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Hidradenocarcinomas are rare, aggressive sweat gland tumors typically occurring in the scalp and upper extremities. They have rarely been described in the lower extremity. Due to their rarity, there is little consensus on optimal adjuvant therapy for these tumors after resection. Regardless, it is important to plan tumor excision and subsequent reconstruction with adjuvant therapy in mind. This case report describes a patient for whom a local muscle flap with skin graft provided adequate wound coverage after excision of hidradenocarcinoma and negative-pressure wound therapy. The surgical site then withstood adjuvant radiation therapy. When radiation is planned to a wound bed after tumor excision, a local muscle flap is the excellent first choice over skin graft alone regardless of wound bed characteristics.

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Supplemental Digital Content is available in the text.

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Vascular grafts, as either interpositional conduits or bypass grafts, can be used for revascularization procedures in the upper extremity. Vein grafts are more readily available and can be easier to harvest. Arterial grafts may provide superior patency rates compared with vein grafts. Arterial grafts can be located and harvested with consistent and reliable anatomy throughout the body.

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CASE: A fifty-six-year-old man had an open radiocarpal and intercarpal dislocation with a radial styloid fracture, an open triangular fibrocartilage complex tear, and complete bodily extrusion of the lunate. We performed irrigation and debridement and an immediate total wrist arthrodesis. One year postinjury, the fusion had healed without infection, and the patient had functional digital range of motion, 80° of active pronation, and 60° of active supination without distal radioulnar joint instability; he had only mild pain with strenuous activities. CONCLUSION: In this severe case, we believed that total wrist arthrodesis was the most reliable treatment option, and it produced an acceptable result.

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BACKGROUND: The exact risk that poor glucose control introduces to patients undergoing surgical closure has yet to be fully defined. METHODS: The authors retrospectively analyzed a prospectively collected database of patients seen at their wound care center to evaluate the effects of chronic and perioperative glucose control in high-risk patients undergoing surgical wound closure. Hemoglobin A1c and blood glucose levels for the 5 days before and after surgical closure were recorded and compared with the primary endpoints of dehiscence, infection, and reoperation. Univariate and multivariate analyses were performed. RESULTS: Seventy-nine patients had perioperative glucose levels and 64 had hemoglobin A1C levels available for analysis. Preoperative and postoperative hyperglycemia (defined as any blood glucose measurement above 200 mg/dl) as well as elevated A1C levels (above 6.5 percent or 48 mmol/ml) were significantly associated with increased rates of dehiscence (odds ratio, 3.2, p = 0.048; odds ratio, 3.46, p = 0.028; and odds ratio, 3.54, p = 0.040, respectively). Variability in preoperative glucose (defined as a range of glucose levels exceeding 200 points) was significantly associated with increased rates of reoperation (odds ratio, 4.14, p = 0.025) and trended toward significance with increased rates of dehiscence (p = 0.15). In multivariate regression, only perioperative hyperglycemia and elevated A1c were significantly associated with increased rates of dehiscence. CONCLUSIONS: In primary closure of surgical wounds in high-risk patients, poor glycemic control is significantly associated with worse outcomes. Every effort should be made to ensure tight control in both the chronic and subacute perioperative periods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

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INTRODUCTION: For patients undergoing prosthetic breast reconstruction whose device was removed because of infection or exposure, there is no published information examining long-term outcomes. Despite initial failure, many patients want to pursue breast reconstruction. METHODS: A retrospective review was performed of immediate prosthetic breast reconstruction failures during a 5-year period. RESULTS: A total of 26 patients (29 breasts) were identified who failed primary prosthetic 2-stage reconstruction. On average, the device was removed 262 days from the initial expander placement. Of these breasts, 19 were removed for infection, 7 for exposure, and 3 for a combination of both. Of these 29 failures, secondary reconstruction was attempted in 20 (69%). Among secondary reconstructions, 13 were with a device and 7 with autologous tissue. Of the 13 (92.3%) secondary device reconstructions, 12 were successful.Those in whom secondary reconstruction was attempted were younger at initial reconstruction (48 vs 57 years; P = 0.038), had lower body mass indexes (BMIs) (26.0 vs 29.4; P = 0.27), and smaller breasts (650 vs 979 g; P = 0.23) than those who did not attempt secondary reconstruction.Of the nipple-sparing mastectomy patients, 100% underwent secondary reconstruction, whereas only 61% of skin-sparing mastectomy patients underwent secondary reconstruction (P = 0.14).For patients undergoing secondary reconstruction, those receiving a second device reconstruction had lower BMIs (24.7 vs 28.5; P = 0.18) and smaller breasts (489 vs 946 g; P = 0.08) than those with autologous reconstructions; 15% of secondary implant reconstructions underwent irradiation versus 43% of the secondary autologous reconstructions (P = 0.29). CONCLUSIONS: After failed prosthetic breast reconstruction, a second attempt with an implant in properly selected patients has a high success rate (92.3%).

