Delayed vascular complication after collagenase injection for Dupuytren disease

BACKGROUND

Vascular adverse events after collagenase injection for Dupuytren disease are absent in large trials and systematic reviews. The aim of this study is to present a case series of delayed vascular complications after collagenase treatment.

METHODS

A prospective evaluation of 1181 consecutively treated patients at one orthopedic department identified three patients reporting symptoms of possible vascular complication. Baseline demographics and description of symptoms were collected, with a physical examination documenting extension deficit and neurovascular status. All patients completed the Cold Intolerance Symptom Severity (CISS) scale (range 4-100, lower is better) and underwent Doppler sonography examination of the digital arteries.

RESULTS

All patients were treated in the small finger and two had an isolated proximal interphalangeal joint contracture. All patients had a delayed presentation of a few months, with episodes of white discoloration of the treated finger relieved within 30 min and associated with variable pain, paresthesia, stiffness and weakness. Two of the patients reported cold exposure as an episode trigger and had a pathological CISS score (40 and 36, respectively). Doppler sonography identified a nonpatent ulnar digital artery in one patient.

CONCLUSIONS

Delayed vascular complication after collagenase treatment is rare, but surgeons and patients should be aware of the risk, especially when treating the small finger.

Responsiveness of the patient-specific Canadian occupational performance measure and a fixed-items activity limitations measure in patients with dupuytren disease

BACKGROUND

Patients with Dupuytren disease experience various activity limitations. Treatment aims to reduce finger joint contractures to improve hand function and activity performance. For assessing improvement different patient-centered measures have been used. The Canadian Occupational Performance Measure (COPM) was developed as an interview-based outcome measure to detect changes over time in patients' perception of their performance and satisfaction in self-identified activity issues. The 11-item disabilities of the arm, shoulder and hand (QuickDASH) scale consists of fixed items that ask patients to rate the difficulty in performing specific daily activities. Few studies have compared the responsiveness of these two types of patient-reported measures in Dupuytren disease.

PATIENTS AND METHODS

We included 30 patients with Dupuytren disease enrolled in a prospective cohort study of collagenase injection. We used the COPM (score range 1-10), the QuickDASH (score range 0-100) and measurement of finger joint contracture before and 5 weeks after treatment.

RESULTS

Using the COPM the patients identified 107 activity problems (55 in self-care, 19 in productivity and 33 in leisure). The two most common activity problems were to wash self (21 patients) and to don gloves (19 patients). A clinically important improvement with 3 points or greater from baseline to 5 weeks was seen for performance in 77 activities (72%). The median COPM performance score improved from 4.4 at baseline to 9.0 at 5 weeks and the median QuickDASH score improved from 13.6 to 2.5. Responsiveness (Cohen's d) for the COPM performance was 2.6 (95% CI 1.9-3.3) and for the QuickDASH 0.6 (95% CI 0.1-1.1).

CONCLUSION

The COPM had about 6-fold larger responsiveness than the QuickDASH, which supports use of an individualized measure when assessing treatment effects in Dupuytren disease.

Surgically treated adult acquired flatfoot deformity: Register-based study of patient characteristics, health-related quality of life and type of surgery according to severity

BACKGROUND

Population-level data describing patient characteristics and interventions used in surgical treatment of adult acquired flatfoot deformity (AAFD) is lacking.

METHODS

We analyzed baseline patient-reported data including PROMs and surgical interventions for patients with AAFD reported to the Swedish Quality Register for Foot and Ankle Surgery (Swefoot) 2014-2021.

RESULTS

625 feet with primary AAFD surgery were registered. Median age was 60 (range 16-83) years and 64% were women. Mean preoperative EQ-5D index and Self-Reported Foot and Ankle Score (SEFAS) were low. In stage IIa (n = 319) 78% had medial displacement calcaneal osteotomy and 59% had flexor digitorium longus transfer, with some regional variations. Spring ligament reconstruction was less common. In stage IIb (n = 225), 52% had lateral column lengthening, and in stage III (n = 66), 83% had hind-foot arthrodesis.

CONCLUSIONS

Patients with AAFD have low health-related quality of life before surgery. Treatment in Sweden follows best-available evidence but regional variations exist.

LEVEL OF EVIDENCE

III.

EPOS trial: the effect of air filtration through a plasma chamber on the incidence of surgical site infection in orthopaedic surgery: a study protocol of a randomised, double-blind, placebo-controlled trial

INTRODUCTION

There is controversy regarding the importance of air-transmitted infections for surgical site infections (SSIs) after orthopaedic surgery. Research has been hindered by both the inability in blinding the exposure, and by the need for recruiting large enough cohorts. The aim of this study is to investigate whether using a new form of air purifier using plasma air purification (PAP) in operating rooms (ORs) lowers the SSI rate or not.

METHODS AND ANALYSIS

Multicentre, double-blind, cluster-randomised, placebo-controlled trial conducted at seven hospitals in 2017-2022. All patients that undergo orthopaedic surgery for minimum 30 min are included. Intervention group: patients operated in OR with PAP devices turned on.

CONTROL GROUP

patients operated in OR with PAP devices turned off. Randomisation: each OR will be randomised in periods of 4 weeks, 6 weeks or 8 weeks to either have the devices on or off.

PRIMARY OUTCOME

any SSI postoperatively defined as a composite endpoint of any of the following: use of isoxazolylpenicillin, clindamycin or rifampicin for 2 days or more, International Classification of Diseases codes or Nordic Medico-Statistical Committee codes indicating postoperative infection. In a second step, we will perform a chart review on those patients with positive indicators of SSI to further validate the outcome. Secondary outcomes are described in the Methods section. Power: we assume an SSI rate of 2%, an SSI reduction rate of 25% and we need approximately 45 000 patients to attain a power of 80% at a significance level of 0.05.

ETHICS AND DISSEMINATION

The study is approved by the Swedish Ethical Review Authority. The interim analysis results from the study will be presented only to the researchers involved unless the study thereafter is interrupted for whatever reason. Publication in a medical journal will be presented after inclusion of the last patient.

TRIAL REGISTRATION NUMBER

NCT02695368.

Trapeziectomy for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term

BACKGROUND

Symptomatic osteoarthritis of the basal joint of the thumb (trapeziometacarpal joint) is a common disabling condition mainly affecting women. It is frequently treated with complete removal of the trapezium with or without soft-tissue interposition. There is limited evidence about whether removal of the trapezium affects stability of the wrist joint and increases the risk of developing wrist osteoarthritis. The aim of this study was to evaluate the long-term prevalence of OA in wrists with previous trapeziectomy compared to wrists with intact trapezium.

METHODS

Patients treated with surgery for trapeziometacarpal osteoarthritis at one orthopedic department were invited 10-29 (mean 17) years postoperatively for bilateral radiographic examination. We included radiographs from 114 hands with trapeziectomy and 46 hands with intact trapezium; 38 patients had unilateral trapeziectomy and intact contralateral trapezium. The radiographs were blinded so that the intact trapezium or the trapezial space after trapeziectomy was not visible. The radiographs were then evaluated for radiocarpal/midcarpal osteoarthritis independently by two assessors using three different osteoarthritis grading systems, including the Kellgren-Lawrence classification. The patients rated their satisfaction with the function of each of their hands on a visual analog scale (VAS) from 0 to 100 (higher score better).

RESULTS

The prevalence of osteoarthritis ranged from 20 to 26%, mostly mild (Kellgren-Lawrence grade 1). The prevalence of osteoarthritis did not differ between wrists with previous trapeziectomy and those with intact trapezium, both in the whole cohort and in the subgroup of patients with unilateral trapeziectomy and intact contralateral trapezium. There was no significant difference in hand function VAS scores between hands with previous trapeziectomy and hands with intact trapezium in the whole cohort or in the subgroup.

CONCLUSIONS

Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term.

Measuring symptoms severity in carpal tunnel syndrome: score agreement and responsiveness of the Atroshi-Lyrén 6-item symptoms scale and the Boston symptom severity scale

Purpose

To assess score agreement between the Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale and compare their responsiveness in patients with carpal tunnel syndrome before and after carpal tunnel release surgery.

Methods

This prospective cohort study included 3 cohorts that completed the A-L and Boston scales (conventional score 1–5) on the same occasion: a preoperative and short-term postoperative cohort (212 patients), a mid-term postoperative cohort (101 patients), and a long-term postoperative cohort (124 patients). Agreement was assessed with Lin’s concordance correlation coefficient and Passing-Bablok regression analysis. Analyses using item response theory were conducted on responses from the preoperative/short-term postoperative cohort including testing of item infit/outfit. Reliability was assessed with Cronbach alpha. Overall and sex-specific effect sizes were calculated using Cohen’s d.

Results

Lin’s CCCs were high (0.81–0.91). Passing-Bablok analysis showed constant and proportional differences in all cohorts except preoperative to short-term postoperative change. Both scales showed high reliability (alpha, 0.88–0.93). The IRT-based analyses showed infit/outfit values within the desired range. With IRT-based scoring, the A-L scale had significantly higher responsiveness than the Boston scale, overall (d, 2.02 vs 1.59), in women (d, 2.22 vs 1.77) and in men (d, 1.74 vs 1.36).

