Scientific Abstract Presentations: Hand Session 5 Saturday, September 28 Sat, Sep 28 8:00-9:30 a.m. PDT

Purpose:
Pediatric fingertip injuries involving the nailbed are extremely common, yet there is still no consensus on treatment protocols. The literature shows a range of practice patterns, and the current practice of repairing simple nailbed laceration injuries may result in overtreatment (1). The aim of this study is to assess whether there are specific variables in our population that could predict which patients with nailbed lacerations may have equivalent outcomes with fewer procedural interventions.

Methods:
A retrospective chart review was conducted at a single children's hospital for patients 0-18 years old with nailbed injuries from September 2017 through September 2023. Patients were excluded from the study if no x-ray was obtained at their initial visit or if they lacked at least one follow-up visit. Patients were excluded for complicating injuries such as Seymour or Salter-Harris fractures, or complete amputation of the digit. Descriptive statistics were generated. Chi-square and Fisher exact tests were used to analyze categorical variables and the Kruskal-Wallis for continuous variables.

Results:
238 patients were included in the study, accounting for 254 fingertip nailbed injuries. 131 were male (55.04%), 107 were female (44.96%), and the mean age at time of injury was 6.12 years. Median follow-up was 16 days following nailbed repair and trephination, and 9.5 days following conservative treatment. Two hundred forty-two (95.28%) injuries were due to crush injury of which 148 (58.27%) were attributed to a door. Nearly half of patients (46.85%) injured the surrounding tissue, 67 (26.38%) with subungual hematoma, and 114 (44.89%) with partial or complete nail avulsion. One hundred eighty-two patients (71.7%) sustained a distal phalanx fracture with the majority characterized as tuft (79.67%) and average displacement of 0.8 mm (range 0-36 mm). Nailbed laceration repair with suture or glue was the most common intervention: 60% treated by emergency department (ED) staff, 89.1% by plastic surgery, and 85.1% by orthopedics. Conservative treatment was less common, 28% by ED staff, 8.7% by plastics, and 5.7% by orthopedics. Trephination was least common: 12% by ED staff, 2.2% by plastics, and 9.2% by orthopedics. Outcomes were analyzed by type of repair (removal and repair, trephination, conservative). There were no differences in infection rates among treatment groups: nailbed repair (3%), trephination (0%), and conservative (2.9%) (p-value = 0.61) or complication rates (0.5%, 0%, 2.9%, respectively) (p-value = 0.21). Of the 7 patients with infection, 6 (85.7%) were repaired with nail removal and repair while 1 (14.3%) was conservatively managed with splinting. Five of the 7 (71.4%) received antibiotics at their initial visit.

Conclusion:
For simple nailbed injuries in our pediatric population, patients had consistently good early outcomes irrespective of intervention. The incidence of overall complications in nailbed injuries is low. The traditional approach requiring nail plate removal, repair, and often sedation may represent overtreatment. Further study into long-term outcomes, and prospective investigation into conservative treatment of uncomplicated nailbed injuries is warranted.

References:
1. Capstick R, Giele H. Interventions for treating fingertip entrapment injuries in children. Cochrane Database Syst Rev. 2014;2014(4):CD009808. Published 2014 Apr 30. doi:10.1002/14651858.CD009808.pub2

Purpose: This study investigates the efficacy of the Supination-External Rotation (Sup-ER) orthosis in addressing the progression of glenohumeral dysplasia (GHD) in patients with brachial plexus birth injuries (BPBI). Although previous research studies have examined the success of the Sup-ER orthosis based on Active Movement Scale (AMS) scores, this study examines whether the Sup-ER orthosis would produce similar results if the outcome variables also included serial, objective ultrasound measurements.

Methods: The Sup-ER orthosis was fabricated for twenty infants diagnosed with GHD subsequent to BPBI. AMS scores of shoulder abduction (SA), forward flexion (FF), supination (Su), and external rotation (ER), as well as alpha angle measurements from ultrasound findings were collected prior to and at each follow-up visit following the fabrication of the Sup-ER orthosis. The success of the Sup-ER orthosis in correcting GHD was confirmed through ultrasound findings and improving AMS scores, leading to the discharge of patients from care. Failure to rectify GHD necessitated a transition to operative management for the patient. Analysis of the outcome measurements were conducted using a two-tailed paired sample t-test. The level of significance was set at p < 0.05.

