Scientific Abstract Presentations: Hand Session 5 Sunday, October 18 Sun, Oct 18 8:00-9:30 a.m. CDT

Purpose: A novel simulator was created to teach metacarpal fixation with Kirschner wires. Using this simulator, we held workshops for junior residents, and validated the curriculum via objective pre- and post-workshop assessments on a cadaver model.

Methods: A novel hand simulator was created using 3D printing and silicone casting. Cost of materials was $25. The beginner model has a transparent silicone skin envelope, and the more advanced model is opaque (Figure 1). A two-hour simulation workshop was held for PGY1 and PGY2 plastic surgery residents (n=5). Survey data was collected.

For objective validation, the participants underwent pre- and post-workshop assessments on cadaveric hands (Figure 2). Their task was to drive K-wires through intact cadaver metacarpals 2-5. X-rays were taken of each attempt, and success or failure was judged on ability to drive K-wires through the entire length of the bone. They got 3 attempts per metacarpal, for a total of 12 attempts. Two fellowship-trained Hand Surgery attendings served as the control group.

Results: Survey data indicated that participant confidence significantly improved, and simulator feedback was resoundingly positive. Additionally, the participants' objective skill significantly improved. Comparing objective pre- and post-assessments on cadavers, the participants' successful K-wire placement rate improved from 11.7% to 71.7% (p < 0.001), compared to the attending control group's 87.5% (Figure 3).

Conclusions: Exposure to this novel training tool significantly improved junior resident confidence and objective metacarpal fixation skill. Because it can be mass produced and shared, the device potentially has wide applicability within hand surgery training.

INTRODUCTION The incidence of Breast Cancer Related Lymphedema ranges from 15-40 % after an axillary lymph node dissection (ALND). Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) reduces the risk of lymphedema after ALND. Radiation of the axillary level I and II increases this risk due to a higher concentration of lymph nodes. We aimed to assess the impact of LYMPHA concerning radiation administered to the axillary level I.

METHODS A single-institution retrospective cohort study included breast cancer patients undergoing ALND and LYMPHA (April 2021 to November 2022) followed by adjuvant radiation (all patients had radiation to axilla level II and III), with a follow-up of at least one year. Lymphedema was defined as a Lymphedema Index (L-Dex) (Bioimpedance Spectroscopy) measurement outside the normal range (±10 L-Dex unit) or an increase of ≥10 units from baseline. The primary outcome was the correlation between the L-Dex of patients with partial or no radiation to level 1 (pnRT) or complete radiation (cRT) to level 1. The secondary outcome was to assess the difference in LLIS (Lymphedema Life Impact Scale) scores.

RESULTS Of 70 patients, 21(30%) received pnRT while 49 (70%) received cRT. Demographic and treatment characteristics were comparable between both cohorts. In the pnRT group, 21 patients (100%) had dissection up to Level 2, while in the cRT group, 35 patients (71.43%) had dissection up to Level 2 and 14 patients (28.57%) up to Level 3 (p=0.006). The baseline and follow-up L-Dex scores for patients receiving pnRT and cRT were comparable at baseline, 3 months, 6 months, 9 months, 12 months, as well as the difference from baseline (Table 1). The LLIS scores were comparable between both cohorts at the same time intervals. 14.3 % patients with pnRT and 10.2% patients with cRT had lymphedema. Univariate and Multivariate analysis controlling for chemotherapy, number of resected lymph nodes, stage, and level of dissection did not show higher odds of a higher L-dex score with cRT as compared to pnRT (Table 2).

CONCLUSION LYMPHA is effective in reducing the incidence of lymphedema even in patients who received radiation to axillary level 1 which is a high risk for lymphedema.

Introduction: Thumb carpometacarpal (CMC) instability is a controversial topic in hand surgery. The literature demonstrates substantial variation in terminology, diagnostic approaches, and surgical techniques, while the supporting evidence remains limited. (1) A comprehensive and systematic overview of current clinical practice is lacking. Therefore, this international survey examined the terminology, diagnostic approaches, and treatment strategies used by surgeons worldwide, and explored variations by geographic region and surgical specialty.

Methods: An international cross-sectional survey was developed in collaboration with experienced hand surgeons and formally approved and endorsed by the research committees of the Federation of European Societies for Surgery of the Hand (FESSH) and the American Association for Hand Surgery (AAHS). The survey was distributed worldwide through national professional societies and FESSH. Subgroup analyses compared responses by geographic region (United States vs. Europe) and surgical specialty (orthopedic vs. plastic surgery).

