Optimizing the Use of Operating Rooms by Transitioning Common Hand Surgeries Into the Office Setting.

PURPOSE: The purpose of this study was to examine the true monetary implications, at the health system level, of moving simple hand procedures, performed with wide-awake local anesthesia no tourniquet surgery, from the ambulatory surgery center (ASC) to office setting. METHODS: We analyzed the costs, revenues, case times, and patient demographics for 2 cohorts of patients who underwent hand and non-hand surgical procedures over a 2-year period. We calculated the mean margin per minute for the top 5 procedures in non-hand orthopedic surgery subgroups, complex plastics hand, and non-hand plastic surgery. We then calculated the following: (1) hours operating room or ASC time gained by moving hand procedures to the office, (2) additional subgroup patients theoretically treated by using the ASC hours gained, and (3) net margin (in dollars) because of additional procedures. RESULTS: Six board-certified hand surgeons performed 623 simple ASC and 808 in-office procedures, consisting of 795 carpal tunnel releases, 84 first dorsal compartment releases, and 446 trigger finger releases. The net margin per minute for simple ASC and in-office hand procedures was $25.01/min and $5.63/min, respectively. In the office setting, hand surgery freed up 821 hours of ASC time, which could be theoretically used to treat over 300 additional patients awaiting outpatient orthopedic hand or plastic surgery. Depending on the subspecialty and type of substituted cases, the theoretical net margin varied from -$150,413 to $3.9 million. CONCLUSIONS: Transitioning simple hand operations out of ASCs realized a mean cost savings of 82% per case ($1,137 vs $206) and effectively opened 821 additional hours of operating room time over a 2-year period. CLINICAL RELEVANCE: Transitioning simple hand operations out of the operating room setting and into the office setting reduces the cost of hand surgical care, improves operating room access for alternate procedures or patients, and validates the sustainability of safe and effective wide-awake local anesthesia no tourniquet surgery from a hospital system's financial standpoint.

Actigraphy to Evaluate Changes in Physical Activity After Autologous Breast Reconstruction.

PURPOSE: Early ambulation and return to preoperative (baseline) ambulatory level is protective against postoperative venous thromboembolism. The duration of decreased physical activity after surgery is unknown for most procedures, as surgeons typically estimate physical recovery based on subjective patient reporting. This study aims to quantify the time it takes to return to baseline ambulatory status after breast reconstruction using actigraphy devices. METHODS: Actigraphy devices were used to evaluate preoperative and postoperative physical activity levels in patients undergoing autologous breast reconstruction at a single academic institution. Steps and resting heart rate (HR) were used as metrics of physical activity and physiological state. "Baseline" physical activity was defined by the average daily step count during the 14 days before surgery. "Return to baseline" occurred when the 7-day daily step average was greater than or equal to 95% of their baseline steps. Study participation was considered complete once a patient returned to baseline or surpassed 8 postoperative weeks. RESULTS: From May 2019 to April 2020, 17 patients were enrolled in the study before deep inferior epigastric perforator breast reconstruction. The mean age was 48.2 years and mean BMI was 27.6. This cohort averaged 7908 ± 3271 preoperative steps. Two patients returned to baseline activity by postoperative day 28. In total, 8 patients returned by postoperative week 8. Preoperative resting HR average was 73.5 ± 9.43 beats per minute. The average resting HR was elevated by 2.59%, 4.28%, and 2.31% at weeks 1, 2, and 3, respectively. The 7-day daily average resting HR had normalized by week 4. CONCLUSIONS: Return to baseline physical activity after surgery may take longer than previously perceived, particularly after physiologically demanding surgeries, such as free flap breast reconstruction. These findings indicate that surgeons may underestimate the impact of surgery on physical decline and, consequently, may undertreat with venous thromboembolism prophylaxis.

Plastic Surgery Patient Expectations for Postoperative Opioid Prescriptions.