Conclusion

The Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale show good agreement but are not equivalent in measuring CTS-related symptoms severity. When using IRT-based scoring, the Atroshi-Lyrén scale demonstrated significantly higher responsiveness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03039-1.

Extended Follow-up of Local Steroid Injection for Carpal Tunnel Syndrome: A Randomized Clinical Trial

IMPORTANCE

Local steroid injection is commonly used in treating patients with idiopathic carpal tunnel syndrome, but evidence regarding long-term efficacy is lacking.

OBJECTIVE

To assess the long-term treatment effects of local steroid injection for carpal tunnel syndrome.

DESIGN, SETTING, AND PARTICIPANTS

This exploratory 5-year extended follow-up of a double-blind, placebo-controlled randomized clinical trial was conducted from November 2008 to March 2012 at a university hospital orthopedic department. Participants included patients aged 22 to 69 years with primary idiopathic carpal tunnel syndrome and no prior treatment with local steroid injections. Data were analyzed from May 2018 to August 2018.

INTERVENTIONS

Patients were randomized to injection of 80 mg methylprednisolone, 40 mg methylprednisolone, or saline.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes were the symptom severity score and rate of subsequent carpal tunnel release surgery on the study hand at 5 years. Secondary outcomes were time from injection to surgical treatment, SF-36 bodily pain score, and score on the 11-item disabilities of the arm, shoulder, and hand scale.

RESULTS

A total of 111 participants (mean [SD] age at follow-up, 52.9 [11.6] years; 81 [73.0%] women and 30 [27.0%] men) were randomized, with 37 in the 80 mg methylprednisolone group, 37 in the 40 mg methylprednisolone group, and 37 in the saline placebo group. Complete 5-year follow-up data were obtained from all 111 participants with no dropouts (100% follow-up). At baseline, mean (SD) symptom severity scores were 2.93 (0.85) in the 80 mg methylprednisolone group, 3.13 (0.70) in the 40 mg methylprednisolone group, and 3.18 (0.75) in the placebo group, and at the 5-year follow up, mean (SD) symptom severity scores were 1.51 (0.66) in the 80 mg methylprednisolone group, 1.59 (0.63) in the 40 mg methylprednisolone group, and 1.67 (0.74) in the placebo group. Compared with placebo, there was no significant difference in mean change in symptom severity score from baseline to 5 years for the 80 mg methylprednisolone group (0.14 [95%CI, -0.17 to 0.45]) or the 40 mg methylprednisolone group (0.12 [95%CI, -0.19 to 0.43]). After injection, subsequent surgical treatment on the study hand was performed in 31 participants (83.8%) in the 80 mg methylprednisolone group, 34 participants (91.9%) in the 40 mg methylprednisolone group, and 36 participants (97.3%) in the placebo group; the number of participants who underwent surgical treatment between the 1-year and 5-year follow-ups was 4 participants (10.8%) in the 80 mg methylprednisolone group, 4 participants (10.8%) in the 40 mg methylprednisolone group, and 2 participants (5.4%) in the placebo group. All surgical procedures were conducted while participants and investigators were blinded to type of injection received. The mean (SD) time from injection to surgery was 180 (121) days in the 80 mg methylprednisolone group, 185 (125) days in the 40 mg methylprednisolone group, and 121 (88) days in the placebo group. Kaplan-Meier survival curves showed statistically significant difference in time to surgical treatment (log-rank test: 80 mg methylprednisolone vs placebo, P = .002 ; 40 mg methylprednisolone vs placebo, P = .02; methylprednisolone 80 mg vs 40 mg, P = .37).

CONCLUSIONS AND RELEVANCE

These findings suggest that in idiopathic carpal tunnel syndrome, local methylprednisolone injection resulted in statistically significant reduction in surgery rates and delay in need for surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT00806871 and NCT02652390.

What Are the Patient-reported Outcomes of Trapeziectomy and Tendon Suspension at Long-term Follow-up?

BACKGROUND

There are multiple options for the treatment of thumb carpometacarpal joint osteoarthritis (CMC1 OA), with evidence for pain relief and improved function. Although simple trapeziectomy has the lowest complication risk, tendon suspension of the first metacarpal and interposition is still the most commonly used surgical procedure in patients with CMC1 OA. Although there are several reports of good short-term results after trapeziectomy and tendon suspension-interposition arthroplasty, few studies have evaluated long-term outcomes. This study is one of the largest and longest follow-up evaluations of a cohort of patients with CMC1 OA who were treated with trapeziectomy and suspension-interposition arthroplasty, capturing 96% of the original cohort for evaluation.

QUESTIONS/PURPOSES

(1) After trapeziectomy and tendon suspension surgery, what are the long-term, patient-reported outcomes and clinical measurements (strength and ROM); and in unilateral procedures, how do these parameters compare with those of the contralateral hand that was not operated on? (2) What is the mean subsidence (unloaded trapezial space), and does pinch strength correlate with the amount of subsidence?

METHODS

From 1998 to 2005, 130 patients underwent trapeziectomy and abductor pollicis longus (APL) suspension-interposition arthroplasty for CMC1 OA at one orthopaedic department. During this period, 15 patients were treated with CMC1 arthrodesis and four were treated with implant arthroplasty, for a total of 149 patients. The surgeons used APL suspensionplasty for most patients, based on age and expected postoperative function; they also employed this procedure to avoid hardware or implant failure issues. The 100 living patients were asked to participate in this retrospective study, 96% (96) of whom were enrolled. The mean age at surgery was 58 ± 7 years. The patients completed a two-item thumb pain scale (modified from the SF-36 body pain scale), a hand pain VAS (average level of pain experienced over the week preceding measurement), and the 11-item QuickDASH. Patient-reported outcomes data were obtained from all 96 patients, and 83% (80) of patients underwent bilateral hand radiography and a physical examination at a mean follow-up of 17 ± 2.4 years. We calculated outcome data for each patient, and in 39 patients with unilateral surgery and intact contralateral CMC1 joint, we compared the operated side with the contralateral side. We compared our outcome data with that from the Swedish National Quality Registry for Hand Surgery (HAKIR), noting comparable outcomes for pain and QuickDASH scores.

RESULTS

At long-term follow-up after trapeziectomy and APL suspension surgery, the mean thumb pain score was 19 ± 26, hand pain VAS score 23 ± 25, and QuickDASH score 26 ± 21. In the patients with unilateral surgery and intact contralateral CMC1 joint, the thumb pain score for the operated side was lower than the contralateral side, specifically 19 ± 25 compared with 29 ± 30 (mean difference -9.8 [95% CI -19.5 to -0.2]; p = 0.045); hand pain VAS score was 24 ± 23 versus 30 ± 25 (mean difference -6.1 [95% CI -15.2 to 3.1]; p = 0.19), and the QuickDASH score was 27 ± 19. Grip strength showed no differences between the operated and contralateral sides (mean 16.7 ± 7.3 kg versus 16.6 ± 6.9 kg, mean difference 0.1 [95% CI -1.6 to 1.8]; p = 0.90), while pinch was different (4.4 ± 1.4 versus 5.0 ± 1.5 kg, mean difference -0.6 [95% CI -0.9 to -0.3]; p = 0.001). The mean trapezial space was 4.4 ± 2.2 mm, and there was no association between the trapezial space and pinch strength (0.07 kg [95% CI -0.04 to 0.18] per mm of space; p = 0.17).

CONCLUSION

The finding of comparable pain and function between operated and unoperated sides at long-term follow-up suggests that trapeziectomy and tendon suspension-interposition arthroplasty provides predictable outcomes, and surgeons can use these data to counsel patients that surgery can potentially return them to comparable use. However, as patients often have asymptomatic radiographic OA on the contralateral side, future studies are needed to examine the impact of asymptomatic disease on function.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Incidence of distal radius fracture in a general population in southern Sweden in 2016 compared with 2001

In this population-based study, we compared the incidence of distal radius fracture in 2016 with that in the same region's adult general population in 2001 using radiographs to identify fracture cases. We showed that the incidence decreased by 24% in 2016 compared with 2001 indicating an important development.

INTRODUCTION

We conducted an epidemiological study on residents of northeastern Skåne in southern Sweden (population 182,000) to determine the overall incidence of distal radius fracture and the incidence according to age, sex, and fracture characteristics in the region's adult population during 2016, and to study the change in incidence in the same general population between 2001 and 2016 using wrist radiographs to identify fracture cases.

METHODS

Two orthopedic surgeons examined all wrist radiographs performed at the only two emergency hospitals in the study region to identify individuals, above 18 years of age, who sustained fracture of the distal radius during 2016. We used Poisson regression analysis adjusting for age, sex, and at-risk population to compare the incidence in 2016 with the incidence in 2001, previously estimated using similar methodology.

