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BACKGROUND Orthopedic and plastic surgery residents receive unique training yet often compete for similar hand surgery fellowships. This study compared didactic hand surgery training during orthopedic and plastic surgery residency. METHODS The Plastic Surgery In-Service Training Exam and Orthopaedic In-Training Examination were analyzed for hand content for the years 2009 to 2013. Topics were categorized with the content outline for the Surgery of the Hand Examination. Differences were elucidated by means of Fisher's exact test. RESULTS Relative to the Orthopaedic In-Training Examination, the Plastic Surgery In-Service Training Exam had greater hand representation (20.3 percent versus 8.1 percent; p < 0.001) with more annual hand questions (40 ± 3 versus 24 ± 2; p < 0.001). The Plastic Surgery Exam questions had more words, were less often level I-recall type, and were less often image-based. The questions focused more on finger and hand/palm anatomy, whereas the Orthopaedic examination was more wrist-focused. The Plastic Surgery Exam emphasized wound management and muscle/tendon injuries, but underemphasized fractures/dislocations. References differed, but Journal of Hand Surgery (American Volume) and Green's Operative Hand Surgery were common on both examinations. The Plastic Surgery Exam had a greater publication lag for journal references (10.7 ± 0.5 years versus 9.0 ± 0.6; p = 0.035). CONCLUSIONS Differences in didactic hand surgery training are elucidated for plastic surgery and orthopedic residents. Deficiencies in the Plastic Surgery In-Service Training Exam hand curriculum relative to the Orthopaedic In-Training Examination may underprepare plastic surgeons for the Surgery of the Hand Examination. These data may assist future modifications to hand surgery training in the United States.

Purpose The results of spinal accessory to suprascapular nerve transfers have been less reliable than other nerve transfers in the upper limb, possibly owing to compression of the nerve by the suprascapular ligament. The posterior approach has been advocated to allow for release of the ligament. The purpose of this study was to determine whether a ligament release is possible from the anterior approach. Methods Nine fresh-frozen cadavers were dissected to determine whether the ligament could be approached and released from the anterior approach. Complete ligament release was demonstrated by subluxation of the nerve out of the suprascapular notch. Results Ligament release was achieved in all specimens, although in one, confirmation of complete release required a posterior approach. Conclusions Release of the suprascapular ligament to eliminate a potential source of compression of the suprascapular nerve during spinal accessory to suprascapular nerve transfer is possible through an anterior approach. Clinical relevance Release of the suprascapular ligament through an anterior approach allows this procedure to be performed through the same approach as brachial plexus exploration and spinal accessory nerve to suprascapular nerve transfer. This method could reduce surgical time and patient repositioning and avoid additional incisions.

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.

Purpose: Hoverboards were recently introduced in the United States consumer market and have rapidly increased in popularity. Concern regarding the safety of hoverboards has largely focused on the risk of fire, drawing media attention and prompting investigation by the United States Consumer Product Safety Commission (CPSC). At our institution, we noted an increase in musculoskeletal injuries related to hoverboard use. We sought to analyze hoverboard injuries to characterize the frequency of injury, pattern of musculoskeletal injury, and provide families with safety information. Methods: An IRB approved retrospective review of all patients with …

