Isolated bilateral triphalangeal thumb with delta phalanx: a case report.

Triphalangeal thumb is characterized by the interposition of an extra-phalanx between two normal ones. In this article the authors present the case of a 24-year-old man with bilateral triphalangeal thumb of opposable type, without any other associated anomaly or genetic syndrome. The patient had triangular delta extra-phalanxes that caused ulnar deviation of both thumbs. Surgical procedure for the correction of the congenital anomaly consisted of a closing wedge osteotomy and distal interphlangeal joint arthrodesis in the left thumb, and a wedge osteotomy in the deformed distal phalanx of the right thumb. Appearance and precision function of hands considerably improved 6 months after the operation, and there was no major stiffness in proximal interphalangeal joints of thumbs.

Versatility of venous flap for coverage of proximal and middle phalanges of fingers.

Owing to paucity of soft tissue in the fingers, the trauma to fingers can cause exposure of tendons, joints, and bone. Several flaps have been used to cover soft tissue defects of the fingers. From 2007 to 2010, we have operated on 18 male patients with skin defects of dorsal phalanges of fingers. We used reverse distally based venous flap with perivenous tissue to cover the defects. Their mean age was 30.6±8.6 (15 to 40). The etiology in all cases was severe trauma. Ten had defect in dorsal aspect of proximal phalanges and in 8 the defect was in the middle phalanges. One of our patients experienced superficial necrosis at the distal margin of the flap that was successfully treated with local wound care and dressing changes. There was 1 case of venous congestion that resolved itself. There were no postoperative wound infections. There were no serious complications. The venous flap with preservation of perivenous areolar network is a good option for coverage of soft tissue defects of proximal and middle phalanges of fingers.

The running Y-V plasty for treatment of linear and cord-like burn contractures.

Linear and cord-like burn scar contractures are commonly treated by severing the scar in a transverse direction and skin grafting or performing Z-plasties. However, skin grafts may result in suboptimal take and contract gradually and the Z-plasty requires undermining flaps in scarred skin which may lead to the distal tip necrosis. In this article the authors present their experience with multiple Y-V plasty technique. From May 2005 to September 2009, 44 linear and narrow cord-like burn contractures in various regions of upper and lower extremities of 32 patients were treated by multiple Y-V plasty technique. The contracted scars were treated successfully in all of the patients. No major post-operative complications or contracture recurrence were observed during the follow up period of 6 to 24 months in this series of patients. By creating a longer length, running Y-V plasty can relax the contracted scar. Considering the advantages and excellent results in the treated patients in this study group, and also other presented series, multiple Y-V plasty can be recommended as a very useful and safe technique for the treatment of linear and cordlike burn contractures.

Modified simple decompression of ulnar nerve in treatment of cubital tunnel syndrome.

BACKGROUND: There are two main surgical approaches, simple ulnar nerve decompression at the elbow, and anterior transposition of the nerve in treatment of cubital tunnel syndrome. Both techniques were reported in literature in details with similar reported success rates. Here, we present a modified simple decompression surgical technique in treatment of cubital tunnel syndrome. METHODS: Fifty eight patients diagnosed with cubital tunnel syndrome undergoing the presented technique were enrolled. This procedure consisted of ulnar nerve decompression at the elbow and a supplementary procedure of inter-muscular septum transverse cut between triceps and brachialis muscle above the elbow. RESULTS: Complete sensory recovery was observed in 35 (60.3%) patients, however, mild and occasional sensory symptoms remained in 15 (25.9%), and moderate symptoms persisted in 6 (10.3%) patients. In two patients (3.4%), no sensory improvement was recorded. Post-operatively, muscular hypotrophy improved completely in 5 out of 12 patients (41.7%). However, in the remaining 7 patients (58.3%) with muscular atrophy, motor recovery never took place. CONCLUSION: The presented modified simple decompression technique was shown to be an effective and safe procedure for the treatment of cubital tunnel syndrome without any complications.

Treatment of facial paralysis: dynamic reanimation of spontaneous facial expression-apropos of 655 patients.

