Scientific Abstract Presentations: Hand 1 Thursday, October 26 Thu, Oct 26 1:30-2:30 p.m. CDT

Hypothesis: To assess factors associated with loss of reduction of volar ulnar fragments following volar locking plate (VLP) fixation of intra-articular distal radius fractures. We hypothesized that volar ulnar fragment (VUF) size and plate placement would be critical variables driving the incidence of volar rim loss of reduction.

Methods: All patients with a volarly displaced, intra-articular distal radius fracture treated with a VLP within the ICUC database, an international collaborative and publicly available dataset, were identified. The primary outcome was volar rim loss of reduction on follow-up imaging, defined as a change in radiographic alignment from intra-operative fluoroscopy, teardrop angle less than 50 degrees, or loss of normal radiocarpal alignment. Secondary outcomes were final range of motion (ROM) of the affected extremity. Radiographic Soong classification was used to grade plate position. Traditional descriptive statistics were used to compare patient, fracture, and treatment characteristics with volar rim loss of reduction. A Random Forest supervised machine learning algorithm was used to classify variable importance for predicting the primary outcome.

Results and Conclusion: Fifty patients with volarly displaced, intra-articular distal radius fractures treated with VLP were identified. Six patients were observed to have a volar rim loss of reduction, but none required reoperation. Volar ulnar fragment size, Soong grade 0, and post-fixation axial plate position in relation to the sigmoid notch were significantly associated (p<0.05) with volar rim loss of reduction. All cases of volar rim loss of reduction occurred when VUF was 10.8 mm or less. The size of the VUF was the most important variable for predicting volar rim loss of reduction, followed by post-fixation axial plate position in relation to the sigmoid notch and the number of volar fragments in the Random Forest machine learning algorithm.

Summary: • Size of the volar ulnar fragment was the variable classified as having the most importance for volar rim reduction loss after VLP and occurred when the size was less than 10.8 mm. • Variables significantly associated (p<0.05) with volar rim reduction loss include volar ulnar fragment size, Soong grade 0, and post-fixation axial plate position in relation to the sigmoid notch. • Fracture characteristics can influence the treatment approach to address these risk factors.

PURPOSE In recent times, intra-articular platelet-rich plasma (PRP) injections have been demonstrated to be effective in the treatment of hip and knee osteoarthritis (OA). This systematic review aims to describe the outcomes of intra-articular PRP injections in carpometacarpal (CMC) OA and its safety profile.

METHODS PRISMA guidelines were respected for the conduct of this systematic review. The title and abstract as well as the full-text assessment were performed in duplicate. Full texts and their data were extracted by two reviewers; and collected data was confirmed by the principal investigator. Any disagreements were resolved through consensus by the third reviewer. Patient characteristics and functional outcomes were analysed as means of central tendency.

RESULTS 16 citations were retrieved; six papers were retained, including 77 total patients. The average follow-up time was 6 months, with four patients lost to follow-up. The time between PRP injections was 3.2 weeks, and the volume per injection was 1.3 mL. Among 56 patients, there was a 62.5% patient satisfaction rate. Regarding functional outcomes, VAS scores decreased by an average of 5.5 (9.4-3.9), Quick Dash scores decreased by an average of 32 (51-19.2) points while no changes were found in Grip strength. Finally two minor adverse events (4.76%) were found among 42 patients.

CONCLUSION PRP injection is a reliable short-term option for a select group of patients in the treatment of basal thumb OA given its favourable functional profile namely pain reduction, grip strength, patient satisfaction, and reasonable safety characters.

SURGICAL PRACTICE PEARLS • Participants will be able to identify a novel modality to combat carpometacarpal joint osteoarthritis. • Participants will be able to quantify improvement in functional outcomes and categorize adverse events associated with PRP injections for CMC OA. • Participants will be able to learn to stratify their CMC OA patients in terms of treatment approach and in turn learn who would benefit the most from the PRP injection.

