Patients' unmet needs and treatment preferences concerning digital ulcers in systemic sclerosis.

INTRODUCTION: Digital ulcers (DUs) significantly impact on quality of life and function in patients with systemic sclerosis (SSc). The aim of our survey was to explore patients' perspectives and their unmet needs concerning SSc-DUs. MATERIALS: SSc patients were invited through international patient associations and social media to participate in an online survey. RESULTS: 358 responses were obtained from 34 countries: US (65.6%), UK (11.5%) and Canada (4.5%). Recurrent DUs are common: >10 DUs (46.1%), 5-10 DUs (21.5%), 1-5 DUs (28.5%), 1 DU (3.9%). Fingertip DUs were most frequent (84.9%), followed by those overlying the interphalangeal joints (50.8%). The impact of DUs in patients is broad, from broad-ranging emotional impacts to impact on activities of daily living, and personal relationships. Half (51.7%) of respondents reported that they received wound/ulcer care, most often provided by non-specialist wound care clinics (63.8%). There was significant variation in local (wound) DU care, in particular the use of debridement and pain management. DU-related education was only provided to one-third of patients. One-quarter (24.6%) were 'very satisfied' or 'satisfied' that the provided DU treatment(s) relieved their DU symptoms. Pain, limited hand function, and ulcer duration/chronicity were the main reasons for patients to consider changing DU treatment. CONCLUSIONS: Our data show that there is a large variation in DU treatment between countries. Patient access to specialist wound-care services is limited and only a small proportion of patients had their DU needs met. Moreover, patient education is often neglected. Evidence-based treatment pathways are urgently needed for DU management.

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.

BACKGROUND: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS: This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS: Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION: Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Acute and outpatient service utilisation prior to, during, and following enrolment in community-based mental health treatment among children and youth in Central Ontario: A proof of concept for cross-sectoral data linkage.

AIM: Given the fragmentation of mental health and addictions (MHA) services for children and youth, comprehensive data on utilisation patterns are lacking. We sought to describe MHA-related service use across the community, acute and outpatient sectors. METHODS: We used linked health-administrative data sets to identify a cohort of individuals aged <18 who received MHA treatment in a large community organisation in Ontario, Canada between 1 April 2007 and 31 March 2012. We described their socio-demographic characteristics, examined their MHA-related concurrent service use in acute care and outpatient physician settings (primary care providers, paediatricians and psychiatrists), and compared service utilisation prior to, during and following enrolment using Poisson regressions. RESULTS: Among 7285 children and youth receiving community MHA treatment, there were 481 concurrent MHA-related emergency department visits, 173 hospitalisations and 12140 outpatient physician visits. The average age at enrolment was 10.5 years, and 64% of clients were enrolled for ≥3 months. MHA-related emergency department use significantly declined from 1 year prior, compared to 1 year following receipt of community MHA treatment (112 vs. 82 visits per 1000 person-years, P < 0.001), particularly in females, ages 10-14, those living in higher-income neighbourhoods and urban areas, and those with anxiety disorders. MHA hospitalisations also declined (45 vs. 32, P < 0.001), while outpatient physician visits increased (1750 vs. 1874, P < 0.001). CONCLUSIONS: Our study suggests that community-based MHA treatment may be effective in diverting children and youth away from acute care and highlights the importance of data linkage as a means to better understand the complexity of cross-sectoral MHA service use.

Pilot study assessing pathophysiology and healing of digital ulcers in patients with systemic sclerosis using laser Doppler imaging and thermography.

OBJECTIVES: Systemic sclerosis (SSc)-related digital ulcers (DU) cause significant pain and disability and are often a primary endpoint in clinical trials. However, their pathophysiology has been little studied. The objectives of this prospective study were to determine whether laser Doppler imaging (LDI) and thermography can identify ischaemic components in both fingertip and extensor surface DU and assess ulcer healing. METHODS: Patients prospectively reported new DU over a year. Patients' DU underwent imaging until the ulcer had healed. Ischaemia was defined as lower blood flow or skin temperature (and inflammation as higher) within the ulcer, compared to a non-affected site. RESULTS: 53 ulcers (19 fingertip, 18 extensor, 16 'other' sites) in 17 patients were imaged (53 with LDI, 52 with thermography). For LDI data 32 (60%) ulcers were ischaemic; median perfusion ulcer/unaffected area; 0.79 (range 0.11-2.9). For thermography data 35 (66%) were ischaemic; 0.98 (0.89 to 1.1). Inflammation in the surrounding area was identified for all ulcers by LDI but not thermography. In the 36 ulcers with repeat imaging, LDI showed trends (with healing) towards increased ulcer perfusion (p=0.23) and decreased hyperaemia in adjacent areas (p=0.59). Skin temperature at the ulcer site showed no significant change (p=0.13) but adjacent area showed decreased temperature (p=0.04 signifying decreased blood flow). CONCLUSIONS: LDI and thermography are sufficiently sensitive to measure ischaemia in both fingertip and extensor ulcers. LDI was better suited to monitoring change in perfusion with healing (due to higher imaging resolution, or vascular changes occurring in more superficial skin layers).

Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence.

PURPOSE: To determine by systematic review the optimal treatment of scaphoid nonunion. METHODS: We conducted a systematic review of the literature with a meta-analysis of proportions to investigate the comparative effectiveness of different surgical techniques. RESULTS: A total of 48 publications (1,602 patients) met the eligibility criteria. Vascularized and nonvascularized bone grafts had an estimated union incidence of 92% and 88%, respectively. Distal radius and iliac crest bone grafts had similar union rates (89% and 87%, respectively) but harvesting of iliac crest bone grafts had more complications. Both screw and K-wire fixation had a higher incidence of union (88% and 91%, respectively) than no fixation (79%). No approach was statistically different. Patients fixed with screws were mobilized earlier than those with K-wire fixation. CONCLUSIONS: Current evidence does not demonstrate a significantly superior method for the treatment of scaphoid nonunion. A multicenter randomized trial would be ideal but the large numbers that would be required may make this unrealistic. We recommend the continued reporting of series with specific assessments and outcome measures to optimize future comparisons in an attempt to determine the best management of scaphoid nonunion. CLINICAL RELEVANCE: The use of bone grafts and the methods of their fixation for scaphoid nonunion are debated issues in hand and wrist surgery, with multiple methods employed. There is no current consensus on optimal treatment. A meta-analysis of proportions of available data from recent studies was deemed the most appropriate way to assimilate the available evidence with the view to inform surgeons of the optimal treatment according to the evidence base.

A Review of Published Radiographic Indicators of Carpometacarpal Dislocation Including Their Application to Volar Dislocations Through a Case Study.

BACKGROUND: Carpometacarpal joint dislocation is an uncommon injury that is at risk of being overlooked on initial presentation. Dislocation in a volar direction is rare, with a number of case reports published in the literature. CASE REPORT: We report a case of volar dislocation at our institution, and review the application of two reported radiographic signs of carpometacarpal dislocation to volar dislocation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Radiographic signs provide an aid to the emergency physician in the busy department. These are particularly helpful to rule out rare injuries. Carpometacarpal dislocations in a volar direction risk being missed by one radiographic sign reported in the literature, as this article highlights.

Foreign body reaction associated with Artelon: report of three cases.

The Artelon carpometacarpal joint implant is a degradable interposition arthroplasty spacer intended for use in thumb carpometacarpal joint osteoarthritis. Recently there have been reported cases of foreign body reaction attributed to the Artelon implant, which raise concerns about the use of this implant. The implant's manufacturers claim excellent biocompatibility. We report 3 cases of persistent pain after thumb carpometacarpal joint arthroplasty performed using Artelon implants. In all 3 cases that required removal of the Artelon implant and trapeziectomy to achieve subsequent symptom relief, foreign body-type reaction associated with the Artelon was seen histologically.

FDP avulsion: A washer technique.

BACKGROUND: Flexor digitorum profundus (FDP) avulsion injuries occur following forced hyperextension of the distal interphalangeal joint (DIPJ). METHODS: We highlight a case report of FDP avulsion injury fixed using a single hole of a plate in combination with a cortical screw to act as a washer. A search and discussion of the literature is included.

Reliability of clinical tests for prediction of occult scaphoid fractures and cost benefit analysis of a dedicated scaphoid pathway.

We reviewed the outcomes of our dedicated clinic for suspected scaphoid fractures. The primary outcome measure was to test the reliability of accurately diagnosing an occult scaphoid fracture with a combination of anatomical snuff box, scaphoid tubercle, longitudinal compression tenderness, ulnar deviation and the pinch test. Cost savings of the new patient pathway was our secondary outcome measure. Between December 2016 and March 2020, 922 patients were recruited at a mean of 12 days post-injury. Sixty-five per cent (n = 602) with a low clinical suspicion were discharged and 35% (n = 320) with a high clinical suspicion had same day MRI scan. Fifty-eight scaphoid fractures were diagnosed and treated with no nonunions reported. Anatomical snuff box tenderness was the most sensitive test (90%). A combination of five tests better excluded an occult fracture (80% accuracy). The dedicated scaphoid clinic pathway resulted in 350 fewer follow-up visits and an overall saving of £59,666.Level of evidence: III.

Practice in Wide-Awake Hand Surgery: Differences Between United Kingdom and Cyprus.