Results: Responses were obtained from 208 surgeons across 38 countries. Most preferred the term "thumb CMC instability" (77%), whereas only 16% used "Stage I thumb CMC arthritis". CMC instability was considered a distinct diagnosis rather than a precursor to CMC osteoarthritis by 29% of respondents. Encounter frequency varied widely, with responses ranging from daily (3%) to rarely (34%). Diagnosis was primarily based on clinical assessment of laxity, supported by radiographs (96%). Non-surgical management was the preferred first-line treatment (88%), with most surgeons proceeding to surgery only if symptoms persisted (76%). A wide range of surgical techniques was reported, with 78% aimed at improving or reconstructing the affected ligaments. The most commonly performed procedure was the Eaton–Littler ligament reconstruction (32%) (2), followed by dorsoradial capsulodesis (22%) (3). United States surgeons reported encountering CMC instability more frequently than European surgeons (p=0.032). Choice of surgical technique differed by specialty (p=0.001), with plastic surgeons favoring ligament reconstruction and orthopedic surgeons more often selecting salvage procedures or arthroscopy.

Conclusions: This international survey provides novel insight into consensus and practice variation in thumb CMC instability, highlighting opportunities to improve and standardize care. The preference for stabilizing interventions supports recognition of thumb CMC instability as a distinct clinical entity from CMC osteoarthritis that warrants targeted treatment. Despite heterogeneous terminology in the literature, there was relative consensus around the term "thumb CMC instability". Therefore, we advise consistent use of this term to improve communication in clinical practice and research.

(1) Jongen IC, Nieuwdorp NJ, Hundepool CA, Van Gelder FS, Schutter AM, Zuidam JM. Ligament reconstruction in thumb carpometacarpal joint instability: A systematic review. JPRAS Open. 2024;39:237-248. (2) Nieuwdorp NJ, Jongen IC, Hundepool CA, et al. The Eaton-Littler Ligament Reconstruction in Thumb Carpometacarpal Joint Instability: Outcomes and Prognostic Factors in 74 Patients. Plast Reconstr Surg. 2025;155(3):533e-542e. (3) Rayan G, Do V. Dorsoradial capsulodesis for trapeziometacarpal joint instability. J Hand Surg Am . 2013, 38: 382–7.

ABSTRACT Background: Aiming to lower healthcare costs and empower patients' decision making, CMS mandated hospitals and health plans to publicly post their negotiated rates for common services and procedures. However, the variation in price for common procedures – like carpal tunnel release (CTR) – across different health insurance plans and hospitals in Wisconsin remains poorly understood. The aim of this study is to characterize payer-specific variation in hospital-based negotiated price for CTR (CPT 64721) across Wisconsin through publicly available price transparency data. Methods: This cross-sectional study analyzed negotiated rates for CTR, CPT 64721, published in August 2025 machine-readable files from three large commercial insurers and their plans in Wisconsin–Anthem BlueCard Preferred, UnitedHealthcare Choice (UHC) EPO, and Wisconsin Physician Services (WPS) Alliance First Health. Prices were analyzed across hospitals and health systems, which were further classified by rural and urban designation as well as size based on staffed bed count. We measured the median rates, interquartile ranges, 10th to 90th percentile ratios, and median rates as a percentage of each hospitals Medicare reimbursement rate. Results: Variance was large across Wisconsin insurers and plans, with median negotiated rates being as low as $1901.12 for WPS and as high as $5,705.90 for UHC, and WPS carrying the largest dispersion of price with a 10/90th percentile ratio of 20.2 compared to 2.56 for Anthem and 1.82 for UHC. Hospital-level analysis showed rural hospitals having higher median negotiated rates across payers despite smaller bed-sizes, with health systems having identical rates within the same insurers. UHC demonstrated higher rates at every urban and rural hospital, except for one institution, and had consistently higher rates as percentage of Medicare from approximately 270% to 440%. Across the five most contracted CBSAs, there was increasing variance in median negotiated price across and within providers, as well as number of published rates. Conclusion: Our analysis highlights that across three large commercial payers, substantial variance exists for a single CPT 64721 within one state. With substantial difference in pricing between hospitals, health systems, their geographic setting and commercial insurance partner, there is an opportunity for more oversight with an emphasis on equity. With policy addressing MRF standardization, payer and hospital posting compliance, patients and providers may be able to make more informed decisions for their cost of care with common services like CTR. Alongside policy advancement, sustained investment from health systems, commercial payers, and key stakeholders in making machine-readable formats more accessible to consumers will be essential for consumer-led health equity and reducing medical debt burden.