RESULTS

The overall incidence in 2016 was 22 (95% CI 20-25) per 10,000; the incidence in women was 34 (95% CI 30-39) and in men was 10 (95% CI 8-12) per 10,000. The overall incidence in 2016 was 0.76 (95% CI 0.70-0.82) of the incidence in 2001 (p < 0.0001). The incidence in the 3 age groups 19-49, 50-79, and ≥ 80 years was 0.91 (95% CI, 0.69-1.20), 0.67 (95% CI, 0.55-0.82), and 0.49 (95% CI, 0.25-0.97) of the incidence in 2001, respectively.

CONCLUSION

In a general population in Sweden, a statistically significant and clinically important decrease in the incidence of distal radius fracture occurred between 2001 and 2016, driven by lower incidence in individuals 50 years or older.

Incidence of referred carpal tunnel syndrome and carpal tunnel release surgery in the general population: Increase over time and regional variations

PURPOSE

To investigate the change in incidence of referred carpal tunnel syndrome (CTS) and carpal tunnel release (CTR) surgery over time and regional variations.

METHODS

From the nationwide patient registry, we identified all adult individuals who had received first-time CTS diagnosis (International Classification of Diseases, 10th Revision code G560) at secondary or tertiary level and first-time CTR surgery during the period of 9 years.

RESULTS

From 2001 through 2009, the incidence (per 100,000 person-years) of CTS diagnosed at secondary or tertiary level increased from 216 to 243 in women and from 95 to 119 in men and of CTR from 117 to 168 in women and from 52 to 78 in men. The mean annual increase in first-time CTR (95% confidence interval) was 5.1% (4.7-5.4) in women and 6.2% (5.6-6.7) in men. The age-standardized 3-year (2007-2009) incidence varied significantly across Sweden's 21 counties; compared to the county with the lowest incidence of CTR, the incidence rates in the other counties were higher by 6-152% (mean 60%) in women and by 20-182% (mean 85%) in men. The proportion of CTS-diagnosed individuals treated with surgery varied across counties from 53% to 81% in women and from 51% to 77% in men.

CONCLUSION

The incidence of referred CTS and of CTR surgery increased over time in both sexes, with large regional variations found in the incidence rates and in the proportion of individuals treated with surgery.

Occupational load as a risk factor for clinically relevant base of thumb osteoarthritis

OBJECTIVE

It is postulated that increased load from pinch and grasp in occupational tasks increases the risk of thumb carpometacarpal (CMC1) osteoarthritis (OA). We sought to characterise the relationship between doctor-diagnosed CMC1 OA and occupation in a large working population.

METHODS

We performed a matched case-control study using a Swedish healthcare register. We identified residents aged 30-65 years in 2013 with physician-diagnosed CMC1 OA from 1998 to 2013. We matched four controls per person with CMC1 OA by age, sex, education and postcode. Swedish Standard Classification of Occupations was used to assign occupation. Occupation was categorised as light, light-moderate, moderate and heavy labour. We used conditional logistic regression to estimate ORs with 95% CIs.

RESULTS

We identified 3462 patients with CMC1 OA and matched 13 211 controls. The mean age of the CMC1 OA group was 63 (SD 7) years, with 81% women. The ORs for CMC1 OA in men were 1.31 (95% CI 0.96 to 1.79) for light-moderate, 1.76 (95% CI 1.29 to 2.40) for moderate and 2.00 (95% CI 1.59 to 2.51) for heavy compared with light work. Women had ORs for CMC1 OA of 1.46 (95% CI 1.32 to 1.61) for light-moderate, 1.27 (95% CI 1.10 to 1.46) for moderate and 1.31 (95% CI 1.07 to 1.59) for heavy compared with light work.

CONCLUSIONS

The association between increased manual load in occupation and risk of CMC1 OA is more pronounced in men than in women, likely due to higher workload in the heavy labour category.

The methodological requirements for clinical examination and patient-reported outcomes, and how to test them

This article presents the methodological requirements for clinical examination and patient-reported outcomes measurements. The assessment of any measurement for clinical research in hand surgery is difficult. A method of measuring a criterion could be 100% reliable but 100% invalid. Bias may be present in our assessment if we do not take into account the methodological requirements related to reliability, validity, and responsiveness of our measures. Reliability refers to intra-observer agreement, inter-observer agreement, or agreement between two methods of assessment, and, for patient-reported measures, internal consistency and test-retest reliability. Validity is the capability of a clinical method to measure what it proposes to measure. Assessing validity involves comparing a measure with one or more other measures, and, if possible, with a reference standard criterion. Responsiveness is the ability to detect important clinical change. The Consensus-based Standards for the Selection of Health Measurement Instruments provides the standards required for design and recommended statistical analyses of patient-reported outcome measures.

Collagenase injections for Dupuytren disease: 3-year treatment outcomes and predictors of recurrence in 89 hands

Background and purpose - Few prospective studies have reported the long-term effect durability of collagenase injections for Dupuytren disease. We assessed the 3-year treatment outcome of collagenase injections and predictors of recurrence.Patients and methods - We conducted a single-center prospective cohort study. Indication for collagenase injection was palpable Dupuytren's cord and active extension deficit (AED) ≥ 20° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. From November 2012 through June 2013, we treated 86 consecutive patients (92 hands, 126 fingers). A hand therapist measured joint contracture before, 5 weeks, and 3 years after injection. The patients rated their treatment satisfaction. Primary outcome was proportion of treated joints with ≥ 20° AED worsening between the 5-week and 3-year measurements. We analyzed predictors of recurrence.Results - 3-year outcomes were available for 83 of the 86 patients (89 hands, 120 treated fingers). Between the 5-week and 3-year measurements, AED worsened by ≥ 20° in 17 MCP (14%) and 28 PIP (23%) joints. At 3 years, complete correction (passive extension deficit 0-5°) was present in 73% of MCP and 35% of PIP joints. Treatment of small finger PIP joint contracture, greater pretreatment contracture severity, and previous fasciectomy on the treated finger were statistically significant predictors of recurrence. Treatment satisfaction was rated as very satisfied or satisfied in 59 of 87 hands. No long-term treatment-related adverse events were observed.Interpretation - 3 years after collagenase injections for Dupuytren disease, improvement was maintained and treatment satisfaction reported in two-thirds of the treated hands, with no adverse events. Complete contracture correction was achieved in 3 of 4 MCP joints, but in only a third of the PIP joints.

Treatment of carpal tunnel syndrome with wrist splinting: study protocol for a randomized placebo-controlled trial

Background

Carpal tunnel syndrome (CTS) is a common cause of pain, weakness, sensory loss, and activity limitations. Currently, the most common initial treatment is use of a rigid splint immobilizing the wrist, usually during night-time, for several weeks. Evidence regarding the efficacy and effect durability of wrist splinting is weak. The treatment is associated with costs and may cause discomfort and limit daily and work activities. No placebo-controlled trials have been performed.

Methods

This is a randomized controlled trial designed to assess the efficacy of a rigid wrist splint compared with soft wrist bandage (placebo) in patients with primary idiopathic CTS. The trial will be conducted at an orthopedic department. Patients, 25 to 65 years old, who seek primary health-care with symptoms of CTS will be screened, and potentially eligible patients will be referred to the study center. Patients who fulfill the trial’s eligibility criteria will be invited to participate. A total of 112 patients who provide informed consent will be randomly assigned to treatment with either a rigid wrist splint or a soft bandage to be used initially for 6 weeks at night and, if possible, during the day. The splints and bandages will be fitted with a temperature-monitoring device to measure the total time during which they have actually been worn. The trial participants will complete a questionnaire that includes the 6-item CTS symptoms scale (CTS-6); the 11-item disabilities of the arm, shoulder, and hand (QuickDASH) scale; and the EuroQol 5-dimension (EQ-5D) health status and quality-of-life measure at baseline and at 6, 12, 24, and 52 weeks after treatment start. The participants will undergo physical examination and nerve conduction testing at baseline and at 52 weeks. The trial’s primary outcomes are the change in the CTS-6 score from baseline to 12 weeks and the rate of carpal tunnel release surgery at 52 weeks.

Discussion

This is the first placebo-controlled randomized trial with electronic monitoring of actual splint use and will provide evidence regarding the efficacy of wrist splinting in patients with CTS.

Trial registration

ISRCTN Registry, ISRCTN81836603. Registered on May 5, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3635-6) contains supplementary material, which is available to authorized users.

A new finger-preserving procedure as an alternative to amputation in recurrent severe Dupuytren contracture of the small finger

Background

Recurrent severe Dupuytren contracture of the small finger’s proximal interphalangeal (PIP) joint is a difficult problem. Further surgery carries high risk of complications and poor outcome. Patients are often offered finger amputation. We have devised a novel surgical procedure consisting of middle phalanx monoblock resection and ligament reconstruction to create a new functioning interphalangeal joint.

