Accessory first lumbrical muscle within the carpal tunnel: a case report.

Carpal tunnel syndrome is the most common entrapment neuropathy in the upper extremity. Palmaris longus, flexor digitorum superficialis, and lumbricals have infrequently been reported as causes of nerve compression. During routine Korean cadaver dissection, we incidentally identified an anatomic variant of first lumbrical muscle within the carpal tunnel in both wrists. The aberrant musculature originated from the radial side of the second FDS muscle at distal forearm level, running separately across the wrist beneath the flexor retinaculum. The dissected anomalous muscle was identified as an additional muscle belly of the first lumbrical muscle. Compression of the median nerve at the wrist might rarely be caused by the presence of such a tendon or muscle anomaly found in this study. Surgeons should be aware of possible anatomic variations in the carpal tunnel, and be prepared to modify their surgical plan accordingly.

Neglected posterior interosseous nerve injury.

Posterior interosseous nerve (PIN) injury is uncommon due to its anatomically deep location. We report a neglected, rare case of PIN injury presenting the loss of extension of thumb, index, and small fingers with weakness of thumb abduction in a 49-year-old male patient. The patient sustained a penetrating injury to his right forearm caused by a kitchen knife that was repaired primarily through an emergency surgery under general anesthesia. During the regular follow-up on the 52nd postoperative day, the patient presented 20° of extension lags in the right thumb and index finger and 30° in the small finger. Wrist extension was intact, and there was no sensory deficit. We explored the wound and traced the PIN completely, identifying a club-shaped neuroma formation at the proximal cut end of the PIN. Delayed nerve repair was performed with a double-strip cable graft. Hand surgeons should be aware of the probable PIN injury in certain situations of forearm-penetrating injury and perform proper preoperative physical examination to rule out neurovascular deficits. Careful exploration and immediate repair of severe PIN are mandatory, even in emergency situations.

Security Comparison of Various Surgical Knots Using Nylon Suture.

OBJECTIVE: To evaluate the strengths of various surgical knot techniques, including square knot, surgeon's knot, granny knot, and random knot with the same three throws. METHODS: The authors tested each of the four knot techniques using four different gauges of nylon (polyamide [Ethicon]): 4-0, 5-0, 6-0, and 7-0. Each knot type was tested 20 times per nylon gauge, for a total of 320 knots tested. The authors used a static pull machine to measure elongation at yield and maximal force to break. RESULTS: A comparison of elongation at yield revealed that the surgeon's knot was superior to the square knot, granny knot, and random knots across all gauges of nylons. Further, a comparison of maximal force to break revealed that the surgeon's knot was superior to the square knot, granny knot, and random knots when using 4-0, 5-0, and 6-0 nylon but not when using 7-0 nylon. CONCLUSIONS: The surgeon's knot was the strongest, and random knot was the weakest when the authors used nylon 4-0, 5-0, and 6-0. While handling fine suture materials such as 7-0 nylon, knot failure appears to be unrelated to the knot technique used. This study provides not only fundamental guidance for tying surgical knots using nylon, but also a rational basis for an adequately strong knot choice in various fields of surgery.

Recurred forehead osteoma disseminated after previous osteoma excision: A case report.

BACKGROUND: Forehead osteoma is a commonly encountered benign facial bone tumor. Endoscopic excision of benign forehead masses is widely performed. Here, we report a rare case of recurrent forehead osteoma that disseminated after a previous osteoma excision. CASE SUMMARY: A 54-year-old female patient had previously undergone endoscopic removal of a single forehead osteoma at 30 years of age. However, she had a recurrent osteoma around the same site and underwent another endoscopic resection at 40 years of age. During her first visit to our outpatient clinic, she presented with a cobblestone-like irregular surface on the forehead and a 3D facial bone computed tomography scan revealed a widely ragged surface of the inoculated osteoma on the outer table of the frontal bone. Under general anesthesia, we performed a radical complete excision of the disseminated osteoma through a bicoronal incision using an osteotome, chisel, mallet, and rasping. We hypothesized that the recurrence may have been caused by the inoculation of residual osteoma remnants from the previous procedure. Craniofacial surgeons should be cautious when removing osteoma particles, particularly when using an endoscopic approach. CONCLUSION: To prevent recurrence, it is essential to conduct additional meticulous burring and a thorough inspection of the surface after copious irrigation.

Gouty tenosynovitis with compartment syndrome in the hand: A case report.

