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Study Design Pilot randomized controlled trial with parallel groups. Introduction Engaging individuals with carpal tunnel syndrome (CTS) awaiting carpal tunnel decompression surgery in a preoperative rehabilitation program may mitigate pain and sensorimotor impairments, enhance functional abilities before surgery, and improve postoperative outcomes. Purpose of the Study To assess the feasibility and the efficacy of a novel preoperative neuromobilization exercise program (NEP). Methods Thirty individuals with CTS were randomly allocated into a four-week home-based neuromobilization exercise group or a standard care group while awaiting surgery. Outcome measures included feasibility (ie, recruitment, attrition, adherence, satisfaction, and safety) and efficacy metrics (ie, median nerve integrity and neurodynamics, tip pinch grip, pain, and upper limb functional abilities) collected before (ie, at the baseline and about four weeks later) and four weeks after surgery. Results Thirty individuals with CTS were recruited (recruitment rate = 11.8%) and 25 completed the study (attrition rate = 16.7%). Adherence (94%) and satisfaction with the program (eg, enjoy the exercises and likeliness to repeat the NEP (≥4.2/5) were high and no serious adverse event was reported. NEP-related immediate pre- and post-surgery beneficial effects on pain interference were documented (P = .05, η2 = .10), whereas an overall increased neurodynamics (P = .04, η2 = .11) and decreased pain severity (P = .01, η2 = .21) were observed. Discussion Engaging in the proposed NEP has limited beneficial effect as a stand-alone intervention on pre- and post-surgery outcomes for individuals with CTS. Expanding the program’s content and attribute by adding other components including desensitization maneuvers and novel therapies promoting corticospinal plasticity is recommended. Conclusion A preoperative NEP completed by individuals with CTS awaiting surgery is feasible, acceptable, and safe. However, given the limited beneficial effectsof the program, revision of its content and attributes is recommended before proceeding to large-scale trials.

Biofilm forms when bacteria surrounded by an extracellular matrix aggregate on a surface. It can develop on many surfaces, including wound dressings; this can be particularly nefarious for burn patients undergoing skin grafting (autograft) for burn wound coverage as they often suffer from compromised immune system function. Autograft donor sites are particularly vulnerable to biofilm formation; as such, timely healing of these sites is essential. Our aim was to apply scanning electron microscopy to compare the efficacy of two types of wound dressings in preventing the formation of bacterial biofilm on burn patient skin graft donor sites. One dressing contained bismuth tribromophenate at a concentration of 3% which confers it bacteriostatic properties (Xeroform™). The other was an absorptive alginate calcium sodium dressing (Kaltostat™). Samples of each wound dressing, which were in contact with the skin graft donor site, were prepared for analysis under the scanning electron microscope (SEM) using an original method developed by our research group that aims to maintain the integrity of the biofilm microstructure. Samples prepared by this method were then analyzed using SEM, which allowed the characterization of biofilm and the evaluation of bacterial density on the studied dressing samples. To this day, this imaging technique has been rarely employed for dressing analysis and this is the first time that it is employed for in situ biofilm visualization for this particular application.

Frostbite causes tissue damage through five major mechanisms, out of which two are amenable to treatment. The first-line treatment is rapid rewarming therapy using water at 40°C to 42°C, which addresses the formation of ice crystals in the intra and extra cellular compartments. The second mechanism is progressive tissue ischemia after rewarming and is only accessible to a second-line therapy represented by thrombolysis. This study aimed to determine the efficacy of thrombolysis. This is a single-center retrospective cohort study, where it was aimed to evaluate two groups of patients. A total of 18 patients were included in this study. Mean times between injury to thrombolytic therapy and admission to thrombolytic therapy was 26.04 hours (SD 13.6) and 9.65 hours (SD 9.89), respectively. All patients suffered injuries ranging from second-degree deep to third degree. The rate of patients having complete, partial, and no angiographic responses were 55.6%, 11.1%, and 33.3%, respectively. The main outcome of interest showed that 11 (61.1%) patients in total had amputations at different levels. Results showed that in the intervention group, five (55.6%) of the patients had amputations compared with six (66.7%) from the control group (P = .6) at comparable levels of amputation. The literature supports that the use of intra-arterial tissue plasminogen activator might be beneficial for severe cases of frostbites; however, it lacks of studies of major significance and results are often controversial. Our study has not shown statistically significant results on amputation levels and cannot support the hypothesis of efficacy of thrombolytic therapy.

Background Although increasingly reported in the literature, most plastic surgeons cannot define the etiology of double capsules. Often an incidental finding at implant exchange, double capsules are frequently associated with macrotextured devices. Several mechanisms have been proposed, including at the forefront that shearing causes a delamination of the periprosthetic capsule into a double capsule. Objectives This study was designed to confirm the hypothesis that mechanical forces are involved in formation of double capsules by histological analysis. Methods A prospective analysis of consecutive implants with double capsules removed over 2 years was performed. Data collected at the time of surgery included Baker classification, reason for explant, implant manufacturer and style, and any presence of a seroma associated with the capsule. Specimens were sent for analysis by histology utilizing hematoxylin and eosin and alpha-smooth muscle actin staining techniques. Results Eight double capsules were collected for specimen analysis. All capsules demonstrated evidence of granulation tissue, alpha-smooth muscle actin positive myofibroblasts, and folds with embedded texture. Fibrosis surrounded weak areas with presence of layering and splitting, creating a potential space that is prone to separation. Tears and folds from granulomatous reaction are also present within the outer layer of the double capsule, which can only be explained by a mechanical shearing force as a pathogenic mechanism. Conclusions Understanding the pathogenesis of double capsules may allow plastic surgeons to refine their indications for macrotextured implants while providing guidance to patients on avoidance of activities that produce shear-forces. The findings support the hypothesis that shearing forces delaminate the capsule into 2 separate distinct capsules. Level of Evidence: 5