BACKGROUND: The opioid epidemic is a healthcare crisis perpetuated by analgesic overprescribing. Despite public health attention on this issue, expectations for pain management and opioid use by plastic surgery patients are poorly understood. This study aimed to evaluate patient expectations of postoperative pain, concern for opioid dependence, and anticipated analgesic plan after plastic surgery. METHODS: New patients presenting to an academic plastic surgery clinic were prospectively enrolled from November 2017 to September 2018. These patients completed a preconsultation survey regarding their pain history and anticipated postoperative pain and analgesics regimens. Responses between cohorts expecting and not expecting postoperative opioids were compared using descriptive and univariate analyses. RESULTS: A total of 168 patients (63.9% female, 36.1% male; mean ± SD age 46 ± 17 years) completed the survey before breast (21.9%), cosmetic (5.3%), craniofacial (3.0%), general reconstruction (13.0%), hand (3.0%), and skin and soft tissue (49.1%) surgeries. Twenty-eight percent of patients expected opioid prescriptions. On a standard visual analog scale, patients who expected opioids anticipated greater postoperative pain (6.9 vs 4.6, P < 0.05). They were more concerned about experiencing pain (5.8 vs 4.9, P < 0.05), expected a longer duration of opioid use (63.0% vs 37.0%, P < 0.05), and were less interested in nonnarcotic analgesic alternatives (57.9% vs 19.8%, P < 0.05). CONCLUSIONS: Less than one-third of plastic surgery patients in this study expect opioid pain medications after surgery. This supports broader use of nonopioid, multimodal pain regimens. Identification and management of patient pain expectations, especially among those anticipating a need for opioids, provide a critical opportunity for preoperative education on the benefits of nonopioid analgesics, thus minimizing opiate prescribing.

Reducing Opioid Prescribing After Ambulatory Plastic Surgery With an Opioid-Restrictive Pain Protocol.

BACKGROUND: Opioids are often prescribed in excess, or unnecessarily, after ambulatory surgery. Perioperative opioid stewardships should be a priority with an emphasis on multimodal pain control. METHODS: In this prospective cohort study, prescribing patterns after implementation of an opioid-restrictive pain protocol, Plastic Surgery Initiative to provide Controlled Analgesia and Safe Surgical Outcomes (PICASSO), were compared with historical controls in an academic plastic surgery department. The protocol was initiated on July 1, 2018, and applied to all adult patients undergoing outpatient plastic surgery. Plastic Surgery Initiative to provide Controlled Analgesia and Safe Surgical Outcomes provides an algorithm for analgesic prescribing based on type of surgery and patient factors. A hospital-based pharmaceutical database was used to identify prescriptions, and univariate analyses were used to compare cohorts. RESULTS: The preprotocol and postprotocol cohorts consisted of 539 and 632 patients, respectively. There was no difference in age (48.2 years vs 48.3 years) or sex (72.2% vs 67.8% female). The proportion of patients filling opioid prescriptions went down from 95% to 76% after PICASSO. The total oral morphine equivalent per opioid prescription (217.5 ± 109.5 vs 87.2 ± 43.4) was significantly less in the PICASSO cohort. Additionally, the proportion of patients receiving nonopioid prescriptions, acetaminophen (60.7% vs 86.9%), ibuprofen (8.7% vs 74.2%), and gabapentin (23.6% vs 57.9%), increased significantly. Opioid refill rates were not increased after implementation (9.1% vs 7.3%, P = 0.35). CONCLUSIONS: The PICASSO pain protocol resulted in a 20% decrease in opioid prescriptions and a 2.5-fold decrease in the oral morphine equivalent per prescription, equivalent to eighteen 5-mg oxycodone pills. This opioid-restrictive protocol can improve the analgesic prescribing culture in a plastic surgery department.

Effect of Posthospital Syndrome on Discharge Disposition and Healthcare Utilization After Primary Total Joint Arthroplasty.

