Metin Erer

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.

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.

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.

Use of free serratus anterior muscle slips for the reconstruction of dorsal-side defects of the hand resulting from hot press injury.

Mutilation of the hand as a result of hot press injury, the common characteristics of which are extensive soft tissue and extensor tendon loss, metacarpal and phalangeal necrosis, exposition of multiple joints, and infection, presents a serious challenge to the hand surgeon. Free transfer of the inferior three slips of the serratus anterior muscle is a useful surgical option for the reconstruction of dorsal-side defects in the hand. The versatility of the three separate slips, which are easily divisible for contouring, enables individual reconstruction of the different digits. Long vascular pedicle, low donor-site morbidity, and durability are other advantages. Four male patients with hot press injury of the dorsal side of the hand were treated with free transfer of serratus anterior muscle slips and split-thickness skin grafts. Follow-up period ranged between 5 and 12 years. Late functional and cosmetic results are presented.

The effect of parenteral pentoxifylline therapy on skin flap survival

SummaryThe effect of pentoxifylline as a hemorrheologic agent on skin flap survival has been observed. A caudally pedicled dorsal flap with an ischemic component in rats was used as the model. The flap survival was calculated to be 0.807±0.049 in the control group (n = 15), where flap survival was found to be 0.9713±0.018 in the pentoxifylline treated group (n = 15) (t = 12.19, p < 0.005). In the meantime, living flap length was measured as 9.96±0.72 in the control group, and 11.84±0.18 in the pentoxifylline treated group. With these results, we have come to the conclusion that parenteral pentoxifylline therapy is effective on ischemic skin flap survival in the rat model.

Foreign Body Penetrations of Hand and Wrist; a Retrospective Study

BACKGROUND Despite significant practical knowledge and experience on foreign body penetration injuries to the hand and/or wrist, deficient management and complications can still be encountered, and ignorance of its causative and eventual social aspects unfortunately is a substantial fact. This study aims to cover the clinical and social properties and the management of these kinds of injuries. METHODS A retrospective analysis of 86 patients requiring evaluation and treatment in a Hand Surgery Division of a university hospital was performed. RESULTS The median age was 32 (min: 4, max: 63). Industrial workers constituted the largest occupational group (n=22, 25.6%). Twenty-three (26.7%) of the cases were elective admissions. Thirteen (15.1%) patients had various comorbidities, and five (5.8%) had psychiatric diagnoses at the time of the injury. The index finger was the most frequent site of injury (n=29, 33.7%). General anesthesia was not necessary for the management of 94.2% of the cases. In 26 (30%) of the patients, neural, tendinous or osseous damage was observed. Twenty-four (30%) patients were included in a postoperative hand physiotherapy program. CONCLUSION The practically well-known general features of the issue and those aspects that may still be overlooked currently are reevaluated herein, in light of our observational data.

Experience with Lateral Arm Flap in Hand and Forearm Defects

The lateral arm flap is currently one of the most frequently used free tissues. Easy dissection, constant anatomy and a long pedicle are the major advantages of this hap. 21 patients who had an upper extremity reconstruction with the lateral arm free flap are reviewed. The aetiology of the defects was electrical burn in 12 patients, thermal burn in 3 patients and trauma in 6 patients. The flap was transferred for distal forearm defects in 15 cases and for distal and volar soft tissue defects of hand in 6 cases. In 19 cases out of 2 1, the flaps were harvested from the ipsilateral limb. In 8 cases the transfers were performed under axillary block anesthesia. All transfers were successful and 4 cases required secondary thinning of flaps. In this presentation, indications and results with lateral arm flap will be discussed.

Accidental radiation injury to the hand: a case report

A 46-year-old patient with severe radiation injury of his hand was presented to our clinic. Five months previously, the patient had repaired a piece of metallic equipment which was later discovered to belong to a gammagraphy machine. The fifth ray of his left hand, having ulceration of the volar–ulnar side of the palm, was resected, and the resulting defect was repaired with a posterior interosseous flap. However, owing to the progressive nature of the disease, the patient developed further necrosis around the flap, and the third and fourth fingers. Therefore, further amputations were needed. Hyperbaric oxygen therapy with sympathectomy was used postoperatively. A radiation ulcer on the abdominal area developed in the tenth postoperative month, this was due to contact of his abdomen with the table on which he put the radiation source. This ulceration was excised and closed primarily. We would like to emphasize in the light of this case that all radiation sources and their management during all phases of application, transport and disposal should be strictly controlled.

Glomus tumors of the hand

SummaryExperience with 15 cases of glomus tumors of the hand is reported. This condition is described as being uncommon but is not so rare as is commonly stated. Many are misdiagnosed or overlooked because of unfamilarity with the condition.

Use of Kirschner Wires as Endoscopic Retractors

We read with great interest the article of Dr. da Silva Freitas [1] titled Poland’s Syndrome: Different Clinical Presentations and Surgical Reconstructions in 18 Cases, which presents an up-to-date and useful therapy scheme. Of special interest to us was the use of the endoscopic technique for latissimus dorsi musculocutaneous flap harvest as an option for reconstruction of pectoralis major muscle agenesis in one of their cases. This demonstrates clearly that the number of endoscopic interventions in the repertoire of the plastic surgeon is growing very rapidly. Unfortunately, the steep learning curve and dependence on expensive equipment can be discouraging for the beginner. Innovative alterations of the technique are therefore of the utmost importance because they can cut down on equipment costs and overcome technical obstacles. The technique for endoscopically assisted harvest of latissimus dorsi muscle has been given detailed description in the literature previously by various authors [2,3]. Except for personal preferences and differences of infrastructure, the technique is well settled and reliable. One of the few technical points about which a disagreement still exists concerns the creation and maintenance of the optic cavity. Various techniques have been used besides carbon dioxide insufflation, with varying degrees of success, such as balloon dissection and hydrodissection [4]. Both of these methods have received positive and negative criticism. We present a simple method for assisting flap dissection and increasing exposure in a patient with Poland’s syndrome. A 19-year-old boy presented with a left pectoralis muscle agenesis. An axillary incision and three 5-mm ports were used for flap harvest and inset. Figure 1 shows the use of two Kirschner wires with a diameter of 3 mm to maintain the subcutaneous working space. The first Kirschner wire is placed through the axillary incision parallel to the anterior axillary line. The second wire is placed parallel and posterior to the first one. When both wires are elevated simultaneously, they create a ‘‘tent’’ over the dissected portion of the muscle, which leads to greater exposure of the working space. As the dissection proceeds, the wires can be repositioned for better visualization. The dissection of the most medial portions of the latissimus dorsi muscle where it fuses with the spinal muscles is especially facilitated. The wires can be used for the recipient site in a similar fashion. This innovation enabled us to control a wide field endoscopically with little effort and to reduce the operation time.