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Dorsal capsulodesis is an important part of the treatment of pre-arthritic scapholunate instability. We designed an experimental study using 14 fresh-frozen cadaver wrists to demonstrate the efficacy of a new horizontal dorsal intercarpal capsulodesis. We sectioned the scapholunate ligament to create a scapholunate dislocation. Several radiographic views, static and 'in stress', were recorded and we statistically compared the scapholunate interval before and after the section of the scapholunate ligament, and after the creation of the capsulodesis. The results showed a significant decrease of the scapholunate interval after the creation of the capsulodesis, especially in neutral and maximal ulnar deviation of the wrist. They also proved that our cadaveric model is reliable. This study demonstrated that this novel capsulodesis reduces the scapholunate interval in a cadaveric model., (© The Author(s) 2014.)

Purpose: The authors present an anatomical study of the flexor digitorum superficialis synovial flap and its clinical application for palmar soft tissue defects in hand trauma., Methods: Green latex was injected into the brachial artery of thirty-one human upper limbs from corpses donated to science. Anatomical features of this pedicled flap were assessed: arterial vascularization, dimensions and covering surface., Results: The anatomical support of this flap is the synovial tissue of the flexor tendons, and particularly the superficial layer of the synovial system, covering the flexor digitorum superficialis (FDS) tendons in the forearm. It is vascularized by four different arteries: a constant collateral branch of the ulnar artery, and three inconstant arterial supports: from collateral branches of the superficial palmar arch, from the radial artery, and from the vasa nervorum of the median nerve. The flap is harvested from proximal to distal on the ulnar pedicle to cover the palmar soft tissue defects of the hand. A clinical application of this synovial flap is presented via a case report for covering a palmar skin defect secondary to a hand injury., Conclusions: The synovial flap contains a constant ulnar pedicle and could be considered a useful alternative to cover palmar soft tissue defects.

Mastocytosis is a group of disorders characterized by abnormal mast cell proliferation, involving the skin in 80% of cases. Cutaneous mastocytosis, which appears in childhood in 60% of cases, usually has a benign course with a gradually regressive evolution before puberty. Mast cell sarcomas, part of the systemic forms of mastocytosis, are very rare tumors characterized by a destructive growth of highly atypical mast cells, with secondary spread, poor prognosis, and low survival rates. We report the first known case of primary cutaneous mast cell sarcoma due to the transformation of a benign solitary mastocytoma in an adult suffering from an unregressive localized cutaneous mastocytosis. Histologic characteristics of the tumor, mutation analysis, and c-Kit expression were compared with available data. Wide surgical excision of the tumor followed by adjuvant local radiotherapy were performed, and for the first time the use of imatinib was attempted, as neoplastic mast cells expressed the CD117 marker. However, they failed to control the progression of sarcoma. To date, no treatment is known to be effective for this disease, which is associated with short-term survival of the patients.

The inflammation which occurs around the silicone prosthesis is a complex process that can provoke the failure of the device and compromise the health of the implanted patient. Toll-like receptors (TLRs), which are transmembrane proteins, are now known to act in the innate immune response and in endogenous inflammation. The aim of our study was to assess the role of TLR4 in the foreign body reaction to a silicone shell prosthesis. Disks of shell silicone prosthesis were implanted in the subcutaneous tissue of C57BL6-TLR4-/- and C57BL6-WT mice. At day 14, inflammatory cell infiltrate and vessel sections around the prosthesis were less numerous in TLR4-/- than in WT mice. A histomorphometric analysis showed that the capsule around the implant was 1.96-fold less thick in depleted TLR4 than in wild-type mice. In addition, vascular endothelial growth factor and transforming growth factor 1 were underexpressed in the surrounding tissue of the prosthesis in TLR4-/- mice. Our study suggests, from this foreign body response model against silicone in mice, that TLR4 plays a key role in the reaction process around silicone implants., (Copyright © 2011 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Introduction: Rheumatoid arthritis (RA) is a heterogeneous disease and its underlying molecular mechanisms are still poorly understood. Because previous microarray studies have only focused on long-standing (LS) RA compared to osteoarthritis, we aimed to compare the molecular profiles of early and LS RA versus control synovia., Methods: Synovial biopsies were obtained by arthroscopy from 15 patients (4 early untreated RA, 4 treated LS RA and 7 controls, who had traumatic or mechanical lesions). Extracted mRNAs were used for large-scale gene-expression profiling. The different gene-expression combinations identified by comparison of profiles of early, LS RA and healthy synovia were linked to the biological processes involved in each situation., Results: Three combinations of 719, 116 and 52 transcripts discriminated, respectively, early from LS RA, and early or LS RA from healthy synovia. We identified several gene clusters and distinct molecular signatures specifically expressed during early or LS RA, thereby suggesting the involvement of different pathophysiological mechanisms during the course of RA., Conclusions: Early and LS RA have distinct molecular signatures with different biological processes participating at different times during the course of the disease. These results suggest that better knowledge of the main biological processes involved at a given RA stage might help to choose the most appropriate treatment.

