J. Henk Coert

Carpal Tunnel Syndrome. Part II: Effectiveness of Surgical Treatments—A Systematic Review

OBJECTIVE To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions to treat carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 25 RCTs were included. Moderate evidence was found in favor of surgical treatment compared with splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term, and for the effectiveness of corticosteroid irrigation of the median nerve before skin closure as additive to carpal tunnel release in the short term. Limited evidence was found in favor of a double-incision technique compared with the standard incision technique. Also, limited evidence was found in favor of a mini-open technique assisted by a Knifelight instrument compared with a standard open release at 19 months of follow-up. However, in the short term and at 30 months of follow-up, no significant differences were found between the mini-open technique assisted by a Knifelight instrument compared with a standard open release. Many studies compared different surgical interventions, but no evidence was found in favor of any one of them. No RCTs explored the optimal timing strategy for surgery. No evidence was found for the efficacy of various presurgical or postsurgical treatment programs, including splinting. CONCLUSIONS Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS. However, there is no unequivocal evidence that suggests one surgical treatment is more effective than the other. More research is needed to study conservative to surgical treatment in which also should be taken into account the optimal timing of surgery. Future research should also concentrate on optimal presurgical and postsurgical treatment programs.

Surgical management of neuroma pain : A prospective follow-up study

&NA; Painful neuromas can cause severe loss of function and have great impact on the daily life of patients. Surgical management remains challenging; despite improving techniques, success rates are low. To accurately study the success of surgical neuroma treatment and factors predictive of outcome, a prospective follow‐up study was performed. Between 2006 and 2009, pre‐ and post‐operative questionnaires regarding pain (VAS, McGill), function (DASH), quality of life (SF‐36), symptoms of psychopathology (SCL‐90), epidemiologic determinants and other outcome factors were sent to patients surgically treated for upper extremity neuroma pain. Pain scores after diagnostic nerve blocks were documented at the outpatient clinic before surgery. Thirty‐four patients were included, with an average follow up time of 22 months. The mean VAS score decreased from 6.8 to 4.9 after surgery (p < 0.01), 19 (56%) of patients were satisfied with surgical results. Upper extremity function improved significantly (p = 0.001). Neuroma patients had significantly lower quality of life compared to a normal population. Employment status, duration of pain and CRPS symptoms were found to be prognostic factors. VAS scores after diagnostic nerve block were predictive of post‐operative VAS scores (p = 0.001). Furthermore, smoking was significantly related to worse outcome (relative risk: 2.10). The results could lead to improved patient selection and treatment strategies. If a diagnostic nerve block is ineffective in relieving pain, patients will most likely not benefit from surgical treatment. Patients should be encouraged to focus on activity and employment instead of their symptoms. Smoking should be discouraged in patients who will undergo surgical neuroma treatment.

Closure of the donor site of the free radial forearm flap: a comparison of full-thickness graft and split-thickness skin graft.

Introduction:Donor-site complications of free radial forearm flaps (FRFF) after closure with a split-thickness skin graft (STSG) have been reported repeatedly. Different types of closure of the donor site have been advocated to reduce donor-site complications. In our practice, a V-Y closure with a local full-thickness skin graft (FTG) is performed generally. Purpose:A retrospective follow-up study was performed comparing subjective and objective outcomes of FTG versus STSG closure. FRFF donor site closure in 34 head and neck cancer patients (15 STSG, 19 FTG) was studied. Results:Both methods of closure showed good function, sensibility, and esthetic outcome. No statistical differences between the 2 methods could be shown. Conclusion:V-Y local donor site closure is a good technique which prevents an additional donor site scar and discomfort when performing an STSG closure.

Carpal Tunnel Syndrome: Hand Surgeons, Hand Therapists, and Physical Medicine and Rehabilitation Physicians Agree on a Multidisciplinary Treatment Guideline—Results From the European HANDGUIDE Study

