Patient-Reported Outcome in Dupuytren's Disease Treated With Fasciectomy, Collagenase or Needle Fasciotomy: A Swedish Registry Study.

Purpose: This registry study compares the patient-reported outcomes of 3 treatments for Dupuytren´s disease: open fasciectomy (OF), collagenase injection (CCH) and percutaneous needle fasciotomy (PNF). Methods: From the Swedish national quality registry for hand surgery (HAKIR) we included 2,585 procedures (in 2,414 patients): 1,200 treatments were OF, 918 CCH, and 467 PNF. The choice between CCH and PNF varied mainly because of regional differences in reimbursement of CCH. We report the results of the validated patient-reported outcome instrument HQ-8. HQ-8 evaluates symptoms in the treated hand and is issued before treatment, 3 and 12 months after treatment and is used for all patients in HAKIR. Results: At 3-month follow-up, patients treated with CCH or PNF experienced less stiffness, weakness, numbness, tingling and sensitivity to cold. At 12 months, the differences among the 3 treatments were smaller, but CCH patients experienced less stiffness and weakness compared to PNF-treated patients. Conclusions: Most randomized controlled trials have not shown significant differences in recurrence rates or patient-reported outcomes between CCH and PNF, but the number of patients has been limited and no randomized controlled trials have included all 3 treatments. In the present study, we compared registry data on patient-reported outcomes for OF, CCH, and PNF in a real-life clinical setting. Our results confirm that the noninvasive treatments (CCH and PNF) cause less disability than OF and indicate a possible advantage of CCH compared to PNF regarding stiffness and weakness at 1 year after treatment based on patient-reported outcomes. Patient-reported residual symptoms are important to consider when informing patients and selecting treatment for Dupuytren´s disease. Type of study/level of evidence: Observational registry study III.

Patient Experiences after Open Trigger Finger Release in Patients with Type 1 and Type 2 Diabetes-A Retrospective Study Using Patient-reported Outcome Measures.

Trigger finger is overrepresented among patients with diabetes mellitus (DM). Whether DM affects the outcome after open trigger finger release (OTFR) in patients with DM is not known. Our aim was thus to explore outcomes after OTFR in patients with type 1 (T1D) and type 2 DM (T2D). Methods: Data included patient-reported outcome measures (PROMs) from all OTFRs performed between 2010 and 2020 registered in the Swedish national registry for hand surgery in individuals over 18 years cross-linked with the Swedish National Diabetes Register (NDR). PROMs included QuickDASH and HQ8, a questionnaire designed for national registry for hand surgery, preoperative and at 3 and 12 months postoperative. HQ8 included pain on load, pain on motion without load, and stiffness. Outcome was calculated using linear-mixed models and presented as means adjusted for age and stratified by sex. Results: In total, 6242 OTFRs were included, whereof 496 had T1D (332, 67% women) and 869 had T2D (451, 52% women). Women with T1D reported more symptoms of stiffness (P < 0.001), and women with T2D reported more pain on load (P < 0.05), motion without load (P < 0.01), and worse overall result at 3 months. At 12 months, however, no differences were found in any of the HQ-8 PROMs among men or women. Women with T2D had slightly higher QuickDASH scores at 3 and 12 months. Conclusion: Patients with T1D and T2D can expect the same results after OTFR as individuals without DM, although the improvement might take longer especially among women with T2D.

Inflammatory reaction to suture materials after flexor tendon repair. A retrospective study of 594 patients.

We report granuloma formation after using FiberWire® for flexor tendon repairs. Four subcutaneous granulomas were identified in 115 patients with FiberWire® core sutures, none in 426 with braided polyester. Foreign body reactions were found in the granuloma cases. We suggest early suture removal if this specific complication is encountered.

Patient-reported outcome measures and their association to the original Strickland classification after flexor tendon repair.