BACKGROUND: The aim of this study is to evaluate the impact of posthospital syndrome (PHS), a physiologically deconditioned state experienced by patients after hospitalizations, on postoperative healthcare utilization and discharge disposition following total hip (THA) and knee (TKA) arthroplasty. METHODS: Insurance claims from the Truven MarketScan Databases were used to perform this cross-sectional study of patients who underwent unilateral, primary THA or TKA between January 2010 and December 2016. PHS, defined as a hospitalization within 90 days before surgery, and non-PHS cohorts were compared. Multivariable logistic regression analyses were used to identify risk of postoperative discharge to an extended care facility (ECF), hospital readmissions, and emergency department visits within 90 days. RESULTS: This study included 115,465 THA and 190,398 TKA patients who underwent elective surgery for osteoarthritis. PHS was identified in 1.9% and 1.6% of cohorts, respectively, and was more common in patients with higher comorbidities. The PHS cohort had higher crude rates of discharge to ECF (THA 38.8% and TKA 33.8%) and readmissions (21.8% and 18%). Adjusted odds ratios showed that PHS increased risk of disposition to ECF (THA 1.9 and TKA 1.4), readmission (2.8 and 2.0), and emergency department encounters (1.6 and 1.4). Among PHS patients, acute hospitalizations within 30 days of surgery and those lasting greater than 5 days had the highest risk of postoperative healthcare utilization. CONCLUSION: In this study of commercially insured patients, those with an acute hospitalization within 90 days before elective total joint arthroplasty were nearly twice as likely to be discharged to an ECF and twice as likely to be readmitted in the global postoperative period.

Risk Factors for Undergoing Elective Abdominal Contouring Surgery Shortly After Hospitalization.

BACKGROUND: Having posthospital syndrome (PHS) at the time of an elective surgery increases the risk of postoperative adverse outcomes. The purpose of this article was to identify incidence and risk factors for having PHS at the time of abdominal contouring surgeries. METHODS: Insurance claims from the Truven MarketScan Databases were used to identify patients who underwent outpatient abdominoplasty, liposuction, or panniculectomy between April 2010 and August 2015. Patients were presumed to have PHS if they were hospitalized within 90 d before surgery. Incidence rates of having PHS were calculated for patient groups defined by demographic data and comorbidities. Statistical inference based on adjusted odds ratios was used to evaluate the association of potential risk factors with PHS. A nonparametric regression method was used to demonstrate nonlinear effects of patient covariates on the risk of PHS. RESULTS: This study included 18,947 patients who underwent abdominal contouring; 77% were female, and the mean age was 48.7 y (SD = 14.7). Six percent (n = 1045) of patients had PHS at the time of surgery. A significantly stronger association with PHS (P < 0.001) was observed in patients with deep venous thrombosis (adjusted odds ratio = 3.56), Elixhauser score > 8 (3.28), and smokers (2.16). Age was found to have a piecewise linear effect on PHS, with odds increasing by 2.1% per year over the age of 45 y. CONCLUSIONS: Older patients have an increased risk of undergoing abdominal contouring surgery in a deconditioned state. Screening at-risk populations for PHS would help identify patients who need rehabilitation before operative intervention.

Effect of Posthospital Syndrome on Health Care Utilization After Abdominal Contouring Surgery.

BACKGROUND: Posthospital syndrome (PHS) is a transient condition after acute hospitalizations when patients are physiologically deconditioned. The objective of this study was to determine if having PHS at the time of abdominal contouring surgery increased the incidence of postoperative adverse medical events. METHODS: We conducted a retrospective cohort study of patients enrolled in the MarketScan Databases who underwent outpatient functional or cosmetic abdominal contouring surgery (ie, abdominoplasty, liposuction, or panniculectomy) from April 2010 to August 2015. Patients were separated into 2 groups based upon PHS exposure, defined by hospitalization within 90 days before surgery. Differential health care utilization within 30 days after surgery was compared between cohorts. RESULTS: Among the 18,947 patients included in the final cohort, 1045 patients (6%) had PHS at the time of abdominal contouring surgery. Patients with PHS experienced more emergency department visits (0.16 vs 0.08 visits; adjusted odds ratio, 1.60; P < 0.001) and more episodes of hospitalization (0.11 vs 0.04 episodes; adjusted odds ratio, 1.70; P < 0.001) within 30 days postoperatively. The mean unadjusted health care utilization after abdominal contouring surgery for patients with PHS was US $7888 (SD, 17,659) versus US $2943 (SD, 9096) in patients without PHS. After controlling for confounders, such as comorbidity burden, PHS was associated with US $3944 greater cost than patients without PHS (P < 0.001). CONCLUSIONS: Among patients undergoing outpatient abdominal contouring surgery, having PHS increased the incidence of adverse medical events requiring medical attention in the 30-day postoperative period. These findings support the inclusion of PHS in preoperative evaluation and preparation for patients seeking abdominal contouring surgery.

