Scientific Abstract Presentations: Hand Session 4 Friday, October 10 Fri, Oct 10 5:00-6:00 p.m. CDT

Introduction: Hand injuries demand timely care, as improper management can lead to debilitating outcomes. However, many hospitals lack on-call hand surgeons, making it necessary to transfer patients to higher-level trauma centers with more specialized resources. While such transfers can improve outcomes for severe hand trauma cases, unnecessary transfers impose significant costs on both patients and the healthcare system. This study aims to examine patterns in interfacility hand trauma transfers, assess their appropriateness, and summarize post-transfer outcomes.

Methods: A medical librarian conducted a comprehensive, PRISMA-compliant literature search across multiple databases, including Embase, Ovid Medline, Scopus, and ClinicalTrials.gov, to identify studies on the interfacility transfer of hand trauma patients. Only English-language articles were included, while non-English articles and those lacking full text were excluded. Two independent reviewers performed deduplication and screening for each study. Data extracted included patient demographics, facility characteristics, injury types, post-transfer interventions, transfer outcomes, and the appropriateness of transfers as rated by experts.

Results: After full-text screening, 36 studies met the inclusion and exclusion criteria, with a total of 49,696 patients included in the analysis. The most common reasons for transfers were fractures, followed by amputations and devascularization. Patients on Medicaid or those who were uninsured were more likely to be transferred. Several studies also reported that over half of the transferred patients were moved unnecessarily. One study showed that more than one-third of patients transferred to the institution were discharged without admission, observation, or procedures, while another found that over 50% of transfers did not result in an examination by a hand surgeon. However, replantation attempts and success rates were higher among transferred patients. Three studies evaluated the use of telemedicine, with all concluding that it effectively increases the accuracy of transfers.

Conclusion: The results of this study highlight the frequent occurrence of unnecessary transfers. Teletriage may offer a solution by ensuring that patients who require higher levels of care are transferred more efficiently, reducing excess costs for both patients and the healthcare system by minimizing unnecessary transfers.

Introduction Distal radius fractures (DRF) account for up to 18% of adult fractures, with malunion occurring in 10–25% of cases. [1] Symptomatic malunion can lead to significant morbidity, including loss of forearm rotation, carpal instability, and arthritis. Effects of DRF malunion can also impact distal radioulnar joint function, including altering the axis of rotation, limiting pro-supination, and placing strain on the triangular fibrocartilage complex.[2] Furthermore, excessive dorsal tilt due to malunion can lead to adaptive carpal instability, potentially leading to ligament attenuation, synovitis, and progressive dynamic instability.[3] Corrective osteotomy is a key surgical intervention, yet consensus is lacking on the optimal surgical approach, fixation technique, and necessity of bone grafting. This systematic review evaluates surgical outcomes of DRF osteotomy, comparing surgical approaches and assessing bone graft utilization.

Methods A PubMed search (2000–2023) identified 17 studies meeting inclusion criteria, which required primary data on DRF malunion correction, surgical approach comparisons, bone graft necessity, and patient-reported outcomes. Data on complication rates, patient satisfaction, and clinical scores were analyzed.

Results • Volar Plate Fixation: Ten studies examined volar plating, with and without bone grafts. Both groups showed significant improvements in function, radiographic parameters, and grip strength. Four non-grafting studies reported no nonunion cases, while one was discontinued due to persistent malunion (20%). • Volar vs. Dorsal Approach: Two studies found both approaches improved outcomes, but volar plating provided greater wrist flexion (p=0.012) and fewer hardware-related complications. • Bone Graft Utilization: Three studies showed mixed results regarding graft necessity, with some demonstrating successful outcomes without grafting.

Conclusion Corrective osteotomy for DRF malunion significantly improves patient outcomes, with volar plate fixation trending towards better outcomes over dorsal plating. The decision to use bone grafts should include consideration of cortical contact after osteotomy, as poor cortical contact has been associated with higher nonunion rates. Given the limitations of the available studies, including small sample sizes, selection bias, and language restrictions, future prospective studies and randomized trials are needed to establish definitive guidelines for optimal surgical management of DRF malunion.

