Outcomes assessment in hand surgery: when are they meaningful?

Reliability and validity of Vancouver Scar Scale and Withey score after syndactyly release

This study aimed to analyze the reliability and validity of the Vancouver Scar Scale (VSS) and the Withey score after syndactyly release. Over a 3-year period, 13 patients who underwent syndactyly release were evaluated. The mean age at the time of syndactyly release was 12 months (range, 8-18 months), and the mean follow-up period was 29 months (range, 17-52 months). We obtained hand photographs and finger motion videos and collected the satisfaction scores for hand function and cosmesis. Three clinicians evaluated the hand photographs and finger motion video of each patient twice using the VSS and the Withey score. The interobserver and intraobserver reliabilities of the VSS and Withey score were determined using intraclass correlation coefficients (ICCs). The validity of the VSS and Withey score was determined using Spearman's correlation test with the functional and cosmetic satisfaction score. The ICCs for the interobserver reliability of VSS were 0.31 and 0.39 for each measurement, and ICCs for the intraobserver reliability of VSS were 0.46, 0.51, and 0.54 for each observer. The ICCs for the interobserver reliability of the Withey score were 0.74 and 0.70, and the ICCs for the intraobserver reliability of the Withey score were 0.91, 0.74, and 0.96. The Withey score was significantly correlated with the satisfaction score for hand function and hand cosmesis, but the VSS was not. The VSS had poor interobserver reliability and fair intraobserver reliability, whereas the Withey score had good interobserver reliability and excellent intraobserver reliability based on photographic evaluation after syndactyly release.

Pain and numbness one month after carpal tunnel release predict patient-reported outcome measures at sixth months

A number of outcome predictors for carpal tunnel release (CTR) for carpal tunnel syndrome (CTS) have been reported. However, some predictors are controversial, and few studies have referred to the early postoperative outcome prognostic factors after CTR. The aim of this study was to investigate whether pain and numbness at 1 month post-CTR were early postoperative predictors of clinical outcomes 6 months after surgery. Pain and numbness were evaluated using the visual analog scale (VAS) preoperatively and at 1 month post-surgery. Patient-reported outcome measures (PROMs), including the Quick Disabilities of the Arm, Shoulder and Hand (QDASH) measure, the Hand20 questionnaire and the Boston Carpal Tunnel Questionnaire (BCTQ), were recorded for each patient 6 months after surgery. The BCTQ consisted of the Symptom Severity Scale (SSS) and Functional Status Scale (FSS). Multivariable linear regression analysis was performed to investigate the association between the VAS scores and PROMs. We retrospectively identified 93 patients who underwent open carpal tunnel release (OCTR) or endoscopic carpal tunnel release. The mean age of the patients was 67.5 years, and 67 patients (72.0%) were female. Sixty patients were treated by OCTR (65.0%). With multivariable linear regression analysis, we found that pain and numbness, evaluated with VAS 1 month post-surgery had significant correlations with QDASH, Hand20, SSS and FSS 6 months after surgery. In conclusion, pain and numbness 1 month after CTR predict PROMs at 6 months.

Clinical Utility of the 6-Item CTS, Boston-CTS, and Hand-Diagram for Carpal Tunnel Syndrome

Background: Self-reported measures are often used in research and clinical practice to diagnose carpal tunnel syndrome (CTS) and guide therapeutic choices. We aimed to assess the clinical utility of the Norwegian versions of two self-reported outcome measures for symptom severity assessment, the 6-item CTS (CTS-6), and Boston-CTS (BCTQ), and of one diagnostic measure, the hand-diagram, by evaluating measurement properties including discriminative ability for severity assessment (CTS-6, BCTQ), and diagnosis of CTS (hand-diagram).

Methods: We performed forward and backward translation and cultural adaptation of the Norwegian CTS-6 and BCTQ. Following COSMIN guidelines, we investigated internal consistency, reliability, construct validity, and discriminative ability for distinguishing between severity levels of CTS in patients with confirmed CTS for the CTS-6 and BCTQ and reliability and discriminative ability for diagnosing CTS for the hand-diagram.

Results: Two hundred and fifty-one patients referred for diagnostic work-up for CTS with nerve conduction studies (NCS) participated. The CTS-6 and BCTQ had acceptable internal consistency (Crohnbach's α = 0.82 and 0.86, respectively), reliability (ICC = 0.86 and 0.90; SEM = 0.24 and 0.20; SDC95% = 0.68 and 0.55, respectively), construct validity (all eight pre-defined hypotheses confirmed) and discriminative ability to distinguish between severity levels of CTS [Area under the curve (AUC) = 0.75, 95% CI 0.64–0.85]. The hand-diagram had acceptable reliability (Cohen's kappa = 0.69) and discriminative ability to diagnose CTS (sensitivity = 0.72, specificity = 0.90).

Conclusion: Our findings support the clinical utility of the CTS-6 and BCTQ for symptom severity assessment and of the hand-diagram for diagnostic screening.

Structural validity of the Boston Carpal Tunnel Questionnaire and its short version, the 6-Item CTS symptoms scale: a Rasch analysis one year after surgery

Background

The Boston Carpal Tunnel Questionnaire (BCTQ) and its shorter version, the Six-Item Carpal Tunnel Symptoms Scale (CTS-6), are widely used for assessing function and/or symptoms in patients with carpal tunnel syndrome. This study examined the structural validity of the BCTQ and CTS-6 among patients who had undergone surgery for treatment of carpal tunnel syndrome.

Methods

The data for this cross-sectional analysis were obtained from 217 adult patients who had undergone carpal tunnel release surgery 1 year earlier. All patients completed the CTS-6, Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the BCTQ at 12 months after surgery. The Rasch Measurement Theory (RMT) was applied to investigate the unidimensionality, residual correlation, differential item functioning, scale coverage/targeting, and person separation of the CTS-6, SSS and FSS of the BCTQ.

Results

The FSS showed unidimensionality and good scale and item fit. All items showed ordered response category thresholds. Eight of the FSS items displayed differential item functioning favoring age or gender. The multidimensional structure of the CTS-6 was absorbed by creating a testlet for frequency of symptoms or testlets for pain and numbness. The testlets supported unidimensionality in the BCTQ SSS. One item in the CTS-6 and two items in the BCTQ SSS showed differential item functioning favoring age or gender. Four items in the BCTQ SSS and two items in the CTS-6 exhibited disordered response category thresholds. Merging of the relevant response categories led to ordered response category thresholds. The person separation indices were 0.73, 0.86 and 0.77 for the CTS-6, BCTQ SSS and FSS, respectively.

Conclusions

Based on the RMT analysis, the CTS-6 has superior psychometric properties compared to the BCTQ SSS in surgically treated patients. The CTS-6 might be more accurate when separated into item sets measuring pain or numbness. The FSS of the BCTQ has acceptable construct validity, although gender differences at some ages were observed in responses.

Shape-texture-identification-STI-A test for tactile gnosis: Concurrent validity of STI2

STUDY DESIGN

Cross-sectional study.

INTRODUCTION

The shape-texture-identification (STI) test (Össur Nordic AB, Sweden) is used to evaluate one aspect of tactile gnosis in nerve disorders, and it has proven good methodological properties.

PURPOSE OF THE STUDY

A new version of the STI test was recently introduced-STI² (www.sensory-test.com). The purpose of this study was to test the concurrent validity in STI².

