Scientific Abstract Presentations: Hand 3 Friday, October 27 Fri, Oct 27 10:30 a.m.-12:30 p.m. CDT

Purpose: Saddle syndrome is thought to be caused by post-traumatic adhesions at the interosseous-lumbrical junction (ILJ) distal to the deep transverse metacarpal ligament (TML) at the metacarpophalangeal joint (MCPJ). Adhesions in this location can impinge on the TML or MCPJ during intrinsic muscle activation, causing pain and restricted range of motion. Given limited indications for surgical exposure of the intrinsics, detailed knowledge of this anatomy is lacking. The purpose of this study was to investigate the intrinsic musculotendinous anatomy surrounding the metacarpal head utilizing cadaveric dissections, and to evaluate the dynamic relationship of the ILJ and TML as it would pertain to the diagnosis of saddle syndrome.

Methods: Ten fresh frozen, matched-pair cadaver arms were used. Skin and palmar fascia were excised from the digitopalmar crease to mid-palm of the index through small fingers. The lumbrical and interosseous muscles were gently dissected within the 2nd through 4th webspaces. Bridging the ILJ and TML, we found a clear delineation of non-tendinous fibrous tissue we referred to as "pseudotendon" (PT). The following distances were measured within each webspace using digital calipers and 2.5x loupe magnification: (A) distal edge of TML to proximal edge of PT, (B) distal edge of TML to intersection of the lumbrical and interosseous tendons or "true tendon" (TT). These were measured with the finger in full extension and in intrinsic(+), achieved by manually positioning the MCPJ in 90° flexion and tensioning the lumbrical tendon with tissue forceps. A value of zero was used for no measurable gap between structures.

Results: TT to TML distance in both neutral and intrinsic(+) was largest in the 2nd webspace and progressively decreased towards the ulnar digits. In intrinsic(+), PT to TML distance was 0mm at all webspaces for every specimen. When moving from neutral to intrinsic(+), TT to TML distance decreased more in the 3rd (63%) and 4th (59%) compared to the 2nd (48%) webspace, consistent with the trend towards a smaller ILJ to TML gap in the ulnar digits. The lumbricals generally had consistent anatomy with short, broad tendinous insertions fusing with the interossei tendons before entering the extensor hood. However, two specimens had 2nd lumbrical muscles with longer, thinner tendons at the ILJ.

Conclusions: We are the first to describe a fibrous pseudo-tendinous region at the ILJ lacking the organization and thickness of the proper interosseous and lumbrical tendons. In the intrinsic(+) position, this tissue abutted the TML in all fingers of every specimen. If this tissue were to scar down following hand trauma and cause a more proximal tissue bridge between the interosseous and lumbrical tendons, TML impingement would occur with intrinsic muscle activation. Furthermore, our evaluation demonstrated a progressively decreasing ILJ to TML gap towards the ulnar digits. However, we found the largest gap loss when moving the finger from neutral to intrinsic(+) at the 3rd webspace, which may support the predilection for saddle deformity within the 3rd webspace in previous reports. Further anatomic studies could help better discern if this phenomenon exists on a larger scale.

Purpose: Proximal Row Carpectomy (PRC) and scaphoid excision with four-corner fusion (4CF) are common motion-preserving, salvage procedures for the treatment of radiocarpal arthritis resulting from scapholunate or scaphoid nonunion advanced collapse. Denervation of the anterior and posterior interosseous nerves (AIN and PIN) has also been described for treatment of severe osteoarthritis. While PIN denervation is performed in combination with PRC or 4CF for treatment of degenerative wrist arthritis, the exact role of neurectomy remains unknown. This study systematically reviews the contribution of PIN neurectomy to PRC and 4CF surgeries in improving postoperative pain and functional outcomes of patients with degenerative arthritis of the wrist.

Methods: A literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through December 2022. The following keywords were employed in the search: "Four Corner Arthrodesis" OR "Four Corner Fusion" OR "Proximal Row Carpectomy" AND "Neurectomy" OR "PIN Neurectomy" OR "Wrist Neurectomy" AND "Quality of Life" OR "Wrist Function." Original articles were included if they met the following criteria: (1) observational, retrospective, or prospective human design, (2) reported outcomes on patients who had undergone PRC or 4CF with PIN or AIN neurectomy, and (3) reported data on objective or subjective clinical results of such a combination. Extracted data comprised study size, indication for surgery, surgical technique, type of neurectomy performed, presence of control group, duration of follow-up, and reported objective and subjective outcomes.

Results: A total of 8 studies met inclusion criteria. The majority (5) were retrospective in nature, while one was prospective, and two were case series. Five examined PRC alone, two examined 4CF, and one examined both PRC and 4CF. Standardized score reporting included Disabilities of Arm, Shoulder and Hand (DASH; evaluates function of upper extremity, not specific to the hand/wrist), Pain-Related Wrist Evaluation (PRWE; specific to wrist function), Mayo Wrist Score, and range of motion. Only one of four studies examining rates of conversion to total wrist arthrodesis (TWA) found that neurectomy was associated with decreased rates of reoperation at 8.1 year follow-up. PRC with PIN neurectomy was associated with improved pain in one retrospective case-control study, while two studies did not find improvement in pain or ROM following isolated PIN neurectomy. Regarding 4CF, no studies examining the effect of neurectomy on pain with an adequate control group were identified.

Conclusion: Our literature review revealed a limited number of studies examining the role of neurectomy in 4CF and PRC. The results of these studies may be limited by the heterogeneity of methodology and reported outcomes as well as lack of control groups. Only one comparative study was found, suggesting no improvement from the addition of PIN neurectomy to PRC. The majority of studies identified did not demonstrate a decreased rate of conversion to TWA following neurectomy. Future case-control studies are needed to elucidate the benefit of neurectomy in PRC and 4CF.

Purpose: Injury to the scapholunate (SL) interosseous ligament (SLIL) is a common cause of carpal instability. Various reconstructive procedures for SL instability have been described, yet no consensus exists regarding the optimal surgical technique. The internal brace augmentation technique, which uses a durable nonabsorbable "suture tape" to enhance stability of the tendon repair, has been utilized in a variety of ligament repair procedures. However, investigation of its clinical outcomes in hand surgery and its more recent application for SLIL injuries is lacking. The aim of this study was to describe clinical outcomes for patients who underwent SLIL repair with internal brace augmentation.

Methods: Following institutional review board approval, patients who underwent SLIL repair with internal brace augmentation by one of three fellowship-trained hand surgeons at a single institution were identified via database search. All patients who underwent surgery greater than one year prior to May 1, 2022 were contacted. Participating patients completed the Quick-DASH (qDASH) and Patient-Rated Wrist Evaluation (PRWE) surveys as well as rated their satisfaction with the surgery on a scale of 1 to 5. Additionally, patients were asked to return to the office for new radiographs and physical examination. Outcomes assessed were wrist range of motion, grip strength, Watson scaphoid shift test, and radiographic measurements including SL angle, SL interval, and evidence of radiocarpal arthritis. If patients could not be contacted but had wrist radiographs and a physical examination performed greater than one year post-operatively, these data were collected in the same fashion.

Results: Outcome data was available for 14 SLIL repairs among 13 patients (12 male). Injuries were considered acute in 8 cases and chronic in 6 cases. Mean length of follow-up was 41 months (n=14, 17 to 64). Mean calculated qDASH and PRWE scores at latest follow-up were 6.1 (0 to 43.2) and 9.6 (0 to 65), respectively, indicating minimal to no pain or disability. The average qDASH score decreased by 32.5 points (P<.05) from before surgery to latest follow-up. Mean patient satisfaction with their surgery was 4.6 out of 5 (3.5 to 5). Only one patient did not feel that they returned to full functional status following surgery, although many noted minor loss of active motion in their injured wrist. Radiographic alignment of the carpal bones was maintained postoperatively. From before surgery to latest follow-up, SL gap decreased from a mean of 4.2 mm (2 to 6.7 mm) to 3.3 mm (2 to 5 mm) (P<0.5), and SL angle decreased from a mean of 79.5° (67° to 97°) to 67.3° (51° to 85°) (P<0.5). There was no radiocarpal joint space narrowing or other radiographic signs of degeneration. All Watson tests were stable.

Conclusions: Our series demonstrated that internal brace augmentation for SLIL repair is an effective technique that may provide long-term wrist stability, as evidenced by our clinical and radiographic findings. Patients are generally satisfied with results of the procedure and are able to return to prior functional status, although minor loss of motion in the injured wrist should be anticipated.

BACKGROUND: Distal radius fractures (DRFs) are the most common upper extremity fracture and require surgical fixation when the fracture is intraarticular. Preoperative CT has emerged as a surgical planning tool to evaluate intraarticular DRFs. While CT affords additional detail in periarticular fractures, it exposes patients to higher doses of radiation than standard radiographs. Our aim is to develop a low dose CT (L-CT) protocol that can be used to decrease the amount of radiation exposure in patients with intraarticular DRFs while still providing a scan with adequate detail to guide surgical decision-making.

METHODS: A single institution prospective study, powered to 41 observations, was conducted on patients with intraarticular DRFs who underwent closed reduction and application of a below-elbow plaster splint that would otherwise undergo CT scan of the wrist as a part of their diagnostic work-up. Observations were defined as total measurements taken by reviewers, with each view undergoing 44 measurements. Patients underwent two CT scans: our standard dose CT scan and another with a 10x dose reduction. Four reviewers recorded articular step and gap measurements in the sagittal and coronal images.

RESULTS: A total of 11 patients were enrolled in the study, which included 7 females and 4 males. The mean age of the study population was 55 years (SD = 20.1). There was a total of 4 reviewers: one attending surgeon, two resident physicians, and one medical student. When comparing low and conventional-dose CTs, there were no significant differences in articular step and gap measurements across all 4 reviewers.

CONCLUSION This study demonstrated that a L-CT protocol provides comparable imaging as a conventional dose CT (C-CT) without significant diagnostic decay in the setting of DRFs. This comes with the added benefit of a 10-fold reduction in radiation exposure to patients. These results suggest that L-CT is an opportunity to reduce effective radiation in patients while also providing clinicians with beneficial pre-operative imaging for intraarticular DRFs.

Purpose: The thumb carpometacarpal joint is the second most affected osteoarthritic joint in the hand, while also being the most operated upon (1). Both epidemiologic and clinical studies demonstrate a female predominance in the prevalence of thumb carpometacarpal osteoarthritis (CMCOA) (2, 3). We aimed to explore sex differences in thumb CMCOA treatment selection, outcomes, adverse events, and study design in existing RCTs.

