Squamous Cell Carcinoma of the Hand: A Retrospective Study in Immunosuppressed and Immunocompetent Individuals.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) of the hand presents a treatment challenge because of the anatomical complexity of this location. Immunosuppressed patients are disproportionately affected by cutaneous SCC. Existing data on SCC of the hand are primarily presented in the orthopedic literature, and may thus be affected by referral bias. OBJECTIVE: Characterization of epidemiology and treatment outcomes for hand versus nonhand cutaneous SCC in immunosuppressed versus immunocompetent patients, across all clinical departments. MATERIALS AND METHODS: Single-institution retrospective cohort study of cutaneous SCC evaluated over 3 years and hand SCC over an additional 5 years. RESULTS: A cohort of 522 hand SCC cases (1,746 total SCC) was ascertained among 1,064 patients, of whom 175 were immunosuppressed. Occurrence on the hand was more common for SCC arising in immunosuppressed versus immunocompetent patients (38% vs 24% of cases respectively). Hand SCC cases demonstrated balanced laterality and comparable spectra of differentiation regardless of immunosuppression. No cases of hand SCC metastasis were observed over greater than 2 years' mean follow-up, and digital amputation was only required in approximately 1% of hand SCCs. CONCLUSION: In our cohort, assessment of hand SCC across all clinical departments suggests more favorable prognosis than reflected in the previous literature.

Surgical Upper Extremity Infections in Immunosuppressed Patients: A Comparative Analysis With Diagnosis and Treatment Recommendations for Hand Surgeons.

Background: Immunosuppression is encountered in patients with oncologic, transplant, and autoimmune disorders. The purpose of this study is to provide guidance for physicians treating surgical hand and upper extremity (UE) infections in immunosuppressed (IS) patients. Methods: We retrospectively reviewed our database of patients presenting with UE infections over 3 years. IS patients were matched randomly to non-IS patients. Patient background, infection presentation, surgical evaluation, and microbiology variables were recorded. Infection variables included mechanism, location, and type. Outcomes included inpatient length of stay (LOS) and need for repeat drainage. Results: We identified 35 IS and 35 non-IS out of 409 UE infection patients. Patients most commonly had a hematologic malignancy (34%) as their IS class, and the most frequent immunosuppressive medication was glucocorticoids (57%). IS patients were more likely to be older and less likely to have a history of drug abuse or hepatitis C virus infections. IS infections were more likely to have idiopathic mechanisms, more likely to involve deeper anatomy such as joints, bone, tendon sheath, or muscle/fascia, and less likely to present with leukocytosis. IS cultures more commonly exhibited atypical Mycoplasma or fungus. There was no difference between IS and non-IS patients regarding LOS or recurrent drainage. Conclusions: Mechanism and white blood cell count are less reliable markers of infection severity in IS patients. Physicians treating infections in IS patients should maintain a higher suspicion for deeper involved anatomy and atypical microbiology. Nonetheless, with careful inpatient management and closer surveillance, outcomes in IS patients can approach that of non-IS patients.

Rectus Abdominis Motor Nerves as Donor Option for Free Functional Muscle Transfer: A Cadaver Study and Case Series.

BACKGROUND: Current management of brachial plexus injuries includes nerve grafts and nerve transfers. However, in cases of late presentation or pan plexus injuries, free functional muscle transfers are an option to restore function. The purpose of our study was to describe and evaluate the rectus abdominis motor nerves histomorphologically and functionally as a donor nerve option for free functional muscle transfer for the reconstruction of brachial plexus injuries. METHODS: High intercostal, rectus abdominis, thoracodorsal, and medial pectoral nerves were harvested for histomorphometric analysis from 4 cadavers from levels T3-8. A retrospective chart review was performed of all free functional muscle transfers from 2001 to 2014 by a single surgeon. RESULTS: Rectus abdominis nerve branches provide a significant quantity of motor axons compared with high intercostal nerves and are comparable to the anterior branch of the thoracodorsal nerve and medial pectoral nerve branches. Clinically, the average recovery of elbow flexion was comparable to conventional donors for 2-stage muscle transfer. CONCLUSION: Rectus abdominis motor nerves have similar nerve counts to thoracodorsal, medial pectoral nerves, and significantly more than high intercostal nerves alone. The use of rectus abdominis motor nerve branches allows restoration of elbow flexion comparable to other standard donors. In cases where multiple high intercostal nerves are not available as donors (rib fractures, phrenic nerve injury), rectus abdominis nerves provide a potential option for motor reconstruction without adversely affecting respiration.

