Factitious disorders in the hand-Main diagnostic traps highlighted with 3 cases.

Every doctor can be confronted, during his career, with patients presenting symptoms they created themselves. Because it is easily accessible, the hand is a favored target organ for these self-inflicted injuries. The diagnosis of factitious disorder of the hand is very difficult, rarely suggested and widely under-estimated. The real issue is detecting it early on to develop a cohesive diagnostic and therapeutic approach. The three clinical cases reported in this article illustrate the difficulty of caring for this pathology at all stages, from diagnosis to treatment. These disorders must be distinguished from malingering. A psychiatrist must be part of the treatment team. The prognosis of factitious disorders is poor. It is vital to maintain contact with the patient once the diagnosis is established. The risk is that the patient consults with other professionals, restarting a new cycle. The featured clinical cases were chosen to remind surgeons that factitious disorders of the hand are a recognized psychiatric disease. It must be evoked in the context of an unusual injury with a vague history. Everything possible must be done to confirm the diagnosis and avoid surgery.

[Osteo-cutaneous Mycobacterium marinum infection of the elbow and reconstruction with radial collateral artery perforator-based propeller flap]. / Infection ostéo-cutanée du coude à Mycobacterium marinum et reconstruction par un lambeau en hélice basé sur une perforante de l'artère collatérale radiale postérieure.

Mycobacterium marinum is an atypical and non-tuberculosis mycobacterium that mainly leads to cutaneous infections. Infections occur through inoculation of the organism through injury to the skin in the presence of contaminated water or fish. The patient often presents with unspecific symptoms and the evolution, in the absence of adequate treatment, is characterized by an expansion of the cutaneous lesion and a spread to deep structures. Infections of tendon sheaths and joints are described, rarely osteomyelitis. Sure diagnosis is hard to obtain and is established from the medical history and microbiological examination. There are no specific therapeutic guidelines. Double or triple antibiotherapy is often effective and should be continued several months after complete resolution of clinical signs. Surgical debridement is required in cases of invasive or resistant infections. We report the case of a young immunocompetent fishmonger with a rare osteocutaneous M. marinum infection of the elbow. Treatment included large surgical excision of infected skin and bone areas and a triple antibiotics administration. Reconstruction have been ensured by a radial collateral artery perforator-based propeller flap, satisfying appropriates functional and cosmetical concerns of this anatomical region. Surgery and appropriate antibiotics treatment were effective and allowed healing of an invasive cutaneous and bone M. marinum infection.

[Abdominoplasty complications: particularities of the post-bariatric patients within a 238 patients series]. / Complications des abdominoplasties: particularités des patients post-bariatriques au sein d'une série de 238 patients.

BACKGROUND: Obesity is one of the health issues that is recently worldwide increasing, as well as in France. Variety of procedures of bariatric surgery have been developed over the past decade and are performed for morbid obesity hence. The demand of plastic surgery increased for body contouring and reshaping after dramatic weight loss, in which the abdominoplasty is considered as one of the most common procedures. The purpose of this study is to clarify the differences between the post-bariatric patients and others, and their influence on the occurrence of complications following abdominoplasty. PATIENTS AND METHODS: Retrospective study involving a group of post-abdominoplasty patients collected from the same center between January 2000 and December 2010. RESULTS: Among 238 reviewed patients' files; 114 of them are post-bariatric patients, and 124 are non-bariatric patients. Several differences were found between these two groups of patients including the maximum BMI, BMI at the time of surgery, the rates of cardiovascular risk factors, and a longer operative time in the post-bariatric group. The complication rate in these patients was significantly higher (55.3% against 26.6%) with mainly healing problems. Major maximum weight, obesity at the time of surgery, long operative time and postoperative drainage system are all considered as risk factors, which carry high rate of complications. CONCLUSION: It appears that abdominoplasty in post-bariatric patients requires specific care because of particularities inherent in this population.