Summary Purpose Our aim is to do a comparative qualitative analysis of patents and “User Manuals” of the Biocell textured implants in order to determine if red flags were omitted when marketing and using Biocell textured implants. Materials and methods We performed a systematic qualitative analysis using the NVivo software version 11 of the patents describing the Biocell textured implants prior to their approval by the FDA and of user guides published by the 3 companies owning the patents (McGhan, Inamed, Allergan). To guide our thematic analysis, we used a form of systems theory known as the complexity theory. Results Four patents related to Biocell and 2 user manuals (McGhan- Inamed and Allergan) were analyzed. Four themes emerged from the patents: invention description, mechanism of action (Tissue ingrowth), the timing of the mechanism of action and hypothetical actions on capsular contractures prevention. Of all patent's content, 34% described the invention, 29% the mechanism of action (tissue ingrowth), 1% the timing of this mechanism of action and 34% a hypothetical action against capsular contracture. Solid evidence was found on the concept of anchoring and very little on capsular contracture. On the user guide side, the main themes were indications and contraindications, surgical techniques and long-term effects. The “directed” content analysis approach of the user guides regarding the patent's themes reflected that 94% of the user guides content related to the patent thematics was about the hypothetical role on capsular contracture while only 4% was about invention description and 1.5% about tissue ingrowth. Conclusions This analysis highlights the discrepancies between patents of Biocell textured implants and user guides for these implants. The indications of use of a treatment or device can evolve quicker than the study of its potential complications and side effects. The BIA-ALCL crisis should serve as a cautionary tale to the plastic surgery community which embraces new technologies eagerly, and sometimes precariously, in a mission to advance patient care.

Summary Background Simulation models are increasingly important for skill acquisition during microsurgery training. Prosthetics, living and non-living biological models have been proposed in the literature in the optics of recreating real-life scenarios in a controlled environment. This study aims to validate and prove the reusability of a novel non-living biological model: the porcine placenta. Methods A prospective comparative study was carried out to assess face and content validities of the proposed model, as well as the reusability and quality of the Thiel-embalming method. Participants were asked answer a questionnaire for each anastomosis they performed on porcine placental vessels of ≤ 2 mm (small) and 2–4 mm (large). Scores were classified according to different subgroups, either small or large vessels and first or second sessions. Reliability analysis of the questionnaire was carried out using Cronbach's α, to ensure an α > 0.7. Median scores for each question were analyzed using boxplots and compared amongst each subgroup using a non-parametric independent Mann-Whitney U test. Results With nine participants, the Cronbach's α for each category of question was 0.867, 0.778, 0.720 and 0.593. Statistical differences were found between responses of small and large vessels on 5/10 questions, where large vessels reported higher validity. No statistical differences were found between scores of the first and second sessions. Conclusion By evaluating face and content validity, the Thiel-embalmed porcine placenta has proven its suitability as a microsurgery model, especially for vessels of larger caliber. Qualities that distinguish this model is its reliable reusability, its low cost-effectiveness, and its ethical acceptability.

Summary Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.

Summary Background The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. However, while estrogens play a crucial role in wound healing, no study has assessed the impact of tamoxifen or aromatase inhibitors on other postoperative breast reconstruction complications, including infections, necrosis, capsular contracture and seroma. As breast cancer patients undergoing Implants-ADMs breast reconstruction are often receiving hormone therapy, it is unclear whether this increased infection risk is associated with increased infections cases. Methods A prospective study was performed on patients undergoing breast reconstruction at an academic institution from 2013 to 2016. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including infections, necrosis, seroma and hematomas, were compared and analyzed using univariate and logistic regression models. Results Among a total of 112 patients (183breasts), 58 patients (91 breasts) were receiving hormone therapy and 54 patients (92 breasts) were not. The hormone therapy group had a higher incidence of postoperative mastectomy skin infection (20.7% versus 7.4%; P = 0.0447), we didn’t find any significant differences in necrosis. Conclusions Hormone therapy was associated with a higher incidence of Infections after breast reconstruction with ADMs and implants. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors. Immediate breast reconstruction surgery with expander/direct implant and use of acellular dermal matrix: does hormone therapy increases the risk of infection?

