Meeting Abstracts

Meeting Abstracts Scientific Session papers

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ABSTRACTS

2018 Annual Meeting Abstracts This booklet contains the abstracts for the Scientific Session papers as submitted by the authors. Abstracts are in presentation order by day and time. These abstracts are also available at www.ASSHAnnualMeeting.org.

Disclaimer The material presented in this continuing medical education program is being made available by the American Society for Surgery of the Hand for educational purposes only. This material is not intended to represent the only, or necessarily the best methods or procedures appropriate for the medical situation discussed, but rather is intended to present an approach, view, statement, or opinion of the authors or presenters, which may be helpful or of interest to other practitioners. The attendees agree to participate in this medical education program sponsored by ASSH with full knowledge and awareness that they waive any claim they may have against ASSH for reliance on any information presented in this educational program. In addition, the attendees also waive any claim they have against ASSH for any injury or other damage, which may result in any way from their participation in the program. All of the proceedings of this ASSH meeting, including the presentation of scientific papers, are intended for limited publication

only, and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker and ASSH. No statement of presentation made is to be regarded as dedicated to the public domain. Any sound reproduction, transcript or other use of the material presented at this course without the permission of the speaker or ASSH is prohibited to the full extent of common law copyright in such material. The approval of U.S. Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed and/or demonstrated in ASSH educational programs may not yet have received FDA approval. The ASSH assumes no responsibility or liability for the use or misuse of any information, materials, or techniques described in the following abstracts and it makes no warranty, guarantee, or representation as to the absolute validity or sufficiency of any information provided.

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ABSTRACTS PAPER 1 Best Papers Top 5 e Thursday, September 13, 2018
2:30e2:35 PM Hand and Wrist; General Principles; Practice Management

Effects of Medicaid Expansion on Hand Trauma and Quaternary Care Level 4 Evidence

Charles Andrew Daly, MD Brian H. Cho, MD Sameer Desale, MS Mihriye Mete, PhD Oluseyi Aliu, MD Aviram M. Giladi, MD, MS COI: There is no financial information to disclose. Hypothesis: Recent studies have shown that underinsured hand trauma patients are more likely to be transferred to quaternary care centers, burdening these patients of limited resource with the social and financial costs of long-distance travel. By increasing insurance coverage, care for less severe upper-extremity conditions may be available closer to a patient’s home. We aim to show that the expansion of Medicaid in the state of Maryland has decreased the number of uninsured transfers to our center and decreased the volume of unnecessary transfers. Methods: All cases of traumatic injuries to the upper extremity at the Level I hand trauma center for the state of Maryland were queried from 2012 to 2017. Injury severity was classified based on necessity for subspecialty hand surgical training and specialized equipment. Bivariate relationships between patients’ insurance status and demographic covariates, including injury type and distance from a hand trauma center, both before and after Medicaid expansion were evaluated. Differences in differences analysis was used to evaluate changes in transfer appropriateness as related to Medicaid expansion. Results: In the 5 years studied, 9,036 acute upper-extremity trauma patients were treated at our institution, 1,018 of whom were transferred from another hospital. Patients with more severe injuries and more compelling indications for transfer were more likely to be transferred a longer distance. With Medicaid expansion in 2014, transfer patients had a significant increase in insured status, from 59.9% to 71%, with a commensurate decrease in uninsured patients from 40.1% to 29.0% (Figure 1-1). After Medicaid expansion, nontransfer patient appropriateness decreased dramatically while the appropriateness of transfers remained consistent (odds ratio for the interaction between expansion and transfer status¼1.45, 95% confidence interval: 1.17-1.79, P ¼ .001) (Figure 1-2). The average distance of patients transferred stayed similar from an average of 46.3 miles prior to 2014 to 48.8 miles after Medicaid expansion in 2014 (P ¼ .417). Summary Points:
Medicaid expansion significantly decreased the proportion of uninsured transferred patients.
Although appropriateness of hand surgical consults and emergency visits decreased post-expansion, the likelihood of transfers being appropriate did not, indicating the possibility that that patients with less severe injuries were treated without transfer.
Medicaid expansion improved individual coverage; however with no significant changes in the distances required to travel. This group of patients was still left with the difficulties associated with economic disadvantage and trauma. Regionalization of hand trauma will amplify this problem unless legislative changes are implemented to mitigate these issues.

