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Cutaneous manifestations of mixed neuroendocrine non-neuroendocrine neoplasms remain a diagnostic rarity. Predominantly identified within internal glandular organs, the digestive tract, and in the hepatobiliary system, this case report illustrates a unique occurrence of a mixed squamous cell and neuroendocrine tumor in the index finger of a justice-affected patient. We discuss the complexities of diagnosis and complications as well as emphasize the importance for hand surgeons to recognize presentations like this and the need for vigilant follow-up and improved care coordination.

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Background: Hand infections represent a common hand condition in the emergency department and one that frequently requires a hand specialist. The purpose of our study is to analyze hospital transfers for hand infections with a primary outcome being potential clinically avoidable transfers and to identify areas for improvement in the care of hand infections. Methods: Retrospective review of The Texas Healthcare Information Collection Database from 2015 to 2019. We analyzed all transfers for hand infections. Statistical analyses included: Transfer diagnosis, surgical interventions, length of stay (LOS), the day of the week that the transfer was initiated and whether or not the transfer or centralization was necessary or potentially avoidable. Results: A total of 3489 patients were transferred from one hospital to another for the management of a hand infection. 1628 (46.6 â€‹%) underwent at least one surgical intervention and 1861 (53.3 â€‹%) were treated non-operatively. Patients undergoing operative interventions had a lower LOS compared to those non-operatively. Transfers admitted during the weekend had decreased average LOS relative to non-weekend transfers, but a 94.7 â€‹% increased odds of receiving a relevant surgical intervention during the hospital admission. Nearly all patients were transferred to urban region hospitals. Of total, 1194 (34.22 â€‹%) were considered potentially avoidable centralizations, which we defined as transfer that resulted in no surgical intervention and discharge to home within 72 â€‹h. Conclusions: Although the reason for centralization was unknown, our analysis showed a high number of transfers that could have been potentially avoidable. We propose the development of specific guidelines, and perhaps the use of remote consultations for areas where hand specialist are not reliably available to help optimize the care of patient with hand infections.

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Background: Thumb carpometacarpal (CMC) joint osteoarthritis is a common degenerative condition that affects up to 15 â€‹% of the population older than 30 years. Poor readability of online health resources has been associated with misinformation, inappropriate care, incorrect self-treatment, worse health outcomes, and increased healthcare resource waste. This study aims to assess the readability and quality of online information regarding thumb carpometacarpal (CMC) joint replacement surgery. Methods: The terms "thumb joint replacement surgery", "thumb carpometacarpal joint replacement surgery", "thumb cmc joint replacement surgery", "thumb arthroplasty", "thumb carpometacarpal arthroplasty", and "thumb cmc arthroplasty" were searched in Google and Bing. Readability was determined using the Flesch Reading Ease Score (FRES) and the Flesch-Kincaid Reading Grade Level (FKGL). FRES >65 or a grade level score of sixth grade and under was considered acceptable. Quality was assessed using the Patient Education Materials Assessment Tool (PEMAT) and a modified DISCERN tool. PEMAT scores below 70 were considered poorly understandable and poorly actionable. Results: A total of 34 websites underwent qualitative analysis. The average FRES was 54.60 â€‹± â€‹7.91 (range 30.30-67.80). Only 3 (8.82 â€‹%) websites had a FRES score >65. The average FKGL score was 8.19 â€‹± â€‹1.80 (range 5.60-12.90). Only 3 (8.82 â€‹%) websites were written at or below a sixth-grade level. The average PEMAT percentage score for understandability and actionability was 76.82 â€‹± â€‹9.43 (range 61.54-93.75) and 36.18 â€‹± â€‹24.12 (range 0.00-60.00) respectively. Although 22 (64.71 â€‹%) of websites met the acceptable standard of 70 â€‹% for understandability, none of the websites met the acceptable standard of 70 â€‹% for actionability. The average total DISCERN score was 32.00 â€‹± â€‹4.29 (range 24.00-42.00). Conclusions: Most websites reviewed were written above recommended reading levels. Most showed acceptable understandability but none showed acceptable actionability. To avoid the negative outcomes of poor patient understanding of online resources, providers of these resources should optimise accessibility to the average reader by using simple words, avoiding jargon, and analysing texts with readability software before publishing the materials online. Websites should also utilise visual aids and provide clearer pre-operative and post-operative instructions.

