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Opinions Regarding Management of Hand and Wrist Injuries in Elite Athletes: A Survey of Consultant Hand Surgeons
PAPER 70
author(s), (2) the cited reference contradicted the statement, or (3) the cited reference was not related to the topic. Minor errors involved oversimplifications or generalizations of a cited reference. If a reference was cited more than once, appropriateness of the citation was assessed for each occurrence. Results: A total of 1,022 citations of fact or conclusion were assessed in 40 articles. All citation listings were accurate. Eighty-five total errors were identified (8.3% of all citations). Of these, 26 major errors and 59 minor errors were identified. Errors were identified in 21 of 40 articles reviewed. Of 26 major errors, 19 (73%) were identified in instances where multiple citations were assigned to a single statement of fact. Summary: The accuracy of citation listings in J Hand Surg Am has improved considerably since a previous review in 2003; nevertheless, the inaccurate use of references to support a statement of fact in scientific articles remains a concern. Inaccurate use of references occurs more frequently when multiple citations are used to support a single statement; and often, review articles are used to support scientific statements.
Clinical Paper Session 16: Evidence/Clinical Guidelines Saturday, October 5, 2013 2:35e2:41 PM Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Hand
Opinions Regarding Management of Hand and Wrist Injuries in Elite Athletes: A Survey of Consultant Hand Surgeons Level 5 Evidence Christopher J. Dy, MD, MSPH © Ekaterina Khmelnitskaya, MD © Krystle A. Hearns, MA Michelle Gerwin Carlson, MD
Hypothesis: Decisions regarding appropriate treatment for hand and wrist injuries in elite athletes, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. There is little recognition in the literature of the need for a different approach when treating these injuries in elite athletes, and timing to return to play. This study further explored the complexities of treating hand and wrist injuries in the elite athlete. Methods: A total of 37 consultant hand surgeons for teams in the National Football League, National Basketball Association, and Major League Baseball completed an electronic survey about the management of common hand injuries. This survey included questions about indications for surgery, return to protected play, and return for unprotected play (Table 1). Cross-tab calculations and chi-square analysis were performed. Responses were compared by sport treated by the surgeon (baseball vs no baseball, football vs no football, and basketball vs no basketball). Results: All but 2 surgeons recommend return to protected play within 3 to 4 weeks after healing of a metacarpal fracture, but 73% recommend waiting 4 to 8 weeks for unprotected play (Table 1). Most surgeons allow patients with
REFERENCES 1. Jackson K, Porrino JA Jr, Tan V, Daluiski A. Reference accuracy in the Journal of Hand Surgery. J Hand Surg Am. 2003;28(3):377e380. 2. Eichorn P, Yankauer A. Do authors check their references? A survey of accuracy of references in three public health journals. Am J Public Health. 1987;77(8): 1011e1012.
Contracted Research with: Orthohelix Surgical Designs (D.S.R., F.J.L.); Axogen (F.J.L.) Royalties/Honoraria: OrthoHelix Surgical Designs (F.J.L.) Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) with: Orthohelix Surgical Designs (F.J.L.) Consulting Fees (eg, advisory boards) received from: Stryker Orthopaedics, Bioventus, Axogen (F.J.L.); Acumed, Synthes, Extremity Medical (M.J.R.)
Table 1: Return to Play Recommendations According to Hand or Wrist Injury Nondisplaced Metacarpal Shaft Fracture Return to Play Immediate When Healed, 3e4 wk PP (n ¼ 37) 14 21 UP (n ¼ 37) 0 5 Scaphoid Fracture Return to Play Immediate When Healed, 4e6 wk PP (n ¼ 37) 12 19 UP (n ¼ 37) 0 9 Pisiform Fracture Treatment and Return to Play Immediate Immediate Excision
n ¼ 37 Return to Play
2 27 6e12 wk Postoperation 6 18
>1 2 wk Postoperation 0 10
7
8 In 6 wk
In 3 mo
11 1
When Skin Healed, 2 wk 19 15
6 20
0 1
No Surgery
Immediate Repair
1
14
Repair at End of Season (If 6 wk) 12
Repair at End of Season (If 3 mo) 3
Repair at End of Season ( 6 mo) 7
2 wk 20 0
6 wk 10 12
3 mo 1 23
6 mo 0 1
4 wk 2 11
4e8 wk 0 14
> 3 mo 0 3
Immediate PP (n ¼ 36) 5 UP (n ¼ 36) 0 Stable PIP Dislocation Return to Play Immediate PP (n ¼ 36) 34 UP (n ¼ 37) 9
4 wk With Splint
> 8 wk Postoperation 0 5
Excision After 4 wk If Not Healed 3
n ¼ 37 11 Hook of Hamate Fracture Return to Play Immediate PP (n ¼36) UP (n ¼ 37 Thumb UCL Tear Treatment
4e8 wk Postoperation
Excision After 8 wk If Not Healed 8
PP, protected play; UP, unprotected play; PIP, proximal interphalangeal.
