United States

Bridging Gaps in Care: Addressing Health Disparities in Colorectal Cancer Screening. 

Jacob Culclasure, M2 student2; Hanna Anhalt, M2 student2; A. Miles Scott, DO1. 
1Prisma Health, Columbia, SC; 2University of South Carolina School of Medicine, Columbia, SC. 

Introduction: Colorectal cancer (CRC) is the third most diagnosed cancer and third leading cause of cancer-related death in both men and women in the U.S., with increasing incidence among individuals under 50 years of age. Early screening and detection improve outcomes by identifying cancers at more treatable stages. Non-adherence to screening guidelines is a major contributor to worse outcomes. Barriers to screening predominantly affect marginalized groups due to remaining systemic injustices. In South Carolina, disparities exceed the national average. 

Methods: An Epic report of patients aged 45-75 seen at FMC Colonial in the past year determined potential factors contributing to CRC screening rates. The report established each patient’s age, insurance status, sex, and race. Pivot tables were produced to describe how each demographic factor contributed to rates of CRC screening and identify areas of intervention. The percentage of patients at goal was calculated by dividing the number of patients up to date on CRC screening by the total number of patients. 

Results: Among 3,397 eligible patients, 57.96% were up to date with recommended screening. Screening rates varied significantly by age group, insurance status, and sex. Only 48.6% of patients aged 45-54 were screened, compared to 59.8% of those 55-64 (p&lt;0.000001) and 65.9% of those 65-75 (p&lt;0.000001). Insurance status was strongly associated with screening. Patients with Medicare (62.2%) and private insurance (60.0%) had significantly higher screening rates compared to those with Medicaid (46.9%) and the uninsured (43.7%). Specifically, Medicaid patients had lower rates than both Medicare (p&lt;0.000001) and private insurance (p&lt;0.00001), and uninsured patients had a lower rate compared to Medicare (p&lt;0.000001) and private insurance (p&lt;0.00001). Differences in screening rates among sexes were less pronounced but still significant, with screening rates higher among females (60.4%) than males (53.9%, p=0.00024). In contrast to existing literature, no significant differences were found between racial groups. 

Conclusion: CRC screening rates in this population were influenced by age, insurance status, and sex, with older, insured, and female patients more likely to be screened. While no statistically significant racial disparities were identified, screening rates were lower among younger adults, males, and uninsured patients. These findings emphasize the need for targeted, clinic-based interventions, such as in-clinic education, counseling on testing options, and connecting patients to state-funded programs to support the uninsured, to improve overall screening rates.

AMA Research Challenge 2025 

Bridging Gaps in Care: Addressing Health Disparities in Colorectal Cancer Screening

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AMA Research Challenge 2024 

Join the AMA Research Challenge poster symposium and semifinals to explore top research posters and score posters in the semifinals (an AMA member exclusive opportunity).

Bridging Gaps in Care: Addressing Health Disparities in Colorectal Cancer Screening. 

Jacob Culclasure, M2 student2; Hanna Anhalt, M2 student2; A. Miles Scott, DO1. 
1Prisma Health, Columbia, SC; 2University of South Carolina School of Medicine, Columbia, SC. 

Introduction: Colorectal cancer (CRC) is the third most diagnosed cancer and third leading cause of cancer-related death in both men and women in the U.S., with increasing incidence among individuals under 50 years of age. Early screening and detection improve outcomes by identifying cancers at more treatable stages. Non-adherence to screening guidelines is a major contributor to worse outcomes. Barriers to screening predominantly affect marginalized groups due to remaining systemic injustices. In South Carolina, disparities exceed the national average. 

Methods: An Epic report of patients aged 45-75 seen at FMC Colonial in the past year determined potential factors contributing to CRC screening rates. The report established each patient’s age, insurance status, sex, and race. Pivot tables were produced to describe how each demographic factor contributed to rates of CRC screening and identify areas of intervention. The percentage of patients at goal was calculated by dividing the number of patients up to date on CRC screening by the total number of patients. 

Results: Among 3,397 eligible patients, 57.96% were up to date with recommended screening. Screening rates varied significantly by age group, insurance status, and sex. Only 48.6% of patients aged 45-54 were screened, compared to 59.8% of those 55-64 (p<0.000001) and 65.9% of those 65-75 (p<0.000001). Insurance status was strongly associated with screening. Patients with Medicare (62.2%) and private insurance (60.0%) had significantly higher screening rates compared to those with Medicaid (46.9%) and the uninsured (43.7%). Specifically, Medicaid patients had lower rates than both Medicare (p<0.000001) and private insurance (p<0.00001), and uninsured patients had a lower rate compared to Medicare (p<0.000001) and private insurance (p<0.00001). Differences in screening rates among sexes were less pronounced but still significant, with screening rates higher among females (60.4%) than males (53.9%, p=0.00024). In contrast to existing literature, no significant differences were found between racial groups. 

Conclusion: CRC screening rates in this population were influenced by age, insurance status, and sex, with older, insured, and female patients more likely to be screened. While no statistically significant racial disparities were identified, screening rates were lower among younger adults, males, and uninsured patients. These findings emphasize the need for targeted, clinic-based interventions, such as in-clinic education, counseling on testing options, and connecting patients to state-funded programs to support the uninsured, to improve overall screening rates.

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**Addison Shenk, a fourth-year medical student from Edward Via Virginia College of Osteopathic Medicine, was the winner of the 2025 AMA Research Challenge and was awarded the grand prize of $10,000, presented by Laurel Road.**

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Objective: This study aims to evaluate recent literature on cancer vaccines, focusing on emerging strategies and advancements in vaccine development. With increasing interest in immunotherapy, novel vaccine delivery mechanisms may enhance efficacy and broaden therapeutic applications.

Methods: A comprehensive literature review analyzing published studies and clinical trial data on cancer vaccines was conducted. Research articles detailing vaccine formulations, immune response mechanisms, and clinical outcomes were included. Particular attention was given to novel approaches, such as nanoparticle-based vaccine delivery.

Results: Recent findings highlight the incorporation of nanoparticles as a promising strategy for cancer vaccine delivery. Nanoparticles enhance antigen presentation, improve immune activation, and enable targeted delivery to tumor-associated antigen-presenting cells. Clinical trials have demonstrated improved vaccine stability and efficacy through nanoparticle-based formulations, suggesting potential advantages over conventional vaccine platforms.

Conclusions: The application of nanoparticle technology in cancer vaccines represents a significant advancement in immunotherapy. These innovations may enhance vaccine efficacy, prolong immune responses, and provide new therapeutic opportunities. Further clinical studies are needed to optimize nanoparticle-based vaccine formulations and assess long-term safety and effectiveness.

Cancer Immunotherapy and Nanoparticles: Enhancing Vaccine Efficacy through Advanced Delivery


The gut microbiome plays a critical role in brain development and function, yet the neural mechanisms underlying microbiome-brain interactions during social processing remain poorly understood. We hypothesized that microbiome depletion fundamentally alters how the brain processes social information across different contexts.


We developed a three-day social context paradigm using FDG-PET neuroimaging in antibiotic-treated (ABX, n=10) and control (CON, n=10) mice. Mice underwent scanning in three contexts: isolation (day 1), familiar social interaction (day 2), and novel social interaction (day 3). Statistical parametric mapping identified brain regions showing significant context-dependent changes in glucose metabolism (p<0.001). ABX mice were administered a broad-spectrum antibiotic cocktail through the drinking water (ampicillin (1 g/L), vancomycin (0.5 g/L), neomycin (1 g/L), and metronidazole (1 g/L) in sterile drinking water), while control mice (CON) received regular drinking water

Microbiome depletion induced distinct context-dependent neural signatures. During transitions from isolation to familiar social contexts, CON mice showed appropriate engagement of social memory circuits (lateral entorhinal cortex, anterior cortical amygdaloid nucleus) with concurrent decreases in primary somatosensory and prelimbic regions. In contrast, ABX mice showed no significant changes between these contexts. When transitioning from isolation to novel social contexts, ABX mice exclusively engaged sensory processing regions (superior colliculus, secondary visual cortex, somatosensory barrel field) without any decreases in regional activity. During familiar-to-novel social transitions, ABX mice further increased sensory processing (visual cortex, somatosensory barrel field), while CON mice showed appropriate motor engagement and decreased somatosensory activity. Notably, ABX mice showed no decreases in neural activity during any context transition.