BACKGROUND: Gout is a common type of inflammatory arthritis caused by the deposition of monosodium urate crystals in the joints and surrounding tissues. It typically appears with abrupt and intense pain, redness, and swelling in the affected joint. It frequently targets the lower extremities, such as the big toe. However, rarely, gout can manifest in atypical locations, including the hands, leading to an uncommon presentation known as gouty tenosynovitis. However, it can result in significant morbidity owing to the potential for severe complications, such as myonecrosis and compartment syndrome. CASE SUMMARY: An 82-year-old male patient with a history of hypertension, cerebral infarction, Parkinson's disease, and recurrent gout attacks sought medical attention because of progressive pain and swelling in the right hand. Imaging findings revealed forearm swelling, raising concerns of possible tenosynovitis, bursitis, septic arthritis, and compartment syndrome. A fasciotomy was performed to decompress the patient's hands and forearms. The procedure revealed diffuse tenosynovitis, tophi with a pus-like discharge surrounding the carpal tunnel, and involvement of the flexor and extensor tendon sheaths. However, microbiological investigations, including Gram staining, acid-fast bacilli, tuberculosis, and non-tuberculous mycobacteria, yielded negative results. The patient was ultimately diagnosed with a severe gouty attack with compartment syndrome and myonecrosis. Septic arthritis and infectious flexor tenosynovitis were ruled out. Serial debridement and inflammation control were initiated, followed by staged closure with a skin graft. CONCLUSION: Septic-like complications can occur in the absence of infection in severe gout attacks with pus-like discharges due to compartment syndrome and myonecrosis. Cultures can be used to differentiate between gouty attacks, septic arthritis, and infectious tenosynovitis. Involvement of the flexor and extensor muscles, as in this case, is rare. This study contributes to the literature by reporting a rare case of successful fasciotomy and serial debridement in an elderly patient with multiple comorbidities.

Successful pedicled vertical rectus abdominis myocutaneous flap reconstruction with negative-pressure wound therapy for deep sternal wound infection: a case report and comprehensive review.

Introduction: Deep sternal wound infection (DSWI) is a serious complication that may occur after median sternotomy, with potentially devastating consequences. By reporting our case and analyzing the existing literature, this article aimed to provide a thorough understanding of the role of negative-pressure wound therapy (NPWT) and the importance of flap choice in managing DSWI accompanied by severe heart injury and high hemodynamic risk. Case description: A 60-year-old woman with severe aortic stenosis, aortic valve regurgitation, and heart failure underwent redo sternotomy, which resulted in an intraoperative right ventricle injury. She required extracorporeal membrane oxygenation support because of low blood pressure and subsequently developed complications, including surgical site hematoma, wound dehiscence, and fat necrosis. She was referred for wound closure, where a significant 10 × 20-cm soft tissue defect in the anterior chest wall was observed. A pedicled vertical rectus abdominis myocutaneous flap addressed the soft tissue defect. The wound showed remarkable improvement at the 8-month follow-up visit. Conclusions: DSWI management is a complex and multifaceted challenge. NPWT, when combined with appropriate surgical strategies, including wound debridement and flap selection, may promote successful wound healing. This case report highlights the successful management of a complex DSWI using a multidisciplinary approach, including debridement, appropriate antibiotic therapy, and free-flap reconstruction, which resulted in favorable outcomes.

Reconstruction of the lower back wound with delayed infection after spinal surgery: A case report.

BACKGROUND: Orthopedic surgeries after device implantation are susceptible to infections and may require device removal in the worst cases. For this reason, many efforts are being made to control infections after spinal surgery; however, the number of infection cases is increasing owing to the increasing number of elderly citizens. CASE SUMMARY: A 75-year-old male with a chronic spinal defect due to previous spine surgery underwent reconstruction using a perforator-based island flap. After bursectomy and confirmation that there was no connection with the deep tissue, reconstruction was performed. However, wound disruption occurred with abscess formation on postoperative day 29, which led to an imaging workup revealing delayed deep tissue infection. CONCLUSION: Infection is one of the most common causes of surgical wound dehiscence and is associated with devastating results if not controlled promptly and definitively. Surgeons should always suspect delayed infections when reconstructing chronic soft tissue defects.

Free flap reconstruction of scalp in a case of advanced lung cancer with brain metastasis: A case report.

