Evaluation of Shoulder Muscle Improvement in Patients Following Free Latissimus Dorsi Muscle Pedicle Flap Transfer.

Aim: This study aimed to evaluate the clinical outcomes, shoulder muscle strength, and donor site morbidity following the free latissimus dorsi (LD) muscle pedicle flap transfer. Materials: Patients with free LD muscle pedicle flap reconstructions and with asymptomatic shoulders (affected and contralateral side) were included. The follow-up duration was 12 months. The combined shoulder range of motion (ROM), Constant-Murley shoulder (CMS), and quick disabilities of the arm, shoulder, and hand (QuickDASH) scores were measured preoperatively and at 1 year postoperatively. The ratio of the isokinetic muscle strength and total work was measured with an isokinetic dynamometer (Cybex 350®) both preoperatively and at sixth month postoperatively. Results: Twenty patients with a mean age of 37.06 ± 9.74 years and a mean body mass index of 23.49 ± 8.6 kg/m2 were included. The difference in shoulder ROM and CMS and increase in QuickDASH were not significant at the first postoperative year. The peak torque and total work performed decreased by 13%-16% for the adductor and extensor functions at the six month postoperatively, and these differences were significant. Although the adductor peak torque was significantly lower in the postoperative test of the operated side, no significant difference was found between the operated and unaffected shoulder peak torque values. Moreover, no significant difference was noted between the operated and unaffected shoulders in all isokinetic tests pre- and postoperatively. Conclusion: The free LD muscle pedicle flap harvest did not decrease function and ROM at the first postoperative year. The muscle strength and total work of shoulders after the LD muscle transfer returned to the preoperative condition at the sixth month, except adductor and extensor muscle strengths. However, adductor and extensor muscle strengths of the operated shoulders were not significantly different postoperatively.

Objectif: La présente étude visait à évaluer les résultats cliniques, la force musculaire de l'épaule et la morbidité au site donneur après un transfert du lambeau pédiculaire libre du grand dorsal. Matériaux: Des patients ayant subi une reconstruction du lambeau pédiculaire libre du grand dorsal et dont les épaules étaient asymptomatiques (côté touché et côté controlatéral) ont participé à l'étude. Le suivi a duré 12 mois. Les chercheurs ont évalué l'amplitude de mouvement (AM) combinée de l'épaule, le score de Constant-Murley (SCM) et le score rapide des incapacités du bras, de l'épaule et de la main (QuickDASH) avant l'opération, puis un an plus tard. Ils ont mesuré le ratio entre la force musculaire isocinétique et le travail total au moyen d'un dynamomètre isocinétique (Cybex 350®) avant l'opération, puis six mois plus tard. Résultats: Au total, 20 patients d'un âge moyen de 37,06 ± 9,74 ans et à l'indice de masse corporelle moyen de 23,49 ± 8,6 kg/m2 ont été inclus dans l'étude. La différence de l'AM et du SCM de l'épaule et l'augmentation du QuickDASH étaient légères pendant l'année suivant l'opération. Le couple de pointe et le travail total effectués avaient diminué de 13 % à 16 % pour la fonction des adducteurs et des extenseurs six mois après l'opération, ce qu'on peut qualifier de différences importantes. Même si le couple de pointe des adducteurs était beaucoup plus faible au test postopératoire du côté opéré, aucune différence importante n'a été observée entre les valeurs du couple de pointe de l'épaule opérée et de celle non touchée. De plus, lors de tous les tests isocinétiques exécutés avant et après l'opération, ils n'ont pas remarqué de différence importante entre l'épaule opérée et l'épaule non atteinte. Conclusion: Le lambeau musculaire pédiculaire libre du grand dorsal ne diminuait pas la fonction et l'AM pendant l'année suivant l'opération. La force musculaire et le travail total des épaules après le transfert du grand dorsal avaient retrouvé leur état préopératoire au sixième mois, sauf la force des muscules adducteurs et extenseurs. Cependant, la force des muscles adducteurs et extenseurs des épaules opérées n'avait pas tellement changé après l'opération.

The predictive effect of neutrophil-lymphocyte and platelet-lymphocyte ratios in the post-operative recurrence of temporomandibular joint ankylosis.

