Scientific Abstract Presentations: Hand Session 1 Thursday, October 9 Thu, Oct 9 3:30-4:30 p.m. CDT

Purpose: Neuroplasticity, a phenomenon describing the brain's capacity to change its structure and function in response to new stimuli, plays a critical role in the recovery process following various upper extremity surgeries. While nerve and tendon repairs and transfers have demonstrated efficacy in restoring function in peripheral nerve injuries (PNI), previous literature emphasizes that many patients still experience difficulties with motor reeducation. The Brain Computer Interface (BCI) systems is a novel technology that creates a direct communication pathway between the brain and an external device, providing an effective therapeutic adjunct to the surgery and motor rehabilitation. The purpose of our work is to thoroughly investigate the prior literature in relation to BCI and upper extremity surgery and ultimately provide support for its potential, translating the myriad of established works into its application in upper extremity surgeries.

Methods: A scoping review examining the use of BCI in association with upper extremity surgeries was performed using PubMed, Embase, and Web of Science databases in adherence with PRISMA guidelines. Our search strategy included combinations of synonyms for BCI, surgical procedures, and upper extremity terms. Our inclusion criteria consisted of all articles that mentioned BCI in the context of upper extremity surgeries including nerve repair, nerve transfer, tendon transfer, amputation, hand transplantation, hand replantation, brachial plexus procedures, and nerve grafts. Exclusion criteria consisted of articles that did not discuss BCI or upper extremity PNI surgeries, non-English texts, studies only focused on rehabilitation, prostheses, stroke, and non-peer reviewed works.

Results: The search strategy generated 635 results from PubMed, 780 results from Embase, and 954 results for Web of Science. Removal of duplications yielded 1308 articles, of which 37 articles were analyzed as full text. Application of our inclusion and exclusion criteria identified one review article, which only casually commented on BCI's potential in peripheral nerve rehabilitation. No studies were identified in assessing BCI's affect in patients undergoing PNI upper extremity surgery.

Conclusions: Altogether, this highlights that BCI technology has yet to be incorporated into the field of plastic surgery. Despite this, abundant evidence in the neuroscience literature strongly suggests its utility and potential as an adjunct to upper extremity surgeries in harnessing and promoting neuroplasticity. Most notably, a 2018 Nature study (Biasiucci et al.) demonstrated that non-invasive BCI, when paired with functional electrical stimulation (FES) therapy, significantly enhanced motor function in chronic stroke patients by promoting activity-dependent neuroplasticity and sustained recovery for 6–12 months, evidenced by functional connectivity in the affected hemisphere on MRI, correlating with improved outcomes. Similarly, the BCI-FES via EEG can be adapted to enhance neuroplasticity in tendon or nerve transfer patients after PNI, effectively fostering motor and sensory rehabilitation. This can be achieved by integrating the technology preoperatively via neural pathway preconditioning, and postoperatively by providing proprioceptive feedback via FES and EEG, thus strengthening post-surgical neural connections. Ultimately, BCI-FES is a non-invasive and cost-effective technology that shows great promise in facilitating functional recovery after PNI upper extremity surgery.

Introduction

Upper extremity injuries often significantly impact daily function, and rehabilitation is critical for restoring function with both nonoperative and surgical management. The use of surface electromyography (sEMG) has emerged as a non-invasive, technology-driven intervention, providing real-time biofeedback to facilitate neuromuscular retraining and recovery. This systematic review aims to evaluate the current utilization and effectiveness of therapeutic sEMG-biofeedback in the rehabilitation of upper extremity injuries.

Methods

A systematic review of literature on the therapeutic use of surface EMGs in human participants was conducted. Electronic databases, including PubMed, MEDLINE, Embase, CENTRAL, Web of Science, CINAHL, ICTRP, and EuropePMC were queried. Studies were included if there was a therapeutic application of sEMG for upper extremity rehabilitation. Exclusion criteria encompassed solely diagnostic applications of sEMGs, invasive modalities (eg, needle EMG, rectal or vaginal EMG probes), non-human studies, engineering studies focused on EMG device development without a therapeutic component, review articles, and non-English publications.

Results

102 studies met inclusion criteria. Of these, there were 32 randomized controlled trials, 32 non-randomized experimental trials, 15 case series, 14 case studies, and 9 classified as "other" study designs. The total participant pool across all studies consisted of 2,561 individuals, of whom 1,905 received sEMG biofeedback therapy for upper extremity rehabilitation. The conditions that were treated varied widely, including post-stroke hemiparesis, cerebral palsy, traumatic injuries, and iatrogenic etiologies (Table 1).

