Daniel A. London

Accuracy of patient recall of hand and elbow disability on the QuickDASH questionnaire over a two-year period

BACKGROUND Patient self-reporting questionnaires such as the QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, are critical to current orthopaedic outcomes research. The use of these questionnaires could introduce recall bias in retrospective, case-control, and cross-sectional studies if no preoperative data has been collected prior to study inception. The purpose of this study was to quantify recall accuracy on the QuickDASH questionnaire as a function of the duration of the recall interval. METHODS This cross-sectional study enrolled 140 patients with nontraumatic hand and elbow diseases. Patients were stratified into groups of thirty-five based on the time since their initial office visit (three months, six months, twelve months, or twenty-four months). All patients had completed the QuickDASH as part of a standard intake form at the time of the initial office visit (actual baseline score). Patients were contacted by phone and asked to recall their upper extremity disability from the time of the initial office visit with use of the QuickDASH questionnaire. Patients also completed the QuickDASH to rate their current disability. Actual and recalled QuickDASH scores for each group were statistically compared. Kruskal-Wallis analysis was used to determine any differences in recall accuracy between the groups. Pearson correlation coefficients quantified relations between recall accuracy and patient age and current function (absolute QuickDASH scores). RESULTS Mean differences between recalled QuickDASH scores and actual scores were all less than the QuickDASH minimal clinically important difference (MCID) of 13 points at different time points: three months (-7.1, p < 0.01), six months (0.8, p = 0.79), twelve months (-2.3, p = 0.43), and twenty-four months (-2.8, p = 0.26). There were no significant differences in recall accuracy across the four groups (p = 0.77). Recalled QuickDASH scores were highly correlated with actual baseline values (rp ≥ 0.74). Recall accuracy was neither correlated with patient age nor current QuickDASH scores (rp ≤ 0.04). CONCLUSIONS Patients with a nontraumatic hand or elbow diagnosis are able to recall prior level of function accurately for up to two years with the QuickDASH questionnaire. Although data collected prospectively remain optimal, our data suggest that research conducted with use of recalled QuickDASH scores produces reliable assessment of disability from common upper extremity diagnoses with acceptable recall bias.

Determining the Michigan Hand Outcomes Questionnaire minimal clinically important difference by means of three methods.

Background: To interpret patient-rated outcome measures, clinicians rely on the minimal clinically important difference. The authors studied the range of minimal clinically important difference scores for the overall Michigan Hand Outcomes Questionnaire score its and subscales in a population with various diagnoses and treatments. Methods: Patients with a single, unilateral, atraumatic hand/forearm diagnosis completed the Michigan Hand Outcomes Questionnaire before treatment and at 4 ± 1 weeks and 12 ± 2 weeks after treatment. Three methods were used to calculate the minimal clinically important difference: two anchor question methods based on satisfaction (mean change and receiver operating characteristic) and a statistical distribution method. Results: One hundred eighty-six patients were enrolled, with a baseline median overall questionnaire score of 60.7. Using the mean change method, a minimal clinically important difference of 13 was calculated for the overall questionnaire score. Using a receiver operating characteristic curve (0.8 effect size), the minimal clinically important difference was 9, with an area under the curve of 0.92. When receiver operating characteristic analysis was based on dichotomization of reported satisfaction, the minimal clinically important difference was 12, with an area under the curve of 0.85. Calculating the difference by statistical distribution gave a value of 8. For the subscales, by all methods, triangulated minimal clinically important difference estimates ranged from 10.9 to 14.4. Conclusions: The minimal clinically important difference for the overall Michigan Hand Outcomes Questionnaire score in atraumatic hand/forearm conditions falls between 8 and 13. Multiple analytic methods produce nonidentical but similar minimal clinically important differences. The authors recommend using difference estimates in these ranges when planning a clinical trial to investigate hand/forearm function across a range of diagnoses and treatments.

Anatomical relationships and branching patterns of the dorsal cutaneous branch of the ulnar nerve.