Purpose Extensor pollicis longus (EPL) rupture is described as a complication after volar plate fixation in distal radius fractures. Although protrusion of screw tips through the dorsal cortex of the distal radius may cause a substantial proportion of EPL ruptures, it may not be the sole cause for EPL rupture after distal radius fracture. The purpose of this study was to identify cases with EPL damage on the acute preoperative Computed Tomography(CT) scan for distal radius fracture.
Methods This retrospective study included adults (≥18 years) with operatively treated distal radius fracture and available preoperative CT within two weeks of injury between January 1st 2017 and July 31st 2018. The cohort consisted of 97 wrists in 96 patients. The median age was 54 (IQR 38-64), 68% (65/96) was female, and median follow-up was 56 months (IQR 24-61). A concomitant fracture was apparent in 63% (61/97). CT scans were reviewed by 3 fellowship-trained musculoskeletal radiologists. Results Lister's Tubercle was involved in 75 % (73/97), of these 73 patients, 13 patients had an entrapped EPL tendon (13/73, 18%). There were two clinically diagnosed EPL ruptures, one of which had EPL entrapment on the injury CT and did not have protruding screws on x-ray. The other patient had Listers' tubercle fracture involvement on the acute CT and the at the time of surgery with dorsal plating was noted to have intra-operative bony spike at Listers' tubercle that was damaging the EPL. Additionally, one patient had visible EPL damage on CT (1/97, 1%), but did not have a documented rupture.
Conclusion - 75% of cases involved fracture extending into Lister's tubercle . - In 18% of those fractures, the EPL was engaged by fragments of a fractured Lister's tubercle. - EPL injury by Listers' tubercle fragments may be an underrecognized cause of tendon rupture

Introduction: Hand infections represent a significant source of morbidity for patients, limiting activities of daily living and often requiring surgical intervention for complete healing. Since these patients often voluntarily seek medical treatment, it presents an excellent opportunity to screen for other social determinants of health (SDOH) that may be related to the etiology of their hand infection. This study aims to utilize demographic data from hand infection patients to explore linkages between hand infection incidence and SDOH.

Methods: A retrospective chart review was conducted for patients who presented to the emergency department of a large community hospital with hand infection during a 1-year window (2021-2022). A variety of patient demographics and social characteristics (employment status, drug use, primary care attachment, social support) were collected from medical records and compiled. This data was then summarized and used to calculate risk ratios (RR) to identify any key risk factors. The most recent Census and city government data was pulled from public sources to determine population demographics for comparison with cohort.

Results: 125 patients met the inclusion criteria (positive for hand infection, age > 18) for analysis. Individuals identifying as Black, Hispanic, American Indian, or Native Hawaiian were disproportionately overrepresented in the cohort when compared to country demographics. Cisgender males represented the majority of patients (83.2%), with the remaining patients consisting almost entirely of cisgender females. Average age was 43.4 years with a standard deviation of 12.9 years. Of covariates examined, homelessness and unemployment status were found to have significant positive risk ratios for hand infection incidence (RR: 348.3, p<0.0001, RR: 76.4, p<0.0001 respectively). 55.2% of patients represented were homeless, and 66.4% were unemployed. Upon visualization of the data, additional factors such as social support, primary care provider attachment status, and active recreational drug use were also noted to have potential contributions to hand infection incidence. Risk ratios were not calculated for these characteristics as wider population data was not available for comparison.

Conclusion: The results of this study suggest that a disproportionate majority of hand infections are acquired by homeless and/or unemployed individuals in the community. In these individuals, the lack of social support, absence of a primary care provider, and active recreational drug use further increases the risk of developing hand infections. While these patterns may be generally referenced in other papers, this study quantitatively defines the strength of association and frequency of associated SDOH factors. These findings strongly advocate for more extensive SDOH screening of patients who present with hand infection.