Most studies used either a combination of visual and auditory (n=45) or visual biofeedback alone (n=40), followed by auditory biofeedback alone (n=10) and other biofeedback modalities (n=7), such as vibratory or tactile feedback. The majority of studies held these sEMG biofeedback therapy sessions in an outpatient clinic setting (n=72), with other settings including 13 inpatient clinics, 5 at home, 2 at the workplace, and 10 at a combination of inpatient and outpatient clinics.

Improvements were observed across multiple functional domains (Table 2). A majority of studies reported enhanced motor function, which was defined as an increased ability to complete daily tasks. Additionally, significant gains were noted in movement patterns, reported pain outcomes, muscle activation, and electrical muscle activity, with many studies demonstrating positive trends in assessment scores.

Eleven studies specifically examined sEMG-biofeedback for postoperative rehabilitation following hand and nerve surgeries (Table 1), targeting muscles such as the abductor digiti minimi, intrinsic and extrinsic hand muscles, interosseus muscles, lumbricals, adductor pollicis longus, flexor digitorum profundus, flexor digitorum superficialis, extensor carpi radialis, flexor carpi ulnaris, flexor carpi radialis, brachioradialis, biceps brachii, triceps brachii, deltoid, and trapezius.

Conclusion

Therapeutic use of sEMG biofeedback has been widely utilized in upper extremity rehabilitation, demonstrating effectiveness across a heterogeneous range of conditions. Most studies reported improvements in motor functional independence. Visual and auditory biofeedback were the most commonly utilized modalities, with outpatient settings being the primary site of treatment. While promising, variations in study design, outcome measures, and intervention protocols highlight the need for further standardized research to establish optimal implementation strategies. Expanding access to home-based and workplace rehabilitation settings may enhance patient engagement and long-term outcomes.

Purpose: Extensive research has examined the outcomes of upper extremity transplants. However, published outcomes primarily provide updates on patient recovery at the time of publication within the context of single-center case series. This study summarizes available literature to examine below-elbow upper extremity transplant functional outcomes in the first seven years post-transplantation.

Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in PubMed, Embase, Cochrane, and Medline. The search yielded 2102 records; 172 passed initial screening and 129 English-language articles were included in the final review. Measures of motor, sensory and psychosocial functions were recorded and categorized according to patient and post-operative year (POY) when the assessment was performed. Quantitative data was compared between years by Kruskal-Wallis and post-hoc Dunn testing with Bonferroni-Holm correction; significance set at p-adj<0.05. Semmes Weinstein monofilament (SWMF); Carroll test; Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); and Hand Transplantation Score System (HTSS) results are reported as median score [interquartile range].

Results: Ninety-four patients (age 37.6±14.0 years) treated at 21 medical centers from 1998 to 2024 were identified. There were 69 males (37.1±13.4 years) and 18 females (38.1±16.9 years); 60.0% of patients received bilateral transplants. Seventy-five patients (79.8%) received below-elbow transplants, 14 patients received above-elbow transplants, and level of transplant was unspecified in 5 patients. At POY1, SWMF test predominantly indicated return of pressure sensitivity without protective sensation (4 [1,4]). SWMF testing at POY2-POY7 demonstrated stable sensation levels (p=0.412, 4 [4,4]), although 18.0% of patients regained light touch by POY7. HTSS showed significant improvement from "good" (61-80) to "excellent" (81-100) between POY1 (63.8 [52.8, 76.9]) and POY6 (p-adj<0.01: 84.0 [81.3, 89.3]) and POY7 (p-adj<0.01: 85.0 [80.5, 89.0]); earlier HTSS increases did not achieve post-hoc significance (POY2=75.0 [70.0, 79.8]; POY3=79.5 [73.4, 85.9]; POY4=76.0 [72.8, 81.0]; POY5=79.0 [76.0, 84.0]). This contrasts with the constant Carroll test results (p=0.192), which remained in the "subpar function" (<90) range for all seven years (POY1=64.0 [56.0, 75.0]; POY2=54.5 [52.0, 69.0]; POY3=58.0 [49.3, 69.5]; POY4=68.5 [64.5, 74.3]; POY5=76.0 [75.0, 79.0]; POY6=59.0 [57.0, 60.0]; POY7=57.0 [46.5, 65.0]). DASH also remained constant (p=0.323), with only POY7 achieving a "good" result (6-15) while the remaining timepoints were "satisfactory" (15-35) or worse (POY1=25.5 [12.3, 42.3]; POY2=30.8 [19.0, 64.0]; POY3=22.0 [8.5, 37.0]; POY4=29.0 [8.2, 59.5]; POY5=20.0 [7.3, 44.5]; POY6=22.5 [3.8, 50.0]; POY7=9.6 [5.0, 14.9]).

