Scientific Abstract Presentations: Hand Session 6 Saturday, September 28 Sat, Sep 28 5:00-6:00 p.m. PDT

Purpose: Work Relative Value Units (wRVU) are used by hospital systems to quantify and evaluate surgeons' performance levels. Prior wRVU analyses have shown plastic surgery procedures to be amongst the more undervalued procedures when operative time is taken into consideration (1). Peripheral nerve surgery, a niche and rising subset of plastic/hand surgery has been analyzed from a pure reimbursement standpoint, finding decreased reimbursement over time (2), but without respect to wRVUs. The authors aimed to compare wRVUs allocated to peripheral nerve-related surgical procedures based on their associated operative times and analyze potential implications.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was performed, and relevant CPT codes for peripheral nerve procedures were identified from 2005 to 2021. The efficiency was determined by using wRVU per unit time that was calculated using the median operative time for each procedure. Co-relation was performed between the median operative time with wRVU and wRVU per minute.

Results: The analysis included 21 CPT Codes with 2402 procedures. The median operative time for procedures involving neuroplasty, suturing of a peripheral nerve, and nerve grafts/transfers were 63.75 minutes, 100 minutes, and 153.7 minutes respectively. Nerve grafts and transfer had the highest operative of 153.78 minutes. "Suture of digital nerve, hand or foot; each additional" had the shortest operative time of 18.5 minutes as an individual procedure. Nerve grafts and transfers generated the maximum wRVU (Mean 16.35) while neuroplasty generated the minimum wRVU (Mean 7.24). The procedure generating a maximum RVU of 20.92 was "Nerve graft including harvest, multiple strands, arm, >4 cm". While the procedure generating a minimum RVU of 4.68 was "Neuroplasty; nerve of hand or foot". Procedures involving the suturing of peripheral nerves generated the highest wRVUs per minute (0.158 wRVU per minute). Nerve Grafts and transfers generated the least wRVUs per minute (0.09 wRVU per minute). Longer operative times were associated with greater wRVUs. Neuroplasty (R=0.86) and procedures involving nerve suturing (R=0.84) had a strong correlation to the median operative time. Nerve grafts and transfer, although requiring the maximum time and generating a maximum wRVU had a positive but moderate co-relation with the median operative time (R=0.67). There was a negative correlation between all the procedures and wRVU per minute.

Conclusions: Longer operative procedures for nerve grafts and transfers were designated with higher wRVU. Surgeons were reimbursed less per operative unit time for these surgical procedures. Nerve grafts and transfers resulted in reduced compensation in wRVUs per minute compared to procedures like neuroplasty or those involving suturing of a peripheral nerve. More complex surgical procedures often yield less financial remuneration, highlighting the disparities in the remuneration system within peripheral nerve procedures.

References: 1. Shim JY, et al. The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties. Plast Reconstr Surg. 2023 2. Nguyen, B. et al. Trends in Peripheral Nerve Surgery: Workforce, Reimbursement, and Procedural Rates. World Neurosurg. (2022).

Introduction: Nerve transfer surgery has revolutionized reconstructive surgery, providing optimism to patients with debilitating nerve injuries. Literature states that recovery amongst patients plateaus around 18 months post-nerve transfer(1,2). Happenstance, the authors had the opportunity to re-examine patients years after their initial nerve transfer surgery and noted further improvements in function compared to their last follow-up at 18 months post-surgery; thereby, questioning the established belief that nerve recovery following nerve transfer plateaus at 18 months. This study seeks to investigate the recovery trajectory beyond this accepted timeline whilst providing insights into patients' experiences undergoing nerve transfer procedures.

Methods: Patients were included in the study if they had undergone nerve transfer surgery and were more than 5 years post nerve transfer. A telephone survey was conducted, focusing on patient-reported outcomes using a Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Qualitative analysis and interviews were employed to elucidate patients' perceptions of recovery and functional status over the extended post-surgical period. Patients were re-examined to compare their current British Medical Research Council (BMRC) muscle grade to the previously documented 18-month post nerve transfer muscle grade, a minimum of 5 years previous.