Microbiome depletion fundamentally alters context-dependent neural processing during social interaction, causing a shift from social memory circuits to compensatory sensory processing. This suggests microbiome-depleted animals maintain social functioning through alternative neural strategies that rely heavily on sensory information rather than appropriate social memory engagement. The absence of neural inhibition during context transitions in microbiome-depleted mice reveals a previously unrecognized mechanism by which microbiome alterations may contribute to social processing deficits in neurodevelopmental and psychiatric conditions.


Compensatory functional connectivity resolves neuro-behavioral dissociation in socially engaged microbiome-depleted mice

Background
Human Respiratory Syncytial Virus (hRSV) is a leading cause of lower respiratory tract infections, particularly affecting infants, older adults, and immunocompromised individuals. The virus exists as two major types, RSV A and RSV B, each with distinct clades that aid in tracking viral evolution. Outbreak timing and severity can differ even within nearby areas, and genetic similarities are often seen across neighboring regions. Ongoing viral evolution poses challenges to long-term vaccine development, underscoring the need for localized genomic surveillance to guide public health efforts. This study analyzed hRSV-positive cases from the Emory Healthcare Microbiology Lab to identify mutations that may impact viral fitness and antigenicity. We summarized the genomic evolution of hRSV during the 2024–2025 season at Emory University Hospital and demonstrated how integrating genomic and clinical data can enhance our understanding of viral adaptation, informing both treatment and vaccine development.

Methods
Residual nasal swabs were collected from 182 hRSV-positive adult patients at Emory University Hospital between September 2024 and March 2025. Nucleic acids were extracted, reverse-transcribed to cDNA, and used to generate multiplex RSV amplicon libraries, which were sequenced using Illumina MiSeq or NextSeq platforms (~2 million reads per sample). Genomes were aligned with MAFFT, clades assigned using Nextclade, and mutations analyzed to track potential immune escape variants.

Results

Among RSV A samples, clades A.D.3.1, A.D.5.2, and A.D.1.5 were most prevalent, while RSV B samples were primarily B.D.E.1, with additional cases of B.D.4.1.1 and B.D.E.1.4. In vaccinated individuals (n = 17), infections involved a genetically diverse mix of strains, with B.D.E.1 (24%), B.D.4.1.1 (18%), and A.D.3.1 (12%) being the most common. No single clade predominated among breakthrough infections. Symptom profiles appeared similar between vaccinated and unvaccinated individuals, with the most notable difference being mortality, which was observed only in unvaccinated patients.

Conclusion
Our analysis revealed that multiple RSV A and B clades co-circulated during the 2024–2025 season, demonstrating substantial viral diversity across the region. Breakthrough infections among vaccinated individuals were linked to a wide range of clades, with no evidence of a single dominant escape variant. While our findings align with broader regional trends, we also identified distinct local variants, reinforcing the importance of continued, localized genomic surveillance. The study was limited by sample size and scope, highlighting the need for expanded surveillance efforts. Ongoing analyses using Nextclade will focus on identifying prevalent escape mutations driving immune evasion. This genetic diversity in both vaccinated and unvaccinated individuals emphasizes the evolving nature of RSV and the need for adaptive public health strategies and vaccine design.