Methods

Two patients requesting small-finger amputation because of severe PIP joint contracture after multiple treatments for Dupuytren contracture were offered and accepted this new procedure. Through a dorsal incision the extensor tendon is incised longitudinally exposing the middle phalanx and interphalangeal joints. The collateral ligaments of both interphalangeal joints are detached from the middle phalanx. The middle phalanx is dissected from soft tissues (including the flexor digitorum superficialis tendon) and removed. The distal phalanx is brought proximally and the ends of the collateral ligaments are sutured with non-absorbable sutures with the joint held in full extension and congruency. The two patients were evaluated at 18 months and 15 months after surgery, respectively.

Results

Both patients regained good finger posture with almost full extension and had normal sensation and no pain. Active flexion in the new interphalangeal joint was 60 degrees and 35 degrees, respectively. Both patients had full metacarpophalangeal joint flexion and extension, normal 2-point discrimination in the small finger and higher grip strength in the treated than the contralateral hand. Radiographs showed a congruent new interphalangeal joint. Both patients were very satisfied with the outcome.

Conclusions

In patients with Dupuytren disease and severe PIP joint contracture after multiple treatments, this novel procedure consisting of middle-phalanx excision and ligament reconstruction creating a new functioning interphalangeal joint has good short-term outcomes and is a favorable alternative to finger amputation. Longer follow-up will show whether these results are durable.

Surgical fasciectomy versus collagenase injection in treating recurrent Dupuytren disease: study protocol of a randomised controlled trial

INTRODUCTION

There is no definitive cure for Dupuytren disease (DD), and recurrence of finger contractures after treatment is common. Surgical fasciectomy is considered the standard treatment method for recurrence, although associated with a high incidence of complications. Collagenase injection, a non-surgical treatment option, has been shown to be a safe and effective method; however, most studies regarding collagenase have involved first-time treatment. Collagenase efficacy in patients with recurrent DD beyond the immediate effect has not yet been determined. The aim of our study is to compare surgical fasciectomy and collagenase injection in treating recurrent DD.

METHODS AND ANALYSIS

The study is a single-centre randomised controlled trial. Inclusion criteria are recurrence of DD in one or more fingers after previous treatment with fasciectomy or collagenase injection, a passive extension deficit ≥30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint, and a palpable cord causing the recurrent contracture. A total of 56 patients will be randomised to either surgical fasciectomy or collagenase injection. A hand therapist blinded to patients' group allocation will measure range of motion at baseline, 3 months, 12 months, 24 months and 60 months. The primary outcomes are the total active extension deficit (MCP plus PIP) at 3 months and the proportion of patients with contracture worsening ≥20° in the treated finger joint at 2 years compared with 3 months. The secondary outcomes include changes in total active motion, active and passive extension deficit from baseline up to 5 years, scores on patient-reported outcome measures, adverse events and costs of treatment.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Regional Ethical Review Board, Lund University, Sweden(2017/623). The trial will be conducted according to the Helsinki Declaration of 1975, revised in 2000. The results of the trial will be disseminated as published articles in peer-reviewed journals.

TRIAL REGISTRATION

NCT03406338; Pre-results.

Basics of Statistics for Clinical Research in Hand Surgery

Statistics, the science of numerical evaluation, helps in determining the real value of a hand surgical intervention. Clinical research in hand surgery cannot improve without considering the application of the most appropriate statistical procedures. The purpose of the present paper is to approach the basics of data analysis using a database of carpal tunnel syndrome (CTS) to understand the data matrix, the generation of variables, the descriptive statistics, the most appropriate statistical tests based on how data were collected, the parameter estimation (inference statistics) with p-value or confidence interval, and, finally, the important concept of generalized linear models (GLMs) or regression analysis.

Examiners' influence on the measured active and passive extension deficit in finger joints affected by Dupuytren disease

Background

The most commonly reported outcome measure in Dupuytren disease is the extension deficit in finger joints. This study aimed to investigate the examiners’ influence on the measured difference between active and passive extension deficit.

Methods

A prospective cohort study was conducted on 157 consecutive patients (81% men, mean age 70 years) scheduled for collagenase treatment for Dupuytren disease. Before injection, one of three experienced hand therapists measured active extension deficit (AED) and passive extension deficit (PED) in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the affected fingers using a hand-held metal goniometer. We included joints with ≥10° AED, and calculated mean AED and PED in MCP and PIP joints measured by each examiner. For adjusted analysis we used a mixed effects model to determine the relationship between the examiner and the AED-PED difference.

Results

For all 291 joints measured, mean AED was 46° (SD 21) and mean PED was 37° (SD 23). Mean difference between AED and PED measured by examiner 1 was 6° (SD 6), by examiner 2 was 9° (SD 9), and by examiner 3 was 12° (SD 9). The mixed effects model analysis showed that the identity of the examining therapist was a significant determinant of the AED-PED difference.

Conclusions

In Dupuytren disease measurement of active and passive extension deficit in finger joint contractures may vary significantly between different examiners. This must be taken into consideration when designing clinical studies and comparing outcomes between studies.

Bilateral anterior interosseous nerve syndrome with 6-year interval

Flexor pollicis longus paralysis related to idiopathic anterior interosseous nerve syndrome is well known, but few reports exist on bilateral disease. A 24-year-old man with no personal or family history of neurological disease developed isolated total loss of active flexion of the right thumb's interphalangeal joint after undergoing a wrist arthroscopy. Surgical exploration 5 weeks after onset showed flexor pollicis longus tendon to be intact; anterior interosseous nerve decompression was done with no abnormalities found. Because of persistent paralysis, electromyography was performed showing findings consistent with anterior interosseous nerve syndrome. After 7 months without recovery, the patient underwent tendon transfer. After 6 years, the patient presented with left-sided isolated flexor pollicis longus paralysis and electromyography indicated anterior interosseous nerve syndrome. Examination 9 months after onset showed persistent complete flexor pollicis longus paralysis but by 15 months spontaneous complete recovery had occurred. Anterior interosseous nerve syndrome can occur bilaterally and is likely to resolve completely without intervention but recovery may take longer than a year.

Sick Leave After Surgery for Thumb Carpometacarpal Osteoarthritis: A Population-Based Study

PURPOSE

Patients undergoing surgery for thumb carpometacarpal (CMC1) osteoarthritis often require sick leave owing to postoperative immobilization, pain, and decreased function. Our goal was to evaluate the amount of sick leave after surgery for 2 common CMC1 arthroplasty procedures.

METHODS

Using registry data from the Skåne region of southern Sweden, cross-linked with employment data showing person-specific sick leave, 2 cohorts of CMC1 surgical patients, between ages 40 and 59 years, were examined. These comprised all persons undergoing soft tissue arthroplasty and prosthetic implant arthroplasty from 2004 to 2012 identified using International Classification of Diseases, 10th Revision, and surgical codes. These subjects were analyzed against an age- and sex-matched reference population cohort.

RESULTS

Surgical cohorts of 326 and 169 subjects undergoing soft tissue and prosthetic CMC1 arthroplasty, respectively, were compared with reference populations of 1,110 and 574 persons. Surgical subjects had a pronounced increase in sick leave in the first 2 months after surgery, followed by diminishing days of leave over time. Mean sick leave time after soft tissue arthroplasty was 202 days in women and 170 days in men. Following prosthetic arthroplasty, mean sick leave was 177 days in women and 188 in men. When we excluded those with documented sick leave in the month before surgery (owing to preoperative CMC1 disability or other medical issues), the mean postoperative sick leave decreased to 137 days in women and 125 days in men after soft tissue arthroplasty compared with 109 and 94 days in women and men after prosthetic implant arthroplasty, and this difference was significant. There were no differences in the length of sick leave between sexes and no correlation with age.

CONCLUSIONS

Soft tissue arthroplasty and implant arthroplasty for patients with CMC1 osteoarthritis are both associated with substantial sick leave time, indicating the impact of surgery on return to work. There were no differences in sick leave by sex or age.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations: A Long-Term Follow-up

BACKGROUND

The long-term effect of distal radial fracture malunion on activity limitations is unknown. Between 2001 and 2002, we conducted a prospective cohort study of all patients with distal radial fracture treated with casting or percutaneous fixation in northeast Scania in Sweden. In that original study, the patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at baseline and at 2 years. We performed a long-term follow-up study of patients who were 18 to 65 years of age at the time of the fracture to investigate the association between fracture malunion and activity limitations.

METHODS

In this long-term follow-up, patients who had participated in the original study completed the DASH questionnaire and a visual analog scale (VAS) for pain and for satisfaction (scored, 0 [best] to 100) and underwent radiographic and physical examinations at 12 to 14 years after the fracture. We defined malunion as dorsal angulation of ≥10°, ulnar variance of ≥3 mm, and/or radial inclination of ≤15°. We also assessed the presence of radiocarpal osteoarthritis and ulnar styloid nonunion. The primary outcome was the change in DASH score from baseline. Secondary outcomes were DASH, pain, and satisfaction scores, wrist range of motion, and grip strength at the time of the follow-up.

