An Evolution of the Surgical Management of Synpolydactyly: A Case Series of 21 Hands.

INTRODUCTION: Synpolydactyly is a rare congenital anomaly characterized by syndactyly and polydactyly in the central hand. Limited treatment guidelines exist for this complex condition. METHODS: A retrospective review of synpolydactyly patients was conducted at a large, tertiary pediatric referral center to describe our surgical experience and evolution of management. The Wall classification system was used to categorize cases. RESULTS: Eleven patients (21 hands) with synpolydactyly were identified. Most of the patients were White and had at least one first-degree relative who also had synpolydactyly. The Wall classification yielded the following results: 7 type 1A hands, 4 type 2B hands, 6 type 3 hands, and 4 uncategorizable hands. Each patient had an average of 2.6 surgeries and an average follow-up time of 5.2 years. The rates of postoperative angulation and flexion deformities were 24% and 38%, respectively, with many of these cases also demonstrating preoperative alignment abnormalities. These cases often required additional surgeries including osteotomies, capsulectomies, and/or soft tissue releases. The rate of web creep was 14% with 2 of these patients requiring revision surgery. Despite these findings, at the time of final follow-up, most patients had favorable functional outcomes, were able to engage in bimanual tasks, and were able to perform activities of daily living independently. CONCLUSIONS: Synpolydactyly is a rare congenital hand anomaly with a significant degree of variability in clinical presentation. The rates of angulation and flexion deformities as well as web creep are not insignificant. We have learned to prioritize correcting contractures, angulation deformities, and skin fusion, over simply trying to delete the "extra" number of bones as this may destabilize the digit(s).

Does Irreducibility Always Mean a Complex Dislocation? An Analysis of 33 Pediatric Metacarpophalangeal Joint Dislocations.

BACKGROUND: Previous failed reduction and certain radiographic indicators historically have been used to differentiate simple and complex metacarpophalangeal joint (MPJ) dislocations in children, the latter of which warrants open reduction. This investigation aimed to determine the necessity for open reduction with these indicators and establish a new treatment algorithm and educational focus for these rare injuries. METHODS: A 12-year retrospective study was conducted on all children with MPJ dislocations at a single pediatric hospital. The rates of successful closed reduction, number of reduction attempts, and radiographic findings were detailed. Operative details and postoperative outcomes were also gathered. RESULTS: Thirty-three patients with a mean age of 11.1 years were included. Most were male [ n = 27 (82%)] and had undergone two or more previous reduction attempts at an outside facility. Stable closed reduction was then achieved outside of the operating room in five patients and in the operating room under general anesthesia in another 14, for a total of 19 of 33 patients (57.6%). The thumb was injured most often [ n = 19 (57.6%)] and more likely to undergo successful closed reduction ( P = 0.04). There was no relationship between number of previous reduction attempts and ability to achieve closed reduction ( P = 0.72). Neither joint-space widening nor proximal phalanx bayonetting was correlated radiographically with failure of closed reduction ( P = 0.22 and P = 1, respectively). CONCLUSIONS: This study supports closed reduction of pediatric MPJ dislocations in the operating room under general anesthesia before conversion to open reduction, regardless of injury characteristics or previous reduction attempts. This strategy is likely to limit unnecessary open surgery and related risks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Passive Manipulation for Proximal Interphalangeal Joint Extension Contractures.

