Necrotizing fasciitis: A highly fatal infection

BACKGROUNDS

Necrotizing fasciitis is a severe bacterial infection characterized by involvement of all skin's layers, including the superficial fascia. Diagnosis and treatment must be as quick as possible. Once suspected, extensive surgical debridement is required.

METHODS

All necrotizing fasciitis, managed in our hospital in Dijon, during the period from January 2011 to May 2021, were retrospectively analyzed. Demographics characteristics of patients, biological parameters, and type of bacteria were collected. Statistical analysis was performed on the cost of hospitalization, as well as on the death rate between type I and II NF and the speed of management. Student's t-test and Chi2 test were performed with a significant level P<0.05.

FINDINGS

A total of 65 patients were included over the period. The mean age was 68.8 years. The average length of stay was 32.4 days, with an average cost of 79,305 €. The main locations were the lower limbs (57%) and the perineum (35%). Cost of hospitalization did not differ between type I and II (P=0.21), unlike mortality rate (P=0.003). Furthermore, the mortality rate according to the speed of management did not vary in our series (P=0.45).

CONCLUSION

Necrotizing fasciitis is quickly fatal if left untreated. Early diagnosis, combined with surgical debridement and probabilistic antibiotic therapy are required. Our study shows the impact of necrotizing fasciitis in terms of cost to society and the importance of prevention of certain risk factors. A global management of the patient is necessary to increase the survival rate.

Time to return to work after total trapeziometacarpal prosthesis

OBJECTIVES

This study assessed return to work and prosthesis survival after trapeziometacarpal prosthesis surgery.

MATERIAL AND METHODS

A multicenter retrospective study was carried out on patients operated on between 2002 and 2020. All working patients who had undergone trapeziometacarpal prosthesis surgery were included. Return to work was defined as resuming the same full-time position. Postoperative events and their specific treatment and failure to return to work were reported.

RESULTS

240 prostheses in 211 patients were included. The complications rate was 7.5%, with 97% prosthesis survival. 94.3% of patients returned to work, at a mean 48 days (range, 29-210 days; SD, 22.7 days), with no significant difference according to age. Twelve patients did not return to work, half of whom because of prosthetic complications.

CONCLUSION

Trapeziometacarpal arthroplasty enables most patients to return to work within 6 weeks. In this series, the prosthetic survival rate was 97%.

The infragluteal fold: An appraisal by MRI combined with an anatomic study

PURPOSE

The gluteal region is a key element of beauty balance and sexual appearance. However, there is no clear anatomical description of the infragluteal fold, nor any classification exists allowing standardizing treatment of this area in case of jeopardisation. The purpose of this study was to perform an anatomical description of the infragluteal fold (IGF) matching radiological and anatomical findings in describing specifically raise of the fibrous component at the bone level.

METHODS

Six volunteers (three males and three females) underwent an MRI scan (Siemens Aera® 1.5 T) of the pelvic region. T1 Vibe Morpho T2, Sag Space 3D, and Millimetric slices were performed in order to obtain a more detailed selection of the gluteal landmark. Trabecular connective tissue of the region was analyzed using Horos® ROI (region of interest) segmentation function. Four fresh cadavers (two males, two females, accounting for 8 hemipelvis) were dissected in order to compare the radiological findings.

RESULTS

The infragluteal fold is a connectival fibrous band extending from the ramus of the ischium (but not involving the ischial tuberosity, for a length of 21 mm ± 2 and 21 mm ± 3), the apex of the sacrum (for a length of 13 ± 2 and 11 mm ± 2), and the coccyx (for a length of 19 mm ± 2 and 20 mm ± 2, all measures referring to volunteers and cadavers, respectively) reaching superficially the dermis of the medial one-third of the cutaneous fold. No significant difference was found between volunteer and cadaver group in MRI measurement of bony origins, or between MRI and cadaveric dissection measurements.

CONCLUSION

Knowledge of this structure will define novel surgical techniques in infragluteal fold restoration.

