WHITE BOOK ON HAND SURGERY IN EUROPE

Transcription

1 WHITE BOOK ON HAND SURGERY IN EUROPE EUROPEAN BOARD OF HAND SURGERY Updated 12 March 2017

2 WHITE BOOK ON HAND SURGERY IN EUROPE produced by the Europea Board of Had Surgery EBHS 1.1 What is had surgery? Had surgery is the field of medicie that deals with problems of the had ad wrist, whether of cogeital, traumatic, degeerative, iflammatory or tumoral origi. The aim is to restore the fuctio of the had, which should be regarded as the key orga of prehesio ad sesibility. I this cotext, had surgeos are also ivolved with complex problems of the whole upper extremity, icludig lesios of the peripheral erves ad the brachial plexus. Had surgeos are also ivolved i the restoratio of prehesio i cases of tetraplegia ad spasticity. Because of their special expertise, had surgeos are also frequetly ivolved i the repair of lower extremity erve lesios. 1.2 The scope of had surgery The scope of had surgery is broad ad requires a wide rage of diverse operative skills ecessary to diagose ad treat, coservatively or surgically, had ad pertiet upper extremity ad peripheral erves affectios. The had surgeo masters microsurgery as well as orthopaedic ad plastic surgery techiques, as applied to the complex ad delicate aatomy of the had ad upper limb. Had Surgery cosiders also the cosmetic aspects of the recostructio of the had. A close cooperatio with other specialists is required, icludig orthopaedic ad trauma surgeos, plastic surgeos, radiologists, paediatric surgeos, rheumatologists, aaesthetists, specialized physiotherapists, occupatioal therapists ad other paramedics for rehabilitatio, orthotics ad prosthetics. The treatmet of a lesio of the had/upper extremity i the earliest phase by a surgeo traied i had surgery offers the patiet the best chaces of early ad best recovery, ad also reduces the costs related to the disability ad time-off work for society. This is particularly true for the had traumas, which are particularly frequet. This book is made by cooperatio of the specialist sectios of UEMS, which deal with the educatio ad qualificatio i had surgery i EU coutries, ad FESSH i order to set the miimal requiremets for a surgeo, who treats the complex problems of the had. The UEMS Coucil has edorsed it i Prague, October 9, Traiig ad Qualificatio i had surgery Qualificatio i had surgery is based o the cliical ad surgical traiig received after basic accreditatio i plastic or orthopaedic surgery i the majority of Europea coutries. I some coutries qualificatio is also possible through geeral, paediatric or trauma surgery; a separate specialty of had surgery exists oly i a few coutries of Europe. Traiig icludes theoretical ad cliical activities. The traiee should be exposed to the followig coditios: 2

3 Aatomy of had ad upper limb. Physiology of muscle, tedo, erve ad joits, blood perfusio ad boe metabolism. Coservative treatmets of had disorders icludig post ijury pai sydromes Operative surgery, icludig micro-surgical techiques Rehabilitatio ad fuctioal splitig I additio, a certified traiig course i microsurgery o laboratory aimals should be icluded i the curriculum. 3

4 2.2 Certificatio: Europea Diploma Examiatio Accordig to the bylaws of EU, qualificatio i Had Surgery is certified atioally by the local authorities. The Europea Diploma i Had Surgery is ot a prerequisite to practice Had Surgery: it is a added qualificatio ad attests the Europea stadard of the surgeo s skill ad kowledge. It is released by the Europea Board of Had Surgery; provider is the Federatio of the Europea Societies for Surgery of the Had. Strict coditios are required to obtai the qualificatio certified by the Diploma. The cadidate is required to report academic records ad traiig posts held ad provide proof of a sigificat umber of operatios as operator or first assistat. Because of the differeces i traiig which exist i differet parts of Europe, differet sets of criteria will have to be utilized accordig to the prevailig patter of traiig i the cadidate s ow coutry. a. I coutries where traiig i had surgery follows accreditatio i Orthopaedic or Plastic Surgery, oe year s traiig with 100% exposure to had surgery i a accredited cetre is sufficiet for the Diploma Examiatio. b. I coutries where traiig i had surgery follows accreditatio i a major surgical specialty other tha Orthopaedic or Plastic Surgery, two years traiig i a accredited cetre with 100% exposure is required, ad at least oe year before this time must have bee spet i either the specialty of Orthopaedic or Plastic Surgery. c. Cadidates from coutries i which had surgery is already a separate specialty i its ow right, may take the Europea Diploma Examiatio without further traiig provided that: I. Their geeral backgroud traiig (miimum duratio 2 years) has icorporated exposure to orthopaedic ad/or plastic surgery for at least oe year. II. Their specialty i Had Surgery has bee for a miimum of three years i a accredited cetre with exposure to both orthopaedic ad plastic surgery techiques, icludig microsurgery. III. They have achieved accreditatio i had surgery i their ow coutries. A coutersiged logbook idicatig performed ad assisted operatios, academic records ad traiig posts held is also required. The logbook cotais 14 subsets, icludig tedo, joit surgery, replatatios ad cogeital coditios ad has a guide to the recommeded umber of required operatios. The cadidate should prove a sigificat umber of operatios as operator or first assistat. If possible, the traiig must be doe i a accredited had surgery traiig ceter or, at least, uder the supervisio of a experieced had surgeo. At this momet the accreditatio of had surgery traiig cetres is based o the proposals made by atioal societies. It is also expected that the cadidates pursue a scietific activity. The cadidates should also have a recommedatio from his/her atioal society for surgery of the had. If the cadidate fulfils the above requiremets he may take the Europea Examiatio. The examiatio is ope, ot oly to had surgeos from Europea member coutries, but also to ayoe who fulfils the above requiremets ad desires to participate ad receive certificatio i this specific competecy, i coformity with Europea stadards. The Europea Board Examiatio i Had Surgery (EBHS) is iteded both as a quality mark, ad to help i the harmoisatio of stadards i EU ad UEMS member coutries. The Europea Board examiatio is ot a alterative to a atioal examiatio, where oe exists. Passig the EBHS Examiatio does ot give the right to work i a member coutry of the EU. Such rights are grated by the Natioal Authority i each coutry. 4