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Figure 1-1: Probability of Appropriateness for Transfer and NonTransfer Patients by Year with Medicaid Expansion January 1st, 2014

Figure 1-2: Payor Mix Over Time by Quarter. BIBLIOGRAPHY 1. Mahmoudi E, Squitieri L, Maroukis BL, Chung KC, Waljee JF. Care transfers for patients with upper extremity trauma: influence of health insurance type. J Hand Surg Am. 2016;41(4):516e525.e3. 2. Hartzell TL, Kuo P, Eberlin KR, Winograd JM, Day CS. The overutilization of resources in patients with acute upper extremity trauma and infection. J Hand Surg Am. 2013;38(4):766e773. 3. Maroukis BL, Chung KC, MacEachern M, Mahmoudi E. Hand trauma care in the United States: a literature review. Plast Reconstr Surg. 2016;137(1):100.ee11.e.

PAPER 2 Best Papers Top 5 e Thursday, September 13, 2018
2:37e2:42 PM Hand and Wrist; Diseases and Disorders; General Principles

Cost-Effectiveness Analysis of Humanitarian Hand Surgery Trips According to WHO-CHOICE Methods Level 4 Evidence

Xuan Qiu, MD Jacob S. Nasser, BS Gloria R. Sue, MD James Chang, MD Kevin C. Chung, MD, MS Grant support received from: 2017 AFSH Residents and Fellows Fast Track Grant COI: There is no financial information to disclose. Hypothesis: International hand surgery outreach programs to low- and middle-income countries (LMICs) provide much needed surgical care to the underserved populations and education to local providers for improved care. The cost-effectiveness of these mission trips has not been studied

despite a long history of such efforts. We performed the first study to examine the economic impact of hand surgery mission trips to LMICs using data from the Touching Hand Project (THP) and ReSurge International, 2 leaders in global hand surgery outreach. We hypothesize that hand surgery outreach is cost-effective in LMICs. Additionally, we predict that drivers of cost-variation exist when these trips are analyzed as a longitudinal cohort. Methods: We analyzed data of the cost for each mission trip and the surgical procedures performed during the trip from the THP and ReSurge International. Using methods from the World Health Organization (WHO-CHOICE), we determined whether the procedures performed on the mission trips are cost-effective. Results: We gathered information on 15 trips from the THP and 17 trips from ReSurge International. In our pilot study, we analyzed 5 hand surgery mission trips in which 159 patients were treated for their hand conditions. Trips varied in the country where they provided the interventions, the number of patients served, the severity of the conditions, and the total cost (Table 2-1). The cost per disability-adjusted life-years (DALYs)-averted ranged from USD $134 to $439, all of which were very cost-effective according to WHO-CHOICE Methods, defined as being less than the gross domestic product (GDP) per capita in the host country (Figure 2-1). The cost-effectiveness of global hand surgery interventions is comparable to that of other medical interventions such as multi-drug resistant tuberculosis treatment in similar regions. We also identified that there was a lack of standardized record keeping for these mission trips. Summary Points:
Hand surgery performed in low- and middle-income countries are considered very cost-effective interventions based on WHO-CHOICE criteria.
A standardized record keeping method is needed for future research and longitudinal comparison.
Understanding the economic impact of global outreach is important to the success and sustainability of surgical outreach efforts, both to allocate resources effectively and to identify areas for decreasing expenditures of these mission trips. Table 2-1: Cost and clinical data summary of hand surgery mission trips as compared with multidrug-resistant tuberculosis (MDR-TB) treatment in the same region

Country Bolivia Bolivia Americas, MDR-TB2 Ethiopia Ethiopia Ethiopia Africa, MDR-TB2

Number of Patients 66 56 N/A 15 8 14 N/A

Disability Weight Range 0.027-0.117 0.027-0.135 N/A 0.028-0.317 0.028-0.317 0.028-0.317 N/A

Total Cost (USD) 40,370 42,350 N/A 10,000 10,000 8,000 N/A

Cost/DALYaverted (USD) 395 439 267 134 242 209 205

GDP per capita (USD)1,2 3,105 3,105 1,702 707 707 707 1,240

1. World Bank database: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD? locations¼BO and https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations¼ET 2. Fitzpatrick C, Floyd K. A systematic review of the cost and cost effectiveness of treatment for multidrug-resistant tuberculosis. Pharmacoeconomics. 2012;30(1):63e80.