Nine POY1 reports evaluated patients' post-operative body image, five of which demonstrated successful integration. Of the remaining four patients, one noted persistent phantom limb pain and another continued to prefer their healthy, non-dominant limb. Qualitative assessments before POY10 indicated 64.3% of patients had assimilated their transplants, 25.0% were satisfied with the outcomes or felt more socially accepted, and 16.7% reported non-natural use or alienation.

Conclusion: Purely functional outcomes of below-elbow upper extremity transplants stabilize early after transplantation, with neither Carroll nor DASH demonstrating significant changes after POY1. HTSS allocates greater emphasis to non-motor domains and thus may indicate that improvement in patients' quality of life beyond POY1 derives from continued sensory and psychosocial recovery.

Purpose: This study aims to develop a severe brachial plexus injury (BPI) rodent model to replicate extensive nerve damage and support future research on neural signal acquisition and functional restoration. We created varying degrees of brachial plexus denervation to determine the ideal model for BPI in rodents. Methods: Seven groups of rats (n=3 per group) were established using different denervation methods to induce varying levels of nerve injury. The left brachial plexus was exposed dorsally. In Groups 1, 2, and 3, the C5 and C7 roots were transected, with 100%, 50%, and 25% preservation of the C6 root, respectively. In Groups 4, 5, and 6, the C5 and C6 roots were transected, with 100%, 50%, and 25% preservation of the C7 root, respectively. Group 7 served as a control with no brachial plexus injury. One month postoperative, musculocutaneous nerve (MCN) and biceps muscle were evaluated through compound muscle action potential (CMAP) recordings, maximum tetanic force measurements, and histological analyses. These assessments illustrate the severity of nerve injury and muscle function across various experimental conditions. A Welch's t-test was performed to compare the experimental groups to control. Results: Group 1 exhibited a mean tetanic force of 345.36 ± 83.02 mN, and a CMAP amplitude of 13.57 ± 1.56 mV, while Group 7 (control group) demonstrated the highest tetanic force at 437.87 ± 93.14 mN, with a CMAP amplitude of 13.30 ± 1.61 mV. Group 2 had a mean tetanic force of 182.96 ± 24.19 mN, and CMAP amplitude of 4.67 ± 2.86 mV. Group 3 presented with a tetanic force of 195.89 ± 38.24 mN, and CMAP amplitude of 1.33 ± 0.60 mV. Group 4 displayed a tetanic force of 200.74 ± 83.33 mN, and CMAP amplitude of 0.75 ± 0.40 mV. Group 5 displayed a tetanic force of 140.02 ± 27.87 mN, and CMAP amplitude of 0.24 ± 0.12 mV. The weakest functional outcomes were observed in Group 6, which exhibited the lowest tetanic force at 114.69 ± 14.52 mN, and CMAP amplitude of 0.30 ± 0.22 mV, indicating the most significant deficits in functional recovery. Groups 5 (p=0.04) and 6 (p=0.03) had a significantly weaker tetanic force, and groups 2 (p=0.04), 3 (p=0.01), 4 (p=0.008), 5 (p=0.007), and 6 (p=0.007) had significantly weaker CMAPs compared to the control. Preliminary histological analysis revealed axonal degeneration in all 6 experimental groups with group 6 showing the most degeneration. H&E revealed a decrease in the cross-sectional area and signs of atrophy of the Bicep muscle in group 6 compared to control. Conclusion: The Group 6 model, which involved 25% preservation of C7 with complete transection of C5 and C6, is the weakest and most suitable model for developing a severe brachial plexus injury (BPI) rodent model. This model simulates extensive nerve damage and provides a reliable platform for studying neural signal acquisition and functional recovery for future research applications in exoskeleton control.

Background: Medical billing in hand trauma is error-prone, requiring anatomical understanding for billers to assign unbundled Current Procedural Terminology (CPT) codes to each repair. Surgeons assist this process by authoring detailed yet concise notes. While the use of machine learning in medical billing has been explored in other surgical fields, there are limited studies on the use of publicly available, open-source artificial intelligence (AI). Here, we assessed the utility of Chat Generative Pre-Trained Transformer (ChatGPT) to enhance coding precision in hand trauma.

Methods: Fifty hand trauma operations of varying complexity were curated from retrospective review of January 2018 to December 2023. Twenty-five of these operative reports were input to ChatGPT-4.0 Medical Coding AI with the prompt: "Provide all related [year] CPT codes that could be assigned to this operation. Assume applicable bundling is applied." The remaining operative reports were input with the same initial query, but after a data dictionary of the Eaton Hand Coding Manual was input for reference. For final query, ChatGPT-4.0 was prompted to select the most appropriate codes when presented with the corresponding human-billed data. Operative report quality was assessed with an expert hand surgeon's adaptation of the Structured Assessment Format for Evaluating Operative Reports (SAFE-OR) questionnaire. CPT coding accuracy was assessed based on documentation support.