5 The Diploma Examiatio is aually orgaized by of the Europea Board of Had Surgery ad usually takes place at the site of the Cogress of the Federatio of Europea Societies for Surgery of the Had, two days prior to the evet, with the participatio of voluteer examiers ivited from the coutries of the examiees, with the idea of providig at least oe examier for each cadidate speakig the same ative laguage. The examiers are proposed by the atioal societies. The format of the examiatio is a multiple choice questios elimiatio test, followed by two 40 miute oral examiatios coducted by two examiers. The chairma of the Examiatio Committee ad two supervisors survey the flow of the examiatio to provide feedback for followig examiatios. The mai topics covered i the orals are trauma, geeral recostructive surgery ad other topics, like systemic diseases, arthritis, Dupuytre, tumours ad cogeital malformatios. The official laguage of the exam is Eglish. 5

6 3.1 Had surgery i Europe Europea had surgeos are represeted by atioal societies cosolidated i the Federatio of Europea Societies for Surgery of the Had (FESSH). At a political level they are represeted through the Europea Board of Had Surgery (EBHS). The Federatio was established i 1990 as a associatio of Europea atioal societies for surgery of the had, to represet these societies ad their members at a supraatioal level, to ratioalize ad uify educatio ad traiig i had surgery while promotig uiformity amog the differet coutries of Europe, to set a qualificatio stadard for the practice of had surgery withi the Coucil of Europe, to improve the idicatios for had surgery for the beefit of the patiets, to defie the highest stadards for treatmet of had pathologies, ad to implemet ad sustai study ad research. At preset FESSH represets 24 atioal had societies (there is o atioal society i Europe which is ot a member of the Federatio) formed by over 4,200 surgeos, whose mai iterest is had surgery. The Federatio is officially represeted by its Secretary Geeral. The Coucil comprises te members: the Secretary Geeral, the Treasurer, the Chairme of the Committees for Examiatio, Traiig, Research, Had Trauma, Joural of Had Surgery, Europea Accreditatio. Professioal Relatios, Techology ad a Historia. The FESSH Examiatio Committee orgaizes each year the Europea Board of Had Surgery Diploma Examiatio. Two delegates from each UEMS Sectio actively ivolved i the activities of the Europea Board act as cotributors to the orgaizatio of the Europea Board Examiatio. The applicats are selected by reviewig the documets submitted, the preparatio of the MCQs for the writte examiatio are provided ad the oral sessios are orgaized; these are held by a group of examiers, maily ivited from the coutries of the examiees. The first Diploma Examiatio was held i Paris i The Traiig Committee aims to stimulate, assist ad foster traiig i Had Surgery i Europe amogst youg surgeos, as well as established oes. The Europea Federatio offers through its website a database of cetres i Europe that provide traiig i all or i particular aspects of had surgery. There, youg surgeos ca fid details of the cetre for traiig, fellowships or research. The cetres offerig these opportuities ca upload oto the database details of the type of experiece offered, fudig ad cotact iformatio. This committee, through a web-based applicatio form, also admiisters the Traiig ad Travellig Awards. Every year awards, curretly fuded at up to 4000 Euros each, are give to surgeos from a member society to visit other Had Cetres i Europe with the purpose of furtherig their kowledge of Had Surgery. The Federatio of Europea Societies for Surgery of the Had promotes scietifically soud basic ad cliical research studies i had surgery. As a example, the Research Committee has promoted activities focused o recostructive had surgery i tetraplegia, by orgaisig a iteret-based survey directed towards patiets livig with tetraplegia i Europe, several dedicated courses i tedo trasfer surgery, ad by orgaisig a 3-moth fellowship i recostructive had surgery i tetraplegia. Complex traumatic lesios of the had represet a substatial chapter i had surgery. Optimal maagemet of these traumas requires specific idividual skills of the surgeos (microsurgery, replatatio surgery) ad a specific orgaisatio of the cetres (permaet availability). For this reaso the Had Trauma Committee is curretly idetifyig ad mappig these cetres throughout Europe. The Joural of Had Surgery, Europea Volume is the official joural of the Federatio, ad icludes ot oly cotributios by Europea authors, but also ay oteworthy paper writte by had surgeos, from ay coutry, which chooses to publish i the Joural. Fially, the Federatio of Europea Societies for Surgery of the Had works o the history of had surgery i Europe, especially reviewig research ad advaces made by Europea had surgeos ad collectig 6

7 meaigful pertiet documets. The history of the Federatio of Europea Societies for Surgery of the Had may be foud i a article published by S. Hovius i the Joural of Had Surgery i 2002, as well as i the attached documet ad o the FESSH website ( 7

8 3.2 Cogress ad Courses i Had surgery i Europe The Federatio of Europea Societies of Surgery of the Had orgaises a cogress each year. At each cogress there is a Istructioal Course i Had Surgery. The lectures are published as a book, distributed at the time of the course. A idepedet Scietific Committee judges the aoymous abstracts of the free papers submitted for presetatio. If possible, the meetigs are orgaised i cojuctio with the Europea Federatio of Societies for Had Therapists. The attedace at the meetigs so far has raged from 400 to over 1,000 registrats. I additio to its aual cogress, the Federatio of Europea Societies for Surgery of the Had orgaises Basic Had Surgery Courses i Easter Europea Coutries (three i the last five years). Educatio is also provided by atioal had surgery societies from yearly atioal meetigs, local ad regioal meetigs, istructioal courses ((Austria, Belgium, Filad, Frace, Germay, Hugary, Italy, Netherlads, Norway, Polad, Rumaia, Spai, Swede, Turkey, UK) ad formal lectures, research presetatio ad iformal discussio. The FESSH cogress is grated Europea CME credits by the Europea Accreditatio Coucil for Cotiuig Medical Educatio (EACCME). 4.1 Multidiscipliary Joit Committee (MJC) o Had Surgery The Multidiscipliary Joit Committee o Had Surgery is a committee of the Uio Européee des Medecis Specialistes (UEMS), whose mai task is to promote the harmoizatio of Had Surgical educatio ad traiig i EU coutries. It was established i 1999 by the iitiatio of UEMS Surgical Sectio, ad all Sectios iterested i Had Surgery are ivited to joi. The Federatio of Europea Societies for Surgery of the Had reported its iterest for collaboratio. The disciplies, i which had surgery is closely liked, ad which were iterested i joiig the Committee by their represetatives were Geeral Surgery, Orthopaedic ad Trauma Surgery, Plastic Surgery, Paediatric surgery. The fuctio of the committee was activated o earlier tha 2008, whe the first meetig with represetatives of UEMS ad FESSH took place o Jauary 26, 2008 i Brussels, after which regular meetigs have bee orgaised. 4.2 Europea Board of Had Surgery (EBHS) The Europea Board of Had Surgery (EBHS), formed by the MJC o Had Surgery ad the Europea Federatio of the Societies of Had Surgery (FESSH), was iitiated i 2010 ad edorsed by the UEMS Coucil i Prague, October 9,

