Scientific Abstract Presentations: Hand Session 5 Saturday, October 11 Sat, Oct 11 2:00-3:30 p.m. CDT

Restoration of tactile sensation is paramount in fingertip reconstruction to ensure optimal hand function (1,2). This systematic review aimed to evaluate the sensory outcomes of innervated (IF) versus non-innervated regional flaps (NIF) used for digital soft tissue defects. A comprehensive search was conducted across PubMed, MEDLINE, Cochrane, and EMBASE databases to identify relevant English-language articles reporting sensibility outcomes. Eleven studies, published between 1983 and 2023, met the inclusion criteria, encompassing a total of 630 flaps in 620 patients.

The analysis revealed a significant superiority in sensory recovery when IF were employed compared to NIF. This was evidenced by significantly better outcomes in static two-point discrimination (2PD), moving two-point discrimination, and Semmes-Weinstein monofilament (SWM) testing. Specifically, innervated flaps demonstrated a weighted mean static 2PD of 6.8 mm (range 3.9-14 mm), compared to 10.1 mm (range 4-18 mm) for non-innervated flaps (p < 0.001). Moving 2PD was also significantly improved in IF (weighted mean 5.5 mm, range 2-10 mm) versus NIF (weighted mean 7.5 mm, range 6-11 mm; p < 0.001). Similarly, IF showed superior SWM scores (weighted mean 4.1, range 3.2-4.6) compared to NIF (weighted mean 4.7, range 3.6-5.1; p < 0.001).

Further analysis indicated that dual-innervated flaps exhibited superior static 2PD (weighted mean 6.5 mm, range 5-11 mm) compared to single-innervated flaps (weighted mean 8.7 mm, range 5-14 mm; p < 0.01). However, no significant difference was observed in SWM scores between single and dual-innervated flaps. Additionally, the review noted that IF demonstrated a quicker return of sensation compared to NIF.

While complications such as cold intolerance, pain, and neuroma formation were reported, the data was inconsistent and often did not differentiate between IF and NIF. Complete flap necrosis occurred at a mean rate of 1.3%, and partial flap necrosis at 6.7%. Other complications included venous congestion (4.8%) and infection (1.7%). These complications were not directly compared between the two flap types.

In conclusion, this systematic review strongly supports the use of neurorrhaphy in regional flap fingertip reconstruction to significantly improve sensory outcomes. The findings highlight the importance of considering nerve coaptation to enhance tactile recovery and potentially reduce complications like neuroma formation. Future high-quality randomized controlled trials are needed to further validate these findings and explore additional functional and patient-centered outcomes.

References: 1. Dunlop RLE, Wormald JCR, Jain A. Outcome of surgical repair of adult digital nerve injury: a systematic review. BMJ Open 2019, 9: e025443. 2. Thorsén F, Rosberg HE, Steen Carlsson K, et al. Digital nerve injuries: Epidemiology, results, costs, and impact on daily life. J Plast Surg 2012, 46: 184-90.

Purpose Radial tunnel syndrome (RTS) is an atypical nerve compression thought to be due to compression of the posterior interosseous nerve in the proximal forearm with typical presentation of pain in the absence of motor weakness. In this study, we evaluated a series of RTS patients and compare the outcomes of those treated with conservative management versus surgical decompression.

Methods An IRB approved retrospective study was conducted to identify RTS patients from 2016 to 2024. Patients presenting with recurrent RTS after being treated by another provider, traumatic radial nerve palsy, or other diagnoses without signs and symptoms of RTS were excluded.

Results This study included 185 patients (201 upper extremities), with 17 patients (9.1%) experiencing symptoms in bilateral upper extremities. The average age was 50.6 ± 13.9 years and 130 patients (70.0%) were female. Of all upper extremities, 124 (61.7%) had symptoms in the dominant hand. Concurrent diagnoses at the time of presentation included 105 upper extremities (52.5%) with lateral epicondylitis, 68 (33.8%) with carpal tunnel, 27 (13.4%) with cubital tunnel, 16 (8.0%) with median/pronator entrapment, and 8 (4.0%) with medial epicondylitis. A total of 174 extremities (86.6%) were treated with steroid injections, with 158 (78.2%) treated with a single injection, 14 (6.9%) treated with two, and 2 (0.1%) treated with three. Otherwise, 140 extremities (69.7%) were treated with physical/occupational therapy and 94 extremities (46.8%) were treated with elbow splinting. In total, 38 patients, 45 extremities (20.5%) progressed to surgical decompression, with an average age of 49.6 ± 14.0 years. All patients experienced significant relief evidenced during follow-up at post-operative week 2. One patient had a hematoma which required operative washout, and one patient experienced recurrence of radial tunnel symptoms which resolved with occupational therapy; there were otherwise no complications. Comparison of patients undergoing surgery versus managed conservatively found a significantly higher instance of bilateral symptoms in the former group (8/38 patients, 21.1% versus 9/147 patients, 6.1%, p=0.005). Extremities undergoing surgery also had a significantly higher incidence of concurrent cubital tunnel (12/45 extremities, 26.7% versus 15/156 extremities, 9.6%, p=0.003) than extremities treated without surgery.