The aim of this study was to examine the relationship between patient-reported outcome measures (PROMs) and the original Strickland classification after flexor tendon injuries in Zones 1 and 2. Data were collected from the Swedish national health care registry for hand surgery (HAKIR). The studied PROMs were the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) and the patient questionnaire from the HAKIR (HQ-8). Complete data of both range of motion (ROM) and PROMs were available for 215 patients at 3 months after surgery, and for 150 patients at 12 months after surgery. We found that QuickDASH values were low and similar between all groups as classified by the Strickland system at 12 months. A statistically significant difference between PROM values (for stiffness and satisfaction) was found only between the Strickland groups Fair and Good, but not between Poor and Fair or Good and Excellent. This suggests that further categorization according to the Strickland classification is less important to the patients as long as they regain 70% of their ROM.Level of evidence: III.

Incidence, demographics and rehabilitation after digital nerve injury: A population-based study of 1004 adult patients in Sweden.

OBJECTIVE: The main objective of this study was to describe the epidemiology of surgically repaired digital nerve injuries in a Swedish population. Secondary objectives were to describe the demographics of the patient population, injury characteristics, post-operative care and rehabilitation. METHODS: From 2012 to 2018, 1004 patients with a surgically repaired digital nerve injury resident in the Stockholm region were identified in the Swedish national quality registry for hand surgery and all medical records were thoroughly reviewed. RESULTS: The incidence rate was 8.3 per 100.000 person-years and these injuries were more common in men than women. The median age at the time of injury was 37 years and a sharp cut was the most common mechanism of injury. Injuries were equally distributed over weekdays and the year, but surgery was most often performed on Mondays. There were no differences in treatment and rehabilitation regimens between sexes, except women were more likely than men to be operated within three days from injury. Timing and content of rehabilitation varied largely between individuals. One third of patients did not receive any sensory relearning and sensory assessment was performed in only 7%. CONCLUSION: The epidemiology shows no major changes over the last decade. However, we found a large individual variation in follow up visits, rehabilitation content and assessments indicating large differences in consumption of health care resources. Our findings expose the need to further improve and evaluate rehabilitation regimens after digital nerve injury.

Patients' experiences of flexor tendon rehabilitation in relation to adherence: a qualitative study.

PURPOSE: To explore patients' experiences of early active motion flexor tendon rehabilitation in relation to adherence to restrictions and outcome of rehabilitation. METHOD: Seventeen patients with a flexor tendon injury in one or several fingers participated in qualitative interviews performed between 74 and 111 days after surgery. Data were analysed using directed content analysis with the Health Belief Model (HBM) as a theoretical framework. RESULTS: Perceived severity of hand function and susceptibility to loss of hand function affected the participants' behaviour. A higher perceived threat increased motivation to exercise and be cautious in activities. During rehabilitation, the perceived benefits or efficacy of doing exercise and following restrictions were compared to the cost of doing so, leading to adherence or non-adherence behaviour. Perceived self-efficacy was affected by previous knowledge and varied through the rehabilitation period. External factors and interaction with therapists influenced the perception of the severity of the injury and the cost and benefits of adhering to rehabilitation. CONCLUSION: Patient's perception of the injury, the effectiveness of exercises, context and social support to manage daily life affected adherence to restriction, motivation and commitment to rehabilitation. The HBM as a theoretical framework can be beneficial for understanding factors that influence patients' adherence.Implications for RehabilitationInformation regarding the injury and consequences for the patient should be presented at different time points and in different ways, tailored to the patient.It' is important to aid patients to perceive the small gradual improvements in hand function to create motivation to adhere to exercise.Strategies to reduce the cost of adherence in terms of managing everyday life should be addressed by individually based strategies.Instructions regarding exercise and restrictions should be less complex and consider the patient's individual needs.

Inter- and intra-rater reliability of the Oberg-Manske-Tonkin classification of congenital upper limb anomalies.