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Vascular bypass is an accepted surgical procedure for treatment of hand and digital ischemia that is the result of identifiable arterial disease. Although vein grafts have traditionally been used as vascular conduits for reconstruction, arterial grafts present a better alternative, physiologically, for reconstruction and may result in superior outcomes. Arteries suitable for grafts are not abundant and, therefore, upper extremity surgeons must be informed about possible donor sites and techniques for harvest.

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PURPOSE: To conduct a systematic review of literature evaluating efficacy of venous and arterial grafts for distal upper extremity bypass surgery. METHODS: A PubMed search using MeSH terms "veins/surgery" OR "arteries/surgery" AND "radial artery/surgery" OR "ulnar artery/surgery" yielded 794 studies. Manual review produced 42 studies based on inclusion criteria of reported distal upper extremity bypass surgery, complete information on graft type used, examined patency of reconstruction, and described method for determining patency. Studies meeting inclusion criteria underwent data extraction focusing on demographics, revascularization site, conduit type, microsurgical technique, subjective/objective outcomes, and postoperative anticoagulation regimens. RESULTS: Sixteen studies met the inclusion criteria. In 145 patients, 152 grafts were performed for upper extremity revascularization, including 120 grafts for revascularization of distal ulnar artery circulation, 31 for distal radial artery circulation, and 1 for both distal ulnar and radial artery occlusions. Overall patency rate was 87% at an average follow-up of 34 months. Of 152 bypass grafts, 19 were arterial conduits. Donor sites included the deep inferior epigastric artery, subscapular artery, thoracodorsal artery, and descending branch of the lateral femoral circumflex artery. At a mean follow-up of 18 months, arterial conduit patency was 100%. The remaining 133 bypass procedures used vein grafts from various donor sites, including the saphenous, cephalic, and basilic veins. At an average follow-up of 37 months, overall vein graft patency rate was 85%. There was a statistically significant difference between patency rates of arterial conduits compared with venous conduits. All studies reported improved ischemic symptoms including reduction of cold sensitivity, pain, and digital ulceration. CONCLUSIONS: This review showed a high patency rate and clinical efficacy of distal upper extremity bypass surgery with a mean follow-up of almost 3 years. There may be a benefit of using arterial versus venous conduits, although further examination is needed given the small number of arterial reconstructions reported.

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PURPOSE: The purpose of this study is to evaluate the effect of Negative Pressure Wound Therapy (NPWT) on closed surgical incisions. We performed a prospective randomized controlled clinical trial comparing NPWT to standard dry dressings on surgical incisions. METHODS: Patients presenting to a high-volume wound center were randomized to receive either a V.A.C. (KCI, San Antonio, TX) or a standard dry dressing over their incision at the conclusion of surgery. These were primarily high-risk patients with multiple comorbidities. The 2 groups were compared, and all incisions were evaluated for infection and dehiscence postoperatively. RESULTS: Eighty-one patients were included for analysis. Thirty-seven received dry dressings, and 44 received NPWT. Seventy-four of these underwent lower extremity wound closure. Average follow-up was 113 days. There were no differences in demographic, preoperative, and operative variables between groups; 6.8% of the NPWT group and 13.5% of the dry dressing group developed wound infection, but this was not statistically significant (P = 0.46). There was no difference in time to develop infection between the groups. There was no statistical difference in dehiscence between NPWT and dry dressing group (36.4% vs 29.7%; P = 0.54) or mean time to dehiscence between the 2 groups (P = 0.45). Overall, 35% of the dry dressing group and 40% of the NPWT group had a wound infection, dehiscence, or both. Of these, 9 in the NPWT group (21%) and 8 in the dry dressing group (22%) required reoperation. CONCLUSIONS: There is a significant rate of postoperative infection and dehiscence in patients with multiple comorbidities. There was no difference in the incidence of infection or dehiscence between the NPWT and dry dressing group. This study is registered with ClinicalTrials.gov. The unique registration number is NCT01366105.

