Adrian Chojnowski

Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis

BACKGROUND Triangular fibrocartilaginous complex (TFCC) tears are common sources of ulnar-sided wrist pain and resultant functional disability. Diagnosis is based on the history and clinical examination as well as radiographic evidence of a TFCC central perforation or a radial/ulnar tear. The purpose of this study was therefore to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in the detection of TFCC injury in the adult population. METHODS Published and unpublished literature databases were searched. Two-by-two tables were constructed to calculate the sensitivity and specificity of MRI or MRA investigations against arthroscopic outcomes. Pooled sensitivity and specificity values and summary receiver operating characteristic curve evaluations were performed. The methodological quality of each study was assessed with use of the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool. RESULTS Twenty-one studies were included in the review, and these series included a total of 982 wrists. On meta-analysis, MRA was superior to MRI in the investigation of full-thickness TFCC tears, with a pooled sensitivity of 0.75 and a pooled specificity of 0.81 for MRI compared with 0.84 and 0.95, respectively, for MRA. MRA and MRI performed at greater field strengths were reported to have greater sensitivity and specificity than those performed at lower field strengths. There were insufficient data to assess the diagnostic test accuracy for partial-thickness TFCC tears. CONCLUSIONS Given its acceptable diagnostic test accuracy, it is recommended that MRA, rather than MRI, be performed in when there are questions about the diagnosis and subsequent management of patients with ulnar-sided wrist pain.

Severity of contracture and self-reported disability in patients with Dupuytren's contracture referred for surgery.

UNLABELLED The purpose of the study was to explore the relationship between preoperative flexion contracture (FC) and self-reported disability in patients undergoing surgical release by fasciectomy or dermofasciectomy. The study design used was a prospective observational study: Dupuytrens disease (DD) is a fibroproliferative disorder of the palmar fascia and may lead to functional deficits requiring surgical intervention. Outcomes are usually reported using digital range of motion although recent studies have also included patient-rated outcome measures with the extensively validated Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire commonly used. One hundred fifty-four patients consecutively enrolled in a prospective randomized trial were assessed before surgery for active range of movement using goniometry and self-reported functioning using DASH questionnaire. The small finger was affected in 69% of patients with a mean FC of 77.8 degrees (standard deviation=43.5°). The mean DASH score was 16 points (range, 0-62). The correlation between severity of FC in all four fingers and DASH was weak (r=0.264, p=0.001). At individual digital level, the correlation between FC and DASH was weak in the index (r=0.26), middle (r=0.28), and ring (r=0.21) fingers but almost absent in the small finger (r=0.07). These results show that the relationship between severity of FC and functional disability measured by the DASH questionnaire appear to be very weak or even absent. LEVEL OF EVIDENCE Level III prospective cohort study.

De la Caffinière thumb trapeziometacarpal joint arthroplasty: 16–26 year follow-up:

Seventy-one patients (93 implants) had a de la Caffinière prosthesis implanted between 1980 and 1989 and were reviewed and reported in 1997. We reviewed this series 10 years later. Similar outcome measures were used as in the original study, pinch and grip strength measured and validated outcome scores obtained (DASH and EQ-5D). Radiographic outcome was assessed. Twenty-six patients with 39 implants were available for review at a mean of 19 years (range, 16–26 years). Survivorship at 26 years was 73.9% (95% CI, 61.2 to 86.6) for re-operation and 26.0% (95% CI, 0 to 52.7) for all failure. Patients had satisfactory power and thumb mobility and continued to be satisfied without pain. Registries should log such prostheses and add to implant survival data.

The QuickDASH score: a patient-reported outcome measure for Dupuytren's surgery.

STUDY DESIGN Retrospective Cohort. INTRODUCTION There is currently no validated patient reported outcome measure (PROM) for Dupuytrens disease. We have performed a retrospective analysis of QuickDASH scores taken before and after surgery for Dupuytrens disease to assess the validity and responsiveness of the QuickDASH and evaluate its suitability to being a PROM for this condition. PURPOSE OF THE STUDY To determine the eligibility of the QuickDASH score as a Patient Reported Outcome Measure for Dupuytrens disease. METHODS Patients were identified from the hand therapy database that had surgery performed between January 2006 and April 2008 who had documented pre- and post-operative QuickDASH scores. RESULTS 69 patients were identified with complete datasets with a mean change in QuickDASH score of -7.14 (p < 0.001) and an improvement of extension deficit by 68.1 degrees (p < 0.001) at a mean 110 day follow-up. The change in QuickDASH score did not correlate with the change in extension deficit. The effect size was 0.545 and the standardised response mean was 0.580. CONCLUSION The QuickDASH is an acceptable PROM for Dupuytrens surgery with limitations. Further research is needed examining PROMs with this common condition. LEVEL OF EVIDENCE n/a.

Splinting after contracture release for Dupuytren's contracture (SCoRD): protocol of a pragmatic, multi-centre, randomized controlled trial

BackgroundSplinting as part of the overall post-surgical management of patients after release of Dupuytrens contracture has been widely reported, though there is variation in practice and criteria for using it. The evidence on its effectiveness is sparse, of poor quality and contradictory with studies reporting negative and positive effects.Methods/DesignA multi-centre, pragmatic, randomized, controlled trial is being conducted to evaluate the effect of static night splinting for six months on hand function, range of movement, patient satisfaction and recurrence at 1 year after fasciectomy or dermofasciectomy. Using a centrally administered computer randomization system consented patients will be allocated to one of two groups: i) splint group who will be given a static splint at approximately 10 to 14 days after surgery to be worn for 6 months at night time only as well as hand therapy; ii) non-splint group, who will receive hand therapy only. The primary outcome measure is the patient-reported Disabilities of the Arm, Hand and Shoulder Questionnaire (DASH). Secondary outcomes are total active flexion and extension of fingers, patient satisfaction and recurrence of contracture. Outcome measures will be collected prior to surgery, 3 months, 6 months and 1 year after surgery. Using the DASH as the primary outcome measure, where a difference of 15 points is considered to be a clinically important difference a total of 51 patients will be needed in each group for a power of 90%. An intention-to-treat analysis will be used.DiscussionThis pragmatic randomized controlled trial will provide much needed evidence on the clinical effectiveness of post-operative night splinting in patients who have undergone fasciectomy or dermofasciectomy for Dupuytrens contracture of the hand.Trial RegistrationCurrent Controlled Trials ISRCTN 57079614