BACKGROUND: Six hundred fifty-five cases of unilateral facial paralysis were treated by different surgical methods to achieve dynamic reanimation of facial muscle movement. In a retrospective study, the recovery of both truly spontaneous smile and facial muscle movement was evaluated independently. METHODS: The authors performed 505 two-stage gracilis, one rectus abdominis, and 14 single-stage latissimus dorsi microneurovascular muscle transfers, in addition to 28 cross-facial facial nerve neurotization procedures. These procedures were based on neurotization of the paralyzed region by the contralateral healthy facial nerve. Procedures involving motor nerves or muscle beyond the territory of the facial nerve included 73 temporalis muscle transpositions, four lengthening temporalis myoplasty procedures, 26 neurotizations by the hypoglossal nerve, and four neurotizations by the spinal accessory nerve. RESULTS: Patients treated by techniques based on the motor function of nerves other than the facial nerve did not recover spontaneous smile. Neurotization by the facial nerve, however, did result in the recovery of spontaneous smile in all satisfactory or better outcomes. Recovery of lip commissure movement based on neurotization by the contralateral healthy facial nerve was better than that of the remaining groups (p < 0.0001). CONCLUSIONS: Temporalis muscle transposition and lengthening myoplasty are acceptable options for patients who are not good candidates for neurotization by the facial nerve. For the restoration of both truly spontaneous smile and facial muscle movement, free microneurovascular muscle transfer neurotized by the contralateral healthy facial nerve has become the authors' first-choice surgical technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Division of the first dorsal compartment of the hand into two separated canals: rule or exception?

BACKGROUND: Tendon entrapment of the first dorsal compartment of the wrist, the de Quervain disease, is a common cause of wrist and hand pain and disability. A group of 50 consecutive patients operated for the treatment of de Quervain disease from 2003 through 2006 were prospectively studied to determine the variation in the pattern of the first extensor compartment. METHODS: Eighty-six percent of the patients were females, and 14% were males. In 80% of the cases the nondominant and in 20% the dominant hand was involved. These interesting findings may rule out the occupation's relation to de Quervain disease. RESULTS: Our study revealed that the compartment is completely separated into two canals in 86% of the patients which was significantly higher than that reported in similar studies. CONCLUSION: The existence of two separated compartments for abductor pollicis longus and extensor pollicis brevis tendons should be considered as a common finding during operation to prevent incomplete treatment and recurrence of the symptoms.

Therapeutic results of sciatic nerve repair in Iran-Iraq war casualties.

BACKGROUND: The sciatic nerve is composed of two independent divisions: tibial and peroneal. The results of the repair of these two nerves are not identical. This retrospective study was carried out with the aim of evaluating the results of different therapeutic procedures for sciatic nerve injuries and conducting a comparative evaluation of peroneal and tibial nerve recovery. METHODS: A total of 648 Iranian casualties of the 1980 to 1988 Iran-Iraq war with sciatic nerve injury were treated with nerve grafting, direct end-to-end coaptation, and neurolysis. Patients were subdivided according to nerve injury site into three groups of upper, middle, and lower thirds of the thigh, and followed from 5 to 12 years. RESULTS: In 77.8 percent of patients, the tibial nerve was injured, and in 88.9 percent, the common peroneal nerve was injured. Protective sensation recovery of the sole was evaluated as good in 69.1 percent of those with upper third injuries, 74.4 percent of those with middle third injuries, and 89.3 percent of those with lower third repairs (p < 0.0001), with an overall success rate of 73.4 percent. The overall motor recovery success rate for the three techniques was 86.3 percent for the tibial nerve and 38.9 percent for the common peroneal nerve. CONCLUSIONS: Results of sciatic nerve injury treatment in this group of war casualties were generally satisfactory. Tibial nerve injury repair in the upper thigh has a higher priority than the peroneal nerve. Motor deficits of the common peroneal nerve can be overcome by tendon transfer or orthopedic devices.

Is it safe to extract the reverse sural artery flap from the proximal third of the leg?

BACKGROUND: The reversed sural artery flap is a well-described method for lower limb reconstruction. However, in the standard technique, the flap is usually not harvested from the proximal third of the leg. We conducted this study to evaluate the efficiency, safety, and success rate of the reversed sural flap harvested from the proximal third of the leg. METHODS: The authors harvested medium to very large sized flaps from or extended to the upper third of the calf in 28 patients to cover the defects in the distal tibia, ankle, heel, foot, and sole. RESULTS: With proximal extension of the flap, we would have a longer and larger flap with a safer pedicle. The majority of flaps resulted in a good coverage of defects. Only the distal 1cm of a large flap developed marginal necrosis in the distal border, which was treated with a secondary skin graft. Six flaps developed venous congestion. In seven other patients, minor complications such as hypertrophic scar in the donor site, rupture of sutures, and superficial epidermolysis occurred. In these 13 patients, the complications did not influence the final outcome. CONCLUSION: Extension of reversed sural island flap to the proximal third of the leg was safe and reliable. It was efficiently used to treat patients with large and far wounds, from the distal leg to the distal foot and the sole with more versatility and easier reach to the recipient site.

Tissue expansion for reconstruction of an unusual form of complex syndactyly.

Tissue expanders can be used over the dorsum of hand and fingers to increase available tissue for flap coverage after release of syndactyly. Herein, we presented an 18-year-old man who had an unusual complex syndactyly in the middle and ring fingers of his right hand. He had also complete fusion of the proximal phalanges. In this report, we described the application of tissue expander to cover separated exposed bones.