Perioperative Antibiotics for Clean Hand Surgery: A National Study.

PURPOSE: Given that surgical site infections remain a common performance metric in assessing the quality of health care, we hypothesized that prophylactic antibiotics are overutilized in soft tissue hand surgery when antimicrobials are not indicated. METHODS: We studied insurance claims from the Truven MarketScan Databases to identify patients who underwent 1 of 5 outpatient hand surgery procedures: open or endoscopic carpal tunnel release, trigger finger release, de Quervain release, and wrist ganglion excision between 2009 and 2015 (n = 305,946). Hospital payment claims for preoperative intravenous antibiotics and prescriptions filled for postoperative oral antibiotics were analyzed. We examined the rate and temporal trend of prophylactic antibiotics use and identified risk factors using multivariable logistic regression. We also calculated health care expenditures related to prophylaxis. RESULTS: Prior to surgery, 13.6% (2009-2015) of patients received prophylactic intravenous antibiotics and trend analysis showed a statistically significant increase from 2009 (10.6%) to 2015 (18.3%), an increase of 72.5%. Preoperative prophylaxis was used most often prior to trigger finger release (17.5%) and least often prior to endoscopic carpal tunnel release (11.2%). Younger age, male sex, lower income, and obese patients had higher odds of receiving antibiotics. The total charge of prophylactic antibiotics medication used in this study equaled $1.6 million. CONCLUSIONS: In 2015, prophylactic intravenous antibiotics were administered to nearly 1 in 5 patients prior to clean soft tissue hand surgery. Although consensus guidelines indicate prophylaxis is not indicated, their use has increased steadily in the United States from 2009 to 2015. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Vascularized Composite Tissue Spare Part Transfer for Central Hand Defect Reconstruction: Case Report.

Injuries to the hand with loss of joints, tendons, nerves, and soft tissue may require complex, innovative reconstructive techniques to achieve a favorable functional and aesthetic outcome. We present a case of a manual laborer who sustained a multifaceted injury from a metal press machine with loss of composite structures including the middle and ring finger metacarpophalangeal joints, flexor and extensor tendons, digital nerves, and dorsal/volar soft tissues. Reconstruction included using the spare parts technique for transferring his ring finger proximal interphalangeal joint as a pedicle to reconstitute the missing metacarpophalangeal joint of his middle finger. The soft tissue from the ring finger was rearranged to provide aesthetic coverage of the hand with like-to-like reconstruction of the glabrous and nonglabrous skin.

Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures.

PURPOSE: To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States. METHODS: We studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N = 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression. RESULTS: In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use. CONCLUSIONS: Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States. CLINICAL RELEVANCE: The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures.

The quality of control groups in nonrandomized studies published in the Journal of Hand Surgery.

PURPOSE: To evaluate control group selection in nonrandomized studies published in the Journal of Hand Surgery American (JHS). METHODS: We reviewed all papers published in JHS in 2013 to identify studies that used nonrandomized control groups. Data collected included type of study design and control group characteristics. We then appraised studies to determine whether authors discussed confounding and selection bias and how they controlled for confounding. RESULTS: Thirty-seven nonrandomized studies were published in JHS in 2013. The source of control was either the same institution as the study group, a different institution, a database, or not provided in the manuscript. Twenty-nine (78%) studies statistically compared key characteristics between control and study group. Confounding was controlled with matching, exclusion criteria, or regression analysis. Twenty-two (59%) papers explicitly discussed the threat of confounding and 18 (49%) identified sources of selection bias. CONCLUSIONS: In our review of nonrandomized studies published in JHS, papers had well-defined controls that were similar to the study group, allowing for reasonable comparisons. However, we identified substantial confounding and bias that were not addressed as explicit limitations, which might lead the reader to overestimate the scientific validity of the data. CLINICAL RELEVANCE: Incorporating a brief discussion of control group selection in scientific manuscripts should help readers interpret the study more appropriately. Authors, reviewers, and editors should strive to address this component of clinical importance.

