Anna L Pratt

Optimal functional outcome measures for assessing treatment for Dupuytren's disease: a systematic review and recommendations for future practice.

BackgroundDupuytrens disease of the hand is a common condition affecting the palmar fascia, resulting in progressive flexion deformities of the digits and hence limitation of hand function. The optimal treatment remains unclear as outcomes studies have used a variety of measures for assessment.MethodsA literature search was performed for all publications describing surgical treatment, percutaneous needle aponeurotomy or collagenase injection for primary or recurrent Dupuytren’s disease where outcomes had been monitored using functional measures.ResultsNinety-one studies met the inclusion criteria. Twenty-two studies reported outcomes using patient reported outcome measures (PROMs) ranging from validated questionnaires to self-reported measures for return to work and self-rated disability. The Disability of Arm, Shoulder and Hand (DASH) score was the most utilised patient-reported function measure (n=11). Patient satisfaction was reported by eighteen studies but no single method was used consistently. Range of movement was the most frequent physical measure and was reported in all 91 studies. However, the methods of measurement and reporting varied, with seventeen different techniques being used. Other physical measures included grip and pinch strength and sensibility, again with variations in measurement protocols. The mean follow-up time ranged from 2 weeks to 17 years.ConclusionsThere is little consistency in the reporting of outcomes for interventions in patients with Dupuytren’s disease, making it impossible to compare the efficacy of different treatment modalities. Although there are limitations to the existing generic patient reported outcomes measures, a combination of these together with a disease-specific questionnaire, and physical measures of active and passive individual joint Range of movement (ROM), grip and sensibility using standardised protocols should be used for future outcomes studies. As Dupuytren’s disease tends to recur following treatment as well as extend to involve other areas of the hand, follow-up times should be standardised and designed to capture both short and long term outcomes.

A prospective randomised clinical trial of the intra-operative use of 5-fluorouracil on the outcome of Dupuytren's disease

5-Fluorouracil reduces proliferation rates of fibroblasts, myofibroblast differentiation and contractility of ocular fibroblasts in vitro. This double-blind randomized clinical trial assesses whether intra-operative topical treatment with 5-fluorouracil reduces the recurrence rate after limited excision of Dupuytren’s tissue. Patients with two-digit disease were randomized to having 5-fluorouracil (25 mg/ml) treatment for 5 minutes on one digit and placebo on the other. Fifteen patients were enrolled with 18 months follow-up. There were no peri-operative complications. Wound healing was not delayed and there was no deterioration in the flexion deformity of the 5-fluorouracil treated digits. Patients were subsequently assessed by joint angle measurement at 3, 6, 12 and 18 months. There was no significant difference between control and 5-fluorouracil treated digits.

Miniplate Fixation for Avulsion Injuries of the Flexor Digitorum Profundus Insertion

This article describes the use of a miniplate and cortical screws in the treatment of five cases of flexor digitorum profundus (FDP) tendon avulsion. One case was type II, three cases were type III and one case was type IV. Near normal joint congruity was restored together with bony union in all cases. Six months after surgery four cases had near normal range of motion at the distal interphalangeal joint compared with the contralateral uninjured finger. These four patients were to return to their previous activities without restriction by 3 months. One repair of a type III avulsion ruptured but the distal interphalangeal joint was pain free and stable and the patient declined further surgery. Miniplate fixation offers some advantages over existing methods of repair and adds to the range of techniques available for reattachment of the FDP tendon in these injuries.

A Prospective Review of Open Central Slip Laceration Repair and Rehabilitation

A prospective review was carried out to evaluate the outcome of surgically repaired open central slip (zone III) injuries which were treated with 3 weeks of proximal interphalangeal joint immobilization within a cylinder splint and then with 3 weeks of controlled mobilization within a Capener coil splint. Thirty-one fingers in 27 patients were assessed by the same independent therapist. All fingers achieved an excellent or good recovery with a mean proximal interphalangeal joint flexion of 94° (range 70–110°) and a mean distal interphalangeal joint flexion of 57° (range 30–81°). Extension deficits of the proximal interphalangeal joint were noted in five fingers (mean 6°, range 3–15°). The results show that a combination of immobilization and controlled mobilization is an effective rehabilitation regime for surgically repaired open central slip injuries.

A Review of Goniometry Use Within Current Hand Therapy Practice

Assessment of hand joint range-of-movement using goniometry has become a more common practice among hand therapists. Available Literature discusses the reliability of goniometry in assessing the hand joints, but Little is known about how therapists use goniometry within their clinical practice. This paper presents the results of a review of clinical practice within the British Isles. A self-completed questionnaire was distributed to members of the British Association of Hand Therapists (BAHT) to establish current practice of goniometry. The response rate was high (56%). Only 41% of respondents reported implementation of a protocol that standardised their measurement techniques to improve reliability; 73.5% reported working within a team. Over 19 styles and makes of goniometers were identified as being in use and the results highlighted differences in application and reading. The paper concludes that more clinically based research in the use of hand goniometry is required to standardise techniques.

