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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 1682–1688

Adapting to the COVID-19 pandemic: A

survey of UK and European hand surgery
units
Abigail V. Shaw a,∗, David G.W. Holmes b, Victoria Jansen c,
Christy L. Fowler d, Justin C.R. Wormald e, Ryckie G. Wade f,
Emma K. Reay g, Matthew D. Gardiner h,i , on behalf of the
#RSTNCOVID Hand Collaborative1
a
Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford
OX3 9DU, UK
b
Department of Orthopaedic Surgery, Leighton Hospital, Mid Cheshire Hospital NHS Foundation Trust,
Middlewich Road, Crewe CW1 4QJ, UK
c
Pulvertaft Hand Centre, University Hospitals of Derby and Burton NHS foundation Trust, Uttoxeter
Road, Derby DE22 3NE, UK
d
Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
e
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS),
University of Oxford, Windmill Road, Oxford OX3 7LD, UK
f
Leeds Institute for Medical Research, University of Leeds, Leeds LS2 9JT, UK

Oral presentation, British Society of Surgery of the Hand Spring Meeting 2021.
1RSTNCOVID Hand Collaborative (alphabetical order)Collaborators: Roger Adlard, Raymond Anakwe, Katerina Anesti, Mohammed Shoaib

Arshad, Richard Baker, Francesco Barberi, James D Bedford, David R Bell, Waseem Bhat, James Carter, Richard Chalmers, Hywel Dafydd,
Anthea R Davy, Marlese P Dempsey, Roisin Dolan, Edmund Fitzgerald O’Connor, Lorenzo Garagnani, Sarali Gonzalez Porto, Jennifer Green-
howe, Catherine A Hernon, Maxim Horwitz, Juliana M F Hughes, Barbara Jemec, Nick Johnson, Alexis Karantana, Tereze Laing, Stephen J
Lipscombe, Alastair Lowrie, Syed S Mannan, Alan Middleton, Adrian Murphy, Samuel E Norton, Gregory O’Toole, Nakul G Patel, Sofija Pejkova,
Jeremy Rodrigues, Simon Richards, Nicholas D Riley, Simon Robinson, Daniel A Shaerf, Jessica Steele, Susan Stevenson, Ryan Trickett, Sarah
C Tucker, Santosh Venkatachalam, Katy L Wallis, Andrew Watts, Emily V West, Michael J Woodruff, Kai Yuen [Link] steering committee
acknowledges the following units for participating in the study: Aberdeen Royal Infirmary, Addenbrooke’s Hospital, Chelsea and Westminster
Hospital, Cumberland Infirmary, Derriford Hospital, Ealing Hospital, Glasgow Royal Infirmary, Guy’s and St Thomas’ Hospital, James Cook
University Hospital, John Radcliffe Hospital, Leeds General Infirmary, Morriston Hospital, Ninewells Hospital, Norfolk and Norwich Univer-
sity Hospital, University Hospital of North Tees, North Tyneside General Hospital, Nuffield Orthopaedic Centre, Ospedale Civile Di Legnano
(Italy), Povisa Hospital (Spain), Queens Medical Centre Nottingham, Royal Bournemouth and Poole Hospitals, Royal Derby Hospital, Royal
Devon and Exeter Hospital, Royal Free Hospital, Royal Oldham Hospital, Royal Preston Hospital, Royal Victoria Infirmary, Salisbury District
Hospital, Southmead Hospital, St Georges’ Hospital, St James’s Hospital, St Mary’s Hospital, St Vincent’s University Hospital, Stoke Man-
deville Hospital, Royal Free Hospital, Leicester Royal Infirmary, University Clinic for Plastic and Reconstructive Surgery Skopje (Macedonia),
University College London Hospital, University Hospital Coventry and Warwickshire, University Hospital of North Durham, University Hospital
of Wales and University Hospital Llandough, Wexham Park Hospital, Whiston Hospital, Wirral University Hospital, Wythenshawe Hospital.
∗ Corresponding author.

