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In the late nineteenth century, American mining engineers and geologists fanned out to potential or existing mines around the world. This paper examines the work of George F. Becker—a forty-year v...

Purpose The combined treatment of trapeziometacarpal joint arthritis and scapholunate advanced collapse (SLAC) wrist presents unique challenges. The consequences of the loss of radial column support caused by scaphoidectomy and trapeziectomy are not well known. The purpose of this study was to evaluate the outcomes of the simultaneous and staged treatment of trapeziometacarpal joint arthritis and SLAC wrist. Methods A retrospective review of patients who underwent surgery for both trapeziometacarpal joint arthritis and SLAC wrist was performed. The wrist and thumb range of motion; grip and pinch strength; pain; quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; and radiographs were analyzed. Results Twenty-four patients who underwent both trapeziectomy and 1 of 3 procedures for SLAC wrist (4-corner fusion [n = 10]), proximal row carpectomy [n = 9], and total wrist arthroplasty [n = 5]) in a single stage (n = 10) or in 2 stages (n = 14) were included. The median age was 63 years. The median follow-up period was 35 months. Twelve (50%) patients underwent complete scaphoidectomy, and 12 (50%) patients underwent partial scaphoidectomy. All 3 procedures resulted in an improvement in pain at rest, pain during activity, and quick Disabilities of the Arm, Shoulder and Hand scores. The final range of motion, grip and pinch strength, and complication rates were consistent with those reported in the literature for isolated procedures. Conclusions Trapeziometacarpal joint arthritis and SLAC wrist may be treated either simultaneously or in stages. Type of study/level of evidence Therapeutic V.

INTRODUCTION Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is a difficult to treat condition characterized by debilitating pain and limitations in functional ability. Neuromodulation, in the form of spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS), have been traditionally used as a treatment for CRPS with variable success. OBJECTIVE This chart review describes the use of implantable PNS systems in the treatment of CRPS of the upper and lower extremities spanning nearly three decades. MATERIALS AND METHODS A retrospective chart review was performed on 240 patients with PNS implanted between 1990 and 2017 at our institution. Of these, 165 patients were identified who had PNS systems implanted for a diagnosis of CRPS. Patient profile, including baseline characteristics, comorbidities, past/current interventions/medications and targeted nerves, was descriptively summarized through standard summary statistics. Patients' pain scores and opioid consumptions at baseline (preimplant), 1 month, 6 months, and 12 months were collected and compared. Device revisions and explants were summarized, and patient functional outcomes were described. RESULTS Pain scores at baseline and at 12-month follow-up were decreased from a mean of 7.4 ± 1.6 to 5.5 ± 2.4 and estimated to be 1.87 (95% CI: [1.29, 2.46], paired t-test p-value

Background Arteriovenous (AV) loops can be utilized in a single- or two-stage approach in free flap reconstruction when proper vessels are not available. However, there exists no consensus on which method leads to superior microsurgical and patient outcomes. The purpose of this article was to review single- versus two-stage AV loops utilized in free flap reconstruction with a focus on complications and overall outcomes. Methods A systematic review of AV loops for autologous free tissue transfer was conducted. Endpoints investigated included flap characteristics, timing to second stage, complications, and outcomes. A Student's t-test and forest plots were used for statistical analysis. Results Thirty-five unique papers discussed utilizing AV loops in a single- or two-stage approach, yielding 260 and 98 single- and two-stage AV loops, respectively. There was a statistically significant higher rate of major complications in two-stage as compared to single-stage AV loops. There was a non-statistically significant difference in rate of minor complications in the single-stage as compared to two-stage AV loops. Overall, there was a statistically significant higher success rate in the single-stage as compared to two-stage AV loops Conclusion There was a statistically significant higher rate of major complications and failures in two-stage AV loops. As well-conducted randomized controlled studies are nearly impossible to perform in this population, the decision to pursue a single- versus two-stage reconstruction should ultimately be determined based on individual patient co-morbidities, the size and etiology of defect, and the type of free tissue transfer planned.

