Eric Havet

Vascular basis of the facial artery perforator flap: analysis of 101 perforator territories.

Background: The facial artery perforator flap was developed to perform more accurate reconstruction of perioral and nasal alar defects. This technique allows tailor-made reconstruction and shifting from the traditional two-stage procedure to a one-stage technique. Cadaveric studies have described the number, location, and size of facial artery perforators. Understanding of the facial artery blood supply can be complete, however, only if the cutaneous supply of each perforator is known. Methods: The authors performed 20 dissections of facial arteries on fresh cadavers. All facial artery perforators greater than 0.5 mm were dissected and the diameters measured. All perforators were selectively injected with 1 ml of diluted ink solution. All these results were statistically analyzed. Results: Twenty facial arteries were dissected, with a mean length of 12.06 cm. The average number of perforators greater than 0.5 mm per facial artery was 5.05. The mean diameter of the perforators was 0.96 mm. A total of 101 perforators were selectively injected, and the mean size of all injected skin areas was 8.05 cm2. Seven main, reliable types of perforator territory were identified. Conclusions: Facial artery perforators seem to be predominantly between 1 and 2 cm lateral to the level of the oral commissure. Seven main types of perforasomes have been identified and appear to be the basis for local flap design. This study improves our understanding of facial vascularization and will allow the face to give up the era of random flaps to take advantage of more accurate reconstructions from the rest of the body.

Traitement des infections ostéoarticulaires par clindamycine chez l’adulte

UNLABELLED The main characteristics of clindamycin are adequate for treatment of osteoarticular infections (OAI): good bone diffusion, broad spectrum of antibacterial activity and oral use. METHOD A number of 61 patients was included in an observational retrospective study of efficacy and tolerance. RESULTS Prosthetic infections accounted for 50.8% of the cases and chronic osteitis for 36.1%. The causative micro-organisms were Staphylococci (72.2%) and Streptococci (15.3%); 86.5% of these strains were susceptible to erythromycin, 9.6% were erythromycin resistant and susceptible to lincomycin. Clindamycin was associated with either ofloxacine, rifampicin, or teicoplanin in 88.5% and the average course duration was 101 days. A surgical procedure was performed in 84% of cases. Complete cure was obtained in 91.1% at 18 months of follow up. Only one cutaneous rash and one Clostridium difficile-associated diarrhea occurred. The other adverse effects were gastrointestinal in 36%, cutaneous in 6.6%, and hematological in 1.6%, but did not lead to discontinuation of therapy. CONCLUSION Clindamycin can be used in OAI in association with or as an alternative to rifampicin, fluoroquinolones, or glycopeptides according to microbiological data.

Vascular anatomical basis of clavicular non-union

The middle third of the clavicle is commonly involved in any injury and account for 5–10% of all fractures in adults. Although non-unions are rare, their treatment has not been well defined yet. This report describes the arterial supply of the clavicle to clarify the pathological mechanism and the surgical procedure of non-unions. This study was based on delineation of the thoraco-acromial and suprascapular arteries with colored latex on 17 specimens (ten cadavers). Observations were made after macroscopic dissection and maceration. The main blood supply to the middle third of the clavicle was the periosteal. This supply came from the two branches of the thoraco-acromial trunk that penetrated the pectoralis major muscle and the deltoid muscle. In 13 cases, these two periosteal branches were anastomosed between these two muscle attachments. Periosteal vascularization was always seen on the superior surface and the anterior border of the bone, but never on the inferior surface or the posterior border. The suprascapular artery contributed to supply the middle third of the clavicle by several periosteal branches and also by an independent branch. This branch was born proximally near the internal, middle thirds union and passed along the posterior face of the subclavius muscle and pierced the bone through the nutria foramina located near the external, middle thirds union. Nevertheless, intraosseous arteries were noted only in four cases. In these cases, they were never more than 2cm long. Our results showed that the periosteal blood supply located between the muscles insertions and the arterial supply from the suprascapular artery could be twice compromised in case of important displacement or severe fracture. If treatments of clavicular fractures or non-unions cannot preserve the periosteal blood supply, bone grafting should be indicated.

Radiological study of the knee joint line position measured from the fibular head and proximal tibial landmarks

Restoring the joint line level is one of the surgical challenges during revision of total knee arthroplasty. The position of the tibial surface is commonly estimated by its distance to the apex of fibular head, but no study evaluating this distance accurately has been published yet. The purpose of this work was to study the distance between the knee joint line and the apex of the fibular head and the proximal tibia, particularly the tibial tuberosity. Variability with clinical data and relations with other local measurements have been evaluated on knee radiographs (an antero-posterior view, a medio-lateral view and an anteroposterior full length view) of 100 subjects (125 knees). Results showed no correlation between the joint line–fibular head apex distance and any clinical data of the patients, or any other performed measurements. Relations between tibial measurements and the sexe or the height of the subjects were noted. Besides, the review of the 25 bilateral cases did not show statistically significant side difference but the descriptive analysis showed too large discrepancies for the joint line–fibular head apex distance to be used as a landmark. We conclude that the fibular head apex cannot be used as a morphologic landmark to determine the knee joint line position. Its interest in clinical and surgical practice must be discussed.