9 EUROPEAN CURRICULUM FOR HAND SURGERY 1. PREFACE Particular Qualificatio Purpose of a Curriculum for Had Surgery i Europe 7 2. INTRODUCTION Learig resources Cliical Experiece Fellowships Readig Meetigs Tutorials Learig Outcomes Assessmet Ogoig work-based assessmet Formal Examiatio Other Tests 9 3. CORE COMPETENCIES OF THE EUROPEAN HAND SURGEON Kowledge ad Uderstadig Basic Sciece Priciples of Had Surgery Practical Skills Requiremets List of procedures Itellectual Skills Educatio Research Audit Teachig Persoal Qualities Team work Delegatio Time Maagemet ad Stress Maagemet Referral Other Skills Coset Documetatio Service Maagemet STRUCTURE OF TRAINING OF EUROPEAN HAND SURGEONS Routes ito Had Surgery Assessmet Formative assessmet Summative assessmet Certificatio i Had Surgery Europea Board of Had Surgery Diploma Recogitio of Had Surgery ad Natioal Diplomas Traiers Traiig Cetres Traiees Persoal resposibility Logbook FUTURE DEVELOPMENTS Fellowship ad Traiig Post Directory Had Trauma Cetres Joit Registry Had Surgery Traiig Cetres Cotiuig Professioal Developmet 16 9

10 1. PREFACE 1.1 Particular qualificatio Had Surgery has developed ito a particular qualificatio with practitioers derived from orthopaedic surgery, plastic surgery, geeral surgery ad occasioally other disciplies such as trauma surgery, paediatric surgery ad emergecy medicie. The term Had Surgery icludes coditios of the had ad wrist ad peripheral erves, icludig the brachial plexus (primary ad secodary surgery). The term, i some cetre, also ivolves elbow coditios. I Europe, differet coutries have differet traiig programmes ad thus differet emphasis o the requiremets for becomig a Had Surgeo. I Filad, Had Surgery is regarded as a separate speciality with traiig i Had Surgery udertake without prior Orthopaedic or Plastic surgical traiig. I some coutries (e.g. Germay, Hugary, Swede) Had Surgery is a particular qualificatio with practitioers formally traied i Had Surgery followig traiig i Orthopaedics, Plastics ad Geeral Surgery. I some coutries (Turkey, UK) Had Surgery is a separate speciality i some cetres ad part of plastic surgery or orthopaedic surgery i others. I other coutries, (Austria, Belgium, Frace, Italy, Netherlads, Norway, Polad, Portugal, Rumaia, Russia, Slovakia, Spai) Had Surgery is a particular qualificatio professed by a Orthopaedic, a Plastic or a Geeral surgeo. Traiig ad qualificatios chage regularly; the FESSH Traiig Committee updates the White Book each year with these chages through the FESSH Delegate etwork. Withi coutries, there are some hospitals with separate had/peripheral erve surgery uits ad others, which maage had coditios withi the orthopaedic or plastic surgery departmet. Eve withi Had Surgery, there are sub-specialities such as brachial plexus, cogeital differeces, micro-vascular surgery ad complex wrist recostructio. 2. INTRODUCTION 2.1 Learig resources The traiee i Had Surgery has may learig resources available Cliical Experiece Traiees will lear from their preset employmet post by observatio, supervised operatig, discussio. This appreticeship is a crucial part of surgical traiig Fellowships Further traiig is gaied from a Had Fellowship. This provides cocetrated experiece, ot diluted by geeral orthopaedic or plastic surgical duties. Some Fellowships provide very specialised traiig withi Had Surgery depedig o the practice ad reputatio of the Cosultat to whom the Fellow is attached. Fellowships are available i Europe; FESSH has developed a Europea Fellowship Directory accessible throught he FESSH website.. Overseas Fellowships are also available across the world, which offer excellet experiece. Observerships are also available, i which the traiee ca visit a cetre with a particular reputatio or expertise, to lear by observatio rather tha practical ivolvemet i patiet care. Costraits o salary, time ad medical registratio make short observerships a valuable opportuity. 10

11 Fudig is available for some fellowships. FESSH offers several Travel Awards of up to 4000 Euros each year.. Natioal Societies also offer support (see idividual Society websites). 11

12 2.1.3 Readig Jourals JouralofHadSurgery,EuropeaVolume JouralofHadSurgery(America) ChirurgiedelaMai(Frace) Hadchirurgie,Mikrochirurgie,PlastischeChirurgie(Germay) Magyar Traumatológia,Ortopédia,Kézsebészet, Plasztikaisebészet(Hugary) RevistaIbero-americaade Cirurgiade lamao (Spai) RivistadiChirurgiadellaMao(Italy) RumaiaJouralof Had ad RecostructiveMicrosurgery ScadiaviaJouralofPlasticadHadSurgery Orthopaedic Surgery Literature Plastic Surgery Literature Microsurgery Literature Had Cliics of North America Iteret sources Pubmed Medscape Web of Sciece Textbooks May are available to cover all aspects of Had Surgery i various depths ad formats Meetigs Meetigs provide educatio from formal lectures, research presetatio ad iformal discussio. There are very may suitable meetigs Natioal Had Surgery Society Meetigs FESSH Aual Meetig Local, regioal ad atioal Meetigs Istructioal Courses (orgaised or edorsed by most atioal Societies) Tutorials Traiig programmes should be ecouraged to provide tutorials for idividual or groups of traiees as a powerful tool for persoal educatio. 2.2 Learig Outcomes The Had Surgery curriculum should lead to the followig outcomes ad core competecies: Kowledge ad Uderstadig Practical Skills Itellectual skills Persoal Qualities Other skills 12