Results: Fourteen out of the twenty patients (70%) fabricated with the Sup-ER orthosis successfully demonstrated resolution of GHD on ultrasound and improvement of AMS scores. The average time of fabrication of the Sup-ER orthosis to the time of discharge from the orthosis was 17.4 (SD 8.3) weeks. In these patients, average SA was 6.6 (SD 0.8) (p < 0.05), SF was 6.6 (SD 0.8) (p < 0.05), ER was 6.7 (SD 0.6) (p < 0.05), and Sup was 6.8 (SD 0.8) (p = 0.08) following discontinuation of the orthosis. Additionally, in these patients the average alpha angle following treatment with the Sup-ER orthosis was reduced to 14.4 (SD 4.9) (p < 0.05). Of the remaining patients (30%), the implementation of the Sup-ER orthosis failed to resolve GHD as evidenced by either ultrasound findings or AMS scores. These patients had to undergo further microsurgical intervention.

Conclusions:
The Sup-ER orthosis is effective in resolving glenohumeral dysplasia, as evidenced by improving AMS scores and serial, objective ultrasound measurements, and should be advocated for in the routine care of patients with BPBI. However, in contrast to previous studies demonstrating universal success of the orthosis, this study shows that a certain portion of patients will fail conservative therapy and require microsurgical intervention.

Background and Purpose: Kienbock's disease is a rare form of idiopathic lunate osteonecrosis that can lead to insidious carpal collapse, wrist pain, and dysfunction. While early-stage disease can be managed with offloading procedures or scaphocapitate fusion (SCF), revascularization procedures have been proposed as an alternative to potentially halt disease progression (1,2). Early evidence suggests lunate revascularization leads to improved patient-reported and functional outcomes at the cost of higher surgical revision rates. The purpose of this investigation is to identify predictive factors that lead to operative revision and conversion to salvage procedures for disease management (3).

Materials and Methods: A multi-center, retrospective study was performed on patients undergoing revascularization surgery for Kienbock's disease from January 1976 to December 2023 from our multi-center institutional database. Relevant demographic, radiographic, and clinical data were collected. Functional and patient-reported outcomes were obtained and analyzed. Hazard ratio and survival analyses were performed to evaluate predictors of unplanned return to the operating room or conversion to a salvage procedure.

Results: A total of 99 patients undergoing revascularization [n=90 pedicled vascular bone grafts (VBGs), four free VBGs, and four arteriovenous implantations] were identified with an average follow-up of 13.1 (51.8) months. 28.2% (28/99) had to return to the operating room for an unexpected complication, including 5.1% (5/99) for infection, 2.0% for (2/99) recalcitrant pain, 9.1% (9/99) for a hardware complication, and 14.1 (14/99) for a nonunion requiring salvage conversion. Survival analysis revealed median time to revision of 2 months for infection, 11 months for hardware complication, and 13 months for conversion to salvage procedure, respectively (p=0.61). Hazard ratio analysis of graft type, revision surgical indication, gender, age, hand dominance, and Lichtman stage revealed a protective association with older age and unplanned operative intervention, with a hazard ratio (95% Confidence Interval) of 0.95 (0.91-0.98).

Summary: While evidence points to the superiority of functional outcomes in vascularized bone grafting in Kienbock's disease (3), over a quarter of patients had to return to the operating room for an unexpected complication, and 14% required a conversion surgery in the setting of nonunion. These real risks need to be weighed against the relative benefit provided by revascularization in the setting of conventional surgical interventions including lunate offloading and salvage procedures.

Citations: 1. Rizzo M, Moran S. Vascularized Bone Grafts and Their Applications in the Treatment of Carpal Pathology. Semin Plast Surg. 2008;22(03). doi:10.1055/s-2008-1081404 2. Nakagawa M, Omokawa S, Kira T, Kawamura K, Tanaka Y. Vascularized Bone Grafts from the Dorsal Wrist for the Treatment of Kienböck Disease. J Wrist Surg. 2016;05(02). doi:10.1055/s-0036-1582427 3. Rames J, Emanuels A, Tunaboylu M, Moran S. A Comparison of Long-term Outcomes Between Lunate Revascularization and Salvage Procedures in Kienbock's Disease . In: ASSH/ASHS: Innovations Across the Pacific in Hand Surgery. ; 2024.

