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Pierre Bourgeois,1– 4 Mirela Mariana Roman,5 Justine Schweicher,6 Pauline Lavoisier,6 Philippe Maquet,6 Clarence Karler,7 Mateusz Lizewski,8 Alessandro Fouarge,8 Nicolas Cuylits,8 Véronique del Marmol,1 Olivier Leduc6 1Service of Dermatology, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium; 2Services of Nuclear Medicine, HIS-IZZ Hospitals, Université Libre de Bruxelles, Brussels, Belgium; 3Multi-Disciplinary Clinic of Lymphology, Institute Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; 4Service of Vascular Surgery, HIS-IZZ Hospitals, Université Libre de Bruxelles, Brussels, Belgium; 5Department of Mammo-Pelvic Surgery, Institute Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; 6Unité de lympho-phlébologie, Haute Ecole Bruxelles-Brabant, Haute Ecole Robert Schuman, Brussels, Belgium; 7Department of Anesthesia-Algologia, Hospital Moliere, Université Libre de Bruxelles, Brussels, Belgium; 8Service of Plastic, Reconstructive and Aesthetic Surgery, Hospital Erasme, Université Libre de Bruxelles, Brussels, BelgiumCorrespondence: Pierre Bourgeois, Department of Dermatology, University Hospital Erasme, Université Libre de Bruxelles, 808, route de Lennik, Brussels, 1070, Belgium, Tel +32495201906, Email pierre.bourgeois@erasme.ulb.ac.beBackground: The number of people within the European population having at least one tattoo has increased notably and with it the number of tattoo-associated clinical complications. The injected inks are known to be removed by the lymphatic vessels and can be found in the draining lymph nodes.Aim of the Study: To report our observations on the lymphatic drainages seen under tattoos using near infrared fluorescence imaging of these lymphatic vessels after the injection of indocyanine green.Material and Methods: Indocyanine green was injected intradermally at the basis of the 20 tattooed area(s) in 19 subjects (nine women and ten men; mean age = 28.6). Ten subjects had only black tattoos (six upper limbs and four lower limbs), five (two upper limbs and three lower limbs) black and white tattoos and five multi-colored tattooed limbs (four lower limbs and one upper limb).Results: The imaging exams revealed alterations in eight individuals, seven of whom had tattoos on their lower limbs. Furthermore, the imaging results showed that the abnormalities might be related to the tattooed limb, the tattoo extent and colour.Conclusion: Alterations of the cutaneous lymphatic channels are frequently observed under tattooed territories. Their causal factors should be more precisely studied in future works and these lymphatic alterations should be considered in tattooed patients when using similar imaging techniques for therapeutic and surgical assessments.Keywords: tattoo, near infra-red fluorescence lymphatic imaging, indocyanine green, lymphatic, lymph vessel

History A 34-year-old man without underlying medical conditions came to the emergency department for evaluation of persistent pain over the volar portion of his right fifth finger after a fall during a football match 3 days before. At physical examination, the injured finger was swollen and purple. Passive and active flexion of the proximal and distal interphalangeal joints were compromised, without interphalangeal instability. Radiography was performed in the emergency department, and the patient was released with a diagnosis of a fifth digit sprain. After the senior radiologist (V.M.C.) reviewed the radiographs, the patient was called back for assessment with ultrasonography (US) on the same day. US was performed with an Aplio 500 unit (Toshiba Medical Systems, Tokyo, Japan) using a multifrequency linear array 7.2-18.0-MHz PLT-1204BX transducer focused at the level of the flexor tendon. The patient was sitting in front of the examiner, with the hand lying palm up on the examination bed. No abnormality was observed during color Doppler US.

Collateral ligament injury of the metacarpophalangeal joint of the fingers is underreported in the literature and widely underestimated by the medical community. Here, the authors present results from a large series of patients and review factors influencing success of surgery.The authors performed a retrospective study of 46 patients who underwent surgical fixation of the metacarpophalangeal collateral ligament using bone anchor in an acute or chronic setting. The diagnosis was predominantly clinical, based on laxity testing of the joint. The authors collected demographic data and intraoperative findings and postoperative results.Following surgery, with a median follow-up of 17 months, all patients presented with a stable joint and complete resolution of pain. The mean flexion of the metacarpophalangeal joint was 77.11 degrees, and mean extension was 0.84 degrees. The authors measured the injured grip strength at a mean of 88.52 percent of the opposite hand, and the mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score used to evaluate disability was 9.56 on a scale of 100 (with 100 being complete disability).Surgical treatment of metacarpophalangeal collateral ligament rupture of the fingers is a safe technique that gives reproducible positive results in terms of mobility, strength, and disability scale score. The authors' results show that anchoring of the ligament should be performed even with prolonged time from injury to surgery.

