Development and Validation of a Low-Cost Drilling Model.

Background: Simulation models enable learners to have repeated practise at their own time, to master the psycho-motor and sensory acuity aspects of surgery and build their confidence in the procedure. The study aims to develop and evaluate the feasibility of a low-cost drilling model to train surgeons in the drilling task. The model targets three aspects of drilling - (1) Reduce plunge depth, (2) Ability to differentiate between bone and medullary canal and (3) Increase accuracy drilling in various angles. Methods: This cross-sectional study was conducted after obtaining ethics approval. We invited Consultants in the field of Orthopaedic or Hand Surgery to form the 'expert' group, and the 'novice' group consisted of participants who had no prior experience in bone drilling. We developed a drilling simulator model made from a polyvinyl chloride (PVC) pipe filled with liquid silicone. This model cost less than US$5. An electric Bosch drill (model GBM 10 RE) with a 1.4 mm K-wire 10 cm in length (6.5 cm outside the drill) was used for drilling. The main outcomes of the study were time taken for drilling, plunge depth, ability to penetrate the far cortex and accuracy. Results: Thirty-one participants were recruited into the study, of which 15 were experts and 16 were novices. The experts performed significantly better for plunge depth (t = -3.65, p = 0.0003) and accuracy (t = -2.07, p = 0.04). The experts required 20% less time to complete the drilling tasks, but it was not statistically significant (t = -0.79, p = 0.43). Conclusions: The low-cost drilling model could be useful in training Residents in the drilling task. It will allow Residents to practise independently at their own time and assess their own performance.

Challenges and Solutions in Prosthetic Fitting of Digits after Flap Reconstruction.

Surgical reconstruction can restore length and function, but cannot adequately resolve the problem of disfigurement. Prosthetic fitting can play a complementary role in enhancing the aesthetic outcomes post reconstruction. However, complex reconstruction involving flaps coupled with the surgical imperative for limb length preservation can lead to outcomes where the reconstructed stumps are challenging to fit with prosthesis. This article describes how prosthetic fitting was tackled in a case of a triple-digit amputation after reconstruction that presented with finger stumps that were bulky, long and stiff in extension contracture, compounded by the presence of substantive scar tissues. We discuss major prosthesis modifications that were unconventional but necessary to enable fitting, the techniques involved, as well as the aesthetic and functional considerations behind the modifications. The results showed that enhanced aesthetic appearance, together with a marginal improvement in hand function, was achieved post-prosthetically, meeting the patient's and the clinical team's fitting objective. Level of Evidence: Level V (Therapeutic).

Surgical Anatomy and Exercises Using the Chicken Thigh Sciatic Nerve for Microsurgery Training.

Introduction Vessel repair in a chicken thigh is commonly used in microsurgery training model. The sciatic nerve is closely associated with the vessels and has been used for training nerve coaptation, which has different technical considerations from vessel anastomosis. We describe in detail the relevant surgical anatomy and training exercises that can be used with this model. Methods With 32 fresh store-bought chicken thighs, 16 were used to analyze the gross and histological features of the sciatic nerve, and 16 were intended to create and perform training models. Results The average visible length of the nerve in the thigh was 51 mm (standard deviation [SD] 2.57 mm). The average diameter of the nerve was 2 mm (SD 0.33 mm) and was largest at its proximal end (3.21 mm, SD 0.27 mm). The nerve consistently branched into two along the chicken thigh, with more branching subsequently. This simulation model is appropriate not only for the classical end-to-end epineural suture, but also for advanced exercises, in terms of longitudinal fasciculus dissection, mismatched size nerve transfer, injured nerve preparation, and vein conduit technique. Dyeing of nerve fascicles enhanced the visibility of nerve surface quality. Conclusion The sciatic nerve in the chicken thigh is a suitable and accessible model for microsurgery training. The branching and fascicular patterns of the nerve lends itself well to both novice training and advanced simulation. We have incorporated this model into our training curricula.

Novices can assess microsurgery performance, and this is enhanced using the Manual Suture Parameters for Training and Assessment (M-SParTA) scoring system.

