Prospective Multicenter Randomized Controlled Trial Comparing Early Protected Movement and Splinting for Fifth Metacarpal Neck Fracture.

BACKGROUND: Fifth metacarpal neck fractures account for 20% of all hand fractures, yet there remains debate with respect to management, particularly when conservative treatment is initiated. The objective of this study is to compare functional and patient-reported outcomes (PROs) in patients treated with early protected movement or splint immobilization. METHODS: This national multicenter prospective randomized controlled trial compared 2 groups; elastic bandage with early protected movement versus immobilization with splinting. Demographic characteristics were collected at baseline. Functional outcomes (grip strength testing) and PROs (Brief Michigan Hand Questionnaire [bMHQ]) were collected at 4, 8, and 12 weeks post-intervention. Grip strength values of the injured hand were normalized to both the non-injured hand (at baseline), and the Canadian reference values. RESULTS: Thirty-seven participants from 5 Canadian centers were randomized into the splint (n = 21) or elastic bandage group (n = 16). There were no significant differences in the bMHQ score between the splint (52.1 ± 27.2) or the elastic bandage (46.6 ± 20.4) groups (P = .51). There were no differences in baseline grip strength between the splint (15.3 ± 8.9 kg) and elastic bandage (19.9 ± 7.5 kg) groups. At 8 weeks, the elastic bandage group had a significantly higher grip strength than the splint group (93% vs 64%, respectively: P < .05), when standardized as a percentage of the Canadian reference values. CONCLUSION: Patients with Boxer's fractures treated with early protected movement had better functional outcomes by 8 weeks post-treatment as compared to the Canadian reference values of those treated with immobilization and splinting. Providers should manage Boxer's fractures with early protected movement.

RENSEIGNEMENTS GÉNÉRAUX: Les fractures du col du cinquième métacarpien représentent 20 % de toutes les fractures de la main, mais leur prise en charge ne fait pas l'unanimité, en particulier lorsqu'un traitement classique est instauré. L'objectif de cette étude consiste à comparer les résultats fonctionnels et les résultats déclarés par le patient traité au moyen d'une protection contre le mouvement instaurée de manière précoce ou d'une attelle pourimmobilization. MÉTHODOLOGIE: Cet essai multicentrique, national, prospectif, contrôlé et mené à répartition aléatoire a comparé 2 groupes recevant les traitements suivants: un bandage élastique et une protection contre le mouvement instaurée de manière précoce, d'une part, et une attelle pourimmobilization, d'autre part. Les caractéristiques démographiques ont été recueillies au début de l'étude. Les résultats fonctionnels (épreuve de force de préhension) et les résultats déclarés par le patient (questionnaire bMHQ [Brief Michigan Hand Questionnaire], question bref de Michigan portant sur les mains) ont été recueillis 4, 8 et 12 semaines après l'intervention. Les valeurs de la force de préhension de la main blessée ont été normalisées en fonction à la fois de la main non blessée (au départ) et des valeurs de référence canadiennes. RÉSULTATS: Trente-sept participants de cinq centres canadiens ont été répartis aléatoirement dans le groupe traité au moyen d'une attelle (n = 21) ou celui traité par un bandage élastique (n = 16). Aucune différence significative sur le plan du score bMHQ n'a été observé entre les groupes traité au moyen d'une attelle (52,1 ± 27,2) ou d'un bandage élastique (46,6 ± 20,4; P = .51). Il n'y avait aucune différence au chapitre de la force de préhension initiale entre le groupe traité au moyen d'une attelle (15,3 ± 8,9 kg) et celui traité par un bandage élastique (19,9 ± 7,5 kg). Après huit semaines, le groupe traité par un bandage élastique présentait une force de préhension significativement plus élevée que celle du groupe traité au moyen d'une attelle (93 % contre 64 %, respectivement: P < .05), après la normalizationdes valeurs en pourcentage par rapport aux valeurs de référence canadiennes. CONCLUSION: Les patients subissant une « fracture du boxeur ¼ traités au moyen d'une protection contre le mouvement instaurée de manière précoce obtenaient de meilleurs résultats fonctionnels huit semaines après le traitement, vis-à-vis des valeurs de référence canadiennes, que ceux traités par une attelle pourimmobilization. Les professionnels de la santé devraient donc prendre en charge les fractures de boxeur au moyen d'une protection contre le mouvement instaurée de manière précoce.

