Purpose To evaluate long-term patency rates and related outcomes after vascular reconstruction of hypothenar hammer syndrome and identify patient- or treatment-related factors that may contribute to differences in outcome.Methods We used color flow ultrasound to determine the patency of 18 vein graft reconstructions of the ulnar artery at the wrist in 16 patients. Validated questionnaires evaluated patients' functional disability with the Disabilities of the Arm, Shoulder, and Hand score, pain with the visual analog scale, and cold intolerance with the Cold Intolerance Symptom Severity survey. Patient demographics, clinical data, and surgical factors were analyzed for association with graft failure. Patients were asked to grade the result of treatment on a scale of 0 to 10.Results Of 18 grafts, 14 (78%) were occluded at a mean of 118 months postoperatively. Patients with patent grafts had significantly less disability related to cold intolerance according to the Cold Intolerance Symptom Severity survey in addition to significantly less pain on the visual analog scale. There was no statistical difference in Disabilities of the Arm, Shoulder, and Hand scores between patients with patent or occluded grafts. Patients graded the result significantly higher in patent reconstructions.Conclusions We noted a higher incidence of graft occlusion than previously reported at a mean follow-up of 9.8 years, which represents a long-duration follow-up study of surgical treatment of hypothenar hammer syndrome. Despite a high percentage of occlusion, overall, patients remained satisfied with low functional disability and all would recommend surgical reconstruction. This study suggests that improved outcomes may result from patent grafts in the long term. Copyright (C) 2015 by the American Society for Surgery of the Hand. All rights reserved.

We previously developed and validated a vortexing-sonication technique for detection of biofilm bacteria on the surface of explanted prosthetic joints. Herein, we evaluated this technique for diagnosis of infected breast tissue expanders and used it to assess colonization of breast tissue expanders. From April 2008 to December 2011, we studied 328 breast tissue expanders at Mayo Clinic, Rochester, MN, USA. Of seven clinically infected breast tissue expanders, six (85.7%) had positive cultures, one of which grew Propionibacterium species. Fifty-two of 321 breast tissue expanders (16.2%, 95% CI, 12.3–20.7%) without clinical evidence of infection also had positive cultures, 45 growing Propionibacterium species and ten coagulase-negative staphylococci. While vortexing-sonication can detect clinically infected breast tissue expanders, 16 percent of breast tissue expanders appear to be asymptomatically colonized with normal skin flora, most commonly, Propionibacterium species.

Hypothenar hammer syndrome (HHS) is characterized by digital ischemia after repetitive traumatic injury to the ulnar artery. Some hypothesize that susceptible patients have an intrinsic vasculopathy such as fibromuscular dysplasia (FMD). To investigate this hypothesis, we reviewed our institutional experience with this syndrome over 25 years. Clinical records were reviewed from all patients who underwent surgical treatment for HHS (1987 to 2011), and histologic features of excised ulnar arteries were characterized. A total of 67 patients (mean age 45 y; range, 21 to 75 y; 65 men) were treated for unilateral or bilateral disease. Common symptoms included digital pain (96% of cases), cold intolerance (79%), cyanosis (70%), numbness (54%), tingling (51%), and ulceration (40%). Angiography showed ulnar artery occlusion (89%), irregularity (56%), tortuosity (46%), and digital emboli (89%). Common pathologic features (from 75 specimens) included: luminal thrombosis (87%); intimal thickening (60%) and fibrosis (57%); internal elastic membrane disruption (95%); medial fibrosis (96%), hypertrophy (43%), neovascularization (49%), dilatation (29%), and disruption (25%); and adventitial neovascularization (53%). Specific features of dysplasia were present in 10 cases (15%), including smooth muscle disorganization and additional smooth muscle bundles outside the external elastic membrane, but typical FMD was not identified. Histologic features in HHS most often represent secondary changes consistent with repetitive trauma. Dysplastic features can be found in occasional cases, but FMD does not appear to contribute to HHS in most patients. Angiography should be interpreted with caution in superficial locations, as a string-of-beads appearance may simply reflect a posttraumatic corkscrew deformity of the ulnar artery.

