Measuring wrist and hand function: common scales and checklists

Should we always perform scaphoid nonunion surgery in patients with minor preoperative symptoms?

The objective of this study was to assess the downsides of surgical treatment of scaphoid fracture nonunion in patients with minor preoperative symptoms. Patients were classified with minor symptoms based on the Patient-Rated Hand/Wrist Evaluation questionnaire. Of the 35 included patients, most patients encountered problems with patient-specific activities; 9% reported worse postoperative functional outcomes, 34% were not satisfied with the treatment and 9% were reoperated. The risk of a worse functional outcome after surgery with the need for further operations and the chance of developing wrist osteoarthritis, along with the possibility of poor patient satisfaction and ongoing daily functional impairment, should be considered during preoperative counselling.Level of evidence: III.

Effects of Wrist Stability Training Combined with Grip Strength Exercise on Pain and Function in Patients with Nonspecific Chronic Wrist Pain

Background and Objectives: Non-specific chronic wrist pain is wrist pain that occurs without a specific cause, such as trauma, and may limit the range of motion of the joints of the wrist and hand, affecting muscle strength, grip strength, and function. This study aimed to determine the effects of grip-strengthening exercises combined with wrist stability training on pain and function in patients with non-specific chronic wrist pain. Materials and Methods: The subjects of the study were 31 patients with wrist pain. To determine the effect of grip-strengthening exercises combined with wrist stability training, 15 participants participated in grip-strengthening exercises combined with wrist stability training and 16 control subjects participated. The experimental group participated in wrist-stability training. Grip-strengthening exercises combined with wrist stability training were performed for 20 min/day twice a week for 4 weeks, and relaxation massage and conservative physical therapy were performed for 20 min/day twice a week for 4 weeks. The control group received relaxation massage and conservative physical therapy for 40 min/day twice a week for 4 weeks. A visual pain scale was used to evaluate the degree of pain before and after treatment, and a patient-rated wrist evaluation was used to evaluate wrist function. Results: The results showed that the visual score significantly decreased in the time effect before and after the intervention in both groups (p < 0.001), patient-rated wrist evaluation significantly decreased (p < 0.001), and grip strength and muscle strength significantly increased (p < 0.001). The results of this study showed that grip-strengthening exercises combined with wrist stability training were effective in improving pain, function, grip strength, and muscle strength in patients with non-specific chronic wrist pain. Conclusions: Grip-strengthening exercises combined with wrist stability training can be used as an effective intervention method to improve pain, function, grip strength, and muscle strength, emphasizing the need for wrist exercise interventions in patients with non-specific chronic wrist pain in the future.

Establishing the Patient Acceptable Symptom State in a Nonshoulder Hand and Upper Extremity Population for the QuickDASH and PROMIS UE Computer Adaptive Tests

PURPOSE

It is unclear what score thresholds on patient-reported outcomes instruments reflect an acceptable level of upper extremity (UE) function from the perspective of patients undergoing hand surgery. The purpose of this study was to calculate the patient acceptable symptom state (PASS) for the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Outcomes Measurement Information System (PROMIS) UE Computer Adaptive Test (CAT), version 2.0, in a population who underwent hand surgery.

METHODS

Adult patients who underwent hand surgery between February 2019 and December 2019 at a single academic tertiary institution were identified. QuickDASH and PROMIS UE CAT version 2.0 scores were collected 1 year after surgery, as were separate symptom- and function-specific anchor questions that queried the acceptability of patients' current state. Threshold values predictive of a patient reporting an acceptable symptom state (PASS[+]) were calculated for both instruments using the 75th percentile score for patients in the PASS(+) group and the Youden Index as determined by receiver operating curve (ROC) analysis.

RESULTS

A total of 222 patients were included. QuickDASH and PROMIS UE CAT scores differed significantly between the PASS(+) and PASS(-) groups. The 75th percentile method yielded PASS values of <16 for the QuickDASH and >43 for the PROMIS UE CAT for both anchor questions. The ROC analysis yielded PASS estimates of <15.9 to <20.5 for the QuickDASH and >38.1 to >46.2 for the PROMIS UE CAT, with ranges calculated from differing threshold values for each of the 2 anchor questions. The ROC-based estimates demonstrated high levels of model discrimination (area under the curve ≥ 0.80).

CONCLUSIONS

We propose PASS estimates obtained using the 75th percentile and ROC methods.

CLINICAL RELEVANCE

Specifically, PASS values in the range of 15.9-20.5 for the QuickDASH and 38.1-46.2 for the PROMIS UE CAT version 2.0 should be used when interpreting outcomes at a population level.

The Brazilian-Portuguese version of the Upper Extremity Functional Index (UEFI): Translation, cross-cultural adaptation and measurement properties for Brazilian adults after a burn injury

OBJECTIVES

To translate, cross-culturally adapt, validate, verify the reliability and estimate the minimal detectable change (MDC) of the UEFI to Brazilian Portuguese (UEFI-Br) for burns.

METHODS

The study was carried out with 131 Brazilian burn cases at two time points, at discharge and at the first outpatient follow-up (15-21 days after discharge) in a Burn Treatment Center. The adaptation process of the UEFI was based on international recommendations. The Burn Specific Health Scale-Brief-Br (BSHS-B-Br) was also applied in order to analyze construct validity of the UEFI-Br and distribution-based methods were used to estimate its MDC.

RESULTS

Intra- and inter-rater reliability were good with ICC of 0.986 (CI 95 %: 0.98-0.99) and 0.969 (CI 95 %: 0.955-0.979), respectively, at discharge and 0.997 (CI 95 %: 0.996-0.998) and 0.987 (CI 95 %: 0.981-0.991), respectively, at the first outpatient follow-up appointment. We found good internal consistency with Cronbach's α values of 0.987 and 0.996, respectively, at the two times. The SEM was 4.42 and 2.31 at the first and second time points, respectively. The UEFI-Br scores demonstrated strong correlation with the Burn Specific Health Scale-Brief-Br (BSHS-B-Br) function domain scores (r = 0.87-0.90). No significant correlation was found between UEFI-Br scores and participants' characteristics. The MDC of the UEFI-Br lies between 11 and 13 points.

CONCLUSION

The Brazilian version of the UEFI-Br, a useful tool to assess upper limb function and disability, is a valid and reliable tool for use with Brazilian burn survivors. The MDC for the instrument was determined to be 11-13 points.

Evaluating Factors Associated With Patient-Perceived Applicability of the QuickDASH Survey in Reflecting Their Goals of Care Prior to Hand Surgery

PURPOSE

Patient-reported outcome measures intend to capture patients' perspectives on their health status. However, the patient-perceived applicability of many of these patient-reported outcome measures is unknown. We hypothesized that patients experiencing greater upper extremity disability and greater pain interference would be more likely to report that the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) survey content is responsive to their daily lives and goals in seeking surgical care.

METHODS

Adult preoperative hand surgery patients at a single tertiary academic center were recruited prospectively. QuickDASH, Patient-Reported Outcomes Measurement Information System Pain Interference computerized-adaptive-testing, and the Godin Leisure-Time Exercise Questionnaire (GLTEQ)-a validated adult physical activity level metric-data were collected. The following two Likert response questions were also asked: question (1) "How applicable is the above questionnaire to your treatment goals for your upper extremity condition?" and question (2) "How applicable is the overall questionnaire to your daily life?" Multivariable binary logistic regression was performed to define the factors associated with patients reporting that the survey was "very applicable."

RESULTS

Of the 133 included patients, the mean age was 49 ± 18 years, 40% were women, and the mean GLTEQ score was 54.1 ± 5.5 (consistent with a high level of activity). For questions 1 and 2, 32% and 29% of the patients reported that QuickDASH was "very applicable," respectively. The multivariable model demonstrated that for every 10-point increase in QuickDASH, there was a 45% to 49% greater odds of respondents reporting that the survey was "very applicable," and for every 5-point increase in pain interference computerized-adaptive-testing, the odds increased by 55% to 70%. No association with GLTEQ was observed.

CONCLUSIONS

Patients with greater upper extremity disability and pain interference were more likely to find the QuickDASH content to be applicable to their daily lives and goals in seeking surgical care.

CLINICAL RELEVANCE

These findings suggest that QuickDASH may not be an optimal instrument when evaluating upper extremity function in cohorts with mild disability and low pain interference.

Comparison of patient preferences and responsiveness among common patient-reported outcome measures for hand/wrist injuries or disorders

BACKGROUND

Patient-reported outcome measures (PROMs) were developed to examine patients' perceptions of functional health. Most studies compare the responsiveness of each type of questionnaire. However, reports of patient preferences among PROMs commonly used with patients with hand/wrist injuries or disorders are limited. This study aimed to compare patient preferences, factors associated with those preferences and responsiveness among the Disability of the Arm, Shoulder, and Hand (DASH), Michigan Hand Outcomes Questionnaire (MHQ), Patient-Rated Wrist/Hand Evaluation (PRWHE) and EQ-5D in patients with hand/wrist injuries or disorders.

MATERIAL AND METHODS

This retrospective cohort study collected data on 183 patients with hand/wrist injuries or diseases who had visited a hand/wrist outpatient clinic or were hospitalized for surgery between 2017 and 2020. Patients had to be at least 18 years old and able to complete the four questionnaires included in the study. The four PROMs (DASH, MHQ, PRWHE and EQ-5D) were administered to the patients prior to treatment. After completing the questionnaires, patients were asked to answer two open-ended questions regarding their preferences. Multinomial logistic regression was used to identify factors related to patient preferences. Results are presented as the relative risk ratio (RRR). The standardized response mean (SRM) was used to evaluate questionnaire responsiveness.