INTRODUCTION Instability and dorsoradial ligament attenuation have been increasingly recognized as critical factors in the development and progression of thumb carpometacarpal (CMC) osteoarthritis. There has also been recognition of the biomechanical value of preserving native anatomy with trapezial-sparing techniques, such as meniscus arthroplasty. We hypothesize that suture tape augmentation of the dorsoradial ligaments at the time of trapezial sparing arthroplasty may play an important role in providing post-operative CMC stability and improving long-term pain and function.

METHODS Our standard technique for CMC meniscus arthroplasty was performed using a dorsal arthrotomy, debridement of the distal articular surface of the trapezium, and placement of meniscus allograft secured by fiberwire suture to the trapezium surface. After right dorsal capsular closure, an internal brace suture tape was placed using suture anchors from the dorsal trapezium to the first metacarpal base. Retrospective review was performed of patients undergoing this technique, with demographics, prior intervention, and radiographic grade of arthritis collected. Radiographic dorsal subluxation was measured pre and post-operatively (reported as quadrants with 1 representing 0-25% joint subluxation, up to 4 representing 75-100%). Post-operative outcomes including pain scores, range of motion and patient satisfaction were compared pre-operatively to final follow-up at an average of 6 months. Any complications and re-operation were recorded.

RESULTS Thirty-three patients underwent thumb CMC arthroplasty with dorsoradial ligament internal brace augmentation from October 2020 through December 2023. Average age was 62 years (range 46 to 79) and 61% were female. Pre-operatively, average Eaton stage was 2.52. Twenty-five patients underwent previous corticosteroid injection, 19 had attempted bracing, and five had undergone previous surgery to the affected joint. At final follow-up, mean dorsal subluxation was 1.87, improved from a mean of 2.09 preoperatively. Mean pain at rest was 1.54 and pain with activity was 3.39 on a 10-point scale. One patient had symptomatic retained suture, while three others reported recurrence of pain after initial improvement, which did not require additional intervention. No other complications were noted. No revision or secondary surgeries were performed.

CONCLUSION This series demonstrates the safety and efficacy of suture tape augmentation of the dorsal capsule for CMC stabilization in a trapezial sparing arthroplasty technique. The role of the dorsoradial ligament in thumb CMC stability and its implications for the progression of arthritis and pain is becoming more recognized in the literature. Further long-term study is needed to evaluate for durability of the technique over time, impact on progression of arthritis and any long-term complications.

Objective: The primary objective of this study was to assess whether double fascicular transfer (DFT) has superior outcomes compared to single fascicular transfer (SFT) for reanimation of elbow flexion.

Methods: Medical Research Council (MRC) grade for elbow flexion was recorded and compared before and after surgery. The effect size was calculated using the risk ratio (RR) and results were compared across different interventions. A meta-regression analysis was performed to further compare the outcomes between SFT and DFT controlling for level of injury.

Results: A total of 59 studies with 1402 patients (mean age 29.3 ± 7.9 years old) were included in the review. The average duration from the time of injury to surgery was 6.2 ± 4.8 months. C5-C6 injury had the best outcomes, with 91.6% and 74.8% of patients recovering MRC grade 3 and 4, respectively. With C5-C7 injury, 86.0% and 69.2% of patients recovered MRC grade 3 and 4, respectively. With C5-C8 injury, 70.9% and 56.4% recovered MRC grade 3 and 4, respectively. Subgroup analysis comparing the severity of BPI showed no significant difference (P<0.05). The aggregated mean DASH score was 38.3 for the SFT group and 27.3 for the DFT group. Meta-regression demonstrated that DFT and C5-C6 injury were significant predictors for achieving MRC grade 3, while DFT and shorter duration of surgical delay were a significant predictor for achieving MRC grade 4.

Conclusion: When controlling for the level of injury, DFT is associated with greater likelihood of achieving MRC grade 3 and 4 power compared to SFT in patients undergoing surgical management of brachial plexus injuries. A shorter duration of surgical delay was a significant predictor for achieving MRC grade 4.

Hypothesis: Postoperative edema is a common problem in upper extremity surgery that can contribute to significant pain and stiffness. Oral corticosteroid medications have great potential to provide an easily accessible solution, but fear that they might increase risk of postoperative infection has limited their usage. We hypothesize that postoperative oral corticosteroid treatment is safe and will not increase the risk of surgical site infections in adult upper extremity surgery.

