Qualitative study informing the development and content validity of the HAND-Q: a modular patient-reported outcome measure for hand conditions.

OBJECTIVES: The purpose of this study was to identify and understand the issues that are relevant to patients with hand conditions. The data were used to develop a patient-reported outcome measure (PROM) for adults with hand conditions (HAND-Q) and refine it with input from patients and clinician experts. DESIGN: Semistructured qualitative interviews were used to understand what matters to patients. Cognitive debriefing was used to refine preliminary HAND-Q scales. SETTING: Hand clinics in tertiary healthcare centres in Canada, Australia and USA. PARTICIPANTS: Eligible participants were English-speaking adults who had experienced hand surgery in the preceding 12 months and were at least 4 weeks post-hand surgery A total of 62 in-depth interviews (females, n=34; mean age=65 years) were conducted to develop an item pool and draft the HAND-Q scales. The preliminary scales were refined through cognitive debriefing interviews with 20 participants and feedback from 25 clinician experts. All interviews were audiorecorded, transcribed verbatim and coded using a line-by-line approach. RESULTS: Qualitative data were organised into two top-level domains of health-related quality of life and satisfaction with treatment outcomes. The scales were refined iteratively, and the field-test version included 319 unique items and 20 independently functioning scales. CONCLUSIONS: The HAND-Q is a comprehensive PROM developed using extensive patient and clinician expert input, following established guidelines for PROM development and validation. In the next phase, the psychometric properties of the HAND-Q will be established in an international field test, following which the HAND-Q will be available for use in clinical research and practice .

The HAND-Q: Psychometrics of a New Patient-reported Outcome Measure for Clinical and Research Applications.

The perspective of the patient in measuring the outcome of their hand treatment is of key importance. We developed a hand-specific patient-reported outcome measure to provide a means to measure outcomes and experiences of care from the patient perspective, that is, HAND-Q. METHODS: Data were collected from people with a broad range of hand conditions in hand clinics in six countries between April 2018 and January 2021. Rasch measurement theory analysis was used to perform item reduction and to examine reliability and validity of each HAND-Q scale. RESULTS: A sample of 1277 patients was recruited. Participants ranged in age from 16 to 89 years, 54% were women, and a broad range of congenital and acquired hand conditions were represented. Rasch measurement theory analysis led to the refinement of 14 independently functioning scales that measure hand appearance, health-related quality of life, experience of care, and treatment outcome. Each scale evidenced reliability and validity. Examination of differential item functioning by age, gender, language, and type of hand condition (ie, nontraumatic versus traumatic) confirmed that a common scoring algorithm for each scale could be implemented. CONCLUSIONS: The HAND-Q was developed following robust psychometric methods to provide a comprehensive modular independently functioning set of scales. HAND-Q scales can be used to assess and compare evidence-based outcomes in patients with any type of hand condition.

Simple Effective Ways to Care for Skin Wounds and Incisions.

Plastic surgeons are medicine's wound experts. Many of the world's poor cannot afford expensive wound management programs. All humans suffer open and closed wounds at some point in their life and must look after them. The purpose of this paper is to provide basic information to the public in very simple terms on how to safely and inexpensively manage wounds. This paper is directed to all nonmedical people, medical students, and other doctors who may not be content experts in this field.

Effective Rejuvenation with Hyaluronic Acid Fillers: Current Advanced Concepts.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Process several patient-specific factors before reaching an optimal treatment strategy with appreciation for facial balance. 2. Define the advantages and disadvantages of various hyaluronic acid preparations and delivery techniques, to achieve a specific goal. 3. Perform advanced facial rejuvenation techniques adapted to each facial zone, combining safety considerations. 4. Prevent and treat complications caused by inadvertent intraarterial injections of hyaluronic acid. SUMMARY: The growing sophistication and diversity of modern hyaluronic acid fillers combined with an increased understanding of various delivery techniques has allowed injectable filler rejuvenation to become a customizable instrument offering a variety of different ways to improve the face: volume restoration, contouring, balancing, and feature positioning/shaping-beyond simply fading skin creases. As more advanced applications for hyaluronic acid facial rejuvenation are incorporated into practice, an increased understanding of injection anatomy is important to optimize patient safety.

