Outcomes of Surgical Management of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Bayesian Perspective.

PURPOSE: To provide a summary of the relevant evidence on outcomes of transaxillary first rib excision (TAFRE), supraclavicular first rib excision with scalenectomy (SCFRE), and supraclavicular release leaving the first rib intact (SCR) for patients with neurogenic thoracic outlet syndrome (TOS), and interpret the treatment effects from a Bayesian perspective. METHODS: A systematic literature search and review were performed. Random-effects meta-analyses were conducted to estimate success rate and complete relief rate of each procedure. The probabilities of specified success rates and complete relief rates were calculated using a Bayesian method. Sensitivity analyses for TOS type, neck trauma, and cervical rib were performed. Complications of each procedure were also reviewed. RESULTS: Data were extracted from 17 studies of TAFRE, 9 of SCFRE, and 14 of SCR to conduct the meta-analyses. The pooled success rate and complete relief rate were 0.76 (95% confidence interval [95% CI)], 0.65-0.85) and 0.53 (95% CI, 0.38-0.68) for TAFRE, 0.77 (95% CI, 0.68-0.85) and 0.57 (95% CI, 0.41-0.72) for SCFRE, and 0.85 (95% CI, 0.76-0.92) and 0.61 (95% CI, 0.35-0.84) for SCR, respectively. The probabilities of success rate greater than 70% were 90%, 87%, and 99% for TAFRE, SCFRE, and SCR, respectively. If the success rate of 80% or greater was considered, the probabilities were 34%, 31%, and 91%, respectively. The probabilities of complete relief rate of 50% or greater were 67%, 71%, and 69% for TAFRE, SCFRE, and SCR, respectively. Sensitivity analyses showed similar results. The complication rates for TAFRE, SCFRE, and SCR were, respectively, 22.5%, 25.9%, and 12.6%. CONCLUSIONS: The SCR has a high probability of success rate greater than 80%; both TAFRE and SCFRE have high probabilities of a success rate greater than 70% but only low probabilities of success rate greater than 80%. The TAFRE and SCFRE have more complications than SCR. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis.

UNLABELLED: Imaging protocols for suspected scaphoid fractures among investigators and hospitals are markedly inconsistent. We performed a systematic review and meta-analysis to assess and compare the diagnostic performance of bone scintigraphy, MRI, and CT for diagnosing suspected scaphoid fractures. Twenty-six studies were included. Sensitivity, specificity, and diagnostic odds ratio were pooled separately and summary receiver operating characteristic curves were fitted for each modality. Meta-regression analyses were performed to compare these modalities. We obtained likelihood ratios derived from the pooled sensitivity and specificity and, using Bayes' theorem, calculated the posttest probability by application of the tests. The pooled sensitivity, specificity, natural logarithm of the diagnostic odds ratio, and the positive and negative likelihood ratios were, respectively, 97%, 89%, 4.78, 8.82, and 0.03 for bone scintigraphy; 96%, 99%, 6.60, 96, and 0.04 for MRI; and 93%, 99%, 6.11, 93, and 0.07 for CT. Bone scintigraphy and MRI have equally high sensitivity and high diagnostic value for excluding scaphoid fracture; however, MRI is more specific and better for confirming scaphoid fracture. We believe additional studies are needed to assess diagnostic performance of CT, especially paired design studies or randomized controlled trials to compare CT with MRI or bone scintigraphy. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Cost-Effectiveness of Diagnostic Strategies for Suspected Scaphoid Fractures.

OBJECTIVES: The aim of this study was to assess the cost effectiveness of multiple competing diagnostic strategies for suspected scaphoid fractures. METHODS: With published data, the authors created a decision-tree model simulating the diagnosis of suspected scaphoid fractures. Clinical outcomes, costs, and cost effectiveness of immediate computed tomography (CT), day 3 magnetic resonance imaging (MRI), day 3 bone scan, week 2 radiographs alone, week 2 radiographs-CT, week 2 radiographs-MRI, week 2 radiographs-bone scan, and immediate MRI were evaluated. The primary clinical outcome was the detection of scaphoid fractures. The authors adopted societal perspective, including both the costs of healthcare and the cost of lost productivity. The incremental cost-effectiveness ratio (ICER), which expresses the incremental cost per incremental scaphoid fracture detected using a strategy, was calculated to compare these diagnostic strategies. Base case analysis, 1-way sensitivity analyses, and "worst case scenario" and "best case scenario" sensitivity analyses were performed. RESULTS: In the base case, the average cost per scaphoid fracture detected with immediate CT was $2553. The ICER of immediate MRI and day 3 MRI compared with immediate CT was $7483 and $32,000 per scaphoid fracture detected, respectively. The ICER of week 2 radiographs-MRI was around $170,000. Day 3 bone scan, week 2 radiographs alone, week 2 radiographs-CT, and week 2 radiographs-bone scan strategy were dominated or extendedly dominated by MRI strategies. The results were generally robust in multiple sensitivity analyses. CONCLUSIONS: Immediate CT and MRI were the most cost-effective strategies for diagnosing suspected scaphoid fractures. LEVEL OF EVIDENCE: Economic and Decision Analyses Level II. See Instructions for Authors for a complete description of levels of evidence.

Treatment of acute scaphoid fractures: systematic review and meta-analysis.

Whether operative treatment is a better option than nonoperative treatment for acute nondisplaced or minimally displaced fractures of the scaphoid is controversial. The type of cast that should be used for nonoperative treatment is not known. We performed a systematic review and meta-analysis of randomized and quasirandomized trials to evaluate the effect of operative versus nonoperative treatment and the effect of different casting methods for nonoperative treatment of acute scaphoid fractures on nonunion rate, return to work, grip strength, range of wrist motion, complications, patient evaluation, and incidence of osteoarthritis. Two investigators assessed trial quality and extracted data. Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures.