Doctors Demystify
Journal Club 2017
12 recent journal articles relevant to hand therapists from journals other than JHT
Read the synopses and Dr. Meals’ comments
Link to the PubMed abstracts to access the full length article if you wish
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January, 2017: Recovery of typing performance following carpal tunnel release
Zumsteg et al: The Effect of Carpal Tunnel Release on Typing Performance. J Hand Surg Am.2017 Jan;42(1):16-23
Patients often ask when they will be able to resume keyboard activity following carpal tunnel release (CTR). Until now, there has been no evidence to support any estimate.
Investigators at Vanderbilt University in Nashville screened nearly 400 patients with CTS and excluded many because of nonsurgical management, other upper extremity pathology, age less than 20 or greater than 70 years, previous carpal tunnel surgery, difficulty with English, or no home computer access to the Internet. Those included all has positive electrodiagnostic testing and typed at least 30 words per minute (wpm) using both hands with fingers resting on the middle row of home keys. Slow typing, unconventional finger positioning, or disinterest in participating left 38 subjects, 11 of whom during the study period either did not have surgery or had bilateral CTR.
The final 27 subjects took one of 10 forms of a standardized 500-character typing test at home before CTR and then took other forms of the same test on the same computer 8-10 days after surgery and again 2, 3, 4, 5, 6, 8, and 12 weeks after surgery. In addition, the subjects completed on-line the Michigan Hand Questionnaire and the Boston Carpal Tunnel Questionnaire (functional and symptom severity components) before surgery, 8-10 days after surgery and again 3, 6, and 12 weeks after surgery.
Each patient underwent open CTR and wore a soft dressing until sutures were removed 8-10 days later. As needed, the investigators contacted patients by phone and reminded them to take the tests at the defined intervals. The typing tests were electronically graded for speed and accuracy.
RESULTS: Average age was 55, 89% were women, 7% were worker compensation cases, 96% were right-hand dominant, and 67% had the right hand operated on. Daily computer use was less than 4 hours in 33%, 4-6 hours in 26%, and greater than 6 hours in 41% of patients.
Average typing speed before surgery was 50 wpm and was 45 wpm 8-10 days later. By 3 weeks after surgery, average typing speed exceeded pre-operative values and continued to improve to nearly 54 wpm at 12 weeks. Typing accuracy remained between 92 and 94% at all time periods. Variations in age, symptom duration, or electrodiagnostic severity did not affect results. The investigators felt that smoking and worker compensation status might affect results, but the numbers were too small (wc =2, smoking = 1) to pursue analysis.
The outcomes measures all showed continued improvement throughout the study period and paralleled the improvement in typing speed.
DISCUSSION: We can now tell patients that on average their typing speed and accuracy will at least equal pre-operative levels within 3 weeks of open CTR. The study focused on peak typing performance and not on endurance or return to work, so individual patients, particularly those with jobs requiring sustained keyboard activity, may require a longer convalescence or may not meet the reported averages.
Average typing speed at 12 weeks exceeded the pre-operative speed, which implies that CTS may impair typing performance.
COMMENT: I liked this study. It was carefully designed and performed. The novel use of home testing and internet reporting facilitated frequent, consistent, and compliant testing for each patient. I suspect we will see more of this type of testing because study subjects frequently become weary of returning to clinic for follow-up testing, especially if they are doing well and a return visit conflicts with their routine activities.
The study did not include patients who did not have electrodiagnostic testing or who had negative testing, and follow-on studies could appropriately look at those groups. Likewise, it would be interesting to observe typing performance in patients with CTS before and after non-operative management with orthoses with or without cortisone injections.
February, 2017: Forearm replantation vs. prosthesis, which do patients think is better?
Pet MA et al: Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation. Injury.2016 Oct 19. [Epub ahead of print]
It is generally understood that patients with amputations through the forearm have better function (task completion, return to work) after replantation than comparable patients with amputation stump closure and prosthetic fitting. What is not known, however, is how patients accept these two treatments with respect to appearance, psychological concerns, and pain.
