[Current role of the latissimus dorsi flap in traumatology: Analysis of the activity of a plastic surgery department in a military hospital]

Reconstructive surgery's workhorse, the latissimus dorsi flap is increasingly abandoned in favour of fasciocutaneous flaps. The purpose of this study was to analyse the methods used to perform this flap and the evolution of its indications in order to define its current place in traumatology. Forty-four cases were recorded retrospectively from January 2000 to December 2020 at HIA Percy, including 37 cases of free flaps, mainly performed for reconstruction of extensive loss of substance with bone and/or joint exposure. It was also performed in 10.8% of cases for salvage after failure of an alternative reconstruction solution. This analysis confirms the value of the latissimus dorsi flap in cases of significant substance loss in the lower limb, but also in burn patients for functional rehabilitation or to allow early rehabilitation.

[Pre-iliac tumor mass syndrome: An atypical rheumatoid nodule]

Rheumatoid arthritis (RA) is a polymorphous chronic inflammatory disease that is common in general population and is responsible for the occurrence of subcutaneous or visceral rheumatoid nodules. Their typical clinical presentations and localizations do not generally pose any diagnostic or therapeutic problem. We report here an atypical fistulized presentation of an unusual iliac rheumatoid nodule in a 65-year-old female patient. The evolution was favorable without recurrence at 6 months after complete surgical resection and appropriate antibiotherapy.

Methylmetacrylate (PMMA) cranioplasty technique: Technical interest of intraoperative modeling and review of the literature

Reconstruction of bone loss in the cranial vault may be necessary for functional or aesthetic reasons following trauma, decompression craniectomy, or craniofacial malformations. Many techniques have been described in the literature, using various materials, each with its own advantages and drawbacks. Reconstruction with polymethylmetacrylate cement has the advantage of a durable result and relative ease of use. In this article we present our cement cranioplasty technique through 4 clinical cases of cranial vault reconstruction, by direct intraoperative modeling on the bone defect. This accessible, effective method, applicable to all sizes of defect, remains an attractive option in the arsenal of techniques available today.

[Prioritization of risk situations in neuro-urology: Guidelines based on the Delphi method from Association française d'urologie (AFU), Association francophone internationale des groupes d'animation de la paraplégie (AFIGAP), Groupe de neuro-urologie de langue française (GENULF), Société française de médecine physique et de réadaptation (SOFMER) and Société interdisciplinaire francophone d'urodynamique et de pelvi-périnéologie (SIFUD-PP)]

PURPOSE

During the COVID-19 pandemic, a care reorganization was mandatory, and affected patients in different areas, including management of neurogenic lower urinary tract dysfunction. This work aims to provide validated schedule concerning the assessment and management of patients in neuro-urology.

METHODS

Based on a literature review and their own expertise, a steering committee composed of urologists and physical medicine and rehabilitation practitioners generated a comprehensive risk-situation list and built a risk scale. A panel of French-speaking experts in neuro-urology was asked to define the timing for each clinical situation and validated these new recommendations through a Delphi process approach.

RESULTS

The 49 experts included in the rating group validated 163 propositions among the 206 initial items. The propositions were divided into four domains - diagnosis and assessment, treatment, follow-up, and complications - and two sub-domains - general (applicable for all neurological conditions) and condition-specific (varying according to the neurological condition (spinal cord injury, multiple sclerosis, brain injury, Parkinsonism, spinal dysraphism, lower motor neuron lesions)).

CONCLUSIONS

This multidisciplinary collaborative work generates recommendations based on expert opinion, providing a validated timing for assessment and management of patients in neuro-urology which may help clinicians to reorganize their patients' list with a personalized medicine approach, in a context of health crisis or not.

