Abstract
Modern hand surgery is thought to have its beginnings during World War II when the Surgeon General of the United States Army asked his civilian general surgical colleague Dr. Sterling Bunnell, who had a special interest and experience in hand reconstruction, to train military surgeons in the management of hand injuries to treat the war casualties (Azoury et al., 2020).
Over many decades, hand surgery has evolved significantly and with it the complexity of surgical procedures. While advances in surgical techniques and technology have improved outcomes in hand surgery, complications can and do still occur, impacting patient recovery and long-term hand function. Understanding and addressing these complications is a critical aspect of patient care and surgical advancement. The Journal has dedicated this Special Issue to the topic of complications in the field of hand surgery.
Complications from hand surgery and how we deal with these complications as a profession vary from country to country. However, there are several common themes, e.g. infection, nerve and vascular injuries, swelling and stiffness, scar-related problems and chronic regional pain syndrome (CRPS), which overlaps different surgical procedures in the hand. While these are all relevant and do impact on the surgical outcomes and patient recovery, the Journal has focused on complications related to surgical treatment of selected topics in hand and wrist surgery, ranging from congenital to soft tissue to bone pathologies, rather than on individual complications. In each article, authors discuss how to avoid as well as deal with these complications should they unfortunately arise in relation to the specific surgical procedures.
The negative impact any surgical complication may have, not only on the patient but also on the operating surgeon, should not be underestimated. As Giddins (2023) points out in his article, the definition of the word ‘complications’ remains ambiguous in the field of surgery, with no clear distinction as to whether the term means a true surgical error or an adverse event. The author proposes a grading in an attempt to quantify the potential impact of that event on the patient, as well as on the surgeon. The article guides us on measures we could adopt as surgeons to mitigate the risks, including the impact of Human Factors in reducing healthcare errors.
Advances in flexor tendon surgery over the last two to three decades, with improvements in suture techniques, concepts in pulley venting and early active flexion rehabilitation, have significantly decreased the complications associated with this procedure (Tang, 2018). In this issue, Chen and Tang (2023) provide an overview of the general as well as site-specific complications including adhesions and joint stiffness, which still remain a problem in hand injuries involving multiple structures. They emphasize the importance of a strong repair to allow early active mobilization to mitigate some of these risks.
Basal thumb arthritis and carpal tunnel syndrome remain the two most common conditions encountered by a hand surgeon. Being common does not necessarily make these any less prone to complications or adverse outcomes. The article by Sprangers et al. (2023) is an up-to-date review of intraoperative and postoperative complications associated with both open and endoscopic carpal tunnel release and should remind us of the possible adverse outcomes when performing even the most common hand surgical procedure that many, particularly outside the field of hand surgery, often take for granted as ‘minor’ procedures.
While excision arthroplasty remains the gold standard for trapeziometacarpal arthritis, joint-preserving procedures are increasingly getting popular. The list of complications for basal thumb arthritis can vary based on the primary procedure undertaken, and the article by Herren (2023) on complications and management of popular procedures for basal thumb arthritis provides a step-by-step approach on how to deal with ongoing symptoms or complications after different treatment interventions. It is important to appreciate different causes for ongoing symptoms after each of these interventions. Equally, one should understand that the majority of these symptoms do settle over a period of time and any revision procedure, particularly for resection arthroplasty, should be delayed for at least 6 months to 1 year to allow time for the natural resolution of symptoms.
Although there is no real evidence to suggest surgical fixation has any significant benefits over non-operative treatment of distal radial fractures in the elderly age group, there is an upward trend globally towards operative intervention for the management of these injuries. Townsley et al. (2023) discuss the general as well as specific risks from surgical treatment based on the time delay after the operative procedure. Tendon-related complications during the early stages can be minimized by taking precautions when drilling and measuring for screw placement. While stable fixation and early mobilization reduces postoperative stiffness, suboptimal reduction should be avoided to decrease the risk of hardware problems and post-traumatic arthritis.
The paper by Boeckstyns and Herzberg (2023) focuses on the realistic outcomes and problems associated with total wrist arthroplasty. Problems of instability have improved with changes in implant design but periprosthetic osteolysis as a result of wear particles and stress shielding may result in aseptic loosening of the components. Wrist arthrodesis provides a much more predictable solution to failed implant than a revision arthroplasty.
Cultural differences in tolerance to accept traumatic fingertip amputations play a significant part in the variation of replantation rates between Eastern and Western societies. Chen and Tang (2023) divide the postoperative complications into four stages based on the time delay after the replantation procedure and consider the treatment options for each, with vascular compromise seen within the first 7 days (Stage 1) still considered the most critical complication after digit replantation.
With the evolution of arthroscopic wrist surgery, management of triangular fibrocartilage complex pathologies has advanced. The risks of nerve and tendon injury remain the commonest due to the proximity of these structures to the surgical field. Meticulous attention when making skin incisions for portals and judicious use of radiofrequency probes should be followed as observed by Mak and Ho (2023).
Hovius and Kruit (2023) looked at complications after surgery for radial polydactyly, which is one of the commonest congenital hand differences in children. Different classifications can affect the assessment of complications and authors discuss strategies to reduce the incidence of short- and long-term complications. They make a good case for centralizing care of these individuals in larger centres to improve the outcomes and reduce complications after corrective surgery.
Complications in hand surgery will happen. Surgical perfection remains an illusion, and even in the best hands, these complications do arise. Functional limitations as a result of these adverse events can be disheartening for patients. Although the focus of this Special Issue is on the complications themselves, as a profession we should be focusing more on how to avoid those complications happening in the first place. Substantial efforts have been made to improve patient safety and reduce preventable harm within the surgical field, but the challenge of changing the mindset and improving the safety culture at a wider systems level largely remains on us as individual surgeons, by providing a strong leadership within each surgical team (Lark et al., 2018). Clear communication between the patient and surgeon can help to manage expectations and optimize recovery. Adoption of the concept of crew resource management from the commercial aviation industry to improve theatre briefing and effective communication within a team and between teams in healthcare settings has shown a statistically significant improvement in patient safety culture (Hefner et al., 2017).
Hand surgery continues to be a beacon of hope for countless individuals seeking to regain their hand’s form and function. By acknowledging the challenges and complexities inherent in this field, we can work towards improving patient outcomes and advancing the frontiers of hand surgery.