RESULTS

Of the 183 patients, most preferred the PRWHE questionnaire (n = 74, 41%), with the main reasons cited being "specific to injuries/diseases and reflects hand/wrist function (n = 23, 31%)" and "easy to complete (n = 22, 30%)." Sex was found to be associated with patient preference after adjusting for demographic data and reasons for choosing a PROM as confounders (RRR = 0.46, P value = 0.049). The PRWHE had the highest SRM, followed by DASH (0.92 and 0.88, respectively).

CONCLUSIONS

The PRWHE is the most preferred by patients and is the most responsive questionnaire. It is recommended for use in clinical practice in situations where a clinician would like to use only one PROM for evaluating patients with various types of hand/wrist problems.

LEVEL OF EVIDENCE

Prognostic III.

Development and Validation of a Survey to Measure Patients' Expectations of Wrist Arthritis Surgery

Background  The purpose of this study was to develop and test a patient-derived expectations survey for wrist arthritis surgery. We hypothesized that preoperative patient expectations are higher in people with greater functional impairment and that postoperative fulfilment of patient expectations correlates with functional improvement. Methods  The study was conducted in four phases. Development (n = 22) Preoperatively, patients were asked open-ended questions regarding expectations of surgery. A draft survey was then assembled. Reliability (n = 35) The survey was administered twice preoperatively. Concordance was measured with weighted kappa values and intraclass correlations (ICC). Validity (n = 58) Validity was assessed by comparing responses from the Expectations Survey to the patient-rated wrist evaluation (PRWE). Responsiveness (n = 18) Responsiveness was calculated by comparing the proportion of expectations fulfilled to PRWE scores 1-year postoperatively. Results   Development Twenty-two distinct items representing the most frequent responses were utilized from the draft survey items of 1,244 expectations volunteered. Reliability Patients had high preoperative expectations of surgery (mean = 76.8); 30% had scores ≥90. Test-retest reliability was high (Cronbach α coefficients = 0.91, 0.93, ICC = 0.86). Endorsement of items = 66 to 100%; and weighted kappa values = 0.39 to 0.96. Validity Patients with greater preoperative expectations (≥63) had more pain, worse function, and worse PRWE scores than those with lower expectations. Responsiveness The proportion of fulfilled expectations was high (mean 0.80, median 0.79), and greater fulfillment (proportion > 0.80, n  = 8) was associated with better postoperative PRWE scores. Conclusion  The patient-derived expectations survey is reliable, valid, responsive, and addresses a spectrum of expectations for patients undergoing surgery for wrist arthritis. Clinical relevance Understanding patient expectations can contribute to customized care given the range of surgical choices for the arthritic wrist.

Field testing and psychometric properties of Thai version of the Boston carpal tunnel questionnaire

Introduction

The Boston Carpal Tunnel Questionnaire (BCTQ) is a widely recommended patient-reported outcome measure to evaluate symptoms and functions in carpal tunnel syndrome (CTS) patients. We aimed to evaluate the translation and cross-cultural adaptation of the Thai version of the BCTQ (Thai BCTQ) and to investigate the psychometric properties including internal consistency, test-retest reliability, construct validity and responsiveness.

Methods

The Thai BCTQ was field tested with 15 healthy volunteers and 15 CTS patients to evaluate the item-objective congruence of each item. Following that, one hundred and twenty-four CTS patients were included for psychometric evaluation in this study. Internal consistency was assessed using Cronbach's alpha. Test-retest reliability was examined using the intraclass correlation coefficient (ICC). To evaluate construct validity, Spearman's rank correlation of the symptom severity scale (Thai BCTQ -S), the functional status scale (Thai BCTQ -F) and the subscales of the Thai MHQ were analyzed. Responsiveness was determined using the standardized response mean (SRM).

Results

Minor modification of the Thai version was made to better explain the term "tingling". The Thai BCTQ-S, Thai BCTQ-F and Thai BCTQ demonstrated adequate Cronbach's alpha values (0.91-0.94) and good test-retest reliability (ICC=0.89-0.98). Regarding related dimensions, a strong correlation (r=0.67, P<0.008) was found between the Thai BCTQ-F and the Function subscale of Thai MHQ as well as between Thai BCTQ-F and the Activities of Daily Living subscale of the Thai MHQ (r=0.75, P<0.008). In unrelated dimensions, there was a relatively weak correlation between the Thai BCTQ-S and the Aesthetics subscale of the Thai MHQ (r=0.32, P=0.0116). The SRM of the Thai BCTQ was 1.46, indicating large responsiveness.

Discussion

The Thai BCTQ has adequate internal consistency in both the symptom and function scales as well as good construct validity and test-retest reliability indicating it is suitable for evaluating Thai CTS patients. This tool also has a high ability to detect clinically significant changes in symptoms and function over time after receiving conservative or surgical treatment.

Cross-cultural translation, reliability and validity of the Thai version of the Patient‑Reported Outcomes Measurement Information System (PROMIS) Parent Proxy Upper Extremity Short Form 8a in children with congenital upper extremity anomalies

BACKGROUND

The PROMIS Parent Proxy Upper Extremity Short Form 8a version 2 (PROMIS Parent Proxy UE-SF) is one of the most commonly used self-assessment questionnaires for evaluating function in children with congenital upper extremity anomalies. However, this English questionnaire is difficult for Thai parents to complete. The purpose of this study is to translate the PROMIS Parent Proxy UE-SF into Thai and test its reliability and validity.

METHODS

The PROMIS Parent Proxy UE-SF was translated into Thai using FACIT translation methodology. This version and the Thai version of the Michigan Hand Questionnaire (Thai-MHQ) were used to evaluate 30 Thai children with different types of congenital upper extremity anomalies. The reliability and validity of the Thai-PROMIS Parent Proxy UE-SF were evaluated by test-and-retest with the intraclass correlation coefficient (ICC) and Cronbach's alpha coefficient. Correlations between the Thai-PROMIS Parent Proxy UE-SF and Thai-MHQ were analysed by Pearson's correlation coefficients.

RESULTS

The children's mean age was 4.47 ± 2.08 years (range 1-9 years). The main diagnoses included thumb duplication (11 children), syndactyly (4 children)4, congenital trigger thumb (3 children) and obstetric brachial plexus palsy (3 children). The children's parents completed the questionnaires, taking 164.23 ± 22.58 s for the Thai-PROMIS and 337.8 ± 49.37 s for the Thai-MHQ. The test-retest reliability of Thai-PROMIS evaluated by ICCs, was 0.9909 (good reliability), and the Cronbach's alpha of all items was 0.923. The Pearson's correlation coefficient between the Thai-PROMIS and Thai-MHQ showed a strong correlation with Domain 2 (activities of daily living, r = 0.7432) and a moderate correlation with the overall Thai-MHQ score (r = 0.699).

CONCLUSIONS

The Thai-PROMIS Parent Proxy UE-SF is a valid, reliable and easy-to-use patient-reported outcome measure for assessing function in children with congenital upper extremity anomalies.

Understanding Health Economics in Hand Surgery

Rising health care costs in the United States, besides evolving payment models that place emphasis on value instead of volume, have led to an increasing number of studies evaluating hand surgery from an economic perspective. To better understand such economics-based studies, this review provides a foundational understanding of what value entails by defining its features of quality and cost. Principles of evaluating value through cost-benefit, cost-effectiveness, and cost-utility analyses are discussed. Models of discounting and clinical decision analyses are also discussed. Understanding such concepts and their evaluation in economic analyses will provide greater insight into the economic landscape of hand surgery and improving patient care.

Association between perceived and objective hand-wrist function in distal radius fracture

The relationship between patient-reported outcome measures and objective measures is important for understanding patient expectations. The aim of this study was to investigate the relationship of each section of the Michigan Hand Outcomes Questionnaire (MHQ) to objective measurements in patients with distal radius fracture (DRF). Eighty-four patients who were treated operatively or non-operatively for DRF were included. Injury severity was assessed by the Modified Hand Injury Severity Score. Joint motion was assessed at 6 and 12 weeks and grip strength at 12 weeks after non-operative treatment or surgery. The MHQ was used to assess hand functionality. The relationships between measurements were analyzed by Spearman correlation analysis. Statistical significance was set at p &lt; 0.05. Fifty-one patients (60.7%) were women and 33 (39.3%) men. Mean age was 48.17 ± 12.26 (range, 20-64) years. Fifty-two (61.9%) patients were treated surgically and 32 (38.1%) non-operatively. Forearm pronation-supination and wrist flexion and ulnar deviation at week 6 and forearm pronation-supination, wrist extension and radial deviation at week 12 correlated with MHQ scores, unlike wrist extension and radial deviation at week 6 and flexion and ulnar deviation at week 12. Gross and fine grip strength at week 12 correlated with MHQ, except for the overall hand function, work performance and pain subsections. The MHQ subsections correlated with joint motion and grip strength in the early period after DRF. These findings clarified patient expectations in the early period.

Soft tissue interpositional arthroplasty as a treatment of proximal interphalangeal joint arthritis in resource-limited health care facility: A case report

Introduction

Treatment of choice for posttraumatic arthritis in proximal interphalangeal (PIP) joints has remained a controversial subject. There is a lack of consensus regarding the optimal approach and treatment options for PIP joint arthritis. In this study, we report our experience in management of PIP joint arthritis using soft-tissue interpositional arthroplasty.

