Aesthetic hand prosthesis: gadget or therapy? Presentation of a new classification

Aesthetic prostheses must fulfill a functional as well as an aesthetic role. The function of these prostheses may be perceived as an additional passive support, or as an instrument of social function and an aid to the patient. This functional role has been observed in the continued use of these prostheses over several years. We reviewed our experience with prescription, fitting and follow-up care in 2847 patients. Classification of these patients was based on their age, level of amputation (with or without functional pinch) and cause of amputation. Analysis of the data ratifies our indications for prosthesis fitting. The long-term wearing of these aesthetic prostheses confirms their use as therapeutic tools.

Ungual prostheses

Whatever the origin and the nature of the trauma, behind every request for ungual prostheses there is always the question of how realistic the effect on others will be. Our publications in 1978, 1988 and 1999 and 30 years of experience in this field have consequently led to a comparative study on the evolution of the quality, fixation and indications of our prostheses. The replacement nail is still a difficult issue as sometimes it is simply a matter for the 'nail boutiques', but can even involve surgery in the more complex cases. Prostheses replicate the volume and shape of the finger. Treating a nail is an intricate task but an essential one for the aesthetic and functional comfort of the patient.

[Arterial vascularization of the foot. Its importance in operations of revascularization of the lower limb]

Vascularization of the foot was studied using 50 intraoperative arteriograms on single legs and 50 cadaver injections. Arterial vascularization was shown to depend on supramalleolar anastomoses, the primary plantar arch and secondary arches. Anastomotic routes are essential for the permeability of femorotibial bypasses and cicatrization of distal trophic lesions when only one tibial artery remains permeable and must be revascularized.

Anastomosis between the internal carotid and vertebral artery in the neck

We report a case of anastomosis between the internal carotid and vertebral a. in the cervical region. This anatomic variation is due to incomplete migration during embryogenesis of the branchial aa., collaterals of the dorsal aorta, towards the ventral aorta. It does not involve persistence of a type I proatlantal a., as described by Lasjaunias. Such anastomoses must be recognised since they may modify surgical tactics in the context of endarterectomy for carotid stenosis.

Retrograde cerebral perfusion: anatomic study of the distribution of blood to the brain

BACKGROUND

Despite apparently good clinical results with retrograde cerebral perfusion during operation on the aortic arch, there is still concern about the real distribution of the blood injected in the superior vena cava to the brain, especially when the internal jugular vein is valvulated (88% of the cases). This anatomic study was carried out to determine how a liquid injected in the superior vena cava reaches the brain.

METHODS

Three groups of adult cadavers (5, 5, and 3 cases, respectively) were injected with latex, colored blue, through a cannula in the superior vena cava. In group I, 600 mL of latex was injected. Group II was identical except that a catheter had been inserted, before the injection, into the internal jugular vein to collapse the internal jugular vein valve, when existing. In group III, the azygos vein was ligated.

RESULTS

The internal jugular vein was not valvulated in 2 cases in group I. In those 2 cases, latex was found up to the jugular foramen. In the other cases in group I, and in all cases in group II, where the internal jugular vein was valvulated, the following veins were injected: internal jugular vein up to the valve (almost no latex beyond), azygos vein, inferior vena cava, renal veins, rachidian and perimedullar venous plexuses, and venous sinuses of the brain. In group III, no opacification was observed beyond ligated azygos vein or valvulated internal jugular vein.

CONCLUSIONS

Despite the fact that this study was carried out on cadavers, one can assume that, during retrograde cerebral perfusion, the azygos vein system is a major way to the central nervous system when the internal jugular vein is valvulated.

