Purpose To compare the long-term outcomes of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with trapeziometacarpal arthrodesis for osteoarthritis (OA) of the basal thumb ...joint. Methods Patients were evaluated for pain, daily functioning, strength, and complications after a mean follow-up of 5.3 years. Generalized estimating equations statistics were used to compare repeated measurements over time in both groups. Results After 5 years, patients who had trapeziectomy with LRTI had significantly better pain reduction and function than the arthrodesis group. Pain and function in the LRTI group continued to improve compared with the results 1 year after surgery, whereas the arthrodesis group did not change. Grip and pinch strength were higher than 1 year after surgery but were not different between groups. In the arthrodesis group, 1 patient was reoperated for nonunion between 1 year and a mean of 5 years after surgery, resulting in a total of 18% nonunion. Another patient underwent reoperation for hardware-related pain. One patient from each group required reoperation because of pain due to scaphotrapeziotrapezoid OA. Conclusions Trapeziectomy with LRTI leads to better pain reduction and functional outcome after between 1 and 5 years compared with trapeziometacarpal arthrodesis in women over 40 years old with OA stages II to III. Type of study/level of evidence Therapeutic IV.
Baseline mindset factors are important factors that influence treatment decisions and outcomes. Theoretically, improving the mindset prior to treatment may improve treatment decisions and outcomes. ...This prospective cohort study evaluated changes in patients' mindset following hand surgeon consultation. Additionally, we assessed if the change in illness perception differed between surgical and nonsurgical patients.
The primary outcome was illness perception, measured using the total score of the Brief Illness Perception Questionnaire (B-IPQ, range 0–80). Secondary outcomes were the B-IPQ subscales, pain catastrophizing (measured using the Pain Catastrophizing Scale (PCS)), and psychological distress (measured using the Patient Health Questionnaire-4).
A total of 276 patients with various hand and wrist conditions completed the mindset questionnaires before and after hand surgeon consultation (median time interval: 15 days). The B-IPQ total score improved from 39.7 (±10.6) before to 35.8 (±11.3) after consultation (p < 0.0001, Cohen's d = 0.36); scores also improved for the B-IPQ subscales Coherence, Concern, Emotional Response, Timeline, Treatment Control, and Identity and the PCS. There were no changes in the other outcomes. Surgical patients improved on the B-IPQ subscales Treatment Control and Timeline, while nonsurgical patients did not.
Illness perception and pain catastrophizing improved following hand surgeon consultation, suggesting that clinicians may actively influence the patients' mindset during consultations, and that they may try to enhance this effect to improve outcomes. Furthermore, surgical patients improved more in illness perceptions, indicating that nonsurgical patients may benefit from a more targeted strategy for changing mindset.
•Illness perception and pain catastrophizing improved following surgeon consultation.•Hand surgeons can influence the patients' mindset during consultations.•Surgical patients experience more treatment control than nonsurgical patients.•Surgical patients improve more after surgeon consultation than nonsurgical patients.•Hand surgeons may not fully exploit the potential of nonsurgical treatment.
The Michigan Hand Questionnaire (MHQ) is a commonly used evaluation for hand problems, but previous work reports conflicting evidence regarding the subscale structures. Rasch analysis uses ...probabilistic modeling of items and responses: if scale items can be fit to the Rasch model, it provides evidence of construct validity and interval-level measurement for precise statistical estimates. We conducted Rasch analysis on the MHQ to evaluate model fit, unidimensionality of the subscales, bias across person factors, and conversion to interval metrics.
We conducted a secondary Rasch analysis of MHQ data from 924 persons with thumb basal joint osteoarthritis using the RUMM2030 software. Modeling was based on responses for the most affected hand and person factors including age, sex, type of work, whether the dominant side was the most affected, and surgical status. The analysis plan followed the published recommendations for examinations of person and item fit, with iterative adjustments as required.
A total of 11 of the 37 items required rescoring to create orderly progression of scoring thresholds. Only the overall hand function and pain subscales could be fit to the Rasch model, demonstrating unidimensionality and good reliability of fit estimates. Dividing the activities of daily living subscale into unilateral and bilateral activities also allowed unilateral activities to fit the model. Persistent misfitting in other subscales suggested local dependency and response bias across multiple person factors.
This Rasch analysis of the MHQ raises concerns regarding the validity and fundamental measurement properties of this widely used outcome evaluation when used as a summary score.
•Summary scores based on (1) items using ordinal scaling and (2) multiple subscales such as the Michigan Hand Questionnaire may add error or bias to statistical analyses for effect or prediction. Rasch analysis is a strategy that can address these concerns in existing scales or while designing new evaluations.•Rasch analysis of the Michigan Hand Questionnaire suggests only the overall hand function and pain subscales, and unilateral activities from the activities of daily living subscale provide valid metrics for statistical calculations. Caution is warranted in using the summary scores as an outcome in clinical trials.
