Christopher J. Dy Named 2023 Kappa Delta Young Investigator Award Winner

The 2023 Kappa Delta Young Investigator Award has been presented to Christopher J. Dy, M.D., MPH, FACS, FAOA, FAAOS, for his research on the ways in which brachial plexus injuries (BPI) affect patients’ quality of life. His research found that existing studies and outcomes did not account for the emotional, psychological and pain-related aspects as patients recovered from BPI surgery and identified a disconnect between surgical outcomes and patient satisfaction. 
 
Defining BPIs
The brachial plexus is a network of nerves that connect the spinal cord to the shoulder, arm and hand, and controls movement and sensation.ⁱ A BPI typically occurs when the arm is forcefully pulled or stretched, most likely due to trauma, such as a fall, sports injury, car accident, motorcycle collision, or knife or gunshot wound. Mild BPI can heal without treatment; however, severe injuries may require surgery and may be life-altering. Patients can have weakness or numbness, loss of sensation, loss of movement and pain, many of which affect their ability to complete everyday activities.ⁱ
 
“While brachial plexus injuries aren’t terribly common, these are challenging as there is no way to tell how injured the brachial plexus is,” said Dy, an associate professor of orthopaedic surgery at Washington University School of Medicine, St. Louis, Mo. “We use a lot of tools to assess the injury—patient examination, MRIs, nerve studies—but none of it is perfect. The level of trauma—if the plexus is stretched a little or so bad that it ruptures into two pieces—will determine if the plexus gets better on its own or if surgery is needed. We need to recognize BPI in the first few months of it happening as the effectiveness of the surgery is time sensitive.”
 
Even following surgical treatment, full function cannot be restored, leaving many BPI patients frustrated and with unmet functional needs. While surgeons consider surgery outcomes a success based on muscle strength, patients may remain dissatisfied as most have limited physical abilities.
 
Understanding the BPI Patient Perspective
In the first phase of research during his residency, Dy worked under the mentorship of Dr. Scott Wolfe to conduct a systemic review of 88 papers with outcomes for 5,189 patients. Of those, 94% of studies included muscle strength assessments, yet only 5% included quality of life evaluations and only 3% included patient satisfaction assessments.
 
With support from Regis O’Keefe, M.D., Ph.D., a Fred C. Reynolds professor and chair of the Department of Orthopaedic Surgery at Washington University, Dy conducted analyses of administrative and insurance databases, posts in the United Brachial Plexus Network, patient interviews, and a validated questionnaire on coping strategies to better understand the patient experience after BPI, including the societal impact, challenges faced by BPI patients during healthcare delivery, and ways BPI affected social, psychological, and physical health. The findings showed:

• Updated estimates of the number of BPI in the United States did not exist. An analysis of insured adults ages 18-64 found there was a statistically significant increase in the number of surgically treated BPI from 2008-2014 (0.47 per 100,000 to 1.03 per 10,000), demonstrating the societal burden of BPI will continue to grow.
• Most BPI patients are young and out of work for more than a year, often changing occupations due to their limited physical abilities. An economic analysis of indirect/societal costs of traumatic BPI found the cost to be $1,113,962 per patient after the injury. Helping patients return to work can help decrease the societal burden of BPI.
• BPI patients struggled to find a surgeon, often received a late diagnosis, and obtained insufficient information about their treatment.
• Surgery is recommended three to five months after the injury for optimal outcomes. However, one-third of patients had a delay in BPI surgery of a year or more after the injury, with patients seen at smaller hospitals at an increased risk. This indicated issues in the referral system at multiple levels.
• In the year following surgery, depression was found in 38% of BPI patients and anxiety in 42%, with both being present in 25%, indicating that BPI patients were significantly more likely to develop new-onset depression or anxiety after surgery.
• BPI patients felt pain wasn’t properly addressed by their healthcare providers and commonly prescribed medications (gabapentinoids and opioids) weren’t effective. Even after adjusting for risk factors for postoperative opioid use, BPI patients were 10 times more likely to use prolonged opioid prescriptions, showing the need to proactively address pain and include pain in patient-reported outcomes.
• While BPI patients were more likely to use both healthy and unhealthy coping strategies, such as substance abuse, emotional support, venting and humor, harmful coping strategies may have a negative impact on recovery after surgery. This illustrated that outcome assessments need to include emotional components. 

