Scientific Abstract Presentations: Top Residents Abstract Session 5 (Hand, Research & Technology) Thursday, September 26 Thu, Sep 26 8:00-9:30 a.m. PDT

Introduction Thumb Carpometacarpal Joint (TCMCJ) Osteoarthritis is a clinically heterogeneous disease without a standardized treatment. (1,2) The beneficial effects of intra-articular Platelet-Rich Plasma (PRP) and Hyaluronic Acid (HA) application have been demonstrated, including pain reduction, improved mobility, and functionality in joints such as knees, shoulders, and in sports medicine. (3-5) The comparison of these two therapies in the knee and hip joints is well-known; however, there is little described regarding the comparison of both for the treatment of TCMCJ Osteoarthritis. (1,5)

The purpose of this work was to compare the degree of hand disability in patients with TCMCJ Osteoarthritis treated with intra-articular PRP and those treated with intra-articular HA using Dash Score.

Methods and Materials A prospective observational study was conducted where 30 patients diagnosed with TCMCJ Osteoarthritis were treated, 16 patients were treated with 3 sessions of intra-articular PRP and 14 patients with 4 sessions of HA in a period of three years. Dash score was applied to the patients at the beginning of the treatment, and then after 1, 3 and 6 months. Statistical analyses were performed according to the distribution of the data, statistical significant p-value was <0.005.

Results Out of the total sample (n=30), a Kruskal-Wallis test showed that there was a statistically significant difference in the Dash score from the beginning to three months after the treatment application (p=0.015 for PRP and p=0.0001 for HA). When comparing both treatments with a Mann Whitney U test, at the beginning of the treatment and at 3 months the Dash Scores were higher for the HA group, without statistical significance (p=0.100, p=0.064), at 6 months there was a statistically significant difference with PRP showing a lower Dash score (p<0.001).

Conclusion The application of both therapies for the management of TCMCJ Osteoarthritis resulted in a statistically significant functional improvement at 3 months post-application. PRP performed better than HA regarding the improvement of patient's pain and function. Both therapies can be considered as a standard treatment, but PRP therapy showed sustained superior results at 6 months making it a great treatment option for those not candidates for surgery.

References 1. Chen L, Jin S, Yao Y, He S, He J. Comparison of clinical efficiency between intra-articular injection of platelet-rich plasma and hyaluronic acid for osteoarthritis: a meta-analysis of randomized controlled trials. Ther Adv Musculoskelet Dis. 2023;15:1759720X231157043. 2. Swärd E, Wilcke M. Effects of intra-articular Platelet-Rich Plasma injections on osteoarthritis in the thumb basal joint and scaphoidtrapeziotrapezoidal joint. PLoS One. 2022;17(3):e0264203. 3. Hasley IB, Bies MM, Hollman JH, Carta KG, Sellon JL, Brault JS. Platelet-Rich Plasma Injection for Thumb Carpometacarpal Joint Osteoarthritis. Arch Rehabil Res Clin Transl. 2023;5(1):100257. 4. Tenti S, Cheleschi S, Mondanelli N, Giannotti S, Fioravanti A. New Trends in Injection-Based Therapy for Thumb-Base Osteoarthritis: Where Are We and Where Are We Going?. Front Pharmacol. 2021;12:637904. 5. Tang JZ, Nie MJ, Zhao JZ, Zhang GC, Zhang Q, Wang B. Platelet-rich plasma versus hyaluronic acid in the treatment of knee osteoarthritis: a meta-analysis. J Orthop Surg Res. 2020;15(1):403.

Introduction While various treatments exist for basal joint osteoarthritis, there is considerable interest in minimally invasive alternatives to provide long-term pain relief and preserve the joint. Recent clinical evidence suggests that intra-articular injection of autologous fat may be beneficial for the treatment of osteoarthritis through anti-inflammatory and chondroprotective effects. Investigations predicting success of fat grafting in the treatment of basal joint arthritis are limited. For this reason, this study seeks to better evaluate the effectiveness of this procedure for basal joint arthritis.

Materials & Methods A single institution, single surgeon retrospective review of all patients over 18 years old who underwent primary autologous fat grafting for basal joint arthritis between January 2010 and March 2023 was conducted. Patients with prior surgery, incomplete records, and less than 3 months follow-up were excluded. Demographic data, diabetes mellitus, obesity, smoking status, Eaton-Littler classification, amount of fat injected, number of revision fat grafting, and need for further procedures (e.g., trapeziectomy) were collected. A multiple linear regression of predictor values was used to determine the need for revision fat grafting or further procedures.