This study explores how novices could effectively evaluate the quality of microsurgical suturing. That would be enhanced with using a novel Manual Suture Parameters for Training and Assessment (M-SParTA), which supported novices with guidance on the objective parameters, in order to increased the accuracy of scoring ability. We also propose the following initial framework to train novices in microsuturing using a standardised task: 1) Exposure; 2) Assessment; 3) Hands-on and self-assessment. The independent learning cycle with targeted supervision provides novices with greater autonomy and a less stressful environment that could enhance skills training.

Functional use of esthetic hand prosthesis: A patient's perspective.

Published reports on the functional benefits of esthetic prosthesis are based on either anecdotal evidence or simplified, nonstandard forms of hand function evaluation performed by the researcher. It is not clear whether and how patients actually make functional use of their prosthesis on a daily basis. We report a case of a patient with a partial hand amputation who was initially ambivalent about fitting an esthetic prosthesis, but went on to make functional use of her prosthesis for activities of daily living, work, and social life at 3 years after injury. We present the patient's own assessment and video recordings, made without influence from rehabilitation personnel that demonstrates this functional use. From this case, we discuss the important factors of a favorable residual limb type, together with targeted modifications made to the prosthesis to optimize function.

Color-matching techniques for creating esthetic hand and finger prostheses.

BACKGROUND: Color matching is a critically important part of, and by far, also the most challenging aspect of producing esthetic silicone prosthesis. There is a knowledge gap in the literature and a lack of opportunities for training in the expertise, particularly regarding color-matching techniques. OBJECTIVE: This article details a color-matching technique that is able to achieve life-like coloration in esthetic prosthesis. TECHNIQUE: Each prosthesis is molded in an outer and inner layers of silicone tinted to different shades and opacities incorporating an intermediate touch-up layer to reproduce the detailed coloration of the hand (because of the presence of veins, finger joint/dermal pigmentations, a vascularized nail bed, and pinkish palm). This method of color-matching prosthesis combining intrinsic and extrinsic techniques simulates the layered anatomy and optical properties of the human skin to effectively replicate its esthetic and life-like coloration. Technical tips for achieving an accurate color match to the patient's skin, including pigment formulation adjustments for a tanned vs. a fair skin, and for painting the touch-up details are discussed. Methods for modifying the color tones of completed prosthesis and for minimizing metameric color differences when the prosthesis is viewed under different light sources are also presented. DISCUSSION: The technique is instrumental in achieving good outcomes for life-likeness and esthetic coloration in the prostheses fitted at our center. Studies previously published that investigated patients' evaluation of important esthetic characteristics of their prosthesis after a period of adjustment to fitting have shown a generally high level of patient satisfaction.

Chicken Feet: A Model for Practising Locoregional Flaps of the Hand.

Background: The aim of this study was to determine the feasibility of the chicken foot model for surgical trainees interested in practising the designing, harvesting and inset of locoregional flaps of the hand. Methods: A descriptive study was performed to demonstrate the technical aspects of harvesting four locoregional flaps in a chicken foot model: fingertip volar V-Y advancement flap, four-flap and five-flap Z-plasty, cross-finger flap and first dorsal metacarpal artery (FDMA) flap. The study was performed in a surgical training laboratory on non-live chicken feet. No participants were involved in this study, apart from authors performing the descriptive techniques. Results: All flaps were successfully performed. Anatomical landmarks, soft tissue texture and flap harvest, as well as inset closely resembled clinical experience with patients. Maximal flap sizes were 12 × 9 mm for volar V-Y advancement, 5 mm limbs for Z-plasties, 22 × 15 mm for cross-finger flaps and 22 × 12 mm for FDMA flaps. The maximal webspace deepening with four-flap/five-flap Z-plasty was 20 mm and the FDMA pedicle length and diameter was 25 and 1 mm, respectively. Conclusions: Chicken feet can be effectively used as simulation models for hand surgical training with respect to gaining familiarity with the use of locoregional flaps of the hand. Further research requires testing for reliability and validity of the model on junior trainees.

Clinical intervention of a tighter-than-tolerated fit of aesthetic hand and finger prosthesis via controlled silicone swelling: A novel, speedier and versatile alternative method.

