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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.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.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; p0.001). 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).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.Risk, III.

BACKGROUND Health-care expenditures in the U.S. are continually rising, prompting providers, patients, and payers to search for solutions to reduce costs while maintaining quality. The present study seeks to define the out-of-pocket price that patients undergoing hand surgery are willing to pay, and also queries the potential cost-cutting measures that patients are most and least comfortable with. We hypothesized that respondents would be less accepting of higher out-of-pocket costs. METHODS A survey was developed and distributed to paid, anonymous respondents through Amazon Mechanical Turk. The survey introduced 3 procedures: carpal tunnel release, cubital tunnel release, and open reduction and internal fixation of a distal radial fracture. Respondents were randomized to 1 of 5 out-of-pocket price options for each procedure and asked if they would pay that price. Respondents were then presented with various cost-saving methods and asked to select the options that made them most uncomfortable, even if those would save them out-of-pocket costs. RESULTS There were 1,408 respondents with a mean age of 37 years (range, 18 to 74 years). Nearly 80% of respondents were willing to pay for all 3 of the procedures regardless of which price they were presented. Carpal tunnel release was the most price-sensitive, with rejection rates of 17% at the highest price ($3,000) and 6% at the lowest ($250). Open reduction and internal fixation was the least price-sensitive, with rejection rates of 11% and 6% at the highest and lowest price, respectively. The use of older-generation implants was the least acceptable cost-cutting measure, at 50% of respondents. CONCLUSIONS The present study showed that most patients are willing to pay a considerable amount of money out of pocket for hand surgery after the condition, treatment, and outcomes are explained to them. Furthermore, respondents are hesitant to sacrifice advanced technology despite increased costs.

INTRODUCTION This study used a conjoint analysis-based survey to assess which factors are most influential when considering treatment with a prosthesis or transplant after a unilateral hand amputation. METHODS Overall, 469 respondents were recruited using Amazon Mechanical Turk and asked to assume that they experienced a hand amputation. To determine preferences for a prosthetic, respondents chose among 11 pairs of alternatives with variations in the following attributes: appearance, function, maintenance, and learning time. Respondents were then presented with descriptions of the risks and outcomes of hand transplantation. The most compelling reasons for and against a transplant were determined and characteristics predictive of support for a transplant were identified. RESULTS The most important attributes for a prosthesis were "lifelike appearance" and "myolectric function." For hand transplantation, respondents were most concerned about immunosuppression side effects (n = 323, 69%) and the intense nature of surgery (n = 275, 59%), whereas the most positive benefit was the concept of the transplant being "natural" (n = 339, 72%). When faced with the choice of a hand transplant or a prosthetic, approximately 50% of respondents chose a transplantation. Younger age, previous medical experiences, a perceived "familiarity with medical issues," and the regular attendance of religious services were associated with strong support for a hand transplantation (P < 0.01). CONCLUSIONS When considering a hand prosthesis, respondents are motivated most by appearance and function. Meanwhile, with hand transplantation, the risks of immunosuppression and the intense nature of surgery and recovery are predominant concerns. These findings may help inform patient-physician discussions when considering treatment after unilateral hand amputation.

Animal models suggest POCD may be caused by brain monocyte influx. To study this in humans, we developed a flow cytometry panel to profile CSF samples collected before and after major non-cardiac surgery in in 5 patients age ≥ 60 years who developed POCD and 5 matched controls who did not. We detected 12,654±4895 cells/10 ml CSF sample (mean±SD). Patients who developed POCD showed an increased CSF monocyte/lymphocyte ratio and MCP-1 receptor downregulation on CSF monocytes 24 hours after surgery. These pilot data demonstrate that CSF flow cytometry can be used to study mechanisms of postoperative neurocognitive dysfunction. CLINICAL TRIAL NUMBER AND REGISTRY URL: , https://clinicaltrials.gov/ct2/show/NCT01993836 (This manuscript describes a nested case-control study, performed within the larger cohort study, .)