Genomic Epidemiology of Human Respiratory Syncytial Virus in Vaccinated and Unvaccinated Adults in Atlanta, GA (2024-2025)

Background
The Perivascular Fat Attenuation Index (FAI) has emerged as a novel non-invasive biomarker for predicting major adverse cardiovascular events (MACE) and assessing coronary plaque vulnerability. Elevated FAI values are associated with key clinical factors including Type 2 Diabetes Mellitus (T2DM), young age, coronary in-stent restenosis (ISR), stress-related neural activity, non-ST elevation acute coronary syndrome (NSTE-ACS), and high-risk plaque features. This meta-analysis aims to comprehensively evaluate the predictive value of lesion-specific FAI for MACE across these variables, ultimately enhancing cardiovascular risk stratification and clinical decision-making.

Methods
A systematic analysis of studies published between 2018 and 2025 was conducted using PubMed and Embase. Hazard Ratios (HRs) associated with elevated FAI for MACE were collected and compared across high-risk patient subgroups, including individuals with type 2 diabetes mellitus (T2DM), in-stent restenosis (ISR), young adults, stress-related neural activity (NSR), non-ST elevation acute coronary syndrome (NSTE-ACS), high-risk plaque features, and cardiac transplant recipients.

Results
Seven studies (n>6,000 patients) found that elevated lesion specific FAI values were significantly associated with a higher risk of MACE across all subgroups. The CRISP-CT study confirmed these findings, revealing that high-risk plaque features combined with elevated FAI values significantly increased the risk of cardiac mortality (HR = 7.33, p < 0.001). In patients with T2DM, those with lesion-specific FAI values higher than -83.5 Hounsfield Units (HU) exhibited a significantly increased risk of MACE (HR = 2.40, p = 0.001) and a higher prevalence of high-risk plaques. Young patients (≤45 years) with elevated FAI (≥ -75.2 HU) demonstrated a significantly increased risk of MACE (HR = 19.257, p = 0.004). Stress-related neural activity correlated positively with higher FAI values (r = 0.49, p < 0.001), suggesting that stress-induced activation may increase plaque vulnerability. Patients with ISR showed significantly higher peri-stent FAI values compared to those without ISR (-87.2 ± 7.3 HU vs -78.1 ± 6.2 HU, p < 0.001). In the NSTE-ACS and cardiac transplant subgroups, FAI values ≥ -70.1 HU were associated with increased plaque vulnerability and ultimately a higher risk of adverse cardiovascular outcomes. 

Conclusion
Lesion-specific FAI is a unique non-invasive biomarker for predicting MACE in high-risk populations, including T2DM patients, young adults, ISR patients, those with stress-induced neural activity, NSTE-ACS, and cardiac transplant recipients. The strong correlation with high-risk plaque features suggests that FAI can significantly enhance cardiovascular risk stratification and guide personalized intervention strategies. Integrating FAI into clinical practice may improve predictive accuracy and enable more precise and effective management of cardiovascular risk.


The Predictive Value of Perivascular Fat Attenuation Index in Risk
Stratification for Major Adverse Cardiovascular Events

Background
Melanoma is one of the deadliest forms of skin cancer, but it is curable if detected early. Some melanomas closely mimic benign moles (melanocytic nevi), making diagnosis challenging and increasing the risk of diagnostic errors, morbidity, and mortality. Early melanoma originates in the epidermis, the outermost epithelial layer of the skin; however, the role of epidermal keratinocytes in melanoma initiation and progression is not fully understood, leaving their potential as diagnostic or therapeutic targets largely unexplored. To identify key gene signatures of the keratinocyte microenvironment in melanoma progression, we utilized single cell spatial transcriptomics, which enables in-situ gene expression analysis of individual cells while simultaneously accounting for their spatial context within the tumor microenvironment. 

Methods
We used spatial transcriptomics to visualize in situ gene expression of ~6000 genes at a single-cell-level within seven samples: three invasive melanomas, one melanoma in situ, one dysplastic nevus, one common nevus, and one basal cell carcinoma. Multiple fields of view (FOVs) consisting of the epidermal components of both lesional tissue and adjacent non-lesional skin were included from each sample. To visualize cell types and expression patterns across all samples simultaneously, we performed dimensionality reduction and cell clustering using the R package Seurat. Subsequently, the smiDE package was used to perform differential gene expression of keratinocytes, and clusterProfiler was used for Gene Ontology enrichment analysis. 