Methods: A retrospective study was performed at a single institution between November 2021 and November 2023. All adult patients who underwent clean upper extremity surgery including both soft-tissue and hardware implantation cases were collected. Exclusion criteria included patients under the age of 18, administration of antibiotics in the immediate postoperative period, and those with less than 30 days of follow-up. Patient demographic factors and operative details were collected including age, sex, BMI, laterality, smoking status, medical comorbidities calculated as Charlson Comorbidity Index, administration of perioperative antibiotics, prescription of postoperative oral steroids, and length of procedure. Primary outcome measures were diagnosis of surgical site infection by 14 days and 30 days. Secondary outcomes included management with antibiotic treatment, operative washout, or hardware removal if diagnosed with an infection. Categorical variables were compared using Fisher's exact test, and continuous variables were compared using Wilcoxon rank-sum test. Significance was defined by p-value < 0.05.

Results: A total of 958 patients were included for analysis – 249 received a one-week course of postoperative oral steroids (methylprednisolone) and 709 did not. The two groups were similar in terms of demographic factors and comorbidities. Both groups had identical surgical site infection rates of 4.4% with no statistical difference. There was a significant difference in the distribution of hardware (18% vs. 31%) versus soft tissue (82% vs. 69%) cases between the steroids and no steroids groups, respectively, so sub-group analysis was performed. This demonstrated that there was no difference in infection rates between the steroid and no steroid cohorts when separated into hardware implantation group and soft tissue group.

Summary points: Postoperative oral steroid administration is safe in adult upper extremity surgery and does not increase the risk of surgical site infection even with hardware implantation.

Introduction : The first replantation done in the world was an arm level replant done in 1962. Since then many centres across the world have been attempting this difficult level replantation. Literature is sparse on functional outcome achieved in such cases.

Aim of our study is to evaluate the outcome of major replantation of crush avulsion amputations at elbow and arm level.

Methods: From 2000 to 2019, 33 elbow and arm level replantation have been done at our institution. Of these 30 were successful. 21 patients who had a minimum follow up of 1 year were available for review. Average follow-up period is 32 months (1 to 13 years). There were 20 male and 1 female patients. Mean age was 28 years (10-60 years). 16 cases (71.42 %) were due to industrial accidents, of which conveyor belt injury accounted for 40%. The levels of the replantation were - forequarter (n=1), proximal arm (n=11), distal arm (n=4), elbow (n=5). Motor and sensory evaluation and Chen's Grading was done for evaluation.

Results: Overall success rate was 90.9% (n=30) with three failures. 21 patients were analysed by Chen's criteria. Chen 1 – 0, Chen 2 – 9, Chen 3 – 12, Chen 4 – 0. Chen 2 (Good) patients (9/21) were able to resume gainful activity. Chen 3 (Fair) patients (12/21) were satisfied and used their hand for activities of daily living. 13 secondary procedures were performed in nine patients to improve the outcomes.

Conclusion: All 21 patients had fair to good results with useful function and protective sensations. They had high levels of satisfaction with psychological well being. As all had protective sensation, they fare better than those with prosthesis fitted at arm level. Hence replantation in carefully selected individuals gives high rates of success and patient acceptance.

INTRODUCTION Thumb and finger collateral ligament tears can present a challenging clinical problem due to poor healing potential of the injured ligament. Current surgical techniques are limited: primary repair is not always feasible due to poor tissue quality, augmentation with tendon graft can lead to stretching and recurrent instability, and internal brace augmentation can be complicated by over-tightening, stiffness, and infection. Cadaveric knee medial collateral ligament (MCL) allograft has previously been studied in vitro and shown good biomechanical properties that may lessen graft attenuation long-term. We describe the feasibility and early outcomes for a novel technique for collateral ligament reconstruction/repair using augmentation with cadaveric knee MCL allograft.

METHODS Adult patients undergoing thumb and finger collateral ligament repair were screened for participation in the study at a single academic institution. For metacarpophalangeal (MCP) repairs, the torn collateral ligament was repaired in a standard fashion and cadaveric knee MCL allograft was secured using anchors in the metacarpal head and proximal phalanx base. For proximal interphalangeal (PIP) repairs, bone tunnels and fiberwire suture were used to secure the graft. Patient demographics, VAS pain scores, and radiographs were collected pre-operatively and at 6 weeks, 6 months, and 1 year post-operatively. Post-operative complications were recorded.

