Early Discharge and Patient-Initiated Follow-Up in Hand Surgery: A New Norm Following Simple Hand Surgery?

AIMS: The demand for elective hand surgery has increased substantially over the last 10 years. With COVID-19 providing an added challenge of restrictions on face-to-face consultations, already overflowing follow-up clinics will be stressed further. Our aim is to assess the viability, effectiveness, and safety of an early discharge directly from the operating theatre following common hand surgery procedures with the safety net of open-access follow-up. METHODS: All eligible patients undergoing open-hand surgery under local anaesthesia between February 2019 and December 2020 were offered early discharge. Informed consent was obtained in the clinic, and they were counselled on rehabilitation immediately prior to surgery. Patients were given a custom-made "open-access business card" with clear post-operative instructions and hand exercises, along with information on how to get in touch to request clinic follow-up. A review was completed at a minimum of two months following surgery. Administrative support staff were briefed beforehand to minimise any delays in follow-up requests and either book patients who requested follow-up into a routine elective clinic or utilise ring-fenced emergency elective clinic slots depending on the patient's individual requirements. RESULTS: A total of 105 patients were included in this study, with an average age of 60 years. The average interval between surgery and review was 20 weeks. Eighty-nine patients had a successful early discharge, with 16 patients requesting clinic follow-up. The average time to follow up in the clinic was 35 weeks (range: four to 84 weeks). There were no complications that we were made aware of, and the most common reason for returning to the clinic was a new complaint, unrelated to the surgery. CONCLUSIONS: Although virtual follow-up is now well established in both the fracture and elective clinic settings, early discharge is largely uncharted water. Our pilot demonstrates that early discharge and patient-initiated follow-up for common elective hand surgical procedures under local anaesthesia are efficient, safe, and viable.

Acquired Radial Club Hand: An Algorithm to Manage Radial Deficiency.

Introduction Loss of radius either due to trauma or infection results in a deformity resembling a congenital radial club hand. This deformity results in difficulty to perform hand functions and cosmetic appearance and is called acquired radial club hand. There are a few case reports for the treatment of this severe deformity, but there are no proper guidelines for the management of this disease. From our experience, we decided to provide treatment guidelines for acquired radial club hand. Objectives To evaluate the outcome of radial deformity treatment in acquired radial club hand injuries and develop a treatment algorithm. Patients and methods It is a case series study of 11 patients with acquired radial club hand. It was conducted at a tertiary care hospital in Pakistan, from year 2016 to 2022. Basic principles of management of infection and trauma were followed. For the treatment of radial deformity, different options were opted according to the type of deformity, following the principles of treatment of congenital radial club hand. The outcome was graded on functional activity, pain, and bony union. Results Out of 11 patients, 36.36% showed excellent results, 27.27% showed good results, 27.27% showed fair results, and 9.09% showed poor results. Results were excellent in all patients with avascularized bone graft and distraction lengthening, with or without the Darrach procedure. Of the patients in whom distraction lengthening was performed, one patient showed excellent results while the other patient achieved similar results after the Darrach procedure of ulnar shortening. In the case of one bone formation by radioulnar synostosis, the results were variable. Two of the patients showed good outcomes while the other two had fair outcomes. Results in the case of ulnar centralization were mixed with good, fair, and poor results in one patient each. After three months of follow-up, 87% of the patients showed fair to excellent results. Conclusion With our experience, we recommend an algorithm for the treatment of acquired radial club hand.

Carpal Tunnel Decompression Under Wide Awake Local Anaesthesia No Tourniquet Technique (WALANT): A Cost Effective and Outcome Analysis.

Introduction Wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, resource-friendly, and safe. This can be used as an alternative to hand surgery procedures in outpatient units. It can be performed in clinics or operating rooms. Methods We retrospectively evaluated the outcomes of WALANT for carpal tunnel decompression (CTD) over two years. Measured results include wound infections, relief of symptoms, paraesthesia, haematoma, Visual Analogue Scale (VAS), hospital anxiety and depression scale score (HADS) and cost-effectiveness. Results Eighteen patients underwent CTD under the WALANT technique over two years. VAS score was recorded at 3.1 ± 1.2 during the procedure and 1.67 ± 0.933 at two weeks follow-up. Persistent paraesthesia was found in only one patient at follow-up. Minimal bleeding was recorded during the procedure. No wound infections, revision surgery or post-operative haematoma formation were found. Hospital Anxiety and Depression Scale (HADS) was reported as 4.77 ± 2.1 after surgery. WALANT was also cost-effective, with an overall amount of £20. Conclusion Performing carpal tunnel decompression under WALANT in one stop upper limb clinic is a safe and cost-effective technique with no significant patient-related complications.

Intraneural Lipoma: A Rare Cause of Median Nerve Compression.

Intraneural lipomatous tumors are rare lesions that mostly affect the upper extremities. These slowly growing tumors can have a serious neurological and functional impact when they reach a significantly large size. We report herein a case of a 53-year-old female who presented with a large median nerve intraneural lipomatous tumor causing compression-related signs. She was treated with monoblock excision of the tumor that was completely residing between the median nerve fibers. At her last follow-up, no median nerve deficits were recorded, and the patient went to full resolution.

Chronic Exertional Compartment Syndrome of the Hand With Simultaneous Carpal Tunnel Syndrome and Ulnar Nerve Neuropathy: A Clinical Case Report.

