A proposed methodology for uncertainty extraction and verification in priority setting partnerships with the James Lind Alliance: an example from the Common Conditions Affecting the Hand and Wrist Priority Setting Partnership

Background

To report our recommended methodology for extracting and then confirming research uncertainties – areas where research has failed to answer a research question – derived from previously published literature during a broad scope Priority Setting Partnership (PSP) with the James Lind Alliance (JLA).

Methods

This process was completed in the UK as part of the PSP for “Common Conditions Affecting the Hand and Wrist”, comprising of health professionals, patients and carers and reports the data (uncertainty) extraction phase of this. The PSP followed the robust methodology dictated by the JLA and sought to identify knowledge gaps, termed “uncertainties” by the JLA. Published Cochrane Systematic Reviews, Guidelines and Protocols, NICE (National Institute for Health and Care Excellence) Guidelines, and SIGN (Scottish Intercollegiate Guidelines Network) Guidelines were screened for documented “uncertainties”. A robust method of screening, internally verifying and then checking uncertainties was adopted. This included independent screening and data extraction by multiple researchers and use of a PRISMA flowchart, alongside steering group consensus processes.

Selection of research uncertainties was guided by the scope of the Common Conditions Affecting the Hand and Wrist PSP which focused on “common” hand conditions routinely treated by hand specialists, including hand surgeons and hand therapists limited to identifying questions concerning the results of intervention, and not the basic science or epidemiology behind disease.

Results

Of the 2358 records identified (after removal of duplicates) which entered the screening process, 186 records were presented to the PSP steering group for eligibility assessment; 79 were deemed within scope and included for the purpose of research uncertainty extraction (45 full Cochrane Reviews, 18 Cochrane Review protocols, 16 Guidelines). These yielded 89 research uncertainties, which were compared to the stakeholder survey, and added to the longlist where necessary; before derived uncertainties were checked against non-Cochrane published systematic reviews.

Conclusions

In carrying out this work, beyond reporting on output of the Common Conditions Affecting the Hand and Wrist PSP, we detail the methodology and processes we hope can inform and facilitate the work of future PSPs and other evidence reviews, especially those with a broader scope beyond a single disease or condition.

National variation between clinical commissioning groups in referral criteria for primary total hip replacement surgery

The referral criteria used by the UK clinical commissioning groups for primary total hip replacement surgery appear inconsistent; the criteria rarely follow National Institute for Health and Care Excellence criteria. With established guidelines available, it is unclear why the clinical commissioning groups have referral criteia with less evidence base, without obviously addressing particular issues in their locality.

Gender differences in carpal tunnel relative cross-sectional area: a possible causative factor in idiopathic carpal tunnel syndrome

Previous research has not established a consistent difference in hand size or carpal tunnel cross-sectional area between patients with and without carpal tunnel syndrome. We tested the hypothesis that there would be no difference in relative carpal tunnel sizes between men and women. We defined relative carpal tunnel size as the cross-sectional areas at the inlet (level of the pisiform) and outlet (level of the hook of the hamate) of the carpal tunnel divided by the length of the capitate (as a measure of hand size). We made the measurements on the magnetic resonance imaging scans of 50 men and 50 women taken for symptoms unrelated to carpal tunnel syndrome. The mean relative cross-sectional area was appreciably smaller in women than men (p < 0.05). This suggests that the carpal tunnel cross-sectional area relative to the size of the hand is constitutionally smaller in women than in men. This could in theory be a significant factor in patients developing carpal tunnel syndrome.

LEVEL OF EVIDENCE

V.

Vein grafts to augment flexor tendon repairs: a biomechanical study on strength and gap resistance

The ultimate tensile repair strength and gap formation of the pig extensor tendons repaired with a standard 4-strand Savage with epitendinous suture repair, was compared with a new technique of adding a vein sleeve. Force and displacement data were recorded, and video images during linear cyclic loading up to failure. At 35 N, video-graphic observation detected significantly smaller gap lengths in the standard and vein repair specimens compared with standard repair specimens (p = 0.047). The incidence of 3 mm gaps between the repaired tendon ends in the standard repair group was 20 %, but no 3 mm gaps were seen in the standard and vein specimens. The addition of a vein sleeve increased the ultimate tensile strength of the standard repair from 50.4 N (4.5) to 55.4 N (4.5); this was statistically significant (p = 0.03). This study demonstrated that the addition of a vein graft prevented gap formation and increased ultimate tensile strength of tendon repair.

Thumb carpometacarpal joint total arthroplasty: a systematic review

Thumb carpometacarpal joint total arthroplasty has been undertaken for many years. The proponents believe the short-term outcomes are better than trapeziectomy and its variants, but the longer term complications are often higher. This systematic review of all peer reviewed articles on thumb carpometacarpal joint total arthroplasty for osteoarthritis shows that there are reports of many implants. Some are no longer available. The reported outcomes are very variable: for some there are good long-term outcomes to beyond 10 years ; for others there are unacceptably high early rates of failure. Overall the published evidence does not show that total arthroplasty is better than trapeziectomy and its variants yet there is a higher complication rate and significant extra cost of using an implant. Future research needs to compare total arthroplasty with trapeziectomy to assess short term results where the arthroplasties may be better, long-term outcomes and the healthcare and personal costs so that surgeons and patients can make fully informed choices about the treatment of symptomatic thumb carpometacarpal joint osteoarthritis.

The outcome of conservative treatment of spiral metacarpal fractures and the role of the deep transverse metacarpal ligaments in stabilizing these injuries

We carried out a prospective study to assess the outcome of spiral metacarpal fractures treated with early mobilization even in the presence of malrotation. We treated 30 patients of whom we assessed 25. Of these, 23 had an excellent outcome and two had good outcomes. Objectively all the fractures united with some shortening of between 2-5 mm. Only two cases reported mild dysfunction: one patient had a residual malrotation of 5° and one had some discomfort when boxing. We also carried out simple biomechanical studies on a cadaver and two patients undergoing ray amputations. These showed that, as the distal fracture fragment migrates proximally, any malrotation in a closed injury with intact deep transverse metacarpal ligaments corrects with flexion, which also helps to limit the shortening. Spiral metacarpal fractures, whether central or border, whether single or multiple, can usually be treated reliably with early mobilization as any malrotation corrects with flexion and the degree of shortening is limited.

Overview of indications, preferred methods and technical tips for hand fractures from around the world

This article presents techniques used by six senior surgeons from different parts of the world. Our commentaries on treating hand fractures are included, together with the methods we use. While non-operative treatment is appropriate and effective for the majority of the hand fractures (including those many practitioners currently treat surgically), we describe how we try to manage difficult cases with less invasive surgical methods. We recommend simple, efficient, non-operative or less invasive operative methods for almost all fractures, except for some open or very complex injuries.

Contact areas of the scaphoid and lunate with the distal radius in neutral and extension: correlation of falling strategies and distal radial anatomy

The functional neutral of wrist movement is about 10° extension yet the distal radius has a volar tilt. This has not previously been explained. Assuming that the contact area between the carpus and the distal radius increased in wrist extension this would also help stabilize the carpus on the distal radius in positions where typically there is greater loading. To test this hypothesis we reconstructed three-dimensional structures of the carpal bones and distal radius using computed tomography scans of 13 normal wrists. The contact areas of the scaphoid with the distal radius were measured and were found progressively increased from flexion 20°, neutral, extension 20°, to extension 40°. The maximal increases in the contact area of the scaphoid and the distal radius was at full wrist extension. No significant changes in the contact areas of the lunate with the distal radius were found between the different positions. The contact characteristics provide greater stability to the carpus on the distal radius, and to help spread forces from impact to the wrist reducing the transmitted peak forces and thus the risk of distal radius and carpal injuries.

A systematic review of the non-operative treatment of nightstick fractures of the ulna

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically.

We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required.

Cite this article: Bone Joint J 2013;95-B:952–9.