Le choix du traitement pour une fracture du scaphoide depend de son type et de sa localisation. Pour les fractures non deplacees, la prise en charge standard reste l’immobilisation prolongee. Cependant, l’approche percutanee tend a se generaliser. Nous rapportons notre experience sur un echantillon de 155 patients consecutifs traites par vissage percutane (VP). Nous avons conduit une etude retrospective sur le VP de fractures fraiches du scaphoide peu deplacees. Les patients sont inclus de 2008 a 2017. Cent cinquante-cinq fractures ont ete analysees. La moyenne de suivi est 9 mois. L’âge median des patients est de 28 [22–41,3] ans. Quatre-vingt-cinq pour cent des patients sont des hommes. Quatre-vingt-quinze pour cent sont droitiers et 67 % ont lese leur main gauche. Peu de comorbidite ont ete relevees, 1,4 % de patients diabetiques et 15 % de tabagiques. Le delai entre le traumatisme et la 1re consultation est de 3 [1–12] jours et celui entre le traumatisme et la chirurgie de 10 [6–24] jours. La fracture de Schernberg type III est la plus frequente (61,5 %). En postoperatoire, 90 % des patients ne presentaient plus de douleur. La flexion moyenne est de 60° et l’extension moyenne de 62°. La force de la main lesee par rapport a la main controlaterale saine est de 80 %. Les angles scapho-lunaire (53,8°) et radio-lunaire (5,1°) en postoperatoire temoignent d’une restitution de l’anatomie normale. Les index radio-ulnaires sont negatif dans 24,2 % des cas et neutre dans 62,1 % des cas. Le taux de non-consolidation est de 5 %. La demographie de ce sous-groupe est similaire a celle de l’ensemble des patients hormis un nombre augmente de fractures Schernberg type II. La mediane de reprise du travail est de 4 semaines. Cette etude permet d’approfondir nos connaissances sur la demographie des patients beneficiant du VP pour fracture scaphoidienne non deplacee et les resultats de cette technique. L’etude des patients evoluant vers une pseudarthrose suivant cette technique permettrait d’aider a l’elaboration de criteres de selection des patients pour le traitement orthopedique ou le VP. Cette etude est, a notre connaissance, la plus grande serie de cas realisee sur le VP pour les fractures du scaphoide. En conclusion, il s’agit d’une grande cohorte de fractures peu deplacees traites par VP. Cette methode s’avere etre une option fiable avec un tres faible taux de complications, qui permet une reprise du travail et des activites quotidiennes precoces.

Introduction: The lumbar artery perforator (LAP) flap takes an important place in lumbosacral reconstruction and in breast reconstruction. Although studies on the location of lumbar perforators in women are common, no anatomical study has focused solely on male subjects. Our objective is to facilitate the surgical approach to the LAP flap in male subjects by precisely ascertaining the characteristics of the perforators. Methods: We performed a retrospective review of computed tomographic angiography images of a cohort of 30 patients evaluating the perforator position from the 4 lumbar arteries. In addition, 4 characteristics were studied: the length, the diameter, the path of the lumbar pedicle, and the thickness of tissues available for transfer. Results: One hundred five lumbar perforating vessels were analyzed on 60 posterior hemi-bodies, of which 86% came from the third and fourth lumbar arteries. The average location was situated 7.4 cm from the midline and in a 6-cm vertical wide area. The position of the lumbar perforator was independent of body mass index, abdominal circumference, and subject size. Our results, compared to previous studies, show no difference in this position between men and women. Conclusions: The LAP flap is useful for regional reconstructions and as a free flap for both women and men. We provide male-specific tracking values for the dissection of lumbar perforating vessels. Dominant perforators were found to be situated in a wide region of 4 cm × 6 cm in the lumbosacral region at 7.4 cm from the midline.

