Should we always perform scaphoid nonunion surgery in patients with minor preoperative symptoms?

The objective of this study was to assess the downsides of surgical treatment of scaphoid fracture nonunion in patients with minor preoperative symptoms. Patients were classified with minor symptoms based on the Patient-Rated Hand/Wrist Evaluation questionnaire. Of the 35 included patients, most patients encountered problems with patient-specific activities; 9% reported worse postoperative functional outcomes, 34% were not satisfied with the treatment and 9% were reoperated. The risk of a worse functional outcome after surgery with the need for further operations and the chance of developing wrist osteoarthritis, along with the possibility of poor patient satisfaction and ongoing daily functional impairment, should be considered during preoperative counselling.Level of evidence: III.

Morphological risk factors for scaphoid fracture: a case-control study.

PURPOSE: Most patients with a clinically suspected scaphoid fracture and normal initial radiograph are unnecessarily treated. Previously developed prediction rules using demographic and clinical risk are unable to accurately predict occult fractures. Adding other risk factors could enhance this. Therefore, we aim to explore if there are morphological risk factors of the wrist for sustaining a scaphoid fracture. METHODS: We retrospectively included adult patients with a clinically suspected scaphoid fracture between 2013 and 2019 in our case-control study. There were 82 patients with a scaphoid fracture and 158 patients with a wrist contusion. Morphological risk factors were identified using statistical shape modelling (SSM) and linear measurements. Independent wrist shape variations on posteroanterior and lateral radiographs were captured in modes using SSM. Associations between outcomes and a scaphoid fracture were explored using logistic regression and the reliability was assessed. RESULTS: Of the 15 posteroanterior modes and 8 lateral modes identified and linear measurements performed, 1 PA mode was associated with a scaphoid fracture (PA mode 4; OR 1.40, CI 1.04-1.93, p = 0.031). We described this mode as an ulna plus and narrower distal radius with more volar tilt and radial inclination. The reliability of the posteroanterior modes and linear measurements was mostly good/excellent and moderate/poor for the lateral modes. CONCLUSION: There was one complex wrist shape significantly associated with a scaphoid fracture. Since the association was weak and the shape is difficult to identify radiographs, we believe this morphological risk factor would not enhance identifying occult scaphoid fractures in the future.

Impact of the COVID-19 lockdown on patient-reported outcome measures in Dutch hip and knee arthroplasty patients.

BACKGROUND AND PURPOSE: During the first COVID-19 lockdown elective surgery was greatly reduced. Prioritization of patients with greater need and expected benefit in terms of quality of life was advised. The lockdown also potentially affected follow-up outcomes. Therefore, our study compared patient-reported outcome measures (PROMs) retrieved during the lockdown of Dutch primary total hip and knee arthroplasty (THA, TKA) patients with previous years. PATIENTS AND METHODS: We performed cross-sectional analyses using national data from the Dutch Orthopaedic Registry (LROI). All primary elective THA and TKA patients with preoperative or postoperative PROMs (EQ-5D-3L index, OHS/OKS) during the first COVID-19 lockdown between March and July 15, 2020 were included. Patients with PROMs during the same months in 2018 plus 2019 were used as control. Finally, 33,453 THA and 27,335 TKA patients were included. Patient characteristics were compared during versus before the lockdown. Subsequently, the lockdown effect on PROMs scores was analyzed with multivariable linear regression. RESULTS: During the COVID-19 lockdown, THA and TKA patients had a lower age and BMI preoperatively, and more often had surgery in private clinics. Both preoperative PROMs in THA patients, but not in TKA patients, were worse (EQ-5D: Adjusted mean difference (AMD) -0.021, p < 0.001) during the lockdown compared with prior years. Both postoperative PROMs in THA and TKA patients were better during the lockdown (12-month EQ-5D in THA: AMD 0.010, p = 0.003; and in TKA: AMD 0.013, p < 0.001). INTERPRETATION: During the COVID-19 lockdown, THA patients had slightly worse preoperative PROMs, suggesting selection of patients with greater urgency. Postoperative PROMs in both THA and TKA patients differed minimally. Overall, the observed differences were likely not clinically relevant.

Patient-reported physical functioning and pain improve after scaphoid nonunion surgery: A Cohort Study.