PURPOSE To describe the variable branching patterns of the dorsal cutaneous branch of the ulnar nerve (DCBUN) relative to identifiable anatomical landmarks on the ulnar side of the wrist. METHODS We dissected the ulnar nerve in 28 unmatched fresh-frozen cadavers to identify the DCBUN and its branches from its origin to the level of the metacarpophalangeal joints. The number and location of branches of the DCBUN were recorded relative to the distal ulnar articular surface. Relationships to the subcutaneous border of the ulna, the pisotriquetral joint, and the extensor carpi ulnaris tendon were defined in the pronated wrist. RESULTS On average, 2 branches of the DCBUN were present at the level of the distal ulnar articular surface (range, 1-4). On average, 2.2 branches were present 2 cm distal to the ulnar articular surface (range, 1-4). At least 1 longitudinal branch crossed dorsal to the extensor carpi ulnaris tendon prior to its insertion at the base of the fifth metacarpal in 23 of 28 specimens (82%). In 27 of 28 specimens (96%), all longitudinal branches of the DCBUN coursed between the dorsal-volar midpoint of the subcutaneous border of the ulna and the pisotriquetral joint. In 20 of 28 specimens (71%), a transverse branch of the DCBUN to the distal radioulnar joint was present. CONCLUSIONS During exposure of the dorsal and ulnar areas of the wrist, identification and protection of just a single branch of the DCBUN are unlikely to ensure safe dissection because multiple branches normally are present. The 6U, 6R, and ulnar midcarpal arthroscopy portals may place these branches at risk. In the pronated forearm, the area between the DCBUN and the pisotriquetral joint contained all longitudinal branches of the DCBUN in 96% of specimens. CLINICAL RELEVANCE During surgery involving the dorsal and ulnar areas of the wrist, multiple longitudinal branches and a transverse branch of the DCBUN are normally present and must be respected.

The Impact of Obesity on Complications of Elbow, Forearm, and Hand Surgeries

PURPOSE To compare the rates of postoperative complications in obese and nonobese patients following elbow, forearm, and hand surgeries. METHODS This case-control study examined 436 patients whose body mass index (BMI) was over 35 and who underwent hand, wrist, forearm, or elbow surgery between 2009 and 2013. Controls were patients (n = 433) with a BMI less than 30 who had similar surgeries over the same period, and who were frequency-matched by type of surgery (ie, bony, soft tissue, or nerve), age, and sex. Postoperative complications were defined as infection requiring antibiotic or reoperation, delayed incision healing, nerve dysfunction, wound dehiscence, hematoma, and other reoperation. Medical comorbidities (e.g., hypertension, diabetes, stroke, vascular disease, kidney disease, and liver disease) were recorded. Chi-square analyses were performed to explore the association between obesity and postoperative complications. Similar analyses were performed stratified by surgery type and BMI classification. Logisticregression modeling was performed to identify predictors of postoperative complications accounting for surgery type, BMI, the presence of comorbidities, patient age, and patient sex. This same model was also run separately for case and control patients. RESULTS The overall complication rate was 8.7% with similar rates between obese and nonobese patients (8.5% vs. 9.0%). Bony procedures resulted in the greatest risk of complication in both groups (15% each group). Multivariate analysis confirmed surgery type as the only significant predictor of complications for nonobese patients. However, among obese patients, both bony surgery and increasing BMI were associated with greater complication rates. CONCLUSIONS Not all obese patients appear to be at any higher risk for complications after elbow, forearm, and hand surgery compared with nonobese patients. However, there appears to be a dose-dependent effect of BMI among obese patients such that increasing obesity heightens the risk of complications, especially for those with a BMI greater than 45. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Pediatric proximal phalanx fractures: outcomes and complications after the surgical treatment of displaced fractures.