© Speaker has nothing of financial value to disclose
e47
scaphoid fractures to return to protected play within 4 to 6 weeks of injury, whereas 76% wait at least 6 to 12 weeks and 24% wait more than 12 weeks before allowing unprotected play. Most surgeons allow return to protected play within 2 weeks of hook of hamate fractures, but 54% of surgeons wait until 6 weeks to allow unprotected play. Most surgeons recommend repair of thumb ulnar clateral ligament (UCL) tears immediately or within 6 weeks of injury, but 27% recommend waiting until the end of the season. Nearly 70% of surgeons recommend return to protected play within 2 weeks of thumb UCL repair and 67% recommend waiting at least 3 months before unprotected play. All but 2 surgeons permitted immediate return to protected play after a stable proximal interphalangeal joint dislocation. Basketball surgeons were less likely to recommend early protected play than non-basketball surgeons. Baseball surgeons were more likely to recommend early unprotected play after scaphoid fixation. Football surgeons were more likely to recommend earlier protected play after thumb UCL injuries, whereas basketball surgeons were less likely to recommend earlier protected play. Summary: There is wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries in elite athletes. These findings emphasize the need to individually tailor treatment decisions to the patient’s desires and demands, particularly in the high-performance athlete. Contracted Research: NIH/NIAMS T32 Research Fellowship (grant AR07281) RJOS/Zimmer Research Grant (M.G.C.) * ASSH Resident/Fellow Fast Track Grant (C.J.D.)
PAPER 71 Clinical Paper Session 16: Evidence/Clinical Guidelines Saturday, October 5, 2013 2:45e2:51 PM Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Hand
The Impact of Depression and Pain Catastrophization on Patient-Rated Outcomes Before and After Treatment for Atraumatic Hand Conditions Level 1 Evidence
© Daniel London, BA © Jeffrey Stepan, BS Martin I. Boyer, MD, FRCS(C) © Ryan Patrick Calfee, MD
compared with unaffected patients, but they would demonstrate a response to treatment comparable to unaffected patients. Methods: Sample size estimates indicated 50 depressed and/or pain catastrophizing patients and 200 unaffected patients provided 94% power to detect a 10-point difference in Michigan Hand Questionnaire (MHQ) scores. A total of 256 patients presenting to an orthopedic hand clinic were prospectively enrolled in this cohort investigation. Patients prescribed treatment for atraumatic conditions were eligible for inclusion. At enrollment, all patients completed the Center for Epidemiologic StudieseDepression Scale (CES-D), the Pain Catastrophizing Scale (PCS), and the MHQ (0e100 scale, where 100 ¼ perfect function). One and 3 months after treatment, patients recompleted the MHQ. Participants’ psychological comorbidity status was categorized as either affected (depressed: CES-D ¼ 16, or pain catastrophizing: PCS ¼ 30) or unaffected (CES-D < 16 and PCS < 30). Diagnoses and treatments between affected and unaffected patients were examined. The effects of time, patients’ status, and their interaction on MHQ scores were evaluated by mixed modeling. Results: Of the 256 patients enrolled, 50 were affected and 206 were unaffected. Diagnoses and treatments were similar between groups (Table 1). At the time of enrollment, unaffected patients’ mean MHQ score (64.9, 95% confidence interval [CI]: 62.5e67.3) was significantly higher than affected patients’ mean MHQ score (48.1, 95% CI: 43.3e53.0). Affected and unaffected patients demonstrated similar significant absolute improvement over baseline at 3 months after treatment (affected: 12.4, 95% CI: 7.5e17.4; unaffected: 12.9, 95% CI: 10.4e15.3). Thus, affected patients still rated their hand function as worse compared with unaffected patients (unaffected: 77.7, 95% CI: 75.0e80.5; affected: 60.58, 95% CI: 54.96e66.18) at final follow up (Fig. 1). Summary: Patients who are depressed and/or pain catastrophizers report worse selfrated hand function at baseline and after treatment compared with unaffected patients. At 3 months after treatment, both depressed and/or pain catastrophizing patients and unaffected patients rate their hand function as significantly improved compared with pretreatment. Although depressed and/or pain catastrophizing patients report worse self-related hand function at both baseline and at follow-up, these patients show similar absolute improvement in self-rated hand function after treatment compared with unaffected patients.