Traumatic atlanto-axial rotatory subluxation after surgical correction of prominent ears: Case report and review of the literature

Corrective surgery of prominent ears may be justified for social or aesthetic reasons during childhood or adulthood. Post-operative complications occur in approximately 0 to 8.4% of cases. This case describes a rare atlanto-axoid rotatory subluxation after bilateral surgical correction of prominent ears under general anesthesia. Orthopedic treatment was done after two months of medical roaming outside of our center. The one-year post-operative clinic consultation and radiological exam were normal. Only the psychological impact of the episode remained. Traumatic atlanto-axial rotatory subluxation is a rare complication but should be considered after post-operative torticollis in order to aid with diagnosis and allow doctors to implement the appropriate course of treatment.

[Evaluation of the risk of postoperative bleeding complications in hand surgery without interruption of anticoagulant Vitamin K Antagonist (VKA), a retrospective study]

OBJECTIVE

The management of patients on Vitamine K Antagonist (VKA) anticoagulation is a public health issue with surgery being the primary cause of VKA interruption. The aim of this study was to evaluate the bleeding risk in patients operated on hand surgery without interruption of VKA treatment.

PATIENTS AND METHODS

This retrospective, monocentric study was conducted between 2013 and 2015. The inclusion criteria were, as follows: patients on VKA over 18 years of age who had emergency or scheduled surgery without interruption of VKA treatment; INR inferior to 3 analyzed less than 24h before surgery. Exclusion criteria were, as follows: INR superior to 3; interruption of VKA treatment with or without switch to heparin treatment. The primary evaluation parameter was any form of bleeding that occurred during the first 7 post-operative days. The secondary criteria were other surgical complications.

RESULTS

There were 93 patients and 104 procedures. The mean age was 74.36 years (from 27 to 90) with a sex ratio male-to-female of 2.47. The scheduled surgeries were 61.5% against 36.5% for the emergency cases. The mean INR was 2.29 (from 1.07 to 3). One patient presented a postoperative hematoma on the 4th postoperative day, which did not require any revision surgery. There were no other complications reported.

CONCLUSION

The results of this series suggest a small bleeding risk in hand surgery without interruption of VKA treatment provided that IRN is inferior to 3 less than 24hours before the procedure.

Are prostaglandins or calcium channel blockers efficient for free flap salvage? A review of the literature

The free flap failure rate is less than 5%. The responsible mechanisms of postoperative secondary ischemia are mostly vascular. The main postoperative complication leading to flap failure is thrombosis. Different strategies have been reported to improve the reliability of flaps and decrease the risk of partial or total necrosis: thus, pharmacologic agents have been studied to reduce the risk of microvascular thrombosis. The aim of this review was to evaluate the effect of calcium channel blockers and prostaglandins on free skin flap survival. A systematic review of the literature was performed to identify articles studying the efficacy of calcium channel blockers and prostaglandins on free flap survival. After full text reading, eleven articles were finally included. Eight articles investigated the role of prostaglandins in free tissue transfers, two in rats subjects, one in rabbits, five in humans. Two articles studied the effect of calcium channel blockers on free flaps, one in rats subjects, one in rabbits. One article studied in different groups the effect of calcium channel blockers and prostaglandins on free flaps in rabbits. Literature regarding the efficacy of calcium channel blockers and prostaglandins to salvage free flap is poor and mainly based on animal models. Nevertheless, studies on prostaglandins showed a slight efficiency of these molecules for free flap salvage. Results are less reliable for calcium channel blockers and dependent on the molecule used. In conclusion, there is a lack of evidence to use them in clinical practice.

Isolated unilateral temporalis muscle hypertrophy: First case in an 8-year-old boy and review

INTRODUCTION

Isolated unilateral temporalis muscle hypertrophy (IUTMH) was first described in 1990 and few cases have been published since then. This disease occurs mainly in adults. There is no clear etiology of IUTMH, but bruxism is one of the risk factors. Only two cases have been described before the age of 20 years. To our knowledge, no cases have been described in persons younger than 15 years old. We report the first case of IUTMH in an 8-year-old and review the literature.

MATERIAL AND METHODS

This section is separated into 3 parts: (1) search for and description of clinical cases of IUTMH in our department; (2) literature search to find similar cases; (3) data analysis of all cases found.

RESULTS

Ten patients, including our case, were found over a period of 23 years: five females and five males with a mean age of 32.8 years. One patient was 15 years old. Time between onset and diagnosis was 16.7 months. Half of the patients reported pain and three had experienced bruxism. Most of the patients had non-surgical treatment. One patient evolved favorably with no treatment. One recurrence occurred 10 years later.

