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BACKGROUND: Premature fusion of the metopic suture (ie, metopic craniosynostosis) can be difficult to discriminate from physiological closure of the metopic suture with ridging (MR). Yet, MCS is treated surgically, whereas MR is treated nonsurgically. Often, the diagnosis can be made by physical examination alone, but in difficult cases, a computed tomography (CT) scan can add additional diagnostic information. METHODS: We de-identified, randomized, and analyzed the CT scans of patients with MCS (n = 52), MR (n = 20) and age-matched normative controls (n = 52) to identify specific findings helpful in distinguishing between MCS and MR. Four expert clinicians were blinded to the clinical diagnosis and assessed each CT for features of the orbits, frontal bones, and inner table of calvaria. RESULTS: Although no single feature was diagnostic of MCS, we identified several signs that were correlated with MCS, MR, or controls. Features such as "posteriorly displaced frontal bone" and "frontal bone tangent to mid-orbit or medial" demonstrated higher correlation with MCS than MR and the addition of other features improves the accuracy of diagnosis as did inclusion of the interfrontal divergence angle. CONCLUSION: The presence of a closed metopic suture in addition to other CT scan findings may improve the accuracy of diagnosing MCS, MR, and normocephaly.
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Rhinophyma is the final stage in the evolution of acne rosacea, a common vasoactive dermatosis. Individuals with rhinophyma present with a typical, disfiguring nasal appearance consisting of bulbous enlargement, erythema, and telangiectasia with a sebaceous, oily skin surface. This classic appearance permits a facile diagnosis but may also lead the physician to overlook a coexistent malignancy. We report the occurrence of a diffuse large B-cell lymphoma (DLBCL) arising synchronously with a marked rhinophyma. A wide local excision of the malignancy was performed, and the defect was reconstructed with forehead flaps. The rhinophyma was treated with a skin graft and cheek flaps. Following surgery, chemotherapy was used to manage the systemic disease. This case demonstrates the necessity for clinical scrutiny in the diagnosis and treatment of rhinophyma. It is imperative to entertain a high degree of suspicion when non-typical changes are observed within a rhinophymatous lesion or in adjacent areas of the nose.
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Aesthetic vulvovaginal surgery has become the final frontier of cosmetic surgery. Accordingly, there has been an increased interest in plastic surgical procedures for the female genitalia. Labiaplasty is the most common among such procedures, and the number of practitioners and techniques has varied widely in the medical literature. This article will focus on the problems and pearls encountered by the author in treating enlargement of the labia minora and clitoral hood. The content will focus on the technical aspects of the labiaplasty surgery and ways to avoid common complications encountered during this procedure.
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Genitales Femeninos/cirugía , Satisfacción del Paciente/estadística & datos numéricos , Cirugía Plástica/métodos , Vulva/cirugía , Estudios de Cohortes , Femenino , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Medición de Riesgo , Cirugía Plástica/efectos adversos , Vagina/cirugía , Cicatrización de Heridas/fisiologíaRESUMEN
BACKGROUND: Pain control following abdominoplasty is a major source of concern for the patient and surgeon alike. Pain pumps and opiate medications are currently the frontline therapies. With the following technique, Exparel (liposomal bupivacaine, 72-hour duration of action) has been used for transversus abdominis plane (TAP) blocks under direct visualization during abdominoplasty with the goal of improving pain control during the early and intermediate recovery period. MATERIALS AND METHODS: In this pilot study, 13 consecutive patients were treated with the direct, fascial-splitting technique to reach the TAP plane. Using a spinal needle, 20 mL of liposomal bupivacaine was injected deep to the internal oblique fascia bilaterally under direct vision. Primary and secondary endpoints of total opiate use and patient reported pain scores were assessed. RESULTS: All 13 patients met inclusion criteria as abdominoplasty patients with adequate follow-up data. The average visual analog scale pain score was 2.5 on postoperative day 1 and 1.7 on postoperative day 3. The average total opiate use (the number of 10 mg oxycodone tabs consumed) was 7.5 or 75 mg per patient. CONCLUSIONS: This pilot study demonstrates the safety and efficacy of liposomal bupivacaine TAP blocks under direct vision. Favorable pain control was demonstrated. This represents an exciting opportunity to decrease postoperative pain in the early and intermediate recovery period after abdominoplasty.
