Atakan Aydin

Tibialis posterior tendon transfer for persistent drop foot after peroneal nerve repair.

Despite advances in the surgical treatment of peroneal nerve injuries, a significant fraction of patients do not recover adequately. Among 35 patients who had previous repair of the peroneal nerve, 19 had permanent drop foot, and 16 of these patients underwent tibialis posterior (TP) tendon transfer. Mean duration of paralysis was 26.7 (range, 7 to 192) months. TP tendon was carried to the anterior compartment via the circumtibial route, and then attached to the tibialis anterior, extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons using tendon-tendon anastomosis. All patients except for one achieved active dorsiflexion to or beyond neutral. Mean preoperative drop foot angle increased from -33.8 degrees to + 9.7 degrees. According to the Stanmore system, the results were excellent in 10 patients (62.5%), good in 4 (25.0%), fair in 1 (6.2%), and poor in 1 (6.2%). The average Stanmore score was 85, which corresponded to an excellent result. We believe that the TP tendon transfer is a straightforward and reliable solution in the treatment of drop foot.

Actinomycosis of the frontal and parotid regions.

Cervicofacial actinomycosis still occurs infrequently and should be included in the differential diagnosis of neoplasms, and chronic suppurative and granulomatous lesions of the head and neck region. The authors present two cases of actinomycosis. Patient 1 was a 32-year-old man who was first seen with a firm, suppurative mass at his left frontal region. Patient 2 was a 36-year-old woman with an indurated mass at her left parotid area. Both patients were diagnosed histopathologically with cervicofacial actinomycosis, but each patient had a different clinical course and different response to antimicrobial and surgical treatments.

Dorsal metacarpal island flap in syndactyly treatment.

Web space reconstruction is an important component of syndactyly treatment. There are several methods for a skin graft–free reconstruction. Previously, the dorsal metacarpal island flap based on a direct cutaneous branch of the dorsal metacarpal artery has been used as an island V-Y advancement for web defects in syndactyly. In this study, dorsal metacarpal artery flap was raised similarly as an island but was used instead as a transposition flap in a series of 19 web defects. Early results of a median (range) follow-up of 3 (1–5) years reveal neither recurrence of the deformity nor web creeping. Such utilization of the flap enables a better use of the skin territory proximal to the pedicle and a more comfortable reconstruction of the web space.

The results of surgical repair of sciatic nerve injuries

OBJECTIVES The aim of this study was to evaluate surgical treatment and follow-up results of patients who presented to our department with sciatic nerve injuries. METHODS The study included 13 patients (12 males, 1 female; mean age 23 years; range 11 to 35 years) who underwent surgical treatment for sciatic nerve injuries. The etiologies of sciatic nerve injuries were penetrating trauma in five patients, firearm injuries in four patients, and motor vehicle accidents in four patients. Injuries involved the knee level in five patients, and above-the-knee level in eight patients. Peroneal nerve involvement was seen in all the patients, and the tibial nerve was involved in 11 patients. Primary repair was performed in six patients, neurolysis in three patients, and nerve grafting in three patients. One patient underwent neurolysis for the peroneal portion, and nerve grafting for the tibial portion. Muscle strength and reflex changes were recorded at every stage of the treatment. Muscle strength was assessed according to the British Medical Research Council scale. The Semmes-Weinstein monofilament test was used for sensory evaluation. The mean follow-up period was 4 years (range 1 to 6 years). RESULTS In 11 patients with tibial nerve injuries, the soleus/gastrocnemius strength was measured as follows: M1 in one patient, M3 in four patients, M4 in four patients, and M5 in two patients. Plantar sensation was absent in four patients, while seven patients had at least adequate protective sensation. In 13 patients with a peroneal nerve injury, the strength of the anterior tibial muscle was measured as follows: M0 in three patients, M2 in three patients, M3 in one patient, M4 in three patients, and M5 in three patients. Of these, four patients had persistent insensitivity in the dorsum of the foot, while six patients had protective sensation, and three patients had normal sensation. Two patients with inadequate anterior tibial muscle strength following nerve repair underwent posterior tibial tendon transfer for restoration of foot dorsiflexion. The greatest functional improvement was obtained in cases in which neurolysis was performed; patients undergoing primary repair had better outcomes compared to those where nerve grafts were used. The results were better in thigh level injuries than those in the gluteal region. CONCLUSION Low expectations after sciatic nerve repair in the past are now being rapidly replaced by a more optimistic approach. Advances in microsurgery and use of treatment algorithms based on scientific research account for this significant improvement in outcomes after sciatic nerve surgery. Tendon transfers can enhance the success rate and be combined with nerve repair in selected cases.

Sensory recovery of the reverse homodigital island flap in fingertip reconstruction: a review of 66 cases

OBJECTIVES The location of the fingertip entitles it to have significant cosmetic and functional values, but also places it at high risk for injury. During repair, finger length and function should be maintained, and stiffness and neuroma should be avoided. Various flaps have been described for reconstruction of distal finger defects with bone, tendon, or joint exposures, including reverse flow homodigital island flap. In this study, we present our experience of reverse flow homodigital island flap in terms of sensory recovery. METHODS Sixty-six patients (70 fingers) with fingertip amputations were included in the study. Patients were treated with homodigital island flaps. All patients underwent sensitivity assessment by 2-point discrimination and Semmes-Weinstein monofilament tests at 6, 12, and 18 months during follow-up, and complications were recorded. RESULTS Monofilament testing results were normal in 64 fingers (91.4%), and diminished light touch was found in six fingers. Two-point discrimination results were normal (<6 mm) in 40 fingers and fair (6-10 mm) in 30 fingers (mean 5.7 mm, range 4-9 mm). Complications included one partial flap necrosis, three flexion contractures, and two neuromas. CONCLUSION In repair of injuries to areas in which sensory feedback is critical, such as the index finger, the homodigital flap may be the treatment of choice.