Purpose The optimal management of single-digit traumatic amputations in adults remains controversial. Replantation is generally recommended for thumb, pediatric, and multiple-digit injuries. However, its functional benefit over revision amputation for isolated, non-thumb, single-digit injuries is uncertain (1,2). This review synthesizes contemporary evidence comparing patient-reported functional outcomes following replantation and revision amputation in adults with isolated, non-thumb, single-digit traumatic amputations.

Methods and Materials A systematic search of PubMed/MEDLINE, Embase, and Google Scholar identified studies published from January 2005 to December 2025. Eligible studies included adult patients with traumatic, non-thumb, single-digit amputations managed with either replantation or revision amputation that reported outcomes using the Disabilities of the Arm, Shoulder, and Hand (DASH) and/or the Michigan Hand Questionnaire (MHQ) (3). DASH scores were inverted to ensure directional consistency with MHQ scores. Standardized mean differences were calculated using Hedges' g with inverse-variance weighting to enable pooling across outcome instruments. Risk of bias was assessed using the Newcastle–Ottawa Scale.

Experience Five retrospective cohort studies comprising 1,304 patients were included, of whom 451 underwent replantation and 853 underwent revision amputation. Reported follow-up ranged from 12 to 24 months. Mean age ranged from 40.3 to 53.9 years, and all cohorts were predominantly male (74–90%).

Results Replantation was associated with higher pooled functional scores than revision amputation. This corresponded to a small standardized effect size favoring replantation (Hedges' g = 0.36) and a pooled mean difference of 4.16 points. Newcastle–Ottawa Scale scores ranged from 3 to 6, indicating a moderate risk of bias, primarily driven by inherent selection differences between treatment groups.

Conclusion Replantation confers a statistically significant but modest functional advantage over revision amputation for isolated single-digit traumatic amputations in adults. For many patients, this difference is unlikely to be clinically meaningful (4,5).

1. Tessler O, Bartow M, Tremblay-Champagne M, et al. Long-Term Health-Related Quality of Life Outcomes in Digital Replantation versus Revision Amputation. J Reconstr Microsurg. 2017;33(06):446-451. doi:10.1055/s-0037-1601052
2. Chen J, Zhang AX, Chen QZ, Mu S, Tan J. Long-term functional, subjective and psychological results after single digit replantation. Acta Orthop Traumatol Turc. 2018;52(2):120-126. doi:10.1016/j.aott.2017.09.001
3. Arcidiacone S, Panuccio F, Tusoni F, Galeoto G. A systematic review of the measurement properties of the Michigan Hand Outcomes Questionnaire (MHQ). Hand Surg Rehabil. 2022;41(5):542-551. doi:10.1016/j.hansur.2022.08.005
4. Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal Clinically Important Differences of 3 Patient-Rated Outcomes Instruments. J Hand Surg. 2013;38(4):641-649. doi:10.1016/j.jhsa.2012.12.032
5. London D, Stepan J, Calfee R. Determining the Michigan Hand Outcomes Questionnaire Minimal Clinically Important Difference by Means of Three Methods. Plast Reconstr Surg. 2014;133(3):616-625. doi:10.1097/PRS.0000000000000034

Background: Approximately 17,000 new spinal cord injuries (SCIs) occur annually in the United States, with an estimated 282,000 individuals currently living with SCIs. Restoration of upper extremity function remains a top reconstructive priority for these patients, as improved arm function significantly enhances independence and quality of life. Historically, tendon transfer was the primary surgical modality for restoring elbow extension in individuals with tetraplegia. More recently, nerve transfers have gained popularity, demonstrating functional outcomes comparable to tendon transfers while offering potential advantages such as shorter postoperative immobilization periods and decreased surgical morbidity. However, direct comparative data between tendon and nerve transfer techniques is limited. We hypothesize nerve transfer is not inferior to biceps-to-triceps tendon transfer. Methods: A literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Ovid MEDLINE, PubMed, Ovid Journals, and Embase databases. Primary outcomes included Motor Research Council (MRC) and Manual Muscle Testing (MMT) scores with meaningful recovery defined as an MRC or MMT score ≥ 3. Study-level outcomes were weighted by sample size. Differences in meaningful recovery rates between nerve transfer and BTT were assessed using Welch's weight tests. Continuous MRC scores were analyzed using random-effects meta-analysis and meta-regression. Subgroup analysis was performed in the tendon transfer cohort to determine if outcomes differed between adult and pediatric patients. All tests were two-sided with p < 0.05 considered statistically significant. Results: Following the literature review 32 studies met inclusion criteria for analysis. Patients undergoing BTT (161 arms) were significantly younger compared to those undergoing nerve transfer (117 arms) (20.9 ± 8.2 years vs 32.8 ± 12.7 years; p < 0.0001). There was no significant difference in percent meaningful recovery (MRC ≥ 3) between nerve and BTT transfer cohorts (68.5% and 70.5% respectively; p = 0.8607). The pooled BTT transfer MRC score, 3.46, was not significantly different from the pooled nerve transfer MRC scores, 2.93 (mean difference, 0.53 MRC points; 95% CI, −0.17 to 1.23; p = 0.1568). Within the nerve transfer cohort, lower cervical injuries (C5 or below) were associated with significantly higher MRC scores compared with upper cervical injuries (C2–C4) (median 4 vs 3; Mann–Whitney U = 70.5, p = 0.028). Within the tendon transfer cohort there was no significant difference in meaningful recovery between children (76.55%) and adults (69.25%) (p = 0.5155). Conclusion: Nerve transfer is not inferior to BTT and provides comparable functional outcomes for restoration of elbow extension in patients with tetraplegia. While not all patients are candidates for nerve transfer the study provides guidance when counseling patients regarding reconstructive options and surgical planning.

