Scientific Abstract Presentations: Hand Session 1 Thursday, October 15 Thu, Oct 15 1:30-3:00 p.m. CDT

Introduction Research productivity within surgical specialties have shown specialty-dependent trends, such as correlations with academic rank, gender, location of medical school or residency training, and practice setting (1). Previous studies have demonstrated that hand fellows from plastic surgery residencies (H-PS) are more productive than orthopedic surgery graduates (H-OS) (2). The purpose of our study is to evaluate whether this trend continues through fellowship, by comparing research output of hand surgery fellows before and after beginning their fellowship and comparing output between H-PS and H-OS fellows.

Methods A single independent reviewer searched for fellows' research profiles using the Elsevier Scopus Author Search and Google Scholar for the 2023-2024 fellowship year. Out of 189 estimated fellows, a total of 108 fellows' information was obtained (2, 71, and 35 fellows respectively for general, orthopedic, and plastic surgery residency graduates). For each fellow, the h-index, total number of publications, publications before and after their fellowship start date (July 2023), first author publications, the maximum number of citations on a single paper, and the total number of citations across all publications were collected. Each of these variables was analyzed using descriptive statistics and unpaired t-tests.

Results H-PS had greater H-indices (mean = 7.09) compared to H-OS (mean = 3.77) with p = 0.008 and nearly twice the number of total lifetime publications, 18.14 and 9.89 respectively with p = 0.008. H-PS and H-OS also produced 5.29 and 2.93 lifetime first-author publications respectively with p = 0.02. H-PS produced greater than three times the number of total lifetime citations (p = 0.007). For publications occurring during the fellowship year, H-PS produced 14.89 while H-OS produced 6.03 with p = 0.001.

Conclusion Our study is consistent with previous studies suggesting that H-PS fellows are more productive than H-OS in terms of overall numbers, and this trend appears to continue when looking specifically at research output during the fellowship year. Although these results are best understood as an estimate of research productivity since some publications occurring after July 2023 are likely resulting from research completed during residency, these results highlight possible differences in hand fellowship research opportunities for fellows from differing residency backgrounds. Further research may be warranted to identify specific causes of these differences, including mentorship availability, research opportunities, and fellows' career goals.

REFERENCES 1. Therattil, P. J., Hoppe, I. C., Granick, M. S., & Lee, E. S. (2016). Application of the H-index in academic plastic surgery. Annals of Plastic Surgery, 76(5), 545–549. https://doi.org/10.1097/sap.0000000000000382

2. Siegel, N., Lopez, J., Cho, A., & Lifchez, S. D. (2020). A bibliometric analysis of research productivity during residency for 125 hand surgery fellows. Journal of Surgical Education, 77(3), 710–716. https://doi.org/10.1016/j.jsurg.2019.12.015

Background Smoking is associated with increased complications after carpal tunnel release (CTR) and distal radius fracture (DRF), but the ideal timing of CTR post-DRF is unclear.(1-4) We assessed whether smoking history affects outcomes of acute (≤24 hours) vs delayed (1-14 days) CTR after DRF. Methods We conducted a retrospective cohort study using TriNetX, including adults with DRF who underwent CTR and had a diagnosis of CTS between fracture and release. Timing of CTR was classified as acute (≤24 hours) or delayed (1-14 days), and patients were grouped by smoking history. The main outcomes were a 30-day and 90-day postoperative complication composites (infection, hematoma/seroma, wound dehiscence, ED visit, reoperation, complex regional pain syndrome, and mortality). Propensity score matching (PSM) balanced baseline characteristics; outcomes were compared within smoking groups by timing. Results Among 15,248 eligible adults undergoing CTR after DRF with CTS, the distribution of acute vs delayed CTR was similar in ever-smokers (3,137 acute vs 3,486 delayed) and non-smokers (4,032 acute vs 4,593 delayed). After PSM, 3,117 ever-smokers and 3,964 non-smokers were balanced in each timing cohort. In ever-smokers, acute vs delayed CTR showed no differences in 30-day surgical site infection, reoperation/reintervention, ED visits, inpatient admission, median nerve injury, and at 90 days, complex regional pain syndrome (all p>0.05). Similarly, in non-smokers, acute vs delayed CTR showed no differences in hematoma/seroma, ED visits, reoperation/reintervention, or hospitalization/readmission (all p>0.05). Overall, tobacco history did not appear to modify the relationship between timing (acute vs delayed) and postoperative outcomes. Conclusion Tobacco use history did not affect the optimal timing of CTR after DRF or short-term postoperative complication rates.