Hypothesis: Evidence suggests that patient-rated hand function is affected by depression and pain catastrophization; however, the impact of these comorbidities on response to treatment is unknown. We hypothesized that patients affected by depression and/or pain catastrophization would have worse patient-rated hand function at baseline and 3 months after treatment Table 1: Participant Diagnoses and Treatments According to Patient Status
Variable Diagnosis Arthritis Cyst/mass Dupuytren disease Nerve compression Tendonitis Ulnar-sided wrist pain Arthritis and tendonitis Nerve compression and tendonitis Other Treatment Aponeurotomy Brace/medication/therapy Injection Surgery Other
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Participant Status Unaffected Affected N % N % 51 14 10 35 74 5 5 8 4
24.8 6.8 4.9 17.0 35.9 2.4 2.4 3.9 1.9
14 0 2 14 9 2 2 4 2
28.0 0 4.0 28.0 18.0 4.0 4.0 8.0 4.0
Figure 1: Mean MHQ scores over time based on patients’ status as being either unaffected or affected. Both groups demonstrated significant improvement from baseline to 3 months after treatment. The affected group’s mean MHQ score was always significantly less than the unaffected group’s mean MHQ score. Error bars represent 95% confidence intervals.
9 52 97 47 1
4.4 25.2 47.1 22.8 0.5
2 19 16 13 0
4.0 38.0 32.0 26.0 0
1. Karels CH, Bierma-Zeinstra SMA, Burdorf A, Verhagen AP, Nauta AP, Koes BW. Social and psychological factors influenced the course of arm, neck and shoulder complaints. J Clin Epidemiol. 2007;60(8):839e848. 2. Linton SJ, Nicholas MK, MacDonald S, et al. The role of depression and catastrophizing in musculoskeletal pain. Eur J Pain. 2011;15(4):416e422.
REFERENCES
© Speaker has nothing of financial value to disclose
author(s), (2) the cited reference contradicted the statement, or (3) the cited reference was not related to the topic. Minor errors involved oversimplifications or generalizations of a cited reference. If a reference was cited more than once, appropriateness of the citation was assessed for each occurrence. Results: A total of 1,022 citations of fact or conclusion were assessed in 40 articles. All citation listings were accurate. Eighty-five total errors were identified (8.3% of all citations). Of these, 26 major errors and 59 minor errors were identified. Errors were identified in 21 of 40 articles reviewed. Of 26 major errors, 19 (73%) were identified in instances where multiple citations were assigned to a single statement of fact. Summary: The accuracy of citation listings in J Hand Surg Am has improved considerably since a previous review in 2003; nevertheless, the inaccurate use of references to support a statement of fact in scientific articles remains a concern. Inaccurate use of references occurs more frequently when multiple citations are used to support a single statement; and often, review articles are used to support scientific statements.
Clinical Paper Session 16: Evidence/Clinical Guidelines Saturday, October 5, 2013 2:35e2:41 PM Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Hand
Opinions Regarding Management of Hand and Wrist Injuries in Elite Athletes: A Survey of Consultant Hand Surgeons Level 5 Evidence Christopher J. Dy, MD, MSPH © Ekaterina Khmelnitskaya, MD © Krystle A. Hearns, MA Michelle Gerwin Carlson, MD
Hypothesis: Decisions regarding appropriate treatment for hand and wrist injuries in elite athletes, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. There is little recognition in the literature of the need for a different approach when treating these injuries in elite athletes, and timing to return to play. This study further explored the complexities of treating hand and wrist injuries in the elite athlete. Methods: A total of 37 consultant hand surgeons for teams in the National Football League, National Basketball Association, and Major League Baseball completed an electronic survey about the management of common hand injuries. This survey included questions about indications for surgery, return to protected play, and return for unprotected play (Table 1). Cross-tab calculations and chi-square analysis were performed. Responses were compared by sport treated by the surgeon (baseball vs no baseball, football vs no football, and basketball vs no basketball). Results: All but 2 surgeons recommend return to protected play within 3 to 4 weeks after healing of a metacarpal fracture, but 73% recommend waiting 4 to 8 weeks for unprotected play (Table 1). Most surgeons allow patients with
REFERENCES 1. Jackson K, Porrino JA Jr, Tan V, Daluiski A. Reference accuracy in the Journal of Hand Surgery. J Hand Surg Am. 2003;28(3):377e380. 2. Eichorn P, Yankauer A. Do authors check their references? A survey of accuracy of references in three public health journals. Am J Public Health. 1987;77(8): 1011e1012.