Analysis of failed Van Straten LPM proximal interphalangeal prostheses

The two-piece Van Straten Leuwen Poeschmann Metal (LPM) prosthesis was intended for the proximal interphalangeal joints. However, revision rates of 29% after 19 months were reported, as well as massive osteolysis. Five failed LPM titanium-niobium coated cobalt chromium components were obtained, three distal and two proximal, and subjected to a forensic retrieval analysis. Components were analyzed using a Talysurf contacting profilometer, ZYGO noncontacting profilometer, and environmental-scanning electron microscope. All components were heavily worn. In some regions the titanium-niobium coating had been scratched and penetrated. Elsewhere this coating had been removed where there was minimal scratching, which may have been due to corrosion between the coating and substrate. The osteolysis reported clinically was likely to be linked to the wear debris from the failed titanium-niobium coating and substrate.

Optimal configuration of the spiral linking technique for tendon repair. Biomechanical evaluation

A previous study described a new spiral linking technique for tendon repairs and demonstrated that it was strong enough to be used in clinical practice as an alternative to the Pulvertaft tendon weave repair. However the repairs were less stiff, needed slightly more tendon length for the same repair and were a little bulkier. In this study two variables have been changed with a view to improving the spiral technique. At first the number of spirals was reduced consecutively, keeping the same number of standard mattress sutures. Once the optimal number of spirals had been identified, repairs with different numbers of sutures were tested using an alternative cross-stitch technique. The spiral repair technique using two spirals linked with six sutures was at least as strong and stiff as a four-weave Pulvertaft technique and was also easier to do.

Analysis of NHSLA claims in hand and wrist surgery

Claims for negligence are increasing in medical practice. We analysed data provided by the UK NHS Litigation Authority (NHSLA) on all hand and wrist surgery from 1995-2001. The numbers of claims increased from 13 to 40, but the number being successfully defended also increased from 2 to 13 during this period. Claims were most commonly attributed to errors at surgery (56%) or in outpatient clinics (24%). Strikingly the claims are clustered to a few common conditions, particularly the treatment of carpal tunnel syndrome (22%) and wrist fractures (48%). There were no claims related to complex hand surgery. We recommend better training for 'routine surgery', better description of distal radius fracture parameters at each clinic visit and better training in emergency departments (ED).

A report on the early failure of the LPM proximal interphalangeal joint replacement

The LPM (Van Straten Medical, Netherlands) proximal interphalangeal joint replacement was introduced to the United Kingdom in October 2000, and 257 implants were sold. We have audited the results of this prosthesis, and obtained data for 164 of the 257 implants. Forty-seven (29%) of the 164 have been revised and another 33 (20%) are showing clinical and radiological signs of failure at a maximum follow-up of 6 years. Massive osteolysis leading to aseptic loosening is the commonest cause of failure. We believe that all patients who have had this prosthesis inserted should be kept under regular clinical and radiographic review.

Pasteurella multocida infection of a total hip arthroplasty. A case report

The authors report a case history of a diabetic woman requiring revision hip arthroplasty of a Charnley total hip prosthesis that was infected with Pasteurella multocida. The infection of the loose prosthesis followed a cat bite to the same leg. Advice is given on the management of patients with infection following animal inoculations, and the subject of increased risk with a loose prosthesis is discussed.

Chicken pox infection (varicella zoster virus) and acute monoarthritis: evidence against a direct viral mechanism

A 9 year old boy developed acute monoarthritis of the left knee concurrent with the appearance of a varicella zoster virus (VZV) rash. Repeated VZV DNA hybridisation of the cells within the synovial fluid and synovial membrane failed to show any evidence of intracellular virus. Virus was isolated from synovial fluid 24 hours after the start of clinical infection but not later. These findings suggest that the mechanism of the arthritis is not due to viral replication inside the swollen joint.

Stercoral perforation of the colon proximal to an end colostomy

Stercoral perforation of the colon is rare, and has not previously been reported as a postoperative complication, proximal to an end colostomy. Two such cases are reported; in addition in one the stercoral perforation was recurrent, emphasizing the multifocal nature of the disease. Both cases demonstrate the failure of standard techniques to deal with scybala in the loaded proximal colon. It is, therefore, suggested that intra-operative orthograde colonic lavage is indicated to protect a terminal colostomy from the risk of stercoral perforation in such cases.