PURPOSE: We investigated closed passive manipulation as an alternative to surgery for certain proximal interphalangeal (PIP) joint extension contractures. METHODS: We retrospectively reviewed all patients with PIP joint extension contractures treated with passive manipulation at our institution between 2015 and 2019. The included patients were a minimum of 12 weeks from their initial injury/surgery (median 179 days; interquartile range: 130-228 days), had plateaued with therapy, and underwent a 1-time passive manipulation. All included fingers had congruent PIP joints and no indwelling hardware that could have had direct adhesions. Most (80%) patients had a direct injury to the finger ray(s) that led to the contractures. Most (75%) patients had the manipulation performed under local anesthesia in the office. Available measures of passive range of motion (PROM) and active range of motion (AROM) immediately, within 6 weeks, between 6 and 12 weeks, and at >12 weeks after the manipulation were recorded. RESULTS: Twenty-eight patients and 46 digits met the criteria. The median PIP joint PROM improved from 50° to 90° immediately following the manipulation. The median PROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks following manipulation were 80°, 85°, and 85°, respectively. The median AROM immediately after the manipulation improved from 40° to 90°, and the median AROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks were 70°, 50°, and 60°, respectively. None of the patients experienced worsening of PIP joint range of motion. One patient who had 4 fingers manipulated had a 45° distal interphalangeal joint extension lag for one of the fingers after the manipulation. Eight fingers underwent later flexor tenolysis or reconstruction to improve AROM after the gains in PROM via manipulation were maintained. CONCLUSIONS: Passive manipulation is an alternative to surgical release for select PIP joint extension contractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Targeted Muscle Reinnervation for Treatment of Postresection Interdigital Neuroma: A Cadaveric Feasibility Study.

BACKGROUND: Symptomatic postresection interdigital neuroma is a frustrating problem that causes debilitating foot pain. Implementing the concepts of targeted muscle innervation, this study offers a novel nerve transfer involving the resected third common plantar digital nerve (CPDN) to the motor nerve branch of the third dorsal interosseous muscle (DIMB) to improve postresection pain. METHODS: Ten fresh feet from seven cadaveric donors were used for this study. CPDN and DIMB lengths and diameters were measured, along with nerve overlap after the transfer with ankle in neutral position and in maximal dorsiflexion. Motor entry point to the calcaneal tuberosity and to the fifth metatarsal tuberosity were measured and used to evaluate the ratio relative to foot length. Means, standard deviations, and P values were calculated for each measure and between sexes and feet (right and left). RESULTS: In all specimens, the nerve transfer was technically feasible, without notable size mismatch between the donor and recipient nerves. CPDN, DIMB, and important anatomical reference points were identifiable in all specimens. Average CPDN length was 30.1 ± 8.2 mm. The average DIMB length was 14.4 ± 3.9 mm. The overlap between the donor and recipient in neutral ankle position at the transfer site was 6.4 ± 1.8 mm. CONCLUSIONS: Given their anatomical locations, a nerve transfer between the third CPDN and third DIMB is surgically feasible. This novel technique is a viable option that can be used instead of the conventional technique of muscle implantation or more proximal re-resection for symptomatic postresection interdigital neuroma.

Arterial Perfusion of the Proximal Phalanx Revisited: New Insights Based on Micro-Computed Tomography.

PURPOSE: To characterize the periosteal and endosteal arterial perfusion of the proximal phalanx using micro-computed tomography angiography (micro-CTA). METHODS: Cadaveric upper extremities were injected with a barium sulfate/gelatin suspension. Phalanges were imaged using micro-CTA and analyzed with a focus on osseous arterial anatomy. Periosteal and endosteal perfusion was characterized by number of vessels, length, anatomic course, and caliber. RESULTS: The base of the proximal phalanx had a significantly greater number (8.0 ± 3.5) of periosteal vessels than those of the shaft (4.1 ± 1.6) and head (1.3 ± 1.1). One-third (34.4%) of the specimens demonstrated a complete absence of periosteal vessels in the head. A nutrient endosteal vessel was noted in 100% of the specimens. Entering at the junction of the middle and distal third of the bone (25.8 ± 3.9 mm from base), the nutrient vessel entered the proximal phalanx of the index finger along its ulnar aspect (8 of 8 specimens), the middle finger along its radial aspect (6 of 8), the ring finger along its ulnar aspect (5 of 8), and the little finger along its radial aspect (7 of 8). The nutrient vessel branched into proximal and distal extensions toward the shaft and head, respectively, with an average endosteal length of 10.7 ± 5.2 mm and average diameter of 0.36 ± 0.11 mm. CONCLUSIONS: Periosteal contributions to the perfusion of the proximal phalanx appear to diminish distally. The endosteal arterial anatomy remains consistent, with a single nutrient vessel entering the intramedullary canal with reliable laterality on each digit. This is often the only vessel supplying the head of the proximal phalanx, making this area particularly susceptible to vascular compromise. CLINICAL RELEVANCE: An understanding of the patterns of perfusion of the proximal phalanx provides some insight into clinically observed pathology, as well as guidance for operative management.