Contracted Research with: Orthohelix Surgical Designs (D.S.R., F.J.L.); Axogen (F.J.L.) Royalties/Honoraria: OrthoHelix Surgical Designs (F.J.L.) Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) with: Orthohelix Surgical Designs (F.J.L.) Consulting Fees (eg, advisory boards) received from: Stryker Orthopaedics, Bioventus, Axogen (F.J.L.); Acumed, Synthes, Extremity Medical (M.J.R.)
Table 1: Return to Play Recommendations According to Hand or Wrist Injury Nondisplaced Metacarpal Shaft Fracture Return to Play Immediate When Healed, 3e4 wk PP (n ¼ 37) 14 21 UP (n ¼ 37) 0 5 Scaphoid Fracture Return to Play Immediate When Healed, 4e6 wk PP (n ¼ 37) 12 19 UP (n ¼ 37) 0 9 Pisiform Fracture Treatment and Return to Play Immediate Immediate Excision
n ¼ 37 Return to Play
2 27 6e12 wk Postoperation 6 18
>1 2 wk Postoperation 0 10
7
8 In 6 wk
In 3 mo
11 1
When Skin Healed, 2 wk 19 15
6 20
0 1
No Surgery
Immediate Repair
1
14
Repair at End of Season (If 6 wk) 12
Repair at End of Season (If 3 mo) 3
Repair at End of Season ( 6 mo) 7
2 wk 20 0
6 wk 10 12
3 mo 1 23
6 mo 0 1
4 wk 2 11
4e8 wk 0 14
> 3 mo 0 3
Immediate PP (n ¼ 36) 5 UP (n ¼ 36) 0 Stable PIP Dislocation Return to Play Immediate PP (n ¼ 36) 34 UP (n ¼ 37) 9
4 wk With Splint
> 8 wk Postoperation 0 5
Excision After 4 wk If Not Healed 3
n ¼ 37 11 Hook of Hamate Fracture Return to Play Immediate PP (n ¼36) UP (n ¼ 37 Thumb UCL Tear Treatment
4e8 wk Postoperation
Excision After 8 wk If Not Healed 8
PP, protected play; UP, unprotected play; PIP, proximal interphalangeal.
© Speaker has nothing of financial value to disclose
e47
scaphoid fractures to return to protected play within 4 to 6 weeks of injury, whereas 76% wait at least 6 to 12 weeks and 24% wait more than 12 weeks before allowing unprotected play. Most surgeons allow return to protected play within 2 weeks of hook of hamate fractures, but 54% of surgeons wait until 6 weeks to allow unprotected play. Most surgeons recommend repair of thumb ulnar clateral ligament (UCL) tears immediately or within 6 weeks of injury, but 27% recommend waiting until the end of the season. Nearly 70% of surgeons recommend return to protected play within 2 weeks of thumb UCL repair and 67% recommend waiting at least 3 months before unprotected play. All but 2 surgeons permitted immediate return to protected play after a stable proximal interphalangeal joint dislocation. Basketball surgeons were less likely to recommend early protected play than non-basketball surgeons. Baseball surgeons were more likely to recommend early unprotected play after scaphoid fixation. Football surgeons were more likely to recommend earlier protected play after thumb UCL injuries, whereas basketball surgeons were less likely to recommend earlier protected play. Summary: There is wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries in elite athletes. These findings emphasize the need to individually tailor treatment decisions to the patient’s desires and demands, particularly in the high-performance athlete. Contracted Research: NIH/NIAMS T32 Research Fellowship (grant AR07281) RJOS/Zimmer Research Grant (M.G.C.) * ASSH Resident/Fellow Fast Track Grant (C.J.D.)