A tighter-than-tolerated fit of aesthetic hand prosthesis is conventionally rectified by stretching the affected segment to plastic deformation. This method is not only time-consuming, but also ineffective in stretching irregular, non-cylindrical prosthesis segments apart from the "wrist and digits". This study investigates controlled silicone swelling as an alternative method of expanding aesthetic hand and finger prosthesis to address a tight fit. The technique of "controlled" swelling that minimizes oil uptake to as little as is necessary to achieve the desired magnitude of elastomer expansion was demonstrated using experimental test samples. Brush-coats of a cosmetics-grade oil, KF-96A-10CS, 2 a time, were applied on CosmesilTM samples to obtain elastomer expansion. The same technique of staggered oil delivery was used on tight-fitting segments of patients' prosthesis, with test-fitting of each incremental expansion till satisfactory outcomes were achieved. Percentage circumference increases in swelled test samples and in all rectified/ patients' prostheses were then compared to validate the effectiveness of the method. Circumference increases in the test samples after each 2 coats were significantly different (P <.001). Representative (unreinforced) Samples 1, 2, and 3 recorded circumferential increases of 4.0% to 11.4% within 30 minute after swelling by 2.6% to 9.7% from 2 to 6 oil coats. This largely correlated with patient data, where circumferential increases of 3.6% to 9.5% from 2 to 6 oil coats were collectively recorded in all fit-rectified finger prostheses. Swelling in the expanded proximal segment of all 24 finger prostheses was estimated to be within 9.7%. Of these, 22 (92%) required 2 to 4 oil coats, inferring a lower still swelling of 6.5%. The rapid and consistent elastomer expansion enabled prosthetic fit rectification to be achieved in a much shortened time. Clinical outcomes indicated that low swelling magnitudes involving small amounts of 2 to 6 brush-coats of oil have no adverse effects on the prostheses. None of the participating patients had reported any incidence of discernible change in all of the important properties of their prostheses. Outcomes based on the CosmesilTM-KF-96A-10CS elastomer-oil combination demonstrated that controlled silicone swelling involving minimal use of oil is an effective method of intervention for a tighter-than-tolerated prosthetic fit of silicone hand and fingers.

Pedicled Osteo-Onchyocutaneous Island Flap for Finger Macrodactyly: A Review of Literature.

We present a case of middle finger macrodactyly reconstructed in a single stage using multiple techniques. We elevated a pedicled osteo-onychocutaneous island flap, excised the remnant distal phalanx with a segment of 1 digital nerve and skin over the dorsum of the middle phalanx, performed epiphysiodesis and reduction of the middle phalanx as well as soft-tissue debulking, and inset the flap over the dorsum of the middle phalanx. Follow-up at 12 months revealed a satisfactory aesthetic and functional outcome.

Prosthetic fitting in a double-digit amputation with concomitant postoperative shortening and contracture of the adjacent digits: optimizing aesthetic and functional outcomes.

This report discusses the considerations behind the special modifications made on the finger prostheses fitted for a patient with crushed index, middle, ring, and little fingers resulting in a double-digit amputation with significant postoperative scarring, discoloration, shortening, and contracture of the salvaged index and middle fingers. The deformity and discoloration of the salvaged fingers were factored into the approach taken in the planning, fabrication, and fitting of prosthesis for the amputated digits. Length reduction with increased flexion planned into the prostheses, in addition to color matching them in two different shades, contributed to good aesthetic and functional outcomes.

3D-printed Poly-Lactic Co-Glycolic Acid (PLGA) scaffolds in non-critical bone defects impede bone regeneration in rabbit tibia bone.

BACKGROUND: An increasing number of bone graft materials are commercially available and vary in their composition, mechanism of action, costs, and indications. OBJECTIVE: A commercially available PLGA scaffold produced using 3D printing technology has been used to promote the preservation of the alveolar socket after tooth extraction. We examined its influence on bone regeneration in long bones of New Zealand White rabbits. METHODS: 5.0-mm-diameter circular defects were created on the tibia bones of eight rabbits. Two groups were studied: (1) control group, in which the bone defects were left empty; (2) scaffold group, in which the PLGA scaffolds were implanted into the bone defect. Radiography was performed every two weeks postoperatively. After sacrifice, bone specimens were isolated and examined by micro-computed tomography and histology. RESULTS: Scaffolds were not degraded by eight weeks after surgery. Micro-computed tomography and histology showed that in the region of bone defects that was occupied by scaffolds, bone regeneration was compromised and the total bone volume/total volume ratio (BV/TV) was significantly lower. CONCLUSION: The implantation of this scaffold impedes bone regeneration in a non-critical bone defect. Implantation of bone scaffolds, if unnecessary, lead to a slower rate of fracture healing.