13 2.3 Assessmet It is evisaged that a idividual s expressio of a iterest i had surgery should be supported by formal assessmet Ogoig work-based assessmet A traiee should be regularly assessed by formal idividual appraisal from his supervisor or traier. The appraisal should have a structured form so that learig goals are set, reviewed mid term ad the reviewed at the ed of traiig. This ca iclude structured practice Based Assessmet where basic ad advaced procedures are formally demostrated to the Traier the discussed ad marked Formal Examiatio Europea Diploma i Had Surgery, edorsed by the Europea Board of Had Surgery of UEMS ad provided by FESSH (see 4.3 Certificatio i Had Surgery) Natioal Diplomas i Had Surgery Other Tests Examples for self assessmet iclude America Society for Surgery of the Had Self Assessmet Questioaire Joural of Had Surgery (Europea) So you thik you have read this Joural? 3. CORE COMPETENCIES OF THE EUROPEAN HAND SURGEON 3.1 Kowledge ad Uderstadig Basic Sciece Aatomy of the had ad upper limb Embryology of the Had ad Upper Limb Physiology of muscle, erve ad boe metabolism Priciples of ifectio, microbiology Healig of woud, tedo, boe, erve Aatomy ad physiology of blood supply to limb icludig ski Imagig (MRI, Ultrasoud, Plai radiographs, CT) Pathology of rheumatic, degeerative ad eoplastic disorders Biomechaics of the had ad wrist Priciples of Had Surgery Examiatio of erves, tedos, vascular system, joits Ijured had - woud care, maagemet of skeletal, vascular, tedo ad erve ijuries Treatmet of fractures ad maluios of the had Ligamet ruptures ad joit istabilities of the had Arthroscopy of the had ad wrist Amputatios i the had ad upper limb Burs of the had Recostructive surgery of mutilated had Maagemet of upper limb erve ijuries, icludig brachial plexus ijuries Maagemet of tetraplegia, stroke, brai ijury ad cerebral palsy Tedo trasfers Cogeital abormalities of had ad upper limb 13

14 Arthrosis of the had ad wrist The arthritic had i rheumatoid arthritis ad other iflammatory arthritides, e.g. LES ad scleroderma Dupuytre s cotracture Overuse sydromes Nerve compressio sydromes Ifectios of the had Vascular disorders (ic ischaemia, HAVS) Tumours of the had Psychiatric maifestatios, secodary gai etc. Priciples of had Therapy Complex regioal pai sydrome Ski grafts Local, distat ad free flaps Extravasatio ijuries Ehacig wouds icludig specialised dressigs ad vacuum therapy Spasticity 3.2 Practical Skills Requiremets Had Surgery has a very large repertoire of procedures for which the surgeo eeds detailed kowledge of the complex aatomy of the had ad wrist, as well as competecy i microsurgery, recostructive plastic surgery ad orthopaedics. Some procedures requirig specific practice skill should be udertake by oly a few (e.g. pollicisatio of the thumb, brachial plexus exploratio) whereas others (e.g. trigger figer, carpal tuel) ca be udertake by may practitioers with surgical qualificatio ad basic traiig; still other procedures, although complex ad rarely performed, ca be performed by a traied Had Surgeo by applyig familiar techiques to familiar aatomy. Had Surgery cotais such a broad spectrum of procedures, ad comprises complex subspecialities. Therefore experiece ad competece i each ad every topic ad procedure caot be expected. Competece ca be classified as: Has observed Ca do with assistace Ca do but may eed assistace Competet to do without assistace icludig complicatios ad List of procedures Herei follows a descriptio with the operatios to be performed idepedetly by the traiee or, for operatios of a higher degree of difficulty, as a participat. Microvascular experiece is essetial. Surgical procedures ca be listed accordig to the aatomical structures ivolved: A) Ski ad subcutaeous tissue 1. Free ski graft 2. Pedicled local flaps 3. Regioal ad\or islad flaps 4. Free flap with microvascular aastomosis 5. Treatmet of retractig scars of the had ad wrist 6. Applicatio of vacuum therapy 7. Dupuytre s icludig PNF, collagease, limited ad radical surgery 8. Extravasatio 9. Ifectio 14

15 B) Tedos 1. Flexor tedo repair 2. Flexor tedo graft 3. Flexor pulley recostructio 4. Flexor tedo teolysis 5. Trigger figer release 6. Extesor tedo repair 7. Extesor tedo graft 8. Extesor tedo teolysis 9. Tedo sheath syovialectomy 10. Tedo recostructio i rheumatoid arthritis 11. Tedo trasfers (ijury, paralysis, spastic coditios) 12. Free muscular flap with microvascular aastomosis 13. Flexor sheath ifectio C) Boe ad Joits 1. Closed reductio ad fixatio of fractures ad dislocatios 2. Ope reductio ad fixatio of fractures ad dislocatios 3. Corrective osteotomies 4. Treatmet of o-uio 5. Boe resectios 6. Boe grafts ad substitutes 7. Free boe trasfers with microvascular aastomosis 8. Figer joit ligamet or palmar plate repair\recostructio 9. Wrist ligamet repair\recostructio 10. Arthrolysis 11. Digital\wrist arthroplasty (icl. allo-arthroplasty) 12. Wrist partial ad total fusio, PRC 13. Had Arthrodesis 14. Deervatio 15. Syovectomy 16. Arthroscopy 17. DRUJ recostructio 18. Fractures i childre E) Nerves 1. Microsurgical repair of erve lesios 2. Nerve graftig ad eurotisatio ad coduits 3. Neurolysis 4. Neuroma F) Vascular 1. Tumours ad malformatios 2. Ischaemia (ic Kiebock s, Rayauld s) 3. Replatatio 4. Revascularisatio G) Other 1. Cogeital disorders 2. Childre s disorders 5. Ocology- biopsy (trascutaeous, ope); excisio, recostructio 4. Brachial plexus repair\recostructio 5. Neuromas 6. Nerve tumours 7. Treatmet of erve compressio sydromes G) Blood vessels 1. Microsurgical arterial aastomosis 2. Microsurgical veous aastomosis 3. Vei graft 4. Advetitiectomy List of procedures should also iclude operatios for the treatmet of complex trauma of the had, special diseases, malformatios: A) Amputatios 1. Had level 2. Carpal or forearm\upper limb level B) Replatatio i limb amputatios 1. Digital or metacarpal level 2. Carpal or forearm\upper limb level 15