National audience; Introduction. - ANCA-vasculitis are associated with high morbidity and mortality. Large use of cyclophosphamide as induction immunosuppressive therapy is limited by its side effects. All recent literature trends in decreasing cumulative dose while optimizing maintenance therapy. Methods. - This retrospective multicentric analysis included ANCA-vasculitis patients with renal impairment and de novo diagnose followed in Rennes and Vannes hospitals for 2 years minimum. The primary endpoint was to analyze relapse free survival comparing oral and intravenous administration of cyclophosphamide. Results. - From 01/01/2003 to 01/03/2016, 91 patients were included (45 oral and 46 intravenous group). Patients in oral group were 10 years younger (P < 0,001), with higher maintenance therapy (P < 0,001) and steroids (P < 0,001) duration. With a Cox model adjusted on age, steroid and maintenance therapy duration, oral cyclophosphamide showed no benefice in decreasing relapse free survival (OR 0,80; 95%IC 0,38-1,66; P = 0,55). No difference was observed on either mortality or renal survival. Oral group at 1-year trends to achieve more leucopenia (40 vs 24%) and infection (30 vs 22%) episodes, but less hospitalization (40 vs 65%), without reaching statistical significance. Conclusion. - In this retrospective multicentric analysis, oral cyclophosphamide induction was not associated with better relapse free survival after adjustment with age, steroid and maintenance therapy duration. Maintenance therapy duration is believed to better prevent ANCA-vasculitis relapse. (C) 2020 Societe francophone de nephrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.

International audience; Background: Emergency start (ES) of dialysis has been associated with worse outcome, but remains poorly documented. This study aims to compare the profile and outcome of a large cohort of patients starting dialysis as an emergency or as a planned step in France.Methods: Data on all patients aged 18 years or older who started dialysis in mainland France in 2012 or in 2006 were collected from the Renal Epidemiology and Information Network and compared, depending on the dialysis initiation condition: ES or Planned Start (PS). ES was defined as a first dialysis within 24 h after a nephrology visit due to a life-threatening event. Three-year survival were compared, and a multivariate model was performed after multiple imputation of missing data, to determine the parameters independently associated with three-year survival.Results: In 2012, 30.3% of all included patients (n = 8839) had ES. Comorbidities were more frequent in the ES than PS group (≥ 2 cardiovascular diseases: 39.2% vs 28.8%, p < 0.001). ES was independently associated with worse three-year survival (57% vs. 68.2%, p = 0.029, HR 1.10, 95% CI 1.01–1.19) in multivariate analysis. Among ES group, a large part had a consistent previous follow-up: 36.4% of them had ≥3 nephrology consultations in the previous year. This subgroup of patients had a particularly high comorbidity burden. ES rate was stable between 2006 and 2012, but some proactive regions succeeded in reducing markedly the ES rate.Conclusion: ES remains frequent and is independently associated with worse three-year survival, demonstrating that ES deleterious impact is never overcome. This study shows that a large part of patients with ES had a previous follow-up, but high comorbidity burden that could favor acute decompensation with life-threatening conditions before uremic symptoms appearance. This suggests the need of closer end-stage renal disease follow-up or early dialysis initiation in these high-risk patients.

Background Skin coverage remains a significant hurdle in large-sized burns. Recent advances have allowed to grow Bilaminar Cultured Skin Autografts (BCSGs) from patients’ own donor sites. The aim of this study was to report long-term outcomes in patients with large-sized burns having received BCSGs. Methods Nine patients received BCSGs from January 2010 to May 2015. Except one patient who died during hospitalization, all patients were contacted. Four agreed to partake in the study. Patients were tested with the Vancouver Scar Scale (VSS), QuickDASH questionnaire and Burn Specific Health Scale (BSHS). Incisional biopsies of BCSGs were compared with patients’ autografts. Results From nine patients, mean age was 40 years and mean TBSA was 70.3%. For the four patients included, score averaged was 2.25 on the VSS, 29.5 on QuickDASH, 36/36 for psychosocial items and 63/84 for functional abilities on the BSHS. Compared with autografts, BCSGs demonstrated better pliability VSS and functionality. Biopsies showed no evidence of malignancy or atypical changes, but areas of hyperpigmentation. Conclusion This is the first report investigating the long-term outcome of a newly developed BCSG. BCSGs demonstrated comparable results with patients’ autografts, functional outcomes on self-reported questionnaires and excellent psychological states. Precaution given the extensive unexpected hyperpigmentation must be taken and a randomized controlled study is underway.

Acellular dermal matrices have become a mandatory tool in reconstructive breast surgery. Since their introduction, they have been considered to be nonreactive and nonimmunogenic scaffolds. However, some patients who undergo implant-based breast reconstruction with acellular dermal matrices develop postoperative cutaneous erythema overlying their matrices, a condition commonly referred to as red breast syndrome. The aim of this study was to gain a better understanding of this phenomenon. An analysis was conducted on consecutive patients who underwent acellular dermal matrix- and implant-based breast reconstructions and developed red breast syndrome that was treated surgically between April of 2017 and June of 2018 at the authors' institution. During surgery, 1-cm specimens of acellular dermal matrix were sampled and analyzed by scanning electron microscopy. Observations were charted to score and record the presence and thickness of biofilm, and for identification of bacteria. These measurements were performed using Adobe Photoshop CS6 Extended software. Six postmastectomy breast reconstruction patients were included, all with AlloDerm Ready-to-Use-based reconstructions. All specimens were colonized by various bacteria ranging from Gram-negative bacilli to Gram-positive microorganisms. Biofilm was present in all studied specimens. The cause of skin erythema overlying acellular dermal matrix grafts, and the so-called red breast syndrome, may be related to contamination with various bacteria. Although contamination was omnipresent in analyzed samples, its clinical significance is variable. Even if acellular dermal matrix-based reconstructions are salvaged, this could come at the price of chronic local inflammation.

