Small Joint Denervation of the Hand and Thumb Base: History, Anatomy, Technique, and Outcomes.

Painful arthritis of the small joints of the hand is a common condition affecting older adults, with distal interphalangeal joint and thumb carpometacarpal joint being the two most common locations. Younger adults may also develop painful arthritis after trauma and with inflammatory arthropathy. Traditional surgical approaches address the structure of the joints with either arthrodesis or arthroplasty with or without an implant. In recent decades, denervation has been reported as an alternative treatment for painful small joints that are mobile and stable. Publications on denervation often report faster surgery and recovery times than traditional surgeries that manipulate the small joint bony structures. This article reviews the history, anatomy, surgical techniques, and outcomes of denervation of the small joints of the hand.

Identifying Health-Related Quality of Life Domains After Upper Extremity Transplantation.

OBJECTIVE: To identify the most important health-related quality of life (HRQOL) domains and patient-reported outcomes after upper extremity transplantation (UET) in individuals with upper extremity amputation. DESIGN: Verbatim audio-recordings of individual interviews and focus groups were analyzed using qualitative, grounded theory-based methods to identify important domains of HRQOL and provide guidance for outcomes measurement after UET. SETTING: Individual interviews were conducted by phone. Focus groups were conducted at 5 upper extremity vascularized composite allotransplantation (VCA) centers in the US and at an international conference of VCA experts. PARTICIPANTS: Individual phone interviews were conducted with 5 individuals with lived experience of UET. Thirteen focus groups were conducted with a total of 59 clinical professionals involved in UET. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Twenty-eight key HRQOL domains were identified, including physical functioning and medical complications, positive and negative emotional functioning, and social participation, relations, and independence. We identified key constructs for use in evaluation of the potentially substantial physical, medical, social, and emotional effects of UET. CONCLUSIONS: This study provides an overview of the most important issues affecting HRQOL after UET, including several topics that are unique to individuals with UET. This information will be used to establish systematic, comprehensive, and longitudinal measurement of post-UET HRQOL outcomes.

How Many Plastic Surgeons Does It Take to Write an Article? A 10-Year Bibliometric Analysis of Authorship Inflation.

BACKGROUND: Publications measure academic productivity; they can affect research funding and career trajectory. There is a trend of increased authors per publication in surgery journals. We sought to determine whether authorship inflation exists in the plastic surgery literature and identify independent predictors of the number of co-authors. METHODS: We performed a bibliometric analysis of articles published in 3 high impact plastic surgery journals at 2-year intervals between 2010 and 2020. For each publication, we collected details on year of publication, article type, plastic surgery topic, gender of senior author, geographical origin of study, and the number of authors. RESULTS: A total of 5593 articles were collected. The median number of authors per article increased over time (ρ = 0.20, P < 0.001). Cohort studies, basic science investigations, literature reviews, and systematic reviews experienced a significant increase in the number of authors per article from 2010 to 2020 (P < 0.001). The rise in the number of authors was consistent across all plastic surgery topics (P < 0.001). Both male and female senior authors had a significant increase in the number of co-authors (P < 0.001). The regression model demonstrated that article type (cohort studies, basic science investigations, and systematic reviews) predicted more co-authors, whereas geographical region (Africa, Middle East, South and Southeast Asia, and United Kingdom and Ireland) and plastic surgery topics (aesthetic and hand surgery) predicted fewer authors. CONCLUSIONS: The number of authors per publication is increasing in plastic surgery. Author proliferation was consistent across most article types and unaffected by gender. Possible reasons behind this trend include research complexity, increased collaboration, or gift authorship.

Article Factors Influencing Gender Disparities in Senior Authorship of Plastic Surgery Publications.