Searching for an Alternative Method to Evaluate Surgical Knowledge: Does a Drawing and Labeling Quiz Predict In-Service Exam Performance and Enhance Learning?

BACKGROUND: The best methods to assess surgical knowledge are still debated. The authors used a non-multiple-choice test as a pre- and post-conference assessment to measure residents' knowledge gains with comparison to a standard summative assessment tool. METHODS: At one didactic conference, plastic surgery residents at a single institution were given a pre-test of drawing and labeling structures in the extensor mechanism of the finger and within the carpal tunnel. The quiz was followed by a lecture on the same material and a subsequent post-test. Scores were correlated with in-service exam performance. RESULTS: Pre-test scores (n = 13) were positively correlated with postgraduate year (PGY) until PGY-3. Performance on labeling structures was higher than performance on the respective drawing prompt. Residents' ability to label structures increased more strongly with PGY than their ability to draw structures. The post-test (n = 8) demonstrated that teaching improves performance on labeling questions (pre-test score = 62%; post-test score = 87%). Improvement was observed across all PGYs. Pretest results were positively correlated with in-service exam performance. CONCLUSIONS: Our study suggests that a knowledge test focused on drawing and labeling structures given to surgical residents is a valid, nontraditional method for assessing resident knowledge. Such a quiz would offer programs an alternative method for regularly evaluating residents aside from in-service questions, in order to identify residents who may need targeted training for the in-service exam and to inform teaching plans.Additionally, residents could use quiz feedback to guide study efforts and prime conference-related learning.

A Subperiosteal Proximal Phalanx Osteoid Osteoma: A Challenging Diagnosis.

A relatively rare tumor, osteoid osteoma most commonly affects the lower extremity. In 10% of the cases, it can affect the hand and wrist. We present a case of osteoid osteoma in the proximal phalanx of ring finger that was initially misdiagnosed as a soft tissue lesion. The soft tissue lesion was resected, but the symptoms recurred shortly thereafter, leading to repeat diagnostic workup. Despite X-rays, magnetic resonance imaging, and tissue biopsy, the diagnosis remained elusive until surgical re-exploration. Based on the lessons learned from this case and the experience reported in literature, we discuss the intricate nature of osteoid osteoma diagnosis in the hand, the obstacles often encountered, and how to approach these challenging patients in a stepwise and critical fashion.

A Systematic Review of Sensory Outcomes of Digital Nerve Gap Reconstruction With Autograft, Allograft, and Conduit.

BACKGROUND: Direct comparison of nerve autograft, conduit, and allograft outcomes in digital nerve injuries is limited. This study aims to compare the outcomes of nerve autografts, allografts, and conduits relative to primary repair (PR) through a systematic review. METHODS: A review of literature related to digital nerve gap repairs was conducted using PubMed/MEDLINE. Included articles were human clinical studies on digital nerve injuries repaired with nerve autograft, allograft, bovine collagen conduit, or PR. Patient characteristics, injury details, and complications were collected. Greater than 6-month outcomes included static 2-point discrimination, the British Medical Research Council Scale, or Semmes-Weinstein. RESULTS: Four autograft, 4 allograft, 5 conduit, and 7 PR publications were included. Allografts had the most repairs (100%) with static 2-point discrimination less than 15 mm, followed by autografts (88%), conduits (72%), and PR (63%). In British Medical Research Council Scale results, autografts (88%) and allografts (86%) were similar for patients with at least S3+ sensibility, compared to conduit (77%) and PR (39%). For Semmes-Weinstein, autografts demonstrated 93% normal sensation or diminished light touch, compared to allografts (71%), PR (70%), or conduits (46%). Conduits had the highest complication rate (10.9%), followed by autografts (5.7%), allografts (3.0%), and PRs (0.4%). CONCLUSIONS: Although a randomized clinical trial would provide strongest evidence of superiority, this review presents the highest percentage of patients with normal to near normal sensory recovery in allograft and autograft repairs with low rates of complications. Nerve conduit studies reported a higher rate of incomplete recovery of sensation and complications.