Results
Our analysis spanned 144 of FOVs, including a total of 147,541 cells across all samples. Cell clustering revealed multiple keratinocyte populations, with some populations more prevalent in malignant samples. In these keratinocytes, the top enriched pathways included keratinocyte differentiation, epidermal proliferation, viral immune response, and wound healing. Initial results discovered 33 upregulated genes within the epidermal keratinocyte microenvironment of melanomas but not nevi, including but not limited to damage associated molecular patterns (DAMPs) S100A7, S100A8, and S100A9, and wound-associated keratins KRT6B and KRT6C. Wound-associated keratins and S100A8/9 were also upregulated in the basal cell carcinoma microenvironment, suggesting that they are associated with both melanocytic and keratinocytic cutaneous malignancies. Additionally, upregulated genes unique to melanomas included DSC2, DYNLL1, LCN2, and RAB11A. 

Conclusion
Our findings identify a keratinocyte population in the tumor microenvironment of melanoma, which exhibits a wound-like proliferative state. Our results build a foundation for identifying biomarkers and therapeutic targets in the epithelial microenvironment of melanoma.

Transcriptionally aberrant keratinocytes shape the tumor microenvironment in melanoma

Background
Reconstructing large segmental tibial defects remains challenging for surgeons. When defects are extensive and involve soft tissue loss, the vascularized free fibular flap (VFFF) offers advantages, including shorter treatment duration and single-site harvest of bone and soft tissue. This study reviews long-term outcomes of VFFF in the reconstruction of segmental tibial defects performed by a single surgeon at our institution.
Methods
The surgical case log of the senior author was reviewed for all adult patients who underwent VFFF reconstruction for tibial defects between 2007 and 2023. Electronic health records were used to collect demographic, clinical, and surgical data, including age, sex, race, comorbidities, etiology of injury, defect size, ankle joint involvement, need for soft tissue coverage, fixation method, and duration of external fixation.
Outcomes included ED visits; unplanned readmissions and reoperations; pin site infections; flap fractures; time to and achievement of full weight-bearing; ambulation without aids; NRS pain scores; time to return to work/avocation; flap success rate; conversion to amputation; and long-term donor/recipient site complications.
Results
Fifteen patients (80% male, mean age 41.4) met inclusion criteria. Most cases resulted from high-energy trauma complicated by nonunion and infection; three cases (20%) involved oncologic resection, and one case involved primary chronic osteomyelitis. The average tibial defect size was 10.91 cm (SD = 2.25), and ankle arthrodesis was performed in 4 patients (27%).
Soft tissue reconstruction was required in 13 patients (87%), with an average defect size of 117 cm² (SD = 40.84). A VFFF skin paddle was used in 11 patients; 3 (20%) required an additional ALT flap. Fixation methods included internal or external fixation, with or without subsequent conversion to a Taylor spatial frame.
The mean number of unplanned reoperations was 1.13. Pin site infections and flap fractures occurred in 3 patients each (20%). Full weight-bearing was achieved in 73% of patients, and 47% were able to ambulate without mobility aids, including orthotic braces. The mean NRS pain score at final follow-up was 1.64 (SD = 2.73), and time to return to work averaged 1.55 years (SD = 1.28). Flap success rate was 93%, with one additional patient electing amputation.
Recipient site complications included lymphedema (N = 3), venous stasis (N = 1), and foot drop (N = 1). Donor site complications included one case of claw toe, which was surgically corrected.
Conclusion
Our study demonstrates that VFFF is an effective option for reconstructing large segmental tibial defects with associated soft tissue loss, achieving an 93% flap success rate and an acceptable complication profile.