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INTRODUCTION AND IMPORTANCE: Hemangioma is a neoplastic disorder of vascular structures that can manifest at any site of the body. It is a rare ailment in general, and the intramuscular type is particularly uncommon and accounts for approximately 1 % of all hemangiomas. The presentation of hand hemangioma differs from other sites due to the restricted space and compression of vital structures, which frequently manifests as pain and functional impairment alongside mass. In this article, we present a case of trauma-induced dual-plane hemangioma in the hand. CASE PRESENTATION: A 55-year-old right-handed individual, without any significant medical background, sought medical attention for a painful mass on his right hand that had developed over the past year. He indicated a history of blunt trauma to the hand, with the mass becoming apparent two months post-injury. With the growth of the mass, the severity of pain progressively escalates; however, there is no loss of function observed. The diagnosis was established through duplex ultrasonography, and the patient received surgical excision utilizing the WALANT technique. Intraoperatively, the hemangioma was identified in two planes: one beneath the skin over the thenar eminence and another within the adductor pollicis muscle. The follow-up period proceeded without any complications or recurrence of the condition. CLINICAL DISCUSSION: Hand hemangiomas are relatively rare, and a history of trauma may lead to misdiagnosis as other conditions. There are various management strategies that are not suitable for hand hemangiomas. While surgical excision can alleviate symptoms, it carries the risk of increasing disability if muscle tissue is excised. CONCLUSION: Trauma-induced dual-plane hemangioma in the hand is a phenomenal condition that has been successfully treated surgically. Despite the removal of a portion of the adductor pollicis, both functional and aesthetic satisfaction was achieved. Hence, it is advisable to employ surgical management for such a presentation.

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PURPOSE: Time-driven activity-based costing (TDABC) provides a more accurate and granular estimation of direct variable costs compared with traditional accounting methods. This study used TDABC to quantitatively compare the same-day facility costs of open carpal tunnel release (CTR) performed under monitored anesthesia care (MAC) versus wide awake local anesthesia no tourniquet (WALANT). METHODS: We retrospectively identified 474 unilateral CTR (182 MAC and 292 WALANT) performed at an orthopedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, surgical characteristics, and itemized costs were compared between those treated under MAC (MAC-CTR) and WALANT (WALANT-CTR). Multivariable regression was performed to determine the independent effect of MAC on true facility costs. RESULTS: Total facility costs were $170 higher in MAC-CTR compared with WALANT-CTR ($652 vs $482). Monitored anesthesia care-CTR cases had higher personnel costs ($537 vs $394), likely because of higher surgery personnel ($303 vs $185) and postanesthesia care unit personnel costs ($117 vs $95). Monitored anesthesia care-CTR cases also had higher supply costs ($119 vs $81). When controlling for demographics and comorbidities, MAC-CTR was independently associated with an increase in personnel costs by $150.65 (95% CI, $131.09-$170.21), supply costs by $24.99 (95% CI, $9.40-$40.58), and total facility costs by $175.66 (95% CI, $150.18-$201.09) per case. CONCLUSIONS: Using TDABC, MAC-CTR was found to be 35% more costly to the facility compared with WALANT-CTR. Notably, WALANT-CTR facility costs presented here do not include additional cost savings from anesthesiologist service fees or preoperative laboratory clearance required for MAC-CTR surgeries. To reduce costs related to CTR surgery, greater efforts should be made to reduce the number of intraoperative personnel and maximize the use of WALANT-CTR in an outpatient setting. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.

