Biomedical subjects
Publications and source records attributed to G Dautel.
Pigmented villonodular synovitis of the wrist is an uncommon disease. It is also very rare in childhood and adolescence. The authors report a case with good outcome after surgery and review the literature concerning this.
Cutaneous flaps are not entirely satisfactory when used for soft tissue defects of the palm, because the skin cover is too mobile. Use of muscle flaps can therefore be advocated for this recipient site. A case is reported where the pronator quadratus muscle has been used as a free muscle flap for coverage of a small defect of the palm.
26 patients with at least one clinical symptom that could indicate a tear of the scapho-lunate interosseous ligament but normal static and dynamic radiographs were examined by arthroscopy. We found that a diagnosis of scapho-lunate instability could be established by dynamic manoeuvres during radio-carpal and mid-carpal arthroscopy. Five patients were found to have true scapholunate instability. Six tears of the interosseous ligament without instability were also detected but it was doubtful if the tear was the origin of the painful symptomatology. This experience suggests that dynamic manoeuvres during arthroscopy are superior to other methods in diagnosing scapholunate instabilities at the pre-radiographic stage.
The posterior interosseous flap has been used for resurfacing in 23 cases of hand injury in the past 5 years. There was complete necrosis in two cases, partial necrosis in three and temporary post-operative nerve palsy in one.
Diagnosis of scapholunate instability can be established even when static and dynamic X-Rays are normal. Dynamic manoeuvres during wrist arthroscopy are superior to other testing methods in diagnosing scapholunate instability at these early stages. Evaluation of ligament remnants during arthroscopy is also helpful when selecting the appropriate treatment option.
In this work on vascularization of digital nerves, we have studied the anatomy of the deep network of venae comitantes of digital arteries, and the system of superficial palmar venules. 22 specimens of nerve and artery were dissected as one unit and were infused with Microfil prior to study under the microscope. The deep venous network, a satellite of the digital artery, can be classified into four types. A true network of deep venae comitantes exists in three of these four types, drained by deep veins arising from the transverse anastomotic arches between the palmar digital pedicles. Vascularization of the digital nerve is supplied by numerous anastomotic vessels connecting epineurial vessels, digital artery and the periarterial network (venae comitantes and vasa vasorum). This anatomical configuration lends itself to vascularized nerve grafting; for example, it is possible to use a nerve/artery graft taken as a unit from an amputated finger unsuitable for replantation. Two types of valves in this superficial venous network have been identified and their function is discussed.
Lipofibroma is a rare, benign nerve tumour corresponding to diffuse fibroadipose infiltration of the nerve, dissociating the fasciculi without invading them. The authors report a case of lipofibroma of the median nerve in a 32 year old man presenting with a soft swelling of the palmar surface of the thumb. Treatment consisted of intraneurodissection of the tumour arising exclusively from the medial collateral nerve of the thumb. With a follow-up of two years, there has been no recurrence of the tumour, but the patient has persistent decreased sensation of the ulnar half of the thumb pulp. The features of the lipofibroma and the therapeutic options are discussed in the light of the data reported in the literature.
Any transplanted muscle flap undergoes atrophy to an extent depending mainly on its innervation. Other factors such as the tension at rest and the duration of ischemia play a secondary role. An experimental study was carried out in rats to quantitatively assess the extent of atrophy according to the mode of transplant reinnervation. The gracilis muscle was used as an experimental model of pedicled flap after verifying the axial nature of its vasculature. Results were assessed after three months from a histological point of view and in terms of postoperative weight in four different groups of 13 rats. The first three groups reproduced situation encountered in clinic: intact nerve, sutured nerve, resected nerve. A graft sensory neurotization technique was implemented in the fourth group by diverting a neighboring sensory nerve. The best trophic results were obtained when the motor nerve remained continuous. The sensory neurotization technique did not significantly influence the trophic evolution after three months.
The presence of distal intermetacarpal anastomoses between dorsal and palmar vascular networks makes it possible to raise distally-based cutaneous island flaps oriented along the axis of the dorsal metacarpal arteries. These flaps receive a reverse-flow vascularisation. Distal intermetacarpal anastomoses were found consistently in 35 hands from adult cadavers. The exact location of these anastomoses varied with the course of the dorsal metacarpal artery. Thus, island flaps can be raised consistently from the dorsal aspect of the hand and rotated around a distal intermetacarpal pivot. These flaps are suitable for covering the dorsal aspect of the proximal phalanx and the proximal interphalangeal joint.
