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BACKGROUND AND PURPOSE:  The duration of antibiotic coverage in hand tissues during surgery is unknown. We investigated the time the free concentration of cefuroxime was above the minimal inhibitory concentration (fT>MIC) of 4 µg/mL in hand tissues after single and repeated administration. METHODS:  In a prospective, unblinded randomized study 16 patients (13 female, age range 51-80 years) underwent trapeziectomy. Microdialysis catheters were placed in the metacarpal bone (primary effect parameter), synovial sheath, and subcutaneous tissue. Patients were randomized to postoperative administration of either intravenous single administration of cefuroxime (1,500 mg) (Group 1, n = 8) or repeated dosing (2 x 1,500 mg) with a 4 h interval (Group 2, n = 8). Samples were taken over 8 h. RESULTS: The fT>MIC of 4 µg/mL was found to be significantly longer in the metacarpal bone in Group 2 compared with Group 1 with a mean difference of 199 min (95% confidence interval 158-239). The same trend was evident in the remaining compartments. A concentration of 4 µg/mL was reached in all compartments in both groups within a mean time of 6 min (range 0-27 min). In Group 1, the mean concentrations decreased below 4 µg/mL between 3 h 59 min and 5 h 38 min. CONCLUSION:  The fT>MIC was longer after repeated administration compared with single administration in all compartments. A single administration of cefuroxime 1,500 mg provided antimicrobial hand tissue coverage for a minimum of 3 h 59 min. Cefuroxime administration in hand surgeries should be done minimum 27 min prior to incision to achieve sufficient coverage in all individuals. Cefuroxime readministration should be considered in hand surgeries lasting longer than 4 h from time of administration.

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BACKGROUND: The reconstruction of complex wounds of the hand still has challenges in achieving aesthetic, functional and sensory recovery. We presented our experience of using the polyfoliate and chimeric radial collateral artery perforator flaps (RCAPF) to repair complex hand defects, aiming to explore the feasibility of special-form RCAPFs in hand coverage and enhance the comprehension of their respective indications. METHODS: From June 2014 to March 2021, 26 cases (19 males and 7 females, mean 44.4 years) underwent defect and sensation reconstruction of their hands with special-form RCAPFs, which manifested as multiple adjacent or irregular single wounds and composite tissue defects complicated with a degree of nerve injury. The clinical effects of the free RCAPFs were evaluated by integrating the postoperative and long-term follow-up outcomes of all cases. RESULTS: Altogether 8 polyfoliate flaps, 17 chimeric flaps and 1 polyfoliate-chimeric flap were harvested. Of them, 23 flaps survived uneventfully in one stage. Venous congestion occurred in 3 cases, two of which survived through vascular exploration and another one was finally repaired by the contralateral RCAPF. The follow-up results showed that the appearance of both the recipient and donor sites mostly recovered satisfactory. All the bone flaps properly healed. The BMRC sensory evaluation results of all skin flaps were S4 in 8 flaps, S3 in 18 flaps, and S2 in 9 flaps. CONCLUSIONS: The free RCAPFs can be designed in various forms with a reliable blood supply, contributing to reconstructing simple and multiple wounds of the hand with or without bone defects and dead space.