Results Forty-two patients were identified, and thirty-two patients were included in the study. Half of the patients were female, with an average age of 65.1 years at time of surgery. Diabetes and obesity rates were 9.4% and 37.5%, respectively. A total of 42 procedures were performed, 42.9% of which were of the right hand. Average time of follow-up was 8.2 months. Revision rate was 11.9%, and further procedure rate was 21.4%. An average of 7.4cc (SD = 3.7) of autologous fat was injected in procedures that required no further revisions or surgeries, while an average of 4.5cc (SD = 1.0) was injected in patients requiring revision. The model predicting need for revision found diabetes mellitus (p < 0.05) and amount of fat injected (p < 0.05) as significant positive and negative predictors, respectively. The model predicting need for further procedures found no significant predictors.

Conclusions Autologous fat grafting has been demonstrated to be a safe and reliable method minimally invasive treatment for basal joint arthritis, with appropriate patient selection. Patients with diabetes have higher revision rates, and a larger volume of fat injected predicts fat grafting success. Further studies are required to identify patients who progress to further surgeries, as this decision may be a combination of patient factors and preference.

Background: Guyon's canal release (GCR) is commonly performed concurrently with anterior interosseous nerve to ulnar motor nerve transfers (AIN-to-UMNT) based on the rationale that decompression reduces potential distal "roadblocks" to axonal regrowth.(1–4) The purpose of this study was to determine if GCR improves clinical and electrodiagnostic recovery outcomes among patients undergoing AIN-to-UMNT for severe ulnar neuropathy.

Methods: A ten-year retrospective, single-center cohort study of AIN-to-UMNT performed with or without GCR from January 2013 to November 2023 included five surgeons' cases, four of whom routinely released Guyon's canal at the time of AIN-to-UMNT, and one who routinely did not. Patients with electrodiagnostic studies performed pre-operatively and at least six months post-operatively were included. Demographic data, including age, BMI and co-morbidities, surgical details, and pre- versus post-operative clinical and electrodiagnostic findings were compared using Chi-square or Fisher's exact tests for categorical data and independent t-tests or Mann-Whitney U-tests for numerical data after assessing normality.

Results: Among 175 AIN-to-UMNT performed, 77 patients had both pre-operative and post-operative electrodiagnostic data; 45.5% had concurrent GCR (n=35 with GCR). There was no significant difference (p<0.05) between groups in terms of mean follow-up duration (GCR: 14.1 months; non-GCR: 15.7 months), age and body mass index, as well as incidence of diabetes mellitus, hypothyroidism, smoking and alcohol abuse. GCR and non-GCR groups did not differ significantly in terms of pre-operative sensory nerve action potentials (SNAPs) at the fifth digit (p=0.19) or compound muscle action potentials (CMAPs) at the abductor digiti minimi (ADM) (p=0.32) or the first dorsal interosseous (FDI) (p=0.19). Further, at 6-month, 12-month and 18-month follow-up, the change from pre- to post-operative SNAP amplitude at the fifth digit and FDI CMAP amplitudes did not differ significantly between groups, except ADM CMAP amplitudes at 12 months which favoured GCR (p=0.01). A higher proportion of non-GCR patients had developed nascent motor unit action potentials at 6-month (54.8% vs 42.8%) and 12-month follow-up (73.8% vs 54.2%). At latest follow-up, there was no significant difference between groups in terms of the pre- to post-operative change in grip or pinch strength (p<0.05).

Conclusions: The results of this large retrospective cohort study suggest that GCR may not provide significant clinical or electrodiagnostic benefit. Future research directions will include analysis of sub-populations who could benefit from concurrent GCR with AIN-to-UMNT.

References: 1. Barbour J, Yee A, Kahn LC, MacKinnon SE. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation. J Hand Surg. 2012;37(10):2150-2159. doi:10.1016/j.jhsa.2012.07.022 2. Power HA, Kahn LC, Patterson MM, Yee A, Moore AM, Mackinnon SE. Refining Indications for the Supercharge End-to-Side Anterior Interosseous to Ulnar Motor Nerve Transfer in Cubital Tunnel Syndrome. Plast Reconstr Surg. 2020;145(1):106e-116e. doi:10.1097/PRS.0000000000006399 3. Doherty CD, Miller TA, Larocerie-Salgado J, Byers BA, Ross DC. Reverse End-to-Side Anterior Interosseous Nerve-to-Ulnar Motor Transfer for Severe Ulnar Neuropathy. Plast Reconstr Surg. Published online 2020:306E-313E. doi:10.1097/PRS.0000000000007059 4. Gontre G, Polmear M, Carter JT, Castagno C, Herrera FA. Primary Repair versus Reverse End-to-Side Coaptation by Anterior Interosseous Nerve Transfer in Proximal Ulnar Nerve Injuries. Plast Reconstr Surg. 2023;152(2):384-393. doi:10.1097/PRS.0000000000010395