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PURPOSE:  Digital replantation is a technically difficult microsurgery requiring significant surgical skill. The aim of this study was to investigate postoperative outcomes associated with the surgical learning curve for microvascular digital replantation. METHODS:  A prospectively maintained surgical database of consecutive patients who underwent digital replantation from 2002 to 2012 was reviewed. All cases were performed by a single surgeon and began immediately after the surgeon's fellowship. A total of 46 patients were identified. Outcomes of digital replantation were tested for association with time since fellowship, total microvascular operative experience, and location and type of injury. RESULTS:  Overall, 38/46 (82.6%) of patients underwent a successful digital replantation. There was a significant difference between survival percentages over the years (p=0.04), with improvement seen over time. Total microvascular experience was significantly associated with successful outcomes (p<0.001). After 100 hours of microvascular experience, there was a significant increase in the survival odds ratio (OR 8.5, 95% CI 1.5-47.9). Crush and thumb injuries were more likely to have detrimental outcomes. CONCLUSIONS:  There was marked improvement in replant survival over time, with a significant increase in odds of survival after 100 hours of microvascular experience. One hundred operating hours under the microscope occurred around 2 years in practice for this high-volume surgeon. There is strong evidence that a steep learning curve occurs in microvascular digit replantation surgery.

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Hand surgery services were required to rapidly adapt to the coronavirus disease 2019 (COVID-19). Two years following the initial wave, hand surgery units continue to adapt and recover from the pandemic. The aim of the RSTN COVID-19 Hand Recovery survey was to evaluate what adaptions made to hand surgery services during COVID-19 have been maintained in the COVID recovery phase. A survey was distributed to hand surgery units, across the UK and Ireland. The survey was completed by consultant hand surgeons across 39 hospitals. Most practices returned to pre-pandemic standards. The main changes that endured were the increase in consultant-led triaging for referrals and utilisation of video conferencing platforms for teaching and meetings. Changes made during the pandemic, such as increased use of WALANT, out of theatre operating and use of telemedicine were not sustained during the recovery period. The COVID-19 pandemic allowed the opportunity for hand surgery services to adapt their services. Several changes that were implemented have since been proven to be more efficient and equally effective for patients. However, these changes have not been sustained and the barriers preventing permanent implementation should be scrutinised. We call on hand surgery units to evaluate their current practice to ensure that patients are provided a streamlined and sustainable service.

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BACKGROUND: Robot-assisted implant surgery has emerged as a novel digital technology, and the accuracy need further assessment. PURPOSE: This study aimed to compare the accuracy of single dental implant placement between a novel semi-active robot-assisted implant surgery (RAIS) method and the conventional free-hand implant surgery (FHIS) method through a multicenter, randomized controlled clinical trial. MATERIALS AND METHODS: Patients requiring single dental implant placement were recruited and randomized into RAIS and FHIS group. Deviations at the platform, apex, and angle between the planned and final implant positions were assessed in both groups. Additionally, the evaluation of instrument and surgical complications was examined. RESULTS: A total of 140 patients (median age: 35.35 ± 12.55 years; 43 males, 97 females) with 140 implants from four different research centers were included, with 70 patients (70 implants) in the RAIS group and 70 patients (70 implants) in the FHIS group. In the RAIS and FHIS groups, the median platform deviations were 0.76 ± 0.36 mm and 1.48 ± 0.93 mm, respectively (p < 0.001); median apex deviations were 0.85 ± 0.48 mm and 2.14 ± 1.25 mm, respectively (p < 0.001); and median angular deviations were 2.05 ± 1.33° and 7.36 ± 4.67°, respectively (p < 0.001). Similar significant difference also presented between RAIS and FHIS group in platform vertical/horizontal deviation, apex vertical/horizontal deviation. Additionally, implants with self-tapping characteristics exhibited significantly larger deviations compared with those without self-tapping characteristics in the RAIS group. Both RAIS and FHIS methods demonstrated comparable morbidity and safety pre- and post-operation. CONCLUSIONS: The results indicated that the RAIS method demonstrated superior accuracy in single dental implant placement compared with the FHIS method. Specifically, RAIS exhibited significantly smaller deviations in platform, apex, and angular positions, as well as platform and apex vertical/horizontal deviations. This clinical trial was not registered prior to participant recruitment and randomization. https://www.chictr.org.cn/showproj.html?proj=195045.

