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Available online at

ScienceDirect
www.sciencedirect.com

Original article

Early postoperative dressing removal in hand surgery: Novel concepts

for individualized surgical dressing management
Retrait de pansement précoce ou différé après chirurgie de la main:
vers un protocole personnalisé
F. Atlan *, I. Ashkenazi, K. Shehadeh, D. Ben-Shabat, I. Shichman, G. Eisenberg,
Y. Rosenblatt, D. Tordjman, T. Pritsch, S. Factor
Tel Aviv Medical Center, Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine and Tel Aviv University, Weizmann St. 6,
6423906 Tel Aviv-Yafo, Israel

A R T I C L E I N F O A B S T R A C T

Article history: Postoperative dressing protocols after clean surgery without implant vary widely. The purpose of this
Received 1st February 2021 study was to elucidate whether early postoperative dressing removal is a valid option, as compared to
Received in revised form 12 March 2021 untouched dressing or twice-weekly dressing change approach. A prospective randomized study was
Accepted 21 March 2021
conducted on patients who underwent carpal tunnel release (CTR) or trigger finger release (TFR)
Available online xxx
between January and November 2020. Patients were randomly distributed into 3 groups: surgical
dressing untouched until first follow up (SDU); surgical dressing changed twice a week in a health
Keywords:
maintenance organization (HMO); and surgical dressing removed at first postoperative day (SDR). Data
Carpal tunnel release
Trigger finger
collected included patient characteristics, pre-and post-operative functional (QuickDASH) and
WALANT autonomy (Instrumental Activities of Daily Living performance (IADL)) scores, Vancouver scar scale
Postoperative dressing (VSS) and potential complications. Eighty-four patients were included: 28 (33.3%), 29 (34.5%) and 27
COVID19 (32.1%) in the SDU, HMO and SDR groups, respectively. Deterioration in mean IADL score at 2-week
Early dressing removal follow-up was statistically significant in the HMO group (mean delta 3.35, p = 0.008). Quick DASH score
Early active motion improved significantly between preoperative and 2-week follow-up values only in the SDU group (mean
Scar delta 9.12, p = 0.012). Other parameters, including wound complications, did not differ significantly
between groups. Early removal of postoperative dressing and immediate wound exposure was a safe
option after CTR and TFR. An untouched bulky dressing correlated with early functional improvement.
Finally, iterative dressing change in HMO showed no benefit and led to significant deterioration in early
postoperative autonomy.
IRB approval: 0548-18-TLV.
Level of evidence: I.
C 2021 Published by Elsevier Masson SAS on behalf of SFCM.

R É S U M É

Mots-clés: Le protocole de pansement postopératoire après chirurgie propre sans implant varie largement selon les
Libération du canal carpien chirurgiens. Le but de cette étude était de déterminer si l’ablation précoce du pansement postopératoire
Doigt à ressaut était une option valide, comparée à un pansement chirurgical laissé intouché ou changé deux fois par
WALANT
semaine. Une étude prospective randomisée a été conduite sur les patients opérés d’une libération du
Pansement postopératoire
canal carpien (CTR) ou d’un doigt à ressaut (TFR) entre Janvier 2020 et Novembre 2020 dans notre
COVID19
Ablation précoce du pansement
institution. Les patients ont été répartis de manière randomisée en trois groupes: pansement chirurgical
Mobilisation précoce intouché jusqu’à la consultation de contrôle (SDU); changé deux fois par semaine par une infirmière
Cicatrice (HMO), ou retiré au premier jour post-opératoire (SDR). Les données collectées incluaient: les
caractéristiques de chaque patient, une évaluation pré- et post-opératoire de scores fonctionnel

* Corresponding author at: Orthopedic Division, Tel Aviv Medical Center, 6 Weitzman St., Tel Aviv 6423906, Israel.
E-mail address: drfranckatlan@gmail.com (F. Atlan).

https://doi.org/10.1016/j.hansur.2021.03.011
2468-1229/ C 2021 Published by Elsevier Masson SAS on behalf of SFCM.

