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One of the most important factors in ensuring optimal outcomes for hand trauma patients is fast access to microsurgeons trained and able to perform finger replantation. Providing tools on various techniques used for digit replantation can support doctors and specialists to achieve better outcomes with their patients. The aim of the project would be to develop additional virtual surgical simulators specifically designed for microsurgical revascularization skill training and skill maintenance. With the intention of providing an accessible alternative to animal lab simulations. Some common issues of the use of animal based simulation such as the need for general anesthesia, obtaining the animals, and maintaining the animals(Mehrzad et al., 2018). The survey from the NSSH articulates that the surgeons using the lab as a method of training outside of the OR were substantially more comfortable and confident practicing microsurgery(Mehrzad et al., 2018). A realistic example of this would be to build on preexisting interactive virtual simulation in cooperation with foundations such as NSSH to insure a national understanding of the injuries and procedures. Another aspect of the study would be to create an interactive digital map of which hospitals are performing digit replantation and those that don’t provide. The simulator could be adapted for those hospitals that don’t perform replantations on the steps they can take.

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A cross-sectional survey study of 500 ASSH members in 2016 showed 77.7% of respondents agreed or strongly agreed that their training program should have microsurgery training outside of the operating room. As well as only 60% of residents agreed or strongly agreed they were comfortable with the idea of performing microsurgery(Mehrzad et al., 2018).

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Can virtual surgical simulation improve hand trauma care in the United States

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Can virtual surgical simulation improve hand trauma care in the United States

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It is unclear why emergency departments do not have a better understanding of hand trauma transfer protocols that would allow for better outcomes for patients what measures are being taken to address the severe shortage of on-call hand specialists(Maroukis et al., 2016).

Can virtual surgical simulators aid hand-surgeons and provide better outcomes for patients?

Can virtual surgical simulators provide accessible microsurgical training methods to help address the shortage of specialists available?

Can the advancement of virtual surgical simulators provide accessible training methods for microsurgeons who do not feel confident performing microsurgery for digital replantation?

Can virtual surgical simulators establish a reliable database of the various microsurgical techniques used for digit replantation adequate for surgeons needs and give them confidence to attempt and succeed at replantation?

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Low-fidelity simulators to practice and maintain microsurgical skills

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Low-fidelity simulators to practice and maintain microsurgical skills

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Low-fidelity simulation in microsurgery has been used as a method of training and maintaining surgical abilities. Live animal models are considered the gold standard in microsurgery (Javid et al., 2019). In a Simulation-based training and assessment in urological surgery it is highlighted that virtual reality simulators and 3d-printed models should be used to anticipate complex cases(Aydin et al., 2016).

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The American Society for Surgery of the Hand

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The American Society for Surgery of the Hand

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The American Society for Surgery of the Hand or ASSH was founded in 1946 to refine care for hand trauma patients (www.assh.org, n.d.). A survey administered by the ASSH to members includes 1005 survey responses from 2010 and 672 from 2019. The results showed that the number of surgeons with obligatory hand call decreased from 2010 (70%) vs 2019 (50%). There was also an increase in the number of surgeons not taking hand calls in 2010 (18%) vs 2019 (34%).

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Figure 1 Case distribution per hospital type (2001-2014) (Cho et al., 2018).

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Factors such as availability of hand specialists, hospital resources even race/ethnicity or insurance status impact the quality of hand trauma care and therefor hand trauma outcomes(Maroukis et al., 2016).

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In a systematic review of survival and functional outcomes of the replantation of finger avulsion injuries (Sears and Chung 2011) yielded 1398 studies on traumatic amputation or replantation cases. The compiled data showed that avulsion injury replantations have a lower overall survival rate at 66% compared to 80-90% survival rate for general finger replantation. Their study also highlights that there was very little consistency in techniques chosen to perform the revascularization. The lack of information on injury location, technique used as well as missing published date are all limitations to this study.

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In a comparative study of attitudes regarding digit replantation in the US and Japan (Nishizuka et al., 2015) it was found that cost of the procedure and time away from work were the two most common considerations when deciding between amputation and replantation. Appearance was equally as important to the American and Japanese participant's, however the rate of replantation is only decreasing in the US(Sears and Chung 2011).