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Purpose: Effective patient-doctor communication is linked to improved patient functional and physiological health status, better adherence to physician recommendations, and increased patient satisfaction. However, studies show that patients have difficulty understanding and recalling information discussed during a medical encounter. The purpose of this study was to assess patient engagement, patient-doctor communication, and patient-doctor interactions with the utilization of a patient encounter card to help aid in communication. Methods: New patients presenting to a single hand surgeon during an 8-month period between 2019 and 2020 were recruited for this study. Patients were recruited in pre and postintervention phases, defined by the rollout of a patient encounter card. Patients studied in the preintervention group were defined as the control population and experienced a typical office visit. The postintervention group experienced a typical office visit with the addition of a patient encounter card distributed to patients prior to meeting with the physician and screened by the physician during the visit to guide the encounter. Patient satisfaction and engagement surveys were collected during patient checkout process. Results: Two hundred eighty-seven patients (70% participation rate) were enrolled in the preintervention (145) and postintervention (142) phases. The utilization of a patient encounter card for setting a visit agenda resulted in a significant increase in self-reported patient engagement, improving from 74% to 88%. In both phases, 98% of patients felt that the physician listened well or very well and reported high levels of confidence in the provider being able to address their primary health concerns (72% and 79%, respectively). Overall, patient satisfaction was maintained pre and postintervention (96% and 98%, respectively). Conclusions: Use of the encounter card improved patients' feelings of engagement during their visits. Further research is required to determine the impact of these tools on providers' engagement and patient outcomes to improve quality of care in hand surgery. Type of study/level of evidence: Therapeutic II.

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Purpose: Flexor carpi radialis (FCR) tendinitis is an uncommon but important cause of volar radial wrist pain that can be a diagnostic and therapeutic challenge. We present a series of patients with FCR tendinitis managed successfully with an algorithm developed by the senior author. Methods: A retrospective review of patients treated for FCR tendinitis at a hand practice was performed. The percent of the FCR rupture, determined with magnetic resonance imaging (MRI) and intraoperative confirmation, determined specific treatment. Patients with less than 50% rupture on MRI were treated conservatively. Surgery was indicated if this failed to yield relief or MRI suggested >50% rupture. On intraoperative examination, patients with less than 50% rupture underwent tenosynovectomy and excision of trapezial osteophytes. Patients with greater than 50% rupture underwent an FCR-sacrificing procedure. Patient-reported outcomes including severity of pain with activities of daily living and ability to return to previous levels of activity were obtained. Results: Sixteen patients were treated for FCR tendinitis. Five were treated conservatively, with complete relief of symptoms and return to full activity without sequelae in three of five cases. Four of the 11 surgical patients were found to have <50% tendon rupture and underwent an FCR-sparing procedure. The remaining seven patients had >50% tendon involvement, which required an FCR-sacrificing procedure. All surgical patients achieved satisfactory results in both functional and clinical outcomes. Conclusions: This series demonstrates acceptable patient outcomes using the described FCR algorithm utilizing 50% FCR involvement as a benchmark. Type of study/level of evidence: Therapeutic IV.