METHODS

Using a cross-sectional design, this methodological study compared STI² to the original version based on 2 cohorts; 1 including 20 persons (1 affected finger and corresponding finger on in opposite hand) with affected sensibility after hand injuries and 1 healthy group including 20 persons (digits II and V in both hands). The agreement between the 2 versions of the instrument was calculated statistically by a percentage comparison of the test results and weighted kappa.

RESULTS

The 112 tested fingers showed a complete agreement, or 1-point accepted deviation, between the 2 tests in 92% with weighted kappa of 0.74 and 95% confidence interval of 0.63-0.89. The result showed that there is no significant deviation between the 2 versions of the test.

DISCUSSION

The use of standardizes and evidence based assessment tools in clinical practice is paramount for a patient centered healthcare. Previous research has shown good psychometric proprties in the STI-test. This study contributes to the scientific evidence of the instrument.

CONCLUSION

As the new STI² proved good agreement within the accepted deviation, we conclude that there is evidence to use the new STI² test in assessment of tactile gnosis.

Systematic Review of the Use of Patient Reported Outcome Measures in Studies of Electively-Managed Hand Conditions

Background: Electively-managed conditions account for over 100 000 inpatient surgeries a year in the English National Health Service alone, with further procedures in other regions of the UK, or performed on an outpatient basis. To quality assure this care and to conduct research, effective outcome measurement is critical. Traditional surgeon-centric outcome measures correlate poorly with hand function and are seldom important to patients. There has been an advent in the use of patient reported outcome measures (PROMs) in hand surgery although consensus of PROM choice appears to be lacking. This systematic review aimed to describe the use of relevant PROMs in clinical research of electively-managed hand conditions. Methods: A PRISMA-compliant methodology was used. A bespoke search strategy was developed in conjunction with a search strategist, and applied to Medline, EMBASE, CINAHL and PSYCHINFO from 1992 to June 2017. Pre-specified stepwise inclusion criteria were used to identify studies describing adult patients undergoing treatment for electively-managed hand conditions distal to the distal radius, with clinical outcomes measured using one or more PROMs. Results: Of 4554 results, 834 met inclusion criteria. PROMs identified included 9 disease-specific, 8 site-specific and 4 generic quality of life measures. Across all, the Disabilities of the Arm, Shoulder and Hand (DASH) was the most commonly used (overall frequency 41.0%). The most commonly reported disease-specific measure was the Boston Carpal Tunnel Questionnaire (overall frequency 23.0%). The most commonly reported generic quality of life of measure was the SF-36 (overall frequency 4%). Time-analysis demonstrated predominance of site-specific PROMs since the year 2000. Conclusions: Various PROMs have been used to study electively-managed hand conditions, with site-specific PROMs most popular. However, there appears to be limited consensus on choices. A future systematic evaluation of the published psychometric properties of identified PROMs may inform standardisation of measurement.

Patient-reported quality of life and hand disability in elderly patients after a traumatic hand injury - a retrospective study

Background

Hand injuries occur at any age and cause disability in hand and arm function as well as impaired quality of life, but no study has focused on hand disability and quality of life in the elderly after a hand injury. Globally, the population over 60 years of age is expected to double by 2050 and more hand injuries are estimated among the elderly population. Our goal is to obtain more information and a better understanding of problems elderly patients experience after a hand injury to be able in the future to optimally relocate resources in the health care sector with respect to numbers and injury pattern as well as to health status of these patients.

Methods

Patients aged more than 65 years with a traumatic hand/wrist/forearm injury treated (July 1st 2013 - June 30th 2014) at department of Hand Surgery, Malmö, Sweden were included. Health-related outcome questionnaires, i.e. QuickDASH, SF-36, Visual Analogue Scale (VAS), Cold Intolerance Severity Score (CISS), and general information were mailed to the patients (time from injury: > 1.5–2.5 years). The participants were compared in groups according to age, gender, cold intolerance, injury severity and previous occupation.

Results

One hundred and thirty-seven participants responded [response rate 55%; non-responders (n = 113); only difference between groups was that non-responders were older]. Women were older than men at the time of injury (p = 0.04) and differed regarding living conditions. The main differences in QuickDASH, all VAS questions, and the majority of SF-36 subscales (p < 0.05) were found in the participants with CISS > 50, who experienced more impairment. More serious injuries (Modified HISS) were found to have higher QuickDASH and CISS score as well as more functional impairment (p < 0.05). Few differences were found in groups divided according to age, gender (although men experiencing less functional impairment in QuickDASH), previous occupation and injured hand.

Conclusions

Patients aged more than 65 years at the time a hand injury was sustained, generally experience a high-level quality of life and limited functional problems after such an injury, but patients with CISS > 50 and with a more serious injury were more severely affected.

Comparison of clinical outcomes after ulnar shortening osteotomy for ulnar impaction syndrome with or without arthroscopic debridement

Forty-four patients who had been diagnosed with ulnar impaction syndrome and who were scheduled to undergo ulnar shortening osteotomy were randomized into two groups, one treated by ulnar shortening osteotomy alone and the other treated by ulnar shortening osteotomy combined with arthroscopic debridement. The response to treatment, including the pain numeric rating scale in an ulnar provocation test and the Disability of the Arm, Shoulder and Hand score was assessed at 3 and 12 months after surgery. The mean pain and disability scores showed significant clinical improvement at the 12-month follow-up in both groups. The pain scores at 3 months of follow-up were significantly better in the ulnar shortening osteotomy with arthroscopic debridement group. However, no significant differences were observed between the two groups in the disability scores at 3 and 12 months, or in the pain scores at 12-month follow-up. We conclude that similar improvements in symptom severity and hand function occurred in the long term in patients both with and without concomitant arthroscopic debridement. This information regarding concomitant arthroscopy could be used in the informed consent discussion with patients scheduled for ulnar shortening osteotomy. Level of evidence: II.

The Prognostic Value of Pain Sensitization in Patients With Lateral Epicondylitis

PURPOSE

Pain sensitization is a contributing factor to conditions of chronic pain. The aim of this study was to evaluate the influence of pain sensitization on the prognosis of lateral epicondylitis (LE) treated by self-stretching exercises and the use of a counterforce brace.

METHODS

We enrolled 131 patients who presented with isolated LE symptoms for less than 6 months. We initially measured pain sensitization by assessing patients' pressure pain thresholds (PPTs) in the contralateral middorsal forearm and administering a pain sensitization questionnaire (PSQ). For outcome assessments, we assessed the self-administered, patient-reported Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire at 6 and 12 months' follow-up.

RESULTS

Initial PSQ scores correlated moderately with baseline DASH scores and slightly with symptom duration; PPTs correlated slightly with baseline DASH scores. After we accounted for confounding variables, patient-reported disability was associated with lower PPTs, higher PSQ scores, and manual labor at 6 months. These 3 factors accounted for 36% of variance in the DASH scores; however, at 12 months only the PSQ score was associated with higher DASH scores, accounting for 14% of variance.