Case presentation

A 12-year-old female, right-handed, complains of stiffness on the left ring finger. There was a flexion deformity accompanied by limitation on both active and passive flexion-extension range of motion (ROM) of the PIP joint. Soft tissue interpositional arthroplasty was then performed using middle phalanx periosteum as interpositional material. Postoperative follow-up showed improvement in both active and passive ROM of PIP joint, improvement in joint function, and a good pain relief. Overall, the patient was satisfied with the outcomes of the procedure.

Clinical discussion

Arthrodesis, implant arthroplasty, and interpositional arthroplasty are the treatments of choice for stiff fingers that are caused by bone problems. In this study, we report a case of PIP joint arthritis treated with interpositional arthroplasty. It was able to provide ROM improvement and good functional results. Periosteum is used as an interposition material because of its in-situ nature thereby reducing donor site related morbidity and postoperative complications. In addition, the use of the periosteum makes this procedure relatively inexpensive and makes it a suitable treatment of choice in limited resources areas.

Conclusion

Soft tissue interpositional arthroplasty shows promising results as a treatment option for arthritis of PIP joint, especially in limited resource areas.

•

Interpositional arthroplasty provides good clinical outcomes for PIP joint arthritis.

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The use of periosteum as interposition material reduces morbidity and complications.

•

Interpositional arthroplasty is a proper treatment option for limited resource area.

Establishing the Minimal Clinically Important Difference and Substantial Clinical Benefit for the Pain Visual Analog Scale in a Postoperative Hand Surgery Population

PURPOSE

Although the pain visual analog scale (VAS-pain) is a ubiquitous patient-reported outcome instrument, it remains unclear how to interpret changes or differences in scores. Therefore, our purpose was to calculate the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

METHODS

Adult postoperative patients treated by 1 of 5 fellowship-trained orthopedic hand surgeons at a single tertiary academic medical center were identified. Inclusion required VAS-pain scores at baseline (up to 3 months before surgery) and follow-up (up to 4 months after surgery), in addition to a response to a pain-specific anchor question at follow-up. The MCID estimates were calculated with (1) the 1/2 standard deviation method; and (2) an anchor-based approach. The SCB estimates were calculated with (1) an anchor-based approach; and (2) a receiver operator curve method that maximized the sensitivity and specificity for detecting a "much improved" pain status.

RESULTS

There were 667 and 148 total patients included in the MCID and SCB analyses, respectively. The 1/2 standard deviation MCID estimate was 1.6, and the anchor-based estimate was 1.9. The anchor-based SCB estimate was 2.2. The receiver operator curve analysis yielded an SCB estimate of 2.6, with an area under the curve of 0.72, consistent with acceptable discrimination.

CONCLUSIONS

We propose MCID values in the range of 1.6 to 1.9 and SCB values in the range of 2.2 to 2.6 for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

CLINICAL RELEVANCE

These MCID and SCB estimates may be useful for powering clinical studies and when interpreting VAS-pain score changes or differences reported in the hand surgery literature. These values are to be applied at a population level, and should not be applied to assess the improvement, or lack thereof, for individual patients.

Evaluation of the PROMIS Upper Extremity Against Validated Patient-Reported Outcomes in Patients With Early Carpometacarpal Osteoarthritis

PURPOSE

Internal consistency, construct, and criterion validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) v1.2 were evaluated in patients with early-stage carpometacarpal (CMC) osteoarthritis (OA). We hypothesized that in patients with early CMC OA, PROMIS UE scores would: (1) be lower than those in asymptomatic controls; (2) correlate with established patient-reported outcomes; (3) correlate with pinch and grip strengths; and (4) not correlate with radiographic disease progression.

METHODS

Patients with early CMC OA (modified Eaton stage 0 or 1) and matched asymptomatic control patients completed the PROMIS UE, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation at 2 time points. The PROMIS UE's internal consistency was evaluated by Cronbach's alpha, construct validity by Spearman correlation coefficients among the patient-reported outcome measures, and criterion validity using measures of strength. A floor or ceiling effect was indicated if more than 15% of patients achieved the lowest or highest possible score.

RESULTS

The PROMIS UE had high internal consistency. Patients with early CMC OA had a lower score than healthy controls (average, 42 vs 54, respectively). We observed moderate to high correlations between the PROMIS UEv1.2, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation and good criterion validity when compared to key pinch and grip strengths. The PROMIS UE did not correlate to radiographic disease severity.

CONCLUSIONS

The PROMIS UE had a high correlation with Australian and Canadian Osteoarthritis Hand Index and a moderate correlation with Patient-Rated Wrist-Hand Evaluation. The PROMIS UE had high internal consistency and good criterion validity.

CLINICAL RELEVANCE

The PROMIS UE is a valid assessment for disability in patients with early CMC OA and can serve as a clinical adjunct to an outcome assessment.

Establishing the Substantial Clinical Benefit in a Non-Shoulder Hand and Upper Extremity Population for the QuickDASH and PROMIS Upper Extremity and Physical Function Computer Adaptive Tests

PURPOSE

It is unclear what score changes on the abbreviated Disabilities of the Arm, Hand, and Shoulder (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive test (CAT), and PROMIS physical function (PF) CAT represent a substantial improvement. We calculated the substantial clinical benefit (SCB) for these 3 instruments in a non-shoulder hand and upper extremity population.

METHODS

Adult patients treated between March 2015 and September 2019 at a single academic tertiary institution were identified. The QuickDASH, PROMIS UE CAT v2.0, and PROMIS PF CAT v2.0 scores were collected using a tablet computer. Responses to the QuickDASH both at baseline and follow-up 6 ± 4 weeks later, and a response to the anchor question "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" were required for inclusion. A second anchor question querying treatment-related improvement was also used. The SCB was calculated using an anchor-based approach comparing the mean change difference between groups reporting no change and a maximal change for both anchor questions.

RESULTS

Of 1,119 included participants, the mean age was 48 ± 17 years, 53% were women, and half were recovering from surgery. Score changes between baseline and follow-up were significantly different between groups reporting no improvement and maximal improvement on both anchor questions. The SCB values ranged between 16.9 and 22.8 on the QuickDASH, 5.9 and 7.1 on the UE CAT, and 3.5 and 6.7 on the PF CAT.

CONCLUSIONS

These score improvements for the QuickDASH, UE CAT, and PF CAT represent a substantial clinical improvement in a non-shoulder hand and upper extremity population.

CLINICAL RELEVANCE

These SCB estimates may assist with the interpretation of outcome scores at a population level.

Applying Health Utility Outcome Measures and Quality-Adjusted Life-Years to Compare Hand Allotransplantation and Myoelectric Prostheses for Upper Extremity Amputations

BACKGROUND

An amputation of the upper extremity not only is devastating for the patient's physical, emotional, and social well-being but also constitutes a financial stress for both the patient and the health care system. The objective of this study was to determine the utility and quality-adjusted life-years of hand allotransplantation versus myoelectric prostheses and to compare these measures in patients afflicted with unilateral versus bilateral amputations.

METHODS

A survey was administered on bilateral amputees, unilateral amputees, replantation patients, and healthy controls. Patient demographics, functional patient-reported outcomes, quality-of-life questionnaires, and utility outcome measures were calculated for four different scenarios: hand transplantation and myoelectric prostheses with or without complications.

RESULTS

Five bilateral amputees, 12 unilateral amputees, nine replantation patients, and 45 healthy controls completed the survey. The highest quality-adjusted life-years were obtained in the replantation patient group for the scenario of myoelectric prosthesis without complications (mean, 34.8 years). Altogether, there was no statistically significant difference between hand transplantation and myoelectric prostheses (p = 0.36). On subgroup analysis, unilateral amputees reported significantly higher quality-adjusted life-years for myoelectric prostheses rather than hand transplantation (6.4; p = 0.0015), whereas bilateral amputees did not demonstrate a significant difference (-2.4; p = 0.299).

CONCLUSIONS

Utility and quality-adjusted life-years do not differ significantly between hand transplantation and myoelectric prostheses, except in unilateral amputees with myoelectric prostheses, who had higher quality-of-life scores. Based on trends from this pilot study, myoelectric prostheses may be considered for unilateral amputees, whereas no superiority can be demonstrated between both treatments in bilateral amputees.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Psychometric analysis of the questionnaires for the assessment of upper limbs available in their Italian version: a systematic review of the structural and psychometric characteristics

INTRODUCTION

There is no systematic review that analyzes the psychometric properties of questionnaires in Italian. Previous studies have analyzed the psychometric characteristics of instruments for the measurement of pathologies of upper limbs and their joints in different languages. The aim of the present study was to analyze the psychometric properties of the questionnaires published in Italian for the evaluation of the entire upper limb or some of its specific regions and related dysfunctions.

EVIDENCE ACQUISITION

For the development of this systematic review, the following databases were used: PubMed, Scopus, Cochrane, Dialnet, Cinahl, Embase and PEDro. The selection criteria used in this study were: studies of transcultural adaptation to Italian of questionnaires oriented to the evaluation of upper limbs or any of their structures (specifically shoulder, elbow and wrist/hand), and contribution of psychometric variables of the questionnaire in its Italian version.

EVIDENCE SYNTHESIS

After reading the titles and applying the inclusion and exclusion criteria to the complete documents, 16 documents were selected: 3 for the upper limb, 8 for the shoulder, 1 for the elbow and 4 for the wrist and hand. The cross-sectional psychometric variables show levels between good and excellent in all the questionnaires. Longitudinal psychometric variables had not been calculated in the vast majority of the analyzed questionnaires.