16 3. Lower limb C) Treatmet of thermal bur, chemical ijury, electrical trauma D) Magled had treatmet E) Fasciotomy 1. Acute 2. Chroic F) Ifectios of the Had 1. Treatmet of woud ifectio icl. tedo sheath 2. Treatmet of paroychial or pulp ifectio 3. Treatmet of osteomyelitis or septic arthritis 4. Necrotisig fasciitis G) Tumours 1. Resectio of ski ad soft tissue tumour 2. Resectio of boe tumour 3. Resectio of tumour-like lesio H) Cotracture. 1. Dupuytre s 2. Volkma s 3. Stiffess 4. Burs I) Treatmet of cogeital malformatios of the had 3.3 Itellectual Skills Educatio A Had Surgeo must be able to critically assess a research article or podium presetatio, to uderstad the stregths ad weakesses of the material ad to apply it to his ow practice Cotiuig Medical Educatio Educatio is a life-log process; the Had Surgeo should take persoal resposibility to use all resources to improve ad update his kowledge ad practice Research The Had Surgeo should udertake some research durig his/her traiig, At the very least, a thorough uderstadig of the basics of research is essetial: formulatig a hypothesis desigig a appropriate methodology to test that hypothesis usig appropriate statistics to report the research deducig appropriate coclusios form the data uderstadig the limitatios of a study epidemiological priciples Audit The Had Surgeo should review the outcome of his ow practice. As a miimum, a log book should be kept. Procedures with ucertai outcomes or surgeo-depedet outcomes such as joit replacemet, scaphoid fracture fixatio, tedo graftig, should be routiely moitored for quality. Validated scorig schemes are available for example the QuickDASH, Patiet Evaluatio Measure (PEM) ad Michiga Had Score Teachig Teachig is part of learig. Also, a idividual has a resposibility to pass o acquired kowledge ad skills so that others ca beefit. The Had Surgeo should also teach the patiet so they are better iformed of their coditio ad the treatmet optios. 3.4 Persoal Qualities 16

17 3.4.1 Team workig Had Surgeos work with theatre teams, therapists, urses, juior doctors ad may others who are ivolved i the care of patiets. The Had Surgeo will ofte be the leader of the team ad should develop the ecessary qualities of leadership Delegatio May problems i Had Surgery ca be shared with others. The Had Surgeo should develop skills of delegatio so that patiet care ca be safely delegated to the appropriate practitioer to help provide a efficiet, safe ad cost-effective service Time Maagemet ad Stress Maagemet Surgery is stressful. It requires log hours with may competig demads o time ad skill. Some decisios are ucertai; some procedures are very complex with potetially serious complicatios ad ucertai outcome. The Had Surgeo must lear to maage time ad cope with stress Referral The Had Surgeo must appreciate the resposibility of askig for advice or referrig to aother practitioer whe a case is beyod his expertise or comfort. 3.5 Other Skills Coset Iformed coset is importat i developig the cofidece of a patiet by egagig them i the choice of treatmet ad avoidig medico-legal issues with uexpected outcomes Documetatio Clear cotemporaeous documetatio is importat for may reasos: to allow proper hadover, for example post-operative istructios; to record the basis of cliical decisios; for medico-legal protectio; to collect data for research ad audit Service Maagemet A Had Surgeo must be able to prioritise ad also develop the skills to maage their service with the skills, resources ad persoel available. 17

18 4. STRUCTURE OF TRAINING OF EUROPEAN HAND SURGEONS Stadards of postgraduate medical educatio have bee developed (see referece list) upo which the traiig of Had Surgeos i Europe should be based. 4.1 Routes ito Had Surgery Traied Had Surgeos derive from four routes: a) A idividual who trais i a coutry where Had Surgery is a speciality i its ow right b) A traied ad accredited Orthopaedic or Plastic Surgeo who develops Had Surgery as a particular qualificatio c) A traied ad accredited Surgeo (ot Orthopaedics or Plastics) who develops Had Surgery as a particular qualificatio iterest A accredited Orthopaedic or Plastic Surgeo who develops Had Surgery as a particular qualificatio iterest will cover a broad rage of Had Surgery ad so less specific Had Surgery traiig is required compared with a idividual who has traiig, with or without accreditatio, i aother major surgical disciplie. Had Surgery certificatio therefore has to take accout of these differet routes. 4.2 Assessmet Assessmet takes two forms, formative ad summative Formative assessmet This is a ogoig process i which the traiee has teachig, advice ad review of his/her progress. It allows the traiee to grow i kowledge ad cofidece; gaps are idetified ad filled. Regular appraisal ad documetatio of progress Assessmet i the workplace Case based discussio Observatio of history- takig, examiatio, surgical procedures Assessmet outside the workplace Case presetatios, research presetatios, teachig of colleagues Summative assessmet This is a formal test of whether the traiee has reached a appropriate stadard. The requiremets for the Diploma, which provides the summative assessmet, are described below 4.3 Certificatio i Had Surgery Europea Board of Had Surgery Diploma This recogises the varied routes ito Had Surgery across Europe. Because of the differeces which exist i traiig i differet parts of Europe, differet sets of criteria will have to be utilised accordig to the prevailig patter of traiig i the cadidate s ow coutry. a) I coutries where traiig i had surgery follows accreditatio i Orthopaedic or Plastic Surgery, oe year s traiig with 100% exposure to had surgery i a accredited cetre is sufficiet for the Diploma Examiatio. b) I coutries where traiig i had surgery follows accreditatio i a major surgical speciality other tha Orthopaedic or Plastic Surgery, two years traiig i a accredited cetre with 100% exposure is required. c) Cadidates from coutries i which had surgery is a separate speciality i its ow right, may take the Europea Diploma Examiatio without further traiig provided that: I. Their geeral backgroud traiig (miimum duratio 2 years) has icorporated exposure to orthopaedic ad/or plastic surgery for at least oe year. 18