Great emphasis is presently being made on shared decision making and patient-centric treatment, so viability and function of a replanted part are only two measures of success. Patients, providers, and payers would benefit from a more global assessment—patient-reported outcomes (PROs).
Investigators at University of Washington, University of Michigan, and Union Memorial Hospital in Baltimore pooled their 20 year experience of managing amputations through the forearm and have provided some answers.
They contacted all patients previously treated for unilateral forearm amputations and asked them to complete DASH and Michigan Hand Questionnaire outcomes measures and asked those with prostheses to describe the type(s) of prostheses used. A total of 187 patients met inclusion criteria, but only 31 could be contacted and agreed to participate. There were 9 patients in the replantation group and 22 in the prosthetic rehabilitation group. The groups were evenly matched for sex, age at injury, current age, income, race, tobacco use, alcohol abuse, and medical and psychiatric comorbidities. Mean follow-up from time of amputation to completion of the questionnaires was 9.1 years for the replantation group and 10.4 years for the prosthetic group.
Seven of the 9 patients receiving replantation had sustained electric saw injuries, and these were mainly through the distal forearm. The prosthetic group had a wide spectrum of injury mechanisms, and most of the amputations were through the mid-forearm.
Fourteen of the prosthetic patients used body-powered prostheses, nine used myoelectric prostheses, and two used passive prostheses at least some of the time. Nine patients reported using multiple types of prostheses. Five patients had been fitted with prostheses but quit using them because of pain, awkwardness, or expense.
RESULTS:
. The MHQ scores for pain, ability to work, and performance of ADLS with two hands were not significantly different between the groups. The mean DASH scores between the groups were not significantly different.
DISCUSSION:
Limb replantation is an expensive and time consuming endeavor, both for the surgery itself and for the subsequent rehabilitation. In order to recommend it and justify it, not only should the functional results be better, but also the PROs should be better. This study is largest to compare replantation vs. prosthetic fit in a relatively large number of patients with injuries restricted to the forearm. The authors note that the group sizes were different and that the levels of amputation in the forearm were different. None-the-less they conclude that amputations through the forearm should be replanted when possible.
COMMENT:
These injuries are relatively rare, so combining the experience from three large centers was appropriate. The follow-up period was long, which gives a better view of outcome but reduced the number of patients who the investigators could find and query.
This study serves as a baseline for future studies comparing PROs for prostheses, replantation, and transplantation. Another helpful comparison would be studying PROs between patients with body-powered prostheses (the main type used in this study) with modern myoelectric prostheses, which may offer superior function that would result in improved patient-rated outcomes.
March, 2017: Do exercises help hand osteoarthritis?
Østerås N et al: Exercise forhandosteoarthritis. Cochrane Database Syst Rev.2017 Jan 31;1:CD010388
Osteoarthritis in the hand is a common cause of joint pain, stiffness, and loss of function, especially in older individuals. No cure is available, and medications that reduce pain and inflammation often produce side effects that are worse than the arthritic symptoms. Exercise benefits hip and knee arthritis, but its effect on hand arthritis is unclear.
A new Cochrane Review addresses this issue. The authors found 7 randomized, controlled clinical trials that compared exercise to no exercise or compared different exercise regimens. The assessors in most studies were blinded to any treatment received.
Overall, the authors graded the quality of evidence as low because the participants were unblinded and because the studies were imprecise (low numbers of participants and wide confidence intervals for pain, function, and joint stiffness). The authors graded the quality of evidence very low for quality of life, adverse events, and withdrawals secondary to adverse events because the studies addressing these issues were few and the confidence intervals were very wide.
Five studies (381 participants) indicated a 5% reduction in pain for the exercise group compared to the control group. Four studies (369 participants) showed a 6% improvement in hand function for the exercise group over the control group. One study (113 participants) evaluated quality of life and found a .3% improvement for the exercise group over the control group. Four studies (369 participants) indicated a 7% reduction in finger joint stiffness in the exercise group versus the control group.