CONCLUSIONS

Pain sensitization during the early stages of LE correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. More research is needed to show whether early identification and treatment of pain sensitization will enhance LE treatment outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Ultrasound-guided versus blind corticosteroid injections for De Quervain tendinopathy: a prospective randomized trial

A total of 154 patients with De Quervain tendinopathy were randomized into a blind injection group or an ultrasound-guided injection group to compare effectiveness and complications of steroid injection. The visual analogue scale score for pain, Finkelstein test result, and Disability of the Arm, Shoulder, and Hand (DASH) score were assessed at 12 and 24 weeks follow-up. At 12 weeks, the DASH scores were significantly better in the ultrasound-guided group, but the mean difference was less than the minimum clinically important difference. There was no difference in the DASH scores between the groups at 24 weeks. The pain scores were not significantly different between the two groups at 12 and 24 weeks. The incidence of treatment failure did not significantly differ between two groups. Incidences of soft tissue atrophy or skin depigmentation were significantly greater in patients with blind injection than with ultrasound-guided injection. We conclude that ultrasound-guided steroid injection for De Quervain tendinopathy reduces steroid-associated complications but has similar pain relieving and functional outcomes as blind injection.

LEVEL OF EVIDENCE

I.

Validity and reliability of the Functional Dexterity Test in children

STUDY DESIGN

Clinical measurement study.

INTRODUCTION

The Functional Dexterity Test (FDT) has not been validated in children.

PURPOSE OF THE STUDY

To determine reliability and validity of the FDT in a pediatric population.

METHODS

Intraclass Correlation Coefficients (ICCs) were used to calculate interrater and test-retest reliability in typically developing children. Pearson correlation coefficients were used to compare FDT speed with the Jebsen-Taylor Hand Function Test (JHFT) and with 2 activities of daily living tasks to establish validity in children with congenital hand differences.

RESULTS

The FDT demonstrated excellent interrater (ICC, 0.99) and test-retest (ICC, 0.90) reliability. Pearson correlation coefficients exceeded 0.67 for JHFT subsets of fine dexterity and were all less than 0.66 for JHFT subsets of gross grasp. Correlations with the activities of daily living tasks were good to excellent. FDT speeds in TD children exceeded those of children with congenital hand differences (P < .001), demonstrating discriminant validity.

DISCUSSION

Children with congenital hand differences are often treated early in life, making it important to reliably assess hand function of these young children to distinguish developmental change from changes due to interventions. The FDT can reliably measure functional progress over time, help clinicians monitor the efficacy of treatment, and provide families realistic feedback on their child's progress.

CONCLUSION

The FDT is a valid and reliable instrument for the measurement of fine motor dexterity in children.

Prognostic value of clinical and radiological findings for conservative treatment of idiopathic ulnar impaction syndrome

Ulnar impaction syndrome (UIS) is a common source of ulnar-sided wrist pain, yet not all cases of radiographic ulnar impaction are symptomatic. We retrospectively analyze clinical or radiologic factors that affect prognoses of conservative treatment for idiopathic UIS. A total of 114 patients who had been diagnosed with UIS were treated with 6 weeks of short arm orthosis followed by formal physiotherapy for 6 weeks, with lifestyle modification to limit aggravating movements. The response to treatment, including pain numeric rating scale on an ulnar provocation test, grip strength, Disability of the Arm, Shoulder, and Hand score (DASH), was assessed at 24-week follow-up. For the 24-week follow-up, 29 patients (25%) underwent ulnar shortening osteotomy due to persistent symptoms after conservative treatment, and 18 (16%) patients had pain scores of greater than 5, but they had not undergone surgery. After controlling for confounding variables, female gender (odds ratio (OR) 1.39), duration of symptom (OR 1.27), high pain NRS score on provocation test (OR 1.45), and enhanced carpal or distal ulna bone on MRI (OR 1.82) were associated with a higher likelihood of treatment failure. Knowledge of the factors offers physicians insight into predicting prognoses and helps patients set realistic expectations.

Validity and responsiveness of the Simple Test for Evaluating Hand Function

Introduction

Despite widespread use of the Simple Test for Evaluating Hand Function, we were unable to find studies to affirm the validity and responsiveness in patients with trauma and inflammatory diseases. The aim of this study was to demonstrate the criterion validity and responsiveness of the Simple Test for Evaluating Hand Function, a tool which is widely used in Japan.

Methods

Thirty patients between the ages of 20 and 82 years with distal radius fracture (n = 10), and cervical spondylosis myelopathy (n = 20) were included in this study. Concurrent validity was tested by examining the correlation between Simple Test for Evaluating Hand Function, the Purdue Pegboard Test, and the Disabilities of the Arm, Shoulder and Hand questionnaire. In addition, standardized response means were calculated to compare the responsiveness of the Simple Test for Evaluating Hand Function with Purdue Pegboard Test and Disabilities of the Arm, Shoulder and Hand.

Results

The correlation coefficient between Simple Test for Evaluating Hand Function and Purdue Pegboard Test was 0.70, and the correlation between Simple Test for Evaluating Hand Function and Disabilities of the Arm, Shoulder and Hand was −0.55 (p < 0.05). Standardized response mean shows that the Simple Test for Evaluating Hand Function (0.69) is more responsive than the Purdue Pegboard Test (0.53), and less responsive than Disabilities of the Arm, Shoulder and Hand (0.97).

Conclusions

The Simple Test for Evaluating Hand Function demonstrates concurrent validity and responsiveness as a performance based assessment of dexterity in patients with distal radius fracture and cervical spondylosis. We conclude that the Simple Test for Evaluating Hand Function could be used as a measure of dexterity or clinical change after therapy intervention. The Purdue Pegboard Test may be used for patients with an occupation that requires integrated fine motor skills and bimanual activity, whereas the Simple Test for Evaluating Hand Function may be more suitable for patients who use a variety of unilateral grips such as pinch and span. The Simple Test for Evaluating Hand Function and Disabilities of the Arm, Shoulder and Hand can complement each other when measuring someone’s activity and participation level.

Outcome measurement in plastic surgery

Outcome measurement in plastic surgery is often surgeon-centred, and clinician-derived. Greater emphasis is being placed on patient-reported outcomes (PROs), in which the patients' perspective is measured directly from them. Numerous patient-reported outcome measures (PROMs) have been developed in a range of fields, with a number of good quality PROMs in plastic surgery. They can be deployed to support diagnosis, disease severity determination, referral pathways, treatment decision-making, post-operative care and in determining cost-effectiveness. In order to understand the impact of disease and health interventions, appropriate PROMs are a logical choice in plastic surgery, where many conditions involve detriment of function or cosmesis. PROMS can be classified as disease-specific, domain-specific, dimension-specific, population-specific and generic. Choosing the correct outcome and measure can be nebulous. The two most important considerations are: is it suitable for the intended purpose? And how valid is it? Measurement that combines being patient-centred and aligning with clinicians' understanding is achievable, and can be studied scientifically. Rational design of new PROMs and considered choice of measures is critical in clinical practice and research. There are a number of tools that can be employed to assess the quality of PROMs that are outlined in this overview. Clinicians should consider the quality of measures both in their own practice and when critically appraising evidence. This overview of outcome measurement in plastic surgery provides a tool set enabling plastic surgeons to understand, implement and analyse outcome measures across clinical and academic practice.

