Nonresponder bias in hand surgery: analysis of 1945 cases lost to follow-up over a 6-year period

Responsiveness and validity of the Normal Hand Score in patients undergoing carpal tunnel decompression

LEVEL OF EVIDENCE

II.

Equitable Integration of Patient-Reported Outcomes Into Clinical Practice-Opportunities, Challenges, and a Roadmap for Implementation

Patient-reported outcome measures (PROMs) provide a standardized assessment from the patient about their own health status. Although originally developed as research tools, PROMs can be used in clinical care to complement objective functional measures (eg, range of motion) and are increasingly integrated to guide treatment decisions and predict outcomes. In some situations, when PROMs are used during clinical care they can improve patient mortality, outcomes, engagement, well-being, and patient-physician communication. Guidance on how PROMs should be communicated with patients continued to be developed. However, PROM use may have unintended consequences, such as when used implemented without accounting for confounding factors (eg, psychological and social health) or in perpetuating healthcare disparities when used imprecisely (eg, lack of linguistic or cultural validation). In this review, we describe the current state of PROM use in orthopaedic surgery, highlight opportunities and challenges of PROM use in clinical care, and provide a roadmap to support orthopaedic surgery practices in incorporating PROMs into routine care to equitably improve patient health.

Predictors of Postoperative Patient-Reported Outcome Measure Response Rates Among Patients With Rotator Cuff Repair

BACKGROUND

Patient-reported outcome measures (PROMs) contribute to evaluating and improving the quality of patient care. Patient outcomes after rotator cuff repair (RCR) have been researched; however, the relationship between PROM response rates and individual and health care correlates has not been thoroughly investigated.

PURPOSE

To examine differences in individual and health care factors among patients who had undergone RCR based on their PROM response rates.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Shoulder-specific and general PROMs were solicited via email and text message of all patients who underwent RCR between 2016 and 2020. Three subgroups were classified: (1) complete responders completed all 1-year postoperative PROMs, (2) partial responders answered enough questions to produce ≥1 usable score, and (3) nonresponders did not respond to a single measure. Correlates were assessed using analysis of variance and chi-square tests. Adjusted multinomial logistic regression models identified predictors of 1-year PROM response.

RESULTS

Of 2195 patients included at the 1-year follow-up, 34% were complete responders; 11%, partial responders; and 55%, nonresponders. Patients had a mean age of 61.8 years, 63% were men, and 90% were White. Pre- and postoperative PROM scores were similar across responder groups. In stepwise selection, 1-year responses (complete or partial) were associated with older age, later year of surgery, White race, and having workers' compensation insurance. The strongest predictor of PROM response was having workers' compensation insurance.

CONCLUSION

Patients with workers' compensation insurance compared with other insurance types responded to PROMs at disproportionately higher rates. This could distort postoperative PROM scores in the population studied because there are known differences among patients with this insurance status.

Statistics for the hand surgeon. Part 1: principles and application to hand surgery research

Hand surgeons have the potential to improve patient care, both with their own research and by using evidenced-based practice. In this first part of a two-part article, we describe key steps for the analysis of clinical data using quantitative methodology. We aim to describe the principles of medical statistics and their relevance and use in hand surgery, with contemporaneous examples. Hand surgeons seek expertise and guidance in the clinical domain to improve their practice and patient care. Part of this process involves the critical analysis and appraisal of the research of others.

Patient-Reported Outcome in Dupuytren's Disease Treated With Fasciectomy, Collagenase or Needle Fasciotomy: A Swedish Registry Study

Purpose

This registry study compares the patient-reported outcomes of 3 treatments for Dupuytren´s disease: open fasciectomy (OF), collagenase injection (CCH) and percutaneous needle fasciotomy (PNF).

Methods

From the Swedish national quality registry for hand surgery (HAKIR) we included 2,585 procedures (in 2,414 patients): 1,200 treatments were OF, 918 CCH, and 467 PNF. The choice between CCH and PNF varied mainly because of regional differences in reimbursement of CCH. We report the results of the validated patient-reported outcome instrument HQ-8. HQ-8 evaluates symptoms in the treated hand and is issued before treatment, 3 and 12 months after treatment and is used for all patients in HAKIR.

Results

At 3-month follow-up, patients treated with CCH or PNF experienced less stiffness, weakness, numbness, tingling and sensitivity to cold. At 12 months, the differences among the 3 treatments were smaller, but CCH patients experienced less stiffness and weakness compared to PNF-treated patients.

Conclusions

Most randomized controlled trials have not shown significant differences in recurrence rates or patient-reported outcomes between CCH and PNF, but the number of patients has been limited and no randomized controlled trials have included all 3 treatments. In the present study, we compared registry data on patient-reported outcomes for OF, CCH, and PNF in a real-life clinical setting. Our results confirm that the noninvasive treatments (CCH and PNF) cause less disability than OF and indicate a possible advantage of CCH compared to PNF regarding stiffness and weakness at 1 year after treatment based on patient-reported outcomes. Patient-reported residual symptoms are important to consider when informing patients and selecting treatment for Dupuytren´s disease.

Type of study/level of evidence

Observational registry study III.

Patient reported symptoms and disabilities before and after neuroma surgery: a register-based study

Residual problems may occur from neuroma despite surgery. In a 12-month follow-up study using national register data, symptoms, and disabilities related to surgical methods and sex were evaluated in patients surgically treated for a neuroma. Among 196 identified patients (55% men; lower age; preoperative response rate 20%), neurolysis for nerve tethering/scar formation was the most used surgical method (41%; more frequent in women) irrespective of affected nerve. Similar preoperative symptoms were seen in patients, where different surgical methods were performed. Pain on load was the dominating symptom preoperatively. Women scored higher preoperatively at pain on motion without load, weakness and QuickDASH. Pain on load and numbness/tingling in fingers transiently improved. The ability to perform daily activities was better after nerve repair/reconstruction/transposition than after neurolysis. Regression analysis, adjusted for age, sex, and affected nerve, showed no association between surgical method and pain on load, tingling/numbness in fingers, or ability to perform daily activities. Neuroma, despite surgery, causes residual problems, affecting daily life. Choice of surgical method is not strongly related to pre- or postoperative symptoms. Neurolysis has similar outcome as other surgical methods. Women have more preoperative symptoms and disabilities than men. Future research would benefit from a neuroma-specific ICD-code, leading to a more precise identification of patients.

Neuromas cause severe residual problems at long-term despite surgery

Pain, and disabilities after neuroma surgery, using patient reported outcome measurements (PROMs), were evaluated by QuickDASH and a specific Hand Questionnaire (HQ-8). The 69 responding individuals (response rate 61%; 59% women; 41% men; median follow up 51 months) reported high QuickDASH score, pain on load, cold sensitivity, ability to perform daily activities and sleeping difficulties. Individuals reporting impaired ability to perform daily activities and sleeping problems had higher scores for pain, stiffness, weakness, numbness/tingling, cold sensitivity and QuickDASH. Only 17% of individuals reported no limitations at all. No differences were observed between sexes. Surgical methods did not influence outcome. Symptoms and disabilities correlated moderately-strongly to each other and to ability to perform regular daily activities as well as to sleeping difficulties. Pain, cold sensitivity, sleeping difficulties and limitation to perform daily activities were associated to higher QuickDASH. A weak association was found between follow up time and QuickDASH score as well as pain on load, but not cold sensitivity. A major nerve injury was frequent among those with limitations during work/performing other regular daily activities. Despite surgical treatment, neuromas cause residual problems, which affect the capacity to perform daily activities and ability to sleep with limited improvement in long-term.

Age-related changes in patients with upper limb thalidomide embryopathy in the United Kingdom

We report the  long-term upper limb disability, health-related quality of life (HRQoL), functional impairment, self-perception of appearance and prevalence of neuropathic pain in patients with upper limb thalidomide embryopathy in the United Kingdom. One-hundred and twenty-seven patients responded to our electronic questionnaire. Mean Quick Version of the Disabilities of Arm, Shoulder, and Hand score was 54.3 (SD 22.6). Median EuroQoL 5-Dimension 5-Likert index, Work and Social Adjustment Scale, Derriford Appearance Scale 24 and Neuropathic Pain Scale were 0.6 (IQR 0.4 to 0.7), 15.5 (IQR 8.0 to 23.5), 35.5 (IQR 28.0 to 50.5), and -0.8 (IQR -1.4 to 0.8), respectively. Thirty-three patients (26%) reported neuropathic pain. Finger changes associated with radial longitudinal deficiency were an independent predictor of more severe upper limb disability. Eighty-nine patients (70%) reported deteriorating HRQoL with increasing age. Patients with upper limb thalidomide embryopathy experience age-related worsening of symptoms and function, highlighting the need for ongoing specialist care and support.Level of evidence: IV.

