The role of preoperative radiological assessment of vascular injury on surgical decision making in mutilating injuries of the upper extremity.

Preoperative assessment of the extent of vascular injury is important in patients with mutilating injuries of the upper extremity. The aim of this report was to discuss the influence of computed tomography angiography (CTA) and digital subtraction angiography (DSA) on the operating room decision-making in mutilating injuries and limb-salvage procedures of the traumatic upper extremity. Four DSA and 3 CTA were performed in 7 patients with a mean age of 28.3 (range, 4-48) years. The results of the DSA and CTA altered the preoperative planning. In 5 patients, the reconstructive decision of the type of flap was altered, whereas in all 7 patients, either the level or type of anastomosis was changed after radiologic investigations. The mean follow-up period was 37.8 months. During the follow-up period, all patients underwent subsequent procedures such as sensory restoration, tendon reconstruction, or capsulotomy. The effects of radiologic results in which flap selection, target donor vessel, and level and type of anastomosis have changed are discussed in correlation with intraoperative findings.

Comparison of analgesic efficacy of intravenous Paracetamol and intravenous dexketoprofen trometamol in multimodal analgesia after hysterectomy.

BACKGROUND: [corrected] We aimed to evaluate analgesic efficacy, opioid-sparing, and opioid-related adverse effects of intravenous paracetamol and intravenous dexketoprofen trometamol in combination with iv morphine after total abdominal hysterectomy. MATERIALS AND METHODS: Sixty American Society of Anesthesiologist Physical Status Classification I-II patients scheduled for total abdominal hysterectomy were enrolled to this double-blinded, randomized, placebo controlled, and prospective study. Patients were divided into three groups as paracetamol, dexketoprofen trometamol, and placebo (0.9% NaCl) due to their post-operative analgesic usage. Intravenous patient controlled analgesia morphine was used as a rescue analgesic in all groups. Pain scores, hemodynamic parameters, morphine consumption, patient satisfaction, and side-effects were evaluated. RESULTS: Visual Analog Scale (VAS) scores were not statistically significantly different among the groups in all evaluation times, but decrease in VAS scores was statistically significant after the evaluation at 12(th) h in all groups. Total morphine consumption (morphine concentration = 0.2 mg/ml) in group paracetamol (72.3 ± 38.0 ml) and dexketoprofen trometamol (69.3 ± 24.1 ml) was significantly lower than group placebo (129.3 ± 22.6 ml) (P < 0.001). Global satisfaction scores of the patients in group placebo was significantly lower than group dexketoprofen trometamol after surgery and the increase in global satisfaction score was significant only in group placebo. CONCLUSION: Dexketoprofen trometamol and Paracetamol didn't cause significant change on pain scores, but increased patients' comfort. Although total morphine consumption was significantly decreased by both drugs, the incidence of nausea and vomiting were similar among the groups. According to results of the present study routine addition of dexketoprofen trometamol and paracetamol to patient controlled analgesia morphine after hysterectomies is not recommended.

Evaluation of arteriovenous fistulas made with the diamond-shaped anastomosis technique.

BACKGROUND: Obtaining vascular access suitable for long-term use in hemodialysis patients is of utmost importance. In these patients, autogenous methods are generally used for access. There are various techniques for obtaining autogenous access in hemodialysis patients. MATERIAL/METHODS: Our objective was to evaluate the outcomes of the "diamond-shaped anastomosis" technique used as a surgical technique during the creation of arteriovenous fistulas in patients with chronic renal failure. We randomly selected and retrospectively examined 67 patients on whom the "diamond-shaped anastomosis" technique had been performed. RESULTS: We found an 89% patency rate in the 67 randomly selected patients on whom we applied this technique in the early stage (first 6 months). CONCLUSIONS: Maintaining fistula patency in the early postoperative period is important in fistula functioning. The diamond-shaped anastomosis is a simple technique with proven efficiency. This method can be applied in all situations and contributes to postoperative early stage latency.

Utility of the omentum in sacral reconstruction following total sacrectomy due to recurrent and irradiated giant cell tumour of the spine.