References 1. Allen JG, Harder J, Hernandez E, Bourland B, MacKay B. The effect of smoking on open carpal tunnel release recovery. Hand Surg Rehabil. 2024;43(1):101626. doi:10.1016/j.hansur.2023.11.011 2. Kaneko A, Naito K, Obata H, et al. Influence of Smoking in the Clinical Outcomes of Distal Radius Fractures. J Hand Microsurg. 2022;14(3):212-215. doi:10.1055/s-0040-1715425 3. Hess DE, Carstensen SE, Moore S, Dacus AR. Smoking Increases Postoperative Complications After Distal Radius Fracture Fixation: A Review of 417 Patients From a Level 1 Trauma Center. HAND. 2020;15(5):686-691. doi:10.1177/1558944718810882 4. Mack GR, McPherson SA, Lutz RB. Acute median neuropathy after wrist trauma. The role of emergent carpal tunnel release. Clin Orthop. 1994;(300):141-146.

Background Hand fractures account for twenty percent of all fractures, with metacarpal fractures dominating at ~44%. Closed reduction with percutaneous K-wire fixation is a minimally invasive and widely used technique for phalengeal and metacarpal fractures. K-wire fixation can be a challenging skill to master, requiring tactile precision and high visuospatial coordination. Resident physicians face duty hour restrictions and other barriers leading to reduced hands-on operative learning opportunities. Mixed-Reality (MR) simulators can bridge the gap in training by providing high-fidelity simulations of technically complex plastic surgery procedures. Here we introduce a novel MR simulator for metacarpal fracture reduction and K-wire fixation, and evaluate it through validation, skill acquisition, and procedural skill transfer to cadaveric hands. Methods Our team created a three part MR simulator: a 3D printed hand bone model with 5th metacarpal and Bennett's fracture sites cast in silicone, a 3D printed K-wire driver with movable parts and an application to track the sensors in the models, provide audiovisual feedback, and capture virtual radiographs. First, plastic surgeons and residents (n =18) evaluated the simulator using ten different parameters on a Likert scale addressing realism and educational utility. Skill acquisition was assessed using improvement in time to fixation and distances between ideal and placed entry/exit points for K-wire insertion in three consecutive training sessions. Skill transfer was assessed by comparing the same variables between trained and untrained cohorts in sixteen residents performing K-wire fixation in cadaveric hands. Mean/Median differences, percentile shift analysis, and empirical cumulative distribution function (ECDF) were used for groupwise comparison. Results Target registration error and 3D printing accuracy of the model was measured at <0.13mm and <1mm respectively. Qualitative parameters evaluating anatomical accuracy, fluoroscopy, K-wire simulation all achieved median scores ranging from 4 to 5. Across three sessions in eight residents we observed a mean reduction in time to fixation and distance from ideal to placed entry and exit points. Mean time to fixation reduced from 65.63 ± 37.66s in session 1 to 41.11 ± 12.81s by session 3. For the K-wire traversing the 1st metacarpal the distance between ideal and placed entry point decreased from 7.31 ± 8.96 mm to 5.23 ± 3.87 by session 3. Evaluating K-wire fixation on cadaveric hand fractures, a mean reduction in time to fixation and number of attempts was observed in the MR trained cohort. ECDF plots indicated a sustained left shift in the MR trained cohort after 6.1 mins and 3 attempts. In addition, reduced distance from ideal to placed entry and exit points were observed for both primary and stabilizing K-wires (6/7) for both metacarpal fractures. Interestingly, percentile shift analysis indicated these improvements to be prominent in less experienced residents. Conclusion We validated a novel MR simulator for training plastic surgery residents in K-wire fixation of metacarpal fractures and demonstrated procedural skill acquisition and transfer. Adoption of such simulators into plastic surgery curricula will provide accessible opportunities for practice, metrics for tracking progress, and accelerate skill acquisition, thereby contributing to improved patient safety and outcomes.

Purpose: Letters of recommendation (LORs) play a critical role in fellowship applications. However, there is concern that written materials in selection processes don't purely reflect applicant merit, but may also encode subtle identity-based variation. Ethnic disparities in tone and authenticity scores of personal statements were identified in otolaryngology residency applications (1). Similarly, gender- and race-based differences in descriptive language have been documented in LORs in radiation oncology (2). The review by Machen et al. highlights that LORs contain biases against women and those historically underrepresented in medicine (3). No prior study has evaluated whether such differences exist in hand surgery fellowship applications. Understanding LOR patterns across gender may help identify potential biases in the evaluation process, promote equitable review practices, and inform future fellowship selection and applicant advising.

Materials and Methods: LORs from applications to a single hand surgery fellowship program submitted between the years 2022 and 2025 were analyzed using the Linguistic Inquiry and Word Count (LIWC) framework. Applicants were categorized by gender and interview invitation status. LORs were concatenated and analyzed as a single composite text. LIWC summary and category-level variables were extracted for univariate analysis. Independent multivariable logistic regression models were adjusted for application year, total word count, and applicant gender. Gender interaction terms were tested in secondary analyses. Multiple comparisons were addressed using false discovery rate (FDR) correction, with adjusted q-values <0.05 considered statistically significant.