Methods: In accordance with PRISMA-E 2012 criteria, we searched MEDLINE, Embase, Cochrane CENTRAL, and CINAHL to locate adult thumb CMCOA RCTs. Studies not in English nor assessing isolated thumb CMCOA were excluded. Following retrieval, half were screened by 2 independent reviewers. The remainder were screened in duplicate by a Machine Learning model and 1 reviewer. Full text studies were then assessed, and data was extracted by 2 independent reviewers. A meta-analysis with a random effect model on the proportion of included female patients was performed.

Results: A total of 4628 studies were retrieved, and 280 underwent full-text review, resulting in 75 RCTs included, encompassing 4756 patients. 74 (98.7%) studies reported the sex of the participants. The random effect model indicated the proportion of female participants in thumb CMCOA RCTs was 88.2% [95% CI: 85.1% to 91.1%]. Exclusive female enrolment was seen in 16 RCTs (21.3%). Sex distribution in treatment arms was reported in 66 (88.0%) studies. Subgroup analysis based on sex was performed only in 4 (5.3%) studies, of which 4 (5.3%) assessed efficacy and 1 (1.3%) complication rates.

Conclusions: Sex differences are rarely explored in thumb CMCOA RCTs. Very few studies assessed sex differences in clinical outcomes, efficacy, or complication rates. Future RCTs should aim to examine differences in outcomes based on sex.

References: 1. Batra S, Kanvinde R. Osteoarthritis of the thumb trapeziometacarpal joint. Curr. Orthop. 2007;21:135–144. 2. Armstrong AL, Hunter JB, Davis TR. The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. J. Hand Surg. Br. 1994;19:340–341. 3. Dahaghin S. Prevalence and pattern of radiographic hand osteoarthritis and association with pain and disability (the Rotterdam study). Annals of the Rheumatic Diseases 2005;64:682–687. Available at: http://dx.doi.org/10.1136/ard.2004.023564.

Purpose: Radial tunnel syndrome (RTS) is a painful compressive neuropathy of the the posterior interosseous nerve, often associated with by repetitive motion and manual labor. Surgical release of the PIN in the forearm is an effective treatment for these symptoms. It is common for patients with RTS to present with multiple compressive neuropathies of the upper extremity, which may be related to these same demographic or occupational factors. This study assesses the relationship between patient demographic data, occupational data, and the likelihood of radial tunnel release surgery being performed concurrently with additional procedures on the upper extremity.

Methods: An IRB-approved, retrospective chart review was conducted of all patients who underwent radial tunnel release (RTR) for RTS at our institution between 2015 and 2021.Data were collected and analyzed from electronic medical records and billing sheets at the operating surgeon's clinic and corresponding hospitals. RTR performed prophylactically at time of radial nerve laceration repair or other nerve surgery were excluded. Descriptive statistics were computed for all study variables. Comparisons between categorical variables were compared with Chi-square or Fishers test and continuous variables were compared via Wilcoxon tests.

Results:Of the764 patient records identified, 110 records (surgeries) met inclusion criteria. 55.96% were female, and 43.52% had Medicaid listed for primary insurance.The mean BMI at the time of injury was 32.92 (SD±6.63). The mean age at the time of surgery was 50.09 years (SD±11.71). Nearly all surgeries (97.27%) were diagnosed with at least one related diagnosis. The three most common were Carpal Tunnel Syndrome (82.73%), Cubital Tunnel Syndrome (50.91%) and Pronator Syndrome (35.45%). Ninety-six surgeries had a concurrent upper extremity nerve release (performed at the same time as RTR), of which 78.18% was Carpal Tunnel. There were 23 records that had concurrent upper extremity surgery (performed at the same time as RTR), with Trigger Finger Release (n=5) being the most common after the 'Other' category. Females had a significantly higher distribution of number of related diagnoses (p=0.0117) and number of concurrent upper extremity surgeries (p= 0.0444) occurring at the same time as RTR. The likelihood of having at least 1 related diagnosis was 98.36% vs 95.83%, in females vs males respectively (p=0.5816). There was a higher percentage of females who had a concurrent upper extremity nerve release compared to males (91.80% vs 81.25%, p=0.1021).There was no significant relationship between BMI nor Age with related diagnosis, concurrent upper extremity nerve decompression or surgery.

Conclusion: Carpal Tunnel Syndrome is the most prevalent comorbid compressive neuropathy and most common concurrent surgical procedure with RTR. A majority of patients treated with surgical decompression of the radial tunnel underwent decompression of an additional upper extremity nerve. There is no clear effect of demographics on comorbid diagnosis, concurrent nerve decompression or surgery. The next phase of this study will be to evaluate our institutional outcomes after radial tunnel release and the effect these factors have on symptomatic relief .

Purpose: Nerve wraps may be used to bolster nerve repair sites, particularly in the case of size-mismatched coaptations or cable grafts. Although more commonly used for compressive neuropathies to prevent adhesions and recurrent stenosis, the primary goal of nerve wraps at coaptation sites is to restore epineurial continuity, thus theoretically reducing axonal escape and intraneural scar infiltration. We posit that autologous fascia has the potential to serve as an ideal nerve wrap, as it is composed of native collagen and has a composition closely resembling epineurium. Specifically, we hypothesize that autologous fascia nerve wraps will (1) readily incorporate into the epineurium at the coaptation site and (2) provide a barrier to contain regenerating axons and reduce inflammatory cell infiltration. We evaluated these hypotheses in a rat sciatic nerve transection and repair model as well as a size-mismatched sciatic-to-common peroneal nerve transfer model.