Background: Proximal row carpectomy (PRC) is considered a common option for motion-preserving surgery for the treatment of advanced wrist osteoarthritis, however, in patients with advanced arthritis of the mid-carpal joint or proximal capitate, this procedure traditionally had not been an option[1]. To overcome this issue, techniques for resurfacing the arthritic capitate have been developed, including a titanium alloy prosthetic hemi-arthroplasty resurfacing device[2-4], although pyrocarbon implants and autologous resurfacing are more prevalent in the literature. The objective of this study is to assess the efficacy, safety, and patient reported functional outcomes with PRC alone versus with titanium alloy capitate hemiarthroplasty. Hypothesis: We hypothesize that there will be functional and satisfactory differences between patients in the PRC alone and PRC with capitate hemiarthroplasty (PRC+CHA) groups, but that complications will not be significantly increased. Methods: A retrospective case-control study was conducted of all patients of the senior author at a single institution between 2018-2023. Children, acute wrist trauma/lunate or perilunate dislocations, and patients with insufficient follow up were excluded. Data including demographics, surgery type, pre-and post-operative Quick Disability of the Arm, Shoulder, and Hand (QDASH) scores, pre-and post-operative physical examination, radiographic studies, and complications were collected. Groups were compared using statistical analysis. Results: 44 patients were identified who underwent PRC, 15 had PRC+CHA and 2 underwent PRC alone. A comparison of QDASH scores showed that both groups had statistically significantly improved scores post-operatively compared to pre-operatively with an average post-op score of 45.6 and 42.2 (p=0.002 and 0.032). However, there was not a significant difference noted between cohorts. There was a significantly decreased time in splint among the group with PRC+CHA, an average of 31 days as opposed to 100 days (p=0.046). Complication rates are detailed in Table 1; PRC+CHA had 0% reoperative complications with a minor complication rate of 13%; PRC alone had 17% overall complication rate with 3 (10%) patients requiring reoperation. Summary points: • Capitate resurfacing with titanium alloy hemiarthroplasty does not have higher complication rate than PRC alone. • QDASH scores between PRC alone and PRC + capitate resurfacing both showed significant improvement post-operatively. • There was significantly shorter recovery time in PRC+CHA group compared to PRC alone. • Titanium alloy capitate hemiarthroplasty can be a safe and effective option for motion preserving wrist procedure in patients with pre-existing proximal capitate arthritis.

References 1. Giacalone, F., et al., Resurfacing Capitate Pyrocarbon Implant versus Proximal Row Carpectomy Alone: A Comparative Study to Evaluate the Role of Capitate Prosthetic Resurfacing in Advanced Carpal Collapse. Plast Reconstr Surg, 2017. 140(5): p. 962-970. 2. Fulchignoni, C., D. Caviglia, and L. Rocchi, Resurfacing capitate pyrocarbon implant after proximal row carpectomy: A litterature review. Orthop Rev (Pavia), 2020. 12(Suppl 1): p. 8679. 3. Rieussec, C., et al., Comparison of proximal row carpectomy with RCPI® versus proximal row carpectomy with Eaton's capsular interposition in the management of advanced wrist osteoarthritis. Orthop Traumatol Surg Res, 2023: p. 103783. 4. Tang, P. and J.E. Imbriglia, Osteochondral resurfacing (OCRPRC) for capitate chondrosis in proximal row carpectomy. J Hand Surg Am, 2007. 32(9): p. 1334-42.

