Prospective Clinical Trial Comparing Trapezial Denervation With Trapeziectomy for the Surgical Treatment of Arthritis at the Base of the Thumb.

BACKGROUND: Trapeziectomy is considered to be the "gold standard" procedure for first carpometacarpal joint (first CMCJ) osteoarthritis. First CMCJ denervation offers the potential benefit of a shorter procedure with bone and joint preservation and swift postoperative rehabilitation. This trial aimed to compare functional outcomes, patient satisfaction, quality of life, and cost effectiveness following these treatments. METHODS: This study was a prospective clinical trial commencing December 2005 to November 2013. A range of functional outcomes assessments were used preoperatively at 6 and 12 mo and 5 y after surgery. These included measurements of strength/motion, visual analogue score, Michigan Hand Outcomes and the European Quality of Life-5 Dimensions questionnaires. Data were analyzed using a two-sample t-test and Mann-Whitney test. RESULTS: A total of 45 patients were studied of 55 recruited. Age ranged from 41 to 72 (mean = 59). Thirty-five patients underwent denervation and 10 initially had trapeziectomy. Nine patients were converted to trapeziectomy within an average of 6 to 12 mo. There was no significant difference in the functional outcomes at different points of follow-ups. Similarly, there was no significant difference in the time of return to work or cost effectiveness. Denervation achieved a success rate of just above 70%, whereas no revisions were required for the trapeziectomy group. CONCLUSIONS: There was no difference between the two treatments. First CMCJ denervation does not appear to be superior to trapeziectomy. However, the advantage of rapid rehabilitation makes it more favored by patients but at the expense of 30% reoperation rate. LEVEL OF EVIDENCE: Level II.

A fresh look at preoperative body washing.

National guidelines do not support preoperative body washing to reduce surgical site infections, instead recommending bathing or showering with soap. Yet preoperative body washing continues to be widely used in many hospitals across Europe. This paper suggests that existing trials of preoperative body washing, upon which guidelines are based, are dated and proposes a new investigation of preoperative body washing using modern definitions of surgical site infection with standardised patient follow up, modern surgical techniques and well designed trials. This paper provides a critique of existing guidelines and describes a randomised trial with 60 participants to compare the effect of soap and two antiseptic washing products on colony forming units (CFUs) for up to six hours. Chlorhexidine gluconate and octenidine were significantly more effective than soap in reducing CFUs in the underarm, and chlorhexidine was significantly more effective than soap in reducing CFUs in the groin.

Can a normal range of elbow movement predict a normal elbow x ray?

BACKGROUND: Elbow injuries account for approximately 2-3% of presentations to the emergency department. This is associated not only with a very high rate of x rays but also with a very high rate of "missed fractures" This study examines which components of elbow examination have the best correlation with a normal radiograph. DESIGN SETTING: A district general hospital's emergency department seeing 83,000 new attendances per annum (pa) (approximately 1600 elbow injuries pa). METHODS: After estimating the power before data collection, all patients presenting with elbow injuries were considered for inclusion, and were excluded only if they were unable to follow instructions owing to either reduced conscious levels or mental conditions. A proforma was completed after patient examination, indicating the features of clinical examination, and the results of radiographs if any. The formal report of all radiographs taken was sought from the radiology department. RESULTS: 407 patients were entered into the study, of whom 331 received a radiograph of the elbow. Full extension of the elbow had a specificity of 0.916 (95% confidence interval (CI) 0.863 to 0.969, sensitivity 0.478) for detection of a normal radiograph. An equal range of movement ROM had a specificity of 0.976 (95% CI 0.940 to 0.991, sensitivity 0.211). Subgroup analysis of patients aged < 16 years showed a specificity of equal ROM of 1 (95% CI 0.941 to 1.000) for the detection of a normal x ray. Logistic regression analysis showed that best predictive values were achieved by a combination of full extension, flexion and supination. CONCLUSION: A two-tier clinical rule for management of elbow injury is proposed: (1) Those patients aged < or = 16 years with a ROM equal to the unaffected side may be safely discharged; (2) Those patients with normal extension, flexion and supination do not require emergent elbow radiographs.