Background After thumb amputations, restoration of function and aesthetic can be accomplished with microvascular free toe flaps. However, many patients in clinical practice do not choose this reconstruction despite positive reported outcomes. This study aims to determine patients' perceptions with respect to free toe flaps to improve areas of informed consent. Methods A retrospective survey was administered to patients with thumb amputations. Participants were required to complete a questionnaire about patient demographics, the Brief Michigan Hand Questionnaire (bMHQ), the standard gamble/time trade-off questionnaires for utility scores, and a questionnaire investigating potential reasons for electing not to undergo a free toe transfer. Results Thirty patients were enrolled in the study wherein 53% underwent a replantation procedure, 27% a revision amputation, and 20% a delayed reconstruction. Mean normalized score on the bMHQ was recorded as 63.54. Utility questionnaires yielded mean measures of 0.8967 and 0.86 on the standard gamble and time trade-off, respectively. From 14 elements, a majority (87%) stated flap failure as a major source of concern, followed by lack of understanding of risks and benefits (80%) and prolonged hospital stay (53%). Cultural/religious beliefs, aesthetic appearance of the foot, and concerns about footwear were not reported as important reasons in 90, 80, and 79% of patients, respectively. Conclusion A better understanding of patients' attitudes and beliefs with respect to free toe flaps will allow surgeons to better address their concerns during informed consent. This study emphasizes the importance to discuss about failure rates, risks, and benefits of the operation and prolonged hospital stay.

Background To prevent postoperative thrombosis, indications for anticoagulation in finger replantation have been described, but no consensus has yet been found for cessation protocols. The aim of this study is to investigate cessation methods of intravenous anticoagulation after finger replantation. Methods A retrospective review of all patients treated for a finger replantation between December 2014 and July 2016 was performed. Only those who required postoperative treatment with intravenous heparin were extracted. Primary outcome was survival of finger at hospital discharge and data collection focused on postoperative anticoagulation regimens. Results 108 patients with replantation were treated with intravenous heparin and included in the analysis. When anticoagulated, survival rate was 60% (n = 65) at hospital discharge, wherein arterial and venous thrombosis accounted for 60 and 40% respectively. Descriptive analysis failed to demonstrate an increase in failure rates when tested for duration of intravenous heparin, fixed or variable infusion rates of anticoagulation and need for vascular grafts. However, there was a 2.8-fold (P = .009) increase in the survival rate with progressive weaning of anticoagulation rather than abrupt discontinuation. Subgroup analysis demonstrated similar findings when considering arterial thrombosis alone (OR 5.2, P = .012), but did not show any significant difference for venous thrombosis (OR 1.7, P = .344). Conclusions Progressive tapering of intravenous heparin is associated with an increased survival rate after finger replantation, particularly for arterial thrombosis. Further prospective and randomized trials are necessary to elucidate the optimal duration, method of infusion and indications for vascular grafts.

Summary Background Macro-texturing of breast implants was developed with the double goal of improving implant stabilization within the breast cavity and decreasing the rate of capsular contractures. However, recent evidence suggests that double capsular formation, a potentially worrisome phenomenon associated with late seromas and biofilms, occurs with preponderance in macro-textured implants. Our objective was to analyze histologically different regions of double capsules to determine if they are more prone to mechanical movements. Methods A prospective analysis including patients undergoing second-stage expander to definitive breast-implant reconstruction post-mastectomy was conducted after intraoperative identification of the double capsule phenomenon. Two samples were collected from each capsules around the implant, located centrally and laterally. The specimens were sent for histological analysis by the institution's pathologist. Results In total, 10 patients were identified intraoperatively with partial double capsule phenomenon. Among samples retrieved from the lateral aspect of the breast implant, all were associated with delamination and fractures in the collagen matrix of the double capsules. This phenomenon was not observed in any sample from the dome of the breast. Conclusions Breast-implant macro-texturing plays an important role on delamination of capsules on lateral portions of the breast, which may have an etiologic role in double capsule formation. Manufacturing implants with macro-texturing on one side and smooth surface on the other could diminish mechanical shear forces responsible for these findings.

National audience; Introduction. - Intoxication induced by glycyrrhizin is a common cause of hypokalaemia by pseudo-hyperaldosteronism. Observation. - We hereby present the observation of a 68-year old patient hospitalised following a full hip-prosthesis operation after a deep hypokalaemia at 2.5mM was observed, with ECG signs (flat T waves and appearance of U waves). The kaliuresis was not adapted at 8,4mmol/mmol of creatininuria. We noted a history of axonal and demyelinising polyneuropathy, of psoriasis and chronic ethylism.The evolution after intravenous potassic supplementation and then per os was favourable leading to a normalisation of the blood and urinary potassic concentrations. The blood concentrations of renin and of aldosterone upon admission were lower than the detection threshold and the tests carried out 7 days later were normal with a plasmatic renin of 35.2 pg/mL and a plasmatic aldosterone of 74 pg/mL, therefore indicating a toxic cause. It is the interview of the patient that allowed for the diagnosis, identifying a daily, prolonged and important consumption (around 1L every 2-3 days for several years) of a pastis produced by supermarket brand Lidl (R). The composition of the drink mentions 'liquorice infusion' without giving any more information as regards to the real concentration; it was later estimated at 170 mg/L by the distributor. Discussion. - The consumption of glycyrrhizin is a well-known aetiology for pseudo-hyperaldosteronism. It is commonly mentioned amongst excessive consumers of liquorice or of non-alcoholic anise drinks. Drinks that are derived from original pastis contain varying levels of glycyrrhizin, which is used as a flavour enhancer and can become toxic in cases of prolonged and important consumption. (C) 2020 Societe francophone de nephrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.