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BACKGROUND: Baseline mindset factors are important factors that influence treatment decisions and outcomes. Theoretically, improving the mindset prior to treatment may improve treatment decisions and outcomes. This prospective cohort study evaluated changes in patients' mindset following hand surgeon consultation. Additionally, we assessed if the change in illness perception differed between surgical and nonsurgical patients. METHODS: The primary outcome was illness perception, measured using the total score of the Brief Illness Perception Questionnaire (B-IPQ, range 0-80). Secondary outcomes were the B-IPQ subscales, pain catastrophizing (measured using the Pain Catastrophizing Scale (PCS)), and psychological distress (measured using the Patient Health Questionnaire-4). RESULTS: A total of 276 patients with various hand and wrist conditions completed the mindset questionnaires before and after hand surgeon consultation (median time interval: 15 days). The B-IPQ total score improved from 39.7 (±10.6) before to 35.8 (±11.3) after consultation (p < 0.0001, Cohen's d = 0.36); scores also improved for the B-IPQ subscales Coherence, Concern, Emotional Response, Timeline, Treatment Control, and Identity and the PCS. There were no changes in the other outcomes. Surgical patients improved on the B-IPQ subscales Treatment Control and Timeline, while nonsurgical patients did not. CONCLUSIONS: Illness perception and pain catastrophizing improved following hand surgeon consultation, suggesting that clinicians may actively influence the patients' mindset during consultations, and that they may try to enhance this effect to improve outcomes. Furthermore, surgical patients improved more in illness perceptions, indicating that nonsurgical patients may benefit from a more targeted strategy for changing mindset.

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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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Objective: To investigate the effectiveness of the perforator-based propeller flaps (PPFs) based on digital artery (DA) and dorsal metacarpal artery (DMA) in repairing hand wounds. Methods: The clinical data of 45 patients with hand wounds between January 2018 and March 2023 were retrospectively analyzed. There were 27 males and 18 females with an average age of 41.2 years (range, 14-72 years). The causes of injury included twist injury in 15 cases, crush injury in 19 cases, and cut injury in 11 cases. The injured parts included 32 cases of digits, 10 cases of dorsal hand, and 3 cases of palmar hand, all of which had tendon, joint, and bone exposure. The time from injury to operation ranged from 2 to 8 hours (mean, 4.3 hours). The wound sizes after debridement ranged from 1.8 cm×1.0 cm to 5.0 cm×3.5 cm. Twenty-eight cases were repaired by the PPFs based on DA and 17 cases were repaired by the PPFs based on DMA. The flap size ranged from 2.5 cm×1.1 cm to 8.5 cm×4.0 cm. The defects of the donor sites in 14 patients were closed directly and the defects in the left 31 patients were resurfaced with free full-thickness skin graft from the proximal medial forearm. Results: All the flaps survived after operation. Two cases of the PPF based on DA and 1 case of the PPF based on DMA underwent partially blisters at the distal end and healed after dressing change. The incisions in the donor site healed by first intention and the skin grafts survived. All patients were followed up 10-33 months, with a mean of 15.4 months. At last follow-up, the static two-point discrimination of the PPFs based on DA and DMA were 4-14 mm and 8-20 mm with the averages of 8.1 mm and 13.3 mm, respectively. According to the Michigan Hand Outcomes Questionnaire, 20 patients were very satisfied with the appearance of the PPF based on DA and 8 patients were satisfied; 8 patients were very satisfied with the appearance of the PPF based on DMA and 9 patients were satisfied. Based on the Vancouver Scar Scale (VSS), the appearance scores of the donor site of the PPFs based on DA and DMA were 2-7 and 4-9, with the averages of 4.2 and 6.1, respectively. Conclusion: The two kinds of PPFs are reliable in blood supply and easy to harvest, which provide a good method for emergency repair of small and medium area wounds in the hand.

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Objective evaluation of microsurgical technique quality is vital for successful training in neurosurgery. This study aimed to assess the accuracy of automatically detecting a neurosurgeon's proper posture and hand positioning using computer vision. We employed the RTMPose neural network model to identify key anatomical points in the neurosurgeon's projection and calculated various angles formed by connecting these points. By utilizing machine learning on these angles, we were able to classify images of the surgeon's posture and hands into correct positions and various types of errors with an accuracy of at least 0.9. Computer vision enables successful detection and objective assessment of the neurosurgeon's posture and hand positions. The high accuracy of this detection can pave the way for a new training approach in neurosurgery.