Effect of Metabolic Syndrome on the Functional Outcome of Corticosteroid Injection for Lateral Epicondylitis: Retrospective Matched Case-Control Study

Both obesity and diabetes mellitus are well-known risk factors for tendinopathies. We retrospectively compared the efficacy of single corticosteroid injections in treating lateral epicondylitis in patients with and without metabolic syndrome (MetS). Fifty-one patients with lateral epicondylitis and MetS were age- and sex-matched with 51 controls without MetS. Pain severity, Disability of the Arm, Shoulder, and Hand score, and grip strength were assessed at base line and at 6, 12 and 24 weeks post-injection. The pain scores in the MetS group were greater than those in the control group at 6 and 12 weeks. The disability scores and grip strength in the MetS group were significantly worse than those of the control group at 6 weeks. However, there were no significant differences at 24 weeks between the groups in terms of pain, disability scores and grip strengths. After 24 weeks, three patients (6%) in the control group and five patients (10%) in the MetS group had surgical decompression (p = 0.46). Patients with MetS are at risk for poor functional outcome after corticosteroid injection for lateral epicondylitis in the short term, but in the long term there was no difference in outcomes of steroid injection in patients with and without MetS.

The reliability and validity of the Korean version of the Upper Limb Functional Index

[Purpose] The purpose of this study was to establish the reliability and validity of Upper Limb Functional Index (ULFI), which has been translated into Korean, in treating patients with upper limb complaints. [Subjects and Methods] Fourty-nine subjects with upper limb disorder, 20 males and 29 females, participated in this study. Reliability was determined by using the intra class correlation coefficient and Cronbach’s alpha for internal consistency. Validity was examined by correlating ULFI scores with Disability of Arm, Shoulder and Hand (DASH). [Results] Test-retest reliability was 0.90. The criterion-related validity was established by a comparison with the Korean version of DASH. [Conclusion] The Korean version of ULFI was shown to be a reliable and valid instrument for assessing upper limb complaints.

Effects of metabolic syndrome on the functional outcomes of corticosteroid injection for De Quervain tenosynovitis

Metabolic syndrome is a constellation of medical conditions that arise from insulin resistance and abnormal adipose deposition and function. In patients with metabolic syndrome and De Quervain tenosynovitis this might affect the outcome of treatment by local corticosteroid injection. A total of 64 consecutive patients with De Quervain tenosynovitis and metabolic syndrome treated with corticosteroid injection were age- and sex-matched with 64 control patients without metabolic syndrome. The response to treatment, including visual analogue scale score for pain, objective findings consistent with De Quervain tenosynovitis (tenderness at first dorsal compartment, Finkelstein test result), and Disability of the Arm, Shoulder, and Hand score were assessed at 6, 12, and 24 weeks follow-up. Treatment failure was defined as persistence of symptoms or surgical intervention. Prior to treatment, patients with metabolic syndrome had mean initial pain visual analogue scale and Disability of the Arm, Shoulder, and Hand scores similar to those in the control group. The proportion of treatment failure in the metabolic syndrome group (43%) was significantly higher than that in the control group (20%) at 6 months follow-up. The pain visual analogue scale scores in the metabolic syndrome group were higher than the scores in the control group at the 12- and 24-week follow-ups. The Disability of the Arm, Shoulder, and Hand scores of the metabolic syndrome group were higher (more severe symptoms) than those of the control group at the 12- and 24-week follow-ups. Although considerable improvements in symptom severity and hand function will likely occur in patients with metabolic syndrome, corticosteroid injection for De Quervain tenosynovitis is not as effective in these patients compared with age- and sex-matched controls in terms of functional outcomes and treatment failure.

LEVEL OF EVIDENCE

III.

Outcomes Assessment After Hand Burns

Accurately assessing function and disability after hand burns is imperative to improving the management of patients. The biological, social, and psychological impact of these injuries should be considered. The International Classification of Functioning Disability (ICF) and Health Core Sets for Hand Conditions provides a guide to what should be measured and reported. Although many outcomes measures instruments are available to assess patients with hand or burn injuries, few are validated in the subpopulation of hand burns. Further efforts are required to investigate the ability of current assessment instruments to evaluate hand burn outcomes within the ICF framework.

Recovery, responsiveness and interpretability of patient-reported outcome measures after surgery for Dupuytren's disease

This prospective cohort study investigated the responsiveness and interpretability of the Disabilities of the Arm, Shoulder and Hand (DASH) and Unité Rhumatologique des Affections de la Main (URAM) outcome measures for assessing recovery after fasciectomy and dermofasciectomy for Dupuytren's disease. DASH outcome scores at 1 year were significantly better than at 6 weeks, suggesting that recovery is not complete by 6 weeks. Of the 101 patients recruited to the DASH cohort, 71 completed preoperative, 6 week and 1 year postoperative DASH scores; 68 of them completed preoperative and 1 year postoperative DASH scores and an external anchor question. In the URAM cohort, 30/44 completed the preoperative and the 1 year postoperative URAM scores and the anchor question. The DASH score exhibited moderate responsiveness but poor interpretability on receiver operating characteristic curve analysis, such that a minimal important change could not be estimated. The URAM score showed acceptable responsiveness, and an MIC of 10.5 on receiver operating characteristic analysis.

LEVEL OF EVIDENCE

II.

Minimal important difference after hand surgery: a prospective assessment for DASH, MHQ, and SF-12

INTRODUCTION

Minimal important difference (MID) score is an important measure for surgical clinical research and impacts on treatment decisions. Our approach considered patient satisfaction as the relevant anchor criteria. The aims of this study were: determine after surgery MID for three relevant questionnaires: Disabilities of the Arm, Shoulder and Hand (DASH), Michigan Hand Questionnaire (MHQ), and Short Form 12 (SF-12); and assess the correlation between these scores and patient reported satisfaction.

METHODS

Adult patients where surgery was indicated for any hand/wrist conditions. Study was conducted in a teaching hospital, São Paulo, Brazil. Participants responded to DASH, SF-12, MHQ, and a Likert satisfaction scale before and three months after a procedure. Satisfaction was considered as the anchor for determining MID after a procedure. The correlation between satisfaction and the instruments were measured. Two statistical approaches were utilized for determining MIDs and were used for consistency and generalizability purposes. For MID determination, receiver operating curves were utilized and MID cut-offs were followed by sensitivity and specificity measures.

RESULTS

Fifty patients were included with no follow-up losses. MID for DASH was 18.8 and 15.4. MID for MHQ was 14.7 for both approaches. Data from SF-12 was not reliable after statistical analyses and demonstrated poor correlation with patient satisfaction. MID for DASH and MHQ were found and demonstrated larger standards than literature-reported patients when surgery was not the main intervention. DASH and MHQ had moderate correlation with patient reported satisfaction. SF-12 MID was not reliable and had poor correlation to patient satisfaction. These data suggests that ambulatory hand surgery patients may have greater expectations regarding improvement than other patients.

Cross-cultural adaptation, reliability and validity of the Turkish version of the Upper Limb Functional Index (ULFI)

STUDY DESIGN

Clinical measurement.

BACKGROUND

The Upper Limb Functional Index (ULFI) is a patient reported outcome (PRO) measure with sound clinimetric properties and clinical viability for determination of upper limb function.

PURPOSE-METHODS

The aims of this study were to cross-culturally adapt the ULFI for Turkish-speaking patients (ULFI-Tk) and investigate the reliability and validity in patients with upper limb problems. Patients (n=l02, age 49.1±16.6) with upper limb disorders were consecutively recruited. All participants completed the ULFI-Tk and the Disability of Arm, Shoulder and Hand Turkish-version (DASH-Tk) criterion at baseline and day-three.