CONCLUSIONS

Italian versions of the questionnaires show good basic structural and psychometric characteristics for the evaluation of patients with musculoskeletal disorders of the upper limb and its joints (shoulder, elbow and wrist/hand).

Comparison between patient-reported and physician-estimated pain and disability in hand and wrist disorders

Background

Pain and disability are important components of the assessment of hand problems, but it is unknown how physician estimates compare to patient self‐reports.

Objective

To analyse differences between patient‐reported and physician‐estimated pain and disability in patients with hand or wrist disorders and to analyse factors influencing these differences.

Methods

Observational study of patients with hand or wrist disorders seen during multidisciplinary outpatient consultations. Patients, rehabilitation medicine (RM) consultants, RM trainees and plastic surgeons completed visual analogue scales (VASs) to rate the level of self‐reported (patients) or estimated (physicians) pain and disability. Multilevel analyses were performed to evaluate differences in VAS‐pain and VAS‐disability scores between patients and physicians and to evaluate the influences of diagnosis, physician experience and medical specialty.

Results

Complete data were obtained for 250 patients. Levels of pain and disability estimated by physicians were lower compared to patient self‐reports. Ratings differed among medical specialties. Pain was underestimated to a greater extent by plastic surgeons compared to RM consultants. Disability was underestimated to a greater extent by RM consultants compared to plastic surgeons. Estimates of pain and disability did not differ between consultants and trainees in RM. Type of diagnosis did not influence the degree of underestimation of pain and disability.

Conclusions

Physicians underestimate pain and disability compared to self‐reports in patients with hand or wrist disorders. Ratings differ among medical specialties: plastic surgeons underestimate pain more, while RM consultants underestimate disability more. Physician experience and diagnosis do not influence the degree of underestimation of pain and disability.

Establishing the Minimal Clinically Important Difference for the PROMIS Upper Extremity Computer Adaptive Test Version 2.0 in a Nonshoulder Hand and Upper Extremity Population

PURPOSE

Our primary purpose was to calculate the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 (v2.0) for a nonshoulder hand and upper extremity population. Secondarily, we calculated the PROMIS Physical Function (PF) CAT v2.0 and the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) MCID.

METHODS

Adult patients treated by 1 of 5 fellowship-trained hand surgeons between March 2015 and September 2019 at an academic tertiary institution were identified. The PROMIS UE CAT v2.0, PROMIS PF CAT v2.0, and QuickDASH were collected via tablet computer. Inclusion required response to at least 1 of the instruments at both baseline and follow-up (6 ± 4 weeks), and a response to the anchor question: "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" An additional anchor question assessing treatment-related improvement was also asked. The MCID was calculated using an anchor-based approach using the mean change difference between groups reporting no change and slight change for both anchor questions, and with the 1/2 SD method.

RESULTS

Of 2,106 participants, mean age was 48 ± 17 years, 53% were female, and 53% were recovering from surgery. Of these patients, 381 completed the PROMISE UE CAT v2.0, 497 completed the PROMIS PF CAT v2.0, and 2,018 completed the QuickDASH. The score change between baseline and follow-up was significantly different between anchor groups for both anchor-based MCID calculations. Anchor-based MCID values were 3.0 to 4.0 for the UE CAT, 2.1 to 3.6 for the PF CAT, and 10.3 for the QuickDASH. The MCID values per the 1/2 SD method were 4.1, 4.1, and 10.2, respectively.

CONCLUSIONS

We propose MCID ranges of 3.0 to 4.1 for the PROMIS UE CAT v2.0, and 2.1 to 4.1 for the PROMIS PF CAT v2.0. The observed QuickDASH MCID values (10.2-10.3) are within the range of previously published values.

CLINICAL RELEVANCE

These MCID estimates will aid in interpreting clinical outcomes and in powering clinical studies.

Self-identified functional limitations improve in patients with degenerative wrist arthritis after surgery

STUDY DESIGN

This is a prospective cohort pilot study.

BACKGROUND

Degenerative wrist arthritis leads to pain, loss of strength, mobility, function, and impairments in psychological well-being. Accurate assessment of functional limitations that are unique to the individual is essential for successful treatment that best meets those specific needs.

PURPOSE OF THE STUDY

To identify and determine if self-identified functional limitations improve in patients who underwent surgery for degenerative wrist arthritis.

METHODS

Patients with degenerative wrist arthritis who were scheduled for surgery were prospectively recruited (n = 14, mean age + SD = 42 + 16, 10 males, 4 females) into a pilot study that measured self-identified functional limitations and outcomes. Inclusion criteria included a diagnosis of scapholunate advanced collapse, scaphoid nonunion advanced collapse, scapholunate interosseous ligament tear, or Kienböck disease. Exclusion criteria included a history of neuromuscular disease or concomitant ipsilateral musculoskeletal injury. Data were collected during two 20-minute sessions, preoperatively and one year postoperatively, utilizing the Patient-Rated Wrist Evaluation and the Canadian Occupational Performance Measure.

RESULTS

All patients reported significant decreases (P < .001) in total pain (mean change = 17.6, SD = 8.5) and total disability (mean = 17.8, SD = 9.1) on the Patient-Rated Wrist Evaluation from presurgery to postsurgery, with a large effect size of d > 0.8. Patients also reported significant improvements (P < .001) in mean performance (mean = 3.5, SD = 1.5) and mean satisfaction (mean = 4.0, SD = 2.1) with self-identified activities on the Canadian Occupational Performance Measure, with an effect size of d > 0.8.

CONCLUSION

Patients with degenerative wrist arthritis reported significant postoperative improvement in both performance and satisfaction in self-identified activities. Consideration of patient-specified goals can inform both patients and clinicians during the surgical decision-making process and allow for more individualized care.

Using Carpal Tunnel Questionnaire in clinical practice: A systematic review of its measurement properties

INTRODUCTION

Carpal Tunnel Questionnaire (CTQ) is widely used for assessing condition-specific impairments in individuals with carpal tunnel syndrome (CTS) or for assessing outcomes after carpal tunnel surgery (carpal tunnel release [CTR]). A systematic review of its measurement properties can greatly facilitate its evidence-based use in clinical practice. The purpose of this study was to systematically locate, appraise, and synthesize the evidence concerning the reliability, responsiveness, validity, minimal detectable change (MDC), and minimal clinically important difference (MCID) for the CTQ and its scales.

STUDY DESIGN

This is a systematic review of measurement properties.

METHODS

Using predefined keywords, PubMed, CINAHL, PsychInfo, and ProQuest were searched to locate primary studies that assessed measurement properties of the CTQ. The methodological quality of the included studies was assessed using a standardized tool. Data concerning the measurement properties were extracted and synthesized. The pooled estimates for the indices of test-retest reliability, standard error of measurement, responsiveness, MDC, and MCID were calculated from the included studies.

RESULTS

A total of 34 articles were deemed eligible and included in this review. The methodological quality of these 34 studies was generally good. Most studies suggested that the CTQ and its scales had good test-retest reliability and internal consistency. However, few studies found that the Symptom Severity Scale had more than one factor. The responsiveness of the CTQ and its scales was excellent across the studies. The pooled estimates for the MDC₉₀ and MCID for Symptom Severity Scale/Functional Status Scale were 0.72/0.79 and 1.05/1.13, respectively.

DISCUSSION

The results of this review support the use of CTQ and its scales in assessing conditions-specific impairments in individuals with CTS or after CTR. However, an effort should be made to review and modify the content of the symptom severity scale due to multiple reports challenging its unidimensional structure.

CONCLUSIONS

The totality of evidence emerging from this systematic review suggests that the CTQ and its scales provide reliable and valid estimate of impairments resulting from CTS or after CTR.

Total Wrist Arthroplasty Alignment and Its Potential Association with Clinical Outcomes

Purpose  There is a lack of quantitative research that describes the alignment and, more importantly, the effects of malalignment on total wrist arthroplasty (TWA). The main goal of this pilot study was to assess the alignment of TWA components in radiographic images and compare them with measures computed by three-dimensional analysis. Using these measures, we then determined if malalignment is associated with range of motion (ROM) or clinical outcomes (PRWHE, PROMIS, QuickDash, and grip strength). Methods  Six osteoarthritic patients with a single type of TWA were recruited. Radiographic images, computed tomography images, and clinical outcomes of the wrists were recorded. Using posteroanterior and lateral radiographs, alignment measurements were defined for the radial and carpal components. Radiographic measurements were validated with models reconstructed from computed tomography images using Bland-Altman analysis. Biplanar videoradiography (<1mm and <1 degree accuracy) was used to capture and compute ROM of the TWA components. Linear regression assessed the associations between alignment and outcomes. Results  Radiographic measures had a 95% limit-of-agreement (mean difference ±  1.96 × SD) of 3 degrees and 3mm with three-dimensional values, except for the measures of the carpal component in the lateral view. In our small cohort, wrist flexion-extension and radial-ulnar deviation were correlated with volar-dorsal tilt and volar-dorsal offset of the radial component and demonstrated a ROM increase of 3.7 and 1.6 degrees per degree increase in volar tilt, and 10.8 and 4.2 degrees per every millimeter increase in volar offset. The carpal component's higher volar tilt was also associated with improvements in patient-reported pain. Conclusions  We determined metrics describing the alignment of TWA, and found the volar tilt and volar offset of the radial component could potentially influence the replaced wrist's ROM. Clinical Relevance  TWA component alignment can be measured reliably in radiographs, and may be associated with clinical outcomes. Future studies must evaluate its role in a larger cohort.

