Outcomes of single digit replantation for amputation proximal to the flexor digitorum superficialis insertion: A systematic review with meta-analysis.

BACKGROUND: A single digit amputated proximal to the flexor digitorum superficialis (FDS) insertion is a relative contraindication to replantation. The aim of this study is to conduct a systematic review on replantation of these injuries to synthesize best available evidence on outcomes. METHODS: This review was registered in PROSPERO under registration number CRD42021277305. A MEDLINE, CENTRAL, and EMBASE databases search yielded 1536 studies. Primary clinical studies on single digit replantation and functional outcome with at least 10 cases were included. Data on revision amputation and replantation distal to the FDS were collected as comparators. Data extracted included demographics, type of digit, level of injury, secondary surgeries, duration of sick leave, survival, function, and patient-reported outcomes. All studies were assessed using the Risk of Bias In Non-randomized Studies of Intervention (ROBINS-I) tool and data synthesis was completed using RevMan and Microsoft Excel. RESULTS: Six studies representing 182 replanted single digits that were amputated proximal to the FDS insertion were included. The average PIPJ motion of replanted single digits was 50° in those amputated proximal to the FDS insertion compared to 82.5 in those amputated distal to the FDS. The average Michigan Hand Questionnaire (MHQ) score was 84.78 in replantation group versus 76.81 in the amputation group which was statistically significant (p < .00001). Mean Disability of Arm, Shoulder, and Hand Questionnaire (DASH) score was 12 in replantation group compared to 18.5 in amputation group, however this was not statistically significant (p = .17). CONCLUSION: Few studies exist on outcomes of single digit replantations proximal to FDS insertion. Although range of motion is inferior in the replant group, this has increased since initial studies were performed, and patient satisfaction and patient reported outcomes are high. This is promising evidence for achieving reasonable outcomes in replantation of single digits amputated proximal to the FDS. LEVEL OF EVIDENCE: Level III.

The Role and Duty of Global Surgery in Increasing Sustainability and Improving Patient Care in Low and Middle-Income Countries.

Global health is one of the most pressing issues facing the 21st century. Surgery is a resource and energy-intensive healthcare activity which produces overwhelming quantities of waste. Using the 5Rs (Reduce, Reuse, Recycle, Rethink, and Research) provides the global surgical community with the pillars of sustainability to develop strategies that are scalable and transferable in both low and middle-income countries and their high-income counterparts. Reducing energy consumption is necessary to achieving net zero emissions in the provision of essential healthcare. Simple, easily transferrable, high-income country (HIC) technologies can greatly reduce energy demands in low-income countries. Reusing appropriately sterilized equipment and reprocessing surgical devices leads to a reduction of costs and a significant reduction of unnecessary potentially hazardous waste. Recycling through official government-facilitated means reduces 'informal recycling' schemes, and the spread of communicable diseases whilst expectantly reducing the release of carcinogens and atmospheric greenhouse gases. Rethinking local surgical innovation and providing an ecosystem that is both ethical and sustainable, is not only beneficial from a medical perspective but allows local financial investment and feeds back into local economies. Finally, research output from low-income countries is minimal compared to the global academic output. Research from low and middle-income countries must equal research from high-income countries, thereby producing fruitful partnerships. With adequate international collaboration and awareness of the lack of necessary surgical interventions in low and middle-income countries (LMICs), global surgery has the potential to reduce the impact of surgical practice on the environment, without compromising patient safety or quality of care.

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.

Bilateral Vocal Cord Fibrosis: A Delayed Complication of Button Battery Ingestion.

A 14-month-old girl initially presented to the Accident and Emergency (A&E) department following a choking episode and subsequent vomiting. The child left the department before being seen but re-presented the following morning with stridor, drooling, and increased work of breathing. A chest and lateral neck soft tissue X-ray performed in the A&E department revealed an ingested button battery in the oesophagus. Emergency oesophagoscopy was performed and a 22 mm button battery was removed from the oesophagus at the level of the cricopharyngeus muscle, with no immediate complications. Following extubation, the patient was initially well but later required a prolonged hospital stay due to recurrent episodes of stridor, voice changes and aspiration pneumonia. Follow-up microlaryngoscopy and laryngeal electromyography (EMG) diagnosed bilateral vocal cord palsy and cricoarytenoid fibrosis. This case highlights the need for increased public awareness, urgent diagnosis and standardised management of battery ingestion, and discusses the potential for the development of serious latent complications.

Quantifying the Limitations of Clinical and Technology-based Flap Monitoring Strategies using a Systematic Thematic Analysis.

BACKGROUND: Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly reported limitations of these techniques in clinical practice. METHODS: A systematic review was conducted according to PRISMA guidelines using MEDLINE, EMBASE, and Web of Science with search criteria for postoperative free flap monitoring techniques. Search results were independently screened using defined criteria by two authors and a senior clinician. Limitations of the techniques found in the discussion section of eligible articles were recorded and categorized using thematic analysis. RESULTS: A total of 4699 records were identified. In total, 2210 articles met the eligibility criteria and were subsequently reviewed, with 195 papers included in the final analysis. The most frequently reported limitations of clinical monitoring were interpretation requiring expertise (25% of related papers), unsuitability for buried flaps (21%), and lack of quantitative/objective values (19%). For noninvasive technologies, the limitations were lack of quantitative/objective values (21%), cost (16%), and interpretation requiring expertise (13%). For invasive technologies, the limitations were application requiring expertise (25%), equipment design and malfunction (13%), and cost (13%). CONCLUSIONS: This is the first systematic review to quantify the limitations of different flap monitoring techniques, as reported in the literature. This information may enhance the choice in monitoring strategy for a reconstructive service, and inform the development and refinement of new flap monitoring technologies.