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For the purpose of this investigation, virtual surgical simulators refers to the use of virtual reality and interactive simulations as a supplemental means of training and maintaining microsurgical skill (Costa, Summa, and Srinivasan 2021).

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Aydin, A., Raison, N., Khan, M.S., Dasgupta, P. and Ahmed, K. (2016). Simulation-based training and assessment in urological surgery. Nature Reviews Urology, [online] 13(9), pp.503–519. doi:10.1038/nrurol.2016.147.

Bamba, R., Malhotra, G., Bueno, R.A., Thayer, W.P. and Shack, R.B. (2018). Ring Avulsion Injuries: A Systematic Review. Hand (New York, N.Y.), [online] 13(1), pp.15–22. doi:10.1177/1558944717692094.

Cho, H.E., Zhong, L., Kotsis, S.V. and Chung, K.C. (2018). Finger Replantation Optimization Study (FRONT): Update on National Trends. Journal of Hand Surgery, [online] 43(10), pp.903-912.e1. doi:10.1016/j.jhsa.2018.07.021.

Costa, F., di Summa, P.G. and Srinivasan, J. (2021). Microsurgery Arena: A New Device to Develop Microsurgical Skills. Plastic and Reconstructive Surgery - Global Open, 9(8), p.e3782. doi:10.1097/gox.0000000000003782.

Davis Sears, E. and Chung, K.C. (2011). Replantation of Finger Avulsion Injuries: A Systematic Review of Survival and Functional Outcomes. The Journal of Hand Surgery, 36(4), pp.686–694. doi:10.1016/j.jhsa.2010.12.023.

Eberlin, K.R., Payne, D.E.S., McCollam, S.M., Levin, L.S. and Friedrich, J.B. (2021). Hand Trauma Network in the United States: ASSH Member Perspective Over the Last Decade. The Journal of Hand Surgery, [online] 46(8), pp.645–652. doi:10.1016/j.jhsa.2021.03.018.

Guillery, M., (2022) 'Ring avulsion illustration [Digital drawing].

Javid, P., Aydın, A., Mohanna, P., Dasgupta, P. and Ahmed, K. (2019). Current status of simulation and training models in microsurgery: A systematic review. Microsurgery, 39(7), pp.655–668. doi:10.1002/micr.30513.

Maroukis, B.L., Chung, K.C., MacEachern, M. and Mahmoudi, E. (2016). Hand Trauma Care in the United States. Plastic and Reconstructive Surgery, 137(1), pp.100e111e. doi:10.1097/prs.0000000000001879.

Mehrzad, R., Prsic, A., Basta, M. and Bhatt, R. (2018). A Cross-Sectional Survey Study among Hand Surgeons in the United States on Standardizing Microsurgery Training. Journal of Hand and Microsurgery, 11(01), pp.035–044. doi:10.1055/s-0038-1669365.

Nishizuka, T., Shauver, M.J., Zhong, L., Chung, K.C. and Hirata, H. (2015). A Comparative Study of Attitudes Regarding Digit Replantation in the United States and Japan. The Journal of Hand Surgery, [online] 40(8), pp.1646–1656, 1656.e1-3. doi:10.1016/j.jhsa.2015.05.026.

www.assh.org. (n.d.). ASSH. [online] Available at: https://www.assh.org/s/.

www.youtube.com. (n.d.). Jimmy Fallon Explains His Finger Injury. [online] Available at: https://www.youtube.com/watch?v=CztT_pBFQv8 [Accessed 23 Oct. 2022].

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Figure 2 Ring avulsion illustration (Guillery 2022)

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This is an illustration of a class two ring avulsion injury

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Ring Avulsion injuries occur when a metal ring on a finger or another appendage and an immobile object meet with speed and force. There are three classes of the injury. Class 1: There is adequate circulation left in the finger Class 2: There is inadequate circulation and Class 3: Complete degloving injury or complete amputation (Bamba et al., 2018). In the United States hand injuries are the most common type of injury treated in emergency departments, they also represent more than 12% of all trauma cases in the US (Maroukis et al., 2016).