Shepard P. Johnson

Evidence-based education in plastic surgery

Summary: Educational reforms in resident training have historically been driven by reports from medical societies and organizations. Although educational initiatives are well intended, they are rarely supported by robust evidence. The Accreditation Council for Graduate Medical Education recently introduced competency-based training, a form of outcomes-based education that has been used successfully in nonmedical professional vocations. This initiative has promise to advance the quality of resident education, but questions remain regarding implementation within plastic surgery. In particular, how will competency-based training impact patient outcomes, and will the methodologies used to assess competencies (i.e., milestones) be accurate and validated by literature? This report investigates resident educational reform and the need for more evidence-based educational initiatives in plastic surgery training.

A Methodology for Determining Standard of Care Status for a New Surgical Procedure: Hand Transplantation.

Background: Hand allotransplantation was initially criticized as unethical and unlikely to succeed. The results proved to be better than anticipated, now raising the issue of whether hand transplantation is the standard of care. The purpose of this article is to outline a reasonable methodology for determining whether a surgical procedure is the standard of care, and then to apply that methodology to hand transplantation. Methods: Publications on ethics and definitions of medical (not legal) standard of care were reviewed. All hand transplantations completed in the United States were evaluated regarding their status as experimental, standard of care, or both. Then, the stakeholders, physicians, public insurers, and regulators were examined to determine whether they accepted hand transplantation as the standard of care. Utility and incremental cost-utility ratio were determined. Hand transplantation was considered the standard of care when stakeholders were using, insuring, and regulating the procedure. Results: The public expresses a desire for hand transplantation. A minority of surgeons consider the procedure the standard of care. Ethical committees, institutional review boards, and scholarly articles deem the procedure ethical. A series of institutions have carried out the procedure with a record of successes. Some institutions perform the surgical procedure as the standard of care. Scholarly work demonstrates beneficial outcomes. Some commercial and federal government insurers are willing to cover the cost of the procedure. Utility determination justifies the procedure. There are no incremental cost-utility ratio analysis studies that justify the procedure. Conclusion: Hand transplantation is moving from acceptance as an ethical surgical experiment to the standard of care.

The Importance of Hand Appearance as a Patient-Reported Outcome in Hand Surgery.

Summary: Hand appearance is meaningful to patients because hands are an essential part of human interactions, communication, and social integration. Recent literature indicates that hand aesthetics is an important, measurable patient-reported outcome. In hand surgery, several outcome instruments exist that accurately measure functional outcomes, but aesthetics is often overlooked or imprecisely measured. This makes comparison of disease burden and effectiveness of therapies, as they pertain to aesthetics, difficult. This special topic article outlines the aesthetic features of the hand, how literature is evaluating the appearance of the hand in outcomes research, and proposes a novel approach to assessing hand aesthetics.

The Clinical Implications of the Oblique Retinacular Ligament

The oblique retinacular ligament originates from the flexor tendon sheath, courses past the proximal interphalangeal joint, and merges with the lateral extensor tendon. There has been disagreement regarding the contribution of the oblique retinacular ligament to coordinated movements between the proximal and distal interphalangeal joints. Landsmeer postulated that it acts as a dynamic tenodesis that tightens with proximal interphalangeal joint extension, causing obligatory distal interphalangeal joint extension. However, studies have shown that the oblique retinacular ligament is variably present and often attenuated, which diminishes its presumed role in finger movement. Despite this, the concept of a checkrein linking interphalangeal joint motion heralded the development of effective and reproducible surgical interventions for swan-neck and mallet deformities. This article examines the controversy regarding the existence of the oblique retinacular ligament, its plausible functionality, and clinical implications in the practice of hand surgery.

Addressing Medical Errors in Hand Surgery

Influential think tanks such as the Institute of Medicine have raised awareness about the implications of medical errors. In response, organizations, medical societies, and hospitals have initiated programs to decrease the incidence and prevent adverse effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error by a physician is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain physician-patient trust. Furthermore, equipping hand surgeons with a guide for addressing medical errors will help identify system failures, provide learning points for safety improvement, decrease litigation against physicians, and demonstrate a commitment to ethical and compassionate medical care.