INTRODUCTION: Female plastic surgeons publish fewer and lower impact articles. To better understand how to address this gender gap, we explored the temporal trends in female senior authorship and evaluated predictive factors for female senior authorship. METHODS: A retrospective review of articles published in the 3 highest impact plastic surgery journals published from 2010 to 2020 was conducted. Trends with female senior authorship across time were analyzed with respect to study type, subspeciality, and geographical origin. RESULTS: Of the 5425 articles included, 13% (n = 720) had a female senior author, and female senior authorship increased across time ( R = 0.84, P = 0.033). Over the decade, an increased proportion of cohort studies ( R = 0.82, P = 0.045), systematic reviews ( R = 0.96, P = 0.003), breast-related articles ( R = 0.88, P = 0.022), and reconstruction-related articles ( R = 0.83, P = 0.039) were published by female senior authors. Subspecialty and geography predicted female senior authorship; articles focused on aesthetic (odds ratio [OR] = 1.3, P = 0.046) and breast (OR = 1.7, P < 0.001) subspecialties or those originating from Canada (OR = 1.7 P = 0.019), Europe (OR = 1.5, P < 0.001), and Latin America (OR = 3.0, P < 0.001) were more likely to have a female senior author. Articles from East Asia were less likely to have female senior authors (OR = 0.7, P = 0.005). CONCLUSION: Female senior authorship in plastic surgery has increased over the last decade, and the proportion of female plastic surgeons leading cohort studies and systematic reviews is increasing. Sex of the senior author is influenced by plastic surgery subspecialty and geographical origin, but article type did not impact the odds of female senior authorship.

Selective Thumb Carpometacarpal Joint Denervation Versus Trapeziectomy and Ligament Reconstruction With Tendon Interposition for Painful Arthritis: A Prospective Study With 2 Years of Follow-Up.

PURPOSE: Thumb carpometacarpal (CMC) joint denervation is a relatively novel method for the management of osteoarthritis-associated pain by selective transection of articular nerve branches of the CMC joint. This study compared functional/patient-reported outcomes after CMC denervation with those after trapeziectomy and ligament reconstruction with tendon interposition (T + LRTI) over a 2-year follow-up period. We hypothesized that the outcomes of denervation and T + LRTI would be similar over the course of the study and at the final 2-year follow-up. METHODS: Adults with Eaton stage 2-4 disease, no evidence of CMC subluxation, and no history of thumb injury/surgery were included. Pain scores, brief Michigan Hand Questionnaire (bMHQ), Kapandji score, 2-point discrimination, and grip/key/3-point pinch strength were measured at 3-, 6-, 12-, and 24-months after surgery. On average, T + LRTI patients underwent 7 weeks of splinting, with release to full activity at 3 months; denervation patients were placed in a soft postoperative dressing for 2 weeks, with release to full activity as tolerated at 3 weeks. RESULTS: Thirty-three denervation and 20 T + LRTI patients were included. Preoperative characteristics were similar between both groups. Two denervation patients underwent secondary T + LRTI during the study period; one denervation patient underwent fat grafting to the CMC joint at an outside institution. Data prior to secondary surgeries were included in the analysis. The average tourniquet times (minutes) for denervation and T + LRTI were 43.5 ± 11.8 and 82.7 ± 14.2 minutes, respectively. For denervation and T + LRTI, the postoperative bMHQ scores were significantly higher than those at baseline at all time points. No significant differences were found between both groups for bMHQ, sensation, or strength measures. CONCLUSIONS: Carpometacarpal denervation is well tolerated, with shorter tourniquet times and faster return to full activity than T + LRTI. For the study cohort, the conversion rate to T + LRTI at 2 years was 9%. Both procedures demonstrated durable improvement in bMHQ compared with the preoperative state with similar long-term outcomes over 2 years of follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Typical and atypical properties of peripheral nerve allografts enable novel strategies to repair segmental-loss injuries.