Introduction: Surgery is a demanding field that requires excellence in both operational outcomes and safety metrics. The implementation of duty hours and subsequent limitations in operative experience has driven the demand for new educational techniques to accelerate learning for trainees (1). The rapid advancement of 3-dimensional (3D) printing technology has allowed for the development of a growing number of 3D printed models for surgical training, including within hand surgery. Previous models have been used to simulate metacarpal or phalangeal fracture fixation (2,3) but have not included the carpus which tends to be a more difficult bone to fix. In this study, we present a downloadable, affordable, and easy-to-create simulator to teach scaphoid fracture fixation. Methods: The model (Figure 1) was developed using geometry extracted from a computed tomography (CT) scan. This model is made of 3-D printed bones encased in silicone and allows trainees to practice the techniques of percutaneous scaphoid fixation using fluoroscopy and cannulated compress screws. The model was piloted with plastic surgery residents at an accredited plastic surgery residency program during a didactics session. Each trainee was provided with three hands with which to practice the fracture fixation. The time to complete each attempt was recorded. Residents were provided with a questionnaire before and after the session. Results: A total of seven residents participated in the study, three junior residents and four senior residents. The average completion times from start to when the trainee felt satisfied with their fixation were 8.21, 5.91, and 3.05 minutes, respectively. Data was collected about the quality of the fixation. The last trial took significantly less time than the first trial (p<.05). Residents agreed that the training session was helpful and that they would like additional sessions with the hand model in the future. Before the training session, residents were neutral about the utility of non-cadaveric models, including 3D printed models, for surgical training. After the session, they were significantly more likely to agree that non-cadaveric models were both useful to develop surgical skills and realistic compared to the OR (p<.05). Discussion: The growing demand for simulated surgical training and the rapid development of 3D-printing technology has led to several recent hand bone fracture fixation models (2,3). Our model expands previous work with a unique focus on scaphoid fracture fixation. Residents responded positively to the model and demonstrated an improved fixation time after multiple fixation training attempts. The model has a strong focus on simplicity of design and manufacture, critical for other groups to reproduce it. This model has now become an important part of our core residency didactic program since its implementation to good effect.

References: 1. Agha RA, Fowler AJ. The role and validity of surgical simulation. Int Surg. 2015;100(2):350-7. 2. Farrell DA, Miller TJ, Chambers JR, Joseph VA, McClellan WT. Three-Dimensionally-Printed Hand Surgical Simulator for Resident Training. Plast Reconstr Surg. 2020;146(5):1100-2. 3. Prsic A, Boyajian MK, Snapp WK, Crozier J, Woo AS. A 3-Dimensional-Printed Hand Model for Home-Based Acquisition of Fracture Fixation Skills Without Fluoroscopy. J Surg Educ. 2020;77(6):1341-4.