Eyelid Chemical Burns: A Multidisciplinary And Challenging Approach

During second- and third-degree eyelid sulfuric acid burns, many surgeons prefer to wait until primary wound separation occurs before grafting. However, this approach may miss the chance to recover the eyelids and can cause ectropion, resulting in delayed eyeball healing with exposure keratitis. We propose that early eyelid release and grafting makes a significant difference in long-term outcomes and improves eyeball healing. Here, we present the case of a woman who presented second- and third-degree burns of the eyelids secondary to physical domestic assault with acid, who had an early surgical management with a full-thickness skin graft. Ten days after surgery, we found that the graft had survived totally, and the donor site of the right arm had already healed. Eyelids were successfully grafted and the functions of both eyelids were well recovered, allowing complete cover of the eyeball. Two months after surgery, functional and cosmetic results were satisfying, with no postoperative lagophthalmos or difficulties with exposure-related problems. Case reports of eyelid chemical burns are very few. No specific and codified management of eyelid chemical burns was found in the literature search. This case report demonstrated that a multidisciplinary approach led by both ophthalmologists and plastic surgeons must be decided early (<6h) in order to achieve synergistic and coordinated management between the eye and the eyelid. There is a significant improvement in ocular healing with early excision and grafting of eyelids after sulfuric acid burn.

[Catheters in urology: Indications and management in daily practice for the nurse]

The urology nurse cares for patients wearing many different types of urinary catheters. Her role in the management of these devices in external care, clinical units, operating room or at home is fundamental. We performed a state of the art of good practices and of the up to date knowledge regarding the indication, placement, and specific care of these devices, which are every day more numerous on the market. Indwelling bladder catheter are placed, daily managed and removed by nurses, depending on an initial medical indication. The type of catheter must be adapted to the patient and to the clinical situation. Its daily care and management should allow not only the best comfort for the patient, but also an efficient management of the associated infectious risk. The placement of ureteral catheters (simple monoJ, double J or nephrostomy), are mainly of surgical initial indication. We developed what we thought was compulsory knowledge about them for an operating theater's nurse. The associated care for urology's nurses is also detailed. This inventory of available urinary catheter's, of their indications and management, aims to be a help for the urology nurse in her daily practice. Her/his role is essential in the choice of the adequate catheter and in its correct management, not only for the urologist but also for the patient himself.

FUrTIHF: French urinary tract infections in healthcare facilities - five-year historic cohort (2014-2018)

BACKGROUND

Urinary tract infections (UTIs) are common and diverse. Even when not severe, UTIs regularly lead to hospitalization, but their hospital burden remains unknown. This study aimed to estimate the national incidence of hospitalized UTIs in France.

METHODS

A historic five-year cohort of adult patients hospitalized with UTIs in France was extracted from the medico-administrative databases using an ICD-10 code algorithm built by a multidisciplinary team. The performance parameters were estimated blindly, by reviewing 1122 cases, using medical reports as the gold standard, giving a global predictive positive value of 70.4% (95% confidence interval 66.6-74.1). The national incidence of UTIs was then estimated.

RESULTS

A total of 2,083,973 patients with UTIs were hospitalized over the period, giving an adjusted incidence rate of ∼900 cases/100,000 inhabitants, stable over the period, higher in females and increasing with age; 1.2% were device-associated UTIs. Unspecific acute cystitis represented almost two-thirds of cases (63.5%); followed by pyelonephritis (23.6%) and prostatitis (12.4%). More than three-quarters of patients had at least one comorbid condition (76.8%).

CONCLUSIONS

This national cohort study is the first to date to estimate the incidence of UTI-related hospitalizations in France. UTIs represent a substantial burden of care. Further analysis will provide data for more informed goal-of-care discussions targeting each type of UTI, their management and outcomes.

[Urinary tract infections in adults: Comparison of the French and the European guidelines]

INTRODUCTION

Acute urinary tract infections (UTIs) in adult are now a major public health issue in terms of morbidity, mortality and in terms of costs for society. The latest French guidelines and the European Association of Urology guidelines differ in some points. The aim of this article is to compare the guidelines of these two societies in order to highlight their differences but also their common points in the management of UTIs.

METHODS

A comparative analysis of the latest French and European guidelines was carried out. The authors defined the following sub-sections: terminology, pyelonephritis, male UTIs, pregnancy urinary tract infections and cystitis.

RESULTS AND CONCLUSION

The guidelines of these two societies are not very different in terms of diagnostic and therapeutic management. The major differences are in the duration of antibiotic therapies, where French guidelines continue to recommend long term treatments where EAU sometimes recommends only 5 days of antibiotics, as in the case of simple acute pyelonephritis.

LEVEL OF EVIDENCE

3.