Background: We conducted a study including patients with gastric banding or gastroplasty who previously underwent plastic or functional surgery to assess the risk of pulmonary aspiration., Methods: A retrospective case-control study was performed including all patients undergoing a plastic or functional surgery over a 5-yr period (2000-2005) at Rouen University Hospital. Two groups were defined: the postbariatric group included patients who previously had bariatric surgery (laparoscopic adjustable gastric banding or Mason's vertical gastroplasty) before undergoing the plastic surgery; all other patients were assigned to the control group. Data included all anesthetic management and were recorded in the hospital computer database. The incidence of pulmonary aspiration was the outcome variable., Results: One hundred ninety-eight plastic and functional operations (66 cases and 132 controls) were performed. Pulmonary aspiration was significantly (P<0.006) higher in the postbariatric group (4 patients: 6%) than in the nonbariatric group (0 patient). For this complication, all patients had previously undergone gastric banding. One patient who did not receive prokinetic prophylaxis required intensive care for severe pulmonary alteration., Conclusion: The risk of perioperative pulmonary aspiration in a patient after weight loss due to gastric banding was considered significant.

Several flaps have been described to treat severe soft tissue defects of the finger dorsal side. Many authors studied vascular organization of the hand on its dorsal side; most of them insisted on deep vascularization into the intermetacarpal spaces, which is formed by the dorsal metacarpal arteries. Those dorsal metacarpal arteries are the anatomical support of many flaps, which do not preserve the dorsal interosseous muscles fascias. Only few authors described dorsal vascular organization at the level of the proximal phalanx; however, using a rotation point of a flap distally to the metacarpal head with a donor site on the dorsal aspect of the hand could cover all distal soft tissue defect of long finger. In order to determine the technical limitations of dorsal digito-metacarpal flap procedures, we studied number and location of arterial anastomoses between the reticular subcutaneous dorsal network and the rest of the vascularization at this level, which was formed by the deeper dorsal metacarpal arteries, common palmar digital arteries and proper palmar digital arteries, and between the dorsal digital arteries. Twenty-four long fingers from embalmed cadavers were studied after a reverse flow injection of colored latex and dissected layer-by-layer preserving the digital-metacarpal arterial network. At the level of the hand, the dorsal metacarpal arteries of the third and fourth intermetacarpal spaces were inconstant. When present, two or three arteries anastomosed in star shape with the reticular network. No such arterial anastomosis was observed proximally to the level of the intertendinous connections (junctura tendinorum) that bridge the extensor digitorum communis tendons. When no dorsal metacarpal artery was present, some communicant arteries arose from the common palmar digital arteries. Moreover, all the nutrient branches were more numerous distally to the intertendinous connections (junctura tendinorum). At the level of the metacarpophalangeal joints, the hand cutaneous network was always anastomosed with the dorsal cutaneous network. At the level of fingers, the dorsal cutaneous network was always supplied by four branches arising from the proper digital artery. Our study supported the reliability of dorsal digitometacarpal flaps, supplied by numerous palmodorsal digital anastomoses and by a rich plexiforme network joining the hand skin supply and that of the dorsal finger skin. During the procedure, we recommend limiting the surgical dissection of the flap at the level of the middle phalanx.

Unlabelled: In reconstructive techniques, the use of the composite gracilis skin flap may be complicated by a total or partial necrosis of the cutaneous paddle. Our study was aimed to describe the vascular anatomy of the gracilis muscle and the related skin, in order to have a better understanding of the skin's blood supply, and to help in determining a safer cutaneous paddle during transfer., Materials and Methods: We performed a detailed anatomical description of the gracilis vessels on 32 human cadavers' thighs. Selective injections of methylene blue and then colored fluid latex were carried out in the principal pedicle of the gracilis, to color and to measure the perforator vessels and the associated cutaneous paddle. The contour and the anatomical situation of the paddles were digitized in order to have precise data and to try to model a standard theoretical skin paddle., Results: The 32 dissections showed that the principal pedicle of the gracilis originated mainly from the adductor artery (26/32), it penetrated into the muscle 92.8 mm (78-114) below the pubis with a small dispersion of the values that assessed a rather reliable parameter of location. Each muscle had 1-6 perforators (at mean 3.78); 80% of these perforators had their exits from the opposite side to the principal pedicle, included within a 60 mm length of muscle. A skin paddle was quite constantly colored (31/32), located over the proximal half of the muscle with a complex design. Its mean dimensions of length and width were 110 (72-158) and 91.4 mm (65-144), respectively. The computerized surface of the paddle was at a mean of 79.5 cm(2) (42.4-139.3), and it was significantly correlated to the number of the perforators from the muscle., Discussion: Our quantitative values concerning the skin paddle related to the perforator arteries may be of significant interest to the surgeon who aims to harvest a composite musculocutaneous gracilis flap, in order to improve its reliability by reducing the risk of cutaneous necrosis.