How Many Trigger Fingers Resolve Spontaneously Without Any Treatment?

INTRODUCTION: There is very little information in the literature evaluating the natural history of adult trigger fingers and their rate of spontaneous resolution over time. METHODS: A consecutive case series of patients with trigger finger was generated. For each patient, we recorded whether the patient's disease resolved from either no treatment versus active treatment options and over what time period. RESULTS: Three hundred forty-three patients with trigger finger were included in the study. Fifty-two percent of patients resolved without any treatment whatsoever after waiting a mean (and median) of 8 months from initial consultation. The thumb was the most frequent digit to resolve without treatment (72%). CONCLUSIONS: We found that just over half of patients with trigger fingers who are referred to our office resolve spontaneously without any intervention.

HISTORIQUE: Très peu de publications portent sur l'évolution naturelle des doigts à ressort chez les adultes et sur leur taux de résolution spontanée au fil du temps. MÉTHODOLOGIE: Les chercheurs ont produit une série de cas consécutifs de patients ayant un doigt à ressort. Pour chaque patient, ils ont vérifié si le problème s'était résolu sans traitement ou après un traitement actif ainsi que le laps de temps nécessaire pour parvenir à ce résultat. RÉSULTATS: Au total, 343 patients ayant un doigt à ressort ont participé à l'étude. Le problème s'est résolu sans traitement chez 52 % des patients au bout d'une période moyenne (et médiane) de huit mois après la première consultation. C'est le pouce qui guérissait le plus souvent sans traitement (72 %). CONCLUSION: Les chercheurs ont découvert qu'un peu plus de la moitié des patients ayant un doigt à ressort qui sont dirigés vers leur bureau guérissent spontanément sans intervention.

Minimal Pain Local Anesthetic Injection with Blunt Tipped Cannula for Wide Awake Upper Blepharoplasty.

Supplemental Digital Content is available in the text.

Local Anesthetics: What's New in Minimal Pain Injection and Best Evidence in Pain Control.

SUMMARY: Local anesthesia in plastic surgery is undergoing a revolution. In the last 10 years, significant improvements in technique have permitted surgeons to do more and more under pure local anesthesia to increase patient safety and convenience while maintaining total patient comfort during the injection of the local anesthesia and while the procedure is accomplished. Many procedures which used to require sedation are now being performed without it. This article explores some of the new advances in local anesthesia such as painless blunt-tipped cannula local anesthetic infiltration, decreased pain with sharp needle tip injection, and long-lasting local anesthetics with delayed release from liposomal encapsulation. This article also examines the best evidence of the last 10 years of advances of pain control with local anesthesia.

Minimally invasive anesthesia in wide awake hand surgery.

Tumescent minimally invasive local anesthesia is eliminating the need for sedation and proximal nerve blocks as well as all of their risks, costs, and inconveniences. It has facilitated advances in procedures such as hand fracture reduction, tendon repair, and tendon transfer by allowing the surgeon to see cooperative patient active movement during the surgery. It has improved the patient experience for simple hand operations such as carpal tunnel release.

General anaesthesia versus thoracic paravertebral block for breast surgery: a meta-analysis.

BACKGROUND: Thoracic paravertebral block (TPVB) offers an attractive alternative to general anaesthesia (GA) for ambulatory breast surgery. The aim of this meta-analysis was first to evaluate the safety and efficacy of TPVB for breast surgery, and second to compare TPVB with GA with regard to postoperative pain, nausea and vomiting, opioid consumption and length of hospital stay. METHODS: An electronic and manual search of English- and French-language articles on TPVB in breast surgery (published from January 1980 to June 2010) yielded 41 citations. Two levels of screening identified 11 relevant studies. The Mantel-Haenszel method (fixed effect) was used to perform the meta-analysis. RESULTS: Eleven studies were retained for analysis. When TPVB was used instead of GA, pain scores were significantly decreased at 1 and 6 h postoperatively (mean difference of 2.48 (95%confidence interval (CI): 2.20-2.75) and 1.71 (95%CI: 1.64-1.78), respectively). Furthermore, postoperative analgesic consumption was significantly lower in patients who received TPVB compared with GA (relative risk (RR) 0.23, (95%CI: 0.15-0.37)). TPVB was also associated with significantly less postoperative nausea and vomiting (RR 0.27 (95%CI: 0.12-0.61)). Increased patient satisfaction and a shorter hospital stay also favoured TPVB over GA. CONCLUSIONS: TPVB provides effective anaesthesia for ambulatory breast surgery and can result in significant benefits over GA. However, further studies are required to determine whether these advantages would still be present if an optimal technique for outpatient GA is employed. Adjunctive ultrasonography may contribute to improve the safety of TPVB in breast surgery and requires further investigation.