RESULTS

Of 85 eligible patients, 63 (74%) responded to the questionnaires and underwent examinations. Malunion was found in 25 patients, osteoarthritis was found in 38 patients, and styloid nonunion was found in 9 patients. Compared with patients without malunion, those with malunion had significantly worse DASH scores from baseline to 12 to 14 years (p = 0.002); the adjusted mean difference was 11 points (95% confidence interval [CI], 4 to 17 points). Similarly, follow-up scores were significantly worse among patients with malunion; the adjusted mean difference was 14 points (95% CI, 7 to 22 points; p < 0.001) for DASH scores, 10 points (95% CI, 0 to 20 points; p = 0.049) for VAS pain scores, and 26 points (95% CI, 11 to 41 points; p = 0.001) for VAS satisfaction scores. No differences were found in range of motion or grip strength. Osteoarthritis (mostly mild) and styloid nonunion had no significant association (p > 0.05) with DASH scores, VAS pain or satisfaction scores, or grip strength.

CONCLUSIONS

Patients who sustain a distal radial fracture at the age of 18 to 65 years and develop malunion are more likely to have worse long-term outcomes including activity limitations and pain.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prevalence and incidence of doctor-diagnosed Dupuytren's disease: a population-based study

The prevalence and incidence of doctor-diagnosed Dupuytren's disease in the general population is unknown. From the healthcare register for Skåne region (population 1.3 million) in southern Sweden, we identified all residents aged ⩾20 years (on 31 December 2013), who 1998 to 2013 had consulted a doctor and received the diagnosis Dupuytren's disease (International Classification of Diseases 10th Revision code M720). During the 16 years, 7207 current residents (72% men) had been diagnosed with Dupuytren's disease; the prevalence among men was 1.35% and among women 0.5%. Of all people diagnosed, 56% had received treatment (87% fasciectomy). In 2013, the incidence of first-time doctor-diagnosed Dupuytren's disease among men was 14 and among women five per 10,000. The annual incidence among men aged ⩾50 years was 27 per 10,000. Clinically important Dupuytren's disease is common in the general population.

LEVEL OF EVIDENCE

III.

The Spanish version of the Patient-Rated Wrist Evaluation outcome measure: cross-cultural adaptation process, reliability, measurement error and construct validity

BACKGROUND

The Patient-Rated Wrist Evaluation (PRWE) is a widely used measure of patient-reported disability and pain related to wrist disorders. We performed cross-cultural adaptation of the PRWE into Spanish (Spain) and assessed reliability and construct validity in patients with distal radius fracture.

METHODS

Adaptation of the English version to Spanish (Spain) was performed using translation/back translation methodology. The measurement properties of the PRWE-Spanish were assessed in a sample of 40 consecutive patients (31 women), mean age 58 (SD 19) years, with extra-articular distal radius fractures treated with closed reduction and cast. The patients completed the PRWE-Spanish and the standard Spanish versions of the 11-item Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EQ-5D questionnaires at baseline (health status before fracture) and at 8, 9, 12, and 13 weeks after treatment. Internal-consistency reliability was assessed with the Cronbach alpha coefficient and test-retest reliability with the intraclass correlation coefficient (ICC) comparing responses at 8 and 9 weeks and responses at 12 and 13 weeks. Cross-sectional precision was analyzed with the Standard Error of the Measurement (SEM). Longitudinal precision for test-retest reliability coefficient was analyzed with the Standard Error of the Measurement difference (SEMdiff) and the Minimal Detectable Change at 90% (MDC₉₀) and 95% (MDC₉₅) confidence levels. For assessing construct validity we hypothesized that the PRWE-Spanish (lower score indicates less disability and pain) would have strong positive correlation with the QuickDASH (lower score indicates less disability) and moderate negative correlation with the EQ-5D Index (higher score indicates better health); Spearman correlation coefficient (r) was used.

RESULTS

For the PRWE total score, Cronbach alpha was 0.98 (SEM = 2.67) at baseline and 0.96 (SEM = 4.37) at 8 weeks. For test-retest reliability ICC was 0.94 (8 and 9 weeks) and 0.96 (12 and 13 weeks) with SEMdiff 7.61 and 6.18 and MDC₉₅ 13.74 and 12.11, respectively. The PRWE-Spanish scores had strong positive correlation with the QuickDASH scores at baseline (r = 0.71) and at 8 weeks (r = 0.79) and moderate negative correlation with the EQ-5D Index (r = -0.44 and r = -0.40, respectively).

CONCLUSIONS

The PRWE-Spanish showed high internal-consistency and test-retest reliability and good construct validity in patients with distal radius fracture.

Collagenase injections for Dupuytren's disease: prospective cohort study assessing 2-year treatment effect durability

OBJECTIVES

To assess 2-year durability of joint contracture correction following collagenase injections for Dupuytren's disease.

DESIGN

Prospective cohort study.

SETTING

Orthopaedic Department in Sweden.

PARTICIPANTS

Patients with palpable Dupuytren's cord and active extension deficit (AED) ≥30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. A surgeon injected 0.80 mg collagenase into multiple cord parts and performed finger manipulation under local anaesthesia after 24-48 hours. A hand therapist measured joint contracture before and 5 weeks after injection in all treated patients. Of 57 consecutive patients (59 hands), 48 patients (50 hands) were examined by a hand therapist 24-35 months (mean 26) after injection. Five of the patients had received a second injection in the same finger within 6 months of the first injection.

OUTCOME MEASURES

Primary outcome was proportion of treated joints with ≥20° worsening in AED from 5 weeks to 2 years.

RESULTS

Between the 5-week and the 2-year measurements, AED had worsened by ≥20° in seven MCP and seven PIP joints (28% of the treated hands; all had received a single injection). Mean AED for the MCP joints was 54° before injection, 6° at 5 weeks and 9° at 2 years and for the PIP joints 30°, 13° and 16°, respectively. For joints with ≥10° contracture at baseline, mean (95 % CI) baseline to 2 years AED improvement was for MCP 49° (41-54) and for PIP 25° (17-32). No treatment-related adverse events were observed at the 2-year follow-up evaluation.

CONCLUSIONS

Two years after collagenase injections for Dupuytren's disease, improvement was maintained in 72% of the treated hands. Complete contracture correction was seen in more than 80% of the MCP but in less than half of the PIP joints.

Reliability and construct validity of the Spanish version of the 6-item CTS symptoms scale for outcomes assessment in carpal tunnel syndrome

Background

The purpose of this study was to assess the reliability and construct validity of the Spanish version of the 6-item carpal tunnel syndrome (CTS) symptoms scale (CTS-6).

Methods

In this cross-sectional study 40 patients diagnosed with CTS based on clinical and neurophysiologic criteria, completed the standard Spanish versions of the CTS-6 and the disabilities of the arm, shoulder and hand (QuickDASH) scales on two occasions with a 1-week interval. Internal-consistency reliability was assessed with the Cronbach alpha coefficient and test-retest reliability with the intraclass correlation coefficient, two way random effect model and absolute agreement definition (ICC_2,1). Cross-sectional precision was analyzed with the Standard Error of the Measurement (SEM). Longitudinal precision for test-retest reliability coefficient was assessed with the Standard Error of the Measurement difference (SEMdiff) and the Minimal Detectable Change at 95 % confidence level (MDC₉₅). For assessing construct validity it was hypothesized that the CTS-6 would have a strong positive correlation with the QuickDASH, analyzed with the Pearson correlation coefficient (r).

Results

The standard Spanish version of the CTS-6 presented a Cronbach alpha of 0.81 with a SEM of 0.3. Test-retest reliability showed an ICC of 0.85 with a SRMdiff of 0.36 and a MDC₉₅ of 0.7. The correlation between CTS-6 and the QuickDASH was concordant with the a priori formulated construct hypothesis (r 0.69)

Conclusions

The standard Spanish version of the 6-item CTS symptoms scale showed good internal consistency, test-retest reliability and construct validity for outcomes assessment in CTS. The CTS-6 will be useful to clinicians and researchers in Spanish speaking parts of the world. The use of standardized outcome measures across countries also will facilitate comparison of research results in carpal tunnel syndrome.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0963-5) contains supplementary material, which is available to authorized users.

Cast-treated distal radius fractures: a prospective cohort study of radiological outcomes and their association with impaired calcaneal bone mineral density

INTRODUCTION

We hypothesized that treating distal radius fractures with cast only or closed reduction and cast is associated with high malunion risk and that the risk is higher in patients with low bone mineral density (BMD).

