Health-related quality of life in patients with conditions affecting the hand: meta-analysis.

BACKGROUND: Health state utility values provide the quality component of quality-adjusted life years and are essential for health economic analyses, such as the National Institute for Health and Care Excellence Technology Appraisal. The aims of this systematic review were to: catalogue utility values for health states experienced by patients with hand conditions; provide pooled utility estimates for common hand conditions; and determine how utilities have been estimated. METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted (registered in PROSPERO, the international prospective register of systematic reviews (CRD42021226098)). Five databases were searched from inception until April 2023 (Embase, MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL)). All studies that reported primary utility values for hand health states in adult patients were eligible for inclusion. Pooled utility estimates were determined across conditions and intervention status using random-effects meta-analysis. RESULTS: A total of 10 254 articles were identified; 57 studies met the full inclusion criteria and reported 363 distinct health state utility values. Health state utility values were estimated using a range of methods; the most common measure was the EQ-5D. Pooled utility estimates for carpal tunnel syndrome and hand osteoarthritis before surgical intervention were 0.69 (95% c.i. 0.66 to 0.73) and 0.63 (95% c.i. 0.60 to 0.67) respectively. CONCLUSION: Pooled utility estimates for patients with untreated carpal tunnel syndrome and hand osteoarthritis are 11% and 18% lower than age-matched population norms respectively. Hand conditions have a significant detrimental impact on health-related quality of life and this study provides catalogued utility values for use in future economic analyses to support the delivery of value-based hand surgery.

Modified Scoring of the QuickDASH Can Achieve Previously-unattained Interval-level Measurement in Dupuytren Disease and Carpal Tunnel Syndrome.

Background: Rasch measurement theory can be used to identify scales within questionnaires and to map responses to more precise continuous scales. The aim of this article was to use RMT to refine the scoring of the QuickDASH in patients with Dupuytren disease and carpal tunnel syndrome (CTS). Methods: Data were collected between 2013 and 2019 from a single center in the UK. Preoperative QuickDASH responses from patients diagnosed with Dupuytren disease and CTS were used. RMT was used to reduce the number of items in the QuickDASH and examine the reliability and validity of each subscale. Results: The preoperative QuickDASH responses of 750 patients with Dupuytren disease and 1916 patients with CTS were used. The median age of participants was 61 years, and 46% were men. Exploratory factor analysis suggested two distinct subscales within the QuickDASH: task items 1-6 and symptom items 9-11. These items were fitted to the Rasch model, and disordered response thresholds were collapsed. In Dupuytren disease, the two worst responses or each item were disordered. After collapsing these options, good Rasch model fit was demonstrated. CTS responses fitted without modification. Item targeting was more appropriate for CTS than Dupuytren disease. Conclusions: This study proposes a modification to the scoring system for the QuickDASH that provides high-quality, continuous, and condition-specific scales for the QuickDASH. The identification of distinct subscales within the QuickDASH can be used to identify distinct improvements in hand function and/or symptoms in previous, current, and future work.

Wide Awake Local Anesthetic No Tourniquet in Hand and Wrist Surgery: Current Concepts, Indications, and Considerations.

Background: Traditionally, the use of a pneumatic arterial tourniquet was requisite for safe and effective surgery of the hand. The use of arterial tourniquets necessitates the use of regional or general anaesthesia. Wide-awake local anaesthetic no tourniquet (WALANT) has emerged as a novel technique to overcome the limitations of tourniquet use in conjunction with regional/general anaesthesia. This review aimed to examine the safety and effectiveness of WALANT and provide guidance for surgeons with limited WALANT experience. Methods: A literature review of MEDLINE was performed up to March 2021 to identify all articles related to the use of WALANT in hand surgery. Any article reporting original data related to the use of WALANT was eligible for inclusion. Results: A total of 101 articles were identified through database searching. Of these, 79 met full inclusion criteria and described the use of WALANT in 19 elective and trauma procedures. Current data suggest that WALANT is safe and effective for use in a range of procedures. Conclusions: WALANT surgery is increasing in popularity as evidenced by the variety of surgical indications reported in the literature. There is limited comparative data on the cost-effectiveness of WALANT compared to conventional methods. Current data suggest that WALANT is safe, better tolerated by patients and associated with direct and indirect cost savings.