Materials and Methods: A total of 84 Lewis rats were divided into six groups (n = 14 per group): sciatic transection with repair +/- fascia wrap (matched repair), sciatic-to-common peroneal nerve transfer +/-fascia wrap (mismatched repair), sciatic transection without repair (positive control), and sham surgery (negative control). Fascia grafts were obtained from gluteal muscles near the coaptation sites. Animals were harvested at either 4 weeks or 12 weeks post-operative for histologic evaluation of the coaptation site and evaluation of cytokine expression in the nerve and dorsal root ganglia (DRG) using ELISA.

Results: At 4 weeks post-operative, groups that received fascia nerve wraps demonstrated significantly reduced expression of pro-inflammatory cytokines, TNF-α and IL-1β, at the DRG relative to groups that underwent nerve repair alone. Additionally, fascia wrap groups demonstrated significantly greater expression of anti-inflammatory cytokines, TGF-β and IL-10, relative to nerve repair alone.

Conclusion: Autologous fascia wraps are a simple adjunct that can reduce inflammation in both size-matched and size-mismatched nerve coaptations. Fascia grafts are technically straightforward to harvest, ubiquitously available, and may be a useful tool in the peripheral nerve surgeon's armamentarium.

Introduction: Arthrodesis of the metacarpophalangeal (MP) joint of the thumb is a common procedure to treat patients with arthritis or instability. Studies reporting hardware complications and nonunion rates after thumb MP joint arthrodesis report on small sample sizes. We aim to describe the hardware complication and nonunion rate among patients undergoing thumb MP joint arthrodesis and compare the nonunion rate and time to radiographic union between 2 arthrodesis techniques.

Methods: A database spanning 5 urban hospitals in a single metropolitan region in the United States was searched for patients that underwent thumb MP joint arthrodesis between January 1, 2004, and January 1, 2020. After reviewing patient records, we identified 122 thumbs that underwent MP joint arthrodesis and had a minimum follow-up of 3 months. The primary outcome was unexpected reoperation after hardware complications and non-union. A bivariate analysis was performed to compare the nonunion rate and time to radiographic union between tension band and screw fixation arthrodesis.

Results: Twenty-one out of 122 thumbs (17%) had hardware complications after MP joint arthrodesis, and 11 out of 122 thumbs (9%) developed a nonunion. Patients who underwent screw fixation arthrodesis had no events of hardware complications and subsequent hardware removal. There were no significant differences between the tension band arthrodesis group and the screw fixation arthrodesis group in terms of the nonunion rate (9/65 vs 2/45) and time to radiographic union (108 days vs 90 days).

Conclusion: Although the used surgical technique for thumb MP joint arthrodesis should be decided on an individual basis, our data suggests that screw fixation has fewer hardware complications and, as a consequence, fewer reoperations.

Introduction: The most popular video hosting website and overall second-most visited website is YouTube - a resource commonly used by patients. Trigger finger, also known as stenosing tenosynovitis, has a prevalence of approximately two percent in the general population. However, the quality, reliability, and comprehensiveness of relevant information available on YouTube regarding surgical treatments have not been studied. Therefore, the purpose of this study is to assess the quality of YouTube videos discussing trigger finger release. The effects of video category, author type, and search term on video quality were also investigated.

Methods: In February 2023, three search terms were utilized to identify videos discussing trigger finger release on YouTube: "open trigger finger release surgery", "percutaneous trigger finger release surgery", and "steroid injection trigger finger". The top 50 video results for each search term were recorded. Two trained reviewers used the modified Ensuring Quality Information for Patients (EQIP) criteria to systematically score each video on a scale of 0 to 27 with consideration of video content, identification, and structure. Interrater reliability was assessed using the Kappa interrater agreement score, where a score of 1 represents perfect agreement between raters. Videos with a score of 13 or above, representing the 75th percentile, were considered high-quality. The average view count, length, and EQIP scores were compared based on search terms and authorship.

Results: After removing duplicates, a total of 103 unique videos were assessed with an average score of 10.53 (SE 0.340) overall. The Kappa interrater agreement score was 0.886, which signifies strong agreement. The average video length was 4.05 minutes and the average view count was 100,065 views. "Open trigger finger release surgery" had the highest average score of 11.74 (SE 0.465), followed by "Percutaneous trigger finger release surgery" with an average score of 11.04 (SE 0.543), and "Steroid injection trigger finger" with an average score of 10.40 (SE 0.472). However, there was not a significant difference between the mean scores of the three search terms (p = 0.163). Physicians authored the majority of videos (79.6%) with an average score of 10.59, of which 59.8% were orthopedic surgeons and 19.5% were plastic surgeons. Patients authored only 1.9% of all videos. There was no significant difference in scores based on physician type (p = 0.413) . Of all videos, only 31 had a score of 13 or greater, deeming them high-quality. Physicians authored 80.6% of the high quality videos.

Conclusion: YouTube is a free, accessible resource for patients, but it contains minimal quality-control measures or peer-review processes to confirm the validity of health-education videos. This study demonstrates that high-quality YouTube videos on trigger finger release are most commonly created by physicians. Hand surgeons should be encouraged to create more educational content on YouTube in order to provide trustworthy, accessible content to the patient population. Given that trigger finger typically presents in middle aged patients, surgeons should consider tailoring their educational content to this audience. Further, older audiences are more susceptible to misinformation online, so promoting trusted educational resources is especially important.

PURPOSE: The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this study was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow.

METHODS: This retrospective study utilized surgical logs of the senior authors to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at one year was determined from post-operative visit notes.