Benign nerve tumours in the upper limb: a registry-based study of symptoms and surgical outcome

Surgery for benign nerve tumours is performed for pathoanatomical diagnosis and symptomatic relief, but might cause residual problems. We aimed to assess patient-reported symptoms and disability before and after surgery at a national level. In total, 206 cases surgically treated for a benign peripheral nerve tumour 2010-2019 registered in the Swedish Quality Registry for Hand Surgery (HAKIR; response rates 22-34%) were analysed. Surgery reduced overall disability in the affected limb (QuickDASH 18/100 [IQR 5-36] preoperatively and 5/100 [IQR 0-22] 12 months postoperatively), improved ability to perform daily activities (HQ-8; 11/100 [IQR 0-50] preoperatively and 0/100 [IQR 0-20] 12 months postoperatively) and decreased three evaluated pain modalities: pain at rest (HQ-8; 20/100 [IQR 0-40] preoperatively and 0/100 [IQR 0-10] 12 months postoperatively), pain on motion without load (HQ-8; 20/100 [IQR 0-40] preoperatively and 0/100 [IQR 0-10] 12 months postoperatively), and pain on load (HQ-8; 24/100 [IQR 1-69] preoperatively and 1/100 [IQR 0-30] 12 months postoperatively). Cold sensitivity was a minor problem both before and after surgery (HQ-8; 0/100 [IQR 0-30] preoperatively and 1/100 [IQR 0-40] 12 months postoperatively). We conclude that surgery for benign peripheral nerve tumours provides good symptomatic relief with low risk for residual problems.

Evaluating the Performance of an Automated Patient-Reported Outcomes Collection Platform in a Postoperative Hand Surgery Population

PURPOSE

Reliable collection of postoperative patient-reported outcome measures (PROMs) is critical to understanding surgical outcomes and the value of care. Automated PROMs collection, triggered by the electronic medical record at the 1-year postoperative anniversary, may provide a simple way to acquire outcomes for patients who have been discharged from clinic. The purposes of this study were to (1) evaluate the percentage of responses with an automated PROMs collection platform and (2) identify whether such a system may introduce selection bias by comparing responders with nonresponders.

METHODS

Adult patients (aged ≥18 years) undergoing hand and upper-extremity surgeries between August 2017 and January 2019 were included. Preoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected using tablet computer. Postoperative QuickDASH scores were collected using a single electronic survey request 1 year after surgery via an email with a personalized REDCap link. Univariate and multivariable regression analyses were performed to identify factors that differed between responders and nonresponders.

RESULTS

A response rate of 27% (269 of 1010) was observed for the eligible postoperative patients. On multivariable analysis, the following were associated with greater odds of response: older age, Caucasian race (vs unknown), longer surgery duration, attending the first postoperative visit, and responding to the preoperative QuickDASH.

CONCLUSIONS

The poor response rate that was observed highlights that an automated single email postoperative contact for PROMs collection is insufficient-active follow-up via reminder emails and/or telephone calls is needed. Outcome researchers and clinicians must be aware of potential selection biases, such as age and race, that may exist with automated PROMs collection.

CLINICAL RELEVANCE

Single email postoperative contact to obtain postoperative PROMs is insufficient.

Patient Experiences after Open Trigger Finger Release in Patients with Type 1 and Type 2 Diabetes-A Retrospective Study Using Patient-reported Outcome Measures

Trigger finger is overrepresented among patients with diabetes mellitus (DM). Whether DM affects the outcome after open trigger finger release (OTFR) in patients with DM is not known. Our aim was thus to explore outcomes after OTFR in patients with type 1 (T1D) and type 2 DM (T2D).

Methods

Data included patient-reported outcome measures (PROMs) from all OTFRs performed between 2010 and 2020 registered in the Swedish national registry for hand surgery in individuals over 18 years cross-linked with the Swedish National Diabetes Register (NDR). PROMs included QuickDASH and HQ8, a questionnaire designed for national registry for hand surgery, preoperative and at 3 and 12 months postoperative. HQ8 included pain on load, pain on motion without load, and stiffness. Outcome was calculated using linear-mixed models and presented as means adjusted for age and stratified by sex.

Results

In total, 6242 OTFRs were included, whereof 496 had T1D (332, 67% women) and 869 had T2D (451, 52% women). Women with T1D reported more symptoms of stiffness (P < 0.001), and women with T2D reported more pain on load (P < 0.05), motion without load (P < 0.01), and worse overall result at 3 months. At 12 months, however, no differences were found in any of the HQ-8 PROMs among men or women. Women with T2D had slightly higher QuickDASH scores at 3 and 12 months.