DISCUSSION

IUTMH can occur in childhood in a high-stress environment. Diagnosis is based on the history and clinical and imaging findings. Biopsy helps to confirm the diagnosis, but electromyograms and neurological tests contribute little. Bruxism should be taken into account. The treatment with the least inconvenience must be given.

Surgical approaches in neck dissection: Comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach

BACKGROUND

Surgical approaches in neck dissection: comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach.

METHODS

This single-center retrospective study compares a new transverse incision for cervicotomy to the classical approach described by Paul André in neck dissections. The evaluation criteria were: number of lymph nodes analyzed, operative time, complications, patient satisfaction and aesthetic aspects of the scar.

RESULTS

A total of 34 patients were included in this study, from September 2009 until January 2015. The number of lymph nodes analyzed is not affected by this new approach compared to the classical one (P=0.9). The scar has a significantly more discreet appearance in the transverse cervicotomy group (P=0.023) likewise; patient satisfaction is higher in this group (P=0.006).

CONCLUSIONS

Aesthetic and functional impairment can be reduced using this new transverse cervical approach hidden in the natural creases of the neck described by Langer.

Classification proposed of malignant intraosseous odontogenic tumors (MIOT)

Malignant intraosseous odontogenic tumors (MIOT) of the jaws are very rare. The diagnosis is difficult. Clinical, paraclinical and histological diagnostic criteria, strict are well established. But the International Union Against Cancer (UICC) does not provide TNM classification that will allow harmonization of the treatment. Indeed, despite their location, they cannot be classified as primary tumors of the oral cavity because of their localization in the bone marrow, making them systematically classified as T4. We propose a classification taking into account the clinical and radiological data.

[Custom-made implant for complex facial reconstruction: A case of total replacement of temporo-mandibular joint, zygomatic arch and malar bone]

INTRODUCTION

Total prosthetic replacement of the temporo-mandibular joint (TMJ) has become a common procedure, but it is usually limited to the TMJ itself. We report about one case of complex prosthetic joint reconstruction extending to the neighbouring bony structures.

CASE

A 57-year-old patient, operated several times for a cranio-facial fibrous dysplasia, presented with a recurring TMJ ankylosis and a complexe latero-facial bone loss on the right side. We performed a reconstruction procedure including the TMJ, the zygomatic arch and the malar bone by mean of custom made composite prosthesis (chrome-cobalt-molybdenum-titanium and polyethylene). Five years postoperatively, mouth opening, nutrition, pain and oral hygiene were significantly improved.

DISCUSSION

Nowadays technical possibilities allow for complex facial alloplastic reconstructions with good medium term results.

Functional and radiographic evaluation of the treatment of traumatic bone loss of the hand using the Masquelet technique

This study was a retrospective evaluation of 18 patients with traumatic bone loss affecting the fingers, hand and wrist who were treated using the induced-membrane technique. Sixteen men and two women, mean age 54years (27-74) presented a hand injury including bone loss. Sixteen patients were treated on an emergency basis and two following nonunion of their fractures. There were 13 cases of open fracture of the phalanx and 5 cases of metacarpal fractures. These patients were treated with debridement and the injuries were covered when necessary. To address the bone loss, the first step of the induced-membrane technique involved placing a cement spacer (polymethylmethacrylate [PMMA]) without antibiotics in the defect. During the second step, the cement spacer was removed and replaced by autologous cancellous bone graft. The graft was placed within the biological tube left empty after removal of the cement. For each patient, bone union was assessed with radiographs and/or CT scan. Failure was defined as nonunion at 1year. In 16 patients, the fractures had healed after 4months (1.5-12months) on average. Two failures were noted (one nonunion treated using a PIP prosthesis and one case of delayed union). Mobility of the fingers, evaluated using the Total Active Motion (TAM) was 145° (75°-270°). The Kapandji score reached 8 for the thumb. Grip strength reached 21kg/F and pinch strength was 5kg/F; these values were 50% of those in the healthy hand. The induced-membrane technique is simple and can be used to treat traumatic bone loss in an emergency, thus avoiding amputation and limb shortening, while preserving limb function. It provides immediate stability and allows early mobilization.