Collateral ligament injury of the metacarpophalangeal (MCP) joint of the fingers is underreported in the literature and widely underestimated by medical community. Here, we present results from a large series of patients and review factors influencing success of surgery. We performed a retrospective study of 46 patients who underwent surgical fixation of the MCP collateral ligament using bone anchor in an acute or chronic setting. The diagnosis was predominantly clinical based on laxity testing of the joint. We collected demographic data as well as peroperative findings and postoperative results. The MCP joint and proximal interphalangeal joint amplitude of motion were measured using a goniometer. The grip strength was evaluated using a Jamar hydraulic hand dynamometer (4MD Medical Solutions, Lakewood, NJ, USA) and was compared to the opposite hand. The stability of the collateral ligament was assessed by a stress of the MCP joint in a fully flexed position. A postoperative Quick-DASH score was available for 17 patients. This scoring system ranges from 0 (no disability) to 100 (most severe disability). We decided to perform postoperative radiography only if clinical instability remained, and radiography was not necessary in our cohort. Post-surgery, with a median follow-up of 17 months, all patients presented with a stable joint and a complete resolution of pain. The mean flexion of the MCP joint was 77.91°, and extension was a mean of 0.84°. We measured the injured grip strength at a mean of 88.52% of the opposite hand, and the mean Quick-DASH score used to evaluate disability was 9.56 on a scale of 100 (with 100 complete disability). Importantly, time from injury to surgery did not influence postoperative results. The diagnosis of MCP collateral ligament rupture is predominantly clinical based on presentation with pain and swelling of the MCP joint with a clear lateral laxity of the MCP joint in flexion. Although in our series, operative delay did not influence postoperative results and a direct repair was always achievable, some authors have described a destruction of the remnant ligament in chronic lesions of MCP joint requiring reconstructive technique. Surgical treatment of MCP collateral ligament rupture with bone anchors is a safe technique that gives reproducible positive results that are not influenced by demographic data, or time to treatment. This pathology is not rare, and a better diagnosis would increase the incidence in future reports.

Basal thumb arthroplasty is a commonly performed procedure to treat trapeziometacarpal (TMC) arthritis. The risk of failure is highly fluctuating in the literature, and only few report the functional results of secondary trapeziectomy resulting from failed joint replacement. We aim to describe our large series of patients with secondary trapeziectomy. Retrospective study of 32 patients undergoing secondary trapeziectomy after failed TMC arthroplasty with a mean follow-up of 48.8 months (± 26.8). We realized an objective evaluation of the mobility of the thumb and the strength of the hand, a subjective evaluation with visual analogic scales and DASH questionnaire, and a radiologic evaluation to assess the thumb shortening. The mean age at revision surgery is 62 years old, and is composed of 28 women for 4 men. The survival of the prosthesis is 19.5 months, and not reaching one year in 66% of the cases. The major indications for revision were loosening of the trapezial implant in 56% of the cases, and luxation of the prosthesis in 22%. The handgrip strengths of the 2 hands are comparable, as well as the key pinch strength (P

Background: The purpose of this prospective study was to evaluate craniofacial morphology in children with complete unilateral cleft lip and palate treated at the Brussels cleft center after a 1-stage complete closure at 3 months and compare the results with a series of children operated on at 3 and 6 months of age according to the Malek surgical protocol. Methods: A series of 72 consecutive patients who were operated on for nonsyndromic complete unilateral cleft lip and palate were included in this study at approximately the age of 10 years. Thirtyfour were treated according to the Malek surgical treatment protocol: the soft palate was closed at a mean (SD) age of 3.04 (0.20) months, followed by simultaneous repair of the lip and hard palate at 6.15 (0.67) months. Thirty-eight underwent 1-stage all-in-one (AIO) closure of the lip and hard and soft palates at 2.98 (0.16) months. Craniofacial morphology was evaluated by means of a digital cephalometric analysis. Cephalometric data were compared with a noncleft control group (n = 40) matched according to age. The same 2 series of children were followed up until 15 years of age, and the results were again compared. Results: Statistical analysis (analysis of variance with post hoc Tukey test) showed in both groups who were operated on a decreased anteroposterior growth compared with the children without cleft at 10 years but the AIO group only was not different from the group without cleft. The maxillary (MxPI/SN) plane was significantly (P = 0.002) increased in the Malek cleft group compared with the AIO group with cleft. At 15 years of age, a difference was not observed anymore between the 2 groups for the anteroposterior growth or for the maxillary plane inclination. Conclusions: One-stage AIO closure based on the Malek surgical principles provided good anteroposterior midfacial morphology and resulted in less opening of the maxillary plane to the anterior cranial base.

