Compression of Ulnar Nerve by Ganglion Cyst in Guyon's Canal-a Case Report

Background

Compression of the ulnar nerve at the level of Guyon's canal is a very rare compressive neuropathy. Due to the vast range of symptoms that can manifest depending on the degree of ulnar nerve compression, the clinical picture is not consistent.

Objective

The aim of the study is to outline the diagnostic techniques and therapeutic options.

Case report

We reported a case of ganglion cyst-induced compression of the ulnar nerve in Guyon's canal. A 45-year-old female patient underwent surgical ulnar nerve release in Guyon's canal at the Clinic for Plastic and Reconstructive Surgery.

Discussion

After a thorough medical history and physical examination, the diagnosis of the syndrome is made, and ultrasound and magnetic resonance imaging (MRI) testing are used to determine the origin of the neuropathy. A ganglion cyst was identified pathohistological one month following the surgical excision of the soft tissue tumor. In order to hasten the patient's nerve recovery, physical therapy was recommended, and the patient was monitored for the following two years. After two years of treatment, the patient has made a very good recovery of the functionally damaged hand, as determined by a modified Bishop scoring method for evaluating functional ulnar nerve recovery.

Conclusion

In virtually all cases, early surgical intervention can lead to an outstanding functional recovery. If the symptoms are more severe and continue or get worse for more than three months, early surgical intervention is the gold standard for treating Guyon's canal syndrome. If soft tissue formations are compressing the ulnar nerve in Guyon's canal, MRI is thought to be the gold standard for diagnosis.

Non Invasive Detection of Coronary Sinus Flow Changes Over Time After CABG

Background

Coronary New blood in the vascular bed after Coronary Artery Bypass Grafting (CABG) may represent a turning point between ischemia and normal tissue nutrition. Its quantification can help to better understand coronary artery hemodynamics after revascularization.

Objective

Quantification of coronary sinus blood flow changes over time after Coronary Artery Bypass Grafting (CABG) using Transthoracic Echocardiography (TTE).

Methods

Prospective basic research, with repeated measurements on hospital sample of 61 patients whom CABG was conducted. We performed TTE recordings to measure CS flow before and two times after CABG (1 and 6 postoperative day). We measure CS diameter, Velocity Time Integral (VTI) and systemic hemodynamic data. Data needed for LV mass calculation were recorded once. During statistical analysis we define: α = 0,01, β = 0,01 (power = 1-β β= 0,99), Sample size = 60, Effect size= 0,68. We used ANOVA for Repeated Measures as main statistical test in SPSS.

Results

Preoperatively we found low overall CS flow of 181 ±72 ml/min (0,68 ±0,30 ml/gram-LV/min). After surgery there was constant increase of CS flow from 276 ±79 ml/min (1,13 ±0,35 ml/gram-LV/min) first postoperative day, to 355 (±99) ml/min (1,30 ±0,46 ml/gram-LV/min) sixth postoperative day.

Discussion

Amount of new blood was statistically significant after CABG with P<0,001. Same result was found after classifying patients per number of graft received, with the highest amount of new blood after four bypasses. Amount of new blood was not different if patient gets two or three bypasses.

Conclusion

There was significantly new amount of blood in coronary bed after CABG, with constant increase over first 6 days.

Our Experiences in the Treatment of Anterior Chest Wall Infections (2015 - 2021)

Background:

Sternotomy is a classical surgical procedure for approaching the heart and mediastinum. Sternotomy wound infections can be superficial or deep.

Objective:

The aim of this study is to retrospectively evaluate the results of two treatments for deep sternal wound infection (DSWI), closed treatment (debridement, refixation and retrosternal irrigation) and open treatment (debridement, VAC therapy and then pectoral flap).