RATIONALE: Reconstruction of wound complications in patients with advanced cancer with distant metastases is challenging for plastic surgeons. This may be due to the cancer patients' hypercoagulability and potential intolerance to general anesthesia. This article aimed to discuss the risk of free-flap reconstruction in such cases. PATIENT CONCERNS: The patient was a 58-year-old female with advanced non-small cell lung cancer and brain metastasis. The patient underwent brain radiotherapy and chemotherapy through the Ommaya Reservoir. DIAGNOSES: A year ago, she underwent several local flap closures for recurrent wound healing failure due to wound complications, including infection, wound dehiscence, and subsequent device removal. INTERVENTIONS: A radial forearm free flap was created under general anesthesia. The patient was discharged in the third postoperative week since the flap remained stable. OUTCOMES: At follow-up a month thereafter, the patient exhibited signs of recovery without any complications even while continuing her chemotherapeutic regimen. LESSONS: Free flap placement is not an absolute contraindication in cancer patients with distant metastases. Nevertheless, it is associated with clinical challenges and operator hesitancy. This is a case of a successful free flap in a cancer patient with hypercoagulability and suspected floating tumor cells. Postoperative management, in this case, is appropriate.

Successful reconstruction of an ankle defect with free tissue transfer in a hemophilia A patient with repetitive hemoarthrosis: A case report.

BACKGROUND: Hemophilia, an uncommon yet consequential hereditary bleeding disorder, manifests as two clinically indistinguishable forms that hinder the normal functioning of the coagulation cascade. This impairment renders individuals more susceptible to excessive bleeding during significant surgical interventions. Moreover, individuals with severe hemophilia frequently encounter recurring hemarthrosis, resulting in progressive joint destruction and, subsequently, the need for hip and knee replacement surgeries. CASE SUMMARY: The patient was a 53-year-old man with hemophilia A as the underlying disease and had self-injected factor VIII twice weekly for several decades. He had undergone ankle fusion surgery for recurrent hemarthrosis at the Department of Orthopedic Surgery 1 mo prior and was referred to our department because of skin necrosis after a hematoma at the surgical site. An anterolateral thigh perforator free flap was created after three cycles of factor VIII administration in addition to the concomitant administration of tranexamic acid (TXA) (Transamin 250 mg cap, 1 cap tid, q8h). After the operation, from postoperative days (PODs) 1-5, the factor VIII dose and interval were maintained, and q12h administration was tapered to q24h administration after POD 6. Because the patient's flap was stable 12 d after the operation, factor VIII administration was tapered to twice a week. At 6 mo follow-up, the patient recovered well without any complications. CONCLUSION: To the best of our knowledge, there are very few reports of successful free flaps in patients with hemophilia, and none have been reported in patients with hemophilia A. Moreover, there are several reports on the efficacy of TXA in free flaps in general patients; however, there are no case reports of combining factor VIII and TXA in patients with hemophilia. Therefore, we report this case to contribute to future academic research.

Toenail Paronychium Flap: Novel Surgical Approach for Ingrowing Toenail and Review of the Literature of Conventional Surgical Methods.

Ingrown toenails are most common among school-age children and adolescents though they can be observed at any age. Causes of ingrown toenails are increased curvature, trauma, and external pressure. Treatment of ingrown toenails can be broadly characterized as conservative and surgical. Conservative treatment can be performed using various methods, such as a gutter splint, dental floss, and cotton. Surgical treatments may be divided into two main approaches; narrowing of the nail plate and debulking of periungual tissues. However, these various conservative and surgical treatments have high recurrence rates, and thus, the author used a permanent surgical method based on the use of a paronychium flap to treat a 15-year-old male adolescent with excessive periungual tissues and curved ingrown toenails who did not improve despite conservative and several surgical treatments over 4 years. Subsequently, toenail shape was maintained without recurrence 22 months after surgery, and there were no complaints of inflammation or pain while walking. This simple surgical method can be performed on patients with advanced ingrown toenails due to excessive periungual tissues and nail curvature and can be expected to have permanent effects.

Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery: A case report.

BACKGROUND: Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence. They require immediate and appropriate management before they progress to an irreversible condition. Although negative pressure wound therapy (NPWT) can prevent wound progression by increasing microcirculation, the inappropriate application of NPWT on complication-threatened transferred and replanted tissues can induce an adverse effect. CASE SUMMARY: A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap. While applying a heating pad directly to the flap site, she sustained a deep second to third-degree contact burn over 30% of the transferred flap on postoperative 7 d. As the necrotic changes had progressed, we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d. After 4 d of NPWT application, the exposed fatty tissues of the flap changed to dry and brown-colored necrotic tissues. Upon further debridement, we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery. CONCLUSION: Although NPWT has been shown to be successful for treating various wound types, the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer.