[Alopecia reconstruction by expansion after a scalp burn injury caused by Taser(®): a case report]. / Reconstruction avec prothèse d'expansion d'une alopécie secondaire à une brûlure du cuir chevelu par Taser(®)

BACKGROUND: Scarring alopecia resulting from burns may be difficult to treat and involves various plastic surgery techniques such as expanded scalp flaps. OBSERVATION: Herein, we report the case of a 19-year-old male patient who suffered burning of the scalp with scarring alopecia following an attack with a Taser(®) electrical gun. Given the extent and site of alopecia, we decided to create a prosthesis by means of scalp expansion. The cosmetic result was satisfactory. DISCUSSION: Several scalp reconstruction techniques have been described for scarring alopecia, with the most widely used being expansion, scalp flaps, repeated excision and hair implants. CONCLUSION: The present case suggests that scalp expansion offers an effective method for the reconstruction of scarring alopecia following burns with a Taser(®) device.

[Freestyle free perforator flaps for heel reconstruction]. / Couverture du talon par lambeaux libres perforants de type "freestyle".

INTRODUCTION: Heel coverage requires the surgeon to considerate of multiple parameters: the type of defect, the exposed tissues, the weight-bearing requirements, the donor site morbidity, and the shape of the reconstructed heel allowing at best normal footwear. Although many methods of coverage exist, they are often chosen at the cost of a compromise between all the parameters described. In recent years, perforator freestyle free flaps offer plastic surgeons an unparalleled freedom that can adapt the constraints of the reconstruction while minimizing the functional and scar donor site morbidity. PATIENTS AND METHODS: We present four cases of heel defect of different origins treated by three types of tailored perforator freestyle free flaps (ALT, TAP and SCIP Flaps). End-to-side anastomosis to the posterior tibial vessels was used in three flaps while one flap was anastomosed to the internal plantar artery in an end-to-end fashion. RESULTS: No postoperative complication occurred. This approach allowed, in all patients, a reconstruction of excellent quality with minimal cicatricial morbidity. All patients were walking effectively at 21 days postoperatively. CONCLUSION: Perforator freestyle free flaps offer a solution of first choice for heel reconstruction. At the price of a linear hidden scar, they offer a functional, aesthetic and durable coverage.

Surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: when gloves should be changed.

INTRODUCTION: Double gloving is recommended in orthopedic surgery, notably in total hip arthroplasties (THA) to prevent contamination of the surgical site. HYPOTHESIS: Systematic glove changes during the key phases of hip prosthesis implantation reduce the frequency of occult perforations and bacterial loading of glove surfaces. PATIENTS AND METHODS: During 29 THA implantation procedures, we evaluated the bacterial contamination of the outer glove surface and its perforation rate. Contaminations were sought by placing the gloved fingertips on blood geloses (incubation, 48 h at 37°C), and perforations were sought using a water test (NF EN 455-1). RESULTS: One intervention was excluded from the study because an initial contamination was detected, leaving 28 cases analyzed. Fifteen interventions (53.6%) presented contaminated geloses (26 contaminated glove changes for 3.38% of the gloves used). These contaminations were found on the gloves of all of the gloved personnel, with no distinction as to the right or left side. Thirty-eight percent of the contaminations occurred during joint reduction, whereas the other surgical stages grouped 15-26% of the contaminations (P<0.05). Twenty-nine bacteria were identified: 62% coagulase-negative staphylococci (16% of which were methicillin-resistant). Twenty-eight perforations were identified (3.5% of the gloves used), 67.8% of which were located on the operator and 64.3% on the dominant side. Eighty percent of the perforations occurred during the "surgical incision" and the "cup and stem implantation" stages (respectively, 5.0% and 5.5% of the gloves used during the surgical time) (P<0.05), without being associated with an increased risk of bacterial contamination. At the 12-month clinical follow-up, no infectious complications were found. On the gloves worn by the 20 surgical team members contaminated during these 28 surgical procedures, replacing contaminated gloves with new sterile gloves rendered all the bacteriological samples of the subsequent surgical stages negative in 16 cases (80%). DISCUSSION: Increasing the number of outer glove renewals, notably during certain surgical stages at risk for contamination (prosthesis reduction) or perforation (surgical incision/femoral cementing) can reduce the risk of contamination and perforation. The bacteria isolated suggest a cutaneous origin. Regularly changing gloves has resulted in a sterile state in 80% of cases. LEVEL OF EVIDENCE AND TYPE OF STUDY: Level III prospective diagnostic study.