The implementation of the wide-awake local anesthetic no tourniquet (WALANT) approach to surgical procedures in Cyprus has led to significant cost savings. In the United Kingdom, the implementation of WALANT has led to shorter waiting times for hand surgical procedures, cost savings for the National Health Service, and high patient satisfaction rates. In both countries, patient education is a prerequisite for WALANT surgery. It increases the satisfaction rate among patients and enhances the patient-surgeon relationship. Patients need to know they can participate actively in a procedure, because a patient moving the hand during a procedure can improve the outcome.

The management of chronic non-arthritic scapholunate dissociation: a systematic review.

A systematic review was conducted to identify the best management for chronic scapholunate dissociation. EMBASE, MEDLINE, and CENTRAL were searched from 1965-2016. A narrative synthesis was performed. One thousand, one hundred and ninety-one citations were identified, of which 17 had final analysis. In all interventions, the pain score at 2 years reduced from 6.0 to 2.8 with similar effect from capsulodesis and tenodesis techniques. Overall there was an 18% loss of flexion arc. Radial to ulnar arc improved in capsulodesis (+19%; n = 45) and worsened in tenodesis (-6%; n = 45). Grip strength was better in capsulodesis (+31%; n = 64 versus + 11%; n = 56). There was insufficient evidence to link radiological outcome with clinical outcome. Rates of complications (20%) and CRPS (3.8%) were high, with implications for patient consent. Due to heterogeneity in data collection, the lack of comparative studies and short-term follow-up, no conclusion regarding the superiority of a single technique was possible. Longer term comparative studies are required, as are natural history studies. A minimum data set has been advised. LEVEL OF EVIDENCE: II.

Reliability of digital ulcer definitions as proposed by the UK Scleroderma Study Group: A challenge for clinical trial design.

INTRODUCTION: The reliability of clinician grading of systemic sclerosis-related digital ulcers has been reported to be poor to moderate at best, which has important implications for clinical trial design. The aim of this study was to examine the reliability of new proposed UK Scleroderma Study Group digital ulcer definitions among UK clinicians with an interest in systemic sclerosis. METHODS: Raters graded (through a custom-built interface) 90 images (80 unique and 10 repeat) of a range of digital lesions collected from patients with systemic sclerosis. Lesions were graded on an ordinal scale of severity: 'no ulcer', 'healed ulcer' or 'digital ulcer'. RESULTS: A total of 23 clinicians - 18 rheumatologists, 3 dermatologists, 1 hand surgeon and 1 specialist rheumatology nurse - completed the study. A total of 2070 (1840 unique + 230 repeat) image gradings were obtained. For intra-rater reliability, across all images, the overall weighted kappa coefficient was high (0.71) and was moderate (0.55) when averaged across individual raters. Overall inter-rater reliability was poor (0.15). CONCLUSION: Although our proposed digital ulcer definitions had high intra-rater reliability, the overall inter-rater reliability was poor. Our study highlights the challenges of digital ulcer assessment by clinicians with an interest in systemic sclerosis and provides a number of useful insights for future clinical trial design. Further research is warranted to improve the reliability of digital ulcer definition/rating as an outcome measure in clinical trials, including examining the role for objective measurement techniques, and the development of digital ulcer patient-reported outcome measures.

Scaphotrapeziotrapezoidal Joint Osteoarthritis: A Systematic Review of Surgical Treatment.

BACKGROUND: The management of scaphotrapeziotrapezoidal (STT) joint osteoarthritis (OA) remains controversial. This systematic review aims to review the evidence for surgical interventions specific to STT OA. METHODS: Medline and Embase libraries were searched using a pre-defined search strategy in October 2014. All study designs and languages were included and evaluated by two reviewers (VMD and LM) against the inclusion/exclusion criteria. The study eligibility criteria included papers discussing surgical treatment of STT OA, and the review was conducted using the PRISMA guidelines. RESULTS: 295 unique results were identified from the search strategy after duplicates were filtered. 21 articles met the eligibility criteria. CONCLUSIONS: Trapezial excision and partial trapezoidal excision is an effective treatment with low morbidity and complications, although can lead to weakness of the thumb. Distal scaphoid excision remains an effective pain relief treatment with improved grip and pinch strengths post-operatively. The procedure is technically less demanding than arthrodesis, does not carry the risks of non-union and complication rate of STT joint arthrodesis, and has a shorter immobilisation requirement. It produces reliable results, but is contraindicated if there is either scapholunocapitate pathology or midcarpal instability. STT joint fusion has a place, typically producing 75% range of movement of the non-operated wrist. However it has a higher associated complication rate, and simultaneous radial styloidectomy is recommended to reduce ongoing pain from impingement. Implant arthroplasty using a graphite-coated pyrocarbon implant has been used more recently. The patients gained significant pain relief, although there have been reports of implant dislocation secondary to surgical errors. A reduction in post-operative wrist extension and radial deviation has been noted. From this systematic review, we have composed a treatment algorithm for the surgical management of STT joint OA.

