Rigid versus semi-rigid orthotic use following TMC arthroplasty: a randomized controlled trial.

INTRODUCTION: The trapeziometacarpal (TMC) joint of the human thumb is the second most common joint in the hand affected by osteoarthritis. TMC arthroplasty is a common procedure used to alleviate symptoms. No randomized controlled trials have been published on the efficacy of different post-operative orthotic regimes. METHOD: Fifty six participants who underwent TMC arthroplasty were allocated to either rigid orthotic or semi-rigid orthotic groups. Both groups started an identical exercise program at two weeks following surgery. Outcome measures were assessed by an assessor blinded to group allocation. The primary outcome was the Patient Rated Wrist and Hand Evaluation (PRWHE) and secondary outcomes included the Michigan Hand Questionnaire (MHQ), thumb palmar abduction, first metacarpophalangeal extension and three point pinch grip. Measures were taken pre-operatively, at six weeks, three months and one year post-operatively. Between-group differences were analyzed with linear regression. RESULTS: Both groups performed equally well. There was no significant between-group difference for PRWHE scores (0.47, CI -11.5 to 12.4), including subscales for pain and function, or for any of the secondary outcomes at one year follow-up. CONCLUSION: We found no difference in outcomes between using a rigid or semi-rigid orthosis after TMC arthroplasty. Patient comfort, cost and availability may determine choice between orthoses in clinical practice. LEVEL OF EVIDENCE: 1b RCT.

Prognosis and prognostic factors for patients with persistent wrist pain who proceed to wrist arthroscopy.

UNLABELLED: Wrist pain is common. People with persistent pain commonly undergo arthroscopic investigation. Little is known about the prognosis or prognostic factors for these patients. The purpose of the study was to evaluate prognosis and prognostic factors for pain and functional disability in patients with persistent wrist pain who proceed to arthroscopic investigation. The study design used was a prospective cohort study. One hundred and five consecutive participants who underwent arthroscopic investigation for undiagnosed wrist pain for at least four-week duration were recruited. Patient-rated wrist and hand evaluation (PRWHE) scores were determined at baseline (before arthroscopy) and one year after arthroscopy. One-year follow-up data were obtained for 97 (92%) of 105 participants. Mean PRWHE total score declined from 49 of 100 (standard deviation [SD] 18.5) at baseline to 26 of 100 (SD 20.4) at one year. Two prognostic factors were identified: baseline PRWHE and duration of symptoms. These factors explained 19% and 5% of the variability in the final PRWHE score, respectively. Results of provocative wrist tests and arthroscopic findings did not significantly contribute to prognosis in this cohort. This study provides the first robust evidence of the prognosis of persistent wrist pain. Participants who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year; however, most continued to have some pain and disability. Duration of pain and PRWHE at baseline explained 24% of the one-year PRWHE score. LEVEL OF EVIDENCE: Level 2.

Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study.

QUESTION: What is the diagnostic value of provocative wrist tests and magnetic resonance imaging (MRI) for suspected wrist ligament injuries? DESIGN: Cross-sectional study. PARTICIPANTS: 105 people presenting to hand clinics with wrist pain and suspected wrist ligament injuries were evaluated prospectively. OUTCOME MEASURES: The integrity of wrist ligaments was tested with seven provocative tests. The results were compared to the reference standard of arthroscopy. In a subgroup of 55 participants, MRI findings were also compared to arthroscopy. The provocative tests were the scaphoid shift test (SS test), lunotriquetral test (LT test), midcarpal test (MC test), distal radioulnar joint test (DRUJ test), triangular fibrocartilage complex (TFCC) stress test (TFCC test), TFCC stress test with compression (TFCC comp test), and the gripping rotatory impaction test (GRIT). RESULTS: Most provocative tests and MRI findings were of little or no value for diagnosing wrist ligament injuries. Exceptions were the SS test (+ve LR 2.88 and -ve LR 0.28), MC test (+ve LR 2.67) and DRUJ test (-ve LR 0.30), all of which were of mild diagnostic usefulness. MRI was moderately useful for diagnosing TFCC injuries (+ve LR 5.56, -ve LR 0.15), and was mildly useful for diagnosing scapholunate (SL) ligament injuries (+ve LR 4.17, -ve LR 0.32) and lunate cartilage damage (+ve LR 3.67, -ve LR 0.33). Adding MRI to provocative tests improved the accuracy of diagnosis of TFCC injuries slightly (by 13%) and lunate cartilage damage (by 8%). CONCLUSION: Provocative wrist tests of SL ligament injuries and midcarpal ligament injuries are mildly useful for diagnosing wrist injuries. MRI diagnostic findings of SL ligament injuries, lunate cartilage damage, and TFCC are mildly to moderately useful. MRI slightly improves the diagnosis of TFCC injury and lunate cartilage damage compared to provocative tests alone.

Current practice in the diagnosis and treatment of carpal instability--results of a survey of Australian hand therapists.

A postal survey of all 85 full Australian Hand Therapy Association (AHTA) members was carried out to determine the current practice of the diagnosis and treatment of carpal instability by AHTA members. There was an 87% return rate. On average therapists saw 3.8 patients/month with carpal instability. Time from onset of pain or injury was a median of eight weeks (inter-quartile range 0-26 weeks). Ulnar pain was reported in 39% of patients, central pain in 17%, radial pain in 13%, and combined in 34%. Mean pain intensity at rest was 3.5/10 (SD 2.8), and with aggravating activity was 7.7 (SD 2.2). Forty-seven percent of patients reported difficulties with grip-related activities. Mean grip strength was 67% of the contralateral side. The most commonly used tests used were scaphoid shift, lunotriquetral ballotment, triangular fibrocartilage complex, and midcarpal stress tests. The most used treatments were patient education (advice and activity modification), splinting the wrist, and isometric exercising of the wrist musculature.