Reconstruction of the lumbosacral region after surgical excision of irradiated and recurrent spinal giant cell tumours remains a challenging problem. In this case report, we describe the use of the pedicled omentum flap in reconstruction of an irradiated and infected wide sacral defect of a 19-year-old male patient. The patient had radiotherapy and subsequent wide surgical resection after recurrence of the tumour. A myocutaneous flap from the gluteal area had failed previously. Local flap options could not be used because of the recent radiotherapy to the gluteal area. Since the patient had a laparotomy for tumour resection and a colostomy, abdominal muscles were not considered reliable for reconstructive procedures. A pedicled omentum flap was chosen as a reconstructive option because of its rich blood supply, large surface area, and angiogenic capacity. This report aims to describe the use of the pedicled omentum flap for reconstruction of the lumbosacral area following surgical resection of a spinal tumour, when gluteal and abdominal flap options for reconstruction are jeopardised.

Use of inferior gluteal artery and posterior thigh perforators in management of ischial pressure sores with limited donor sites for flap coverage.

BACKGROUND: Reconstructive surgery for ischial pressure sore defects presents a challenge because of high rates of recurrence. The aim of this study was to describe the use of inferior gluteal artery (IGA) and posterior thigh perforators in management of ischial pressure sores with limited donor sites. PATIENTS AND METHOD: Between September 2005 and 2009, 11 patients (9 male, 2 female) with ischial sores were operated by using IGA and posterior thigh perforator flaps. The data of patients included age, sex, cause of paraplegia, flap size, perforator of flap, previous surgeries, recurrences, complications, and postoperative follow-up. RESULTS: Nine IGA and 5 posterior thigh perforator flaps were used. Six patients presented with recurrent lesions, 5 patients were operated for sacral and contralateral ischial pressure sores previously. In 2 patients, IGA and posterior thigh perforator flaps were used in combination. Patients were followed for an average of 34.3 months. In 2 recurrent cases, readvancement of IGA perforator flap and gluteus maximus myocutaneous flap were treatment of choice. CONCLUSION: Treatment of patients with recurrent lesions or multiple pressure sores is challenging because of limited available flap donor sites. In this study, posterior thigh perforator flaps were preferred in patients in whom the previous donor site was the gluteal region. IGA perforator flaps were the treatment of choice in patients for whom posterior thigh region was previously used. Alternately, preserved perforators of previous conventional myocutaneous flaps enabled us to use these perforators in recurrences.

Use of custom-made stockings to control postoperative leg and foot edema following free tissue transfer and external fixation of fractures.

Patients with lower extremity trauma treated with free tissue transfer and external fixation of fractures almost always have postoperative edema of the foot and leg. Although compressive elastic stockings have been advised to be worn by patients with venous or lymphatic insufficiency, no such stocking has been described for postoperative use by patients with external fixators. The aim of the present report was to describe a custom-made elastic compression stocking for patients who have undergone soft tissue reconstruction and fracture fixation with external fixators. These custom-made stockings can help to decrease postoperative edema during the nonambulatory and nonweight-bearing ambulatory period. They are easy to apply, affordable, and can be tailored from regular compression stockings according to the needs of the patients.

Superior and inferior gluteal artery perforator flaps in reconstruction of gluteal and perianal/perineal hidradenitis suppurativa lesions.

BACKGROUND: Hidradenitis suppurativa is a debilitating disease with a tendency to form abscesses, sinus tracts, and scar formation. In this report, our experience with reconstruction of hidradenitis lesions of the gluteal and perianal/perineal area using superior and inferior gluteal artery perforator flaps (SGAP and IGAP) are discussed. PATIENTS: A prospective study was conducted in collaboration with the general surgery department for patients with gluteal and perianal/perineal hidradenitis suppurativa between December 2005 and May 2010. Data of each patient included age, sex, disease localization, duration of symptoms, comorbidities, size of defect after excision, perforator flap chosen, complications, and postoperative follow-up. RESULTS: Eleven SGAP and six IGAP flaps were used in 12 patients with gluteal and perianal/perineal involvement. There was one flap necrosis for whom delayed skin grafting was performed. The mean follow-up period was 20 months without recurrences. CONCLUSION: Patients with gluteal and perineal/perianal hidradenitis suppurativa are usually neglected by surgeons because of lack of collaboration of general and plastic surgery departments. Most surgical treatment options described in the literature such as secondary healing after excision and skin grafting prevent patients from returning to daily life early, and cause additional morbidities. Fasciocutaneous flaps other than perforator flaps may be limited by design such that both gluteal regions may have to be used for reconstruction of large defects. SGAP and IGAP flaps have long pedicles with a wide arc of rotation. Large defects can be reconstructed with single propeller flap designs, enabling preservation of the rest of the perforators of the gluteal region.