Conclusion Radial tunnel is a clinical diagnosis and is often complicated by other symptoms in the affected extremity. Our data reveals a higher occurrence in female patients and mostly in the dominant hand. Over half of all patients presented with lateral epicondylitis or other symptoms, though almost everyone complained mostly of pain in the proximal forearm. The vast majority of these patients were effectively treated with a single steroid injection; those who progressed to surgery often had symptoms affecting bilateral extremities and concurrent cubital tunnel, and experienced significant improvement almost immediately post-operatively

Introduction Brachial plexus birth palsy (BPBP) is a serious complication of birth. When evaluating infants for BPBP, potential barriers to care must be considered to promote successful follow-up. This study aims to assess the role of socioeconomic and geographic context on clinical and surgical outcomes for BPBP patients. We hypothesize that geographic location (urban vs. rural) and socioeconomic factors, as measured by the Area of Deprivation Index (ADI) and Social Vulnerability Index (SVI), influence the likelihood of surgical intervention and recovery outcomes in children with BPBP.

Methods A retrospective review of BPBP patients at Children's Hospital of Pittsburgh from 2010 to 2023 was conducted. Demographic, clinical, and geographic data, including ADI and SVI scores, were collected. Surgical intervention rates and Active Movement Scale (AMS) scores at follow-up were the primary outcomes. Multivariate regression analyses were performed to evaluate the relationship between geographic and socioeconomic factors and surgical intervention as well as recovery, with p<0.05 set as the significance threshold.

Results 293 children met inclusion criteria. 51.9% were female, 71.0% were White, and 65.2% were from urban areas. 28.3% of all patients with BPBP underwent surgical intervention. Rural patients were 2 times more likely to undergo surgery than urban patients (OR 2.07, CI 1.23-3.49, p=0.006). Patients living farther from the hospital were also more likely to undergo surgery (OR 1.006, CI 1.002-1.01, p=0.005). Patients with lower initial AMS scores, those with shoulder dystocia or Horner's syndrome, and females were more likely to undergo surgery (p<0.001, p=0.04, p=0.02, p=0.04, respectively). At follow-up, rural patients had lower AMS scores than urban patients (β=-5.229, p=0.02), and females had higher scores than males (β=4.935, p=0.02). White patients had higher AMS scores than non-White patients (β=8.939, p<0.001), while Black patients had lower scores than others (β=-11.47, p<0.001). Increased distance from the hospital was associated with lower AMS scores (β=-0.07, p<0.001). The mean ADI score was 71.7 (SD 20.2), and the mean SVI was 0.41 (SD 0.24), with no significant relationship to surgical intervention or AMS scores.

Conclusion

This study demonstrates that socioeconomic indices did not significantly correlate with surgical decisions or recovery outcomes, suggesting that traditional measures may not fully capture disparities in BPBP management. However, rural patients and those living farther from the hospital were more likely to undergo surgery and had poorer recovery outcomes, highlighting potential barriers to care. These findings underscore the need for targeted interventions-such as improved rural outreach, telemedicine follow-ups, and enhanced rehabilitation access-to optimize functional recovery and reduce disparities in BPBP treatment.