MATERIALS AND METHODS

We prospectively studied 130 patients aged 40 years or older with distal radius fractures treated with cast only (87 patients) or closed reduction and cast (43 patients). Radiographs were obtained before treatment, after reduction (in the closed reduction group), and at 1 year. We measured calcaneal BMD with DXA scanner and calculated T scores. We calculated radiological changes from baseline (initial radiographs in cast only and post-reduction radiographs in closed reduction patients) to 1 year. We assessed the relationship between BMD status (normal, osteopenia or osteoporosis) and baseline-to-1-year worsening in volar tilt, ulnar variance, and radial inclination with analysis of covariance adjusting for baseline radiological values. We used receiver operating characteristic (ROC) analysis to determine the ability of T scores to distinguish patients with severe malunion (dorsal tilt >25° and/or ulnar variance ≥5 mm) from those with less severe or no malunion.

RESULTS

In both treatment groups, baseline radiological variables had deteriorated at 1 year, more in the closed reduction group. Compared to patients with normal BMD, those with osteoporosis had significantly greater worsening in volar tilt and radial inclination but did not differ in ulnar variance worsening. Severe malunion was found in 34 fractures (26 %, 15 in cast only group); T scores had a modest ability in distinguishing severe malunion (area under ROC curve 0.67, 95 % CI 0.56-0.78, p = 0.003).

CONCLUSIONS

Closed reduction and cast is not an effective treatment for distal radius fractures if radiological graphic outcomes are considered. There is a higher risk of malunion involving dorsal and radial tilt in patients with osteoporosis. Calcaneal BMD measurement may have some benefit in predicting the risk of severe malunion.

Collagenase treatment of Dupuytren's contracture using a modified injection method: a prospective cohort study of skin tears in 164 hands, including short-term outcome

BACKGROUND AND PURPOSE

Treatment of Dupuytren's contracture (DC) with collagenase Clostridium histolyticum (CCH) consists of injection followed by finger manipulation. We used a modified method, injecting a higher dose than recommended on the label into several parts of the cord, which allows treatment of multiple joint contractures in 1 session and may increase efficacy. We studied the occurrence of skin tears and short-term outcome with this procedure.

PATIENTS AND METHODS

We studied 164 consecutive hands with DC, palpable cord, and extension deficit of ≥ 20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint (mean patient age 70 years, 82% men). A hand surgeon injected all the content of 1 CCH vial (approximately 0.80 mg) into multiple spots in the cord and performed finger extension under local anesthesia after 1 or 2 days. A nurse recorded skin tears on a diagram and conducted a standard telephone follow-up within 4 weeks. A hand therapist measured joint contracture before injection and at a median of 23 (IQR: 7-34) days after finger extension.

RESULTS

A skin tear occurred in 66 hands (40%). The largest diameter of the tear was ≤ 5 mm in 30 hands and > 10 mm in 14 hands. Hands with skin tear had greater mean pretreatment MCP extension deficit than those without tear: 59º (SD 26) as opposed to 32º (SD 23). Skin tear occurred in 21 of 24 hands with MCP contracture of ≥ 75º. All tears healed with open-wound treatment. No infections occurred. Mean improvement in total (MCP + PIP) extension deficit was 55º (SD 28).

INTERPRETATION

Skin tears occurred in 40% of hands treated with collagenase injections, but only a fifth of them were larger than 1 cm. Tears were more likely in hands with severe MCP joint contracture. All tears healed without complications. Short-term contracture reduction was good.

Sickness absence from work among persons with new physician-diagnosed carpal tunnel syndrome: a population-based matched-cohort study

Background

Carpal tunnel syndrome is common among employed persons. Data on sickness absence from work in relation to carpal tunnel syndrome have been usually based on self-report and derived from clinical or occupational populations. We aimed to determine sickness absence among persons with physician-diagnosed carpal tunnel syndrome as compared to the general population.

Methods

In Skåne region in Sweden we identified all subjects, aged 17–57 years, with new physician-made diagnosis of carpal tunnel syndrome during 5 years (2004–2008). For each subject we randomly sampled, from the general population, 4 matched reference subjects without carpal tunnel syndrome; the two cohorts comprised 5456 and 21,667 subjects, respectively (73% women; mean age 43 years). We retrieved social insurance register data on all sickness absence periods longer than 2 weeks from 12 months before to 24 months after diagnosis. Of those with carpal tunnel syndrome 2111 women (53%) and 710 men (48%) underwent surgery within 24 months of diagnosis. We compared all-cause sickness absence and analyzed sickness absence in conjunction with diagnosis and surgery.

Results

Mean number of all-cause sickness absence days per each 30-day period from 12 months before to 24 months after diagnosis was significantly higher in the carpal tunnel syndrome than in the reference cohort. A new sickness absence period longer than 2 weeks in conjunction with diagnosis was recorded in 12% of the women (n = 492) and 11% of the men (n = 170) and with surgery in 53% (n = 1121) and 58% (n = 408) of the surgically treated, respectively; median duration in conjunction with surgery was 35 days (IQR 27–45) for women and 41 days (IQR 28–50) for men.

Conclusions

Persons with physician-diagnosed carpal tunnel syndrome have substantially more sickness absence from work than age and sex-matched persons from the general population from1 year before to 2 years after diagnosis. Gender differences were small.

Intervention randomized controlled trials involving wrist and shoulder arthroscopy: a systematic review

Background

Although arthroscopy of upper extremity joints was initially a diagnostic tool, it is increasingly used for therapeutic interventions. Randomized controlled trials (RCTs) are considered the gold standard for assessing treatment efficacy. We aimed to review the literature for intervention RCTs involving wrist and shoulder arthroscopy.

Methods

We performed a systematic review for RCTs in which at least one arm was an intervention performed through wrist arthroscopy or shoulder arthroscopy. PubMed and Cochrane Library databases were searched up to December 2012. Two researchers reviewed each article and recorded the condition treated, randomization method, number of randomized participants, time of randomization, outcomes measures, blinding, and description of dropouts and withdrawals. We used the modified Jadad scale that considers the randomization method, blinding, and dropouts/withdrawals; score 0 (lowest quality) to 5 (highest quality). The scores for the wrist and shoulder RCTs were compared with the Mann–Whitney test.

Results

The first references to both wrist and shoulder arthroscopy appeared in the late 1970s. The search found 4 wrist arthroscopy intervention RCTs (Kienböck’s disease, dorsal wrist ganglia, volar wrist ganglia, and distal radius fracture; first 3 compared arthroscopic with open surgery). The median number of participants was 45. The search found 50 shoulder arthroscopy intervention RCTs (rotator cuff tears 22, instability 14, impingement 9, and other conditions 5). Of these, 31 compared different arthroscopic treatments, 12 compared arthroscopic with open treatment, and 7 compared arthroscopic with nonoperative treatment. The median number of participants was 60. The median modified Jadad score for the wrist RCTs was 0.5 (range 0–1) and for the shoulder RCTs 3.0 (range 0–5) (p = 0.012).

Conclusion

Despite the increasing use of wrist arthroscopy in the treatment of various wrist disorders the efficacy of arthroscopically performed wrist interventions has been studied in only 4 randomized studies compared to 50 randomized studies of significantly higher quality assessing interventions performed through shoulder arthroscopy.

Prevalence of doctor-diagnosed thumb carpometacarpal joint osteoarthritis: an analysis of Swedish health care

OBJECTIVE

While the prevalence of radiographic thumb carpometacarpal (CMC1) osteoarthritis (OA) is well-described, little is known about clinically symptomatic disease presenting to physicians for care. We sought to determine the prevalence of doctor-diagnosed CMC1 OA.

METHODS

Using health care data from Skåne in southern Sweden (population 1.24 million), we identified all adults ages >20 years who consulted a physician at least once and received a diagnosis for CMC1 OA (International Classification of Diseases, Tenth Revision, code M18). Data from the 15-year period 1998–2012 were analyzed. Using cross-referencing with the Swedish population register to exclude subjects who were deceased or had relocated, we obtained point estimates of the proportion of the population consulting for CMC1 OA.

RESULTS

The prevalence of doctor-diagnosed CMC1 OA in adults was estimated at 1.4% (2.2% in women and 0.62% in men). The mean±SD age in the prevalent CMC1 cohort (n=11,111) was 67.7±11.4 years; 78.5% of diagnoses were in women. Prevalence peaked in women ages 70–74 years with an estimate of 5.3% and in men ages 80–84 years with an estimate of 1.7%. Age at initial diagnosis also differed, with women presenting between ages 60–69 years and men presenting between ages 70–79 years.

CONCLUSION

The clinically important prevalence of CMC1 OA is 3 to 4 times higher in women than men. By the end of2012, more than 1 in 20 elderly women had consulted a physician for CMC1 OA over the last 15 years. The high prevalence of this subset of hand OA is a concern in an aging population.

A simple visual analog scale for pain is as responsive as the WOMAC, the SF-36, and the EQ-5D in measuring outcomes of revision hip arthroplasty

BACKGROUND AND PURPOSE

Little is known about the comparative performance of patient-reported outcome measures in revision hip arthroplasty. We compared the performance of the WOMAC, the SF-36, the EQ-5D, and a pain-related visual analog scale (VAS) in revision hip arthroplasty.