Free flap reconstruction in acute burns has high failure rates, relating mainly to a systemic inflammatory state. The “vulnerable phase” can last for 6 weeks after burn and can cause thrombosis of the flap microcirculation with patent arterial and venous anastomoses. Revision surgery alone may be unsuccessful, but thrombolysis can lead to flap salvage. We describe a case of successful flap salvage with thrombolysis after unsuccessful revision surgery by permeable arterial and venous anastomoses in a patient in the acute burn phase suffering from microcirculatory thrombosis. Thrombolysis in these cases has not been described to date, but it could contribute to salvaging flaps by radiological intervention alone. A 23-year-old man was admitted with a 38% TBSA burn, including loss of all eyelid skin. The right eye was reconstructed in a satisfactory manner, but the left eye required urgent corneal coverage on day 32 with a dorsalis pedis fasciocutaneous free flap. The flap was hypo-perfused postoperatively, but anastomoses were found to be permeable on exploration. Angiography performed postoperatively after revision confirmed anastomotic patency, but failed to demonstrate small vessel beds within the flap. Thus, r-tPa was given at the anastomosis site and immediately the flap recovered completely. However, a total of 10 packed red blood cell transfusions were needed over the next 9 days. Thrombolysis in the context of free flap microvascular compromise may improve the overall success rates, especially in acute-phase burn patients where this etiology may be found, due to a vulnerable inflammatory period.

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) for trapeziometacarpal joint osteoarthritis may have both postoperative benefits and complications. This study sought to determine the health state utility outcome measures of trapeziectomy with LRTI. Patients who underwent trapeziectomy with LRTI were invited to complete the brief Michigan Hand Questionnaire and utility questionnaires outcomes using a visual analogue scale , time trade-off and standard gamble. Quality-adjusted life years (QALYs) were derived from these utility measures. For this study 32 patients were recruited, with a mean age of 61. Most patients (27/32) perceived the procedure as successful. Utility measures and QALYs serve the purpose of comparing different surgical procedures in terms of their impact on the quality of life of patients as a function of the benefits and complications of each procedure. In this study, the utility of trapeziectomy with LRTI was less than has been described for open palmar fasciectomy but more than for total wrist arthrodesis.Level of evidence: IV

Negative pressure wound therapy (NPWT) represents one of the many solutions for complex wounds of the upper extremity. The goal of this study was to investigate the most common indications for definitive treatment of wound defects in the upper extremity with NPWT and to report revision surgery outcomes after its use. A systematic review of the literature was performed. The following keywords and their combinations were used: "upper extremity," "arm," "forearm," "wrist," "hand," "finger" AND "negative-pressure wound therapy," "VAC therapy," "vacuum assisted closure." A total of 45 articles were included, regrouping 404 cases of NPWT in the upper extremity. The forearm was involved in 53% of cases, followed by hand (36%), fingers (10%), and arm (1%). Seventeen different indications were cited, the most common of which were radial forearm flap reconstruction (23%), burn wounds (18%), and compartment syndromes (17%). Of the cases, 90% did not require any subsequent surgical procedure, as opposed to 6% considered partial failures requiring minor revisions and 4% total failures requiring major revisions. Closure of radial forearm flap donor site required the most revision procedures when treated with NPWT. NPWT can be used for several indications pertaining to the reconstruction of the upper extremity. Positive outcomes as a definitive treatment are demonstrated in this systematic review, which reaffirms NPWT as a potent tool for reconstructive endeavours.

Background Sensory and motor disturbances are characteristic of musculoskeletal injuries and conditions. Rehabilitation interventions aimed at remediating these disturbances are traditionally exclusively targeted to the affected area. However, there is some evidence of bilateral changes in sensory and motor function associated with unilateral injuries and conditions suggesting central changes. Deficits on specific cognitive tasks have also been documented in persons with chronic pain. Purpose The purpose of the present study was to determine if participants with unilateral pain arising from heterogeneous wrist/hand injuries and conditions demonstrate bilateral changes in sensory and motor functions as well as cognitive deficits. Design/methods Sensory (Pressure Pain Thresholds, Two Point Orientation Discrimination), Motor (grip strength and Purdue Pegboard), and Cognitive function (Stroop test and mental rotation task) were measured in 30 participants with wrist/hand pain and 30 healthy control participants in an observational cross-sectional study. Results Participants with unilateral wrist/hand pain demonstrated differences in cognitive function measured with the Stroop test (p = 0.03). They also demonstrated bilateral sensorimotor differences in pressure pain thresholds (p = 0.03), grip strength (p = 0.00) and Purdue pegboard test (p = 0.03) results compared to healthy control participants. Conclusion Cognitive as well as bilateral alterations in sensory and motor function in participants with musculoskeletal injuries and conditions suggest central changes are involved in their pathophysiology. These findings in persons with heterogeneous injuries/conditions suggest that these changes are not specific to an injury/condition. Bilateral sensorimotor changes have important implications with regards to the pathophysiology of musculoskeletal disorders of the wrist/hand, for rehabilitative interventions and research.