INTRODUCTION: Precise physical examination techniques are essential for accurate diagnosis and informed decision-making in hand surgery. With advancements in AI, Large Language Models (LLMs) integrated with Retrieval-Augmented Generation (RAG) hold the potential to deliver detailed, contextually accurate guidance on hand assessments. This study explores the capacity of such AI systems to comprehensively address queries regarding key physical examination tests, including their procedures, diagnostic objectives, clinical presentations, and implications for surgical decision-making. Additionally, the analysis incorporates the anatomical foundations relevant to these assessments, providing a holistic evaluation of the AI's effectiveness in supporting clinical practice. METHODS: The analysis includes ten widely recognized hand examination techniques: Allen's test, Tinel sign, Phalen's test, Durkan's test, Finkelstein's test, Bunnell's test, Watson's test, Wartenberg's sign, Froment's sign, and Jeanne's sign. Two RAG models powered by LLMs, namely Gemini-1.0-pro-002 and Gemini-1.5-pro-001, were compared to assess their ability to respond to targeted queries accurately. The study posed 80 detailed questions to both models, encompassing aspects like procedural steps, diagnostic relevance, and interpretation of results for the selected hand examinations. Evaluation metrics included precision, recall, and F1 score to measure the accuracy of the responses. Accuracy distribution was also analyzed, categorizing responses into low, medium, and high accuracy levels for a comprehensive performance assessment. RESULTS: The Gemini-1.5-pro-001 RAG LLM model demonstrated superior performance metrics, achieving precision (0.73), recall (0.79), and an F1 score of (0.76). It maintained a well-proportioned accuracy distribution, with 16% of responses falling within the low accuracy range, 22% in the medium range, and 61% in the high accuracy range. In contrast, the Gemini-1.0-pro-002 RAG LLM model yielded lower performance metrics, with precision (0.67), recall (0.51), and an F1 score of (0.58). Its accuracy distribution was comparatively skewed, with 38% of responses in the low range, 20% in the medium range, and 41% in the high range. The significant difference in recall between the Gemini-1.5-pro-001 and Gemini-1.0-pro-002 models underscore the enhanced ability of the former to identify and retrieve relevant information. This improvement, driven by its improved training methods, optimized retrieval, and enhanced reasoning capabilities, enables Gemini-1.5-pro-001 to provide more comprehensive and accurate responses across a broader range of queries. These features make it a reliable and effective tool for providing accurate, contextually relevant information in clinical and educational settings. CONCLUSION: This study highlights the capability of RAG-enhanced LLMs to deliver comprehensive and accurate information on hand examination techniques. The improved performance of the Gemini-1.5-pro-001 model, compared to its counterpart, demonstrates its proficiency in generating precise and contextually meaningful responses. By pushing the boundaries of AI integration in clinical and educational domains, these models show promise in supporting medical decision-making, aiding surgeons and clinicians, and elevating the educational experience for medical students and trainees.

Purpose: Crush injuries to the hand can result in severe and debilitating injuries. Outcomes following crush injury fractures of the hand are not well characterized, and specific patient demographic and injury characteristics may be associated with higher risk of complications. This study evaluates hand crush injuries presenting to the emergency room and investigates factors associated with complications following such injuries.

Methods: Adult patients presenting to the emergency department with acute fractures of the phalanges or metacarpals following crush injury to the hand between July 2011 and May 2024 were retrospectively identified. Injuries classified as mangled were excluded. Patient demographics, injury characteristics including fracture patterns, and treatments including surgeries were collected. Complications were defined as: infections, wound healing complications (necrosis, hematoma), loss of reduction, and any unplanned operations during a patient's follow-up period. Bivariate and binary logistic regression analyses were conducted to evaluate predictive variables associated with complications (significance set at p < 0.05).

Results: Of 262 patients that met inclusion criteria, the average age of presentation was 42.7 (SD 15.1) years old. There were 33 (12.6%) patients that experienced a complication, including eleven cases of infection (three osteomyelitis), seven cases of soft tissue necrosis, and two cases of reduction loss. There were 18 (6.9%) unplanned operations or re-operations, with the most common reason being loss of reduction or non-union (n=7, 2.7%). The average follow-up duration was 96 (SD 169) days following initial presentation. Over half of injuries occurred at work (53.8%, n=141). The distal phalanx was most frequently fractured (79.4%, n=208), followed by proximal phalanx (11.5%, n=30), metacarpal (9.2%, n=24), and middle phalanx (8.4%, n=22). The majority were open (74.4%, n=195) and 49.6% were comminuted fractures (n=130). Amputation injury occurred in 24.0% of cases (n=63). One quarter of patients (24.0%, n=63) required operative intervention, which included 40 fracture reduction and fixations (15.3%) and 12 revision amputations (4.6%). On bivariate analysis, older age, diabetes mellitus, and prior/active history of smoking were significantly associated with complications including unplanned reoperation. Amputation injuries, fractures to more than one finger, middle phalanx fractures, and operative intervention were also significantly associated with complications. Binary logistic regression analyses adjusted for age, diabetes, and smoking history demonstrated that, for injury pattern, comminuted fractures and amputation injuries were significantly associated with complications, while open fractures and intraarticular fractures were not. For fracture location, middle phalanx and metacarpal fractures were significantly associated with complications, while proximal and distal phalanx fractures were not. Conclusion: Demographic factors, including older age, diabetes, and smoking may be associated with complications or unplanned operation following hand crush injury. Fracture characteristics, including metacarpal, middle phalanx fractures, and amputations may be associated with greater complications. These findings may guide risk stratification and patient management following such injuries.