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BACKGROUND: During a robot-assisted minimally invasive surgery, hand tremors in a surgeon's manipulation of the master manipulator can cause vibrations of the slave surgical instruments. METHODS: This letter addresses this problem by proposing an improved Enhanced Band-Limited Multiple Linear Fourier Combiner (E-BMFLC) algorithm for filtering the physiological tremor signals of a surgeon's hand. The proposed method uses the amplitude of the input signal to adapt the learning rate and a dense division of the combiner bands for the higher amplitude bands of the tremor signals. RESULTS: By using the proposed improved E-BMFLC algorithm, the compensation accuracy can be improved by 4.5%-8.9%, as well as a spatial position error of less than 1 mm. CONCLUSION: The results show that among all filtering methods, the improved E-BMFLC filtering method has the highest number of successful experiments and the lowest experimental time.

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AIMS: Pyogenic flexor tenosynovitis (PFT) comprises 2.5-9.4% of all primary hand infections. Management is variable, including surgical intervention, systemic antibiotics, or both. However, there are no evidence-based treatment guidelines. We conducted a systematic review to determine the best evidence for existing interventions and a meta-analysis to summarise published data quantitatively. METHODS: MEDLINE and Embase (OVID) databases were searched in January 2023 and March 2024. Screening and data extraction were performed in duplicate. The risk of bias was assessed using National Institute of Health study assessment tools. A protocol is available on PROSPERO (CRD42023411142), and the review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data analysis was performed in RStudio. RESULTS: 24 studies (n = 1108 patients) were included following screening of 2386 abstracts. All were retrospective (18 case series and six cohort studies). Surgical interventions were assessed in 22 studies, combined with specific antibiotic regimes in four studies. Two studies described non-operative management alone. The pooled mean hospital stay for those undergoing operative intervention was 8.3 days (SD 7.5, n = 552), compared to 4.76 days (SD 0.12, n = 58) for non-operative intervention. Two studies reported PROMs (DASH), reporting no difference when comparing operative and non-operative interventions. Most studies were of poor quality (20), with four being fair. CONCLUSIONS: There is insufficient evidence in favour of one intervention regarding hospital stay or PROMs, including the superiority of operative management or non-operative approaches. Given the prevalence of PFT, management should be guided by robust data. Future experimental studies of surgical techniques and comparisons with non-operative management are warranted.

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BACKGROUND: Adequate postoperative pain treatment is important for quality of life, patient satisfaction, rehabilitation, function, and total opioid consumption, and might lower both the risk of chronic postoperative pain and the costs for society. Prolonged opioid consumption is a well-known risk factor for addiction. Previous studies in upper extremity surgery have shown that total opioid consumption is a third of the amount prescribed, which can be explained by package size. The aim of this study was to examine whether implementation of prepacked takehome analgesia bags reduced the quantity of prescribed and dispensed opioids. MATERIAL AND METHODS: We introduced prepacked take-home analgesia bags for postoperative pain treatment in outpatient surgery. The bags came in two sizes, each containing paracetamol, etoricoxib, and oxycodone. The first 147 patients who received the prepacked analgesia bags were included in the study, and received a questionnaire one month after surgery covering self-assessed pain (visual analog scale of 0-10) and satisfaction (0-5), as well as opioid consumption. Prescription data after introducing the analgesia bags were compared with data before the bags were introduced. RESULTS: Of the 147 patients included in the study, 58 responded. Compared to standard prescription (small bag group: 14 oxycodone immediate release capsules (5 mg), large bag group: additional 28 oxycodone extended release tablets (5 mg), based on the smallest available package), the patients in the small analgesia bag group received 50% less oxycodone and 67% less for the large bag group. Patients with small bags consumed a median of 0.0 mg oxycodone and those with large bags consumed a median of 25.0 mg oxycodone. The median satisfaction was 5.0 (range: 2-5) and the median pain score was acceptable at the first postoperative day. Prescription data showed a significant reduction of 60.0% in the total amount of prescribed opioids after the introduction of prepacked analgesia bags. CONCLUSIONS: The introduction of prepacked analgesia bags dramatically reduced the quantity of opioids prescribed after outpatient hand surgery. Patient satisfaction was high and the postoperative pain level was acceptable. KEY WORDS: analgesia, hand surgery, opioids, outpatint surgery, wrist surgery.

