Giant hamartoma of the breast.

Hamartoma of the breast is a rare clinico-pathologic entity. Its clinical diagnosis can be extremely difficult; however, diagnosis is not difficult when it is made on the basis of a combination of radiologic and pathologic features. Its differential diagnosis includes a circumscribed fibrocystic mass, fibroadenoma, lipoma, cystosarcoma phylloides, and various carcinomas. A high index of suspicion is mandatory. In this study, we report a case of giant hamartoma of the breast in a young postlactational female patient, including treatment of the tumor by excisional biopsy and correction of the resulting breast deformity by mastopexy. Clinical, radiologic, and pathologic features are discussed.

Crossover innervation after digital nerve injury: myth or reality?

Several clinical studies promulgate the concept that some degree of crossover innervation occurs after digital nerve injuries are sustained and that the intact digital nerve might even substitute for the loss of nerve function on the injured side. Other studies strongly dispute the existence of this phenomenon. An excellent model for evaluation of crossover innervation is bilateral sharp digital nerve lacerations because there is no confusion of anomalous innervation from an intact contralateral nerve. This model avoids problems seen with replanted digits such as the inherent ischemia, multistructural injury, and the frequent crush component. The author evaluates the role of crossover innervation after digital nerve injury by comparing recovery of sensibility after unilateral and bilateral epineural neurorrhaphies. A retrospective review of 74 sharp unilateral and bilateral epineural digital nerve repairs in 54 patients using microsurgical techniques was performed by measurement of Weber's two-point discrimination (2PD). Fifty-four unilateral digital nerve repairs were performed in 46 patients who ranged in age from 8 to 54 years (mean age, 30.8 years). Concomitant flexor tendon injuries occurred in 50% of patients. Injury to repair was less than 1 day in 14.3% of patients, 2 to 7 days in 34.7%, 8 to 30 days in 40.8%, and 31 to 300 days in 10.2%. Follow-up ranged from 6 to 68 months (average follow-up, 13.8 months). Twenty bilateral digital nerve repairs were performed in 8 patients who ranged in age from 6 to 37 years (mean age, 27.6 years). Concomitant flexor tendon injuries occurred in 80% of patients. Injury to repair was less than 1 day in 10% of patients, 2 to 7 days in 60%, 8 to 30 days in 20%, and 31 to 300 days in 10%. Follow-up ranged from 6 to 77 months (average follow-up, 15.8 months). In this series, 2PD averaged 7.8 mm after unilateral digital nerve repairs compared with 7.1 mm after bilateral nerve repairs. Recovery of sensibility was also stratified into groups according to modified American Society for Surgery of the Hand guidelines: excellent, <6 mm; good, 6 to 10 mm; fair, 11 to 15 mm; and poor, >15 mm or protective sensation. Unilateral digital nerve repairs produced excellent results in 27.8% of patients, good in 46.3%, and fair in 25.9% compared with bilateral nerve repairs with excellent results in 15% of patients, good in 70%, and fair in 15%. There was no significant difference in recovery of sensibility after unilateral and bilateral digital nerve repairs. Crossover innervation did not appear to influence the long-term outcome after digital neurorrhaphy.

Free tissue transfer provides durable treatment for large nonhealing venous ulcers.

BACKGROUND: Most venous ulcers (VUs) will heal with conventional treatment, which focuses on improving regional venous hemodynamics. This treatment, however, often fails to heal large, recurrent VUs that are associated with severe lipodermatosclerosis (LDS). These complicated ulcers may require correction of local venous hemodynamics and replacement of the surrounding LDS with healthy tissue. We report our experience managing 24 especially difficult VUs with debridement and free flap coverage. PATIENTS AND METHODS: Between 1987 and 1997, 25 free flap procedures were performed in 22 patients for 24 recalcitrant VUs. Ulcers had been present for a mean of 5.24 years and had failed to heal with conservative therapy and split-thickness skin grafts (STSGs) (mean, 2.2). Eleven patients (46%) had exposed bone, tendon, or joint. At operation the area of LDS was excised, and all perforating veins were ablated. The defects after excision ranged from 100 to 600 cm(2) (mean, 237 cm(2)). The free flap was inset within the defect and covered with an STSG. RESULTS: We healed all 24 ulcers with free tissue transfer (one patient required a second flap after the first failed). There were no deaths. Local complications that required repeat STSG occurred in three (13%) of the 24 successful flap transfers. Four other flaps had minor local complications that healed with local wound care. Follow-up was available for 21 of the 24 successful flap transfers. No recurrent ulcers were identified in the territory of the flap after a mean of 58 months, but three patients had new ulcers in the same leg after 6 to 77 months. Patients with severe complications were hospitalized longer than those with minor or no complications (45.7 vs 12.8 days, P <.01), and their hospital charges were greater ($76,681 vs $30,428, P <.01). CONCLUSION: Free tissue transfer can provide rapid healing and long-term relief from severe VUs that are unable to be treated with conventional therapy. This technique improves venous hemodynamics, removes all liposclerotic tissue, provides an abundant blood supply, and resolves the tissue-related components of chronic ulceration. Although further work is needed to determine the optimal indications, this technique provides a durable treatment for especially recalcitrant ulcers.

