Preventing facial pressure injuries among health care staff working in diverse COVID-19 care environments.

The aim of this study was to determine the impact of a specially designed care bundle on the development of facial pressure injuries among frontline health care workers wearing personal protective equipment (PPE) during the COVID-19 pandemic. This was a mixed methods study. First, a pre-posttest observational design was employed to evaluate the impact of the pre-piloted intervention, a care bundle including skin cleansing and hydration, protective material use, facemask selection and skin inspection, developed in line with international best practice guidelines. Data were collected using survey methodology. Frontline COVID-19 staff working in acute, community and ambulance services were invited to participate. Then, judgemental and volunteer sampling was used to select participants to undertake semi-structured interviews to elicit feedback on their perceptions of the care bundle. The sample included 120 acute hospital staff, 60 Ambulance staff, 24 Community Hub staff and 20 COVID-19 testing centre staff. A survey response rate of 61% was realised (n = 135/224). Of the participants, 32% (n = 43) had a facial pressure ulcer (FPI) pre-intervention and 13% (n = 18) developed an FPI while using the care bundle. The odds ratio (OR) was 0.33 (95% CI: 0.18 to 0.61; P = .0004), indicating a 77% reduction in the odds of FPI development with use of the care bundle. Analysis of the qualitative data from 22 interviews identified three key themes, the context for the care bundle, the ease of use of the care bundle and the care bundle as a solution to FPI development. The care bundle reduced the incidence of FPI among the participants and was found to be easy to use. Implementation of skin protection for frontline staff continues to be important given the persistently high incidence of COVID-19 and the ongoing need to wear PPE for protracted durations.

Prospective Clinical Trial Comparing Trapezial Denervation With Trapeziectomy for the Surgical Treatment of Arthritis at the Base of the Thumb.

BACKGROUND: Trapeziectomy is considered to be the "gold standard" procedure for first carpometacarpal joint (first CMCJ) osteoarthritis. First CMCJ denervation offers the potential benefit of a shorter procedure with bone and joint preservation and swift postoperative rehabilitation. This trial aimed to compare functional outcomes, patient satisfaction, quality of life, and cost effectiveness following these treatments. METHODS: This study was a prospective clinical trial commencing December 2005 to November 2013. A range of functional outcomes assessments were used preoperatively at 6 and 12 mo and 5 y after surgery. These included measurements of strength/motion, visual analogue score, Michigan Hand Outcomes and the European Quality of Life-5 Dimensions questionnaires. Data were analyzed using a two-sample t-test and Mann-Whitney test. RESULTS: A total of 45 patients were studied of 55 recruited. Age ranged from 41 to 72 (mean = 59). Thirty-five patients underwent denervation and 10 initially had trapeziectomy. Nine patients were converted to trapeziectomy within an average of 6 to 12 mo. There was no significant difference in the functional outcomes at different points of follow-ups. Similarly, there was no significant difference in the time of return to work or cost effectiveness. Denervation achieved a success rate of just above 70%, whereas no revisions were required for the trapeziectomy group. CONCLUSIONS: There was no difference between the two treatments. First CMCJ denervation does not appear to be superior to trapeziectomy. However, the advantage of rapid rehabilitation makes it more favored by patients but at the expense of 30% reoperation rate. LEVEL OF EVIDENCE: Level II.

Study to Assess Outcome After Open and Closed Carpal Tunnel Decompression.

Carpal tunnel decompression (CTD) is the most commonly performed surgical procedure within a hand unit. We have analyzed data on outcomes after carpal decompression performed by both open and closed techniques to assess whether outcomes differed between the 2 procedures. Data were jointly gathered from 2 units. The aim was to assess the outcome after CTD. Completed data were gathered from 621 CTD procedures performed on 484 patients. Of the procedures, 358 were performed via a standard open CTD technique and 263 procedures were performed via a closed single-port Agee technique. Assessments were performed by means of the Levine-Katz questionnaire, Semmes-Weinstein monofilament testing, grip strength, and pinch-grip strength testing. Assessments were performed both preoperatively and 6 months postoperatively. A randomly selected 10% of patients were also assessed at 12 months. The results were statistically better after closed CTD at the 6-month postoperative stage. However, the difference became less marked by 12-month postoperative stage. Our results show that CTD whether performed by an open or closed technique resulted in a similar outcome at the 12-month postoperative stage. However, those procedures performed by a closed technique offered a more rapid recovery in the first 6 months postoperative than by an open technique.

Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition.

PURPOSE: To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improve the outcome of trapezial excision for the treatment of basal joint arthritis after a minimum follow-up of 5 years. METHODS: We randomized 174 thumbs with trapeziometacarpal osteoarthritis into 3 groups to undergo simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void and retained for 4 weeks, and a thumb spica was used for 6 weeks in all 3 groups. We reviewed 153 thumbs after a minimum of 5 years (median, 6 y; range, 5-18 y) after surgery with subjective and objective assessments of thumb pain, function, and strength. RESULTS: There was no difference in the pain relief achieved in the 3 treatment groups, with good results in 120 (78%) patients. Grip strength and key and tip pinch strengths did not differ among the 3 groups and range of movement of the thumb was similar. Few complications persisted after 5 years, and these were distributed evenly among the 3 groups. Compared with the results at 1 year in the same group of patients, the good pain relief achieved was maintained in the longer term, irrespective of the type of surgery. While improvements in grip strength achieved at 1 year after surgery were preserved, the key and tip pinch strengths deteriorated with time, but the type of surgery did not influence this. CONCLUSIONS: The outcomes of these 3 variations of trapeziectomy were similar after a minimum follow-up of 5 years. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term.

Building capacity: getting evidence-based practice into healthcare professional curricula.

Fostering a culture of clinical effectiveness in healthcare is crucial to achieving optimum outcomes for patients. Evidence-based practice (EBP) is a cornerstone of clinical effectiveness. An EBP capacity-building project commenced in Ireland in 2016, in collaboration with the Centre of Evidence-Based Medicine in Oxford. A key part of this project, reported here, was the development of a competency framework for education in EBP and clinical effectiveness to ensure responsiveness of education standards and curricula of healthcare professionals in this area. METHODS: Following a review of national and international reports, professional guidance documents and empirical literature pertaining to clinical effectiveness education (CEE), a preliminary competency framework was developed. Stakeholder consultations were conducted over a 6-month period, which consisted of 13 focus groups (n=45) and included representatives from clinical practice, higher education and professional training sectors, regulator/accrediting bodies, the Department of Health (Ireland) and patient/service user groups. RESULTS: An overarching interprofessional competency framework for CEE was proposed and included the following domains: EBP, quality improvement processes, implementation strategies and collaborative practice: a total of 16 competencies and 60 indicators. CONCLUSION: A competency framework for CEE for health and social care professionals is presented. It is intended that this framework will provide guidance to healthcare educators and regulators in the construction and revision of curricula, learning outcomes, teaching and assessment strategies, and graduate/clinician attributes.

A randomized controlled trial of real versus sham acupuncture for basal thumb joint arthritis.

We report a single-blinded randomized controlled trial comparing acupuncture to sham (non-penetrating) needling for relief of symptoms of basal thumb joint arthritis. Seventy acupuncture naive patients with basal thumb joint arthritis were randomized to receive true acupuncture or sham needling with 35 patients in each arm. Blinded baseline and post-treatment assessments included visual analogue pain scores for different grips and movement. Function was assessed using the Nelson questionnaire. Both groups showed statistically and clinically significant improvements in pain at week one post-treatment compared with baseline, but there was no difference between the treatment groups. The pain relief was comparable with published data for some standard treatments. Acupuncture did not perform better than sham needling in this study, indicating that pain relief may have been achieved through non-specific mechanisms. Level of evidence: I.

Metacarpal osteotomy for correction of acquired phalangeal rotational deformity.

Symptomatic phalangeal rotation deformities require corrective osteotomy. Surgery at the phalangeal level is technically demanding and has a higher complication rate. We describe the surgical technique of metacarpal base osteotomy for rotation correction of the digit. This technique is simple, allows early rehabilitation, and has a lower complication rate.

Outcomes of silicone arthroplasty for rheumatoid metacarpophalangeal joints stratified by fingers.