Results: LORs from 397 applicants (256 male, 141 female) were analyzed. Of these, 95 applicants were invited for interviews and 302 were not. After FDR correction, no LIWC variable demonstrated significant univariate differences by applicant gender. Invited applicants had significantly higher total letter word counts (median 1922 vs 1689 words; U=18189.0, p<0.001) with LORs that demonstrated lower politeness scores (median 0.52 vs 0.65; U=11038.5, p<0.001) and lower prosocial language (median 1.10 vs 1.28; U=11225.5, p=0.001). Multivariable regression demonstrated higher total word count (OR=1.0009, CI [1.0004, 1.0013], p<0.001), lower prosocial language (OR=0.39, CI [0.20, 0.75], p=0.005), and lower politeness score (OR=0.18, CI [0.06, 0.59], p=0.004) were associated with higher odds of invitation. Secondary analyses demonstrated no significant gender interactions.

Conclusion: No global linguistic differences were observed by gender status. LORs of invited applicants were observed to have higher total letter word count, lower politeness scores, and lower prosocial language on both univariate and multivariate analyses with no significant differences between gender. These findings suggest that LORs emphasizing communal framing may be associated with a less favorable selection outcomes in hand surgery fellowship applications.

References: 1. Stack TJ, Berk GA, Ho TD, et al. Racial and Ethnic Bias in Letters of Recommendation and Personal Statements for Application to Otolaryngology Residency. ORL. 2023;85(3):141-149. doi:10.1159/000529795 2. Chapman BV, Rooney MK, Ludmir EB, et al. Linguistic Biases in Letters of Recommendation for Radiation Oncology Residency Applicants from 2015 to 2019. J Cancer Educ. 2022;37(4):965-972. doi:10.1007/s13187-020-01907-x 3. Machen JL, Gandhi SM, Moreland CJ, Salib S. Promoting Equity in Letters of Recommendation: Recognizing and Overcoming Bias. Am J Med. 2023;136(12):1216-1221. doi:10.1016/j.amjmed.2023.08.002

Purpose Metacarpal fractures are common hand injuries with variable severity, and management often relies on surgeon judgment. Existing classification systems describe fracture anatomy but inadequately reflect clinical severity or operative decision-making. The Metacarpal Injury Severity Score (MISS) was developed to stratify severity and predict operative management and outcomes. This study evaluates MISS by examining its association with operative recommendations, care timelines, and postoperative outcomes.

Methods We performed an IRB-approved retrospective study of 588 patients with metacarpal fractures treated from 2020–2025. Injury severity was assessed using the Metacarpal Injury Severity Score (MISS; Table 1), calculated across six domains (0–18) and categorized as low (0), intermediate (1–3), or high (≥4). Operative recommendation was the primary outcome, with care timelines and postoperative outcomes as secondary outcomes. Descriptive, comparative, and multivariable analyses were performed. Follow-up from the time of diagnosis ranged from one week to approximately six to twelve months, depending on the patient.

Results Among 588 patients (mean age 37.6 years; 70.7% male), MISS values ranged from 0–12 (median 1, IQR 1–2), with 56.8% of injuries classified as low severity. Operative management recommendations increased in a graded fashion with MISS score, occurring in 17.1% of MISS = 0, 59% of MISS = 1–3, and 94.8% of MISS ≥4 injuries (p < 0.001). In multivariable analysis, severe MISS (≥4) was the strongest independent predictor of operative recommendation (OR 16.4; 95% CI 5.9–68.3; p < 0.001). Among MISS = 0 injuries, operative decisions were commonly associated with thumb or small-finger involvement and shaft-level fractures, whereas higher MISS injuries were driven by comminution and soft-tissue injury. While time from injury to medical evaluation did not differ by MISS, higher MISS severity was associated with significantly shorter time to surgical consultation (p < 0.001). Severe injuries (MISS ≥4) demonstrated higher postoperative morbidity, including infection, delayed union, sensory deficits, and higher reoperation rates compared with non-severe injuries (19.0% vs. 2.3%).

Conclusion Increasing MISS values demonstrated a strong, graded association with operative management recommendation, with near-universal operative consideration among high-severity injuries. Higher MISS scores reflected greater anatomic complexity and were associated with expedited surgical consultation, increased postoperative morbidity, and higher reoperation rates. Operative management in MISS = 0 injuries was influenced by digit involvement and fracture characteristics, indicating that MISS captures structural severity while allowing appropriate clinical judgment in low-severity cases. Overall, these findings support MISS as a clinically meaningful and reproducible severity metric for anticipating care pathways and resource utilization.