RESULTS

The ULFI-Tk demonstrated good internal consistency (α=0.87), moderate criterion validity (DASH-Tk:r=0.68;p<0.05), moderate reliability (ICC2:1=0.72,CI=0.58-0.80) and strong error measurement (SEM=2.94;MDC90=5.35). Exploratory factor analysis demonstrated a dual factor structure that explained 31.2% of total variance.

CONCLUSIONS

The ULFI-Tk is a reliable and valid PRO that could be used to assess upper limb musculoskeletal disorders in Turkish speaking patients

LEVEL OF EVIDENCE

Class 2.

What patients want from the treatment of Dupuytren's disease--is the Unité Rhumatologique des Affections de la Main (URAM) scale relevant?

Patients awaiting surgery for Dupuytren's contractures listed the problems from their Dupuytren's disease that had led them to request surgery and their relative priorities of the results of surgery. The listed problems were compared with the nine items comprising the Unité Rhumatologique des Affections de la Main (URAM) Dupuytren's disease-specific outcome measure. One hundred and ten patients reported 278 problems. Ninety-four different combinations of problems were provided by patients, and over half (55%) of the problems were not captured by items in the URAM scale. The long-term outcome from surgery was relatively more important to patients than speed of recovery. The URAM tool may not be relevant to patients in the UK, and further assessment of its face validity is required before it is used.

Outcomes in orthopedics and traumatology: translating research into practice

Clinical research is focused in generating evidence that is feasible to be applicable to practitioners. However, translating research-focused evidence into practice may be challenging and often misleading. This article aims is to pinpoint these challenges and suggest some methodological safeguards, taking platelet-rich plasma therapies and knee osteochondral injuries as examples. Studies and systematic reviews involving the following concepts will be investigated: clinically relevant outcomes, systematic errors on sample calculation, internal and external validity. Relevant studies on platelet-rich plasma for muscle-tendon lesions and updates on osteochondral lesions treatment were included in this analysis. Authors and clinicians should consider these concepts for the implementation and application of dissemination of the best evidence. Research results should be challenged by a weighted analysis of its methodological soundness and applicability. Level of Evidence V, Therapeutic Studies - Investigating the Results of Treatment.

Evaluation of Non Diseased Specified Outcome Measures in Hand Injuries to Assess Activity and Participation Based on ICF Content

The objective of the study is to provide information about non disease specified outcome measures which evaluate disability in patients who have impairments in hand and upper extremity and to find the extent to which they are evaluating "disability" based on ICF hand Core Set (activity limitation and participation restriction). MEDLINE, CINAHL, GOOGLE SCHOLAR , OVID and SCIENCE DIRECT databases were systematically searched for studies on non disease specified outcome measures used to evaluate upper extremity function; only studies written in English were considered. We reviewed titles and abstracts of the identified studies to determine whether the studies met predefined eligibility criteria (eg, non disease specified out come measures used in hand injured patients). All the outcome measures which had eligibility included. After full text review ,7 non disease specified outcome measures in hand were identified. Studies were extracted, and the information retrieved from them. All the outcome measures which had incuded, were linked with ICF hand core set disability part (activity and participation). All of them only linked to 16 (42 %) components of ICF hand Core Set, which were most activity and less participation from ICF. None of the non disease specified out come measures in hand injuries cover all domains of disability from the ICF Hand Core Set.

Clinical evaluation of upper limb function: Patient's impairment, disability and health-related quality of life

Musculoskeletal disorders substantially impacts physical activity, mental state, and quality of life (QOL). Generally, comprehensive assessment of upper limb function requires measures of impairment or disability as well as health-related quality of life. A growing number of outcome instrument have been introduced to evaluate upper limb function and disability, and these measures can be categorized as patient- or clinician-based, and as condition specific or general health-related QOL evaluations. The upper limb outcome instruments reviewed in this article assess different aspect of upper limb conditions, and the measures are affected by differences in cultural, psychological, and gender aspect of illness perception and behavior. Therefore, physician should select/interpret the outcome instruments addressing their primary purpose of research. Information about regional instruments for upper limb condition and health-related QOL in upper limb disorder may help us in decision-making for treatment priority or in interpretation of the treatment outcomes.

Review of thumb carpometacarpal arthritis classification, treatment and outcomes

Thumb carpometacarpal osteoarthritis (CMC OA) is a common disease, affecting up to 11% and 33% of men and women in their 50s and 60s, respectively, which leads to pain, laxity and weakness of the CMC joint. Based on the staging of the CMC OA, different forms of treatment can be used, including both conservative and surgical measures. Surgical options include osteotomy, trapezial excision, ligament reconstruction with or without tendon interposition, and various prosthetic interpositional implants with or without trapezial excision. The present article reviews the staging of CMC OA, the evaluation of hand function using patient-reported questionnaires, and outcomes of both conservative and surgical treatments. The present review also introduces a commercially available interpositional spacer surgical technique for CMC OA and the early evidence that the literature has shown for improving hand function, strength and stability of the thumb CMC joint postoperatively.

How to use outcomes questionnaires: pearls and pitfalls

Patient-reported outcomes serve as an essential and perhaps more relevant means for assessing patients' response to treatment than clinical measures alone. Many of the procedures performed in plastic surgery are associated with aesthetic outcomes. Therefore, it is pertinent to thoroughly understand the patient's perspective of achieved results. Surgeons need to possess knowledge and skills about outcomes assessments and understand how to apply them to improve quality of care delivered based on evidence. This article discusses the appropriate use of outcome questionnaires to rigorously evaluate treatment methods based on patient satisfaction and the outcome measurement instruments frequently used in plastic surgery.

To what degree do shoulder outcome instruments reflect patients' psychologic distress?

BACKGROUND

Psychologic distress contributes to symptom severity in patients with several musculoskeletal disorders. While numerous shoulder outcome instruments are used it is unclear whether and to what degree psychologic distress contributes to the scores.

QUESTIONS/PURPOSES

We asked (1) to what degree shoulder outcome instruments reflect patients' psychologic distress, and (2) whether patients who are strongly affected by psychologic distress can be identified.

METHODS

We prospectively evaluated 119 patients with chronic shoulder pain caused by degenerative or inflammatory disorders using the Constant-Murley scale, Simple Shoulder Test (SST), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. To evaluate psychologic distress, we measured depression using the Center for Epidemiologic Studies-Depression (CES-D) scale and pain anxiety using the Pain Anxiety Symptom Scale (PASS). Demographic and clinical parameters, such as pain scores, ROM, and abduction strength, also were measured. We then assessed the relative contributions made by psychologic distress and other clinical parameters to the quantitative ratings of the three shoulder outcome instruments.

RESULTS

Quantitative ratings of shoulder outcome instruments correlated differently with psychologic distress. Constant-Murley scores did not correlate with psychologic measures, whereas SST scores correlated with PASS (r = 0.32) and DASH scores correlated with PASS and CES-D (r = 0.36 and r = 0.32). Psychologic distress contributed to worsening SST and DASH scores but not to Constant-Murley scores. DASH scores were more strongly influenced by pain anxiety and depression than the other two outcome instruments.