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Músculos Abdominales/inervación , Abdominoplastia , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Bloqueo Nervioso/métodos , Dolor Postoperatorio/prevención & control , Estudios de Seguimiento , Humanos , Inyecciones , Liposomas , Proyectos Piloto , Resultado del TratamientoRESUMEN
BACKGROUND: Premature cranial suture fusion may prevent neonatal skull malleability during birth, increasing the risk of unplanned cesarean delivery and neonatal birth trauma caused by cephalopelvic disproportion. We sought to determine the incidence of perinatal maternofetal complications in cases of craniosynostosis. METHODS: Records of children presenting with nonsyndromic craniosynostosis to a tertiary pediatric hospital from 1996 to 2012 were reviewed retrospectively with focus on birth history and birth-related complications. RESULTS: Six hundred eighteen births were reviewed. Rates of cesarean delivery among mothers of children with craniosynostosis [n = 201 (32.5 percent)] exceeded the overall regional rate of 24.5 percent (OR, 1.50; p < 0.0001). Unplanned cesarean delivery occurred in 19.7 percent of births, and were most associated with nulliparous mothers, breech fetal presentations, and lambdoid or multisuture synostosis patterns. Eleven neonates (1.8 percent) exhibited cranial birth trauma, including cephalohematoma and subgaleal hematoma. Neonates with sagittal or multisuture synostosis patterns were more likely to suffer birth trauma and had a higher mean head circumference than those who did not (81st versus 66th percentile, p < 0.05). CONCLUSIONS: In the setting of craniosynostosis, birth trauma is increased-for mothers in the form of increased cesarean delivery risk, and for fetuses in the form of subgaleal and subperiosteal perinatal bleeding. Difficult maternal labor may be mediated especially by multisuture or lambdoid synostosis, whereas fetal birth trauma may be mediated to a greater extent by large head size. Prenatal diagnosis of craniosynostosis could influence decision-making in the management of labor. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.
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Traumatismos del Nacimiento/epidemiología , Cesárea/estadística & datos numéricos , Craneosinostosis/epidemiología , Parto Obstétrico/estadística & datos numéricos , Resultado del Embarazo/epidemiología , Traumatismos del Nacimiento/etiología , Causalidad , Cefalometría/métodos , Cefalometría/estadística & datos numéricos , Cesárea/efectos adversos , Estudios de Cohortes , Comorbilidad , Intervalos de Confianza , Craneosinostosis/diagnóstico , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Femenino , Humanos , Incidencia , Recién Nacido , Puntaje de Gravedad del Traumatismo , Masculino , Edad Materna , Relaciones Materno-Fetales , Oportunidad Relativa , Embarazo , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Intralesional laser therapy for the treatment of vascular malformations (VMs) has been previously reported for select patient populations. Larger studies, over a wider variety of indications, are needed to better define the potential role of this technology. In the current study, a 12-year, retrospective review of 44 patients who underwent 73 intralesional Nd:YAG or diode laser treatments of VMs was performed. The most commonly encountered lesions were venous malformations (66%) and the most commonly involved anatomic locations were the head and neck regions (41%) and lower extremity (39%). Primary indications for treatment were enlargement (73%) and pain (52%). Lesion size was reduced in 94% of cases after treatment and pain was improved in 91% of cases. Minor postoperative complications occurred in 16 (36%) patients. There was no difference in treatment response among various VM subtypes or anatomic locations (P=0.497, P=0.866) or in the incidence of complications (P=0.531, P=0.348). Age was the only factor associated with an increased risk of complications (odds ratio, 1.034; P=0.038). When used in accordance with the suggested guidelines, intralesional laser therapy is a safe and effective treatment modality for VMs of varying compositions and locations.