Please cite this article as: F. Atlan, I. Ashkenazi, K. Shehadeh et al., Early postoperative dressing removal in hand surgery: Novel concepts
for individualized surgical dressing management, Hand Surg Rehab, https://doi.org/10.1016/j.hansur.2021.03.011
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(QuickDASH) et d’autonomie (Instrumental Activities of Daily Living performance (IADL)), une

évaluation de la cicatrice selon la Vancouver Scar Scale (VSS) et la survenue de potentielles
complications. Quatre-vingt-quatre patients ont été inclus, parmi lesquels 28 (33,3%), 29 (34,5%) et 27
(32,1%) dans les groupes SDU, HMO et SDR, respectivement. Le score IADL moyen à deux semaines était
significativement inférieur au score préopératoire dans le groupe HMO (delta moyen 3,35, p = 0,008). Le
score QuickDASH moyen à deux semaines était significativement meilleur que le score préopératoire
dans le groupe SDU (delta moyen 9,12; p = 0,012). Les autres paramètres, dont les complications de site
opératoire, n’ont pas montré de différence significative entre les groupes. L’ablation précoce du
pansement post-opératoire et l’exposition immédiate de la plaie chirurgicale sont une option possible
après CTR et TFR. Un pansement chirurgical intouché jusqu’à la consultation de contrôle est corrélé à une
amélioration fonctionnelle précoce. Enfin, la réfection itérative de pansement chirurgical ne présente pas
d’avantage en comparaison avec les autres options et s’accompagne d’une détérioration significative de
l’autonomie en phase post-opératoire précoce.
Niveau de preuve. – I.
C 2021 Publié par Elsevier Masson SAS au nom de SFCM.

1. Introduction naire (QuickDASH) to assess the global upper-limb function,

Postoperative dressing protocols after clean surgery without
implant or internal device vary widely, depending on surgeon’s
preference, based on common practice rather than evidence.
Literature regarding this topic is scarce [1–5], and no practical
conclusion has emerged so far [6].
Even fewer studies focused on the topic specifically in hand
surgery, where scar complications can impair functional outcome
[7]. However, the implications of postoperative dressing manage-
ment for infection rate, early functional results and cost-
effectiveness are substantial and worth studying [8].
The purpose of this prospective randomized study was to
compare the results of three different postoperative dressing
protocols, including dressing removal at postoperative day 1,
following clean elective hand surgery (i.e., carpal tunnel or trigger
finger release), in terms of wound complications (i.e., dehiscence or
infection) [9], early functional results [10–12], esthetic results
[13,14], and patient satisfaction.
We hypothesized that early postoperative dressing removal
could safely be considered and that there would be no significant
differences in terms of complications between the various groups.
2. Patients and methods
2.1. Study design and preoperative evaluation
We conducted a prospective single-center randomized clinical
study of patients who underwent either carpal tunnel or trigger finger
release between January and November 2020. In accordance with
review board approval and the Declaration of Helsinki, all participants
provided written informed consent, agreeing to the collection of
clinical data in a secured local database. Upon inclusion, the patients
were randomly distributed into 3 groups, prior to surgery:
- SDU group: surgical dressing untouched until first follow-up
consultation;
- HMO group: surgical dressing changed twice a week in health
maintenance organization (HMO);
- SDR group: surgical dressing removed at first postoperative day
(POD 1).
The only exclusion criterion was refusal to participate.
Clinical information collected at baseline included age, gender,
dominant hand, comorbidities, and any ongoing anticoagulation
treatment.
Patients underwent complete orthopedic examination, with
baseline Quick Disabilities of Arm, Shoulder and Hand question-
regardless of cause of impairment [15,16], and baseline Instru-
mental Activities of Daily Living (IADL) to assess functional
autonomy [17].
2.2. Surgical technique
Surgery was performed by a senior board-certified hand
surgeon for all patients (TP, YR, FA, or DT). Surgery was performed
under local anesthesia (lidocaine 2% + adrenaline 1:100,000) with
the patient in a supine position on a hand-operating table. Skin
closure used non-absorbable nylon suture (Ethilon 3-0, EthiconTM,
Somerville NJ, USA). Initial dressing, in theater at end of procedure,
comprised Vaseline gauze, sterile gauze, cotton pad and elastic
bandage.
The surgeon was blinded to the designated dressing protocol.
2.3. Postoperative protocol
The specific postoperative protocol per group was detailed in
the patient’s discharge papers. SDU patients kept the dressing
untouched until the first follow-up consultation, weeks post-
operatively. A protective plastic bag maintained by an elastic band
was recommended for daily showering or bathing to avoid wetting,
and the need to keep the dressing clean and dry was emphasized.
HMO patients were instructed to visit their health maintenance
organization twice a week to have the dressing changed and the
wound checked and cleaned by a registered nurse. Type of dressing
was at the nurse’s discretion. Patients were instructed to keep the
wound strictly dry and covered until the first follow up
consultation. The same plastic bag protection instructions as
mentioned above were given for showering or bathing.
SDR patients were to remove the dressing completely at POD1:
i.e., early surgical wound exposure. They were advised to keep the
wound clean by simple local care twice a day with water and 4%
chlorhexidine gluconate solution. Showering and wetting the hand
was allowed without any particular precautions.
Patients were asked to strictly adhere to the given post-
operative protocol during the follow-up period of 2 weeks.
Immediate active mobilization in complete flexion and extension
was advised, both orally during surgery and in writing on the
discharge papers.
An urgent medical consultation was recommended if any of the
following complications occurred:
- For all groups: increasing pain, resistant to class 2 pain-killers, or
aggravation of any preoperative neurological deficit.
- For the SDR group: wound disunion or fluid effusion from the
wound,

