Introduction
Appropriate facilities are essential to the efficient function of a hand surgery service. However, different units vary considerably in terms of the amenities available, the number of hand surgeons, the scope of practice, and their research emphasis. Some are orthopedic-based services, some plastic surgery–based practices, and some encompass a combination of the two specialties. This chapter presents details of several units of differing sizes, in terms of number of hand surgeons and patients, in three different parts of the world: America, Europe, and Asia. They are either plastic or orthopedic surgery–based units. These institutes could be considered representative of the common hand surgery units. Many other prominent units offer training for a particular skillset (e.g., microsurgery, arthroscopy, congenital anomalies), which are not presented here.
This chapter provides a picture of hand practice in private, government, and academic settings, with or without basic research facilities, so any hand surgeons, particularly the younger ones, can find practical information to build or expand their practice. This chapter includes information of unique aspects of national settings in some countries and international education, which may prove useful to those looking to refine their practice system, training, or continuing education.
Hand surgery setting in Saint John, Canada (Donald Lalonde)
General settings
Our hand surgery service has four hand surgeons with a plastic surgery background, trainees, and a hand therapy team. Our hand surgery unit undertakes clinical research projects but is not involved in animal-related basic science research.
Operating hand cases in three settings
We have three facilities for operating on hand cases: (1) A traditional “main” operating theater in the hospital with full sterility and special ventilation. We now do very little surgery in this theater, with cases mostly confined to free tissue transfers, brachial plexus cases, pediatric surgery, permanent implants, major trauma/infection, and fractures requiring major dissection with plate and screw fixation or bone grafting. (2) A minor procedure room in the hospital with no special ventilation. (3) A minor procedure room in the office with no special ventilation. Almost all of our hand surgery is now performed in a minor procedure room. As the setup in the hospital and the office minor procedure rooms is almost identical, these are described as one in the following text.
In our experience, surgical anesthesia outside the main operating theater is as safe as in it. Pure local anesthesia is safer than sedation. Surgery does not cause thromboembolism, malignant hyperthermia, aspiration pneumonia, urinary retention, or overnight admission because of nausea and vomiting. These are all caused by sedation and are all eliminated with wide-awake local anesthesia with no tourniquet (WALANT).
The only two drugs that are given to patients with pure tumescent local anesthesia (WALANT) are lidocaine and epinephrine. These are possibly the two safest drugs given by surgeons, providing they administer safe doses. Billions of doses of this drug combination have been given by dentists since 1948 with no monitoring and a tremendously good safety record. We administer less than 7 mg/kg of 1% lidocaine mixed with 1:100,000 epinephrine to eliminate the need for monitoring in minor procedure rooms. True anaphylaxis to lidocaine is extremely rare, if it exists at all.
If we are doing larger procedures such as skin grafting, forearm tendon transfers, or spaghetti wrists, we mix no more than 50 mL of 1% lidocaine with 1:100,000 epinephrine in 150 to 250 mL of saline to provide a dilute solution of local anesthesia, which provides 3 hours of pain-free operating time.
Many colleagues have questioned whether the incidence of infection is higher with minor procedure room field sterility than with traditional main operating theater full sterility. According to our studies, the answer to this important question is “no” for Kirschner wire insertion. There is also ample evidence that soft tissue surgeries, such as carpal tunnel release, also have a very low infection rate in a minor procedure room setting, which is no worse than that in a main operating theater. The only evidence that special ventilation has any value in decreasing infection rates is in lower-limb joint replacement surgery, where infection has a massively morbid impact on patients. In contrast, infection in soft tissue hand surgery has very minimal morbidity when it does occur, which is very uncommon.
Layout and workflow of the minor procedure room area
We have a reception room with chairs and a receptionist, three injection stretchers in three small injection rooms, two minor procedure rooms, one nurse, and one surgeon (only three healthcare workers). Patients roll up their sleeve and stay clothed. The surgeon injects the first four patients with minimal pain, while the nurse prepares the first patient in one of the two minor procedure rooms. All patients are injected supine to decrease the risk of fainting. The stretchers are capable of Trendelenburg positioning to increase cerebral blood flow to abort impending vasovagal attacks. Most patients feel fine after injection and can go back to sit with their family. The occasional patient with a vasovagal attack is left lying down. This can be achieved with only one stretcher outside one minor procedure room, but the flow is not so efficient and rapid.
By the time the surgeon starts operating on the first patient, at least 30 to 45 minutes have elapsed, achieving total local anesthesia with minimal bleeding. We educate the patient to decrease postoperative complications while we are injecting the local anesthesia, as well as while we are operating.
The hand therapists work nearby making splints and come into the minor procedure room to watch tendon and fracture surgery and to provide postoperative instruction. After the surgery, the patient sits up and goes home directly, as after a dental procedure, without any need for a recovery room.