Introduction: Currently, typical management for Dupuytren's Disease (DD) depends on severity with both non-surgical and surgical approaches available. Early stages may be amenable to collagenase injections and needle aponeurotomy, however, these less invasive options are associated with a higher incidence of recurrence. For advanced stages, surgical options such as open fasciectomies are considered, but adjuvant treatments such as radiation therapy (RT) may be considered for poor surgical candidates patients with aggressive disease. RT remains an active area of research in DD. Radiation can soften the subcutaneous nodules that lead to contracture and can stabilize or even regress the disease. Individual variability in DD progression, recurrence, and treatment morbidity underscore the importance of continuing to explore new interventions, such as RT. Our systematic review aimed to compare complications and treatment outcomes of RT to traditional surgical and non-surgical treatments for Dupuytren's disease, such as needle aponeurotomy, steroid injections, and Collagenase injections based on most recent evidence in the last ten years. We also assessed the role of RT alone vs an adjuvant therapy with surgery.

Methods: This systematic review was registered with Prospero and conducted in accordance with PRISMA guidelines. A comprehensive literature search was performed in MEDLINE, Embase, Web of Science, Cochrane Central, and ClinicalTrials.gov for studies published in the last 10 years by an experienced librarian. Eligible studies included adult patients with DD who received RT either alone or as adjunct therapy. Two reviewers independently conducted screening and data extraction, and the NIH quality assessment tool was used to evaluate study validity.

Results: A total of 5 studies met our inclusion criteria, pooling 291 patients with 1 study comparing adverse effects of RT as an adjuvant to limited fasciotomy with observation cohort as a control and 4 studies comparing the effectiveness of RT with no controls. Three of the five studies used RT alone and two used partial fasciotomy followed by RT for DD treatment. All 4 studies that compared RT symptoms reported a statistically significant reduction in DD symptoms without any adverse events and the paper that compared adverse side effects reported minimal side effects up to 48 month follow-up. Ciernek et al. reported decrease from Stage II to Stage I in Tubiana scoring. Zirbs et al. and Stark et al. reported a decrease in DD symptoms by an average of 67% from patient questionnaires. Banks et al. reported a decrease in mean volume and enhancement of palm by 1.2cm 3 . A total of 178 patients who experienced adverse events were found in total (each paper having 136 patients , 0 patients, 3 patients, and 39 patients experiencing adverse events with one paper not reporting).

Discussion: Overall, RT has been reported to be effective with or without adjunct therapy in the four articles extracted from our systematic review. There were minimal to no side effects reported from RT in all five studies, which was highlighted in a study that examined only the side effects of radiation therapy for DD reported that there were no adverse events in patients who received radiation therapy as an adjuvant to limited fasciotomies or collagenase injections, suggesting that RT is a feasible and safe procedure when compared to patients who only receive surgical interventions. All studies that compared effectiveness of RT concluded that RT successfully reduced DD symptoms. In conclusion, radiation therapy of 30-36 Gy has been effective in reducing symptoms of DD, and well tolerated with minimal long-term adverse effects in newer studies since 2015. Further investigations with larger sample size, longer follow up period, and examining control groups are necessary to assess utility of RT alone vs adjunct to surgical treatments.

Introduction Postoperative complications following upper extremity fracture fixation remain a significant challenge (1,2). Frailty may better predict postoperative risk than comorbidities alone by capturing cumulative physiologic burden and resilience to stress; however, its role in traumatic upper extremity fracture fixation remains poorly defined (3,4). The purpose of this study is to evaluate the utility of the 5-item modified frailty index (mFI-5) in predicting postoperative complications after upper extremity fracture fixation, with and without soft tissue reconstruction.

Methods The ACS-NSQIP database (2010–2022) was queried to identify adult patients undergoing traumatic upper-extremity fracture fixation. Patients were stratified into non-frail (mFI-5 <2) and frail (mFI-5 ≥2) cohorts. Thirty-day postoperative surgical complications included superficial, deep, and organ space surgical site infection, wound dehiscence, and wound-related reoperation. Univariate and multivariable logistic regression analyses were performed with stratification by fracture location, fixation method, and presence of soft tissue reconstruction (p<0.05).

Results A total of 90,587 patients were identified (mFI-5 <2: 82,627; mFI-5 ≥2: 7,960; mean age 50.8 ± 19.1 years). Frail patients had significantly higher complication rates on univariate analysis (p<0.001). On multivariable analysis, frailty remained associated with higher odds of complications following fracture fixation alone (p<0.001), while outcomes did not differ with concomitant soft tissue reconstruction (p=0.338). Frailty increased complication risk after open fixation (p<0.001), but not percutaneous fixation (p=0.815). Hand, wrist, and forearm fractures did not significantly influence outcomes.

Conclusion Frailty, as measured by the mFI-5, independently predicts postoperative complications following traumatic upper extremity fracture fixation. While soft tissue reconstruction was not associated with increased complication risk in frail patients, this may reflect underlying injury patterns rather than an independent effect of reconstruction. Percutaneous fixation mitigates frailty-associated risk, whereas open fixation is associated with higher complication rates. The mFI-5 is a practical risk-stratification tool informing perioperative planning and postoperative monitoring.