Utilization of a 3D Printed Simulation Training Model to Improve Microsurgical Training.

Simulation is integral to the development and maintenance of micro- surgical skills. Several simulation models have been described ranging from bench- top to live animal models. High fidelity models are often burdened by cost and ethical issues limiting widespread implementation. This study aims to determine the feasibility of a microsurgical training platform using the Konjac noodle model. Methods: A prospective cohort study was conducted at our institution. A progressive microsurgical training curriculum was developed. A bespoke three-dimensional printed training platform was produced to enable residents to record training and assessment tasks. Microsurgical skills were blindly assessed before and after completing the training program using the University of Western Ontario Microsurgical Skills Assessment instrument. Results: Plastic surgery residents at various stages of training were recruited (n = 10). A significant improvement in vessel preparation from a pre-training median of 3 (IQR 2 -4) versus a post-training of 4 (IQR 3 -5, P = 0.0035) and suturing with a pre-training median of 3 (IQR 2 -4) versus a post-training of 4 (IQR 3 -5, P = 0.0047) domains of the University of Western Ontario Microsurgical Skills Assessment score was demonstrated after completion of the training program. There was a significant improvement in the global rating score (3 ± 1 versus 5 ± 1, P = 0.0045). Participants felt more confident performing a microsurgical anastomosis following the training program. Conclusion: The use of the Konjac noodle model and video-based assessment using a three-dimensional printed model is an effective teaching tool that improves resident's microsurgical skills.

The Use of Botulinum Toxin in the Management of Hidradenitis Suppurativa: A Systematic Review.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by suppurative infection, sinus tract, and abscess formation. International management guidelines are largely consensus-based. Botulinum toxin (BTX) has been widely used in the treatment of apocrine and eccrine gland disorders, such as hyperhidrosis, although the effectiveness of BTX in the treatment of HS remains unknown. The aim of this systematic review was to understand the published evidence of BTX safety and effectiveness in the management of HS. Methods: We conducted a PRISMA-compliant, prospectively registered (PROSPERO, CRD42021228732), systematic review. We devised bespoke search strategy and applied it to the Cochrane Central Register of Controlled Trials, Medline, Embase, and OpenGrey up until March 2022. We included all clinical studies that reported outcomes following BTX treatment in patients diagnosed with HS (both adult and pediatric). Results: A total of 4658 studies were identified, of which six met full inclusion criteria reporting data on 26 patients. The six identified studies included one randomized control trial, one case series, and four case studies. The one included randomized control trial demonstrated a significant reduction in the Dermatology Life Quality Index score at 3 months following treatment with BTX. Conclusions: The effectiveness and safety of BTX in the treatment of HS remain unknown. This systematic review identified a paucity of high-quality clinical data. Evidence of treatment effectiveness is likely to come from registry-based cohort studies using established core outcome sets in the first instance.

Developing Machine Learning Algorithms to Support Patient-centered, Value-based Carpal Tunnel Decompression Surgery.

Background: Carpal tunnel syndrome (CTS) is extremely common and typically treated with carpal tunnel decompression (CTD). Although generally an effective treatment, up to 25% of patients do not experience meaningful benefit. Given the prevalence, this amounts to considerable morbidity and cost without return. Being able to reliably predict which patients would benefit from CTD preoperatively would support more patient-centered and value-based care. Methods: We used registry data from 1916 consecutive patients undergoing CTD for CTS at a regional hand center between 2010 and 2019. Improvement was defined as change exceeding the respective QuickDASH subscale's minimal important change estimate. Predictors included a range of clinical, demographic and patient-reported variables. Data were split into training (75%) and test (25%) sets. A range of machine learning algorithms was developed using the training data and evaluated with the test data. We also used a machine learning technique called chi-squared automatic interaction detection to develop flowcharts that could help clinicians and patients to understand the chances of a patient improving with surgery. Results: The top performing models predicted functional and symptomatic improvement with accuracies of 0.718 (95% confidence interval 0.660, 0.771) and 0.759 (95% confidence interval 0.708, 0.810), respectively. The chi-squared automatic interaction detection flowcharts could provide valuable clinical insights from as little as two preoperative questions. Conclusions: Patient-reported outcome measures and machine learning can support patient-centered and value-based healthcare. Our algorithms can be used for expectation management and to rationalize treatment risks and costs associated with CTD.

