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Background: Nerve transfers to reinnervate ulnar intrinsic musculature can restore function in severe ulnar neuropathy, and supercharged end-to-side (SETS) nerve transfers have garnered early adoption. Given the relative expendability of the abductor digiti minimi (ADM), redirecting its axons to more critical components of the ulnar motor nerve (UMN) in a turbocharged end-to-side (TETS) nerve transfer with concomitant anterior interosseous SETS nerve transfer (AIN) as a super-turbocharged end-to-side (STETS) or twin-charged double nerve transfer may improve functional recovery.

Methods: A retrospective study of patients undergoing the STETS AIN/ADM to UMN double nerve transfer or TETS ADM to UMN nerve transfer for severe ulnar neuropathy between 2020 and 2022 was performed. Primary outcomes were improvement in first dorsal interosseous (FDI) strength and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Dichotomous and continuous variables were compared with χ² and t tests, respectively.

Results: Fifty patients with severe ulnar nerve injuries were identified with at least 1-year surgical follow-up. Preoperative symptom duration was an average of 11.3 months. The STETS cohort (n = 42) reported significantly decreased DASH scores from 58 to 28 (P < .001) and improved FDI Medical Research Council (MRC) score from 0.7 to 3.3 (P < .001). The TETS cohort (n = 8) reported significantly decreased DASH scores from 54 to 23 (P = .016) and improved FDI MRC score from 2.0 to 3.6 (P = .008).

Conclusions: Distal transfer of the ADM nerve to the ulnar deep motor branch in a turbocharged fashion is reported. The findings suggest that the STETS double nerve transfer may improve patient outcomes and warrants further investigation with prospective cohort studies.

In response to the widespread occurrence of limb loss and the transformative potential of extremity vascularized composite allotransplantation (VCA), we examine the impact of warm and cold ischemia duration on limb survival and functional recovery. Our insights into warm ischemia are largely derived from relevant literature on replantation and revascularization. Studies indicate that achieving reperfusion within 5 to 6 hours of warm ischemia is critical for limb survival, and within 3 hours for curbing significant functional deficits. For limbs preserved in static cold conditions, as is standard practice in VCA, reperfusion should be attained within 10 to 12 hours of cold ischemia. However, our analysis exposes a lack of data on extremity functional recovery following cold ischemia, particularly in humans or large animal models. This underscores a gap in the literature that could guide clinical ischemia management in VCA if addressed. We anticipate optimal functional recovery between 3 and 6 hours of cold ischemia, as supported by outcomes in rats. Prolonged ischemia times are also associated with graft rejection, posing unique challenges to VCA. Tissues exhibit diverse responses, with muscle and nerve being highly susceptible to ischemic damage, and skin acquiring heightened immunogenicity. Ischemia management emerges as a focus for future policy and research initiatives. On the horizon, exploring updated transplantation protocols, vascular shunts, stabilizing perfusion solutions, and subnormothermic machine perfusion could mitigate ischemic damage and enhance clinical outcomes in extremity VCA.

Background: The treatment of distal radius fractures may require manipulation of the fracture assisted by finger traction, causing pain both at the fracture site and at the fingers. The usual type of anesthesia used does not anesthetize the fingers.

Methods: We conducted a prospective cohort study with two groups, hematoma block (HB) and hematoma with associated median nerve block (MHB). Characteristic variables of the patients were collected. The main variable for the analysis was pain, measured using the Visual Analogical Scale (VAS). It was measured prior to the injection (VAS1), during fracture reduction (VAS2), and 30 minutes after the injection (VAS3) in both groups.

Results: The study included a total of 140 fractures (70 anesthetized with HB), 78% were women. There were no significant differences in the variables age, sex, Elixhauser index. and need for surgery between the groups. In the HB group, the VAS means were VAS1 5.23 cm (SD 2.31), VAS2 5.80 cm (SD 2.52), and VAS3 1.89 cm (SD 1.94); while in the MHB group, VAS1 5.13 cm (SD 2.36), VAS2 3.15 cm (SD 1.70), and VAS3 1.09 cm (SD 1.38). Area of greatest pain during fracture reduction in the HB group was finger traction in 78% cases (p < .05), while in the MHB group it was the manipulation of the fracture site in 71% cases (p < .05).

Conclusions: The study demonstrates that the use of hematoma with associated median nerve block decreases pain perception in patients with distal radius fracture that needs closed reduction, when compared to HB alone.

Background: Our objective is to evaluate the utilization fraction (UF) of surgical instruments during a commonly performed ambulatory hand surgery case as an avenue for cost reduction, increased operating room efficiency, and systems quality improvement.