Background: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been associated with worse outcomes after spinal surgeries[1-2]. However, there is a paucity of literature specifically analyzing the effects of serotonergic antidepressants (SSRIs/SNRIs) on open reduction and internal fixation (ORIF) for distal radius fractures. As patients undergoing ORIF may be taking serotonergic antidepressants before their surgery, it is unclear as to whether these medications may predispose them to worse recovery outcomes. The purpose of our retrospective study was to explore the impact of prior serotonergic antidepressant usage on postoperative complications and hardware-related issues following ORIF of the distal radius, using a nationally matched cohort analysis.

Methods: On January 19, 2025, we analyzed anonymous electronic health records across 67 healthcare organizations via the United States Collaborative Network on TriNetX, a federated research database. A preliminary total of 72,743 adult patients (≥18 years old) who underwent ORIF were identified from January 2005 to January 2025. Patients were then divided into two cohorts: Cohort A (9,068 patients) who used SSRIs or SNRIs within 3 months before ORIF and Cohort B (63,680 patients) with no documented history of SSRIs/SNRIs prescription. 1:1 propensity–matching was performed for sex, gender, age, body mass index, ethnicity, race, and co-morbid conditions (i.e., depression, anxiety, hypothyroidism, hypertension, diabetes, alcohol-related disorder, obesity, chronic kidney disease, liver disease, congestive heart failure, nicotine dependence, cerebrovascular diseases). Primary outcomes examined readmission, transfusion, acute postoperative pain, anemias, wound disruption, skin infection, and sepsis at 14-days and 90-days. Secondary outcomes evaluated hardware failure, surgical revision of nonunion, the incidence of carpal tunnel syndrome, and lesion of the median nerve at 2-years. Statistical analysis was calculated using multivariate regressions, and significance was set at p<0.05.

Results: Following 1:1 propensity–matching, both balanced cohorts consisted of 7,055 patients for comparative analysis. Patients with prior SSRIs/SNRIs usage experienced significantly elevated risks for readmission, transfusion, acute postoperative pain, and anemias at both 14-days and 90-days (all p<0.005) when compared to the control group. Additionally, wound disruption, skin infection, and sepsis were significantly higher at 90-days (all p<0.05). At 2-years, the SSRIs/SNRIs patients displayed significantly greater rates of hardware failure, surgical revision of nonunion, incidence of carpal tunnel syndrome, and lesion of the median nerve (all p<0.05).

Conclusion: Preoperative usage of serotonergic antidepressants significantly elevated postoperative risks for complications and adverse hardware-related outcomes in adult patients undergoing ORIF of the distal radius. We encourage hand surgeons to consider discussing the risks and benefits of continuing these antidepressants with patients during the preoperative period. Future prospective studies should distinguish the relationship between different antidepressant medications, co-morbid psychiatric disorders, and complications in surgical fixation of the fractured distal radius.

References: 1. Adelstein J, Moyal A, Strony J, et al. Serotonergic Antidepressants are Associated With Higher Rates of Hematoma After Anterior Cervical Spine Surgery. Spine. 9900; Publish Ahead of Print doi: 10.1097/BRS.0000000000005168. 2. Schadler P, Shue J, Moawad M, et al. Serotonergic Antidepressants Are Associated with Increased Blood Loss and Risk for Transfusion in Single-Level Lumbar Fusion Surgery. Asian Spine J. 2017;11(4):601-609. doi:10.4184/asj.2017.11.4.601

Title: Antithrombotic Management in Minor Hand Surgery: Current Practices in Canada

Purpose: Withholding antithrombotic medications before surgery can increase thromboembolic risk, yet their continuation may raise bleeding concerns. Many patients undergoing minor hand surgery take these medications, requiring careful perioperative management. However, guidelines lack clarity on how to classify bleeding risk, leading to differences in interpretation of available guidelines. This study examines the perioperative approaches of Canadian plastic surgeons managing antithrombotic therapy in minor hand surgery.

Methods: A cross-sectional electronic survey was distributed to Canadian plastic surgeons in 2024. Respondents provided clinical management preferences for patients on antithrombotic therapy undergoing cyst excision, trigger finger release, and carpal tunnel release.

Results: Seventy-four surgeons participated. Most (93.7%) classified these procedures as low-risk of bleeding, but this dropped to 71.2% for patients on Apixaban and 59.9% for those on Warfarin. Medication management varied: 26.6% would hold Aspirin, 37.8% would hold Warfarin, and 47.7% would hold Apixaban. Surgeon demographics, hand surgery fellowship training, access to thrombosis experts, use of guidelines, and tourniquet preferences had no significant influence on these decisions.