BACKGROUND: Since all patients with a scaphoid nonunion are generally treated surgically to prevent progressive osteoarthritis, it is important to set postoperative expectations regarding physical functioning and pain. Previous study mainly focus on postoperative scaphoid union and physician-based outcomes. Therefore we aim to report the change from preoperative to postoperative patient-reported outcomes to inform patients with a scaphoid nonunion about their postoperative expectations. MATERIAL AND METHODS: Data were prospectively collected as part of usual care at the Xpert Clinic in the Netherlands. Adult patients who underwent scaphoid nonunion surgery minimally 3 months after a scaphoid fracture, were eligible for inclusion. Only patients with complete preoperative and postoperative questionnaires regarding our primary outcome (Patient Rated Hand/Wrist Evaluation (PRWHE) were included. As secondary outcomes, we assessed the Visual Analog Scale (VAS) pain and hand function, range of motion of the injured wrist measured by a hand therapist, and patient satisfaction with questionnaires. RESULTS: We included 118 patients with complete preoperative and postoperative (11 - 92 months) PRWHE questionnaires. The median PRWHE score improved significantly from 47 [IQR 27 - 62]) preoperative to 11 [IQR 5 - 23] postoperative (p<0.001). Postoperative improvement in pain and physical functioning was also observed in the PWRHE subdomains pain and disability separately (p<0.001), VAS pain, and VAS function (p<0.001). There was no difference between preoperative and postoperative range of motion of the injured wrist. Satisfaction with the hand improved significantly from preoperative to postoperative (p<0.001). Good or excellent satisfaction with the treatment result was reported by 69% of the patients and 86% would undergo the treatment again. CONCLUSIONS: Patients can expect an improvement in physical functioning and pain after scaphoid nonunion surgery. Most patients are satisfied with the treatment result.

What Is the Impact of the COVID-19 Pandemic on Quality of Life and Other Patient-reported Outcomes? An Analysis of the Hand-Wrist Study Cohort.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic, and its associated lockdowns in many parts of the world, have changed our daily lives and may have a psychological impact on around the globe. However, it is unknown how this influences the patient-reported outcome measures (PROMs) of patients involved in ongoing clinical research and medical care. For both the current and potential future lockdowns, it is important to determine if PROMs collected during such a period can be interpreted with confidence. QUESTIONS/PURPOSES: (1) Is there a difference in quality of life between patients in the COVID-19 period group (March 23, 2020 to May 4, 2020) and patients in a reference period group (from the same period in 2018 or 2019)? (2) Is there a difference in pain, hand function, anxiety, depression, and illness perception between patients in the COVID-19 period group and patients in the reference period group? METHODS: This study was part of a large cohort study with routine outcome measures of patients with hand and wrist conditions. To answer our research questions, we analyzed two samples because not all PROMs were sent to participants at the same time points after treatment. The first sample consisted of all participants who completed PROMs on quality of life (QoL), pain, and hand function at their final follow-up time point, which was either 3, 6, or 12 months post-treatment. The second sample consisted of participants who completed PROMs 3 months post-treatment on anxiety, depression, and illness perception. Each sample consisted of two groups: a COVID-19 period group and a reference period group. We included 1613 participants in the first sample (COVID-19 period group: n = 616; reference period group: n = 997) and 535 participants in the second sample (COVID-19 period group: n = 313; reference period group: n = 222). The primary outcome was QoL, expressed in the EuroQol 5-Dimensions questionnaire (EQ-5D) index score. Secondary outcomes were the other domains on the EQ-5D, as well as pain, hand function, anxiety, depression, and illness perception. RESULTS: We found no between-group differences in the EQ-5D index score (standardized mean difference 0.035; p = 0.98). Furthermore, there were no between-group differences in PROM scores for hand function, anxiety, or depression. There were, however, a few small differences in subdomain items regarding pain and illness perception, but we believe in aggregate that these are unlikely to make a clinically important difference in our main finding. CONCLUSION: The COVID-19 pandemic and its associated lockdown had no influence on QoL and had little influence on secondary outcomes in participants who were part of the Hand-Wrist Study Cohort. This finding implies that PROMs data collected during this period can be used with confidence in clinical research. Our findings indicate that when a pandemic like this occurs again, we can continue to use PROMs for analysis in clinical research or routine outcome measures. LEVEL OF EVIDENCE: Level III, therapeutic study.

Clinically SUspected ScaPhoid fracturE: treatment with supportive bandage or CasT? 'Study protocol of a multicenter randomized controlled trial' (SUSPECT study).