RESULTS A total of 8 patients were enrolled from September 2023 to January 2024 - 3 patients undergoing thumb MCP ulnar collateral ligament repair, 4 patients undergoing finger PIP collateral repair, and 1 patient undergoing finger MCP collateral repair. The cohort included 5 males and 3 females, ages ranged from 24 to 70 years old, and 3 patients had prior failed surgery on the affected joint. Indications for surgery included instability in the setting of primary osteoarthritis (3), instability in the setting of post-traumatic arthritis (2), and subacute traumatic ligament injury (3). All patients undergoing PIP ligament repair had concomitant meniscus arthroplasty. To date, 5 patients have completed 6-week follow-up. Average pain score at rest decreased from 3.4 pre-operatively to 1.4 post-operatively, while pain scores with activity decreased from 5.4 to 3.2. No complications are noted, and radiographs demonstrate appropriate joint alignment with no evidence of arthritis progression in any patients at an average of 68 days of follow-up.

CONCLUSION Cadaveric knee collateral ligament allograft appears to be a promising alternative to tendon graft and internal brace augmentation by providing similar biomechanical properties as the native ligament. Longer-term follow-up as part of the present study will provide information on expected pain and function outcomes of the current technique.

Introduction Hand surgery is a unique subspecialty that exists at the intersection of orthopedic surgery and plastic surgery. However, the percentage of hand surgery fellows from a plastic surgery background has dropped to nearly 10% over the past decade for unclear reasons. This study sought to evaluate the mentorship in plastic surgery, using publications as a proxy, to determine if academic exposure is a limiting factor in plastic surgery residents pursuing hand surgery fellowships.

Methods All published articles in the Journal of Hand Surgery and Hand from 2011-2020 were reviewed. The lead author and senior author were extracted, and preferred gender, as available on online documentation, articles, or references, were marked as male, female, or other (representing nonbinary and genderqueer). The training background of authors was recorded as orthopedic surgery, plastic surgery, or other based on the listed affiliation. Article topics were categorized as fracture, nerve, pediatric, reconstructive (traumatic soft tissue surgery), shoulder/elbow, soft tissue (nontraumatic soft tissue surgery), tendon, tumor/oncology, and hand/wrist arthritis. The author h-index was recorded as a measure of author impact. Statistical analysis was completed using chi-squared tests with Bonferonni corrections or generalized estimating equations as appropriate.

Results A total of 3150 articles were reviewed. Plastic surgeons comprised 25% of all authors, twice as high as the rate applying into hand surgery. Approximately 5% of papers had both plastic and orthopedic surgery authors. Plastic surgeons were overrepresented in nerve, pediatric, and reconstructive papers compared to the population average. By the h-index, plastic surgery trained authors and orthopedic surgery trained authors had equivalent impact. This gap was more pronounced when looking at female authorship in each discipline, as only 18% of orthopedic surgery trained first authors and 9% of orthopedic surgery senior authors were female, compared to 26% and 16% of plastic surgery trained authors (p < 0.01). These values showed no discernable trend over the decade.

Conclusions Plastic surgeons publish at a proportional rate to their participation in hand surgery, suggesting adequate academic exposure. This also suggests that extrinsic pressures outside of mentorship in hand surgery may be driving plastic surgeons away from hand surgery fellowships. Maintaining the contribution of both fields to hand surgery is critical in ensuring further development of the field and optimal patient outcomes

Access to a certified hand therapist plays a crucial role in enhancing post-surgical functional outcomes and reducing morbidity in complex hand surgery and trauma cases. Unfortunately, the availability of Certified Hand Therapists (CHT) is uneven across regions, particularly in less populous states such as Mississippi. The financial and time-related burden of traveling to a CHT to receive appropriate rehabilitation care impacts patients recovering from hand surgery and hand trauma. This study investigates the accessibility of CHT services in Mississippi by analyzing physical proximity to certified hand therapists and assessing the resultant economic implications, specifically focusing on transportation costs.

County level distances to the nearest CHT were mapped and evaluated. The associated cost of personal vehicle transport was calculated using 2024 Internal Revenue Service (IRS) standard mileage rates of $0.67 per mile. Distance from a CHT and travel costs were stratified based on published 2023 Rural Urban Continuum Codes (RUCC).