Distal radius fractures (DRFs) are among the most common fractures. Lower socioeconomic status (SES) has been linked to poorer health and surgical outcomes across various specialties. Therefore, this study aimed to investigate the relationship between SES and complications following distal radius fractures (DRFs) treated with volar plate fixation (VPF). Considering the multifactorial nature of SES, we used the Area Deprivation Index (ADI), a census-based composite metric, to represent socioeconomic deprivation. We hypothesized that greater neighborhood socioeconomic deprivation predisposes patients to postoperative complications after VPF of DRFs. A retrospective review of medical charts at a single institution from 2013 to 2020 identified 618 patients who underwent VPF. Patients were mostly middle-aged (55 ± 17 years), predominantly female (74.6%), White (82.2%), overweight/obese (58.1%), and American Society of Anesthesiologists (ASA) class > 1 (83.6%). Fractures were mostly due to falls (87.8%), predominantly intra-articular (89.7%), with 30.3% undergoing supplemental external fixation. ADIs were obtained using documented ZIP codes. Patients were stratified into three ADI groups: Group 1 (percentiles 0-33) denoted least deprivation, Group 2 (percentiles 33-66) encompassed intermediate deprivation, and Group 3 (percentiles 66-100) indicated the highest deprivation. Primary outcomes included major, minor, and any complication. Major complications were defined as those necessitating additional surgery following initial fixation. Statistical analyses were performed using SPSS version 29.0 (IBM, Armonk, NY). Variables found to be significantly associated with outcomes were included in main effects multivariable binomial logistic regression models assessing the effect of ADI score on primary outcomes. This analysis revealed that ASA class, supplemental external fixation, and prolonged operative time were associated with increased complication rates. Specifically, ADI Group 3 emerged as a significant predictor of any complication (OR 3.05; p = 0.003) and minor complications (OR 3.03; P = 0.016), but not major complications (OR 2.85; p = 0.056). ADI Group 2 did not significantly predict any, major, or minor complications. ASA class 2 (OR 2.81; p = 0.050), ASA class 3-4 (OR 3.41; p = 0.027), operation time (OR 1.01; p = 0.014), and supplemental external fixation (OR 2.380; p = 0.004) were all significant predictors for any complication. Stratified multivariable regression analysis revealed that ADI Group 3 was a significant predictor of any complication among patients belonging to ASA class 3-4 (OR 3.249; 95% CI, 1.21-8.76) and among patients who required supplemental external fixation (OR 2.758; 95% CI, 1.02-7.47). In patients belonging to ASA class 2 or lower and in patients who did not receive external fixation, the odds of experiencing any complication were increased, though not significantly. Collectively, these results demonstrate an association between SES and complications after VPF. Additionally, there appears to be a more pronounced interaction between lower SES (higher ADI) and the occurrence of postoperative complications in individuals predisposed to poorer outcomes-specifically, those with a high comorbidity burden (i.e. ASA class 3-4) and severe fractures (i.e. presence of additional external fixation). This underscores the importance for surgeons to carefully consider the potential association between SES and surgical outcomes, particularly for patients with higher perioperative risk profiles.

Background: Distal radius fracture (DRF) represents 17.5% of all fractures and is the most common fracture in adults (1). Sub-optimal treatment can lead to irreversible loss of hand function and worsening pain. There may be disparities between white and non-white (including Asian, Hispanic/Latino, Black/African American, and Native American or Hawaiian/Pacific Islanders) patients in terms of treatment choice, time from diagnosis to intervention, and outcomes.

Hypothesis: Non-white patients with DRF will have differences in access to surgery and be offered surgical interventions less frequently and further may experience delays in receiving treatment.

Methods: A retrospective cohort study was conducted utilizing TriNetX, a global health research network with access to over 111 million de-identified patient records. Patients over the age of 18 with a diagnosis of DRF were identified and data including demographics, fracture pattern (intra vs extra articular) and types of intervention (operative vs non-operative) was collected between the years 2002-2023. Cohorts were matched for diabetes, osteoporosis, obesity, smoking status, and fracture pattern. Gender, age, race, and ethnicity were then compared.

Results: 608,377 patients with a diagnosis of DRF were identified utilizing ICD 10 codes. 108,623 patients with DRF who underwent operative management (CPT 25606, 25607, 25608, 25609) were compared to 56,108 patients who underwent nonoperative management (CPT 25600, 25605). 66.8% of patients received nonoperative treatment with a mean time to treatment of 34.793 days compared to 32.7% who had primary operative treatment with a time to treatment of 29.23 days. 9.58% of patients underwent non-operative and converted to operative treatment after 76.783 days. Intra-articular fractures were the most common fracture pattern with no difference seen in age (58.3 yrs vs 58.1) with white patients and women being the most prevalent demographics. After matching, intra-articular and women were more likely to undergo operations and extra-articular and Black/African American were more likely to undergo closed treatment which supports existing literature (1,2,3). Medical co-morbidities were more prevalent in the intra-articular and operative groups.

Summary Points:

Intra-articular fractures, white patients and women were more likely to be offered surgical intervention.

Non-surgical intervention was received 34.793 days after diagnosis compared to surgical intervention at 29.23 days with conversion from non-surgical to surgical on average 76.783 days after diagnosis.

Sources:

1) Candela V.; Di Lucia P.; Carnevali C.; et al. Epidemiology of distal radius fractures: a detailed survey on a large sample of patients in a suburban area. J Orthop Trauma. 2022:23. 2) Benitez T.; Ouyang Z.; Khouri A. N.; et al. Medicare eligibility and racial and ethnic disparities in operative fixation for distal radius fracture. JAMA Netw Open. 2023:6. 3) Fanuele J.; Koval K.J.; Lurie J.: et al. Distal radial fracture treatment: what you get may depend on your age and address. J Bone Joint Surg Am. 2009:91.1313-1319.