1. Taleb C, Zemirline A, Lebailly F, et al. Minimally invasive osteotomy for distal radius malunion: A preliminary series of 9 cases. Orthopaedics and Traumatology: Surgery and Research. 2015;101(7). doi:10.1016/j.otsr.2015.07.016
2. Katt B, Seigerman D, Lutsky K, Beredjiklian P. Distal Radius Malunion. J Hand Surg Am. 2020;45(5):433-442. doi:10.1016/J.JHSA.2020.02.008
3. De Smet L, Verhaegen F, Degreef I. Carpal Malalignment in Malunion of the Distal Radius and the Effect of Corrective Osteotomy. J Wrist Surg. 2014;03(03). doi:10.1055/s-0034-1384823

Background Traumatic digit amputations affect about 45,000 individuals yearly (1).Choosing between replantation and revision amputation involves balancing functional recovery, joint mobility, and rehabilitation time. While replantation can restore anatomy and sensation, it carries a risk of joint stiffness. Revision amputation may allow faster rehabilitation but can limit fine motor function. The purpose of our paper is to compare functional outcomes, success rates, and clinical implications of digit replantation and revision amputation, providing evidence-based guidance for individualized treatment decisions and underscoring the need for standardized outcome reporting.

Methods A systematic literature search was conducted across PubMed, CINAHL, Embase, Web of Science, and Medline following PRISMA guidelines. Studies reporting digit replantation and revision amputation outcomes were included. Extracted data included patient demographics, smoking history, mechanism of injury, Tamai classification, and functional outcome measures such as Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Michigan Hand Outcomes Questionnaire (MHQ) scores, and Proximal Interphalangeal Joint (PIPJ) range of motion (ROM). Meta-analysis was performed using random-effects models, calculating mean differences (MD) for functional outcomes and risk ratios (RR) for success rates, with heterogeneity assessed using I² statistics.

Results A total of 6,538 studies were screened, of which 63 met inclusion criteria for the systematic review, and 41 contained sufficient data for meta-analysis. The mean survival rate for revision amputation was 97.3%, while the mean survival rate for replantation was 91.5%. The pooled risk ratio was 0.97 (95% CI [0.78, 1.20]), indicating no significant difference in success rates between procedures. Functional outcomes varied across studies. DASH scores favored replantation with a mean difference of -5.14 (95% CI [-5.32, -4.97]), suggesting better functional recovery. MHQ scores showed minimal differences between groups, with a mean difference of -1.71 (95% CI [-1.85, -1.56]), indicating similar patient-reported hand function. PIPJ ROM was significantly lower in replantation patients, with a mean difference of -25.65 (95% CI [-25.83, -25.47]), suggesting potential stiffness or reduced mobility. Heterogeneity was high for all functional outcomes (I² > 99%), indicating variability among studies.

Conclusion Replantation and revision amputation have comparable success rates, suggesting that treatment decisions should be based on functional goals rather than procedural survival. Replantation offers better functional recovery, as reflected by lower DASH scores, but may lead to reduced joint mobility, as indicated by lower PIPJ ROM. High variability across studies highlights the need for standardized reporting on patient selection and rehabilitation outcomes. Future research should focus on long-term patient satisfaction, rehabilitation protocols, and predictors of functional success to refine clinical decision-making.

References Dubernard C, Pluvy I, Facca S, Liverneaux P. The future of hand allotransplantation. J Hand Surg Glob Online. 2019;1(1):1-7. doi:10.1016/j.jhsg.2018.12.001