The fasciocutaneous lateral arm flap is a workhorse flap in upper extremity reconstruction. However, its adipofascial variant is not widely used. The technique can be used in various clinical scenarios. The adipofascial flap can be transposed to circumferentially wrap the radial nerve with a pliable, vascularized fat and fascial envelope, mimicking the natural fatty environment of peripheral nerves. This technique has the advantage of providing a scar tissue barrier, a barrier to hardware irritation and a milieu for vascular regeneration of the nerve. Suggested applications include nerve coverage in the setting of posterior humerus plating to prevent adhesions; anticipation of bone grafting in the setting of an open fractures with bone loss, infection, or with the use of the Masquelet technique; in revision total elbow arthroplasty or endoprosthetic humerus replacement; and in the setting of neurolysis, repair or nerve grafting. The technique is straightforward and does not require microvascular expertise.

Facial fractures resulting from blunt-mechanism trauma, although common, have been infrequently evaluated in large studies that do not include confirmation of fractures based on author review of available patient radiographic studies. An 8-year review (1998-2006) of the R Adams Cowley Shock Trauma Registry was performed with institutional review board approval. Patients diagnosed with blunt-mechanism facial fractures were identified by the International Classification of Diseases, Ninth Revision (ICD-9) codes and their facial fractures confirmed by author review of computed tomographic scans. Individual fractures were classified and grouped according to the facial thirds. Intra- and interreader variability was calculated, and confirmed fracture patterns were compared to fracture patterns listed by ICD-9 codes. Concomitant injuries and demographic data were additionally evaluated. Four thousand three hundred ninety-eight patients with 8127 fractures were identified. Intra- and interreader variability was 2% and 7%, respectively. ICD-9 coding misdiagnosed 12.5% of all fractures. Eighty-two percent of patients sustained associated injuries, including basilar skull fractures (7.6%) and cervical spine fractures (6.6%). 1.1% had at least one fracture in each facial third (panfacial fracture pattern). Significant relationships were found between demographic parameters, concomitant injuries, specific fractures, and fracture patterns. Studies investigating facial fractures should report fracture patterns confirmed by author review of available radiographic imaging. Large retrospective data sets containing confirmed fractures and capable of addressing rare fracture patterns can be compiled with low inter- and intrauser variability, and are useful for generating mechanistic hypotheses suitable for evaluation in prospective series or by directed biomechanical studies.

The aim of this article was to assess how regional facial fracture patterns predict mortality and occult intracranial injury after blunt trauma.Retrospective chart review was performed for blunt-mechanism craniofacial fracture patients who presented to an urban trauma center from 1998 to 2010. Fractures were confirmed by author review of computed tomographic imaging and then grouped into 1 of 5 patterns of regional involvement representing all possible permutations of facial-third injury. Mortality and the presence of occult intracranial injury, defined as those occurring in patients at low risk at presentation for head injury by Canadian CT Head Rule criteria, were evaluated. Relative risk estimates were obtained using multivariable regression.Of 4540 patients identified, 338 (7.4%) died, and 171 (8.1%) had intracranial injury despite normal Glasgow Coma Scale at presentation. Cumulative mortality reached 18.8% for isolated upper face fractures, compared with 6.9% and 4.0% for middle and lower face fractures (P0.001), respectively. Upper face fractures were independently associated with 4.06-, 3.46-, and 3.59-fold increased risk of death for the following fracture patterns: isolated upper, combined upper, panfacial, respectively (P0.001). Patients who were at low risk for head injury remained 4 to 6 times more likely to suffer an occult intracranial injury if they had involvement of the upper face.The association between facial fractures, intracranial injury, and death varies by regional involvement, with increasing insult in those with upper face fractures. Cognizance of the increased risk for intracranial injury in patients with upper face fractures may supplement existing triage tools and should increase suspicion for underlying or impending neuropathology, regardless of clinical picture at presentation.