Study Design Cross-sectional. Introduction Pain severity, sensory and motor impairment, and psychological (distress and anxiety) and social factors have previously been related to self-reported disability in persons with wrist and hand pain. Purpose of the study The purpose of this study to determine the relative contribution of pain severity, measures of impairment (sensory and motor function), psychosocial factors, and pain interference on self-reported disability experienced by persons with heterogeneous orthopedic injuries and conditions of the wrist and hand. Methods Measures of disability and pain severity as well as measures of sensory (pressure pain thresholds, joint position sense), motor (grip strength, Purdue pegboard), and cognitive performance (Stroop test) and psychosocial variables related to pain and participation (West Haven-Yale Multidimensional Pain Inventory) were administered to 60 participants with wrist and hand pain. Pearson product correlations controlled for age and sex, and multiple linear regression was performed to determine the relationship between measures of impairment, pain severity, psychosocial variables, and pain interference with self-reported disability assessed with the Disability of Arm, Shoulder and Hand (DASH) questionnaire. Results The best-fitting regression model with DASH scores entered as the dependent variable (F4,50 = 28.8, P Conclusion Pain interference appears to be an important factor explaining the link between impairment, pain severity, and self-reported disability. Addressing pain interference may be important to improve outcomes in this population.

Summary Introduction Despite positive outcomes reported in the literature, some surgeons remain reluctant to the systematic use of venous couplers in free flap tissue transfer. In our institution, the use of the coupler devices for venous anastomosis in free flap breast reconstruction has yet to be adopted by all surgeons. The purpose of the study was to compare postoperative outcomes of coupler-assisted venous anastomoses with hand-sewn techniques in free flap breast reconstruction. Methods An analysis of collected data was performed on cases of breast reconstruction with free tissue transfer after mastectomy in breast cancer or BRCA-positive patients from 2010 to 2016. Patients were divided into two groups: coupler device and hand-sewn. The primary outcome was survival rate of free flaps. Secondary outcomes included potential complications, as well as surgical characteristics (recipient artery/vein, coupler size, type of hand-sewn anastomosis, size of sutures, number of venous anastomoses, ischemia time, operative time) Results We included 289 cases in our study. There were no significant differences between groups in terms of post-operative complications or survival rate of the free flaps. Ischemia time was significantly lower in both immediate and delayed reconstruction cases. Operative and anesthesia times were significantly lower only in immediate unilateral cases. Conclusion Although ischemia time was reduced in the coupler group, we didn’t find any significant difference in the operative and anesthesia time in the subgroup analysis, except for the group of immediate unilateral breast reconstruction. Couplers are safe and efficient; nevertheless, our study shows that their qualities cannot yet justify the disappearance of the manual sutures.

Summary Purpose To assess the utility of the Thiel arterial model in microsurgical research, we compared interrupted horizontal mattress (HM) sutures to simple interrupted (SI) sutures in human vessels. Methods A microsurgical set-up using an operating microscope and Thiel-embalmed arteries was used to practice ten SI and HM anastomoses. Vessel patency, leak and stricture were evaluated using angiography, and vessel wall architecture was evaluated using light microscopy and scanning electron microscopy (SEM). The technique speed was also assessed. Results We have successfully evaluated all outcomes. All anastomoses were patent. The stricture rate was higher with HM than with SI (60% vs. 35% surface area reduction). Three minor leaks occurred with HM sutures versus one with SI sutures. Edges were evenly everted without any intimal flaps with HM compared to SI. The anastomoses were performed faster using HM than SI sutures (7:58 min vs. 12:41 min, respectively). Conclusion This is the first study to evaluate the feasibility of a Thiel-embalmed artery model for research purposes. The HM microvascular suture is a promising technique that requires further in vivo validation.

Spontaneous arterial dissection is a disease whose prevalence is difficult to know and which varies according to the affected artery territory. It can affect the aorta and all medium caliber peripheral arteries including cerebrovascular arteries, coronary arteries and renal arteries. The pathophysiology is common, it is a bleeding in the media. The causes are diverse and vary by territory. Affected patients have few cardiovascular risk factors. Fibromuscular dysplasia is the condition to look for in these few presentations. The vital and functional prognosis may be engaged. Treatment varies depending on territory, severity, and etiology. Conservative treatment is the first-line treatment.

Summary Background Staged expander-to-implant breast reconstruction is plagued by a high prevalence of complications. We have employed an alternative approach of using the infra-mammary crease (IMF) for expander-to-implant exchange. The IMF approach was thought to utilize healthier tissues, which are believed to be less affected by the process of tissue expansion, and reside distant from the field of the radiotherapy boost. Methods A retrospective chart review was performed on all patients undergoing a staged implant-based breast reconstruction from 2009 to 2014. Patients were divided into those that received an IMF vs. a mastectomy scar (MS) approach in the second stage of expander-to-implant exchange. Patient characteristics and postoperative complications were extracted. Results A total of 75 patients undergoing 96-staged reconstructions were included (70 cases MS vs. 26 cases IMF). Patient demographics and implant characteristics were similar between groups. There were no significant differences in overall complications between the groups (11.4% MS vs. 7.7% IMF, P = 0.72). All cases of implant exposure occurred in the MS group and had a history of radiation. However, there was no statistical difference in implant exposure between groups (4.3% MS vs. 0% IMF, P = 0.56) or in the irradiated patients subgroup (20% MS vs. 0% IMF, P = 0.25). Conclusions In conclusion, the IMF approach for the second stage of expander-to-implant exchange is an alternative technique with a similar prevalence of complications as the traditional mastectomy scar approach. This technique may prove useful in reducing postoperative incisional dehiscence and implant exposure, especially in the context of radiotherapy.