Conclusion

Patients with T1D and T2D can expect the same results after OTFR as individuals without DM, although the improvement might take longer especially among women with T2D.

The effect of diabetes mellitus on the outcome of surgery for cubital tunnel syndrome

The aims of this study were to investigate the effect of diabetes mellitus (DM) on patient-reported outcome measures (PROMs) and satisfaction after surgery for cubital tunnel syndrome (CuTS). Pre- and 1-year postoperative QuickDASH, normal hand, and satisfaction scores were prospectively collected from 107 patients over a 6-year period. Patients without DM reported a significant QuickDASH improvement after surgery (preoperative 34.1 versus postoperative 20.5; p < 0.001), but patients with DM did not (preoperative 46.5 versus postoperative 43.2; p = 0.554). Postoperative QuickDASH (43.2 versus 20.5) and normal hand (65 versus 80) scores were significantly worse in patients with DM. Satisfaction rates were excellent in both groups (88% versus 82%; p = 0.480). Our study showed that surgery for CuTS did not lead to an improvement in QuickDASH score in patients with DM and consequently patients with DM reported worse postoperative PROMs compared with those without. However, lack of improvement in PROMs does not affect patient satisfaction.Level of evidence: IV.

Factors associated with self-reported pain and hand function following dorsal wrist ganglion excision

This study aimed to analyse which factors contribute to pain and limited hand function after dorsal wrist ganglion excision. We included 308 patients who underwent surgery between September 2017 and August 2021. Patients completed baseline questionnaires and the patient-rated wrist/hand evaluation questionnaire at baseline and 3 months postoperatively. We observed an improvement in postoperative pain and hand function, but individual outcomes were highly variable. We performed stepwise linear regression analyses to examine which patient characteristics, disease characteristics and psychological factors were associated with postoperative pain and hand function. Higher postoperative pain intensity was associated with recurrence following previous surgery, treatment of the dominant hand, higher baseline pain intensity, lower credibility the patient attributes to the treatment and longer symptom duration. Worse hand function was associated with recurrence following prior surgery, worse baseline hand function and lower treatment credibility. Clinicians should take these findings into account during patient counselling and expectation management.Level of evidence: II.

Long-term functional outcomes after total wrist arthrodesis

Current literature surrounding functional outcomes after total wrist arthrodesis is limited by short follow-up or limited use of validated patient reported outcome measures (PROMs). The primary aim of this study was to describe long-term functional outcomes following wrist arthrodesis. Secondary aims were to describe the incidence of complications and patient satisfaction. This was a retrospective single-center study. Patients with a minimum of 10-year follow-up completed a questionnaire including the Patient-Rated Wrist Evaluation (PRWE), the Quick version of the Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score, the EQ-5D-5L score, and a question assessing satisfaction. Presence of a complication was also assessed. During the study period 66 patients underwent total arthrodesis. At a median follow-up of 15 years, complete patient reported outcomes were available for 34 patients. Thirty-two patients were lost to follow-up. Mean age at surgery was 49 and 16 patients were female. Mean PRWE and Quick-DASH scores were 44.8 (SD 27.7; range 0-96) and 41.9 (SD 23.6; range 2.3-97.7) respectively. Twenty-eight patients were satisfied. Nine patients reported complications. There were six cases of hardware removal and two cases of prominent metalwork. One patient underwent revision surgery for non-union. Presence of a complication did not affect the Quick-DASH or PRWE scores. Median EQ-5D-5L score was 0.7. This long-term follow-up suggests high levels of patient satisfaction and health related quality of life, despite significant functional disability. The complication rates are not insignificant, although the presence of a complication did not affect functional outcomes.

Cold sensitivity and its association to functional disability following a major nerve trunk injury in the upper extremity—A national registry-based study

Aims

To investigate self-reported cold sensitivity and functional disability after a repaired major nerve trunk injury in the upper extremity.

Methods

We identified 735 individuals with a major nerve trunk injury in the upper extremity, surgically treated with direct nerve repair or reconstructed with nerve autografts, in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity, and perceived disability were collected using two questionnaires (HQ-8 and QuickDASH) preoperatively, and at three and 12 months postoperatively.