BACKGROUND: Reankylosis is a frequent pathology in patients who are operated for post-traumatic temporomandibular joint (TMJ) ankylosis. In the current practice, ankylosing spondylitis attacks are monitored with the increases in neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR). In this study, such a relation between TMJ reankylosis and increase in these ratios was evaluated. METHODS: Patients who were operated between January 2010 and December 2019 for unilateral or bilateral TMJ ankylosis were included in this study. Temporomandibular gap arthroplasty with an interpositional silicone block was performed for each patient by the same operative team. Each patient had standard physiotherapy. All ages and genders were included in the study. Due to the complete blood count differences between children and adults, 18 years of age was used as a cutoff between the groups. A need for reoperation was accepted as reankylosis. The NLR and PLR of children without and with reankylosis and adults without and with reankylosis were compared. RESULTS: Twenty-nine children and 38 adults were included in the study. Mean age of the children and adults were 10.8 and 37.3 years, respectively. Eleven children and eight adults had reankylosis. In patients with reankylosis, NLR and PLR were high significantly, regardless of age. In children, PLR was significantly higher in reankylosis patients. In adults, NLR was significantly higher in reankylosis patients. CONCLUSION: PLR and NLR may be utilized for predicting reankylosis, respectively, in children and adults who were operated for ankylosis due to TMJ fractures.

Comparison of four different immobilization methods in the treatment of tendinous mallet finger injury.

BACKGROUND: Although there is consensus that closed tendinous mallet finger injuries should be treated conservatively, the best method of immobilization to be used is not clear and the existing data in the literature are not conclusive. The aim of this study is to compare the results of four different immobilization methods used in the conservative treatment of tendinous mallet finger injury. METHODS: Ninety-six patients with tendinous mallet finger injury were treated with four different immobilization methods (stack orthosis, thermoplastic orthosis, aluminum orthosis, and Kirschner wire [K-wire] immobilization). The patients then were assessed with distal interphalangeal joint extensor lag, total active motion (TAM), grip strength, and Abouna and Brown Criteria. RESULTS: No significant difference was found between four immobilization methods in extensor lag and TAM at the 8th and 12th weeks. According to grip strength assessment, stack orthosis group was found to have significantly better results than the K-wire and aluminum orthosis groups at 12 weeks, while the difference was not significant versus the thermoplastic orthosis group. CONCLUSION: In this first study making multiple comparisons between four immobilization methods used in the treatment of tendinous mallet finger injury, the only significant difference detected between the groups was the superior grip strength with stack orthosis compared with K-wire immobilization and aluminum orthosis.

The relationship between fixation method and early central condylar sagging after bilateral sagittal split ramus osteotomy in orthognathic surgery.

PURPOSE: There is no consensus about the ideal fixation methods and their effects on the condyle after the sagittal split ramus osteotomy (SSRO) procedure. The aim of this study was to compare the incidence, clinical presentation, and treatment of condylar sagging between different fixation methods following SSRO. METHODS: Patients who underwent double jaw surgery between 2007 and 2017 were evaluated retrospectively. Mandibular fixation was maintained using one of three different options: a miniplate and a single bicortical screw, three bicortical screws, or a single bicortical screw. Some patients had malocclusion relapse in the early postoperative period due to condylar sagging, and needed reoperation. The reoperated condylar sagging patients were analysed statistically with respect to their fixation methods. RESULTS: 233 patients (134 females, 99 males) with a mean age of 23.3 years were enrolled in the study. The patients fixated with a single bicortical screw had lower revision surgery rates than those with three bicortical screws or with miniplate with a single bicortical screw (p = 0.034 and p = 0.032, respectively). These differences in central condylar sagging with a need for revision were statistically significant. CONCLUSION: Although a miniplate and a single bicortical screw and three bicortical screws are widely used after SSRO, if the priority is to avoid sagging then it seems that a single screw should be preferred for osteosynthesis.

Heterozygous pathogenic variants in GLI1 are a common finding in isolated postaxial polydactyly A/B.

Postaxial polydactyly (PAP) is a frequent limb malformation consisting in the duplication of the fifth digit of the hand or foot. Morphologically, this condition is divided into type A and B, with PAP-B corresponding to a more rudimentary extra-digit. Recently, biallelic truncating variants in the transcription factor GLI1 were reported to be associated with a recessive disorder, which in addition to PAP-A, may include syndromic features. Moreover, two heterozygous subjects carrying only one inactive copy of GLI1 were also identified with PAP. Herein, we aimed to determine the level of involvement of GLI1 in isolated PAP, a condition previously established to be autosomal dominantly inherited with incomplete penetrance. We analyzed the coding region of GLI1 in 95 independent probands with nonsyndromic PAP and found 11.57% of these subjects with single heterozygous pathogenic variants in this gene. The detected variants lead to premature termination codons or result in amino acid changes in the DNA-binding domain of GLI1 that diminish its transactivation activity. Family segregation analysis of these variants was consistent with dominant inheritance with incomplete penetrance. We conclude that heterozygous changes in GLI1 underlie a significant proportion of sporadic or familial cases of isolated PAP-A/B.