PURPOSE: Clinical guidelines rely heavily on expert opinions and institution protocols to provide recommendations for administration of systemic antibiotic prophylaxis for open extremity fractures to prevent fracture-related infections. We assessed systemic antibiotic prophylaxis, durations, antibiotic types, and antibiotic doses for Gustilo-Anderson Type I, II, and/or III open fractures using the highest level of available evidence, to optimize patient outcomes and minimize bacterial resistance. METHODS: Guidelines from PRISMA, Cochrane, and the GRADE approach were implemented to structure and synthesize this study. Five databases (PubMed, Cochrane Library, Web of Science, Scopus, CINAHL) were systematically and independently searched for randomized controlled trials (RCTs) meeting eligibility criteria. Included patients had open extremity fractures and were treated with prophylactic systemic antibiotics administered perioperatively (preoperative, intraoperative, postoperative). We stratified patients by Gustilo-Anderson Type I, II, and/or III upper and/or lower extremity open fractures and made comparisons between active interventions and/or non-active interventions (placebo) at different prespecified durations to determine the development of fracture-related infections. We then compared different antibiotic types at the same prespecified durations to determine appropriate antibacterial spectrums and performed meta-analyses of the data. RESULTS: Twenty-one (n=21) RCTs met eligibility criteria (Gustilo-Anderson Type I=6, Gustilo-Anderson Type II=4, Gustilo-Anderson Type I/II=12, Gustilo-Anderson Type III=4, Gustilo-Anderson Type I/II/III=21). Summary tables with comparisons, antibiotics, outcomes, p-values, and GRADE level of certainty-evidence were generated to provide evidence-based clinical dosing and durations for upper and lower extremity open fractures, upper extremity open fractures alone, and lower extremity open fractures alone. GRADE level of certainty-evidence ranged from very low to high certainty-evidence. The strongest evidence supports a maximum duration of administration of 1 day following upper and/or lower extremity Gustilo-Anderson open fractures. The most common organisms were cultured from fractures-related infections (gram-positive: Staphylococcus aureus=18.9%; gram-negative: Enterobacter spp.=6.8%). CONCLUSION: We summarized the best available evidence from 21 RCTs which may inform future guidelines and reduce variability in management of antibiotic prophylaxis after upper and/or lower extremity open fractures.

INTRODUCTION: In our setting, index finger pollicization remains the preferred technique in the treatment of Blauth type IIIB to V congenital thumb hypoplasia (1,2). It is a technically demanding procedure that has incorporated several contributions since the publication of the first case series (3-5). The aim of this study is to present the modifications performed by the senior surgeon at our institution during the last 20 years and to analyze the functional and aesthetic outcomes.

MATERIALS AND METHODS: We conducted a retrospective study including all index finger pollicizations performed between January 2005 and January 2024 at La Paz University Hospital. Preoperatively, the degree of thumb hypoplasia was assessed using the Blauth classification, and the degree of radial longitudinal deficiency using the Bayne and Klug classification. Surgical incisions and details are presented, along with an analysis of functional results and complications.

RESULTS: During the study period, 32 index finger pollicizations were performed on a total of 25 patients. 29% were bilateral, and 42% were associated with radial longitudinal deficiency. The median age at surgery was 22.5 months (13-116 months), with an average postoperative follow-up time of 6.52 years (1-16 years). The mean Percival functional scale score was 18 points, and 95% of patients and their families reported satisfaction with the reconstructed thumb. There were no vascular failures, and the reoperation rate was 12.5%.

CONCLUSIONS: Over the past 20 years, we have optimized the index finger pollicization technique at our center. Multiple factors influence the success of thumb reconstruction, and special care must be taken at every step of the surgery. Evaluation of our results demonstrates the benefits of this procedure in terms of hand function and aesthetic appearance.

REFERENCES 1. De Almeida YK, Athlani L, Piessat C, Delgove A, Dap F, Dautel G. Pollicization in the treatment of congenital severe hypoplasia and aplasia of the thumb: a systematic review. Hand Surg Rehabil. 2022;41(1):22-30. doi:10.1016/j.hansur.2021.10.311 2. Barik S, Matic I, Farr S. Long-term results of index finger pollicization for congenital thumb anomalies: a systematic review. J Hand Surg (Eur Vol). 2023. doi:10.1177/17531934231212392 3. Buck-Gramcko D. Pollicization of the index finger. J Bone Amp Jt Surg. 1971;53(8):1605-1617. doi:10.2106/00004623-197153080-00015 4. Littler JW. On making a thumb: one hundred years of surgical effort. J Hand Surg. 1976;1(1):35-51. doi:10.1016/s0363-5023(76)80024-x 5. Scheker LR. Thumb Hypoplasia. In: The Thumb. Springer Singapore; 2019:81-97. doi:10.1007/978-981-10-4400-7_4

Background Anterolateral thigh flap (ALT) has been the workhorse for head and neck reconstructions nowadays. However, anatomical variability of its perforators has been reported, and accurate identification of vascular perforators is critical to the flap harvest. As indocyanine green (ICG) angiography provides real-time perfusion data, this study aims to apply the relationship between artificial intelligence (AI)-assisted ICG angiography readings to help identify perforator anatomy.