Objective Tier-based frameworks currently determine which patients undergo tenosynovial biopsy for amyloidosis at the time of carpal tunnel release, incorporating factors such as age, sex, bilateral involvement, and selected cardiovascular or musculoskeletal comorbidities (1,2). Currently, chronic kidney disease is not included in these criteria despite biological plausibility and recognized systemic overlap with transthyretin amyloidosis (3). Failure to identify high-risk patients may postpone referral and access to disease-modifying therapies (4). We examined whether chronic kidney disease is independently associated with amyloidosis and whether its addition could strengthen screening strategies in a community hospital setting. Methods We conducted a retrospective cohort study of consecutive patients undergoing open carpal tunnel release with concurrent tenosynovial biopsy between March 2022 and October 2023 at a single community institution. Biopsy selection adhered to established Tier I and Tier II guidelines. Samples staining positive for Congo-red were confirmed with mass spectrometry. Demographic variables and comorbidities including chronic kidney disease, diabetes mellitus, atrial fibrillation, heart failure, and spinal stenosis were abstracted from the electronic medical record. Amyloid-positive and amyloid-negative groups were compared using bivariate analysis. Results Among 105 patients (median age 66.0 years; 47.6% female), 9.5% demonstrated confirmed amyloid deposition, with 60% classified as ATTR subtype. Amyloid-positive patients were significantly older (median 81.5 versus 65.0 years). Chronic kidney disease was identified in 70.0% of amyloid-positive patients compared with 25.3% of amyloid-negative patients. Diabetes mellitus was also more prevalent among amyloid-positive individuals (90.0% versus 41.1%). Bilateral carpal tunnel syndrome was observed in 70% of amyloid-positive cases. Among ATTR-positive patients, four of six had chronic kidney disease. Despite confirmed diagnoses, only one patient began amyloid-directed therapy. Conclusion In this community cohort, chronic kidney disease was strongly associated with amyloid positivity and was identified in the majority of ATTR-positive patients. Current Tier-based models may incompletely identify at-risk patients outside tertiary referral centers (2). Expanding Tier II criteria to include chronic kidney disease may improve detection without increasing operative burden or cost. With the growing availability of transthyretin-targeted therapies (5), optimizing biopsy selection during routine carpal tunnel surgery provides an opportunity for plastic surgeons to contribute to earlier systemic disease identification. Refinement of biopsy criteria represents a practical opportunity for plastic surgeons to improve systemic disease recognition during routine carpal tunnel surgery.

References 1. Sperry BW, Reyes BA, Ikram A, et al. Tenosynovial and cardiac amyloidosis in patients undergoing carpal tunnel release. J Am Coll Cardiol. 2018;72(17):2040-2050. 2. Donnelly JP, Hanna M. Cardiac amyloidosis: an update on diagnosis and treatment. Cleve Clin J Med. 2017;84(12 suppl 3):12-26. 3. Ruberg FL, Berk JL. Transthyretin cardiac amyloidosis. Circulation. 2012;126(10):1286-1300. 4. Grogan M, Dispenzieri A. Natural history and therapy of transthyretin cardiac amyloidosis. Curr Cardiol Rep. 2015;17(6):59. 5. Maurer MS, Schwartz JH, Gundapaneni B, et al. Tafamidis treatment for transthyretin amyloid cardiomyopathy. N Engl J Med. 2018;379(11):1007-1016.

Abstract: Ulnar and radial artery injuries are uncommon but clinically significant, comprising approximately 0.74% of trauma admissions in Level I trauma centers (1). In a perfused hand, ligation has historically been considered acceptable when collateral circulation is adequate, though contemporary practice increasingly favors arterial repair (2). This literature review compares repair versus ligation of radial and ulnar artery injuries in the setting of concomitant forearm trauma, emphasizing functional recovery and vasospastic outcomes. Methods: An online literature search identified studies between 1995 and 2023 evaluating management of radial/ulnar artery injuries associated with forearm trauma. Additionally, peer-reviewed articles comparing arterial repair and ligation were reviewed. Studies reporting functional outcomes, vasospastic symptoms, vessel patency, or complications were included. Relevant patient characteristics, operative strategies, and outcomes were extracted and synthesized. Experience: Included studies consisted primarily of retrospective cohort series and literature reviews. Cohorts ranged from isolated single-vessel injuries in perfused hands to combined arterial, nerve, and tendon trauma. Most reports included postoperative functional assessment beyond the immediate recovery period, evaluating patency, cold intolerance, grip strength, and validated patient-reported measures using QuickDASH. Results: In a literature review of radial/ulnar arterial injuries in a perfused hand, total patency rates after repair were approximately 68% for radial repairs and 66% for ulnar repairs, with no significant difference in cold sensitivity between patent repairs and ligated or occluded vessels (3). Individual series similarly reported cold sensitivity and weakness independent of patency (4). However, in cohorts with consistent concomitant injury patterns-ulnar artery with ulnar nerve and flexor tendon injuries-patent repairs were associated with improved functional outcomes and reduced cold intolerance compared with obliterated repairs (5). Current literature demonstrates low major amputation rates overall, with worse outcomes associated with dual-artery injury and greater overall injury burden rather than isolated single-vessel status alone (2). Conclusions: In combined forearm trauma with preserved distal perfusion, arterial repair achieves acceptable patency but does not show superiority in functional or vasospastic outcomes compared with ligation. Functional recovery appears more strongly influenced by associated nerve and soft tissue injury than vessel preservation alone. Arterial management should therefore be individualized based on overall injury complexity and anticipated functional impact. 1. Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. A 5-year review of management of upper-extremity arterial injuries at an urban level I trauma center. Ann Vasc Surg. 2012;26(5):655-664. doi:10.1016/j.avsg.2011.11.011 2. Stuber J, Moore HB, Moore EE, et al. Management of traumatic radial and ulnar artery injuries and risk factors for amputation. J Surg Res. 2023;288:136-143. doi:10.1016/j.jss.2023.05.027 3. Schippers SM, Vles GF, Langenhuijsen JF, et al. Single forearm vessel injury in a perfused hand: repair or ligate? A systematic review. J Hand Surg Am. 2018;43(9):861.e1-861.e8. doi:10.1016/j.jhsa.2018.05.012 4. Aftabuddin M, Islam N, Rahman M, et al. Management of isolated radial or ulnar arteries at the forearm. J Trauma. 1995;38(5):684-688. doi:10.1097/00005373-199505000-00012 5. Keleş MK, Demir A, Çetin A, et al. Evaluation of forearm arterial repairs: functional outcomes related to arterial repair. Ulus Travma Acil Cerrahi Derg. 2017;23(2):117-121. doi:10.5505/tjtes.2016.13617

