An extended distally based reverse posterior interosseous artery flap reconstruction for the thumb and distal defects of the fingers.

BACKGROUND: The reverse posterior interosseous artery flap is useful for covering hand defects. However, its major drawback is the short pedicle that limits the reach of the flap up to the metacarpophalangeal level. The authors performed a new modification extending the distal reach of the flap by including the recurrent branch of the posterior interosseous artery and they aimed to present the results of reconstruction with this technique. PATIENTS AND METHODS: Seven patients with a mean age of 35.2 years (range 17-64 years) underwent extended RPIAF surgery. Six patients were admitted to the emergency department with isolated hand trauma. One patient was present in elective settings with chronic osteomyelitis and skin loss of the thumb related to previous trauma. The defects were located on the distal metacarpophalangeal level (thumb and other fingers). PIA perforators and the recurrent branch were included into the pedicle (Type A) in five cases, whereas the flap was harvested based solely on the recurrent branch (Type B) in two cases. The type B flaps had longer pedicle lengths due to discarding the forearm skin. The donor sites were covered with skin grafts in six patients. RESULTS: The average size of the extended RPIAF was 3 × 3.5 cm to 10 × 6 cm (mean 8.28 × 4.14 cm). All of the flaps completely survived, and no complications were encountered during the postoperative period. Functional recovery of the operated hands were observed during the follow up period 13.5 months (8-24 months). Both the patient and our satisfactory levels were high and all of the patients returned to their works. Quick DASH score was used in the final functional evaluation retrospectively. Due to the pandemic, the evaluation could be made with a telephone. Two patients could not be reached in the evaluation. The mean quick DASH score of five patients was 28.64. CONCLUSION: The extended RPIAF is a reliable choice in distally located thumb and finger defects if the recurrent branch of the posterior interosseous artery is included in the pedicle.

Can a Small Intestine Segment Be an Alternative Biological Conduit for Peripheral Nerve Regeneration?

BACKGROUND: Autologous nerve grafts are used to bridge peripheral nerve defects. Limited sources and donor site morbidity are the major problems with peripheral nerve grafts. Although various types of autologous grafts such as arteries, veins and muscles have been recommended, an ideal conduit has not yet been described. AIMS: To investigate the effectiveness of a small intestinal conduit for peripheral nerve defects. STUDY DESIGN: Animal experimentation. METHODS: Twenty-one rats were divided into three groups (n=7). Following anaesthesia, sciatic nerve exploration was performed in the Sham group. The 10 mm nerve gap was bridged with a 15 mm ileal segment in the small intestinal conduit group and the defect was replaced with orthotopic nerve in autologous nerve graft group. The functional recovery was tested monthly by walking-track analysis and the sciatic functional index. Histological evaluation was performed on the 12th week. RESULTS: Sciatic functional index tests are better in autologous nerve graft group (-55.09±6.35); however, during follow-up, progress in sciatic functional index was demonstrated, along with axonal regeneration and innervation of target muscles in the small intestinal conduit group (-76.36±12.08) (p<0.05). In histologic sections, distinctive sciatic nerve regeneration was examined in the small intestinal conduit group. The expression of S-100 and neurofilament was observed in small intestinal conduit group but was less organised than in the autologous nerve graft group. Although the counted number (7459.79±1833.50 vs. 4226.51±1063.06 mm2), measured diameter [2.19 (2.15-2.88) vs. 1.74 (1.50-2.09) µm] and myelin sheath thickness [1.18 (1.09-1.44) vs. 0.66 (0.40-1.07) µm] of axons is significantly high in the middle sections of autologous nerve graft compared to the small intestinal conduit group, respectively (p<0.05), the peripheral nerve regeneration was also observed in the small intestinal conduit group. CONCLUSION: Small intestinal conduit should not be considered as an alternative to autologous nerve grafts in its current form; however, the results are promising. Even though the results are no better than autologous nerve grafts, with additional procedures, it might be a good alternative due to harvesting abundant sources without donor site morbidity.

Freestyle Perforator-Based Fasciocutaneous Flap Reconstruction in Nicolau Syndrome-Related Tissue Necrosis.

The actual pathology of the Nicolau syndrome (NS) is still unknown. It is thought to involve direct vascular damage and vasospasm. Many NS cases were reported in the literature but a treatment protocol is still not established. However, after demarcation of the necrotic tissue, surgical intervention is mandatory. Five NS cases with extensive tissue necrosis on the upper lateral gluteal region were analyzed retrospectively. Operative technique was described in details for freestyle perforator-based fasciocutaneous flaps from the gluteal region to reconstruct defects of NS-related tissue necrosis. Freestyle perforator-based fasciocutaneous flaps were used for defect closure in all patients. All flaps survived totally. No complications occurred during the follow-up period. Although rare, NS is a serious complication of inadvertent intramuscular injections. Prevention is the best treatment. However, in case of large-tissue necrosis, freestyle perforator-based fasciocutaneous flaps harvested from the gluteal region is a satisfactory option for reconstruction.

Effects of ischemic preconditioning protocols on skeletal muscle ischemia-reperfusion injury.

BACKGROUND: Ischemic preconditioning (IPC) is described as brief ischemia-reperfusion (I/R) cycles to induce tolerance to subsequent in response to longer I/R insults. Various IPC protocols can be performed in four combinations as follows: at early or late phases and on local or distant organs. Although many experimental studies have been performed on IPC, no consensus has been established on which IPC protocol is most effective. The aims of the present study were as follows: (1) to compare the variables of preconditioning in different combinations (in early versus late phases; local versus remote organ implementations) and (2) to determine the most therapeutic IPC protocol(s). MATERIALS AND METHODS: A subtotal hind limb amputation model with clamping an intact femoral pedicle was used for I/R injury. IPC was induced using hind limb tourniquet with 3 × 10 min I/R cycles before longer I/R insult. Forty-nine rats were divided into seven groups (n = 7), sham, IsO (ischemia only), I/R, early ischemic preconditioning (e-IPC), late ischemic preconditioning (l-IPC), early remote ischemic preconditioning (e-RIPC), and l-RIPC (late-remote) groups, respectively. In the sham group, pedicle occlusion was not performed. Six hours ischemia was challenged in the IsO group. Three hours ischemia followed by 3 h reperfusion was performed in the I/R group. The e-IPC group was immediately preconditioned, whereas the l-IPC group was preconditioned 24 h before I/R injury on the same hind limb. In the e-RIPC and l-RIPC groups, the same protocols were performed on the contralateral hind limb. At the end of the experiments, skeletal muscle tissue samples were obtained for biochemical analysis (Malondialdehyde [MDA], catalase, myeloperoxidase [MPO], and nitric oxide end products [NOx]), light microscopy, and caspase-3 immunohistochemistry for determination of apoptosis. RESULTS: Tissue biochemical markers were improved in nearly all the IPC groups compared with IsO and I/R groups (P < 0.05). Similarly, the histologic damage scores were decreased in all the IPC groups (P < 0.05). The lowest damage score was in the e-RIPC group followed by the l-RIPC, e-IPC, and l-IPC groups, respectively. The apoptosis scores were significantly high in the I/R group compared with the e-RIPC and l-RIPC groups (P < 0.05). Although apoptosis scores of the e-IPC and l-IPC groups were lower than the I/R group, this finding was not statistically significant (P > 0.05). CONCLUSIONS: All IPC protocols were effective in reducing I/R injury. Among these protocols, e-RIPC achieved most protection.