Introduction

Previous studies in surgery have identified preoperative laboratory values as markers of operative risk.1 The present study analyzes the effects of preoperative serum hematocrit, albumin, and creatinine on postoperative outcomes in patients undergoing carpal tunnel decompression surgery.

Methods

The American College of Surgeons National Quality Improvement Program (NSQIP) database was queried for carpal tunnel decompression surgeries (CPT 29848, 64721) from 2005-2020. Preoperative serum lab values within 90 days for hematocrit, creatinine, and albumin were collected for each patient, alongside relevant demographic and clinic covariates. Outcomes included return to operating room, non-home discharge, extended postoperative length of stay (75th percentile in our cohort), 30-day medical complication and 30-day wound complication. Since not all patients had all preoperative lab values recorded within the preoperative window, each lab value was assessed in separate cohorts.

Bivariate t-tests and multivariate logistic regressions controlling for covariates were conducted. For any outcome-lab value pairs with significance on regression, area-under-the-receiver-operating-characteristic-curve (AUROC) and corresponding stratifying cut-points were identified. These cutoffs were derived for the entire cohort in the case of albumin and separately for males and females when analyzing hematocrit and creatinine due to sex-specific reference ranges. Each cutoff point was further validated through an additional multivariate logistic regression.

Results

A total of 3,138 patients with hematocrit, 1,440 patients with albumin, and 3,159 patients with creatinine levels were identified.

On multivariate logistic regression, increased hematocrit reduced the odds of medical complications (aOR: 0.889, p<0.001). A predictive hematocrit cutoff of ≤ 39.7% (AUC: 0.77, p<0.001) was identified for medical complications amongst male patients and patients with hematocrit ≤ 39.7% experienced increased odds of medical complications (aOR: 3.555, p=0.010). A predictive hematocrit cutoff ≤ 36.6% (AUC: 0.74, p<0.001) was identified for medical complications in female patients, and patients with hematocrit ≤ 36.6% experienced increased odds of medical complications (aOR: 2.815, p=0.013).

Increased serum albumin was associated with lower odds of medical complications (aOR: 0.479, p=0.035). An overall cohort cutoff of ≤ 3.5 g/dL (AUC: 0.79, p<0.001) was predictive of medical complications and significant on logistic regression when tested as a categorical variable (aOR: 3.144, p=0.007).

Similarly, increased serum creatinine was associated with greater odds of medical complications (aOR: 1.684, p=0.006). A creatinine cutoff of ≥ 1.2 mg/dL (AUC: 0.58, p=0.033) exhibited predictive capabilities for medical complications among male patients. Male patients with creatinine ≥ 1.2 mg/dL had increased odds of medical complications (aOR: 3.024, p=0.033). For female patients, AUROC analysis identified ≥ 1.0 mg/dL (AUC: 0.59, p=0.039) as a threshold for increased medical complications, and female patients with ≥ 1.0 mg/dL creatinine had heightened odds of medical complications (aOR: 3.160, p=0.016).

Conclusion

Multiple preoperative serum values were found to be predictive of post-operative medical complications and discriminative lab value thresholds were identified in this carpal tunnel decompression cohort.

References

Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity: Results From the National VA Surgical Risk Study. Arch Surg. 1999;134(1):36-42. doi:10.1001/archsurg.134.1.36

Purpose: To compare the primary recurrence rate of Dupuytren's disease and patient reported outcomes after various established interventions.

Method: A systematic review was completed following PRISMA guidelines using Medline, Embase and Cochrane. The title and abstract as well as the full-texts were screened in duplicate. Data was extracted by two independent reviewers and conflicts were resolved through consensus or by the third reviewer. Patient demographics, functional outcomes and recurrence rates were collected. Meta-analysis was completed using RevMan 5.4.1 comparing different interventions using a random-effects model at 95% significance.