Intraneural angioleiomyoma of the median nerve presenting as a forearm mass: A case report.

Angioleiomyoma is a solitary form of leiomyoma which is typically encountered in the subcutis. They are mostly seen in lower extremities, and the upper extremity is the second most common location for these lesions. There are only a few reports about the presence of an angioleiomyoma within a peripheral nerve in the upper extremity. Here we report a 56-year-old male patient who was referred to our clinic after an attempt was made for removal of a forearm mass at another institution. The lesion was encased within the median nerve and there was an unusual hypervascularity around the tumor with numerous vessels entering the lesion. Removal of the tumor without apparent damage to nerve fascicles was possible. Histopathological examination of the excision material revealed an intraneural angioleiomyoma. Following surgery, the patient was free of any functional deficits and no evidence of recurrence was observed at one year follow-up. There is no data regarding recurrence in intraneural lesions due to the lack of a large series. It would not be wrong to recommend spare grossly uninvolved fascicles if the nerve in question is not expendable.

'Switch' technique to restore pronation and radial deviation in 17 patients with brachial plexus birth palsy.

We report outcomes of 17 children with brachial plexus birth palsy that underwent extensor carpi ulnaris to brachioradialis and brachioradialis to abductor pollicis longus transfers to correct supination and ulnar deviation deformity. Mean age at the time of surgery was 8.7 years and mean follow-up time was 21 months (8-44). These patients had marked increases in active forearm rotation and Canadian Occupational Performance Measure scores. Activity performance score on the measure increased from 1.1 to 6.7 and satisfaction score increased from 0.8 to 8.7 at final follow-up. We conclude from our patient series that these tendon transfers are effective in correction of the supination and ulnar deviation deformities in brachial plexus birth palsy. Level of evidence: IV.

Use of ultrasound-guided supraclavicular brachial plexus block as an anesthesia technique in a patient with neurofibromatosis type 1: A case report.

Neurofibromatosis type 1 is an autosomal dominant condition characterized by cutaneous and/or plexiform neurofibromas and hyperpigmented café-au-lait spots. It affects multiple endocrine and visceral organs and can be associated with several difficulties such as potential airway (ventilation/intubation) problems, abnormal spinal anatomy, and peripheral neurofibromas. Therefore, anesthesia technique selection becomes more of an issue in terms of avoiding complications and decreasing morbidity and mortality. In the present case, we describe the use of ultrasound and the successful performance of supraclavicular brachial plexus block for surgery on the arm and forearm in a patient with neurofibromatosis type 1.

Is the transposition of the nipple-areolar complex necessary in Simon grade 2b gynecomastia operations using suction-assisted liposuction?

OBJECTIVE: The aim of this study was to assess the efficacy of suction-assisted liposuction (SAL) in Simon grade 2b gynecomastia and its effect on sternal notch to nipple areola (SNN) distance. METHODS: A retrospective analysis was performed on 21 patients with grade 2b gynecomastia who underwent SAL. Preoperative and postoperative SNN distances of the patients were measured, the results were analysed using a Mann-Whitney U test and a p-value <.05 was accepted as statistically significant. Aesthetic results were evaluated by the surgical team considering five criteria: breast size, breast shape, nipple-areolar complex positioning, scarring, and skin tightness of the breast envelope. A 10-point Likert scale was used to assess patient satisfaction with SAL surgery. RESULTS: All of the patients were followed up for an average period of 17.8 months (range = 12-28 months). The mean amount of lipoaspirate was 232 mL per breast (range = 190-310 mL). The mean preoperative SNN distance was 22.3 cm (range = 20-23.5 cm), whereas postoperative was 21.3 cm (range = 19.2-22.8 cm); the difference was statistically significant (p < .05). There was one case of nipple areola necrosis, three hypoesthesia, five persistent pains, and four slight buttonhole deformities. The aesthetic result was evaluated as very good by the surgical team, and the overall patient satisfaction rate in terms of breast shape and volume was 92%. CONCLUSIONS: It was concluded that SAL provides a good aesthetic outcome in patients with Simon grade 2b gynecomastia and shortens the SNN distance by 1 cm, but further clinical studies are required to support this conclusion.