Long-Term Outcomes of the Vascularized Free Fibula Flap in the Reconstruction of Large Segmental Tibial Defects: A Retrospective Review

Title: Cybersecurity Literacy Among Clinical Staff: A Simulated Survey Reveals Risk Exposure And Training Gaps In Healthcare Settings
Author: Temitope Adewuyi MB:BS ECFMG Certified 
Background: As healthcare systems undergo rapid digitization, frontline clinical staff are increasingly exposed to cybersecurity threats such as phishing, ransomware, and HIPAA violations. Despite the sensitivity of patient data and the growing frequency of cyberattacks, cybersecurity education remains fragmented and inconsistently integrated into clinical workflows. This study explores the extent of cybersecurity literacy among medical personnel and identifies key vulnerabilities in digital hygiene and procedural awareness.
Methods: A simulated cross-sectional survey was conducted using modeled data from 100 clinical staff, including physicians, nurses, and administrative personnel. The instrument comprised ten structured items assessing familiarity with phishing detection, password hygiene, multi-factor authentication (MFA), HIPAA compliance, incident reporting, and perceptions of cybersecurity responsibility. Data were synthesized from published trends and benchmarked against national healthcare cybersecurity reports.
Results: Only 38% of respondents could accurately identify phishing email traits, while 62% admitted to reusing passwords across multiple systems. Formal cybersecurity training had been received by just 28% in the past year. Knowledge of HIPAA’s cybersecurity clauses was limited to 41%, and only 36% expressed confidence in recognizing spoofed login portals. While 52% reported using MFA, only 33% believed cybersecurity fell within their clinical role. Additionally, 59% had encountered phishing attempts within six months, 46% understood how to report a suspected cyber incident, and 48% used encrypted messaging tools for patient communication.
Conclusion: The simulated findings reveal significant gaps in cybersecurity literacy among clinical staff, with low training rates, poor password practices, and limited procedural awareness. These vulnerabilities pose a direct threat to patient data integrity and institutional resilience. To mitigate risk, healthcare systems must implement mandatory, role-specific cybersecurity education and foster a culture of digital accountability. Strengthening frontline awareness is essential to safeguarding clinical operations in an increasingly connected care environment.
Keywords: Cybersecurity, clinical staff, HIPAA, phishing, medical education, healthcare technology, data
protection


Cybersecurity Literacy Among Clinical Staff

Despite the prevalence of domestic abuse and its profound dermatological impacts, there remains a scarcity of comprehensive research exploring this issue through a cross-cultural lens. The objective of this review was to synthesize available evidence on the dermatological impacts of domestic abuse across cultural contexts. This systematic review was conducted and reported according to PRISMA guidelines. Research studies focusing on individuals who have experienced domestic abuse in various cultural contexts were included. The primary exposure was domestic abuse, and studies investigating its dermatological impacts were eligible for inclusion. Eleven studies were included in the review. Majority of the included studies were observational studies (n=8) while 4 studies were case reports, covering diverse regions including North America, Europe, South America, Asia, and Australia. The majority of participants were female survivors of intimate partner violence (IPV), with mean ages typically falling in the early to mid-30s. The most frequently reported dermatological injuries included bruises and contusions primarily affecting the face, neck, upper and lower limbs, and scalp. Lacerations and incised wounds were reported in multiple studies, followed by abrasions, ecchymosis, burns, scarring and permanent disfigurement. While the types of injuries were largely consistent across geographical settings, some regional patterns were observed. The findings highlight the global burden of dermatological injuries in survivors of domestic abuse. The findings suggest that while patterns of skin injuries are relatively consistent, cultural and regional factors may influence the nature and severity of injuries, warranting further investigation.