CONCLUSIONS

Shoulder outcome measures reflected different psychologic aspects of illness behavior, and the contributions made by psychologic distress to different shoulder outcome instruments apparently differed. Physicians should select and interpret the findings of shoulder outcome instruments properly by considering their psychologic implications.

LEVEL OF EVIDENCE

Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

How much are upper or lower extremity disabilities associated with general health status in the elderly?

BACKGROUND

Musculoskeletal complaints influence general health status, but the relative contribution of concurrent upper and lower extremity disabilities on patient perceptions of general health is unclear.

QUESTIONS/PURPOSES

We evaluated whether two regional instruments (DASH and WOMAC) reflect a patient's perception of general health measured using the SF-36 and determined whether general health components are explained by upper and lower extremity disabilities.

METHODS

We recruited 272 randomly chosen participants 65 years or older without a history of surgery for musculoskeletal disease or trauma who participated in the Korean Longitudinal Study on Health and Aging. Upper extremity disability was determined with the DASH score and lower extremity disability with the WOMAC; as a measure of general health, we obtained SF-36 scores. Multivariate regression modeling was used to assess the relative contributions made by upper and lower extremity disabilities to general health.

RESULTS

The DASH and WOMAC each was correlated with the physical component summary (PCS) scale and with the mental component summary (MCS) scale to differing extents. Multivariate regression analyses revealed that WOMAC alone, DASH alone, and WOMAC and DASH accounted for 24%, 19%, and 26% of the variance in the PCS scale. However, only the DASH was associated with the MCS scale but accounted for only 2% of the variance.

CONCLUSIONS

We found that in a community-based elderly population, perceived general physical health is associated with upper and lower extremity disabilities, whereas perceived general mental health is associated with only upper extremity disabilities, but to a small extent.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Cross-cultural adaptation and validation of the Korean version of the Michigan hand questionnaire

PURPOSE

The Michigan hand questionnaire (MHQ) is increasingly being used and has been adapted cross-culturally in some Western and Asian countries, but the validation process for an Asian translation of MHQ has not been well described. In this study, we translated and adapted the original MHQ cross-culturally to produce a Korean version, and then assessed the validity and reliability of the Korean version of the MHQ.

METHODS

A total of 176 patients with common hand disorders completed the Korean version of the MHQ and the Disabilities of the Arm, Shoulder, and Hand questionnaire. We included the pain score assessed by a visual analog scale during activity, range of motion, measurement of grip strength, and subjective assessment of the functional state by use of Cooney's scale in the validation process.

RESULTS

There were no major linguistic or cultural problems during forward and backward translations of the MHQ, except for a minor change owing to cultural discrepancies in eating, such as the dominant hand using a spoon and chopsticks instead of both hands using a knife and fork. All subscales of the MHQ showed satisfactory internal consistency. The reproducibility test showed no significant difference. The construct validity revealed a moderate to strong correlation between every subscale of the Korean MHQ against DASH disabilities and symptoms. The aesthetic and satisfaction domains, unique domains of the MHQ, had little correlation with the objective measure of the pain visual analog scale, grip strength, motion and subjective functional state.

CONCLUSIONS

The Korean version of MHQ showed satisfactory internal consistency, test-retest reliability, and validity and demonstrated a significant correlation with the patient-based upper extremity questionnaire and clinical assessment. We found the application and evaluation of the instrument to be feasible and understandable among patients in Korea.

Measuring wrist and hand function: common scales and checklists

INTRODUCTION

A hand and wrist disorder affects a patient's overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers' confidence in the choice and application of these outcome instruments.

METHODS

A literature search (1950-January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n=341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist.

RESULTS

We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties.

CONCLUSIONS

The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve.

Validity and responsiveness of the Jebsen-Taylor Hand Function Test

PURPOSE

The aim of this study was to demonstrate the validity and responsiveness of the Jebsen-Taylor Hand Function Test (JTT) in measuring hand function in patients undergoing hand surgery, compared with the Michigan Hand Outcomes Questionnaire (MHQ).

METHODS

A prospective cohort of patients with rheumatoid arthritis (n = 37), osteoarthritis (n= 10), carpal tunnel syndrome (n = 18), and distal radius fracture (n = 46) were evaluated preoperatively and at 9 to 12 months of follow-up. We administered the JTT and MHQ. We performed correlation and receiver operating characteristic analyses to evaluate the validity of the JTT as a measure of disability. Effect size and standardized response means were calculated to determine responsiveness.

RESULTS

Correlation studies revealed poor correlation of the JTT with MHQ total scores and subsets that relate to hand function. Patients with high MHQ scores generally perform well on the JTT; however, patients with good JTT scores do not necessarily have high MHQ scores. Receiver operating characteristic curves for each condition showed that the change in JTT total score had poor ability to discriminate between high and low MHQ score subjects, with an area under the curve result of 0.52 to 0.66 for each condition. Effect size and standardized response means for all states showed greater responsiveness with the MHQ for each condition compared with the JTT.

CONCLUSIONS

We found poor correlation between the change in JTT and absolute JTT scores after surgery compared with change in MHQ and absolute MHQ scores. In addition, the JTT had poor discriminant validity based on the MHQ as a reference. This study showed that the time to complete activities does not correlate well with patient-reported outcomes. We conclude that the JTT should not be used as a measure of disability or clinical change after surgical intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Which outcome measure is the best? Evaluating responsiveness of the Disabilities of the Arm, Shoulder, and Hand Questionnaire, the Michigan Hand Questionnaire and the Patient-Specific Functional Scale following hand and wrist surgery

The purpose of this study was to determine and compare the responsiveness of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Michigan Hand Questionnaire (MHQ), and the Patient-Specific Functional Scale (PSFS) in patients with carpal tunnel syndrome, wrist pain, finger contracture, or tumor. Eighty-one subjects prospectively completed each questionnaire shortly before and 3 and 6 months after surgery. Data were analyzed using one-way analysis of variance and Newman-Keuls multiple comparison tests. Responsiveness to clinical change was calculated using standardized response means. The DASH was responsive for those with carpal tunnel syndrome (0.77), wrist pain (0.61), and tumor (0.55); the MHQ was responsive for those with carpal tunnel syndrome (1.04), wrist pain (0.87), and finger contracture (0.62); and the PSFS was responsive for those with carpal tunnel syndrome (0.65) and finger contracture (0.64). The interval during which the highest responsiveness occurred for the carpal tunnel, wrist pain, and finger contracture groups was the preoperative to 6-month period. The tumor group experienced the highest responsiveness during the preoperative to 3-month period. Our results indicate that one or more of the instruments evaluated are suitable for outcomes research related to surgery to treat carpal tunnel syndrome, wrist pain, finger contracture, and tumor.

Patient satisfaction with carpal tunnel surgery: self-administered questionnaires versus physical testing

Purpose

A study was designed to compare the strength of correlation between the clinical tests such as grip, pinch and Semmes–Weinstein testing, and the Levine–Katz self-administered symptom severity and functional status questionnaires as well as their correlation with patients' satisfaction following carpal tunnel decompression. The purpose was to determine whether patient-completed outcome instruments would be additive to the physical measures, or could possibly replace the physical measures, in assessing the outcome of carpal tunnel release.