Mobile phone messaging software robots allow clinicians and healthcare systems to communicate with patients without the need for human intervention. The purpose of this study was to (1) describe a method for communicating with patients postoperatively outside of the traditional healthcare setting by utilizing an automated software and mobile phone messaging platform and to (2) evaluate the first week of postoperative pain and opioid use after common ambulatory hand surgery procedures.The investigation was a prospective, multicenter investigation of patient-reported pain and opioid usage after ambulatory hand surgery. Inclusion criteria included any adult with a mobile phone capable of text messaging, who was undergoing a common ambulatory hand surgical procedure at one of three tertiary care institutions. Participants received daily, automated text messages inquiring about their pain level and how many tablets of prescription pain medication they had taken in the past 24 h. Initial 1-week response rate was assessed and compared between different patient demographics. Patient-reported pain and opioid use were also quantified for the first postoperative week. Statistical significance was set as p 0.05.Forty-seven (n = 47) patients were enrolled in this investigation. Total response rate of both pain and opioid medication questions through 7 days was 88.3%. Pain trended down on a daily basis for the first postoperative week, with the highest levels of pain being reported in the first 48 h after surgery. Patients reported an average use of 15.9 ± 14.8 tablets of prescription opioid pain medication.We find that a mobile phone messaging software robot allows for effective data collection of postoperative pain and pain medication use. Patients undergoing common ambulatory hand procedures utilized an average of 16 tablets of opioid medication in the first postoperative week.

BACKGROUND To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans. METHODS Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR. RESULTS In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P

Purpose It is our impression that there is substantial, unexplained variation in hand surgeon recommendations for treatment of peripheral mononeuropathy. We tested the null hypothesis that specific patient and provider factors do not influence recommendations for surgery. Methods Using a web-based survey, hand surgeons recommended surgical or nonsurgical treatment for patients in 2 different scenarios. Six elements of the first scenario (symptoms, circumstances, mindset, diagnosis, objective testing, and expectations) had 2 possibilities that were each independently and randomly assigned to each rater. For the second scenario, 2 different scenarios were randomly assigned to each rater. Multivariable logistic regression sought factors associated with a recommendation for surgery. Results A total of 186 surgeons of the Science of Variation Group completed a survey regarding recommendation of surgery for 2 different patients based on clinical scenarios. Recommendations for surgery did not vary significantly according to provider characteristics. For the various elements in scenario 1, recommendation for surgery was more likely for patients who were self-employed and continued to work and who had objective electrodiagnostic abnormalities. For the 2 vignettes used in scenario 2, a recommendation for surgery was associated with abnormal electrophysiology. Conclusions The findings of this study suggest that—at least in a survey setting—surgeons prefer to offer peripheral nerve decompression to patients with abnormal electrophysiology, particularly those with effective coping strategies. Clinical relevance The role of objective verification of pathophysiology is debated, but it is an influential factor in recommendations for hand surgery.

Radial longitudinal deficiency (RLD) is the most common congenital longitudinal deficiency at birth and represents a wide spectrum of upper extremity anomalies, from mild thumb hypoplasia to absent radius. Radial dysplasia may be isolated or associated with an array of systemic anomalies that should be familiar to pediatric hand surgeons. The management of RLD has evolved greatly since its inception in the late 19th century, largely due to decades of innovation that followed the thalidomide catastrophe of the 1960s. Yet controversy still exists regarding many aspects of RLD. Traditional treatments of radial dysplasia (ie, centralization) are unfortunately wrought with poor outcomes and high rates of recurrence, leading some authors to recommend alternative techniques for this condition. Reconstruction of the hypoplastic thumb, although less controversial, is just starting to see long-term outcomes. This article reviews the etiology, classification, and treatment options for RLD, highlighting recent developments and outcomes.

The purpose of this study was to examine current attitude of hand surgeons toward the Affordable Care Act (ACA). An electronic survey was sent to members of American Society for Surgery of the Hand (ASSH) to examine their attitude toward the Affordable Care Act. 974 ASSH members responded to the survey (33% response rate). The majority of respondents were male (89%), trained in orthopedic surgery (81%), and in private practice (75%). 41% of respondents rated their knowledge of the ACA as average. Respondents disagreed that the ACA would improve healthcare in the United States (median 2, mean 2.06, scale 1-5), while agreeing that the ACA would decrease reimbursements specific to hand surgery (median 4, mean 4.11).