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- For the SDU and HMO groups: fluid effusion through the
dressing, deterioration or wetting of the dressing
2.4. Follow-up and clinical endpoints
At 2-weeks’ follow-up, patients were reviewed by a senior hand
surgeon (TP, YR, FA, or DT) and the following data were collected
as clinical endpoints: postoperative complications (superficial
or deep infection, hematoma, clean dehiscence); IADL score;
QuickDASH score; satisfaction (1-very dissatisfied ;2-dissatisfied;
3-satisfied; 4-very satisfied); and scar on the Vancouver scar scale
(VSS: routinely used to assess scarring after trauma, burns, and
surgical procedures [14]).
2.5. Statistical analysis
Statistical analysis was carried out using x2 or Fisher’s exact test
for categorical variables. All scale variables were tested for
homogeneity of variances before 1-way ANOVA. IBM SPSS 24
(SPSS, Chicago, IL, USA) was used for all analyses, at a significance
level of 0.05.
3. Results
3.1. Demographics
Eighty-four patients (52 female, 62%) were included in the
study, 55 of whom (65.5%) underwent surgery for CTR, and 29
(34.5%) for trigger finger release. There were 28 (33.3%), 29 (34.5%)
and 27 (32.1%) cases in the SDU, HMO and SDR groups,
respectively. Mean age was 64.6 years. 51 cases (61%) involved
the dominant hand. 20 (23.8%) were under anticoagulants (aspirin,
clopidogrel, both, or dabigatran); 21 (25%) had known diabetes;
1 was under corticosteroid therapy. There were no significant
differences in demographics between the 3 groups (p n.s.). Patient
demographics are presented in Table 1. Mean preoperative
QuickDASH score was 44.98 (SD 25.5), and IADL 15.52 (SD 3.4),
both comparable between groups.
3.2. Follow-up and endpoint analysis
All patients (84) completed the 2-week follow-up. Outcome
parameters per group are presented in Table 2.
Overall, there were 3 wound complications. One 62-year-old
SDU patient who underwent carpal tunnel release and retinacular
cyst excision presented superficial infection at follow-up, treated
successfully with oral antibiotics (Augmentin (clavulanic acid)
875 mg twice daily for 1 week). One 78-year-old SDR patient with
chronic ischemic heart disease, under aspirin and clopidogrel at
time of surgery, consulted his family physician within 24 h of
surgery as he was worried by slight diffuse swelling of the hand. On
recommendation by the family physician, he began oral antibiotic
treatment for suspected superficial wound infection (cefuroxime
500 mg twice a day for 5 days). At follow-up, there were no further
no signs of infection. One 30-year-old SDR patient suffered from
minor clean-wound dehiscence after removal of stiches, success-
fully treated by local care (wound cleaning every 2 days, followed

Table 1
Patient demographics.