Methods

From two hand centres, 635 hands (cases) in 490 patients completed preoperative and postoperative assessments including Tinel's sign, Phalen's test, Semmes–Weinstein testing, grip and pinch strength testing and the Levine–Katz self-administered questionnaires. Patients were also asked whether they were satisfied with surgery at the six-month follow-up.

Results

Patients reporting satisfaction with surgery at six months had significantly greater changes in grip strength and Levine–Katz scores than those reporting no satisfaction. At six-months follow-up, grip strength increased slightly from 27.4 to 29.2 kg (6%) ( P = 0.007), pinch strength increased from 7.8 to 8.1 kg (4%) ( P = 0.04), Semmes–Weinstein scores decreased (improved) from 2.37 to 1.89 (20%) ( P < 0.001), Levine–Katz functional status scores decreased from 2.30 to 1.48 (36%) ( P < 0.001) and Levine–Katz symptom severity scores decreased from 2.83 to 1.44 (49%) ( P < 0.001).

Conclusions

Improvement in Levine–Katz scores can be used to assess treatment outcomes after carpal tunnel release as an alternative to physical testing. This study offers further evidence that patient-rated outcome questionnaires offer a more complete picture of the eventual outcomes of carpal tunnel decompression surgery as compared with physical testing.

Are standardized patient self-reporting instruments applicable to the evaluation of ulnar neuropathy at the elbow?

BACKGROUND

This study attempts to confirm that the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure self-administered questionnaire is valid specifically for ulnar neuropathy at the elbow. Validity of the Levine-Katz questionnaire for ulnar neuropathology compared with DASH was also studied.

MATERIALS AND METHODS

Forty-eight patients with isolated ulnar nerve surgery completed a 6-month evaluation. Patients were assigned a clinical stage. The DASH and Levine-Katz questionnaires were administered, and pinch and grip strength were measured preoperatively and postoperatively. Levine-Katz questionnaires were correlated with DASH to establish criterion validity. Construct validity was tested by determining a relationship between scores and clinical stages and by comparing scores preoperatively and postoperatively.

RESULTS

There was a high correlation between DASH scores and symptom severity and functional status. Although correlations were significant between DASH and biomechanical measures, correlation coefficients were lower. Postoperatively, all measures improved significantly.

CONCLUSION

This study confirms that scores on the DASH questionnaire reflect the clinical staging of ulnar neuropathy at the elbow.

Evaluation of activity limitation and digital extension in Dupuytren's contracture three months after fasciectomy and hand therapy interventions

STUDY DESIGN

Longitudinal Case Series.

INTRODUCTION

Dupytren's contracture is thought to result in digital impairments and performance disabilities. No study to date has focused on how patients with Dupuytren's contracture experience limitations in daily activities and the results after surgery.

PURPOSE OF THE STUDY

Describe which activities patients with Dupuytren's contracture defined as the most disabling, how they rated their activity limitations and determine the relationship between activity limitations and digital extension before and three months after surgery and postoperative hand therapy.

METHODS

Self-reported rating of activity limitations, performance, and measures of total digital extension.

RESULTS

The most disabling activities were with self-care (42%), though overall performance was significantly improved following surgery and postoperative hand therapy. The total digital extension was significantly improved 81 degrees and was positively related to performance.

CONCLUSIONS

The results provide new information about activities that patients with Dupuytren's contracture experience as being difficult to perform and describes positive changes in performance and range of motion.

LEVEL OF EVIDENCE

4.

A qualitative study of the experiences and expectations of surgery in patients with carpal tunnel syndrome

The aim of this study was to explore the impact of carpal tunnel syndrome (CTS) on individuals and their expectations of surgical decompression to identify what outcome domains need to be assessed in future clinical trials. This qualitative study used in-depth, face-to-face interviews with nine patients with CTS awaiting surgical decompression. The tape-recorded interviews were transcribed fully, data were coded and categorized independently by two researchers and emerging themes were identified. Patients identified relief of symptoms-tingling, numbness and sleep disturbance, and resumption of important activities-as their most important criteria for judging the success of surgery. Although they recognized the consequences of this disorder were minor in comparison to more serious diseases, patients expressed distress at the impact of this disorder on their quality of life and expressed hope that surgery would address this. The assessment of outcomes of surgical decompression of CTS needs to include measures of symptom resolution as well as of activity limitation and participation restriction. Using existing patient-rated, disease-specific, and region-specific outcome instruments is likely to capture those domains which patients consider important criteria of success.

Measuring outcomes in hand surgery

Outcomes research in hand surgery provides patients and providers with objective, reliable information to assist in making medical decisions. Endpoint measures in outcomes research and the instruments used to evaluate these endpoints are often specific to a particular disease or region. Hand surgery has many different measurable outcomes that can be used to monitor the quality of surgical practice, inform practice guidelines, and aid in the appropriate allocation of healthcare resources. In this article, we review some research techniques available to study the following surgical outcomes of the hand: national trends in surgical care, surgical complications, objective measures of hand function, patient-reported measures of hand function, and economic burden.

Measuring quality of life in prosthetic practice: benefits and challenges

There is an increasing awareness that the inclusion of quality of life as an outcome measure is important in ensuring a client-centred and holistic assessment. This review outlines the benefits of quality of life as an outcome measurement in the field of prosthetics. It introduces the key concepts and challenges in the definition and assessment of quality of life post-amputation, including the relative advantages and disadvantages of adopting generic, disease/condition specific, dimension specific and individualized measures of quality of life. In conclusion, the review delineates and recommends issues and guidelines for consideration when undertaking quality of life research and assessment. A co-ordinated approach by practitioners in the field of prosthetics is necessary to ensure the inclusion of quality of life as an outcome measure and to ensure its measurement in a standardized and rigorous manner.

Critical analysis of outcome measures used in the assessment of carpal tunnel syndrome

Clinicians and researchers are confounded by the various outcome measures used for the assessment of carpal tunnel syndrome (CTS). In this study, we critically analysed the conceptual framework, validity, reliability, responsiveness and appropriateness of some of the commonly used CTS outcome measures. Initially, we conducted an extensive literature search to identify all of the outcome measures used in the assessment of CTS patients, which revealed six different carpal tunnel outcome measures [Boston Carpal Tunnel Questionnaire (BCTQ), Michigan Hand Outcome Questionnaire (MHQ), Disability of Arm, Shoulder and Hand (DASH), Patient Evaluation Measure (PEM), clinical rating scale (Historical-Objective (Hi-Ob) scale) and Upper Extremity Functional Scale (UEFS)]. We analysed the construction framework, development process, validation process, reliability, internal consistency (IC), responsiveness and limitations of each of these outcome measures. Our analysis reveals that BCTQ, MHQ and PEM have comprehensive frameworks, good validity, reliability and responsiveness both in the hands of the developers, as well as independent researchers. The UEFS and Hi-Ob scale need validation and reliability testing by independent researchers. Region-specific measures like DASH have good frameworks and, hence, a potential role in the assessment of CTS but they require more validation in exclusive carpal tunnel patients.