Conclusions: There is considerable variability in perioperative antithrombotic management among Canadian plastic surgeons performing minor hand surgery. Despite considering common minor hand procedures as low-risk, many surgeons elect to hold medications, diverging from existing guidelines. This likely stems from concerns over anticoagulant-related bleeding risks-an issue not explicitly addressed in current recommendations.

Title: Antithrombotic Management in Minor Hand Surgery: Current Practices in Canada

Purpose: Withholding antithrombotic medications before surgery can increase thromboembolic risk, yet their continuation may raise bleeding concerns. Many patients undergoing minor hand surgery take these medications, requiring careful perioperative management. However, guidelines lack clarity on how to classify bleeding risk, leading to differences in interpretation of available guidelines. This study examines the perioperative approaches of Canadian plastic surgeons managing antithrombotic therapy in minor hand surgery.

Methods: A cross-sectional electronic survey was distributed to Canadian plastic surgeons in 2024. Respondents provided clinical management preferences for patients on antithrombotic therapy undergoing cyst excision, trigger finger release, and carpal tunnel release.

Results: Seventy-four surgeons participated. Most (93.7%) classified these procedures as low-risk of bleeding, but this dropped to 71.2% for patients on Apixaban and 59.9% for those on Warfarin. Medication management varied: 26.6% would hold Aspirin, 37.8% would hold Warfarin, and 47.7% would hold Apixaban. Surgeon demographics, hand surgery fellowship training, access to thrombosis experts, use of guidelines, and tourniquet preferences had no significant influence on these decisions.

Conclusions: There is considerable variability in perioperative antithrombotic management among Canadian plastic surgeons performing minor hand surgery. Despite considering common minor hand procedures as low-risk, many surgeons elect to hold medications, diverging from existing guidelines. This likely stems from concerns over anticoagulant-related bleeding risks-an issue not explicitly addressed in current recommendations.

Hypothesis: We hypothesize that patients with thumb carpometacarpal joint (CMCJ) arthritis can be efficaciously treated with corticosteroid injections (CSI), however we suspect that more CSIs leads to a higher conversion rate to surgery.

Methods: A retrospective analysis was performed of all patients with thumb CMCJ arthritis evaluated by a hand surgeon at Metro Health Medical Center between 2000-2024. Patients were stratified into cohorts depending on the number of CSI they received. Propensity-score matching was performed to create similar distributions of hand dominance, affected thumb, and Eaton-littler classification between all cohorts. Hazard ratios (HR) and Kaplan-Meier time to event curves were performed for all cohorts.

Results: 957 patients with thumb carpometacarpal joint arthritis were included in our study: 238 received 0-CSI, 288 received 1-CSI, 300 received 2-to-4-CSIs, 131 received 5-or-more-CSIs. There was an equal distribution of hand dominance (right-90.9%, left-5.5%, ambidextrous-0.4%, unknown-3.1%), affected thumb (bilateral-36.5%, right-30.4%, left-32.9%, unknown-0.2%), and Eaton-Littler classification (1-9.7%, 2-29.7%, 3-27.8%, 4-12.4%, and unknown-0.2%) between all groups. 235 patients underwent surgery, and the rates of surgery were statistically significant between each group (0-CSI-5.5%, 1CSI-25.0%, 2-to-4CSI-32.3%, and 5+CSI-40.5%). Those in 1CSI (HR 14, 95% CI 5.7-35), 2-to-4CSI (HR 19, 95% CI 7.7-46), and 5-or-more-CSI (HR 25, 95% CI 9.9-62) were at significantly higher odds to undergo surgery when compared to 0-CSI (Figure 1). Kaplan-Meier analysis revealed receiving at least 1-CSI lowered the risk of surgery 3-months after their index injection when compared to those not receiving CSI. There was no significant difference in the risk reduction of conversion-to-surgery between the various number of CSI received within the first 54-months after their index injection and those receiving 5-or-more-CSI carried a higher risk-of-conversion-to-surgery after 54-months compared to the other CSI groups (Figure 2).

Summary Points: Patients receiving any number of CSI for treatment of thumb CMCJ arthritis were at significantly higher odds of undergoing surgical intervention compared to those not receiving any CSI regardless of their Eaton-Littler classification. Patients should be counseled on CSIs being most protective against surgery within 3 months after index injection when compared to not receiving any injections and this surgery risk reduction is not paralleled by receiving a higher quantity of CSIs. Hand surgeons should consider surgical intervention 54 months after index CSI, especially in patients that have already received 5 or more injections.

Background: Intramedullary screw fixation (IMF) has recently gained popularity for operative management of phalangeal fractures. We hypothesize that the functional outcome of phalangeal fractures treated with IMF is noninferior to that of K-wires or plating.