Use of Postoperative Radiographs following Operative Fixation of Distal Radius Fractures

Background: Recent studies show that routine postoperative films after open reduction and internal fixation for distal radius fractures rarely alter clinical management. This population study evaluates the use of postoperative radiographs after distal radius fracture fixation. Methods: The authors studied insurance claims from the Truven MarketScan databases to identify patients aged 18 years and older who underwent open reduction and internal fixation for a distal radius fracture between 2009 and 2011. Two years of postoperative data were collected to determine the number and timing of postoperative radiographs and related clinical events, including complications and reoperation. The authors also compared outcomes between cohorts who did and did not undergo radiography on the day of surgery. Results: The authors identified 20,041 patients who met study criteria. On average, 3.8 ± 2.1 radiographs per patient were obtained during the 2-year follow-up, with 3.0 ± 1.4 being obtained within the first 3 months; 59, 81, and 91 percent of patients did not undergo further imaging after 3, 6, and 12 months postoperatively, respectively. Radiographs were obtained on the day of surgery in 47 percent of patients (n = 9372), and more were obtained overall for these patients in the postoperative period (4.4 versus 3.2). Early reoperation rates (within 14 days) following distal radius fractures between patients who did and did not undergo same-day radiography were 5 percent versus 3 percent. Conclusions: On average, four radiographs per patient were obtained following open reduction and internal fixation for a closed distal radius fracture. Nearly 50 percent of individuals underwent radiography on the day of surgery, despite low reoperation rates in the early postoperative period. An evidence-based approach to postoperative radiography has the potential to reduce distal radius fracture–related health care use.

The Quality of Control Groups in Nonrandomized Studies Published in the Journal of Hand Surgery

PURPOSE To evaluate control group selection in nonrandomized studies published in the Journal of Hand Surgery American (JHS). METHODS We reviewed all papers published in JHS in 2013 to identify studies that used nonrandomized control groups. Data collected included type of study design and control group characteristics. We then appraised studies to determine whether authors discussed confounding and selection bias and how they controlled for confounding. RESULTS Thirty-seven nonrandomized studies were published in JHS in 2013. The source of control was either the same institution as the study group, a different institution, a database, or not provided in the manuscript. Twenty-nine (78%) studies statistically compared key characteristics between control and study group. Confounding was controlled with matching, exclusion criteria, or regression analysis. Twenty-two (59%) papers explicitly discussed the threat of confounding and 18 (49%) identified sources of selection bias. CONCLUSIONS In our review of nonrandomized studies published in JHS, papers had well-defined controls that were similar to the study group, allowing for reasonable comparisons. However, we identified substantial confounding and bias that were not addressed as explicit limitations, which might lead the reader to overestimate the scientific validity of the data. CLINICAL RELEVANCE Incorporating a brief discussion of control group selection in scientific manuscripts should help readers interpret the study more appropriately. Authors, reviewers, and editors should strive to address this component of clinical importance.

Outcomes Assessment After Hand Burns

Accurately assessing function and disability after hand burns is imperative to improving the management of patients. The biological, social, and psychological impact of these injuries should be considered. The International Classification of Functioning Disability (ICF) and Health Core Sets for Hand Conditions provides a guide to what should be measured and reported. Although many outcomes measures instruments are available to assess patients with hand or burn injuries, few are validated in the subpopulation of hand burns. Further efforts are required to investigate the ability of current assessment instruments to evaluate hand burn outcomes within the ICF framework.

Concepts in Ulnar Drift Deformity

Ulnar drift occurs when there is a biomechanical imbalance of forces at the metacarpophalangeal (MCP) joint (Fig. 20.1). Ulnar drift deformity is distinct from ulnar deviation, the normal rotation of the proximal phalanx on the metacarpal that facilitates hand grip (Flatt, J Hand Ther 9:282–292, 1996). Classically seen in rheumatoid arthritis, the pathophysiology of ulnar drift is commonly attributed to MCP joint synovitis causing dorsoradial ligament damage and resultant extensor tendon ulnar subluxation (Flatt, J Hand Ther 9:282–292, 1996; Smith et al., JAMA 198(2):150–154, 1966; Backhouse, Ann R Coll Surg Engl 43:154–173, 1968; Smith and Kaplan, J Bone Joint Surg 49(A):31–47, 1967; Snorrason, Acta Med Scand 140:359–363, 1951; Ono et al., Clin Plastic Surg 38:713–727, 2011). More accurately, ulnar drift is a result of multiple factors including innate MCP anatomy, normal hand use, ulnar translation of the flexor tendons, and proximal joint disease (e.g., radial deviation of the wrist). Disruption of stabilizing ligaments at the MCP joint also leads to palmar subluxation of the proximal phalanx and permanent flexion deformities (Flatt, J Hand Ther 9:282–292, 1996; Smith et al., JAMA 198(2):150–154, 1966; Backhouse, Ann R Coll Surg Engl 43:154–173, 1968; Smith and Kaplan, J Bone Joint Surg 49(A):31–47, 1967).