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Purpose: The purpose of this study was to evaluate the efficacy of a web tutorial on perceptions of pain management and usage of opioids after carpal tunnel release surgery (post-CTR). Methods: A web tutorial was developed by the authors, and patients were consented and enrolled if they were over the age of 18 years, could speak and understand English, and were having CTR. Patients were randomized to either view or not view the web tutorial before surgery, and all patients took a 19-question online survey approximately 2 weeks after surgery to assess their views on pain management and their self-reported opioid usage. All patients received standard-of-care instructions for postoperative pain management and were prescribed fifteen 5 mg tablets of oxycodone. Independent sample t tests, Wilcoxon rank sum tests, and chi-square tests were used to evaluate variables of interest. Results: Sixty-seven patients were enrolled, with 17 lost to follow-up; therefore, 50 patients were included in the final study cohort and completed the online survey (n = 25/group). There were no statistically significant differences in age, gender (patient reported gender), race, and opioid use history between the groups, but there was a difference in education level with the group that did not watch the video having proportionally more participants whose highest level of education was postgraduate (36% vs 8%) and high school (24% vs 16%). There were no differences between groups in the perceptions of pain post-CTR based on survey statements, in reported opioid consumption on post-op day 1, or in perceived risk of prolonged opioid use. Conversely, on post-op days 2-6 (8% vs 28%) and 7-14 (0% vs 20%), fewer participants from the group that watched the video reported any opioid usage compared with the group that did not watch the video. Conclusions: Our web tutorial did not notably impact the way patients perceived pain management or opioid risks post-CTR. However, a smaller proportion of the group that watched our tutorial reported opioid consumption post-CTR relative to the group that did not view our tutorial, suggesting that web tutorials may be a viable way to encourage patients to confer to minimal opioid usage and pain management regimens. Type of study/level of evidence: Therapy/Prevention, Etiology/Harm IV.

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Purpose: The American Society for Surgery of the Hand developed the Surgery Training and Educational Platform (STEP) in order to assess essential skills in hand surgery. The American Society for Surgery of the Hand designed modules spanning both osseous and soft tissue skills aimed to be cost effective for the purpose of orthopedic surgical education. The STEP curriculum was adapted and implemented at a single military orthopedic residency program. Methods: The following six modules were implemented: (1) depth of plunge, (2) scaphoid pinning, (3) phalangeal fracture pinning, (4) microsurgery, (5) full-thickness skin graft harvest, and (6) wrist arthroscopy. Both first- (PGY1) and second-year (PGY2) residents participated. Scores were calculated according to the original STEP curriculum criteria and were compared with historic data from the previous year. All residents responded to an evaluation questionnaire following the performance of the tasks. Results: The PGY2 cohort outperformed PGY1 cohorts across all modules except for the depth of plunge and scaphoid fixation modules. In the phalangeal pinning module, PGY2s did significantly better when compared with pooled PGY1 performance and their own PGY1 performance (P < .05). In the microsurgery module, PGY2s scored better than pooled PGY1s. In the full-thickness skin grafting module, PGY2s outperformed PGY1s (P < .05). On the post-task evaluation, residents unanimously responded that this was a valuable exercise, but the time required to complete all the modules was significant, similar to that of the previous year survey. Conclusions: The STEP simulation is a cost effective and reliable program to engage residents in hand surgery-related skills. However, adaptations should be encouraged according to institutional resources to provide the most inclusive training platform possible per institutional constraints. The STEP simulation is interpreted by residents as a valuable exercise but requires a significant time commitment that could be a barrier to implementation and regular use. Type of study/level of evidence: Therapeutic IV.