Purpose: Lymphedema is a common, debilitating condition following lymph node dissection and affecting 1 in 3 breast cancer patients. Current interventions focus on symptom management rather than prevention. There are no models looking at which patients are at highest risk and the timeline for development of lymphdemea. This decade-long study aimed to identify lymphedema predictors and develop an algorithm estimating both risk and onset. Methods: All patients undergoing axillary lymph node dissection (ALND) at Yale Cancer Center (YCC) between 2013–2024 were included. Demographic and clinical variables were collected, including age, BMI, race, ethnicity, chemotherapy, radiation, and comorbidities. Two multivariate regression models were developed to assess risk factors for lymphedema development and predict time to lymphedema diagnosis. Results: Among 15,666 ALND cases, 2,345 patients (14.9%) developed lymphedema, with an average onset of 20.5 months post-surgery. Independent risk factors included BMI >30 (OR 1.385, 95% CI 1.255–1.528, p<0.0001), chemotherapy (OR 2.445, 95% CI 2.189–2.734, p<0.0001), diabetes (OR 1.168, 95% CI 1.040–1.312, p=0.0085), Black/African American race (OR 1.443, 95% CI 1.248–1.666, p<0.0001), and radiation (OR 1.960, 95% CI 1.777–2.162, p<0.0001). Radiation (β=-4.496, 95% CI -6.376 to -2.617, p<0.0001), Black/African American race (β=-4.159, 95% CI -6.876 to -1.442, p=0.027) and Asian race (β=-6.796, 95% CI -12.76 to -0.8300, p=0.0256) were associated with earlier onset, while preexisting diabetes was linked to delayed presentation (β=2.813, 95% CI 0.6189 to 5.008, p=0.0120). The model demonstrated adequate calibration (Hosmer-Lemeshow p=0.7985), with statistically significant discriminative ability (AUC = 0.6873, 95% CI: 0.6755–0.6990, p<0.0001). Conclusions: This is the largest study to date to develop a clinically applicable prediction model for cancer-related lymphedema after axillary lymph node dissection (ALND). This model incorporates patient-specific demographics, clinical information and comorbidities. The Yale Cancer Center (YCC) lymphedema prediction model can be integrated into lymphedema care to proactively identify high-risk patients, estimate the timing of onset, and implement novel preventative strategies such as immediate lymphatic reconstruction. This predictive approach shifts the focus from late-stage management to prevention of this incurable condition, improving patient outcomes and long-term quality of life.

Background: Emerging evidence suggests that glymphatic system dysfunction contributes to amyloid-beta deposition and the progression of Alzheimer's Disease (AD). In animal models, impaired meningeal lymphatic drainage has been linked to cognitive decline, while restoring lymphatic function has improved cognitive outcomes. Axillary lymph node dissection (ALND) is a major risk factor for cancer-related lymphedema, yet its potential link to AD remains unexplored. This study investigates the association between lymphedema and AD development following ALND. Methods: We conducted a longitudinal analysis of 15,666 patients who underwent ALND at a tertiary cancer center from 2013 to 2024. Demographic and clinical data, including lymphedema diagnosis and AD onset, were collected. A multivariate regression model was used to assess risk factors for AD after ALND and evaluate the relationship between lymphedema and AD development. Results: Of the 15,666 patients, 2,345 (14.9%) developed lymphedema, with a mean onset of 20.5 months post-ALND. Among the 8,095 patients aged 60 or older at the time of ALND, 243 (3%) developed AD. Significant predictors of AD included older age at ALND (OR=1.1, 95% CI 1.089–1.129, p<0.0001), cerebrovascular disease (OR=6.1, 95% CI 1.203–2.222, p=0.0016), preexisting depression (OR=3.6, 95% CI 2.704–4.789, p<0.0001), African American race (OR=1.817, 95% CI 1.162–2.752, p=0.0065), and Hispanic/Latino ethnicity (OR=2.116, 95% CI 1.270–3.378, p=0.0026). Lymphedema diagnosis was associated with a lower risk of AD (OR=0.3, 95% CI 0.1679–0.6240, p=0.0013). Conclusion: This is the first and largest study to investigate the relationship between cancer-related lymphedema and AD following ALND. While known risk factors for AD were confirmed, the unexpected inverse association between lymphedema and AD warrants further research. Future studies should explore the potential influence of lymphatic dysfunction and extremity lymphedema treatment on neurodegenerative pathways and cognitive outcomes.

Background: Optimal interventions for limb salvage after lower extremity fractures require collaboration between orthopedic and plastic surgery teams, as early flap coverage significantly impacts the incidence of infection and fracture nonunion. The objective of this study was to investigate the incidence of hardware failure, bone union and limb salvage in patients who underwent free flap reconstruction in combination with open reduction and internal fixation of open leg fractures. Methods: This retrospective analysis includes adult patients with open leg fractures and significant soft tissue loss requiring free flap coverage. Baseline patient characteristics, flap-related factors (type of free flap, flap dimensions, and delay in coverage), and incidence of hardware failure, amputation, and non-union were extracted and analyzed. Results: A total of 39 patients with a mean age of 38.8 ± 16.0 years old and a mean BMI of 26.6 ± 6.3were included. The most common type of fracture was open tibia/fibular grade IIIB (59.0%). Free split latissimus dorsi flap was the most frequently performed flap (71.8%). Hardware failure occurred in 41.0% of patients, primarily due to infection. Mean time interval between initial injury to definitive free flap coverage was 81.4 ± 106.3 days in patients with hardware failure, which compared with patients without hardware failure (20.0 ± 17.2 days), was statistically significant (P ≤ 0.05). Bone union was achieved in 79.5% of patients, and limb amputation was required in 12.8% of cases. Conclusion: The timing of flap reconstruction is the most significant predictive factor for hardware failure following free flap reconstruction in patients with open leg fractures.