[Skin engineering for severe burns]

Severe burned patients need definitive and efficient wound coverage. Outcome of massive burns has been improved by using cultured epithelial autografts (CEA). Despite fragility, percentages of success take, cost of treatment and long-term tendency to contracture, this surgical technique has been developed in few burn centres. First improvements were to combine CEA and dermis-like substitute. Cultured skin substitutes provide earlier skin closure and satisfying functional result. These methods have been used successfully in massive burns. Second improvement was to allow skin regeneration by using epidermal stem cells. Stem cells have capacity to differentiate into keratinocytes, to promote wound repair and to regenerate skin appendages. Human mesenchymal stem cells contribute to wound healing and were evaluated in cutaneous radiation syndrome. Skin regeneration and tissue engineering methods remain a complex challenge and offer the possibility of new treatment for injured and burned patients.

Grafting both acute wound site and adjacent donor site with the same graft: an easy and safe procedure to improve healing and minimize pain in elderly and bedridden patients

In harvesting skin to cover the defect caused by a burn, a second wound is created, the donor site wound. We propose an alternative method to manage the donor site: taking a split-thickness skin graft (STSG) from a donor site adjacent to the burn wound to be treated, and meshing at a 3:1 ratio to cover both sites at once. The main objective of this study is to evaluate the effectiveness of covering both burn wound and adjacent donor site with the same STSG in elderly and bedridden patients. We retrospectively reviewed the medical records of 6 patients over 60 years old or/and bedridden presenting with a small burn wound who underwent STSG of both burn wound and adjacent donor site between April 2016 and November 2016 in the Department of Plastic Surgery and Burn Treatment at Percy Military Hospital (France). Their data were compared with data of five patients who had undergone the usual STSG procedure during the same period. There was a statistically significant difference between patients who underwent adjacent STSG procedure and those who underwent usual STSG procedure in healing time (days) mean (SD) (7,33 ± 1,03 vs. 16,2 ± 0,83; p = 0,007) and Numeric Rating Scale pain mean (SD) at day 2 (0,33 ± 0,33 vs. 2,4 ± 1,35; p = 0,04). Grafting both acute burn wound and adjacent donor site with the same graft seems to be an easy method to improve healing and minimize pain in the STSG donor site in elderly and bedridden patients.

[Lower urinary tract dysfunction in normal pressure hydrocephalus: Review of the literature]

INTRODUCTION

Lower urinary tract dysfunction in normal pressure hydrocephalus has received little attention from the scientific community. The aim of this review article was to discuss diagnostic and therapeutic options for these patients.

SOURCES

A literature review of MedLine publications on urinary incontinence in normal pressure hydrocephalus was conducted. The following keywords were used: "hydrocephalus, normal pressure" and "bladder dysfunction" or "urinary incontinence" or "overactive bladder" or "urinary bladder, neurogenic". Prospective and retrospective studies as well as previous reviews were analyzed.

RESULTS

Urinary symptoms in normal pressure hydrocephalus are mainly represented by overactive bladder, which is a significant burden for the concerned patients. Isolated overactive bladder is more frequent (64%) than urinary incontinence (57%). Detrusor overactivity is seen in 95.2% of the cases. Neuro-surgery is efficient on urinary symptoms for 61.5% of the patients. Bladder recovery after surgery relates with increased mid-cingulate perfusion, probably linked with a functional restoration of the mid-cingulate that normally inhibits the micturition reflex. Medical options, added or not to surgery, include anticholinergic drugs unable to pass through the blood-brain barrier, Transcutaneous Electrical Nerve Stimulation and sacral neuromodulation.

CONCLUSION

There is actually an insufficient concern about urinary symptoms in normal pressure hydrocephalus. This article highlights the importance of a harmonization of neuro-urological practices in the pre-therapeutic evaluation of patients suffering from normal pressure hydrocephalus.

[Congenital undescended testis: Should open processus vaginalis have any impact on the elected surgical approach?]

PURPOSE

Compare the position of the undescended testis at clinical examination and under general anesthesia with the patency of an open processus vaginalis.