The authors report the case of a 30-year-old male with 52% TBSA high-voltage electrical injury of the upper half of the body. Injuries included a cervical burn with associated alteration of the left brachial plexus as well as extensive soft tissue burn of the right hand. Three months later, he developed osteomyelitis of the right thumb metacarpal bone requiring amputation proximal to the metacarpophalangeal joint. Following initial management, the patient had a permanent distal left upper extremity paralysis with nonfunctional but relatively undamaged ipsilateral hand digits. The right hand remained functional with four intact digits and a thumb stump. Usually, late reconstruction of proximal thumb amputation is performed by pollicization or free toe transfer procedures. In this particular case, right thumb reconstruction was done by free transfer of the left little finger. Four months postoperatively, the patient demonstrated a functional pinch between the reconstructed thumb and the ipsilateral digits along with improving sensation. This uncommon surgical procedure restored a functional thumb with minimal donor site morbidity. The decision-making process and operative technique are presented in detail along with a review of the thumb reconstruction literature.

Despite significant improvements in surgical technique and perioperative care, the management of patients requiring chest wall resection and reconstruction is an ongoing challenge for thoracic surgeons. A successful approach includes a thorough assessment of the patient and the lesion, an adequate biopsy to confirm tissue diagnosis, and a well-established treatment plan. In the case of a primary tumor of the chest wall, the extent of the resection should not be limited by the size of the resulting defect. Following resection, chest wall reconstruction mandates an appreciation for restoration of functional and structural components. An algorithmic approach to chest wall reconstruction begins with the assessment of the nature of the defect, taking into consideration factors such as infection, tumor location, previous radiation therapy, and surgical intervention. The latter factors bear influence on the type of tissue required as well as whether reconstruction can be performed in a single stage or whether it is better delayed. Finally, patient factors including lifestyle and work, as well as prognosis, are considered to determine the best reconstructive option.

Summary Background Venous congestion/insufficiency plays a major role in failure of finger replantation. Despite acceptable salvage rates with postoperative anticoagulation or leeching, operative technique remains the most important predictor of success. However, there are no indications in the literature on the benefit of anastomosing single versus multiple veins. Methods A retrospective review of finger amputations from 2011 to 2013 was conducted. The analyzed endpoint was the finger survival rate at discharge depending on the number of veins repaired: multiple veins (group 1), only one vein (group 2), or no veins (group 3). Proportions were compared using v2 tests/Fisher's exact tests; p- value Results Seventy-two patients with complete digital amputation were operated including 101 fingers. Twenty-seven fingers (26.7%) failed before hospital discharge, with 78% of failures due to venous complications versus 22% with an arterial etiology. Group 2 had 15 replantation failures due to venous causes as opposed to only one from group 1, representing a 1.27-fold (95% confidence interval (CI): 0.99, 1.34) increased relative risk of failure ( p = 0.032). Similarly, five fingers from group 3 suffered venous complications, resulting in a 1.49-fold (95% CI: 1.02, 1.73) increased likelihood of failure in comparison to group 1 ( p = 0.008). No significant difference was observed between having only one vein repaired versus none (RR: 1.1792, 95% CI: 0.83, 2.10, p = 0.502). Conclusion Efforts toward favoring two-vein repair lead to better survival of the replanted fingers. More cases need to be analyzed before formulating conclusions on specific levels of amputation with regard to venous anastomoses.

Breast implants are amongst the most widely used types of permanent implants in modern medicine and have both aesthetic and reconstructive applications with excellent biocompatibility. The double capsule is a complication associated with textured prostheses that leads to implant displacement; however, its etiology has yet to be elucidated. In this study, 10 double capsules were sampled from breast expander implants for in-depth analysis; histologically, the inner capsular layer demonstrated highly organized collagen in sheets with delamination of fibers. At the prosthesis interface (PI) where the implant shell contacts the inner capsular layer, scanning electron microscopy (SEM) revealed a thin layer which mirrored the three-dimensional characteristics of the implant texture; the external surface of the inner capsular layer facing the intercapsular space (ICS) was flat. SEM examination of the inner capsule layer revealed both a large bacterial presence as well as biofilm deposition at the PI; a significantly lower quantity of bacteria and biofilm were found at the ICS interface. These findings suggest that the double capsule phenomenon's etiopathogenesis is of mechanical origin. Delamination of the periprosthetic capsule leads to the creation of the ICS; the maintained separation of the 2 layers subsequently alters the biostability of the macro-textured breast implant.

Complications of carpal tunnel release, while infrequent, include incomplete release resulting in persistent symptoms or recurrence due to postoperative scarring, as well as iatrogenic damage to nerves and vessels. We present the case of a patient who underwent carpal tunnel release with resolution of symptoms in the immediate postoperative period. At one and a half years post release he started to experience numbness and tingling in a median nerve distribution triggered by repetitive ulnar to radial deviation of the wrist, with no symptoms at rest. Dynamic ultrasound showed a subluxation of the median nerve from one side of the palmaris longus tendon to the other. The patient's symptoms were triggered as the median nerve squeezed in between the palmaris longus and flexor digitorum superficialis tendons.