Recovery of sensibility after digital neurorrhaphy: a clinical investigation of prognostic factors.

A multicenter retrospective review of 172 epineural digital nerve repairs using microsurgical techniques was performed. A total of 71 men and 25 women ranged in age from 5 to 64 years (mean age, 33.3 years). Sharp injuries occurred in 55.6% of patients and mild crush occurred in 44.4%. Isolated nerve injuries occurred in only 24.6% of patients. The majority of digital nerve injuries involved other structures: flexor tendons (33.5%), tendons and fractures (9.0%), and fractures (4.2%). Replantations were performed in 18 digits (21.6%) and revascularizations in 7 digits (7.2%). Injury to repair was less than 1 day in 47.8%, 2 to 7 days in 22.6%, 8 to 30 days in 23.3%, and 31 to 300 days in 6.3%. Follow-up averaged 22.2 months (range, 6-77 months). The authors found a significant correlation between age and recovery of sensibility as measured by Weber's two-point discrimination test (p < 0.001). Patients older than 40 years demonstrated significantly poorer recovery of sensibility than patients younger than 40 years. A trend of better sensibility return was noted in the younger age decades (<40) with declining age; however, the intergroup differences were not significant. There was also a significant correlation between severity of injury and recovery of sensibility (p < 0.001). Sharp injuries (8.2 mm) demonstrated significantly improved recovery of sensibility compared with mild crush (10.8 mm). Fractures (11.1 mm), fractures and tendon involvement (11.4 mm), and replantations (11.8 mm) demonstrated significantly diminished recovery of sensibility compared with isolated nerve injuries (7.9 mm), tendon involvement (8.1 mm), and revascularizations (9.3 mm). There did not appear to be any significant difference in recovery of sensibility according to gender, digit involved, radial or ulnar side of digit, median or ulnar nerve distribution, level of injury (except for the metacarpophalangeal joint and the distal palmar crease where most replantations occurred), or time interval from injury to repair. There was a weak negative correlation between length of follow-up and recovery of sensation.

Arteriovenous malformation of the forehead, anterior scalp, and nasal dorsum.

Management of complex and relentless large arteriovenous malformations with long term control and acceptable aesthetic results can be accomplished. This outcome requires selective intra-arterial embolization, judicious surgical resection, composite reconstruction with free tissue transfer, other ancillary procedures, or both, and careful serial follow-up examinations to rule out recurrent or persistent disease.

Upper extremity infections in patients with diabetes mellitus.

Forty-five consecutive diabetic patients with 46 upper extremity infections who underwent surgical debridement were retrospectively reviewed. The infections involved the skin or subcutaneous tissue in 19 patients and the fascia, tendon, muscle, or bone in 27. Twenty-three infections (50%) required a single operation and 23 required more than 1. Eighteen infections (39%) required an amputation and there were 3 deaths directly related to an infection. Six of 7 infections in which anaerobic organisms were cultured culminated in amputation. Four patients were diagnosed with necrotizing fasciitis. Twenty-one cultures (46%) were polymicrobial. An increased rate of amputation was associated with deep infections below the subcutaneous tissue, renal failure, and infections with gram-negative, anaerobic, or polymicrobial cultures. An increased rate of repeat surgery and a prolonged hospitalization were associated with deep infection and polymicrobial infections.

Topical and systemic calcium channel blockers in the prevention and treatment of microvascular spasm in a rat epigastric island skin flap model.