Secondary Procedures after Severe Upper Extremity Injury.

Upper extremity trauma is one of the most common types of injuries, accounting for 20 to 40 percent of injured patients presenting to the emergency department. In severe upper extremity injury, the likelihood of secondary procedures to improve function and resolve outstanding clinical problems is high. Secondary procedures are performed later than initial primary surgery, usually after wound healing and with a discernible time gap of days, weeks or occasionally longer. They should be considered as separate procedures from the primary surgery, with due diligence given to planning for it. When approaching secondary procedures, the key principles are anchored in early preparation, patient engagement, optimal timing and sequencing, reviewing and considering alternatives, and finally knowing when to stop. Although secondary procedures after upper extremity injuries can be a complex undertaking, the careful application of these principles and considerations will optimise outcomes.

Randomized controlled trial comparing the effectiveness of mass and spaced learning in microsurgical procedures using computer aided assessment.

Spaced-learning refers to teaching spread over time, compared to mass-learning where the same duration of teaching is completed in one session. Our hypothesis is that spaced-learning is better than mass-learning in retaining microsurgical suturing skills. Medical students were randomized into mass-learning (single 8-h session) and spaced-learning (2-h weekly sessions over 4 weeks) groups. They were taught to place 9 sutures in a 4 mm-wide elastic strip. The primary outcome was precision of suture placement during a test conducted 1 month after completion of sessions. Secondary outcomes were time taken, cumulative performance, and participant satisfaction. 42 students (24 in the mass-learning group; 18 in spaced-learning group) participated. 3 students in the spaced-learning group were later excluded as they did not complete all sessions. Both groups had comparable baseline suturing skills but at 1 month after completion of teaching, the total score for suture placement were higher in spaced-learning group (27.63 vs 31.60,p = 0.04). There was no statistical difference for duration and satisfaction in either group. Both groups showed an improvement in technical performance over the sessions, but this did not differ between both groups. Microsurgical courses are often conducted in mass-learning format so spaced learning offers an alternative that enhances retention of complex surgical skills.

A Comparison of Casting Versus Splinting for Nonoperative Treatment of Pediatric Phalangeal Neck Fractures.

BACKGROUND: Phalangeal neck fractures account for 13% of pediatric finger fractures. Al Qattan type I (undisplaced) fractures are treated nonoperatively. There is increasing evidence that Type 2 (displaced) fractures achieve remarkable fracture remodeling with nonoperative treatment and patients frequently make a full functional recovery. The options available for nonoperative management of these fractures are either a plaster cast or a removable splint. We hypothesized that there would be no significant difference in radiologic outcome in pediatric phalangeal neck fractures (Types I and II) treated with splint or cast immobilization. METHODS: This is a retrospective study of patients aged 18 and below with phalangeal neck fractures treated nonoperatively from 2008 to 2017. Radiographs were compared at <1 week and >3 weeks after injury. Translation and angulation in coronal and sagittal planes were measured and compared using Student t tests. Baseline variables were compared using χ or Fisher exact tests. RESULTS: There were 47 patients with phalangeal neck fractures treated nonoperatively during the study period. There were 9 type I and 38 type II fractures. The mean age was 10 years with 40 males and 7 females. Fractures occurred in 33 dominant and 14 nondominant hands and involved 29 proximal and 18 middle phalanges. Nineteen children were treated in casts and 28 with removable splints. The mean duration of follow-up was similar between the 2 groups. The most affected phalanx was the proximal phalanx of the small finger and the most common fracture pattern was type IIA. There was no significant difference in clinical and radiologic outcomes between children who were treated in casts and those treated in removable splints. CONCLUSION: There was no difference in the clinical and radiologic outcomes in pediatric phalangeal neck fractures treated with cast or splint immobilization. Splinting has the added benefits of increased comfort and hygiene and we routinely offer splinting as a viable alternative in the nonoperative treatment of Al Qattan type I and type II phalangeal fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Level III-therapeutic studies.