Chronic exertional compartment syndrome is a reversible form of compartment syndrome that occurs with exertion and is relieved with rest. Chronic exertional compartment syndrome most commonly occurs in the lower leg and has only rarely been reported in the hand. We report a case of exertional compartment syndrome in the left hand of a 37-year-old male heavy equipment technician with concurrent carpal tunnel syndrome and ulnar neuropathy. Physical examination showed non-exertional numbness and tingling in all five digits while at rest with a reproducible Tinel's test over the carpal tunnel and Guyon's canal. Acute swelling and hand muscle weakness appeared after repetitive pinch and usage of the thenar and intrinsic musculature with acute sensory and motor changes in the ulnar nerve distribution. Elective fasciotomies were performed in the first dorsal interosseous and thenar compartments with concomitant release of the carpal tunnel and ulnar nerve at the wrist. The patient exhibited a full recovery from symptoms with no residual functional deficits. Although rare, patients that perform repetitive hand motions can develop chronic exertional compartment syndrome. To our knowledge, this is the first reported case of chronic exertional compartment syndrome in the hand that occurred with chronic overuse neuropathies and an acute ulnar neuropathy with intrinsic hand muscle weakness at the same time. It is important for providers to conduct a thorough history and physical examination to differentiate multiple hand pathologies that may present simultaneously.

Academic Impact of Hand Surgery Units Across the United Kingdom: A Bibliometric Analysis.

Quantifying the academic impact of hand surgery units can serve as a useful parameter for clinicians interested in academia when applying for fellowships or consultant posts. The aim of this study is to measure and rank the academic impact of hand surgery units across the United Kingdom (UK) using bibliometric analysis. UK hand surgery units were identified from the British Society for Surgery of the Hand (BSSH) website and additional manual internet searches. Predefined search strings were used to identify papers about or relating to hand surgery. Using the Clarivate Analytics Web of Science bibliometric analysis tool, cumulative (1900-2021), 10-year (2011-2021), and 3-year (2018-2021) research output data was collected from UK hand surgery units and ranked using the following parameters: number of papers (Np), number of citations (Nc), and the h-index (a metric evaluating the cumulative impact of academic output). The top three units according to the 10-year h-index were The Pulvertaft Hand Centre (15), John Radcliffe Hospital (10), and Norfolk and Norwich University Hospital (10). The units with the greatest number of papers published in the last 10 years were the Pulvertaft Hand Centre (70), Chelsea & Westminster Hospitals (45), and Broomfield Hospital (44). The units with the single most cited papers were Wrightington Hospital (189), the Pulvertaft Hand Centre (152), and St John's Hospital & Royal Hospital for Sick Children (152). The academic impact of hand surgery units varies greatly across the UK. Hand surgery units with a historically strong academic record have generally maintained a similar high output of research over the last decade. The 10-year h-index of hand surgery units can be particularly useful for hand surgeons with a strong academic interest.

Risk for Persistent Peripheral Neuropathy After Repair of Brachial Artery Injuries.

Background Brachial artery lacerations are limb-threatening injuries requiring emergent repair. Concomitant peripheral nerve symptoms are often only identified postoperatively. This study evaluated the prevalence of peripheral nerve deficits among this population as the indications for early nerve exploration have not been definitively established. Methods We reviewed all patients sustaining a brachial artery injury at one pediatric and two adult Level I Trauma Centers between January 1, 2007, and December 31, 2017. We recorded patient demographics, comorbidities, intoxication status, injury mechanism, concomitant injuries, type of repair, and intraoperative peripheral nerve exploration findings. Pre-and post-operative and long-term peripheral nerve function examination findings were analyzed. Differences between categorical variables were determined with Chi-square and Fisher's exact tests. Results Thirty-four patients sustained traumatic brachial artery lacerations requiring operative repair. Injury mechanisms included tidy (clean cut) laceration (n=11, 32%), gunshot wound (n=9, 26%), blunt trauma (n=8, 24%), and untidy laceration (n=6, 18%). Preoperatively, 15% had a normal peripheral nerve examination, 26% had localizable symptoms, 38% had non-localizable symptoms, and 21% were taken to the operating room without formal nerve assessment. Thirty-two percent underwent formal nerve exploration, and 81% underwent nerve repair. At an average follow-up of 2.5 years, 27% of patients underwent exploration, and 39% did not have localizable peripheral nerve deficits (p=0.705). Conclusions Brachial artery injuries are associated with a clinically significant risk for long-term peripheral nerve symptoms. Early nerve exploration in patients with peripheral nerve symptoms after a brachial artery injury may be warranted, although there is no statistically significant likelihood for improved peripheral neurological outcomes.

Giant cell tumours in fingers among the Inuit population in Greenland.

OBJECTIVE: Giant cell tumours (GCTs) of the tendon sheets in fingers are rare. We therefore find it of interest to report on 5 cases identified in the Inuit population in Greenland within 16 months prior to this study. MATERIAL AND METHODS: The Inuit account for 56,000 people of the total population in Greenland. From November 2010 to 16 months prior to this study, we diagnosed 5 cases (0.6% of all orthopaedic operations) with a GCT of the flexor tendon sheet of a finger. The patients were aged between 10 and 54 years, and 4 were women. All of them had noticed slow-growing tumours over 3 or more years and were referred for a suspected ganglion. RESULTS: In two cases, the tumour was located at the distal interphalangeal (DIP) joint in the thumb and in one case at the third finger. Two other patients had tumours at the metacarpophalangeal (MCP) joint of the third finger and the thumb, respectively; one of these two had a communicating tumour to the DIP joint. The last patient had two tumours on the same finger, one at the MCP joint and the other at the DIP joint. In one case, the tumour had also eroded the cortex of the first phalanx of the thumb, and the largest tumour measured 5 cm. CONCLUSION: GCTs of the flexor tendon sheets in fingers are rare. It could be a coincidence that we have seen 5 cases within a short period of time. It is not possible to identify past cases through a register. A tumour in a finger is not the most common location for a ganglion, especially not at the DIP level. Therefore, a large tumour at this location is more likely to be a GCT.