We review data showing that peripheral nerve injuries (PNIs) that involve the loss of a nerve segment are the most common type of traumatic injury to nervous systems. Segmental-loss PNIs have a poor prognosis compared to other injuries, especially when one or more mixed motor/sensory nerves are involved and are typically the major source of disability associated with extremities that have sustained other injuries. Relatively little progress has been made, since the treatment of segmental loss PNIs with cable autografts that are currently the gold standard for repair has slow and incomplete (often non-existent) functional recovery. Viable peripheral nerve allografts (PNAs) to repair segmental-loss PNIs have not been experimentally or clinically useful due to their immunological rejection, Wallerian degeneration (WD) of anucleate donor graft and distal host axons, and slow regeneration of host axons, leading to delayed re-innervation and producing atrophy or degeneration of distal target tissues. However, two significant advances have recently been made using viable PNAs to repair segmental-loss PNIs: (1) hydrogel release of Treg cells that reduce the immunological response and (2) PEG-fusion of donor PNAs that reduce the immune response, reduce and/or suppress much WD, immediately restore axonal conduction across the donor graft and re-innervate many target tissues, and restore much voluntary behavioral functions within weeks, sometimes to levels approaching that of uninjured nerves. We review the rather sparse cellular/biochemical data for rejection of conventional PNAs and their acceptance following Treg hydrogel and PEG-fusion of PNAs, as well as cellular and systemic data for their acceptance and remarkable behavioral recovery in the absence of tissue matching or immune suppression. We also review typical and atypical characteristics of PNAs compared with other types of tissue or organ allografts, problems and potential solutions for PNA use and storage, clinical implications and commercial availability of PNAs, and future possibilities for PNAs to repair segmental-loss PNIs.

Public Perceptions and Information Needs of VCA Transplantation and Donation: A Mixed Methods Study.

Vascularized Composite Allotransplantation (VCA) involves transplantation of multiple tissues from a donor to a recipient (e.g., skin, muscle, bone). Little is known about the US public's perceptions of and attitudes toward VCA organ donation. This multi-site, cross-sectional, mixed methods study involved focus groups and surveys to assess members of the general public's attitudes about VCA, and willingness and barriers to donate VCA organs. Qualitative data were analyzed by thematic analysis; quantitative data were analyzed by descriptive statistics. In focus groups (n = 6, 42 participants), most participants were female (57%) and Black (62%) with mean age of 42.6 years. Three main themes emerged: 1) awareness and perceptions of VCA, 2) purpose of VCA donation, 3) and barriers to VCA donation. Participants had heard little about VCA and sought information about VCA donation. Participants perceived VCA as challenging their concepts of "normality" and voiced concerns that VCA would create "Frankenstein[s]." Barriers to VCA donation included disruptions to end-of-life arrangements and information gaps regarding the donation process. Participants reported moderate to high willingness to donate their hands (69%) and face (50%) Public education efforts should address the specific needs and concerns of the public to facilitate VCA donation and family authorization.

A New Consideration for Corticosteroid Injections: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19) Vaccination.

Corticosteroid injection (CSI) is a commonly used tool in hand surgery that is often given little consideration as a potential detriment to vaccination efficacy. The authors reviewed guidelines issued by relevant societies for the timing of CSI around the severe acute respiratory syndrome coronavirus 2 vaccination period and the evidence used to support them. Ultimately, providers and patients should be adequately educated on the theoretical risks and benefits before proceeding with CSI immediately before, during, or immediately after coronavirus disease 2019 vaccination.

Noninvasive evaluation of intragraft immune responses in upper extremity transplantation.

In vascularized composite allotransplantation (VCA), invasive tissue biopsies remain the gold standard in diagnosing rejection carrying significant morbidity. We aimed to show feasibility of tape-stripping for noninvasive immune monitoring in VCA. Tape-stripping was performed on allografts and native skin of upper extremity transplant recipients. Healthy nontransplanted individuals served as controls. The technique was also used in swine on naïve skin in nontransplanted animals, native skin of treated, transplanted swine, nonrejecting VCAs, and rejecting VCAs. Extracted protein was analyzed for differences in cytokine expression using Luminex technology. Significantly decreased levels of INFγ and IL-1Ra were seen between human allograft samples and native skin. In swine, rejecting grafts had increased IL-1Ra compared to naïve and native skin, decreased levels of GM-CSF compared to native skin, and decreased IL-10 compared to nonrejecting grafts. Unsupervised hierarchical clustering revealed rejecting grafts separated from the nonrejecting (P = 0.021). Variable importance in projection scores identified GM-CSF, IL-1Ra, and IL-2 as the most important profiles for group discrimination. Differences in cytokine expression are detectable in human VCA patient native skin and VCA graft skin using a noninvasive tape-stripping method. Swine studies suggest that differences in cytokines between rejecting and nonrejecting grafts are discernable.