Cost per DALYs-averted as a Ratio of GDP per Capita in the Host Country/Region2 100%

very cost-effective

80%

60%

40%

20%

0%

34.2%

12.7%

14.1%

15.7%

2015, Bolivia

2016, Bolivia

2005, Americas, MDR-TB

29.6%

18.9%

2015, Ethiopia

16.5%

2016, Ethiopia

2017, Ethiopia

2005, Africa, MDR-TB

Figure 2-1: Cost per DALYs-averted as a Ratio of GDP per Capita in the Host Country/Region

This research was supported by a Residents & Fellows Fast Track Grant from the American Foundation for Surgery of the Hand.

PAPER 3 Best Papers Top 5 e Thursday, September 13, 2018
2:44e2:49 PM Hand and Wrist; Nerve

Predictors of Contralateral Carpal Tunnel Release at Time of Unilateral Surgery Level 4 Evidence

Dafang Zhang, MD Stein J. Janssen, MD Brandon E. Earp, MD Philip E. Blazar, MD COI: Consulting Fee: Acumed (Earp) Ownership Interest: Pfizer, Johnson and Johnson (Earp) Other: Arthrex (Earp) Hypothesis: We assessed factors at time of unilateral carpal tunnel release to create a prediction formula for future contralateral carpal tunnel release. Our null hypothesis was that there are no identifiable predictors for future contralateral carpal tunnel release at the time of unilateral surgery. Methods: In an institutional review boardeapproved retrospective study, we identified 1,013 patients who underwent carpal tunnel release at a tertiary care referral center from July 2008 to June 2013. A multivariate Cox model was used to identify independent factors associated with subsequent contralateral carpal tunnel release. A prediction formula was created and its accuracy calculated by receiver operating characteristic analysis. The external validity of our formula was tested using a sample of 100 random patients who underwent carpal tunnel release at a second tertiary care referral center from October 2004 to October 2017. Results: Preoperative contralateral carpal tunnel symptoms (odds ratio, 16.4; P < 0.001) and contralateral electrodiagnostic study severity (odds ratio, 1.26; P ¼ 0.001) were associated with increased likelihood of contralateral carpal tunnel release, whereas black race (odds ratio, 0.41; P ¼ 0.002) and chronic kidney disease (odds ratio, 0.18; P ¼ 0.003) were associated with decreased likelihood of contralateral carpal tunnel release. A prediction formula for the probability of undergoing contralateral carpal tunnel release at 5.5 year follow-up was constructed (Figure 3-1, Table 3-1). External validation demonstrated that our model remained stable with a good accuracy and good model calibration. Summary Points:
We derived and externally validated a prediction formula for future contralateral carpal tunnel release, which may be considered for prognostication.
A patient with no contralateral hand carpal tunnel syndrome symptoms and a normal contralateral electrodiagnostic study at time of unilateral carpal tunnel release has only a 3% probability of contralateral carpal tunnel release at 5.5 years.
A patient with contralateral hand carpal tunnel syndrome symptoms and a normal contralateral electrodiagnostic study at time of unilateral carpal tunnel release has a 37% probability of contralateral carpal tunnel release at 5.5 years.
A patient with contralateral hand carpal tunnel syndrome symptoms and severe contralateral electrodiagnostic results has a 65% probability of contralateral carpal tunnel release at 5.5 years.

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Table 3-1: Predicted probabilities for contralateral carpal tunnel release at 5.5-year follow-up. Contralateral CTS symptoms Yes Yes Yes Yes Yes Yes Yes No No No No No No No

Preoperative contralateral EMG severity Severe Moderate-severe Moderate Mild-moderate Mild Trace/borderline Normal Severe Moderate-severe Moderate Mild-moderate Mild Trace/borderline Normal

Predicted probability 0.65 0.60 0.56 0.51 0.46 0.41 0.37 0.10 0.09 0.07 0.06 0.05 0.04 0.03

trial. Procedures (Figure 4-1) were separated into 2 tiers based on anticipated postoperative pain. Patients completed the Pain Catastrophizing Scale (PCS) and Mindfulness Attention Awareness Scale (MAAS) preoperatively (Figure 4-2A). Patients completed a pain medication diary for 2 weeks postoperatively and were contacted on postoperative days 3, 8, and 15 to review their medication usage and pain levels. Spearman’s correlations and Mann Whitney U tests were performed to evaluate the association between PCS/MAAS scores and postoperative opioid use, average patient-reported pain levels, and refill rates (Figure 2B). Results: A total of 71 patients (57% male), mean age 60.2, were included in the analysis (46.4% tier 1 procedures, 53.5% tier 2 procedures). The average total number of opioids used at 2 weeks postoperatively across all procedures was 6.78 pills (range 0-49). Age and sex were not associated with postoperative opioid use. Tier 2 procedures were associated with increased postoperative opioid use, higher average postoperative week 1 pain, and higher refill rates (P ¼ .05) (Figure 4-2B). Summary Points:
Patients demonstrating higher pain catastrophizing scores preoperatively used more opioids postoperatively after a range of ambulatory hand surgeries.
In the setting of the opioid epidemic, hand surgeons should be aware of painrelated psychological factors that can influence postoperative opioid use.
Further studies evaluating predictors of postoperative opioid use may help identify patients for preoperative pain education and pain coping/ reduction techniques. Tier 1 Trigger finger release Carpal tunnel release De Quervain’s release Ganglion cyst excision Arthroscopy