Peripheral chemoreflex inhibition with hyperoxia decreases sympathetic nerve traffic to muscle circulation [muscle sympathetic nerve activity (MSNA)]. Hyperoxia also decreases lactate production during exercise. However, hyperoxia markedly increases the activation of sensory endings in skeletal muscle in animal studies. We tested the hypothesis that hyperoxia increases the MSNA and mean blood pressure (MBP) responses to isometric exercise. The effects of breathing 21% and 100% oxygen at rest and during isometric handgrip at 30% of maximal voluntary contraction on MSNA, heart rate (HR), MBP, blood lactate (BL), and arterial O2saturation (SaO2) were determined in 12 healthy men. The isometric handgrips were followed by 3 min of postexercise circulatory arrest (PE-CA) to allow metaboreflex activation in the absence of other reflex mechanisms. Hyperoxia lowered resting MSNA, HR, MBP, and BL but increased SaO2compared with normoxia (all P < 0.05). MSNA and MBP increased more when exercise was performed in hyperoxia than in normoxia (MSNA: hyperoxic exercise, 255 ± 100% vs. normoxic exercise, 211 ± 80%, P = 0.04; and MBP: hyperoxic exercise, 33 ± 9 mmHg vs. normoxic exercise, 26 ± 10 mmHg, P = 0.03). During PE-CA, MSNA and MBP remained elevated (both P < 0.05) and to a larger extent during hyperoxia than normoxia ( P < 0.05). Hyperoxia enhances the sympathetic and blood pressure (BP) reactivity to metaboreflex activation. This is due to an increase in metaboreflex sensitivity by hyperoxia that overrules the sympathoinhibitory and BP lowering effects of chemoreflex inhibition. This occurs despite a reduced lactic acid production.

Sympathetic overactivity is implicated in the increased cardiovascular risk of cigarette smokers. Excitatory nicotinic receptors are present on peripheral chemoreceptor cells. Chemoreceptors located in the carotid and aortic bodies increase ventilation (Ve), blood pressure (BP), heart rate (HR), and sympathetic nerve activity to muscle circulation (MSNA) in response to hypoxia. We tested the hypothesis that nicotine replacement therapy (NRT) increases MSNA and chemoreceptor sensitivity to hypoxia. Sixteen young healthy smokers were included in the study (8 women). After a randomized and blinded sublingual administration of a 4-mg tablet of nicotine or placebo, we measured minute Ve, HR, mean BP, and MSNA during normoxia and 5 minutes of isocapnic hypoxia. Maximal voluntary end-expiratory apneas were performed at baseline and at the end of the fifth minute of hypoxia. Nicotine increased HR by 7±3 bpm, mean BP by 5±2 mm Hg, and MSNA by 4±1 bursts/min, whereas subjects breathed room air (all P P P P 2 saturation during hypoxia and the apneas remained unaffected. In conclusion, sympathoexcitatory effects of NRT are not because of an increased chemoreflex sensitivity to hypoxia. NRT increases myocardial oxygen consumption in periods of reduced oxygen availability.

Background— Heart failure is characterized by increased ventilation during exercise, which is positively related to increased peripheral and central chemoreceptor sensitivity. Heart transplantation does not normalize the ventilatory response to exercise, and its effects on the chemoreflex control of ventilation remain unknown. We tested the hypothesis that chemoreceptor sensitivity is increased in heart transplant recipients (HTRs) and linked to exercise hyperpnea. Methods and Results— We determined the ventilatory, muscle sympathetic nerve activity (MSNA), and circulatory responses to isocapnic hypoxia and hyperoxic hypercapnia 7±1 years after transplantation in 19 HTRs with a normal left ventricular ejection fraction of 60±2%. Results were compared with those of 11 closely matched referent subjects. Sixteen patients and 10 referent subjects also underwent cycle ergometer exercise tests. HTRs compared with referent subjects presented higher MSNA (52±4 versus 34±3 bursts/min; P P P P 2 output, was steeper in HTRs than in referent subjects (38±2 versus 29±1 L/mm Hg; P r =0.57; n=16; P r =0.50; n=16; P Conclusions— Peripheral chemoreceptor sensitivity is increased in HTRs and is related to exercise hyperpnea after heart transplantation.

The treatment of locally advanced metastasized melanoma is challenging because there is no level 1 evidence to guide clinical decision-making. Moreover, the treatment options available fail to improve overall survival and are associated with considerable morbidity. Here, we show that systemic treatment with BRAF inhibitor vemurafenib substituted by dual BRAF/MEK inhibition (dabrafenib and trametinib) before surgery can offer the potential to cure the initially difficult or inoperable melanoma. A 62-year-old woman was diagnosed with an AJCC stage IIIB melanoma harboring the BRAF V600E mutation after a complete initial evaluation. Clinically, the patient presented a large primary lesion that was surrounded by ∼25 secondary epidermotropic lesions both satellite and 'in transit' with a diameter between 1 and 6 mm. Following multidisciplinary consultation, the patient was started on 960 mg twice-daily vemurafenib, which was stopped and resumed at 720 mg twice daily, and finally substituted with the combination dabrafenib and trametinib to reduce the persistent side effects. Successive clinical examinations had shown a progressive reduction in the thickness of the melanoma lesions. After about 5 months of therapy, surgery was performed and the histopathological analysis showed an almost complete regression of tumor cells. The treatment with dabrafenib/trametinib was continued only 3 months after surgery and stopped at the patient's request. The patient currently remains in complete remission at 8 months after surgery. The case presented here supports the use of neoadjuvant treatment with BRAF inhibitors in advanced 'in transit' melanoma.