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CASE: We present a 67-year-old woman with long finger extrinsic extensor tightness and a 56-year-old man with limited index finger flexion due to extrinsic extensor tightness secondary to tendon transfers for radial nerve palsy. Both patients underwent prior surgical procedures that led to limited range of motion (ROM). Subsequently, they elected for central tendon tenotomy (CTT), which demonstrated postoperative ROM improvement and satisfactory patient outcomes. CONCLUSION: Surgical management of extrinsic extensor tendon tightness of the hand is generally addressed by performing tenolysis to improve tendon excursion. We present a novel and simple technique of CTT with pertinent anatomy, descriptive cases, and a cadaveric video.

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California's Controlled Substance Utilization Review and Evaluation System (CURES) was mandated in 2018 to monitor and limit opiate prescriptions. This study evaluated the effects of this legislation on postoperative opioid prescriptions of patients undergoing soft tissue hand surgery. Patients receiving carpal tunnel release, trigger finger release, and ganglion excisions 18 months prior to and 18 months after CURES were selected. The primary outcome was milligram morphine equivalent (MME) prescribed at the surgical encounter and at first postoperative visit. There were 758 patients in the pre-CURES cohort and 701 patients in the post-CURES cohort. In the pre-CURES cohort, there was 116.9 ± 123.8 MME prescribed post op and 10.2 ± 70.8 at first follow-up, whereas post-CURES had 58.8 ± 68.4 MME and 1.1 ± 14.1 for post-op and first follow-up respectively. Findings of this study indicate state regulations may play a role in reducing narcotic consumption following soft tissue hand surgery. (Journal of Surgical Orthopaedic Advances 33(2):122-124, 2024).

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OBJECTIVE: Microsurgical interventions involve the interaction of numerous variables, making objective analysis of skill proficiency challenging. This difficulty is even more pronounced in low-resource contexts. Continuous improvement methodologies such as Kaizen-planning, doing, checking, acting (PDCA) and micromovements science (MMS) can address this issue. This study aimed to demonstrate the advantages of designing and implementing microsurgical training programs using these methodologies. METHODS: Following an extensive literature review of Kaizen-PDCA and MMS, and under the guidance of experienced neurosurgeons and engineers, a microvascular bypass training program was developed using the human placenta. Subsequently, the training program was used to analyze and describe the process of a trainee neurosurgeon in Argentina with no prior experience in microvascular anastomosis, as the operator gained proficiency. RESULTS: The trainee required 12 attempts to achieve the program goals. The longest procedural time was during the first attempt (1 hour 49 minutes 05 seconds with 2 mistakes), while the shortest time was during the fourth attempt (53 minutes 29 seconds with 3 mistakes). After 12 attempts, the trainee made no mistakes, and the procedural time was reduced to 57 minutes 37 seconds. The final learning curve demonstrated a regular pattern and reached a plateau after 7 attempts. CONCLUSIONS: The training program and methodology effectively assessed, facilitated, and demonstrated the acquisition of microsurgical skills. Kaizen-PDCA and MMS enabled the effective use of expert experience, detailed evaluation of microsurgical procedures, and integration into a continuous improvement cycle. The program structure could also be valuable for teaching, evaluating, and enhancing similar surgical procedures.