One-way ANOVA analysis revealed a significant difference in both the distance traveled to CHT and the associated travel costs when stratified by RUCC (ps <0.05). On average, the distance to a CHT in Mississippi is 27.6 miles or 55.2 miles round trip, incurring a cost of $36.98 per visit. However, residents of the farthest county from a CHT travel 86.4 miles or 172.8 miles round trip, resulting in a financial burden of $115.78 per visit to a certified hand therapist.

This heightened cost for individuals residing farthest away poses substantial geographic, economic, and time-related barriers to accessing CHT services. Moreover, these barriers have a pronounced impact on the well-being of patients and their families, considering the frequency of required visits for adequate rehabilitation and functional recovery, typically occurring once or twice per week over several months. This study emphasizes the urgency of addressing disparities in CHT access to ensure equity across the state.

Background Early and accurate diagnosis is critical to preserve function and reduce healthcare costs in hand and wrist injury patients. As such, artificial intelligence (AI) models have been developed for the purpose of diagnosing fractures through imaging. The purpose of this systematic review and meta-analysis is to determine the accuracy of AI models in identifying hand and wrist fractures and dislocations. Methods Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Diagnostic Test Accuracy guidelines, Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to October 10, 2023. Studies were included if they utilized an AI model (index test) for detecting hand and wrist fractures and dislocations in pediatric (<18 years) or adult (>18 years) patients through any radiologic imaging, with the reference standard established via image review by a medical expert. Results was synthesized via bivariate analysis. Risk of bias was assessed using via the QUADAS-2 tool. This study was registered with PROSPERO (CRD42023486475). Results A systematic review identified 36 studies. Most studies assessed wrist fractures (27.90%) via X-ray imaging (94.44%), with radiologists serving as the reference standard (66.67%). AI models demonstrated an AUC 0.946, positive likelihood ratio 7.690 (95% CI 6.400-9.190) and negative likelihood ratio 0.112 (0.0848-0.145) in diagnosing hand and wrist fractures and dislocations. The diagnostic accuracy of unaided clinicians in diagnosing hand and wrist fractures and dislocations was as follows: AUC 0.953, positive likelihood ratio 11.000 (8.240-14.600), and negative likelihood ratio 0.157 (0.102-0.228). In comparison, the diagnostic accuracy of AI-aided clinicians in diagnosing hand and wrist fractures and dislocations was: AUC 0.972, positive likelihood ratio 19.100 (13.600-26.000), and negative likelihood ratio 0.129 (0.0734-0.206). There was a significant difference in positive likelihood ratio between the diagnostic performance of unaided vs. AI-aided clinicians in diagnosing hand and wrist fractures and dislocations (p-value 0.0032). Examining only studies characterized by a low risk of bias, sensitivity analysis did not reveal any difference from the overall results. Conclusion In demonstrating the accuracy of AI models in hand and wrist fracture and dislocation diagnosis, we can justify further validation and feasibility studies, as well as its clinical integration. Strengths of this study include rigorous methodology, robust synthesis of 36 studies, and moderate overall certainty of evidence per GRADE assessment.