Clinical application of distal ulnar artery perforator flap in hand trauma.

The clinical value of distal ulnar artery perforator flap in composite defects of the hand is demonstrated in a case series of nine patients with severe injuries of the hand. Soft tissue loss with a mean diameter of 3 × 4 cm on the dorsum of the hand, volar and dorsal side of the wrist and palm was reconstructed with this flap. The mean size of flaps was 5.2 × 5.2 cm. Tendon and nerve injuries, and metacarpal fractures accompanied the soft tissue loss in seven patients. Subsequent reconstructive procedures were; Hunter rod placement and tendon grafting in two patients, nerve grafting in one, primary extensor or flexor tendon repair in three, and metacarpal bone fixation in one patient. The mean follow-up period was 18 months. No complications related to the flap were observed. In this article, the advantage and disadvantages of distal ulnar artery perforator flap in hand and wrist reconstruction is discussed together with a review of literature.

Lateral intercostal artery perforator flap used in salvage of exposed tissue expander of breast: case report.

Management of an exposed tissue expander in breast reconstruction patients remains a challenging problem. For large defects that cannot be repaired primarily, local flap options are limited. In this case report, we describe the use of lateral intercostal artery perforator (LICAP) flap in salvage of an exposed tissue expander of a patient who had delayed immediate breast reconstruction after mastectomy. The postoperative recovery was uneventful and tissue expansion followed by radiotherapy was well tolerated by the flap. We believe this is the first article to describe the use of LICAP flap in salvage of an exposed tissue expander of the breast due to mastectomy flap necrosis in the early postoperative period.

Boyd amputation in adults.

BACKGROUND: Foot ulcerations resulting in amputation are one of the most devastating consequences of diabetes mellitus and peripheral arterial disease. In foot amputations, Boyd amputation has been even less accepted than Syme amputation due to its dependence on calcaneotibial osseous union in adults. METHODS: Fifteen Boyd amputations were performed for 14 adults. The indications for amputation were diabetic ulceration of the foot in eight patients, ischemic disease of the lower extremity in four and salvage of the deformed foot due to peripheral neuropathy in one patient. One patient with scleroderma had bilateral amputations due to digital ischemic necrosis. RESULTS: Complete wound healing was documented in seven feet of six patients. Further revisions to a more proximal amputation level were required in seven patients. CONCLUSION: Despite the high failure rate, we believe Boyd amputation is still a good option in some patients to try to preserve length.

[Odontogenic and nonodontogenic jaw cysts: experience in 25 cases]. / Cenenin odontojenik ve odontojenik olmayan kistleri: 25 olguda deneyimlerimiz.

OBJECTIVES: We retrospectively evaluated the patients with jaw cysts treated at our center. PATIENTS AND METHODS: The study included 25 patients (14 males, 11 females; mean age 33+/-19 years; range 7 to 69 years) who underwent surgery for odontogenic or nonodontogenic jaw cysts. RESULTS: The most common presentation was a swelling in the jaw with or without dental problems. Involvement was in the mandible in 18 patients, and in the maxilla in seven patients. The lesions consisted of eight radicular, six dentigerous, two nasoalveolar, two globulomaxillary cysts, and three keratocysts. Four patients had gingival, nasopalatine, residual, and median mandibular cysts, respectively. Marsupialization, curettage, extensive burring, enucleation, or marginal resection were performed depending on pre- and intraoperative findings. The defects were repaired with a corticocancellous iliac bone block graft in three patients and cancellous iliac bone chips in five patients. During a mean follow-up of 14 months (range 12 to 46 months), recurrence was seen in only one patient with a keratocyst. CONCLUSION: A good preoperative assessment, complete removal of the cystic lesion, and close radiographic follow-up are essential for a successful outcome in jaw cysts. In selected cases, reconstruction of the defects with autogenous corticocancellous iliac bone graft yields highly satisfactory results.

Effects of hyperbaric oxygen therapy on fibrovascular ingrowth in porous polyethylene blocks implanted under burn scar tissue: an experimental study.

