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Sensory Outcomes in Digital Nerve Repair Techniques: An Updated Meta-analysis and Systematic Review.

ABSTRACT: Background: Injuries to digital nerves are common with trauma to the hand, often requiring surgery. Surgical management of these injuries can be performed using several techniques: direct repair (neurorrhaphy), autograft, allograft, and conduit repair. In light of increasing the availability and use of various digital nerve repair techniques, a new systematic review and meta-analysis was undertaken to comparatively review the available evidence to determine any differences in outcomes to better guide treatment in cases with digital nerve gaps. Methods: Current literature on sensory outcomes of various digital nerve repair techniques was reviewed using static 2-point discrimination (S2PD), moving 2-point discrimination (M2PD), Semmes-Weinstein monofilament testing (SWMF), and complication rates as outcomes of interest. After inclusion and exclusion criteria were applied, 15 articles were reviewed and 625 nerve repairs were analyzed. Results: The average gap length for allograft repair, autograft repair, and conduit repair was 15.4, 24.7, and 13.4 mm, respectively. For S2PD outcomes, autograft repair was statistically superior to all other forms of repair. Allograft trended higher than neurorrhaphy and conduit repair, but results were not statistically significant. For SWMF outcomes, autograft repair was statistically superior to conduit repair and neurorrhaphy; it was statistically comparable with allograft repair. Allograft performed statistically superior to conduit repair relative to M2PD. Conclusions: Based on the current updated meta-analysis using newer data and techniques, we found that all available techniques have reasonable outcomes. Yet when managing a digital nerve injury with a gap, thereby excluding direct neurorrhaphy, both autograft and allograft performed comparably and were superior to conduit repair.

SUBMITTER: Herman ZJ

PROVIDER: S-EPMC7076611 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Sensory Outcomes in Digital Nerve Repair Techniques: An Updated Meta-analysis and Systematic Review.

Herman Zachary J ZJ Ilyas Asif M AM

Hand (New York, N.Y.) 20190501 2

<b>Background:</b> Injuries to digital nerves are common with trauma to the hand, often requiring surgery. Surgical management of these injuries can be performed using several techniques: direct repair (neurorrhaphy), autograft, allograft, and conduit repair. In light of increasing the availability and use of various digital nerve repair techniques, a new systematic review and meta-analysis was undertaken to comparatively review the available evidence to determine any differences in outcomes to ...[more]

PMID: 31043071

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Project description:ObjectivesA systematic review to assess the evidence supporting surgical repair of digital nerve injury versus no repair in adults in terms of clinical outcomes.DesignA Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review with methodology based on the Cochrane Handbook of Systematic Reviews of Interventions.Data sourcesDatabases included OvidMEDLINE, EMBASE, AMED, clinicaltrials.gov and the Cochrane Database of Systematic Reviews, searched from inception until 10 November 2018.Eligibility criteriaAdult digital nerve injury in which either direct repair or no repair was undertaken and an outcome measure was recorded.Data extraction and synthesisStudy data extracted included demographics, injury type and extent, timing, treatment details, outcome data and time points, adverse outcomes, hand therapy and return to work. The National Institute of Health quality assessment tool for case series was used to assess risk of bias.ResultsThirty studies were included. One compared surgical repair with non-repair. All studies were case series of between 15 and 110 nerve injuries, with heterogeneous patient, injury and treatment characteristics. Two studies detailed nerve repair without magnification. Static 2-point discrimination (s2PD) was the most commonly reported outcome measure. Return of protective sensation was achieved in most cases in the nerve repair and no nerve repair groups. Repair resulted in better s2PD than no repair, but <25% repaired nerves achieved normal levels. Adverse outcomes were similar between repair and no repair groups.ConclusionsOnly level IV evidence is available to support surgical repair of digital nerves in adults. Return of normal sensibility is uncommon and almost all unrepaired nerves regained protective sensation by 6 months and all patients declined further surgery. There was no difference in adverse outcomes. There is currently a lack of high-quality evidence to support surgical repair of digital nerve injuries in adults and further research is needed.Prospero registration numberCRD42017065092.

