An exceptional case of xanthomatous infiltration of the musculoskeletal and integumentary systems.

Tendinous and subcutaneous xanthomas are most commonly associated with primary hyperlipidemia. Xanthomatosis caused by cholesterol deposition can be a high risk marker for cardiovascular disease related to premature atherosclerosis; thus, early recognition of this diagnosis may reduce mortality and morbidity. Achilles tendon involvement is most common, followed by the extensor tendons of the hand and elbow. We present an exceptional case of tendinous and tuberous xanthomas, with intraoperative and histologic correlation, in a 34-year-old female manifesting with xanthomatous deposits of nearly all ankle tendons, plantar aponeurosis, extensor tendons of the hands, and various locations within the integumentum. To the authors' knowledge, only four studies to date have focused specifically on imaging findings of multifocal xanthomas. Thus, the radiographic and MR imaging descriptions of xanthomas in this report further add to the existing literature by helping to identify imaging characteristics of this multifocal systemic disease. The diagnosis of this condition should alert the physician to the presence of a dyslipidemia that can be treated with dietary modifications and/or drug therapy.

Acroparesthesia and carpal tunnel syndrome: a historical perspective.

This article presents the history of acroparesthesia and its contribution to the discovery of idiopathic carpal tunnel syndrome (CTS). We used primary sources from the middle of the nineteenth century onward to show that the first short descriptions of patients with nocturnal and early morning paresthesias, numbness, pain, and weakness in the hands, without accompanying physical signs, were published around 1850. The condition was named acroparesthesia in 1890 and, in the following years, was accepted as a disease in medical textbooks. Almost all of the patients with acroparesthesia, described at the end of the nineteenth and the first half of the twentieth century, would today be diagnosed with idiopathic CTS. Although physicians proposed many hypotheses for the etiology of acroparesthesia throughout its 100-year history, they did not understand that the condition arose from compression of the median nerve in the carpal tunnel, and the concept of acroparesthesia did not lead to the discovery of CTS. Even Russell Brain-who, in 1946 and 1947, showed that the "syndrome of partial thenar atrophy" was due to compression of the median nerve in the carpal tunnel-did not realize that acroparesthesia shared the same origin. This understanding developed in the late 1940s and through the 1950s, and the disease came to be accepted under the name carpal tunnel syndrome.

Carpal tunnel syndrome, syndrome of partial thenar atrophy, and W. Russell Brain: a historical perspective.

This article presents the history of the discovery of compression of the median nerve in the carpal tunnel without an identifiable cause as a distinct clinical entity. By analyzing primary sources, we show that, at the beginning of the twentieth century, physicians described patients with paresthesias and numbness in the hands, most prominent at night, accompanied by bilateral symmetrical atrophy along the radial side of thenar eminence. At the time, the 2 most influential hypotheses regarding etiology were, first, compression of the lower trunk of the brachial plexus by a cervical or first rib, and second, compression of the thenar branch of the median nerve as it passes beneath the anterior annular ligament of the wrist. The condition was named syndrome of partial thenar atrophy and was considered a distinct clinical entity. In 1946, after extensive analysis, neurologist Walter Russell Brain concluded that both sensory and motor symptoms of the syndrome were caused by "compression neuritis" of the median nerve in the carpal tunnel. At his suggestion, surgeon Arthur Dickson Wright performed decompression of the nerve by "an incision of the carpal ligament," with excellent results. Brain presented this work at the Royal Society of Medicine in London in 1946 and published his landmark paper in Lancet the following year. In so doing, he established the basis for the disease we know today as idiopathic carpal tunnel syndrome. Unfortunately, in 1947, Brain did not realize that another "condition" with the same clinical picture but without atrophy of the thenar muscles, known as acroparesthesia at the time, was actually the same disease as syndrome of partial thenar atrophy, but of lesser severity. As a result of Brain's influence, 7 other papers were published by 1950. Between 1946 and 1950, there were at least 10 papers that presented, in total, 31 patients (26 women) who exhibited symptoms of compression of the median nerve without an identifiable cause and underwent section of the transverse carpal ligament.

