Margin status is an important prognostic factor for local recurrence after partial mastectomy for breast malignancy. Options for intraoperative evaluation of margin status include gross examination of the specimen, frozen section, and “touch preparation” cytology. This study evaluates the accuracy of gross examination without other intraoperative pathological analysis as a method of determining margin status. Records of 254 consecutive patients undergoing partial mastectomy for 255 breast malignancies (199 invasive, 56 DCIS) over 6 years were analyzed retrospectively. All women underwent en bloc excision of the primary lesion with gross examination of margin status by the surgeon and pathologist. All suspicious areas were reexcised, and the specimen was inked, serially sectioned at 2–3 mm intervals and examined with hematoxylin and eosin (H&E) stains. Specimens with tumor <2 mm from a margin were considered margin-positive and those with all tumor ≥2 mm from the margin were designated margin-negative. One hundred fourteen (45%) of the 255 segmental resections were considered to have grossly tumor-free margins, and intraoperative reexcision was not performed. Ninety-six (84%) of these specimens had histologically negative margins. Gross examination prompted intraoperative reexcision in 141 (55%) cases. Ninety-five (67%) of these 141 resections had tumor-free margins on histopathology. Overall, the final margin was involved in 64 of the 255 partial mastectomies. Seventeen (27%) women with initially margin-positive resections underwent mastectomy, while 46 (72%) underwent reexcision, which was margin-negative in 41 (89%). After a median follow-up of 42 months, there have been eight (3.5%) local recurrences. The initial margin-positive rate was similar in ductal carcinoma in situ (DCIS) (30%) and invasive carcinoma (24%). Margin status was correlated with nodal status; there was no correlation with age, tumor size, grade hormone receptor status, or type of diagnostic biopsy. Gross examination of the resection specimen does not reflect margin status in at least 25 per cent of women undergoing partial mastectomy for breast malignancy. Other techniques for evaluation of margin status should be considered to reduce the need for reexcision of involved margins. We are currently designing a prospective clinical trial to examine the efficacy of new techniques for intraoperative evaluation of margin status.

Background: Targeted muscle reinnervation has emerged as a technique to reduce neuroma and phantom limb pain after below-knee amputation; however, the incidence of postoperative complications remains unknown. This multi-institutional study assessed the risk of postoperative complications among patients who underwent targeted muscle reinnervation at the time of below-knee amputation. Methods: Patients who underwent below-knee amputation with targeted muscle reinnervation were propensity score–matched 1:3 to patients who underwent below-knee amputation alone. Study outcomes included the incidence of major or minor complications within 60 days. Regression models were used to estimate the relative risk of major and minor complications. Results: Overall, 96 patients were matched, including 31 patients who had below-knee amputation with targeted muscle reinnervation and 65 who had below-knee amputation alone. In the matched sample, a higher incidence of major complications (29 percent versus 24.6 percent), readmission (25.8 percent versus 18.5 percent), and reoperation (19.4 percent versus 10.8 percent) was seen after both procedures compared with below-knee amputation alone. Patients who underwent both procedures displayed a higher incidence of minor complications (25.8 percent versus 20.0 percent), blood transfusion (22.6 percent versus 18.5 percent), and wound healing complications (45.2 percent versus 33.8 percent) and longer operative time (mean ± SD, 188.5 ± 63.6 minutes versus 88 ± 28.2 minutes). There was no statistically significant difference in the risk of major (relative risk, 1.20; 90 percent CI, 0.68, 2.11) or minor (relative risk, 1.21; 90 percent CI, 0.61, 2.41) complications between the two cohorts. Conclusions: Despite an increased incidence of postoperative complications, undergoing below-knee amputation with targeted muscle reinnervation does not confer a statistically significant increased risk of major or minor complications. Future studies are needed to delineate patient selection criteria when assessing the suitability of targeted muscle reinnervation at the time of major limb amputation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Paragangliomas of the organ of Zuckerkandl are rare tumors with only several case reports noted in the literature. Synchronous paraganglioma occur sporadically, and on occasion, in association with several genetic syndromes. Paraganglioma of the organ of Zuckerkandl with synchronous carotid body paraganglioma is described herein. Traditionally, surgical resection of abdominal paraganglioma involved an exploratory laparotomy. In this manuscript, we describe one of the first reported laparoscopic resections of this tumor and review the literature on multiple paragangliomas and their associated genetic syndromes.

Background: Trigger finger is one of the most common hand abnormalities, with a prevalence of 2 percent of the general population. Conservative treatment with corticosteroid injections at the A1 pulley has been shown to be a cost-effective first-line treatment. However, additional patient factors have not fully been described regarding steroid injection efficacy. The authors hypothesize that patients presenting with longer chronicity of symptoms before treatment and elevated blood glucose would have reduced success rates of steroid injection therapy. Methods: A retrospective chart review of 297 patients at a single institution was performed between 2013 and 2019. Patients were included if they presented with the diagnosis of trigger finger and were treated with initial corticosteroid injection at the A1 pulley. Results: Steroid injection therapy alone was successful in 65 percent of patients. Patients received on average of 1.61 steroid injections. Patients who failed treatment received an average of 1.85 injections compared to 1.49 for those who had successful corticosteroid injection therapy (p = 0.001). Presence of ipsilateral hand disease was associated with significant increase in failure of steroid injections (43.4 percent versus 30.8 percent; p = 0.032). Diabetic patients with hemoglobin A1c levels greater than 6.5 percent had a significantly higher rate of failing steroid injection therapy (71.9 percent versus 38.1 percent; p < 0.001). Patients who presented with greater than 2.5 months of symptoms had a higher failure rate of corticosteroid therapy (40.4 percent versus 29.5 percent; p = 0.048). Conclusion: Patients with a coexisting diagnosis of diabetes and a hemoglobin A1c level greater than 6.5 percent, ipsilateral concomitant hand disease, or presence of symptoms for greater than 2.5 months should be counseled regarding higher risk of failure of local corticosteroid injection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Context: The treatment of rotator cuff tears has become one of the most common orthopaedic sports procedures. The development of a synovio-cutaneous fistula is a rare, but serious, complication that has been described after rotator cuff repair. The purpose of this report is to present the local rotational flap as a treatment option for synovio-cutaneous fistulas of the shoulder and to emphasize the importance of recognizing when primary closure may not be sufficient for adequate repair.Case Reports: A 67-year-old male who previously underwent a right rotator cuff and a biceps tendon repair presented with a persistently draining shoulder fistula. The decision was made to proceed with extensive debridement and closure using vascularized tissue. A 63-year-old male presented for a postoperative wound complication following attempted open debridement of a left torn rotator cuff. The wound was initially managed conservatively, but a persistently draining fistula necessitated the use of vascularized tissue for closure of the wound. The recovery of both patients was uneventful with no recurrent fistula formation. Both patients had improved shoulder range of motion following surgery and resolution of their pain. Conclusions:The excessive tension placed on the rotator cuff tendons and deltoid during repair and the resultant inflammation may contribute to tissue necrosis and facial dehiscence over the glen humeral joint, allowing for fistula formation. Surgeons should be aware that when adequate soft tissue coverage cannot be accomplished over the glen humeral joint via primary closure, there are local flaps available to provide complete coverage over the joint.

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