PURPOSE: Textbook outcomes (TOs) represent a composite metric of multiple specific criteria that can be used to identify and compare rates of baseline success in surgical procedures. This study aimed to analyze the impact of mental health diagnoses on the rate of TOs for operative management of distal radius fractures (DRFs) with volar plating at a single center.

METHODS: A textbook outcome was defined by a 3-round Delphi survey of 24 hand surgeons with expertise in operative management of DRFs. An IRB-approved retrospective review of all distal radius fractures managed with volar plating cases at our center from July 2022 to December 2024 was performed. Inclusion criteria were age >18 and <65, ASA Class

RESULTS: The finalized textbook outcome comprised 16 criteria spanning intraoperative events, postoperative complications, radiographic alignment, fracture union, distal radioulnar joint stability, and functional range of motion. At our institution, 98 patients met inclusion criteria, with 71 (72.4%) meeting all criteria for a textbook outcome.

Of the 98 cases, 27 (27.8%) patients were placed into the MHD group and 71 (73.2%) in the Non-MHD group. Each group of patients had similar baseline characteristics and rates of medical comorbidities. The MHD group had a lower proportion of textbook outcomes compared to the non-MHD group (51.9% versus 80.3%, p=0.010). Of the MHD group, the most common reasons for not meeting a TO were limited wrist range of motion (29.6%), hardware complications (14.8%), and complications requiring reoperation (11.1%).

CONCLUSIONS: Patients with diagnosed mental health conditions are less likely to meet criteria for a composite textbook outcome for operative management of DRF with volar plating. These patients are at risk for hardware complications, reoperation, and limited wrist range of motion. Coordination with mental health professionals throughout surgery and the recovery process could play a valuable role in these procedures.

PURPOSE: Vascularized medial femoral condyle (MFC) and medial femoral trochlea (MFT) free bone flaps are established options for scaphoid nonunion, yet standardized definitions of success and patient-reported experiences remain limited. This study defined textbook outcomes (TOs) for MFC/MFT reconstruction and evaluated quantitative and qualitative outcomes at a single center.

METHODS: A Delphi survey of 24 certified hand surgeons established consensus TO criteria for scaphoid nonunion treated with MFC/MFT. An IRB-approved retrospective review covering 2018–2025 evaluated clinical outcomes between flap types. Semi-structured interviews were conducted with a subset of patients to characterize the overall experience and recovery themes. The interviews were structured as 30 minute question and answer sessions with opportunities to elaborate and share relevant comments. Each interview's transcript was recorded and saved to the institution's cloud drive. Transcripts and notes from each meeting were reviewed and the software atlas.ti was used to help identify themes and subthemes among the participants' experiences.

RESULTS: 40 patients underwent reconstruction and 73% achieved a TO. There were no significant differences in union rates (96.3% MFC vs. 100% MFT, p>0.05), TO rates (75.0% MFC vs. 66.7% MFT, p>0.05), return to pain-free hand function, or return to pain-free lower extremity activity between groups. The most common TO criterion failure was delayed return to pain-free hand activity (12.5%). Patients with depression or anxiety had lower TO rates compared to controls (33.3% vs. 79.4%, p=0.039).