Reconstruction of the aortic arches of a 28-day human embryo (stage 13) using the Born technique

We present a reconstruction of the aortic arches of a human embryo at stage 13. Only a few original observations have been reported during the last 110 years and only two with three-dimensional reconstructions. The reconstruction technique originated in 1885. Modern computerized reconstruction techniques have no evident advantages and are more expensive. Aortic arch malformations are responsible for disorders which cannot be understood without a knowledge of their embryology. The embryonic aortic system is a typical example of Haeckel's law of recapitulation. A human embryo at stage 13 was prepared in 5 mm sagittal sections so as to reconstruct the entire dorsal aorta, the second (transient) arch, the third and fourth arches, and the sixth arches responsible for the pulmonary artery, pharynx, larynx and tracheoesophageal axis. They are only 5 pairs of arches in man. At this stage, the most important vessel is represented by the dorsal aorta with a cerebral route, due to predominance of the development of the central nervous system and its vascularisation over other organs. Vascularisation of the lower limbs appears before their macroscopic development and is probably one of the factors responsible for their growth. Many such reconstructions are necessary if conclusions are not to be based on too few specimens to be sound. A better knowledge of embryology lead to a new understanding of aortic arch malformations.

Colour Doppler and duplex sonography and angiography of the carotid artery bifurcations. Prospective, double-blind study

We undertook a prospective double-blind study of 128 carotid artery bifurcations using colour Doppler and duplex sonography and angiography. Sixty-four patients with cerebrovascular events were admitted for angiography. All underwent sonography within 24 h of angiography. Standard duplex sonography and colour Doppler imaging without spectral analysis were performed, on the same device, by two sonographers, using defined morphological and haemodynamic criteria. Digital radiological data on vessel diameter were interpreted independently by two radiologists. The two sonographic methods gave similar grading of stenosis, compared to angiography, with an accuracy ranging from 96% in severe to 83% in minor stenoses. Colour Doppler studies gave better area measurements than standard duplex sonography, except for major stenoses. Discrepancies between ultrasonography and angiography were due mainly to minor stenoses and large plaques of calcification on the vessel walls, which masked very segmental 70% stenoses in 2 cases. Angiography is limited by its own resolution, does not show uncalcified vessel walls and does not give cross-sectional data. It would therefore be inappropriate for showing small plaques, the full extent of ectasia or for defining the carotid bulb accurately. The advantages of colour methods were in investigating sinuous or deep vessels and hypoechoic plaques. Analysis of the residual lumen of a stenosis and its extent could be determined more rapidly. Haemodynamic quantification of stenoses by standard duplex sonography may be difficult because of limited sample volume and error in estimation of angle, whereas colour Doppler allows semiquantitative estimation of haemodynamics.(ABSTRACT TRUNCATED AT 250 WORDS)

[Angiographic study of collateral circulation in coronary occlusion]

To define the collateral circulation pathways between coronary arteries, 101 coronarographies of patients who had at least one occlusion of a coronary artery (left-anterior descending artery, circumflex, right coronary) were analysed. We found 12 collateral pathways for the right coronary, 8 for the anterior descending artery, and 4 for the circumflex artery. These collateral circulation pathways have been mapped and compared to those of literature.

[Vascular complications of lumbar disk surgery. Report of two cases and review of the literature on 122 cases]

We report two cases of right lumbar common iliac arteriovenous injury after an operation on the L4-L5 disk. One case was an arteriovenous fistula disclosed 5 years after the operation and in the other case, a postoperative acute haemorrhage. A retrospective study is carried out in the literature aiming at establishing the frequency of vascular injury in lumbar disk surgery, their nosologic definition, and the provided treatment. One hundred and twenty two observations were taken into account. The frequency cannot be determined. 78 of these observations (63.9%) reported an arteriovenous fistula between two elements of the aortic-cava intersection, with acute revelation (6.4%), sub-acute (19%) or late as a right cardiac failure (64%). Thirty one cases of acute haemorrhages through isolated arterial wound (25.4%), 3 cases of arterial or venous thrombosis (2.5%) and 10 cases of false aneurysms (8.2%) were found. The treatment was always surgical, sometimes in high emergency. In the case of haemorrhage the death rate was 21% and in the event of fistula 1.3%. Morbidity was 11.5%, mostly due to a post-phlebitic syndrome. These results reduce the mildness reputation of lumbar disk surgery all the more as recording of the complications is under estimated and most of them are found far from the initial act.