Figure 3-1: Prediction formula for contralateral carpal tunnel release at time of unilateral surgery. BIBLIOGRAPHY 1. Steyerberg EW, Vickers AJ, Cook NR, et al. Assessing the performance of prediction models: a framework for traditional and novel measures. Epidemiology. 2010;21(1):128e138. 2. Collins GS, Reitsma JB, Altman DG, Moons KG. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. BMJ. 2015;350:g7594.

PAPER 4 Best Papers Top 5 e Thursday, September 13, 2018
2:51e2:56 PM Hand and Wrist; General Principles

Tier 2 Cubital tunnel release Interposion arthroplasty Dupuytren’s contracture release Tendon transfers, tenolysis, tenodesis, tendon centralizaon/stabilizaon Arthrodesis fingers/MCP Arthroplasty fingers/MCP Carpectomy, styloidectomy, ulnar shortening

Figure 4-1: Included Ambulatory Hand Procedures Stratified into Tiers Based on Anticipated Postoperative Pain

Figure 4-2A: Pain Catastrophizing and Mindfulness Attention Awareness Scale Scores (†: PCS¼ Pain Catastrophizing Scale. Range of scale is 0-52; MAAS¼ Mindfulness Attention Awareness Scale. Range of scale is 1-6.)

Pain Related Psychological Factors Influence Postoperative Opioid Use After Ambulatory Hand Surgery Level 4 Evidence

Hayley A. Sacks, BA Jeffrey G. Stepan, MD, MSc Lauren E. Wessel, MD Duretti T. Fufa, MD Grant support received from: 2016 AFSH Residents and Fellows Fast Track Grant COI: Consulting Fee: Medartis (Fufa) Contracted Research: Medatis (Fufa) Hypothesis: Pain related psychological factors, including pain catastrophization and dispositional mindfulness, have been shown to influence patient pain levels and outcomes after orthopedic surgery. Less is known about the relationship between these factors and postoperative opioid use after hand surgery. The purpose of this study is to examine the association between preoperative pain catastrophization and mindfulness and postoperative opioid use in patients undergoing ambulatory hand surgery. Methods: Patients undergoing ambulatory hand surgery at our institution between May 2017 and January 2018 were prospectively enrolled in an ongoing clinical S4

Figure 4-2B: Association between PCS/MAAS Score and Postoperative Pain and Opioid use (V¼ Median [range] for continuous variables, Number of patients [% of cohort] for categorical variables, r¼ Spearman’s correlation coefficient; *¼ significant P values are defined as 0.6) (Table 5-2). The matched adjusted risk ratio of a secondary procedure was 49.4, 27.4, and 27.9 for the FCA group at the 1-, 5-, and 10-year intervals, respectively (P < .0001). Summary Points:
In Stage II SLAC / SNAC wrists, we did not detect a significant difference in rate of conversion to TWA between propensity matched cohorts PRC and FCA at the 1- and 10-year follow-up periods. The overall rate of conversion to TWA with minimum 10-year follow-up in the propensity matched cohort analysis was 4.3% for FCA and 4.6% for PRC (P ¼ 0.87).
Patients who underwent FCA are significantly more likely to undergo secondary procedures, compared to PRC.
In a large, propensity matched, retrospective study performed in a VA patient population, the optimal surgical treatment of Stage II SLAC / SNAC pattern of wrist arthritis appears to favor PRC over FCA.

This research was supported by a Residents & Fellows Fast Track Grant from the American Foundation for Surgery of the Hand. BIBLIOGRAPHY 1. Darnall BD. Pain psychology and pain catastrophizing in the perioperative setting: a review of the impacts, interventions, and unmet needs. Hand Clin. 2016;32(1):33e39.