An increasing number of women are entering the medical profession, but plastic surgery remains a male-dominated profession, especially within academia. As academic aspirations and advancement depend largely on research productivity, the authors assessed the number of articles authored by women published in the journal Plastic and Reconstructive Surgery.Original articles in Plastic and Reconstructive Surgery published during the years 1970, 1980, 1990, 2000, 2004, and 2014 were analyzed. First and senior authors with an M.D. degree and U.S. institutional affiliation were categorized by gender. Authorship trends were compared with those from other specialties. Findings were placed in the context of gender trends among plastic surgery residents in the United States.The percentage of female authors in Plastic and Reconstructive Surgery increased from 2.4 percent in 1970 to 13.3 percent in 2014. Over the same time period, the percentage of female plastic surgery residents increased from 2.6 percent to 32.5 percent. By 2014, there were more female first authors (19.1 percent) than senior authors (7.7 percent) (p0.001). As a field, plastic surgery had fewer female authors than other medical specialties including pediatrics, obstetrics and gynecology, general surgery, internal medicine, and radiation oncology (p0.05).The increase in representation of female authors in plastic surgery is encouraging but lags behind advances in other specialties. Understanding reasons for these trends may help improve gender equity in academic plastic surgery.

Background: The purpose of this study was to examine the current attitude of hand surgeons toward the Act (ACA), assess their self-described knowledge of the law, and ascertain projected changes in practice plans. Methods: An electronic survey was sent to members of American Society for Surgery of the Hand (ASSH). Results: A total of 974 ASSH members responded to the survey (33% response rate). The majority of respondents were male (89%), trained in orthopaedic surgery (81%) and in private practice (75%). 41% of respondents rated their knowledge of the ACA as average. 84% reported receiving no education on the law. In general, respondents disagreed that the ACA would improve healthcare in the United States (median 2, mean 2.06, scale 1-5), while agreeing that the ACA would decrease reimbursements specific to hand surgery (median 4, mean 4.11). They also disagreed that the ACA would improve access to emergent (median 2, mean 2.10) and elective hand surgery (median 2, mean 2.30). 37% of respondents believed that implementation of the ACA would cause them to retire earlier than planned. Stratified analysis revealed that private-practice and male respondents had a more negative outlook on the ACA compared to academicpractice and female surgeons. Conclusion: The majority of responding hand surgeons have an unfavorable attitude toward the ACA, particularly private-practice and male members. Only a small percentage of respondents reported sufficient preparation for the coming changes related to the ACA. These findings suggest an opportunity for increased education and advocacy from professional organizations.

BACKGROUND: Infant dura mater plays a critical role in calvarial development. This investigation examines the expression of nitric oxide synthase isoforms in the craniofacial skeleton and the influence of nitric oxide signaling on the growth and differentiation of fetal dural and calvarial bone cells. METHODS: Sections of fetal and adult calvaria were evaluated for endothelial and inducible nitric oxide synthase expression by immunohistochemistry. Primary fetal (E18) murine dural cell and calvarial osteoblast cultures were treated with 1 microM or 10 microM DETA-NONOate, a nitric oxide donor compound, or 1 mM N-monomethyl-l-arginine (l-NMMA), a nitric oxide synthase inhibitor. Controls were left untreated. Cell proliferation was measured at 48 hours, and mRNA transcripts for Runx2, alkaline phosphatase, and osteopontin were measured by reverse transcription and quantitative real-time polymerase chain reaction at 2 to 18 days. Experiments were performed in triplicate. RESULTS: Fetal, but not adult, dural cells express endothelial nitric oxide synthase. DETA-NONOate stimulated osteoblast mitogenesis by 16 percent (p < 0.05) but did not affect proliferation of dural cells. l-NMMA inhibited proliferation of dural cells and calvarial osteoblasts by 35 percent (p < 0.01) and 17 percent (p = 0.05), respectively. Exogenous nitric oxide increased dural cell transcription of Runx2, alkaline phosphatase (p = 0.03), and osteopontin (p = 0.09) and calvarial osteoblast transcription of Runx2 (p = 0.02) and osteopontin (p < 0.01). Fetal calvarial osteoblasts and dural cells treated with l-NMMA demonstrated reduced transcription of Runx2 and alkaline phosphatase (p < 0.05). CONCLUSIONS: Fetal dural cells and calvarial osteoblasts express endothelial nitric oxide synthase. Nitric oxide enhances proliferation and differentiation of fetal dural cells and calvarial osteoblasts. These results suggest that endothelial nitric oxide synthase-derived nitric oxide may play an important role in development of the fetal craniofacial skeleton.