Hand function after nerve repair

Treatment of injuries to major nerve trunks in the hand and upper extremity remains a major and challenging reconstructive problem. Such injuries may cause long-lasting disabilities in terms of lost fine sensory and motor functions. Nowadays there is no surgical repair technique that can ensure recovery of tactile discrimination in the hand of an adult patient following nerve repair while very young individuals usually regain a complete recovery of functional sensibility. Post-traumatic nerve regeneration is a complex biological process where the outcome depends on multiple biological and environmental factors such as survival of nerve cells, axonal regeneration rate, extent of axonal misdirection, type of injury, type of nerve, level of the lesion, age of the patient and compliance to training. A major problem is the cortical functional reorganization of hand representation which occurs as a result of axonal misdirection. Although protective sensibility usually occurs following nerve repair, tactile discriminative functions seldom recover--a direct result of cortical remapping. Sensory re-education programmes are routinely applied to facilitate understanding of the new sensory patterns provided by the hand. New trends in hand rehabilitation focus on modulation of central nervous processes rather than peripheral factors. Principles are being evolved to maintain the cortical hand representation by using the brain capacity for visuo-tactile and audio-tactile interaction for the initial phase following nerve injury and repair (phase 1). After the start of the re-innervation of the hand (phase 2), selective de-afferentation, such as cutaneous anaesthesia of the forearm of the injured hand, allows expansion of the nerve-injured cortical hand representation, thereby enhancing the effects of sensory relearning. Recent data support the view that training protocols specifically addressing the relearning process substantially increase the possibilities for improved functional outcome after nerve repair.

A systematic review of the psychometric properties of the Boston Carpal Tunnel Questionnaire

Background

The Boston Carpal Tunnel Questionnaire (BCTQ) is a disease-specific measure of self-reported symptom severity and functional status. It is frequently used in the reporting of outcomes from trials into interventions for carpal tunnel syndrome. We conducted a systematic review of published studies on the psychometric properties of the BCTQ to determine the level of evidence on the instrument's validity, reliability and responsiveness to date.

Methods

A search of the databases Medline, CINAHL, AMED and PsychInfo was conducted to retrieve studies which investigated one or more of the psychometric properties of the BCTQ. Data abstraction was undertaken by the first two authors.

Results

Ten studies were retrieved which met the inclusion criteria. One study evaluated face and content validity (43 patients) eight studies assessed construct validity (932 patients), four studies tested reliability (126 patients) and nine studies assessed responsiveness (986 patients). Interpretability was evaluated in one study and acceptability in eight studies (978 patients).

Conclusion

The BCTQ is a standardised, patient-based outcome measure of symptom severity and functional status in patients with carpal tunnel syndrome. The evidence base of the psychometric properties indicates that the BCTQ is a valid, reliable, responsive and acceptable instrument and should be included as a primary outcome measures in future CTS trials.

Outcomes research in hand surgery: where have we been and where should we go?

PURPOSE

The outcomes movement began in response to a national emphasis to control cost and to limit geographic variation in medical services. The impact of the outcomes movement on hand surgery research is unknown. We conducted a systematic review of hand surgery studies to assess the past and current states of outcomes research in this specialty.

METHODS

A systematic review of hand surgery outcomes studies was conducted in The Journal of Hand Surgery (American and British volumes) from 1988 to 2004. A Medline search using the 11 Agency for Healthcare Research and Quality categories of outcomes studies was performed. Studies were rated for study design, data endpoints, and level of impact using the Agency for Healthcare Research and Quality-designated impact levels.

RESULTS

A total of 2,236 studies were identified, and 1,188 were included in the analysis. Most studies were rated as level 1 impact (N = 1,090, 92%), and a small number of studies were level 4 impact (N = 98, 8%). Thirty-nine percent were prospective and 45% (N = 529) were retrospective descriptive studies. Data gathered in studies included objective clinical measures (N = 672, 57%), quality of life (N = 374, 31%), morbidity (N = 401, 34%), subjective clinical measures (N = 27, 16%), cost (N = 185, 2%), and mortality (N = 11, 1%).

CONCLUSIONS

Our systematic review of hand surgery outcomes studies found that much of the research is confined to testing new or existing surgical techniques (level 1 impact). We found a small number of studies that did show improvement in patient outcomes as a result of an intervention (level 4 impact). The future direction of outcomes studies should consider the impact of the research goals to change patient or physician behavior to enhance health parameters. More research on economic analysis needs to be conducted in hand surgery to meet the national goal of containing cost and improving the quality of health care.

The minimal clinically important difference of the Carpal Tunnel Syndrome Symptom Severity Scale

PURPOSE

To identify the change score in the Symptom Severity Scale (SSS) of the Carpal Tunnel Syndrome (CTS) Questionnaire that is associated with an important change in clinical status.

METHODS

Twenty-eight patients with CTS treated with a carpal tunnel steroid injection completed the Brigham and Women's Hospital CTS Questionnaire before steroid injections and at the 3-week follow-up visit. Satisfaction was determined by postcare review of the clinical management. To calculate the minimal clinically important difference, receiver operating characteristic curves were created. The area under the curve was calculated to determine and compare the responsiveness of the entire SSS and the pain and sensory questions in isolation.

RESULTS

The SSS of the CTS Questionnaire, including its pain and sensory domain, can show a meaningful clinical improvement after carpal tunnel injection. The SSS, its sensory domain, and its pain domain were statistically better than chance. All 3 measures showed predictive ability; however, the total SSS was the most sensitive in detecting a change. The minimal clinically important difference in the score of the SSS after carpal tunnel steroid injection was found to be 1.04.

CONCLUSIONS

The SSS can be used to distinguish a clinically important change after carpal tunnel injection. A decrease of 1.04 or more in the SSS score may indicate a clinically important change in a patient's state of health.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level I.

The two-point discrimination test--time for a re-appraisal?

The two-point discrimination (2PD) test is the most frequently used test for the assessment of the sensory outcome after nerve repair. Here we focus on factors which explain the enormous and implausible variability in reported 2PD levels after nerve repair. We conclude that the 2PD testing technique is not at all standardized and that its use as the sole test for tactile gnosis recovery should be seriously questioned. Reports of 2PD results should always be accompanied by a detailed description of how the test was performed, especially with reference to the pressure applied and the testing protocol.

Outcome assessment of hand function after radial artery harvesting for coronary artery bypass

The radial artery has gained widespread acceptance as a conduit for coronary artery bypass. Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility of freedom from late conduit atherosclerosis. Although most series describe minimal morbidity, a significant incidence of radial sensory neuropathy and isolated instances of hand claudication and ischemia have been reported. We performed an outcome study utilizing the Short Form-36, the Upper Limb-Disabilities of Arm, Shoulder and Hand, and a modified self-administered hand diagram to compare 288 patients undergoing coronary artery bypass utilizing the radial artery with a control group of 174 patients undergoing coronary artery bypass without the radial artery. The data were analyzed by the t test for continuous variables and the chi-square test for categorical variables, and subsequently a multivariate regression model was constructed. No patients developed hand claudication or ischemia. Although there was an incidence of radial sensory neuropathy of 9.9% associated with radial artery harvest, it was not significantly higher than the incidence in the control group (5.2%, p =.16). Intrinsic patient factors such as obesity, age, diabetes, and peripheral vascular disease were the principal determinants of overall health and quality of life issues.

Assessment of functional outcome in hand transplantation patients

The purpose of this article is to report the criteria used for functional evaluation of hand transplant patients in a one-page clinical examination chart. A satisfactory immunologic status is mandatory for a functional evaluation to take place.