Methods: A systematic review of PubMed and Embase was conducted according to PRISMA guidelines by three independent reviewers. Inclusion criteria included extra-articular middle and proximal phalangeal fractures in adults treated with either IMF, K-wires, or plating. Outcomes of interest were total active motion (TAM) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Exclusion criteria included pediatric populations, cadaveric studies, or lack of relevant inclusion criteria. A random effects meta-analysis evaluated outcomes of interest.

Results: The initial search retrieved 1,377 articles. 303 duplicates were removed, yielding 1074 for title and abstract screening. 142 studies underwent full text review and 28 of these (9 IMF, 8 K-wires, 11 plating) were finally included. There were no significant differences between the three operative interventions for DASH scores. Likewise, TAM was not significantly different across interventions, though IMF trended towards significantly higher TAM compared to plating.

Conclusions: IMF can yield similar functional outcomes compared to K-wires or plating of phalangeal fractures. IMF offers high operative efficiency without the need for prolonged immobilization. Subsequent analyses will focus on meta-regression to parse out inter-study heterogeneity, as well as include additional outcomes such as infection, malunion, and grip strength.

References: Viechtbauer W (2010). "Conducting meta-analyses in R with the metafor package." Journal of Statistical Software, 36(3), 1–48. doi:10.18637/jss.v036.i03.

Background: Targeted muscle reinnervation (TMR) has revolutionized the field of chronic pain management. Originally described as a nerve transfer technique to control myoelectric prostheses, TMR is at the forefront of treating existing and preventing the development of neuromas and phantom pain following limb loss by creating new sensory nerve pathways. We present the story of a good save and little victory in a patient successfully treated with TMR for persistent, debilitating paresthesias from injury to the superficial branch of the radial nerve (SBRN) following radial artery harvest for 4-vessel coronary artery bypass grafting (CABG).

Methods: Electromyography (EMG) assessed function of the superficial branch of the radial nerve. Exploration of the affected arm showed near-complete transection of the SBRN from surgical clips used during the CABG radial artery harvest. Neurolysis and SBRN repair was first performed with nerve graft. Given persistent neuropathic pain, TMR was offered. Pre-operative SBRN block was completed to simulate the potential benefit from TMR. TMR of SBRN to the motor nerve of the extensor carpi radialis brevis (ECRB) muscle was successfully completed.

Results: Our patient had a history of hypertension, hyperlipidemia, tobacco and alcohol use, and uncontrolled diabetes (A1c 12.9%) who presented with chest pain. Workup was notable for elevated troponins and electrocardiogram findings consistent with NSTEMI. Left heart catheterization revealed severe multivessel obstructive coronary artery disease for which CABG was indicated. Following surgery, lifestyle modifications were initially successful. However, the distress and psychological burden of ongoing pain from the SBRN significantly diminished the patient's quality of life. This led to a relapse into smoking and alcohol use, behaviors that had previously contributed to his cardiovascular disease. Ongoing follow-up after completion TMR demonstrates cessation of chronic analgesic use, significantly improved pain, and restored ability to work, care for his children, and effectively engage in activities of daily living.

Conclusion: The applications of TMR have been well-described in treating chronic pain in amputees and preventing symptomatic neuroma formation following major limb loss. As highlighted here, TMR provides not only a spectrum of benefits to amputees experiencing phantom and residual limb pain, but also little victories to those suffering from the psychological burden of chronic pain sustained in trauma or surgery.

Purpose: Longitudinal follow-up after distal radius fracture fixation is essential for monitoring bony healing and optimizing postoperative rehabilitation. It is particularly critical following dorsal spanning plate fixation where hardware removal must be coordinated. The primary aim of this study was to identify factors associated with loss to follow-up for patients undergoing distal radius fracture fixation at a single level 1 trauma center. A secondary aim was to determine hardware removal rates following dorsal spanning plate placement and establish risk factors for loss to follow-up with associated hardware retainment.

Methods and Materials: Adult (age ≥18) patients undergoing distal radius fracture fixation at a level 1 trauma center were identified over a five-year period (2015-2019). Patients were excluded if they were <18 years age, underwent non-operative management, were incarcerated, or had incomplete clinical data. Demographics, injury characteristics, operative details, polytrauma status, distance from hospital, non-cannabinoid recreational drug use, homelessness, psychotic mental illness, dementia, occupation, education level, insurance type, and language were collected from the medical record. Univariate and multivariate logistic regression were performed to determine independent predictors of attending at least one post-operative appointment and undergoing hardware removal for those with spanning fixation.