On two occasions, five surgeons classified a cohort of 150 consecutive patients with congenital upper limb anomalies according to the Oberg-Manske-Tonkin classification (2020 update). We estimated reliability for the main anomaly code by means of Cohen's kappa (Κ) for ten rater pairs for five common and easily distinguishable anomalies (Group 1), and for all the other anomalies (Group 2). Inter-rater reliability for all patients (n = 150) was substantial, almost perfect for Group 1 (n = 64), but only moderate for Group 2 (n = 86). Intra-rater reliability was higher for all groups. We suggest simplifications to the Oberg-Manske-Tonkin classification and highlight specific requirements for instructions to increase its reliability.Level of evidence: I.

Risk factors for reoperation after flexor tendon repair: a registry study.

The aim of this study was to identify risk factors for reoperations after Zones 1 and 2 flexor tendon repairs. A multiple logistic regression model was used to identify risk factors from data collected via the Swedish national health care registry for hand surgery (HAKIR). The studied potential risk factors were age and gender, socio-economics and surgical techniques. Included were 1372 patients with injuries to 1585 fingers and follow-up of at least 12 months (median 37 IQR 27-56). Tendon ruptures occurred in 80 fingers and tenolysis was required in 76 fingers. Variables that affected the risk of rupture were age >25 years (p < 0.001), flexor pollicis longus tendon injuries (p < 0.001) and being male (p = 0.004). Injury to both finger flexors had an effect on both rupture (p = 0.005) and tenolysis (p < 0.001). Understanding the risk factors may provide important guidance both to surgeons and therapists when treating patients with flexor tendon injuries.Level of evidence: III.

Cold sensitivity, functional disability and predicting factors after a repaired digital nerve injury.

To investigate self-reported cold sensitivity and functional disability after a repaired digital nerve injury. We identified 3204 individuals operated with digital nerve repair in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity and perceived disability, were examined using two questionnaires (HQ-8 and QuickDASH), three and 12 months postoperatively. Patients with diabetes (n = 48; 3%) were identified in the Swedish National Diabetes Register (NDR). Cold sensitivity (scored 0-100) was the most prominent symptom among 1553 included individuals (998 men, 555 women; median age 41 [IQR 27-54] years). In the regression analysis, flexor tendon injury, hand fracture and injury to multiple structures predicted worsened cold sensitivity (6.9, 15.5 and 25.0 points; p = 0.005, 0.046 and < 0.001) at 12 months. Individuals with moderate (30-70) and severe (> 70) cold sensitivity had higher QuickDASH scores at three and 12 months postoperatively than individuals with mild cold sensitivity (6.0 and 5.5; 19.8 and 21.0 points; p = 0.001). Flexor tendon injury, injuries to multiple structures and diabetes had significant effect on QuickDASH scores at three, but not at 12, months postoperatively. Cold sensitivity is common after a digital nerve repair and impacts self-reported disability. A concomitant injury, particularly multiple injuries, predicts postoperative cold sensitivity.

Trapeziectomy with or without a tendon-based adjunct: a registry-based study of 650 thumbs.

This study aimed to assess the outcomes after simple trapeziectomy and trapeziectomy with ligament reconstruction and/or tendon interposition based on data in the Swedish national healthcare quality registry for hand surgery (HAKIR). Six-hundred and fifty thumbs were included, and 265 were assessed up to 12 months after operation. There was significant and clinically relevant improvement in patient-reported measures (pain on load, pain on motion without load, pain at rest, stiffness, weakness, and ability to perform activities of daily living and the Quick Disabilities of the Arm, Shoulder and Hand score) and objective measures (strength and thumb mobility) at 3 and 12 months for all procedures. The use of the abductor pollicis longus tendon had better improvement in some respects compared with the use of flexor carpi radialis or extensor carpi radialis tendons. However, overall, the use of a tendon adjuncts yielded no better outcomes than simple trapeziectomy.Level of evidence: III.

What Are the Patient-reported Outcomes of Trapeziectomy and Tendon Suspension at Long-term Follow-up?

