A prospective trial on the use of antibiotics in hand surgery.

BACKGROUND: Postoperative infection is a disastrous complication in the discipline of hand surgery, as it is in any field of surgery in which infection can compromise wound healing and lead to subsequent functional impairment despite the best attempts. Different results with antibiotic use by different authors have been reported. This study was planned to put forth the place of antibiotic use in hand surgery procedures. METHODS: This prospective, randomized, double-blind study included 1340 patients who were placed in one of four groups according to the components of their hands that were injured. Half of each group received antibiotics, and the other half received placebo. RESULTS: Infections among the placebo- and antibiotic-administered patients did not display significant importance (p=0.759). Infections among the four groups were not statistically significant either (p=0.947). Statistical significance was not found between elective and emergency procedures (p=0.552). Operations longer than 2 hours had 2.5 percent infection rates in placebo patients and 3.8 percent in antibiotic patients, which was not statistically significant (p=0.7). In crush/dirty wounds there was no statistical significance in development of infections between placebo and antibiotic use (p=1), nor was there any statistically significant difference between crush and dirty wounds (p=0.929). CONCLUSIONS: The authors do not support the use of antibiotic prophylaxis for surgery of the hand. Its use should be preserved for specific infections or for patients with certain types of risk factors for infection.

An alternative method in mandibular fracture treatment: bone graft use instead of a plate.

In the treatment of the mandibular fractures, one of the main principles is to use the least amount of foreign material. We present an alternative technique that the bone grafts harvested from the fracture borders or from the iliac crest were used instead of plates and the fixation was done with screws. In the study including 24 mandible fractures, the bone grafts harvested from the fracture borders were used in the 10 favorable fractures and the bone grafts harvested from the iliac crest were used in the 14 unfavorable fractures. In the combined mandible fractures, four fractures were fixated with titanium plates and the other side with the bone graft. The patients, who were followed up for 12 to 20 months, were evaluated with macroscopic occlusion, panoramic graphs, and three-dimensional computerized tomographs. The advantage of this technique of fixation with the autogenous tissue is reduced infection rates and reduced operation costs. In the pediatric patients, the second session operation of plate removal is not necessary.

Innervation of three weight-bearing areas of the foot: an anatomic study and clinical implications.

The aim of this cadaver study is to improve our knowledge on the anatomy of the sensory fibres of the three weight-bearing areas of the plantar region. Previous studies mainly focused on the innervation of the heel but the innervation of the other two weight-bearing areas over the most medial and lateral metatarses have been neglected and are not well known. The study was carried out on 10 feet of five male cadavers. The tibial nerve was dissected down to the fat pads over the heel and the first and fifth metatarsal heads under the microscope. The distances of the branching point of the tibial nerve and origins of the medial and inferior calcaneal nerves to a line drawn from the centre of the medial malleolus to the centre of the calcaneous were all measured. The tibial nerve was divided into two branches called the lateral and medial plantar nerves 23.45 mm proximal to the predefined axis. The medial plantar nerve passed underneath the abductor hallucis muscle and gave two sensory branches to the fat pad over the first metatarsal head. The lateral plantar nerve coursed beneath the abductor hallucis and flexor digitorum brevis muscles and supplied innervation of the fat pad over the fifth metatarsal head. The sensory innervation of the heel was provided by medial calcaneal and inferior calcaneal nerves. The medial calcaneal nerve originated from the tibial nerve 41.89 mm proximal to the axis. It divided into two or three branches innervating the fat pad over the heel. The inferior calcaneal nerve originated from the lateral plantar nerve (70%) or the medial calcaneal nerve (30%) 10.66 mm proximal to the axis. This study describes the sensory fibres to the heel and the previously neglected weight-bearing areas over the first and fifth metatarses. Reconstruction of defects in these areas is very difficult so every attempt should be made to protect the sensory fibres during any surgical procedure.

Maxillary artery: anatomical landmarks and relationship with the mandibular subcondyle.