Results: The 50 operations included 126 repairs and 174 procedures. Attending physicians authored the majority of operative reports (58%, p<0.001), with an average of 1.9 days passing between the operation and note signature. Overall SAFE-OR scores were high (96%), and no significant scoring difference (p=1.00) was seen between author types. Despite this, 42 (24.6%) of billed CPT codes were not supported by documentation and 74 CPT codes were omitted or required correction despite accurate procedural description. However, 18 (36%) of operative notes had anatomical inconsistencies or inadequate technique description, which may have resulted in improper coding. Initially, only 29 (30.5%) ChatGPT assignments were supported by documentation; this increased to 47(54%) at final query. Using an imported Eaton Hand Manual, ChatGPT coding was minimally more accurate at initial query (33.6%). However, a dramatic improvement was seen at final query using the Eaton Hand Manual, with 88 supported CPT codes (76%). Among the ChatGPT-assigned codes that were unsupported by documentation, the most common involved add-on codes for split-thickness skin grafts (CPT15101), skin substitute coverage of wounds (CPT15272), and nerve repair using a synthetic conduit (CPT64910). Overcoding by ChatGPT was observed in 31 operative notes (62%), while undercoding by billers occurred in 14 notes (28%).

Conclusions: Despite improved CPT assignment with an iterative query and data dictionary, the performance of ChatGPT Medical Coding AI falls short of billers. Quality improvement may identify consistent discrepancies between documentation and billing, which can improve accurate reimbursement. However, ChatGPT Medical Coding AI was error-prone despite the overall high quality of operative reports in this study. Performance was dependent on user input and exhibited leading bias. Since AI is already marketed for medical billing and used by insurers to review claims, model refinement for unbundled procedures is crucial.

Purpose: Phalangeal and metacarpal fractures are the second and third most common upper extremity fractures. Intramedullary screw (IM nail) fixation is an increasingly used method for fracture fixation of the hand, providing potential benefits of early mobilization and improved functional recovery. There is no consensus on the optimal treatment for extra-articular metacarpal and phalangeal fractures. We therefore asked, is there a difference between intramedullary (IM) nail, K-wire, and plate or screw fixation in (1) adverse events and (2) range of motion?

Methods: A retrospective chart review was conducted at a tertiary academic center of all adults surgically treated for extra-articular phalangeal and metacarpal fractures between January 2012 to August 2024. First, patients treated with IM-nail or plate/screw fixation were included. Then, the IM nail group was randomly matched 1:3 with patients treated with K-wires based on age and sex. Patient charts were reviewed for demographics, fixation method, overall adverse events, graded adverse events (Clavien-Dindo classification), infection treated with antibiotics, re-operation, and total active motion (TAM). This resulted in a cohort of 711 patients, having 873 repairs. Mean age was 39 (SD 16) and majority of patients were male (66%). Overall, there were 167 fractures repaired with IM nail fixation, 443 with K-wires, and 263 with plate or screw fixation. We used multi-level multivariable analysis to account for relevant baseline differences, and other potential confounders.

Results: Compared to K-wires, overall adverse events and re-operation were lower in the IM nail group (adverse events: OR 0.52 [95% CI 0.30 to 0.89, p=0.018, re-operation: OR 0.23 [95% CI 0.11 to 0.47, p<0.000]). After plate/screw fixation, we found a lower rate of infections treated with antibiotics and also a lower re-operation rate (infection with antibiotics: OR 0.33 [95% CI 0.15 to 0.70, p=0.004]; re-operation: OR 0.48 [95% CI 0.26 to 0.87, p=0.016]). The higher re-operation rate after K-wire fixation likely resulted from the removal of buried K-wires in the OR. Fractures treated with IM-nails had greater total active motion 3 months after fixation (B-coefficient 29 [95% CI 2.7 to 56, p=0.031]) compared to K-wires.

Conclusion: Our results support the increasing use of IM nail fixation. Any concern for increased adverse events with intra-medullary hardware seems unfounded, when compared to more time tested methods of fixation such as wires or plates/screws. Compared to K-wire fixation, IM nails might result in a faster recovery, with a quicker regain of finger motion. Our results would benefit from confirmation in a prospective randomized study.

Purpose: Scaphoid nonunion is commonly treated surgically, yet the decision of whether to use a bone graft, and which type to choose, remains controversial. While previous systematic reviews and meta-analyses have largely focused on union rates and radiographic findings, postoperative functional recovery has received less attention. This meta-analysis evaluates functional outcomes following surgical treatment of scaphoid nonunion, comparing fixation without grafting to cancellous, corticocancellous, and vascularized grafts.