References 1. de Souza Serenza F, Rizzato MMSA, Vieira F, McQuade KJ, de Oliveira AS. Kinematic analysis of upper limb fractures: Insights for rehabilitation strategies. Clin Biomech (Bristol). 2025;122:106432. doi:10.1016/j.clinbiomech.2025.106432 2. Dong X. Surgical site infection in upper extremity fracture: Incidence and prognostic risk factors. Medicine (Baltimore). 2022;101(35):e30460. doi:10.1097/MD.0000000000030460 3. Kim DH, Rockwood K. Frailty in Older Adults. N Engl J Med. 2024;391(6):538-548. doi:10.1056/NEJMra2301292 4. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications for clinical practice and public health. Lancet. 2019;394(10206):1365-1375. doi:10.1016/S0140-6736(19)31786-6

Purpose: Toe-to-hand transfer is an established reconstructive option for pediatric patients with congenital or traumatic digital deficiencies, restoring prehensile function and providing sensate digits with preserved growth potential. While survival rates are high, secondary procedures are common and long-term growth patterns remain incompletely characterized. This study evaluates clinical and radiographic outcomes following pediatric toe-to-hand transfer, with emphasis on longitudinal growth.

Methods: A retrospective review was conducted of pediatric patients who underwent toe-to-hand transfer at a single institution. Demographics, operative details, and clinical outcomes were collected. Outcomes included flap survival, reoperations, complications, union, infection, range of motion, sensory recovery, ability to pinch, donor-site morbidity, and return to activity. Serial radiographs were reviewed when available to assess bone length change and fusion-site angular alignment. Bone length change was quantified as a percent length difference based on comparison with prior imaging or with an adjacent native digit or metacarpal measured on the same radiograph.

Results: Fourteen toe-to-hand transfers were performed in 13 patients from October 1998 to August 2025 (mean age 5.7 years, range 1–16 years) with a mean clinical follow-up of 42.3 months (range 1–161 months). Thirteen transfers survived, yielding a survival rate of 93%. Secondary procedures were performed in 11 transfers (79%). Complications occurred in six transfers and included vascular thrombosis resulting in flap loss (n=1), infection (n=1), tissue necrosis (n=2), and contracture or stiffness requiring surgical release (n=3).

Functional outcomes were variably documented. Range of motion was documented in 11 transfers. Transfers to the thumb notably demonstrated preserved carpometacarpal mobility with more limited interphalangeal motion. Some degree of sensory recovery was documented in 6 transfers, and ability to pinch was documented in 6 transfers.

Serial radiographs were available for eight transferred digits with follow-up ranging from 1 month to 8.9 years. Percent change in measured bone length ranged from −7% to +121%, with most transfers demonstrating continued increases. Bone-length ratios remained relatively stable over time, suggesting proportional growth relative to the native hand. Angular deformity showed minimal change over time, with differences generally less than 10°, although greater angular change was observed in patients demonstrating smaller increases in measured bone length.

Conclusion: Pediatric toe-to-hand transfer demonstrated reliable survival and continued longitudinal growth with stable proportional relationships to native digits. Frequent secondary procedures reflect the complexity of optimizing functional outcomes. These findings support toe-to-hand transfer as a durable reconstructive option for pediatric digital deficiencies and suggest transferred digits maintain proportional growth with the native hand.

Background: Intramedullary screw fixation is an emerging technique for metacarpal fracture management that has demonstrated promising functional outcomes. In this study, we present our clinical experience with this method and aim to quantify screw migration following intramedullary fixation of metacarpal fractures.

Methods: A retrospective chart review and radiographic analysis were performed for patients who underwent intramedullary screw fixation of metacarpal fractures via a percutaneous retrograde approach, with a minimum follow-up of 6 weeks. Cases were collected across three institutions involving four surgeons. Patient charts were reviewed, and demographic characteristics, implant parameters, indications, and complications were documented. The baseline position of the screw head relative to the distal cortex was measured on the first postoperative radiograph. The intramedullary screw was used as a known reference object for calibration to minimize potential errors due to magnification or angulation. The distance from the distal tip of the screw head to the distal cortex was measured over time on subsequent postoperative radiographs. Linear mixed-effects models were used to evaluate changes in screw position over time.

Results: Data were collected for 43 metacarpal fractures in 37 patients. The cohort was predominantly male (86%) with a mean age of 34 ± 11 years. Radiographic analysis demonstrated consistent distal migration, with the distance from the distal cortex to the screw head decreasing from 3.65 ± 2.61 mm to 3.10 ± 2.4 mm between the first and second postoperative visits. The proximal distance reciprocally increased, confirming distal screw migration. Oblique fracture patterns had significantly shorter initial distances compared to transverse fractures (2.6 ± 1.8 mm vs 4.3 ± 2.9 mm, p = 0.012), although migration rates did not differ. Age, gender, BMI, and screw type were not associated with migration. Major complications occurred in 9.3% of cases, including two screw removals due to concern for intra-articular penetration.