Twelve patients participated in interviews, with a median age of 23.8 at time of surgery. Eight (75%) underwent MFC grafting, four (25%) underwent MFT grafting, and zero had nonunion. Six main themes were identified: (1) Grafting considered best option; (2) Skepticism of taking bone from healthy knee to fix wrist; (3) Necessity of caretaker during initial recovery; (4) Importance of physical therapy; (5) Surgery not being a 100% fix, and (6) Ability to return to desired activities eventually. Most patients reported pain relief and would recommend the surgery to a patient considering the procedure.

CONCLUSIONS: A consensus TO framework demonstrates high overall success rates for MFC/MFT reconstruction with comparable donor-site outcomes. Patient interviews highlight positive experiences and identify modifiable factors influencing recovery. All patients interviewed would recommend the procedure to someone weighing a decision to have the operation.

Background: Flap reconstruction is an important adjunct for limb salvage following open upper-extremity fracture requiring operative fixation. However, national patterns of flap utilization, predictors of timing, and risk factors for surgical site infection (SSI) in this population remain incompletely characterized. We evaluated predictors of flap reconstruction, factors associated with time to flap coverage, and determinants of in-hospital SSI for upper-extremity fractures using a national trauma cohort.

Methods: A retrospective cohort study was conducted using the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Adult patients who received operative fixation for upper-extremity long-bone fractures (humerus, radius, or ulna) were identified. All wrist and hand trauma were excluded. Flap reconstruction was defined as pedicled or free soft tissue transfer performed during the index admission following fixation. Multivariable logistic regression identified predictors of flap utilization. Multivariable linear regression evaluated predictors of time from admission to flap reconstruction. Among flap patients, univariable analyses evaluated factors associated with in-hospital SSI.

Results: Among 102,624 patients, 1,135 (1.1%) underwent flap reconstruction and 101,489 (98.9%) underwent fixation alone. Patients undergoing flap reconstruction were younger (39.31 vs 40.56 years, p=0.02), more frequently male (70.9% vs 64.6%, p<0.001), and had higher Injury Severity Scores (ISS) (13.84 vs 12.10, p<0.001). Vascular injury was the strongest independent predictor of flap reconstruction (odds ratio [OR] 4.94, 95% confidence interval [CI] 4.21-5.81, p<0.001). Hispanic ethnicity (OR 1.45, p<0.001) and other race (OR 1.34, p=0.028) were associated with increased odds of flap utilization compared with White patients. Falls (OR 0.15), firearm injuries (OR 0.57), and struck-by injuries (OR 0.37) were associated with lower odds compared with motor vehicle trauma (all p<0.001), whereas machinery injuries were associated with increased odds (OR 1.47, p=0.027). Higher ISS independently predicted delayed reconstruction (β 0.17 days per ISS unit, 95% CI 0.09-0.25, p<0.001). Lack of a primary billed payer was associated with delayed reconstruction (β 3.02 days, p=0.009).

Among flap patients, the overall SSI rate was 3.35% (38/1,135). Admission-to-flap timing demonstrated a significant association with SSI (p<0.001), with rates of 1.49% for 0-3 days, 2.58% for 4-7 days, 2.16% for 8-12 days, and 11.38% for reconstruction beyond 12 days. Higher ISS was associated with SSI (univariable OR 1.063 per ISS point, 95% CI 1.037-1.090, p<0.001), with mean ISS 21.63 among SSI cases versus 13.57 without SSI. Age, BMI, diabetes, smoking, hypertension, flap type, antibiotic timing, and debridement timing were not significantly associated with SSI.

Conclusions: Flap reconstruction following open upper-extremity fractures is uncommon nationally but concentrated in high-severity and vascular injuries. Injury severity independently predicted both delayed reconstruction and increased SSI risk. While early reconstruction within 12 days demonstrates low SSI rates, delays beyond 12 days are associated with markedly higher infection rates. These findings support prioritization of timely flap coverage for open upper-extremity fracture and highlight structural variation in access to orthoplastic care, providing a framework for informing future timing benchmarks.

Purpose Upper-extremity trauma is a common cause of emergency department visits and hand surgery consultation and carries a risk of long-term functional impairment when care is delayed. Incarcerated individuals experience disproportionately high rates of these injuries and face barriers to timely care and follow-up, yet outcomes-focused literature in this population remains limited, underscoring the need to characterize injury patterns and care pathways to identify care inequities.