BACKGROUND:Controversy exists about the relative effectiveness of injectable collagenase (collagenase clostridium histolyticum) and limited fasciectomy in the treatment of Dupuytren’s contracture. ...The authors compared the effectiveness of both techniques in actual clinical practice.
METHODS:This study evaluated all subjects treated with collagenase clostridium histolyticum or limited fasciectomy for metacarpophalangeal and/or proximal interphalangeal joint contractures between 2011 and 2014 at seven practice sites. The authors compared the degree of residual contracture (active extension deficit), Michigan Hand Outcomes Questionnaire scores, and adverse events at follow-up visits occurring between 6 and 12 weeks after surgery or the last injection with the use of propensity score matching.
RESULTS:In 132 matched subjects who were treated with collagenase (n = 66) or fasciectomy (n = 66), the degree of residual contracture at follow-up for affected metacarpophalangeal joints was not significantly different (13 degrees versus 6 degrees; p = 0.095) and affected proximal interphalangeal joints had significantly worse residual contracture in the collagenase group compared with those in the fasciectomy group (25 degrees versus 15 degrees; p = 0.010). Collagenase subjects experienced fewer serious adverse events than did fasciectomy subjects and reported larger improvements in the Michigan Hand Outcomes Questionnaire subscores evaluating satisfaction with hand function, activities of daily living, and work performance.
CONCLUSIONS:This propensity score–matched study showed that collagenase clostridium histolyticum was not significantly different from limited fasciectomy in reducing metacarpophalangeal joint contractures, whereas proximal interphalangeal joint contractures showed slightly better reduction following limited fasciectomy. Collagenase provided a more rapid recovery of hand function than did fasciectomy and was associated with fewer serious adverse events.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
To compare the effect of exercises and orthotics with orthotics alone on pain and hand function in patients with first carpometacarpal joint (CMC-1) osteoarthritis (OA) and to predict outcomes on ...pain and hand function of exercises and orthotics.
Prospective cohort study with propensity score matching.
Data collection took place in 13 outpatient clinics for hand surgery and hand therapy in The Netherlands.
A consecutive, population-based sample of patients with CMC-1 OA (N=173) was included in this study, of which 84 were matched on baseline demographics and baseline primary outcomes.
Exercises and orthotics versus orthotics alone.
Primary outcomes included pain and hand function at 3 months, measured using visual analog scale (VAS, 0-100) and the Michigan Hand Outcomes Questionnaire (MHQ, 0-100).
A larger decrease in VAS pain at rest (11.1 points difference; 95% confidence interval, 1.9-20.3; P=.002) and during physical load (22.7 points difference; 95% confidence interval, 13.6-31.0; P<.001) was found in the exercise + orthotic group compared to the orthotic group. In addition, larger improvement was found for the MHQ subscales pain, work performance, aesthetics, and satisfaction in the exercise + orthotic group. No differences were found on other outcomes. Baseline scores of metacarpophalangeal flexion, presence of scaphotrapeziotrapezoid OA, VAS pain at rest, heavy physical labor, and MHQ total predicted primary outcomes for the total exercise + orthotic group (N=131).
Non-surgical treatment of patients with CMC-1 OA should include exercises, since there is a relatively large treatment effect compared to using an orthosis alone. Future research should study exercises and predictors in a more standardized setting to confirm this finding.
To investigate how satisfaction with treatment outcome is associated with patient mindset and Michigan Hand Outcome Questionnaire (MHQ) scores at baseline and 3 months in patients receiving ...nonoperative treatment for first carpometacarpal joint (CMC-1) osteoarthritis (OA).
Cohort study
A total of 20 outpatient locations of a clinic for hand surgery and hand therapy in the Netherlands.
Patients (N=308) receiving nonoperative treatment for CMC-1 OA, including exercise therapy, an orthosis, or both, between September 2017 and February 2019.
Nonoperative treatment (ie, exercise therapy, an orthosis, or both)
Satisfaction with treatment outcomes was measured after 3 months of treatment. We measured total MHQ score at baseline and at 3 months. As baseline mindset factors, patients completed questionnaires on treatment outcome expectations, illness perceptions, pain catastrophizing, and psychological distress. We used multivariable logistic regression analysis and mediation analysis to identify factors associated with satisfaction with treatment outcomes.