Methods: The total number of instruments opened at the start of the case was recorded followed by instruments being divided into those used and not used during the procedure. Total sterile processing costs were estimated at $1.56 per instrument according to data from our institution's central sterilization processing (CSP) department.

Results: Nineteen hand procedures performed by 2 surgeons were included in this study. An average of 120.1 ± 10.9 instruments were opened at the start of each case, while an average of 12.6 ± 5.4 instruments were used per case (Figure 1). This yielded an UF of 10.7% ± 4.8%. Using our internal CSP estimate, we calculated an annual cost of $16 863 to reprocess the current hand tray (Figure 2). Using literature data, this cost ranged from $5 513 to $34 484 annually. The same cost calculations were performed for the theoretical optimized tray (incorporating instruments used at least 20% of the time when opened) containing 23.2 instruments. The annual reprocessing cost of this new tray according to CSP data was $3 260, demonstrating a cost-reduction of $13 603 or 80.7% (Figure 2).

Conclusions: Evaluation of pre- and peri-operative processes is a valuable technique to mitigate increasing healthcare costs and reduce unnecessary healthcare spending, with broad applicability to multiple surgical subspecialties and procedures.

Background: Artificial intelligence offers opportunities to improve the burden of health care administrative tasks. Application of machine learning to coding and billing for clinic encounters may represent time- and cost-saving benefits with low risk to patient outcomes.

Methods: Gemini, a publicly available large language model chatbot, was queried with 139 de-identified patient encounters from a single surgeon and asked to provide the Current Procedural Terminology code based on the criteria for different encounter types. Percent agreement and Cohen's kappa coefficient were calculated.

Results: Gemini demonstrated 68% agreement for all encounter types, with a kappa coefficient of 0.586 corresponding to moderate interrater reliability. Agreement was highest for postoperative encounters (n = 43) with 98% agreement and lowest for new encounters (n = 27) with 48% agreement. Gemini recommended billing levels greater than the surgeon's billing level 31 times and lower billing levels 10 times, with 4 wrong encounter type codes.

Conclusions: A publicly available chatbot without specific programming for health care billing demonstrated moderate interrater reliability with a hand surgeon in billing clinic encounters. Future integration of artificial intelligence tools in physician workflow may improve the accuracy and speed of billing encounters and lower administrative costs.

Background: Patients face increasing financial toxicity (FT), defined as emotional distress due to the cost of medical treatment. However, little is known regarding FT in the context of upper extremity trauma.

Methods: We surveyed patients who sustained traumatic finger amputation (October 21, 2011-January 1, 2021). We collected patient-reported financial distress using the Comprehensive Score for Financial Toxicity (COST-11), where a lower score indicates worse FT. We also collected data of patients' perceptions regarding the costs of their treatment. We used linear regression to assess patient-level characteristics associated with FT as measured by the COST-11 score.

Results: Of the 191 eligible patients, 46 patients completed the survey (response rate of 24%). A total of 41 respondents (89%) received an initial treatment of revision amputation, with the remaining patients receiving a semi-occlusive dressing. Patients with commercial insurance had significantly lower COST-11 scores (ie, worse FT) than patients with Medicare (β = 7.5, 95% CI: 0.5 to 14.5) and Worker's Compensation (β = 8.7, 95% CI: 1.8 to 15.6). Patients who were single/never married had significantly worse FT (β = -11.3, 95% CI: -18.7 to -3.9). Approximately 35% (n = 16) reported that the costs were higher than expected. More than a third of patients (39%) reported decreasing spending on basic items, such as food, at least once since surgery.

Conclusion: Patients face FT when obtaining surgery following traumatic finger amputation. Variation in the FT is associated with type of insurance and marriage status, highlighting how underinsurance and social support likely affect the overall economic well-being of patients.

Background: While mallet finger remains a relatively common injury of the hand, mallet thumb is much rarer in occurrence. Mallet thumb management has been noted infrequently within the literature and reliable evidence regarding the most effective method of management remains absent. The aim of this review is to assess the quality of literature that exists pertaining to mallet thumb to determine whether conservative or surgical management is superior.

Methods: A search was completed in February 2023 of Ovid Medline, Embase, CINAHL, and SPORTDiscus with no limitation on study type, and date of publication. Comparative outcomes of thumb interphalangeal (IP) joint range of motion, tip, lateral pinch and grip strength, complications, outcome measure scores, and follow-up period were recorded. We assessed 103 mallet thumbs (51 surgically and 52 conservatively managed) across the 23 studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: While recommendations remain weak due to low quality of evidence, our review found a lower complication rate and higher IP joint flexion in thumbs managed conservatively.