BACKGROUND: There are multiple options for the treatment of thumb carpometacarpal joint osteoarthritis (CMC1 OA), with evidence for pain relief and improved function. Although simple trapeziectomy has the lowest complication risk, tendon suspension of the first metacarpal and interposition is still the most commonly used surgical procedure in patients with CMC1 OA. Although there are several reports of good short-term results after trapeziectomy and tendon suspension-interposition arthroplasty, few studies have evaluated long-term outcomes. This study is one of the largest and longest follow-up evaluations of a cohort of patients with CMC1 OA who were treated with trapeziectomy and suspension-interposition arthroplasty, capturing 96% of the original cohort for evaluation. QUESTIONS/PURPOSES: (1) After trapeziectomy and tendon suspension surgery, what are the long-term, patient-reported outcomes and clinical measurements (strength and ROM); and in unilateral procedures, how do these parameters compare with those of the contralateral hand that was not operated on? (2) What is the mean subsidence (unloaded trapezial space), and does pinch strength correlate with the amount of subsidence? METHODS: From 1998 to 2005, 130 patients underwent trapeziectomy and abductor pollicis longus (APL) suspension-interposition arthroplasty for CMC1 OA at one orthopaedic department. During this period, 15 patients were treated with CMC1 arthrodesis and four were treated with implant arthroplasty, for a total of 149 patients. The surgeons used APL suspensionplasty for most patients, based on age and expected postoperative function; they also employed this procedure to avoid hardware or implant failure issues. The 100 living patients were asked to participate in this retrospective study, 96% (96) of whom were enrolled. The mean age at surgery was 58 ± 7 years. The patients completed a two-item thumb pain scale (modified from the SF-36 body pain scale), a hand pain VAS (average level of pain experienced over the week preceding measurement), and the 11-item QuickDASH. Patient-reported outcomes data were obtained from all 96 patients, and 83% (80) of patients underwent bilateral hand radiography and a physical examination at a mean follow-up of 17 ± 2.4 years. We calculated outcome data for each patient, and in 39 patients with unilateral surgery and intact contralateral CMC1 joint, we compared the operated side with the contralateral side. We compared our outcome data with that from the Swedish National Quality Registry for Hand Surgery (HAKIR), noting comparable outcomes for pain and QuickDASH scores. RESULTS: At long-term follow-up after trapeziectomy and APL suspension surgery, the mean thumb pain score was 19 ± 26, hand pain VAS score 23 ± 25, and QuickDASH score 26 ± 21. In the patients with unilateral surgery and intact contralateral CMC1 joint, the thumb pain score for the operated side was lower than the contralateral side, specifically 19 ± 25 compared with 29 ± 30 (mean difference -9.8 [95% CI -19.5 to -0.2]; p = 0.045); hand pain VAS score was 24 ± 23 versus 30 ± 25 (mean difference -6.1 [95% CI -15.2 to 3.1]; p = 0.19), and the QuickDASH score was 27 ± 19. Grip strength showed no differences between the operated and contralateral sides (mean 16.7 ± 7.3 kg versus 16.6 ± 6.9 kg, mean difference 0.1 [95% CI -1.6 to 1.8]; p = 0.90), while pinch was different (4.4 ± 1.4 versus 5.0 ± 1.5 kg, mean difference -0.6 [95% CI -0.9 to -0.3]; p = 0.001). The mean trapezial space was 4.4 ± 2.2 mm, and there was no association between the trapezial space and pinch strength (0.07 kg [95% CI -0.04 to 0.18] per mm of space; p = 0.17). CONCLUSION: The finding of comparable pain and function between operated and unoperated sides at long-term follow-up suggests that trapeziectomy and tendon suspension-interposition arthroplasty provides predictable outcomes, and surgeons can use these data to counsel patients that surgery can potentially return them to comparable use. However, as patients often have asymptomatic radiographic OA on the contralateral side, future studies are needed to examine the impact of asymptomatic disease on function. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Construct validity, floor and ceiling effects, data completeness and magnitude of change for the eight-item HAKIR questionnaire: a patient-reported outcome in the Swedish National Healthcare Quality Registry for hand surgery.