Minimal Clinically Important Difference of the PROMIS Upper-Extremity Computer Adaptive Test and QuickDASH for Ligament Reconstruction Tendon Interposition Patients

PURPOSE

To calculate the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) for ligament reconstruction tendon interposition (LRTI) patients.

METHODS

Adult patients treated with LRTI for trapeziometacarpal OA by fellowship-trained hand surgeons between December 2014 and February 2018 at an academic tertiary institution were included. Outcomes were prospectively collected at each visit by tablet computer, including the QuickDASH, PROMIS UE, Pain Interference, Depression, and Anxiety CATs. Inclusion required a response to the anchor question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" on a 6-option Likert scale, as well as preoperative (≤120 days before surgery) and follow-up (2-26 weeks) outcomes. We calculated MCID both by an anchor-based approach using the mean score of the minimal change group, and with the 0.5 SD method.

RESULTS

Of 145 included participants, mean age was 63 ± 8 years and 74% were female. Anchor-based MCID estimates for the total cohort were 4.2 for the PROMIS UE CAT and 8.8 for the QuickDASH. The MCID estimates using the 0.5 SD method were 4.8 and 11.7, respectively.

CONCLUSIONS

We propose MCID values of 4.2 to 4.8 for the PROMIS UE CAT and 8.8 to 11.7 for the QuickDASH when powering clinical studies or when assessing improvement among a cohort of patients who have undergone LRTI surgery.

CLINICAL RELEVANCE

Minimal clinically important difference estimates are helpful when interpreting clinical outcomes after LRTI and for powering prospective trials.

Measurement Properties of Outcome Measures Used to Assess Physical Impairments in Patients After Distal Radius Fracture: A Systematic Review

OBJECTIVES

Individuals with distal radius fractures (DRF) may experience difficulty with gripping an object, painful wrist movements, sensorimotor difficulties, and swelling around the wrist and hand. A comprehensive review of the existing evidence concerning the measurement properties of common physical impairment measures can provide a valuable resource to guide hand therapy practice while managing DRF. The primary objective was to locate and assess the quality of literature on the measurement properties for the measures of physical impairment used in individuals with DRF.

METHODS

Two reviewers searched PubMed, CINAHL, and EMBASE. A combination of DRF, measurement properties, and physical impairments were used as keywords, and articles were independently assessed using the Consensus-Based Standards for the Selection of Health Measurement Instruments critical appraisal tool. Primary studies were included if they examined at least 1 of the following: reliability, validity, responsiveness, or indices of true and meaningful changes for measures of physical impairment in the DRF sample. A total of 19 articles were included in this review. The quality of the studies ranged from 46% to 92%. This review suggests that measures such as assessment of grip strength and supination and pronation range of motion (ROM), using various goniometric devices, showed good intrarater and interrater reliability, construct validity, and responsiveness in individuals with DRF.

CONCLUSION

Acceptable reliability and responsiveness were reported in grip and wrist ROM assessments for measuring changes in wrist and hand function after DRF; however, wrist ROM assessed using traditional goniometric techniques were less reliable in individuals with DRF.

IMPACT

This study provides insight into which objective tools might be better suited for measuring outcomes related to DRF.

Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis

Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores (P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level (P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation (P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.

Mid-term outcome of volar plate fixation for scaphoid nonunion

AIMS

Fixation of scaphoid nonunion with a volar locking plate and cancellous bone grafting has been shown to be a successful technique in small series. Few mid- or long-term follow-up studies have been reported. The aim of this study was to report the mid-term radiological and functional outcome of plate fixation for scaphoid nonunion.

METHODS

Patients with a scaphoid nonunion were prospectively enrolled and treated with open reduction using a volar approach, debridement of the nonunion, and fixation using a locking plate and cancellous bone grafting, from the ipsilateral iliac crest. Follow-up included examination, functional assessment using the patient-rated wrist/hand evaluation (PRWHE), and multiplanar reformation CT scans at three-month intervals until union was confirmed.

RESULTS

A total of 49 patients with a mean age of 31 years (16 to 74) and a mean duration of nonunion of 3.6 years (0.4 to 16) were included. Postoperatively, the nonunion healed in 47 patients (96%) as shown on CT scans. The mean time to union was 4.2 months (3 to 12). Due to impingement of the plate on the volar rim of the radius and functional limitation, the hardware was removed in 18 patients. At a median follow-up of 38 months in 34 patients, the mean active range of motion (ROM) improved significantly from 89° to 124° (SD 44°; p = 0.003). The mean grip strength improved significantly from 52% to 79% (SD 28%; p < 0.001) of the contralateral side. The mean PRWHE score improved significantly from 66 to 17 points (SD 25; p < 0.001).

CONCLUSION

Locking plate fixation supplemented with autologous cancellous bone grafting is a successful form of treatment for scaphoid nonunion. Functional outcomes improve with the passage of time, and mid-term results are excellent with a significant improvement in ROM, grip strength, and functional outcome as measured by the PRWHE. Cite this article: Bone Joint J 2020;102-B(12):1697-1702.

Is reduction of routine radiograph use in patients with distal radius fractures cost effective? Analysis of data from the multicentre, randomised controlled WARRIOR trial

OBJECTIVE

To assess the cost effectiveness of a reduced imaging follow-up protocol of distal radius fractures compared with usual care.

DESIGN

An economical evaluation conducted alongside a multicentre randomised controlled trial (RCT).

SETTING

Four level-one trauma centres in the Netherlands.

PARTICIPANTS

341 patients participated (usual care (n=172), reduced imaging (n=169)).

INTERVENTIONS

Patients were randomised to usual care (routine radiography at 1, 2, 6 and 12 weeks) or a reduced imaging strategy (radiographs at 6 and 12 weeks only for a clinical indication).

OUTCOME MEASURES

Functional outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and quality-adjusted life years (QALYs) using the EuroQol-5Dimensions-3 Levels (EQ-5D-3L). Costs were measured using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation, seemingly unrelated regression analysis and bootstrapping were used to analyse the data.

RESULTS

Clinical overall outcomes of both groups were comparable. The difference in DASH was -2.03 (95% CI -4.83 to 0.77) and the difference in QALYs was 0.025 (95% CI -0.01 to 0.06). Patients in the reduced imaging group received on average 3.3 radiographs (SD: 1.9) compared with 4.2 (SD: 1.9) in the usual care group. Costs for radiographic imaging were significantly lower in the reduced imaging group than in the usual care group (€-48 per patient, 95% CI -68 to -27). There was no difference in total costs between groups (€-401 per patient, 95% CI -2453 to 1251). The incremental cost-effectiveness ratio (ICER) for QALYs was -15 872; the ICER for the DASH was 198. The probability of reduced imaging being cost effective compared with usual care ranged from 0.8 to 0.9 at a willingness to pay of €20 000/QALY to €80 000/QALY.

CONCLUSIONS

Implementing a reduced imaging strategy in the follow-up of distal radius fractures has a high probability of being cost effective for QALYs, without decreasing functional outcome. We, therefore, recommend imaging only when clinically indicated.

TRIAL REGISTRATION NUMBER

The Netherlands trial register (NL4477).

Correlation of HISS and Strickland Score with the Michigan Hand Outcome Questionnaire in hand injuries

BACKGROUND

The widely used Hand Injury Severity Score (HISS) has intrinsic drawbacks like inability to score vascular status and questionable correlation with Disability of Arm, shoulder and Hand. We compared it with the Strickland score which is easier to calculate and has provision for evaluation of vascular status. We assessed correlation of both the scores with the Michigan Hand Outcome Questionnaire (MHQ).

METHODS

In a prospective study of 1574 patients admitted with hand injuries, we recorded their HISS and Strickland scores and followed them up for a year and later interviewed for MHQ score. Statistical correlation was done comparing the HISS and Strickland score with the MHQ using the SPSS package.

RESULTS

Majority of these injuries were in manual labourers (47.5%) with agricultural or industrial background with a mean age of 25 years (18-26 years). Using the One-way ANOVA test we found a significant correlation between the HISS and MHQ (P Value < 0.001). Using the Unpaired T-test, statistically significant association (P < 0.001) was seen between the Strickland score and MHQ. The correlation between HISS and Strickland Score done by One-way ANOVA Test was also found to be significant (P Value < 0.001). On evaluating the group of patients with a Strickland score >10, we observed that the MHQ was almost similar between those who underwent amputation with those who underwent a successful salvage, though not statistically significant.

CONCLUSION

HISS and Strickland score correlated significantly with each other and with the MHQ. Strickland score was easy and quicker to determine the salvagability of hand injury. However, small group of patients who may benefit from salvage in spite of a high Strickland score where factors like patient's age, occupation, comorbid health condition, motivation, expenses, and social environment needs to be taken into account in decision making.

Translation, cross-cultural and construct validity of the Dutch-Flemish PROMIS® upper extremity item bank v2.0

PURPOSE

To develop a Dutch-Flemish translation of the PROMIS® upper extremity (PROMIS-UE) item bank v2.0, and to investigate its cross-cultural and construct validity as well as its floor and ceiling effects in patients with musculoskeletal UE disorders.

METHODS

State of the art translation methodology was used to develop the Dutch-Flemish PROMIS-UE item bank v2.0. The item bank and four legacy instruments were administered to 205 Dutch patients with musculoskeletal UE disorders visiting an orthopedic outpatient clinic. The validity of cross-cultural comparisons between English and Dutch patients was evaluated by studying differential item functioning (DIF) for language (Dutch vs. English) with ordinal logistic regression models and McFadden's pseudo R²-change of ≥ 2% as critical value. Construct validity was assessed by formulating a priori hypotheses and calculating correlations with legacy instruments. Floor/ceiling effects were evaluated by determining the proportion of patients who achieved the lowest/highest possible raw score.

RESULTS

Eight items showed DIF for language, but their impact on the test score was negligible. The item bank correlated, as hypothesized, moderately with the Dutch-Flemish PROMIS pain intensity item (Pearson's r = - 0.43) and strongly with the Disabilities of the Arm, Shoulder and Hand questionnaire, Subscale Disability/Symptoms (Spearman's ρ = - 0.87), the Functional Index for Hand Osteoarthritis (ρ = - 0.86), and the Michigan Hand Outcomes Questionnaire, Subscale Activities of Daily Living (ρ = 0.87). No patients achieved the lowest or highest possible raw score.

CONCLUSIONS

A Dutch-Flemish PROMIS-UE item bank v2.0 has been developed that showed sufficient cross-cultural and construct validity as well as absence of floor and ceiling effects.

Structural validity and construct validity of the Dutch-Flemish PROMIS® physical function-upper extremity version 2.0 item bank in Dutch patients with upper extremity injuries

INTRODUCTION

Aim of this study was to validate the Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank in patients with upper extremity injuries.

MATERIALS AND METHODS

Cross-sectional study. Structural validity was assessed using Confirmatory Factor Analysis examining unidimensionality. In addition, a bi-factor model was fitted. Internal consistency was assessed by Cronbach's alpha. Construct validity was examined by assessing correlations with legacy instruments Disability of Arm Shoulder and Hand, Patient Reported Wrist Evaluation and Michigan Hand Questionnaire subscale Activities in Daily Life.

RESULTS

A total of 303 patients (144 female) with mean age of 50 years (standard deviation 18) were included. Confirmatory Factor Analysis showed Comparative Fit Index of 0.94, a Tucker Lewis Index of 0.93, a Root Mean Square Error of Approximation of 0.12 and a Standardized Root Mean Residual of 0.09. Factor loadings were all above 0.70. Bifactor analysis showed an omega-H of 0.79 and Explained Common Variance of 0.67. The correlations with the legacy instruments were as expected or higher than expected.

CONCLUSION

The Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank measures a unidimensional trait and sufficient construct validity was found.IMPLICATIONS FOR REHABILITATIONCompleting Patient Reported Outcomes is time-consuming for patients and interpretability of outcomes is sometimes unclear due to some variation in psychometric properties.Computerized Adaptive Testing reduces the burden for patients by using an algorithm which decreases the amount of questions that need to be answered to 4 to 7 items.The Dutch-Flemish Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0 item bank measures a unidimensional trait and has sufficient structural validity, internal consistency and construct validity.After calibration of the Patient-Reported Outcomes Measurement Information System Physical Function - Upper Extremity version 2.0, the item bank is operable to use with Computerized Adaptive Testing.

Validity of the Patient-Rated Wrist Evaluation questionnaire in rheumatoid arthritis

BACKGROUND

The Patient-Rated Wrist Evaluation (PRWE) is a patient-reported questionnaire focusing on symptoms and function in wrist pathologies. It consists of 15 questions regarding pain and functional activities of the wrist. Rheumatoid arthritis (RA) is a multi-systemic disease characterized by inflammation of the wrist and hand joints in almost all patients. This study aims to test the validity of PRWE in patients with RA.

METHOD

Seventy-five patients with RA from a single outpatient clinic participated in the study. Patients filled out the Michigan Hand Outcomes Questionnaire (MHOQ) and grip strength of both hands were measured. Patients filled out the PRWE questionnaire consecutively once for the dominant and once for the non-dominant hand. Correlations between PRWE and MHOQ and grip strength scores were analyzed by Spearman's correlation method.

RESULTS

Our results demonstrated that there was a very strong correlation between the PRWE and the MHOQ and a moderate correlation between the PRWE and grip strength (P < .001). PRWE also showed negative and fair correlation with grip strength of both hands (P < .001).

CONCLUSIONS

The Patient-Rated Wrist Evaluation is a valid tool for evaluating wrist involvement in patients with RA. PRWE may be preferred in the busy clinical setting since it has simple and short questions. Additionally, it may provide a sensitive follow-up tool for patients separately using its subscales of pain and function.

Distal Scaphoid Excision in Treatment of Symptomatic Scaphoid Nonunion: Systematic Review and Meta-analysis

Background: Current treatment options for persistent scaphoid nonunion are limited to salvage procedures such as proximal row carpectomy (PRC) or 4-corner fusion (4CF). Several small studies have demonstrated that distal scaphoid excision may provide a simpler alternative with faster recovery. The purpose of this study was to determine the efficacy of distal scaphoid excision as a treatment option for symptomatic scaphoid nonunion. Methods: The MEDLINE and PubMed databases were searched for the use of distal scaphoid excision in scaphoid nonunions. Studies included reported on either the functional or patient-centered outcomes following distal scaphoid excision for symptomatic scaphoid nonunion. Results: Six articles described the outcomes of 70 patients with an average of 11.7 patients per study. Functional outcomes including flexion-extension arc, radial-ulnar deviation, and grip strength improved by an average of 98.95%, 58.96%, and 131.08%, respectively. Patient-derived outcomes included the Modified Mayo Wrist Score, which improved by 92.6%, and the Disabilities of the Arm, Shoulder and Hand, which improved by 137.17%. An average of 68.75% of patients experience complete relief of pain with 20.83% of patients experiencing pain with strenuous activity. The average postoperative visual analog scale (0-10) was 0.71. On average, 93.33% of patients returned to work with an average time of return being 6.89 weeks. Complete satisfaction was reported by 87.80% of patients. Complications included progression into 4CF or PRC and newly developed midcarpal arthritis. Conclusions: Given favorable outcomes, our analysis suggests that distal scaphoid excision may be a favorable, low-risk treatment for scaphoid nonunion without eliminating more extensive options such as 4CF and wrist arthrodesis.

Optoelectronic measurement of wrist movements in various casts and orthoses used in scaphoid fractures

We developed an optoelectronic motion analysis protocol to measure anatomical and functional ranges of wrist motion in Colles'-type and scaphoid-type splints and casts. The protocol was used to study the restriction of wrist motion in casts and splints in ten healthy volunteers. Scaphoid-type casts were no more restrictive to wrist motion than Colles'-type casts, but casts were significantly more restrictive than removable splints. Removable splints were more restrictive than no immobilization. Results suggest there is no benefit in using scaphoid-type casts rather than Colles'-type casts to reduce wrist motion.

Prosthetic Rehabilitation and Vascularized Composite Allotransplantation following Upper Limb Loss

BACKGROUND

Upper limb loss is a devastating condition with dramatic physical, psychological, financial, and social consequences. Improvements in the fields of prosthetics and vascularized composite allotransplantation have opened exciting new frontiers for treatment and rehabilitation following upper limb loss. Each modality offers a unique set of advantages and limitations with regard to the restoration of hand function following amputation.

METHODS

Presented in this article is a discussion outlining the complex considerations and decisions encountered when determining patient appropriateness for either prosthetic rehabilitation or vascularized composite allotransplantation following upper limb loss. In this review, the authors examine how psychosocial factors, nature of injury, rehabilitation course, functional outcomes, and risks and benefits may affect overall patient selection for either rehabilitative approach.

RESULTS

This review summarizes the current state of the literature. Advancements in both prosthetic and biological strategies demonstrate promise with regard to facilitating rehabilitation following upper limb loss. However, there remains a dearth of research directly comparing outcomes in prosthetic rehabilitation to that following upper extremity transplantation.

CONCLUSIONS

Few studies have performed a direct comparison between patients undergoing vascularized composite allotransplantation and those undergoing prosthetic rehabilitation. Upper extremity transplantation and prosthetic reconstruction should not be viewed as competing options, but rather as two treatment modalities with different risk-to-benefit profiles and indications.

Construct validity of the Patient-Rated Wrist and Hand Evaluation questionnaire (PRWHE) for nerve repair in the hand

BACKGROUND

Many tools have been described for outcome assessment after nerve repair. The Patient-Rated Wrist and Hand Evaluation (PRWHE) have been shown to be valid for several hand conditions.

OBJECTIVES

To explore the construct validity of the PRWHE in comparison to cold intolerance, pain and dysfunction questionnaires; the Rosén score and its subcomponents; and threshold sensibility, dynamometry and dexterity tests for nerve repair of the hand.

STUDY DESIGN

Clinical measurement.

METHODS

Construct validity was analysed through Pearson's correlation coefficient in a convenience sample of 32 adult patients after long-term median and ulnar nerve repair.

RESULTS

The PRWHE total score was highly to moderately associated with the Disability of Arm, Shoulder and Hand (r = 0.83), Cold Intolerance Symptom Severity (r = -0.60) and McGill's Pain (r = 0.58) questionnaires. In addition, it was correlated to motor (r = -0.55) and sensor subdomains (r = -0.56) of the Rosén score. Substantial to high associations were found for the motor, sensory impairment and dexterity test.

CONCLUSIONS

The PRWHE was shown to be valid, based on construct validity, for patients with nerve repair of the hand.

Evaluation of Version 2.0 of the PROMIS Upper Extremity Computer Adaptive Test in Nonshoulder Upper Extremity Patients

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) was recently updated to version 2.0 (v2.0). We hypothesized that the PROMIS UE CAT v2.0 would exhibit improved performance characteristics compared with the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) when administered to a nonshoulder upper extremity patient population.