Results: A total of 44 articles were included, yielding 5413 patients accounting for 3111 Collagenase Clostridium histolyticum injections (CCH), 1760 percutaneous needle fasciotomies (NF), and 1023 open fasciectomies. The average age was 64.82 years old, and men were predominant (83.2%). Average wait time for treatment was 34.33 months. DASH scores improved from on average 15.75 to 5.1, from 18.08 to 2.98, and from 55.00 to 6.97 for CCH, NF, and open fasciectomy, respectively. Forest plots totalling eight articles comparing CCH and NF did not show a significant difference in terms of recurrence rate (p= 0.86), although open fasciectomy had a significantly lower recurrence rate than CCH (p= 0.004). All Forest plots showed low heterogeneity (I2 of 0 to 28%).

Conclusions: Open fasciectomy for Dupuytren's disease was significantly associated with lower rates of recurrence relative to CCH and by inference to NF. All interventions showed improvement in patient reported outcomes, although selection of treatment should remain tailored to the needs of each patient.

Learning objectives: 1) Learn about the current evidence for recurrence rates after different interventions for Dupuytren's disease 2) To better understand the demographics of patients with Dupuytren's disease

PURPOSE: Dupuytren's disease (DD) is one of the most common disorders of the hand, affecting 5.7-11.7% of the global population. This study seeks to evaluate the long-term efficacy of the two most prominent treatment modalities, injectable collagenase Clostridium histolyticum versus open fasciectomy. We hypothesize that those who had an open fasciectomy to treat their contracture will have significantly less recurrence, greater degree of deformity improvement, and fewer procedural interventions in the long-term. METHODS: We conducted a retrospective review of all electronic medical records of patients who underwent open fasciectomy or collagenase injection to treat their persistent Dupuytren's contracture between April 2011 and April 2021. All procedures were performed by one of five senior surgeons at the same Veterans Affairs Hospital hand surgical center. Therapeutic administration and documentation for both fasciectomy and collagenase injection patients were managed by a single licensed hand therapist. RESULTS: Two hundred and thirty-two patients were treated for DD, with 247 collagenase injections and 44 open fasciectomies performed in this sample. At the time of review, collagenase patients were on average 6.51 years post-intervention, with 162 patients more than 5 years. Open fasciectomy patients were on average 4.56 years post-operation, with 12 patients more than 5 years at the time of review. The average decrease in flexion deformity was significantly different between groups; collagenase decreased contractures on average by 29.40°, whereas open fasciectomy decreased contractures on average by 38.59° (P < 0.001). The frequency of contracture resolution across all joints was significantly lower in the collagenase group compared to the fasciectomy group, with 38.18% (155 of 406 treated joints) vs 70.0% (56 of 80 treated joints) of contractures resolved, respectively (P < 0.001). A significant difference was observed in the rate of recurrence after resolution between groups; of the contractures that were initially classified as resolved, 50 of 155 (32.2%) treated with collagenase and 6 of 56 (10.7%) treated with open fasciectomy recurred (P = 0.0017). In a multivariable binary logistic regression, The use of open fasciectomy compared to collagenase injections to treat contracture was associated with a 74.2% decrease in the likelihood of recurrence. CONCLUSION: This study found that treatment of DD with collagenase injection is associated with a significantly lower degree of deformity correction, lower rate of resolution, and increased rate of recurrence, prolonging treatment trajectory when compared to open fasciectomy.

Background: While several studies have investigated the impact of COVID-19 on residency and fellowship from the applicants' perspective, fewer studies have investigated the program director's perspective. Therefore, the aim of this study is to assess the impact of virtual interviews on the hand fellowship matching process by surveying program directors.

Methods: A 21-question survey was conducted through Google Forms and distributed through a standardized email to hand fellowship program directors. Questions utilized a 5-point Likert scale with the opportunity for respondents to answer some questions in a free-response format. All data was imported into Microsoft Excel (Redmond, Washington) which was used to create tables, figures, and perform statistical analysis. The Mann-Whitney U Test and Kruskal-Wallis Test were used to obtain statistical significance. P-values < 0.05 were considered to be statistically significant results.