Results: Of 68 contacted patients, feedback was obtained from 23 patients who underwent surgery between 5 and 9 years ago (response rate = 33.8%). Presenting complaints varied among patients, leading to diverse recovery trajectories; however,15 (65.2%) patients reported continued and meaningful functional recovery beyond the original follow-up timeline. Of the patients who had upper limb surgery (n=21), their current upper limb function reported DASH score average was 22.1, 95% Confidence Interval (CI) [13.8, 30.4]. 19 (82.6%) patients resumed work and/or pre-illness leisure activities. The average satisfaction score is 4.0 out of 5, (95%CI [3.5, 4.5]). 21 (91.3%) patients expressed willingness to undergo the procedure again.

Discussion: Our study unveils a nuanced narrative of sustained improvement in upper limb function well beyond the presumed 18-month milestone. Contrary to prevailing expectations, our findings indicate that recovery post-nerve transfer surgery is dynamic, marked by ongoing gains in neuromuscular function and quality of life. Significantly, most respondents expressed satisfaction with surgical outcomes, citing tangible enhancements in daily activities and overall well-being. Furthermore, the majority of patients expressed readiness to undergo the procedure again if found in similar circumstances, highlighting the profound impact of nerve transfer surgery on their lives. This study aims to address the traditional recovery timeline in nerve transfer surgery whilst advocating for a patient-centric approach by recognizing prolonged and dynamic recovery trajectories. Emphasizing the enduring benefits of nerve transfer procedures, our findings hold crucial implications for clinical practice, emphasizing the necessity of extended follow-up and personalized rehabilitation strategies to optimize outcomes for patients undergoing nerve transfer surgery.

References: 1. Hill, Joshua L. et al. 2019. "The Stages of Rehabilitation Following Motor Nerve Transfer Surgery." Journal of Musculoskeletal Surgery and Research 3: 60. doi:10.4103/jmsr.jmsr7918. 2 Larocerie-Salgado, Juliana et al. 2022. "Rehabilitation Following Nerve Transfer Surgery." Techniques in Hand & Upper Extremity Surgery 26(2): 71. doi:10.1097/BTH.0000000000000359.

PURPOSE Hirayama disease (HD) is a rare, nonfamilial, monomelic amyotrophy in which patients present with muscle atrophy and weakness of the forearms and hands, either unilateral or bilateral, and without sensory loss. Current treatment guidelines describe the role of conservative treatments including cervical collars and neurotropic medications, as well as spinal surgery in select patients. (1, 2) Upper extremity surgery has not yet been incorporated into the treatment algorithm of HD. The objective of this study is twofold: to present a case series of HD patients treated with the incorporation of nerve and tendon transfers and joint fusions into the existing treatment algorithm and to perform a literature review of interventions.

METHODS Three cases of HD treated surgically with nerve and tendon transfers and fusion are retrospectively reviewed. The subjective and objective results from surgery are reported. A literature review is performed on PubMed using "Hirayama disease" and "peripheral nerve surgery", "nerve transfer", "tendon transfer", "hand surgery" or "upper extremity surgery" as search terms to identify studies describing surgical treatment of HD outside of spinal surgery.

RESULTS Three HD patients (4 limbs) were identified. The average age was 23 years-old (range: 16-33). Patients presented with intrinsic muscle atrophy, hypothenar and thenar atrophy. The disease had been present for an average of 6.5 years (range: 1.5-15) prior to referral. Two patients had unilateral involvement while one had bilateral involvement. Two patients (3 limbs) were treated with an anterior interosseous (AIN) to ulnar motor nerve transfer while a patient with delayed presentation underwent thumb metacarpophalangeal joint fusion and Zancolli lasso to the fingers. All patients had subjective and objective improvements post-operation.
The literature reveals three independent case reports of HD patients treated with upper extremity surgery. Two papers describe using a tendon transfer while one paper describes an AIN to ulnar motor nerve transfer. All patients demonstrated functional improvements in follow-up. (3, 4, 5)

CONCLUSIONS HD can be successfully treated with a combination of upper extremity surgery and nerve transfers. To the authors' knowledge, this is the first literature review and the largest case series presenting such interventions in HD.