E-mail address: [Link]@[Link] (A.V. Shaw).

[Link]
1748-6815/© 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 1682–1688
g
Department of Hand Surgery, James Cook University Hospital, South Tees NHS Foundation Trust,
Marton Road, Middlesborough TS4 3BW, UK
h
Department of Plastic Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Wexham
Street, Slough SL2 4HL, UK
i
Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and
Musculoskeletal Sciences (NDORMS), University of Oxford, Roosevelt Drive, Oxford OX3 7FY, UK

Received 19 July 2021; accepted 10 November 2021

KEYWORDS Summary Hand surgery services had to rapidly adapt to the coronavirus disease 2019 (COVID-
COVID-19; 19) pandemic. The aim of the Reconstructive Surgery Trials Network #RSTNCOVID Hand Surgery
Hand surgery; survey was to document the changes made in the UK and Europe and consider which might
Survey persist.
A survey developed by the Reconstructive Surgery Trials Network, in association with the British
Association of Hand Therapists, was distributed to hand surgery units across the UK and Europe
after the first wave of COVID-19. It was completed by one consultant hand surgeon at each of
the 44 units that responded.
Adult and paediatric trauma were maintained but elective services stopped. Consultations were
increasingly virtual, and surgery was more likely to be under local anaesthetic and in a lower
resource setting.
Many of the changes are viewed as being beneficial. However, it is important to establish that
they are clinically and cost effective. These survey results will help prioritise and support future
research initiatives.
© 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-
sevier Ltd. All rights reserved.

Introduction hand surgery unit survey completed by consultant surgeons,

a hand therapy survey completed by hand therapists and a
The severe acute respiratory syndrome coronavirus 2 (SARS– service evaluation, assessing changes to the management
CoV–2) outbreak was declared a pandemic by the World of common hand trauma conditions during the pandemic. In
Health Organisation on the 11th March 2020.1 In the UK, this publication, we present the results of the hand surgery
the National Health Service prioritised caring for patients unit survey.
with the coronavirus disease 2019 (COVID-19) and deliver- The aim of the #RSTNCOVID Hand Surgeon survey was to
ing emergency care and cancer services. Hand surgery ser- describe how hand surgery services in the UK and Europe
vices were affected by the need to reduce patients’ risk of were modified during COVID-19 and identify changes that
exposure to the virus whilst accessing services and the redi- should be prioritised for further research.
rection of resources to COVID-19 patients.
The British Association for Plastics, Reconstructive and
Aesthetic Surgeons (BAPRAS), British Society for Surgery of
the Hand (BSSH) and British Association of Hand Therapy Materials and methods
(BAHT) published guidance on how to adapt hand surgery
services during the pandemic.2–4 Clinicians were encouraged The #RSTNCOVID Hand steering group developed the sur-
to pause elective surgery and see urgent referrals only. For vey. It was piloted at two units and amended based on feed-
hand trauma, it was advised to minimise visits to health- back. The survey investigated changes made to the delivery
care settings by increasing non-operative management of of hand surgery during the first wave of the COVID-19 pan-
injuries, delivering procedures in outpatient settings or as a demic [Supplementary file 1]. Respondents were asked to
day case where possible, increasing the use of remote con- make the comparison to their previous practice. For the pur-
sultations and sharing self-management strategies. poses of the survey, ‘before COVID-19’ was defined as prior
The Reconstructive Surgery Trials Network (RSTN), the to the 23rd March; the date of national lockdown in the UK.
UK network for plastic and hand surgery clinical trials es- The ‘COVID-19 period’ was defined as the 23rd March to 1st
tablished #RSTNCOVID to document the change in service June, as a significant number of UK lockdown restrictions
provision and management of common conditions during the were lifted on 1st June. Five-point Likert scales (e.g., al-
first wave of COVID-19. This effort was part of the Royal ways/very often/sometimes/rarely/never) were used.
College of Surgeons of England’s COVID-19 research portfo- The surveys were distributed via the RSTN and were com-
lio.5 #RSTNCOVID Hand was comprised of three projects; a pleted between June and September 2020 by one consultant