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Láseres de Semiconductores/uso terapéutico , Láseres de Estado Sólido/uso terapéutico , Malformaciones Vasculares/cirugía , Factores de Edad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Cranial vault remodeling (CVR) for craniosynostosis is a procedure with the potential for significant blood loss. Aminocaproic acid (ACA) has been used at our institution during CVR for its antifibrinolytic effects. The purpose of this study was to investigate the effect of ACA on blood loss and transfusion rates during primary CVR. METHODS: Three hundred eighty-three patients with craniosynostosis underwent primary CVR at a single institution by a single surgeon over 15 years. Patients were included if they received either ACA or no antifibrinolytic. The estimated blood loss (EBL) and volume of blood transfused was recorded. Thrombotic-related complications were identified. Comparisons were made between subgroups using independent Student t test and Fisher exact test. RESULTS: Among the study population, 148 patients met inclusion criteria. ACA was given to 30 patients, while 118 patients received no antifibrinolytic. There was no difference in the average intraoperative EBL between the ACA (322 mL) and control groups (327 mL, P > 0.05). Additionally, the incidence of transfusion was not significantly different between subgroups (97% vs. 86%, respectively, P > 0.05). Patients treated with ACA, however, received lower average perioperative transfusion volumes (25.5 mL/kg) compared to control patients (53.3 mL/kg, P < 0.0001). Furthermore, patients in the ACA subgroup were less likely to require a second unit of blood (21% vs. 43%, P < 0.0001) and therefore had fewer exposures to donor blood antigens (ARR = 22%, NNT = 4.6). CONCLUSIONS: The use of intraoperative ACA minimizes blood transfusion volumes and donor exposures in children who undergo primary CVR for craniosynostosis. Antifibrinolytics should be considered for routine use in pediatric craniofacial surgery.
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Ácido Aminocaproico/uso terapéutico , Antifibrinolíticos/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea , Craneosinostosis/cirugía , Presión Arterial/fisiología , Estudios de Cohortes , Transfusión de Eritrocitos , Hematócrito , Humanos , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Cráneo/cirugía , Trombosis/etiologíaRESUMEN
Objective : To determine if autologous fat grafting to the posterior pharynx can reduce hypernasality in patients with cleft palate and mild velopharyngeal insufficiency (VPI). Design : Retrospective case series. Setting : Tertiary care center. Patients : Eleven patients with cleft palate status after palatoplasty (with or without secondary speech surgery) with nasendoscopic evidence of VPI. Interventions : Autologous fat was harvested and injected into the posterior pharynx under general anesthesia. Main Outcome Measures : Pre- and postoperative subjective, nasometry, and nasendoscopy data. Apnea-hypopnea indices (AHIs) were also assessed. Comparisons were made using Fisher's exact test, Student's t tests, and relative risk (RR) assessments. Results : An average of 13.1 mL of fat was injected (range: 5 to 22 mL). Mean follow-up was 17.5 months (range: 12 to 25 months). Statistically significant improvements in speech resonance were identified in nasometry (Zoo passage; p â=â .027) and subjective hypernasality assessment (p â=â .035). Eight of the patients (73%) demonstrated normal speech resonance after posterior pharyngeal fat grafting (PPFG) on subjective or objective assessment (p â=â .001). All five patients with previous secondary speech surgeries demonstrated normal speech resonance on similar assessment (RR â=â 1.8; p â=â .13). Complete velopharyngeal closure was observed in seven patients on postoperative nasendoscopy. No changes in AHIs were observed (p â=â .581). Conclusion : PPFG may be best used as an adjunct to secondary speech surgery. In this series, PPFG was not accompanied by the negative sequelae of hyponasality, sleep apnea, or airway compromise.
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Resultado del Tratamiento , Insuficiencia Velofaríngea , Fisura del Paladar/cirugía , Humanos , Faringe/cirugía , Estudios Retrospectivos , Insuficiencia Velofaríngea/cirugíaRESUMEN
It is wise to recall the dictum "children are not small adults" when managing pediatric orbital fractures. In a child, the craniofacial skeleton undergoes significant changes in size, shape, and proportion as it grows into maturity. Accordingly, the craniomaxillofacial surgeon must select an appropriate treatment strategy that considers both the nature of the injury and the child's stage of growth. The following review will discuss the management of pediatric orbital fractures, with an emphasis on clinically oriented anatomy and development.