RESULTS: Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss [n = 12, (57%)]. Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. Flap success was 100% (n = 21). At one year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension.

CONCLUSION: Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Purpose: Carpal tunnel syndrome is one of the earliest manifestations of amyloidosis. Consequently, there is an interest in risk-stratifying patients at the time of carpal tunnel release (CTR) to predict who will develop systemic manifestations of amyloidosis. The primary objective of this systematic review was to examine the factors associated with the diagnosis of amyloidosis following CTR, and secondarily, assess the incidence of amyloidosis following CTR.

Methods and Materials: A systematic review was performed using PubMed, Scopus, and Web of Science, following modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Two independent reviewers screened 983 studies and 23 studies evaluating the diagnosis of amyloidosis following carpal tunnel release were included. Case series and case studies were excluded. Data on patient factors associated with amyloidosis diagnosis, amyloid subtypes, tenosynovial biopsies, study design, and patient demographics were collected.

Results: Factors significantly associated with amyloidosis diagnosis following CTR were older age (79% of studies), >1 CTR (66.7% of studies), and male sex (75% of studies). The reported incidence of amyloidosis following carpal tunnel release was 3.8% (IQR: 0.6% - 10.9%). The median sample size was 114 (IQR: 83 – 217.5) CTR patients, and the median age of the patient cohorts was 66.7 (IQR: 57 – 71.3). In the 16 studies that examined tenosynovial biopsies during CTR, 11.6% (IQR: 5.1% - 25.6%) of biopsies were positive for amyloid. Of the (n=11) studies that reported follow-up, the median follow-up length was 8 years (IQR: 7.9 – 15)

Conclusion: Most studies found that older age, male sex, and >1 CTR are associated with a higher incidence of amyloidosis following CTR. The absolute incidence of amyloidosis diagnosis following CTR varies depending on patient selection criteria, but the development of appropriate risk stratification may help diagnose patients in earlier stages of amyloidosis.

Purpose: Acute limb ischemia (ALI) is a vascular emergency requiring immediate treatment via surgical revascularization to preserve the limb, as prolonged ischemia can cause ischemia-reperfusion injury (IRI) leading to compartment syndrome (CS). If CS can be anticipated, revascularization can be immediately followed by a prophylactic fasciotomy to limit additional injury. While the extent of IRI has been shown to be influenced by both the magnitude and duration of ischemia, there is currently limited literature on the indications for prophylactic fasciotomy following revascularization for ALI, especially for the upper extremity. The objective of this study is to investigate the incidence of CS after upper extremity revascularization and compare the outcomes following prophylactic versus therapeutic compartment release.

Methods: Patients within the Cleveland Clinic Healthcare System who received an upper extremity revascularization for acute limb ischemia between 2003 and 2022 were reviewed. Patients who did not show signs of CS but underwent fasciotomy due to high risk of developing CS were considered to have had a "prophylactic" fasciotomy, while those who underwent fasciotomy after manifesting CS symptoms were classified as having a "therapeutic" fasciotomy. Demographic information, medical history, ischemia duration and etiology, available physical exam findings, length of hospitalization, and complications were recorded. Ischemia duration was compared between the prophylactic and therapeutic fasciotomy groups using Mann-Whitney U tests, and Fisher's exact tests were used to compare complications rates between the groups. Pearson's test was used to find correlations between ischemia time and outcomes.

Results: A total of 384 patients underwent revascularization for ALI during the study period. Fifty-one patients of these patients were reviewed. The average age of the patients 67±2.3 years, and 49% were female. The etiology of limb ischemia included arterial thrombus or embolus (92%), aneurysm repair (4%), or iatrogenic aortic dissection from a previous intervention (4%). Of these, 11 patients (24%) received a prophylactic fasciotomy, and 11 (24%) developed compartment syndrome intraoperatively or within 24 hours of the revascularization procedure and subsequently underwent a therapeutic fasciotomy. The median ischemia time was 16 hours (IQR=22) for the prophylactic group and 8 hours (IQR=8) in the therapeutic group (p=0.008). The patients who underwent revascularization but did not receive a fasciotomy (27) had an ischemia time of 8 hours (IQR=19), suggesting a trend toward a difference with the prophylactic fasciotomy group (p=0.08). The median length of hospitalization for the prophylactic and therapeutic groups was 10 (IQR=16) and 17 (IQR=13) days, respectively (p=0.58). For all patients, length of hospitalization positively correlated with ischemia duration prior to revascularization (r=0.35, p=0.14). The complications in the prophylactic and therapeutic groups respectively included hematoma (9% vs. 18%, p=0.5), muscle necrosis (9% vs. 36%, p=0.16), and limb amputation (9% vs. 18%, p=0.5), showing a higher complication rate in the therapeutic group.

Conclusion: Ischemia time is a significant factor in the decision to perform upper extremity prophylactic fasciotomy following revascularization. Prophylactic fasciotomy may result in lower postoperative complication rates than therapeutic fasciotomy.

Purpose: Electrical burns to the upper extremity are the most common type of electrical burn and a preventable cause of emergency department visits. This project aims to characterize the demographic trends and common causes of upper extremity electrical burns from 2017 to 2021.

Methods: The National Electronic Injury Surveillance System database, which surveys emergency department visits, was retrospectively queried for all electrical burns to the upper extremity from 2017 to 2021. Information about patient demographics, area of upper extremity injury, location of patient during injury, and cause of injury was gathered and analyzed.

