Hypothenar hammer syndrome: long-term results of vascular reconstruction.

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. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Surgical management of subungual melanoma: mayo clinic experience of 124 cases.

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.

Microbial biofilms and breast tissue expanders.

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.

Surgical pathology of hypothenar hammer syndrome with new pathogenetic insights: A 25-year institutional experience with clinical and pathologic review of 67 cases.

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.

Soft-tissue reconstruction of external hemipelvectomy defects.

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.

Pilot study of association of bacteria on breast implants with capsular contracture.

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 >or=20 CFU bacteria/10 ml sonicate fluid; 18 were removed for reasons other than significant capsular contracture, among which 1 (5%) had >or=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.

Poland's syndrome.

The main purpose of surgical correction in Poland's syndrome is to improve chest wall symmetry and correct breast hypoplasia. Creation of an anterior axillary fold and smoothing out the infraclavicular defect greatly improves the final result. Cardiorespiratory function may be impaired, but serious conditions requiring early operative correction are rare. When present, unilateral costochondral agenesis involves one to three segments in the mid-anterior chest and sternal depression to that side. Operative planning in such cases includes a multi-layered approach to provide a solid base for soft tissue reconstruction of the more superficial layers.

Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC(R)) dressing for irradiated extremity sarcoma defects.

BACKGROUND: 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. METHODS: The records of 17 preoperatively radiated patients with extremity sarcomas reconstructed with STSGs in conjunction with VAC(R) therapy were reviewed regarding details of radiation treatment, wound closure, and outcomes. RESULTS: STSGs healed without complications (>95% of the graft take) in 12 (71%). Minor loss (6% - 20% surface) was noted in 3 patients (17.6%) and complete loss in 2 (11.7%). Two patients (11.7%) required flap reconstructions and 12 (88%) healed without further operative procedures. CONCLUSION: Although flap coverage is an established treatment for radiated wounds, STSG in conjunction with liberal utilization of VAC therapy is an alternative for selected patients where acceptable soft tissue bed is preserved. Healing of the preoperatively radiated wounds can be achieved in the vast majority of such patients with minimal need for additional reconstructive operations.

Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery.

OBJECTIVE: The best management for patients with small- to medium-sized vestibular schwannomas (VS) is controversial. METHODS: : A prospective cohort study of 82 patients with unilateral, unoperated VS less than 3 cm undergoing surgical resection (n = 36) or radiosurgery (n = 46). Patients undergoing resection were younger (48.2 yr versus 53.9 yr, P = 0.03). The groups were similar with regard to hearing loss, associated symptoms, and tumor size. The mean follow-up period was 42 months (range, 12-62 mo). RESULTS: Normal facial movement and preservation of serviceable hearing was more frequent in the radiosurgical group at 3 months (P < 0.001), 1 year (P < 0.001), and at the last follow-up examination (P < 0.01) compared with the surgical resection group. Patients undergoing surgical resection had a significant decline in the following subscales of the Health Status Questionnaire 3 months after surgery: physical functioning (P = 0.006), role-physical (P < 0.001), energy/fatigue (P = 0.02), and overall physical component (P = 0.004). Patients in the surgical resection group continued to have a significant decline in the physical functioning (P = 0.04) and bodily pain (P = 0.04) subscales at 1 year and in bodily pain (P = 0.02) at the last follow-up examination. The radiosurgical group had no decline on any component of the Health Status Questionnaire after the procedure. The radiosurgical group had lower mean Dizziness Handicap Inventory scores (16.5 versus 8.4, P = 0.02) at the last follow-up examination. There was no difference in tumor control (100 versus 96%, P = 0.50). CONCLUSION: Early outcomes were better for VS patients undergoing stereotactic radiosurgery compared with surgical resection (Level 2 evidence). Unless long-term follow-up evaluation shows frequent tumor progression at currently used radiation doses, radiosurgery should be considered the best management strategy for the majority of VS patients.

Postpneumonectomy empyema: results after the Clagett procedure.

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. A muscle 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.

Head and neck reconstruction with a second free flap following resection of a recurrent malignancy.

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.

Management of the irradiated bronchus after lobectomy for lung cancer.

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 artery reconstruction combined with myocutaneous flap coverage: a complex and durable rescue operation.

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.