Successful Repair of Symptomatic Extremity Muscle Herniation with Synthetic Mesh

Sir: Muscle herniation in the extremities is the result of an acquired fascial defect, causing pain or discomfort on physical exertion of the affected limb in symptomatic cases. The treatment options for symptomatic extremity muscle herniation in the lower limb are well documented in the literature and include conservative management (activity limitation, compressive stockings, and so on), wide fasciotomy, direct approximation of the fascial defect, tibial periosteal flap, partial muscular excision, and patch repair with autologous fascia lata or synthetic mesh.1 To date, however, the use of synthetic mesh to correct symptomatic extremity muscle herniation has been reported only in a single case by Siliprandi et al., who utilized Mersilene mesh (Ethicon, Inc., Somerville, N.J.) to achieve symptomatic relief and cosmetic correction of anterior tibialis muscle herniation in a lower extremity.2 Based on the success of this isolated case report, the authors' goal was to expand the clinical experience in the literature with synthetic mesh repair of lower extremity muscle herniation, in addition to reporting its novel use in a case of upper extremity muscle herniation. Three patients with symptomatic extremity muscle herniation secondary to trauma were treated. Two defects were located in lower extremity and the remaining defect was in the upper extremity (Table 1). Repair was achieved using a single layer of Prolene mesh (Ethicon) as an inlay, secured in place under minimal tension with 2.0 Prolene (Ethicon) in an interrupted fashion. Skin closure was performed in two layers. Postoperatively, the patient was immobilized for 1 week, at which time passive range of motion exercises were initiated (Figs. 1 and 2).Table 1: Summary of CasesFig. 1.: Preoperative view of symptomatic forearm herniation. The visible mass is tender, located over the proximal third of the flexor surface on his right forearm, and accentuated by elbow flexion and forearm pronation.Fig. 2.: Follow-up (postoperative) view at 6 months after mesh repair. The patient had complete resolution of his preoperative pain and bulging, and is shown with the forearm in a flexed and pronated position.Presented in this report are the repairs of three cases of symptomatic extremity muscle herniation using synthetic patches of Prolene mesh. This permanent mesh is nonreactive and durable. Much like the repair performed using harvested fascia lata, the synthetic mesh repair is robust and under no tension, which theoretically decreases the rate of hernia recurrence.3 Potential disadvantages are an increased risk of infection with a synthetic, nonabsorbable foreign body and the risk of adhesions between the mesh and the underlying structures. To minimize the latter, we utilized a short period of immobilization coupled with early range-of-motion exercises. All patients had complete resolution of their preoperative symptoms (at rest and during activity), in addition to no visible bulging at follow-up, which ranged from 12 to 26 months. In addition, with this technique there is no donor-site morbidity and shorter operative times due to the obviated need for graft harvest. We believe that this technique is a favorable option for the treatment of symptomatic extremity muscle herniation, particularly for larger fascial defects, where the donor-site morbidity of sizeable fascial harvests can be substantial.4 In addition, we have shown that this technique can be effectively utilized for symptomatic extremity muscle herniation in the forearm, a novel application. DISCLOSURE None of the authors has any commercial associations or financial interests in any of the products used in or results derived from this research project. Miroslav S. Gilardino, M.D., M.Sc. Division of Plastic and Reconstructive Surgery McGill University Health Center Montreal, Quebec, Canada Jon B. Loftus, M.D. Department of Orthopedic Surgery Upstate Medical University Syracuse, N.Y. Jean-Paul Brutus, M.D. Division of Plastic and Reconstructive Surgery University of Montreal Montreal, Quebec, Canada

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