METHODS

45 patients with aseptic prosthetic loosening following primary hip arthroplasty completed the WOMAC, the SF-36, the EQ-5D, and a VAS for pain-at baseline and 2 years after revision. Responsiveness of the measures was compared with the effect size (with ≥ 0.8 being considered large). Agreement between scales measuring the same type of outcome (pain or physical function) was assessed with the Bland-Altman method.

RESULTS

The mean preoperative scores for the pain and physical function scales of WOMAC and SF-36, EQ-5D index, and VAS for pain improved statistically significantly 2 years after revision. The effect size for the WOMAC pain was 1.7, that for SF-36 pain was 1.4, that for WOMAC physical function was 1.6, that for SF-36 physical function was 0.8, and that for EQ-5D index was 1.2. The VAS for pain had an effect size of 2.1, which was larger than that for SF-36 pain and for the EQ-5D index (p ≤ 0.03) but not for WOMAC pain (p = 0.2). The limits of agreement between WOMAC pain, SF-36 pain, and the VAS scale measuring pain-and between the WOMAC and SF-36 scales measuring physical function-were wide. Internal-consistency reliability was high for the WOMAC and SF-36 scales but low for the EQ-5D.

INTERPRETATION

In patients with first-time revision hip arthroplasty done for aseptic loosening, the WOMAC, SF-36, and EQ-5D showed high responsiveness in measuring patient-reported outcomes and the simple VAS for pain performed equally well.

Costs for collagenase injections compared with fasciectomy in the treatment of Dupuytren's contracture: a retrospective cohort study

OBJECTIVES

To compare collagenase injections and surgery (fasciectomy) for Dupuytren's contracture (DC) regarding actual total direct treatment costs and short-term outcomes.

DESIGN

Retrospective cohort study.

SETTING

Orthopaedic department of a regional hospital in Sweden.

PARTICIPANTS

Patients aged 65 years or older with previously untreated DC of 30° or greater in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joints of the small, ring or middle finger. The collagenase group comprised 16 consecutive patients treated during the first 6 months following the introduction of collagenase as treatment for DC at the study centre. The controls were 16 patients randomly selected among those operated on with fasciectomy at the same centre during the preceding 3 years.

INTERVENTIONS

Treatment with collagenase was given during two standard outpatient clinic visits (injection of 0.9 mg, distributed at multiple sites in a palpable cord, and next-day finger extension under local anaesthesia) followed by night-time splinting. Fasciectomy was carried out in the operating room (day surgery) under general or regional anaesthesia using standard technique, followed by therapy and splinting.

PRIMARY AND SECONDARY OUTCOME MEASURES

Actual total direct costs (salaries of all medical personnel involved in care, medications, materials and other relevant costs), and total MCP and PIP extension deficit (degrees) measured by hand therapists at 6-12 weeks after the treatment.

RESULTS

Collagenase injection required fewer hospital outpatient visits to a therapist and nurse than fasciectomy. Total treatment cost for collagenase injection was US$1418.04 and for fasciectomy US$2102.56. The post-treatment median (IQR) total extension deficit was 10 (0-30) for the collagenase group and 10 (0-34) for the fasciectomy group.

CONCLUSIONS

Treatment of DC with one collagenase injection costs 33% less than fasciectomy with equivalent efficacy at 6 weeks regarding reduction in contracture.

Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial

BACKGROUND

Steroid injections are used in idiopathic carpal tunnel syndrome (CTS), but evidence of efficacy beyond 1 month is lacking.

OBJECTIVE

To assess the efficacy of local methylprednisolone injections in CTS.

DESIGN

Randomized, placebo-controlled trial. (ClinicalTrials.gov: NCT00806871).

SETTING

Regional referral orthopedic department in Sweden.

PATIENTS

Patients aged 18 to 70 years with CTS but no previous steroid injections.

INTERVENTION

Three groups (37 patients each) received 80 mg of methylprednisolone, 40 mg of methylprednisolone, or placebo. The patients and treating surgeons were blinded.

MEASUREMENTS

Primary end points were the change in CTS symptom severity scores at 10 weeks (range, 1 to 5) and rate of surgery at 1 year. Three patients had missing 10-week data. All patients had 1-year data.

RESULTS

Improvement in CTS symptom severity scores at 10 weeks was greater in patients who received 80 mg of methylprednisolone and 40 mg of methylprednisolone than in those who received placebo (difference in change from baseline, -0.64 [95% CI, -1.06 to -0.21; P = 0.003] and -0.88 [CI, -1.30 to -0.46; P < 0.001], respectively), but there were no significant differences at 1 year. The 1-year rates of surgery were 73%, 81%, and 92% in the 80-mg methylprednisolone, 40-mg methylprednisolone, and placebo groups, respectively. Compared with patients who received placebo, those who received 80 mg of methylprednisolone were less likely to have surgery (odds ratio, 0.24 [CI, 0.06 to 0.95]; P = 0.042). With time to surgery incorporated, both the 80- and 40-mg methylprednisolone groups had lower likelihood of surgery (hazard ratio, 0.46 [CI, 0.27 to 0.77; P = 0.003] and 0.57 [CI, 0.35 to 0.94; P = 0.026], respectively).

LIMITATION

The study was conducted at 1 center, and wrist splinting had previously failed for all patients.

CONCLUSION

Methylprednisolone injections for CTS have significant benefits in relieving symptoms at 10 weeks and reducing the rate of surgery 1 year after treatment, but 3 out of 4 patients had surgery within 1 year.

PRIMARY FUNDING SOURCE

Region of Scania Research and Development Foundation and Hässleholm Hospital Organization.

Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT

BACKGROUND

Little is known about the influence of compliance with neuromuscular training (NMT) on the knee injury rate in football.

AIM

To evaluate team and player compliance with an NMT programme in adolescent female football and to study the association between compliance and acute knee injury rates.

METHODS

Prospective cohort study based on a cluster randomised controlled trial on players aged 12-17 years with 184 intervention teams (2471 players) and 157 control teams (2085 players). Exposure and acute time loss knee injuries were recorded. Team and player compliance was recorded by the coaches on a player attendance form. The intervention group was divided into tertiles of compliance. Injury rates were compared by calculating rate ratios (RRs) and 95% CIs using exact Poisson tests with the low-compliance tertile as reference. Seasonal compliance trends were analysed using linear regression.

RESULTS

Players in the high-compliance tertile had an 88% reduction in the anterior cruciate ligament (ACL) injury rate (RR 0.12, 95% CI 0.01 to 0.85), whereas the rate in the control group players was not significantly different from those in the low-compliance tertile (RR 0.77, 95% CI 0.27 to 2.21). A significant deterioration occurred in team (b=-3.0% per month, 95% CI -5.2 to -0.8) and player (b=-5.0% per month, 95% CI -7.1 to -2.9) compliance over the season.

CONCLUSIONS

Players with high compliance with the NMT programme had significantly reduced ACL injury rate compared with players with low compliance. Significant deterioration in team and player compliance occurred over the season.

The effect of a biphasic injectable bone substitute on the interface strength in a rabbit knee prosthesis model

Background

In joint prosthetic surgery, various methods are used to provide implant stability. We used an injectable bone substitute, composed of calcium sulfate/hydroxyapatite, as bone defect filler to stabilize a tibia prosthesis in an experimental rabbit model. The aim of the study was to investigate and compare the stability of prosthetic fixation with and without the use of an injectable bone substitute.

Methods

Sixteen rabbits were used and the tibia prostheses were implanted bilaterally, one side with the prosthesis alone and the other side with the prosthesis and calcium sulfate/hydroxyapatite (Cerament™). The rabbits were randomly divided into two groups and euthanized after 6 and 12 weeks, respectively. The prosthesis was extracted measuring the pull-out force in an Instron tester, and the bone surrounding the former prosthesis site was analyzed by histology, histomorphometry, and micro-computed tomography.

Results

At 6 weeks no difference in maximum pull-out force was found between the prostheses fixed with or without Cerament™. At 12 weeks the maximum pull-out force for the prostheses with Cerament™ was significantly higher than that for the prostheses without Cerament™ (p = 0.04). The maximum pull-out force at 12 weeks was significantly higher than that at 6 weeks for the prostheses fixed with Cerament™ (p = 0.03) but not for the prostheses without.

Conclusion

We conclude that early prosthesis-bone interface strength is not influenced by a bone substitute. However, during remodeling, the bone substitute might provide improved mechanical support for the prosthesis. The results support further studies of the use of injectable calcium sulfate/hydroxyapatite in fixation of prosthetic joint implants.

Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of neuromuscular training in reducing the rate of acute knee injury in adolescent female football players.

DESIGN

Stratified cluster randomised controlled trial with clubs as the unit of randomisation.

SETTING

230 Swedish football clubs (121 in the intervention group, 109 in the control group) were followed for one season (2009, seven months).

PARTICIPANTS

4564 players aged 12-17 years (2479 in the intervention group, 2085 in the control group) completed the study.

INTERVENTION

15 minute neuromuscular warm-up programme (targeting core stability, balance, and proper knee alignment) to be carried out twice a week throughout the season.

