Looking at delivering hand surgery in modern-day healthcare systems.

1. Redefining
Hand Surgery Service
Mr Vaikunthan Rajaratnam
MBBS(Mal),AM(Mal),FRCS(Ed),FRCS(Glasg),FICS(USA),
Dip Hand Surgery(Eur), Dip MedEd(Dundee), MIDT Dist. (OUM),
MBA(USA), FHEA(UK), FFST(Ed)
MSSH
20 Oct 2018

2. Auditing the
current state
How are you doing it now?
Why are you doing it this way?
Who are your “enemies”?
What are your obstacles?
When can you make a change?

3. BACKGROUND
“Two Years Experience of Day Case
Emergency Hand Surgery in Birmingham”
(University Hospital Birmingham, 2006)1
•Increased day surgery cases from 4% to
60%
•Estimated saving of 1656 days in 2004/2005
•Complaints fell by 99% reduction
•BSSH recommendation that hand surgery
be delivered via day surgery and regional
anesthesia2
1 Mahon, A. (2006). Two years experience of day-case emergency hand surgery in Birmingham. FESSH Congress, Glasgow.
2 British Society for Surgery of the Hand, 2007. Hand Surgery in the UK manpower, resources, standards and training.

4. OBJECTIVES
• Reduce unnecessary admissions
• Optimize DSOT usage
• Early detection and intervention
• Consultant led and delivered care
• Optimise management in ED

5. Patient presents to A&E
Meets admission criteria?ADMIT
Open injury
Simple Complex
Deliver care in A&E Review by Orthopedics
Book as P4
Consent
Non traumatic, closed injury
Complete Hand referral
form
Benefit from early surgery
Book as P4
Inform patient, Consent
Continue to SOC
No
No
Yes
No
Yes

6. Results
76.45% of unnecessary
admissions avoided
578 bed days saved
48 patients referred to SOC
recruited for early surgery
196.3% increase in DSOT
utilization with 100% consultant
delivered and supervised care
19% of hand injuries settled in
A&E

7. Conclusion
Hand Surgery Referral system
• reduced unnecessary
admissions
• Optimize utilization of
hospital resources
• Improved quality and
safety care
• A scalable and replicable

8. Hand Referral Form

9. MUST ALL OPEN INJURIES IN THE HAND
BE TREATED ACUTELY?
OUR EXPERIENCE WITH OPEN HAND
INJURIES AS ELECTIVE DAY SURGERY
Wei Ping Sim1, Zhiren Benjamin Liang1, Vaikunthan Rajaratnam1
1Department of Hand Surgery, KTPH

10. Study Population
• 232 cases
• Mean age 36.87 years (SD = 14)
Female
(21) 9%
Male (211)
91%
Gender
>1 Region
(2) 1%
Wrist (6)
2%
Hand (19)
8%
>1 Finger
(41) 18%
1 Finger
(164) 71%
Non Open
Fracture
Cases (154)
66%
Open…

11. Types of Surgeries
• Soft tissue
debridement,
tendon repair,
surgical fixation,
terminalisation
and skin grafting
made up >80% of
total cases

12. Time to Surgery
• Time to surgery was
calculated from the
time patient present
at the ED to the time
patient arrive in the
Operating Theatre
2
59
66
71
28
6
0
10
20
30
40
50
60
70
80
<6 6-24 24-48 48-72 72-120 >120
NumberofPatients
Time to Surgery (Hours)
Time to Surgery

13. Results
• 3 cases (1.3%) of deep seated infection with positive cultures intra-operative
SN Diagnosis Operative
Description
Time to
Surgery
(H)
IV
Antibiotics
in ED
Antibiotics on
Discharge from
ED
Cultures Outcome
1 Open bony mallet of
finger
Surgical fixation 47.3 N Augmentin MSSA; E.
Cloacae;
Proteus
Vulgaris
Infection
resolved
2 Ring finger open tuft
fracture, index finger
nail bed laceration
Soft tissue
debridement
9.2 N Clindamycin MSSA;
Strept.
Agalactiae
Infection
resolved
3 Open proximal
phalanx fracture with
cut radial digital nerve
(RDN)
Surgical fixation of
proximal phalanx
fracture and RDN
nerve graft
19.4 Cefazolin Augmentin Citrobacter
Koseri
Finger ray
amputation

14. Conclusion
Delayed timing - did not
impact on outcomes
Treating open injuries-
electively - safe and effective
Optimum pathway of care
delivery

15. WIDE AWAKE SURGERY
SCOPE IN HAND SURGERY USING
SURGEON ADMINISTERED LOCAL/REGIONAL ANAESTHESIA (SALoRA)
Wei Ping Sim1, Shoun Tan1, Vaikunthan Rajaratnam1
1Hand and Reconstructive Microsurgery Service,
Department of Orthopaedic Surgery, KTPH