Open tibia/fibula in the elderly: A retrospective cohort study.

The incidence of open tibia/fibula fractures in the elderly is increasing, but current national guidelines focus on the aggressive treatment of high-energy injuries in younger patients. There is conflicting evidence regarding whether older age affects treatment provision and outcomes in open fractures. The aim of this study was to determine if elderly patients are sustaining a different injury to younger patients and how their treatment and outcomes differ. This may have implications for future guidelines and verify their application in the elderly. In this retrospective single centre cohort study (December 2015-July 2018), we compared the injury characteristics, operative management and outcomes of elderly (≥65 years) and younger (18-65 years) patients with open tibia/fibula fractures. An extended cohort examined free flap reconstruction. In total, 157 patients were included. High-energy injuries were commoner in younger patients (88% vs 37%; p<0.001). Most were Gustilo-Anderson IIIb in both age groups. Elderly patients waited longer until debridement (21:19 vs 19:00 h) and had longer inpatient stays (23 vs 15 days). There was no difference in time to antibiotics, operative approach or post-operative complications. Despite the low-energy nature of elderly patients' injuries, the severity of soft tissue insult was equivalent to younger patients with high-energy injuries. Our data suggest that age and co-morbidities should not prohibit lower limb reconstruction. The current application of generic guidelines appears suitable in the elderly, particularly in the acute management. We suggest current management pathways and targets be reviewed to reflect the greater need for peri-operative optimisation and rehabilitation in elderly patients.

Perspectives: A surgeon's guide to machine learning.

The exponential increase in the volume and complexity of healthcare data presents new challenges to researchers and clinicians in analysis and interpretation. The requirement for new strategies to extract meaningful information from large, noisy datasets has led to the development of the field of big data analytics. Artificial intelligence (AI) is a general-purpose technology in which machines carry out tasks traditionally thought to be only achievable by humans. Machine learning (ML) is an approach to AI in which machines can "learn" to perform tasks in an automated process, rather than being explicitly programmed by a human. Research aiming to apply ML techniques to classification, prediction and decision-making problems in healthcare has increased 61-fold from 2005 to 2019, mirroring this sense of early promise. The field of healthcare ML is relatively young, and many critical steps are needed before adoption into clinical practice, including transparent, unbiased development and reporting of algorithms. Articles claiming that machines can outperform, or replace, doctors in high-level tasks, such as diagnosis or prognostication, must be carefully appraised. It is critical that surgeons have an understanding of the principles and terminology of AI and ML to evaluate these claims and to take an active role in directing research. This article is an up-to-date review and primer for surgeons covering the core tenets of ML applied to surgical problems, including algorithm types and selection, model training and validation, interpretation of common outcome metrics, current and future reporting guidelines and discussion of the challenges and limitations in this field.

Factors Associated with the Development, Progression, and Outcome of Dupuytren Disease Treatment: A Systematic Review.

BACKGROUND: The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease. METHODS: A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool. RESULTS: This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome. CONCLUSIONS: This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence.

Alternative physical treatments for deep venous thrombosis prophylaxis in surgical patients: a systematic review.