Skin and Scars Across Cultures: The Dermatological Impacts of Domestic Abuse - A Systematic Review

Introduction
Preventive services are cornerstones of population health, yet uptake remains suboptimal and inequitable. Health literacy, defined as the capacity to obtain, process, and understand basic health information, is a recognized driver of individual and community health. This study aims to understand the relationship between health literacy and preventive care utilization. Based on prior literature, we used educational attainment and spoken home language as proxies for health literacy in our sample. 
Methods
We analyzed data from the 2023 National Health Interview Survey, identifying adults eligible for five USPSTF-recommended preventive services: colonoscopy, Pap smear, mammography, non-diabetics blood sugar testing, and annual influenza vaccination. Each outcome was modeled via survey-weighted logistic regression, assessing home language (English vs. non-English) and education level as primary predictors. Additionally, a composite metric, defined as receiving at least three of the five preventive care services per USPSTF guidelines, was modeled similarly. All models adjusted for age, race/ethnicity, and insurance coverage.
Results
A total of 21,110 respondents were included in our sample, representing 184.5 million US adults after survey weighting. Lower educational attainment was linked to significantly reduced odds of guideline-concordant screening for pap smears (OR 0.59, 95% CI 0.49-0.72, p<0.001), mammogram (OR 0.62, 95% 0.51-0.77, p<0.001), blood sugar testing (OR 0.64, 95% CI 0.54-0.76, p<0.001), and influenza vaccination (OR 0.47, 95% CI 0.43-0.51, p<0.001), but not colonoscopy. Non-English speakers had significantly lower odds of Pap smear (OR 0.65, 95% CI 0.50-0.85, p<0.001) and blood sugar testing (OR 0.81, 95% CI 0.66-0.99, p<0.04), but not the other services. In our composite model, respondents with lower education had 41% lower odds of obtaining at least three of the five preventive care services (OR 0.59, 95% CI 0.54-0.64, p<0.001), whereas home language was not a significant predictor. 
Discussion
Using education and home language as proxies for health literacy, we identified clear disparities in preventive‐care uptake. Targeted interventions such as expanded language assistance and interpretation services, in addition to culturally sensitive health resources, may aid in closing these gaps in preventive health behaviors.


Bridging Health Literacy Gaps: The Impact of Education and Language on Guideline-Concordant Screening and Vaccination

INTRODUCTION: In surgery, textbook outcomes represent a composite metric of multiple variables that indicate baseline success in a specific procedure. These outcomes can be compared across surgeons and institutions. This study aimed to define a textbook outcome for the operative repair of scaphoid nonunion using medial femoral condyle (MFC) or medial femoral trochlea (MFT) vascularized bone flaps and identify the rate of textbook outcomes at our center.

METHODS: Three hand surgeons with expertise in scaphoid nonunion reconstruction using MFC/MFT grafts defined the criteria for a textbook outcome. After obtaining IRB approval, a retrospective review of cases from 2017 to 2024 at a single institution was performed. A textbook outcome was defined as meeting the following criteria: no flap loss, no intraoperative complications, a length of stay of less than two nights, radiographic union at three months postoperative on CT scan, return to baseline hand activities and pain-free hand activities at final follow-up, return to baseline and pain-free lower extremity activities by postoperative day 90, no recipient or donor site infections requiring intravenous antibiotics, no systemic complications, no emergency room admissions or hospital readmissions within 90 days, no mortality, and no surgical complications requiring reoperation.

RESULTS: A total of 38 patients met the inclusion criteria, with 27 (71.1%) achieving a textbook outcome. The most common criteria not met were surgical complications requiring reoperation (10.5%), return to baseline hand activities at final follow-up (7.9%), pain-free hand activities at final follow-up (7.9%), and return to baseline lower extremity activities by postoperative day 90 (7.9%). Of the 11 cases that did not achieve a textbook outcome, 5 violated one criterion (45.4%), 3 violated two criteria (27.3%), and 3 violated more than two criteria (27.3%).

CONCLUSION: Textbook outcomes are useful quality metrics for evaluating surgical success. By utilizing 13 criteria for scaphoid nonunion reconstruction with vascularized MFC or MFT grafts, cases can be assessed and compared using a single metric. Statistical analysis can help identify predictors of textbook outcomes, offering future opportunities to improve patient outcomes.

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