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PURPOSE: The purpose of this study was to provide updated data on oncologic outcomes following definitive surgical treatment of soft tissue sarcoma of the hand in a cohort of 109 patients, as well as to characterize risk factors for poor oncologic and functional outcomes. METHODS: We analyzed data from 109 consecutive patients who had definitive surgical treatment for soft tissue sarcoma of the hand performed between 1996 and 2019 by a single surgeon at a sarcoma center. Primary outcomes included functional outcome (assessed by Musculoskeletal Tumor Society scores), disease-free survival (DFS), and overall survival (OS). We compiled descriptive data and used a multivariable linear model to identify factors associated with functional outcomes. Kaplan-Meier methods were used to estimate 5- and 10-year DFS and OS. RESULTS: Patients had a median age of 36 years at presentation. Median follow-up was 6.1 years among patients alive at the end of follow-up. The median Musculoskeletal Tumor Society score was 29; functional outcome was worse among patients with high-grade tumors or complications. Among the 107 patients who became disease-free, there were four local recurrences (one with metastasis), six distant recurrences, and one death without recurrence. All local recurrences were deep tumors (two myxofibrosarcoma and two myxoinflammatory fibrosarcoma). Estimated 5- and 10-year DFS rates were 89% (95% confidence interval [CI]: 83% to 96%) and 88% (95% CI: 80% to 95%). There were seven deaths, and the estimated 5- and 10-year OS rates were 95% (95% CI: 90% to 100%) and 92% (95% CI: 84% to 100%). Larger tumor size and higher stage at diagnosis were associated with shorter DFS and OS in univariable analyses; low event rates precluded multivariable analysis of survival. CONCLUSIONS: Aggressive disease-specific surgical and multidisciplinary treatment can yield long DFS and OS, and good functional outcomes. However, complications and high-grade tumors are associated with worse functional scores. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

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BACKGROUND: Patient informed consent is a crucial subject in preoperative care of patients before elective hand surgery, ensuring that patients have the necessary information and a comprehensive understanding to make autonomous decisions. The use of video-based informed consent systems is an innovative concept to enhance the consent process with multimedia tools. In addition to the conventional process, mostly relying on verbal communication and written documents, the video-based approach aims to present information in a standardized and visually appealing format. METHODS: In this study, 33 patients were asked to watch a video on a tablet about the planned elective hand surgery after a conventional pre-treatment consultation including informed consent throughout verbal explanations and paper forms by an attending physician or resident. All patients were asked to complete a questionnaire after watching the video. RESULTS: An overwhelming majority of participants, specifically 97.0%, stated that the video improved their understanding of the upcoming surgery. 90.9% of the participant would refer the video to other patients undergoing elective hand surgery, while 72.7% of participants indicated that they would have appreciated the opportunity to view an informational video before undergoing different types of surgeries in the past. CONCLUSION: The use of a video-based patient information system in elective hand surgery had a positive impact on patient education and satisfaction with the informed consent process. Therefore, it is a powerful tool in preoperative management to guarantee a standardized and educative informed consent.

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Background: The use of robotic systems for microsurgery has gained popularity in recent years. Despite its drawbacks, such as increased learning time and lack of haptic feedback, robot-assisted microsurgery is beneficial for emergency care due to its reduced risk of tremor and fatigue. The Symani Surgical System® is 1 example of this advanced technology. The device offers a range of possibilities in the field of microsurgery by combining precision and dexterity, revolutionizing microsurgical procedures. This article explores the applications of the Symani in microsurgical procedures in emergency hand trauma care, highlighting its advantages and limitations. Material and Methods: We present the results of 62 anastomoses of blood vessels under .8 mm diameter after hand trauma. 31 anastomoses were conducted using the Symani Surgical System®, and the other 31 were done as a control group in hand-sewn technique. Study Sample: The patient characteristics, including sex, age, and risk factors, were matched. Results: We found no significant differences in the anastomosis surgery length when performed with the Symani (arterial 17.3 ± 1.9 min; venous 11.5 ± 1.3 min) vs the hand-sewn technique (arterial 16.1 ± 1.4 min; venous 10.2 ± 1.8 min). Additionally, the learning curve consistently decreased over time, with the 10th surgery taking 30% (arterial) less time. Conclusion: Our study indicates that robot-assisted microsurgery can help surgeons maintain a relaxed and focused state while producing results comparable to hand-sutured procedures in emergency care.

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