Experimental model of trigger finger through A1 pulley constriction in a human cadaveric hand: a pilot study.

PURPOSE: Although it can be reasonably assumed that trigger digits occur as the result of a size mismatch in the pulley-tendon system, it is unclear whether locking, histological changes, and nodule formation occur owing to an intrinsically too small pulley or an enlarged digital flexor tendon. Our purposes in this feasibility study were to (1) create a model of trigger digit by pulley constriction in nonpreserved human tissue, (2) measure the change in work of flexion as the force of pulley constriction increased, (3) compare the work of flexion between nontriggering and triggering conditions, and (4) determine whether triggering can occur at the A2, A3, and A4 pulleys under similar conditions. METHODS: Using a tensiometer, we studied the work of flexion in 4 fingers (thumb, index, middle, and ring) in a human cadaveric hand. The load of flexion was measured as the A1 to A4 pulleys were incrementally constricted in order to induce triggering. Work of flexion was analyzed for differences among trial conditions. RESULTS: Triggering was successfully induced in all 4 digits through constriction of the A1 pulley. No triggering occurred in any of the A2, A3, or A4 pulley systems in this model. CONCLUSIONS: We successfully created a trigger model in a human cadaveric hand. Our results demonstrate that the A1 pulley can cause triggering from manual constriction of the pulley alone. CLINICAL RELEVANCE: A trigger model such as this may allow investigations of pathophysiology, and this may result in novel treatment strategies and modalities.

Differential Pulley Release in Trigger Finger: A Prospective, Randomized Clinical Trial.

BACKGROUND: The palmar aponeurosis or "A0 pulley" may play a role in trigger finger pathology. This study assesses the involvement of the A0 pulley in patients receiving trigger finger release. METHODS: This single-surgeon, prospective, randomized clinical trial was conducted among consenting patients with symptomatic trigger finger. Intraoperative coin toss was used to randomize initial release of either the A0 or A1 pulley. Following release, active flexion and extension of the affected digit were examined. The remaining pulley was then released in sequence, and clinical trigger status was recorded. RESULTS: Thirty fingers from 24 patients were released; 17 fingers received A0 release first, and 13 received A1 release. Following initial A0 release, 8 fingers (47%) demonstrated complete resolution of symptoms, 4 (24%) demonstrated improvement but incomplete resolution of triggering, and 5 (29.4%) demonstrated no improvement. Following initial A1 release, 6 fingers (46%) demonstrated complete resolution, 3 (23%) demonstrated improvement but incomplete resolution of triggering, and 4 (31%) demonstrated no improvement. All patients demonstrated complete resolution after surgical release of both sites. Neither initial A1 release nor initial A0 release was statistically associated with complete, incomplete, or failed symptom resolution. CONCLUSIONS: These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in our study. Although larger trials are needed to validate these results, our study suggests that release of both A0 and A1 pulleys may offer greater symptom resolution than release of the A1 pulley alone.

Analysis of Strengths in Exposure to Cases During Plastic and Orthopaedic Hand Surgery Fellowships.

INTRODUCTION: Prospective residents interested in hand surgery must decide to apply for hand surgery fellowships sponsored by different specialties. This study compares case volumes reported during plastic surgery and orthopaedic hand surgery fellowships. METHODS: The American Council for Graduate Medical Education case logs of accredited hand surgery fellowships were analyzed for hand surgery cases (2012 to 2013 to 2020 to 2021). The reported case volume was compared by specialty. Temporal trends were described, intrapathway variabilities calculated, and interpathway differences calculated with Student t -tests. RESULTS: Two hundred plastic surgery (13%) and 1,323 orthopaedic (87%) hand surgery fellows were included. The number of orthopaedic hand surgery fellowships increased from 58 in 2012 to 2013 to 70 in 2020 to 2021 (21% increase), whereas the number of plastic surgery fellowships was stable at 16. Orthopaedic hand surgery fellows reported more hand surgery cases (764 ± 22 versus 628 ± 226), arthroscopy cases (53 ± 54 versus 23 ± 38), and miscellaneous hand surgery cases (42 ± 23 versus 31 ± 18) than plastic surgery hand fellows. Plastic surgery hand fellows reported more cases in wound closure with graft, wound reconstruction with flap, nerve injury, and vascular repair. Overall, orthopaedic surgery offered more experience in 15 case categories (58%), while plastic surgery offered more experience in five case categories (19%). Six case categories (23%) had no difference between specialties. DISCUSSION: Although orthopaedic hand surgery fellowship affords more cases overall, plastic surgery hand fellowships have unique strengths in wound reconstruction with grafts and flaps, nerve injury, and vascular repair. Ultimately, results from this study create a benchmark to improve future training opportunities for hand surgery fellows and orthopaedic surgery residents.

Sex, Race, Insurance, and Pain: Do Patient Sociodemographics Influence Postoperative Opioid Prescriptions Among Hand Surgeons?

BACKGROUND: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. METHODS: We performed a retrospective analysis of all hand surgeries (N = 5278) at a single academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, sex, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. RESULTS: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without (P < .0001), and patients with a history of chronic pain were prescribed 36.7 MME more than those without (P < .0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men (P = .0048), and Hispanics were prescribed 16.6 MME more than whites (P = .0091) overall. Both Hispanic and black patients were also prescribed more than whites following carpal tunnel release (+19.0 and + 20.0 MME, respectively; P < .001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare (P < .0001), but 25.0 MME less than those with Medicaid (P < .0001). There were no differences across age groups. CONCLUSIONS: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons at our institution. These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations.

Does the severity of bilateral carpal tunnel syndrome influence the timing of staged bilateral release?

A retrospective chart analysis was performed of 66 patients with bilateral carpal tunnel syndrome (CTS) who underwent either single endoscopic carpal tunnel release (ECTR) or staged bilateral ECTR to determine the frequency and timing of contralateral surgery. Bilateral CTS patients with contralateral severe CTS underwent bilateral staged ECTR 86% of the time and the second operation was performed 6 ± 5 weeks after the initial ECTR. Patients with contralateral moderate CTS underwent bilateral staged ECTR 74% of the time with a mean of 11 ± 3 months between operations. Patients with contralateral mild CTS underwent bilateral staged ECTR 20% of the time and averaged 7 ± 3 years between procedures. For patients with bilateral CTS, the severity of CTS on the contralateral side to the initial release affects both the frequency and timing of the contralateral surgery. This information may be used to establish guidelines for treatment with bilateral simultaneous CTR.

Mild intraoperative hypothermia reduces free tissue transfer thrombosis.

Patients undergoing free tissue transfer are particularly susceptible to hypothermia. The goal was to investigate the impact of intraoperative core body temperature on free flap thrombosis. Two hundred twelve cases of free flap reconstruction at Yale-New Haven Hospital between 1992 and 2008 were reviewed. Free flap thrombosis was defined by complete flap necrosis or direct visualization of arterial or venous thrombosis. Temperature measurements were calibrated to bladder temperatures as measured by Foley catheter sensor. Through logistic regression analysis, maximum and minimum intraoperative temperatures were determined to be statistically significant predictors of free flap thrombosis. The optimal temperature was calculated to be 36.2 °C, and maximum intraoperative temperatures between 36.0 °C and 36.4 °C showed lower thrombosis rates than super-warmed patients ( P < 0.03). Therefore, free flap patients should be mildly hypothermic at 36.0 °C to 36.4 °C, compared with normothermia at 37.5 °C, as measured in the bladder. A prospective randomized trial investigating thrombosis rates and intraoperative temperature should be undertaken.