PURPOSE: Previous studies have demonstrated that outcomes for the ulnar digits appear to be worse than those of the radial digits after silicone metacarpophalangeal joint arthroplasty (SMPA) for the rheumatoid hand. This study examines various components of hand deformities in an effort to understand SMPA outcomes in terms of metacarpophalangeal (MCP) joint range of motion and alignment. We hypothesize that the ulnar fingers will have less improvement, marked by greater ulnar drift, extension lag, and less MCP joint arc of motion than the radial fingers. METHODS: Sixty-eight surgical patients were recruited from 3 sites in this multicenter, international prospective cohort study. All patients had a diagnosis of rheumatoid arthritis, were between the ages of 18 and 80, and were eligible to have SMPA based on measured hand deformities (extensor lag and ulnar drift). Ulnar drift, extension lag, and arc of motion for the MCP joint of each finger were measured at baseline (before surgery) and 1 year after SMPA. RESULTS: All fingers showed an improvement in ulnar drift from baseline to 1 year after surgery. The smallest improvement was in the index finger, and the largest improvement was in the little finger. Similarly, the largest improvement in extension lag was seen in the little finger, and the smallest improvement was seen in the index finger. In terms of MCP joint arc of motion, all fingers moved to a more extended posture and gained an improved arc of motion, but the biggest improvement was observed in the 2 ulnar fingers and less in the 2 radial fingers. CONCLUSIONS: Our hypothesis that the ulnar fingers would have worse outcomes than the radial fingers was not proven by this study. Although experiences have indicated that it is more difficult to maintain posture for the ring and little fingers after SMPA owing to the deforming forces, sufficient correction of the deformities in the ulnar fingers is possible, if adequate bone resection and realigning of the extensor mechanism are carefully performed during the procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

A multicenter clinical trial in rheumatoid arthritis comparing silicone metacarpophalangeal joint arthroplasty with medical treatment.

PURPOSE: Metacarpophalangeal (MCP) joint deformities caused by rheumatoid arthritis can be treated using silicone metacarpophalangeal joint arthroplasty (SMPA). There is no consensus as to whether this surgical procedure is beneficial. The purpose of the study was to prospectively compare outcomes for a surgical and a nonsurgical cohort of rheumatoid arthritis patients. METHODS: The prospective study was conducted from January 2004 to May 2008 at 3 referral centers in the United States and England. Over a 3-year period, 70 surgical and 93 nonsurgical patients were recruited. One year data are available for 45 cases and 72 controls. All patients had severe ulnar drift and/or extensor lag of the fingers at the MCP joints. The patients all had 1-year follow-up evaluations. Patients could elect to have SMPA and medical therapy or medical therapy alone. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales, grip and pinch strength, Jebson-Taylor test, and ulnar deviation and extensor lag measurements at the MCP joints. RESULTS: There was no difference in the mean age for the surgical group (60) when compared to the nonsurgical group (62). There was also no significant difference in race, education, and income between the 2 groups. At 1-year follow-up, the mean overall MHQ score showed significant improvement in the surgical group but no change in the nonsurgical group, despite worse MHQ function at baseline in the surgical group. Ulnar deviation and extensor lag improved significantly in the surgical group, but the mean Arthritis Impact Measurement Scales scores and grip and pinch strength showed no significant improvement. CONCLUSIONS: This prospective study demonstrated significant improvement for RA patients with poor baseline functioning treated with SMPA. The nonsurgical group had better MHQ scores at baseline, and their function did not deteriorate during the 1-year follow-up interval.

Diagnosis and treatment of swellings in the hand.

Patients commonly present to their general practitioner with swellings of the hand. These include a variety of diagnoses with certain lesions (for example, ganglion) being more common than others. Some may even be familiar as they are often site specific. For those that are not routinely seen, or for those that look suspicious, referral to a hand surgeon is usually customary. This article aims to provide general practitioners with clear and concise information and terms of reference on the common hand swellings that they may encounter.

Basal thumb arthritis.

Basal thumb arthritis is a common condition seen in hand clinics across the United Kingdom and is often associated with other pathological conditions such as carpal tunnel syndrome and scaphotrapezial arthritis. Typically, patients complain of pain localised to the base of the thumb. This pain is often activity related, particularly after excessive use involving forceful pinch. A detailed history and examination is normally all that is needed to make the diagnosis. Provocative manoeuvres may be helpful in localising symptoms to the basal joint with degenerative changes or synovitis. Radiographs are useful for confirming the diagnosis and staging the disease in order to plan for surgery. The mainstay of initial treatment of basal thumb arthritis of any stage is activity modifications, rest, nonsteroidal anti-inflammatory drugs, exercises and splinting. A variety of surgical procedures are available to treat the condition when conservative measures have failed, in order to control symptoms and improve function. We review the current literature and discuss the clinical aspects of this condition, staging, and treatment options available, and the difficulties treating this group of patients.