BACKGROUND: Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established. MATERIALS AND METHODS: Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures. RESULTS: This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes. CONCLUSION: The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

An Anatomical Study of the Palmaris Brevis, Transverse Carpal Ligament, and the Recurrent Motor Branch of the Median Nerve.

Background: The anatomical structures in relation to the carpal tunnel release are the palmaris brevis muscle (PBM), transverse carpal ligament (TCL), and the recurrent motor branch of the median nerve (RMBMN). Our aim is to describe the gross morphology in the Korean population of the PBM, TCL, and RMBMN specifically looking for anomalies, and to determine the muscles encountered during a standard carpal tunnel release. Material and Methods: A total of 30 cadaveric hands were dissected. A longitudinal line drawn from the third web space to the midpoint of the distal wrist crease served as the reference line (RL). The PBM and TCL were classified according to its shape and location. The length, width, and thickness of the TCL were measured. The ratio of the lengths of PBM and TCL to RL was calculated. The course of the RMBMN was dissected specifically looking for anomalies. We also looked at the muscle fibers encountered during a standard carpal tunnel release to identify the muscle. Results: PBM was classified into three different types based on the shape. The average thickness of the PBM and TCL were 0.89 ± 0.16 mm and 1.43 ± 0.40 mm, respectively. The distal border of the TCL was thicker than the proximal border. The average ratio of the length of the PBM to the RL was 25.65 ± 8.62% and TCL to the RL was 24.00 ± 3.37%. The distribution of the RMBMN was classified into three different types. A few accessory branches of the RMBMN were also noted. And 36 muscle fibers were noted within the TCL in line with the RL. Conclusion: We clarified findings and added quantitative information about the anatomical structures surrounding carpal tunnel. A thorough knowledge of the anatomy and anomalies around the carpal tunnel is helpful for surgeons to ensure optimal surgical results.

The Osteogenic Differentiation of Human Dental Pulp Stem Cells through G0/G1 Arrest and the p-ERK/Runx-2 Pathway by Sonic Vibration.

Mechanical/physical stimulations modulate tissue metabolism, and this process involves multiple cellular mechanisms, including the secretion of growth factors and the activation of mechano-physically sensitive kinases. Cells and tissue can be modulated through specific vibration-induced changes in cell activity, which depend on the vibration frequency and occur via differential gene expression. However, there are few reports about the effects of medium-magnitude (1.12 g) sonic vibration on the osteogenic differentiation of human dental pulp stem cells (HDPSCs). In this study, we investigated whether medium-magnitude (1.12 g) sonic vibration with a frequency of 30, 45, or 100 Hz could affect the osteogenic differentiation of HDPSCs. Their cell morphology changed to a cuboidal shape at 45 Hz and 100 Hz, but the cells in the other groups were elongated. FACS analysis showed decreased CD 73, CD 90, and CD 105 expression at 45 Hz and 100 Hz. Additionally, the proportions of cells in the G0/G1 phase in the control, 30 Hz, 45 Hz, and 100 Hz groups after vibration were 60.7%, 65.9%, 68.3%, and 66.7%, respectively. The mRNA levels of osteogenic-specific markers, including osteonectin, osteocalcin, BMP-2, ALP, and Runx-2, increased at 45 and 100 Hz, and the ALP and calcium content was elevated in the vibration groups compared with those in the control. Additionally, the western blotting results showed that p-ERK, BSP, osteoprotegerin, and osteonectin proteins were upregulated at 45 Hz compared with the other groups. The vibration groups showed higher ALP and calcium content than the control. Vibration, especially at 100 Hz, increased the number of calcified nodes relative to the control group, as evidenced by von Kossa staining. Immunohistochemical staining demonstrated that type I and III collagen, osteonectin, and osteopontin were upregulated at 45 Hz and 100 Hz. These results suggest that medium magnitude vibration at 45 Hz induces the G0/G1 arrest of HDPSCs through the p-ERK/Runx-2 pathway and can serve as a potent stimulator of differentiation and extracellular matrix production.

Temporal Hollowing Augmentation With Polyetheretherketone Patient-Specific Implant.

Temporal hollowing is a common complication of surgical dissection in the temporal region. As it is a serious cosmetic problem, the need for reconstruction is increasing. Advances in medical imaging, computer software, 3-dimensional printing technology, and biochemistry have enabled surgeons to use patient-specific implants for correction of craniofacial deformities. Titanium, polymethylmethacrylate, and polyetheretherketone are representative materials of the alloplastic implant. In this article, the authors report the first case of temporal hollowing augmentation using a polyetheretherketone patient-specific implant.