The integrated plastic surgery match is among the most competitive residency matches in recent years. Although previous studies have correlated applicant characteristics with successful match outcomes, none have comprehensively investigated the role of geography in the match. This study elucidates regional biases in the match.Plastic surgery residents who matched during 2011-2015 were eligible for study inclusion. Names of residents were obtained from official residency program websites and cross-referenced with data obtained from the Student Doctor Network. For each resident, region of residency program and medical school were compared.From 67 programs, 622 residents were identified. Most graduated from US medical schools (97.9%). A total of 94 residents matched at a home institution (15.1%). Half of the residents matched in the same region as their medical school (48.9%). Programs in the South matched the greatest number of residents from the same region (60.8%), whereas West programs matched the least (30.8%, p0.001). No regional differences existed regarding residents matching at their home institution (p = 0.268). More women matched at West programs (43.1%) versus East programs (30.6%, p0.05).A significant number of residents matched at their home institution. Roughly, half matched at a program in the same region as their medical school. Whether this regional phenomenon stems from applicant or program factors remains unknown. Yet, given the limited number of interviews and the high costs of interviewing, applicants and programs can use these data to help optimize the match process.

Purpose: The aim of these studies was to evaluate the biologic response of fetal dural cell cultures to compressive mechanical force. Methods: Primary cell cultures from the dura mater of E18 CD-1 mice were subjected to 2 PSI of intermittent hydrostatic compression (IHC) at a frequency of 0.5 Hz. Quantitative measures of the expression of Osterix (Osx), osteopontin (OP), endothelial nitric oxide synthase (eNOS) and Noggin were performed by RT-PCR following 3, 6, and 12 hours of exposure to IHC. Nitric oxide production was quantified through the measurement of NO metabolites following 6 hours of exposure to IHC. Results: IHC resulted in an increase in Osx, OP, and eNOS expression compared with controls at all time points. The expression of Noggin decreased at all time points. Exposure to IHC resulted in a significant increase in the production of NO metabolites at 6 hours when compared with controls. Conclusions: These experiments indicate that dural cell biology is significantly altered following exposure to IHC. Specifically, IHC promotes production of NO and osteodifferentiation in fetal dural cell cultures, with increases in the expression of osteoinductive genes and decreases in inhibitors of osteogenesis.

These experiments evaluate the efficacy of a demineralized bone matrix putty engineered as a hybrid construct for sustained, site-directed gene transfer using an adenoviral vector. In vitro experiments were performed to evaluate the optimal dosing for gene transfer to fetal calvarial osteoblasts and dural cells and for the sustainability of gene transfer from the hybrid constructs. In the dosing experiments, hybrid constructs were created by combining 0.5 mL of demineralized bone matrix putty (DBX; SYNTHES Maxillofacial, Monument, CO) with 1 x 10(8), 1 x 10(7), or 1 x 10(6) particle-forming units (PFU) of an adenoviral vector carrying the gene encoding green fluorescent protein (AdGFP). These constructs were then placed in direct contact, or in transwell coculture, with fetal murine calvarial osteoblasts or dural cells at a multiplicity of infection (MOI = viral particle/cell ratio) of 1000, 100, and 10. The sustainability of gene transfer was tested through transfer of the hybrid construct to wells containing untransfected cells every 24 hours for 30 days. In both experiments, gene transfer was determined through the visualization of GFP using fluorescence light microscopy 24 hours after the onset of transfection. Optimal dosing for gene transfer occurred at an MOI of 10 for calvarial osteoblasts and 100 for dural cells. At greater concentrations, toxicity was observed in the majority of samples. Gene transfer to fetal dural cells and calvarial osteoblasts was sustained throughout the 30-day period. These experiments suggest that adenoviral vectors could be successfully incorporated within demineralized bone matrix to provide effective, sustained, site-directed gene transfer.