Variable HMO group SDU group SDR group Total p-Value

Total (%) 29 (35) 28 (33) 27 (32) 84 (100)

Age (SD) 62.1 (12.9) 67.3 (14.1) 64.6 (15.4) 64.6 (14.1) 0.52
Gender
Male (%) 9 (31) 13 (46) 10 (37) 32 (38)
Female (%) 20 (69) 15 (54) 17 (63) 52 (62) 0.49
Preoperative IADL (SD)a 16.4 (2.6) 14.8 (4.4) 15.5 (3.1) 15.5 (3.4) 0.27
Preoperative QuickDASH 43.7 (27.3) 49.5 (28.8) 39.7 (22.9) 44.9 (25.5) 0.83
Dominant hand involvement
Yes (%) 18 (62) 19 (68) 14 (52) 51 (61)
No (%) 11 (38) 9 (32) 13 (48) 33 (39) 0.5
Occupational status
No work (%) 4 (14) 3 (11) 5 (19) 12 (14)
Unemployed (%) 3 (10) 2 (7) 5 (19) 10 (12)
Retired (%) 7 (24) 11 (39) 5 (19) 23 (27)
Office work (%) 7 (24) 4 (14) 7 (26) 18 (21)
Manual work (%) 8 (28) 8 (29) 5 (19) 21 (25) 0.65
Operation type
Carpal tunnel release (%) 18 (62) 20 (71) 17 (63) 55 (65) 0.34
Trigger finger release (%) 11 (38) 8 (29) 10 (37) 29 (35) 0.74
Operation site
Thumb (%) 3 (10) 2 (7) 3 (11) 8 (10)
3rd finger (%) 6 (21) 5 (18) 1 (4) 12 (14)
4th finger (%) 1 (3) 1 (4) 3 (11) 5 (6)
Multiple fingers 1 (3) 0 (0) 3 (11) 4 (5)

Diabetes
Yes (%) 8 (28) 5 (18) 8 (30) 21 (25)
No (%) 21 (72) 23 (82) 19 (70) 63 (75) 0.54
Anticoagulation therapy
No (%) 21 (72) 24 (86) 19 (70) 64 (76)
Aspirin (%) 4 (14) 3 (11) 6 (22) 13 (15)
Plavix (%) 1 (3) 1 (4) 0 (0) 2 (2)
Aspirin + plavix (%) 2 (7) 0 (0) 2 (7) 4 (5)
Pradaxa (%) 1 (3) 0 (0) 0 (0) 1 (1) 0.54
Steroids
Yes (%) 0 (0) 1 (4) 0 (0) 1 (1)
No (%) 29 (100) 27 (96) 27 (100) 83 (99) 0.65

IADL: Instrumental Activities of Daily Living performance; DASH: Disabilities of Arm, Shoulder and Hand questionnaire.
a
Values are presented as mean and standard deviation.

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Table 2
Postoperative outcomes.

Variable HMO group SDU group SDR group Total p-Value

Total (%) 29 (35) 28 (33) 27 (32) 84 (100)