19 II. Their speciality i Had Surgery has bee for a miimum of three years i a accredited cetre with exposure to both orthopaedic ad plastic surgery techiques, icludig microsurgery. III. They have achieved accreditatio i had surgery i their ow coutries. A coutersiged logbook idicatig performed ad assisted operatios, academic records ad traiig posts held is also required. The logbook cotais 14 subsets, icludig tedo, joit surgery, replatatios ad cogeital coditios ad has a guide to the recommeded umber of operatios. The cadidate should prove a sigificat umber of operatios as operator or first assistat. If possible, the traiig should be doe i a accredited had surgery traiig ceter. At this momet the accreditatio of had surgery traiig cetres is based o the proposals made by atioal societies. It is also expected that the cadidates pursue a scietific activity. The cadidates should also have a recommedatio from his/her Natioal Society for Surgery of the Had. If the cadidate fulfils the above requiremets he may take the Europea Examiatio. The examiatio is ope, ot oly to had surgeos from Europea member coutries, but also to ayoe who desires to participate ad receive certificatio i this specific competecy, i coformity with Europea stadards. The examiatio ivolves Log book submissio Elimiatio MCQ Two 40 miute oral examiatios by two examiers each Recogitio of Had Surgery ad Natioal Diplomas Status of each FESSH member Coutry Please ote: this documet is regularly updated. If the criteria chage, please immediately iform FESSH Office (office@fessh.com). Austria Update Jue 2016: Had Surgery is a established specialty. Trauma, Orthopaedic, Plastic & Recostructive, Geeral or Paediatric Surgeos that have fiished their specialty traiig the go through a maximum 3 year special educatio i Had Surgery at defied cetres to achieve the title of a Had surgeo ("Spezialisiert i Hadchirurgie"). Durig 2011/2012 may of the regular members of the Austria Society for Had Surgery achieved the title of Had surgeo by iterim regulatio (defied by a list of surgical procedures accordig to the FESSH certified log book ad reviewed by a committee). Startig from 2013 approved cetres start regular had surgical traiig. Belgium Update Jue 2016: Had Surgery is ot a separate specialty, but follows traiig i orthopaedic, plastic or geeral surgery. There is o official examiatio, but 4 uiversities orgaize a course with a dissertatio ad a examiatio (Uiversité Libre de Bruxelles, Uiversité Catholique de Louvai, Uiversité de Liege, Uiversité de Lille II). Traiig occurs over a period of 2 years with: 4 theoretical modules ad a practical module (dissectio) per year ad 1 year traiig i a specialized had cetre. Further details ca be obtaied from: olivier.barbier@uclouvai.be 19

20 Bulgaria Update December 2016: Had Surgery is ot a separate specialty. However, it is certified by takig a traiig course followed by a examiatio. The preset Had surgeo should be a orthopaedic surgeo to acquire Had Surgery certificate. The course is oe moth, but ca be separated i 4 week-log courses performed at differet time of the year. It icludes lectures ad practical parts. The exam is orgaised by the presidet of the Natioal Society (presetly Prof. Margarita Kateva) ad takes place i the uiversity hospitals i Sofia. The examiers are professors from the Society. Czech Republic Update Jue 2016: The atioal curriculum is ot established yet. It is supposed that to achieve the Had Surgery specialty as a particular competece, it will be ecessary to complete each of the six theoretical ad practical courses of Had Surgery, orgaized by the Czech Society for Had Surgery, ad to have practical experiece i Had Surgery, proved by sufficiet period of practice with a sufficietly large umber of Had Surgery operatios, performed or assisted, ad with fial examiatio. However, traiig requiremets ad atioal exam are ot established yet. We also cosider, that specializatio i Had Surgery should be automatically grated to ayoe who successfully obtais Europea Had Diploma. Demark Update Jue 2016: Had Surgery is ot a separate specialty ad there is o examiatio. Had Surgery is a part of Orthopaedic Surgery as a subspecialty. The Daish Society for Surgery o the Had, DsfH, has made recommedatios for educatio i Had Surgery, where the Surgeo, after Certificatio i Orthopaedic Surgery, has to trai for at least 2 years o a miimum of two differet specialised Had Surgery uits. Estoia Update Jauary 2017: Estoia Society for Surgery of the Had i cooperatio with the Estoia Associatio of Traumatology ad Orthopaedics have set criteria for ad give out the certificate of Had Surgery subspecialty that is ot yet accepted by the Govermet health care authorities. Filad Update Jue 2016: Had Surgery is recogized as a separate specialty. After 3 years of geeral traiig, icludig Orthopaedics, Plastics ad Paediatric Surgery, there is a 3 years traiig program orgaized by the Had Cetres of the Uiversity Hospitals completed by a fial atioal examiatio i Had Surgery. Frace Update Jue 2016: Had Surgery is ot a separate specialty, but a particular competece is delivered by the "Coseil Natioal de l'ordre des Médecis" (Frech Natioal Medical Associatio) followig the aalysis of a applicatio form by the Frech Had Surgery Society. To qualify as a Had surgeo, the orthopaedic or plastic surgeo must sped 1 year as residet ad 2 years as Fellow i Had Surgery traiig cetres accredited by the "Collège de Chirurgie de la Mai" (Had Surgery College). The traiee must pass a Uiversity Diploma of Had Surgery (2 years) ad a Uiversity Diploma of Microsurgery (1 year). A Uiversity Diploma i Microsurgery ca be obtaied i almost all uiversities. There are 4 Uiversities where a Diploma of Surgery of the Had ca be achieved: DIU Chirurgie de la mai Paris; DIU Chirurgie de la mai régio Sud (Bordeaux, Greoble, Lyo, Marseille, Motpellier, Nice); DIU Chirurgie de la mai régio Est (Strasbourg, Nacy, Besaço); DIU Chirurgie de la mai régio Ouest (Brest, Ager, Cae, Nates, Rees, Poitiers, Roue). 20