More positive pretreatment outcome expectations were associated with a higher probability of being satisfied with treatment outcomes at 3 months (odds ratio, 1.15; 95% confidence interval, 1.07-1.25). Only a relatively small part (33%) of this association was because of a higher total MHQ score at 3 months. None of the other mindset and hand function variables at baseline were associated with satisfaction with treatment outcomes.
This study demonstrates that patients with higher pretreatment outcome expectations are more likely to be satisfied with treatment outcomes after 3 months of nonoperative treatment for CMC-1 OA. This association could only partially be explained by a better functional outcome at 3 months for patients who were satisfied. Health care providers treating patients nonoperatively for CMC-1 OA should be aware of the importance of expectations and may take this into account in pretreatment counseling.
•Satisfaction after nonoperative treatment for osteoarthritis of the first carpometacarpal joint is not yet optimal.•Positive expectations of treatment outcomes are associated with higher satisfaction.•Optimizing expectations might improve treatment outcomes and satisfaction.
No patient-reported instrument assesses patient-specific information needs, treatment goals, and Personal Meaningful Gain (PMG, a novel construct evaluating individualized, clinically relevant ...improvement). This study reports the development of the Patient-Specific Needs Evaluation (PSN) and examines its discriminative validity (i.e., its ability to distinguish satisfied from dissatisfied patients) and test-retest reliability in patients with hand or wrist conditions.
A mixed-methods approach was used to develop and validate the PSN, following COSMIN guidelines, including pilot testing, a survey (pilot: n=223, final PSN: n=275), cognitive debriefing (n=16), expert input, and validation. Discriminative validity was assessed by comparing the satisfaction level of patients who did or did not achieve their PMG (n=1,985) and test-retest reliability using absolute agreement, Cohen's kappa, and ICCs (n=102). We used a sample of 2,860 patients to describe responses to the final PSN.
The PSN has only five questions (completion time ±3 minutes) and is freely accessible online. The items and response options were considered understandable by 90-92% and complete by 84-89% of the end-users. The PSN had excellent discriminative validity (Cramer's V: 0.48, p<0.001) and moderate to high test-retest reliability (Kappa: 0.46-0.68, ICCs: 0.53-0.73).
The PSN is a freely available patient-centered decision-support tool that helps clinicians tailor their consultations to the patient's individual needs and goals. It contains the PMG, a novel construct evaluating individualized, clinically relevant treatment outcomes. The PSN may function as a conversation starter, facilitate expectation management, and aid shared decision-making. The PSN is implementation-ready and can be readily adapted to other patient populations.
I.
Mental health influences symptoms, outcomes, and decision-making in musculoskeletal healthcare. Implementing measures of mental health in clinical practice can be challenging. An ultrashort screening ...tool for mental health with a low burden is currently unavailable but could be used as a conversation starter, expectation management tool, or decision support tool.
(1) Which items of the Pain Catastrophizing Scale (PCS), Patient Health Questionnaire (PHQ-4), and Brief Illness Perception Questionnaire (B-IPQ) are the most discriminative and yield a high correlation with the total scores of these questionnaires? (2) What is the construct validity and added clinical value (explained variance for pain and hand function) of an ultrashort four-item mental health screening tool? (3) What is the test-retest reliability of the screening tool? (4) What is the response time for the ultrashort screening tool?
This was a prospective cohort study. Data collection was part of usual care at Xpert Clinics, the Netherlands, but prospective measurements were added to this study. Between September 2017 and January 2022, we included 19,156 patients with hand and wrist conditions. We subdivided these into four samples: a test set to select the screener items (n = 18,034), a validation set to determine whether the selected items were solid (n = 1017), a sample to determine the added clinical value (explained variance for pain and hand function, n = 13,061), and a sample to assess the test-retest reliability (n = 105). Patients were eligible for either sample if they completed all relevant measurements of interest for that particular sample. To create an ultrashort screening tool that is valid, reliable, and has added value, we began by picking the most discriminatory items (that is, the items that were most influential for determining the total score) from the PCS, PHQ-4, and B-IPQ using chi-square automated interaction detection (a machine-learning algorithm). To assess construct validity (how well our screening tool assesses the constructs of interest), we correlated these items with the associated sum score of the full questionnaire in the test and validation sets. We compared the explained variance of linear models for pain and function using the screening tool items or the original sum scores of the PCS, PHQ-4, and B-IPQ to further assess the screening tool's construct validity and added value. We evaluated test-retest reliability by calculating weighted kappas, ICCs, and the standard error of measurement.