Complication
No (%) 28 (97) 28 (100) 25 (93) 81 (96)
Wound dehiscence (%) 0 (0) 0 (0) 1 (4) 1 (1)
Superficial infection (%) 1 (3) 0 (0) 1 (4) 2 (2) 0.47
Need for unscheduled consultation
No (%) 28 (97) 26 (93) 25 (93) 79 (94)
Pain (%) 1 (3) 1 (4) 0 (0) 2 (2)
Wound (%) 0 (0) 1 (4) 1 (4) 2 (2)
Dressing (%) 0 (0) 0 (0) 1 (4) 1 (1) 0.75
Satisfaction
Very satisfied (%) 6 (21) 7 (25) 5 (19) 18 (21)
Satisfied (%) 21 (72) 18 (64) 21 (78) 60 (71)
Dissatisfied (%) 2 (7) 1 (4) 1 (4) 4 (5)
Very dissatisfied (%) 0 (0) 2 (7) 0 (0) 2 (2) 0.72
Postoperative IADL (SD)a 13.1 (5.6) 13.9 (4.5) 14.8 (3.9) 13.8 (4.8) 0.52
Postoperative QuickDASH score (SD) 46.9 (28) 40.3 (25.2) 38.3 (24.5) 42.2 (25.9) 0.55
VSS (SD) 2 (1.9) 1.7 (1.5) 1.8 (1.7) 1.9 (1.7) 0.83

IADL: Instrumental Activities of Daily Living performance; DASH: Disabilities of Arm, Shoulder and Hand questionnaire; VSS: Vancouver Scar Scale.
a
Values are presented as mean and standard deviation.

by gauze Vaseline and mupirocin dressing). There was no deep
infection requiring surgical debridement.
Mean preoperative IADL and QuickDASH scores were compa-
rable between groups (Table 1). Deterioration in mean IADL score
at 2 weeks’ follow-up was statistically significant in the HMO
group (mean delta 3.35, p = 0.008). No significant difference was
observed between preoperative and 2-week postoperative IADL
scores in the other two groups. QuickDASH score improved
significantly only in SDU at 2 weeks (mean delta 9.12, p = 0.012).
Satisfaction at last follow-up did not differ significantly
between groups. Overall, 93% were satisfied or very satisfied
(21.5% and 71.5% respectively), and 5% and 2% were dissatisfied or
very dissatisfied, respectively.
Mean VSS at 2 weeks’ follow-up was 1.885 (SD 1.72) and did not
differ significantly between groups (p. n.s.).
4. Discussion
Despite the development of various types of active and
interactive measures to address specific wound related issues,
the optimal postoperative dressing protocol on clean wounds in
elective surgery remains controversial [2].
Eberhardt et al. [6] performed a meta-analysis regarding the
optimal time for dressing removal in the healing of surgical
wounds. They concluded that no higher rates of wound infection or
other wound complications were associated with early dressing
removal. Another meta-analysis published in 2014 by Toon et al.
[3] concluded that ‘‘There is currently no conclusive evidence
available from randomized trials about the benefits, or harms, with
regard to wound complications of early or delayed postoperative
showering or bathing’’. Further prospective randomized studies
are lacking but needed.
Complication and satisfaction rates and need for unscheduled
medical consultation before first follow-up did not differ between
the 3 groups. Similarly to previous studies in the field, the present
study demonstrated that a variety of dressing strategies can be
applied safely and effectively. There were no significant short-term
differences between the groups in terms of wound-related
complications or scar quality.
Early dressing removal with immediate wound exposure is
often avoided due to fears of non-compliance and complications
such as wound infection, but may in fact have advantages for
certain patients.
Firstly, patients do not need to adhere to protection instructions
regarding bathing and showering, thus avoiding the need for
assistance and associated loss of autonomy. The complexity of
wound protection dressing, transient functional impairment and
related loss of autonomy may be important factors for patients
when considering surgery. Especially in elderly patients, the
associated fears can sometimes discourage them from undergoing
surgery that could their quality of daily life.
Secondly, with early dressing removal patients are able to use
their hand at an earlier stage, as range of motion is not limited by a
bulky dressing and the level of apprehension is less.
Importantly, in the light of the recent COVID-19 pandemic, a
need arose for modern individualized treatment plans that allow
minimal contact with medical institutions. Elective outpatient
management was completely disrupted, and most routine follow-
up consultations had to be suspended, as only urgent cases were
prioritized. In fact, the design of the present study was also
impacted and limited by the pandemic, as patients could not
adhere to their scheduled 6-week and 3-month follow-up
consultations.
Minimal health-care center contact, especially for elderly
patients and patients at risk of infectious disease, can be
advantageous and could help mitigate the impact of the COVID-
19 pandemic on postoperative care, while still ensuring adequate
treatment and optimal management with limited resources. It
minimizes exposure to infectious threats and consequent morbi-
dity and mortality.
However, although it theoretically allows more freedom of use
of the hand, an exposed wound can cause irritation and more easily
raise concerns about post-surgical complications in certain
patients. In the present series, 1 patient in the SDR group consulted
a physician due to his concern about the visible postoperative
appearance of the hand and surgical site, and was even prescribed
oral antibiotics, although an infectious process was very unlikely
less than 24 h after surgery.
Early wound exposure with simple postoperative instructions
for compliant patients can be considered a safe option for
postoperative management in selected patients, minimizing
minimal health-care center contact and enabling early return to
use and maximal maintenance of autonomy.