The reconstruction of the columella poses a significant challenge to the plastic surgeon. A multitude of techniques have been developed to address this issue; however, the end result is often unsatisfactory or comes at too high a morbid cost. Gillies described an alar margin flap in 1949 that never gained significant popularity. This technique had been refined by Servant over the past two decades in his work on Noma noses in Africa. We describe a two-stage columella reconstruction technique with a nostril alar rim threshold flap and provide the results of our case series. Under local anaesthesia, a full-thickness alar flap is raised by placing an incision along the alar-facial groove and carrying it around the lateral crus. This flap is then rotated on its medial pedicle and inserted into the nasal tip. Three weeks after the first stage, the flap is divided to the desired columellar length and the remaining ala relocated to the alar-facial groove. At the same time, the contralateral ala can be adjusted to match the donor side. We performed a retrospective study of all our columellar reconstructions using this local flap. Our case series consisted of seven patients, and satisfactory cosmetic results were obtained in all cases. The nostril alar rim threshold flap is a useful technique for columellar reconstruction, producing near-anatomic results that can be performed as a two-stage outpatient procedure under local anaesthesia. This technique is particularly well suited for columellar reconstruction in patients of African descent.

Abstract. A personal goal intervention program was offered to early retirees aged 50 to 65 years with the objective of increasing their subjective well-being. The program was aimed at helping the participants set, plan, pursue, and realize their personal goals. A subsample of 21 participants with suicidal ideas was identified from a larger sample (N = 354) of retirees living in the community who took part in the study to evaluate the program. The experimental (n = 10) and control (n = 11) groups were compared on their answers to 16 goal and psychological well-being questionnaires. By the end of the program, the experimental group had improved significantly more than the control group on hope, goal realization process, serenity, flexibility, and positive attitude toward retirement. The levels of depression and psychological distress significantly decreased. These gains were maintained 6 months later. The positive results obtained from this study could lead to an innovative way to help people with suicidal ideations.

A personal goal-based intervention was offered to retired people aged 50 to 65 years with the objective of increasing their subjective well-being and their mental health. More specifically, the program presented here was aimed to promote the setting, planning, and realization of personal projects through a learning process based on a cognitive approach. At the end of the program, the experimental group (n = 117) had improved significantly more than the control group (n = 177) on all the goal and subjective well-being indicators, and this gain was maintained six months later. Some ideas to make the program more effective are discussed.

An extensive study of both sequence and recent 3D structural data concerning GTPase interacting domains of Ras- and Rho-specific GTPase-activating proteins (GAPs) shows that these two subfamilies share a same 3D scaffold and are thus related to each other. This relationship has heretofore remained undetected although these domains of similar size are both totally α-helical and activate nearly structurally identical targets (Ras and Rho proteins). In this report, sequence similarities correlated to 3D structures of p120rasGAP and p50rhoGAP were detected using the sensitive two-dimensional method hydrophobic cluster analysis (HCA). These patterns were further extended to other members in each subfamily and the geometry orientation of crucial arginines R789 in p120 and R282 in p50 and of important stabilizing residues like p120R903 and p50N391 was confirmed. This overall structural relationship is centered on an invariant motif of three consecutive helices that we suggest to name the `cradle fold'. This observation opens new perspectives to understand how small GTPases are specifically regulated.

Inferior vena cava filter placement is performed to prevent pulmonary risk secondary to deep venous thrombosis. Indications for this treatment are limited to patients experiencing recurrences under well-managed anticoagulant treatment or presenting with contraindication to anticoagulant treatment. Nowadays, as these clinical situations are rare, this device is less and less used, all the more since, for several years now, thrombosis, fracture, or infectious complications as well as filter migration have been reported. Filter migrations are responsible for atypical and varied clinical presentations likely to defer diagnosis. To treat them, the filter is extracted, which is very risky in patients with a thromboembolic history. In our center, during a period of 14 years, we retrospectively collected and studied partial or complete vena cava filter migration cases that had been treated by extraction. We are reporting four very different clinical cases and, more specifically, the second published case of migration to a renal vein, which mimicked a systemic disease. Because of its very atypical clinical presentations, cava filter migration is an unappreciated and certainly underdiagnosed complication. However, this complication must not question cava filter placement when it is justified. In contrast, it prompts early filter extraction or long-term radiological surveillance.

ex-role attitudes measured by the Personal Attributes Questionnaire (PAQ) were used to investigate postdivorce experience. Subjects (124 Canadian francophones, males and females), recently divorced, were classified into androgynous, masculine, feminine, and undifferentiated according to their scores on the PAQ. Postdivorce adjustment and attachment to exspouse constituted the dependent variables. Two different models were tested. First, the androgyny model suggests that androgynous subjects, with both their masculine and feminine characteristics, are better able to adapt to different situations, including divorce. The masculinity model suggests that masculine and androgynous subjects (who have masculine traits) are better able to cope with divorce, which requires coping traits such as autonomy and independence. Results support the androgyny model for postdivorce adjustment. Androgynous subjects received the highest adjustment scores, compared to the three other groups. Results also support the ma...