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INTRODUCTION: In patients who require additional surgery for velopharyngeal insufficiency (VPI), a higher incidence of obstructive sleep apnea (OSA) may be incurred. Although this phenomenon has been demonstrated with the posterior pharyngeal flap, the effect of dynamic sphincter pharyngoplasty (DSP) on OSA is less clear. The purposes of this case series were to (1) determine the incidence of OSA after DSP, (2) assess the changes in polysomnography after DSP, and (3) identify risk factors for the development of OSA after DSP. Our global hypothesis is that OSA and VPI exist on a continuum and that speech outcomes should not be considered in isolation. METHODS: For a 13-year period, 146 patients with idiopathic VPI, submucous cleft palate, cleft palate only, or cleft lip and palate underwent DSP for VPI. The diagnosis of OSA was defined as the prescription of continuous positive airway pressure therapy by a pediatric sleep medicine physician. The incidence of OSA preoperatively and postoperatively was compared using Fisher exact test. When available, preoperative and postoperative apnea-hypopnea indices (AHIs) were compared using the pairwise, 2-tailed, Student's t-test. Patient factors, such as obesity (body mass index ≥ 95th percentile), the presence of a craniofacial syndrome, surgical history, and a preexisting OSA diagnosis, were noted. A multiple logistic regression was performed to elucidate risk factors for the development of OSA. RESULTS: The average age at surgery was 9.2 years (range, 4-40 y), and the mean follow-up time was 4.5 years (range, 1 mo to 12 y). The incidence of OSA increased after DSP, from 2 to 33 patients (1.4%-22%, respectively; P = 0.05). In 23 patients (16%), both preoperative and postoperative AHIs were available. There was a significant increase in AHI after DSP, from 3.1 to 8.4 episodes per hour of sleep (P = 0.001). Previous tonsillectomy/adenoidectomy was predictive of OSA after DSP (relative risk = 2.4; P = 0.04). CONCLUSIONS: We report an increased incidence of OSA and higher-than-average AHIs postoperatively after DSP. Preoperative tonsillectomy/adenoidectomy predicted the development of OSA after DSP. A high index of suspicion for development of OSA must be maintained in patients who undergo secondary speech operations for VPI. Clinical screening for OSA should be used in this population, with a low threshold for polysomnographic evaluation. The surgeon must be wary that improvements in speech after DSP may change airway dynamics and increase the risk of OSA.
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Faringe/cirugía , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Apnea Obstructiva del Sueño/epidemiología , Adenoidectomía/estadística & datos numéricos , Adolescente , Adulto , Índice de Masa Corporal , Niño , Preescolar , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Presión de las Vías Aéreas Positiva Contínua/estadística & datos numéricos , Anomalías Craneofaciales/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Michigan/epidemiología , Obesidad/epidemiología , Polisomnografía , Estudios Retrospectivos , Factores de Riesgo , Tonsilectomía/estadística & datos numéricos , Insuficiencia Velofaríngea/cirugía , Adulto JovenRESUMEN
INTRODUCTION: The role of genetic phenomena has been given central importance in the development of craniosynostosis. Proponents have dismissed the role of force as a key etiologic factor. Nonetheless, compressive forces on the developing calvarium have been shown to result in premature suture fusion. The purpose of this study was to determine whether cyclical loading of the murine calvarium could induce suture fusion in cocultured calvarial specimens. MATERIALS AND METHODS: Calvarial coupons from postnatal day 21, B6CBA wild-type mice (n = 24) were harvested and cultured. A custom appliance capable of delivering compressive loads was applied perpendicular to the sagittal suture in vitro. Six coupons were subjected to 0.3 g of force for 30 minutes each day for a total of 14 days. Six additional coupons were cocultured within the same medium. Control groups were devised. Histologic analysis of suture phenotype was performed. RESULTS: Sagittal sutures cocultured with unloaded specimens remained patent. In contradistinction, 4 of 6 specimens cocultured with loaded coupons demonstrated craniosynostosis (P = 0.03). Increased osteoid, alkaline phosphatase staining, and bone sialoprotein expression were observed when compared with matched controls. DISCUSSION: An in vitro model of force-induced craniosynostosis via paracrine effects has been devised. Premature fusion of the murine sagittal suture was induced in unloaded specimens cocultured with cyclically loaded calvarial coupons. These results implicate that abnormal forces may act through soluble factors to cause premature suture fusion in vitro. The findings support our global hypothesis that epigenetic phenomena play a crucial role in the pathogenesis of nonsyndromic craniosynostosis.