[Cardiac surgery in aged patients; immediate and medium-term results in 100 patients over 75 years of age]

With improved operative technique and postoperative care, progressively older patients are being referred for cardiac surgery. One hundred out of 633 patients operated between September 1990 and December 1992, were over 75 years of age (Group I). These patients were compared with the last 100 patients under 75 years of age (Group II). Both groups were operated by the same surgical team with the same anaesthetic, cardiopulmonary bypass and myocardial protection techniques. The average age of the groups was 79.5 +/- 3.1 and 62.1 +/- 9.2 years, respectively. The procedures performed were: myocardial revascularisation (Group I, 28 cases; Group II, 59 cases), aortic valve surgery alone or associated with coronary bypass (56 and 22 cases respectively), and mitral valve surgery alone or associated with another procedure (11 and 12 cases). There were no significant differences between the two groups with respect to true low output state, the duration of mechanical ventilation and of intensive care and hospital stay. On the other hand, there were significant differences in: the number of blood transfusions (44 cases versus 20, p < 0.001), the occurrence of atrial fibrillation (52 cases versus 29, p < 0.001) and neuropsychiatric disturbances (27 cases versus 5, p < 0.0001). There were no cases of mediastinitis in either group. The hospital mortality was 6% in Group I and 5% in Group II (NS). The medium-term mortality after an interval of 5 to 32 months in the over 75 age group was 7 cases, including 4 cases of cerebrovascular accident. An enquiry was performed in the 87 survivors of Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of subclavian syndrome on the basilar artery

Fifty-five patients with a permanent or intermittent subclavian steal syndrome demonstrated by continuous wave Doppler were included in a prospective study: 25 patients without vertebro-basilar symptoms, 8 symptomatic patients with defined vertebro-basilar symptoms and 22 with hemodynamic vertebro-basilar occurrences. The basilar artery velocity was recorded by Transcranial Doppler Sonography in baseline conditions, and after a hyperaemia test to the upper limb. A spontaneous, incomplete basilar steal was diagnosed in seven patients, and a complete basilar steal in one patient, (14.5% of the cases). After hyperaemia test, 18 other incomplete basilar steal were observed. The occurrence of a basilar steal was higher in the vertebro-basilar group (57% of the cases) especially in 7 of the 8 cases with defined vertebro-basilar symptoms; it was lower in the patients without vertebro-basilar occurrences (36% of the cases). This basilar steal was also seen in five of the six symptomatic patients with opposite vertebral artery stenosis above a 50% diameter. Transcranial Doppler Sonography could help to define a subgroup of subclavian steal syndrome with a high risk of strokes.

[Retrograde cerebral perfusion for replacement of the aortic arch. Apropos of a case]

The authors report a case of cerebral protection with retrograde cerebral perfusion during aortic arch surgery. The duration of retrograde cerebral perfusion and the favorable neurological outcome seem to confirm the promising results of this technique developed in Japan.

Surgical anatomy and dissection of the petrous and peripetrous area. Anatomic basis of the lateral approaches to the skull base

The purpose of this study is to review the topographic anatomy of the petrous and peripetrous structures, with emphasis on the relationships important to the lateral approaches to the posterior and lateral skull base. Surgical exposure of the clivus, the posterior aspect of the petrous bone, the ventral aspect of the brain stem, and of all the intradural structures in the area, remains difficult because of the presence of the so-called "petrous and peripetrous complex". However, the lateral approach to the skull base is the most suitable approach if the lesion lies lateral to the cavernous portion of the internal carotid artery, and of course if the lesion develops laterally behind the petrous apex. Consequently, neurosurgeons should be familiar with the anatomy of the intrapetrous cavities and their contents, and with the relationships in the area. Middle cranial fossa dissections (dry and fresh specimens) allow us to study the anatomical relationships between the intrapetrous carotid artery, the facial nerve, the porus, the cochlea, the geniculate ganglion and the petrosal nerves, the trigeminal ganglion and nerve, the auditory tube and the middle ear. While briefly reviewing some approaches (anterior petrosectomy, sub-temporal preauricular infratemporal fossa approach, pre-sigmoid approach), we explore the concept of the approach and the limitations of surgical technique and exposure.