Results: There were 520 total electrical burn injuries from 2017 to 2021, which accounted for 3.3% of all burn injuries. Four hundred twenty-four (81.5%) electrical burns were in the upper extremity, primarily in the hand (49.5%) or fingers (43.9%). Patients who were male (57.3%), less than 10 years old (61.0%), or white (39.6%) sustained the most injuries. Electrical items that were most commonly responsible were electrical outlets or receptacles (20.3%), hair curlers/curling iron/clips and hairpins (12.3%), electrical wiring (6.4%), and desk supplies (5.9%). Patients were most commonly injured in their own home (63.0%) or at school (7.1%).

Conclusion: This data indicates that electrical burns prompting emergency department visits occur most often at home, and children are usually the victims. Recognizing and acknowledging the factors that contribute to electrical burns can prevent them from happening and alleviate emergency department burden from these injuries.

Purpose: Complications after major amputation can lead to requiring additional procedures, delayed recovery and decreased quality of life. Stump infection and neuroma formation, two common post-amputation complications, are analyzed in this study. Besides biological criteria such as age, sex and comorbidities, we investigated the lesser explored impact of race, socioeconomic status, insurance and the hospital care received. Methods: The National Inpatient Sample (NIS), a large, all-payer inpatient care database in the United States was utilized for our investigation. We relied on diagnosis-related group (DRG) codes to create a dataset of patients with musculoskeletal amputations. ICD-9 codes were subsequently used to identify neuroma formation and stump infections. Multivariate logistic regression model, controlling for a variety of relevant patient/hospital characteristics, was employed to assess the various relationships within our study. Results: The multivariate regression model predicted mostly contrasting patterns in the two complications studied. Lower socioeconomic status and non-white race was associated with a significantly higher risk of infection and lower risk of neuroma. Patients on Medicaid, in comparison to those who are privately insured, were 46% percent less likely to receive a neuroma diagnosis and 30% more likely to be diagnosed with post-amputation infection. White race was associated with 54% higher diagnosis of neuroma and 33% less of infection. In regards to the impact of older age and comorbidities, every year increase in age contributed to 2% decrease in neuroma formation and 0.5% increase in likelihood of infection post-amputation. Each added chronic condition added 5% to the risk of infection and separately analyzed, these conditions decreased the rate of neuroma formation by at least 34%. Conclusion: The observed impact of chronic conditions and age on infection and neuroma formation reflect the underlying pathophysiology and incidence of these complications. Contrarily, the relationship between socioeconomic status and rate of neuroma formation is likely due to barriers to follow-up care reflecting as lower diagnosis of neuroma formation and higher rates of infection, indicating an important need for increased surveillance in vulnerable populations towards improving post-amputation outcomes.

INTRODUCTION

Carpal tunnel syndrome (CTS), cubital tunnel syndrome (CuTS), thumb carpometacarpal (CMC) arthritis, and wrist ganglion cysts are common pathologies affecting the upper extremity. Despite their high incidence, there is a lack of comprehensive analysis regarding demographic disparities associated with these conditions. Our study aims to quantify prevalence of these conditions and treatment rates and identify any delays in management of these pathologies.

METHODS

Utilizing PearlDiver Mariner insurance claims database, the Medicare 5% national sample administrative (SAF5) dataset was analyzed for diagnosis and treatment of these common UE pathologies based on race and gender from 2015 to 2016. Inclusion criteria were records with male or female gender designations as well as racial designations of either White, Black, Asian, Hispanic, or Native American. Outcomes include diagnosis rates, treatment rates, and time from diagnosis to treatment.

RESULTS

The study included 96,811 patients of which the majority were White and female. Comorbidity burden was higher in all non-white racial groups except Native American. Diagnosis trends included lower rates of diagnoses of all pathologies except CTS in most minority groups. Males had higher rates of CTS and CuTS with lower rates of thumb CMC arthritis and ganglion cysts. Disparities in treatment offered across ethnicity were most prominent in CTS and thumb CMC arthritis, with the majority of non-White racial groups exhibiting higher odds of no treatment and lower odds of both operative and non-operative management compared to White patients. Black and Hispanic patients were most severely affected, having a degree of disadvantaged treatment in all four diagnoses. Males had unfavorable odds of treatment in all diagnoses with the exception of a higher rate of operative management in both CTS and CuTS. The most prominent disparity in time from diagnosis to treatment was seen in the management of CTS, where Black, Hispanic, Native American, and female patients had a delay in referral for non-operative treatment, operative treatment, or both.

CONCLUSION

Our study sheds light on health disparities in the management of upper extremity pathologies and highlights the importance of providing timely and appropriate treatment options for these vulnerable patient populations.

Introduction: Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the upper extremity that occurs due to trauma during birth. While the incidence is low, numerous risk factors are associated with PBPP, many of which are related to large fetal size or birth-related trauma. Our study characterizes risk factors for PBPP and quantifies the importance of these risk factors to predicting likelihood of PBPP.

Methods: A retrospective review of patients with PBPP presenting to our institution between 2008 and 2020 was conducted. Variables collected included demographic information, birth history, and the presence of risk factors e.g., shoulder dystocia, maternal diabetes, fetal macrosomia, history of a prior child with PBPP, prolonged labor (>24 hours), and difficult birth requiring vacuum or forceps. Active Movement Scale (AMS) scores, management (surgical vs. conservative) and outcomes were also recorded for each patient.

