Management of wounds of exposed or infected knee prostheses.

Skin damage after total knee arthroplasty may jeopardise the functional benefit of the prosthesis. In such cases standard treatment is aimed at avoiding arthrodesis, sometimes replacing the implant and, in exceptional cases, amputation. In most cases early and adequate coverage of the soft tissue defect may make it possible to salvage the prosthesis. Ten patients with skin damage after total knee arthroplasty were treated by debridement of the wound, which was then covered with a pedicled gastrocnemius muscle flap. This was supported by local irrigation and systemic antibiotics. Seven patients were reviewed after a mean follow-up of 28 months (range 14-59). Six patients kept their prostheses and one had a relapse caused by infection at 22 months, which required removal of the prosthesis and secondary arthrodesis. The gastrocnemius muscle flap provides good quality coverage, permits early mobilisation and fast rehabilitation, and reduces the rate of arthrodesis after failure of total knee arthroplasty.

[Use of skin expansion in resurfacing defective amputation stumps of the lower limbs. 6 case reports]. / Utilisation de l'expansion cutanée dans le resurfaçage des moignons d'amputation de jambe défectueux. A propos de 6 cas.

Better procedures and materials have enabled us to improve the results of skin expansion under knee level and extend its indications. We have used such procedures to cover defective amputation stumps in the lower extremity. When the local conditions are suitable, skin expansion permits the use of healthy skin from the lateral sides of the stump to provide coverage for the ulcerated areas, thus fulfilling the main goals which are to keep the bone shaft as long as possible and cover the stump with sensitive skin, so that a prosthesis can be fitted. In two cases, we also performed skin expansion at a distance to reduce the residual scar at the donor site (expanded flap from the other leg, expanded full-thickness skin graft) when the amount of healthy skin available around the stump was insufficient; the functional results were satisfactory. Skin expansion has become a choice strategy for this type of indication, but it must be performed perfectly to avoid complications or failures (our two first cases). It is important to take precautions at various stages of the operation which must be carefully staged.

[Prospective study of 100 cases of breast hypertrophy]. / Etude prospective à propos de 100 cas d'hypertrophie mammaire.

The authors performed a prospective study of 100 consecutive cases of mammary hypertrophy. Sixty were treated by McKissock's technique and forty by Thorek's technique. The patients were reviewed at the second and sixth postoperative months. A general study of the population was performed to specific their demand, which was functional in 90% of cases, and the various symptoms were quantified. 74% of cases presented with psychological problems and a desire for aesthetic improvement was expressed by 67% of cases. Postoperatively, a functional improvement was obtained in 99% of cases, while psychological disorders resolved in 100% of cases. The satisfaction rate was very high: 79% of patients were very satisfied and 20% were satisfied. Some defects observed by the patients or surgical team are analysed. The complications observed, always minor, are reported. Breast reduction provides an unquestionable benefit for patients with mammary hypertrophy. Two simple and perfectly defined techniques were used to treat all these cases with a maximal satisfaction rate and a minimal complication rate.

[Malignant melanoma in children. Apropos of 6 cases]. / Le mélanome malin de l'enfant. A propos de six cas.

Six cases of malignant melanoma were observed in children aged 5-14 years, over a 14-year period: both sexes were equally affected. In three cases, the melanoma was a primary tumor, which indicates that this diagnosis should always be born in mind in children and any suspicious lesion should be biopsied and removed. Three cases had a family history: dysplastic naevus in two cases and malignant melanoma in one case, which confirms the increased risk in some families. Histologically, nodular forms were more frequent than those which spread superficially and the tumors were quite thick when diagnosed (mean thickness: 3.9 mm). Treatment includes wide excision and coverage with skin grafts associated with immuno or chemotherapy in some cases. Mean follow-up was 38 months and no death occurred during this period.

[Use of "foot-bank" tissue to cover amputation stumps. Apropos of 4 cases]. / Utilisation du "pied-banque" pour la couverture des moignons d'amputation. A propos de 4 cas.

PURPOSE OF THE STUDY: The authors report 4 cases of plantar skin free transfer to cover an amputation stump. MATERIAL AND METHODS: In two cases, operated as emergencies, a flap based on the posterior tibial pedicle was harvested from a non-reimplantable extremity. In one case the calcaneum was included in the flap to provide a stump wide enough to hold a prosthesis. The two others cases concerned planned amputation of non-functional extremities, with free transfer of the available plantar skin areas. RESULTS: All 4 patients healed well and the skin coverage provided a good quality stump which was rapidly equipped with prostheses. DISCUSSION: Covering amputation stumps with a free flap from the foot bank has proven to be a reliable procedure, economic for the patient, affording a good physiologic bearing surface. CONCLUSION: This method should proposed in emergency amputations according to local conditions, and may also be advantageous in some cases of secondary surgery.

[Coverage flaps for loss of substance of the scalp. Our experiences apropos of 42 cases]. / Les lambeaux de couverture des pertes de substance du cuir chevelu. Notre expérience à propos de 42 cas.

We report our experience with 42 coverage flaps for tissue loss involving the scalp. Malignant tumors of the scalp were the major cause of tissue loss. Repair modalites and outcome are reported. This series included 23 local flaps, one pediculated regional flap, and 18 free flaps associated with three cranioplasties and four dura mater plasties due to invasion of the subjacent tissues. We discuss therapeutic indications and insist on selection criteria which depend on etiology (localization, form depth), local factors (integrity of the pericranium and subjacent structures) and general factors (age, sex, physical and psychological status, socioprofessional context, patient expectations). In all cases, we opted for tissue repair which offers greater safety with minimum function and esthetic morbidity.