[Arterial vascularization of the colon. The middle mesenteric artery]

In its modal disposition, the arterial vascularisation of the colon is on the dependence of the superior and inferior mesenteric arteries anastomosed by the way of "arcade de Riolan". Some more exceptional schemes can complicate this distribution: arteria colica media, medium mesenteric artery, intermesenteric arcus. This rare arterial dispositions can have a big practical importance, in the case of colic transposition, and more recently in the case of the utilization of the right gastroepiploic artery for coronary by-pass.

[Macroscopic vascularization of the adult sternum. Implications of removal of the internal thoracic arteries]

The most of the arterial vascularisation of the adult sternum is on the dependence of the internal thoracic arteries. The best results of the aorto-coronary by-pass starting from this arteries are however subjected to more infectious complications. The study of this arterial supply, in "surgical" conditions, after sternotomy and ablation of one or two internal thoracic arteries show this devascularization. The residual arterial supply is only constituted by thin branches coming from intercostal arteries.

[Paraplegia after surgery of the suprarenal aorta (26 cases reported during a national survey)]

Although their frequency is probably underestimated, medullary complications of abdominal aorta surgery are rare but serious, and may be the cause of medico-legal actions. Referral of a patient allowed the collection of 26 unpublished cases: 18 with aneurysms, including 6 ruptured lesions and 12 undergoing cold surgery, and 8 with aorto-iliac occlusion, these 26 cases representing 0.16% of abdominal aorta interventions performed during the same period. Mortality (6 cases) was due principally to neurological complications, total in 4 cases, partial in 3 and persistent in 13. Risk factors were perioperative collapse (explaining the elevated frequency in ruptured aneurysms) and the occlusion of the internal iliac arteries. Duration of clamping was not significant. No certain method of prevention could be elucidated, either by a literature review or by analysis of the personal series.

Reconstruction of an abnormal artery observed in an 11 mm embryo: considerations on the embryologic origin of the subclavian artery

The retro-oesophageal right subclavian a. is a classical variant. We report the first case recognised in the embryo (11 mm subject reconstructed by Born's method). Four other adult cases are analysed (1 dissection and 3 clinical cases) and compared with 250 clinical observations of the supraaortic trunks. In the modal state it arises from the 7th arterial segment. The origin of the subclavian and vertebral aa. and the arrangement of the supraaortic trunks allow the distinction of three types, whose embryologic origin is discussed.

[Efficacy of intra-arterial fibrinolysis in subacute atheromatous ischemia of the lower limbs]

The study of 44 patients treated with intra-arterial fibrinolysis is reported. All these patients had an impending subacute ischemia of the lower limbs, a major complication of atheromatous disease. The criteria for patient selection were clinical, hemodynamic and radiological. The procedure of the treatment associating Urokinase, Heparin and Naphthidrofluril are defined, as well as its follow-up. The results have been evaluated according to the clinical and radiological improvement. 2 patients died when the treatment ceased and 10 were amputated, ie 27% of failures. The fibrinolytic treatment allowed identifying the patients who might quickly receive an additional treatment. In our experience, this treatment seems to improve the prognosis of impending subacute ischemia.

[Corono-radicular caries: a histoclinical approach]

Due to aging and gingival recession, the radicular structures are exposed to cariogenic attacks from the oral cavity. This phenomenon leads to a constantly higher frequency of root caries. The aspect of these carious lesions was analysed by a histological and an SEM study. To conclude the study, a clinical description of the lesions and an epidemiological survey were realized on 112 patients for 16 months.