Methods:

Retrospective analysis of two methods of treatment of DSWI in the period of six years. The first group (G1): surgical debridement, sternum fixation with, if necessary, retrosternal irrigation. The second group (G2): surgical debridement, open sternum with VAC therapy and subsequent pectoral flap with sternum refixation if necessary. Sternotomy wound infection will be classified according to the depth of the affected areas and the time of infection. Risk factors, outcome, local findings, number of revisions, number of hospital treatment days, types of isolates, etiology of sternotomy, time from onset of sternal instability to first surgical treatment will be observed.:

Results:

The number of patients with DSWI was 16, which represents 1% of all sternotomy in the observed period. Mortality in the DSWI group was 35%. Surgical myocardial revascularization was initially performed in 73% of patients with DSWI. Two risk factors for DSWI were in 32% of patients and 25% had diabetes mellitus. The average time for DSWI development in G1 was 10 days (min 0, max 30) and in G2 was 20 days (min 12, max 30). Number of revisions in G1 (min 1, max 2), G2 (min 1, max 3). Average number of hospital days were in G1 23.50 days (SD 13.15), and in G2 38.17 days (SD 28.65). The sternum was osteomyelitic and fragmented in 20% of patients. More than one revision occurred in 40% of patients. The main initial isolate was Enterococcus faecalis in 27% of all DSWI (dominantly in G1 2/3 of all):

Conclusion:

We found that there is no statistically significant difference in observed treatments, and that each treatment has its own indications. We suggested that studies with a larger sample are needed for a definite opinion on this issue.

The New Method of Pocket Forming for Breast Implant Placement in Augmentation Mammaplasty: Dual Plane Subfascial

Introduction:

Breast augmentation is one of the most frequently performed aesthetic surgical procedures in the world. The most important preoperative decisions which influence the final appearance of the augmented breast are the breast implant pocket choice and selection of the most appropriate implant. Described pocket locations are subglandular, subfascial, partially retropectoral, totally submuscular and dual plane.

Aim:

We have introduced a new method of pocket forming for implant placement, which is combination of Tebbett’s dual-plane 2 or 3 and Graf’s subfascial. We named it as dual plane subfascial.

Methods:

Between January 2016 and April 2018, total of 27 patients were operated using dual plane subfascial breast augmentation. The pinch test in the medial pole less than 2,0 cm and in upper pole less than 2,5 cm are indications for this technique. In our modification, in primary cases a dissected flap in front of muscle is fasciocutaneous (not cutaneous as in Tebbett’s technique). It will be finally located caudally of pectoral muscle and in front of the lower pole of implant. Fasciocutaneous flap in primary cases and two independent levels of soft tissue coverage (fascial and cutaneous) in secondary cases (subglandular to dual plane subfascial conversion) in front of the lower pole of implants provide better coverage than cutaneous flap alone.

Results:

Hematoma and infection did not occur in any patient in our study. A capsular contracture grade I/II without the need for reoperation occurred in two patients. In one patient with secondary augmentation minimal bottoming out was noticed (before reoperation patient had significant bottoming out deformity). Minimal palpability of implants is recorded in three patients.

Conclusion:

Dual plane subfascial is a good option in primary breast augmentation with a well set indication especially in the breasts with the upper pinch test less than 25 mm and medial pinch test less than 20 mm. The idea can be followed even in secondary breast augmentation (subglandular to dual plane subfascial conversion). There is additional soft tissue in front of the implant which led to a less implant palpability, especially in thin patient with smaller amount of subcutaneous fat.

Results of primary reparing of hand extensor tendons injuries using surgical treatment

Injuries of hand extensor tendons occur as isolated or combined injury or multiple tendons injuries associated with injuries of other hand structures. Clinical pictures of these injuries depends on the level of occurred injury, and can be expressed in loss of function extension of one or more fingers, wrist and creating contractures.

PATIENTS AND METHODS

This is five-year retrospective study of 87 patients operated at Clinic for Plastic and reconstructive surgery, Clinical Centre University of Sarajevo. We studied the efficiency of primary surgical treatment in hand extensor tendons injuries in the prevention of hand dysfunction.