Impact of Time Interval between Radiation and Free Autologous Breast Reconstruction.

Background To evaluate whether the timing of surgery after radiation in autologous breast reconstruction affects major complications. Methods We performed a retrospective review of 454 free flaps (331 patients) for breast reconstruction at a single institution from 2003 to 2014. Charts were reviewed for age, BMI, laterality, flap type (TRAM, msTRAM, DIEP), surgeon, donor vessels (IMA, TD), chemotherapy, smoking, diabetes, hypertension, DVT, venous anastomoses, vein size, and time from radiation (none, < 12 months, or ≥ 12 months). The primary outcome of major complications was defined as partial/total flap loss, thrombosis, ischemia, or hematoma requiring return to the operating room. To identify independent predictors of major complications, a multivariate logistic regression was constructed. Alpha = 0.05 indicated significance in all tests. Results Average age was 47.4 ± 8.4. Free flaps consisted of msTRAM (41.1%), TRAM (29.6%), or DIEP (29.3%). The donor vessel was IMA in 66.9% of flaps or TD in 33.0% of patients with 90.7% using only one vein and 9.3% with two veins. The average IMA/TDV size was 2.5 cm ± 0.5. Preoperative radiation occurred in 31.2% of flaps. There were 54 flaps with at least one major complication (11.7%). On multivariate regression, only flap type (OR =4.04, p < .01) and vein size (OR = 0.13, p = 0.02) independently predicted major complications. Conclusion There was no significant difference in major complications between flaps who had reconstruction within 12 months and greater than 12 months after radiation. Only having a more muscle sparing technique or smaller vein size were independent risk factors for major complications.

Recurrent Compartment Syndrome Leading to the Diagnosis of McArdle Disease: Case Report.

Glycogen storage disorders are rare diseases of metabolism that are usually diagnosed when a patient presents with recurrent fatigue, muscle pains, and exercise intolerance. In this case report, we describe a patient who presented with the second episode of nontraumatic compartment syndrome over a 10-year span. Because of the obscure presentation, we performed a muscle biopsy, which on muscle phosphorylase staining revealed McArdle disease (glycogen storage disease type V).

Early reexploration for suspected thrombosis after pancreas transplantation.

BACKGROUND: Graft thrombosis is the most common cause of early graft loss after pancreas transplantation. Early reexploration may permit salvage or timely removal of the thrombosed graft. METHODS: This was a retrospective review of 345 pancreas transplants performed at a single center between January 2003 and December 2009. Early reexploration was defined as within 1 week of pancreas transplantation. RESULTS: Of the 345 transplants, there were 35 early reexplorations. The graft was compromised in 20 cases (57%): 10 venous thromboses, 3 arterial thromboses, 2 combined arterial and venous thrombosis, 2 thromboses secondary to allograft pancreatitis, and 3 cases of positional ischemia without thrombosis. Of these allografts, three reperfused once repositioned and six were successfully thrombectomized for a graft salvage rate of 45%. One of the thrombectomized grafts remained perfused but never functioned and was removed at retransplantation. The 10 remaining compromised grafts that were deemed unsalvageable and required allograft pancreatectomy. Nine of these recipients were retransplanted (eight within 2 weeks) and one was not a retransplantation candidate. CONCLUSIONS: Reexploration for suspected graft thrombosis after pancreas transplantation resulted in a negative laparotomy rate of 43%, but permitted graft salvage in 45% of compromised grafts.