Results: A total of 93 surveys were distributed, of which 35 responses were obtained, corresponding to a 37.6% response rate. 17 program directors (48.6%) were an Orthopedic hand fellowship, 9 program directors (25.7%) were a Plastic Surgery hand fellowship, and 9 program directors (25.7%) were from a combined program. Overall, 62.9% of program directors reported moderate to high levels of satisfaction with the virtual interview process. Program directors reported to place more emphasis on applicant's CV, calls from colleagues, and applicants that they had met previously. When surveys were stratified by program director age (30-50 and 51+), we determined that there was a significant difference in respondents' confidence in their ability to match their top choice to the same extent had interviews been in person (P-value=0.03572). When surveys were stratified by type of program, we found that there were no significant differences between questions. Lastly, when surveys were stratified by length of program director tenure (0-5 years and 6+ years), we determined that there was a significant difference in the convenience of virtual interviews when compared to that of in-person interviews (P-value=0.03752). Furthermore, most program directors stated that they were highly likely to continue to offer virtual interviews in future cycles

Discussion: With several parenting organizations and program directors affirming that they are comfortable with proceeding with virtual interviews, it is essential for hand fellowship applicants to understand what factors program directors may perceive as more important during the application process. The virtual interview process is a long-term solution for minimizing costs and time to applicants and institutions alike. It is possible that the virtual interview process may effectively achieve suitable matches between applicants and institutions.

Purpose: Brachial plexus birth injury (BPBI) is a common birth injury that has a variable incidence rate worldwide. The spectrum of disease prognosis ranges from spontaneous recovery to lifelong debilitating disability, particularly of the shoulder joint. Surgery is the mainstay treatment for patients with BPBI to prevent shoulder deformity in the form of glenohumeral dysplasia (GHD), however, there is no clear-cut criteria for applying various surgical interventions. The surgical procedures can range from nerve grafting to nerve transfer or tendon transfer for restoring shoulder function. Herein, we report three cases of infants who underwent end-to-side spinal accessory nerve to suprascapular nerve transfers for treatment of GHD due to brachial plexus birth injury.

Methods: Three infants who underwent end-to-side nerve transfer of the spinal accessory nerve to the suprascapular nerve for the treatment of GHD due to BPBI were followed. Preoperative diagnosis, pre- and postoperative Active Motion Scale (AMS) scores, pre- and postoperative ultrasound findings, surgical exploration findings, surgical techniques, postoperative complications, postoperative rehabilitation, and postoperative range of motion results are included in this report.

Results: The age range for the three subjects was 4 months to 7 months. All patients presented with a history of BPBI and subsequent GHD. Each patient had participated in therapy since birth and used a Sup-ER splint. Preoperative ultrasound of the shoulder joint demonstrated an ossific nucleus posterior to the scapular line in all cases. The patients underwent brachial plexus exploration, which revealed C5/C6 or C6/C7 neuromas. External rotation was not observed in any patient with 0.5mA and 2.0mA stimulation. Therefore, all patients were indicated for an end-to-side transfer of the spinal accessory nerve to the suprascapular nerve. No patients experienced complications. Postoperative therapy was continued, but bracing was discontinued. At 4 months, 7 months, and 10 months postoperative for the 3 patients respectively, each patient demonstrated full shoulder range of motion, shoulder AMS improvement, and ultrasound revealed an ossific nucleus anterior to the scapular line.

Conclusions: We report 3 cases of patients with BPBI and concurrent GHD who were successfully treated with end-to-side spinal accessory to suprascapular nerve transfers. This is a novel procedure that addresses gray areas in which patients may not be indicated for a tendon transfer nor an end-to-end nerve transfer. Due to the incidence of BPBI and the lack of definitive treatment protocols, we believe that this report may help guide pediatric hand and upper extremity surgeons in tackling this common problem.