Is Eight Weeks' Immobilisation of the Distal Interphalangeal Joint Adequate Treatment for Acute Closed Mallet Finger Injuries of the Hand? A Critical Review of the Literature

The evidence for the period of splint immobilisation for mallet finger injuries was systematically reviewed in order to establish if eight weeks of distal interphalangeal joint immobilisation was adequate treatment for acute closed injuries and hence to develop a more evidence-based treatment regime. Databases were searched and relevant studies identified using a list of keywords. All articles reporting outcomes from the use of splints in the conservative treatment of acute closed mallet finger injuries published between January 1981 and December 2001 were included in this review. A total of nine papers met the inclusion criteria and were reviewed using a critical appraisal checklist. No randomised controlled trials were found. There was a lack of consistency in the treatment immobilisation period and evaluation outcomes, which made direct comparison of data impossible. The lack of robust evidence does not allow us to establish if an eight-week immobilisation period using a dorsal splint with the distal interphalangeal joint in extension is best practice. However, most papers advocate a regime to minimise skin complications and that additional protection at night following the immobilisation period is important.

What are we measuring? A critique of range of motion methods currently in use for Dupuytren’s disease and recommendations for practice

BackgroundRange of motion is the most frequently reported measure used in practice to evaluate outcomes. A goniometer is the most reliable tool to assess range of motion yet, the lack of consistency in reporting prevents comparison between studies. The aim of this study is to identify how range of motion is currently assessed and reported in Dupuytren’s disease literature. Following analysis recommendations for practice will be made to enable consistency in future studies for comparability. This paper highlights the variation in range of motion reporting in Dupuytren’s disease.MethodsA Participants, Intervention, Comparison, Outcomes and Study design format was used for the search strategy and search terms. Surgery, needle fasciotomy or collagenase injection for primary or recurrent Dupuytren’s disease in adults were included if outcomes were monitored using range of motion to record change. A literature search was performed in May 2013 using subject heading and free-text terms to also capture electronic publications ahead of print. In total 638 publications were identified and following screening 90 articles met the inclusion criteria. Data was extracted and entered onto a spreadsheet for analysis. A thematic analysis was carried out to establish any duplication, resulting in the final range of motion measures identified.ResultsRange of motion measurement lacked clarity, with goniometry reportedly used in only 43 of the 90 studies, 16 stated the use of a range of motion protocol. A total of 24 different descriptors were identified describing range of motion in the 90 studies. While some studies reported active range of motion, others reported passive or were unclear. Eight of the 24 categories were identified through thematic analysis as possibly describing the same measure, ‘lack of joint extension’ and accounted for the most frequently used.ConclusionsPublished studies lacked clarity in reporting range of motion, preventing data comparison and meta-analysis. Percentage change lacks context and without access to raw data, does not allow direct comparison of baseline characteristics. A clear description of what is being measured within each study was required. It is recommended that range of motion measuring and reporting for Dupuytren’s disease requires consistency to address issues that fall into 3 main categories:-Definition of termsProtocol statementOutcome reporting

Early Active Motion Rehabilitation Versus Immobilisation For Thumb Extensor Tendon Repairs: A Review Of Two Case Studies:

Following positive outcomes reported in recent literature, early active motion within a static splint is now a recognised rehabilitation regime for finger extensor tendons. This paper discusses the available literature on thumb extensor tendon rehabilitation, and the justification for introducing early motion for this injury. The early active motion regime for the thumb extensor tendon used at our unit is described and compared against the traditional static splint regime. Two case studies are presented to illustrate the problems associated with these regimes and the patient outcomes achieved. Outcomes were analysed utilising Total Active Motion (Kleinert and Verdan 1983), Kapandjis opposition (1992) and Whites assessment of tendon repair (1956). Both patients made a full, uncomplicated recovery after their thumb extensor tendon repair, but the patient who followed the Early Active Motion regime regained motion and light function sooner than the patient who underwent four weeks of immobilisation. This enabled an earlier discharge (eight rather that 12 weeks) and less therapy intervention overall. These are all factors that need to be considered when deciding upon which rehabilitation regime to use.

MCP Joint Arthroplasty Case Study: The Mount Vernon Static Regime:

At the Hand Therapy Unit, Mount Vernon Hospital, Middlesex we have been rehabilitating patients after metacarpophangeal joint arthroplasty using a dynamic extension splint for many years. Over the last five years the therapists along with one of our consultants have developed a protocol to replace the use of dynamic splints with two static splints. This paper presents our protocol within a case study format. Our clinical experience using this protocol has been very favourable.

Patients' concerns with the journey through flexor tendon rehabilitation - a prospective patient-centred satisfaction survey

Flexor tendon rehabilitation is an involved and protracted process during which everyday activities are difficult. The aim of this study was to conduct a patient-centred satisfaction assessment, tailored to hand therapy patients undergoing flexor rehabilitation, to gain an understanding of their experience, and to identify potential areas for improving the quality of their care. A prospective questionnaire survey, incorporating elements of generic patient-centred and upper limb outcome measures, was completed, over a six month period, by consenting hand therapy patients during their rehabilitation at three, seven and 12 weeks post-flexor-tendon surgery. Forty-three subjects fitted the inclusion criteria for the study. Thirty-two subjects (74%) gave informed written consent and were recruited to this study. Two thirds (12 out of 18) of males and all females had difficulties with everyday activities at seven weeks. More females (7 out of 8 [88%]) than males (11 out of 18 [61%]) responded that life was not in their control. Five out of eight females and six out of 14 males reported feeling concerned about their hand at 12 weeks. Interestingly, approximately 40% of respondents wanted more information throughout rehabilitation, with half of females requesting more at seven and 12 weeks. This study suggests that there should be a strong therapist-led emphasis on providing verbal and written information throughout flexor rehabilitation to increase knowledge and reduce associated anxiety. The importance of this in improving patients’ experience of the process cannot be overestimated.