INTRODUCTION: Venous thromboembolism (VTE) represents a major cause of morbidity and mortality. A variety of novel physical therapies have been proposed for patients in whom standard prophylaxis, including early mobilisation, is contraindicated. This article presents a systematic literature review of alternative physical treatments for VTE prophylaxis, focusing on surgical and trauma patients. METHODS: Following protocol registration in PROSPERO, a systematic review was conducted in accordance with PRISMA. MEDLINE and EMBASE databases were searched for all studies indexed before 27th of July 2019. Two authors independently screened these articles. Data gathering for eligible articles was also undertaken in parallel by two authors. A formal risk of bias assessment was conducted for each study along with an assessment on the quality of the evidence using the GRADE framework. RESULTS: A total of 272 abstracts were identified. After exclusion of duplicates and non-eligible articles, 10 publications were reviewed in detail. Two studies involving electrostimulation, another using a portable intermittent compression device and one study using postoperative calf massage reported a statistically significant reduction in the incidence of deep venous thrombosis when used in conjunction with LMWH. The remaining six articles did not show any significant benefits. DISCUSSION: All studies reporting significant benefits have methodological flaws, with a high risk of bias. The evidence base informing alternative physical treatments as prophylactic measures in VTE is limited. Our data suggest that the use of these physical modalities can be beneficial in patients who also received LMWH, whilst these alone are of no benefit. LEVEL OF EVIDENCE: II - Systematic Review Systematic Review Registration Number PROSPERO CRD42019133684.

Return to Sport After Metacarpal and Phalangeal Fractures: A Systematic Review and Evidence Appraisal.

BACKGROUND: Fractures of the metacarpals and phalanges account for more than half of all upper extremity fractures sustained by competitive athletes. PURPOSE: To determine which management strategy is best for expediting return to preinjury levels of competition in adult athletes with metacarpal and/or phalangeal fractures. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A methodology compliant with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was used. A custom search strategy was designed and applied to MEDLINE and In-Process, Embase, EMCARE, and CINAHL. RESULTS: Overall, 3135 records were identified, of which 8 met full inclusion criteria. All patients returned to preinjury levels of competition, at a mean of 30.6 days for phalangeal fractures and 21.9 days for metacarpal fractures. Meta-analysis demonstrated delayed return-to-sport time for operatively managed metacarpal fractures as compared with nonoperatively managed ones (28.5 vs 22.0 days). All studies were of fair or poor quality, and none were randomized. CONCLUSION: Optimal management strategies for athletes with metacarpal and phalangeal fractures remain equivocal. Injury, treatment, and sport-specific factors may confound results and preclude accurate estimation of optimal treatment strategies at present.

A systematic review assessing the quality of clinical practice guidelines in chronic venous disease.

OBJECTIVE: Our aim was to assess the methodologic quality of clinical practice guidelines (CPGs), which inform the diagnosis and management of chronic venous disease (CVD), using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. METHODS: A systematic review was performed through the Medline and Embase databases to identify CPGs relevant to CVD. The included articles were evidence-based CPGs available in English and reported in the past 20 years. Consensus documents, expert opinions, and studies providing guidance for diagnosis or treatment alone were excluded. Four independent reviewers assessed the CPGs using the AGREE II tool across six domains. Overall quality scaled scores were calculated for each guideline, and the interrater reliability was measured using an intraclass correlation coefficient. SPSS, version 25 (IBM Corp, Armonk, NY) was used for statistical analysis. RESULTS: Six CPGs reported from 2004 to 2018 were identified; all were of European and North American origin. The interrater reliability when scoring each CPG was high, with an intraclass correlation coefficient of >0.8 (P ≤ .002) for all six CPGs. One CPG had an average score of 95.83% across all domains, qualifying as a high quality CPG. The remaining five CPGs had scores ranging from 29% to 71%. The CPGs generally performed poorly in outlining stakeholder involvement and evaluating the applicability of the guideline to clinical practice. CONCLUSIONS: Scores from the AGREE II tool were reproducible when different users evaluated the CPGs. We identified one CPG for CVD of high methodologic quality. The AGREE II appraisal tool can be used to identify aspects of CPGs that can be developed to improve their methodologic quality.

A patient with chronic fingertip pain.

Isolated chronic fingertip pain is an uncommon presentation with a broad differential diagnosis, including but not limited to, subungal neuroma, subungal haematoma, subungal exostosis and glomus tumour. We present an interesting case of a young lady with debilitating chronic fingertip pain diagnosed with a glomus tumour of her right index finger. Surgical excision provided complete resolution from pain, return to work and restoration of quality of life. Here we discuss clinical and radiological features of this rare benign neoplasm.