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Suturas Craneales/crecimiento & desarrollo , Craneosinostosis/genética , Craneosinostosis/patología , Comunicación Paracrina/genética , Cráneo/crecimiento & desarrollo , Fosfatasa Alcalina/metabolismo , Animales , Biomarcadores/metabolismo , Técnicas de Cocultivo , Suturas Craneales/metabolismo , Suturas Craneales/patología , Modelos Animales de Enfermedad , Sialoproteína de Unión a Integrina/metabolismo , Ratones , Fenotipo , Cráneo/metabolismo , Cráneo/patología , Estrés MecánicoRESUMEN
Ongoing research in bone biology has brought cutting-edge technologies into everyday use in craniofacial surgery. Nonetheless, when osseous defects of the craniomaxillofacial skeleton are encountered, autogenous bone grafting remains the criterion standard for reconstruction. Accordingly, the core principles of bone graft physiology continue to be of paramount importance. Bone grafts, however, are not a panacea; donor site morbidity and operative risk are among the limitations of autologous bone graft harvest. Bone graft survival is impaired when irradiation, contamination, and impaired vascularity are encountered. Although the dura can induce calvarial ossification in children younger than 2 years, the repair of critical-size defects in the pediatric population may be hindered by inadequate bone graft donor volume. The novel and emerging field of bone tissue engineering holds great promise as a limitless source of autogenous bone. Three core constituents of bone tissue engineering have been established: scaffolds, signals, and cells. Blood supply is the sine qua non of these components, which are used both individually and concertedly in regenerative craniofacial surgery. The discerning craniofacial surgeon must determine the proper use for these bone graft alternatives, while understanding their concomitant risks. This article presents a review of contemporary and emerging concepts in bone biology and their implications in craniofacial surgery. Current practices, areas of controversy, and near-term future applications are emphasized.
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Huesos/fisiología , Huesos Faciales/cirugía , Cráneo/cirugía , Ingeniería de Tejidos/métodos , Biología , Trasplante Óseo/métodos , Humanos , Células Madre Mesenquimatosas/fisiología , Procedimientos de Cirugía Plástica/métodos , Ciencia , Andamios del TejidoRESUMEN
The Internet has changed the way in which we gather and interpret information. Although books were once the exclusive bearers of data, knowledge is now only a keystroke away. The Internet has also facilitated the synthesis of new knowledge. Specifically, it has become a tool through which medical research is conducted. A review of the literature reveals that in the past year, over 100 medical publications have been based on Web-based survey data alone. Because of emerging Internet technologies, Web-based surveys can now be launched with little computer knowledge. They may also be self-administered, eliminating personnel requirements. Ultimately, an investigator may build, implement, and analyze survey results with speed and efficiency, obviating the need for mass mailings and data processing. All of these qualities have rendered telephone and mail-based surveys virtually obsolete. Despite these capabilities, Web-based survey techniques are not without their limitations, namely, recall and response biases. When used properly, however, Web-based surveys can greatly simplify the research process. This article discusses the implications of Web-based surveys and provides guidelines for their effective design and distribution.