Upper-Extremity Venous Thromboembolism Following Operative Treatment of Distal Radius Fractures: An Uncommon but Dangerous Complication.

PURPOSE: Distal radius fractures are the most common long bone fracture in the United States, with an estimated incidence of 640,000 cases per year. Operative fixation presents a theoretical risk factor for the development of upper-extremity venous thromboembolism (UE-VTE). Additionally, patients presenting with distal radius fracture commonly have preexisting comorbidities that further increase the risk of UE-VTE. Finally, UE-VTE is considered the highest risk for eventual development of pulmonary embolism. Despite this, scant attention has been paid to studying UE-VTE in this population. The purpose of this study was to measure the incidence of this complication and to identify possible medical factors that increased the risk of developing UE-VTE. METHODS: We queried the Truven MarketScan Commercial Claims and Encounters Database for all patients who experienced a distal radius fracture and were subsequently treated with open reduction and internal fixation between 2012 and 2016. Patients were identified using relevant Common Procedural Terminology codes. Demographic and medical variables were tabulated. Our primary outcome was the development of ipsilateral UE-VTE or pulmonary embolism in the first 60 days after surgery. RESULTS: The study included 24,494 patients. The mean age was 50.7 years (range, 18-91), and 58% were women. There were 79 cases (0.3%) of UE-VTE and 19 cases of pulmonary embolism in the study population (24.1% of all UE-VTE cases; 0.08% of total sample). Multivariable logistic regression showed that coexisting heart failure and estrogen use were associated with increased risk of UE-VTE. CONCLUSIONS: Although uncommon, the development of UE-VTE after open reduction and internal fixation for distal radius fractures is a concerning complication. Coexisting heart failure and estrogen use are associated with increased risk of UE-VTE. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Trauma-induced Rejection in Vascularized Composite Allotransplantation.

: Vascularized composite allotransplantation (VCA) is a relatively new field in reconstructive medicine. Likely a result of the unique tissue composition of these allografts-including skin and often a bone marrow component-the immunology and rejection patterns do not always mimic those of the well-studied solid organ transplantations. While the number and type of VCAs performed is rapidly expanding, there is still much to be discovered and understood in the field. With more patients, new findings and patterns emerge and add to our understanding of VCA. Here, we present a case report of an upper extremity transplant recipient with trauma-induced rejection.

Polyethylene glycol-fusion repair of sciatic allografts in female rats achieves immunotolerance via attenuated innate and adaptive responses.

Ablation/segmental loss peripheral nerve injuries (PNIs) exhibit poor functional recovery due to slow and inaccurate outgrowth of regenerating axons. Viable peripheral nerve allografts (PNAs) as growth-guide conduits are immunologically rejected and all anucleated donor/host axonal segments undergo Wallerian degeneration. In contrast, we report that ablation-type sciatic PNIs repaired by neurorrhaphy of viable sciatic PNAs and a polyethylene glycol (PEG)-fusion protocol using PEG immediately restored axonal continuity for many axons, reinnervated/maintained their neuromuscular junctions, and prevented much Wallerian degeneration. PEG-fused PNAs permanently restored many sciatic-mediated behaviors within 2-6 weeks. PEG-fused PNAs were not rejected even though host/donors were neither immunosuppressed nor tissue-matched in outbred female Sprague Dawley rats. Innate and adaptive immune responses to PEG-fused sciatic PNAs were analyzed using electron microscopy, immunohistochemistry, and quantitative reverse transcription polymerase chain reaction for morphological features, T cell and macrophage infiltration, major histocompatibility complex (MHC) expression, apoptosis, expression of cytokines, chemokines, and cytotoxic effectors. PEG-fused PNAs exhibited attenuated innate and adaptive immune responses by 14-21 days postoperatively, as evidenced by (a) many axons and cells remaining viable, (b) significantly reduced infiltration of cytotoxic and total T cells and macrophages, (c) significantly reduced expression of inflammatory cytokines, chemokines, and MHC proteins, (d) consistently low apoptotic response. Morphologically and/or biochemically, PEG-fused sciatic PNAs often resembled sciatic autografts or intact sciatic nerves. In brief, PEG-fused PNAs are an unstudied, perhaps unique, example of immune tolerance of viable allograft tissue in a nonimmune-privileged environment and could greatly improve the clinical outcomes for PNIs relative to current protocols.

Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study.

BACKGROUND: Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS: This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS: The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS: These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.

Kinematic Analysis of the Distal Radioulnar Joint in Asymptomatic Wrists Using 4-Dimensional Computed Tomography-Motion Pattern and Interreader Reliability.

PURPOSE: The aim of this study was to determine the normal measurement values and interobserver performance of the distal radioulnar joint during wrist pronation-supination using 4-dimensional computed tomography (CT). METHODS: Four-dimensional CT examinations were performed on the asymptomatic contralateral wrists of 10 patients with unilateral chronic wrist pain. Measurements were conducted using the modified radioulnar (mRU) line and epicenter (Epi) methods. Volar subluxation of the ulnar head was demonstrated with negative values. Wilcoxon rank sum test was used to determine the measurement changes. Interobserver agreements were assessed using interclass correlation coefficients. RESULTS: In pronation, mRU line measurements (median, 0.09; interquartile range, 0-0.15) were significantly larger than in supination (median, -0.1; interquartile range, -0.18 to 0; P = 0.008).The Epi measurements were not significantly different in pronation (median, 0.03; interquartile range, 0.01-0.07) and supination (median, 0.06; interquartile range, 0.01-0.1; P = 0.799). There was an excellent inter-observer agreement between the two readers using mRU and Epi methods in pronation (0.982, 0.898), midpoint (0.994, 0.827) and supination (0.989, 0.972) positions, respectively. CONCLUSIONS: Using 4-dimensional CT examination, distal radioulnar joint kinematics in asymptomatic wrists demonstrate excellent interobserver agreements with increased volar ulnar subluxation with supination as detected using mRU, but not the Epi method.

The Ethics of Hand Transplantation: A Systematic Review.

PURPOSE: We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) allotransplantation and how these concerns have changed over time. METHODS: We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE allotransplantation. Inclusion criteria were papers that were on the topic of UE allotransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change. RESULTS: We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0-7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002. CONCLUSIONS: Upper extremity transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies. CLINICAL RELEVANCE: Because UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.

From Auto- to Allotransplantation: Immunomodulatory Protocol for Hand and Arm Transplantation.

AIM: To achieve a favorable risk-benefit balance for hand transplantation, an immunomodulatory protocol was developed in the laboratory and translated to clinical application. METHODS: Following donor bone marrow infusion into transplant recipients, hand and arm allografts have been maintained on low-dose tacrolimus monotherapy. RESULTS: Good-to-excellent functional recovery has been achieved in patients compliant with medication and therapy, thus restoring autonomous and productive lives. CONCLUSION: The risk-benefit balance can be tilted in favor of the hand transplant recipients by using an immunomodulatory protocol with minimum immunosuppression.

Blood product utilization in human upper-extremity transplantation: challenges, complications, considerations, and transfusion protocol conception.