METHODS

The UE CAT v2.0, Physical Function (PF) CAT v2.0, and the QuickDASH were each prospectively administered via tablet computer to all patients presenting to a tertiary hand and upper extremity clinic between April 2017 and October 2017. Patient responses were analyzed, and the mean, range, floor and ceiling effect, and correlations between instruments were calculated.

RESULTS

Among 825 patients, the mean UE CAT v2.0 score was 38.3 (SD 10.7) with a range of 15 to 61 and interquartile range of 15.4. The UE CAT v2.0 had a strong correlation with the QuickDASH (r = -0.749) and the PF CAT v2.0 (r = 0.719). No patient scored between 56 and 60, indicating a gap in scoring in that range. The UE CAT v2.0 demonstrated a floor effect of 1%, a ceiling effect of 6.9%, and a high internal consistency with a Cronbach alpha of 0.99.

CONCLUSIONS

The PROMIS UE CAT v2.0 demonstrated improved ceiling effects, range, and a decreased gap in scoring compared with prior versions. Limitations of the PROMIS UE CAT v2.0 are still present, but updates have led to an incremental improvement over prior versions, demonstrating the ability to influence PROMIS instrument performance through upgrades.

CLINICAL RELEVANCE

The updated PROMIS UE CAT v2.0 still demonstrates a ceiling effect and gap in scores at the upper end of the instrument, both of which may limit discrimination between different levels of upper extremity function for high-functioning patients.

Single-shot CT after wrist trauma: impact on detection accuracy and treatment of fractures

OBJECTIVE

To evaluate accuracy of fracture detection and therapeutic impact of a single-shot CT protocol as a primary imaging tool in all patients with clinical suspicion of wrist injury, and evaluate the resulting impact on therapy.

MATERIALS AND METHODS

We performed a single-institution study on all patients with suspicion of fractures of the wrist and carpus. All patients underwent conventional radiography, thereafter single-shot wrist CT, and then 1-year follow-up. Physicians and radiologists prospectively scored likelihood of fracture presence on a five-point scale before and after CT. Three surgeons proposed a treatment regimen (functional, cast, reduction, or operative) based on clinical and radiological data, first with knowledge of conventional radiography, and then with knowledge of CT. The reference standard for fracture presence was based on all data. We performed receiver operating characteristic (ROC) analyses and calculated proportion of wrists with treatment changes due to CT imaging.

RESULTS

Ninety-eight patients participated (63% female, mean age 53, range, 18-87 years old) with 100 wrist CTs. Conventional radiography detected true-positive fractures in 45, and CT in 61 wrists. The areas under the curve for fracture detection were 0.85 (95% CI 0.77-0.93) for conventional radiography and 0.97 (95% CI 0.93-1.00) for CT. Treatment changed in 24 (24%, 95% CI 16-33%) - 31 (31%, 95% CI 23-41%) wrists, mostly involving a decrease in the rate of cast immobilization.

CONCLUSIONS

Single-shot CT in patients with clinical suspicion of wrist injury increases accuracy of fracture detection. This has a significant impact therapy in this population, mainly on cast immobilization.

TRIAL REGISTRATION

We registered the study at www.clinicaltrials.gov , NL43482.091.13.

Asymptomatic reference values for the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation - electronic data collection and its clinical implications

The purpose of this study was to establish normal asymptomatic population values for the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation in healthy, asymptomatic individuals of different age, gender, ethnicity, handedness and nationality, using electronic data collection. Two-hundred and ninety-two Australian and 293 Canadian citizens with no active wrist pain, injury or pathology in their dominant hand, were evaluated. Participants completed an electronically administered questionnaire and were assessed clinically. There was no statistically significant association between both wrist scores and nationality. There was a statistically significant association between both wrist scores and age, demonstrating that as age increased, normal wrist function declined. This study has established an electronic, asymptomatic control group for future studies using these scores. When using the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation, the control group can be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin. Level of evidence: II.

Danish version of the Patient-Rated Wrist/Hand Evaluation questionnaire: Translation, cross-cultural adaptation, test–retest reliability and construct validity

Introduction

In Denmark, there is a growing need for valid, reliable and standardized patient-rated outcome measures for use in clinical practice and research. The Patient-Rated Wrist/Hand Evaluation (PRWHE) is a self-reported assessment of hand-related disorders that measures pain and functional difficulties in activities of daily living. The purpose of this study was to: (1) translate and cross-culturally adapt the PRWHE into Danish and (2) assess the reliability and construct validity of the Danish version in patients with hand-related disorders.

Methods

The PRWHE was translated and cross-culturally adapted into Danish using the dual-panel approach. A total of 97 patients with diverse hand-related disorders and a mean age of 52.6 years (SD 15.2) participated in the psychometric testing. They were assessed on two occasions. Test–retest reliability was assessed using the Intraclass Correlation Coefficient (ICC2.1) to assess test–retest, Cronbach’s alpha to assess internal consistency and a Bland–Altman plot to estimate measurement error. Construct validity was investigated by evaluating the relationship between the Danish PRWHE (PRWHE-DK) and the Danish validated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH).

Results

Psychometric testing demonstrated an excellent test–retest reliability (ICC2.1 = 0.94) and internal consistency (alpha = 0.96). A systematic error of 1.5 and a measurement error of ± 16.1 were found. Furthermore, a strong correlation was found between PRWHE-DK and DASH ( r = 0.71).

Conclusions

The PRWHE-DK is a reliable, valid instrument for patients with different kinds of hand-related disorders, and can be used in clinical practice and multi-cultural research studies to measure pain and functional disability.

Association Between Radiological and Patient-Reported Outcome in Adults With a Displaced Distal Radius Fracture: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the association between alignment, as determined by plain radiographs, and patient-reported outcome in adults with a displaced distal radius fracture. We also determined which specific radiological parameters are associated with patient-reported outcomes.

METHODS

We performed a systematic literature search to identify studies that evaluated the association between radiological and patient-reported outcome in adults with a displaced distal radius fracture and who had an average follow-up of at least 12 months. Radiological outcome was determined as acceptable or unacceptable reduction, defined by radiological parameters. Patient-reported outcome was assessed with the Disability of the Arm, Shoulder, and Hand, the Quick-Disability of the Arm, Shoulder, and Hand, and the Patient-Rated Wrist Evaluation questionnaires.

RESULTS

Sixteen articles were included, comprising 1,961 patients with a distal radius fracture. A significant mean difference of 4.15 points in patient-reported outcomes (95% confidence interval [CI], 0.26-8.04) was found in favor of an acceptable radiological reduction. Moreover, a significant mean difference of 5.38 points in patient-reported outcomes (95% CI, 1.69-9.07) was found in favor of an acceptable dorsal angulation, and 6.72 points (95% CI, 2.16-11.29) in favor of an acceptable ulnar variance.

CONCLUSIONS

An unacceptable radiological reduction is significantly associated with worse patient-reported outcomes in adults with a displaced distal radius fracture. Dorsal angulation and ulnar variance are the most important radiological parameters. Despite the statistical significance, the mean difference of each association did not meet the threshold of the minimally clinically important difference and therefore were unlikely to be clinically important.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Operative Treatment of Intra-Articular Distal Radius Fractures With versus Without Arthroscopy: study protocol for a randomised controlled trial

Background

In the past several years, an increase in open reduction and internal fixation (ORIF) for intra-articular distal radius fractures has been observed. This technique leads to a quicker recovery of function compared to non-operative treatment. However, some patients continue to have a painful and stiff wrist postoperatively. Arthroscopically assisted removal of intra-articular fracture haematoma and debris may improve the functional outcomes following operative treatment of intra-articular distal radius fractures. The purpose of this randomised controlled trial is to determine the difference in functional outcome, assessed with the Patient-Rated Wrist Evaluation (PRWE) score, after ORIF with and without an additional wrist arthroscopy in adult patients with displaced complete articular distal radius fractures.

Methods

In this multicentre trial, adult patients with a displaced complete articular distal radius fracture are randomised between ORIF with an additional wrist arthroscopy to remove fracture haematoma and debris (intervention group) and conventional fluoroscopic-assisted ORIF (control group). The primary outcome is functional outcome assessed with the PRWE score after three months. Secondary outcomes are wrist function assessed with the Disability of the Arm, Shoulder and Hand (DASH) score, postoperative pain, range of motion, grip strength, complications and cost-effectiveness. Additionally, in the intervention group, the quality of reduction, associated ligamentous injuries and cartilage damage will be assessed. A total of 50 patients will be included in this study.

Discussion

Although ORIF of intra-articular distal radius fractures leads to a quicker resume of function compared to non-operative treatment, some patients continue to have a painful and stiff wrist postoperatively. We hypothesise that, due to the removal of fracture haematoma and debris by an additional arthroscopy, functional outcomes will be better compared to the non-arthroscopically treated group.

Trial registration

ClinicalTrials.gov, NCT02660515. Registered on 13 January 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2409-2) contains supplementary material, which is available to authorized users.