OBJECTIVE To achieve consensus on a multidisciplinary treatment guideline for carpal tunnel syndrome (CTS). DESIGN Delphi consensus strategy. SETTING Systematic reviews reporting on the effectiveness of surgical and nonsurgical interventions were conducted and used as an evidence-based starting point for a European Delphi consensus strategy. PARTICIPANTS In total, 35 experts (hand surgeons selected from the Federation of European Societies for Surgery of the Hand, hand therapists selected from the European Federation of Societies for Hand Therapy, physical medicine and rehabilitation physicians) participated in the Delphi consensus strategy. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Each Delphi round consisted of a questionnaire, analysis, and feedback report. RESULTS After 3 Delphi rounds, consensus was achieved on the description, symptoms, and diagnosis of CTS. The experts agreed that patients with CTS should always be instructed, and instructions combined with splinting, corticosteroid injection, corticosteroid injections plus splinting, and surgery are suitable treatments for CTS. Relevant details for the use of instructions, splinting, corticosteroid injections, and surgery were described. Main factors for selecting one of the aforementioned treatment options were identified as follows: severity and duration of the disorder and previous treatments received. A relation between the severity/duration and choice of therapy was found by the experts and reported in the guideline. CONCLUSIONS This multidisciplinary treatment guideline may help physicians and allied health care professionals to provide patients with CTS with the most effective and efficient treatment available.

Effectiveness of interventions for secondary Raynaud's phenomenon: a systematic review.

OBJECTIVES To present an evidence-based overview of the effectiveness of (non)surgical symptomatic interventions to treat secondary Raynauds phenomenon (RP). DATA SOURCES The Cochrane Library, PubMed, Embase, PEDro, and CINAHL were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted data and assessed the methodologic quality. DATA SYNTHESIS If pooling of data was not possible, a best-evidence synthesis was used to summarize the results. Of the 5 reviews and 19 RCTs included, 1 RCT studied acupuncture and another RCT reported on percutaneous radiofrequency thoracic sympathectomy. All others concentrated on the effectiveness of drugs (oral or intravenous [IV]). It appeared that calcium channel blockers significantly reduce the frequency and severity of Raynaud attacks, and are therefore effective in the treatment of secondary RP. Iloprost (oral and IV) was also found to be effective. Limited evidence was found for atorvastatin. For other traditional and more recently discovered interventions, no clear favorable effects were found. CONCLUSIONS This review shows that there is clear evidence in favor of calcium channel blockers and iloprost (oral and IV) to treat secondary RP. For all other interventions, only limited, conflicting, or no evidence was found. More high-quality, well-designed RCTs are needed in this field, especially for new interventions based on recent knowledge about the pathophysiology of secondary RP.

Computed tomography for the detection of thumb base osteoarthritis: comparison with digital radiography

ObjectiveTo compare computed tomography (CT) with digital radiography for the detection of osteoarthritis (OA) of the first carpometacarpal (CMC1) and scaphotrapeziotrapezoid (STT) joint.Materials and methodsWe retrospectively identified patients who were assessed for CMC1 OA or STT OA at our hand surgery outpatient clinic between January 2008 and March 2011, and who had both a digital radiograph and a CT scan of the hand within a 3-month period. CT and radiographic images were scored independently by two musculoskeletal radiologists for joint space narrowing (JSN), osteophytes, subchondral sclerosis, bone cysts, and erosions in the CMC1 and STT joints.ResultsThirty patients were identified. The inter-reader reliability of CT for the detection of CMC1 OA (ICC 1.00) and STT OA (ICC 0.80) was higher than radiography (ICC’s 0.15 and 0.45). In comparison with their own radiographical scoring, both readers detected with CT 3 more patients with CMC1 OA, and 13 and 5 more patients with STT OA.ConclusionComputed tomography had a higher inter-reader reliability and detection rate for both CMC1 and STT OA, compared with radiography. As surgical treatment selection of thumb base OA depends on the presence of pathology in the CMC1 and STT joints, CT may improve treatment selection and surgical planning.

Ultrasonographic quantification of intrinsic hand muscle cross-sectional area; Reliability and validity for predicting muscle strength

OBJECTIVE To investigate whether ultrasonographic measurement of the cross-sectional area (CSA) of the intrinsic hand muscles can be used to predict muscle strength in a valid and reliable manner, and to determine if this method can be used for follow-up of patients with peripheral nerve injury between the wrist and elbow. DESIGN Repeated-measures cross-sectional study. SETTING Clinical and academic hospital. PARTICIPANTS Healthy adults (n=31) and patients with ulnar and median nerve injuries (n=16) between the wrist and elbow who were visiting the Erasmus Medical Center or Maasstad Hospital were included in the study (N=47). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Correlation between measured muscle CSA and strength and assessment of inter- and intrarater reliability. Ultrasound and strength measurements of the intrinsic hand muscles were conducted bilaterally. To establish validity, the CSA of 4 muscles (abductor digiti minimi, first dorsal interosseus, abductor pollicis brevis, opponens pollicis) was compared with strength measurements of the same muscles conducted with the Rotterdam Intrinsic Hand Myometer. Repeated measures were conducted to assess inter- and intrarater reliability. RESULTS The assessed CSA strongly correlated with strength measurements, with correlations ranging from 0.82 to 0.93 in healthy volunteers and from 0.63 to 0.94 in patients. Test-retest reliability showed excellent intrarater reliability (intraclass correlation coefficient range, 0.99-1.00) in patients and volunteers and good interrater reliability (intraclass correlation coefficient range, 0.88-0.95) in healthy volunteers. CONCLUSIONS We found that ultrasound is a valid and reliable method to assess the CSA of specific muscles in the hand. Therefore, this technique could be useful to monitor muscle reinnervation in patients suffering from peripheral nerve injury as a valuable addition to strength dynamometers.

Dupuytren disease : european hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline: results from the HANDGUIDE Study

Background: Multidisciplinary treatment guidelines for Dupuytren disease can aid in optimizing the quality of care for patients with this disorder. Therefore, this study aimed to achieve consensus on a multidisciplinary treatment guideline for Dupuytren disease. Methods: A European Delphi consensus strategy was initiated. A systematic review reporting on the effectiveness of interventions was conducted and used as an evidence-based starting point for this study. In total, 39 experts (hand surgeons, hand therapists, and physical medicine and rehabilitation physicians) participated in the Delphi consensus strategy. Each Delphi round consisted of a questionnaire, an analysis, and a feedback report. Results: After four Delphi rounds, consensus was achieved on the description, symptoms, and diagnosis of Dupuytren disease. No nonsurgical interventions were included in the guideline. Needle and open fasciotomy, and a limited fasciectomy and dermofasciectomy, were seen as suitable surgical techniques for Dupuytren disease. Factors relevant for choosing one of these surgical techniques were identified and divided into patient-related (age, comorbidity), disease-related (palpable cord, previous surgery in the same area, skin involvement, time of recovery, recurrences), and surgeon-related (years of experience) factors. Associations of these factors with the choice of a specific surgical technique were reported in the guideline. Postsurgical rehabilitation should always include instructions and exercise therapy; postsurgical splinting should be performed on indication. Relevant details for the use of surgical and postsurgical interventions were described. Conclusion: This treatment guideline is likely to promote further discussion on related clinical and scientific issues and may therefore contribute to better treatment of patients with Dupuytren disease.

Implication of long-distance regulation of the HOXA cluster in a patient with postaxial polydactyly

Apparently balanced chromosomal inversions may lead to disruption of developmentally important genes at the breakpoints of the inversion, causing congenital malformations. Characterization of such inversions may therefore lead to new insights in human development. Here, we report on a de novo inversion of chromosome 7 (p15.2q36.3) in a patient with postaxial polysyndactyly. The breakpoints do not disrupt likely candidate genes for the limb phenotype observed in the patient. However, on the p-arm the breakpoint separates the HOXA cluster from a gene desert containing several conserved noncoding elements, suggesting that a disruption of a cis-regulatory circuit of the HOXA cluster could be the underlying cause of the phenotype in this patient.

Metric properties of advanced imaging methods in osteoarthritis of the hand: a systematic review

Objective To assess the value of advanced imaging techniques in the detection of hand osteoarthritis (OA) and hand OA progression. Methods PubMed/Medline and Embase were searched until April 2012 for studies on imaging of hand OA that presented quantitative data on validity, reliability or responsiveness. Articles presenting only data on conventional radiography (CR) were excluded. Methodological quality was assessed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist for validity, the Quality Appraisal of Reliability Studies (QAREL) for reliability and the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) for responsiveness. Results Of 627 citations, 25 studies on ultrasonography (US), MRI or scintigraphy were included. No studies on CT, positron emission tomography or single photon emission CT met our eligibility criteria. Validity was generally assessed against healthy controls, CR or clinical examination. Overall, US and MRI detected more disease than CR and found significant differences between patients and healthy controls. Scintigraphy detected fewer pathological joints than CR. Intra- and inter-reader reliability varied for US (κ=0.01–1.0) and MRI (κ=0.15–0.84 and intraclass correlation coefficient=0.21–0.99) and was good for scintigraphy (κ=0.61–0.84). There were no responsiveness studies for MRI. US responsiveness studies showed a reduction of soft-tissue changes after treatment which correlated with decrease in pain (r=0.7–0.8). For scintigraphy, scores decreased over time while CR showed progression of hand OA. Conclusions MRI and US seem to be the most promising candidates for early detection of hand OA and for future use in clinical trials. However, further research is needed to improve scoring methods, to compare US with MRI, to confirm reliability of MRI and to further determine the responsiveness of US and MRI.