Incorporating Patient Needs in Outcomes
Due to the individualized nature of how BPI affects patients, qualitative research—interviews with surgeons and patients—was conducted to gain a better understanding of the patient experience as well as which factors impact patient recovery and satisfaction. The interviews found that BPI patients were unprepared for the functional and emotional aspects of recovery, how to deal with the severe neuropathic pain, and the adjustment to life after BPI. They also felt left out of the decision-making process, not receiving rationale for certain decisions made by their surgeon such as timing and the type of surgical intervention.
 
Based on these findings, Dy and his colleagues are developing a BPI Journey Guide that will include information requested by patients, including physical and emotional aspects of recovery, expectation setting for functional outcomes, pain management, communication with the healthcare team, and caregiver needs. They also have incorporated patient measures for self-management skills and shared decision making at the Complex Nerve Clinic at Washington University Orthopaedics.
 
Additionally, the research team has spearheaded use of the Impact of BPI questionnaire, which includes sections to address symptoms, emotions, limitation, disability, and improvement (expected and actual). In a pilot prospective observational cohort study of eight patients utilizing the questionnaire and surgeon-graded measures, patients were assessed before surgery and one-year postoperative. The study found a sharp decline in improvement (expected vs. actual) at the one-year mark and the need to assess outcomes up to five years following surgery. With funding from an R01 grant from the National Institutes of Health, Dy’s team is undertaking a multicenter prospective observational cohort study of BPI patients throughout the United States to further this research.
 
“Our research is really shifting the emphasis to have a broader perspective, not just looking at surgeon grading, but what matters to patients,” Dy said. “Patients have no idea how bad this injury can be, as it is impossible to conceptualize; however, we can use the educational guide to coach patients through the process. Eventually, I would love to demonstrate the usefulness of the guide so we can involve care navigators and coaches to help support patients through this injury.”
 
In 1947, at its golden anniversary, the Kappa Delta Sorority established the Kappa Delta Research Fellowship in Orthopaedics, the first award ever created to honor achievements in the field of orthopedic research. The first annual award, a single stipend of $1,000, was made available to the AAOS in 1949 and presented at the AAOS Annual Meeting in 1950. The Kappa Delta Awards have been presented by the AAOS to persons who have performed research in orthopaedic surgery that is of high significance and impact. The sorority has since added two more awards and increased the award amounts to $20,000 each. Two awards are named for the sorority national past presidents who were instrumental in the creation of the awards: Elizabeth Winston Lanier and Ann Doner Vaughn. The third is known as the Young Investigator Award. 
 
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS provides education to help orthopedic surgeons and allied health professionals best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues.
 
Funding Disclosure

• Title: NIH/NIAMS R01 AR079139-01 – “Establishing the Validity, Responsiveness, And Appropriateness of Patient-Reported Outcome Measures for Adult Traumatic Brachial Plexus Injury”; PI: Dy CJ; Source: National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases).
• Title: NIH/NIAMS R03 AR077109-01A1 – “Enhancing Patient Education Through a ‘Journey Guide’ For Adult Traumatic Brachial Plexus Injury”; PI: Dy CJ. Source: National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases).
• Title: NIAMS K23 Career Development Award – “Understanding Barriers to Delivery of Care for Patients with Adult Traumatic Brachial Plexus Injury” (K23 AR073928); PI: Dy CJ; Mentors: James A, Wright RW. Source: National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases).
• Title: OREF Mentored Clinician Scientist Grant – “Understanding Barriers to Delivery of Care for Brachial Plexus Injury” PI: Dy CJ; Source: Orthopaedic Research and Education Foundation. Amount funded: $20,000. 08/01/20 to 07/30/2021.
• Title: CHEP Pilot Funding – “Demonstrating the Economic Value of Brachial Plexus Injury reconstruction”, PI: Dy CJ; Source: Washington University Center for Health Economics and Policy Pilot Funding Program.
• Title: ICTS JIT Core Usage Funding – “A Population-based Assessment of mental health Conditions in Patients with Brachial Plexus Injuries”; PI: Dy CJ; Source: Washington University School of Medicine Institute of Clinical and Translational Sciences Grant.
• Title: ICTS JIT Core Usage Funding – “A population-based analysis of referral patterns for surgical treatment of brachial plexus injuries”; PI: Osei DA; Co-Investigator: Dy CJ. Source: Washington University School of Medicine Institute of Clinical and Translational Sciences Grant.

Reference 
ⁱ American Academy of Orthopaedic Surgeons. OrthoInfo. Brachial Plexus Injuries. https://orthoinfo.aaos.org/en/diseases–conditions/brachial-plexus-injuries/. Accessed 12/21/2021.