We identified four items and used these in the screening tool. The screening tool items were highly correlated with the PCS (Pearson coefficient = 0.82; p < 0.001), PHQ-4 (0.87; p < 0.001), and B-IPQ (0.85; p < 0.001) sum scores, indicating high construct validity. The full questionnaires explained only slightly more variance in pain and function (10% to 22%) than the screening tool did (9% to 17%), again indicating high construct validity and much added clinical value of the screening tool. Test-retest reliability was high for the PCS (ICC 0.75, weighted kappa 0.75) and B-IPQ (ICC 0.70 to 0.75, standard error of measurement 1.3 to 1.4) items and moderate for the PHQ-4 item (ICC 0.54, weighted kappa 0.54). The median response time was 43 seconds, against more than 4 minutes for the full questionnaires.
Our ultrashort, valid, and reliable screening tool for pain catastrophizing, psychologic distress, and illness perception can be used before clinician consultation and may serve as a conversation starter, an expectation management tool, or a decision support tool. The clinical utility of the screening tool is that it can indicate that further testing is warranted, guide a clinician when considering a consultation with a mental health specialist, or support a clinician in choosing between more invasive and less invasive treatments. Future studies could investigate how the tool can be used optimally and whether using the screening tool affects daily clinic decisions.
Level II, diagnostic study.
Baseline mindset factors are important factors that influence treatment decisions and outcomes. Theoretically, improving the mindset prior to treatment may improve treatment decisions and outcomes. ...This prospective cohort study evaluated changes in patients' mindset following hand surgeon consultation. Additionally, we assessed if the change in illness perception differed between surgical and nonsurgical patients.
The primary outcome was illness perception, measured using the total score of the Brief Illness Perception Questionnaire (B-IPQ, range 0–80). Secondary outcomes were the B-IPQ subscales, pain catastrophizing (measured using the Pain Catastrophizing Scale (PCS)), and psychological distress (measured using the Patient Health Questionnaire-4).
A total of 276 patients with various hand and wrist conditions completed the mindset questionnaires before and after hand surgeon consultation (median time interval: 15 days). The B-IPQ total score improved from 39.7 (±10.6) before to 35.8 (±11.3) after consultation (p < 0.0001, Cohen's d = 0.36); scores also improved for the B-IPQ subscales Coherence, Concern, Emotional Response, Timeline, Treatment Control, and Identity and the PCS. There were no changes in the other outcomes. Surgical patients improved on the B-IPQ subscales Treatment Control and Timeline, while nonsurgical patients did not.
Illness perception and pain catastrophizing improved following hand surgeon consultation, suggesting that clinicians may actively influence the patients' mindset during consultations, and that they may try to enhance this effect to improve outcomes. Furthermore, surgical patients improved more in illness perceptions, indicating that nonsurgical patients may benefit from a more targeted strategy for changing mindset.
•Illness perception and pain catastrophizing improved following surgeon consultation.•Hand surgeons can influence the patients' mindset during consultations.•Surgical patients experience more treatment control than nonsurgical patients.•Surgical patients improve more after surgeon consultation than nonsurgical patients.•Hand surgeons may not fully exploit the potential of nonsurgical treatment.
To investigate if shorter immobilization is noninferior to longer immobilization after Weilby procedure for thumb carpometacarpal osteoarthritis DESIGN: Prospective cohort study with propensity score ...matching.
Data collection took place in 16 outpatient clinics for hand surgery and hand therapy.
A total of 131 participants with shorter immobilization and 131 participants with longer immobilization (N=262).
Shorter immobilization (3-5 days plaster cast followed by a thumb spica orthosis including wrist until 4 weeks postoperatively) was compared with longer immobilization (10-14 days plaster cast followed by a thumb spica orthosis including wrist until 6 weeks postoperatively) after Weilby procedure for first carpometacarpal joint osteoarthritis. Propensity score matching was used to control for confounders.
Outcomes were pain measured with a visual analog scale and hand function measured with the Michigan Hand Outcomes Questionnaire at 3 and 12 months. Secondary outcomes were complications, range of motion, grip and pinch strength, satisfaction with treatment, and return to work.
No significant differences were found in visual analog scale pain (effect size, 0.03; 95% confidence interval CI, -0.21 to 0.27) or the Michigan Hand Outcomes Questionnaire (effect size, 0.01; 95% CI, -0.23 to 0.25) between the groups at 3 months or at 12 months. Furthermore, no differences were found in complication rate or in other secondary outcomes.
In conclusion, shorter immobilization of 3-5 days of a plaster cast after Weilby procedure is equal to longer immobilization for outcomes on pain, hand function, and our secondary outcomes. These results indicate that shorter immobilization is safe and can be recommended, since discomfort of longer immobilization may be prevented and patients may be able to recover sooner, which may lead to reduced loss of productivity. Future studies need to investigate effectiveness of early active and more progressive hand therapy following first carpometacarpal joint arthroplasty.
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