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 A.V. Shaw, D.G.W. Holmes, V. Jansen et al.

per hand surgery unit. If more than one consultant in a unit During COVID-19, almost all stopped their elective hand ser-
completed the survey, the first complete response was used. vices; only four adult (9%) and three paediatric (7%) services
Study data were collected and managed using Research continued. None of the injection clinics or one-stop carpal
Electronic Data Capture (REDCap) electronic data capture tunnel clinics continued.
tools hosted at Kennedy Institute of Rheumatology, Univer- Elective referrals were mostly triaged by consultants
sity of Oxford.6 , 7 REDCap is a secure, web-based application both before and during the pandemic; the number of units
designed to support data capture for research studies, pro- reporting that they did not triage elective referrals at all
viding (1) an intuitive interface for validated data entry; (2) halved during COVID-19 (Supplementary Table 3A). Clinic
audit trails for tracking data manipulation and export proce- appointments switched from being mainly face-to-face to
dures; (3) automated export procedures for seamless data mainly by telephone or video (Supplementary Table 3B).
downloads to common statistical packages; and (4) proce- Surgery was less likely to be performed in the main oper-
dures for importing data from external sources. Descriptive ating theatre, but there was not increased use of minor
statistics were used to summarise survey data. For free text operation theatres or clinic settings, suggesting an overall
answers, themes and frequency of these themes were iden- reduction in the number of elective procedures performed
tified. (Supplementary Table 3C).

Hand trauma services

Results
All units had established adult hand trauma services and
Completed surveys were received from 50 consultant hand
most also treated children (41, 93%). Only one unit stopped
surgeons, representing 44 hand surgery units. Six dupli-
accepting adult trauma and three units (7%) stopped pae-
cate responses were discarded. Responses were distributed
diatric trauma. One further unit centralised its paediatric
across the UK (England 34, Scotland 3, Wales 2), the Repub-
trauma service to the local children’s hospital where the
lic of Ireland (2) and Italy (1), Spain (1) and North Mace-
unit already provided a hand surgery service.
donia (1). Surveys were completed between 16th June and
During COVID-19, there was an increase in triaging of re-
21st September 2020, by plastic (61%) and orthopaedic (39%)
ferrals (Supplementary Table 4A). This was more likely to be
consultant hand surgeons. Twenty-eight units provided a
performed by a registrar or consultant rather than a more
combined orthopaedic and plastic hand surgery service,
junior team member (Supplementary Table 4B). Whilst most
seven were solely orthopaedic and nine were plastic surgery
appointments remained face-to-face, there was increased
alone.
use of telephone and video formats (Supplementary Table
The BSSH issued guidance early in the pandemic.3 Of the
4C). The most predominant format suggested under the
39 UK units, 29 (74%) always followed the guidelines, 8 (21%)
‘other’ options were email exchanges incorporating photos
units followed them ‘sometimes’ and two (5%) units did not.
of injuries. There was a reduction in the use of the main
Reasons for the latter included: development of local guide-
operating theatre, but a large increase in the use of clinic
lines, consideration of patients on a case-by-case basis and
rooms for operating (Table 1).
continued provision of pre-pandemic services.
A majority of units (33, 75%) reported providing antibi-
otics for simple open hand wounds, at least until definitive
treatment, which was reported to stay the same with the
Scope of service advent of COVID-19.