Vasospasm is a frustrating problem commonly encountered in microvascular surgery. Extreme arterial vasoconstriction usually occurs intraoperatively, shortly after release of the vascular clamps, but can be a problem for 48 to 72 hours postoperatively. Failure to alleviate vasospasm can have disastrous consequences in replanted and revascularized tissues, ultimately resulting in microsurgical failure. The authors investigated the efficacy of topical and systemic administration of two commonly prescribed calcium channel blockers-nifedipine and verapamil-in both the prevention and treatment of vasospasm in a rat epigastric island skin flap model. Superficial epigastric island skin flaps were elevated in 60 Sprague-Dawley rats. Femoral vessels were isolated from the inguinal ligament to a point 1 cm distal to the origin of the epigastric vessels, and the feeding vessels were ligated. The flap was returned to its natural anatomic bed and was sutured into place, leaving the femoral vessels exposed. The femoral artery and vein were transected, and anastomoses were performed under the operating microscope. A block of ice was then applied directly to the anastomotic site for 1 minute to induce additional vasospasm. Groups I through III received topical application of solutions of 0.5 ml of either 0.9% normal saline (control), verapamil (2.5 mg per milliliter), or nifedipine (5 mg per milliliter) directly to the anastomotic site immediately prior to release of the vascular clamps. Groups IV through VI received intraperitoneal injections of 1.0-ml solutions of either 0.9% normal saline (control), verapamil (2.5 mg per milliliter), or nifedipine (5 mg per milliliter) at 30 minutes prior to performing the anastomoses. Thermocouple temperature probes reflecting blood flow were placed at the center of the skin flap in a subcutaneous position, at the proximal femoral artery, and at the takeoff of the epigastric artery. Accurate, direct temperature measurements of the isolated skin flap and femoral vessels were recorded at 10, 20, and 30 minutes after release of the vascular clamps. Topical and systemic administration of verapamil and nifedipine moderated significantly the temperature declines observed at 10 minutes at the level of the femoral artery proximally and distally compared with controls. Following this decline, groups I through III (topical) demonstrated significant recovery of temperature toward baseline, with verapamil and nifedipine showing significantly better recovery of temperature than controls. Groups IV through VI (systemic) demonstrated a stabilization of temperature without any significant additional recovery of temperature toward baseline. Verapamil was more effective than nifedipine in its actions when administered topically or systemically. The authors' results suggest a potential role for topical and systemic administration of verapamil and nifedipine in preventing, or at least minimizing, the deleterious effects of vasospasm on flap survival, as demonstrated by its temporizing effect on temperature change across the anastomosis in their model.

Open fractures of the hand.

Open fractures of the hand are a challenging clinical problem for the orthopedic surgeon. The fracture is often comminuted with substance loss. Additionally, the fracture site can be contaminated by foreign material. The soft tissue envelope is violated with a variable degree of tissue devitalized. The wound contamination and tissue destruction lead to a rate of infection that can be much higher than that for a closed fracture. Initially, management of a significant soft tissue injury must take precedence over definitive fracture fixation. Proper staging of debridement, wound closure, and definitive fixation is paramount in minimizing infection while obtaining fracture union.

Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases.

Twenty-five patients underwent soft-tissue reconstruction of the different anatomic regions of the foot and ankle using the microvascular radial forearm free flap. The patients, 19 men and 6 women, ranged in age from 3 to 80 years (mean, 48.4 years). Indications for the surgery included diabetes and/or vascular insufficiency (10 patients), trauma (9 patients), tumor (3 patients), gunshot wound (2 patients), and burn (1 patient). Osteomyelitis occurred in patients with traumatic (3 patients) and diabetic (3 patients) wounds. The weight-bearing surface of the foot was involved in eight patients. Defects ranged in size from 45 to 210 cm2 (mean, 100.4 cm2). The radial forearm flap was successful in 23 of 25 cases (92 percent). Flap complications included flap loss (two patients), infection (three patients), and minor wound dehiscence at the flap-leg skin interface (two patients). Recurrent ulceration occurred in two patients; both were diabetics with weight-bearing flaps. Donor site complications included partial skin graft loss with tendon exposure in two patients; both healed with conservative management. Recurrent or persistent osteomyelitis was not seen in any of the patients. Of the eight patients with weight-bearing flaps, four were ambulatory, one had limited ambulation, one was nonambulatory, one had too short a follow-up, and one suffered flap loss. Two patients required modified shoes. Debulking was performed in one patient. Follow-up ranged from 2 to 72 months (mean, 24.9 months). The radial forearm flap meets most of the anatomic prerequisites for the ideal foot flap. It facilitates the restoration of normal foot contour by replacing "like-with-like," allowing patients to use normal shoes without the need for debulking (except in one patient); it provides a durable and stable weight-bearing plantar surface during ambulation; it achieves excellent aesthetic results without the dryness or cracking of the hypertrophied skin-grafted muscle; and it permits sensory reinnervation. We have found it especially useful for resurfacing the dorsum, ankle, and forefoot, moderate-sized defects, weight-bearing surfaces, and osteomyelitic wounds.