Introduction: Neuropathic pain (NP) following extremity amputation is common and may be related to symptomatic neuroma. 1Targeted Muscle Reinnervation (TMR) has demonstrated efficacy in its treatment,2 but can also be utilized primarily, as NP prophylaxis. However, TMR's effectiveness varies among patients, and it is uncertain which patients are likely to achieve the desired NP mitigation. In prior studies, we have identified patient characteristics that seem to be associated with NP mitigation.3,4 Therefore, we aimed to construct a customized Machine Learning (ML) model incorporating these patient factors to predict patient responses to Primary and Secondary TMR, to aid in improving patient selection.

Methods: Patients undergoing Primary or Secondary TMR at a tertiary care center between 2018 and 2024 were eligible for inclusion (Follow-up: >6 months). Patients were excluded if <18 years old, if they underwent minor or bilateral amputation, or if no pain data was available. Patients were identified if they achieved sustained pain mitigation (Pain remission for Secondary, Pain prophylaxis for Primary TMR, defined as a pain score of ≤3 for ≥3 months until final follow-up). Data on demographic, comorbidity, and surgical factors were collected through chart review. Bayesian and nonparametric modeling techniques were utilized to build a prediction model capturing the associations between patient features and the binary outcome of pain mitigation. Prediction accuracy was calculated through a relevant vector machine (RVM) model with radial basis function kernels.

Results: A total of 77 Primary and 101 Secondary TMR patients were included (median follow-up: 2.0 years) of whom 55.8% and 63.4% achieved sustained pain mitigation, respectively. The RVM training prediction accuracy were 0.86, and 0.85, and the test prediction accuracy were 0.77 (AU-ROC score 0.83), and 0.80 (AU-ROC score 0.92), respectively, indicating that the model was able to predict with good accuracy (Table 1). In contrast, if the model would be randomly guessing, the chance levels would be 0.56, and 0.60, respectively.

Discussion: This novel, custom RVM model is able to predict whether Primary and Secondary TMR patients will achieve NP mitigation or not with good accuracy. This tool could aid in preoperative counseling and improve patient selection for TMR. Such prediction models could eventually become an integral part of data-driven clinical decision-making in managing post-amputation neuropathic pain, by providing predictions of the likelihood of TMR surgical outcomes based on personalized patient features. Further, we aim to increase the accuracy of this model by ongoing prospective research on surgical outcomes.

1. Hwang CD, Hoftiezer YAJ, Raasveld FV et al. Biology and Pathophysiology of Symptomatic Neuromas. Pain. 2.Dumanian GA, Potter BK, Mioton LM, et al. Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A RaTrial. Ann Surg. 2019;270(2):238-246. doi:10.1097/SLA.0000000000003088
2. Raasveld F V., Mayrhofer-Schmid M, Johnston BR, et al. Targeted muscle reinnervation at the time of amputation to prevent the developmepain. J Plast Reconstr Aesthet Surg. 2024;97:13-22. doi:10.1016/J.BJPS.2024.07.055
3. Raasveld F V., Mayrhofer‐Schmid M, Johnston BR, Hwang CD, Valerio IL, Eberlin KR. Pain Remission Following Delayed Targeted Muscle RAmputees. Microsurgery. 2024;44(8). doi:10.1002/MICR.31258

Purpose Prior studies suggest carpal tunnel syndrome (CTS) is primarily associated with structural, genetic, and biological factors, while occupational and environmental contributors, such as repetitive hand use, demonstrate weaker inconsistent correlations (1-3). CTS commonly presents between the fourth and sixth decades of life, raising the question: Why do some individuals develop CTS as they age? This study examines age-related variations in carpal tunnel and median nerve volumes and cross-sectional areas in individuals without CTS using MRI to explore potential anatomical predispositions for CTS development.

Methods This single-institution study utilized MRI scans of the wrist from individuals aged 20-70 years. Participants were grouped into decade-based cohorts: 20-30, 31-40, 41-50, 51-60, and 61-70 years. Exclusion criteria included prior wrist trauma or wrist surgery, diabetes, rheumatoid arthritis, or a clinical diagnosis of CTS to ensure observed changes were age-related rather than pathological.