Methods: We used PRISMA guidelines to conduct a systematic review and meta-analysis of 135 studies. In studies with multiple arms featuring different graft types, each arm was analyzed independently, yielding 41 study arms for evaluation with the outcome of Modified Mayo Wrist Score (MMWS) and 39 study arms using Disability of the Arm, Shoulder, and Hand (DASH) as an outcome. To account for inter-study variability, we employed a random-effects model for the meta-analysis. Additionally, we performed a subgroup comparison using the Q-statistic to analyze differences between graft types. All statistical analyses were conducted using R.

Results: Across the 41 surgical arms (n=985 patients) that assessed MMWS as an outcome, the overall effect was a 34.0-point improvement (95% CI: 20.8 - 47.2). Fixation without bone grafting demonstrated the greatest improvement (41.7 points), which was significantly greater than all other graft types (p < 0.001). Both vascularized (31.5 points, 95% CI: 19.4 - 43.5) and cancellous autograft (29.4 points, 95% CI: 20.9 - 37.9) bone grafts showed significantly greater improvement in MMWS (p < 0.001) than corticocancellous grafts (20.1 points, 95% CI: -4.9 - 45.0).

1076 subjects were included across the 39 study arms that measured DASH as an outcome. The overall improvement was 30.1 points (95% CI: 24.3 - 33.7) across studies. There were no significant differences in DASH improvement between cancellous (27.2 points, 95% CI: 19.3 -34.9), corticocancellous (46.7 points, 95% CI: 11.1 - 82.1), and vascularized bone grafts (32.1 points, 95% CI: 21.7 - 42.5). No studies evaluating fixation without bone grafting reported DASH as an outcome.

Conclusions: Scaphoid nonunion surgery results in substantial functional recovery across all graft types. Among the treatment options, fixation without grafting demonstrated the greatest improvement in MMWS, significantly outperforming all bone graft types. Cancellous and vascularized grafts yielded better MMWS outcomes compared to corticocancellous grafts, possibly due to their selection for cases requiring additional structural support. The existing literature indicates that patients can expect considerable functional improvement following reduction and fixation of scaphoid nonunion, regardless of the graft type used. Therefore, graft selection should be guided by factors such as carpal alignment, the presence of avascular necrosis, and donor site morbidity, in addition to functional recovery.

Purpose: Scaphoid nonunion is commonly treated surgically, yet the decision of whether to use a bone graft, and which type to choose, remains controversial. While previous systematic reviews and meta-analyses have largely focused on union rates and radiographic findings, postoperative functional recovery has received less attention. This meta-analysis evaluates functional outcomes following surgical treatment of scaphoid nonunion, comparing fixation without grafting to cancellous, corticocancellous, and vascularized grafts.

Methods: We used PRISMA guidelines to conduct a systematic review and meta-analysis of 135 studies. In studies with multiple arms featuring different graft types, each arm was analyzed independently, yielding 41 study arms for evaluation with the outcome of Modified Mayo Wrist Score (MMWS) and 39 study arms using Disability of the Arm, Shoulder, and Hand (DASH) as an outcome. To account for inter-study variability, we employed a random-effects model for the meta-analysis. Additionally, we performed a subgroup comparison using the Q-statistic to analyze differences between graft types. All statistical analyses were conducted using R.

Results: Across the 41 surgical arms (n=985 patients) that assessed MMWS as an outcome, the overall effect was a 34.0-point improvement (95% CI: 20.8 - 47.2). Fixation without bone grafting demonstrated the greatest improvement (41.7 points), which was significantly greater than all other graft types (p < 0.001). Both vascularized (31.5 points, 95% CI: 19.4 - 43.5) and cancellous autograft (29.4 points, 95% CI: 20.9 - 37.9) bone grafts showed significantly greater improvement in MMWS (p < 0.001) than corticocancellous grafts (20.1 points, 95% CI: -4.9 - 45.0).

1076 subjects were included across the 39 study arms that measured DASH as an outcome. The overall improvement was 30.1 points (95% CI: 24.3 - 33.7) across studies. There were no significant differences in DASH improvement between cancellous (27.2 points, 95% CI: 19.3 -34.9), corticocancellous (46.7 points, 95% CI: 11.1 - 82.1), and vascularized bone grafts (32.1 points, 95% CI: 21.7 - 42.5). No studies evaluating fixation without bone grafting reported DASH as an outcome.