Results: 173 patients presented to our institution with PBPP between 2008 and 2020. Our cohort was 54.9% Male and 45.1% Female. 86.5% of births were vaginal deliveries and 14.5% were Cesarean; all were single gestations. Within our cohort, 73 patients (42.2%) had the presence of at least one risk factor. Among these patients, 48 (27.7%) had shoulder dystocia, 13 (7.5%) had maternal diabetes mellitus, 10 (5.8%) had prolonged labor, 6 (3.5%) had fetal macrosomia, 1 (0.01%) had a difficult birth that ultimately required forceps, and 43 (24.9%) had another reported risk factor. Other reported risk factors included difficult birth (n=18, 10.4%), maternal preeclampsia (n=6, 3.5%), induced labor (n=3, 1.7%), and head dystocia (n=2, 1.2%). No patients were born to parents who had history of a prior child with PBPP. Fetal macrosomia was associated with 10.45 times greater risk of PBPP (RR 10.45, CI 1.25-87.32, p=0.007) and shoulder dystocia was associated with a 9.05 times greater risk of PBPP (RR 9.05, CI 4.72-17.36, p<0.001). Long labor (>24 hours) was associated with 8.36 times greater risk of PBPP (RR 8.36, CI 1.83-38.07, p<0.001) and maternal diabetes mellitus was associated with 4.7 times greater risk of PBPP (RR 4.70, CI 1.51-14.61, p=0.003).

Conclusion: Numerous risk factors were identified that increase the risk of delivering a child with PBPP, most notably: fetal macrosomia, shoulder dystocia and prolonged labor. These risk factors may be utilized to screen patients to prepare families for the possibility of delivering a child with PBPP, and ultimately may be used by our OBGYN colleagues to inform their decision-making during the delivery process.

Purpose: Zone 2 flexor tendon lacerations involving both the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) are managed with either isolated repair of the FDP tendon or concomitant repair of the FDP and FDS tendons. The purpose of this systematic review is to review outcomes and complications of isolated FDP repair in comparison to combined FDP and FDS repair for zone 2 flexor tendon injuries.

Methods: A systematic review was carried out in accordance with PRISMA guidelines. The electronic databases of MEDLINE, EMBASE and PubMed were searched for relevant studies from inception to April 2022. Studies reporting outcomes for adult patients with acute primary surgical repair of zone 2 flexor tendon injuries involving both FDS and FDP tendons were included. Quantitative analyses were conducted using the Mantel-Haenszel method and random effects models. Pooled results were reported as odds ratios (OR) with 95% confidence intervals (CI). All statistical tests were two-tailed with a priori statical significance defined as p<0.05. Statistical heterogeneity was assessed using the I2 statistic.

Results: Eleven studies with 494 digits were included. Meta-analyses of studies comparing postoperative outcomes of isolated FDP repair against combined FDS with FDP repair using the Strickland criteria (n=4; OR = 1.16, p = 0.78) and Tang criteria (n = 2; OR = 0.99, p = 0.98) favored combined repair, however not statistically significant. Additionally, no significant differences were found in studies (n=5) that compared reoperation rates in the two treatment groups, with meta-analysis favoring combined repair (OR = 1.09, p = 0.88).

Conclusion: This review suggests that in primary repair of zone 2 flexor tendon injuries, isolated repair of FDP provides no significant differences in post-operative range of motion and reoperation rates to repair of FDP with FDS. Future prospective comparative studies are needed to confirm this finding.

Introduction Neonatal brachial plexus injury (BPI) is a rare but devastating complication of birth. An upper trunk BPI can result in the loss of shoulder external rotation and abduction and often leads to glenohumeral joint dysplasia (GJD). The latissimus dorsi/teres major tendon transfer (LTT) is a procedure used to restore external rotation and shoulder abduction and potentially reduce the incidence of GJD. Historically, this tendon transfer has been performed when the child is older and has demonstrated impaired shoulder function. In this study, we sought to assess feasibility and short-term outcomes of LTT combined with BPI reconstruction.

Methods A retrospective review of patients was performed. Inclusion criteria were patients under 18 years of age at Riley Children's Hospital with BPI who underwent LTT between 2021-2022.

Results Eighteen patients underwent LTT between 2021-2022 at the mean age of 2.2 +/- 2.2 years. Five patients (27.8%) underwent the transfer concurrently with BPI nerve reconstruction, 8 (44.4%) underwent staged LTT, and 5 (27.8%) patients underwent LTT with no previous or concurrent BPI reconstruction. Of the 8 patients that underwent staged repair, 7/8 (88%) had MRI evidence of GJD prior to their tendon transfer. There were no major complications in any subgroup. Average follow-up was 7.54 months. The mean age at surgery for patients undergoing staged LTT was 2.1 years old compared to 6 months in the concurrent group. In the staged cohort, available post-operative mean AMS scores were 3.5 for shoulder abduction, 1.67 for shoulder external rotation. and 4.83 for shoulder forward flexion. In the concurrent cohort, mean AMS scores were 3.2 for shoulder abduction, 1.8 for external rotation, and 3.6 for shoulder forward flexion.

Conclusions In this study, we found that LTT can be safely and efficiently combined with BPI reconstruction. Patients in the concurrent surgery cohort achieved similar shoulder functional scores as those in the staged surgery cohort, but these scores were achieved at a younger age (i.e. 1.5 years earlier) and without a second surgery. In addition, a simultaneous or early approach may provide the very young pediatric patient shoulder stability needed to prevent GJD while also avoiding the need for a second anesthetic exposure. Future studies will focus on comparative assessment of long-term shoulder functional outcomes.