Although multiple breast reduction outcomes studies have been performed, none has specifically identified the impact of advanced age. The authors aimed to study the impact of age on breast reduction outcome.Medical records for all patients billed for Current Procedural Terminology code 19318 over the past 10 years (1999 to 2009) at a large academic institution were analyzed under an institutional review board-approved protocol. A total of 1192 consecutive patients underwent 2156 reduction mammaplasties performed by 17 plastic surgeons over a 10-year period. Breast reduction techniques included inferior pedicle/Wise pattern in 1250 patients (58.9 percent), medial pedicle/Wise pattern in 360 (16.9 percent), superior pedicle/nipple graft in 305 (14.4 percent), superior pedicle/vertical pattern in 206 (9.7 percent), and liposuction in three (0.14 percent). The average patient age was 36 years. Age groups were divided into younger than 40 years, 40 to 50 years, and older than 50 years. Multiple logistic regression analysis was performed to identify significant relationships.Women older than 50 years more likely experienced infection (odds ratio, 2.7; p = 0.003), with trends toward wound healing problems (odds ratio, 1.6; p = 0.09) and reoperative wound débridement (odds ratio, 5.1; p = 0.07). There was a trend toward infection in women aged 40 to 50 years (odds ratio, 1.7; p = 0.08). Advanced age did not exacerbate fat necrosis or seroma development.Age older than 50 years impairs breast reduction outcomes, particularly infection, and may negatively impact wound healing. Hormonal deficiency may partially account for this finding.Risk, IV.

The objective of this study was to identify novel tumor-suppressor genes in melanoma, using an integrative genomic approach. Data from: (i) earlier reports of DNA loss and gain in malignant melanoma accompanied by comparative genomic hybridization high-definition array data of the entire human genome; (ii) microarray expression data from melanoma-derived cell lines identifying genes with significantly increased expression due to methylation using a pharmacologic demethylating strategy; and (iii) publicly available RNA expression microarray data of primary tumors and benign nevi were integrated using statistical tools to define a population of candidate tumor-suppressor genes. Twenty-seven genes were identified in areas of deletion that demonstrated diminished expression in primary melanomas relative to benign nevi and were significantly increased in expression by 5-Aza treatment. Seven genes of these 27 genes demonstrated methylation and deletion in a validation cohort of 14 separate primary tumors. These were: CHRDL1, SFRP1, TMEM47, LPL, RARRES1, PLCXD1, and KOX15. All of these genes demonstrated growth-suppressive properties with transfection into melanoma-derived cell lines. Seven putative tumor-suppressor genes in malignant melanoma were identified using a novel integrative technique.

BACKGROUND:: Patients presenting with traumatic craniomaxillofacial fractures often have occult concomitant injuries. This study was designed to determine whether facial fracture patterns are associated with a particular constellation of concomitant head and neck injuries. METHODS:: A retrospective review of 4786 consecutive patients diagnosed with maxillofacial fractures at a dedicated urban trauma center from 1998 to 2005 was conducted; maxillofacial fractures and cervical spine injuries were grouped by dividing the craniomaxillofacial skeleton and cervical spine into thirds. Univariate and multivariate logistic regression analyses were used to identify associations between facial fractures and other traumatic injuries. RESULTS:: Among all patients with facial fractures, 461 (9.7 percent) also had cervical spine injuries and 2175 (45.5 percent) had associated head injuries. Fractures of the upper face were associated with increased likelihood of mid lower cervical spine injuries, severe intracranial injuries, and increased mortality rates. Unilateral mandible injuries were associated with an increased likelihood of having upper cervical spine injuries, whereas unilateral midface injuries were associated with basilar skull fractures and several intracranial injuries. Finally, bilateral midface injuries were associated with basilar skull fracture and death. CONCLUSIONS:: Craniomaxillofacial fractures are commonly associated with head and cervical spine injuries that involve predictable patterns of force dispersion from the maxillofacial skeleton and transmission to the cranial vault and cervical spine. These results suggest that concomitant injuries should be investigated closely with distinct types of facial fractures. Language: en