The effect of ischemic preconditioning on secondary ischemia in myocutaneous flaps.

We sought to determine the effect of ischemic preconditioning (IPC) on secondary ischemia in myocutaneous flaps in a rat model. Forty rectus abdominis myocutaneous flaps were elevated in 40 rats, and the animals were randomized into control or IPC groups (20 flaps each group). All flaps were then subject to primary ischemia for 2 hours via pedicle clamping. Twenty-four hours later, the control and IPC flaps were randomized to two groups each of 1 or 2 hours of secondary ischemia (4 groups, 10 flaps per group). Flap survival was evaluated on postoperative day 5 by measuring the percentage area of flap survival by a blinded observer. Mean flap survival area and total necrosis rates were compared between the groups. In the 1-hour secondary ischemia groups, IPC improved mean flap survival area from 11 +/- 7% to 36 +/- 22%, and the total necrosis rates from 40 to 0%. These differences were statistically significant (p < 0.006, p < 0.05, respectively). In the 2-hour secondary ischemia groups, differences were not statistically significant (p = 0.2, p = 0.4, respectively). IPC improves the survival of myocutaneous flaps subjected to secondary ischemia of 1 hour in this rat free flap model.

Carpal tunnel syndrome associated with the use of aromatase inhibitors in breast cancer.

Aromatase inhibitors (AI) inhibit peripheral conversion of androgens to estradiol and are commonly used as hormonal therapy for postmenopausal women with hormone receptor-positive breast cancer in the metastatic and adjuvant settings. Joint-related symptoms, however, are seen in a significant proportion of patients. Carpal tunnel syndrome (CTS) is a common nerve entrapment disorder affecting the median nerve. We describe 6 patients with newly diagnosed CTS after initiation of adjuvant AI therapy. Aromatase inhibitors were discontinued in several patients secondary to this toxicity with some switching to tamoxifen and most subsequently experiencing relief of their symptoms. Potential pathophysiologic roles of hormonal manipulation with AIs and other risk factors that might contribute to CTS are discussed. Aromatase inhibitors might accentuate the occurrence of CTS and potentially other nerve entrapment syndromes, and a more systematic approach should be used to better understand the clinical significance and incidence of these symptoms.

Functional and Quality of Life Outcomes of a Hand Surgery Mission to Honduras.

Background: The objective of this study was to assess functional, quality of life, and satisfaction outcomes of a hand surgery short-term surgical mission (STSM) to Honduras, and determine whether patient demographics and surgery characteristics during a surgical mission correlate with outcome. Methods: A total of 63 patients who received upper extremity surgery at a week-long hand surgery STSM to Honduras in March 2013 participated in the study. A before-after study design was used. Before receiving surgery, participants completed the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and the Short Form 12 Health Survey version 2 (SF12v2). Four months postoperatively, participants completed the QuickDASH, SF12v2, and Satisfaction Survey. Results: The mean QuickDASH score significantly improved preoperatively to postoperatively. Demographics measures of age, sex, education, and income did not correlate with QuickDASH scores. Preoperative QuickDASH statistically significantly correlated with surgery type: Carpal tunnel patients had the highest scores (worst functioning). Postoperatively, mass excision and scar contracture/skin graft patients were correlated with the lowest scores. Carpal tunnel and tendon surgery patients showed greatest correlation with QuickDASH improvement. SF-12 scores revealed improvements in mental domains and declines in physical domains. Conclusions: Hand surgery performed during STSMs can result in significant functional improvement, regardless of socioeconomic status. Patients benefited from both simpler and more complex operations. Four months after surgery, general health-related quality of life measures showed improved mental indices. Measured physical indices declined despite improved QuickDASH scores. This may be due to the early general postoperative state. Further outcome research in STSMs in additional countries and specialties is required to expand our conclusions to other STSM contexts and guide best practices in STSMs.

Growth factor expression with different wound treatments after laser resurfacing.

BACKGROUND: Many studies have demonstrated that the specific method of wound dressing used may affect the healing process. However, the effect of the method of wound dressings on the expression of growth factors is not well documented. OBJECTIVE: The aim of this study was to evaluate the effects of different methods of treatment on the healing process and the expression of growth factors (epidermal growth factor, basic fibroblast growth factor, transforming growth factor-beta(2) [TGF-beta(2)], platelet-derived growth factor-A, and platelet-derived growth factor-B) by histologic study, immunohistochemistry, and reverse transcription-polymerase chain reaction. METHODS: In this study, we produced wounds with a CO(2) laser on the backs of rats and used 4 different methods of wound treatment: occlusive dressing material, petrolatum ointment, beta-sitosterol ointment, and exposure to air (untreated) as a control. Five-millimeter biopsy specimens were obtained 1, 3, 5, 7, and 10 days after surgery for histologic evaluation and expression of growth factors from four different dressing sites. RESULTS: By microscopic examination, there was an acceleration of wound healing in the occlusive dressing wounds, as well as a lesser improvement in healing times with the petrolatum and beta-sitosterol-treated wounds, compared with the air-exposed control subjects. With immunohistochemistry, we observed that the tissue expression of TGF-beta(2) remained at a clearly lower level during the entire duration of wound healing in the occlusive dressing wound compared with the other treatment wounds. With reverse transcriptase-polymerase chain reaction, however, our data did not reveal statistically significant differences among the messenger RNA levels. CONCLUSIONS: Our results suggest that a decrease in the expression level of TGF-beta(2) under occlusive dressings could provide an environment in which the growth of human epidermal keratinocytes and re-epithelialization is promoted.

Decision-making and Management of Ulnar Polydactyly of the Newborn: Outcomes and Satisfaction.

BACKGROUND: Polydactyly is the most common congenital hand deformity. There is currently no consensus among pediatricians or hand surgeons regarding optimal management of ulnar (post-axial) type B polydactyly leading to uncertainty in initial treatment decisions for infants with this type of deformity. METHODS: Parents of newborns with type B ulnar polydactyly were enrolled in a prospective, nonrandomized trial from 2010 to 2012. At enrollment they were offered: 1) no treatment, 2) suture ligature, 3) immediate excision under local anesthesia, and 4) delayed excision at four months of age under general anesthesia. After choosing a treatment option, parents were asked to complete an initial survey on their motivation for choosing a particular option, and then additional surveys at one and three month follow-up visits regarding outcomes and satisfaction. RESULTS: Fourteen newborns were enrolled in the study. Eleven patients had bilateral polydactyly for a total of 25 hands involved in the study. With statistical significance, parents chose an immediate bedside excision over all options. No surgical complications were noted and satisfaction scores were 9.8 or higher in all groups. CONCLUSIONS: A majority of parents whose children are born with type B post-axial polydactyly prefer to have the deformity addressed immediately with excision under local anesthesia at the bedside. This can be accomplished safely, with a satisfaction score of 9.8 out of 10 and no appreciable residual deformity. This may reduce emotional distress or embarrassment in parents who would otherwise have to deal with the deformity for at least a four-month period.

Differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation.