Analysis of the risk factors that determine composite graft survival for fingertip amputation.

The composite graft is the only surgical method that is able to maintain digital length and provide soft tissue coverage without donor site morbidities in microsurgically non-replantable fingertip amputations. This study aimed to explore the risk factors that determine the survival of composite grafts. Clinical characteristics associated with graft survival were retrospectively analysed by a comparison between the graft survival and failure groups. Of 94 patients who underwent a composite graft for fingertip amputation, the graft survived in 84 (89%). Surviving grafts showed reperfusion within 1 week. Multivariate analysis revealed that graft failure was independently associated with a crushing injury. Based on the risk factors from the comparison analyses and a review of previously published studies, a cutting injury, grafting the injured finger within 5 hours of injury, and being a non-smoker are associated with good results. In these circumstances, excellent outcomes with a high success rate can be achieved by composite graft in most adult patients as an alternative treatment to microsurgical replantation. Level of evidence: IV.

Delayed formation of sterile abscess after zygomaticomaxillary complex fracture treatment with bioabsorbable plates.

We present a patient who showed a sterile abscess after facial bone fixation with bioabsorbable plates and screws. He had zygomaticomaxillary complex and periorbital fracture due to falling down. The displaced bones were treated by open reduction and internal fixation successfully using bioabsorbable plate system. However, at postoperative 11 months, abrupt painless swelling was noted on the previous operation sites, left lateral eyebrow and lower eyelid. By surgical exploration, pus-like discharge and degraded materials were observed and debrided. The pathologic analysis revealed foreign body reaction with sterile abscess. This complication followed by bioabsorbable device implantation on maxillofacial bone surgery has been rarely reported in which we call attention to the maxillofacial plastic surgeons.

Anatomical study of the first dorsal extensor compartment for the treatment of de Quervain's disease.

INTRODUCTION: Anatomical variations of the first dorsal extensor compartment (1st EC) are commonly noted. MATERIALS AND METHODS: Forty cadaver hands were dissected to define the 1st EC. Through the gross findings, we classified the contents according to the presence of septation, subcompartment, and variation of tendons. Bony cross-section of the wrist was performed to reveal any bony pattern within the 1st EC. We also measured the anatomical structures of the 1st EC. RESULTS: A septum that results in subcompartments was present in 24, complete in 2 and incomplete in 22 hands distally. The mean size of the 1st EC was 20.69±12mm in length, and 8.65±0.67mm in width. The mean length of the septum was 11.18±5.18mm, while the mean width of the subcompartment was 3.18±0.40mm. All the subcompartments enclosed only extensor pollicis brevis (EPB) tendons. The mean number of abductor pollicis longus and EPB tendon slips was 2.6±0.5 and 1.1±0.2, respectively. The bony floor of the 1st EC was classified into five types. Two distinctive grooves separating two tendons with protruding osseous ridge (type I, n=9), two distinctive grooves separating two tendons without protruding osseous ridge (type II, n=10), a single distinct groove with osteophytes (type III, n=16), indistinct groove with fibrous septum separating two tendons (type IV, n=4), and indistinct groove without fibrous septum (type V, n=1). CONCLUSION: Knowledge about the 1st EC abnormality is mandatory for the successful treatment of de Quervain's disease.

Long-term Fate of Denervated Skeletal Muscle After Microvascular Flap Transfer.

BACKGROUND: Muscle flap is a valuable option in soft tissue reconstruction. Denervated skeletal muscle is known to undergo degeneration. However, information regarding histological and genetic changes in muscle free flap without reinnervation over long-term follow-up remains unclear. METHODS: We collected flap muscles obtained during secondary exploration surgery after more than 15 years of previous muscle free flap without reinnervation. Compared with normal muscle and fat, histomorphometric and gene expression analysis of flap muscle were performed. RESULTS: During the study period, we collected 5 samples of previous muscle free flap. The mean ± SD postoperative duration after free flap was 18.6 ± 4.0 years. All flap muscles were replaced with adipose tissue based on gross and histological findings. In flap muscle, the expression of gene related to muscle-specific MYH2 gene was downregulated, whereas the expression of genes related to adipose, fibroadipogenic progenitor, and blood vessel was upregulated compared with that of normal muscle. Vascular density and pattern were also similar to those in normal fat. CONCLUSIONS: We demonstrated that muscle free flap without reinnervation eventually converts into adipose tissue regardless of spontaneous reinnervation during muscle regeneration. The long-term findings of the present study will be valuable for muscle flap selection and prognosis.