Primary care management of patients with carpal tunnel syndrome referred to surgeons: are non-operative interventions effectively utilised?

AIM: To investigate the non-operative primary care management (splintage, task modification advice, steroid injections and oral medications) of carpal tunnel syndrome before patients were referred to a hand surgeon for decompression. DESIGN AND SETTING: Preoperative data were obtained on age, gender, body mass index, employment, symptom duration, and preoperative clinical stage for patients undergoing carpal tunnel decompression (263 in the USA, 227 in the UK). RESULTS: Primary care physicians made relatively poor use of beneficial treatment options with the exception of splintage in the US (73% of cases compared with 22.8% in the UK). Steroid injections were used in only 22.6% (US) and 9.8% (UK) of cases. Task modification advice was almost never given. Oral medication was employed in 18.8% of US cases and 8.9% of UK cases. CONCLUSIONS: This study analyses the non-operative modalities available and suggests that there is scope for more effective use of non-operative treatment before referral for carpal tunnel decompression.

Hydrodilatation (distension arthrography): a long-term clinical outcome series.

OBJECTIVES: To describe and compare the medium to long-term effectiveness of hydrodilatation and post-hydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. METHODS: Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2-year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of "normal" function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures. RESULTS: A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2-year follow-up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2-year follow-up period. A significant improvement was observed in all outcomes measures over this period (p<0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used. CONCLUSIONS: Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.

Seven-Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study.

OBJECTIVE: Rheumatoid arthritis (RA) causes destruction of the metacarpophalangeal (MCP) joints, leading to hand deformities, pain, and loss of function. This study prospectively assessed long-term functional and health-related quality-of-life outcomes in RA patients with severe deformity at the MCP joints. METHODS: RA patients between ages 18 to 80 years with severe deformity at the MCP joints were referred to 1 of the 3 study sites. Subjects who elected to undergo silicone metacarpophalangeal joint arthroplasty (SMPA) while continuing with medical management were followed in the SMPA cohort. Subjects who elected to continue with medical management alone without surgery were followed in the non-SMPA cohort. Objective measurements included grip and pinch strength as well as arc of motion, ulnar drift, and extensor lag of the MCP joints. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Radiographs of SMPA implants were assessed and graded as intact, deformed, or fractured. RESULTS: MHQ scores showed large improvements post-SMPA, and baseline-adjusted expected outcomes in the SMPA group were significantly better at year 7 in function, aesthetics, satisfaction, and overall score compared to non-SMPA. SMPA subjects did not improve in grip or pinch strength, but achieved significant improvement and maintained the improvement long term in ulnar drift and extensor lag. CONCLUSION: Benefits of the SMPA procedure are maintained over 7 years with low rates of implant fracture or deformity. Non-SMPA patients remained stable in their hand function over the 7-year study duration.

Diagnostic criteria and staging of hand-arm vibration syndrome in the United Kingdom.

In the United Kingdom the diagnosis of Hand-arm Vibration Syndrome varies depending on the purpose of that diagnosis. The criteria differ in three situations. More than 100,000 miners and ex-miners with claims for HAVS have been examined using a Medical Assessment Process which included the use of standardised tests. This contract is unique but it has had significant effects on the two other processes. The Industrial Injuries Disablement Benefit Scheme provides a benefit that can be paid to an employed earner because of an accident or Prescribed Disease. New recommendations have been published to remove the anomalies in the present format for assessing HAVS. If implemented the new scheme will recognise the Stockholm Workshop Scales and workers with neurological problems will also be compensated. The Health and Safety Executive will issue new guidance in the near future on the hazards of hand-arm vibration. Health surveillance in the workplace will be fundamental and the HSE propose a tiered approach with levels 1 to 5. Specialist occupational nurses and doctors with training in the diagnosis and assessment of HAVS will be needed for levels 3 and 4. Only at this level may a diagnosis of HAVS be made. The Medical Assessment Process has demonstrated that it is possible to examine a large number of claimants in a standardised manner. The IIAC and HSE recommendations contain very important improvements on the existing positions in the UK and it must be hoped that they will be implemented in the near future.