The inter-optic course of a unique precommunicating anterior cerebral artery with aberrant origin of an ophthalmic artery: an anatomic case report

Background and importanceSome variations of the cerebral arterial circle of Willis, such as an inter-optic course of the anterior cerebral artery are exceedingly rare. Imaging of very rare anatomical features may be of interest.Clinical presentationIn a 67-year-old male individual, the unique precommunicating part of the left anterior cerebral artery was found to course between both optic nerves. There was an agenesis of the right precommunicating cerebral artery. This variation was associated with an aberrant origin of the ophthalmic artery, arising from the anterior cerebral artery. The anatomic features, the possible high prevalence of associated aneurysms of the anterior communicating artery complex as well as implications for surgical planning or endovascular treatments are outlined and embryologic considerations are discussed.ConclusionTo the best of our knowledge, this is a very rare illustrated case of an inter-optic course of a unique precommunicating anterior cerebral artery with aberrant origin of an ophthalmic artery.

Arterial anatomical basis of the dorsal digito-metacarpal flap for long fingers

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.

Perforator arteries of the medial upper arm: anatomical basis of a new flap donor site.

The development of perforator flaps’ concept based on knowledge on vascular anatomy of the skin represents a major improvement in reconstructive surgery. Succeeding description about vascular territories and anatomical basics of the main donor sites, the study of hidden donor sites, such as medial upper arm, constitutes a new step and an additional refinement. 20 upper limbs of 10 fresh adult cadavers were studied with colored latex injections. The origin and distribution of the perforator arteries of the superior ulnar collateral artery and the brachial artery were investigated. We have noted constant perforator arteries and described the limits of vascular territories of the medial upper arm.

The article critique as a problem-based teaching method for medical students early in their training: a French example using anatomy

In France, “article critique” became a particular teaching method in the second part of the medical curriculum. It approaches a reading exercise of scientific medical papers similar to that of journal club. It could be compared to reviewing a paper as performed by reviewers of a scientific journal. We studied the relevancy of that teaching method for the youngest medical students. Our questions were about the understanding and the analyzing ability of a scientific paper while students have just learned basic medical sciences as anatomy. We have included 54 “article critique” written by voluntary students in second and third years of medical cursus. All of the IMRaD structure items (introduction, materials and methods, results and discussion) were analyzed using a qualitative scale for understanding as for analyzing ability. For understanding, 89–96% was good or fair and for the analyzing ability, 93–100% was good or fair. The anatomical papers were better understood than therapeutic or paraclinical studies, but without statistical difference, except for the introduction chapter. Results for analyzing ability were various according to the subject of the papers. This teaching method could be compared to a self-learning method, but also to a problem-based learning method. For the youngest students, the lack of medical knowledge aroused the curiosity. Their enthusiasm to learn new medical subjects remained full. The authors would insist on the requirement of rigorous lessons about evidence-based medicine and IMRaD structure and on a necessary companionship of the students by the teachers.

Does inter-tibiofibular graft still have a role in the treatment of lower-limb non-union?

INTRODUCTION Tibial non-union is a complication that poses a real challenge for surgeons. Several forms of treatment, depending on the type of non-union, have been described. The present study sought to assess results for treatment of tibial non-union by inter-tibiofibular graft (ITFG). MATERIAL AND METHOD An exhaustive cohort study was performed on the files of 33 patients: 25 male, 8 female; mean age, 44years. Twenty cases involved high-energy trauma. Twenty-four were open fractures. Twenty-two concerned diaphyseal fracture, 10 of which were complex segmental. Eleven concerned distal fracture, including 4 complete articular fractures. There were 17 cases of septic non-union. There were no cases of severe bone defect. ITFG was performed at a mean 8.7 months post-trauma, as first-line treatment in 30 cases and in second line in 3. RESULTS Thirty-one patients showed bone consolidation, at a mean 7.2 months. The 2 failures resulted from technical error. Trauma kinetics emerged as a risk factor for failure. DISCUSSION ITFG remains a useful treatment option in tibial non-union, whether infected or not. The present results are comparable with those of the literature. Although the present series comprised only tight non-union, a study of the literature showed that ITFG can treat bone defects up to 4 or 5cm. Functional results showed tibiotalar joint stiffening, due more to immobilization and non-weight-bearing than to syndesmosis. ITFG thus remains relevant to the treatment of tibial non-union. LEVEL OF EVIDENCE IV, retrospective study.

Risk of sural nerve injury during lateral distal Achilles tendinoscopy: A Cadaver Study

BACKGROUND The risk of damage to cutaneous sensory nerves located near portals has been evaluated for both conventional arthroscopy and extra-articular posterior ankle endoscopy. The objective of the anatomic study reported here was to assess the risk of injury to the sural nerve or lateral calcaneal nerve while using the distal lateral portal for the Achilles tendinoscopy procedure described by Vega et al. in 2008. MATERIALS AND METHODS We dissected the sural nerve and its branch, the lateral calcaneal nerve, of 13 human cadaver ankles in the prone position. We defined P as the point where the Achilles peritendon was opened during the distal lateral approach used for the study technique. P was adjacent to the lateral edge of the Achilles tendon, 2 cm proximal to the postero-superior edge of the calcaneal tuberosity. T was defined as the attachment site of the most lateral fibres of the Achilles tendon to the postero-superior edge of the calcaneal tuberosity. We evaluated the origin of the lateral calcaneal nerve relative to T and we measured the shortest distances separating P from the sural nerve and lateral calcaneal nerve. RESULTS A lateral calcaneal nerve was identified in 10 (77%) ankles and originated a mean of 39.1mm (range, 25.0-65.0mm) proximal to T. P was at a mean distance from the sural nerve of 12.3mm (range, 5.0-18.0mm) and from the lateral calcaneal nerve of 6.8mm (range, 4.0-9.0mm). The median difference between these two distances was statistically significant (P=0.002). DISCUSSION While using the distal lateral portal for Achilles tendinoscopy, the lateral calcaneal nerve is at greater risk for injury than is the sural nerve. LEVEL OF EVIDENCE Level IV. Anatomic Study.