Pollicization of Biphalangeal Index Finger for Type IV Thumb Hypoplasia: A Case Report Describing Preoperative Planning, Intraoperative Decision-Making, and Technical Modifications.

BACKGROUND: Index finger (IF) pollicization is the standard treatment for severe congenital thumb hypoplasia. The procedure requires a supple and anatomically normal IF. No guidelines exist for IF pollicization in patients who have concomitantly underdeveloped IF, specifically when the digit has only 2 phalanges and 1 interphalangeal joint. METHODS: We present a case of a 20-month-old boy with congenital type IV thumb hypoplasia who also had biphalangeal IF. We proposed an IF pollicization operation that required significant modifications to the traditional procedure. RESULTS: Preoperative planning and intraoperative execution are described. The modifications to the traditional procedure included: (1) removal of proximal third of IF metacarpal; (2) creation of a de novo thumb carpometacarpal (CMC) joint by fibrous union whereby the IF CMC joint cartilaginous components are maintained and the remaining distal IF metacarpal is translocated down and secured to this cartilage (in contrast to the traditional use of IF metacarpophalangeal joint as a de novo thumb CMC joint); (3) preservation of IF joints at their "natural" position and function; (4) maintenance of intrinsic muscles at their original distal insertion sites; and (5) important adjustments to skin incision. CONCLUSIONS: Pollicization of biphalangeal IF can be executed in a safe and efficient manner. Early recovery has shown promising signs. Long-term results, including the de novo thumb CMC joint function, remain to be evaluated.

Partial Hand Transplant: Lessons Learned From Cadaveric Dissection Studies.

As the field of vascularized composite allotransplantation continues to expand, new upper extremity transplant candidates are being considered. We recently evaluated a bilateral amputee who had a mid-forearm amputation and a contralateral metacarpal hand amputation. In the latter limb, a "partial" hand transplant that preserved the majority of the patient's existing hand, including a partially severed thumb with intact thenar muscle function, was proposed. The feasibility of this partial hand transplant was studied in fresh-frozen cadaver limbs. This report details the proposed approach, the cadaveric dissections, and the lessons learned from these dissections. Issues of osteosynthesis, microvascular planning, and intrinsic muscle recovery are discussed, all of which are critical considerations for partial hand transplant candidates. Ultimately, the partial hand approach was felt to be inferior to a more conventional distal forearm transplant in this particular candidate. Practical, functional, and ethical implications of such decision are presented.

Soft-Tissue Reconstruction of the Complicated Knee Arthroplasty: Principles and Predictors of Salvage.

BACKGROUND: Total knee arthroplasty is a common orthopedic procedure in the United States and complications can be devastating. Soft-tissue compromise or joint infection may cause failure of prosthesis requiring knee fusion or amputation. The role of a plastic surgeon in total knee arthroplasty is critical for cases requiring optimization of the soft-tissue envelope. The purpose of this study was to elucidate factors associated with total knee arthroplasty salvage following complications and clarify principles of reconstruction to optimize outcomes. METHODS: A retrospective review of patients requiring soft-tissue reconstruction performed by the senior author after total knee arthroplasty over 8 years was completed. Logistic regression and Fisher's exact tests determined factors associated with the primary outcome, prosthesis salvage versus knee fusion or amputation. RESULTS: Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up, 1.8 years), with a salvage rate of 61.1 percent, mostly using medial gastrocnemius flaps. Patients referred to our institution with complicated periprosthetic wounds were significantly more likely to lose their knee prosthesis than patients treated only within our system. Patients with multiple prior knee operations before definitive soft-tissue reconstruction had significantly decreased rates of prosthesis salvage and an increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (Gram-negative greater than Gram-positive organisms) and particularly at the time of definitive reconstruction, which also trended toward an increased risk of amputation. CONCLUSIONS: In revision total knee arthroplasty, prompt soft-tissue reconstruction improves the likelihood of success, and protracted surgical courses and contamination increase failure and amputations. The authors show a benefit to involving plastic surgeons early in the course of total knee arthroplasty complications to optimize genicular soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The State of Prophylactic Mesh Augmentation.

Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and clinicaltrials.gov for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only-based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.

Incisional Hernia in the United States: Trends in Hospital Encounters and Corresponding Healthcare Charges.

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.

Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience.

BACKGROUND: Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. METHODS: Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. RESULTS: A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: "conservative management," "excision of mesh with primary closure," "single-stage reconstruction," "immediate staged repair," and "repair in contaminated field." Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional ("secondary") repairs after recurrence, 75% were eventually able to achieve "hernia-free" state. CONCLUSIONS: This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

The thumb ulnar pulp is a critical component of key pinch and precision manipulation. Injuries to this area should be reconstructed with robust, sensate tissue that restores bulk and contour. The existing reconstructive options, however, have substantial risks and drawbacks. We describe an anterograde homodigital neurovascular island flap that provides both sensate and durable coverage of the ulnar thumb pulp. The flap uses innervated glabrous tissue, limits donor site morbidity to the thumb and first web space, and does not require microvascular anastomoses or nerve coaptation. The flap has been previously described for nonthumb fingertip injuries, but it has not been applied to the thumb. We discuss several important technical modifications that are essential to raising and insetting this flap in the thumb, review potential pitfalls, and highlight key steps to ensuring judicious intraoperative decision making and success.

Concurrent panniculectomy in the obese ventral hernia patient: Assessment of short-term complications, hernia recurrence, and healthcare utilization.

BACKGROUND: Panniculectomy (PAN) is often performed concurrently with ventral hernia repair (VHR) in the obese patient. However, the effectiveness and safety profile of this common practice are not fully established in part because of paucity of comparative effectiveness studies. In this study, a comparative analysis of early complications, long-term hernia recurrence, and healthcare expenditures between VHR-PAN and VHR-only patients is presented. METHODS: From the Healthcare Cost and Utilization Project database, obese patients who underwent VHR with and without concurrent PAN were identified. Multivariate cox proportional-hazards regression modeling was performed to compare outcomes between the two groups. RESULTS: The final cohort included 1013 VHR-PAN and 18,328 VHR-only patients. The VHR-PAN patients experienced a longer adjusted length of hospital stay (6.8 days vs. 5.2 days; p < 0.001), a higher rate of in-hospital adverse events (29.3% vs. 20.7%; AOR = 2.34 [2.01-2.74]), and a higher rate of 30-day readmissions (13.6% vs. 8.1%; AOR = 2.04 [1.69-2.48]). However, the 2-year rate of hernia recurrence was lower in the VHR-PAN group (7.9% vs. 11.3%; AOR = 0.65 [0.51-0.82]). Both groups generated considerable hospital charges ($104,805 VHR-PAN vs. $72,206 VHR-only, p < 0.001). CONCLUSION: Performing a concurrent PAN in the obese hernia patient is associated with a higher rate of early complications and greater healthcare expenditures, but overall a substantially lower incidence of 2-year hernia recurrence. The literature review presented here also highlights a substantial need for further comparative effectiveness studies to create the needed framework for evidence-based guidelines.

Chemical component separation: a systematic review and meta-analysis of botulinum toxin for management of ventral hernia.

BACKGROUND: Ventral hernia represents a surgical challenge plagued by high morbidity and recurrence rates. Primary closure of challenging hernias is often prohibited by severe lateral retraction and tension of the abdominal wall musculature. Botulinum toxin injections have recently been identified as a potential pre-operative means to counteract abdominal wall tension, reduce hernia size, and facilitate fascial closure during hernia repair. This systematic review and meta-analysis reviews outcomes associated with botulinum toxin injections in the setting of ventral hernia, and demonstrates an opportunity to leverage this mainstream aesthetic product for use in abdominal wall reconstruction. METHODS: A literature review was conducted according to PRISMA guidelines using MeSH terms 'ventral hernia', 'herniorrhaphy', 'hernia repair', and 'botulinum toxins'. Relevant studies reporting pre- and postinjection data were included. Outcomes of interest included changes in hernia defect width and lateral abdominal muscle length, recurrence, complications, and patient follow-up. Qualitative findings were also considered to help demonstrate valuable themes across the literature. RESULTS: Of 133 results, 12 were included for qualitative review and three for quantitative analysis. Meta-analysis revealed significant hernia width reduction (mean = 5.79 cm; n = 29; p < 0.001) and lateral abdominal wall muscular lengthening (mean = 3.33 cm; n = 44; p < 0.001) following botulinum injections. Mean length of follow-up was 24.7 months (range = 9-49). CONCLUSIONS: Botulinum toxin injections offer tremendous potential in ventral hernia management by reducing hernia width and lengthening abdominal wall muscles prior to repair. Although further studies are needed, there is a significant opportunity to bridge the knowledge gap in preoperative practice measures for ventral hernia risk reduction.

