Reinier Feitz

Comparison of Arthroplasties With or Without Bone Tunnel Creation for Thumb Basal Joint Arthritis: A Randomized Controlled Trial

PURPOSE To compare the results for treatment of basal thumb osteoarthritis with and without the use of a bone tunnel at the base of the first metacarpal. METHODS Women aged 40 years or older with stage IV osteoarthritis were randomized to 1 of 2 treatments. Patients were evaluated preoperatively and postoperatively at 3 and 12 months by assessing pain, outcome function measures, range of motion, strength, time to return to work or activities, satisfaction with the results, and complication rate. RESULTS A total of 79 patients were enrolled in this study. Three months after surgery, Patient-Rated Wrist and Hand Evaluation pain and total scores were significantly improved in the bone tunnel group compared with the tunnel-free group. At 12 months, however, we found no significant differences for all outcome scores between groups. In addition, we observed no significant differences between groups in strength, duration to return to work or activities, patient satisfaction, and complication rates. CONCLUSIONS After the bone tunnel technique, patients have better function and less pain 3 months after surgery than do those in the non-bone tunnel group, which indicates faster recovery. However, 12 months after surgery, the functional outcome was similar. Because of faster recovery, we prefer the bone tunnel technique in the treatment of stage IV osteoarthritis. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

Comparative Effectiveness of Percutaneous Needle Aponeurotomy and Limited Fasciectomy for Dupuytren's Contracture: A Multicenter Observational Study.

Background: Percutaneous needle aponeurotomy is a less invasive surgical alternative to limited fasciectomy for Dupuytren’s contracture, but appeared less efficacious in a previous randomized clinical trial. This study compared the effectiveness of both techniques in contemporary clinical practice. Methods: The authors evaluated prospectively gathered data from all patients who were treated with percutaneous needle aponeurotomy or limited fasciectomy between 2011 and 2014 at six hand surgery practice sites in The Netherlands. The degree of total active extension deficit, Michigan Hand Outcomes Questionnaire subscores, and complications evaluated at 6 to 12 weeks after treatment were compared after propensity score–based inverse-probability weighting to account for the differences in baseline characteristics between the treatment groups. Results: After inverse-probability weighting, 78 percutaneous needle aponeurotomy patients and 103 limited fasciectomy patients remained with similar characteristics (88 percent Tubiana grade I or II). The degree of total residual extension deficit at follow-up was similar between the weighted groups (percutaneous needle aponeurotomy, 21 degrees; limited fasciectomy, 18 degrees; p = 0.330). Furthermore, percutaneous needle aponeurotomy was associated with a lower mild complication rate (percutaneous needle aponeurotomy, 5.2 percent; limited fasciectomy, 24.3 percent; p < 0.001) and larger increases in the subdomain scores of satisfaction (p < 0.001), work performance (p < 0.001), activities of daily living (p = 0.009), and overall hand function (p = 0.001). Conclusions: This multicenter observational study found that, among patients with mildly to moderately affected digits, percutaneous needle aponeurotomy reduced contractures as effectively as limited fasciectomy does in clinical practice. Furthermore, percutaneous needle aponeurotomy provided a more rapid functional recovery and had a lower rate of mild complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Trapeziometacarpal Arthrodesis or Trapeziectomy with Ligament Reconstruction in Primary Trapeziometacarpal Osteoarthritis: A 5-Year Follow-Up

PURPOSE To compare the long-term outcomes of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with trapeziometacarpal arthrodesis for osteoarthritis (OA) of the basal thumb joint. METHODS Patients were evaluated for pain, daily functioning, strength, and complications after a mean follow-up of 5.3 years. Generalized estimating equations statistics were used to compare repeated measurements over time in both groups. RESULTS After 5 years, patients who had trapeziectomy with LRTI had significantly better pain reduction and function than the arthrodesis group. Pain and function in the LRTI group continued to improve compared with the results 1 year after surgery, whereas the arthrodesis group did not change. Grip and pinch strength were higher than 1 year after surgery but were not different between groups. In the arthrodesis group, 1 patient was reoperated for nonunion between 1 year and a mean of 5 years after surgery, resulting in a total of 18% nonunion. Another patient underwent reoperation for hardware-related pain. One patient from each group required reoperation because of pain due to scaphotrapeziotrapezoid OA. CONCLUSIONS Trapeziectomy with LRTI leads to better pain reduction and functional outcome after between 1 and 5 years compared with trapeziometacarpal arthrodesis in women over 40 years old with OA stages II to III. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Predictors of Patient Satisfaction with Hand Function after Fasciectomy for Dupuytren's Contracture.

Background: This study examined patient satisfaction with hand function after fasciectomy for Dupuytren’s contracture and determined which preoperative patient- and disease-specific factors predicted this satisfaction. Methods: Demographics and disease-specific factors were assessed from a prospective cohort of 194 patients who completed the Michigan Hand Outcomes Questionnaire preoperatively and underwent limited fasciectomy between 2011 and 2014 at six hand surgery practice sites. To evaluate satisfaction with hand function, patients were asked to complete the Michigan Hand Outcomes Questionnaire during the first year after fasciectomy. After patients were classified into a satisfied and an unsatisfied category using the question that specifically pertains to satisfaction with hand function, the authors applied multivariate logistic regression modeling to identify independent predictors of patient satisfaction. Results: At an average of 10 months (range, 6 to 12 months) after fasciectomy, 84 percent (n = 163) of the patients were satisfied with their hand function. In multivariate analyses adjusting for the degree of postoperative residual contracture (p < 0.001) and complications (p < 0.001), a higher preoperative Michigan Hand Outcomes Questionnaire hand appearance subscore and male gender predicted a higher likelihood of becoming satisfied after fasciectomy. Other patient- and disease-specific factors did not show evidence for an association with patient satisfaction. Conclusions: The findings of this study suggest that providers should consider assessing concerns about the appearance of the hand in patients with Dupuytren’s contracture. They also highlight the importance of complication prevention and full contracture correction from the patient’s perspective. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Effect of a Bone Tunnel During Ligament Reconstruction for Trapeziometacarpal Osteoarthritis: A 5-Year Follow-up

PURPOSE To compare in trapeziometacarpal (TMC) osteoarthritis the effects of trapeziectomy with tendon interposition and ligament reconstruction (LRTI) with or without a bone tunnel after a mean follow-up of 5 years. METHODS We randomized 79 women (aged 40 years or older) with stage IV TMC osteoarthritis to either trapeziectomy with LRTI using a bone tunnel (Burton-Pellegrini) or a tendon sling arthroplasty (Weilby). Before surgery and at 3 months and 1 year after surgery, patients were evaluated for pain, function, strength, satisfaction, and complications. Of these patients, 72% were evaluated after a mean follow-up of 5 years (range, 3.8-6.4 years). RESULTS There were no significant differences in function and pain (Patient-Rated Wrist and Hand Evaluation) between treatment groups after a mean follow-up of 5 years. In addition, grip and pinch strength, satisfaction, and persisting complications did not differ between groups. Three patients in the Weilby group had repeat surgery (2 for symptomatic scaphotrapezoidal osteoarthritis and 1 elsewhere) and one in the Burton-Pellegrini group operated on again elsewhere. Furthermore, 3 patients who were first conservatively treated for a trigger finger or neuroma were operated on again because conservative therapy failed. Two more patients were operated on again because of de Quervain tendinitis and carpal tunnel syndrome. The overall treatment effect of both groups together showed no significant differences between results at 1 and 5 years after surgery, except for grip strength, which improved for both groups. CONCLUSIONS This study showed that improved function, strength, and satisfaction obtained at 1 year after trapeziectomy with LRTI with or without the use of a bone tunnel for stage IV TMC thumb osteoarthritis was maintained after 5 years. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

Better patients’ treatment experiences are associated with better postoperative results in Dupuytren’s disease:

This prospective study investigates the extent to which a better experience with healthcare delivery is associated with better postoperative treatment outcomes after surgery for Dupuytren’s contracture. Patients undergoing limited fasciectomy or percutaneous needle fasciotomy for Dupuytren’s contractures completed the Michigan Hand Outcomes Questionnaire before and 3 months after surgery, together with a patient reported experience measure, while hand therapists assessed the straightness of the finger with a goniometer. Regression analyses were used to examine associations. We found that a better experience with healthcare delivery was associated with better patient-reported outcomes, while association with residual extension deficit was minimal. Strongest associations were seen with communication of the physician, postoperative care and information about the treatment. Experience with the treatment explained up to 12% of the variance in treatment outcome. These findings suggest that patient reported treatment outcomes in Dupuytren’s disease can be improved by improving the treatment context. Level of evidence: II

Predicting outcome after hand orthosis and hand therapy for thumb carpometacarpal osteoarthritis; a prospective study

OBJECTIVES (1) To identify predictive factors for outcome after splinting and hand therapy for carpometacarpal (CMC) osteoarthritis (OA) and to identify predictive factors for conversion to surgical treatment; and (2) to determine how many patients who have not improved in outcome within 6 weeks after start of treatment will eventually improve after 3 months. DESIGN Observational prospective multicenter cohort study. SETTING Xpert Clinic in the Netherlands. This clinic comprises 15 locations in the Netherlands, with 16 European Board certified (FESSH) hand surgeons and over 50 hand therapists. PARTICIPANTS Between 2011 and 2014, patients with CMC OA (N=809) received splinting and weekly hand therapy for 3 months. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Satisfaction and pain were measured with a visual analog scale and function with the Michigan Hand Questionnaire at baseline, 6 weeks, and 3 months posttreatment. Using regression analysis, patient demographics and pretreatment baseline scores were considered as predictors for the outcome of conservative treatment after 3 months and for conversion to surgery. RESULTS Multivariable regression model explained 34%-42% of the variance in outcome (P<.001) with baseline satisfaction, pain, and function as significant predictors. Cox regression analysis showed that baseline pain and function were significant predictors for receiving surgery. Of patients with no clinically relevant improvement in pain and function after 6 weeks, 73%-83% also had no clinically relevant improvement after 3 months. CONCLUSION This study showed that patients with either high pain or low function may benefit most from conservative treatment. We therefore recommend to always start with conservative treatment, regardless of symptom severity of functional loss at start of treatment. Furthermore, it seems valuable to discuss the possibility of surgery with patients after 6 weeks of therapy, when levels of improvement are still mainly unsatisfactory.

Comparative Effectiveness of Collagenase Injection for Dupuytren Contracture

Introduction Questions persist regarding the relative effectiveness of injectable collagenase (CCH) in the treatment of Dupuytren contracture. This study assessed the effectiveness of CCH as compared with limited fasciectomy (LF) in clinical practice.

Predicting Outcome After Surgery for Carpometacarpal Osteoarthritis: A Prospective Study

Objective: Research on carpometacarpal (CMC) osteoarthritis (OA) is primarily focused on comparing surgical outcome of different techniques, in case series or comparative studies. Many studies do not demonstrate significant differences in outcome between surgical techniques. However, it has been reported that a relatively large part of treated patients have significant residual pain and functional limitations, or even deterioration of their initial complaints. Overall outcome may also be improved by selecting “the right patients” for surgical treatment. Therefore, the aim of this study is to (1) describe the outcome of widely used techniques for CMC OA in a large, multicenter cohort and (2) identify predictive factors of poor surgical outcome, defined in terms of pain, complications, hand function, and patient satisfaction to predict possible failure after surgical treatment. Materials and Methods: We included 668 patients in a multicenter, prospective study between 2011 and 2015, who were surgically treated for CMC OA with trapeziectomy with ligament reconstruction and tendon interposition (LRTI).Outcome parameters, registered preoperatively, 3 months and 12 months after surgery, included pain (visual analogue scale [VAS]), function (Michigan Hand Questionnaire [MHQ]), complications, and satisfaction with the hand. Postoperative outcomes were compared with baseline levels. Multiple imputation was performed after missing value analysis. Baseline pain, function and strength, sociodemographics, and hand surgical history were analyzed as possible predictors for outcome after surgery, by multivariate regression analysis. Results: For all measurements, outcomes improved significantly after surgery, with effect sizes greater than 0.8 for pain, total MHQ score, and patient satisfaction outcomes. However, we found a residual rest pain of 19 (VAS 0-100) after 1 year. In total, there were 327 complications in 229 patients, of which 43% required no or conservative treatment. Univariate analysis showed that only a few of the baseline variables correlated with postoperative outcome measurements at 12 months. These associated variables were combined with predictors selected from literature and were considered in multivariable analyses. For pain and the number of complications, the multivariable regression models could only explain 2% of the variance in the model. For self-reported satisfaction of the hand, this was only 5%. For the MHQ score, the multivariable regression analysis could explain 17% of the variance in the model, with a history of De Quervain tendinitis, smoking, lower baseline MHQ total score, and increased preoperative pain, independently predicting a worse postoperative MHQ score. Conclusions: After surgical treatment for CMC OA, improvements in pain, strength, and function in our study are highly significant and clinically relevant. Despite the large overall improvement, we found significant percentages of patients with unfavorable outcomes (residual pain and functional deficits) in this large cohort, which is also in line with present literature. Based on this study, we conclude that we cannot predict which patients will have bad surgical results after surgical treatment for thumb CMC OA, despite our relatively large sample of baseline characteristics and large cohort. Our study suggests that we need to look beyond the commonly evaluated predictive factors (age, gender, baseline functional scores, etc) and treatment algorithms to improve outcome of all patients with CMC OA.

Surgeon Volume Influences Treatment Outcome in the Dupuytren Disease Surgery

Objective: High surgeon procedural volume has been linked to better outcomes for a variety of surgical procedures, but the impact of surgeon volume on outcomes of Dupuytren surgery remains uncertain. Materials and Methods: We used data from a quality-of-care registry from 6 hand surgery practice sites between 2011 and 2014. We included 561 patients with the Dupuytren disease who underwent fasciectomy (71%) or percutaneous needle fasciotomy (29%) by 16 hand surgeons. Outcomes were the degree of residual contracture and adverse events assessed at 6 to 12 weeks after treatment. Relations between volume and outcomes were examined using linear and logistic regression models, with adjustment for patient characteristics and the type of procedure. Nonlinearity was assessed with restricted cubic splines. Results: Overall, mean residual contracture (total active extension deficit) at follow-up was 24°, which corresponded to a postprocedure improvement of 65%. Forty-seven percent of patients experienced at least 1 adverse event, with neuropraxia (12%), scar sequelae (12%), and wound healing problems (8%) being the three most common events. Surgeon volume was inversely related to the degree of residual contracture: Every 58 additional procedures performed annually were associated with 5° less residual contracture at follow-up (P, .03). Moreover, surgeon volume had an inverse effect on overall events (odds ratio per 50 additional procedures, 0.86, P, .01). Conclusions: Even among experienced hand surgeons, patients treated by surgeons performing high volumes of Dupuytren surgery had better outcomes in terms of residual contracture and adverse events. The findings of this study suggest that surgeons may improve outcomes by increasing their annual procedural volume for these specific interventions.