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Purpose: Due to the Coronavirus Disease-19 pandemic, the fellowship application process has transitioned from in-person interviews to virtual interviews. Although several studies have assessed the impact of Coronavirus Disease-19 on residency and fellowship interviews, fewer studies have investigated the program director's perspective. Therefore, the aim of this study was to assess the experience of virtual interviews on hand fellowship program directors and understand some of the important factors that may make an applicant more competitive. Methods: A 21-question survey was conducted through Google Forms and distributed through a standardized email to hand fellowship program directors and coordinators. Questions used a 5-point Likert scale with the opportunity for respondents to answer some questions in a free-response format. Statistical analysis was conducted with significance assigned to P values < .05. Results: Ninety-three surveys were distributed, of which 35 responses were obtained, corresponding to a 37.6% survey response rate. Program directors reported that they tended to place more emphasis on applicant's curriculum vitae, calls from colleagues, and applicants that they had previously met. In addition, program directors felt that applicants were able to accurately represent themselves through the virtual format. Finally, most program directors stated that they were highly likely to continue to offer virtual interviews. Conclusions: With several parenting organizations and program directors affirming that they are comfortable with proceeding with virtual interviews, it is essential for hand fellowship applicants to understand what factors program directors may perceive as more important. It is possible that the virtual interview process may effectively achieve suitable matches between applicants and institutions. Type of study/level of evidence: Decision analysis IIIb.

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Treatment of children with upper-extremity trauma, congenital hand differences, cerebral palsy, and brachial plexus birth injuries requires specialized training, given the spectrum of pathology and complexities of treating an individual who is still developing. Although a limited number of dedicated pediatric hand surgery fellowships are available, mastering the large breadth of the field should ideally begin early in training and may take several different pathways. The authors seek to provide a comprehensive list of resources for trainees interested in pediatric hand surgery, including training opportunities, educational tools, and networking organizations. By shining a light on these pediatric hand surgery resources, we hope to encourage future trainees to plan ahead, so that they are well-prepared for the care of children with complex upper limb reconstructive needs.

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LEVEL OF EVIDENCE: III.

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Opioid prescribing after carpal tunnel release (CTR) is not well understood. We assessed CTR opioid prescribing within a quality collaborative after the dissemination of guidelines. Post guidelines, the odds of receiving a prescription decreased by 67%. Quality collaboratives can change practice patterns.Level of evidence: III.

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Meta-analysis (MA) is a fundamental statistical tool for combining the results of different studies to obtain potentially high-level evidence that can be implemented in clinical practice. Although its use in clinical research is increasing, MAs are still relatively rare in hand surgery. Therefore, it should be important for every hand surgeon to not only know how to interpret a MA, but also how to perform one. The purpose of this first of a two-part article is to introduce the principles of MA and describe the main models and methods used to pool effect estimates.

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Scapholunate ligament lesion is the most common ligament lesion in the wrist. We assessed the reliability of sonography in detecting it during Watson test. Twenty patients with scapholunate ligament lesion confirmed on MRI and intraoperatively were assessed preoperatively between July 2020 and April 2023. Sonography was performed on the scaphoid dorsal subluxation in wrist neutral and during Watson test and compared with the healthy contralateral side. Dorsal subluxation was measured by two independent investigators and intra- and inter-observer reliability were assessed. We found a significant difference between dorsal subluxation of the scaphoid in the healthy (0.89 mm, SD 0.67 mm) compared to the pathological side (1.67 mm, SD 0.95 mm). Reliability was very good and the standard error of measurement was less than 0.4 mm for all measurements. Sonography during Watson test demonstrated high reliability in diagnosing scapholunate lesions. LEVEL OF EVIDENCE: III.

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Introduction: For infants with ulnar polydactyly, surgical removal of the supernumerary digit can be performed under general or local anesthetic. This study evaluated the wait times, surgical duration, and sedation times associated with performing the procedure under local versus general anesthetic in infants with ulnar polydactyly. Methods: The databases of three surgeons at our institution were reviewed for children less than 2 years of age who underwent surgery for non-syndromic ulnar polydactyly. Data collection included patient demographics, wait times, duration of surgery and sedation and complications. Results: The study included children (n = 55) who received treatment under local (n = 22) or general (n = 33) anesthesia. The wait times for the local anesthetic group were significantly shorter than the general anesthetic group (p < 0.05) for: referral to first consultation appointment; referral to surgery date, and decision date to surgery date. The duration of surgery (17.9 ± 6.9 vs 36.6 ± 20.2 min) and sedation time (26.3 ± 11.1 vs 74.8 ± 29.1 min) were significantly shorter in the local anaesthetic group (p < 0.05). There were no differences in complication rates between the groups. Conclusion: In this single-institution retrospective analysis, treatment of non-syndromic ulnar polydactyly with local anesthetic and bottle sedation was associated with shorter wait times, and duration of surgery and sedation. Level of Evidence: III, retrospective chart review and quality improvement initiative.