Background: The outcomes literature on proximal phalanx fractures in children is sparse. The purpose of this study is to report the complications and outcomes of displaced proximal phalanx fractures after treatment with closed reduction and percutaneous pinning (CRPP). Methods: A retrospective chart review identified 105 patients treated with CRPP of displaced proximal phalanx fractures. Specific complications were recorded for all patients. Thirty-one of these patients returned >1 year after surgery for assessment including visual analogue scales (VAS) of pain level, functional ability, and esthetics. Objective measurements included range of motion, grip and pinch strength, and finger deformity. Radiographs were taken to assess deformity. Results: Five of the 105 patients (4.8%) had a complication including infection, pin site complication, or malunion. Of the entire group, 36 had stiffness and 31 ultimately underwent hand therapy to regain motion. Subcondylar fractures were associated with a greater likelihood of stiffness. In the 31 patients returning for assessment, the median VAS score was 0 for pain (none), function (full), and esthetics (perfect). Range of motion, grip, and pinch strength were equivalent to the contralateral side. Seven of the 31 patients (22.6%) had a measureable coronal plane deviation averaging 5 degrees (range, 3 to 13 degrees) on radiographs. Deviation was associated with subcondylar fractures and a worse esthetic VAS. Deviation was not associated with worse outcomes overall. Conclusions: Pediatric patients with a displaced proximal phalanx fracture treated with CRPP have an initial notable complication rate related to stiffness; subcondylar proximal phalanx fractures are more commonly affected. At >1-year follow-up, patients had full motion, no pain, and were happy with both function and appearance despite minor deformity in some. These complication data may help better inform patients and families before surgical intervention. Level of Evidence: Level IV—therapeutic.

Response to “Letter Regarding ‘Perioperative Celecoxib and Postoperative Opioid Use in Hand Surgery: A Prospective Cohort Study’”

In Reply We thank Castro Alves and Kendall for their interest in our article. We would like to address their concerns. When conducting this study, we did not have a standard intraoperative analgesic regimen. Our patients were routinely given propofol for sedation but the amount was not standardized. Some patients received additional anxiolytic medications. These medications may have briefly reduced discomfort in the hours after surgery but they should not have reduced pain over the first week afterward. Second, it is true that many of our patients received Bier blocks. Our standard Bier block uses a forearm-based tourniquet that is deflated at the conclusion of the procedure. During wound closure, those patients were routinely injected with bupivacaine hydrochloride and epinephrine injection at the incision site. The alternative anesthesia approach for these small procedures is to perform local anesthetic infiltration at the incision site while the patient is sedated with propofol. When injecting local anesthesia, our surgeons commonly use a mixture of lidocaine and bupivacaine in this setting. The patients included in this series had no longer-acting regional nerve blocks that would have provided pain relief into the next day. Therefore, all patients’ incisions were routinely infiltrated with bupivacaine. Thus, we believe that the choice of anesthesia technique was unlikely to influence our findings dramatically. Finally, they raise a reasonable point about patients who were lost to follow-up and the possibility of that imparting bias to our data. We have now reexamined our data to evaluate the demographics of those lost to follow-up versus those who completed the study. Fortunately, there were no significant differences between these patient groups regarding mean patient age (52 vs 49 years), sex distribution (41% vs 33% male), preoperative visual analog pain scores (3.1 vs 3.7), or estimates of pain associated with standard painful experiences (3.9 vs 4.3). Although these group similarities do not ensure that patients were lost completely at random, we feel comfortable stating that there were no substantial differences between study participants who completed the study and those who dropped out. Our thanks for bringing this point to our attention.

The (in)stability of 21st century orthopedic patient contact information and its implications on clinical research: A cross-sectional study

Background: In clinical research, minimizing patients lost to follow-up is essential for data validity. Researchers can employ better methodology to prevent patient loss. We examined how orthopedic surgery patients’ contact information changes over time to optimize data collection for long-term outcomes research. Methods: Patients presenting to orthopedic outpatient clinics completed questionnaires regarding methods of contact: home phone, cell phone, mailing address, and e-mail address. They reported currently available methods of contact, if they changed in the past 5 and 10 years, and when they changed. Differences in the rates of change among methods were assessed via Fisher’s exact tests. Whether participants changed any of their contact information in the past 5 and 10 years was determined via multivariate modeling, controlling for demographic variables. Results: Among 152 patients, 51% changed at least one form of contact information within 5 years, and 66% changed at least one form within 10 years. The rate of change for each contact method was similar over 5 (15%–28%) and 10 years (26%–41%). One patient changed all four methods of contact within the past 5 years and seven within the past 10 years. Females and younger patients were more likely to change some type of contact information. Conclusion: The type of contact information least likely to change over 5–10 years is influenced by demographic factors such as sex and age, with females and younger participants more likely to change some aspect of their contact information. Collecting all contact methods appears necessary to minimize patients lost to follow-up, especially as technological norms evolve.