Conclusions: Scaphoid nonunion surgery results in substantial functional recovery across all graft types. Among the treatment options, fixation without grafting demonstrated the greatest improvement in MMWS, significantly outperforming all bone graft types. Cancellous and vascularized grafts yielded better MMWS outcomes compared to corticocancellous grafts, possibly due to their selection for cases requiring additional structural support. The existing literature indicates that patients can expect considerable functional improvement following reduction and fixation of scaphoid nonunion, regardless of the graft type used. Therefore, graft selection should be guided by factors such as carpal alignment, the presence of avascular necrosis, and donor site morbidity, in addition to functional recovery.

Purpose: Scaphoid nonunion is commonly treated surgically, yet the decision of whether to use a bone graft, and which type to choose, remains controversial. While previous systematic reviews and meta-analyses have largely focused on union rates and radiographic findings, postoperative functional recovery has received less attention. This meta-analysis evaluates functional outcomes following surgical treatment of scaphoid nonunion, comparing fixation without grafting to cancellous, corticocancellous, and vascularized grafts.

Methods: We used PRISMA guidelines to conduct a systematic review and meta-analysis of 135 studies. In studies with multiple arms featuring different graft types, each arm was analyzed independently, yielding 41 study arms for evaluation with the outcome of Modified Mayo Wrist Score (MMWS) and 39 study arms using Disability of the Arm, Shoulder, and Hand (DASH) as an outcome. To account for inter-study variability, we employed a random-effects model for the meta-analysis. Additionally, we performed a subgroup comparison using the Q-statistic to analyze differences between graft types. All statistical analyses were conducted using R.

Results: Across the 41 surgical arms (n=985 patients) that assessed MMWS as an outcome, the overall effect was a 34.0-point improvement (95% CI: 20.8 - 47.2). Fixation without bone grafting demonstrated the greatest improvement (41.7 points), which was significantly greater than all other graft types (p < 0.001). Both vascularized (31.5 points, 95% CI: 19.4 - 43.5) and cancellous autograft (29.4 points, 95% CI: 20.9 - 37.9) bone grafts showed significantly greater improvement in MMWS (p < 0.001) than corticocancellous grafts (20.1 points, 95% CI: -4.9 - 45.0).

1076 subjects were included across the 39 study arms that measured DASH as an outcome. The overall improvement was 30.1 points (95% CI: 24.3 - 33.7) across studies. There were no significant differences in DASH improvement between cancellous (27.2 points, 95% CI: 19.3 -34.9), corticocancellous (46.7 points, 95% CI: 11.1 - 82.1), and vascularized bone grafts (32.1 points, 95% CI: 21.7 - 42.5). No studies evaluating fixation without bone grafting reported DASH as an outcome.

Conclusions: Scaphoid nonunion surgery results in substantial functional recovery across all graft types. Among the treatment options, fixation without grafting demonstrated the greatest improvement in MMWS, significantly outperforming all bone graft types. Cancellous and vascularized grafts yielded better MMWS outcomes compared to corticocancellous grafts, possibly due to their selection for cases requiring additional structural support. The existing literature indicates that patients can expect considerable functional improvement following reduction and fixation of scaphoid nonunion, regardless of the graft type used. Therefore, graft selection should be guided by factors such as carpal alignment, the presence of avascular necrosis, and donor site morbidity, in addition to functional recovery.

Purpose: Scaphoid nonunion is commonly treated surgically, yet the decision of whether to use a bone graft, and which type to choose, remains controversial. While previous systematic reviews and meta-analyses have largely focused on union rates and radiographic findings, postoperative functional recovery has received less attention. This meta-analysis evaluates functional outcomes following surgical treatment of scaphoid nonunion, comparing fixation without grafting to cancellous, corticocancellous, and vascularized grafts.

Methods: We used PRISMA guidelines to conduct a systematic review and meta-analysis of 135 studies. In studies with multiple arms featuring different graft types, each arm was analyzed independently, yielding 41 study arms for evaluation with the outcome of Modified Mayo Wrist Score (MMWS) and 39 study arms using Disability of the Arm, Shoulder, and Hand (DASH) as an outcome. To account for inter-study variability, we employed a random-effects model for the meta-analysis. Additionally, we performed a subgroup comparison using the Q-statistic to analyze differences between graft types. All statistical analyses were conducted using R.

Results: Across the 41 surgical arms (n=985 patients) that assessed MMWS as an outcome, the overall effect was a 34.0-point improvement (95% CI: 20.8 - 47.2). Fixation without bone grafting demonstrated the greatest improvement (41.7 points), which was significantly greater than all other graft types (p < 0.001). Both vascularized (31.5 points, 95% CI: 19.4 - 43.5) and cancellous autograft (29.4 points, 95% CI: 20.9 - 37.9) bone grafts showed significantly greater improvement in MMWS (p < 0.001) than corticocancellous grafts (20.1 points, 95% CI: -4.9 - 45.0).