Introduction: The aim of this study was to evaluate the construct validity, floor and ceiling effects, data completeness and magnitude of change over time for the eight-item patient questionnaire (HQ-8) in the Swedish Healthcare Quality Registry for hand surgery (HAKIR). Methods: Construct validity was investigated through predefined hypotheses and correlation statistics between the single items in HQ-8 (pain on load, pain on motion without load, pain at rest, stiffness, weakness, numbness, cold sensitivity and ability to perform daily activities) and QuickDASH. Floor and ceiling effects and data completeness were analysed at preoperative (n = 13,197), three months (n =10,702) and one year (n = 9,986) responses from hand surgery patients. Effect sizes were calculated for pre- and postoperative change scores in elective conditions and postoperative scores for acute conditions. Results: Correlation coefficients at pre, 3 and 12 months ranged from 0.44 to 0.79 in the total group. No ceiling effect occurred, but a floor effect for the total group was noted for all items at all follow-ups. Missing responses were < 2.6% except for cold sensitivity. The effect sizes varied from small to large for individual items in elective diagnoses. For acute injuries, small effect sizes were found. Discussion: This study provides evidence of construct validity of HQ-8, lack of ceiling effect, expected floor effect, good data completeness and an ability to detect changes over time. The results indicate that HQ-8 measures unique aspects of disability. The HQ-8 could complement the Quick-DASH in describing patient-reported outcomes after hand surgery.

A smartphone application to facilitate adherence to home-based exercise after flexor tendon repair: A randomised controlled trial.

OBJECTIVE: Evaluate the effect of a smartphone application on exercise adherence, range of motion and self-efficacy compared to standard rehabilitation after repair of the flexor digitorum profundus tendon. DESIGN: Prospective multi-centre randomised controlled trial. SETTING: Four hand surgery departments in Sweden. SUBJECTS: A total of 101 patients (35 women) (mean age 37.5 ± 12.8) were randomised to control (n = 49) or intervention group (n = 52). INTERVENTION: A smartphone application to facilitate rehabilitation. MAIN OUTCOME MEASURES: Adherence assessed with the Sport Injury Rehabilitation Adherence Scale at two and six weeks (primary outcome). Secondary outcomes were self-reported adherence in three domains assessed at two and six weeks, self-efficacy assessed with Athlete Injury Self-Efficacy Questionnaire at baseline, two and six weeks. Range of motion and perceived satisfaction with rehabilitation and information were assessed at 12 weeks. RESULTS: Twenty-five patients were lost to follow-up. There was no significant between group difference in Sport Injury Rehabilitation Adherence Scale at two or six weeks, mean scores (confidence interval, CI 95%) 12.5 (CI 11.8-13.3), 11.8 (CI 11.0-12.8) for the intervention group, and 13.3 (CI 12.6-14.0), 12.8 (CI 12.0-13.7) for the control group. Self-reported adherence for exercise frequency at six weeks was significantly better for the intervention group, 93.2 (CI 86.9-99.5) compared to the controls 82.9 (CI 76.9-88.8) (P = 0.02). There were no differences in range of motion, self-efficacy or satisfaction. CONCLUSION: The smartphone application used in this study did not improve adherence, self-efficacy or range of motion compared to standard rehabilitation for flexor tendon injuries. Further research regarding smartphone applications is needed. LEVEL OF EVIDENCE: I. Randomised controlled trial.

DendroPrime as an adhesion barrier on fracture fixation plates: an experimental study in rabbits.