PAPER 5 Best Papers Top 5 e Thursday, September 13, 2018
2:58e3:03 PM Hand and Wrist

Risk of Fusion or Reoperation After FCA or PRC for Stage II SLAC/SNAC: A Propensity Matched Cohort Study of 1,118 Patients Level 3 Evidence

Andrew R. Tyser, MD Brittany Garcia, MD Andrew Stephens, BS Nikolas H. Kazmers, MD, MSE Brian Sauer, PhD Chao-Chin Lu, PhD COI: There is no financial information to disclose. Hypothesis: The optimal choice of surgical treatment for Stage II scapholunate advanced collapse (SLAC) and scaphoid non-union advanced collapse (SNAC) patterns of wrist arthritis remains unclear. Four corner arthrodesis (FCA) and proximal row carpectomy (PRC) have demonstrated similar clinical outcomes. We hypothesized that patients undergoing a PRC have a lower risk of secondary operations and conversion

BIBLIOGRAPHY 1. Wagner ER, Werthel JD, Elhassan BT, Moran SL. Proximal row carpectomy and 4-corner arthrodesis in patients younger than age 45 years. J Hand Surg Am. 2017;42(6):428e435.

Table 5-1: Unmatched and Propensity Matched Patient Cohort Demographic information. Full population Variable Names Age at exposure, mean (SD) Male Female BMI, mean (SD) Married Race White Non-white Smoking Smoking Pre-operative Employment Status Employed Number of Inpatient Admissions, mean (SD) Number of VA drug class code count, mean (SD) Number of ED visits, mean (SD) Comorbidity Diagnoses Distinct count, mean (SD) Infection Musculoskeletal system and connective tissue Cancer Diabetes Gout and other crystal arthropathies Mental Health Alcohol-related disorders Substance abuse Blood disorders Nervous system

Matching weights adjusted cohorts Standard FCA (N ¼ 228) PRC (N ¼ 228) difference 55.5(11.6) 55.4(5.9) 0.01 224(98.2) 224(98.2) 0.00 4(1.8) 4(1.8) 0.00 29.6(5.3) 29.6(2.6) 0.02 122(53.5) 123(53.9) 0.01

FCA (N ¼ 236) 55.1(11.8) 232(98.3) 4(1.7) 29.6(5.3) 129(54.7)

PRC (N ¼ 903) 58.0(10.6) 883(97.8) 20(2.2) 30.1(5.6) 453(50.2)

Standard difference 0.26 0.04 0.04 0.08 0.09

169(71.6) 49(20.8)

645(71.4) 204(22.6)

0.00 0.04

.96 .55

164(71.9) 48(21.1)

161(70.8) 51(22.3)

0.03 0.03

.79 .74

72.0(30.5)

357(39.5)

0.19

.01

70(30.7)

70(30.7)

0.00

.99

57(24.2) 0.3(0.7) 9.8(7.7) 27.1(27.9)

223(24.7) 0.3(0.7) 11.6(9.1) 28.9(26.4)

0.01 0.01 0.21 0.07

.86 .92 .01 .34

52(22.8) 0.3(0.8) 10.1(7.7) 27.9(28.1)

52(23.0) 0.3(0.4) 10.0(4.3) 27.9(12.4)

0.00 0.01 0.01 0.00

.96 .93 .94 .98

3.9(2.2) 35(14.8) 225(95.3) 58(24.6) 40(16.9) 10(4.2) 93(39.4) 32(13.6) 26(11.0) 7(3.0) 98(41.5)

4.1(2.3) 181(20.0) 852(94.4) 184(20.4) 196(21.7) 54(6.0) 322(35.7) 122(13.5) 105(11.6) 37(4.1) 358(39.6)

0.09 0.14 0.04 0.10 0.12 0.08 0.08 0.00 0.02 0.06 0.04

.22 .07 .55 .16 .11 .30 .29 .98 .79 .42 .60

4.0(2.1) 35(15.4) 219(96.1) 58(25.4) 40(17.5) 10(4.4) 93(40.8) 32(14.0) 26(11.4) 7(3.1) 98(43.0)

4.0(1.1) 35(15.4) 219(96.0) 59(26.1) 40(17.5) 11(4.7) 92(40.3) 31(13.8) 27(11.8) 7(3.0) 98(42.9)

0.00 0.00 0.00 0.02 0.00 0.01 0.01 0.01 0.01 0.00 0.00

.99 1.00 .96 .87 1.00 .89 .91 .94 .89 .96 .9881

P value