Results: Of 353 patients who underwent operative treatment, 299 had fractures repaired with non-spanning fixation alone (e.g., volar plating) while 54 underwent placement of a dorsal spanning plate. Of patients with non-spanning fixation, 235 of 299 returned for follow-up (79%). Of patients with a dorsal spanning plate, 50 of 54 (93%) returned for follow-up and hardware removal. Non-cannabinoid recreational drug use (odds ratio 0.13; p=0.001), homelessness (0.08; p=0.03), unemployment (0.27; p<0.001), and Medicaid insurance type (0.27; p<0.001) were significantly associated with loss to follow-up. By contrast, those with private insurance (3.4; p<0.001) or worker's compensation claim (5.8; p=0.04) were significantly more likely to follow-up on univariate regression. Patients with dorsal spanning plates were significantly more likely to follow-up than those with non-spanning fixation (odds ratio 3.3; p=0.02) even among high-risk patients (i.e., those with non-cannabinoid recreational drug use, homelessness, unemployment, or Medicaid status). Of this high-risk cohort with spanning plates, 15 of 16 (93.8%) returned for hardware removal-though a longer average time to plate removal was found for those with non-cannabinoid recreational drug use (168 days; p=0.03) and homelessness (196 days; p=0.020) compared with patients with spanning plates that did not have those risk factors (112.86 days).

Conclusions: Non-cannabinoid recreational drug use, homelessness, unemployment, and Medicaid insurance were found to predict loss to follow-up after distal radius fracture fixation. However, these risk factors did not apply to those treated with dorsal spanning plates, as patients frequently presented for hardware removal regardless.

Background: Establishing a dedicated trauma operating room (DTOR) has proven benefits in orthopedic surgery, including improved efficiency, access, scheduling, and patient outcomes. However, DTORs remain underutilized in hand surgery, where timely, sterile procedures are essential.

Purpose: This purpose of this study is to measure the impact of a dedicated trauma operating room (DTOR) for hand surgery on the proportion of after-hours cases and wait times from consultation to surgery at an urban tertiary-care center in Toronto, Ontario.

Methods: This retrospective cohort study included adult patients undergoing hand trauma surgery at Toronto Western Hospital during two periods: pre-DTOR implementation (August 1, 2018 - January 31, 2020; N=599) and post-DTOR implementation (August 1, 2022 - January 31, 2024; N=541). The main outcomes were the proportion of emergency cases performed after-hours and the wait times from consultation to surgery. Multivariable logistic and negative binomial regression were used to estimate associations with binary and continuous outcomes, respectively. Other outcomes, including caseload, surgical complications, and revision surgeries, were assessed using univariate analysis.

Results: After DTOR implementation, after-hours cases decreased from 18% (N=109/599) to 8% (N=45/541). Adjusting for covariates, DTOR implementation was associated with fewer emergency hand surgeries being performed after-hours (Odds Ratio=0.47, 95% CI 0.23-0.95, p=0.03). Wait times were similar before and after-DTOR implementation (6 days vs. 8 days, pre vs. post-DTOR; Rate Ratio=1.03, 95% CI 0.91-1.16, p=0.64). There was no difference in the hand trauma caseload pre vs. post-DTOR implementation (p=0.09). There were fewer complications (5% vs. 2%, pre vs. post-DTOR; p=0.03) and revisions (10% vs. 3%, pre vs. post-DTOR; p<0.0001) following DTOR implementation.

Conclusions: The implementation of DTOR was associated with reduced proportions of emergency hand surgeries being performed after-hours, without compromising wait times. Additionally, there were lower complication and revision rates after DTOR implementation. The results of this study support the use of DTORs to enhance surgical efficiency and improve patient outcomes in hand surgery centers.

Purpose Complete management of major upper extremity amputation patients includes transition from acute surgical care to long-term prosthetic care. Prosthetics are fundamental to final mobility, integration in society, and quality of life. Additionally, advancements beyond static prosthetics have progressed rapidly in the past 15 years. Myoelectric control now includes technologies like pattern recognition which yields dozens of complex motor functions from few viable neuromuscular units, for example. However, providing this newer technology to patients heavily relies on insurance coverage, as their high costs remain a barrier to most patients. The purpose of this study was to investigate the rate and quality of insurance coverage of advanced upper extremity prosthetics to identify real-world barriers to obtaining technologies which fully capitalize on modern microsurgical reconstructive techniques.

Methods Review of the ten largest health insurance providers' (Aetna, Anthem, Blue Cross, Centene, Cigna, Humana, Kaiser, Medica, Medicare, United) coverage plans, contracts, and web-based platforms was conducted to identify quantity and quality of coverage for upper extremity prostheses. Limitations, exceptions, and vague exclusionary language was noted whenever present. Local prosthetists were reviewed for expert insight into access barriers for amputee patients and anecdotal local denial rates. Public insurance claims databases were additionally accessed to determine most recent rates of coverage.