Snowblower injuries to the hand.

A retrospective review of 22 patients who sustained snowblower injuries to the hand was performed. There were 17 men and 5 women, ranging in age from 20 to 68 years (average age, 39.7 years). Fifty percent were manual laborers, 25% were unemployed, 15% were office workers, and 10% were not categorized. The dominant hand was involved in 86% of patients. In all patients, injuries occurred during an attempt to unclog manually the snowblower of wet snow. Patients were evaluated initially in the emergency room, where their wounds were irrigated and debrided, subungual hematomas drained, and nail bed lacerations repaired. Patients with more extensive injuries were taken to the operating room for definitive treatment including open or closed reduction of fractures, fingertip replacement as composite grafts or skin grafts, revision amputations, tenorrhaphies, and digital nerve repairs. All injuries occurred distal to the metacarpophalangeal joints. Only 1 patient sustained an injury to the proximal phalanx. Ten patients injured only 1 finger, 6 patients injured 2 fingers, and 6 patients injured 3 fingers. The middle and ring fingers were most commonly injured (39.6% and 33.3% respectively), followed by the index and little fingers (16.7% and 8.3% respectively), and the thumb (2.1%). Phalangeal fractures were the most common type of injury, occurring in 29.2% of patients, and usually involved the distal phalanx. This was followed in frequency by nail bed injuries (22.9%), amputations (22.9%), tendon lacerations (14.6%), soft-tissue avulsions (6.3%), and digital nerve injuries (4.2%). Snowblower injuries can involve bone, soft tissue, nail bed structures, nerves, and tendons, and may even result in amputation of one or several fingers. These injuries are localized to the distal portions of the fingers. The middle and ring fingers are most commonly involved, with relative sparing of the thumb. Fractures are the most frequent injury, followed by nail bed injuries and amputations. Snowblower injuries are often managed as open fractures with intravenous antibiotics; irrigation and debridement; and repair of bone, soft tissue, and nail bed structures.

Dupuytren's disease in African-Americans.

Seventeen African-American patients were operated on for Dupuytren's contracture over a 14-year period. Six-month minimum follow-up was available for 16 patients. The initial deformity, and results of surgical release of Dupuytren's contracture in this population was similar to that described in North Europeans.

"Spaghetti wrist": management and results.

A retrospective review of 60 patients with "spaghetti wrist" lacerations operated on by the authors between July of 1988 and June of 1996 was completed. Spaghetti wrist injuries were defined as those occurring between the distal wrist crease and the flexor musculotendinous junctions involving at least three completely transected structures, including at least one nerve and often a vessel. A total of 41 men and 19 women, average age of 29.0 years (range, 5 to 54 years), sustained spaghetti wrist injuries. The most frequent mechanisms of injury were accidental glass lacerations (61.0 percent), knife wounds (23.7 percent), and suicide attempts (8.5 percent). An average of 7.8 structures were injured including 5.8 tendons, 1.2 nerves, and 0.73 arteries. The most frequently injured structures were flexor carpi ulnaris (66.7 percent), median nerve (60.0 percent), flexor digitorum superficialis 2-5 (59.2 percent), ulnar nerve (58.3 percent), and ulnar artery (56.7 percent). A predilection for injury to the ulnar structures was observed. The flexor carpi ulnaris was more commonly injured than the more superficial central and radial palmaris longus (48.3 percent) and flexor carpi radialis (45.0 percent). The most common pattern of injury involved the ulnar nerve and artery and flexor carpi ulnaris, or so-called ulnar triad (41.7 percent). Combined median nerve, flexor carpi radialis, and palmaris longus lacerations occurred in 26.7 percent. Simultaneous lacerations of both median and ulnar nerves occurred in 23.3 percent. No distinct pattern of injury was noted in patients with simultaneous injury to both nerves. Simultaneous lacerations of both ulnar and radial arteries occurred in 6.7 percent; neither artery was injured in 33.3 percent. In the subset of 19 patients available for follow-up examination, range of motion was excellent in 12 patients and good in 7 patients. In 12 patients with sufficient follow-up, intrinsic muscle recovery was good in 7 patients and fair to poor in 5 patients. Sensory return was disappointing: seven patients recovered only protective sensation and five patients demonstrated return of two-point discrimination that ranged from 7 to 12 mm in three patients and from 2 to 6 mm in two patients.