Addressing medical errors in hand surgery.

Influential think tanks such as the Institute of Medicine have raised awareness about the implications of medical errors. In response, organizations, medical societies, and hospitals have initiated programs to decrease the incidence and prevent adverse effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error by a physician is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain physician-patient trust. Furthermore, equipping hand surgeons with a guide for addressing medical errors will help identify system failures, provide learning points for safety improvement, decrease litigation against physicians, and demonstrate a commitment to ethical and compassionate medical care.

The clinical implications of the oblique retinacular ligament.

The oblique retinacular ligament originates from the flexor tendon sheath, courses past the proximal interphalangeal joint, and merges with the lateral extensor tendon. There has been disagreement regarding the contribution of the oblique retinacular ligament to coordinated movements between the proximal and distal interphalangeal joints. Landsmeer postulated that it acts as a dynamic tenodesis that tightens with proximal interphalangeal joint extension, causing obligatory distal interphalangeal joint extension. However, studies have shown that the oblique retinacular ligament is variably present and often attenuated, which diminishes its presumed role in finger movement. Despite this, the concept of a checkrein linking interphalangeal joint motion heralded the development of effective and reproducible surgical interventions for swan-neck and mallet deformities. This article examines the controversy regarding the existence of the oblique retinacular ligament, its plausible functionality, and clinical implications in the practice of hand surgery.

Revision Thumb Carpometacarpal Arthroplasty.

Revision thumb carpometacarpal (CMC) arthroplasty alleviates persistent pain and instability after nonimplant or implant CMC arthroplasty. Metacarpal subsidence onto the scaphoid causing impingement, missed diagnosis such as scaphotrapezoid arthritis, and metacarpophalangeal hyperextension are common causes of failed CMC arthroplasty. Literature shows that revision CMC arthroplasty has satisfactory outcomes. Currently, the mantra of revision is to restore the metacarpal height and treat concomitant pathology, but no single operation is a universal solution. Revision CMC arthroplasty has a relatively high complication rate, lower patient satisfaction than primary CMC arthroplasty, and may result in the need for further operative intervention.

Innovation in Delivering a Live, Virtual Cadaver Dissection Course.

SUMMARY: The availability of advanced telecommunication technology and the social restrictions introduced by a global pandemic have compelled the medical community to explore new avenues of surgical education. Although cadaver courses have long been a fundamental method for learning surgical anatomy and improving operative preparedness, the COVID-19 pandemic has made traditional dissections less practical. The need for quality virtual learning experiences motivated the authors to design and assess the feasibility of organizing a live, virtual upper extremity peripheral nerve cadaver dissection course. Three phases were critical when developing the course: preplanning, planning, and execution. The success of the live, virtual cadaver dissection depended not only on a detailed curriculum, but the technological audio-video-internet needs to effectively communicate and interact with the viewers. Virtual learning mitigates the risks of in-person dissection courses during a global pandemic and can be enhanced with interactive media (e.g., illustrations and schematics) to augment learning experiences.

Trigger Finger Corticosteroid Injection With and Without Local Anesthetic: A Randomized, Double-Blind Controlled Trial.

Background: The first-line treatment for trigger finger is a corticosteroid injection. Although the injectable solution is often prepared with a local anesthetic, we hypothesize that patients receiving an injection with anesthetic will experience more pain at the time of injection. Methods: C Patients with trigger finger were prospectively randomized into 2 cohorts to receive triamcinolone (1 mL, 40 mg) plus 1% lidocaine with epinephrine (1 mL) or triamcinolone (1 mL, 40 mg) plus normal saline (1 mL, placebo). Both patient and surgeon were blinded to the treatment arm. The primary outcome was pain measured using a (VAS) immediately following the injection. Results: Seventy-three patients with a total of 110 trigger fingers were enrolled (57 lidocaine with epinephrine and 53 placebo). Immediate postinjection pain scores were significantly higher for injections containing lidocaine with epinephrine compared with placebo (VAS 3.5 vs 2.0). Conclusions: In the treatment of trigger finger, corticosteroid injections are effective and have relatively little associated pain. This study shows there is more injection-associated pain when lidocaine with epinephrine is included with the corticosteroid. Therefore, surgeons looking to decrease injection pain should exclude the anesthetic, but they should discuss the trade-off of foregoing short-term anesthesia with patients. Using only a single drug (ie, corticosteroid alone) is not only less painful but is also more simple, efficient, and safe; this has therefore become our preferred treatment method.