Comparison of Ultrasound-Guided Axillary Brachial Plexus Block Properties in Diabetic and Nondiabetic Patients: A Prospective Observational Study.

PURPOSE: Patients with diabetes mellitus (DM) type 2 may have subclinical peripheral nerve neuropathy. We performed this study to compare the differences in duration of axillary brachial plexus blocks in patients with type 2 DM and without DM (NODM). Our hypothesis was that the sensory block duration would be prolonged in patients with DM. METHODS: A total of 71 patients who were scheduled for elective forearm and/or hand surgery were enrolled in this study. Before surgery, they received ultrasound-guided axillary brachial plexus blocks with a mixture of 10 mL lidocaine 2% and 20 mL bupivacaine 0.5%. After surgery, all patients received 1 g paracetamol every 6 hours as needed. The primary end point was sensory block duration. Secondary end points were motor block duration, time until first pain (numeric rating scale [NRS] 4 or greater), highest NRS pain scores, and rescue analgesic consumption (NRS 4 or greater) through the first 2 postoperative days. RESULTS: In all, 67 patients completed the study: 22 in the DM group and 45 in the NODM group. Sensory and motor block durations were longer in the DM group than in the NODM group (mean [range], 773.5 [479-1155] vs 375 [113-900] minutes, and 523 [205-955] vs 300 [110-680] minutes). Time until first pain was 855 (590-1,285) minutes in the DM group and 500 (200-990) minutes in the NODM group. The highest NRS scores were also significantly lower in the DM group at 6 and 12 hours. Paracetamol consumption was lower in the DM group through the first 2 postoperative days. CONCLUSIONS: The presence of DM was associated with longer duration of the sensory block after axillary brachial plexus block. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

The effects of limited adventitiectomy on vascular anastomosis: An experimental study in rats.

OBJECTIVE: Blockages in anastomotic vessels cause complete loss of free tissue transfer and replanted limb. Many studies have been conducted in the last 30 years to solve this problem. There are insufficient studies dealing with the effects of the limited adventitiectomy done before surgery for sympathetic overactivity leading situations. The aim of this experimental study is to reveal the effects of limited adventitiectomy. METHODS: In this study, limited adventitiectomy was performed in a wide area before surgery, and the effect of this practice on the vessel diameter and anastomosis was investigated. RESULTS: Rapidly growing dilatation and increase in vessel diameter was observed, and dilatation continued in the limited adventitiectomy group. CONCLUSIONS: The preoperative performed limited adventitiectomy is a useful preparation for super microsurgery. Especially in clinical practice before the free flap surgery, limited adventitiectomy can be applied if the recipient site is expected to have vascular problems.

Is there a profit to use the lateral antebrachial cutaneous nerve as a graft source in digital nerve reconstruction?

BACKGROUND: The digital nerves are commonly injured in emergency hand surgery practice. Lateral antebrachial nerve is of the autologous graft options available in forearm for digital nerve reconstruction. In this report, we aimed the evaluation of this nerve as an autologous nerve source for digital nerve repair. PATIENTS AND METHODS: The overall sensorial results of the lateral antebrachial cutaneous nerve grafting and associated donor site morbidity in neglected digital nerve injuries of 15 patients in Zones 1 and 2 were evaluated Average length of the harvested lateral antebrachial cutaneous nerve grafts was 1.81 cm (0.75-3 cm.). RESULTS: Patients have been followed up for 20.7 months in average (range: 9.3-41 months). According to Highet and Sander criteria modified by Mackinnon and Dellon, nine patients were graded as S4, whereas six patients had S3+ values. According to modified ASSH guidelines for stratification of static 2PD results, excellent results were obtained in five patients, good results were achieved in eight patients and moderate results were obtained in two patients. Both the donor and recipient sites were evaluated with Semmes-Weinstein monofilament tests where satisfactory results have been obtained. Only two patients reported minimal cold intolerance at the donor site apart from the mild hypoesthesia noted at the anterolateral aspect of the middle forearm. CONCLUSION: Quite favorable clinical results with minimal donor site sensorial deficiency, anatomical and histomorphological similarity and being available in close location to surgical area brings up a matter to utilization of LABCN for digital nerve reconstruction.

A distinctive presentation of diplopodia: a Y-metatarsal combining the extra foot and the extra digit of the main foot.