21 Germay Update Ja 2017: Had Surgery is a particular competece (i.e. Zusatzbezeichug). After 6 years of traiig for ay surgical specialty (usually Geeral Surgery, Plastic Surgery or Orthopaedic Surgery), surgeos eed a further 3 years traiig of Had Surgery with completio of a logbook, fiished by a oral examiatio i Had Surgery. Greece Update Jue 2016: Had Surgery is ot a separate specialty ad there is ot ay examiatio. There are 6 Had Trauma Cetres qualified by FESSH: 4 i public uiversity hospitals ad 2 i private oes. The 4 public uiversity hospitals trai residets of Orthopaedics for 6 to 12 moths durig their 6 year residecy. The Helleic Society is tryig to establish the prerequisites for Had Specialty. Hugary Update Jue 2016: Had Surgery has bee recogized as a separate specialty sice After traiig i Orthopaedics & Trauma (80%) or Geeral Surgery, there is a two-year tailor-made traiig programme, accepted by the Hugaria Had Surgery Board, as well as a practical ad theoretical oral examiatio. The oral examiatio takes mi that ivolves at least 4 topics i Had Surgery as well as a radiological evaluatio. The examiatios are orgaized ad held by the 4 Hugaria medical uiversities, which are also resposible for the orgaizatio ad holdig of the prescribed courses that are ecessary for the examiatio. A small miority of Hugaria had surgeos derive from Geeral Surgery ad Trauma. The Hugaria Had Society hopes to achieve the recogitio of the Europea Diploma as equivalet to a atioal examiatio. Irelad Update Jue 2016: Had Surgery is ot a separate specialty. Had Surgery is icorporated i traiig programmes for Plastic ad Recostructive Surgery ad Orthopaedic Surgery. Itercollegiate specialty exams are udertake i commo with UK traiees. Additioal had fellowship traiig is ecouraged. There is o madatory Had Surgery examiatio. Optioal examiatios are: 1) Diploma Examiatio of the Europea Board of Had Surgery; 2) Diploma i Had Surgery, British Society for Surgery of the Had ad Uiversity of Machester. Israel Update Jue 2016: Had Surgery is a established specialty sice 1990, which is approved by the Israeli Medical Associatio ad the Miistry of Health. Orthopaedic or plastic surgeos, havig fiished their specialty traiig, are eligible for Had Surgery traiig at defied cetres. The traiig period is 2.5 years, icludig specified procedures (icludig microsurgery traiig), ad with oral ad writte examiatios at the ed of the period. After completig the requiremets, the surgeo is awarded the title Had Surgery Specialist with a licece umber. Italy Update Jue 2016: Had Surgery is a Supplemet Diploma (Particular Competece) delivered either withi the Specialty of Orthopaedics ad Traumatology or the Specialty of Plastic ad Recostructive Surgery. The Supplemet Diploma is a itegrative part of the Specialty Diploma ad is obtaied by achievig 45 Had Surgery CFU (Crediti Formativi Uiversitari : Uiversity Educatioal Credits) withi the total of 300 CFU required for the Specialty Diploma i Orthopaedics or Plastic Surgery. Had Surgery is ot a separate specialty ad there is o special examiatio. There are Uiversity Masters i Had Surgery i which the participat must atted 1500 hours of teachig (i.e. 800 lectures ad 700 cliical). Each Master gives 60 formative credits. The educatioal path to become a Had Surgeo passes from Orthopaedics or Plastic Surgery specialties. Thus, Had Surgery is a further diploma of Plastic ad 21

22 Orthopaedics. Surgery schools: durig the 5 years residecy program oly those schools recogized as Had Trauma Cetres are allowed to certificate ad provide a "Had Surgery profile". Latvia Update Ja 2017: Had Surgery has bee recogized by Latvia Medical Society as a subspecialty of Plastic Surgery or Orthopaedic Surgery sice It has a separate examiatio (practical ad writte) after compulsory traiig (fellowship) for oe year i a certified istitutio i the coutry or abroad. Most Had Surgeos i Latvia are Plastic Surgeos with 6 years of postgraduate traiig. There are two cetres where cadidates ca udergo traiig: 1) Cetre of Plastic ad Recostructive Microsurgery of Latvia, Departmet of Had Surgery (affiliated with Riga Stradņš Uiversity) ad 2) the Hospital of Traumatology ad Orthopaedics. Netherlads Update Jue 2016: Had Surgery is ot a separate specialty. The Netherlads does ot offer a Had Surgery examiatio. However, the Europea Board of Had Surgery (EBHS) examiatio is recommeded by the Netherlads Society for Surgery of the Had. There are o bidig criteria to classify or defie a Had surgeo. There are o set criteria by which a idividual ca be classified as a Had surgeo. Curretly, we are i the process of producig a defiitio ad of settig criteria for surgeos to be recogised as Had Surgeos i The Netherlads. Most Had Surgeos have traied i Plastic Surgery, occasioally i Orthopaedics. Two cetres offer a Had Surgery fellowship for the duratio of 12 moths. Oe of the requiremets to obtai the Had Surgery fellowship certificate is to pass the EBHS Diploma Examiatio. Norway Update Jue 2016: There remais a Diploma i Had Surgery awarded by the Norwegia Society for Surgery of the Had. To obtai the Diploma, the cadidate has to be a specialist i Orthopaedic, Plastic Surgery or Geeral Surgery ad i additio has to fulfil certai criteria (detailed i the Log Book made by the Had Society). Polad Update Jue 2016: Had Surgery is presetly ot a separate specialty i Polad ad there is o specialist examiatio. Had Surgery, together with microsurgery, is a obligatory part of traiig durig Geeral Surgery, Orthopaedic-Traumatology, ad Plastic-Recostructive Surgery. I the first two, there is a obligatory participatio i a oe week course devoted to Had ad Microsurgery. However, sice 2009 we have made efforts to establish Had Surgery as a separate sub-specializatio or competecy. The required documets have bee submitted to the Miistry of Health, icludig a specializatio program which was produced i cooperatio with the British Society for Surgery of the Had. The programme is partly based o this British program. It eeds Parliametary approval to be accepted, which will be a log ad hard process. Portugal Update Jauary 2017: Had Surgery is ot a separate specialty ad there is o examiatio. There is o formal traiig programme or examiatio; thus, there are o set criteria by which a idividual ca be classified as a Had surgeo. Romaia Updated Jue 2016: There is o formal traiig ad o examiatio. Had surgeos derive from Plastic Surgery. 22