Background: Despite the advances in microsurgery, upper limb reconstruction remains challenging, especially in the forearm due to its complex anatomy and functional demands. Successful management requires a multidisciplinary approach between orthopedic and plastic surgeons, as well as effective postoperative rehabilitation. The purpose of this study is to report our experience with complex forearm reconstruction following extensive tumor resection to provide the best possible reconstructive solution in a single operation. Methods: A retrospective review was conducted on patients who underwent complex forearm reconstruction after tumor at Mayo Clinic Rochester between 1994 and 2024. Demographics, operative details, functional outcomes, and compilations were collected. Variables were analyzed using appropriate statistical tests. Results: Twenty-eight patients were identified, with an average age of 49.3±22.2 years at the time of the surgery. The defects resulted from tumor removal including sarcoma (89.3%, n=25), schwannoma (3.6%, n=1), desmoid tumor (3.6%, n=1), and giant cell tumor of bone (3.6%, n=1). The types of complex reconstructions included the free fibula flap (42.8%, n=12), pedicled radial forearm flap (10.7%, n=3), anterolateral thigh flap (42.8%, n=12), and flow-through greater saphenous vein perforator flap (3.6%, n=1). In addition, 5 patients received vascularized nerve grafts and 12 patients underwent skin grafting within the same operation. The average oncologic defect was 9.8 cm. The average BMI at the time of surgery was 27.4 kg/m2. The median follow-up period was 6.5 years, ranging from 3 months to 30 years. The reoperation rate was at 67.8% (n=19) given the malignancy of the original diagnosis and the procedure's complexity. Reasons for reoperation included five tumor recurrences, three hardware removals due to discomfort and decreased function, two tenolyses, eight flap debulking, two wound debridement due to infection, eight scar revisions, and two flaps underwent re-exploration. There was one amputation due to sarcoma recurrence. There was no flap failure or compartment syndrome occurred among this cohort. Two patients have passed away as of 2/28/2024, both aged over 80, due to causes unrelated to their reconstructive procedures. Eleven patients returned to regular employment. The average QuickDash score was 35.9 indicating a mild disability in activities. The average pronation was 65.2 degrees and the average supination was 60 degrees. All patients achieved acceptable functional outcomes with the assistance of hand therapy. The average pain score in the affected extremities was 0.2 (0=no pain, 10=severe pain). Donor-site morbidity was minimal, with only one case experiencing wound dehiscence in the medial aspect of the anterior thigh. Conclusions: Preservation of the upper limb and restoration of hand function are the primary goals of complex forearm reconstruction. While reoperation and complication rates may not be low due to the complexity of the anatomy and surgical techniques, successful reconstruction can maximize functional recovery, as well as minimize the likelihood of amputation.

4/2023-2/2024

Introduction

Procedures performed using Wide-Awake Local Anesthesia No Tourniquet (WALANT) allow hand surgery patients to avoid the drawbacks of general anesthesia, while also allowing providers to perform procedures in clinics. However, having patients awake during the procedure can cause operative anxiety. One recently proposed solution has been the incorporation of Virtual Reality (VR) technology during WALANT procedures. We hypothesize using VR during WALANT guided procedures will reduce patient anxiety during the operation.

Methods

84 participants undergoing WALANT procedures were randomly assigned to either the VR group (n=40) or the control group (n=44). VR patients viewed one of the "Our Planet" docuseries videos on a Meta Quest 2 VR device during their procedure. The control group underwent WALANT with no device. Patient reported outcomes (PROs) including pre-operative and post-operative surveys regarding anxiety (APAIS), surgical satisfaction (SSQ-8), and VR side-effects (VRISE) were administered to both groups to subjectively assess patient anxiety. Additionally, objective anxiety measurements were acquired using pre-operative, intra-operative and post-operative systolic (SBP) and diastolic blood pressures (DBP) and heart rates (HR). Two-tailed independent t-tests were used with an alpha of 0.05.

Results

There were no differences in mean procedure time between groups (p=0.358). There were no significant differences in any of the validated questionnaires we administered pre- and post-operatively as subjective metrics. However, the post-operative APAIS score was lower in the VR group (11.25) than the control group (13.55) (p=0.09). The objective metrics we examined as a proxy for anxiety showed a significant difference between the control and VR groups regarding sitting HR prior to the procedure. The mean HR for the VR group was 81 bpm while for the control group it was 76 bpm (p=0.04). However, the paired mean difference between pre-op sitting HR and post-op sitting HR showed no difference between groups (p=0.149). There were no other significant differences in objective metrics between groups, including pre-operative sitting or supine vitals (SBP, DBP, HR), intra-operative supine vitals, and post-operative sitting vitals.

Discussion

We had several novel findings that deviated from our hypothesis. (1) The subjective patient anxiety questionnaires did not show any significant differences between groups. The APAIS survey score decreased from 12 to 11.25 for the VR group while only decreasing from 13.88 to 13.54 for the control group. This larger decrease for the VR group approached significance and may indicate greater reductions in anxiety over the course of a WALANT procedure for the VR group. (2) The VR group saw a larger decrease in mean sitting HR when comparing HR before the procedure to HR after the procedure, which may indicate anxiety reduction over the course of the entire WALANT procedural experience, but not necessarily reduction in intraoperative anxiety. These trends demonstrate that VR may impact patient experience throughout an entire WALANT procedure, as opposed to a targeted reduction in intraoperative anxiety.

Summary/Conclusion

Virtual reality technology has the potential to improve patient experience during WALANT and reduce the sympathetic response induced by being awake during surgery, but does not objectively reduce intraoperative arousal or anxiety.