Coexistent digital gouty and infective flexor tenosynovitis.

Flexor tenosynovitis of the hand is often caused by trauma or infection. Gouty tenosynovitis is an uncommon presentation of the condition and is usually misdiagnosed as infection with the patient undergoing surgery. The coexistence of infection and gout causing flexor tenosynovitis has never been described before in the literature; we report the first ever case and emphasise the importance of its awareness for optimal treatment. A 54-year-old man was initially diagnosed and treated as having infective flexor tenosynovitis and, later, due to a lack of improvement in his symptoms, was discovered to also have gout. We review the literature and suggest management strategy for use in daily clinical practice, including an algorithm, for this presentation.

Differential diagnosis of critical digital ischemia in systemic sclerosis: Report of five cases and review of the literature.

OBJECTIVES: Critical digital ischemia is a rare, but serious complication of systemic sclerosis (SSc) and is not always due solely to the non-inflammatory angiopathy that characterizes the SSc disease process. Our objective was to illustrate the range of presentations and causes of critical digital ischemia in patients with SSc in order to highlight how optimal management is dependent upon establishing the correct diagnosis. METHODS: Five cases exemplifying differential diagnoses were identified and their case notes reviewed in order to extract clinically relevant data and images. A review of the literature was performed in PubMed in English. RESULTS: Causes of critical digital ischemia included typical micro-angiopathic changes and proximal (large vessel) disease. One case highlighted the difficulty of ascertaining whether an inflammatory cause is also present in SSc/SLE overlap syndrome. Two cases demonstrated embolic causes (thromboembolism due to atrial fibrillation and septic emboli). CONCLUSIONS: Critical digital ischemia in patients with SSc requires thorough investigation in order to avoid missing additional potentially modifiable causes including large vessel disease, inflammation, embolism, infection, and paraneoplastic syndromes. A firm evidence base for current medical and surgical interventions is lacking, highlighting the need for further research into the optimum management of this rare, but painful, debilitating, and limb-threatening complication of SSc.

Raynaud's phenomenon (secondary).

INTRODUCTION: Raynaud's phenomenon is episodic vasospasm of the peripheral vessels. It presents as episodic colour changes of the digits (sometimes accompanied by pain and paraesthesia), usually in response to cold exposure or stress. The classic triphasic colour change is white (ischaemia), then blue (de-oxygenation), then red (reperfusion). Raynaud's phenomenon can be primary (idiopathic) or secondary to several different conditions and causes. When secondary (e.g., to systemic sclerosis), it can progress to ulceration of the fingers and toes. This review deals with secondary Raynaud's phenomenon. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of surgical interventions in complicated secondary Raynaud's phenomenon? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found two studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: botulinum toxin, simple debridement/surgical toilet of ulcers, peripheral sympathectomy (digital, digital plus sympathectomy of the ulnar and/or radial artery, ligation of the ulnar artery), cervical/thoracic sympathectomy, arterial reconstruction (venous graft, arterial graft, balloon angioplasty), and amputation.

Automatic generation of statistical pose and shape models for articulated joints.

Statistical analysis of motion patterns of body joints is potentially useful for detecting and quantifying pathologies. However, building a statistical motion model across different subjects remains a challenging task, especially for a complex joint like the wrist. We present a novel framework for simultaneous registration and segmentation of multiple 3-D (CT or MR) volumes of different subjects at various articulated positions. The framework starts with a pose model generated from 3-D volumes captured at different articulated positions of a single subject (template). This initial pose model is used to register the template volume to image volumes from new subjects. During this process, the Grow-Cut algorithm is used in an iterative refinement of the segmentation of the bone along with the pose parameters. As each new subject is registered and segmented, the pose model is updated, improving the accuracy of successive registrations. We applied the algorithm to CT images of the wrist from 25 subjects, each at five different wrist positions and demonstrated that it performed robustly and accurately. More importantly, the resulting segmentations allowed a statistical pose model of the carpal bones to be generated automatically without interaction. The evaluation results show that our proposed framework achieved accurate registration with an average mean target registration error of 0.34 ±0.27 mm. The automatic segmentation results also show high consistency with the ground truth obtained semi-automatically. Furthermore, we demonstrated the capability of the resulting statistical pose and shape models by using them to generate a measurement tool for scaphoid-lunate dissociation diagnosis, which achieved 90% sensitivity and specificity.