Equipment in our minor procedure room
Equipment includes (1) 25 basic sets of instruments ( Fig. 1.1 ), so we can comfortably operate on 15 to 20 patients per day. We also have extra instruments wrapped separately ( Box 1.1 ). Other items include (2) A mini C-arm; (3) four Kirschner wire drivers, both electric and battery-operated; (4) a larger ultrasound machine as well as personal portable ultrasound probes that fit on our phone to visualize the soft tissues of the hand ( Figs 1.2 and 1.3 ); and (5) a nitrogen tank to harvest skin grafts with an air dermatome ( Fig. 1.4 ).
- 1.
Use 27- or 30-gauge needles, not big needles.
- 2.
Do not force local anesthetic in quickly! Slow down!
- 3.
Buffer acidic local anesthetic 10 mL:1 mL with 8.4% bicarbonate.
- 4.
Insert the needle perpendicular to the skin.
- 5.
Do not inject into the dermis.
- 6.
Use sensory noise for needle insertion.
- 7.
Inject more than 2 mL before moving the needle at all.
- 8.
Do not advance sharp needle tips anywhere that is not numb.
- 9.
Reinsert needles in numb skin 1–2 cm inside the tumescent border.
- 10.
Always inject too much local anesthetic rather than not enough.
- 11.
Inject enough local anesthetic that you can see it and feel it 2 cm beyond where you will cut or manipulate bones.
- 12.
Ask for patient pain feedback every time so you can ascertain how often they felt pain.
- 13.
Use blunt-tipped cannula injection for large areas.
- 14.
Always inject from proximal to distal.
- 15.
Bathe the bone circumferentially before long bone fixation with plates or wires.
Hand surgery setting in Leuven University hospitals, belgium (Ilse Degreef)
General settings
Our Hand Surgery Unit was created within the Orthopedic and Traumatology Surgery Department of our university hospital in an academic setting. Today, we have four European Board Hand Surgery (EBHS) certified hand surgeons fully appointed to the hospital. To obtain an acceptable quality of life, a sufficiently large team is advisable, certainly if 24/7 availability is required to cover hand trauma (see later in text). We offer one to three fellowships in hand surgery and have a continuous rotation of four subspecialty residents. We cooperate with the plastic surgery department, which does not focus on hand surgery. Through academic appointments at Leuven University (connected to the hospital), we have research groups in hand surgery and a Dupuytren Fund to achieve and provide research funding. Also, all staff members (consultants) have teaching assignments in the biomedical faculty, and we teach students in their theoretical and practical training modules. Also, in collaboration with all of the Belgian universities, we coordinate the Belgian Hand Surgery Certificate (BHSC), a postacademic 2-year training and certification in hand surgery in preparation to obtain the EBHS diploma later.
Subspecialization
All hand surgeons have general training in orthopedics and/or traumatology but focus on hand surgery as their main field of interest. As a tertiary referral center, we undertake all subspecializations within hand surgery: pediatric hand surgery, hand trauma, arthroscopy, arthroplasty, neurosurgery, microsurgery, Dupuytren surgery, and elbow surgery, with a large interdisciplinary network within our hospital.
Outpatient setting
For elective patients, a six-office outpatient department is available to our hand unit for daily primary and secondary referral consultations of hand and elbow pathologies. Registration of the complaints and documentation of the pathology are IT supported with an electronic medical file system. We have available a mobile trolley with measuring instruments: Jamar and Key Pinch dynamometers, sensory discriminators, and wireless ultrasound ( Fig. 1.5 ). Also on this trolley are information brochures on specific hand problems and informed consent forms on current research projects.
For emergency patients, we have a level 1 trauma center, and patients either come directly to the emergency room or are transferred from other hospitals if in need of immediate hand surgical attention. To offer the best possible care, we are a European recognized Hand Trauma and Replantation Center (HTRC) with a 24/7 availability.
A European Certified Hand Therapist and a splint maker are available for any patients needing hand therapy. We also work together with a psychologist specializing in hand (trauma) care and social assistants for reintegration of patients. We have weekly multidisciplinary meetings on Monday to coordinate and optimize reeducation after hand trauma and/or surgery.
Surgery planning
Once a need for surgery is determined and informed consent obtained, patients requiring the help of an anesthesiologist are immediately referred to their (adjacent) preoperative assessment clinic, where a specialist nurse provides necessary information. Admission scheduling is done by the management team, who ensure all surgical requests are resolved before surgery and a date for surgery scheduled in the most suitable theater with the appropriate level of hospitalization, in consultation with the patient and the requesting surgeon. Three days before the procedure, the patient is contacted with the exact hour of admission.
Operative setting
Two main facilities with permanent nursing teams are available in the hospital for hand surgery. Both are equipped with laminar flow systems. Up to four operating rooms can be used for hand surgery simultaneously ( Fig. 1.6 ). Currently, all procedures can be performed in both facilities, and patient flow efficiency has been optimized to make both small ambulatory procedures and larger surgeries possible in both settings. However, the larger facility, originally constructed for inpatients and major procedures, is preferred for complex and elaborate, time-consuming procedures for reasons of infrastructure and nursing expertise. The largest operating room has an emergency standby function for major (hand) trauma.