Diplopodia is a rare congenital anomaly and has been described as extra digits, metatarsals, and tarsal bones that form an extra foot or foot-like structure. Various skeletal deformities and anomalies involving other organ systems can accompany diplopodia. Treatment consists of surgery, splinting, and physical therapy, planned according to each patient's specific condition. We present a patient who had diplopodia with distinctive anatomic features (with postaxial polydactyly and without any anomaly of the tibia or fibula) compared with the previously reported cases, and concomitant anomalies, including left renal agenesis and anal atresia.

Free pre-expanded lateral circumflex femoral artery perforator flap for extensive resurfacing and reconstruction of the hand.

Resurfacing and reconstruction of extensive scars, severe contractures and deformities of the hand are still challenging cases for plastic surgeons. Treatments usually necessitate thin, pliable and broad flaps. Additionally, minimising the donor-site morbidity is an indisputable requisite. The pre-expanded perforator flap technique has been shown to provide extensive, thin and pliable skin with increased vascularity while reducing the donor-site morbidity. Utilisation of free pre-expanded lateral circumflex femoral artery perforator flap in an aesthetic and functional reconstruction of severe post-burn hand deformity is demonstrated. The successful functional and aesthetic outcome that was achieved in the early postoperative period and which still persists after 23 months of follow-up indicates that our technique could be preferably used in the extensive coverage of the hand.

Effects of microarterial anastomosis torsion on survival of oblique groin flap in rats.

A microanastomosis might tolerate a torsion up to 360°, but the effects of arterial microanastomosis torsion on the survival of the flap it supplies are unclear. The aim of this study was to investigate the consequences of microarterial anastomosis torsion on the groin flap in rats. Forty Sprague-Dawley rats were divided into five groups. An oblique groin flap was harvested as an island flap and a patch-to-side arterial anastomosis was performed with torsion angles of 0°, 90°, 180°, 270°, and 360°. Six of eight flaps in Group I (0° torsion), six of eight flaps in Group II (90°), three of eight flaps in Group III (180°), and none of the flaps in Groups IV and V (270° and 360°) were found to be viable after 1 week. The patency and flap survival rates observed in Groups II, III, IV, and V were compared with those in Group I using Fisher's exact test. The patency rates and flap survival rates in Groups IV and V were significantly lower compared with those in Group I. Our data show that skin flaps can survive even if their arterial pedicle is anastomosed with a torsion of up to 180°.

[Reconstruction of the head and neck with free osteoseptocutaneous flap in elderly heavy smokers]. / Agir sigara içici yasli hastalarin bas-boyun rekonstrüksiyonunda serbest osteoseptokutan flep uygulamalari.

OBJECTIVES: We evaluated complications of free flap reconstruction following oncological head and neck surgery in elderly patients who smoked heavily. PATIENTS AND METHODS: The study included eight patients (2 females, 6 males; mean age 68.5 years; range 65 to 74 years) over 65 years of age, who smoked heavily (at least 1 pack/day). All cases but one with mandibular ameloblastoma had intraoral squamous cell carcinoma. Two patients underwent reconstruction with free radial forearm osteoseptocutaneous flap following bilateral maxillary resection, and six patients with free fibular osteoseptocutaneous flap following mandibular resection. Postoperative complications, in particular those associated with the donor and recipient sites were evaluated. RESULTS: No partial or total flap loss was observed. Wound healing problems were seen in three patients (37%), which were at the donor site in two patients, and at the recipient site in one patient. Psychogenic disorders were observed in two patients (25%). No other complications were encountered. CONCLUSION: Aside from some recipient- and donor-site-related healing problems, heavy smoking and advanced age cannot be regarded as contraindications for free flap reconstruction.

Hard palate perforation due to invasive aspergillosis in a patient with acute lymphoblastic leukemia.

Invasive aspergillosis (IA) is a major cause of morbidity and mortality in immunosuppressed patients. Primary oral invasive aspergillosis is a rare condition. We present an acute lymphoblastic leukemia (ALL) patient with hard palate perforation due to invasive aspergillosis. Two months after the appearance of the fungal lesions, perforation of the hard palate was seen despite amphotericin-b and itracanazole therapy. After debridement of necrotic tissue the patient was followed for spontaneous closure for 6 months but it was seen that the fistula persisted despite the disappearance of the infection. The patient was operated for closure of the palatal fistula and there was no recurrence in 6 months of follow up. Surgical and medical management was performed successfully. Invasive oral aspergillosis is a potentially lethal disease and it should be considered in immunosuppressed patients with oral lesions.