Treatment of osteonecrosis of the femoral head with free vascularized fibular transfer.

Thirty-one free vascularized fibular bone grafts were performed for treatment of osteonecrosis of the femoral head in 26 patients. Twenty-four men and 2 women ranged in age from 16 to 48 years (mean, 32 years). Twenty-one patients had unilateral disease. Five patients had bilateral disease and underwent staged bilateral free vascularized fibular grafts 3 months apart. Associated etiological factors included alcohol (9 patients), steroid use (7 patients), and trauma (1 patient). The condition was considered idiopathic in the remaining 9 patients. Radiological staging by Ficat included stage I in 1 hip, stage II in 15 hips, stage III in 14 hips, and stage IV in 1 hip. A skin island flap was used for monitoring purposes to check the patency of blood flow to the grafted fibula. One flap failed by venous occlusion and was left as a nonvascularized bone graft. Thirty hips were followed. Pain was relieved in 28 hips (93.3%) and aggravated in 2 hips (6.7%). On radiographic evaluation, 26 hips (86.7%) demonstrated excellent preservation of the femoral head contour. Progressive collapse of the femoral head (>1-2 mm) occurred in two hips, with 1-mm depression in one hip with stage III disease and 2-mm collapse in one hip with stage IV disease. Follow-up ranged from 12 to 40 months (mean, 21 months). In conclusion, even in this relatively short follow-up period, the free vascularized fibular bone graft is an excellent treatment modality for preserving the femoral head and relieving symptoms in patients with osteonecrosis of the femoral head.

The chiasma of the flexor digitorum superficialis tendon.

Forty cadaver hands (160 fingers) were dissected to study the morphology and variations of the chiasma of the flexor digitorum superficialis tendon. Ten types of chiasma were noted. One chiasma did not fit into any of the patterns. The long and ring fingers had a very similar distribution of types of chiasma but the index and small both had different patterns. The length of chiasma showed a marked variability which appeared to be independent of phalangeal length.

Use of the free innervated dorsalis pedis tendocutaneous flap in composite hand reconstruction.

We used the free dorsalis pedis flap including the extensor digitorum longus or the extensor hallucis brevis, and/or the superficial peroneal nerve to reconstruct composite loss of skin and tendons on the dorsum of the hand. Between February 1992 and February 1996 we treated 7 patients with composite tissue loss on the dorsal hand caused by trauma or burn. Six men and 1 woman had an average age of 26 years (range, 19-42 years). Flap size ranged from 3 x 4 cm to 9.5 x 9 cm. The follow-up period ranged from 10 to 44 months. At 1 week postoperatively, active flexion and passive extension commenced, and progressive resistance exercises were performed for an additional 5 weeks. Two-point discrimination of the transferred flaps averaged 25 mm. Recovery rates for range of motion of the metacarpophalangeal joints in the operated fingers ranged from 83% to 99% (average, 91.4%). All transferred flaps showed similar color match and skin texture compared with the normal skin of the hand. The advantages of this procedure are mass action reconstruction with multiple tendons, provision of similar skin texture, sensory reinnervation, one-stage operation, faster healing with less adhesion formation, and early mobilization. The disadvantages are donor site scarring and weak extension of the toe.

Upper extremity infections in patients with the human immunodeficiency virus.

Twenty-eight patients with upper extremity infections and positive for the human immunodeficiency virus (HIV) were identified. The risk factor for HIV infection was intravenous drug injection in 24 patients, homosexual contact in 3, and heterosexual contact in 1. Eight of the patients had the acquired immunodeficiency syndrome. Two of the cases were prolonged herpetic infections of more than 6 months' duration that did not respond to oral acyclovir. The other 26 cases were bacterial in origin. Twenty-six of 28 cases responded to therapy with resolution of the infection. One patient refused surgical treatment and one died of systemic illness before resolution of the hand infection.

The "Tic-Tac-Toe" classification system for mutilating injuries of the hand.