BACKGROUND: The maxillary artery can be injured during procedures in the subcondylar portion of the mandible. Thorough knowledge of this region is mandatory to avoid accidental puncture of the maxillary artery, which can lead to profuse bleeding that is hard to control. METHODS: In 16 halves of eight embalmed cadaver heads, the maxillary artery was dissected from the branching point to the entrance point to the maxillary sinus. Its anatomical relationships with certain landmarks were recorded numerically. RESULTS: The mean distance of the branching point of the maxillary artery to the tragal pointer was 16.2 mm (range, 14.97 to 16.80 mm) in the horizontal plane and 21.4 mm (range, 19.14 to 23.53 mm) in the vertical plane. The mean vertical distance of the branching point to the Frankfort horizontal plane was 25.7 mm (range, 24.86 to 27.47 mm). The mean distance of the branching point of the maxillary artery to the tip of the condyle was 22.4 mm (range, 21.66 to 23.99 mm). The mean distance of the artery to the medial border of the subcondylar portion of the mandible was 6.8 mm (range, 4.06 to 8.47 mm). The mean distance between the deepest point of the sigmoid notch and the junction of the maxillary artery and sigmoid notch was 5.1 mm (range, 4.97 to 5.95 mm). The mean distance of the maxillary artery-sigmoid notch junction to the tragal pointer was 22.9 mm (range, 20.95 to 25.05 mm). CONCLUSIONS: The maxillary artery can be injured during surgical procedures performed in the temporomandibular region. Its relationship with the subcondylar portion of the mandible varies.

Prefabrication of a conjoint flap containing xenogenic tissues: a preliminary report on an experimental model.

Conjoint flaps are the compound flaps possessing multiple independent flaps, each with an independent vascular supply, but linked by a common indigenous source vessel. We have developed a new model of flap prefabrication using autogenic and xenogenic tissues in rats. Flaps were prepared at abdomino-inguinal regions of 20 male wistar albino rats. Autologous muscle, fascia, cartilage, bone grafts and acellular human dermal matrix (Alloderm, LifeCell Corp., Branchburg, NJ) were wrapped on the branches of external iliac, inferior epigastric and femoral arteries. The feasibility of prefabricating autogenic and xenogenic tissue containing flaps was investigated experimentally. Four weeks later, flaps were dissected and histopathological evaluation was undertaken. New blood vessel development was detected in all specimens with varying degrees. To our surprise, acellular dermal matrix (Alloderm), which was used as a xenogenic graft, exhibited a better revascularization potential than autogenic grafts in this prefabrication process, and a relatively dense network of new vessel formation was seen. As acellular dermal matrix is an allogenic tissue for human beings and has a superior revascularization potential, it can be prefabricated together with different autogenic tissues, and this flap can be used to reconstruct massive composite tissue defects, such as the defects occurring after tumor resection in head and neck region. With this method, donor site morbidity will be dramatically reduced. This is the first attempt of conjoint flap prefabrication using autogenic tissues combined with xenogenic tissues, which creates a new type of flap combining tissues from different species. We believe that new flap prefabrication models will be developed in the future, on the basis of this study.

Rare occupational disease of hair dressers: interdigital pilonidal sinus.

Interdigital pilonidal sinus is a rare occupational disease related to work with short hair. Hair dresser's disease is the interdigital pilonidal sinus encountered in male barbers. A case of pilonidal sinus in the interdigital web is reported. We performed surgical excision and primary closure. There were neither complications nor recurrence in the third month after excision. We propose that surgical excision is inevitable and that any primary treatment can improve the patients' postoperative comfort. Thus, primary closure or closure with a flap, instead of secondary healing, should always be the first choice of treatment for a defect due to excision of an interdigital pilonidal sinus.

Z plasty closure of lower lip defects after tumor excision.

Reconstruction of the defects of the lower lip should provide a sensate, functional, and aesthetic lip structure. Defects of the lower lip, up to 30% of the total width, can be closed primarily, which gives a better result than any known flap operation unless the contracture of the linear scar tissue distorts the anatomic landmarks. Taking this possibility into consideration and to prevent scar contracture, we have performed Z plasty to the skin component while closing the resultant central defects of the lower lip after tumor excision. This modification improved our cosmetic results.

Recurrent granular cell tumor: how to treat.