Upper and lower eyelid reconstruction.

Reconstruction of the eyelids can range from simple repair to the integration of multiple complex procedures. Knowledge of eyelid anatomy, adequate preoperative planning, and meticulous surgical technique will optimize the anatomical and functional result. The purpose of this article is to review the relevant anatomy for eyelid reconstruction, to simplify defect analysis and preoperative planning, and to provide options for reconstruction of this complex area.

Erratum to: The Wide-Awake Approach to Dupuytren's Disease: Fasciectomy under Local Anesthetic with Epinephrine.

[This corrects the article DOI: 10.1007/s11552-009-9239-y.].

The Wide-Awake Approach to Dupuytren's Disease: Fasciectomy under Local Anesthetic with Epinephrine.

The Wide-Awake Approach to Dupuytren's contracture involves fasciectomy under local anesthetic with epinephrine and no tourniquet. The goal of this study is to show that the Wide-Awake Approach produces equivalent outcomes to fasciectomy under general anesthetic with a tourniquet, with fewer risks to the patient. A multicenter retrospective review was conducted on 111 patients with fasciectomies under local or general anesthetic between 2001 and 2007. Data on patient demographics, comorbidities, cost, as well as range of motion was collected and evaluated using Microsoft Excel and SAS. Of 148 fingers, 102 were treated under local and 46 under general anesthetic. The average postoperative Total Active Motion (TAM) for general anesthetic patients was 199.0 ± 29.6 (D5), 223.9 ± 29.3 (D4), 234.6 ± 14.6 (D3), and 246.7 ± 14.4 (D2). The average postoperative TAM for local anesthetic patients was 168.3 ± 62.2 (D5), 195.9 ± 67.5 (D4), 173.0 ± 72.6 (D3), and 177.5 ± 31.8 (D2). There were no significant differences between any of these individual groups (p = 0.09, 0.26, 0.12, and 0.20, respectively); however, when pooled, the overall TAM was significantly greater in the general anesthesia group (222.0 ± 29.7 vs. 186.0 ± 63.0, p = 0.002.). Complication rates and types were similar with both techniques. The Wide-Awake Approach to Dupuytren's contracture avoids general anesthetic risks and has cost benefits to healthcare providers. Although it yields similar range of motion outcomes to fasciectomy performed under general anesthesia, total active motion may be better with fasciectomy done under general anesthesia.

MOC-PS(SM) CME article: self-assessment and performance in practice: the carpal tunnel.

LEARNING OBJECTIVES: After studying the article, the participant should be able to: 1. Conduct an appropriate history and physical examination for a patient suspected of having carpal tunnel syndrome. 2. Understand the role of provocative and other diagnostic tests pertinent to the diagnosis of carpal tunnel syndrome. 3. Understand the goals of the surgical treatment of carpal tunnel syndrome and how to obtain these. 4. Appreciate the common complications of carpal tunnel surgery and their management. SUMMARY: The purpose of this article is to review important aspects of the history, physical examination, diagnosis, and management of carpal tunnel syndrome. Associated diseases, predisposing factors, and prognostic features are explored. The significance of diagnostic studies and the variety of anesthetic techniques with which to perform the surgery are reviewed. Evidence regarding the different surgical approaches, such as the open versus the endoscopic, is examined. Postoperative care issues such as therapy and splinting are examined. Finally, complications of carpal tunnel surgery and their management are outlined.