During the pandemic, most hand services extended their

scope of practice to take over minor injury care (n=16, Anaesthetic choice for hand trauma
36%) or worked directly within the emergency department procedures
(n = 19, 43%). During this period, most respondents felt
there had been no change in how closely orthopaedic and Before COVID-19, general or regional anaesthesia (RA) was
plastic surgeons worked together (n = 17, 61%). the preferred choice for most of the procedures assessed
Guidelines to reduce patient contact, followed by avail- (Table 2). During the first wave, there was a move towards
ability of resources, were felt to be the main factors impact- using wide-awake local anaesthesia no tourniquet (WALANT)
ing service provision (Supplementary Table 1). Staff sickness for many procedures. Extensor tendons were already largely
and redeployment affected units less commonly but were performed under local anaesthetic (LA)/ WALANT, but there
felt to have had an impact in 38 (87%) and 39 (89%) of units was an increase in the use of WALANT for flexor tendon
to some degree, respectively. The availability of personal surgery. There was also increased use of RA for phalangeal
protective equipment (PPE) was rarely felt to affect service and metacarpal fixation.
provision, with 13 (30%) reporting a shortage at some point
during the first wave (Supplementary Table 2).
Imaging access in clinic

Elective hand services Permanent access to a mini C-arm increased from 11 units
(25%) to 19 units (43%) with a further six having access on
All units usually provided adult elective hand surgery and demand (increased from two units). Ten units (23%) had ac-
most (38, 86%) provided a paediatric elective hand service. cess to ultrasound in clinic, which did not change.

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 1682–1688

Table 1 Setting for trauma surgery. n = number of units selecting response; fre-
quency of responses ranked in order using greyscale colouring (darkest = highest fre-
quency).

∗ Percentages may not total 100 due to rounding.

Table 2 Anaesthetic type for hand trauma procedures. % of units selecting anaes-
thetic type as their preferred method for each procedure. (WALANT, wide-awake
local anaesthesia no tourniquet; GA, general anaesthetic; MCPJ, metacarpopha-
langeal; UCL, ulnar collateral ligament; ORIF, open reduction internal fixation)

∗ Percentages may not total 100 due to rounding.

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 A.V. Shaw, D.G.W. Holmes, V. Jansen et al.