Introduction : Chez les nourrissons présentant une polydactylie cubitale, il est possible de procéder à l'ablation chirurgicale du doigt excédentaire sous anesthésie locale ou générale. La présente étude visait à évaluer les temps d'attente, la durée de l'opération et la durée de la sédation associés à l'intervention lorsqu'elle était effectuée sous anesthésie locale ou générale chez les nourrissons présentant une polydactylie cubitale. méthodes : Les chercheurs ont fouillé les bases de données de trois chirurgiens de leur établissement pour en extraire les cas d'enfants de moins de deux ans ayant subi une opération de la polydactylie cubitale non syndromique. La collecte de données incluait les caractéristiques des patients, les temps d'attente, la durée de l'opération et de la sédation et les complications. Résultats : La présente étude incluait des enfants (n=55) qui avaient été traités sous anesthésie locale (n=22) ou générale (n=33). Le temps d'attente du groupe sous anesthésie locale était beaucoup plus court que celui du groupe sous anesthésie générale (p<0,05) pour ce qui est de la période entre l'orientation et la première consultation, l'orientation et la date de l'opération, ainsi que la date de la décision et la date de l'opération. La durée de l'opération (17,9 ± 6,9 minutes par rapport à 36,6 ± 20,2 minutes) et de la sédation (26,3 ± 11,1 minutes par rapport à 74,8 ± 29,1 minutes) était beaucoup plus courte dans le groupe sous anesthésie locale (p<0,05). Il n'y avait pas de différence entre les groupes à l'égard des taux de complications. Conclusion : Dans cette analyse rétrospective mono-institutionnelle, le traitement de la polydactylie cubitale non syndromique accompagné d'une anesthésie locale et d'une sédation par bonbonne était associé à une diminution du temps d'attente ainsi que de la durée d'opération et de sédation.

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INTRODUCTION: The regional hand trauma service in Greater Manchester, United Kingdom, underwent significant reorganisation early in the COVID-19 pandemic, with a shift from predominantly general anaesthesia (GA) procedures to the adoption of a Wide-Awake Local Anaesthetic No Tourniquet (WALANT) technique. We implemented strategies targeted towards optimising patient experience, largely applicable to most healthcare settings. METHODS: Four domains were explored: (i) compliance in timing to nationally agreed treatment guidelines, (ii) the role of patient information leaflets, (iii) the introduction of a post-operative analgesia protocol, and (iv) broadly evaluating the environmental impact following the implementation of a same-day 'see and treat' service. RESULTS: Following reorganisation to a predominantly WALANT service, we observed an increase in compliance with nationally agreed standards for the treatment of common hand injuries. Patient education and peri-operative counselling reduced anxiety, whereas post-operative pain was better managed with the introduction of an analgesic protocol. Using a travel carbon calculator, it can be inferred that there are significant reductions in carbon emissions generated when patients are evaluated and treated on the same day as their clinical presentation. CONCLUSIONS: It is widely acknowledged that WALANT benefits patients and the healthcare system. We contemplated whether further incremental changes in clinical practice could further improve patient experience. Given our findings, we advocate a multi-modal approach with a greater focus on patient outcomes (trials are currently underway, e.g., WAFER) supplemented by universally accepted validated patient-reported outcome measures (PROMs).