Carpal tunnel syndrome, the search for a cost-effective surgical intervention: a randomised controlled trial.

OBJECTIVE: There is insufficient evidence regarding the clinical and cost-effectiveness of surgical interventions for carpal tunnel syndrome. This study evaluates the cost, effectiveness and cost-effectiveness of minimally invasive surgery compared with conventional open surgery. PATIENTS AND METHODS: 194 sufferers (208 hands) of carpal tunnel syndrome were randomly assigned to each treatment option. A self-administered questionnaire assessed the severity of patients' symptoms and functional status pre- and postoperatively. Treatment costs were estimated from resource use and hospital financial data. RESULTS: Minimally invasive carpal tunnel decompression is marginally more effective than open surgery in terms of functional status, but not significantly so. Little improvement in symptom severity was recorded for either intervention. Minimally invasive surgery was found to be significantly more costly than open surgery. The incremental cost effectiveness ratio for functional status was estimated to be 197 UK pounds, such that a one percentage point improvement in functioning costs 197 UK pounds when using the minimally invasive technique. CONCLUSIONS: Minimally invasive carpal tunnel decompression appears to be more effective but more costly. Initial analysis suggests that the additional expense for such a small improvement in function and no improvement in symptoms would not be regarded as value-for-money, such that minimally invasive carpal tunnel release is unlikely to be considered a cost-effective alternative to the traditional open surgery procedure.

Patient expectations and long-term outcomes in rheumatoid arthritis patients: results from the SARA (Silicone Arthroplasty in Rheumatoid Arthritis) study.

Little evidence exists to understand the influence of patient expectations on outcomes for silicone metacarpophalangeal arthroplasty (SMPA). The purpose of this paper is to compare long-term treatment outcome experiences regarding hand function/appearance for a surgical and nonsurgical cohort of rheumatoid arthritis (RA) patients and contrast them to expectations at baseline. This sample is part of a larger multicenter prospective cohort study of RA patients enrolled from 2004 to 2008. A total of 169 RA patients with severe deformities at the metacarpophalangeal (MCP) joints were recruited in the original study. Expectations for SMPA were collected at enrollment. A follow-up patient-reported questionnaire was completed at long-term follow-up. Baseline expectation questionnaires were collected from 137 patients, and follow-up data from 84 patients (average 6.7 years follow-up). At baseline, a significantly higher percent of patients who chose surgery expected to do "Anything I want" or "More activities than I do now" 1 year from enrollment than those who chose nonsurgical treatment. At follow-up, surgical patients remained more likely to indicate that they were currently able to do "Anything" or "More activities" than nonsurgical patients. A higher percentage of surgical patients were "very satisfied" or "quite satisfied" with their treatment compared to nonsurgical patients. RA subjects who chose SMPA reported greater expectations for surgery prior to surgery and also greater levels of hand function and satisfaction at long-term follow-up.

The effect of swan neck and boutonniere deformities on the outcome of silicone metacarpophalangeal joint arthroplasty in rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis patients with swan neck deformities are postulated to have greater metacarpophalangeal joint arc of motion because of their need to flex the joint to make a fist, whereas the boutonniere deformity places the fingers into the flexed position, creating less demand on the joint for grip. This study analyzes the effect of these deformities on the joint's arc of motion and hand function. METHODS: The authors measured the metacarpophalangeal joint arc of motion in 73 surgical patients. Data were allocated into groups by finger and hand deformity. Linear regression models were used to analyze the effect of the deformity on the joint's arc of motion. Functional outcomes were measured by the Michigan Hand Outcomes Questionnaire and the Jebson-Taylor Test. RESULTS: Nineteen fingers had boutonniere deformity, 95 had swan neck deformities, and 178 had no deformity. The no-deformity group had the least arc of motion at baseline (16 degrees) compared with the boutonniere (26 degrees) and swan neck (26 degrees) groups. Mean arc of motion in the no-deformity group compared with the boutonniere group at baseline was statistically significant, but all groups had similar arc of motion at long-term follow-up. Only mean Jebson-Taylor Test scores at baseline between the boutonniere and no-deformity groups were significantly different. CONCLUSIONS: The results did not support the hypothesis that swan neck deformities have better arc of motion compared with boutonniere deformity. Boutonniere deformity has worse function at baseline, but there was no difference in function among groups at long-term follow-up.