Conclusion: These findings demonstrate a need for future research to shift toward ensuring standardized patient-rated outcome measures are utilized and functional outcomes are included in research planning and operationalization in order to contextualize clinical outcomes.

Background: The purpose of this study was to determine the clinical outcomes of mucous cystectomy and osteophytectomy using a random nonadvancement flap technique.

Methods: This was a therapeutic outcomes study of patients who underwent mucous cystectomy under local anesthesia by 1 of 2 hand fellowship-trained surgeons between 2012 and 2022. The key features of the surgical technique include designing a random nonadvancement flap with the cyst at its base; transecting the cyst pedicle as the flap is elevated; resecting the cyst wall from the undersurface of the reflected flap; decompressing the distal joint by removing marginal osteophytes; and insetting the flap without advancement. Patient demographic and disease-specific data were extracted from medical records and compiled in an electronic database. At minimum 1-year follow-up, patients were queried by telephone regarding wound complications, cyst recurrence, and satisfaction with outcome.

Results: The study cohort included 64 cysts in 61 patients, mean age 63 ± 10 years. The index or middle finger was affected in 63% of cases. At early postoperative follow-up, digital pain improved or resolved in 97% of cases. There were no complications of wound dehiscence or infection. At median 5-year follow-up in 34 cases, all patients except 1 were satisfied with the surgical outcome. There were 2 cyst recurrences in the study cohort (3%) and only 1 secondary procedure.

Conclusions: Our study demonstrated that mucous cystectomy and distal joint osteophytectomy using a random nonadvancement flap is an effective surgical technique with low procedure complication and cyst recurrence rates and high patient satisfaction.

Background: The "supercharge" end-to-side (SETS) anterior-interosseous-nerve (AIN) to ulnar-motor nerve transfer is used to improve intrinsic muscle recovery in cases of severe ulnar nerve compression or proximal axonotmetic injuries. Previous work has found differing intrinsic muscle recovery after this transfer. The objectives of this study were to examine the patterns of recovery in first dorsal interossei (FDI) and abductor digiti minimi (ADM) and the impact of AIN transfer to a specific fascicular location on the ulnar-motor nerve.

Methods: A retrospective review of one fellowship-trained surgeon's consecutive patients at a single center from December 2019 to September 2021 was conducted. Patients who had an AIN to ulnar-motor nerve transfer for any indication were included and were excluded if they had less than 9 months follow-up.

Results: Seventeen patients were included (88% male, mean age 55 ± 14 years). At early follow-up, compound muscle action potential amplitudes for ADM and FDI did not increase. Compound muscle action potential amplitude for ADM significantly increased at late follow-up (P < .01). Average British Medical Research Council (BMRC) strength increased at early follow-up for FDI (P < .05), but not ADM. The proportion of patients with BMRC ≥ 3 increased for FDI (P < .01) and ADM (P < .05) at late follow-up. Volar-ulnar AIN insertion position did not have a clear effect on outcomes.

Conclusions: The SETS AIN to ulnar-motor nerve transfer demonstrates clinical and electrophysiologic evidence of intrinsic muscle recovery and reinnervation, with differing recovery of outcomes. The role of specific fascicular targeting is still unclear and required further examination as does the mechanism behind differing intrinsic recovering.

Background: The purpose of this study was to evaluate differences in 90-day clinical outcomes between patients treated with generic volar locking plates (VLPs) and conventional VLPs in distal radius fractures. Secondary aims included assessing for differences in surgical characteristics and cost between the groups.

Methods: From November 2022 to April 2023, a prospective block-randomized study was undertaken in which surgeons alternated between using a generic VLP and a conventional VLP each month. The institution's chargemaster database was cross-referenced for implant cost. Primary outcomes were 90-day readmission, reoperation, and mortality rates. Secondary outcomes included estimated blood loss, tourniquet time, and implant cost.

Results: A total of 66 patients were included. Most were women (n = 61, 92.4%), with an average age of 61.0 ± 11.5 years. There were no significant differences in age, sex, smoking status, AO Foundation/Orthopaedic Trauma Association classification, or tourniquet time between patients who received generic and conventional implants. The average total cost was higher with conventional implants than generic implants($1348.61 ± 100.77 and $702.38 ± 47.83, respectively; P < .001). The largest difference in cost came from pegs and screws that were used ($640.77 ± 90.93 vs $268.47 ± 45.93, P < .001). No patients experienced complications such as readmission, reoperation, or death within 90 days.

Conclusions: Total implant cost was lower for procedures where generic VLPs were used. Cost differences between generic and conventional implants are driven by the variable selection of pegs and screws. With no differences in 90-day outcomes, surgeons may consider using generic implants as a way of increasing the value of care delivery.