1076 subjects were included across the 39 study arms that measured DASH as an outcome. The overall improvement was 30.1 points (95% CI: 24.3 - 33.7) across studies. There were no significant differences in DASH improvement between cancellous (27.2 points, 95% CI: 19.3 -34.9), corticocancellous (46.7 points, 95% CI: 11.1 - 82.1), and vascularized bone grafts (32.1 points, 95% CI: 21.7 - 42.5). No studies evaluating fixation without bone grafting reported DASH as an outcome.

Conclusions: Scaphoid nonunion surgery results in substantial functional recovery across all graft types. Among the treatment options, fixation without grafting demonstrated the greatest improvement in MMWS, significantly outperforming all bone graft types. Cancellous and vascularized grafts yielded better MMWS outcomes compared to corticocancellous grafts, possibly due to their selection for cases requiring additional structural support. The existing literature indicates that patients can expect considerable functional improvement following reduction and fixation of scaphoid nonunion, regardless of the graft type used. Therefore, graft selection should be guided by factors such as carpal alignment, the presence of avascular necrosis, and donor site morbidity, in addition to functional recovery.

Purpose Spinal cord injuries (SCI) are devastating and cause significant alteration to patients' activities of daily living. Depending on the level of injury, various upper extremity motor functions may be compromised. Tendon transfers and nerve transfers are two options available to plastic surgeons when reconstructing elbow extension, grip, pinch, and release. This systematic review was aimed at assessing and comparing the strength outcomes of tendon and nerve transfers for functional reconstruction of the upper extremity.

Methods This review was registered with PROSPERO (CRD42024595503) and followed the PRISMA guidelines. Embase, Scopus, and MedLine were queried for citations that presented strength outcomes for patients having undergone tendon and/or nerve transfers to restore upper extremity function after a spinal cord injury. Data points extracted included publication information, patient demographics, operative information, pre and post-operative strength outcome data, patient reported outcomes, and complication data. Weighted averages were used to report patient demographic data

Results 594 citations were screened for 50 included studies with a total of 956 patients who were on average 31.8 years old (range: 5-76). Patients who had nerve transfers had surgery an average of 24.5 months after injury (range: 5-142), and patients who had tendon transfers had surgery an average of 67.5 months after injury (range: 7-336). There were forty separate nerve transfer procedures and thirty-eight separate tendon transfer procedures reported on. Of studies reporting individual strength outcomes for elbow extension recovery, 68% of patients who underwent nerve transfers, 79% of patients who underwent a biceps to triceps tendon transfer, and 70% of patients who underwent a deltoid to triceps tendon transfer achieved M3 or greater strength. For grip and pinch reconstruction, the brachioradialis was the most common donor for tendon transfers and the brachialis was the most common nerve transfer donor. Patients with a greater number of pre-operative functional muscles below the elbow had better strength outcomes for both nerve and tendon transfers to restore grip and pinch. Patients who had a brachialis to anterior interosseous nerve (AIN) transfer had variable strength outcomes. Of studies reporting individual strength outcomes for this transfer, 49% of patients achieved M3 or greater strength, with better outcomes in younger patients. For finger and thumb extension, the supinator to posterior interosseous nerve (PIN) transfer was most commonly utilized with 78% of patients with individual strength outcomes reported achieving M3 strength or better.

Conclusions There is no gold standard for the functional reconstruction of the upper extremity after a spinal cord injury. The choice of procedure(s) remain patient specific. Patients have achieved significant strength recovery from both nerve and tendon transfers. Dedicated research is needed to identify predictive factors for poor outcomes in brachialis to AIN nerve transfers. More robust nerve transfer patient series are needed to directly compare pooled strength results to tendon transfer patients. In addition, more homogenous follow up protocols are needed for strength measurement and patient reported outcome measures for both nerve and tendon transfers.