Effects of hyperbaric oxygen (HBO) therapy on biointegration of porous polyethylene (PP) implanted beneath dorsal burn scar and normal skin were experimentally examined in Sprague-Dawley rats. In Group One (n=20), daily HBO treatments were given after the implantation of PP material under dorsal burn scar, whereas, in Group Two (n=20) no treatment was given following the same surgical procedure. In Group Three (n=20), PP was placed under dorsal normal skin and subsequently HBO therapy protocol was applied while Group Four (n=20) stayed without HBO treatment after the implantation. One, 2, 3 and 4 weeks after the implantations, sections were respectively taken from five rats from each group. Biointegration process and effects of HBO therapy were evaluated microscopically and the ratio of fibrovascular ingrowth (FVI) was determined for each rat. The results showed significantly superior FVI in Group One compared to Group Two and again FVI into PP under normal skin treated with HBO revealed better results against Group Four (p<0.05). Well-vascularized capsule formation and tissue integration was delayed both in Group Two and in Group Three in the first 3 weeks. In conclusion, HBO therapy enhances biointegration of PP in hypoxic burn scar areas via improving collagen synthesis and neovascularization; otherwise, it apparently delays tissue ingrowth into porous structure implanted in normal healthy tissues.

A congenital true teratoma with cleft lip, palate, and columellar sinus.

Teratomas, the most common extragonadal germ cell tumor of childhood, involve at least two of the ectodermal, mesodermal, and endodermal layers. Of the teratomas seen in the first 2 months of life, 82% are sacrococcygeal. The head and neck region is the second most common location for teratomas in early infancy, accounting for five (14%) of those cases. We describe a female neonate with a teratoma of the nasopharyngeal area, bilateral cleft palate/lip, and columellar sinus pathologies. The mass, which was 8 x 5 x 7 cm and soft in consistency, blocked the airway and prevented oral feeding. On macroscopic examination of the excised mass, there was a notable typical cilia arrangement and lower eyelid appearance. The patient, who was diagnosed with a well-differentiated teratoma after the pathologic examination, did not have any complications in the postoperative period.

Triple Z flap technique for reconstruction of triangular defects in problem areas.

BACKGROUND: Reconstruction of defects close to important structures where standard flaps cannot easily be used may sometimes challenge surgeons. Classic reconstructive options for such defects close to problem areas may not always yield the best result. METHODS: The authors used the triple Z flap technique for triangular defects close to problem areas in 18 patients. The defects were triangular or close to triangular in shape, and three Z flaps were planned on each side of the defect. Flaps were transposed and the defects were reconstructed without any complications. RESULTS: The results were quite satisfying for both the patient and the surgeon. Neither retraction nor any distortion was observed. CONCLUSION: The triple Z flap technique can be used in selected cases where local flap choices are scarce and it is difficult to achieve good anatomical and aesthetic results.

In vivo observation of leukocyte-endothelium interaction in ischemia reperfusion injury with the dorsal window chamber and the effects of pentoxifylline on reperfusion injury.

OBJECTIVE: Ischemia reperfusion injury can cause failure in microsurgical operations. Interaction between leukocytes and endothelium is recognized as an integral step in ischemia reperfusion injury. Pentoxifylline is a methylxanthine derivative that has pharmacological properties that can be beneficial in ischemia reperfusion injury. The aim of this study was to investigate the in vivo effect of pentoxifylline on leukocyte-endothelium interaction in ischemia reperfusion injury. METHODS: Intravital fluorescent microscopy was used to observe leukocyte-endothelium interaction in a "dorsal window chamber" model. Twenty-eight postcapillary veins were analyzed in group 1, and twenty-two in group 2. Group 1 received 25 mg/kg pentoxifylline 20 min before reperfusion. Group 2 received an equivalent volume of 0.9% saline at the same time. The period of ischemia was 4 h. RESULTS: Quantification of leukocyte 'sticking' and 'rolling' was done before ischemia and at 30, 60, and 120 min after reperfusion. Offline video analysis was used for evaluating the results. Statistical evaluation showed that pentoxifylline significantly attenuated leukocyte 'sticking' and 'rolling' in postcapillary venules. It was also effective in preventing 'no-reflow' when compared with the control group. CONCLUSION: These results indicate pentoxifylline diminishes leukocyte-endothelium interaction, and may have a therapeutic role in preventing ischemia reperfusion injury in microsurgical operations.