Background: Optimal surgical management of subungual malignant melanoma (SMM) has been debated.Methods: Our tumor registry was reviewed for surgically treated cases of SMM from 1914 to 2010. Resection levels were compared with outcome.Results: During a 96-year period, 124 cases of SMM were identified (65 men and 59 women). Mean age at diagnosis was 58 years. Mean length of symptoms before diagnosis was 2.2 years. Lesions occurred on the hand (n = 79) and foot (n = 45). The thumb (33.8%) and hallux (25.0%) were affected most. At diagnosis, most had local (83.9%) and regional nodal involvement (12.9%). Mean follow-up was 9.4 years.Mean Breslow depth was 3.1 mm. Amputations were most commonly performed on the thumb at the proximal phalanx or metacarpophalangeal joint (43.9%), and on the hallux at the proximal phalanx or metatarsophalangeal joint (69.0%).Disease progression occurred in 61 (49.2%) patients, and most commonly occurred as regional nodal (62.3%) and distant metastasis (42.6%). Disease progression-free survival rates at 5, 10, and 15 years were 57.1%, 49.9%, and 47.0%, respectively. Fifty-three patients died of melanoma-related causes. Disease-specific survival rates at 5, 10, and 15 years after surgery were 59.3%, 49.3%, and 45.2%. Overall survival rates at 5, 10, and 15 years were 60.5%, 43.8%, and 33.1%.In 116 patients who underwent amputation, resection level outcome analysis with univariate and multivariate analysis adjusting for tumor depth and clinical involvement demonstrated that level of resection was not significantly associated with progression-free, overall, or disease-specific survival.Conclusions: Diagnosis of subungual melanoma is often delayed and carries a poor prognosis. Conservative resections are warranted as resection level does not influence outcome when histologically free margins are obtained. Amputation through the proximal phalanx or the metatarsophalangeal joint is required in the hallux and toes. Fingers require resection through the distal interphalangeal joint. For the thumb, although resection through the interphalangeal joint proved adequate, secondary efforts should be directed toward maximizing function and quality of life. Function-preserving resections in the thumb with nail removal, partial distal phalanx resection, and volar flap reconstruction are easily performed and preserve length, maximize joint and sensory function, and improve cosmesis.

Background: External hemipelvectomy is the ultimate salvage procedure for locally advanced pelvic tumors, infections, and failed revascularizations. It is associated with high wound morbidity requiring surgical management. In this study, the authors analyzed their experience with primary and secondary reconstruction of hemipelvectomy wounds. Methods: The records of 160 consecutive hemipelvectomy patients from the authors' institution were reviewed to identify the incidence of soft-tissue coverage problems and approaches to their management. Results: At the time of hemipelvectomy, a musculocutaneous hemipelvectomy flap was sufficient for closure in 159 patients, one patient needed a free lower leg fillet flap, and none required pedicle flaps. No hemipelvectomy hernias were observed, although abdominal wall reconstruction was performed in three patients. Wound complications were encountered in 62 patients (39 percent), and 51 patients required operative débridement. Thirty-three patients healed by secondary intention, and 25 underwent delayed reconstruction with local tissue rearrangements (n = 15), split-thickness skin grafting (n = 6), and pedicled flaps (n = 6). All pedicled flaps were contralateral inferiorly based rectus abdominis muscle (n = 2) and musculocutaneous (n = 4) flaps. Conclusions: Hemipelvectomy is associated with high wound morbidity. When the hemipelvectomy flap has a musculocutaneous design, hernias are exceedingly rare. Although immediate reconstruction is accomplished with a hemipelvectomy flap in the vast majority of cases, secondary reconstructions are often required for management of wound complications. For large defects, a contralateral inferiorly based rectus abdominis muscle or musculocutaneous flap is the reconstruction of choice. The rectus abdominis muscle should therefore always be preserved in hemipelvectomy patients by careful preoperative planning, especially when creation of an ostomy is considered.

ABSTRACT Capsular contracture is the most common and frustrating complication in women who have undergone breast implantation. Its cause and, accordingly, treatment and prevention remain to be elucidated fully. The aim of this prospective observational pilot study was to test the hypothesis that the presence of bacteria on breast implants is associated with capsular contracture. We prospectively studied consecutive patients who underwent breast implant removal for reasons other than overt infection at the Mayo Clinic from February through September 2008. Removed breast implants were processed using a vortexing/sonication procedure and then subjected to semiquantitative culture. Twenty-seven of the 45 implants collected were removed due to significant capsular contracture, among which 9 (33%) had ≥20 CFU bacteria/10 ml sonicate fluid; 18 were removed for reasons other than significant capsular contracture, among which 1 (5%) had ≥20 CFU/10 ml sonicate fluid ( P = 0.034). Propionibacterium species, coagulase-negative staphylococci, and Corynebacterium species were the microorganisms isolated. The results of this study demonstrate that there is a significant association between capsular contracture and the presence of bacteria on the implant. The role of these bacteria in the pathogenesis of capsular contracture deserves further study.