Methods ICG angiography is routinely used in our head and neck reconstructions to identify the possible perforators, which was recorded by video data. From November 2023 to April 2024, we retrospectively reviewed 40 cases of ALT flaps in head and neck reconstructions. Grayscale analysis of perioperative ICG angiography videos was conducted, with pixel intensity values tracked over time. A threshold will be set to identify potential perforator sites, which will be temporally sequenced and validated against actual intraoperative perforator locations by the AI assistance. The threshold will be adjusted to optimize sensitivity and specificity for perforator prediction.

Results The prototype of predictive model for ALT perforators by ICG angiography was developed. We further established a grayscale intensity threshold that yields a high number of true positive identifications of perforator sites. The refined threshold enhances the predictive model's accuracy, potentially improving the efficacy of surgical planning in ALT flap reconstructions.

Conclusion The study aims to advance the current application of ICG angiography in reconstructive flap surgeries. By employing a data-driven approach to define a grayscale intensity threshold, we are able to refine the predictive accuracy of perforator identification. The results could lead to precise surgical planning, reduced operative times, and improved patient outcomes, marking a step forward in reconstructive microsurgery protocols.

Background: In 2023, more than 110,000 Americans died from an opioid overdose. (1) Despite increasingly stringent restrictions on prescribing opioids, overdoses and deaths continue to soar, making clear the need for additional patient-focused tools to facilitate safe usage and weaning of opioids. Literature suggests that plastic surgery patient populations (breast and hand surgery patients) (2, 3) have among the highest rates of new persistent opioid use. We created an automated, electronic medical record (EMR)-integrated tool that queries patient daily regarding their pain and medication usage and provides immediate and specific targeted recommendations to patients regarding their opioid and non-opioid medication usage and automated surveillance of patient behavior to clinicians.

Methods: Using the Epic Care Companion platform, a novel pathway was developed using a multidisciplinary approach including physicians, informaticists, nurses, and patients, called Opioid Program for You (OPY). All patients undergoing plastic surgery procedures and receiving postoperative opioid therapy at the M-Health Fairview Ambulatory Surgery Center were enrolled in the OPY pathway.

Patients receive daily notifications for tasks that query their medication usage and pain levels. Based on responses, OPY provides tailored guidance on their opioid and non-opioid medications through three stages – pain control, weaning, and disposal. "Red flag" alerts are generated by OPY and referred to the clinical team for patterns of problematic behavior. These are reviewed by a care coordinator and escalated as necessary. The pathway is completed once patients report no further opioids.

Results: 489 patients were enrolled in the OPY pathway, ranging from ages 18-88. Of these patients, 365 were female, 116 were male, and 8 were nonbinary. Of those enrolled, 218 patients did not interact with the OPY application. 106 patients completed all daily OPY tasks. 84 patients completed greater than 50% of tasks, but not all. 12 "red flag" alerts were generated, with zero patients requiring additional clinical intervention. Of the patients who utilized OPY, 75% underwent breast procedures and 13% underwent hand procedures.

Conclusion: OPY is a novel Care Companion-based tool that is a viable option for providing detailed and robust outpatient guidance on maximizing pain control and minimizing narcotic usage. Further work is needed to deploy this tool to all non-plastic surgery procedures at the M-Health Fairview System and study the effectiveness this tool in comparison to standard guidance. This platform provides the opportunity to develop a database on the normative trajectory of pain following common surgical procedures as well as to test the effectiveness of various messaging forms on motivating patient weaning and disposal.

References: 1. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2024. 2. Marcusa DP, Mann RM, Cron DC, et. al. Prescription Opioid Use among Opioid-Naive Women Undergoing Immediate Breast Reconstruction. Plast Reconstr Surg. 2017;140(6):p1081-1090. 3. Johnson SP, Chung KC, Zlong L, et al. Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures. J Hand Surg. 2016;41(10):p947-957e.

Background: Artificial intelligence (AI) has unleashed new frontiers in the ways machines can assist with human tasks and holds an undisputed role within healthcare. AI is of particular benefit to surgical fields given their emphasis on timely decision-making and hands-on manipulation. Proper integration of AI into surgical practice may yield disruptive advances in clinical quality improvement and health resource optimization. The present study comprehensively reviews current applications and emits future directions of AI-based technologies in reconstructive breast surgery in an effort toward eventual widespread adoption.