Wound closure, follow-up and patient information Remote consultations (n = 20 responses), increased use
of LA, WALANT and RA (n = 18), and a more streamlined ser-
Most units used non-absorbable sutures for both elective vice for patients with decreased waiting times in clinic and
(n = 23, 55%) and trauma (n = 29, 66%) hand surgery be- for theatre (n = 11) were the best changes. The increase
fore the pandemic. This preference changed to absorbable in the use of minor operating procedure rooms (n = 7),
sutures for both elective (n = 18, 82%) and trauma (n = 36, increased consultant input and decision-making for trauma
84%) hand surgery during the first COVID-19 wave. Antimi- (n = 7), and improved teamwork with other specialties and
crobial sutures were not the predominant choice of suture the hand therapists (n = 5) were also highlighted. The major
type in any of the units before or during COVID-19. themes identified regarding what changes had not worked
Wound reviews (n = 42, 95%) and suture removal (n = 37, included reduced access to theatre (n = 10 responses), dif-
84%) were usually performed in hospital. However, there ficulties with assessing and managing some patients via re-
was a move towards units encouraging patients to remove mote clinics (n = 6), inefficiency in theatre turnover (n = 4)
their own sutures (increase from three units (7%) to 15 units and the lack of elective capacity for dealing with the back-
(34%) and performing their own wound reviews (increase log of cases (n = 4).
from three units [7%] to 29 [66%]). No units used virtual The biggest change following the pandemic was felt
wound reviews, either via video or email before COVID-19, likely to be the use of remote consultations (n = 18), the
but this was used in 22 (50%) of units during the pandemic. remote or reduced follow-up of trauma patients (n = 6) and
There was no change in the reported use of community increased use of LA, WALANT and RA (n = 8). Streamlining
settings, e.g., general practice for either suture removal of services to reduce patient visits and waiting times and
(n = 21, 48%) or wound reviews (n = 23, 52%) due to COVID- reduced theatre capacity (n = 5) were both felt to also be
19. likely enduring changes.
Trust produced paper leaflets were the predominant
source of patient information provided for hand trauma pa-
tients across the units both before and during COVID-19 Discussion
(n = 34,77%) (Supplementary Table 5). The use of trust
produced information sent via email, information via text This study shows that in a short space of time there was
message and app-based information doubled. Even so, apps a rapid reorganisation of hand surgery services. As services
were still used infrequently (n = 6, 14%). start to return to the ‘next’ normal, they will need to con-
sider what, if any, changes will be kept and what further
IT access adaptations are needed to meet new challenges, such as
increased elective waiting lists.8 With less than 10% of sur-
IT access for staff improved in several areas during the pan- veyed units providing an elective service during the initial
demic. Around half of the units had remote access to the wave of the pandemic, the backlog of chronic hand condi-
hospital desktop before COVID-19 (n = 23, 52%), increas- tions and untreated traumatic injuries is likely to represent
ing to over three-quarters (n = 34, 77%). Video consultation a substantial burden to health services.
and conferencing were rarely used in units before COVID-19 There was a rapid change to remote delivery of care.
(in four (9%) and five (11%) units, respectively), increasing This was delivered throughout the patient journey from ini-
to three-quarters of units using video consultation software tial triaging of referrals, assessment of the injury and sub-
(n = 33, 75%) and almost all units using video conferencing sequent hand therapy and follow-up. NHS England provided
software (n = 42, 95%) during the pandemic. There was a initial guidance on the management of remote consultations
little change in access to image exchange software (n = 14, and working early in the pandemic.9 Whilst there was sup-
32% vs n = 15, 34%). port for this change in the comments, it will not be suit-
able for all circumstances. Challenges include IT literacy,
access for patients and misdiagnoses. Virtual management
Education and training of fracture clinics and remote consultations in hand surgery
were established in the UK pre-pandemic, but there is lim-
Around half of units (n = 23, 52%) maintained their full ited previous literature.10–12 It is likely that better electronic
educational programme. A minority (n = 7, 16%) discon- patient information is needed to support this change and
tinued completely. Almost all respondents (n = 39, 89%) research into the effect of remote consultations on patient
utilised webinar-based training or eLearning. Particularly, care and satisfaction.
useful webinars highlighted included Pulvertaft Hand Cen- There was a move towards performing surgery under
tre (n = 23 responses), BSSH (n = 17), BAPRAS (n = 10) and WALANT before the pandemic for both elective and trauma
Plastic Surgery Trainees Association (PLASTA) (n = 7) webi- hand surgery.13 , 14 This appears to have accelerated and
nars. was adopted for a broad range of procedures, particu-
larly tendon injuries. There is currently a systematic re-
view ongoing to assess outcomes of flexor tendon injuries
Strengths and weaknesses of change during when repaired under WALANT compared to regional or gen-
COVID-19 eral anaesthesia.15 WALANT was particularly well suited
for the pandemic as it allowed procedures to move out
Respondents completed free text boxes to report positive of the main operating theatres and avoid the need for an
and negative changes and what they felt would be the anaesthetic team, who were largely redeployed to inten-
biggest change post COVID-19. sive care. Concerns were raised around patient choice for