A risk model and cost analysis of post-operative incisional hernia following 2,145 open hysterectomies-Defining indications and opportunities for risk reduction.

BACKGROUND: Incisional hernia (IH) is a complication following open abdominal hysterectomy. This study addresses the incidence and health care cost of IH repair after open hysterectomy, and identify perioperative risk factors to create predictive risk models. METHODS: We conduct a retrospective review of patients who underwent open hysterectomy between 2005 and 2013 at the University of Pennsylvania. The primary outcome was post-hysterectomy IH. Univariate/multivariate cox proportional hazard analyses identified perioperative risk factors. We performed cox hazard regression modeling with bootstrapped validation, risk stratification, and assessment of model performance. RESULTS: 2145 patients underwent open hysterectomy during the study period. 76 patients developed IH, and all underwent repair. 31.3% underwent reoperation, generating higher costs ($71,559 vs. $23,313, p < 0.001). 8 risk factors were included in the model, the strongest being presence of a vertical incision (HR = 3.73 [2.01-6.92]). Extreme-risk patients experienced the highest incidence of IH (22%) vs. low-risk patients (0.8%) [C-statistic = 0.82]. CONCLUSIONS: We identify perioperative risk factors for IH and provide a risk prediction instrument to accurately stratify patients in effort to offer risk reductive techniques. SUMMARY: Open hysterectomies account for a magnitude of surgical procedures worldwide. This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2145 cases. With an increasing emphasis on prevention in healthcare, we create a risk model to improve outcomes after open hysterectomies in effort to identify high-risk patients, facilitate preoperative risk counseling, and implement evidence-based strategies to improve outcomes.

Complex Truncal Masses in the Setting of CLOVES Syndrome: Aesthetic and Functional Implications.

BACKGROUND: Congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal abnormalities (CLOVES) is a complex overgrowth syndrome with dramatic aesthetic and functional implications. The truncal masses characteristic of CLOVES syndrome are described as vascular malformations or lipomatous lesions with variable vascular components. Herein, we describe our single-institution experience with surgical excision of CLOVES-related truncal masses and discuss future directions in treatment of these complex anomalies. METHODS: A single-institution retrospective review was performed for patients diagnosed with CLOVES syndrome. Patients undergoing excision of truncal vascular malformations were included. Outcome measures included perioperative characteristics [estimated blood loss (EBL), specimen size/anatomic location, blood-product requirement], as well as length-of-stay [LOS], and complication profile. Mean follow-up was 23.4 months (range 4.2-44). RESULTS: Three consecutive patients were reviewed, accounting for 4 surgical operations. One patient underwent two operations for two distinct masses. All lesions were located on the upper back or flank with various degrees of muscular involvement. One patient required no transfusions with an uneventful 2-day hospitalization. The remaining three patients had an EBL ranging from 1500 to 6450 mL, requiring 9-13 units of packed red blood cells and 5-8 units of fresh frozen plasma during LOS (averaging 5 days). Mean weight of resected masses was 6.26 lbs (range 2.04-12 lbs) and mass dimensions ranged between 1778.9 and 15,680 cm3. One patient with recurrence was subsequently treated with a combination of sclerotherapy and rapamycin, leading to significant mass reduction. CONCLUSIONS: Management of CLOVES syndrome requires a collaborative and multimodal approach. Although surgical debulking is one treatment option, non-invasive medical modalities and sclerotherapy should be considered prior to surgical resection. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .