Residents and Fellows Papers Abstract Book

73RD ANNUAL MEETING OF THE ASSH SEPTEMBER 13 – 15, 2018 BOSTON, MA

822 W Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Fax: (847) 384-1435 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

Paper 1: Neuroprotective Effect of Lidocaine Administration Prior to Nerve Transection Session 1: Nerve – Wednesday, September 12, 2018, 8:37-8:39 AM

Nerve;General Principles N/A - not a clinical study

Jeena M. Easow, MD Harvey Chim, MD Christopher J. Salgado, MD Nicole L. Miller, BS Denise Manfrini, BS Elizabeth Medina, BS

COI There is financial information to disclose.

Hypothesis Following coaptation of peripheral nerves in reconstruction, multiple limitations exist in the regeneration process. Lidocaine may serve as a neuroprotectant prior to nerve transection through inhibition of calcium influx and thus preservation of donor axons. The usefulness of this local anesthetic as a neuroprotective agent was investigated in a rat sciatic nerve model.

Methods The sciatic nerves of 41 Sprague-Dawley rats were injected with normal saline (n = 9), 1% Lidocaine (n = 11), 1% Lidocaine w/ 10% calcium gluconate (CG) (n = 11), and 10% calcium gluconate (n = 10). Following injections, the sciatic nerves were transected, labeled with Fluorogold nerve tracer and microsurgically anastomosed. Animals underwent behavioral testing preoperatively and postoperatively at 8 or 12 weeks.

Results Walking track analysis and gridwalk testing demonstrated enhanced recovery of locomotion in rats that were administered Lidocaine prior to nerve transection compared to other groups. At 8 weeks, Lidocaine and Lidocaine w/ CG-treated rats had significantly improved Sciatic Functional Index (SFI) scores compared to saline-treated rats (p < 0.05). At 12 weeks, Lidocaine and Lidocaine w/ CG-treated rats had significantly improved SFI scores compared to saline and CG- treated rats (p < 0.05). Gridwalk analysis of foot slip errors indicated Lidocaine-treated rats had significantly lower mean foot slips compared to saline-treated rats (p < 0.05), and Lidocaine w/

CG rats had significantly lower mean foot slips compared to saline, CG, and Lidocaine-treated rats (p < 0.05). At 12 weeks, Lidocaine-treated rats had the lowest level of mean foot slips, which was significantly less than that of Lidocaine w/ CG-treated rats (p < 0.05).

Summary Points • This study affirms that administration of Lidocaine prior to nerve transection is an effective intervention to preserve donor axons for planned nerve transfers and may have potentially beneficial clinical applications that warrant further studies.

Bibliography 1: Sulaiman W, Gordon T. Neurobiology of peripheral nerve injury, regeneration and functional recovery: From bench top research to bedside application. Ochsner J. 2013;13:100-108. 2: Yu P., Matloub H.S., Sanger J.R., Narini P. Gait analysis in rats with peripheral nerve injury. Muscle Nerve. 2001; 24:231-239. 3: De Medinaceli L., Freed W.J., Wyatt R.J. An index of the functional condition of rat sciatic nerve based on measurements made from walking tracks. Exp Neurol. 1982; 77:634-643. 4: Puigdellívol-Sánchez A. et al. On the use of fast blue, fluoro-gold and diamidino yellow for retrograde tracing after peripheral nerve injury: uptake, fading, dye interactions, and toxicity. J Neurosci Methods. 2002; 115:115-112 5: Lei B., Cottrell J., Kass S. Neuroprotective Effect of Low-dose Lidocaine in a Rat Model of Transient Focal Cerebral Ischemia. Pain Medicine. 2001; 95:445-451.

Paper 2: Local Delivery of Supplemental Agrin at the Time of Injury Prevents Motor Endplate Degradation Session 1: Nerve – Wednesday, September 12, 2018, 8:40-8:42 AM

Hand and Wrist;Nerve N/A - not a clinical study

Winnie Palispis, MD Henry Hoang, BS Jennifer Uong, BS Justin P. Chan, BA Ranjan Gupta, MD

COI There is no financial information to disclose.

Hypothesis One reason for poor recovery after nerve injury is end-organ atrophy, i.e. degradation of the neuromuscular junctions (NMJ). Agrin has been well characterized as an essential component of NMJ formation; thus, we hypothesize that direct local delivery of agrin after traumatic nerve injury will preserve motor endplates.

Methods A denervation model was created in 6-week-old wildtype and KOAGD (agrin deficient) mice by excising a 10 mm right sciatic nerve segment and suturing the proximal nerve stump to the gluteal muscle to prevent regeneration. Genotyping was performed by Transnetyx. To establish difference between KOAGD and wildtype mice after nerve injury, hindlimb muscles were harvested at 1,2 4,8, and 16 weeks post denervation. For the second part of the study, KOAGD mice were injected with supplemental agrin (1uM Agrin) or phosphate buffered solution (PBS) at the site of injury, and hindlimb muscles were harvested at the same timepoints. Muscles were processed for immunohistochemistry. NMJs were visualized with confocal microscopy (n=6). Motor endplates were labeled with alpha-bungarotoxin, presynaptic terminals with synaptophysin, and axons with neurofilament. VolocityTM 3D software was used to quantify acetylcholine receptor (AchR) surface area and volume. Unpaired t-test was used to compare wildtype and KOAGD mice without treatment. Two-way ANOVA was used to compare agrin deficient denervated muscles treated with PBS or agrin injections at each time point. Significance is defined as p < 0.05.

Results In this study, we found that KOAGD mice appear to have inferior morphometric qualities compared to control wildtype mice. AChR surface area and volume of KOAGD mice were reduced relative to control mice with a statistically significant reduction at 8 weeks post- denervation. Confocal images demonstrated a shift from pretzel like morphology to towards plaque like profiles. However, when these KOAGD mice were supplemented with agrin, these animals were able to retain superior motor endplate morphology over controls. Average surface area of agrin supplemented denervated endplates were significantly greater than control endplates in all analyzed timepoints (Fig.1). Agrin injected mice demonstrated stable motor endplates up to the 16 week timepoint while PBS injected mice did not have any motor endplates detected at 16 week post denervation (Fig. 2).

Summary Points • KOAGD mice demonstrated inferior NMJ profiles and reduced surface area and volume compared to wildtype mice after denervation. • Supplemental agrin delivered locally is effective in preserving motor endplates in denervated mice hindlimbs. • Data from these experiments support that this adjuvant therapy will prolong the window of opportunity for surgical intervention.

Bibliography 1: Bezakova G, Helm JP, Francolini M, Lømo T. Effects of purified recombinant neural and muscle agrin on skeletal muscle fibers in vivo. J Cell Biol. 2001;153(7):1441-1452. doi:10.1083/jcb.153.7.1441. 2: Furey MJ, Midha R, Xu Q-G, Belkas J, Gordon T. Prolonged target deprivation reduces the capacity of injured motoneurons to regenerate. Neurosurgery. 2007;60(4):723-32-3. doi:10.1227/01.NEU.0000255412.63184.CC. 3: Chao T, Frump D, Lin M, et al. Matrix metalloproteinase 3 deletion preserves denervated motor endplates after traumatic nerve injury. Ann Neurol. 2013;73(2):210-223. doi:10.1002/ana.23781. 4: Sakuma M, Gorski G, Sheu SH, et al. Lack of motor recovery after prolonged denervation of the neuromuscular junction is not due to regenerative failure. European Journal of Neuroscience. 2015. 5: Frank E, Gautvik K, Sommerschild H. Cholinergic receptors at denervated mammalian motor end-plates. Acta Physiol Scand. 1975;95(1):66-76. doi:10.1111/j.1748-1716.1975.tb10026.x.

Paper 3: Primary Targeted Muscle Reinnervation in the Upper Extremity Reduces Neuromas and Phantom Limb Pain Session 1: Nerve – Wednesday, September 12, 2018, 8:43-8:45 AM

Nerve;Diseases and Disorders;Practice Management Level 4 Evidence

Joseph Meyerson, MD

COI There is financial information to disclose.

Hypothesis Approximately 40,000 Americans are living with a major amputation of the upper extremity. An estimated 25% develop a painful neuroma, and up to 67% experience phantom limb pain. Targeted muscle reinnervation (TMR) is a surgical procedure that reroutes transected peripheral nerves to the motor unit of freshly denervated muscle, potentially preventing neuroma formation and lessen the prevalence of phantom limb pain (PLP).

Methods We performed a retrospective study of our centers TMR of upper extremity amputations undergoing primary (at index amputation) and secondary (symptomatic nerve pain after amputation) procedures. Data included reason for amputation, level of amputation, patient age, months of follow up, postoperative neuroma, postoperative PLP and time to prosthetic use.

Results Thirteen patients with upper extremity amputations were identified (2 forequarter, 5 trans- humeral, 6 trans-radial). Oncologic resection and skeletal trauma were the most common indications for amputation. Only two patients had TMR performed secondarily, all others were concurrent with amputation. Ages ranged from 22-63 years old with average follow up of 13 months (range 1-29 months). None of the 13 patients developed a painful neuroma. Phantom limb pain at 1, 3, 6, and 12 months was 46%, 33%, 25%, and 20%. Patients began using their prosthetic 2-6 months after surgery, and at least one patient at each amputation level was using a myoelectric prosthetic.

Summary Points Our data suggests that regardless of the cause of or level of amputation, upper extremity TMR drastically decreases neuroma pain, phantom limb pain, time to prosthetic use in the postoperative upper extremity amputee. Novel information in this data is noted by the large number patients undergoing primary TMR in the upper extremity.

Paper 4: Ex-situ Normothermic Limb Perfusion: A Protocol for Extended Limb Preservation Session 1: Nerve – Wednesday, September 12, 2018, 8:46-8:48 AM

Elbow and Forearm;Diseases and Disorders;General Principles N/A - not a clinical study

Vahe Fahradyan, MD Edoardo Dalla Pozza, MD Maria Madajka, PhD Frank Papay, MD Antonio Rampazzo, MD Bahar Bassiri Gharb, MD

COI There is financial information to disclose.

Hypothesis Ischemia and reperfusion injury remains one of the major limiting factors for the success of both replantation and vascularized composite allotransplantation. A normothermic ex-situ perfusion is a novel approach to organ preservation that prolongs the viability of the limb by maintaining the physiologic cellular metabolism avoiding the deleterious effects of both hypoxia and cooling. This study aimed to develop an ex-situ normothermic limb perfusion protocol to preserve the viability and function of amputated limbs for over 24 hours.

Methods A total of 23 swine limbs were perfused using an oxygenated colloid solution at 38°C containing washed RBCs. The first 13 limbs were used to optimize the perfusion protocol. The subsequent 5 limbs (Group A) were perfused for 12 hours and the following 5 (Group B) as long as muscle contractility and peripheral perfusion was present. Electrolytes were balanced by partial perfusate exchanges. Limb viability was compared in the 2 groups by muscle contractility, compartment pressure, tissue oxygen saturation, indocyanine green (ICG)-angiography, thermography and histology.

Results Perfused limbs were able to retain physiological parameters and function for 12 hours in group A and up to 44 (24–44) hours in group B. Limbs in group A had lower final weight increase (0.54%±0.07 VS 14.11%±16.27) (p=0.008) and compartment pressure (16.23±7.10 VS

24.75±7.79) (p=0.175) compared to group B. Final myoglobin and CK mean values were lower in group A compared with group B (875±291.4ng/mL VS 1010.6±323.6ng/mL and 53344±14850.34U/L VS 71881±20475ng/mL). In group B surface temperature (35.37±0.69°C vs 33±1.44°C, p=0.01) and tissue oxygen saturation (69.31±9.3% vs 58.69±8.4%, p=0.048) were significantly higher than in group A. Contractility and ICG-angiography were comparable in the two groups.

Summary Points • EX Situ normothermic perfusion has the potential to significantly prolong limb viability. • Implementation of this technology can significantly impact the paradigm of limb preservation increasing the number of limbs that can be replanted and the radius for limb procurement prior to transplantation.

Paper 5: Silastic Arthroplasty of the Distal Interphalangeal Joint: a Long Term Follow Up Session 1: Nerve – Wednesday, September 12, 2018, 8:49-8:51 AM

Hand and Wrist Level 4 Evidence

Ryan Tarr, DO

COI There is financial information to disclose.

Hypothesis Silastic distal interphalangeal (DIP) joint arthroplasty provides a functional and durable alternative to DIP joint arthrodesis by providing an improved arc of motion and a pain free joint over a long term follow up.

Methods A retrospective review was performed on 47 patients (88 DIP joints) who had undergone a DIP silastic arthroplasty with at least 5 years of follow up. Exclusion criteria included other surgery on digit, less than 5 year follow up, and cognitive decline. Patients were sorted into two groups; group A, physical exam and questionnaires, or group B, just questionnaires, based on patient preference. Average extensor lag, range of motion, joint stability, and joint deformity were measured, as well as revision rate. Patients were also given a QuickDASH survey and a subjective outcomes survey on function, appearance, pain and dexterity. Fourty-four of the patients were female. Average age at surgery was 57 years. A single surgeon performed all procedures.

Results The average follow up was 153 months (12.7 years). Average extensor lag was 9 degrees with an average arc of motion of 33 degrees. An obvious deformity was noted in 33% of patients; however stability of at least 1 collateral ligament was found intact in all but 2 patients. Average revision rate was 8%, with seven revisions performed on performed on 8 digits. Average QuickDASH score was 19.5. More than 80% of patients reported improvements in appearance and pain, with more than 60% reporting better strength and dexterity. Overall satisfaction was high, with 75% of patients reporting very satisfied with their replacement.

Summary Points • Silastic DIP arthroplasty is a good alternative to joint arthrodesis for patients desiring to maintain motion while relieving pain at the DIP joint.

• Joint motion and stability were maintained at long term follow up compared to previous studies reviewing a shorter term follow up. • Revision rate was 8%, which is comparable to published arthrodesis data. Interestingly, the right hand accounted for 86% of revisions. Although handedness was not evaluated, this may indicate that dominant hand daily stress puts the implant at risk for failure compared to non-dominant hand. • Patients were largely happy with both appearance and pain relief of the digit and all but seven patients were satisfied with results.

Bibliography Reference 1: Sierakowski A et al. Joint replacement in 131 painful osteoarthritic and post- traumatic distal interphalangeal joints; Journal of Hand Surgery (European). 2011; Vol 37(4) 304– 309. Reference 2: Zimmerman N. Silicone interpositional arthroplasty of the distal interphalangeal joint. Journal of Hand Surgery, 1989 Sept; Vol 14(5): 882-887 Reference 3: Snow J et al. Implant arthroplasty of the distal interphalangeal joint of the finger for arthritis; Plastic and Reconstructive Surgery. 1977 Oct; Vol 60(4): 558-560. Reference 4: Brown L. Distal interphalangeal joint flexible implant arthroplasty; Journal of Hand Surgery. 1989 Jul;14(4): 653-656. Reference 5: Stern, P. Distal interphalangeal joint arthrodesis: An analysis of complications; 1992 Nov;17(6):1139-45

Paper 6: Smoking Increases Post-Operative Complications after Distal Radius Fracture Fixation: A Review of 417 Patients from a Level 1 Trauma Center Session 2: Distal Radius Fractures – Wednesday, September 12, 2018, 9:32-9:34 AM

Hand and Wrist Level 4 Evidence

Daniel E. Hess, MD

COI There is financial information to disclose.

Hypothesis If smoking impacts bone healing and implant fixation, then current smokers with surgically managed distal radius fractures will have higher post-operative incidence of complications, especially involving bony union and hardware integration.

Methods A retrospective review was performed of all patients who were treated operatively for distal radius fractures at a Level 1 trauma center between January 2010 and April 2015 based on CPT codes (25607, 25608, and 25609). Each chart was reviewed for basic demographic information, comorbidities (smoking status, diabetes mellitus (DM), and body mass index (BMI)), details about the operative procedure, and early complications. Notable physical exam findings were also noted such as wrist stiffness and distal radius tenderness to palpation. Statistical analysis was performed to compare the smoking and non-smoking groups. To control for confounding differences in the smoking and non-smoking groups a hierarchical multivariable regression analysis was also performed.

Results Four-hundred-and-seventeen patients were included in the study and 24.6% were current smokers at the time of surgery. The overall complication rate for smokers was 9.8% compared to 5.6% in non-smokers. The smoking cohort showed significantly higher rates of hardware removal, nonunion, revision procedures, wrist stiffness, and distal radius tenderness. When controlling for the confounding variables of diabetes and BMI, smokers still had significantly higher rates of the same complications.

Summary Points • Patients who smoke have a statistically significant higher rate of post-operative distal radius tenderness, hardware removal, and revision procedures compared to those who do not smoke in a review of 417 total patients undergoing surgical fixation for distal radius fractures. • This information can be used to educate patients on post-operative expectations and alert surgeons of common complications.

Paper 7: Distal Radioulnar Joint Instability: Intraoperative Assessment with the Squeeze & Ulnar Pull Tests Session 2: Distal Radius Fractures – Wednesday, September 12, 2018, 9:35-9:37 AM

Hand and Wrist N/A - not a clinical study

Joseph A. Gil, MD Lindsay Kosinski, MD Kalpit N. Shah, MD Julia A. Katarincic, MD Sanjeev Kakar, MD, MBA

COI Royalty: Arthrex, Innomed (Kakar) Consulting Fee: Arthrex, Sonex (Kakar) Other: JBJS, BJJ (Kakar)

Hypothesis The radioulnar stress test allows for intraoperative assessment of the distal radioulnar joint (DRUJ) once the radius is fixed but is limited by its subjective nature. The purpose of this study is to describe and examine the ability of the "squeeze" and "ulnar pull" tests to detect DRUJ instability.

Methods Eight fresh frozen cadaveric upper extremities without evidence of DRUJ instability (mean age 52.6 14.9 years) were obtained. We sequentially sectioned the extensor carpi ulnaris subsheath, deep head of pronator quadratus, dorsal and volar radioulnar ligaments, the foveal attachment of the triangular fibrocartilage complex, and the distal oblique bundle. After each sectioning, a PA radiograph was obtained under two conditions: a simulated "squeeze test" and an "ulnar pull test". The " is performed by applying an interosseous force to the forearm and monitoring for DRUJ diastasis on an PA radiograph (Figure 1A). A custom jig was designed to simulate the ", where a 44N interosseous force was applied 7 cm proximal to the DRUJ (Figure 1A). The " was performed by applying a tensile force to the ulna via a threaded hook (Figure 1B). The " demonstrates the maximum diastasis that occurs in the coronal plane with a 44 N tensile force applied. Additionally, we compared the diastasis that occurs with this test to the diastasis that is created by an indirect application of force with the squeeze test (Figure 1B). An ANOVA test was utilized to compare the mean diastasis after sequential sectioning of the DRUJ stabilizers.

Results Mean diastasis seen with the " and the " after each component of the DRUJ was sectioned is depicted in Figure 2. The " detected a significant change after the dorsal and volar radioulnar ligaments were sectioned (P=0.018; Figure 2B). The " first detected a significant change after the foveal insertion of the TFCC was sectioned (P<0.001; Figure 2A). The " in comparison was able to detect a significant change after the dorsal and volar radioulnar ligaments were sectioned (P=0.014; Figure 2C).

Summary Points • The " is able to detect a significant increase in diastasis after the foveal attachment of the TFCC was sectioned while the " was able to detect a significant increase after the dorsal and volar ligaments were sectioned. • This study provides the practitioner with an objective test for evaluating DRUJ instability intraoperatively.

Bibliography 1: Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Orthop Relat Res. 2000;(376):229- 235. http://www.ncbi.nlm.nih.gov/pubmed/10906880. Accessed December 4, 2017. 2: Nakamura T, Iwamoto T, Matsumura N, Sato K, Toyama Y. Radiographic and Arthroscopic Assessment of DRUJ Instability Due to Foveal Avulsion of the Radioulnar Ligament in Distal Radius Fractures. J Wrist Surg. 2014;3(1):012-017. doi:10.1055/s-0033-1364175. 3: Omokawa S, Iida A, Fujitani R, Onishi T, Tanaka Y. Radiographic Predictors of DRUJ Instability with Distal Radius Fractures. J Wrist Surg. 2014;3(1):002-006. doi:10.1055/s-0034-1365825. 4: Pickering GT, Nagata H, Giddins GEB. In-vivo three-dimensional measurement of distal radioulnar joint translation in normal and clinically unstable populations. J Hand Surg Eur Vol. 2016;41(5):521-526. doi:10.1177/1753193415618110. 5: Takemoto R, Sugi M, Immerman I, Tejwani N, Egol KA. Ulnar variance as a predictor of persistent instability following Galeazzi fracture-dislocations. J Orthop Traumatol. 2014;15(1):41- 46. doi:10.1007/s10195-013-0266-7.

Paper 8: Predictors of Postoperative Complications in 10,623 Patients Undergoing Elective Hand Surgeries: Who Should be Operated On in an Outpatient Setting? Session 2: Distal Radius Fractures – Wednesday, September 12, 2018, 9:38-9:40 AM

Hand and Wrist;General Principles Level 2 Evidence

Kalpit N. Shah, MD Steven F. Defroda, MD Bo Wang Arnold-Peter C. Weiss, MD

COI Royalty: Medartis, Extremity Medical, Arthrosurface (Weiss) Receipt of Intellectual Property Rights: IlluminOss Medical (Weiss) Ownership Interest: IlluminOss Medical (Weiss)

Hypothesis Many stand-alone, outpatient surgery centers use arbitrary patient factors in deciding who should have surgical procedures there. We hypothesize that objective patient factors and comorbidities are predictive of post-operative complications after outpatient hand surgery.

Methods Patients undergoing elective hand surgeries (152 CPT codes isolated from all available hand surgery CPT codes representing truly elective surgery) in an outpatient setting under non-general anesthesia between 2005 and 2015 were identified in the National Surgical Quality Improvement Program (NSQIP) database. The primary outcome was postoperative complications, which included 30-day mortality, surgical or medical complications (UTIs were excluded), incidence of return to the operating room (OR) or readmission for reasons related to their surgery. Multiple logistic regression was used to study the association between patient variables and comorbidities to post-operative complications.

Results Of 10,623 patients undergoing elective hand surgeries between 2005 and 2015, 159 (1.5%) developed a total of 207 medical or surgical complications, death, return to the OR or had to be readmitted. In multiple logistic regression analysis, ASA class, steroid use, dialysis use, bleeding disorder and smoking status were significant predictors for complication.

Summary Points • The analysis based on the NSQIP database may help identify and exclude those who are at risk for significant complications post-operatively and should not be operated on at a stand-alone outpatient surgery centers. • These factors included ASA class 4, current steroid use, current dialysis use, bleeding disorder and smoking status. • The result of this study can help surgeons choose patients appropriately for the proposed venue of the surgery.

Paper 9: Rates of Corrective Osteotomy after Distal Radius Fractures Treated Nonoperatively and Operatively Session 2: Distal Radius Fractures – Wednesday, September 12, 2018, 9:41-9:43 AM

Hand and Wrist;Diseases and Disorders;Practice Management Level 2 Evidence

Hannah A. Dineen, MD Shawn Feinstein, MD Dax Varkey, MD Jamie Jarmul, PhD Reid W. Draeger, MD

COI Ownership Interest: GlaxoSmithKline stock (Draeger)

Hypothesis Distal radius fractures occur commonly and can be a significant cause of morbidity in the aging population; yet the rates of osteotomy for malunited fractures have not been described for nonoperative and operative treatment. We hypothesized that the rate of corrective osteotomy would be lower in fractures treated operatively than nonoperatively.

Methods Using the PearlDiver patient record database, we used CPT coding to identify 43,525 patients within the Humana database from 2007-2015 who sustained a distal radius fracture. The rates of osteotomy after both closed and open treatment of distal radius fractures were evaluated and stratified by age and gender. The cost of treatment for each group was analyzed. Osteotomy rates were compared between groups using the chi-square test of significance.

Results The rates of osteotomy with closed vs open treatment were significantly different (0.5% vs. 0.3%; p=0.002). The rate of osteotomy for patients over the age of 50 was significantly higher than rate of osteotomy for patients under the age of 50, regardless of treatment (0.3% vs. 0.1%; p=0.007). In males, the rates of osteotomy for closed vs. open treatment was not significantly different (0.29% vs. 0.24%, p=0.5696). However, in females, the rate of osteotomy for closed vs. open was significantly different (0.0059% vs. 0.003%, p<0.001). The average cost per patient (regardless of outcome) for closed treatment was $477 and the average cost for open treatment was $1,309. If an osteotomy was required in the case of closed treatment, the average overall

cost was $4,152. If an osteotomy was required in the case of open treatment, the average overall cost was $5,965.

Summary Points • Osteotomy after distal radius fracture occurs infrequently but is seen more frequently in fractures treated nonoperatively. • Female patients are more likely to undergo an osteotomy after closed treatment of a distal radius fracture than male patients. • This information can be used to help counsel patients when making shared decisions regarding treatment.

Bibliography 1: Buijze GA, Prommersberger KJ, González Del Pino J, Fernandez DL, Jupiter JB. Corrective osteotomy for combined intra- and extra-articular distal radius malunion. J Hand Surg Am. 2012 Oct;37(10):2041-9. 2: Jenkins NH, Mintowt-Czyz WJ. Mal-union and dysfunction in Colles’ fracture. J Hand Surg 1988;13B:291–293. 3: Lozano-Calderon SA, Brouwer KM, Doornberg JN, Goslings JC, Kloen P, Jupiter JB. Long-term outcomes of corrective osteotomy for the treatment of distal radius malunion. J Hand Surg 2010;35E: 370–380. 4: Mulders MA, d'Ailly PN, Cleffken BI, Schep NW. Corrective osteotomy is an effective method of treating distal radius malunions with good long-term functional results. Injury. 2017 Mar;48(3):731-737. 5: Ring D, Gonzalez del Pino J, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal part of the radius. J Bone Joint Surg 2005;87A: 1503–1509.

Paper 10: Determination of the Optimal Location for Bone Graft Harvest in the Distal Radius Session 2: Distal Radius Fractures – Wednesday, September 12, 2018, 9:44-9:46 AM

Hand and Wrist;Elbow and Forearm;General Principles N/A – not a clinical study

Andrew P. Matson, MD Andrew E. Federer, MD Erin M. Meisel, MD Stephen R. Barchick, BA David S. Ruch, MD Marc J. Richard, MD

COI Royalty: Acumed (Ruch) Speaker's Bureau: Acumed (Ruch and Richard), DePuy Synthes (Ruch and Richard), DJO, Medartis (Richard) Consulting Fee: Acumed, Depuy Synthes, DJO, Medartis (Richard) Fees for Non-CME Services Received: Arthrosurface (Richard)

Hypothesis Cancellous bone volume and relative density are greatest in the most distal regions of the distal radius. Reproducible differences exist among sub-regions of the distal radius with regard to these parameters.

Methods Thirty-four consecutive wrist computed tomography (CT) scans in 33 patients without distal radius pathology were included. For each subject, six spherical regions of interest (ROI) were identified and distinguished primarily as either distal (10 mm from articular surface) or proximal (20 mm from articular surface), and secondarily as radial, central, or ulnar. In each spherical ROI, volumetric measurements and mean Hounsfield unit (HFU) values were recorded by two observers. Statistical tests utilized included the Student’s T-test, least squares mean difference values adjusted using Tukey’s method, and intraclass correlation (ICC) coefficient.

Results Compared to proximal bone, distal bone had larger volume (0.82 vs 0.27 cm3, p<0.001) and greater density (178 vs. 152 HFU, p<0.001) on average. Among the six spherical ROIs, the distal

central sub-region had the largest average volume (1.20 cm3) and was significantly larger than all other sub-regions (p<0.001). The distal ulnar sub-region had the greatest average density (193 HFU), and was significantly higher than two of the three proximal sub-regions (central and ulnar, p<0.001). ICC coefficient was excellent between observers for both volume (0.94) and density (0.99).

Summary Points • Cancellous bone radiographic density and volume are greatest in the distal regions of the distal radius compared to its more proximal regions. • The distal-central sub-region consistently has the greatest volume measurements, and there is a trend toward greatest radiographic density in the distal-ulnar sub-region. • We recommend centering a corticotomy for distal radius cancellous bone graft at 10 mm proximal to the articular surface, with an ulnar bias relative to the coronal midline of the bone.

Paper 11: Long-term Radiographic and Clinical Outcomes of the Shoulder in Birth Brachial Plexus Palsy Session 3: Congenital – Wednesday, September 12, 2018, 11:07-11:09 AM

Shoulder and Arm;Congenital and Pediatric Problems;Nerve Level 4 Evidence

Kristen Lynn Ploetze, MD Charles Goldfarb, MD Summer Roberts Lindley Wall, MD, MSc

COI Speaker's Bureau: Arthrex (Goldfarb) Consulting Fee: Arthrex (Goldfarb)

Hypothesis The shoulder of adults with birth brachial plexus palsy will have radiographic evidence of joint deformity and degeneration. Additionally, they will have limitations in function, but report minimal pain and overall satisfaction.

Methods Patients older than 18 years were identified by review of medical records at Shriners Hospitals for Children for a diagnosis of birth brachial plexus palsy. 174 records were reviewed, and accurate contact information was secured for 27 patients. 18 patients returned for evaluation including bilateral shoulder radiographs, physical examination including range of motion, Mallet classification, and patient-reported outcome measures including Visual Analog Scale (VAS) for shoulder pain and function, ASES shoulder score, QuickDash and PROMIS domain measures.

Results The mean age of the patients was 43 years. Ten patients had a history of shoulder surgery at an average age of 6.2 years of age. 14 patients demonstrated degenerative changes on radiographs with joint incongruity, osteophyte formation, and joint space narrowing. 10 patients had evidence of glenoid retroversion, posterior humeral translation, or a biconcave glenoid. In addition, three patients had complete posterior dislocation of the humeral head. One patient had bilateral severe degenerative changes with symmetric glenoid version. Four patients with normal glenoid version had no evidence of degeneration. Mean global Mallet score was 22. The mean VAS for pain was low, at 2. The mean VAS for function was 6. The mean ASES score was 59. Total ASES score is weighted 50% for pain and 50% for patient-reported function with a higher

score indicating greater pain and limitations in function. In a patient population with minimal pain, this indicates marked limitations in shoulder function. 15 patients reported they were unable to reach the small of their back. 14 patients reported they were unable to reach behind their heads. 5 patients reported they were unable to manage toilet hygiene with their affected extremity; three additional patients reported considerable difficulty. The mean QuickDash score was 25. Mean PROMIS Physical Function, Pain Interference, Anxiety and Depression domains were 48, 45, 47.4, and 45.1, respectively.

Summary Points • Adult BBPP patients have glenohumeral degenerative changes in correlation to the degree of the deformity of the glenohumeral joint. • Adult BBPP patients experience minimal shoulder pain, despite high levels of degenerative changes and deformity. • There are significant deficits in range of motion, strength, and function as assessed with the ASES and the QuickDash. • PROMIS scores in adult BBPP patients are near normal on average.

Paper 12: The ReSurge Global Training Program: Surgical Training and Capacity Building in Hand Surgery in the Developing World Session 3: Congenital – Wednesday, September 12, 2018, 11:10-11:12 AM

Hand and Wrist;General Principles;Practice Management N/A – not a clinical study

Gloria R. Sue, MD

COI There is financial information to disclose.

Hypothesis The ReSurge Global Training Program (RGTP) is a novel paradigm for surgical training and capacity building in the developing world. Hand surgery is one of the central components of this training program. Many surgeons in the developing world have an interest in developing proficiency in hand surgery. The RGTP consists of an online curriculum in hand surgery, network of expert hand surgeons, visiting educator trips, trainee identification and tracking system, and an outreach program designed for trainees who have achieved proficiency in hand surgery. We hypothesize that the RGTP would be an effective model for providing hand surgery training to surgeons in the developing world.

Methods A curriculum on hand reconstruction including congenital, post-burn, and trauma reconstruction was created. Milestones for these topic were established. A retrospective review of the components of the RGTP pertaining to hand surgery from July 2014 through June 2017 was performed. Trainee milestones scores were analyzed to observe trends towards competency.

Results There were 18 visiting educator trips that included dedicated hand surgery training during the study period. These trips took place in 7 low- and middle-income countries. A total of 29 trainees were evaluated during this time with 120 distinct submodule evaluations within hand surgery. 6 trainees were evaluated on more than one occasion. There was a trend towards improved milestones ratings for trainees over time.

Summary Points • The ReSurge Global Training Program is a model for surgical training and capacity building in hand surgery in developing countries • Trainees demonstrated objective improvement in surgical competency with ongoing participation in this program • This training approach provides long-term solutions for unmet reconstructive needs in hand surgery in the developing world

Paper 13: Trends in Pediatric Traumatic Upper Extremity Amputations Session 3: Congenital – Wednesday, September 12, 2018, 11:13-11:15 AM

Hand and Wrist;Congenital and Pediatric Problems;General Principles Level 4 Evidence

New! In 2018, this top scored pediatric/congenital abstract submission accepted for podium presentation received a special scholarship in honor of Dr. Flatt. Dr. Flatt passed away in 2017 and will long be remembered for his many contributions to the Hand Society. The AFSH thanks William H. Seitz, Jr., MD for his gift in honor of Dr. Flatt and in support of this new Flatt Scholarship.

Venus Vakhshori, MD Gabriel Bouz, BS Cory K. Mayfield Ram Kiran Alluri, MD Milan Stevanovic, MD, PhD Alidad Ghiassi, MD

COI Ownership Interest: Medtronic, Zimmer Biomet, Axogen, Stryker (Alluri)

Hypothesis Traumatic upper extremity amputation in a child can be a life altering injury, yet little is known about the epidemiology or healthcare costs of these injuries. We hypothesized that pediatric traumatic upper extremity amputations are most common in adolescent males, with distal levels affected more frequently than proximal levels.

Methods Using the Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) from 1997 to 2012 [1], patients aged 20 years old or younger with upper extremity traumatic amputations were identified. National estimates of incidence, demographics, costs, hospital factors, patient factors, and mechanisms of injury were assessed.

Results Between 1997 and 2012, 6,130 cases of traumatic upper extremity amputation occurred in children. This resulted in a $166 million cost to the healthcare system. Males are 3.4 times more likely to be affected by amputation than females, with an increasing disparity between genders in older patients. Pediatric amputations are most common during the summer months, and this

increase is largely due to explosive and firearm use. The frequency of amputation has declined 41% from 1997 to 2012. The overwhelming majority of amputations (92.54%) involved digits. Having the extremity or digit being caught between objects is the most frequent cause of traumatic pediatric amputations. The most common age group to suffer amputation is older children, aged 15 to 19 years old, followed by very young children, aged 0 to 4 years old. Alcohol abuse, depression, and psychoses are disproportionately more frequent in 15 to 19 year old patients affected by above elbow amputation.

Summary Points • Pediatric amputations cost an average of $27 million annually to treat. The incidence of these injuries is declining. • Amputation injuries are most common in July and August, with the increased incidence resulting from explosive use. • Males aged 15 to 19 years old are most likely to be affected by traumatic upper extremity amputation. • Digital amputations are the most common amputation injury and are most frequently caused by digits being caught between objects.

Bibliography 1: KID Database Documentation. Healthcare Cost and Utilization Project (HCUP). Rockville (MD): Agency for Healthcare Research and Quality (US); 2017.

Paper 14: Matti-Russe Technique for Scaphoid Nonunions in Pediatric Patients Session 3: Congenital – Wednesday, September 12, 2018, 11:16-11:18 AM

Hand and Wrist Level 4 Evidence

Irshad A. Shakir, MD Ugochi Okoroafor, MD Joao Panattoni Filho, MD

COI There is financial information to disclose.

Hypothesis To evaluate the long term clinical and radiologic outcomes after surgery for scaphoid nonunion using the Matti-Russe Technique in the pediatric population.

Methods A retrospective review was performed of patients less than 17 years of age, with a scaphoid nonunion that was treated with the Matti-Russe technique. This technique consisted of open reduction with intercalated bone graft and no internal fixation with hardware. Union was determined by radiographic evaluation. Computed tomography was obtained in 7 of 10 patients in this series and showed bony bridging in more than 50% of the scaphoid width in 3 different views. Intrascaphoid, scapholunate, and radiolunate angles were calculated. We reviewed wrist range of motion and complications. We obtained postoperative Mayo and Disability of the Arm and Hand scores (DASH).

Results There were 10 patients who underwent the Matti-Russe technique. The average age was 14.7 years old (range: 13-17). All 10 of these patients had a scaphoid waist nonunion. There were 9 males and 1 female with an average follow up of 13 months. The average amount of time to surgery from the date of injury was 12.3 months. All 10 patients went on to radiographic union at or before 6 months from surgery. Preoperative intrascaphoid, and radiolunate angles were 29, 62, and 20 degrees. Postoperative intrascaphoid, and radiolunate angles improved to 16, 38, and 10 degrees, which was significant. Seven out of 10 patients completed postoperative outcomes measures. The average postoperative Mayo wrist score was 87.9 (range 60-100). The average postoperative DASH score was 1.9 (range 0-4.5). There were no associated complications nor reoperations.

Summary Points The Matti-Russe technique is a safe and effective treatment for scaphoid nonunion in the pediatric population. It facilitates scaphoid union without the need for screw fixation and avoiding potential complications with hardware.

Bibliography Reference 1: Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. J Hand Surg Am. 2015;40(9):1797-1805 e1793. Reference 2: Rhee PC, Jones DB, Shin AY, Bishop AT. Evaluation and Treatment of Scaphoid Nonunions. JBJS Rev. 2014;2(7).

Paper 15: Operative vs. Non-operative Management of Type II Supracondylar Humeral Fractures in Children: An Expected Value Decision Analysis & Direct Cost Comparison Session 3: Congenital – Wednesday, September 12, 2018, 11:19-11:21 AM

Elbow and Forearm;Congenital and Pediatric Problems;Practice Management Level 4 Evidence

Burke Gao, MD Joseph A. Gil, MD Shashank Dwivedi Aristides I. Cruz, MD

COI There is no financial information to disclose.

Background Supracondylar humeral fractures account for up to 15% of pediatric fractures. Although most orthopaedic surgeons agree on Gartland Type I and III fracture management, debate remains regarding Type II fracture management. By comparing the costs and expected utility produced by operative and non-operative management, this study helps health-care providers make management decisions which maximize patient utility and reduce health-care costs.

Hypothesis Comparing charges and expected utilities of operative and non-operative management of Type II supracondylar humeral fractures in children can provide evidence-based recommendations for cost-savings and improvements in patient satisfaction.

Methods A literature review was conducted to find transition probabilities and utility values associated with operative and non-operative treatment. We defined operative management as closed reduction with percutaneous pinning, and non-operative management as closed reduction with casting performed in the emergency department. A decision tree was created, and fold-back analysis was performed to determine optimal management. One-way deterministic sensitivity analysis was conducted by varying the failure rate of non-operative management. Charges were recorded from patients aged 0-15 receiving treatment for type II supracondylar humeral fractures at a tertiary care, urban, pediatric hospital from 1/1/16 to 12/31/16. In our reporting,

we subdivided non-operative management charges into patients requiring readmission (for surgery) and patients not requiring readmission.

Results Both mean charges for non-operative management not requiring readmission ($4,138.05 ± $1,527.78) and mean charges for non-operative management requiring readmission ($11,392.24 ± $1,895.82) were less than mean charges for early operative management ($15,019.57 ± $2,693.30). Early operative management, however, yielded better patient utility. Non-operative treatment yielded a utility value of 92.7 while early operative management yielded a utility value of 99.2. On sensitivity analysis, it was found that when the failure rate of non-operative management fell below a threshold of 2.5%, non-operative management yielded higher expected utility values.

Summary Points • Operative management yields higher overall utility compared to non-operative management, but non-operative management may incur lower costs than operative management. • Our results suggest that operative management yields superior—albeit costlier—patient satisfaction. • In theoretical settings where the likelihood of loss of reduction following casting is very low (<2.5% vs. average 23%), non-operative management may provide equal or better utility to patients. This suggests that in such institutions, non-operative management can produce equal patient satisfaction and be cost-saving compared to operative management. It should be warned, that such non-operative failure rates are entirely theoretical, and to our knowledge, have not yet been reported as possible.

Paper 16: A Comparison of Magnetic Resonance Imaging and Ultrasonographic Evaluation of Zone II Partial Flexor Tendon Lacerations: A Cadaveric Study Session 4: Flexor Tendon – Wednesday, September 12, 2018, 2:07-2:09 PM

Hand and Wrist N/A - not a clinical study Evidence Grant received from: Prodev Grant - University of Pennsylvania Center for Biomedical Engineering

Kristin L. Buterbaugh, MD Nikolas Kazmers, MD Josh Gordon, MD Viviane Khoury David Steinberg, MD

COI Ownership Interest: Johnson & Johnson (Steinberg) Other: Pontis Orthopaedics (Gordon)

Hypothesis Identifying zone II high-grade partial flexor tendon lacerations is clinically challenging. When involving greater than 50% of the tendon, such injuries often require surgical intervention. Reliable noninvasive tests are critical for optimizing clinical decision-making. Our team previously investigated the use of ultrasound in the evaluation of partial flexor tendon lacerations using a cadaveric model. Our findings support the use of ultrasound for identification of high-grade zone II flexor digitorum profundus lacerations(1). In the present study we propose the following null hypothesis: magnetic resonance imaging (MRI) and ultrasound demonstrate equivalent performance metrics when used for the evaluation high-grade partial flexor tendon lacerations cadaveric specimens.

Methods Dissection of 32 digits in eight fresh-frozen above-elbow cadaveric specimens was performed. The FDP was exposed between the A3 and A4 pulleys through mid-lateral incisions. Tendons were randomly selected to remain intact, or receive low- or high-grade lacerations, 10-40% and 60-90% of radioulnar width, respectively. Lacerations were randomly assigned to the radial or ulnar aspects of the tendon and were localized with digital calipers prior to creating sharp partial transections. Dynamic ultrasound was performed with a linear-array 14 MHz transducer by a

blinded fellowship-trained musculoskeletal radiologist. Standard test performance metrics were calculated. The same specimens underwent MRI on a 3T Trim Avanto hand coil. The images were read by the same blinded radiologist. Test performance metrics were calculated and compared with those computed for ultrasonographic evaluation.

Results The number and degree of lacerations along with ultrasound and MRI findings are shown in Table 1. Test characteristics of ultrasound in comparison to MRI in the same cadaveric specimens are outlined in Table 2. Ultrasound misdiagnosed three (30%) high-grade tears as low-grade. For lacerations detected, ultrasound correctly identified the side of laceration in 91% of specimens. MRI misdiagnosed six (60%) high-grade tears as low-grade. For lacerations detected, MRI correctly identified the side of the laceration in 40% of specimens.

Summary Points • Both ultrasound and MRI were better at detecting the presence of a high-grade laceration than the absence of one. • MRI was more specific than ultrasound in identification of both high-grade and low-grade partial flexor tendon lacerations. • Ultrasound was more sensitive for detecting the presence of a laceration and was also more accurate in identifying the location of the tear. • While less specific, ultrasound is a reasonable and less expensive alternative to MRI when evaluating for clinically significant high-grade partial flexor tendon lacerations.

Bibliography 1: Kazmers NH, Gordon JA, Buterbaugh KL, Bozentka DJ, Steinberg DR, Khoury V. Ultrasonographic Evaluation of Zone II Partial Flexor Tendon Lacerations of the Fingers: A Cadaveric Study. J Ultrasound Med. 2017 Sep 29. (Epub ahead of print).

Paper 17: In-Office Wide-Awake Hand Surgery Versus Surgery in an Ambulatory Surgery Center: A Comparison of Clinical Outcomes and Healthcare Costs at an Academic Institution Session 4: Flexor Tendon – Wednesday, September 12, 2018, 2:10-2:12 PM

Hand and Wrist;Practice Management Level 4 Evidence

Justin Rabinowitz, MD Thomas Kelly Eric Angermeier, MD Kyle Kokko, MD, PhD

COI There is financial information to disclose.

Hypothesis There is growing interest among hand surgeons to perform common hand procedures in the office wide awake, without sedation to decrease costs, increase efficiency, and improve patient experience. Our study compares clinical outcomes and healthcare costs of an A1-pulley release when being performed in the office and in the operating room at a US academic institution.

Methods A retrospective chart review was performed on consecutive patients from January 2017 to January 2018 who underwent single digit A1- pulley release either wide awake in an office setting or in an ambulatory surgical center with monitored anesthesia care (MAC). Clinical outcomes were measured using a patient questionnaire and modified Disabilities Arm Shoulder and Hand (DASH) scores. Financial analysis was performed for each subject. Office reimbursements included the professional fee, while ambulatory reimbursements included the professional fee, anesthesiology fee, and hospital fees. Independent samples t-test and Pearson's chi-square test were used to determine significance for quantitative and categorical variables, respectively.

Results A total of 75 patients were included in this study. The wide awake group included 42 patients (17M, 26F) with an average age of 62 and the ambulatory group included 33 patients (12M, 21F) with an average age of 59. Both groups had improvement in post-operative quick DASH scores. When asked about subsequent surgery, 100% of the wide awake patients reported they would

prefer to be wide awake again. Eighty percent of the wide awake patients said the procedure was less painful or comparable to a procedure at the dentist. Wide awake patients reported lower preoperative anxiety (p=.044). Eighty-four percent of wide awake patients said their experience was better than they expected, compared to 23% of the sedated patients. There was a similar distribution of insurance carriers between the two groups (p=0.457). The wide awake group had significantly higher professional reimbursement compared to the ambulatory surgery group for all insurance carriers ($607.65 vs. $298.83; p=0.001). The ambulatory surgery group had significantly higher total healthcare costs compared to the wide awake group for all insurance carriers ($2148.62 vs. $607.65; p=0.001), a more than 250% increase in healthcare spending.

Summary Points • Clinical outcomes were similar following single digit A1-pulley release performed wide awake versus sedated in an ambulatory surgical center. • A-1 pulley release performed in an ambulatory surgical center had higher healthcare costs compared to performing the same procedure in the office. • Physician reimbursement was significantly higher for procedures performed wide awake in the office.

Bibliography 1: Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A critical Analysis of the First 100 Procedures. Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. J Hand Surg Am. 2017 Mar;42(3):e139-e147. doi: 10.1016/j.jhsa.2016.11.019. Epub 2016 Dec 20. 2: An Economic Analysis of MAC Versus WALANT: A Trigger Finger Release Surgery Case Study. Codding JL, Bhat SB, Ilyas AM. Hand (N Y). 2017 Jul;12(4):348-351. doi: 10.1177/1558944716669693. Epub 2016 Sep 14. 3: A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States. Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL Ann Plast Surg, 66 (3) (2011), pp. 245–248

Paper 18: The Effect of Counseling on Post-Operative Opioid Consumption after Outpatient Hand Surgery: A Prospective Randomized Trial Session 4: Flexor Tendon – Wednesday, September 12, 2018, 2:13-2:15 PM

Hand and Wrist;General Principles Level 2 Evidence

Talia Chapman, MD Kristin Sandrowski, MD Sommer Hammoud, MD Asif Ilyas, MD

COI Speaker's Bureau: DePuy Synthes (Ilyas) Royalty: Globus Medical (Ilyas) Consulting Fee: Globus Medical (Ilyas)

Hypothesis Postoperative pain management and opioid consumption following outpatient hand surgery may be influenced by a number of variables including pre-operative counseling, type of procedure or anesthetic, and patient demographics. A prospective randomized study was undertaken to understand the effect of pre-operative opioid counseling on opioid consumption and to understand typical opioid consumption patterns following common outpatient hand surgeries. The hypothesis was that patients who received pre-operative opioid counseling would consume less post-operative opioid medication and experience greater satisfaction with pain management.

Methods Two hundred-twenty patients undergoing outpatient hand surgery by six fellowship-trained hand surgeons were prospectively randomized to receive pre-operative opioid counseling. Data collected included patient demographics, procedure and anesthesia type, and amount and type of opioid prescribed. An electronic survey was administered on post-operative day three to ascertain the number of pills taken, daily visual analog pain scores (VAS), adverse events, and attitude toward their pain experience. Statistical tests used to perform this analysis included unpaired t-tests and Fisher’s exact tests for continuous and dichotomous variables, respectively.

Results Post-operative data was available for a total of 134 patients. Sixty-two patients were randomized to receive pre-operative counseling and 72 were not counseled. On average, 13 pills were prescribed to each patient. Average number of pills consumed (4.8 vs 4.7) and visual analog pain scores over the first three post-operative days were not significantly different between the two groups. Older patients had significantly lower VAS pain scores (p=0.0001) and took fewer pills (p= 0.005). Patients who underwent bone procedures consumed more pills than patients who underwent soft tissue procedures which trended toward significance (6 vs 4.1; p=0.1). Patients who were not counseled (p=0.03) and chronic opioid users (p=0.007) were more likely to think that the number of pills that they were prescribed was insufficient.

Summary Points • There was no significant decrease in opioid consumption after pre-operative counseling for outpatient hand procedures. • Patient who received pre-operative opioid counseling were more likely to be satisfied with their post-operative pain experience. • Patients without counseling and those with a history of chronic opioid use were not satisfied with the number of opioids prescribed. • More opioids were prescribed than needed, on an average of 3:1.

Paper 19: Extensor Carpi Ulnaris Tenodesis to the Distal Ulna for the of Recalcitrant Instability and Tendinopathy Session 4: Flexor Tendon – Wednesday, September 12, 2018, 2:16-2:18 PM

Hand and Wrist;Diseases and Disorders Level 4 Evidence

William R. Smith, MD Kevin Lutsky, MD Robert Takei Greg Gallant, MD, MBA Moody Kwok, MD Pedro Beredjiklian, MD

COI Ownership Interest: Wright Medical Inc. Matador, LLC Dimension Orthotics, LLC (Beredjiklian)

Hypothesis Extensor carpi ulnaris (ECU) instability and tendinopathy are increasingly being recognized as a source of ulnar sided wrist pain. Despite the variety of sheath reconstruction options, surgical results can be variable and unpredictable. We present a series of patients with recalcitrant ECU dysfunction and degenerative changes treated with tenodesis to the distal ulna.

Methods Electronic medical record (EMR) data for patients treated surgically with ECU tenodesis to the distal ulna by the senior surgeon over a three-year period were reviewed. Patients were identified via search of Current Procedural Terminology (CPT) codes 25301 and 25337. Patients with less than one year of follow up, incomplete medical records, or those under 18 years of age were excluded. All patients underwent and failed a course of conservative treatment prior to surgery. Demographic information analyzed included: age, gender, body mass index, past medical history, medications, date of injury, mechanism of injury (high vs. low energy), concomitant procedures, date of surgery, post-operative complications, QuickDASH score, and clinical measurements of wrist and forearm range of motion obtained at last follow-up.

Results CPT search of the EMR identified 15 patients. Three patients were excluded for follow-up of less than one year, resulting in a final cohort of 12 patients with an average age of 48 years (range 22-74). Average follow up was 17.9 months (range 12-28). Patient demographics are detailed in

Table 1. Intraoperative inspection of the ECU tendon of each patient revealed severe tendinosis with parenchymal tearing and instability. A tenodesis of the tendon to the distal ulna using a suture anchor was performed in all cases. Five patients with evidence of concomitant triangular fibrocartilage complex pathology on preoperative MRI underwent arthroscopic debridement and one patient underwent repair. Average postoperative range of motion was as follows: wrist extension – 62° (range 53-70); wrist flexion - 48° (range 40-56); forearm pronation - 79° (range 65-90); forearm supination - 66° (range 55-75). The average quickDASH score at latest follow-up was 14 (range 0-32), with only one patient failing to achieve significant resolution of pain. No complications were noted.

Summary Points • ECU tenodesis to the distal ulna with a suture anchor is an effective, previously unreported treatment option for ECU instability and tendinopathy, providing symptomatic relief with preservation of function.

Bibliography 1: Extensor Carpi Ulnaris Subsheath Reconstruction. Ruchelsman DE, Vitale MA. J Hand Surg Am. 2016 Nov;41(11) 2: Diagnosis and anatomic reconstruction of the extensor carpi ulnaris subluxation. MacLennan AJ, Nemechek NM, Waitayawinyu T, Trumble TE. J Hand Surg Am. 2008 Jan;33(1):59-64 3: Allende C, Le Viet D. Extensor carpi ulnaris problems at the wrist— classification, surgical treatment and results. J Hand Surg 2005;30B:265–272. 4: Giant Cell Tumors. Papanastassiou ID, Savvidou OD, Chloros GD, Megaloikonomos PD, Kontogeorgakos VA, Papagelopoulos PJ. Hand (N Y). 2017 Nov 1 5: A Biomechanical Comparison of Extensor Carpi Ulnaris Subsheath Reconstruction Techniques. Puri SK, Morse KW, Hearns KA, Carlson MG. J Hand Surg Am. 2017 Oct;42(10)

Paper 20: Methods to Optimize Operating Room Efficiency Under the Control of the Scheduling Surgeon Session 4: Flexor Tendon – Wednesday, September 12, 2018, 2:19-2:21 PM

Practice Management Level 4 Evidence

Andrew Z. Mo, MD Daniel Polatsch, MD Steven Beldner, MD

COI Consulting Fee: Skeletal Dynamics (Polatsch)

Hypothesis In the present healthcare environment, it has become increasingly important to maximize efficiency and decrease unnecessary costs. One study estimated the average utilization cost of an operating room (OR) per minute to be $62. There are numerous factors affecting OR turnover time, with some studies having investigated several such as the effect of factors on turnover time, surgeon presence in the OR, level of case complexity, specific surgeons, and American Society of Anesthesiologists (ASA) class. Case-to-case laterality has not been studied in the literature to date. We hypothesized that ipsilateral procedure laterality between would decrease turnover time between procedures.

Methods A total of 512 hand surgery procedures performed by 2 senior attending hand surgeons between May 2016 and February 2017 were identified. A retrospective review was performed, analyzing the turnover times between ipsilateral and contralateral sided procedures. Variables collected included turnover time, case complexity, surgical site laterality, utilization of implants, use of fluoroscopic imaging, and whether cases were performed before OR staff breaks. Case complexity was defined as either cases that involved multiple procedures or cases that involved the use of adjuncts such as microscopy or arthroscopy. An unpaired, two tailed t-test was used to assess the effects of multiple factors on turnover time.

Results Of 486 eligible cases, the average turnover time was 29 minutes. Turnover time was significantly increased by whether the patient was in the room prior to staff break times (p<0.001), the use of arthroscopy (p<0.01), the use of fluoroscopic imaging (p<0.02), and increased case complexity (p<0.04). Factors that did not affect turnover time were gender (p<0.86), case-to-case laterality

(p<0.59), surgeon identity (p < 0.40), the OR (p < 0.07), and dedicating an OR to one side (p<0.21).

Summary Points • Case-to-case laterality does not appear to affect OR turnover time. • In light of the significance of turnover time differences pre- and post-staff breaks, one may benefit from booking smaller procedures earlier in the day prior to staff breaks to maximize efficiency.

Bibliography 1: Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233-236. doi:10.1016/j.jclinane.2010.02.003.

Paper 21: Outcomes of the Adams-Berger Ligament Reconstruction for the Distal Radioulnar Joint Instability in 95 Consecutive Cases Session 5: Scaphoid – Wednesday, September 12, 2018, 3:37-3:39 PM

Hand and Wrist Level 4 Evidence

Joshua A. Gillis, MD

COI There is financial information to disclose.

Hypothesis To evaluate the outcomes and complication rate for Adams-Berger anatomic reconstruction of the distal radio-ulnar joint (DRUJ).

Methods We conducted a retrospective chart review to evaluate adult patients that had undergone reconstruction of the DRUJ for instability with the Adams-Berger procedure between 1998-2015 within our institution. Charts were reviewed for patient demographics, mechanism of injury and pre-surgical physical findings, surgical related data and follow-up data.

Results 95 wrists in 93 patients were included. Mean (SD) age at surgery was 37.3 years (12.7 years) and follow-up time was 65.8 months (63.2 months). At the last follow-up, 90.8% of patients had a stable DRUJ, 5.3% did not and 3.4% had some laxity. At last clinical follow-up, 27.5% and 48.4% of patients described either no pain or mild pain, respectively. Overall, graft survival was 87.4%, with twelve patients undergoing revision surgery with a mean time of revision from primary reconstructive surgery of 13.3 months. Grip strength increased with a decrease in pronosupination (p5 years follow-up.

Paper 22: A Novel Targeting Device for Scaphoid Fracture Fixation Session 5: Scaphoid – Wednesday, September 12, 2018, 3:40-3:42 PM

Hand and Wrist;Diseases and Disorders N/A - not a clinical study

Matthew C. DeWolf, MD

COI There is financial information to disclose.

Hypothesis: A customized 3-D printed apparatus for percutaneous retrograde screw fixation of scaphoid fractures (the Fixation Approaches to Scaphoid Trauma, FAST, Procedure) is more accurate, faster, and has less radiation exposure to the surgical team than fluoroscopy-guided percutaneous fixation.

Methods We devised a complete system that allows the surgeon to define an optimal insertion point and trajectory on 3D renditions of CT data, and then to construct a guide to position a k-wire in the desired trajectory in cadaver arms. After defining the intended insertion point and trajectory, a 3D printer is programmed to produce the components that perfectly guides a K-wire into the intended position.

With this system, we conducted experiments in which orthopedic residents placed casts outfitted with special openings (windows) designed to accommodate the k-wire guides on 7 cadaver arms. Following casting, pre-op CTs were acquired and treatment planning to define the k-wire trajectory was done. Custom guiding inserts were designed based on 3D models of the skeleton and stereolithography (STL) files suitable for 3D printing were produced and made into guide blocks. Finally, the residents placed the blocks into the windows and inserted the k-wires in place. Post-op CTs were used to verify the correct placement of the k-wires and we were able to confirm correct position in all 14 cases.

We had the same 7 residents perform standard percutaneous pinning utilizing a mini c-arm. The following data was collected: • Number of images used in the procedure • Fluoroscopy time (seconds) • Radiation Exposure (mGray) • Operating Room Time (minutes)

• Number of passes through the scaphoid • Was the K-wire in the central 1/3rd (Yes/No) • Was there a cortical breach (Yes/No) A 2 tailed paired Student T Test was used to determine P-values.

Results • FAST Procedure vs Standard Percutaneous Pinning (Table 1) • FAST is Faster (30 seconds versus 21 minutes) • FAST is More Accurate (all within central axis of the scaphoid) • FAST has no radiation exposure to the surgeon • FAST Procedure planned trajectory courses along the exact planned path (Figure 1)

Summary Points • The FAST Procedure is a faster, more accurate, and more reliable way to perform percutaneous pinning for orthopaedic residents. • K-wire placement follows the exact intended path • Future direction includes human trials for the management of non-displaced scaphoid waist fractures.

Paper 23: Biomechanical Strength of Retrograde Fixation in Proximal Third Scaphoid Fractures Session 5: Scaphoid – Wednesday, September 12, 2018, 3:43-3:45 PM

Hand and Wrist;Diseases and Disorders;General Principles N/A - not a clinical study

Charles Andrew Daly, MD

COI There is financial information to disclose.

Hypothesis Traditionally, proximal pole scaphoid fractures are treated dorsally. In cases of nonunion without AVN minimization of dorsal soft tissue trauma is key. Surprisingly, no study has specifically posed to evaluate the biomechanical strength of retrograde fixation of fractures of the proximal pole. The primary goal of this study is to investigate the biomechanical strength of retrograde fixation of fractures of the proximal pole as compared to antegrade. Our hypothesis is that retrograde fixation will be similar in cyclic load testing and load to failure to antegrade fixation of the scaphoid.

Methods Fourteen cadaveric scaphoids underwent proximal pole osteotomy. Fixation was performed in an antegrade or retrograde fashion based on randomization with careful attention given to achieving a central position within the proximal pole fragment. Each specimen underwent cyclic loading from 80 N to 120 N at 1 Hz until 2 mm of fracture displacement occurred or 4,000 cycles was reached. The specimen that reached the 4,000-cycle limit were loaded to failure.

Results Average load to failure was similar between antegrade and retrograde screw fixation (396.5 N versus 394.6 N) (p = 0.353). In all, 3 failures occurred during the cyclic loading phase of testing. 2 of these failures occurred in the antegrade group (at 2,529 and 3,212 cycles) with a single failure in the retrograde group (at 3,700 cycles). This difference did not reach statistical significance. The average screw length was 25.5 mm for the antegrade group and 23.3 mm for the retrograde group which was not statistically different. Screw cutout was the method of failure for each of the specimen.

Summary Points • For fixation of the proximal pole of the scaphoid, retrograde screw fixation is biomechanically equivalent to antegrade in this study. • We have demonstrated that surgical technique does not have to be limited by fear of poor biomechanical fixation. • Screw length appears to be similar between the groups. While in this ex vivo testing scenario fixation strength was similar, this has yet to be proven in vivo or with clinical outcomes. • Without exposure of the proximal pole of the scaphoid critical examination of radiographs are required to ensure central position of the screw and guidewire within the proximal pole of the scaphoid. • Surgeons can now make their decision for fixation technique based on approaches to bone grafting, concern for tenuous blood supply, and surgeon experience without fear of poor biomechanical properties.

Bibliography 1: Brogan DM, Moran SL, Shin AY. Outcomes of Open Reduction and Internal Fixation of Acute Proximal Pole Scaphoid Fractures. Hand (N Y). 2014 Oct 25;10(2):227–32. doi:10.1007/s11552- 014-9689-8 2: Compson JP. The anatomy of acute scaphoid fractures: a three-dimensional analysis of patterns. J Bone Joint Surg Br. 1998 Mar;80(2):218–24. 3: Faucher GK, Golden ML, Sweeney KR, Hutton WC, Jarrett CD. Comparison of screw trajectory on stability of oblique scaphoid fractures: a mechanical study. The Journal of Hand Surgery. 2014 Mar;39(3):430–5. doi:10.1016/j.jhsa.2013.12.015 4: Jeon I-H, Micic ID, Oh C-W, Park B-C, Kim P-T. Percutaneous screw fixation for scaphoid fracture: a comparison between the dorsal and the volar approaches. The Journal of Hand Surgery. 2009 Feb;34(2):228–36.e1. doi:10.1016/j.jhsa.2008.10.016 5: McCallister WV, Knight J, Kaliappan R, Trumble TE. Central placement of the screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone Joint Surg Am Case Reports. 2003 Jan;85-A(1):72–7.

Paper 24: Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of SLAC/SNAC Wrist: A Cost-Utility Analysis Session 5: Scaphoid – Wednesday, September 12, 2018, 3:46-3:48 PM

Hand and Wrist Level 3 Evidence

David A. Daar, MD, MBA Ajul Shah, MD Joshua T. Mirrer, MD Vishal Thanik, MD Jacques Hacquebord, MD

COI Other: Arthrex (Hacquebord)

Hypothesis We hypothesized that a cost-utility analysis (CUA) of proximal row carpectomy (PRC) versus three methods of four-corner arthrodesis (4CA) (i.e., K-wire fixation, plate fixation, and screw fixation) for the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) would reveal PRC to be the most cost-effective treatment option.

Methods A CUA was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A decision tree was created to illustrate the various health states, and a systematic literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analog scale survey of expert hand surgeons was performed to estimate utilities. Overall cost, probabilities, and quality- adjusted life-years (QALYs) were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed.

Results Forty studies yielding 1730 SLAC/SNAC wrists were identified. Decision tree analysis determined that both 4CA with screw fixation and PRC were cost-effective options, but 4CA with screw was the optimal treatment strategy. 4CA with K-wire fixation and 4CA with plate fixation were dominated (inferior) strategies and therefore not cost-effective. This was true for both societal and health care perspectives. One-way sensitivity analysis demonstrated that when the QALYs for a successful 4CA Screw are lower than 26.36, PRC becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model.

Summary Points • 4CA with screw fixation and PRC are both cost-effective treatment options for SLAC/SNAC wrist due to their lower complication profile and high efficacy, with 4CA with screw as the most cost-effective treatment strategy. • 4CA with plate and K-wire fixation should be avoided from a cost-effective standpoint. • Despite its limitations, this study can serve as a framework for providers with regards to resource allocation and implementing policies consistent with efficiencies in both hospital and societal costs when treating patients with SLAC/SNAC wrist.

Bibliography 1: Saltzman BM, Frank JM, Slikker W, Fernandez JJ, Cohen MS, Wysocki RW. Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: a systematic review. J Hand Surg Eur Vol. 2015;40(5):450–457. 2: Berkhout MJL, Bachour Y, Zheng KH, Mullender MG, Strackee SD, Ritt MJPF. Four-Corner Arthrodesis Versus Proximal Row Carpectomy: A Retrospective Study With a Mean Follow-Up of 17 Years. J Hand Surg. 2015;40(7):1349- 1354. doi:10.1016/j.jhsa.2014.12.035. 3: Sanders GD, Neumann PJ, Basu A, et al. Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA. 2016;316(10):1093. doi:10.1001/jama.2016.12195.

Paper 25: Advanced Imaging Adds Little Value in Diagnosis of TFCC Tear Session 5: Scaphoid – Wednesday, September 12, 2018, 3:49-3:51 PM

Hand and Wrist;General Principles;Practice Management Level 2 Evidence

Daniel Cunningham, MD, MHSc Tyler Pidgeon, MD Eliana B. Saltzman, MD Richard C. Mather, MD David S. Ruch, MD

COI Royalty: Acumed (Ruch) Speaker's Bureau: Acumed, DePuy Synthes (Ruch)

Hypothesis Triangular fibrocartilage complex (TFCC) tear is a prevalent cause of radiographically-occult ulnar-sided wrist pain that presents a considerable diagnostic challenge to the orthopaedic surgeon. After history and physical exam (H&P), diagnostic tests may include injection and/or advanced imaging with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) followed by diagnostic and treatment arthroscopy. These supplemental diagnostic tests vary substantially in cost. This study's hypothesis was that advanced imaging adds little value in the diagnosis of TFCC tear.

Methods A simple-chain decision model was constructed to assess several diagnostic algorithms for patients with radiographically-occult ulnar-sided wrist pain failing initial conservative management. Patients in the model progressed to initial operative or non-operative treatment based on results of diagnostic testing with the possibility of moving on to diagnostic and treatment arthroscopy based on failure of non-operative management. Diagnostic algorithms included H&P alone, H&P plus injection, H&P plus advanced imaging (MRI or MRA), and H&P plus injection and advanced imaging (MRI or MRA). Literature was reviewed to determine distributions for disease prevalence, diagnostic test sensitivity and specificity, and treatment success rates. 1-year post-diagnosis utilities were modeled on published pre-surgical and post- surgical Disabilities of the of the Arm, Shoulder, and Hand (DASH) scores. Costs were extracted from the Humana database (PearlDiver) using United States dollars. TreeAge Pro Healthcare (Williamstown, MA) was used to estimate baseline costs and effectiveness as well as incremental

cost-utility ratios (ICUR) across a range of willingness-to-pay (WTP) through a 50,000-trial probabilistic sensitivity analysis that drew from the pre-defined, literature-driven distributions.

Results As shown in Figure 1, all diagnostic strategies resulted in similar mean effectiveness (95% CI), ranging from 0.821 (0.404, 0.978) for H&P alone to 0.824 (0.400, 0.980) for H&P, injection, and MRA. However, mean costs differed considerably between strategies, ranging from $3,291.87 ($939.40, $7,520.96) for H&P alone to $5,190.33 ($2,020.18, $10,296.30) for H&P, and MRA. H&P alone or H&P and injection were the most cost-effective strategies for TFCC tear diagnosis. Strategies that incorporated MRI or MRA added a mean of $805.02 to $1,898.46 without appreciably improving effectiveness. H&P, and advanced imaging strategies were dominated by the other diagnostic strategies. As shown in Figure 2, H&P and injection were most commonly cost-effective across WTP up to $200,000.

Summary Points • Advanced imaging adds considerable cost and little value in the diagnosis of TFCC tear • H&P and injection represent cost-effective strategies for diagnosis of TFCC tear

Bibliography 1: Chan 2014 CORR "Prevalence of Triangular Fibrocartilage Complex Abnormalities Regardless of Symptoms Rise With Age: Systematic Review and Pooled Analysis" 2: Tay 2007 JHS "The “Ulnar Fovea Sign” for Defining Ulnar Wrist Pain: An Analysis of Sensitivity and Specificity" 3: Wolf 2012 JHS "Arthroscopic Repair of Ulnar-Sided Triangular Fibrocartilage Complex (Palmer Type 1B) Tears: A Comparison Between Short- and Midterm Results" 4: Smith 2014 JBJS "Diagnostic Accuracy of Magnetic Resonance Imaging andMagnetic Resonance Arthrography for Triangular Fibrocartilaginous Complex Injury" 5: Park 2010 Orthopedics "The Rate of Triangular Fibrocartilage Injuries Requiring Surgical Intervention"