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 1682–1688

anaesthetic, the additional time taken to inject patients gests that these changes were reflected in the UK and Eu-
with LA and the quality of the bloodless field. The pre- rope and continued throughout the first wave. A survey by
ferred anaesthesia type for phalangeal and metacarpal frac- the Kleinert Society of members, with responses predomi-
ture fixation moved from general anaesthesia to regional. nantly from the USA, covered a similar time period in the
These would be the next procedures to be increasingly first COVID-19 wave to our survey. It showed similarly re-
performed under WALANT and have been reported in the duced clinic and elective surgery volumes.36 However, con-
literature.16 , 17 trary to our findings, telemedicine was not widely used and
There was a reduction in the use of main operating the- felt to have multiple drawbacks.
atres and increased use of minor operating theatres and The limitations of this study include those associated
clinic rooms. The available evidence suggests that outpa- with surveys, specifically reporting and selection bias. The
tient operating is safe and does not increase the risk of in- service evaluation performed at the same time should cor-
fection,18 but it remains uncertain owing to a lack of high- roborate the findings. There was also a predominance of re-
quality research. Recommendations have been produced on sponses from the UK.
the minimum facilities required to carry out minor surgical Through necessity rapid changes were made to service
procedures; a naturally ventilated room with easily cleaned delivery. Understandably, there was little patient involve-
surfaces and scrub-up facilities is sufficient.19 Further stud- ment or rigorous evaluation of the changes. Now is the
ies are important to establish the infection rate following time to formally engage patients and the public in service
procedures in outpatient settings. redesign and assess the clinical effectiveness of new ap-
Changes were often more economically and environmen- proaches to delivering care.
tally sustainable. Delivery of care can be in low-cost settings
and potentially delivered closer to patients’ homes. Fewer
trips to hospital by both healthcare workers and patients re- Declaration of Competing Interest
duce the carbon footprint of services.20 The use of WALANT
and an outpatient setting consumes significantly fewer re- The author(s) declare no potential conflicts of interest with
sources than a general anaesthesia in the main operating respect to the research, authorship and/or publication of
theatre as well as reduces the carbon emissions from the this article.
use of anaesthetic gases.21–23 There was a move from the
use of paper leaflets towards electronic patient information
or trust produced leaflets sent via email. Sustainability in Funding
surgery is a current focus for the Royal College of Surgeons
of England.24 The authors received no financial support for the research,
Many of the changes challenged and accelerated the authorship and/or publication of this article.
move away from established dogma. Whilst the safety of LA
with adrenaline is well established in hand surgery across
the world, it has not necessarily been widely adopted. Ethical approval
The British National Formulary still states that it should be
avoided in digits and anecdotally, medical schools continue N/A.
to teach this.25 , 26 A recent Cochrane review concluded that
further research was needed.27
Absorbable sutures in hand trauma are safe and reduce Supplementary materials
the need for follow-up.28 , 29 Selected patients can safely
perform their own follow-up. Skin cancer patients are al- Supplementary material associated with this article can be
ready taking increasing responsibility for their own health- found, in the online version, at doi:10.1016/[Link].2021.11.
care and show a preference for patient-led surveillance and 052.
fewer scheduled clinic visits.30 NHS England is supporting
providers to roll out patient-initiated follow-up moving for- CRediT authorship contribution statement
ward.31
At least three-quarters of the units reported provid- Abigail V. Shaw: Conceptualization, Formal analysis,
ing antibiotics for simple open hand wounds, at least un- Writing – original draft, Writing – review & editing.
til definitive treatment. The routine use of antibiotics has David G.W. Holmes: Conceptualization, Writing – review
not been shown to reduce the infection rate in simple hand & editing. Victoria Jansen: Writing – review & editing.
wounds requiring surgery,32 , 33 and BSSH does not recom- Christy L. Fowler: Writing – review & editing. Justin C.R.
mend their use in these injuries.34 Antibiotic stewardship Wormald: Formal analysis, Writing – review & editing.
must be addressed by units and individuals to reduce the Ryckie G. Wade: Formal analysis, Writing – review & edit-
risk of antimicrobial resistance. ing. Emma K. Reay: Writing – review & editing. Matthew D.
Two previous surveys have examined the impact of Gardiner: Conceptualization, Writing – original draft, Writ-
COVID-19 on hand surgery worldwide.35 , 36 An initial survey ing – review & editing.
early in the pandemic, carried out in March 2020, showed
that the majority of surgeons had already modified their
practice; many had stopped elective operations, were per-
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