Purpose: Distal upper extremity nerve injuries (DUENI) cause substantial disability and work limitations, with recovery trajectories influenced by both medical and socioeconomic factors. While financial hardship can negatively impact outcomes, its specific effects on postoperative recovery and outcomes remain poorly understood. This study assessed the financial toxicity impact on physical function, quality of life, and return to work after DUENI surgery, and whether patient factors were associated with these. Methods: We included patients who underwent DUENI surgery for nerve injuries distal to the elbow crease (2016-2023) at two level-I trauma centers. A cross-sectional survey was conducted, including the primary outcomes of functional status (QuickDASH-9), quality of life (EQ5D index), and time to return to work (RTW). The financial impact was assessed using the validated financial burden (composite score: 0–6) and dichotomized worry score. Regression models examined relationships between financial toxicity and outcomes, with separate analyses for digital (zone 1: Fingertip to A1 pulley) and non-digital (zone 2: A1 pulley to elbow crease) DUENI patients. Results: Of the 133 patients who completed the survey, 103 were males (77.4%). The median age was 41.0 years (IQR: 33-61), and 78.2% (n=104) had digital nerve injuries, while 21.8% (n=29) had non-digital nerve injuries. Financial hardship independently showed associations with reduced quality of life (β=-0.019; p=0.035) and delayed RTW (OR 1.66; p=0.011). Among all, 20.3% of patients (n=27) reported high financial worry (worry score ≥4), although most patients were insured (97.7%, n=130) with relatively low social vulnerability scores (median ADI: 16.0; IQR: 10-29). These 27 patients demonstrated significantly delayed RTW beyond 6 months (28.1% vs 15.7%; p=0.012). Non-digital injuries showed stronger associations between financial hardship and poor outcomes compared to digital injuries (β=-0.049 vs -0.005; p=0.016). High financial worry independently predicted delayed RTW (OR=1.66; p=0.007), with both financial burden (Hazard Ratio=0.82 per point increase; p=0.008) and non-digital injury location (Hazard Ratio=0.71; p=0.034) independently associated. The impact of financial worry was highest in patients with multiple nerve involvement (interaction p=0.023). Conclusion: Financial toxicity significantly impacts functional recovery, quality of life, and RTW after DUENI surgery, particularly in non-digital injuries. Notably, finding these associations in a well-insured population implies potentially greater impact in more socioeconomic challenged regions. The associations found between early financial hardship and the long-term outcome metrics suggest a potential benefit of integrating early socioeconomic screening and consultation as part of multidisciplinary care, enabling more comprehensive risk-targeted support strategies to improve long-term DUENI patient outcomes.

Background: Scapholunate (SL) ligament injuries are rare in children and adolescents. As such, there lacks a definitive consensus on treatment for partial and complete ligament tears (1) The objective of this study is to discuss the management and outcomes of patients with SL ligament injury at a single large academic pediatric institution.

Patients and Methods: A retrospective chart review was conducted of all patients 19 years of age and younger from January 2011 to October 2024 presenting with SL ligament injuries. Patient demographics, mechanism of injury, and time to presentation were recorded with the following primary outcomes measured; pre- and post-treatment change in SL angle and interval, wrist extension and flexion, and need for reoperation or extended treatment.

Results: Twelve patients were identified with an average age of 14.8 years (range: 8 to 19 years), and all 12 (100%) had dorsal wrist pain, four (33%) had a positive Watson's test, and three (25%) complained of pain without a clunk during the Watson's test. Mechanisms of injury included a direct blow to the wrist (8%) and a fall or sports-related injury (92%), namely, cheerleading, football, tennis, volleyball, or wrestling. All patients received magnetic resonance imaging depicting a partial or complete SL ligament tear. Three patients were noted to have dorsal intercalated segment instability (DISI) prior to treatment. The average time from injury to treatment was 22.7 weeks (range: 3.1 to 78.2 weeks). Five patients with a partial tear and one patient with a complete tear underwent casting for an average of 6.3 weeks (range: 4 to 10 weeks), and of the remaining six patients, four received wrist arthroscopy and pinning, one underwent open repair and pinning, and one patient with a complete tear and static DISI deformity underwent SL reconstruction with a vascularized third metacarpal–capitate bone-ligament-bone graft. One patient with recurring DISI deformity, who underwent arthroscopic pinning, required reoperation. The average pre-treatment SL angle and interval were 57.3° (range: 34.7° to 95°, n=9) and 2.3 mm (range: 1 to 4.4 mm, n=11), respectively, and the average post-treatment SL angle and interval were 51.9° (range: 42.8° to 68.7°, n=8) and 1.9 mm (range: 1.1 to 2.9 mm, n=8), respectively. Average active wrist extension and flexion post-treatment was 64° and 62° (range: 35° to 90° extension; 20° to 90° flexion), respectively. At mean follow up of 25.1 weeks (range: 6 to 82.6 weeks), all patients either returned to full pre-injury activity or showed improved wrist range of motion and strength.

Conclusions: A high degree of suspicion is required to provide timely diagnosis and treatment for SL ligament injuries. Depending on the injury, both operative and nonoperative interventions can restore proper wrist function; however, further studies are required to determine injury-based standards of care.

References 1. van Kampen RJ, Fox PM, Baltzer HL, Moran SL. Long-term Outcomes following Operative Management of Pediatric Scapholunate Ligament Injuries. J Wrist Surg. 2022;12(1):56-62. doi:10.1055/s-0042-1757779