Methods We conducted a single-institution retrospective chart review of patients presenting with upper-extremity trauma between 2017 and 2025. A total of 130 incarceration-exposed patients were identified based on medical record documentation of custody, jail, or prison status. Demographic characteristics, injury details, management, care timelines, and clinical outcomes, including follow-up and complications, were collected. Analyses were descriptive, with continuous variables summarized using measures of central tendency and categorical variables reported as frequencies and percentages. Follow-up from the time of injury ranged from one week to approximately six to twelve months, depending on the patient.

Results Among 130 patients, the cohort was predominantly male (95.4%) with a mean age of 35.8 years; 30.7% were actively incarcerated at the time of injury and 25.0% were incarcerated after injury. Fractures accounted for 83% of injuries, most commonly involving the hand (63%), with metacarpal (41%) and radial (23%) fractures predominating and most fractures being closed (92%). Tendon and nerve injuries were less frequent (N = 16 each), primarily affecting the hand, with flexor tendon injuries in Zones II–III and digital nerve involvement predominating. Injuries most commonly resulted from falls (28%) and assault (27%). Initial medical evaluation was typically the same day, with a median of 4 days to hand surgery consultation, though only 31% underwent operative intervention. Overall follow-up was limited, with 48% of patients lost to follow-up; however, 71.8% of surgical patients completed follow-up. Among those with documented follow-up, most had no postoperative complications, with reoperation and wound-related complications being the most common adverse outcomes.

Conclusion This study examined upper-extremity injuries and care pathways among patients with incarceration exposure, an underrepresented population. Simple, fracture-dominant hand injuries were most common, with relatively low rates of operative intervention, suggesting that most injuries were managed nonoperatively. Injuries most often resulted from falls and assault and primarily involved the hand and forearm, with associated tendon and nerve injuries also predominantly affecting the hand. Although initial surgical consultation was generally prompt, follow-up was limited, with many patients lost to follow-up, suggesting that barriers to continuity of care may play a key role in recovery in this population.

Importance Early mobilization after digital replantation (<7 days post operation) may improve tendon glide and reduce stiffness (1,2). However, concerns for vascular compromise and construct failure exist with early motion (3). Despite these potential benefits, little evidence exists on what the optimal rehabilitation protocol is to minimize risk while maximizing functional outcomes for the patient.

Objective To assess the efficacy and safety of early vs late rehabilitation and synthesize factors allowing early motion in digital replantation.

Data Sources A systematic review was conducted using PubMed, Embase, Web of Science, and The Cochrane Library. Studies were screened for eligibility by two authors.

Study Selection Among 612 identified, 23 studies comprising 1,640 digits met the inclusion criteria and were selected for the meta-analysis.

Data Extraction and Synthesis Extraction was conducted by multiple reviewers using the Rayyan platform for systematic reviews and in accordance with PRISMA guidelines. Data were pooled by a random-effects model.

Main Outcomes and Measures Digit survival and total active motion (TAM).

Results After mean follow-up of 25.2 months (SD 24.4 months), the main outcome (digit survival) was not significantly different in the early (<7 postoperative day [POD]) and delayed (>7 and <21 POD) motion cohorts (risk ratio [RR], 0.98; 95% CI, [0.90-1.06]). Likewise, the mean difference of TAM was similar in both cohorts (mean difference, +29.83°; 95% CI, [-74.31°-+133.96°]). However, in the early motion group, the union rate was significantly increased (RR, 1.11; 95% CI, [1.07-1.16]).

Conclusions and Relevance These results suggest that early motion protocols are generally safe and effective in the postoperative management of digital replantation. While early mobilization showed a trend toward increased TAM, inconsistencies in measurement and underreporting in the literature likely prevented this from reaching statistical significance. In addition, the significantly increased union rate suggests that adjuncts that enable early motion increase the odds of union or reflect potential biological benefits to early mechanical loading. This meta-analysis may help inform decision-making in postoperative management of digital replantation.

1. Prsic A, Friedrich JB. Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit. Hand Clin. 2019;35(2):221-229. doi:10.1016/j.hcl.2019.01.003
2. Bregman D, Nicholson L. Indications for replantation and factors that predict success. Eur J Orthop Surg Traumatol. 2024;34(7):3661-3668. doi:10.1007/s00590-023-03671-2
3. Bonastre Juliá J, Ojeda Regidor Á, Martínez-Méndez J, et al. Clinical Outcomes in Ring Avulsion Fingers and Systematic Review of the Literature. Ann Plast Surg. 2020;85(6):631. doi:10.1097/SAP.0000000000002453