Project description:BackgroundOutcome after nerve repair of the hand needs standardized psychometrically robust measures. We aimed to systematically review the psychometric properties of available functional, motor, and sensory assessment instruments after nerve repair.MethodsThis systematic review of health measurement instruments searched databases from 1966 to 2017. Pairs of raters conducted data extraction and quality assessment using a structured tool for clinical measurement studies. Kappa correlation was used to define the agreement prior to consensus for individual items, and intraclass correlation coefficient (ICC) was used to assess reliability between raters. A narrative synthesis described quality and content of the evidence.ResultsSixteen studies were included for final critical appraisal scores. Kappa ranged from 0.31 to 0.82 and ICC was 0.81. Motor domain had manual muscle testing with Kappa from 0.72 to 0.93 and a dynamometer ICC reliability between 0.92 and 0.98. Sensory domain had touch threshold Semmes-Weinstein monofilaments (SWM) as the most responsive measure while two-point discrimination (2PD) was the least responsive (effect size 1.2 and 0.1). A stereognosis test, Shape and Texture Identification (STI), had Kappa test-retest reliability of 0.79 and inter-rater reliability of 0.61, with excellent sensibility and specificity. Manual tactile test had moderate to mild correlation with 2PD and SWM. Function domain presented Rosén-Lundborg score with Spearman correlations of 0.83 for total score. Patient-reported outcomes measurements had ICC of 0.85 and internal consistency from 0.88 to 0.96 with Patient-Rated Wrist and Hand Evaluation with higher score for reliability and Spearman correlation between 0.38 and 0.89 for validity.ConclusionsFew studies included nerve repair in their sample for the psychometric analysis of outcome measures, so moderate evidence could be confirmed. Manual muscle test and Rotterdam Intrinsic Hand Myometer dynamometer had excellent reliability but insufficient data on validity or responsiveness. Touch threshold testing was more responsive than 2PD test. The locognosia test and STI had limited but positive supporting data related to validity. Rosén-Lundborg score had emerging evidence of reliability and validity as a comprehensive outcome following nerve repair. Few questionnaires were considered reliable and valid to assess cold intolerance. There is no patient-reported outcome measurement following nerve repair that provides comprehensive assessment of symptoms and function by patient perspective.

Project description:BackgroundOver the past five decades, microsuturing has been established as the "gold standard" for nerve repair. Alternative techniques such as fibrin glue, protein "welds", and nerve connectors have been met with variable enthusiasm. While advancements in this area continue, there is little data on surgeon attitude and acceptance of these new techniques.MethodsA short questionnaire was electronically distributed to the members of the American Society for Surgery of the Hand and the American Association of Hand Surgery. Survey questions ascertained demographic information of participants (specialty, years in practice, practice setting, etc.), attitudes about current techniques (what techniques currently used, why, etc.), and attitudes about new techniques (openness to trying, factors that would persuade for/against, etc.). The surveys were distributed and administered online. Data gathered from responses was analyzed looking for general trends and stratified based on demographic data.ResultsThe majority of responders still consider microsuturing as the gold standard for primary nerve repair, and it is by far the most utilized technique. However, over 90 % also reported that they either currently use or would consider using alternate techniques. Common barriers to utilizing alternate techniques included lack of data regarding outcomes and unfamiliarity with new techniques. Only 40 % of responders considered metal as safe around nerves, but most consider absorbable polymers safe. None of the underlying demographic variables including years in practice, number of nerve repair surgeries performed per month, practice setting, or specialty affected these general trends.ConclusionsMost surgeons performing nerve repairs prefer suturing as their primary repair technique, but a vast majority is open to utilizing alternate repair techniques, especially those that improve outcomes with a faster and easier procedure. While not able to direct clinical practice guidelines, this study can be used to direct focus and funding of further alternate nerve repair techniques.

Project description:BACKGROUND:The diagnosis and management of sepsis remain a global health care challenge. Digital technologies have the potential to improve sepsis care. OBJECTIVE:The aim of this paper was to systematically review the evidence on the impact of digital alerting systems on sepsis related outcomes. METHODS:The following databases were searched for studies published from April 1964 to February 12, 2019, with no language restriction: EMBASE, MEDLINE, HMIC, PsycINFO, and Cochrane. All full-text reports of studies identified as potentially eligible after title and abstract reviews were obtained for further review. The search was limited to adult inpatients. Relevant articles were hand searched for other studies. Only studies with clear pre- and postalerting phases were included. Primary outcomes were hospital length of stay (LOS) and intensive care LOS, whereas secondary outcomes were time to antibiotics and mortality. Studies based solely on intensive care, case reports, narrative reviews, editorials, and commentaries were excluded. All other trial designs were included. A qualitative assessment and meta-analysis were performed. RESULTS:This review identified 72 full-text articles. From these, 16 studies met the inclusion criteria and were included in the final analysis. Of these, 8 studies reviewed hospital LOS, 12 reviewed mortality outcomes, 5 studies explored time to antibiotics, and 5 studies investigated intensive care unit (ICU) LOS. Both quantitative and qualitative assessments of the studies were performed. There was evidence of a significant benefit of digital alerting in hospital LOS, which reduced by 1.31 days (P=.014), and ICU LOS, which reduced by 0.766 days (P=.007). There was no significant association between digital alerts and mortality (mean decrease 11.4%; P=.77) or time to antibiotics (mean decrease 126 min; P=.13). CONCLUSIONS:This review highlights that digital alerts can considerably reduce hospital and ICU stay for patients with sepsis. Further studies including randomized controlled trials are necessary to confirm these findings and identify the choice of alerting system according to the patient status and pathological cohort.