Results

We included 281 individuals, who had responded the questionnaires, where 197 (70%) were men (median age 34 [interquartile range 25–52] years) and 84 (30%) were women (median age 41 [25–55]). Cold sensitivity (scored 0–100) was the most prominent symptom 12 months postoperatively after an injured and repaired/reconstructed median (p<0.001) or ulnar (p<0.001) nerve, while individuals with a radial nerve injury showed milder symptoms. Concomitant injuries did not affect cold sensitivity scores. Individuals with ulnar nerve injuries scored higher in stiffness (p = 0.019), weakness (p<0.001) and ability to perform daily activities (p = 0.003) at 12 months postoperatively than median nerve injuries. Individuals with a median, ulnar or radial nerve injury with severe (>70) cold sensitivity had 25, 37 and 30 points higher QuickDASH scores, respectively (p<0.001), at 12 months postoperatively than individuals with mild (<30) cold sensitivity. There were no differences in QuickDASH score or cold sensitivity score at 12 months postoperatively between direct nerve repair or nerve reconstruction with nerve autografts. Neither age, nor sex, affected QuickDASH score at 12 months postoperatively.

Conclusion

Cold sensitivity after surgery for a major nerve trunk injury in the upper extremity can be substantial with impaired ability to perform daily activities, where an ulnar nerve injury may have a worse outcome.

Loss to patient-reported outcome measure follow-up after hip arthroplasty and knee arthroplasty

Aims

The aim of this study was to determine satisfaction rates after hip and knee arthroplasty in patients who did not respond to postoperative patient-reported outcome measures (PROMs), characteristics of non-responders, and contact preferences to maximize response rates.

Methods

A prospective cohort study of patients planned to undergo hip arthroplasty (n = 713) and knee arthroplasty (n = 737) at a UK university teaching hospital who had completed preoperative PROMs questionnaires, including the EuroQol five-dimension health-related quality of life score, and Oxford Hip Score (OHS) and Oxford Knee Score (OKS). Follow-up questionnaires were sent by post at one year, including satisfaction scoring. Attempts were made to contact patients who did not initially respond. Univariate, logistic regression, and receiver operator curve analysis was performed.

Results

At one year, 667 hip patients (93.5%) and 685 knee patients (92.9%) had undergone surgery and were alive. No response was received from 151/667 hip patients (22.6%), 83 (55.0%) of whom were ultimately contacted); or from 108/685 knee patients (15.8%), 91 (84.3%) of whom were ultimately contacted. There was no difference in satisfaction after arthroplasty between initial non-responders and responders for hips (74/81 satisfied vs 476/516 satisfied; p = 0.847) or knees (81/93 satisfied vs 470/561 satisfied; p = 0.480). Initial non-response and persistent non-response was associated with younger age, higher BMIs, and worse preoperative PROMs for both hip and knee patients (p < 0.050). Being in employment was associated with persistent non-response for hip patients (p = 0.047). Multivariate analysis demonstrated that younger age (p < 0.038), higher BMI (p = 0.018), and poorer preoperative OHS (p = 0.031) were independently associated with persistent non-response to hip PROMs. No independent associations were identified for knees. Using a threshold of > 66.4 years predicted a preference for contact by post (area under the curve 0.723 (95% confidence interval (CI) 0.647 to 0.799; p < 0.001, though this CI crosses the 0.7 limit considered reliable).

Conclusion

The majority of initial non-responders were ultimately contactable with effort. Satisfaction rates were not inferior in patients who did not initially respond to PROMs.

Cite this article: Bone Jt Open 2022;3(4):275–283.

Long-term outcomes following surgical repair of acute injuries of the thumb metacarpophalangeal joint ulnar collateral ligament

The primary aim of this study was to describe the long-term patient reported outcomes following surgical repair of acute injuries to the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL). The secondary aims were to describe the long-term health related quality of life, patient satisfaction and complication rate. From a single surgeon series, 30 patients were identified over an 11 year period (February 2000-February 2011). QuickDASH, EQ-5D-5L, and satisfaction scores were collected from 22 patients (73%) at mean 183 month follow up. The median QuickDASH score was 2.27. Median EQ-5D-5L was 0.88. Satisfaction rate was 82%, Net Promotor Score was 90. Significantly worse QuickDASH scores were seen in patients that developed MCP joint arthrosis or had had subsequent ipsilateral hand injuries (median 39.7 vs 2.27; p = 0.002). All the patients employed at the time of surgery returned to work without long-term adaptations. Surgical repair of acute UCL injury generally provides an excellent long-term functional outcome and satisfaction rate. Complications are rare but where MCP joint arthrosis develops functional outcomes can be significantly worse.