Background The significance of the oral vestibule is often underappreciated in composite craniomaxillofacial reconstruction, and its deficiency results in considerable incompetence. Results of traditional vestibuloplasty techniques are unpredictable when the recipient bed is compromised in the setting of trauma or irradiation. The authors present an alternative approach for restoring the intractable oral vestibule with free tissue transfer. Methods An institutional review board-approved retrospective review of patients who underwent oral vestibular reconstruction was conducted at R Adams Cowley Shock Trauma Center and Johns Hopkins Hospital from 2002 to 2007. Results Thirteen patients were identified: six defects resulted from tumor extirpation, six resulted from traumatic injury, and one resulted from infection. There were eight men and five women, with a mean age of 46 years. Thirteen free tissue transfers of the oral vestibule were conducted: six ulnar forearm and seven anterolateral thigh perforator flaps. The average follow-up was 17 months. There were no flap failures and only one complication noted, which did not result in negative sequelae. The functional results were good, with all patients experiencing increased labial excursion and subjective improvement in the handling of food bolus and saliva. Conclusions Preservation of oral vestibular height, width, and volume is essential for aesthetic appearance and functional competence. Free tissue transfer provides an innovative alternative in the management of the intractable and obliterated oral vestibule. It can be performed successfully, providing excellent results predictably.

Earlier studies of mitochondrial mutations in melanoma have focused on analysis of selected mitochondrial genes and the displacement loop (D-loop) region using conventional sequencing. In this study we use data from a whole mitochondria-sequencing array, the MitoChip v2.0, to characterize the mutations that are present throughout the mitochondrial genome. The mitochondrial genome of DNA derived from 14 fresh melanoma specimens and two melanoma cell lines, and autologous lymphocytes or immortalized B cells, respectively, were sequenced using the MitoChip v2.0. Paired comparative sequence analysis was carried out to define somatic mutations. Somatic mitochondrial DNA mutations were identified in 12/16 (75%) melanomas, compared with germline lymphocyte DNA. One hundred mutations were present among these 12 melanomas. A disproportionate number of mutations occurred in the D-loop. Furthermore, 9/16 (56.3%) melanomas carried mutations, which resulted in amino acid substitutions in functional genes. In the 10 samples carrying nicotinamide adenine dinucleotide dehydrogenase (ND) complex mutations, multiple mutations were present at a rate significantly greater than the expected frequency based on the size of ND complex genes (P=0.028, Fisher's exact test). Mitochondrial mutation is a frequent occurrence in melanoma. The high rate of missense mutations and the propensity for the ND complex implicate a role for alterations in mitochondrial respiratory function in melanoma carcinogenesis. Mutations of the noncoding D-loop are of unclear significance, but may be associated with alterations in transcription or replication. Further studies are needed to delineate the timing and functional significance of these mutations, and their role in the pathogenesis of this disease.

Wound complications after spinal surgery are relatively uncommon; however, they can be associated with a significant amount of morbidity. Wound breakdown after spinal surgery is due to a wide variety of causes, ranging from the trivial to life threatening. Prevention and appropriate management of wound complications is of utmost importance. Various studies report rates of wound complications ranging from 1.9% (Weinstein et al, 2000) to 20% (Klink et al, 1994). Sequelae associated with wound infection include prolonged length of hospital stay, multiple operations, meningitis, pseudoarthrosis, osteomyelitis, and loss of hardware. Spinal surgery is unique in its reliance on high-profile hardware for correction of defects. Loss of hardware is equivalent to ultimate failure of the procedure. Incidence of wound complication can be decreased through several preoperative and intraoperative strategies. Salvage of hardware is crucial in the event of wound complication. Important principles in management of wound complication are early detection, adequate debridement, and muscle flap coverage of hardware. In this paper, we address predisposing factors for wound complications, steps that can be taken to minimize risk of infection at time of operation, and management of wound complications once they occur.