In the last decades of the nineteenth century, American mining engineers fanned out around the globe to potential or existing mines in China, Mexico, Siberia, South Africa, and beyond. This article examines the rise and work of mining engineer John Hays Hammond and the mining engineers, geologists, and capitalists with whom he worked. The paper reveals ways that a segment of the investor class depended upon members of the emerging professional middle class of university-trained mining experts for collaboration—and even inspiration—regarding possible sources of remunerative investment. The search for raw materials abroad opens up a chapter in the history of U.S. capitalism in which mining engineers like Hammond encouraged and facilitated a new phase of export of redundant U.S. capital and manufactured goods in a direction where investment would be secure, labor recruitable, and profits attractive and subject to repatriation. Filling in this vital narrative makes an essential contribution to the ongoing recovery of the history of the U.S. and world capitalism in the era of rapid industrialization.

BACKGROUND The medial gastrocnemius muscle flap is commonly used for the reconstruction of defects around the knee and proximal leg. The flap can be raised using either a medial or a posterior midline incision, although no studies have been done comparing the 2 different surgical approaches. METHODS We compared the reach of the medial gastrocnemius muscle flap using either of the 2 incisions in a series of 25 fresh cadavers. All muscle flaps were elevated without division of the muscle origin. Muscle reach was calculated using the distance from a fixed bony point with the leg fully extended and the muscle under no tension. Muscle width measurements were used to calculate surface area of coverage. RESULTS Muscle flaps elevated through the posterior midline incision group reached 2.02 cm farther than flaps through the medial incision (P < 0.05). This resulted in 20.3 cm increase in surface area for the posterior midline incision group over the medial incision group (P < 0.05). The posterior midline incision allowed for better visualization of the vascular pedicle and dissection of fascial attachments around the pes anserinus. CONCLUSIONS The posterior midline incision for the elevation of the medial gastrocnemius pedicled muscle flap allows for a safe, thorough mobilization of the muscle resulting in increased muscle reach and increased surface area when compared with the medial incision. Furthermore, the posterior midline incision provides better access to the gastrocnemius muscle origin and the lateral muscle head.

Deep soft tissue defects after complicated primary or revision total knee arthroplasty (TKA) can be devastating to the patient and technically challenging. The purpose of this review was to (1) discuss different methods used to provide coverage for deep defects of the knee following TKA, as well as to (2) report on their success rates. A comprehensive literature search was performed. Reports were only included if they (1) were case series, (2) were level III studies or above (including retrospective cohort studies and meta-analyses), (3) were in English, and (4) discussed the outcome of graft or flap coverage of soft tissue defects after total knee arthroplasty. A total of 28 case series and four retrospective comparative studies were retrieved. In 16 studies, 195 out of 241 patients who received gastrocnemius flaps (81%) experienced successful outcomes. In seven studies including 84 patients that underwent fasciocutaneous flap coverage, over 90% of patients experienced successful outcomes. In the four studies examining 144 patients with delayed versus prophylactic soft tissue reconstruction, up to 81% of patients experienced a successful outcome. Various factors must be taken into consideration when assessing full-thickness defects over a TKA and collaboration between plastic and orthopaedic surgeons is required to select the optimal approach.

BACKGROUND We report new data for a rare face transplant performed 3 years ago. Granulomatosis with polyangiitis (GPA) (Wegener) is a severe autoimmune necrotizing vasculitis and parenchymal inflammatory disease that can affect any organ including those of the craniofacial region. Skin involvement manifests as malignant pyoderma. This account (1) highlights the technical details of face transplantation for this unique indication, (2) reports the 3-year posttransplant outcome, and (3) describes relevant immunological aspects. METHODS A Le Fort III near-total face and near-total scalp transplant was performed after extensive trauma and subsequent bone and soft tissue infection in a patient with GPA. Incisions were planned along facial aesthetic subunits. The vascular pedicle comprised the facial and superficial temporal arteries bilaterally. The functioning left eye was preserved and fitted into the donor tissues. RESULTS The procedure took 21 hours, and transfusion was limited to 4 units of packed red cells. Early medical and surgical complications were successfully treated. At 3 years, acceptable aesthetic outcome was achieved with adequate color match and scalp hair growth. The patient has recovered light touch, temperature, and 2-point discrimination and has evidence of symmetric cheek elevation albeit with limited eyelid and frontalis function. GPA relapse did not occur. Four acute rejections were fully reversed. CONCLUSIONS This case represents a new underlying disease (trauma + GPA) leading to face transplantation and a unique clinical scenario where allografting was indicated for potentially life-threatening and sight-preserving reasons and not for mere functional and aesthetic concerns. Despite complexity, 3-year clinical outcome is encouraging, and the patient is no longer at risk for dural exposure, meningitis, and related morbidity.