Topographic anatomy of the lumbar lateral vertebral groove. Anatomical basis of the surgical approach to extra foraminal herniated disc

The study of numerous dissections, sections and X-rays of the lumbar spine has enabled us to clarify the connections of the lumbar spinal nerves at their emergence from the intervertebral foramen and in the lateral vertebral groove. This work naturally leads to the study of the extra foraminal herniated disc by an extra isthmian approach or to percutaneous surgery of thoracolumbar discs.

A rare embryologic variation: carotid-anterior cerebral artery anastomosis or infraoptic course of the anterior cerebral artery

Carotid-anterior cerebral artery anastomosis constitutes an anomaly of the anterior part of the arterial circle of the brain. The anterior cerebral a. arises a few millimeters above the emergence of the internal carotid from the cavernous sinus, at the usual level of origin of the ophthalmic a. It travels medially, beneath the optic n., and then describes a curve with a superolateral concavity to arrive at the anterior part of the optic chiasma, where it anastomoses with the anterior communicating a. This asymptomatic variant of course is often associated with other cerebral vascular anomalies, especially arterial aneurysms. On the basis of 2 new cases discovered by chance, together with a review of the literature, various hypotheses capable of explaining the embryologic origin of these anomalies are discussed.

The principal artery of the psoas major muscle

The psoas major m. has a complex arterial supply, derived from the lumbar, iliolumbar, obturator, external iliac and common femoral a. The branches arising from the external iliac a., though quite often multiple and slender, are represented in 75% of cases by a single large-caliber vessel. This principal artery of the psoas m. is probably responsible for the curves of the external iliac a. in the aged and also in certain competitive athletes.

Scanographic study of the calcaneus: normal anatomy and clinical applications

To facilitate the interpretation of the scanographic findings in fractures of the calcaneus, the authors have achieved an anatomo-radiologic correlation in terms of the classical coronal, sagittal and horizontal planes. Clinically, the sagittal plane can be obtained only by reconstruction. The 2 other planes permit study of the sustentaculum tali and posterior talar surface only in different sections, without their respective relationships. The authors therefore suggest a new double-oblique view, practicable in the injured patient, with a forward tilt of 20 degrees and medial rotation of 35 degrees, perpendicular to the sinus tarsi. This serves for anatomo-radiologic correlation and shows both anatomic structures together. By itself, it provides as much information as the three classical views and appears adequate for the assessment of fractures.

A study in organogenesis: the arterial supply of the anorectal region in the human embryo and fetus. Anatomic and embryologic bases of anorectal malformations

The development of the anorectal region is based on differentiation of the terminal portion of the hindgut. The origin of anorectal malformations is still unknown but seems to occur very early in the embryologic period. To gain a better understanding of their development, a study of the arterial supply of the anorectal region was made in 26 embryos and 50 fetuses.

[Primary aortoduodenal fistula of tuberculous origin]

This case of aorto-duodenal fistula was due to fistulization of a tuberculous lymph node between an atheromatous aneurysm of the infra-renal aorta and the third part of the duodenum. CAT scan provided the diagnosis of an aorto-duodenal fistula. The tuberculous origin of the fistula was confirmed by bacteriological and histological examinations. The outcome was favourable after revascularisation "in situ" combined with epiplooplasty and prolonged antituberculous drug therapy.

Brachial artery entrapment: compression by the supracondylar process

Ischemia occurring during hyperextension of the upper limb in a 25-year-old woman led to the discovery of a supracondylar spur responsible for compression of the brachial artery with anomalous insertion of the pronator teres muscle. Resection of all abnormal structures provided immediate relief of symptoms. When atypical arterial symptoms of thoracic outlet syndrome occur in the upper limb, the brachial artery entrapment syndrome should be considered.