Practice profiles in breast reduction: a survey among Canadian plastic surgeons.

BACKGROUND: Breast reduction is an increasingly common procedure performed by Canadian plastic surgeons. Recent studies in the United States show that use of the inferior/central pedicle inverted T scar method is predominant. However, it is unknown what the practice preferences are among Canadian plastic surgeons. OBJECTIVE: The goal of the present study was to assess trends in breast reduction surgery among Canadian surgeons, including patient selection criteria, surgical techniques and outcomes. METHOD: Surveys were distributed to plastic surgeons at the Canadian Society for Plastic Surgery meetings in 2005 and 2006. Completed surveys were obtained from 140 respondents, and results were analyzed with Excel and SAS software. RESULTS: There was a 40% response rate. The majority of surgeons (66%) used more than one technique for breast reduction. Most commonly, surgeons use the inverted T scar technique (66%) followed by vertical scar techniques (26%). The most popular vertical scar techniques included the Hall-Findlay (14%) and Lejour (13%) methods. Most surgeons (55%) reported complication rates of less than 5% and the most common complication reported was wound dehiscence. There was no difference in overall complication rates between inverted T scar and vertical scar surgeries. The majority of surgeons (98%) carried out breast reduction either exclusively as day surgery or in combination with same-day admission. Breast reduction performed as day surgery resulted in cost savings of $873 per patient. CONCLUSIONS: Canadian plastic surgeons are performing more vertical scar breast reductions than American surgeons. However, both groups rely predominantly on inverted T scar techniques.

The Canadian plastic surgery workforce survey: interpretation and implications.

BACKGROUND: Few studies have monitored physician supply in Canada, and no studies have specifically examined the Canadian plastic surgery workforce. METHODS: In this study, data were gathered by three methods. A survey was distributed to all members of the Canadian Society of Plastic Surgeons in October of 2004. Opinions on the availability of plastic surgery services were solicited. A second survey that focused on demographics and workload was distributed in December of 2004. Finally, the locations of all Canadian trainees graduating between 1995 and 2005 were reviewed. RESULTS: The response rate to the first survey was 42 percent. Seventy-eight percent of respondents felt that there was a shortage of plastic surgeons in their community. The response rate to the second survey was 40 percent. Twenty-eight percent of respondents were within 5 years of retirement and 3.2 percent stated that they planned to emigrate by 2010. The mean waiting time for an elective consultation was 32 +/- 33 weeks. Review of all 179 plastic surgery graduates over the past 10 years revealed that 23 percent now practice outside of Canada. CONCLUSIONS: When these results are projected to the total workforce, they indicate that there will be a future shortage of plastic surgeons in Canada. To prevent a further deficit, there is a need to increase the number of plastic surgery trainees in Canada, to offer incentives for graduates to stay in Canada, and to possibly recruit more foreign-trained plastic surgeons to practice within Canada.

Finger injection with high-dose (1:1,000) epinephrine: Does it cause finger necrosis and should it be treated?

OBJECTIVES: Accidental finger injections with high-dose (1:1,000) epinephrine is a new and increasing phenomenon. The purpose of this study is to document the incidence of finger necrosis and the treatment for this type of injury. The necessity or type of treatment required for this type of injury has not been established. METHODS: The literature was reviewed from 1900 to 2005 by hand and by Internet to document all cases of high-dose (1:1,000) finger epinephrine injection. In addition, the authors added five additional cases. RESULTS: There are a total of 59 reported cases of finger injections with high-dose epinephrine, of which, 32 cases were untreated. There were no instances of necrosis or skin loss, but neuropraxia lasting as long as 10 weeks and reperfusion pain were carefully documented. Treatment was not uniform for those who received it, but phentolamine was the most commonly used agent. CONCLUSIONS: There is not one case of finger necrosis in all of the 59 reported cases of finger injections with 1:1,000 epinephrine in the world literature. The necessity or type of treatment of high-dose epinephrine injection injuries remains conjecture, but phentolamine is the most commonly used agent in the reported cases, and the rationale and evidence for its use are discussed.