23 Russia Updated Ja 2017: Had Surgery is ot a separate specialty. It is icluded as a obligatory part i residecy traiig program for both Orthopaedic ad Plastic Surgery specialties, which last 2-3 years. Most of the Had Surgeos are certified i Orthopaedics ad Geeral Surgery. Still, there are ot ay established criteria to be board certified i Had Surgery. Fellowship programs i medical specialties i geeral, specifically i Had Surgery, are ot yet established. Curretly, there are 23 Had Surgery departmets ad cetres i differet regios of the coutry; two of them are private oes. Sice 2014, four of them have bee validated as the Europea Had Trauma Cetre by the FESSH Trauma Committee, i.e. located i: Moscow, Sait Petersburg, Yaroslavl ad Tomsk. Spai Update Jauary 2017: There is o specialty recogitio ad o examiatio. Traiig is through Orthopaedics or Plastic Surgery. The Natioal Society (SECMA) has prepared a documet that has bee submitted to the Miistry of Health for the creatio of a Area of Special Qualificatio. Regulatios for this procedure have bee stated by a govermet decree, but ot yet put ito practice. The procedure cosists of a request for the creatio of a Area of Special Qualificatios i Had Surgery, made by the Natioal Commissios of the Specialties of Orthopaedic Surgery &Traumatology, ad Plastic, Reparative ad Aesthetic Surgery, that must be elevated to the Miistry. By ow, there is o iformatio of the process from the Miistry, but there is support from the Natioal Commissios of the Specialties. Swede Update April 2016: For may years (i.e ) Had Surgery was a separate specialty i Swede. Durig the period Had Surgery was a brach specialty of Orthopaedic Surgery requirig a full orthopaedic traiig ad the additioal two years of traiig i Had Surgery. From May 1st, 2015, the Natioal Board of Health ad Welfare i Swede re-established Had Surgery as a basic specialty with its ow structured traiig. To be a had specialist, a miimum of 5 years of traiig ad attedace of several courses are required. The traiig has to be at least 3 years of Had Surgery ad icluded i the 5 years must be traiig i related specialties, like Orthopaedic Surgery ad Plastic Surgery. The Swedish Society for Surgery of the Had strogly recommeds the residets or fresh cosultats to take the Europea Board of Had Surgery Diploma Examiatio ad recommeds the diploma to etitle to a mothly salary raise of Euros. Switzerlad Update Ju 2016: Had Surgery is recogized as a separate specialty. After 2 years of geeral traiig i Geeral Surgery, there is a 4-year traiig programme i at least 2 differet cetres. The traiee must atted 6 atioal or iteratioal cofereces or courses ad must be the first author of a peer-reviewed article i Had Surgery. The traiee must also give 2 oral presetatios at a had surgical cogress ad complete a log book. The Europea Board of Had Surgery Examiatio, orgaized by FESSH, is the official examiatio for Had Surgeos from Turkey Update Jue 2016: Had Surgery is a established specialty sice After a 5 to 6 years of Plastic Surgery or Orthopaedic Surgery traiig surgeos eed a further 2 years of Had Surgery traiig, completed by a oral ad writte exam ad a case surgery. After completig the requiremets, the physicia establishes the title of Had surgeo with a diploma ad licese umber by Miistry of Health. Curretly, Had Surgery traiig is available at 9 differet hospitals. These are Istabul Uiversity Faculty of Medicie; Istabul Uiversity Cerrahpasa Faculty of Medicie; Akara Uiversity Faculty of Medicie; Uludag Uiversity Faculty of Medicie; Mersi Uiversity Faculty of Medicie; Pamukkale Uiversity Faculty of Medicie; Afyo Uiversity 23

24 Faculty of Medicie; Baltalimai Boe ad Joit Diseases Teachig Hospital (Istabul) ad Sisli Etfal Teachig Hospital (Istabul). Besides that, 12 other established Had Surgery cetres actively work cliically ad soo to be registered as a residecy traiig cetre. Ukraie Update July 2016: Had Surgery is ot a separate specialty i Ukraie ad there is o examiatio i the field. Had surgeos derive from Orthopaedic ad Plastic Surgery. Uited Kigdom Update July 2016: Had Surgery is ot a separate specialty, although holdig of the EBHS Diploma ad appropriate traiig has led to recogitio by the licesig body (Geeral Medical Coucil). There is a atioal Had Diploma ru by BSSH & the Uiversity of Machester, which is a oe-year programme of educatio i Had Surgery, culmiatig i a examiatio leadig to the Diploma i Had Surgery beig. Had Surgeos gai their board examiatios i Orthopaedic or Plastic Surgery ad ca the specialise i Had Surgery. At least oe year as a Fellow i a recogized cetre i the UK or abroad, is expected, although there are o formal requiremets for someoe to promote themselves as a Had surgeo. For further details: Traiers Traiers will be traied Had Surgeos who are able to provide the time, ethusiasm ad resource to support the educatioal eeds of the traiee. The Traier should be recogised by his or her peers as a idividual with the proper attitude, reputatio ad credetials to trai. 4.5 Traiig Cetres There are very may excellet cetres for traiig i Had Surgery throughout Europe. Formal recogitio is a future optio (see 5.) 4.6 Traiees Persoal resposibility The traiee has a persoal resposibility to follow the curriculum. This meas dedicatio of time to readig ad observig ad to arragig time with the traier. Had Surgery is diverse ad a idividual traiee will have deficiecies i experiece. A traiee with a orthopaedic backgroud may eed to make special effort to fill gaps i kowledge of the plastic surgical aspects of had surgery. Fellowship traiig ad observerships, ofte meaig travel away from home, is usually required Logbook The traiee must keep a log book of procedures that have bee performed or participated i. The logbook should form a part of the ogoig formative assessmet of the Traiee, as well as a marker for etry ito summative assessmet (i.e. Diploma). A adequate rage of procedures should be accumulated to allow competet uassisted performace of may procedures ad at least a uderstadig of more complex procedures. 24