16. Introduction
• Hand surgeries
local/regional
anaesthesia
• Popularity of WALANT D
Lalonde - 2015
• Our experience of
Surgeon Administered
Local/Regional
Anaesthesia (SALoRA)
without sedation

17. • Elective single trigger finger release
• 71, Chinese, Male
• Chronic medical issues: well controlled DM, HTN, HLD, Brachiofacial
stroke >10years ago, grade II chronic renal impairment
• Total Mepivacaine 88mg with adrenaline 44mcg injected (max
recommended dose 7 mg/kg mepivacaine)
• Developed tachycardia 150-200 intraoperatively
• Required anaesthetist intervention with IV metoprolol
• Operation time – 15 min
Negative Experience with WALANT

18. SALoRA
• Surgeon
Administered
Local/Regional
Anaesthesia
• Local anaesthetic
infiltration without
adrenaline use
• Tourniquet use as
required
• No sedation

19. Study Population
Female,
36% (719)
Male, 64%
(1275)
Gender
Other
Surgerie…
Surgeries
done…
Surgeries during Time Period
Total: 3016
• 1994 surgeries (66%) performed using SALoRA
• Mean age 45.78 years (SD = 16)
• 96% unilateral limb, 4% bilateral upper limbs
Elective,
61%
(1217)
Emergency
, 39%
(777)
Elective vs Emergency Surgery

20. Region of Surgery
Elbow 0% (5)
Forearm 1% (14) >1 Region 1%
(21)
>1
Fingers
4% (80)
Wrist 5%…
Hand 44% (883)
1 Finger 45%
(887)

21. Types of Surgeries
• Trigger finger, soft
tissue debridement,
soft tissue excision,
carpal tunnel
release, surgical
fixation and soft
tissue
reconstruction/repai
r made up >80% of
total cases
performed under
SALoRA

22. Types of Surgeries - Elective
• Trigger finger, soft
tissue excision and
carpal tunnel release
made up >80% of
Elective cases

23. Types of Surgeries - Emergency
• Soft tissue
debridement,
surgical fixation and
soft tissue
reconstruction
made up >80% of
Emergent cases

24. Arm Tourniquet Use
Bilateral, 3%
(66)
Right, 35%
(693)
Left, 30% (598)
No Tourniquet,
32% (637)
• 68% of patients tolerated arm tourniquet
use with no issues
• Longest tourniquet duration: 104min
• Shortest tourniquet duration: 2min
• Median arm tourniquet duration: 20min
• Mean: 24min (SD = 15)

25. Conclusion
SALoRA with tourniquet
• Wide spectrum
• Effective
• Productive
• Optimum resource
management
• Inclusion in curriculum
of hand surgery training

26. Stroke Hand
Service

27. Treatment Options
Non-surgical
1. Tone reduction modalities
a. Medications: muscle relaxants
such as baclofen,
benzodiazepines
b. Injections: Botox
2. Physical Therapy
a. Stretching
b. Adaptive strategies and devices
c. Incorporation of spastic limb in
ADLs
d. Post-op: immobilization,
mobilization, incorporation
3. Orthoses
Surgical
1. Tendon/ muscle procedures
a. Muscle/tendon lengthening
i. Fractional lengthening
ii. Z lengthening
iii. Muscle slide
b. Tendon transfers
2. Joint/Bone procedures
a. Arthrodesis
b. Osteotomy
3. Nerve procedures
a. Neurectomy
4. Amputations
New modalities in red

28. Stroke Hand Service pathway
Referral sources: Post inpatient discharge, Outpatient Stroke-Hand clinic
General spasticity Regional and focal spasticity
Oral agents
Therapist: Exercises and Splints Determine Contracture Versus Spasticity
SpasticityContracture
● Lengthening
procedures
● FDS to FDP transfer
● Osteotomy
● Arthrodesis
Patient has volitional
control?
No
● Observe
● Prevent
contracture
Botox injectionYes
Improvement
seen
● Hyperselective
neurectomy
● Tendon transfer
No improvement
● Observe
● Repeat Botox
● Contracture
release

29. Hot Hand Clinic

30. Total One Stop Hand
Surgery (TOSHS)
Service

31. The ideal
hand service
• How do you want your
service to be?
• Try it out
• Assess and evaluate it
• Use PREM
• Measure the “success”
• Get stakeholder buy in

32. Developing the processes
Research Research the process/outcomes
Get Feedback
Do Do clinical process reengineering
Design Design care pathways

33. The Future
Big Data
Artificial
Intelligence
Robotics
Neural
prosthesis
Community
based
practice
Ergonomics
Prevention

34. Enjoy the experience !