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Recolección de Datos/métodos , Internet , Guías como AsuntoRESUMEN
INTRODUCTION: Venous thromboembolism (VTE) has been identified as a major public health issue. Postbariatric body contouring surgery represents a major challenge for VTE prophylaxis due to the presence of multiple risk factors and broad areas of dissection that potentially increase the risk of postoperative bleeding. AIM: To define current VTE prophylaxis practices among surgeons of the American Society of Plastic Surgeons, performing postbariatric body contouring surgery in the United States. MATERIAL AND METHODS: A total of 4081 surveys were sent to registered members of the American Society of Plastic Surgeons by e-mail. We received 596 (14.6%) responses. RESULTS: A total of 596 surgeons returned completed surveys, with 83% of respondents in private practice and 17% in academic practice. Deep venous thrombosis (DVT) was reported by 40% surgeons, pulmonary embolism (PE) by 34%, and 7% had at least 1 patient having died of a postoperative PE. About 39% to 48% participant surgeons reported providing no chemoprophylaxis to their postbariatric body contouring patients. The most common reason for not using routine prophylaxis was the concern for bleeding (84%), followed by lack of evidence specific to plastic surgery practice (50%). Academic surgeons were more likely to provide chemoprophylaxis when compared with those in nonacademic practice (P < 0.05). CONCLUSION: For postbariatric body contouring surgery, DVT has occurred in over one-third of plastic surgeons' practices with 7% of surgeons reporting a patient death from PE. A substantial proportion of surgeons performing postbariatric body contouring are not using chemoprophylaxis due to bleeding risk and perceived lack of evidence. VTE prophylaxis in postbariatric body contouring remains a topic that deserves further study.
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Actitud del Personal de Salud , Cirugía Bariátrica/efectos adversos , Complicaciones Posoperatorias/prevención & control , Pautas de la Práctica en Medicina/estadística & datos numéricos , Tromboembolia/prevención & control , Trombosis de la Vena/prevención & control , Anticoagulantes/uso terapéutico , Cirugía Bariátrica/estadística & datos numéricos , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Encuestas y Cuestionarios , Tromboembolia/epidemiología , Tromboembolia/etiología , Estados Unidos/epidemiología , Trombosis de la Vena/epidemiología , Trombosis de la Vena/etiologíaRESUMEN
Current practice patterns for venous thrombembolism (VTE) prophylaxis in autogenous breast reconstruction are unknown. A web-based survey on VTE prophylaxis was distributed to all American Society of Plastic Surgery members in the United States with a clinical interest in autogenous tissue breast reconstruction (N = 3584). A total of 606 completed surveys were returned for a response rate of 16.9%. Overall compliance with established guidelines was low (25%). High volume surgeons (43% vs. 22%) and surgeons in academic practice (42% vs. 22%) were significantly more likely to report prophylaxis regimens consistent with American College of Chest Physicians guidelines (ACCP) recommendations. Subgroup analysis of 72 surgeons who specifically report conformance to ACCP guidelines demonstrated only 38% actually provided prophylaxis consistent with ACCP recommendations. VTE is a potentially fatal complication of autogenous breast reconstruction. Further research is necessary to create VTE prophylaxis guidelines specific to patients undergoing these procedures. The need for surgeon education on appropriate prophylaxis cannot be overemphasized.
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Neoplasias de la Mama/cirugía , Adhesión a Directriz , Mamoplastia/efectos adversos , Pautas de la Práctica en Medicina/normas , Tromboembolia Venosa/prevención & control , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Mamoplastia/normas , Mastectomía/métodos , Evaluación de Necesidades , Pautas de la Práctica en Medicina/tendencias , Encuestas y Cuestionarios , Gestión de la Calidad Total , Trasplante Autólogo , Estados Unidos , Tromboembolia Venosa/etiologíaRESUMEN
Rheumatologists and hand surgeons have historically demonstrated strikingly divergent attitudes toward the benefits of surgical intervention, either total wrist fusion or total wrist arthroplasty, for the rheumatoid wrist. A utility analysis was conducted to compare a national random sample of hand surgeons and rheumatologists regarding their opinions about surgical management of severe rheumatoid wrist disease. A web-based trade-off utility survey was developed, and participants were presented with survey scenarios comparing well-controlled rheumatoid arthritis with operative and non-operative management. Utility values were calculated for each scenario, and a decision analytic model was constructed. Utility values for rheumatologists and hand surgeons did not differ significantly for any scenario. Total wrist arthroplasty was associated with the highest expected gain in quality-adjusted life-years for each subgroup. This decision analytic model demonstrates similar opinions between two subspecialties that have historically demonstrated divergent attitudes towards rheumatoid hand surgery.