INTRODUCTION: Some scaphoid fractures become visible on radiographs weeks after a trauma which makes normal radiographs directly after trauma unreliable. Untreated scaphoid fractures can lead to scaphoid non-union progressing to osteoarthritis. Therefore, the general treatment for patients with a clinically suspected scaphoid fracture and normal initial radiographs is immobilisation with below-elbow cast for 2 weeks. However, most of these patients are treated unnecessarily because eventually less than 10% of them are diagnosed with an occult scaphoid fracture. To reduce overtreatment and costs as a result of unnecessary cast treatment in patients with a clinically suspected scaphoid fracture and normal initial radiographs, we designed a study to compare below-elbow cast treatment with supportive bandage treatment. We hypothesise that the functional outcome after 3 months is not inferior in patients treated with supportive bandage compared to patients treated with below-elbow cast, but with lower costs in the supportive bandage group. METHODS AND ANALYSIS: The SUSPECT study is an open-labelled multicentre randomised controlled trial with non-inferiority design. A total of 180 adult patients with a clinically suspected scaphoid fracture and normal initial radiographs are randomised between two groups: 3 days of supportive bandage or 2 weeks of below-elbow cast. We aim to evaluate the functional outcome and cost-effectiveness of both treatments. The primary outcome is the functional outcome after 3 months, assessed with the Quick Disability of the Arm, Shoulder and Hand score. Secondary outcomes include functional outcome, recovery of function, pain, patient satisfaction, quality of life and cost-effectiveness measured by medical consumption, absence from work or decreased productivity. ETHICS AND DISSEMINATION: The Medical Ethics Committee of the Erasmus MC Medical Centre, Rotterdam, approved the study protocol (MEC-2017-504). We plan to present the results after completion of the study at (inter)national conferences and publish in general peer-reviewed journals. TRIAL REGISTRATION NUMBER: NL6976.

Adipose Tissue-Derived Stem Cell Sheet Application for Tissue Healing In Vivo: A Systematic Review.

Adipose tissue-derived stem cells (ASCs) are known to be tissue-healing promoters due to their cellular plasticity and secretion of paracrine factors. Cultured ASC sheets provide a novel method of ASC application and can retain ASCs at the targeted tissue. The purpose of this systematic review is to evaluate preclinical studies using ASC sheet transplantation therapy for promoting tissue healing. First, we searched databases to identify studies of ASC sheet therapy in different experimental animal models, and then determined the quality score of studies using SYRCLE's risk bias tool. A total of 18 included studies examined the role of ASC sheets on tissue healing and function in models for myocardial infarction, dilated cardiomyopathy, full-thickness skin wounds, hind limb ischemia, esophageal strictures, and oral ulcers. ASC sheet application after myocardial infarction improved survival rate, cardiac function, and capillary density and reduced the extent of fibrosis. Application of ASC sheets to a full-thickness skin wound decreased the wound size and stimulated wound maturation. In the hind limb ischemia model, ASC sheet application improved limb perfusion and capillary density, and decreased the amount of ischemic tissue and inflammation. ASC sheet application to mucosal wounds of the digestive tract accelerated wound healing and decreased the degree of stricture and fibrosis. Taken together, transplanted ASC sheets had a positive effect on tissue healing and reconstruction in these preclinical studies. The reported favorable effects of ASC sheet therapy in various tissue healing applications may be implemented in future translational studies. It is suggested that future preclinical animal model studies of ASC sheet therapy should concern standardization of culture techniques and investigate the mechanisms of action. In addition, clearly indicated experimental setups according to the SYRCLE's guidelines should improve study quality and validity.

Effects of adipose stem cell sheets on colon anastomotic leakage in an experimental model: Proof of principle.

The most dreaded complication of colorectal surgery is anastomotic leakage. Adipose tissue-derived stem cell sheets (ASC sheets) prepared from temperature-responsive culture surfaces can be easily transplanted onto tissues. These sheets are proposed to improve cell transplant efficiency and enhance wound healing. The aim of this study was to investigate whether application of ASC sheets could prevent leakage of sutured colorectal anastomoses. Insufficient suturing of colorectal anastomoses was performed in Wistar rats to create a colorectal anastomotic leakage model. Rats were randomized to ASC sheet application or control group. Leakage, abscess formation, adhesion formation, anastomotic bursting pressure (ABP), and histology were evaluated on postoperative day 3 or 7. ASC sheet application significantly reduced anastomotic leakage compared to controls, without increased adhesion formation. ASC sheet transplantation resulted in more CD3+ T-cells and CD163+ anti-inflammatory macrophages at the anastomotic site than the control group. ABP, vessel density and collagen deposition were not different between groups. Using cell sheet technology, we generated ASC sheets that prevented disruption of sutured colorectal anastomoses as shown by reduced leakage. Increased numbers of anti-inflammatory macrophages and T-cells might have contributed to this positive effect.