PATIENTS AND METHODS

We included children from 2 to 18 years of age operated for a unilateral or bilateral undescended testis between January 2006 and April 2014 at the Annecy Genevois hospital, France. The analysis was conducted considering that the individual was the testis. Testicular position before surgery, under general anesthesia and patency of open processus vaginalis as a surgical finding were prospectively recorded.

RESULTS

Three hundred and six children were included. The analysis was conducted over 401 testes. The position at clinical examination was significantly linked to a persistent open processus vaginalis (P=0.0045). Over the 282 testes considered as candidate for Bianchi's procedure, as to say intra- or supra-scrotal under general anesthesia, 154 had a persistent processus vaginalis (55%).

CONCLUSION

There is a link between a persistent processus vaginalis and the location of the undescended testis which should encourage us not to neglect the inguinal approach, and eventually to question the relevance of Bianchi's procedure.

LEVEL OF EVIDENCE

4.

Die elektrophoretische Beweglichkeit der Spermien des Rindes

1. Die negative Überschußladung der Bullenspermien besitzt bei unseren Versuchsbedingungen eine eingipfelige Verteilungskurve. Dies spricht dagegen, daß die weiblichen und männlichen Spermien unterschiedliche Oberflächenladungen haben.

2. Ein Teil der negativen Überschußladung der Spermienmembran kann auf Neuraminsäuren zurückgeführt werden. Je Spermienzelle werden durch Neuraminidase-Fermentierung 6.2·10-8γ ±2,3·10-8γ Neuraminsäuren freigesetzt. Papier- und dünnschichtchromatographisch konnte dabei N-Acetylneuraminsäure wahrscheinlich gemacht werden.

3. Auf Grund der gleichartigen Wirkung des Sekrets der ableitenden Samenwege und Anhangsdrüsen des Bullen und von Trypsin auf Spermienzellen und auf normale und maligne Leberzellen wird das Vorkommen eines eiweißspaltenden Ferments im Sekret angenommen.

4. Die unterschiedlichen Mittelwerte der elektrophoretischen Beweglichkeit der Spermien bei verschiedenen Bullen und der Spermien des gleichen Tieres bei wiederholten Messungen der ersten Ejakulate sowie die verhältnismäßig breiten Streuungen der Zellpopulationen wird mit diesem im Sekret vermuteten Ferment in Zusammenhang gebracht.

5. Es wurde die elektrophoretische Beweglichkeit der Spermien zweier kurz hintereinander gewonnener Ejakulate verglichen: die elektrophoretische Beweglichkeit der Spermien aus dem zweiten Ejakulat ist gegenüber der der Spermien aus dem ersten Ejakulat um 8.0 ± 3.2% größer. Die elektrophoretische Beweglichkeit der Spermien aus dem Nebenhoden ist gegenüber der der Spermien aus dem ersten Ejakulat um 20,9±4,9% erhöht.

6. Der isoelektrische Punkt von Spermien aus einem ersten Ejakulat liegt bei pH 4.7 bis 4.8. aus dem darauffolgenden zweiten Ejakulat bei pH 4.3 und von Spermien aus dem Nebenhoden bei pH 3.9.

7. Es wird über eine Parallele zwischen der Abnahme der Befruchtungshäufigkeit und Abnahme der elektrophoretischen Beweglichkeit von konservierten Bullenspermien berichtet.

Stem cell therapy: from bench to bedside

Several countries have increased efforts to develop medical countermeasures to protect against radiation toxicity due to acts of bioterrorism as well as cancer treatment. Both acute radiation injuries and delayed effects such as cutaneous effects and impaired wound repair depend, to some extent, on angiogenesis deficiency. Vascular damage influences levels of nutrients, oxygen available to skin tissue and epithelial cell viability. Consequently, the evolution of radiation lesions often becomes uncontrolled and surgery is the final option--amputation leading to a disability. Therefore, the development of strategies designed to promote healing of radiation injuries is a major therapeutic challenge. Adult mesenchymal stem cell therapy has been combined with surgery in some cases and not in others and successfully applied in patients with accidental radiation injuries. Although research in the field of radiation skin injury management has made substantial progress in the past 10 y, several strategies are still needed in order to enhance the beneficial effect of stem cell therapy and to counteract the deleterious effect of an irradiated tissue environment. This review summarises the current and evolving advances concerning basic and translational research based on stem cell therapy for the management of radiological burns.

MRI assessment of local acute radiation syndrome

OBJECTIVES

To describe local acute radiation syndrome and its radiological imaging characteristics.

METHODS

We performed a retrospective study of patients who had suffered skin and deeper radiation damage who were investigated by magnetic resonance imaging (MRI). We compared the clinical findings, C-reactive protein (CRP) levels and MRI results.

RESULTS

A total of 22 MRI examinations were performed between 2005 and 2010 in 7 patients; 6 patients had increased CRP levels and MRI abnormalities. They were treated by surgery and local cellular therapy. One patient had no CRP or MRI abnormalities, and had a spontaneous good outcome. Eighteen abnormal MR examinations demonstrated high STIR signal and/or abnormal enhancement in the dermis and muscle tissues. Three MRI examinations demonstrated skeletal abnormalities, consistent with radionecrosis. The four normal MRI examinations were associated only with minor clinical manifestations such as pain and pigmentation disorders.

CONCLUSION

MRI seems to be a useful and promising imaging investigation in radiation burns management i.e. initial lesion evaluation, treatment evaluation and complication diagnosis. MRI findings correlated perfectly with clinical stage and no false negative examinations were obtained. In particular, the association between normal MRI and low CRP level seems to be related to good outcome without specific treatment.

KEY POINTS

Local acute radiation syndrome (radioepidermitis) mainly affects the skin and superficial tissues. MRI findings correspond with clinical stage (with a strong negative predictive value). MRI outperformed X-ray examination for the diagnosis of bone radionecrosis. Diffusion-weighted imaging shows low ADC in bone and soft tissue necrosis. Perfusion sequence allows assessment of tissue microcirculation impairment.

[Surgical strategy for neck burns and their sequelae]

Burns of the neck are common and expose them to functional and aesthetic complications which are sometimes very serious. Care in the acute stage and treatment of sequelae contribute to a common goal of restoration: Maintain or recreate a chin-neck angle and get a quality skin as close as possible to the original skin, in terms of flexibility, texture, thickness and color. The wide variety of cases encountered requires knowing the armamentarium available to us today, and the anatomical basis and clinical underlying indications.

Cell therapy of burns

Severe burns remain a life-threatening local and general inflammatory condition often with serious sequelae, despite remarkable progress in their treatment over the past three decades. Cultured epidermal autografts, the first and still most up-to-date cell therapy for burns, plays a key role in that progress, but drawbacks to this need to be reduced by using cultured dermal-epidermal substitutes. This review focuses on what could be, in our view, the next major breakthrough in cell therapy of burns - use of mesenchymal stromal cells (MSCs). After summarizing current knowledge, including our own clinical experience with MSCs in the pioneering field of cell therapy of radiation-induced burns, we discuss the strong rationale supporting potential interest in MSCs in treatment of thermal burns, including limited but promising pre-clinical and clinical data in wound healing and acute inflammatory conditions other than burns. Practical options for future therapeutic applications of MSCs for burns treatment, are finally considered.

[Facial locoregional anesthetics: principles and precautions]

Facial locoregional anesthetics (ALR) with nervous blocks are simple and reliable to perform, need little technical resources with a very low iatrogenic risk. These blocks allow anesthesia without deforming wound banks using the same materials as usual local anesthetic procedures. Three principal nervous blocks, in a straight line along the vertical pupil axis, allow managing - even extensive - facial wounds. Few side effects may occur which can be easily prevented. It is a good alternative to local anesthetic for the treatment of extensive and deep areas which is performed with a lower number of injections and a high rate of success. These techniques are easy to learn and practise. These anesthetic techniques allow a nice treatment of different kinds of facial wounds from simple suture to flaps.