Effect of Time to Hand Therapy following Zone II Flexor Tendon Repair.

This population-based study aimed to define how time to hand therapy following isolated zone II flexor tendon repairs impacts complications and secondary procedures. METHODS: Insurance claims from the Truven MarketScan Databases were used to evaluate outcomes after isolated zone II flexor tendon repairs between January 2009 and October 2015. Cohorts differing in time to hand therapy were compared to evaluate the impact on complications, reoperation, and number of therapy sessions. Secondary outcomes analyzed how the number of therapy sessions affected rates of reoperation. RESULTS: Hand therapy was identified in 82% of patients (N = 2867) following tendon reconstruction. Therapy initiation occurred within 1 week, 1-4 weeks, and after 4 weeks in 56%, 35%, and 9% of patients, respectively. Univariate analysis showed no difference in non-tendinous complications (27%, 30%, 29%; P = 0.29) or tendon rupture rates (13%, 13%, 10%; P = 0.42) within 90 days between cohorts. Multivariable analysis showed no difference in rates of tenolysis (6.3%, 6%, 4.4%; P > 0.01). In the early initiation cohort, >23 hand therapy sessions were associated with the highest rates of tenolysis (19%). CONCLUSIONS: Despite being a common fear of hand surgeons, early initiation of hand therapy was not associated with increased tendon rupture rates. Although delayed therapy is a concern for tendon scarring, it did not confer a higher risk of tenolysis. Complication rates do not appear to correlate with timing of hand therapy. Therefore, hand surgeons should promote early mobility following isolated flexor tendon injuries given the known functional outcome benefits.

Treating hand and foot osteoarthritis using a patient's own blood: A systematic review and meta-analysis of platelet-rich plasma.

BACKGROUND: This study summarizes all literature investigating platelet-rich plasma (PRP) in the treatment of osteoarthritis of the hands and feet. MATERIALS & METHODS: This is a PRISMA compliant systematic review of 7 databases and includes a meta-analysis of randomized controlled trial (RCT) data on pain and function. RESULTS: Nine articles were included in the review. Meta-analysis of 4 RCTs shows PRP significantly improves pain and function versus control. More results are significant at longer duration follow-up. CONCLUSIONS: PRP improves pain and function of osteoarthritis. Heterogeneity and risk-of-bias limit current data, requiring more RCTs to determine any regenerative potential of PRP. PROSPERO SYSTEMATIC REVIEW REGISTRATION NUMBER: 136582.

Revascularization and Replantation in the Hand: Presurgical Preparation and Patient Transfer.

Replantation of a digit or hand is most successful when performed at a specialized, high-volume center. However, most patients with amputations initially present to local hospitals. Therefore, patients amenable to replantation frequently require expedited transfer to a tertiary center. To maximize success of digit replants, health care providers from both the referring and the referral hospital must be facile and expeditious at transferring the injured patient. The critical aspects of triage include assessment of the injury, patient communication, interfacility communication, preparation of the amputated part and patient, and a timely transfer.

Outcomes Assessment After Hand Burns.

Accurately assessing function and disability after hand burns is imperative to improving the management of patients. The biological, social, and psychological impact of these injuries should be considered. The International Classification of Functioning Disability (ICF) and Health Core Sets for Hand Conditions provides a guide to what should be measured and reported. Although many outcomes measures instruments are available to assess patients with hand or burn injuries, few are validated in the subpopulation of hand burns. Further efforts are required to investigate the ability of current assessment instruments to evaluate hand burn outcomes within the ICF framework.