Conclusion: Intramedullary screws demonstrate consistent distal migration in the acute postoperative period. Although statistically significant, this migration appears clinically benign in most cases. Oblique fracture patterns result in closer initial screw positioning relative to the articular surface, warranting consideration during preoperative planning.

Background: With over 400,000 procedures performed annually, Carpal Tunnel Release (CTR) is among the most common hand surgeries in the United States. While common, the geographic distribution of CTR surgery and providers has not been investigated. Our study characterizes CTR utilization across communities ranging from metropolitan to rural, in order to elucidate geographic disparities in access to care.

Methods: Nationwide CMS Medicare Provider Utilization and Payment Data was analyzed from 2013-2023 to identify all plastic and orthopaedic surgeons who performed CTR each year. Provider ZIP codes for each CTR case were mapped to Rural-Urban Commuting Area (RUCA) codes, classifying the location of each procedure into one of four settlement types: urban/metropolitan, micropolitan, small town, or rural. The number of CTR-performing surgeons, total CTR case volumes, and median annual CTR cases per surgeon were calculated for each settlement type. Trends over time in surgeon counts and procedure volumes by settlement types were assessed using two-sided Mann-Kendall trend tests (significance level p<0.05).

Results: Between 2013 and 2023, open and endoscopic carpal tunnel releases (CTRs) were billed by as many as 4,369 surgeons. The distribution of CTRs across settlement types was heavily skewed toward urban/metropolitan regions, which accounted for 89.8% of all procedures, followed by micropolitan areas (8.7%), small towns (1.1%), and rural areas (0.3%). Urban/metropolitan surgeons performed a median of 27.2 CTRs per surgeon per year, the highest median annual volume across all settlement categories over the 11‑year period. Median annual CTR volume per surgeon was 20.3 in micropolitan areas, 17.1 in small towns, 22.1 in rural areas, and 20.5 in locations classified as unknown. Over the study period, the number of CTR‑performing surgeons declined across non‑urban regions: 26% in micropolitan areas (p<0.01), from 38% in small towns (p<0.01), and 50% in rural areas (p<0.01).

Conclusion: This study identified significant geographic disparities in the utilization of CTR. Despite 20% of Americans residing in rural areas, only about one-third of one percent of CTR surgeries were performed in those areas, highlighting a dramatic inequity in access to care. Additionally, the number of CTR surgeons in non-urban areas appears to be declining over time, further exacerbating this disparity. These findings highlight an urgent need to address the maldistribution of hand surgery services and restore access for carpal tunnel patients in rural America.

References:

1. Padua L, Cuccagna C, Giovannini S, et al. Carpal tunnel syndrome: updated evidence and new questions. Lancet Neurol. 2023;22(3):255-267. doi:10.1016/S1474-4422(22)00432-X

2. Diaz A, Schoenbrunner A, Pawlik TM. Trends in the Geospatial Distribution of Inpatient Adult Surgical Services across the United States. Ann Surg. 2021;273(1):121-127. doi:10.1097/SLA.0000000000003366

3. Talbott J, Khurana A, Wasson M. The Supply of Surgical Specialists and Subspecialists to the U.S. Medicare Population: National Trends from 2013 to 2019. Acad Med. 2024;99(8):889-896. doi:10.1097/ACM.0000000000005664

4. Timperley J, Shipman SA, Al-Refaie W. Policy Priorities to Improve Access, Equity, and Quality in Surgical Care: Advancing Innovative and Sustainable Solutions. World J Surg. 2025;49(8):2078-2082. doi:10.1002/wjs.12693

5. McCrum ML, Wan N, Han J, Lizotte SL, Horns JJ. Disparities in Spatial Access to Emergency Surgical Services in the US. JAMA Health Forum. 2022;3(10):e223633. Published 2022 Oct 7. doi:10.1001/jamahealthforum.2022.3633

Purpose: Previous studies on simultaneous peripheral nerve decompression have typically focused on simultaneous release limited to combination carpal and cubital tunnel release or double crush release on a single nerve. There are concerns that increasing decompression count may increase risk without improving outcomes. The purpose of this study is to broadly evaluate the efficacy and safety of simultaneously decompressing increasing numbers of distinct extremity sites in a single operation.

Methods: A retrospective review was conducted of patients who underwent single or multiple extremity decompressions between 2015 and 2024 at a single institution. Pre- to postoperative symptoms were recorded binarily. Symptom change postoperatively was evaluated using paired McNemar tests. Longitudinal effects were modeled by generalized estimating equations (GEE) logistic regression assessing time and per decompression interactions. Complication and reoperation risks were analyzed using Firth penalized logistic regression adjusted for demographic and operative covariates, with odds ratios reported per decompression.