Functional outcomes of distal radius fractures with and without ulnar styloid fractures: a meta-analysis

The aim of this meta-analysis was to compare the functional outcomes of patients with a distal radius fracture with and without a concomitant fracture of the ulnar styloid process. A systematic literature search was performed to identify all studies comparing patients with a distal radius fracture with and without an ulnar styloid process fracture. The initial search revealed 511 articles, of which 12 articles with a total of 2243 patients were included; 1196 patients with and 1047 patients without an ulnar styloid process fracture. A statistically significant mean difference of 3.40 points (95% CI 1.33-5.48) in the Disability of the Arm, Shoulder, and Hand score was found in favour of patients without an ulnar styloid process fracture. This difference is less than 10 and therefore not clinically important. No significant difference was found in Patient-Rated Wrist Evaluation scores, range of motion, grip strength, visual analogue scale pain scores, ulnar-sided wrist pain and distal radio-ulnar joint instability between patients with and without an ulnar styloid process fracture after 1 year of follow-up. Moreover, no significant differences were found between ulnar styloid base and nonbase fractures.

LEVEL OF EVIDENCE

I.

Absorbable versus non-absorbable sutures for skin closure after carpal tunnel decompression surgery

BACKGROUND

Carpal tunnel syndrome is a common problem and surgical decompression of the carpal tunnel is the most effective treatment. After surgical decompression, the palmar skin may be closed using either absorbable or non-absorbable sutures. To date, there is conflicting evidence regarding the ideal suture material and this formed the rationale for our review.

OBJECTIVES

To assess the effects of absorbable versus non-absorbable sutures for skin closure after elective carpal tunnel decompression surgery in adults on postoperative pain, hand function, scar satisfaction, wound inflammation and adverse events.

SEARCH METHODS

We searched the following databases on 30 October 2017: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two clinical trials registries on 30 October 2017.

SELECTION CRITERIA

We considered all randomised or quasi-randomised controlled trials comparing absorbable and non-absorbable sutures for skin closure after any form of carpal tunnel decompression surgery in adults.

DATA COLLECTION AND ANALYSIS

The unit of analysis was the hand rather than the patient. We performed meta-analysis of direct comparisons to generate standardised mean differences (SMDs) with 95% confidence intervals (CIs) in pain scores and risk ratios (RRs) with 95% CIs for dichotomous outcomes, such as wound inflammation. The primary outcome was postoperative pain. Secondary outcomes included hand function, scar satisfaction, scar inflammation and adverse events (complications). We assessed the quality of evidence for key outcomes using GRADE.

MAIN RESULTS

We included five randomised trials (255 participants). The trials were all European (UK, Republic of Ireland, Denmark and the Netherlands). Where quoted, the mean age of participants was between 48 and 53 years. The trials measured outcomes between one and 12 weeks postoperatively.Meta-analysis of postoperative pain scores for absorbable versus non-absorbable sutures at 10 days following open carpal tunnel decompression (OCTD) produced a SMD of 0.03 (95% CI -0.43 to 0.48; 3 studies, number of participants (N) = 137; I2 = 43%); the SMD suggests little or no difference, but with a high degree of uncertainty because of very low-quality evidence. At 10 days following endoscopic carpal tunnel decompression (ECTD), the SMD for postoperative pain with use of absorbable versus non-absorbable sutures was -0.81 (95% CI -1.36 to -0.25; 1 study; N = 54); although the SMD is consistent with a large effect, the very low-quality evidence means the results are very uncertain. Only the OCTD studies provided pain data at 6 weeks, when the SMD was 0.06 (95% CI -0.72 to 0.84; 4 studies; N = 175; I2 = 84%), which indicates little or no evidence of difference, but with a high degree of uncertainty (very low-quality evidence). The RR for wound inflammation using absorbable versus non-absorbable sutures after OCTD was 2.28 (95% CI 0.24 to 21.91; N = 95; I2 = 90%) and after ECTD 0.93 (95% CI 0.06 to 14.09; 1 study, N = 54). Any difference in effect on wound inflammation is uncertain because the quality of evidence is very low. One study reported postoperative hand function but found no evidence of a difference between suture types at two weeks (mean difference (MD) -0.10, 95% CI -0.53 to 0.33, N = 36), with similar findings at six and 12 weeks. Only the ECTD trial reported scar satisfaction, with 25 out of 28 people reporting a 'nice' result in the absorbable-suture group, versus 18 out of 26 in the group who received non-absorbable sutures (RR 1.29, 95% CI 0.97 to 1.72, N = 54). These findings are also very uncertain as we judged the quality of the evidence to be very low. All studies were at high risk of bias for most domains. No trials reported adverse events.

AUTHORS' CONCLUSIONS

It is uncertain whether absorbable sutures confer better, worse or equivalent outcomes compared to non-absorbable sutures following carpal tunnel decompression, because the quality of evidence is very low. Use of absorbable suture eliminates the need for suture removal, which could confer considerable savings to patients and healthcare providers alike. We need rigorously-performed, non-inferiority randomised trials with economic analyses to inform choice of suture.

Angular Stable Miniplate Fixation of Chronic Unstable Scaphoid Nonunion

Background  Around 5 to 15% of all scaphoid fractures result in nonunion. Treatment of long-lasting scaphoid nonunion remains a challenge for the treating surgeon. Healing of scaphoid nonunion is essential for prevention of scaphoid nonunion advanced collapse and the subsequent predictable pattern of radiocarpal osteoarthritis. Purpose  The purpose of this study was to investigate the feasibility of fixation of the scaphoid nonunion with a volar angular stable miniplate and cancellous bone grafting. We hypothesized that this technique could be successful, even in patients with previous surgery for nonunion and in patients with a long duration of nonunion. Patients and Methods  A total of 21 patients enrolled in a single-center prospective cohort study. Healing of nonunion was assessed on multiplanar computed tomography scan of the wrist at a 3-month interval. Functional outcome was assessed by measuring grip strength, range of motion, and by means of the patient-rated wrist and hand evaluation (PRWHE) questionnaire. Results  During follow-up, 19 out of 21 patients (90%) showed radiological healing of the nonunion. The range of motion did not improve significantly. Postoperative PRWHE scores decreased by 34 points. Healing occurred regardless of the length of time of the nonunion (range: 6-183 months) and regardless of previous surgery (38% of patients). Conclusion  Volar angular stable miniplate fixation with autologous cancellous bone grafting is a successful technique for the treatment of chronic unstable scaphoid nonunion, even in patients with long-lasting nonunion and in patients who underwent previous surgery for a scaphoid fracture. Rotational interfragmentary stability might be an important determining factor for the successful treatment of unstable scaphoid nonunion. Level of Evidence  Level IV.

A user's survey of the clinical application and content validity of the DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure

STUDY DESIGN

Survey.

PURPOSE OF THE STUDY

To elicit feedback on the clinical use and content validity of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure from frontline users of the instrument.

METHODS

A cross-sectional survey was administered to registered DASH users and inquired about how the DASH was being used and to identify the informational value of items of the DASH (content validity).

RESULTS

About 172 completed the survey. One or both of the DASH and/or QuickDASH were consistently (89.5%) being used. About 90% were using it in adults (21-65 years), and at least 70% were using it across the entire extremity, and to a lesser extent, 10% reported using it in isolated neck injuries. Most respondents (66.9%-75.8%) were using the DASH in musculoskeletal (MSK) disorders, with some applying it for other more unique or non-MSK conditions (2.5%-16.6%). All but 1 of the 30 DASH items had at least 10% endorsement as being informative, and 4 items were identified as being problematic by greater than 20%.

CONCLUSIONS

The DASH is being used as intended (whole extremity and MSK conditions), and in addition, it is being used in different body regions and diverse conditions.

LEVEL OF EVIDENCE

Not applicable (descriptive survey).

Nonunion of a Nondisplaced Radial Neck Fracture: A Case Report

CASE

We describe the case of a 66-year-old man who sustained a nondisplaced radial neck fracture and subsequently developed a symptomatic nonunion. After a period of unsuccessful conservative treatment, a radial head resection was performed.

CONCLUSION

Radial neck fractures, unlike their radial head counterparts, have a low rate of nonunion. Our patient's only positive risk factor was age, but he developed a nonunion. At the 2-year follow-up after excision of the radial head, there was a lack of proximal migration of the radius during axial loading, demonstrating a positive outcome without the need for replacement of the radial head.

Patient reported outcomes of hand function three years after stroke

OBJECTIVE

To comprehensively describe hand function and associated factors among stroke survivors by means of the Michigan Hand Outcomes Questionnaire (MHQ; 6 domains; score 0-100, worst-best).

METHODS

In this cross-sectional study, stroke patients were invited to complete a set of questionnaires on hand function, socio-demographic characteristics, mental functioning, daily activities, quality of life, and caregiver strain. Stroke characteristics were collected retrospectively from medical records. Multiple linear regression analysis adjusted for age, sex, and duration of follow-up was used to identify factors associated with MHQ score.

RESULTS

207 out of 576 eligible patients responded (36%); mean age 63.8 years (SD14.2), 125 males (60.4%). Mean time since stroke was 36.3 months (SD9.9). In 85% of the patients, the MHQ Total score was less than 100 points (median 79.9, IQR 63.0-95.8). The median scores of the domains were: overall hand function 75.0, daily activities 90.5, work 85.0, pain 100, appearance 93.8, and satisfaction with hand function 83.3. A lower MHQ Total score was significantly associated with a lower Barthel Index at hospital discharge, a lower level of education, a supratentorial stroke and with unfavorable outcomes regarding physical and mental functioning, quality of life, and caregiver strain.

CONCLUSION

Patients can perceive limitations on several domains with respect to hand function 2-5 years after stroke. Problems related to the appearance of the hand and satisfaction with hand function can be relevant and should be considered accordingly. Persistent hand problems after stroke are related to a more severe, supratentorial stroke in lower educated patients.