Since Taylor (1976) successfully performed the first vascularised free nerve graft, experimental and clinical data have not provided conclusive support for the superiority of this method of repairing loss of nerve substance. Experimental work yields conflicting results. Histologic results are in favour of vascularised grafts but non-vascularised fascicular grafts placed in a healthy bed recover sufficient neovascularisation within a short period of time (four to six days). In the field of brachial plexus repair, vascularised grafts give consistent results. However, if thrombosis of the anastomoses occurs, the grafts fail completely. In our experience, vascularised nerve grafts used for repairing digital nerves and arteries, have a high rate of thrombosis. There are few potential donor sites. A nerve graft cannot be considered to be physiologically vascularised if it relies only on an artery or on an arterialised vein. Given the present state of immunosuppressant treatments, vascularised allografts are not yet appropriate. Therefore, vascularised nerve grafts have limited applications. In general it is preferable to repair the tissue bed so as to promote revascularisation of conventional nerve grafts.
The vascularization of the gracilis muscle of the rat is oriented mainly along the longitudinal axis of the muscle and arises from a muscular artery originating in the femoral artery. Transillumination study of the muscle after vascular injection with Microfil demonstrated this anatomic disposition. The gracilis muscle was used either as a pedicled transfer or as a free flap with anastomoses placed on the femoral pedicle. Average weight of the muscle before transfer was 429 mg. The cutaneous area of the muscular artery could be used to monitor the flap or to accomplish a composite myocutaneous transfer. This muscle flap is a versatile and reliable model for experimental study of muscle transfer in rats.
Explore the source record for details and available documents.
The development of microsurgical techniques and of pedicled local flaps has improved the prognosis of major injuries of the upper limb. Pedicled muscle-skin flaps from the latissimus dorsi muscle allow repairing losses of substance in the arm-pit and arm while restoring the function of the elbow. In the forearm, the same flap, transferred by microsurgery, ensures the rehabilitation of the wrist and hand. In the hand, the Chinese and posterior interosseous flaps allow covering the losses of substance on both the palmar and the dorsal aspects. Here, the free flaps are used only if the palmar vascular arches of these interosseous anastomoses are affected. Lastly, remote flaps are required only for the contraindications of microsurgery. Thus, using this array of donor sites, the emergent replacement of the most complex losses of sin substance can be performed, thus fostering the repair and protection of fony, neurovascular and tendon lesions.
Pelvic growth in bladder exstrophy was studied in 10 patients. Growth of their pelves in length as well as in width was similar to that found by Tanner. Meanwhile, the speed at which the diastasis of the pubic symphysis increases is variable. Before 5 years of age and during the end of growth it is fast, whereas it is slow between 5 and 10 years of age. There are no radiological abnormalities of hip joint orientation, and the acetabular angles are normal.
Thirty dissections were performed on adult non embalmed cadavers, after vascular injection with MICROFIL or Methylene blue. In contrast to the classical descriptions of a single dorsal metacarpal artery, this study shows the existence of a vascular network with 1 or 2 vessels running over or under the deep aponeurosis. Direct cutaneous arteries provide blood supply to the kite flap when the only dorsal metacarpal vessel of the first web space is in a deep situation. The main source of blood supply to the kite flap is described in each anatomical variation of the dorsal network.
Thirty dissections were performed on fresh, unfixed, adult cadavers after vascular injection of silastic or methylene blue. Analysis of the results led to replacement of the concept of a single dorsal intermetacarpal artery, the constant pedicle of the kite flap, by that of an intermetacarpal vascular system composed of one or two supra- and/or sub-aponeurotic vessels. The existence of distinct direct skin branches of this intermetacarpal vascular system is defined. The various possible modes of vascularisation of the kite flap are listed, defining the situations at risk and leading to precise practical applications in terms of surgical technique.
16 patients (75% women) were operated for a claw nail involving one of the three middle fingers. In 14 cases out of 16, a traumatic amputation, treated by directed healing in 60% of cases, was responsible for the deformity. The average loss of bone substance was 49% (range: 0-90%). The average shortening was 5 mm. The loss of substance was repaired by a local flap in 14 cases. Two early recurrences led to one failure and one good result after a second recession flap. One case of arthritis of the distal interphalangeal joint and one case of septic necrosis of the nail bed were also observed. Eleven subjects were reviewed with a mean follow-up of 4 years (1-7 years). The range of movement of the distal interphalangeal joint was always normal. The pinch force and the growth of the nail were normal in 75% of cases. The finger was cumbersome in one half of cases and 60% of patients complained of pain. Recurrences were observed in 50% of cases and the patients were disappointed in 64% of cases. This is a minor operation in terms of vascular elements, but it is associated with a high rate of recurrence and leaves a short finger. Its indications should be limited to losses of bone substance less than 50%.
Anatomic study of the pelvis of 30 fetuses and newborn children, yielded a precise relationship between the sacrotuberous ligaments and size of the gluteal region. At birth, the distance between the posterior superior iliac spine and the ischium is 40 mm. Closure of the anterior defect in bladder exstrophy sometimes requires an orthopedic surgical procedure. Bilateral posterior iliac osteotomy and section of these ligaments can be easily done by a single medial posterior approach herein described.