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PURPOSE: The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGA-cutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branch's clinical utility. METHODS: The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed. RESULTS: In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm(2), centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm(2) along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment. CONCLUSIONS: The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGA-communicating branch at condyle level. CLINICAL RELEVANCE: Improved understanding of the skin island associated with the DGA's saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest.

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OBJECTIVES: Botulinum toxin A has conventionally been used in the upper extremity to treat spasticity resulting from stroke, paraplegia, and dystonia. Recently, it has been used to relieve symptoms of vasospasm in Raynaud's phenomenon. This review summarizes the current literature on botulinum toxin A in the treatment of Raynaud's phenomenon and examines the proposed mechanisms of action, suggested techniques of administration, and clinical efficacy. METHODS: An Ovid MEDLINE search from 1950 to September 2010 was performed to identify any reports on the use of Botulinum toxin in the treatment of Raynaud's disease or associated vasoconstrictive disorders. All studies pertaining to "Raynaud's disease," "Raynaud's," or "vasoconstriction" were queried and meshed with a secondary search of studies pertaining to "botox" or "botulinum toxin type A." These reports were meshed and subsequently limited to human studies. All studies that met criteria were included and their outcomes evaluated and summarized. RESULTS: Since 2004, there have been 5 studies that have evaluated the use of Botulinum Toxin A for the treatment of Raynaud's. In each study, patients received a range of botulinum toxin injections (10-100 units) in their fingers and hands. The studies have many limitations (lack of controls, variable severity of disease, variability of dosing) but all report favorable clinical results. All showed overall improvement in patient pain as well as a reduction in soft tissue ulceration. CONCLUSIONS: Initial reports on the use of botulinum toxin A for Raynaud's phenomenon are promising. Larger controlled trials with improved study design are warranted. A better understanding of the mechanism of action, appropriate dose and dose frequency, and the efficacy relative to other medical and surgical treatments requires investigation.

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Pain, loss of motion, and instability in the small joints of the hand can result in debilitating loss of function and deformity. Salvage procedures are considered in the setting of complex nonreconstructable fractures, after failure of initial fracture treatment, and for the treatment of severe joint arthritides. This article reviews the merits of various reconstructive options in these settings and examines the pertinent anatomy, clinical challenges, and risk-benefit profiles of each option. The review is limited to salvage reconstructive procedures of the small joints of the hand.

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PURPOSE: The medial femoral condyle (MFC) vascularized corticoperiosteal flap has been well described for the treatment of nonunion with minimal bone loss. Recent applications of this donor site as a corticocancellous flap for large intercalary defects bring into question the vascular territory of bone supplied by the descending genicular artery (DGA). This study's purpose is to delineate the proximal extent of periosteal blood supply of the medial column of the femur provided by the DGA system. METHODS: In 18 cadaveric specimens, the DGA was isolated, measured, and cannulated. Using subtraction techniques of fluoroscopic angiography, the vascular network and proximal-most extent of periosteal perfusion were recorded using radiopaque contrast dye. RESULTS: The DGA branched from the superficial femoral artery 14.2 ± 2.4 cm proximal to the joint line of the knee. The length of the vascular pedicle to its attachment onto the periosteum was 7.7 ± 2.2 cm. All specimens demonstrated a filigree of periosteal vessels dominated by a transverse and a longitudinal branch at the level of the condyle. Proximal perfusion was consistently noted by a large, longitudinal medial metaphyseal periosteal artery. The medial metaphyseal periosteal artery demonstrated that the proximal-most perfusion of the DGA was 13.7 ± 1.3 cm proximal to the joint line. Average femur length was 47.1 ± 3.1 cm. The DGA provided perfusion of 29% ± 2% of the total length of the medial femur. CONCLUSIONS: The DGA provides a large and reliable region of periosteal perfusion, suggesting that corticocancellous MFC harvest might provide the benefits of vascularized bone for large, intercalary nonunion defects conventionally treated with fibula flaps. CLINICAL RELEVANCE: Harvest of MFC osseous flaps extending up to 13.7 cm proximal to the joint line can be perfused from the DGA pedicle. The MFC donor site might, therefore, be a reliable option for vascularized reconstruction of larger bone defects.