Results: 465 patient cases were included with pain, sensory abnormality, Tinel's, and weakness all demonstrating significant improvement following surgery (p<0.0001) at a mean follow-up of 46.9 weeks. The mean decompression count was 3.2 [+/- 2.3]. Increasing decompression count was associated with significantly greater preoperative symptom prevalence for all four symptoms (p<0.05 for all four symptoms). GEE longitudinal modeling demonstrated a significant per decompression effect for sensory symptoms, with an OR of 0.82 [0.79-0.95, p=0.009] showing an 18% decrease in postoperative symptom odds with each increase in decompression count. GEE showed an even stronger trend with Tinel's sign, with a per-decompression OR of 0.76 [0.65-0.87, p<0.001]. However, while pain and weakness showed strong time improvement effects post-operatively (OR 0.17-0.42, p<0.001) there was not a significant interaction with increasing decompression count. This sensory symptom trend remained significant when brachial plexus patients were excluded (p=0.011), and the trend for Tinel's sign remained directionally consistent while approaching significance (p=0.057). Overall complications, most commonly persistent symptoms (32.8%), occurred in 33.8% of patients with no significant association with decompression number (OR 1.07 per decompression, p=0.2). Similarly, reoperation rates were low overall (6.7%) and were also not associated with increased OR per decompression, even when stratifying reoperation location (same, distal, proximal, distinct nerve) on the nerve relative to the index operation.

Conclusions: Increasing simultaneous decompression count is not associated with higher complication or reoperation rates in general or on a per decompression basis. Despite greater preoperative population symptom prevalence, broader simultaneous multilevel nerve decompression yield greater odds of sensory and Tinel's improvement without added morbidity compared with more limited releases. This study supports the safety and potential therapeutic advantage of comprehensive single-stage multilevel nerve decompression in appropriately selected patients.

Background: Upper extremity chronic nerve compression (CNC) causes significant morbidity to hand function and patients demonstrate varied recovery after surgical treatment. To better understand the pathology and subsequent recovery, studies are needed to characterize peripheral nerve changes after compression. We aim to leverage a CNC animal model to characterize peripheral nerve changes proximal and distal to compression and explore whether age alters these responses.

Methods: Twenty-one C57BL/6J male mice underwent left sciatic nerve compression at 20 weeks (n=5; Young (Y); n=10; Late (L)) and 67 weeks (n=6; Aged (A)). Nerves were compressed for 16 weeks in Y and A and 52 weeks in L before bilateral nerves were harvested with the contralateral limb acting as an internal control. Nerves were fixed and epon embedded for analysis. Light microscopy 100X images were randomly selected to calculate histomorphometrics with FIJI and MyelTracer.

Results: Across cohorts, axonal areas proximal to compression were lower than contralateral controls-Young: 17.1 (95% CI 15.3–18.8) vs 20.7 (95% CI 17.9–23.5); Aged: 17.8 (95% CI 15.8–19.9) vs 18.6 (95% CI 13.4–23.8); Late: 24.1 (95% CI 22.3–25.8) vs 26.9 (95% CI 25.0–28.9). Across cohorts, g-ratio proximal to compression was higher than contralateral controls-Young: 0.676 (95% CI 0.67–0.69) vs 0.580 (95% CI 0.56–0.60); Aged: 0.693 (95% CI 0.68–0.71) vs 0.633 (95% CI 0.61–0.66); Late: 0.703 (95% CI 0.70–0.71) vs 0.657 (95% CI 0.65–0.67).

Conclusion: Across cohorts, CNC demonstrated degenerative changes within the peripheral nerve that extended beyond the site of compression. Histologically, small clusters of regenerative axons were observed proximally as well as occasional axons demonstrating features of Wallerian degeneration. The difference in g-ratios seen between compressed and non-compressed nerves further supports a degeneration and regeneration, with higher g-ratio indicating thinner myelin. Data also shows higher g-ratio in the Aged cohort on both the compressed and control side compared to younger mice with the same duration of compression suggesting slower nerve regeneration with age.

Introduction: Proton pump inhibitors (PPIs) represent one of the most frequently prescribed medication classes in the United States. However, they have recently been linked to sub-optimal bone health and delayed fracture healing, perhaps due to acid suppression's effect on mineral absorption [1-2]. The first large database study on this subject sought to determine whether preoperative PPI use results in adverse short-term and long-term postoperative complications and outcomes following surgical treatment of proximal and middle phalanges.

Methods: A retrospective cohort study was performed using the TriNetX Research Network to identify adults who underwent closed, open, or percutaneous procedures to repair proximal or middle phalangeal fractures, with or without pre-existing PPI use. To control for demographics, BMI, and comorbidities (including metabolic or absorptive disorders, gastroesophageal reflux, gastritis, and esophagitis), propensity-score matching was performed to yield comparable cohorts for analysis. Outcomes included dehiscence, infection, and death within 6 months. Long-term outcomes included secondary procedures for debridement or repair, hardware failure, tendinous adhesions, and hand contractures or osteoarthritis within 5 years.