Methods: Systematic literature searches using keywords and MeSH terms were performed on PubMed, Web of Science, and Google Scholar. The main subdisciplines of AI were investigated, which included machine learning, computer vision, natural language processing, and robotics. All studies discussing preoperative, intraoperative, postoperative, and academic applications of AI in breast plastic surgery were examined.

Results: Current preoperative applications include models capable of predicting operative risks and complications, as well as simulating surgical results, thereby enhancing patient counseling and informed consent. Intraoperatively, AI can help with the identification of anatomical structures, dissection plans, and three-dimensional visualization. Robotic surgery shows promise in multiple contexts, such as microsurgical vascular and lymphatic anastomoses, flap harvest, and dermal matrix anchoring. Postoperative applications of AI include discharge likelihood prediction and personalized follow-up scheduling to optimally allocate health resources, followed by at-home patient assistance and redirection. On the academic front, AI may provide personalized analysis and feedback to improve trainee operative skills and clinical knowledge, as well as help with research on key breast reconstruction topics. Despite promise, concerns about privacy and confidentiality, costs, and performance, remain to be addressed. Detailed breakdowns and discussions of current applications, future applications, and research directions, as well as barriers and limitations, are presented herein.

Conclusions: Applications of AI within breast plastic and reconstructive surgery are promising and diverse. The territory yet unchartered remains vast, necessitating further research and development. By centralizing and synthesizing knowledge, the present study assembles efforts in this nascent field, with the goal of enabling the entire plastic surgery community to effectively and responsibly harness the benefits of AI to advance breast reconstruction surgery.

PURSPOSE: Breast implant capsular contracture is a common complication of breast reconstructive surgery, which can be particularly devastating in the setting of post-mastectomy radiation therapy(1) The RHAMM signaling pathway has been implicated in pro-fibrotic diseases(2). NP-110 is a peptide mimetic, developed and validated to block RHAMM signaling pathways, and has been shown to decrease fibrosis in previous models(2,3). Our objective was to test the effect of NP-110 on a novel rodent model for radiation-induced capsular contracture. We hypothesized the RHAMM pathway contributes to the development of capsular contracture.

METHODS:
Our model consisted of female rats who underwent surgery to place a custom 2cc silicone implant under the right 4th mammary fat pad. Four weeks post-surgery, animals received a local injection of 100ug of NP-110, or a scrambled control peptide targeted to the right 4th mammary fat pad. Immediately following injection, all animals were treated with 26Gy of targeted ionizing radiation to the implant and mammary fat pad. The degree of contracture was assessed with Baker grade and Kumar score weekly post radiation. Four weeks post radiation, the implant, capsule, and fat pad were harvested en bloc, processed, and sectioned. Slides were stained for collagen with Masson's trichrome and Picrosirius red. ImageJ software was used to quantify the levels of stain, and therefore amount and bundling of collagen in capsule tissue. Biochemical hydroxyproline and total protein assays were used for quantitative collagen measurement in the fat pad and capsule tissue. Investigators were blinded until the completion of data analysis.

RESULTS:
The animals that received NP-110 showed both clinical and histological decreases in capsule fibrosis. Qualitatively, post-radiation skin and capsule fibrotic change were decreased in the NP-110 group compared to the control group. Histologically, the NP-110 group had significantly lower levels of collagen deposition with both Masson's trichrome (p=0.004) and Picrosirius red (p<0.001) staining. There was no significant difference in the hydroxyproline to total protein ratio between groups when calculated as the total mammary tissue (fat pad + capsule).

CONCLUSION:
Our study uses a novel rodent model for radiation-induced capsular contracture. Local delivery of a RHAMM function-blocking peptide, NP-110, significantly reduced capsule fibrosis. The hydroxyproline analysis was not significant, however this included fat pad tissue. Analysis for collagen staining and bundling in the capsule specifically was significantly reduced in the NP-110 group implicating the RHAMM pathway in development of capsular contracture. Future directions include targeting RHAMM for development of potential therapeutic agents to prevent capsular contracture.

1. Magill LJ, Robertson FP, Jell G, et.al. Determining the outcomes of post-mastectomy radiation therapy delivered to the definitive implant in patients under-going one- and two-stage implant-based breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2017;70:1329–1335.
2. Hauser-Kawaguchi A, Tolg C, Peart T, Milne M, Turley EA, Luyt LG. A truncated RHAMM protein for discovering novel therapeutic peptides. Bioorg Med Chem. 2018 Oct 1;26(18):5194-5203.
3. Truong, J. L. et al. Creating a Favorable Microenvironment for Fat Grafting in a Novel Model of Radiation-Induced Mammary Fat Pad Fibrosis. Plast Reconstr Surg. 2020;145:116–126.