Several classifications of mutilating hand injuries exist in the literature. Unfortunately, each of these provides a categorization that is arbitrarily grouped according to the part of the hand predominantly involved. It is imperative that a comprehensive classification system incorporate the degree and precise location of soft-tissue and/or bony destruction and the vascular integrity in addition to the predominantly involved part of the hand. We therefore devised a new classification system for mutilating injuries of the hand which categorizes them into seven types: (I) dorsal mutilation, (II) palmer mutilation, (III) ulnar mutilation, (IV) radial mutilation, (V) transverse amputations, (VI) degloving injuries, and (VII) combination injuries. These types are subcategorized into three subtypes: (A) soft-tissue loss, (B) bony loss, and (C) combined tissue loss. Vascular integrity is recorded with subscript notation: (0) vascularization intact or (1) devascularization. The hand is then systematically divided into nine numerical zones in "tic-tac-toe" fashion with radial, central, and ulnar columns and proximal, central, and distal rows. The "Tic-Tac-Toe" classification system allows the examining surgeon to describe precisely any mutilating injury of the hand. This system permits accurate assessment of each hand injury by assignment of the appropriate classification type, subtype, vascular status, and zone involvement. Clinical examples illustrate the user-friendliness and practicality of this new classification system.

Lower-limb salvage in a patient with recalcitrant venous ulcerations.

The authors report the salvage of a lower limb with recalcitrant venous stasis ulcers by "sequential" free flaps in a patient with co-existing chronic venous insufficiency and arterial occlusive disease. This presentation is interesting for inclusion of the following: (1) treatment of a recalcitrant venous ulcer by the combination of free-tissue transfer and valvular transplantation; (2) thrombosis of the free flap pedicle at an indeterminate time postoperatively without flap loss or leg ischemia; and (3) performance of a second free flap to the peroneal artery-only, to a one-vessel leg with an excellent clinical outcome at long-term follow-up.

Free tissue transfer in treatment of the recalcitrant chronic venous ulcer.

We propose that a long-term cure for the recalcitrant chronic venous ulcer must involve a dual surgical approach including (1) wide excision of the ulcer and surrounding liposclerotic tissue bed, and (2) replacement by a free flap containing multiple, competent microvenous valves with a normal microcirculation. Advantages of free flaps over skin grafting include improvement of the underlying pathophysiology; increase in blood supply to the area; ability to cover exposed bone, joint, or tendon; and a lower incidence of recurrence. During the past 8 years, 20 consecutive muscle free flaps were performed in 18 patients for 19 recalcitrant venous ulcers (two "sequential" flaps to the ipsilateral leg in 1 patient and a repeat flap after initial failure in 1 patient). Twelve males and 6 females ranged in age from 17 to 76 years (mean, 44 years). Nontraumatic, nonosteomyelitic venous ulcers had been present for an average of 3.5 years (range, 1-10 years) and failed an average of 2.4 skin grafts (range, 0-6 grafts). Defects ranged from 100 to 600 cm2 (mean, 238 cm2). Donor tissues included rectus abdominis (N = 13), latissimus dorsi (N = 5), gracilis (N = 1), and serratus (N = 1) muscles. Recipient vessels included posterior tibial (N = 12), anterior tibial (N = 6), and peroneal (N = 2). In all instances except one, only one vein, usually one of the venae comitantes, was anastomosed in end-to-end fashion. Successful free tissue transfer was accomplished in 18 of 20 flaps (90%). Complications included infection with partial flap and/or skin graft loss (three flaps), and partial skin graft loss (two flaps). There were no recurrences within the flaps; however, breakdown occurred at the junction between the flap and residual adjacent liposclerotic skin in 1 patient. Follow-up average 32.7 months (range, 8-65 months); 3 patients were lost to follow-up. Free muscle transfer can provide a long-term cure for the recalcitrant venous ulcer by replacing the diseased tissue bed with healthy tissue containing multiple, competent microvenous valves and a normal microcirculation. This can be accomplished in one reconstructive procedure with excellent long-term results.

Variations of the flexor digitorum superficialis tendon of the little finger.

Seventy cadaveric hands were dissected to study variations of the flexor digitorum superficialis tendon (FDS) to the little finger. Anatomical variations were present in 13% of hands and 10% of the hands showed an anatomical variation that would preclude independent FDS function in the little finger. The distance of the decussation from the metacarpophalangeal joint was measured. A ratio of this distance to proximal phalangeal length was calculated. The ratio indicated that decussation position was independent of phalangeal size.