PRS Journal Club: Evolving Paradigms in Hand Surgery

Hand surgery has experienced tremendous growth over the last several decades. Although many cornerstone principles have been established and remain foundational to the field, paradigms continue to evolve in the effort to improve care delivery. In the August of 2025 edition of the PRS Journal Club, we discuss 3 examples of paradigm shifts in hand surgery: evolving practice settings, patient transfer protocols, and management of amputated digits. In the first article, “Interfacility Competition and Its Impact on Cost of Carpal Tunnel Release,” Rivedal et al.1 analyzed how health care market characteristics influenced the cost of carpal tunnel release (CTR) and evaluated how health care market competition and facility availability affected out-of-pocket expenses and total insurer payment. Among the many CTR trends uncovered in this study, the authors discovered a variation in health care costs based on practice setting. Decreases in hospital outpatient department market competition were significantly associated with decreases in out-of-pocket expenses and total insurer payment, whereas a decrease in ambulatory surgery center market competition was only significantly associated with a decrease in total insurer payments. They also found that slightly more CTRs were being performed in outpatient clinics. Indeed, as studies have found that CTR can be performed safely without tourniquet or sedation,2 its ability to be performed in different settings has grown alongside the growth of ambulatory settings in plastic surgery.3 In addition, research has found that pricing variation and lack of transparency exist for CTR, particularly in lower-income areas and areas with increased numbers of uninsured patients.4 These findings encourage further research into not only how interfacility competition affects the costs of CTR, but also how the price of this operation is made available to the patient to enable as much cost transparency as possible. With the second article, we move from analyzing how to reduce health care costs in a common elective hand surgery procedure to investigating how a typical interfacility patient transfer paradigm can be optimized. In “Improving Patient Transfer Quality: A Retrospective Study on a Transfer Center for a Canadian Upper Extremity Revascularization Program,” Arsenault et al.5 investigated how a specialized transfer center using a standardized protocol was able to prevent avoidable patient transfers to a quaternary care center for upper extremity traumatic injuries potentially requiring revascularization. The specialized transfer center was run by dedicated nursing staff who followed a standardized protocol when collecting patient information and communicating findings to the on-call hand surgeon, who then decided whether the transfer was appropriate based on objective and defined criteria. The authors found that implementation of this new transfer center and standardized protocol led to a significant decrease in avoidable transfers, and also allowed for patient transfers directly to the operating room, where they were triaged by a hand surgeon, thus bypassing a potentially unnecessary visit to the emergency department. The potential importance of this dedicated transfer center and standardized protocol is augmented in light of research showing a 33% misdiagnosis of patients at the time of referral to a trauma center for treatment of acute hand injuries,6 as well as a 76% incidence of unnecessary transfers for acute hand-related issues referred to a regional tertiary referral center.7 Furthermore, studies have explored how undesirable insurance or uninsured status has, unfortunately, played a role in unnecessary transfers to tertiary referral centers.8 The implementation of a dedicated transfer center with a standardized protocol to ensure communication of all relevant information in acute hand trauma is a promising intervention with potential widespread effects on optimizing efficiency and use of health care resources. The final article challenges a long-standing paradigm in hand surgery regarding the accepted standard for management after digital amputation. In “Toe Transfers Outperform Replantation after Digit Amputations: Outcomes of 126 Toe Transfers,” Lo and Wei9 compared functional outcomes of toe transfers and replanted digits. Using validated functional scoring systems and patient-reported outcomes measures, the authors found that toe transfers outperformed digit replantation, and that 2-point discrimination, active range of motion, and tripod grip were important factors that drove these improved outcomes. Although replantation has long been the accepted standard for amputated digits that meet established indications, microsurgical toe transfers have emerged as a viable alternative. Multiple methods have been established,10 and successful transfers have been reported in the Journal as early as the 1980s.11 Although prior investigation has shown that hospitals with high replant volumes tend to have a high degree of replantation success with regard to ensuring survival of the replanted digit,12 the present study moves from evaluating microvascular success to analyzing functional outcomes, and encourages the reader to consider elective toe transfer as a competitive alternative to emergent replantation in digital amputations. These 3 articles in the August of 2025 edition of the PRS Journal Club highlight the evolution of hand surgery, as we consider the financial implications of moving carpal tunnel releases to ambulatory surgery centers or clinics, develop specialized centers to prevent avoidable interhospital transfers, and consider the functional outcomes of toe transfers as compared with digit replantation. These studies encourage us to evaluate paradigms in our own hand surgery practices and will surely foster further research to enable continued innovation. DISCLOSURE The authors have no funding sources to disclose. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

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