[Distal reimplantation of the extremities]

Over the last two years, 15 patients have undergone revascularization surgery to a total of 17 distal extremities at the level of or distal to the last phalangeal joint. Operations were performed by three surgeons trained in microsurgical techniques, making the series a homogeneous one. Results were analyzed using Tamai and Nakamura's scores. Determinant factors, social and economic costs and effects on occupation are emphasized. The mean success rate of 65% is influenced by the total or partial nature of the section, its localization to the thumb or long fingers and the mechanism of section. The good functional results obtained were due to distal forms of amputation, recognized despite the technical difficulties as being an indication of choice for this reimplantation surgery. All patients in this group were able to return to work, with or without adaptation, within a variable lapse of time.

Endofibrosis of the external iliac artery in bicycle racers: an unrecognized pathological state

Since December 1985, we have operated upon seven bicycle racers for endofibrosis of the external iliac artery. In all instances, the athletes had started cycling early in life and were engaged in top level competition by the age of 17. The principal complaint was intermittent claudication of one lower limb at "near-maximal" exercise. Pain could be reproduced by exertional tests on an ergometric bicycle, and in all cases except one, measurement of ankle systolic pressure of that limb compared with the opposite side and brachial pressures showed a marked decrease on the involved side. Arteriography, performed with multiple views and positions, documented a 5 to 6 cm moderately stenotic (less than 40% diameter) segment, associated with arterial lengthening. Surgical treatment consisted of endarterectomy and shortening of the artery. Four patients were able to return to competition. The origin of this pathology is discussed, based on gross and histologic findings. Under certain predisposing anatomic conditions, abnormal hemodynamics, probably due to a high flow arterial state and an aerodynamic position on the bicycle, provoke repeated trauma which eventually produces the lesion. Practically unrecognized until now with only two previous publications on the subject in the literature, this entity is probably not uncommon.

Extrinsic arterial supply of the great saphenous vein: an anatomic study

The extrinsic arterial supply to the great saphenous vein was studied by dissection following latex injection, diaphanisation and contrast roentgenograms. Arterial supply arises from the external pudendal, superficial femoral, superior genicular and posterior tibial arteries. These branches ensure the irrigation of the vasa vasorum. The role they play in the outcome of bypass with the great saphenous vein is a further argument pleading in favor of the in situ technique.

[Isolated azygos continuation of the inferior vena cava. (Absence of the retrohepatic segment of the inferior vena cava)]

The isolated azygos continuation of the inferior vena cave is a very rare variation of this organ. It is accompanied by the absence of the retrohepatic segment of the vena cava with two new observations, the literature is revised and the origin discussed.

[The so-called anterior tibio-peroneal trunk. Its influence on the mode of revascularization by femoropopliteal bypass]

Femoro-popliteal bypass is difficult to perform when the posterior tibial artery originates at a high level in the lower limb. The problems arising from this anatomical variation, in which the tibio-peroneal trunk is, at least classically, anterior to the popliteal muscle, can be overcome by the technique described.

[The anterior tibial artery and vascularization of the muscles of the anterior compartment of the leg. Application to the anterior compartment syndrome of the leg]

The arterial vascularisation of the anterior loge of the leg is supply by the anterior tibial artery. Three muscles are contained in an inextensible space. Each of this muscles received an arterial supply proportional to his volume. The fragility to ischemy of the extensor hallucis longus is not explained by insufficiency of this arterial branches.

A radio-anatomical study in vivo on pancreatic ducts

Pancreatography using fibroscopy is current practice in medicine and contributes to the diagnosis of diseases of the pancreas. The radiographic images obtained generally represent oblique projections which have little in common with classic anatomical diagrams. An analysis of 60 pancreatographic investigations considered normal (out of a series of 400 investigations made on various diseases of the pancreas) has been followed by a comparison between these radiographic results obtained in vivo with diverse anatomical classifications in current use. The conclusion is reached that pancreatography is morphologically reliable and that there is no correlation between the mode of ramification of the ducts and pathological conditions (with the exception of the pancreas divisum and the annular pancreas).