Background and Methods: Intra-articular fracture dislocations of the proximal interphalangeal joint (PIPJ) are complex injuries that can be difficult to treat. These fractures commonly occur secondary to sports injuries with axial force and hyperextension of the digits. Surgical intervention depends on the extent of joint surface involvement; greater than 50% joint surface involvement requires surgical intervention. Treatment options include open reduction and internal fixation, volar plate arthroplasty, external traction pinning, and hemi-hamate arthroplasty (HHA). HHA aims to restore the buttressing effect of the palmar lip of the middle phalanx to prevent hyperextension and subluxation of the PIPJ. Many of the current reports of HHA outcomes do not include pediatric patients; the mean age of patients in these reports is around 30 years old. Further information is needed regarding the outcomes of HHA in pediatric patients especially due to the high incidence of sports injuries in this population. This case series describes three patients ranging from 13 - 15 years old who underwent HHA for dorsal PIPJ fracture dislocations.

Results/Patients: A 15-year-old female presented two weeks after injuring her right index finger while catching a softball with a non-gloved hand. She had distal interphalangeal joint (DIPJ) extensor lag and decreased range of motion (ROM) at both the DIPJ and PIPJ. Imaging revealed an unstable, comminuted volar lip fracture with dorsal dislocation of the PIPJ involving 40% of the base of the middle phalanx. Treatment included closed reduction percutaneous pinning of the distal phalanx and HHA of the middle phalanx one month after the initial injury. Ten weeks post-operatively, imaging confirmed incorporation of the hamate graft with improved congruence of the articular surface and improved ROM on exam. A 14-year-old male presented for evaluation 3.5 months after sustaining an axial load injury to the right ring finger while playing football. On exam, he had a PIP flexion contracture with significantly limited ROM at the PIPJ. Imaging revealed a comminuted volar lip fracture of the middle phalanx volar base involving 50% of the joint surface. Eight weeks postoperatively he reported intermittent pain with activity however his ROM improved on exam. A 13-year-old male presented for evaluation of pain and inability to flex the left index finger PIPJ one month after sustaining an injury playing basketball. Imaging confirmed an unstable volar lip fracture of the middle phalanx with dorsal dislocation. One month after treatment with HHA, the patient had full ROM with no pain, swelling, or neurovascular deficits.

Conclusions: Each patient in this case series had successful incorporation of the hamate graft at the middle phalanx with improved ROM of the injured digits. None of the patients had evidence of adhesions, traumatic arthritis, or recurrent subluxation of the PIPJ postoperatively. This case series demonstrates HHA is a feasible surgical option for treatment of PIPJ fracture dislocations in the pediatric population. Further research is required to assess the incidence of long-term outcomes and complications that may be unique to the pediatric population.

Background: Recurrent cutaneous infections are a common and morbid reality for patients with secondary lymphedema (LE). These conditions range from cellulitis, erysipelas, lymphangitis, and lymphadenitis. Between 2012-2017, 92% of LE-related hospitalizations in the United States were for cellulitis. In addition, a recent meta-analysis of reports of lymphedema-related infections found that 35% of patients sustained one or more episodes of cellulitis within 1-3 years of a LE diagnosis. In this study, we expand on the current understanding of lymphatic impairment and cutaneous disease in LE by highlighting the immunological processes that contribute to this risk.

Methods: Matched, full-thickness skin biopsies (5mm) were obtained from the normal and LE limb of ten patients with unilateral upper extremity lymphedema. Five patients were identified as having a history of recurrent cellulitis, however, no patients had active disease at the time of biopsy collection. The presence of dermal IL-17-producing CD4+ Tcells and γδ T-cell subsets in both limbs was assessed by immunohistochemistry (IHC) and Immunofluorescence (IF). This was repeated in a mouse model of lymphedema in the presence or absence of Staphylococcus antigen and cytokine production was assessed by qualitative polymerase chain reaction (Q-PCR) and Flow cytometry.

Results: Dermal IL-17-producing cells were higher in LE biopsies when compared to normal. Infection history was not significantly correlated with the quantity of IL-17-producing CD4+ Tcells detected between the normal and LE limbs. Compared to normal skin, the γδ T-cell population was increased in the LE biopsy samples between both groups. A significant increase in IL-17-producing γδ T-cells was observed in patients with a history of infection (p=0.046). In the LE-mouse model, we observed a significant increase in IL-17 producing γδ T-cells in the hindlimb at 11 weeks on flow cytometry in mice inoculated with Staphylococcal epidermidis (S. epidermidis) compared to phosphate buffer saline (PBS) alone (p=0.0171). Similarly, IL-17 mRNA was increased on QPCR in the S.epidermidis treated mice when compared to WT and untreated mice.

Conclusions: T-cells play a major role in LE pathophysiology. Recent clonal studies identify an expansion of unique αβ-Tcells in LE-clinical biopsy samples; however, there are no studies that examine the role of γδ T-cells in the pathogenesis of the disease. Several studies characterize the role of γδ T-cells in chronic inflammatory skin diseases, with recent studies implicating its role in the pathogenesis of autoimmune disorders. With increasing evidence that both autoinflammatory and autoimmune components contribute to the pathophysiology of secondary LE, we investigated the role of this cell type in recurrent infections in this patient population. Identification of IL-17-producing, γδ T-cells as a major source of pathogenic cytokines in patients with recurrent infections, highlights its potential as a therapeutic target for modulating infectious episodes in secondary lymphedema.