Re: Pan ZJ, Xu YF, Pan L, Chen J. Zone 2 flexor tendon repairs using a tensioned strong core suture, sparse peripheral stitches and early active motion: results in 60 fingers. J Hand Surg Eur. 44: 361–6

Abstract

a call on this topic prioritizing it as an important area in need of further evidence. With regards to the perceived ‘safety’ of the proposed trial of digital nerve repair, we infer that this pertains to the incidence of neuroma formation. In our systematic review, neuroma incidence, as far as can be assessed given the limitations of the studies, was not clearly different for the repaired and unrepaired group (Dunlop et al., 2019). Furthermore, with regards to safety in hand surgery trials, we should look to other surgical specialties that have pushed the frontiers of evidence-based medicine in areas of much higher risk. For example, vascular surgeons compared open versus endovascular repair of abdominal aortic aneurysms (Lederle et al., 2019), and neurosurgeons evaluated the use of corticosteroids in severe head injury in prospective randomized controlled trials (CRASH, 2004). At no point do we suggest that we aim to ‘stop trying to repair the nerve altogether’, and we hope that McArthur et al. will reconsider their stated position regarding contributing to a study, which aims to improve the evidence base for this injury. In our view, it is not an acceptable situation to continue a practice for which there is a lack of reliable evidence to demonstrate its benefit, especially when there is an associated risk to the patient, even if it a small one compared with other clinical problems. A large comparative study (such as a trial) in this area is likely to demonstrate a spectrum of outcomes, and could identify which patient groups benefit from surgery. Such a study would allow surgeons to better inform patients of their likely outcome.