REFERENCES 1. Wang H, Tian Y, Wu J, et al. Update on the Pathogenesis, Clinical Diagnosis, and Treatment of Hirayama Disease. Front Neurol. 2021;12:811943. 2. Lyu F, Zheng C, Wang H, et al. Establishment of a clinician-led guideline on the diagnosis and treatment of Hirayama disease using a modified Delphi technique. Clin Neurophysiol. 2020;131(6):1311-1319. 3. Hayden ME, Kim J, Arányi Z, Wolfe SW. Outcome of Tendon Transfer for Monomelic Amyotrophy (Hirayama Disease). J Hand Surg Am. 2023;48(1):90.e91-90.e95. 4. Abreu Tanure A, Rosifini Alves Rezende LG, Pazim AC, Leal Ribeiro M. Supercharged End-to-Side Anterior Interosseous to Ulnar Motor Nerve Transfer for Hirayama Disease: A Case Report. Hand (N Y). 2022;17(4):Np12-np16. 5. Chiba S, Yonekura K, Nonaka M, Imai T, Matumoto H, Wada T. Advanced Hirayama disease with successful improvement of activities of daily living by operative reconstruction. Intern Med. 2004;43(1):79-81.

ABSTRACT:

Objective: We aimed to investigate the difference in neuroma rates between elective and emergent amputations and the contributing factors to persistent pain.

Background: The literature extensively covers the rates of symptomatic neuromas; however, there is a lack of investigation into comparing neuroma rates between elective and urgent surgeries.

 Methods: A retrospective review of 907 patients from 2015-2023 met inclusion criteria. Those who were primarily treated with digit amputations following any injury were included. Demographic data, comorbidities, body mass index, workers compensation cases, surgical data, digit (zone) injuries, and indications for surgery were noted. A total of 1171 amputations were identified. Continuous variables were described as mean and standard deviation, and categorical variables were described as frequencies with percentages. Chi-squared test was used to compare categorical variables. The Shapiro-Wilk test was used to test normality. The student's t-test was used for comparison of means of continuous data. A logistic regression analysis was conducted for predictors of neuromas and persistent pain. A p-value of less than 0.05 was considered significant.

Results: At a mean follow-up duration of 5 months, individuals who received elective procedures (n=401) exhibited a neuroma rate of 4%, whereas those who underwent emergent surgeries (n=506) had a neuroma rate of 3.2% (p=0.5). Patients were predominantly male (74%) with an average age of 52 years. Comorbidities were more frequent in patients who underwent elective surgeries. Thirty-two neuromas were identified. Of the 32 patients, 18 (56%) who developed symptomatic neuroma underwent secondary surgery for neuroma pain, with a median time to surgery of (4) months (IQR, 1.5-4.5). All patients who underwent surgery except for 3 had desensitization therapy before and after surgery. For 18 patients who underwent secondary surgery, the neuroma was excised, and nerve endings were cut proximally to retract in 9 (50%). The digital nerve endings were coapted to each other in 4 (22%), targeted muscle reinnervation (TMR) technique was utilized in 2 (11%), the proximal nerve ending was buried in adjacent tissue (muscle) in 1 (5%), excision and cauterization was used in 1 (5%) and regenerative peripheral nerve interface (RPNI) in 1 (5%). At long-term follow-up, 111 patients reported persistent pain, which we examined for causality.

Conclusion: The neuroma incidence after revision amputation is 3.5%. Blast injuries, age, zone 5 injuries, sarcoma, papillary adenocarcinoma, and 3 or more amputated digits positively influenced the rate of neuromas. Hypertension was the only factor that was associated with reduced neuroma rates. Female gender, alcohol abuse, rheumatoid arthritis, vasculitis, blast injuries, zone 4 and zone 5 injuries, 3 or more amputated digits, middle finger, and ring finger injuries were the predictors of persistent pain. Traction neurectomy and cauterization of the nerves were associated with low neuroma incidence (3.7% and 2.2%, respectively) and persistent pain (13% and 15%, respectively). Nerve coaptation had the highest neuroma rate (26%) and persistent pain rates (40%). We are unable to draw conclusions about RPNI and TMR due to our limited cases. Multicenter studies with objective pain assessment are warranted.