Toll receptors were first identified as an essential molecule for embryonic patterning in Drosophila and were subsequently shown to be a key in antibacterial and antifungal immunity in adult flies. Toll receptors have been conserved throughout evolution. In mammals, TLRs have been implicated in both inflammatory responses and innate host defense to pathogens. The 11 different TLRs recognize conserved molecular patterns of microbial pathogens termed pathogen-specific molecular patterns (PAMPs), that permit to confer responsiveness to a wide variety of pathogens. Endogenous ligands are also able to activate TLRs. All adult tissue is capable to express at least one of member of TLR family, but a largest repertoire of TLRs is found in tissues exposed to the external environment. The TLR activation induce the NF-kappaB translocation to the nucleus and cytokine secretion. Since the primary function of skin is to provide an effective barrier against outside agression, it is likely that keratinocytes may play a role in a rapid and efficient host defence system, and the fact that keratinocytes are capable of expressing a wide variety of TLRs is subsequently not surprising.

Purpose of the Study: Plate fixation of midshaft humerus fractures raises the risk of radial nerve injury. Anterior transposition of the radial nerve has been proposed as a possible solution but few reports have been published. The purpose of the present study was to validate the effect of transposition on the transposed radial nerve and its branches., Material and Methods: We conducted an anatomic study on 10 cadavers. The length of the radial nerve between 2 anatomic landmarks was determined before and after transposition and plate fixation. A clinical evaluation was performed four years after surgery in 6 patients with midshaft humerus fractures treated with plate fixation after radial nerve transposition., Results: The anatomic study demonstrated a mean gain of 11 mm in the length of the radial nerve with no problem for the transposed nerve or its branches. Clinically, osteosynthesis was facilitated and tension on the nerve was reduced., Discussion: These 2 complementary studies demonstrated the releasing effect of transposition on the radial nerve and the facilitated osteosynthesis reported by others. The benefit of transposition is particularly important when bone fixation is particularly difficult to achieve without risk of injuring the radial nerve. Transposition does however require an extensive dissection, and the patient must be informed., Conclusion: The ideal indication for anterior transposition of the radial nerve is an oblique fracture of the mid-third to lower-third of the humeral shaft with radial palsy at onset. A certain degree of comminution facilitates the technique. Indications for this technique could however be widened to include cases of difficult osteosynthesis where the option to transpose the radial nerve is always a peroperative decision.

The authors report anatomical variations of the terminal brachial plexus branches in 42 cadaveric dissections. The results are compared with results reported in literature which revealed a new variation: ulnar nerve originating in posterior beam. This study demonstrates that there exist not one but several brachial plexes which could have potential clinical implications.

Chronic osteomyelitis is a severe long-term bone infection which retains its mechanical qualities. The authors report 10 cases of osteomyelitis of the tibia treated by muscular and fascio-cutaneous flaps and reviewed at one year follow-up. Four cases concerned the third upper part of the tibia, 3 the middle and 3 the lower third. Two total failures at the third lower part and three complications which finally healed with delay were observed. The results of this small series compared with the reports in the literature suggest the value of large excision with coverage by a well vascularized flap and the need for antibiotics. The choice of flap is related to type and site of the bone defect. Another question should be raised concerning the surgical strategy in one--or two--stage management and the duration of antibiotic therapy.

The authors report a new technique for harvesting and anastomosis of the latissimus dorsi free flap. The latissimus dorsi free flap is elevated with the subscapular and circumflex scapular vessels forming a "Y" pedicle. The recipient artery is sectioned and the arterial tree of the flap is anastomosed to the recipient vessel by two end-to-end anastomoses. This technique is particularly useful in leg reconstructive surgery when only one vessel remains: it simplifies transfer (end-to-end anastomosis), anastomoses are easier because more superficial.

Purpose of the Study: Recent anterior dislocations of the proximal interphalangeal (PIP) joint are uncommon injuries. Chronic and irreducible dislocations have been most often reported. This study aims to precise the anatomic and radiologic aspects of these lesions about three cases, and to compare these cases and their treatment with thirteen cases published in the literature between 1966 and 1994., Material and Methods: Three patients presented an anterior dislocation of the PIP joint after direct or twisting traumatism. One had an avulsion of the central slip of the extensor tendon and remained unstable after closed reduction needing pin fixation. Two had a longitudinal tear between central and lateral bands of the tendon with an entrapment of the condyle of the proximal phalanx, and the dislocations were irreducible. After open reduction, the joint was stable., Results: The first case showed a limited flexion after three months. In the two other cases without rupture, full range of motion was recovered after two months., Discussion: These cases have been compared with thirteen cases of recent papers from nine authors. Two types of anterior dislocations of the PIP joint may be described. TYPE I: Without rupture of the central slip fo the extensor tendon. One distal condyle of the proximal phalanx is entrapped between the central slip and a lateral band of the extensor tendon, that are separated by a longitudinal partial tear. The deformity is made by flexion, axial rotation and lateral displacement of the middle phalanx. Open reduction is required and may carry out good functional result., Type Ii: With rupture of the central slip of the extensor tendon. These very unstable lesions need a fixation after closed or open procedure. The treatment is often lately carried out, and the results not so good as in type I., Conclusion: Two different types of PIP joint anterior dislocations are described. Earlier diagnosis and surgical treatment can allow early rehabilitation and better final functional results.