Background: Physicians face unique challenges with family planning and fertility, given the rigorous demands of medical training often fall during peak reproductive years. Many trainees are often forced to make the decision to delay childbearing. In addition, institutional support for fertility treatment and preservation - counseling, education, and insurance coverage - is lacking in surgical training programs. This study sought to assess the awareness and desire for fertility preservation services for plastic surgery trainees in the United States, and the institutional coverage of fertility preservation and treatment services in this cohort.

Methods: An ACEPS-approved survey was distributed to all US plastic surgery residents and fellows via email. The survey included 25 questions and assessed respondents' current or future plans for childbearing, reasons for postponing childbearing, education of and attitude towards oocyte freezing, financial ability to pursue oocyte freezing, and perceived training program attitude towards childbearing.

Results: A total of 117 responses were received, including 78 (67%) integrated plastic surgery residents, 3 (3%) independent plastic surgery fellows, and 36 (30%) attending surgeons or fellows after completing plastic surgery training. 88 (77%) of respondents were female. 77 (66%) of respondents reported that they felt the need to postpone pregnancy due to residency, citing residency schedules too demanding, limited parental leave, and concern for availability of child care as the highest reported reasons for postponing childbearing. 56 (47%) reported they would consider freezing oocytes to preserve fertility, another 19 (16%) identifying as male but reported they would consider discussing oocyte freezing with a female partner. 103 (89%) of respondents had not received education during training regarding oocyte freezing to preserve fertility and postpone pregnancy. 21 (18%) reported that fertility preservation was offered through the insurance provided by their training program. 65 (56%) reported that they would pursue fertility preservation if covered by insurance.

Conclusion: US plastic surgery trainees often postpone having children due to the demands of their training. This delay raises the risk of infertility and pregnancy complications. While fertility preservation and treatments would benefit this group, there is a lack of education and access to these options. Our goal is to raise awareness and highlight the urgent need for improved, affordable access to fertility preservation and treatment for plastic surgery trainees.

Purpose As the transgender population increases, there is an increasing need for patients undergoing gender-affirming surgery to be perceived as their desired identity. Misgendering has been shown to worsen feelings of gender dysphoria; facial feminization surgery can treat this, by reducing distress, allowing correct gender identification, and improving quality of life (1-4). However, there is currently no ideal method to quantitively and anatomically assess facial feminization surgery outcomes. The purpose of this study is to use the largest set of clinical images, compared to the literature to date, to assess the accuracy of a pre-trained artificial intelligence (AI) model in classifying gender and in quantifying facial feminization surgery outcomes.

Methods An online literature search was conducted to collect preoperative and postoperative images of patients who underwent facial feminization surgery. Amazon Rekognition (Amazon, Seattle, WA) is a pre-trained AI facial recognition software which was used to analyze all images (5). Analysis included prediction of male or female gender as well as a confidence score out of 100. Male confidence scores were converted to negative values. Preoperative and postoperative mean confidence scores were calculated and compared using the Wilcoxon signed-rank test.

Results Pre- and postoperative facial photographs were collected for 76 transgender female patients. Preoperatively, 63 patients (82.9%) were classified as female compared to 75 patients (98.7%) postoperatively (p<0.01). Sixty patients (78.9%) had an improvement in female confidence score from preoperatively to postoperatively. The mean preoperative confidence in female appearance was 4.90 (SD 95.31) compared to 88.88 (SD 46.62) postoperatively (p<0.01). Among these, 12 patients (15.8%) were assessed as male to female, one (1.3%) as male to male, and 63 (82.9%) as female to female.

Conclusion This study is the largest cohort, to date, assessing the application of artificial intelligence facial recognition software in facial feminization surgery outcomes. There was a significant difference in confidence in female appearance postoperatively (4.90 vs 88.88, p<0.01) and in proportion of patients identified as female (82.9% vs 98.7%, p<0.01). While limitations are present, this study provides insight into the potential applications of AI in evaluating facial feminization surgery.

1. Cooper K, Russell A, Mandy W, Butler C. The phenomenology of gender dysphoria in adults: A systematic review and meta-synthesis. Clinical Psychology Review. 2020;80:101875. doi:https://doi.org/10.1016/j.cpr.2020.101875

2. Fisher M, Lu SM, Chen K, Zhang B, Di Maggio M, Bradley JP. Facial Feminization Surgery Changes Perception of Patient Gender. Aesthetic Surgery Journal. 2019;40(7):703-709. doi:https://doi.org/10.1093/asj/sjz303

3. Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature. Plastic and Reconstructive Surgery. 2016;137(6):1759-1770. doi:https://doi.org/10.1097/PRS.0000000000002171

4. Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of Life Research. 2010;19(7):1019-1024. doi:https://doi.org/10.1007/s11136-010-9668-7

5. AWS. Amazon Rekognition – Video and Image - AWS. Amazon Web Services, Inc. Published 2017. https://aws.amazon.com/rekognition/