Flaps are currently the predominant method of reconstruction for irradiated wounds. The usefulness of split-thickness skin grafts (STSG) in this setting remains controversial. The purpose of this study is to examine the outcomes of STSGs in conjunction with VAC therapy used in the treatment of irradiated extremity wounds.

Background. The purpose of this study was to analyze our experience with the management of patients with postpneumonectomy empyema treated by the Clagett procedure.Methods. Data were analyzed from our prospective database on 84 consecutive patients with postpneumonectomy empyema from July 1988 to June 2004.Results. There were 73 men and 11 women. Median age was 62 years (range, 35 to 77). Indications for pneumonectomy were malignancy in 77 patients and benign disease in 7. The pneumonectomy was done at our institution in 43 patients and elsewhere in 41. A right pneumonectomy was performed in 66 patients and a left in 18. All patients were managed with the Clagett procedure consisting of open pleural drainage, serial operative debridements, and eventual chest closure after filling the pleural cavity with antibiotic solution. A bronchopleural fistula was present in 55 patients and was closed in all. Amuscle flap was used to reinforce the bronchial stump in 60 patients (71%), 51 with a bronchopleural fistula, and 9 without. Operative mortality was 7.1%. Median follow-up was 1.5 years (range, 0 to 22). Overall, 81% of patients had a healed chest wall without evidence of recurrent infection. The bronchopleural fistula remained closed in all patients. Median overall survival was 3.4 years with a 5-year survival of 44.5%. Age less than 65 years and an interval between pneumonectomy and empyema of greater than 15 weeks were independent predictors of improved long-term survival.Conclusions. The Clagett procedure remains safe and successful in the majority of patients with postpneumonectomy empyema. Age less than 65 years and a long interval between pneumonectomy and empyema are important determinants of outcome.

A retrospective analysis of 12 patients with a head and neck tumor recurrence within a previous free flap treated with extirpation and a second free flap is reported. A 15-year experience at Mayo Clinic, Rochester, from 1988 to 2003 of 12 patients (5 men, 7 women) who underwent 25 free flaps is reviewed. The overall flap survival rate was 92%, with a 100% survival rate in the first free-tissue transfer and 85% survival rate in the second free-tissue transfer. There was 1 minor complication (8%) and there were 2 major complications (15%) among the second free flaps. Overall, 10 of 13 (77%) second free flaps were anastomosed to ipsilateral neck vessels. Moreover, in 5 of 13 cases (38%) the same artery and in 7 of 13 cases (54%) the same vein were used for both the first and second free flaps. Reconstruction of the head and neck with a second free flap in patients with a recurrent tumor is safe and effective. The original recipient vessels can often be used for the second reconstruction.

Tran, Nho V MD*, **; Petty, Paul M MD*; Bite, Uldis MD*; Clay, Ricky P MD, FACSa; Johnson, Craig H MD*; Arnold, Philip G MD, FACS* Author Information

BACKGROUND:Radiation effects make operative dissection difficult, impair subsequent healing, and increase morbidity. This study evaluates tissue reinforcement of the irradiated bronchus as a modality to reduce morbidity after lobectomy for lung cancer.METHODS:We retrospectively reviewed all patients who had preoperative radiotherapy before lobectomy for lung cancer between May 1977 and June 2000.RESULTS:There were 56 patients (33 men and 23 women) who ranged in age from 42 to 80 years (median, 59 years). Bronchial stump reinforcement included no coverage in 24 patients (42.8%), mediastinal tissue (parietal pleura, pericardial fat, or azygos vein) in 16 (28.6%), and muscle (serratus anterior) in 16 (28.6%). Median preoperative radiation dose was 4,600 cGy (range, 3,000 to 9,810 cGy) and did not differ between the groups. There were three deaths (13%) in the no coverage group, one (6%) in the mediastinal tissue group, and one (6%) in the muscle group (NS). Pulmonary complication rate was 67% in the no coverage group, 44% in the mediastinal group, and 25% in the muscle group (p = 0.03). Median duration of chest tube drainage was 8 days in the no coverage group, 6 days in the mediastinal group, and 5 days in the muscle group (p = 0.006). Median hospital stay was 13 days in the no coverage group, 9 days in the mediastinal group, and 7 days in the muscle group (p = 0.02). Patients in the muscle group had reduced hospital stay, duration of chest tube drainage, and pulmonary complications compared with the other two groups (p < 0.05). Subjectively, presence and magnitude of postoperative pain, range of motion, and strength of the upper extremity of the muscle flap side were not different between the groups (p = NS). Follow-up was complete and ranged from 4 to 147 months (median, 17 months).CONCLUSIONS:Tissue reinforcement of the irradiated bronchus after lobectomy reduces postoperative morbidity and hospitalization. Transposition muscle flap may be preferred.