RESULTS AND DISCUSSION

The best recovery results after surgical treatment of hand extensor tendons injury were in zones I, zone II and zone III. But, in zone VII recovery was difficult, and the outcome unpredictable. The most commonly injured zone was zone VI, and in zones of thumb usually violated zone was zone T-III. According to Miller's assessment criteria and recovery functions, after 6 weeks, with excellent finding was 41 (47,1%) and good results 21 (24,0%) of patients, while after 6 months, the excellent results were in 60 (68,9%) and good results in 28,7% of patients, due to well-conducted physical rehabilitation. Only two patient had complications at 6 months after surgery due to very complicated associated injuries of soft tissues and bone structures of the hand.

CONCLUSION

Results depends in extensivity of injury, anatomic zone, lack of infection, concomitant injuries, skills and operative methods of surgeon.

Results of surgery treatment of Dupuytren's contracture in 115 patients

INTRODUCTION

Dupuytren's disease (DD) is a progressive fibroproliferative disorder of the hand causing digital flexion contracture. Treatment goals include removing or releasing the fibrotic cord to allow extension of the affected finger(s) and restoration of hand function.

MATERIAL AND METHODS

In study period from 2001 through 2008, evaluation was performed in 115 patients. Limited or extensive fasciectomy was performed in all patients. Tubiana classification sheme to rate severity of DD was used.

RESULTS

There were 106 male patients ( mean age 62.6 years) and 9 female patients (mean age 66.3 years). Before the operation, 38% of all patients were at Tubiana stage I, 32% were at stage II, 22% were at stage III and 8% were at stage IV. Of all patients, 43% were diagnosed with Dupuytren's in only one finger, 39% in two fingers and 18% in three fingers. In 23% of patients DD were diagnosed on both hands. Limited fasciectomy was peformed in 90.4% of patients and extensive fasciectomy in 9.6% of patients. The Tubiana stage achived after surgery was lower in 98% of patients. As a final result after surgery, 66% of patients didn't have contracture, stage I was reported in 28% and stage II in 3% of patients. There were no patients with Tubiana stage III or more after surgery. Postoperative complications were noted in 18% of patients. Wound healing problems were present 12% of patients. Haematoma was reported 5% of patients. Of all patients 22% had diabetes mellitus.

CONCLUSION

DD is much more common in male than in female patients. Most of the patients are diagnosed at Tubiana stage I and II. Surgical correction has led to an improvement in most patients. Limited fasciectomy is still the gold-standard in DD treatment. Extensive fasciectomy or dermofasciectomy is preformed only in most severe cases.

The results of treatment of basoceltular carcinomas of the head skin

INTRODUCTION

Basocellular skin carcinoma (BCC) is the most common cancer in the human population. BCC almost appeared at adult's people, but it can be found at children, too.

THE AIM

The aim of this study was to determine which the position of BCC on the head skin is the most difficult for the treatment and what the reasons are for it.

METHODS

With the prospective study, from June 2004 to June 2011, were compared the results of treatment of basocellular carcinomas (BCC) of the head skin. The examinees were divided into 3 groups. The first group, the group A (38 patients) was consisted of examinees treated of BCC on the nose. In the second group, the group B (42 patients) was classified of examinees treated of BCC on the face, temple, eyelids and forehead, while the third group, group C (35 patients) was classified of examinees treated of BCC on the scalp. The parameters for comparison the results of treatment were the method of treatment, number of the relapse, elapsed time from surgery to relapse and consequently defacement.

RESULTS

There was found a statistical significant difference in terms of choice of methods of operative treatment for the significantly higher number of operations on the scalp operated with cutaneous transplants. It was confirmed that the localization of the tumors on the scalp, and then on the nose are with the highest incidence of the relapse, whereas the postoperative defacement is mostly on the scalp after skin graft placement. Key

The analysis of reasons for malignant skin tumors late diagnosis

Introduction:

Timely diagnosis is a prerequisite for the successful treatment of malignant skin tumors. Late diagnosis leads a patient into a situation of losing valuable time and chance for cure.