Granulomatosis with polyangiitis (GPA; formerly Wegener's granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten-year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1-year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.

Background Granulomatosis with polyangiitis (Wegener granulomatosis) is a rare disease that commonly starts in the craniofacial region and can lead to considerable facial disfigurement. Granulomas and vasculitis, however, can involve many other tissues (especially pulmonary and renal). Dermatologic and subcutaneous components can lead to malignant pyoderma. Methods The authors describe a unique pathologic condition, where significant Le Fort type trauma was associated with subsequent development of granulomatosis with polyangiitis and malignant pyoderma. Successive operations to excise necrotic tissue and reconstruct the defects were followed by worsening inflammation and tissue erosions. Trauma and surgery in proximity to the eye and sinuses masked the initial clinical presentation and led to delay in diagnosis and disease progression. The resultant facial disfigurement and tissue loss were substantial. Results Despite multiple confounding factors, accurate diagnosis was eventually established. This was based on persistence of sinus inflammations in the absence of infective agents, proven sterility of lung lesions, and antineutrophil cytoplasmic antibody positivity with proteinase 3 specificity. Skin lesion biopsy specimens were identified as pyoderma gangrenosum and later as malignant pyoderma. Institution of immunosuppressive therapy allowed successful control of the disease and wound healing. The resulting craniofacial destruction, however, necessitated facial vascularized composite allotransplantation. Conclusion Recognition of this rare pathologic association is essential, to prevent delays in diagnosis and treatment that can lead to major craniofacial tissue loss. Clinical question/level of evidence Therapeutic, V.

BACKGROUND Insufficient soft-tissue coverage following total knee arthroplasty jeopardizes prosthesis retention and may lead to significant complications. The aim of this study was to evaluate the natural history of total knee arthroplasty following flap reconstruction of soft-tissue defects. METHODS A retrospective review of patients treated with flaps after failed total knee arthroplasty between 1998 and 2013 was conducted. Patients with preexisting soft-tissue defects who required reactive flap reconstruction were included in group 1. Patients with no preexisting soft-tissue defects, but with extensive debridement during revision total knee arthroplasty requiring immediate proactive flap coverage, were included in group 2. RESULTS Fifty-eight patients in group 1 were treated with 86 flaps, and 15 patients in group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p = 0.21). Flap-related complications and number of subsequent flap revisions were comparable in both groups. Patients in group 1 had a higher rate of implant reinfection (58 percent versus 27 percent; p < 0.05), amputations (25 percent versus 0 percent; p < 0.05), and subsequent prosthesis revisions (2.2 versus 0.9; p < 0.05). Functional joint was preserved in 54 percent and 80 percent of cases, respectively. Mean gain in range of motion and quality of life were significantly better in group 2 (p < 0.05). CONCLUSIONS Early proactive soft-tissue coverage of total-knee arthroplasty is critical to long-term success. In cases where reactive treatment is required, significantly worse outcomes and a high rate of complications should be expected. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

We studied anomalies of the common digital arteries by dissecting 33 fresh cadaver hands under magnification. In the majority of the dissected hands (25 hands), common digital arteries took off from the superficial palmar arch and ran superficial and parallel to the flexor tendons. Variations were found in eight out of 33 hands. In four hands the common digital artery to the second web space was replaced by an atypical vessel, originating from the deep palmar arch, that crossed posterior to the index flexor tendons proximal to the A1 pulley. In eight hands, the common digital artery to the fourth web space was replaced by an atypical deeper vessel, originating from the superficial palmar arch and crossing posterior to the little finger flexors. No nerve anomalies were identified. Unrecognized, these atypical arteries to the second and/or fourth web spaces could lead to vascular complications during surgery, especially pollicization.