Results: 71,610 patients without pre-existing PPI usage and 3225 patients with PPI use were identified. After matching, there were 3215 patients in each cohort that were compared. Within 6 months postoperatively, PPI users demonstrated clinically modest, but significantly higher rates of dehiscence (p = 0.0449), infection (p = 0.0191), hematoma (p = 0.0161), seroma (p = 0.0026), sepsis (p = 0.0187), DVT/PE (p = 0.0048), and return to OR (p < 0.0001). Within 5 years postoperatively, PPI users continued to show significantly higher rates of return to OR (p < 0.0001), in addition to hardware complications (p = 0.0021) and postoperative osteoarthritis and contractures of the hand (p = 0.0042).

Conclusions: Although PPIs constitute one of the most frequently prescribed medications in the American population, they may confer higher risk of postoperative complications in the short- and long-term following proximal and middle phalangeal fracture repairs. Further research is warranted on the exact mechanism behind PPIs' effects on bone healing issues in addition to whether counseling on PPI use prior to undergoing orthopedic surgery with should become a more standardized part of preoperative care.

References: [1] Lespessailles, et al. Proton pump inhibitors and bone health: An update narrative review. Int J Mol Sci 2022;23(18):10733. [2] Ito, et al. Association of long-term proton pump inhibitor therapy with bone fractures and effects on absorption of calcium, vitamin B12, iron, and magnesium. Curr Gastroenterol Rep 2010;12(6):448-57.

Purpose In 1992, Medicare adopted the Resource Based Relative Value Scale (RBRVS) as the basis for physician fees under the Medicare Physician Fee Schedule. This scale determines payment using three RVU components that sum to the total RVU for a service: physician work (~51%), practice expense (~45%), and professional liability insurance (~4%). Work RVU (wRVU) is intended to capture physician time, technical skill, mental and physical effort, clinical judgment, and psychological stress associated with a specific service. The American Medical Association Relative Value Scale Update Committee uses specialty society data and physician survey data to inform wRVU valuation and update recommendations. Despite this framework, wRVUs may not reflect procedural effort. Hand surgery represents a substantial share of plastic surgery operative volume, yet its reimbursement valuation relative to other plastic surgery procedures has not been well characterized. We compared wRVU-per-minute for plastic surgery hand procedures versus non-hand plastic surgery cases in a one-to-one case matched cohort. We hypothesized that plastic surgery hand procedures would generate significantly fewer work RVUs-per-minute than non-hand plastic surgery procedures of similar perioperative complexity. Methods A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant use data files was performed from 2012 to 2024. Plastic surgery cases were identified using the NSQIP surgical specialty classification. Hand cases were identified using the primary CPT code and subcategorized as bone& joint, nerve, skin & soft tissue, tendon, and tumor. A one-to-one matched cohort of non-hand plastic surgery cases was constructed using Mahalanobis distance matching incorporating demographics, comorbidities, operative time, care setting, predicted risk, and postoperative utilization. Primary outcomes were wRVU, operative time, and wRVU-per-minute. Annualized wRVU generation was estimated using a standardized annual operative workload and the 2024 Medicare conversion factor. Results A total of 275,610 plastic surgery cases were included, of which 24,589 were hand procedures matched one-to-one to non-hand plastic surgery controls. Overall, hand procedures demonstrated 22.9% lower mean wRVUs than matched controls (12.0 vs 15.6, p<0.001) despite only a 3.1% shorter operative time (64.6 vs 66.7 minutes, p<0.001), resulting in a 20.5% lower wRVU-per-minute (0.186 vs 0.234, p<0.001). Across hand specialties, wRVU-per-minute was lower than matched controls for bone & joint (−25.0%, p<0.001), tendon (−14.8%, p<0.001), tumor (−54.9%, p<0.001), and skin & soft tissue (−15.7%, p<0.001). Nerve procedures were the exception, with 10.0% higher wRVU-per-minute than matched controls (p<0.001). Despite matching to non-hand plastic surgery cases with comparable comorbidities, operative times, and postoperative course, hand surgeons generated fewer annualized wRVUs than matched controls, corresponding to $108,010 lower estimated wRVU-based reimbursement. Conclusions After case level matching on perioperative complexity and closely comparable operative time, plastic surgery hand procedures generated fewer wRVU-per-minute than peer non-hand plastic surgery cases. The largest and most persistent valuation shortfalls were observed in tumor and trauma categories. The findings support reassessment of wRVU valuation to better align reimbursement with the technical complexity and perioperative demands of hand surgery and to avoid systematically undercompensating a subspecialty that provides essential reconstructive, trauma, and tumor care.