Purpose To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. Methods Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. Results Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8–19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1–16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. Conclusions The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. Type of study/level of evidence Therapeutic IV.

Purpose To assess the effect of scaphocapitate arthrodesis (SCA) on grip strength and wrist motion for patients with advanced stages of Kienbock disease. Methods A retrospective review was conducted of patients with advanced stages of Kienbock disease (stages III–IV) who underwent SCA at our institution between 1991 and 2010 with a minimum of 1 year clinical follow-up. Outcome measures included preoperative and postoperative pain, range of motion, grip strength, complications, additional surgery, radiographic changes, and the modified Mayo Wrist and Lichtman Outcome scores. Results Twenty-seven patients (17 males and 10 females) with a mean age of 41 years (range, 15–66 y) at the time of SCA were included in the study. The mean follow-up period was 60 months (range, 12 mo–16 y). Union was achieved in all 27 patients. Significant loss of mean motion was noted from preoperative to postoperative in wrist flexion (14°), extension (11°), and ulnar deviation (9°). However, significant improvement in grip strength was noted (+7 kg). Modified Mayo Wrist scores were mostly fair to poor and Lichtman scores were satisfactory in 32% (n = 7) of patients, yet 74% of patients returned to regular employment. Progressive radiographic carpal collapse and ulnar translocation of the carpus occurred, particularly in patients who had lunate excisions. However, no patients had symptoms attributable to carpal collapse or ulnar translocation that necessitated additional surgery. Conclusions SCA resulted in improved grip strength with correction of carpal alignment in patients with advanced stages of Kienbock disease in medium-term follow-up. Although radiographic carpal collapse and ulnar translocation occurred, patients were not symptomatic. Patients should be counseled that decrease in wrist range of motion will likely occur. Type of study/level of evidence Therapeutic IV.

The purpose of this study was to evaluate the difference in the outcomes of patients with a well-perfused hand who were taken to the operating room (OR) within 6 hours of forearm arterial injury vs patients who were treated in a semiurgent fashion. A review of 201 consecutive patients who were taken to the OR with forearm-level radial or ulnar arterial injury identified 26 patients who had a well-perfused hand at presentation in whom hemostasis was achieved within 15 minutes with manual pressure and no signs of hemodynamic instability. Outcomes of interest included short-version Disabilities of the Arm, Shoulder and Hand (quickDASH) scores and patient-reported cold intolerance. Of the 26 patients, group 1 included 17 patients who were taken to the OR within 6 hours and group 2 included 9 patients who were taken to the OR in a delayed fashion. Minimum follow-up in both groups was 13 months. Average quickDASH score was 24.5 and 14.1 for groups 1 and 2, respectively. Average time spent in the OR was significantly less in group 2 compared with group 1 (1.7 vs 2.8 hours). In the setting of forearm arterial injury with a well-perfused distal limb, there was no difference in functional outcome in patients taken to the OR emergently compared with those who underwent surgery in a delayed manner. With careful evaluation and monitoring, semiurgent operative repair is feasible and may improve certain aspects of patient care and hospital resource use. Outcome measures in this study support semiurgent treatment of these injuries.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans.Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR.In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P.01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73).After the enactment of policy designed to improve access to IBR, Medicaid and Medicare patients experienced the greatest relative increase in rates of IBR. Although policy changes had the most impact on traditionally underserved populations, disparities still exist. Future studies should endeavor to understand why such disparities have persisted.