MRI images were analyzed using Visage Imaging and Materialize Mimics software for volumetric segmentation of the carpal tunnel and median nerve. Standardized anatomical landmarks were used for measurements. Statistical analysis included descriptive statistics, independent t-tests to compare mean differences between age groups, and Fisher's exact test for categorical variables, with significance set at p<0.05.

Results To date, 46 individuals aged 20-30 years, 42 aged 31-40 years, 35 aged 41-50 years, 36 aged 51-60 years, and 30 aged 61-70 years have been analyzed. Carpal tunnel volume exhibited a decreasing trend with age, though this was not statistically significant. The highest mean volume was in the 31-40 age group (4716.06 mm³), while the lowest was in the 61-70 age group (4160.89 mm³), suggesting a steady reduction across cohorts. Similarly, median nerve volume progressively declined from 254.23 mm³ in the 20-30 group to 233.05 mm³ in the 61-70 group, indicating potential age-related nerve atrophy. The carpal tunnel inlet-to-outlet cross-sectional area ratio remained consistent across cohorts, but the median nerve ratio significantly increased with age, suggesting potential increased nerve compression.

Conclusions Aging is associated with a measurable decline in both carpal tunnel and median nerve volumes, suggesting a potential role in CTS risk. Although statistical significance has not been reached, ongoing data collection may clarify these trends. The observed volumetric decline suggests that anatomical changes in the wrist may increase susceptibility to neuropathic symptoms. These findings highlight the importance of age-related anatomical factors beyond traditional CTS risk factors, such as occupation, trauma, diabetes, and hormonal influences. Recognizing these age-related changes may aid in early identification of CTS risk and inform preventive strategies.

References

1. Lozano-Calderón S, Anthony S, Ring D. The quality and strength of evidence for etiology: example of carpal tunnel syndrome. J Hand Surg Am. 2008;33(4):525-538. doi:10.1016/j.jhsa.2008.01.004

2. Boz C, Ozmenoglu M, Altunayoglu V, Velioglu S, Alioglu Z. Individual risk factors for carpal tunnel syndrome: an evaluation of body mass index, wrist index, and hand anthropometric measurements. Clin Neurol Neurosurg. 2004;106(4):294-299.

3. Moghtaderi A, Izadi S, Sharafadinzadeh N. An evaluation of gender, body mass index, wrist circumference, and wrist ratio as independent risk factors for carpal tunnel syndrome. Acta Neurol Scand. 2005;112(6):375-379.

Purpose: Vascularized composite allotransplantation (VCA) is the reconstruction of nerve, muscle, and/or bone to restore defects that cannot be rebuilt with autologous tissue – an example in our practice is patients who sustain hand amputation. Though VCA improves quality of life, unlike lifesaving transplants, it poses unanswered questions on risks/benefits of lifelong immunosuppression (IS). The ideal regimen acts locally at transplant interface to limit systemic toxicities: due to mutual reliance on IS, advances for VCA will improve outcomes for solid organ transplant (e.g. liver/kidney). We use skin allografting as a model of complex transplant, such as murine hindlimb (e.g. hand transplant).

Tissue engineering is the design of therapies to recapitulate growth of skin, soft tissue and bone. Injectable biomaterials are widely used, including adhesives (Artiss), hemostatic agents (FloSeal) and cerebrospinal sealants (DuraSeal). We have expertise in design of injectable microporous annealed particle scaffolds (MAPS), using PEG chemistry (like DuraSeal), paired with coagulation factors (like FloSeal). We have injected MAPS to mouse brains after stroke, improving neurovascular regeneration and in skin, enhancing adnexal regeneration and strength.

Our central hypothesis is MAPS can serve as a tolerance-inducing platform for antigen, enabling allotransplants, weaning systemic immunosuppression. MAPS-immunomodulation is driven by chirality: with 1:1 mixture of L- and D-microgels, optimal healing is linked to recruitment of T cells and CD11b+ antigen-presenting cells (APC). Our materials activate differential APC-signaling, resulting in pro-regenerative phenotypes. We are incorporating FDA-approved drugs used in transplant but delivered via MAPS in controlled fashion. In situ engineering can have impact in a variety of contexts, from hand transplant to skin grafting and other applications of clinical immunology.