Project description:BackgroundPrevious systematic reviews of digital eating disorder interventions have demonstrated effectiveness at improving symptoms of eating disorders; however, our understanding of how these interventions work and what contributes to their effectiveness is limited. Understanding the behavior change techniques (BCTs) that are most commonly included within effective interventions may provide valuable information for researchers and developers. Establishing whether these techniques have been informed by theory will identify whether they target those mechanisms of action that have been identified as core to changing eating disorder behaviors. It will also evaluate the importance of a theoretical approach to digital intervention design.ObjectiveThis study aims to define the BCTs within digital self-management interventions or minimally guided self-help interventions for adults with eating disorders that have been evaluated within randomized controlled trials. It also assessed which of the digital interventions were grounded in theory and the range of modes of delivery included.MethodsA literature search identified randomized controlled trials of digital intervention for the treatment of adults with eating disorders with minimal therapist support. Each digital intervention was coded for BCTs using the established BCT Taxonomy v1; for the application of theory using an adapted version of the theory coding scheme (TCS); and for modes of delivery using the Mode of Delivery Ontology. A meta-analysis evaluated the evidence that any individual BCT moderated effect size or that other potential factors such as the application of theory or number of modes of delivery had an effect on eating disorder outcomes.ResultsDigital interventions included an average of 14 (SD 2.6; range 9-18) BCTs. Self-monitoring of behavior was included in all effective interventions, with Problem-solving, Information about antecedents, Feedback on behavior, Self-monitoring of outcomes of behavior, and Action planning identified in >75% (13/17) of effective interventions. Social support and Information about health consequences were more evident in effective interventions at follow-up compared with postintervention measurement. The mean number of modes of delivery was 4 (SD 1.6; range 2-7) out of 12 possible modes, with most interventions (15/17, 88%) being web based. Digital interventions that had a higher score on the TCS had a greater effect size than those with a lower TCS score (subgroup differences: χ21=9.7; P=.002; I²=89.7%) within the meta-analysis. No other subgroup analyses had statistically significant results.ConclusionsThere was a high level of consistency in terms of the most common BCTs within effective interventions; however, there was no evidence that any specific BCT contributed to intervention efficacy. The interventions that were more strongly informed by theory demonstrated greater improvements in eating disorder outcomes compared to waitlist or treatment-as-usual controls. These results can be used to inform the development of future digital eating disorder interventions.Trial registrationPROSPERO CRD42023410060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=410060.

Project description:BackgroundDeclining perioperative stroke and death rates over the past 3 decades have been paralleled by an increasing use of intraoperative completion studies (ICS) following carotid endarterectomy (CEA). Techniques applied include angiography, intraoperative duplex ultrasound (IDUS), flowmetry, and angioscopy. This systematic review and meta-analysis is aiming on providing an overview of techniques and corresponding outcomes.MethodsA PubMed based systematic literature review comprising the years 1980 through 2020 was performed using predefined keywords to identify articles on different ICS techniques. Pooled analyses and meta-analyses estimating risk ratios (RR) and 95% confidence intervals (CI) were performed to compare outcomes of different ICS modes to nonapplication of any ICS. I2 values were assessed to quantify study heterogeneities.ResultsIdentification of 34 studies including patients undergoing CEA with angiography (n=53,218), IDUS (n=20,030), flowmetry (n=16,812), and angioscopy (n=2,291). Corresponding rates of perioperative stroke were 1.5%, 1.8%, 3.6%, and 1.5%, perioperative stroke or death occurred in 1.7%, 1.9%, 2.2%, and 2.0%. Intraoperative surgical revision rates were 6.2%, 5.9%, and 7.9% after CEA with angiography, IDUS, and angioscopy, respectively. Compared to nonapplication of any ICS, the pooled analysis revealed angiography to be significantly associated with lower rates of stroke (RR 0.47; 95% CI, 0.36-0.62; P<0.0001) and stroke or death (RR 0.76; 95% CI, 0.70-0.83; P<0.0001). IDUS was significantly associated with lower rates of stroke (RR 0.56; 95% CI, 0.43-0.73; P<0.0001) and stroke or death (RR 0.83; 95% CI, 0.74-0.93; P=0.0018), whereas angioscopy showed a significant association with a lower stroke rate (RR 0.48; 95% CI, 0.033-0.68; P=0.0001), but no effect on the combined stroke or death rate. Angioscopy was associated with a higher intraoperative revision rate compared to angiography (RR 1.29; 95% CI, 1.07-1.54; P=0.006). The meta-analyses confirmed lower perioperative stroke or death rates for angiography (RR 0.83; 95% CI, 0.76-0.91) and IDUS (RR 0.86; 95% CI, 0.76-0.98) compared to non-application of any ICS, whereas flowmetry showed no significant association.ConclusionsThis study represents the first systematic literature review and meta-analysis on usage of ICSs in CEA. Data strongly indicate a significant beneficial effect of angiography, IDUS, and angioscopy on perioperative CEA outcomes. Any carotid surgeon should consider implementation of ICSs in his routine armamentarium.

Dataset Information

Sensory Outcomes in Digital Nerve Repair Techniques: An Updated Meta-analysis and Systematic Review.

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Sensory Outcomes in Digital Nerve Repair Techniques: An Updated Meta-analysis and Systematic Review.

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