The perioperative management of a patient receiving a bilateral hand transplant is presented. The anesthetic management required careful fluid administration, homeothermic temperature maintenance, and postoperative analgesia. The role of different anesthesia subspecialties is highlighted.

Federal and Pennsylvania state policies instituted in the late 1990s were designed to improve access to postmastectomy breast reconstruction. We sought to evaluate the impact of these policy changes on access to care among racial minorities. Mastectomy patients ≥18 years old were identified in the Pennsylvania Health Care Cost Containment Council inpatient database (1994–2004) and classified by immediate breast reconstruction (IBR) status. Rates of IBR were calculated by patient characteristics and year. Patients were stratified by race before (1994–1997) and after (2001–2004) policy changes, and relative odds of IBR were estimated by univariate and multivariate logistic regression analyses with adjustment for known confounders. Overall rates of IBR were significantly higher in the time period after policy change compared to before policy change (18.5 vs. 32.7 %, p

The higher prevalence of metopic and sagittal suture synostosis in male infants suggests a role for androgens in early craniofacial development. These experiments characterize the influence of androgen stimulation on growth and differentiation of fetal dural and calvarial bone cells and on cranial suture fusion.Primary murine fetal (E18) dural cells and calvarial osteoblasts were isolated and cultured. Cells were treated for 48 hours with 5alpha-dihydrotestosterone (0 to 1000 nM). Cell proliferation was examined by nonradioactive proliferation assay; mRNA expression of alkaline phosphatase, transforming growth factor (TGF)-beta1, and the bone matrix proteins osteopontin, osteocalcin, and type 1 collagen was determined by reverse-transcriptase polymerase chain reaction. In separate experiments, intact fetal calvariae were grown in tissue culture with 10 nM 5alpha-dihydrotestosterone for 7 and 14 days and then examined histologically.Androgen stimulation at 5 nM increased proliferation of fetal dural cells by 46.0 percent and of fetal calvarial osteoblasts by 20.5 percent. Dural expression of osteopontin, osteocalcin, and type 1 collagen was enhanced by 5alpha-dihydrotestosterone, as was that of TGF-beta1 and alkaline phosphatase. Androgen stimulation increased calvarial osteoblast expression of alkaline phosphatase and TGF-beta1 but induced little change in expression of osteocalcin, osteopontin, and type 1 collagen. In tissue culture, 5alpha-dihydrotestosterone stimulated osteoid formation and fusion of sagittal sutures.Androgen stimulation of dural cells and osteoblasts isolated from fetal calvaria promotes cell proliferation and osteoblastic differentiation and can induce cranial suture fusion. These results suggest that sex steroid hormone signaling may stimulate sutural osteogenesis by means of osteodifferentiation of dural cells, thus explaining the male prevalence of nonsyndromic craniosynostosis.

Male predominance in metopic and sagittal craniosynostosis and in nonsynostotic plagiocephaly suggests a role for circulating androgens in early craniofacial development. Androgens have been documented to play an important role in postnatal skeletal growth, and the androgen receptor has been recently demonstrated in human and rat osteoblast-like cell lines and in human long bones. The purpose of this study was to describe the expression of androgen receptor in the fetal craniofacial skeleton. The heads of E18 fetal CD-1 male and female mice were fixed in 10% formalin, decalcified, and embedded in paraffin. Four- to 6-mum coronal and sagittal sections were stained with a monoclonal antibody specific to androgen receptor, which was detected by an avidinbiotin conjugate and peroxidase system. The sections were then examined for androgen receptor expression patterns. Strong androgen receptor immunoreactivity was observed in the dura mater of developing fetuses. Androgen receptor expression was also noted in cells lining the osteogenic fronts and in calvarial osteoblasts. Similar androgen receptor expression patterns were found in male and female mice. Androgen receptor is abundantly expressed in fetal dura mater and calvarial bone. This study confirms the presence of androgen receptor in the murine fetal craniofacial skeleton, suggesting a potential role for the anabolic effects of androgens in the developing craniofacial skeleton.