Midcarpal instability: a radiological perspective

Midcarpal instability (MCI) is the result of complex abnormal carpal motion at the midcarpal joint of the wrist. It is a form of non-dissociative carpal instability (CIND) and can be caused by various combinations of extrinsic ligament injuries that then result in one of several subtypes of MCI. The complex patterns of injury and the kinematics are further complicated by competing theories, terminology and classifications of MCI. Palmar, dorsal, ulna midcarpal instability, and capitolunate or chronic capitolunate instability are all descriptions of types of MCI with often overlapping features. Palmar midcarpal instability (PMCI) is the most commonly reported type of MCI. It has been described as resulting from deficiencies in the ulna limb of the palmar arcuate ligament (triquetrohamate-capitate) or the dorsal radiotriquetral ligaments, or both. Unstable carpal articulations can be treated with limited carpal arthrodesis or the ligamentous defects can be treated with capsulorrhaphy or ligament reconstruction. Conventional radiographic abnormalities are usually limited to volar intercalated segment instability (VISI) patterns of carpal alignment and are not specific. For many years stress view radiographs and videofluoroscopy have been the methods of choice for demonstrating carpal instability and abnormal carpal kinematics respectively. Dynamic US can be also used to demonstrate midcarpal dyskinesia including the characteristic triquetral “catch-up” clunk. Tears of the extrinsic ligaments can be demonstrated with MR arthrography, and probably with CT arthrography, but intact yet redundant ligaments are more difficult to identify. The exact role of these investigations in the diagnosis, categorisation and management of midcarpal instability has yet to be determined.

A Qualitative Study of the Experiences and Expectations of Surgery in Patients with Carpal Tunnel Syndrome

The aim of this study was to explore the impact of carpal tunnel syndrome (CTS) on individuals and their expectations of surgical decompression to identify what outcome domains need to be assessed in future clinical trials. This qualitative study used in-depth, face-to-face interviews with nine patients with CTS awaiting surgical decompression. The tape-recorded interviews were transcribed fully, data were coded and categorized independently by two researchers and emerging themes were identified. Patients identified relief of symptoms-tingling, numbness and sleep disturbance, and resumption of important activities-as their most important criteria for judging the success of surgery. Although they recognized the consequences of this disorder were minor in comparison to more serious diseases, patients expressed distress at the impact of this disorder on their quality of life and expressed hope that surgery would address this. The assessment of outcomes of surgical decompression of CTS needs to include measures of symptom resolution as well as of activity limitation and participation restriction. Using existing patient-rated, disease-specific, and region-specific outcome instruments is likely to capture those domains which patients consider important criteria of success.

Pyrocarbon metacarpophalangeal joint replacement in primary osteoarthritis

The purpose of this retrospective cohort study was to evaluate the outcomes of 18 primary pyrocarbon metacarpophalangeal joint replacements in 10 patients, performed for primary osteoarthritis. The mean age at operation was 66 years and mean follow-up was 58.6 months. The arc of motion improved from a mean of 30° to 40° and the mean QuickDASH score improved from 35 to 17. All except one patient were satisfied with their outcomes. Radiographically, there has been no evidence of dislocation or overt loosening, although there has been subsidence of some components up to 5 mm. One index finger implant was revised to a silastic implant for perceived alteration of precision pinch. Other complications included one intra-operative fracture that united and an asymptomatic stem fracture of one proximal phalangeal component. We continue to use the implant and aim to review our experience in a further 5 years.

Scaphoid nonunion in the presence of a degenerate carpus: don't rush to salvage surgery.

We retrospectively studied 13 patients with degenerative change associated with a scaphoid nonunion treated by internal fixation and bone graft. All patients had radiological signs of radioscaphoid degenerative change (scaphoid nonunion advanced collapse – scaphoid nonunion advanced collapse - grade II or more) and had surgery more than 2 years after injury. Ten of the 13 patients achieved union at 6 months with all but one of these demonstrating improvement on the Disability of Arm, Shoulder and Hand (DASH) score. Surgeons presented with this difficult patient group might consider reconstruction before salvage procedures.

The diagnostic accuracy of X-ray arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis

The purpose of this study was to evaluate the diagnostic test accuracy of X-ray arthrography in the detection of TFCC tear. Both published and unpublished databases were searched from their inception to August 2010. All studies comparing the diagnostic accuracy of X-ray arthrography (index test) to arthroscopy (reference standard) for patients with suspected TFCC tears were included in this review. Twelve studies assessing 430 patients (430 wrists) satisfied the eligibility criteria and were included. X-ray arthrography presented with a pooled sensitivity of 76.2% and specificity of 92.5% for the detection of complete TFCC tear. The triple-compartment injection X-ray arthrography was superior to the single-compartment injection technique. To conclude, the diagnostic test accuracy of X-ray arthrography is limited. Neither the single- nor the triple-compartment injection arthrography method is acceptable, given their reported low sensitivities. Further evaluation of the diagnostic test accuracy of Magnetic Resonance Arthrography and Magnetic Resonance Imaging is therefore warranted.