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F. Atlan, I. Ashkenazi, K. Shehadeh et al.
Patients that had their dressing changed twice in the early
postoperative period (HMO group) showed significant deterioration
in IADL 2 weeks postoperatively, unlike the other two groups. This
can be because going to change dressings twice a week in an HMO is
a logistic burden disrupting and thus jeopardizing the routine daily
life of patients with fragile autonomy. Although the HMO protocol
allows optimal adjustment of the dressing according to the
capabilities of the patient and ensures appropriate monitoring of
the surgical site by a health-care professional, the present results
question its risk-benefit ratio and cost-effectiveness.
QuickDASH score improved significantly solely in the group
that left their dressing untouched during the whole follow-up
period (SDU group). This may be related to complete wound
protection as well as the requirement to rest the hand.
However, the SDU protocol may unnecessarily limit range of
motion and early active motion, which is generally desirable after
carpal tunnel release [18]. Especially in patients living alone, for
whom the early use of both hands in daily life activities is of
paramount importance, a thick dressing may be inappropriate.
Finally, most patients complain of discomfort and hygiene issues
related to keeping a dressing on for such a long period.
Interestingly, patients with associated diabetes or ongoing
anticoagulation treatment, each constituting 1 in 4 inclusions in
the present study, did not show higher complication rates.
Both type 1 and type 2 diabetes have been shown to negatively
impact the functional result of carpal tunnel release compared to
the non-diabetic population, especially in case of preexisting cold
intolerance [19,20]. Similarly, diabetes is associated with a higher
risk of secondary surgery [21]. However, previous studies
demonstrated that infection rates and wound complications are
not more frequent in the diabetic population [22].
Similarly, carpal tunnel release under uninterrupted anti-
coagulation therapy has a simple postoperative course, not
associated with wound complications [23]. Thus the present
results are in accordance with the existing literature on this point.
In trigger finger release, there is supporting evidence that
wound complications risk is higher in diabetic patients [24].
The present results failed to confirm such increased risk, probably
due to the small number of diabetic patients undergoing trigger
finger release.
The limitations of the study include small sample size and short
follow-up, although the main focus was to reveal differences
between groups in the early stage between surgery and stitch
removal. Moreover, the results are limited to clean elective
surgeries in soft tissue only, with no foreign material implanted.
5. Conclusion
The present results showed that early wound exposure is a safe
option for postoperative management of clean elective surgery
without implanted device, including in patients with diabetes or
ongoing anticoagulation treatment. However, in terms of early
functional improvement, an untouched bulky protective dressing
appeared to be the best option, being the only one showing better
QuickDASH score at 2 weeks’ follow-up. Finally, regular dressing
changes in an HMO center did not show any added value compared
to the other protocols, and significantly impaired daily life
activities at 2 weeks’ follow-up. The study supports the idea that
dressing protocols can and should be tailored to each patient,
considering his/her autonomy, capacities, early functional demand
and preferences.
Additional studies are required, particularly with long-term
follow-up and larger sample sizes in each group.
Hand Surgery and Rehabilitation xxx (xxxx) xxx–xxx
Contributors
All authors that have contributed to this manuscript have agreed on the final
revised version of this manuscript. If necessary, do not hesitate to contact us for
further specifications.
Funding
No funding was received for this project.
Conflict of interest
The authors declare they have no conflicts of interest related to this article.
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