Granular cell tumor is an uncommon lesion usually located in the head and neck region (50%) with a female sex predominance. It is believed to be of primitive neuroectodermal origin. Typical clinical presentation is a small, uninflamed, slowly growing, yellowish mass approximately 2 cm in diameter. Granular cell tumor has a peculiar clinical behavior ranging from clearly benign, locally aggressive, or manifestly malignant. Treatment is surgical excision, but recurrences are possible. In this article, we present a case of recurrent benign granular cell tumor with the discussion of the treatment modalities. The patient was a 16-year-old girl with a 3-year history of a painless mass on the right side of her neck. The mass was excised two times at different centers and diagnosed as granular cell tumor after the pathologic examination. The time interval between the operations and recurrences was approximately 1 year. On physical examination, a yellowish, firm, nodular mass measuring approximately 2 x 1 cm was noted. Cervical lymph nodes were evaluated with ultrasonography preoperatively to exclude metastasis and no pathologic lymph nodes were noted. The lesion was excised under local anesthesia with a 1-cm safe margin and the resulting defect was closed primarily after undermining of the wound edges. Postoperatively, the wound began to heal with a hypertrophic scar and immediate precautions were taken. Topical steroid treatment and silicone blocks were applied. Now the patient is in the sixth postoperative month and followed up every month for signs of recurrence.

A new method in the treatment of ear amputation: experimental and clinical study.

There have been plenty of reconstruction methods for ear amputation, and replantation preserves its importance. In situations where replantation is not feasible, various methods were proposed. We indicate an alternative technique for the ear amputation without replantation indication. The method of replacing of a vascular structure into the tunnel formed on the posterior side of the amputated ear was used instead of replacing the ear cartilage into a vascular area that was described in the literature of ear prefabrication. The dorsal fascial flaps which were prepared from the back of 10 New Zealand rabbits were placed into the amputated ear. The 2 groups, control and the experimental, were consequently the ear that was adapted as a composite graft and the ear with the flap inserted. The ears were examined macroscopically and photographed on postoperative days 3, 7, 14, and 21. On the 21st day, the nourishment pattern of the ear, the dorsal fascia, and the dorsal fascia adapted ear were investigated with digital subtraction angiography (DSA). The group that received applied dorsal fascia possessed increased vascularity. The viability was evaluated with the biopsies taken from the control group and the group that received applied dorsal fascial flap on the 21st day. The cartilage and the connective tissue were viable in the flap-applied group, whereas there was necrosis in the control group. The reflection of the experimental study was performed on 2 subtotal and 1 total ear amputation cases, with the utilization of the superficial temporal artery. The nourishment of the flaps was evaluated with postoperative photographs, angiography, and bone scintigraphy.

A new approach to alar rim defects: mucocartilaginous turnover flap.

The main principle of reconstructive surgery is replacement of the defective tissues with like tissues. A full-thickness defect of the nasal ala should be reconstructed in three layers: innermost mucosal layer, outermost skin, and the cartilage in-between. The aim of this study is to describe a technique for single-stage, three-layer reconstruction of the full-thickness ala nasi defects. This technique was used on three patients with tumors involving the nasal ala. Resulting full-thickness defects are reconstructed with a mucocartilaginous turnover flap planned from the contralateral side. Aesthetically acceptable results are obtained without the compromise of the nasal airway and with minimal donor site morbidity. None of the patients requested a revision operation. In conclusion, this is a novel technique with minimal donor site morbidity and good postoperative results. Moreover, lost tissues are replaced with exactly the same kind of tissues.

Influence of rifampin on capsule formation around silicone implants in a rat model.

This study investigated the effect of rifampin on the thickness of capsules around silicone implants by bactericidal activity against Stapylococcus epidermidis. Silicone blocks (1 x 1 cm) were placed into pockets created for each of the 40 rats included in the study. In group 1, the operation was performed under aseptic conditions. In group 2, standard S. epidermidis was inoculated into the pocket, whereas rifampin and S. epidermidis were applied in group 3. In group 4, only rifampin was applied topically on implants. After 12 weeks, the peri-implant capsules were removed and examined under a photomicroscope and a scanning electron microscope. The mean thickness of the capsules was 63.307 microm in group 1, 111.538 microm in group 2, 43.076 microm in group 3, and 30.384 mum in group 4. The differences between groups 2 and 3 and groups 2 and 4 were found to be statistically significant (p < 0.001). Rifampin appears to be an agent for preventing peri-implant capsule formation.