Methods & Results: We developed MAPS-augmented skin grafting with flow cytometry to study donor trafficking in skin-draining lymph nodes, marrow and spleen. MAPS was synthesized to recapitulate skin biomechanics, compared to human, mice and macaque tissue samples. Computational histology was used to quantify regeneration. We completed a series of allogeneic transplants adjuncted with MAPS and/or CTLA4-Ig. This drug is murine analog of FDA-approved belatacept, clinically used to block T cell costimulation in kidney, heart and hand transplants.

Mismatched animals rejected allografts, with time-dependent contraction and scarring. In matched transplants, MAPS-augmentation led to non-inferior engraftment. At one week, MAPS recruited regulatory T cells (TReg) to skin (51% vs 37% of CD4+ T cells, P=0.0009), graft-draining LN (25% vs. 13%, P<0.0001) and spleen (19% vs. 11%, P<0.001). Additionally, MAPS modulate donor- and host-derived APC costimulatory markers (CD80, CD86) and MHC-II in time-dependent fashion in skin, LN, and memory compartments. When allogeneic skin is transplanted atop a mixture of L/D MAPS, we showed a time- and dose-dependent decrease in the production of donor-specific antibodies, to a degree similar to that observed in mice treated intravenously with CTLA4-Ig.

Conclusions:
Immune-matched mice tolerate biomaterial-skin transplant, recruiting cells associated with tolerance. In clinically-relevant models, delivery of allorgraft with MAPS markedly reduced formation of donor-specific antibodies. Together, these data show injectable MAPS may serve as platform for alloantigen, and when used with costimulation blockade, could reduce need for systemic, intravenous therapies.

Purpose: Up to 30% of peripheral nerve repairs fail (1). PEG prevents Wallerian degeneration by fusing the severed axolemma, leading to improved functional recovery in preclinical and clinical studies (2-5).

This study presents preliminary results from the first randomized clinical trial on PEG-mediated neurorrhaphy in mixed sensory and motor nerves of the distal forearm.

Methods: Patients ages 18-75 with Sunderland V upper extremity nerve injury were randomized into PEG-mediated and standard neurorrhaphy cohorts. Michigan Hand Questionaries (MHQ) and Medical Research Council (MRC) sensory/motor grading were conducted at 1 week, 1 month, 3 months, 6 months, and 12 months post-operation. Statistical analysis performed using a mixed-effect linear regression model.

Results: Nine patients were analyzed: 7 PEG (9 nerves) and 2 non-PEG (3 nerves). Injured nerves were 58% ulnar, 42% median, and 0% radial. The cohorts had similar demographic, except longer surgeries in the PEG cohort (158 vs. 40 minutes). Within 3 months post-surgery, the PEG patients achieved ≥ S3/≥ M3 recovery, while the non-PEG remained ≤ S2/M2. PEG patients had higher estimated MRC sensory (+ 1.65 ± 0.74, p = 0.057), MRC motor (+0.76 ± 0.73, p = 0.32), and mean MHQ (+5.83 ± 1.43, p = 0.005) scores compared to the non-PEG patients at each follow up.

Conclusion: PEG-mediated neurorrhaphy trends toward early clinical functional recovery and significantly improves patient-reported function and quality of life, showing promise in mixed nerve repair of the distal forearm.

References:

1. Vastamäki M, Kallio PK, Solonen KA. The results of secondary microsurgical repair of ulnar nerve injury. J Hand Surg Br. 1993 Jun;18(3):323-6.

2. Krause TL, Bittner GD. Rapid morphological fusion of severed myelinated axons by polyethylene glycol. Proc Natl Acad Sci U S A. 1990;87(4):1471-1475.

3. Riley DC, Bittner GD, Mikesh M, et al. Polyethylene glycol-fused allografts produce rapid behavioral recovery after ablation of sciatic nerve segments. J Neurosci Res. 2015;93(4):572-583.

4. Bamba R, Waitayawinyu T, Nookala R, et al. A novel therapy to promote axonal fusion in human digital nerves. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S177-S183. doi:10.1097/TA.0000000000001203

5. Nemani S, Chaker S, Ismail H, et al. Polyethylene Glycol-Mediated Axonal Fusion Promotes Early Sensory Recovery after Digital Nerve Injury: A Randomized Clinical Trial. Plast Reconstr Surg. 2024;154(6):1247-1256.