We tested the anti-adhesional effect of a new thiol-ene-based coating in a rabbit model. In 12 New Zealand white rabbits, the periosteum and cortex of the proximal phalanx of the second toe of both hind paws was scratched. Stainless steel plates were fixated with screws. One plate was coated with DendroPrime and the other left bare. The non-operated second toes of both hind paws of an additional four rabbits served as controls. Seven weeks after surgery, the soft tissue adhesion to the plates was evaluated macroscopically, and joint mobility was measured biomechanically. Toe joint mobility was about 20% greater and statistically significant in specimens with coated plates compared with the bare plates. Soft tissue overgrowth and, in some cases, synovitis or adhesions between the plate and the tendon were observed on all bare plates but not on any of the coated plates. We conclude that the thiol-ene-based coating can improve joint mobility by about 20%. This material has a potential to reduce adhesion around plates in fracture surgery.

Ulnar Nerve Entrapment in Diabetes: Patient-reported Outcome after Surgery in National Quality Registries.

BACKGROUND: Ulnar nerve entrapment at the elbow (UNE) is overrepresented in patients with diabetes, but the outcome of surgery is unknown. We aimed to evaluate patient-reported outcome in patients with and without diabetes, and to assess potential sex differences and compare surgical treatment methods. METHODS: Data on patients operated for UNE (2010-2016, n = 1354) from the Swedish National Registry for Hand Surgery were linked to the Swedish National Diabetes Register. Symptoms were assessed preoperatively (n = 389), and 3 (n = 283), and at 12 months postoperatively (n = 267) by QuickDASH and HQ-8 (specific hand surgery questionnaire-8 questions). Only simple decompressions were included when comparing groups. RESULTS: Men with diabetes reported higher postoperative QuickDASH scores than men without diabetes. Women scored their disability higher than men on all time-points in QuickDASH, but showed larger improvement between preoperative and 12 months postoperative values. Patients operated with transposition scored 10.8 points higher on QuickDASH than patients who had simple decompression at 12 months (95% confidence interval 1.98-19.6). CONCLUSIONS: Women with diabetes benefit from simple decompression for UNE to the same extent as women without diabetes. Men with diabetes risk not to benefit from simple decompression as much as women do. Ulnar nerve transposition had a higher risk of residual symptoms compared to simple decompression.

A registry based analysis of the patient reported outcome after surgery for trapeziometacarpal joint osteoarthritis.

BACKGROUND: The aim of the study was to evaluate patient reported outcome measures (PROM) before and after trapeziectomy with or without ligament reconstruction and tendon interposition for trapeziometacarpal joint arthritis with special focus on possible differences due to gender, age and surgical method. METHODS: Data from the Swedish quality registry for hand surgery (HAKIR) was analyzed preoperatively, 3 months and 1 year postoperatively for 1850 patients (mean age 63 years, 79% women). RESULTS: One year postoperatively, mean pain at rest was reduced from 50 to 12 of maximum 100. However, pain on load and weakness had not abated to the same extent (mean 30 and 34 of 100, respectively). The mean improvement in PROM did not differ between age groups or gender. The result was similar after trapeziectomy with ligament reconstruction and tendon interposition (86% of the patients) and simple trapeziectomy but few patients were operated with the latter method. CONCLUSION: Pain on load and weakness remains to some extent 1 year after surgery for trapeziometacarpal joint arthritis. The result is similar after trapeziectomy with or without ligament reconstruction and tendon interposition and the same improvement can be expected after surgery regardless of age and gender.

Dynavisc as an Adhesion Barrier in Finger Phalangeal Plate Fixation-a Prospective Case Series of 8 Patients.