Vascular anatomy of plantar muscles.

Many reports on the plantar arteries and the deep plantar arch exist, but none of them focus on the arterial pedicles of the plantar muscles. They mainly discuss the deep plantar arch, its variations, and location. This study plans to determine the location and origin of arterial pedicles of all the plantar muscles as a preliminary study for designing new flaps. The study was carried out on 20 feet from 10 cadavers aged from 35 to 67 years. After an injection of latex via popliteal arteries, dissection of the arteries was carried out under a microscope. Abductor hallucis and flexor hallucis brevis muscles receive their main blood supply from the medial plantar artery; abductor digiti minimi and flexor digiti minimi brevis muscles receive their main blood supply from the lateral plantar artery. The flexor digitorum brevis muscle receives branches from both arteries. Adductor hallucis and plantar interosseous muscles receive branches from plantar metatarsal arteries. Quadratus plantae is directly nourished from a branch of the posterior tibial artery. No distal anastomoses between the medial and lateral plantar arteries were identified, except 1 specimen in which the medial plantar artery made anastomosis with the deep plantar arch. As a result, the arterial pedicles of all the plantar muscles were defined, and based on these findings, new flaps can be planned or existing flaps can be modified.

A comparative study on superior auricular artery island flaps with various pedicles for repair of periorbital defects.

Superior auricular artery (SAA) island flaps elevated from the retroauricular region have perfect color, thickness, and texture match with facial skin. In this article, reconstruction of periorbital defects with SAA island flaps is presented. Flaps were categorized into three types because they were elevated on three different pedicles. A type 1 flap was a superficial temporal vessel pedicled SAA island flap with antegrade blood flow. A type 2 flap was a reverse flow SAA island flap based on the frontal branch of the superficial temporal artery (STA). A type 3 flap was a reverse flow SAA island flap based on the parietal branch of STA. Fourteen patients (9 females and 5 males) aged between 31 years and 74 years were treated with these flaps. Two patients with lower eyelid, two patients with upper eyelid, three patients with malar, two patients with infraorbital, one patient with lateral canthal upper eyelid, and four patients with forehead defects underwent surgical intervention. Sizes of the flaps varied between 3x6 cm and 8x6 cm. Venous congestion was observed in all patients in the early postoperative period and lasted for 5 to 9 (mean, 6.6) days in type 1 flap, 5 to 9 (mean, 6.7) days in type 2 flap, and 2 to 5 (mean, 3.6) days in type 3 flap. Apart from distal necrosis of 1x1 cm in one patient and superficial dermal sloughing in two patients, no complications were encountered. Aesthetically and functionally successful results with minimal donor site morbidity were obtained in all patients during the 2 to 22 (mean 10.8) month follow-up period.

Staged and late-period reconstruction of the crushed hand: prefabricated osseous flap.

The principle of controlled utilization of increased vascularity in the regions of artificially established ischemia constituted the basis of prefabrication of the vascular induction through staged transfers. We have used this principle, and a part of a metacarpal bone was prefabricated with an artery. The artery was inserted into the bone, and a defect was repaired with this prefabricated osseous flap; meanwhile, another defect was amended with a bone graft. The static bone scintigraphy of the hand at the 6-month postoperative stage indicated evident superiority of the vascularity of the prefabricated osseous flap at the ring finger when compared with the bone graft at the middle finger. The angiography demonstrated a high vascular pattern of the flap at its location at the proximal phalanx of the ring finger. The structures that remained healthy after the injury either on the amputated side or on the hand could be used in reconstruction. The tendinous and osseous structures could be used as free grafts, and the vascular structures could be transferred as vascular pedicles, allowing the creation of previously nonexistent flaps and composite tissues that were ideal for reconstruction. Any tissue possessing a vascular supply could be used as a vascular crane in any prefabrication process.