Arteriovenous (AV) loops can be utilized in a single- or two-stage approach in free flap reconstruction when proper vessels are not available. However, there exists no consensus on which method leads to superior microsurgical and patient outcomes. The purpose of this article was to review single- versus two-stage AV loops utilized in free flap reconstruction with a focus on complications and overall outcomes.A systematic review of AV loops for autologous free tissue transfer was conducted. Endpoints investigated included flap characteristics, timing to second stage, complications, and outcomes. A Student's t-test and forest plots were used for statistical analysis.Thirty-five unique papers discussed utilizing AV loops in a single- or two-stage approach, yielding 260 and 98 single- and two-stage AV loops, respectively. There was a statistically significant higher rate of major complications in two-stage as compared to single-stage AV loops. There was a non-statistically significant difference in rate of minor complications in the single-stage as compared to two-stage AV loops. Overall, there was a statistically significant higher success rate in the single-stage as compared to two-stage AV loops CONCLUSION: There was a statistically significant higher rate of major complications and failures in two-stage AV loops. As well-conducted randomized controlled studies are nearly impossible to perform in this population, the decision to pursue a single- versus two-stage reconstruction should ultimately be determined based on individual patient co-morbidities, the size and etiology of defect, and the type of free tissue transfer planned.

Objective Minimally invasive cardiac surgery in patients with breast implants is challenging. Obtaining access to cardiac structures without injuring the prosthesis and at the same time maintaining cosmesis is of particular concern in these patients. Mitral valve surgery can be performed using a right mini-inframammary thoracotomy in female patients with breast implants. We describe our experience with this approach to preserve the cosmetic results of previous breast augmentation. Methods Six female patients with previous breast implantation presented for isolated mitral valve surgery for degenerative disease. Surgery was performed through an inframammary incision, in most cases using the previous surgical incision from breast implantation. Peripheral cannulation was used for cardiopulmonary bypass. The breast prosthesis was explanted through a 6-cm skin incision, and then the mitral valve was approached through a right mini anterior thoracotomy. At the end of mitral surgery, the implant was replaced. Results All patients had satisfactory outcomes. The mitral valve was repaired in five patients and replaced in one patient. Average length of stay was 5.3 days (range, 4–8 days). There were no conversions to median sternotomy. There were no bleeding complications. There were no wound complications or implant infections. Cosmesis was preserved. Conclusions Our experience with this approach has allowed both mitral valve repair and replacement at the same time preserving cosmetic results. This minimally invasive technique may also have applications in performing atrial septal defect closure, Maze procedures for atrial fibrillation, and tricuspid valve surgery in patients with breast implants.

Summary Background Multiple reconstructive procedures are common for the reconstruction of complex facial deformities of skin, soft tissues, bony structures, and functional subunits, such as the nose, lips, and eyelids. However, the results have been unsatisfactory. An innovative approach entailing a single surgical procedure of face allograft transplantation is a viable alternative and gives improved results. Methods On Dec 9, 2008, a 45-year-old woman with a history of severe midface trauma underwent near-total face transplantation in which 80% of her face was replaced with a tailored composite tissue allograft. We addressed issues of immunosuppressive therapy, psychological and ethical outcomes, and re-integration of the patient into society. Findings After the operation, the patient did well physically and psychologically, and tolerated immunosuppression without any major complication. Routine biopsy on day 47 after transplantation showed rejection of graft mucosa; however, a single bolus of corticosteroids reversed rejection. During the first 3 weeks after transplantation, the patient accepted her new face; 6 months after surgery, the functional outcome has been excellent. In contrast to her status before transplantation, the patient can now breathe through her nose, smell, taste, speak intelligibly, eat solid foods, and drink from a cup. Interpretation We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using composite face allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients. Funding None.

On June 5, 1920, Congress established the Women's Bureau, charging it to “formulate standards and policies which shall promote the welfare of wage-earning women, improve their working conditions, increase their efficiency, and advance their opportunities for profitable employment.” Support for the bureau was such that the House passed the bill by a vote of 255 to 10, and the Senate passed it without a recorded vote, though theMonthly Labor Reviewnoted that “there was some opposition.” During a decade when policymakers celebrated the fruits of economic abundance garnered with only the lightest touch from the state, bureau leaders and investigators saw gender research as a form of labor activism that would advance the cause of all workers. The bureau provided a unique site for discourse and deliberation concerning labor standards that did not exist in any other branch of the federal government. No other organization in the federal government thought harder about how policies could be constructed to protect workers, irrespective of gender, from the continued harsh reality of employment in American industry. Along the way, advocates of protective legislation for women sought not only to protect the particular interests of women workers, but also to drive a wedge through a post-Adkinsunderstanding of the “right to contract” and to expand the number of issues that should be seen as affected with a public interest.

