansion tissulaire secondaire. A propos de trois cas survenus par machine agricole.

Total scalp avulsion is an uncommon accident. Three recent cases illustrate our surgical procedure. Small and central hair-bearing avulsed scalps can be treated by secondary scalp expansion (1 case). Large hair-bearing scalp (> 400 cm2) or including aesthetic relief should be treated by microsurgical reimplantation. Venous grafts allow vascular anastomoses beyond the intimal trauma area. Secondary expansion of reimplanted tissue (2 cases) eliminates scalp defects after initial necrosis. Thus, in the cases of total scalp avulsion even with high risk of failure (long time elapsed since injury, significant crush, part being in bad condition, two levels avulsion...), reimplantation has to be performed according to localization and size of avulsion. A secondary procedure with using expansion of the remaining replanted scalp is possible.

[The contribution of MRI in the study of glomus tumors]. / Apport de l'IRM dans l'exploration des tumeurs glomiques.

The glomus tumors of the finger tip are benign. Their diagnosis is clinic but their precise localization is quite difficult by classic imaging. MRI with gadolinium injection seemed a good method to check exactly this lesion and have been tested on 20 patients suspected suffering of glomus tumor. On 18 glomus tumors surgically and histologically confirmed MRI examination have been positive for 16. In two cases MRI and surgery were negative. A good correlation seems observed with surgery for the size (7 tumor of 2 mm) the localization and osseus extension. Addition of T2 and T1 before and after injection weighted acquisitions improved the results. Precise informations on topography and size seems improved the surgical approach.

[Contribution of polyurethane dressing in mammary reconstructive surgery]. / Apport d'un pansement en polyuréthane en chirurgie réparatrice mammaire.

The authors report the use of a new polyurethane dressing, studied in 20 patients undergoing breast surgery. Based on objective criteria, this study analyses the contribution of this dressing in the postoperative course.

[Use of an external brachial flap in the reconstruction of the upper limb. Apropos of 11 cases]. / Utilisation du lambeau brachial externe dans la reconstruction du membre supérieur. A propos de onze cas.

During the last three years, eleven lateral upper arm flaps were used in the reconstruction of skin defects of the upper limb. These flaps were applied: 7 times on the hand; 2 times on the fore-arm; 2 times on the elbow. Ten flaps had a free transfer, one was vascularised by the distal pedicle. In 4 cases we used an emergency free transfer in the treatment of a traumatic defect. In the other cases the flaps were used in the treatment of post-traumatic sequelae such as contracture and/or osteitis. The series contains 10 fascio-cutaneous flaps and 1 osteo-cutaneous flap. We had one failure with an emergency free flap, salvaged without further sequelae by means of a groin flap. The proximity of the donor site in an upper limb reconstruction makes the lateral upper arm flap a good alternative when a pedicle locoregional flap cannot be used due to a lesion of its pedicle in the mechanism of the trauma.

[Ulnar nerve disorders at the elbow. Etiologic approach. Apropos of 40 cases]. / Atteintes du nerf cubital au coude. Approche étiologique. A propos de quarante cas.

The authors analysed the medical records of 40 patients with isolated ulnar nerve entrapment at the elbow with a follow-up ranging between 7 months and 6 years. According to MacGowan's classification, there were 32.5% stage I, 25% stage II and 42.5% stage III. In 82.5% of cases, surgical decompression consisted of simple neurolysis by section of Osborne's arcade, while the other patients underwent transposition in the case of a local anatomical lesion (10%) or medial epicondylectomy (7.5%). The results in this series showed 50% very good, 15% good, 65% fairly good and 20% poor results, comparable to the results reported in other published series. The authors propose a classification into six groups which may have a prognostic significance, based on the mode of onset and the course of the paralysis: primary mononeuropathy (45% of cases in this series), compressions due to a local cause (10% of cases), postural compression (12.5% of cases), rapid-onset post-traumatic compression (10% of cases), sudden onset mononeuropathy (10% of cases) and mononeuropathy related to a systemic disease (10% of cases). The distribution according to MacGowan's classification was fairly homogeneous, but the postoperative results showed marked differences. A review of the literature showed that each author uses a particular technique and no other prognostic elements have been previously proposed.

[Dorsal tenolysis and arthrolysis of the proximal interphalangeal joint. 19 cases]. / Téno-arthrolyse dorsale de l'interphalangienne proximale. A propos de dix-neuf cas.

18 patients suffering from PIP stiffness in extension were treated by dorsal teno-arthrolysis. PIP joint stiffness was due to 3 cases of fracture of P1, 2 cases of fracture of P2, 2 cases of extensor tendons, 8 fractures of P1 associated with section of the extensor tendon, 2 cases of PIP closed trauma (1 sprain, 1 dislocation), and 2 crush injuries of the extensor tendon at the PIP joint. The surgical technique combined a dorsal sinuous approach, tenolysis of the extensor tendon on the dorsum of first phalanx dorsal capsulotomy, and more rarely (3 cases), section of collateral ligaments. The mean pre-operative active flexion was 44 degrees and the mean post operative active flexion was 78 degrees, which represents a gain of 34 degrees of active movement. Thanks to a classification which incorporates the range of active flexion in PIP joint, and the lock of active extension we rated 3 results as excellent, 4 as good, 8 as useful and 4 as insufficient. We therefore improved the range of movement in 15 out of 19 cases, which seams very encouraging.

[Diagnosis of carpal bone fractures]. / Diagnostic des fractures des os du carpe.

The diagnosis of carpal bone fractures has been facilitated by new radiological projections and by the advent of modern imaging methods. Fractures of the scaphoid bone still account for 75% of carpal fractures with their complications (pseudarthrosis, malunion) and their sequelae of arthrosis. However, the frequency of other fractures appears to be increasing due to a better knowledge of their mechanism and to the possibilities of the new imaging methods.

[Value of pulp recession in inveterate hook fingers. Techniques/indications]. / Intérêt du recul de la pulpe dans les crochets invétérés de doigts. Technique/indications.

The aim of this operation is to preserve the sensitivity whenever when a finger has to be amputated. We have reviewed 9 patients operated according to this technique, out of 14 patients for whom an amputation or a shortening arthrodesis was discussed. The results of pulp recession were most encouraging. The incision were located on both sides of the finger and distant from the ungueal matrix. The dorsal skin was elevated in the sub-periosteal plane. Resection of the necessary amount of 2nd phalanx to obtain an extended finger was performed. An osteosynthesis with pins is preferred for a duration of 6 weeks. This operation can be performed for very stiff finger, hooked fingers or dystrophic fingers with a good pulp. In extreme cases of shortening, the nail with its bed ar sacrificed, and the entire pulp is used to cover the distal stump. This principal of pulp recession has been used in two other cases in emergency surgery. The postoperative was marked by finger swelling and some pain of the distal sutured skin. Overall the results were satisfactory and patients were very satisfied to keep their finger, which would otherwise have been doomed.

[Emergency pulp reconstructions]. / Reconstructions pulpaires en urgence.

Pulp reconstructions use numerous techniques ranging from simple debridement to local and microsurgical flaps. The authors analyse the various treatments, in which directed healing still retains numerous indications. Local flaps have a definite place, but they are not devoid of risks (iatrogenic stiffness). The indications are presented schematically in table form together with several examples. A wide range of techniques is necessary in order to treat the various lesions appropriately. Large defects are best treated by microsurgical transfer of great toe pulp with satisfactory results, which justifies their management in specialised centers.