Carotid reconstruction combined with myocutaneous flap coverage is a rare and challenging operation. We reviewed our experience to define the indications and outcome of this complex procedure. Clinical data and neurologic, wound, and vascular complications of all patients who underwent carotid artery reconstruction combined with myocutaneous flap coverage over a 17-year period were retrospectively reviewed. Results from this procedure indicate that pectoralis major myocutaneous flap is a safe and durable option for wound coverage in patients who undergo carotid endarterectomy, resection, and/or reconstruction for neck malignancy, previous irradiation or graft infection. Late outcome is favorable with low neurologic, vascular, and wound complication rates.

The purpose of this study is to introduce the procedure and results of a combined free flap reconstruction with an external ear prosthesis after tumor extirpation from the lateral side of the head. Over the last 3 years, four patients have undergone total auricle extirpation for varying tumor processes. Each was reconstructed with a radial forearm flap, preserving the external auditory meatus. After primary healing and adjuvant therapy, a prosthetic pinna was applied. Combined use of microsurgical techniques with a prosthetic ear has produced an aesthetically superior result for large soft-tissue defects of the side of the head. This combined technique is able to provide the best aspects of both microsurgical and prosthetic reconstructions for a superior result for the patient.

A retrospective analysis of 100 consecutive patients undergoing free fibula harvest at the Mayo Clinic is presented. Every patient was analyzed by reviewing postoperative physical examination data. All patients were evaluated and followed in the early postoperative course by the physical medicine and rehabilitation services. Patients were followed from 3 to 60 months, with an average follow up of 17.42 months. In the patient group, 72 flaps were osseous and 28 osteocutaneous.Thirty-six complications at the donor site were observed in 30 patients. An additional 19 patients required prolonged pharmacologic pain control beyond the first 6 postoperative weeks, with no donor-site complications clinically detectable. Hammertoe was observed in six patients and wound dehiscence in seven patients. Tendon exposure was observed in five patients; partial split-thickness skin graft loss was observed in eight. Numbness of the foot was reported in 10 patients. Fifteen patient had limited maximum ambulatory distance to less than 1000 m. An additional six patients reported difficulty walking stairs.Attention to details and meticulous wound care are required to further reduce wound-healing complications. Immediate postoperative involvement of the physical medicine and rehabilitation services was beneficial in early patient mobilization and achievement of preoperative ambulation levels. After a short rehabilitation period, the majority of patients were able to engage in all daily activities.

The mallet finger deformity is easy to diagnose because the patient is unable to extend the distal phalanx of a finger. A lateral radiograph of the finger usually shows whether this is a fracture-type mallet or a purely tendinous disruption. These injuries are commonly the result of a work-or sports-related injury. The vast majority of these injuries can be treated with splinting with very few long-term sequelae or negative side effects. For those fracturetype injuries that cannot be properly reduced or maintained with an external splint, the Ishiguru technique described in this article is versatile and reliable. Although the majority of mallet fingers can be treated with an external splinting technique, this buttress pinning technique is extremely valuable to the armamentarium of the practicing hand surgeon.

Optimal results after the treatment of distal radius fractures continue to be a challenging problem for today's hand surgeon. Long-term complications as a result of the original injury or its treatment may produce functional difficulties in the distal forearm and secondary problems in the wrist. The modern hand surgeon will often be called on to see these common injuries, and needs to be well versed in the diagnosis and treatment of distal radius fractures. A concerted effort to strive for restoration of the bony anatomy is imperative. Towards that end, we present here the concept of treatment with the combined use of two techniques, both of which in the past have independently shown to be useful and reliable modalities in the treatment of distal radius fractures. The benefits of using multiplanar ligamentotaxis with the Agee wristjack supplemented with Kapandji intrafocal pinning are shown in a case presentation. In properly selected patients this combined technique is useful in the armamentarium of the hand surgeon in treating difficult, unstable distal radius fractures.