Le doigt a ressaut est une pathologie frequente de la main. Bien que la physiopathologie ne soit pas bien connue, le traitement par corticoides en premiere intention est efficace. Le but de cette etude est d’analyser l’evolution des tendons et de la poulie A1 du doigt dans deux groupes d’âge distincts afin de mieux comprendre la physiopathologie et d’analyser l’effet des corticoides sur ces structures. L’etude prospective non randomisee de deux groupes temoins d’âge distincts rassemblant chacun 50 patients non porteurs d’un doigt a ressaut a ete realisee. De plus, 13 patients consecutifs presentant un doigt a ressaut non complique primaire avec une indication d’infiltration ont ete analyses. Les 50 patients non porteurs d’un doigt a ressaut de chaque groupe ont fait l’objet d’une etude echographique dynamique du pouce et de l’annulaire. Differentes mesures d’epaisseurs au niveau des tendons et de la poulie A1 ont ete realisees chez chaque personne. De meme, les patients pathologiques ont beneficie d’une echographie afin d’avoir des valeurs pathologiques. Neuf patients sur 13 ont ete revus 3 a 5 semaines post-injection de corticoides afin d’effectuer de nouvelles mesures. La comparaison des deux groupes sains, avec une moyenne d’âge de 60,8 ans pour l’un et 24,6 ans pour l’autre, met en evidence un epaississement des tendons et de la poulie A1 avec l’âge. On retrouve une difference significative en ce qui concerne l’epaisseur de la poulie (p = 2,2e−16) ainsi que l’epaisseur du tendon dans la poulie (p = 0,004754) et en distale de la poulie (p = 0,0003203) peu importe le doigt. De plus, on constate un epaississement de la poulie A1 avec une difference significative (p = 9,789−07) entre les patients porteurs du doigt a ressaut (moyenne = ± 0,88 mm) et la population saine du meme âge (moyenne = ± 0,46 mm). L’epaisseur de la poulie a diminue post-injection avec une moyenne de 0,48 mm. Notre etude montre donc une modification de la taille des tendons et de la poulie a l’echographie avec l’âge, et prouve l’influence de l’âge sur le doigt a ressaut. De plus, une diminution de l’epaisseur de la poulie en reponse aux corticoides a aussi ete mise en evidence.

Heart transplantation initially normalizes sympathetic hyperactivity directed at the muscle circulation. However, sympathetic activity increases with time after transplantation and the exact mechanisms responsible for sympathetic control in heart transplant recipients remain unclear. We examined the effects of peripheral chemoreflex deactivation caused by breathing 100% oxygen on muscle sympathetic nerve activity (expressed as number of burst per minute and mean burst amplitude), heart rate, and mean blood pressure in 13 heart transplant recipients, 13 patients with essential hypertension, and 10 controls. Heart transplant recipients disclosed the highest sympathetic activity, whereas it did not differ between controls and patients with essential hypertension (51±16 versus 37±14 versus 39±12 burst/min, respectively; P P P P P P P =NS; 95±11 versus 95±13% of amplitude at baseline, P =NS) in control subjects. The sympathetic response to hyperoxia was more marked in heart transplant recipients than in controls (85±9 versus 95±11% of baseline amplitude; P r =−0.75, P

Introduction uncomplicated obesity is linked to an increased risk of sudden cardiac death (SCD). Dynamic ventricular repolarisation (VR) has been validated in heart failure as a prognostic marker for SCD. We thus sought to assess modification of dynamic VR in obese patients in order to identify a possible mechanism leading to SCD during uncomplicated obesity. Methods in 40 uncomplicated obese patients and 40 matched controls, we measured static VR assessed by corrected QT interval, QT dispersion and dynamic VR. Dynamic study of VR, a 24 h-Holter EKG based technique, plots QT interval to heart rate and is quantified by the slope of the obtained correlation line for day and night. Among 40 obese patients 20 patients had reassessment of dynamic VR after weight loss induced by gastroplasty. Results static VR parameters were similar in both groups but slopes were significantly higher in obese patients during day and night. Weight loss normalised all slopes without affecting static VR. Conclusion this study suggests that obesity-induced dynamic VR modification can explain SCD and identify a yet unknown benefit of weight loss.