PAPER 71 Clinical Paper Session 16: Evidence/Clinical Guidelines Saturday, October 5, 2013 2:45e2:51 PM Category: Evaluation/Diagnosis/Clinical Treatment Keyword: Hand
The Impact of Depression and Pain Catastrophization on Patient-Rated Outcomes Before and After Treatment for Atraumatic Hand Conditions Level 1 Evidence
© Daniel London, BA © Jeffrey Stepan, BS Martin I. Boyer, MD, FRCS(C) © Ryan Patrick Calfee, MD
compared with unaffected patients, but they would demonstrate a response to treatment comparable to unaffected patients. Methods: Sample size estimates indicated 50 depressed and/or pain catastrophizing patients and 200 unaffected patients provided 94% power to detect a 10-point difference in Michigan Hand Questionnaire (MHQ) scores. A total of 256 patients presenting to an orthopedic hand clinic were prospectively enrolled in this cohort investigation. Patients prescribed treatment for atraumatic conditions were eligible for inclusion. At enrollment, all patients completed the Center for Epidemiologic StudieseDepression Scale (CES-D), the Pain Catastrophizing Scale (PCS), and the MHQ (0e100 scale, where 100 ¼ perfect function). One and 3 months after treatment, patients recompleted the MHQ. Participants’ psychological comorbidity status was categorized as either affected (depressed: CES-D ¼ 16, or pain catastrophizing: PCS ¼ 30) or unaffected (CES-D < 16 and PCS < 30). Diagnoses and treatments between affected and unaffected patients were examined. The effects of time, patients’ status, and their interaction on MHQ scores were evaluated by mixed modeling. Results: Of the 256 patients enrolled, 50 were affected and 206 were unaffected. Diagnoses and treatments were similar between groups (Table 1). At the time of enrollment, unaffected patients’ mean MHQ score (64.9, 95% confidence interval [CI]: 62.5e67.3) was significantly higher than affected patients’ mean MHQ score (48.1, 95% CI: 43.3e53.0). Affected and unaffected patients demonstrated similar significant absolute improvement over baseline at 3 months after treatment (affected: 12.4, 95% CI: 7.5e17.4; unaffected: 12.9, 95% CI: 10.4e15.3). Thus, affected patients still rated their hand function as worse compared with unaffected patients (unaffected: 77.7, 95% CI: 75.0e80.5; affected: 60.58, 95% CI: 54.96e66.18) at final follow up (Fig. 1). Summary: Patients who are depressed and/or pain catastrophizers report worse selfrated hand function at baseline and after treatment compared with unaffected patients. At 3 months after treatment, both depressed and/or pain catastrophizing patients and unaffected patients rate their hand function as significantly improved compared with pretreatment. Although depressed and/or pain catastrophizing patients report worse self-related hand function at both baseline and at follow-up, these patients show similar absolute improvement in self-rated hand function after treatment compared with unaffected patients.
Hypothesis: Evidence suggests that patient-rated hand function is affected by depression and pain catastrophization; however, the impact of these comorbidities on response to treatment is unknown. We hypothesized that patients affected by depression and/or pain catastrophization would have worse patient-rated hand function at baseline and 3 months after treatment Table 1: Participant Diagnoses and Treatments According to Patient Status
Variable Diagnosis Arthritis Cyst/mass Dupuytren disease Nerve compression Tendonitis Ulnar-sided wrist pain Arthritis and tendonitis Nerve compression and tendonitis Other Treatment Aponeurotomy Brace/medication/therapy Injection Surgery Other
e48
Participant Status Unaffected Affected N % N % 51 14 10 35 74 5 5 8 4
24.8 6.8 4.9 17.0 35.9 2.4 2.4 3.9 1.9
14 0 2 14 9 2 2 4 2
28.0 0 4.0 28.0 18.0 4.0 4.0 8.0 4.0
Figure 1: Mean MHQ scores over time based on patients’ status as being either unaffected or affected. Both groups demonstrated significant improvement from baseline to 3 months after treatment. The affected group’s mean MHQ score was always significantly less than the unaffected group’s mean MHQ score. Error bars represent 95% confidence intervals.
9 52 97 47 1
4.4 25.2 47.1 22.8 0.5
2 19 16 13 0
4.0 38.0 32.0 26.0 0
1. Karels CH, Bierma-Zeinstra SMA, Burdorf A, Verhagen AP, Nauta AP, Koes BW. Social and psychological factors influenced the course of arm, neck and shoulder complaints. J Clin Epidemiol. 2007;60(8):839e848. 2. Linton SJ, Nicholas MK, MacDonald S, et al. The role of depression and catastrophizing in musculoskeletal pain. Eur J Pain. 2011;15(4):416e422.
REFERENCES
© Speaker has nothing of financial value to disclose