Three studies reported treatment-related adverse events and withdrawals secondary to adverse events, which were few and not severe. The adverse events were mainly increased finger joint inflammation and pain. Low quality evidence suggested that withdrawals secondary to adverse events were more common in the exercise group than in the control group.
Two studies (220 participants) reported 6-month data. One study (102 participants) provided 12-month data. The exercise regimens varied widely with respect to frequency, content, and duration. Participants exercised 2-3 times weekly in 4 studies, daily in 2 studies, and 3-4 times each day in one study.
Self-reported adherence to the exercise regimens ranged between 78 and 94% in 3 studies. In another study, 67% of participants completed as least 80% of the scheduled 18 sessions.
The authors conclude that the pooled results showed low-quality evidence for exercise producing small benefits on hand pain, stiffness, and function. The effect sizes were small and whether they “represent a clinically important change may be debated.”
COMMENT: Symptoms of osteoarthritis of the hip or knee may be progressive and unrelenting and thereby contributing greatly to a diminished quality of life. Conversely, osteoarthritis in the finger joints is often migratory and transient, causing major symptoms in one or more joints for months and then becoming quiescent. With multiple fingers, each with closely spaced joints, pain and stiffness in several joints does not usually cause the same degree of functional limitation caused by a painful and stiff hip or knee.
The Cochrane Review highlights the dearth of information supportive of exercises providing a marked benefit on hand arthritis symptoms. The problems include that there are only a few studies, many potential biases, small if any effects, and incomplete compliance.
I reassure patients that the painful, stiff joints that they presently note will likely settle down over a few months and that their current discomfort is not going to be lifelong. I recommend palliating the present symptoms with frequent heat (especially a paraffin bath) and Coban wraps or elasticized digital sleeves. Having a therapist help them with aids or alternative maneuvers for performing daily living activities is also useful. Nn occasional cortisone injection may provide months of relief when other remedies have failed, although the DIP joint is hard to inject. Topical non-steroidal anti-inflammatory cream may also help. I save joint fusions or arthroplasties for the rare joint that is unrelentingly painful and causing disability not merely annoyance.
April, 2017: Update on Total Wrist Arthroplasty
Halim A, Weiss AC TotalWristArthroplasty J Hand Surg Am.2017 Mar;42(3):198-209.
The first total wrist arthroplasty (TWA) was performed in 1890 and was a ball and socket replacement made of ivory. In the 1970s, stemmed silicone spacers were used to replace the proximal carpal row and maintain alignment of the hand on the forearm. Unfortunately, the silicone implants often broke. The next generation of implants took advantage of the well-established concepts that were already successful for total knee and total hip implants. These wrist implants had stems that were cemented into the distal radius and into a central metacarpal. Although pain relief was good, loosening and dislocation caused frequent failures.
The next generation of implants required less bone removal in an attempt to improve stability. Failure, however, was still frequent, particularly from the metallic stems cutting out from the metacarpal and from dislocation of the carpal component on the radius component.
The current implants are designed to maximally preserve bone and to reduce instability. The proximal portion is metallic with a surface simulating the contour of the radius articular surface and a stem that is designed for a cement-less, press-fit into the radius. The distal component has a metal-backed polyethylene surface that simulates the proximal articular surfaces of the lunate and scaphoid combined. The distal component is secured with screws into both the distal carpal row and into the index metacarpal. Five-year survival rates with the modern designs are in excess of 90%, which is markedly higher than for previous designs.
To date, most TWAs have been performed for patients with rheumatoid arthritis. Because of improved implant designs, more patients with posttraumatic and osteoarthritis are now choosing TWA over wrist fusion. Complications are infrequent for either procedure, and one cited study indicated that DASH scores were better for patients receiving TWA than for those with wrist fusions.
The current TWA implant designs may also prove useful even if the patient has had previous surgery, including proximal row carpectomy or wrist fusion. Should a TWA fail, wrist fusion is feasible by using a large bone graft to restore normal carpal height. A novel indication for TWA is for treatment of an acute, severely comminuted distal radius fracture. Two reported cases with one year follow-up and good subjective and objective assessments.