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UNLABELLED: Orthognathic procedures require extensive preoperative planning to maintain high fidelity of fabricated splints to anticipated skeletal and soft tissue changes. The authors report their use of the computer-assisted surgical simulation modeling system in preoperative planning and splint fabrication and the significant reduction in their overall preoperative time. Upper and lower bite registrations were sequentially created on a single bite jig with fast-drying bis-acryl material, which was then mounted to a fiducial-based facebow for facial skeleton indexing. Indexing data were submitted, and occlusal splints were fashioned and returned to the senior surgeon. Between September 2010 and January 2011, 10 consecutive patients were enrolled. Surgical indications included six Le Fort I advancements and four combined Le Fort I/bilateral sagittal split osteotomy cases. Average time for bite registration was 10 minutes 16 seconds ± 1 minute 33 seconds, with an additional 8 minutes 6 seconds ± 4 minutes 45 seconds needed for modeling and virtual splint confirmation. Six patients required cephalometric tracings, for an additional 12 minutes 50 seconds ± 1 minute 10 seconds. Average total session time for all patients was 26 minutes 14 seconds ± 9 minutes 13 seconds. Computer-assisted surgical simulation markedly decreased the time for preoperative splint planning and fabrication time, and had a positive impact on reimbursement rates for orthognathic surgery, as calculated on a per-hourly basis. The improved accuracy generated may lead to decreased operative times and improved outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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Abdominal wall defects present a difficult problem for the reconstructive surgeon. Over the years, numerous implantable materials have becomes available to aid the surgeon in recreating the abdominal wall. This spectrum of implants includes permanent synthetic meshes, absorbable meshes, composite meshes and biomaterials. This review includes the pros and cons for the commercially available abdominal wall implants as well as a review of the literature regarding outcomes for each material. This review will provide the surgeon with current evidence-based information on implantable abdominal materials to be able to make a more informed decision about which implant to use.

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BACKGROUND: The success of a first web space contracture release is dependent on the individual parameters of thumb movement. Examining these parameters individually, it is possible to predict which components are important for providing successful outcomes. METHODS: We identified all patients who underwent a first web space contracture release over 7 years. Patients were examined for the following: radial abduction-abduction of the thumb in the plane of the hand; palmar abduction-abduction of the thumb 90° to the plane of the hand; and opposition-distance between first and fifth palmar digital crease. Measurements were compared between affected and unaffected hands, and correlations between components and patients' Disability of the Arm, Shoulder, and Hand (DASH) scores were determined. RESULTS: Thirty-nine patients underwent release of a first web space contracture; 11 agreed to participate. Opposition distance was significantly greater in the affected hand than in the unaffected hand. Grip strength was significantly lower in the affected hand. There were no significant differences in the radial or palmer abduction angles between hands. There was a moderate relationship between opposition distance and DASH score. There was no relationship between DASH and the other physical measurements. CONCLUSIONS: It is possible to obtain normal radial and palmar abduction angles after first web space release; however, success is not dependent on these absolute angles of abduction. Success of a release is related to the amount of opposition obtained, and it is difficult to achieve equivalent opposition to the unaffected hand. Grip strength and opposition remain decreased following contracture release.

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Unilateral mandibular asymmetry has numerous etiologies. In the absence of current dentofacial deformities, this asymmetry, although not functionally debilitating, can still be troubling to the patient. There are several approaches to correcting this asymmetry, mainly focusing on the facial skeleton. However, with unilateral asymmetry, correction of the hard tissue alone often produces a suboptimal result. The overlying soft tissue becomes stretched, producing an angulated appearance dissimilar to the contralateral normal side. The authors present a case report of a patient with mandibular asymmetry who was treated with our novel technique of intentionally undercorrecting the skeletal asymmetry with alloplastic implants while augmenting the overlying soft tissue with autologous fat grafting.

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Multiple patient comorbidities and environmental factors increase the risk of incisional wound complications. The literature suggests that negative pressure therapy (NPT) on clean closed surgical incisions may help reduce the risk of wound infections and other complications. In this case study, NPT was applied in the operating room to clean closed surgical wounds in four high-risk patients (two men, two women) following coronary artery bypass grafting using bilateral internal mammary arteries, transmetatarsal amputation, and abdominal hysterectomy. All wounds healed well. These results and currently available information suggest that prospective, randomized, controlled clinical studies to assess the safety, efficacy, and cost-effectiveness of NPT in the prevention of postoperative wound complications are warranted. In addition, if studies confirm the validity and reliability of the proposed patient grading system discussed, it may help guide use of NPT in postsurgical patients.

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