Purpose: Adhesion problems are common after plate fixation of finger phalanges and often lead to stiffness and reoperations with plate removal and tenolysis. The aim of this prospective case series was to study the effect of the adhesion barrier gel Dynavisc on total active motion (TAM), postoperative pain, and grip strength after plate fixation of phalangeal fractures. Total active motion at 3 months after surgery was the primary outcome. Methods: Eight patients with a fracture of the proximal phalanx underwent surgery with open reduction and plate fixation. The adhesion barrier Dynavisc was applied between plate and extensor tendon and between tendon and skin. Results in terms of pain, grip strength, and TAM at 2 weeks, 3 months, and 1 year after surgery were collected. Results on TAM were classified according to Page and Stern. Results: After 3 months, only 2 patients had a result classified as excellent. After 1 year, 3 patients fulfilled the criteria for an excellent result. There were no adverse events. Patients with long-standing postoperative pain had a worse outcome on TAM. Conclusions: The antiadhesive effect of Dynavisc in this prospective case series was unconvincing. Only 2 patients had an excellent result on TAM at 3 months. Because the gel is resorbed within 30 days after application, it is questionable whether the gel had a role in improvement that occurred later in the postoperative course. Larger, randomized studies would be required to show any anti-adherent effect of Dynavisc definitively in finger fracture surgery. Type of study/level of evidence: Therapeutic IV.

Open carpal tunnel release and diabetes: a retrospective study using PROMs and national quality registries.

OBJECTIVES: To study patient-reported outcome after open carpal tunnel release (OCTR) for carpal tunnel syndrome (CTS) in patients with or without diabetes using national healthcare quality registries. DESIGN: Retrospective cohort study. SETTING: Data from the Swedish National Quality Registry for Hand Surgery (HAKIR; www.hakir.se) were linked to data from the Swedish National Diabetes Register (NDR; www.ndr.nu). PARTICIPANTS: We identified 9049 patients (10 770 hands) operated for CTS during the inclusion period (2010-2016). PRIMARY OUTCOME MEASURES: Patient-reported outcome measures were analysed before surgery and at 3 and 12 months postoperatively using the QuickDASH as well as the HAKIR questionnaire with eight questions on hand symptoms and disability. RESULTS: Patients with diabetes (n=1508; 14%) scored higher in the QuickDASH both preoperatively and postoperatively than patients without diabetes, but the total score change between preoperative and postoperative QuickDASH was equal between patients with and without diabetes. The results did not differ between patients with type 1 or type 2 diabetes. Patients with diabetic retinopathy scored higher in QuickDASH at 3 months postoperatively than patients with diabetes without retinopathy. In the regression analysis, diabetes was associated with more residual symptoms at 3 and 12 months postoperatively. CONCLUSIONS: Patients with diabetes experience more symptoms both before and after OCTR, but can expect the same relative improvement from surgery as patients without diabetes . Patients with retinopathy, as a proxy for neuropathy, may need longer time for symptoms to resolve after OCTR. Smoking, older age, higher HbA1c levels and receiving a diabetes diagnosis after surgery were associated with more residual symptoms following OCTR.

Upper-limb contracture development in children with cerebral palsy: a population-based study.

AIM: The aim of this study was to investigate the longitudinal development of passive range of motion (ROM) in the upper limbs in a population-based sample of children with cerebral palsy (CP), and to investigate which children are more likely to develop contractures related to functional level, CP subtype, and age. METHOD: Registry data of annual passive ROM measurements of the upper limbs from 771 children with CP (417 males, 354 females; mean age 11y 8mo, [SD 5mo] range 1-18y) were analysed. Mixed models were used to investigate at what age decreased passive ROM occurs. Odds ratios were calculated to compare risks and logistic regression analysis was used to predict contracture development. RESULTS: Thirty-four per cent of the children had developed contractures. Among these children, decreased passive ROM was significant at a mean age of 4 years for wrist extension and 7 years for shoulder flexion, elbow extension, and supination. Children at Manual Ability Classification System (MACS) level V had a 17-times greater risk of contractures than children at MACS level I. INTERPRETATION: One-third of the children in the total population developed upper-limb contractures while passive ROM decreased with age. MACS level was the strongest predictor of contracture development. WHAT THIS PAPER ADDS: In a population-based sample of 771 children with cerebral palsy, 34% developed an upper-limb contracture. Contracture development started at preschool age. The first affected movements were wrist extension and supination. Passive range of motion decreased with age. High Manual Ability Classification System level was the most important predictor of contractures.