This report describes the development of a new technique for harvesting facial allograft for facial transplantation. The coronal-posterior surgical approach for facial/scalp flap harvesting from donor cadavers has been developed to allow extended length to the neurovascular bundles utilized in facial composite allograft transplantation. Cadaveric anatomic dissections were performed to harvest facial/scalp flaps via a posterior-coronal approach. Supraorbital and infraorbital neurovascular bundle lengths were extended by osteotomy of the cranial/orbital bone. The mental nerve lengths were extended into the inferior alveolar neurovascular bundle utilizing a sagittal split ramus osteotomy. This surgical approach extends the length of these craniofacial nerves for future neurorrhaphy. The mean length of the supraorbital, infraorbital, and mental nerves was 3.52 +/- 0.31 cm, 4.65 +/- 0.20 cm, 5.6 +/- 0.14 cm, respectively. Based on anatomical dissection in this cadaver study, the authors introduce a new technique for facial/scalp flap harvesting that extends the neurovascular bundles of sensory nerves of the anterior craniofacial skeleton.

Between February 28 and March 1, 2003, an interdisciplinary group of scholars gathered at the University of California, Santa Barbara to consider the evolution of Americans' thinking about capitalism in the last half of the twentieth century. The conference, organized by Nelson Lichtenstein (University of California, Santa Barbara) and entitled “Capitalism and Its Culture: Rethinking Twentieth-Century American Social Thought,” focused on the years between 1938 and 1973, when capitalism as an idea and a system moved from a term of some contestation to an almost naturalized phenomenon that equated the market with progress, democracy, and civil society. In these mid-century decades, intellectuals increasingly substituted a discourse involving bureaucracy, modernization, and mass culture for earlier concerns over class conflict, social inequality, and the place of the large corporation in the democratic polity. The conference provided an opportunity for scholars of the family, academia, radicalism, feminism, and conservatism to explore the development of and challenges to capitalism and its culture.

We propose improving system availability by performing in-field repair at the chip level. This enables margining and detection of degrading memory cells before the user observes any errors. A 576 Mb embedded DRAM at 1.5 GHz in a 40nm CMOS technology achieves improved resilience to both aging memory cells and cells with variable retention time (VRT). Un-interrupted user access of 6 billion 72-bit read and write operations per second is maintained during background repair.

A classification of palatal fracture types is developed from patterns observed on CT scans, and success with open reduction techniques is correlated with fracture pattern. The six palatal fracture types are as follows: I, anterior and posterolateral alveolar; II, sagittal; III, parasagittal; IV, para-alveolar; V, complex; and VI, transverse. Associated fractures were LeFort I (100 percent), LeFort II and III (55 percent), mandible (48 percent), and dental (55 percent). Large segment, sagittally oriented palatal fractures could be stabilized with rigid internal fixation. Complete rigid fixation of the palate consists of (1) roof of mouth, (2) pyriform or alveolar, and (3) four LeFort I buttress stabilization. Comminuted palatal fractures were managed by standard LeFort I and alveolar buttress fixation, palatal splinting, and intermaxillary, fixation. If complete rigid fixation was employed in the palate in type II, III, and IV fractures, a palatal splint was avoided in 60 percent of these cases. Rigid internal fixation is therefore concluded to facilitate the treatment of certain types of palatal fractures by reduced length of intermaxillary fixation and avoidance of palatal splinting.

Once viewed as a distinct era characterized by intense bigotry, nostalgia for simpler times and a revulsion against active government, the 1920s have been rediscovered by historians in recent decades as a time when Herbert Hoover and his allies worked to significantly reform economic policy. Mark Hendrickson both augments and amends this view by studying the origins and development of New Era policy expertise and knowledge. Policy-oriented social scientists in government, trade union, academic and nonprofit agencies showed how methods for achieving stable economic growth through increased productivity could both defang the dreaded business cycle and defuse the pattern of hostile class relations that Gilded Age depressions had helped to set as an American system of industrial relations.