There has been little discussion in the published literature regarding breast shape preferences. This study was conducted to ascertain previously undocumented differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation, with respect to upper-pole contour. Sixty-six respondents, grouped into three cohort categories (plastic surgeons, breast augmentation patients, and lay people), were asked to evaluate a series of 12 nonptotic breast profiles representing a range of upper-pole contours. Five profiles exhibited convex upper-pole contours, five exhibited concave contours, and two exhibited upper poles with flat slopes. A five-point Likert-type scale was used to rate attractiveness, naturalness, how close the shape was to each respondent's personal ideal, and how close the shape was to what the respondent believed was our society's ideal. Statistical comparisons were made among the three cohorts. The plastic surgeon cohort (n = 11) rated concave upper-pole contours significantly higher than did the patient cohort (n = 13) for attractiveness, naturalness, and personal ideal (p < 0.01). For convex contours, the plastic surgeon cohort gave significantly lower scores than did the patient cohort (p < 0.01). The lay category (n = 42) demonstrated preferences intermediate between those of the other groups. There are no known studies in the literature documenting the breast shape preferences of plastic surgeons and their patients. This study suggests that plastic surgeons and patients seeking breast augmentation may have drastically different images in mind regarding what constitutes an attractive, natural, and ideal breast shape. These findings have potential implications for patient treatment and satisfaction.

The optimal sequence of microvascular repair during prolonged clamping in free flap transfer.

During free flap transfer, the surgeon may decide to begin with repair of the artery or the vein(s) and to unclamp the first vessel as soon as repair is completed or maintain the clamping of both vessels until completion of all repairs. Complications can lead to prolonged clamping times, potentially increasing the risk of tissue ischemia, vascular damage, and thrombosis. The goals of the present study were to determine whether the sequence of vessel repair and the duration of clamping affect the success of free flap transfer in cases requiring prolonged clamping. Sixty abdominal fasciocutaneous free flaps based on the superficial inferior epigastric vessels were created in Sprague-Dawley rats. To model clinical situations in which prolonged clamping is necessary, the study used a 1-hour delay before the repair of the second vessel. Flaps were randomized into four groups. In group I (n = 15), the artery was repaired first, and the arterial clamp was removed immediately to allow arterial inflow. In group II (n = 15), the arterial repair was first, and the arterial clamp was maintained until completion of venous repair. In group III (n = 15), venous repair was first, with venous clamping maintained until completion of the arterial repair. In group IV (n = 15), initial venous repair was followed by immediate unclamping, before arterial repair. On release of all clamps, the patency of arteries and veins was confirmed immediately and after 1 hour using a "milking" test. On the fifth postoperative day, each flap was assessed for necrosis and for patency of the anastomoses. Of 15 flaps in each group, five (33 percent) failed in group I, four (27 percent) failed in groups II and III, and six (40 percent) failed in group IV. Differences between groups were not statistically significant (p = 0.8). These results demonstrate that in cases requiring prolonged occlusive clamping (2 to 3 hours), factors such as venous congestion, possible clamp injury, and presence of static blood in contact with the new anastomosis have relatively equivalent contributions to the risk of failure. Accordingly, no advantage seems to be gained by beginning with the artery or the vein or by using early or delayed unclamping of the first vessel repaired.

Helping hands: a cost-effectiveness study of a humanitarian hand surgery mission.

Purpose. Congenital anomalies and injuries of the hand are often undertreated in low-middle income countries (LMICs). Humanitarian missions to LMICs are commonplace, but few exclusively hand surgery missions have been reported and none have attempted to demonstrate their cost-effectiveness. We present the first study evaluating the cost-effectiveness of a humanitarian hand surgery mission to Honduras as a method of reducing the global burden of surgically treatable disease. Methods. Data were collected from a hand surgery mission to San Pedro Sula, Honduras. Costs were estimated for local and volunteer services. The total burden of disease averted from patients receiving surgical reconstruction was derived using the previously described disability-adjusted life years (DALYs) system. Results. After adjusting for likelihood of disability associated with the diagnosis and likelihood of the surgery's success, DALYs averted totaled 104.6. The total cost for the mission was $45,779 (USD). The cost per DALY averted was calculated to be $437.80 (USD), which is significantly below the accepted threshold of two times the per capita gross national income of Honduras. Conclusions. This hand surgery humanitarian mission trip to Honduras was found to be cost-effective. This model and analysis should help in guiding healthcare professionals to organize future plastic surgery humanitarian missions.