New approach to radiation burn treatment by dosimetry-guided surgery combined with autologous mesenchymal stem cell therapy

The therapeutic management of severe radiation burns remains a challenging issue. Conventional surgical treatment (excision and skin autograft or rotation flap) often fails to prevent unpredictable and uncontrolled extension of the radiation necrotic process. We report here an innovative therapeutic strategy applied to the victim of a radiation accident (December 15, 2005) with an iridium gammagraphy radioactive source (192Ir, 3.3 TBq). The approach combined numerical dosimetry-guided surgery with cellular therapy using mesenchymal stem cells. A very severe buttock radiation burn (2000 Gy at the center of the skin surface lesion) of a 27-year-old Chilean victim was widely excised (10 cm in diameter) using a physical and anatomical dose reconstruction in order to better define the limit of the surgical excision in apparently healthy tissues. A secondary extension of the radiation necrosis led to a new excision of fibronecrotic tissues associated with a local cellular therapy using autologous expanded mesenchymal stem cells as a source of trophic factors to promote tissue regeneration. Bone marrow-derived mesenchymal stem cells were expanded according to a clinical-grade technique using closed culture devices and serum-free medium enriched in human platelet lysate. The clinical evolution (radiation pain and healing progression) was favorable and no recurrence of radiation inflammatory waves was observed during the 11 month patient's follow-up. This novel multidisciplinary therapeutic approach combining physical techniques, surgical procedures and cellular therapy with adult stem cells may be of clinical relevance for improving the medical management of severe localized irradiations. It may open new prospects in the field of radiotherapy complications.

[Experimental and clinical experience of composite tissues allotransplantation in reconstructive surgery]

Composite tissue allotransplantation (CTA) is a new concept in reconstructive surgery to improve major physical defects with no current solution. Although not a life-saving procedure, tissue replacement by CTA offers great potential for improving quality of life but relies on lifelong immunotherapy. This new practice has become achievable with the refinement of microsurgical techniques, with experience gained from limb and scalp replantations, with the development of organ transplantation and the release of new immunosuppressive drugs. Experimental and clinical research made it possible. The first human cases of CTA proved the reality and the feasibility of the concept. While the early functional results of these allografts are encouraging, they will need to be assessed in the long-term, and development of less toxic - more efficient immonu-suppressive drugs will be a permanent requisite to the broadening of CTA. Although long-term outcome and potential adverse effects of chronic immunosuppression remain uncertain, as for organ transplantation, CTA is already a potential solution for some highly selected patients carrying physical disabilities such as large facial defects and bilateral hand amputation.

Use of topical negative pressure with a lipidocolloid dressing: results of a clinical evaluation

OBJECTIVE

To evaluate the protection and acceptability of Urgotul wound dressing in the local management of acute or chronic wounds receiving topical negative pressure (TNP) therapy.

METHOD

This was a prospective multicentre non-comparative open-label trial. At each dressing change the investigating physician clinically evaluated and photographed the wound. Planimetric measurement was undertaken and wound depth was assessed at the start and end of the treatment. Follow-up was undertaken until deemed clinically unnecessary by the investigator.

RESULTS

Sixty-six patients were included (42 acute wounds and 24 chronic wounds) and followed up for an average of 17 days. Dressing changes were deemed entirely painless in 52% of cases (compared with 18% at baseline) and pain between two consecutive dressing changes was absent in 66% of cases (34% at baseline). Removal of the TNP-interface dressing combination was considered'very easy' or 'easy' in 94% of cases and adherence to the wound was recorded as 'absent' in 88%. On average, the dressings were changed every 3.8 +/- 1.1 days (all wounds were considered), and wound area and depth were reduced by 19% and 54% respectively by the end of the follow-up period.

CONCLUSION

Use of the interface dressing in combination with TNP substantially reduced the pain caused by dressing changes. It therefore makes more acceptable the use of this technique, which aims to optimise the management of wounds that are sometimes considered to be in a therapeutic impasse.

[Microsurgery: History of instrumental vascular anastomoses, our experience with eversion-stapling using VCS forceps]

One century, after Carrel in 1906, technics of vascular surgery are the same. After two world wars, peace surgery has been improved by war surgery. Microscopy surgery gave a new way for vascular surgery which became microsurgery with specific instrumentation. We have move from the developing period of microsurgery in the 1970s, to the fully matured period of microsurgery in the 1980s and the the development of clinical free flaps. The 1990s must be the turning point from autogenous tissue transplantation to allogenic transplantation. Ethic comity keeps keys of future! About microvascular anastomoses, many instrumental technics are explored but no-one is better than the classic manual suture. For us, the best instrumental technic is the anastomose with titanium clips VCS((R)) but we only use it in good situation without difficulties.