MAIN OUTCOME MEASURES

The primary outcome was rate of anterior cruciate ligament injury; secondary outcomes were rates of severe knee injury (>4 weeks' absence) and any acute knee injury.

RESULTS

Seven players (0.28%) in the intervention group, and 14 (0.67%) in the control group had an anterior cruciate ligament injury. By Cox regression analysis according to intention to treat, a 64% reduction in the rate of anterior cruciate ligament injury was seen in the intervention group (rate ratio 0.36, 95% confidence interval 0.15 to 0.85). The absolute rate difference was -0.07 (95% confidence interval -0.13 to 0.001) per 1000 playing hours in favour of the intervention group. No significant rate reductions were seen for secondary outcomes.

CONCLUSIONS

A neuromuscular warm-up programme significantly reduced the rate of anterior cruciate ligament injury in adolescent female football players. However, the absolute rate difference did not reach statistical significance, possibly owing to the small number of events.

TRIAL REGISTRATION

Clinical trials NCT00894595.

Bleeding and first-year mortality following hip fracture surgery and preoperative use of low-dose acetylsalicylic acid: an observational cohort study

Background

Hip fracture is associated with high mortality. Cardiovascular disease and other comorbidities requiring long-term anticoagulant medication are common in these mostly elderly patients. The objective of our observational cohort study of patients undergoing surgery for hip fracture was to study the association between preoperative use of low-dose acetylsalicylic acid (LdAA) and intraoperative blood loss, blood transfusion and first-year all-cause mortality.

Methods

An observational cohort study was conducted on patients with hip fracture (cervical requiring hemiarthroplasty or pertrochanteric or subtrochanteric requiring internal fixation) participating in a randomized trial that found lack of efficacy of a compression bandage in reducing postoperative bleeding. The participants were 255 patients (≥50 years) of whom 118 (46%) were using LdAA (defined as ≤320 mg daily) preoperatively. Bleeding variables in patients with and without LdAA treatment at time of fracture were measured and blood transfusions given were compared using logistic regression. The association between first-year mortality and preoperative use of LdAA was analyzed with Cox regression adjusting for age, sex, type of fracture, baseline renal dysfunction and baseline cardiovascular and/or cerebrovascular disease.

Results

Blood transfusions were given postoperatively to 74 (62.7%) LdAA-treated and 76 (54%) non-treated patients; the adjusted odds ratio was 1.8 (95% CI 1.04 to 3.3). First-year mortality was significantly higher in LdAA-treated patients; the adjusted hazard ratio (HR) was 2.35 (95% CI 1.23 to 4.49). The mortality was also higher with baseline cardiovascular and/or cerebrovascular disease, adjusted HR 2.78 (95% CI 1.31 to 5.88). Patients treated with LdAA preoperatively were significantly more likely to suffer thromboembolic events (5.7% vs. 0.7%, P = 0.03).

Conclusions

In patients with hip fracture (cervical treated with hemiarthroplasty or pertrochanteric or subtrochanteric treated with internal fixation) preoperative use of low-dose acetylsalicylic acid was associated with significantly increased need for postoperative blood transfusions and significantly higher all-cause mortality during one year after surgery.

Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture

Fractures of the distal radius in postmenopausal women may cause prolonged pain and disability, but little is known about their natural course beyond the first year. In this study, women of 50-75 years of age, initially treated with cast or external fixation, were examined 1 year after distal radial fracture and then re-evaluated after a mean of 3 (range, 2-4) years. The evaluation included pain, disability (DASH) scores, grip strength and range of motion. In the 49 participating women pain scores, grip strength and range of motion improved significantly, although the mean improvement was moderate or small. In a subgroup of 13 patients with moderate or severe malunion, the 1 year DASH score was significantly worse than in the remaining patients but improved significantly together with grip strength and range of motion. After fractures of the distal radius, pain, grip strength and range of motion continued to improve beyond 1 year, up to 2-4 years. Patients with malunion had more disability at 1 year but showed significant improvement at 2-4 years.

First-time revision using impacted morsellised allograft bone with a cemented Exeter stem

Previously, radiostereometric analysis following hip revision performed using impacted morsellised allograft bone and a cemented Exeter stem has shown continuous subsidence of the stem for up to five years. It is not known whether the subsidence continues thereafter. In our study, 17 of 25 consecutive osteo-arthritic patients with aseptically loose stems who underwent first-time revision using impacted morsellised allograft bone and a cemented Exeter stem were followed by yearly radiostereometric examinations for nine years. The mean subsidence at six weeks was 1.1 mm (0.1 to 2.3), from six weeks to one year 1.3 mm (0 to 2.6), from one to five years 0.7 mm (0 to 2.0), and from five to nine years 0.7 mm (0.1 to 3.1). That from six weeks to nine years was 2.7 mm (0 to 6.4) (95% confidence interval 2.0 to 3.5). The Charnley pain score significantly improved after revision, and was maintained at nine years, but walking ability deteriorated slightly as follow-up extended. Of the eight patients who were not followed for nine years, two had early subsidence exceeding 11 mm.

Our findings show that in osteo-arthritic patients who undergo revision for aseptic loosening of the stem using impacted morsellised allograft bone and a cemented Exeter stem, migration of the stem continues over nine years at a slower rate after the first year, but without clinical deterioration or radiological loosening.

The six-item CTS symptoms scale and palmar pain scale in carpal tunnel syndrome

PURPOSE

To evaluate measurement properties of 2 brief outcome measures for carpal tunnel syndrome: the 6-item carpal tunnel symptoms scale (CTS-6) and the 2-item palmar pain scale (measuring severity of pain in the scar/palm and pain-related activity limitation). Our hypothesis was that the CTS-6 is responsive to change in symptoms after surgical treatment and the pain scale is a valid measure of surgery-related pain.

METHODS

This study followed 447 consecutive patients with carpal tunnel syndrome undergoing open release; 308 completed the CTS-6 and the Disabilities of the Arm, Shoulder, and Hand-short form (QuickDASH) before surgery and the CTS-6, QuickDASH, palmar pain scale, and 2 items regarding global rating of change and treatment satisfaction once after surgery (range, 2-13 mo). The mean scores for the CTS-6 (range, 1-5) and QuickDASH and palmar pain scales (range, 0-100) were calculated (lower score is better). Responsiveness was assessed with the effect size (ES). We estimated the CTS-6 score change indicating minimal clinically important difference based on scores for patients with moderate self-rated improvement.

RESULTS

The mean baseline CTS-6 score was 3.16, mean change after surgery was -1.54 (95% confidence interval [CI], -1.65 to -1.44), and ES was 2.0. The ES was large (2.5) in patients with the largest self-rated improvement and decreased with lower self-rated improvement. A score change of 0.9 indicated a minimal clinically important difference. The mean change in QuickDASH score was -25.4 (95% CI, -27.8 to -23.0), and ES was 1.25. The mean palmar pain score for patients with time since surgery of less than 3 months was 38.5, at 3 to 6 months was 35.4, and greater than 6 months was 19.5; the mean score was significantly higher among patients with lower satisfaction.

CONCLUSIONS

The CTS-6 is highly responsive to change in symptoms, and the palmar pain scale is a valid measure of surgery-related pain. These brief scales can be appropriate primary and secondary outcomes measures in clinical trials studying carpal tunnel syndrome.

Older adults' medication use 6 months before and after hip fracture: a population-based cohort study

OBJECTIVES

To study changes in use of fall-risk increasing drugs (FRIDs) and bone density-related medication in participants with hip fracture before and after the fracture and to analyze differences between five healthcare districts.

DESIGN

Population-based cohort study.

SETTING

Data retrieved from two national databases

PARTICIPANTS

All 2,043 people with hip fracture aged 60 and older in a Swedish county in 2006.

MEASUREMENTS

Changes in FRIDs and bone-active medications prescribed within 6 months before and 6 months after hip fracture and differences between health care districts.

RESULTS

Before hip fracture, 1,308 participants (67.7%) received any FRIDs or combinations; after fracture, 97.7% were treated. Polypharmacy (≥5 drugs) increased 39.3%, excessive polypharmacy (≥10 drugs) increased 36.4%, and use of three or more psychotropic drugs increased 8.6%. After fracture, the use of all analyzed drugs including psychotropic, cardiovascular, opioid, and anticholinergic drugs increased significantly (P<.001). Treatment with calcium and vitamin D increased from 9% before to 27.7% after and with bisphosphonates from 3.5% to 7.6%. Variations in postfracture prescribing between the five health care districts were observed regarding opioids (range 85-64%), bisphosphonates (range 20-4%), and calcium and vitamin D (72-13%) (P<.001, for all comparisons).

CONCLUSION

Two-thirds of participants with hip fracture were prescribed FRIDs before fracture, and the number increased significantly after fracture. Significant variations between healthcare districts in treating osteoporosis and pain were evident; geriatric support could be a contributing factor to the greater treatment in two districts.