Background: Thumb carpometacarpal joint osteoarthritis (CMCJ OA) is a common degenerative condition with reduced quality of life as a result of pain, stiffness, and disability. Previous literature has established benefits of operative management; however the choice of operative technique remains controversial. Purpose: We sought to perform a cost-utility analysis to compare the traditional operative strategy, trapeziectomy with ligament reconstruction and tendon interposition (T+LRTI), with newer methods of suture suspension arthroplasty (SSA) for patients with CMCJ OA. Methods: A Markov microsimulation model was created to model a hypothetical cohort of patients with CMCJ OA presenting with a painful thumb and having failed conservative management. Two surgical treatment strategies: 1) T+LRTI and 2) SSA were compared from a hospital perspective. Outcomes included clinical outcomes (complication and revision rates) and cost-effectiveness outcomes (cost (in 2023, CAN$) and quality-adjusted life-years (QALY)) over a patient's lifetime. The willingness to pay (WTP) was set at $50, 000/QALY. Results: Higher complication rates were observed with T+LRTI (14.56% compared to 9.8%). Secondary revision surgery was more common for SSA (7.06% compared to 5.65%). Overall, SSA generated an incremental QALY of 0.25 compared to T+LRTI. T+LRTI was less costly over a patient's lifetime: $2842.21 compared to $2855.66. SSA generated an incremental cost-effectiveness ratio (ICER) of $53.80/QALY compared to T+LRTI. In modeling uncertainties of key model parameters (utility, cost, revision, complication and success), the primary outcome, ICER, was most sensitive to costs of the operation. Particularly, the cost of the operation for SSA resulted in a spread of the ICER between -3488.79 and 10958.55. The subsequent two-way sensitivity analyses compared the costs of the operation for LRTI + T and SSA and demonstrated that SSA remains the favored procedure. Conclusions: Suture suspension arthroplasty was the most cost-effective strategy (ICER $53.80/QALY), regardless of parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.

Hypothesis:

Administration of antibiotic prophylaxis has been extensively analyzed in adult upper extremity surgery, but data in the pediatric population is still limited. There is no consensus on whether antibiotic prophylaxis is necessary in clean pediatric upper extremity cases. We hypothesize that antibiotic prophylaxis is not necessary and there is no difference in postoperative surgical site infection rates regardless of preoperative antibiotic administration.

Methods:

A retrospective cohort analysis was performed on all pediatric upper extremity surgical cases performed at a single institution by seven pediatric orthopaedic surgeons between November 2021 and November 2023. All clean, soft tissue and hardware implantation cases were included. Exclusion criteria included patients over 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, medical comorbidities calculated as Pediatric Comorbidity Index, administration of perioperative antibiotics, hardware type, 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 338 patients were included for analysis – 133 received antibiotic prophylaxis and 205 did not. The two groups were similar in terms of demographic factors and comorbidities. Overall postoperative infection rate was very low at 1.2%, and there was no difference in infection rates between the group who received antibiotic prophylaxis and the group who did not. Infection rate in the antibiotic prophylaxis group was 0.8% and in the no antibiotics group was 1.5%. Antibiotic prophylaxis was significantly more likely to be administered in hardware cases versus soft-tissue cases (p-value<0.001). Sub-group analysis showed that implantation of hardware was not associated with an increased risk of infection, and again there was no difference in infection rates with or without antibiotic prophylaxis in hardware cases.

Summary points:

Antibiotic prophylaxis is not necessary in pediatric upper extremity surgical cases even when implantation of hardware is involved. Hardware implantation is not associated with increased risk of infection.

Purpose:
Flexor tendon repair is a technically demanding procedure, and surgical simulation may accelerate the learning curve of junior residents. Herein, the purpose of this project was to develop a training program with a 3D printed simulator to teach flexor tendon repair.

Methods: A 3D printed flexor tendon repair simulator was developed to include a surgical platform and an anatomically representative set of finger bones. Replaceable transparent silicone tendons are threaded through pulleys, and tension can be adjusted. We also produced an instructional video that covers core and epitendinous suturing.

With this curriculum, we held 3 separate 2-hour simulation workshops for 11 residents, and these participants were evaluated on their ability to perform cadaveric tendon repairs before and after the workshop. For evaluation, human cadaver fingers were disarticulated and mounted on a separate 3D printed platform, specifically designed to secure the tendons under tension. Participants were anonymously recorded and objectively graded, and anonymous recordings of two hand surgery attendings served our control group. Survey data was also collected to assess model realism, educational utility, and overall usefulness.

Results: Early results indicate that the 2-hour simulation workshop improves resident confidence and skill in flexor tendon repair. Additionally, the simulator's realism, educational utility, and overall usefulness received grades of 4.3/5, 4.3/5, and 4.7/5, respectively.

Conclusions: A 3D printed surgical simulator was developed for flexor tendon repair. Feedback has been uniformly positive, and results indicate improvement in junior resident confidence and skill. Because it can be 3D printed en masse, the device potentially has wide applicability within the hand surgery training curriculum.