Material and methods:

A prospective study was conducted from February 2006 until August 2011 which analyzed the reasons that led to establishing the diagnosis of malignant skin tumors in 220 patients. Patients were divided into two groups: Group A (102 patients), patients with diagnosed melanoma, and group B (118 patients) of patients suffering from basocellular (BCC) and planocellular cell (PCC) skin cancer. Parameters for comparison of analysis results were the reasons for coming to examination and reasons for not coming to the examination, because of which skin cancers were not diagnosed in time.

Goal:

To determine the factors that influences the establishment of late diagnosis and treatment of skin tumors.

Results:

It was confirmed that the prejudices of patients that tumors of the skin „should not be operated because it is dangerous“ is the main reason for late diagnosis. At the same time it is confirmed that the belief that it is unnecessary to operate congenital changes of the skin is the second most important reason for delayed diagnosis of malignant skin tumors.

Sensory recovery after forearm median and ulnar nerve grafting

BACKGROUND

Median and ulnar nerve injuries are common, whether isolated or combined injury of both nerve. A nerve graft, if performed in a tensionless manner, has been shown to generally have better results than an end-to-end approximation performed under tension.

OBJECTIVE

The aim of this study is to analyze the long-term results of sensory recovery after secondary reconstruction median and ulnar nerve by autograft in patients who were treated on Clinic for Plastic and Reconstructive Surgery in the period from January 1st 1993 to December 31st 2005. We analyzed the influence of the patients age, level of injury, the size of the graft and the period between the injury and operation on the late results.

PATIENTS AND METHODS

Evaluation was performed in 55 patients with adequate follow-up. The mean follow-up period was 3.9 years. Reconstructions were applied on the median nerve in 31 patients and ulnar nerve in 24 patients. Criteria for inclusion in the study was median and ulnar nerve grafting in the forearm region. Patients were divided by age in two groups, below 25 and over 25 years, by injury level in the distal and proximal forearm injuries, by the length of autograft up to 5 cm and other group with graft length over 5 cm, by the period between injury and operation in group with denervation time up to 6 months and the group with denervation time over 6 months. Rating of sensibility was presented on the Highet Scale as modified by Dellon and more precise rating of sensibility was presented by Moberg's rating scale of sensibility. Calculation of frequencies and percentual values was performed for all included variables. For establishment of differences between the frequencies the /2-test was used (Chi square test) at the level of statistical importance (p < 0.05) with contingency tables.

RESULTS

We analyzed the results of reconstruction of median and ulnar nerves with respect to factors affecting functionally the result of operation, which are age, injury level, graft length and denervation time. We had 31 patients with median nerve grafting and we achieved sensory recovery S4 in 3 (10%) patients, S3+ in 9 (29%) patients, S3 in 8 (25.5%) patients, 52 in 9 (29%) patients and S2 in 2 (6.5%) patients. We had 24 patients with ulnar nerve grafting and we achieved S4 sensory recovery in 2 (8.5%) patients, S3+ in 6 (25%) patients, 53 in 5 (21%) patients, S2 in 10 (41%) patients and S2 in 1 (4%) patient. There was not significant difference in sensory recovery of median and ulnar nerve (chi-square = 1.00; df = 4; p = 0.909). There was not statistically significant difference by age and level of injury. The results were significantly better in patients with short grafts than in long ones (chi-square = 12.6; df = 4; p = 0.014) and in patients who had undergone surgical repair within 6 months (chi-square = 10; 2 df = 4; p = 0.038).

CONCLUSION

There was not significant difference in sensory recovery of median and ulnar nerves. The graft length and denervation time significantly influenced the functional outcome in sensory recovery. Mechanism of injury impacted on the results. Two point discrimination testing using a paperclip is a cheap, easily and quickly performed reproducible test of tactile gnosis, and should be included in nerve assessment protocols. We recommended using Moberg's rating scale for further research.