Brachioradialis transposition for elbow extension in obstetrical brachial plexus palsy.

Disorders of elbow extension occur following traumatic or neurologic injuries of the triceps muscle. Restoration of elbow extension is an integral part of the entire upper extremity surgical reconstruction to improve the following daily activities: bringing down an object from above, handwriting, using the hand in the supine position, steering a wheelchair, driving a car, and swimming. The transfer of the posterior head of the deltoid muscle to triceps (Moberg procedure) and the transfer of the biceps to triceps (Friedenberg procedure) are previously described procedures for the functional restoration of triceps function. In conditions where these procedures cannot be used, we describe a new technique for restoration of elbow extension. In 4 cases with obstetrical palsy sequela, where shoulder abduction was established with the latissimus dorsi and teres major transfer, restoration of elbow extension was planned to aid in activities performed while the hand is above the head. To achieve this goal, the brachioradialis muscle was transposed bipedically to the triceps muscle.

Tumoral Calcinosis Infiltrating the Biceps Brachii Tendon – Excision and Reconstruction with Allograft: A Case Report

Two patients with limited elbow motion due to tumoral calcinosis underwent resection of calcified masses around the elbow joints. This necessilated removal of the distal two thirds and three fourths of the biceps muscles. The resulting defects were reconstructed with homologous Achilles tendon grafts. Both patients regained M4 muscle power and no recurrences were observed.

External decontamination of wild leeches with hypochloric acid.

BackgroundMedicinal leech, Hirudo medicinalis, has been used in plastic and reconstructive surgery, to relieve venous congestion and to improve the microrevascularization of flaps. In many countries, wild leeches are still provided from local markets and utilised with antibiotic prophylaxies. In this research, results of identification of bacteria in the transport fluid is reported, oral and intestinal floras and the antibiograms of the identified microorganisms are investigated. Also, to avoid possible infections, the ability of hypochloric acid, a disinfectant, to suppress the relevant microorganisms without changing the life style and behavior of leeches in terms of sucking function, is investigated.MethodsBacterial identifications and antibiograms of oral and intestinal flora and transport medium were performed for 10 leeches. The optimum concentration of hypochloric acid which eliminated microorganisms without affecting the viability and sucking function of the leeches were determined by dilution of hypochloric acid to 100, 50, 25, 12.5, 6.25 ppm concentrations in different groups of 25 leeches. Finally, 20 leeches were applied atraumatically to the bleeding areas of rats, the duration of suction was determined and compared statistically between the leeches treated and not treated with hypochloric acid solution.ResultsAeromonas hydrophilia was the most commonly identified microorganism and found to be resistant to first generation cephalosporins, frequently used in prophylaxis at surgical wards. In the next stages of the study, the leeches were subjected to a series of diluted hypochloric acid solutions. Although disinfection of the transport material and suppression of the oral flora of hirudo medicinalis were successful in 100, 50, 25, 12.5, 6.25 ppm concentrations; 12.5 ppm solution was the greatest concentration in which hirudo medicinalis could survive and sucking function was not affected significantly.ConclusionsExternal decontamination of wild leeches with 12.5 ppm hypochloric acid enables bacterial suppression without causing negative effects on leech sucking function and life.

Olecranon bone graft: revisited.

Autogenous bone grafts are frequently in use in the field of reconstructive upper extremity surgery. Cancellous bone grafts are applied to traumatic osseous defects, nonunions, defects after the resection of benign bone tumors, arthrodesis, and osteotomy procedures. Cancellous bone grafts do not only have benefits such as rapid revascularization, but they also have mechanical advantages. Despite the proximity to the primary surgical field, cancellous olecranon grafts have not gained the popularity they deserve in the field of reconstructive hand surgery. In this study, the properties, advantages, and technical details of harvesting cancellous olecranon grafts are discussed.

Brachialis muscle transfer to the forearm for the treatment of deformities in spastic cerebral palsy

The use of the brachialis muscle for tendon transfers in cerebral palsy has not been described previously. In this study, the brachialis muscle was used for transfer in 11 patients with spastic cerebral palsy for the restoration of forearm supination, wrist extension, or finger extension. Four patients underwent brachialis rerouting supinatorplasty. Active supination increased in two (60° and 50°), minimally increased in one (5°), and did not change in one patient. Five patients had a brachialis to extensor carpi radialis brevis transfer. The mean gain in postoperative active wrist extension was 65°. Two patients with finger flexion deformity and no active metacarpophalangeal joint movement underwent a brachialis to extensor digitorum communis transfer, and they attained an improved posture of finger extension although their postoperative metacarpophalangeal flexion–extension movement arc was 5° and 25°. None of the patients developed any loss of active flexion at the elbow. Our preliminary experience suggests that the brachialis muscle may serve as an alternative tendon transfer in cerebral palsy.