Results The majority of large payers do not provide full or even partial coverage for costs of advanced upper extremity prosthetics. Many insurance providers use language to exclude patients from qualifying, and lack of scientific evidence or inadequate proof of "necessity" to obviate liability for coverage of any prosthetic beyond the most basic, despite significant advancements in targeted muscle reinnervation (TMR) and myoelectric control devices. In addition to documentation by an ordering physician, certain payers require additional, specific evaluations by the physician and/or prosthetist, with minimum qualifications of the prosthetist involved. Several states have passed "insurance fairness" laws requiring payers to provide coverage of prosthetics in line with coverage for other medical expenses, however, this only applies to public insurance plans and is typically measured as a percentage of the cost of goods–an insurance provider can successfully meet these terms by providing the appropriate percentage coverage for the cheapest, lowest-level technology device. Ultimately, the delta between coverage and costs can exceed tens of thousands of dollars, an insurmountable barrier for most patients. Around half of upper extremity prosthetic estimates received initial denials, and over 90% of myoelectric control devices were denied once or more, even after an appeals process.

Conclusion Investigation of insurance coverage for modern upper extremity prosthetics reveals a significant gap between costs, coverage, and therefore, access. Though many payers site "lack of evidence" to label myoelectric control anything beyond "investigational", the overwhelming inadequacy of coverage continues to stifle large-scale scientific investigation of outcomes.

BACKGROUND: Nerve and tendon transfers are commonly used surgical techniques to restore upper extremity function for a variety of paralytic conditions including cervical spinal cord, brachial plexus, and isolated peripheral nerve injuries. While both procedures can be effective given appropriate patient selection, there is a lack of data comparing rates of postoperative complications. In this study, we will use a large retrospective cohort to evaluate differences in post-operative complications after these two reconstructive methods. METHODS: A 10-year retrospective cohort analysis was conducted using the TriNetX database which contains data from 107 healthcare organizations between January 2016 and February 2025. Patients who had undergone upper extremity nerve and tendon transfer were identified using International Classification of Disease-10 (ICD-10) and Current Procedural Terminology (CPT) codes. Propensity score matching (PSM) for age, sex, obesity, HgbA1c, steroid and anticoagulation use, and history of malignancy was used to control for baseline characteristics. Thirty-day postoperative incidences of thromboembolic events, superficial infections, bleeding-related complications, other postoperative infections (urinary tract infection, pneumonia, bacteremia, necrotizing fasciitis, c. difficile colitis, sepsis) were obtained using ICD-10 codes. Results were evaluated using TriNetX's Lucid Network. Categorical and continuous variables were compared with Chi-Squared test and Student's t-test respectively. Risk ratios (RR) were calculated for post-operative complications between groups and a p-value of ≤0.05 was considered statistically significant. RESULTS: A total of 24,936 patients were identified, including 834 patients who underwent nerve transfers and 24,102 patients who underwent tendon transfers. The nerve transfer cohort was younger at time of operation (45.1+/-16.3 vs 59.3+/-14.2 years, p < 0.05) and had a higher proportion of male patients (50.7% vs 34.6%, p<0.05). The tendon transfer cohort had a significantly higher incidence of diabetes mellitus (13.8% vs 9.8%, p<0.05), obesity (20.5% vs 15.2%, p<0.05), and long-term steroid use (4.1% vs 2.8%, p<0.05). After 1:1 PSM, 829 matched patients were selected per cohort. The rate of overall complications was significantly higher in the nerve transfer group (8.18% vs. 4.81%, RR= 2.088, p<0.05). Superficial infections were significantly more common in the nerve transfer group (3.73% vs. 2.05%, RR=2.429, p<0.05). No significant differences between groups were observed for other infections (1.81% vs. 1.4%, RR=1.5, p=0.56), thromboembolic events (1.8% vs. 1.2%, RR=1.5, p=0.30) or bleeding-related complications (1.4% vs. 1.2%, RR=1.2, p=0.429). CONCLUSIONS: This study demonstrates that nerve transfers are associated with a significantly increased risk of overall postoperative complications compared to tendon transfers. Tendon transfer patients experienced rates of superficial infections consistent with a clean wound class (1-3%) as previously reported for outpatient hand surgery and extremity/brachial plexus nerve surgery. However, the rate of superficial infections was significantly higher in nerve transfer patients. While this study highlights important differences in complication rates for these procedures, the TrinetX database is limited by the absence of clinically relevant factors including wound site, wound class, and length of surgery. Further retrospective and prospective studies are warranted to explore these differences, as they may play a role in pre-operative decision making and incentivize modifications in peri-operative management for these procedures.