BACKGROUND: Upper-extremity transplantation (UET) is a reality. Immunologic, functional, and graft survival outcomes have been encouraging. However, these complex reconstructions have unique considerations that pose distinct challenges. Transplant programs have reported morbidity and mortality due to significant intraoperative blood losses, but similar data are scant during other phases of recovery. We report experience from two centers on complete blood component demands and utilization with UET. STUDY DESIGN AND METHODS: Inpatient medical records of UET recipients from intraoperative (time from initiation of transplant surgery to exit from the operative suite) and postoperative (exit from the operative suite to discharge from the hospital) phases were retrospectively reviewed. RESULTS: Six patients received various UETs and mean (±SD) postoperative hospital stay was 46 (±14.4) days. Mean (±SD) intraoperative blood unit utilization was 14.8 (±10.2) red blood cells (RBCs), 10.5 (±11.8) plasma, 0.8 (±1.2) platelets (PLTs), and 0.3 (±0.8) cryoprecipitate units. Mean postoperative blood unit utilization was 9.3 (±10.4) RBCs, 5.3 (±6.7) plasma, 1.2 (±2.0) PLTs, and 0.7 (±1.6) cryoprecipitate units. Both intraoperative and postoperative blood utilization for unilateral versus bilateral transplant were different, but not significantly so. However, total inpatient blood use in bilateral transplants was significantly greater than in unilateral transplants. CONCLUSION: Substantial blood loss may occur in UET and require transfusion of many blood components, primarily RBCs and plasma. We propose an UET transfusion protocol and suggest that centers preparing to perform these transplants should actively engage the transfusion medicine service to ensure availability and access to appropriate blood components for the entire hospitalizations of these unique patients.

Outcomes after hand and upper extremity transplantation.

Hand and upper extremity transplantation (HUET) has emerged as the most frequently performed reconstructive procedure in the burgeoning field of vascularized composite allotransplantation (VCA). VCA refers to a form of transplant with multiple tissue types that represents a viable treatment option for devastating injuries where conventional reconstruction would be unable to restore form and function. As hand transplantation becomes increasingly more common, discussions on advantages and disadvantages of the procedure seem to intensify. Despite encouraging functional outcomes, current immunosuppressive regimens with their deleterious side-effect profile remain a major concern for a life-changing but not life-saving type of transplant. In addition, a growing number of recipients with progressively longer follow-up prompt the need to investigate potential long-term sequelae, such as chronic rejection. This review will discuss the current state of HUET, summarizing outcome data on graft survival, motor and sensory function, as well as immunosuppressive treatment. The implications of these findings for VCA in terms of achievements and challenges ahead will then be discussed.

Impact of high resolution 3 tesla MR neurography (MRN) on diagnostic thinking and therapeutic patient management.

OBJECTIVE: To evaluate the impact of magnetic resonance neurography (MRN) on diagnostic thinking and therapeutic choices in patients with suspected peripheral neuropathy. METHODS: IRB approval was obtained for this HIPAA-compliant study. Questionnaires were administered to six surgeons regarding the diagnosis and treatment in 85 patients suspected of having peripheral neuropathy, before (pretest) and after (posttest) MRN. Multiple outcome measures related to diagnostic confidence and surgical decision-making were assessed. RESULTS: The final cohort included 81 patients (30 men and 51 women, age 47 ± 17 years). The following changes were observed from pretest to posttest questionnaires: 23% in nerve involvement (P < 0.05), 48% in degree of confidence of nerve involvement (P < 0.01), 27% in grade of injury (P < 0.05), 33% in differential diagnosis (P < 0.05), 63% in degree of confidence in need for surgery (P < 0.001), 41% in timing of surgery (P < 0.01), 30% in approach to surgery (P < 0.05), 58% in degree of confidence in approach to surgery (P < 0.001), 30% in estimated length of surgery (P < 0.05) and 27% in length of incision (P < 0.05). The dichotomous decision regarding surgical or nonsurgical treatment changed from pro to con in 17%. CONCLUSION: MRN results significantly influenced the diagnostic thinking and therapeutic recommendations of peripheral nerve surgeons. KEY POINTS: • In patients with peripheral neuropathy, MRN significantly impacts diagnostic thinking. • In patients with peripheral neuropathy, MRN significantly impacts therapeutic choices. • 3-T MRN should be considered in presurgical planning of patients with peripheral neuropathy.