The Effect of Written Information on Recall of Surgical Risks of Primary Cleft Palate Repair: A Randomized Controlled Study.

OBJECTIVE: To investigate parents' understanding of the risks of primary cleft palate surgery after counseling with and without the use of a written informational aid. DESIGN: Prospective, randomized, single-blind trial. SETTING: Academic tertiary care center. PARTICIPANTS: Parents of children undergoing primary cleft palate surgery. INTERVENTIONS: Parents were randomized to receive a standard informed consent discussion with or without provision of a written informational aid in the form of a pamphlet. MAIN OUTCOMES MEASURE: Parents' recall of 9 specific surgical risks 3 weeks after informed consent discussion. RESULTS: Forty parents enrolled in and completed the study (20 participants each in the control and intervention groups). There were no statistically significant differences between groups in terms of baseline demographics. The mean number of risks recalled were 3.7 (1.6) for the control group and 4.2 (1.9) for the intervention group (P = .37). The most commonly recalled risks were fistula formation and bleeding, while the least frequent were facial growth restriction and need for further surgery. No differences in risk recall were observed based on participant's gender, level of education, or income. CONCLUSION: Parents of children undergoing primary cleft palate surgery recall less than 50% of counseled risks. The use of a written aid in the form of a pamphlet did not significantly improve recall in this sample. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks.

Donor Site Morbidities of Iliac Crest Bone Graft in Craniofacial Surgery: A Systematic Review.

BACKGROUND: The iliac crest bone graft (ICBG) is criticized for high donor site morbidity. Recent research suggests this morbidity is related to the patient population for which the ICBG is harvested. This systematic review is the first to delineate the type and incidence of ICBG donor site complications in craniofacial surgery. METHODS: Two independent reviewers conducted a systematic review of multiple databases (MEDLINE, EMBASE, CINAHL, PEDRO, and Cochrane Central Register of Controlled Trials) from 1917 to 2017. All studies utilizing the ICBG for craniofacial indications were included. Donor site morbidities, including immediate and chronic pain, hematoma, seroma, infection, hypertrophic/painful scarring, nerve injury, muscle herniation, iliac crest fracture, and gait disturbance, were recorded. A weighted incidence for each morbidity, excluding immediate pain, was calculated. An average visual analog scale score was calculated for immediate pain. RESULTS: Forty-four studies, with 2801 patients, were included. Oral and maxillofacial (50%) and cleft reconstruction (40%) were the primary indications for surgery. Average immediate pain visual analog scale scores on postoperative days 1 and 14 were 6.3 and 1.3, respectively. The incidence of donor site morbidities was as follows: acute (45.7%) and chronic (1.5%) gait disturbance, acute (17.8%) and chronic nerve changes (1.4%), hypertrophic/painful scar (9.1%), chronic pain (3.1%), hematoma (2.2%), seroma (2.0%), infection (1.0%), iliac crest fracture (1.2%), and muscle herniation (0%). CONCLUSIONS: Chronic morbidity was lower than previously documented. Rare chronic morbidity illustrates that the ICBG remains a viable surgical option. The authors hope this review will facilitate surgical planning and informed consent.

Why the p Value Alone Is Not Enough: The Need for Confidence Intervals in Plastic Surgery Research.

BACKGROUND: The p value is one of the most used descriptors in statistical analysis; however, when reported in isolation, it does not convey the effect size of a treatment. The reporting of confidence intervals is an essential adjunct to determine the clinical value of treatment, as it permits an assessment of the effect size. The authors assessed the reporting of confidence intervals in clinical trials within the plastic surgery literature. METHODS: The seven highest impact plastic surgery journals were screened using MEDLINE for clinical trials in the years 2006, 2009, 2012, and 2015. Studies were randomized based on a predetermined sample size, and various characteristics (e.g., Jadad quality score, reporting of statistical significance, journal impact factor, and participation of an individual with formal research training) were documented. RESULTS: Two independent reviewers analyzed 135 articles. There was substantial interrater agreement (kappa = 0.78). Although 86.7 percent of studies reported a p value, only 25.2 percent reported confidence intervals. Of all journals assessed, Plastic and Reconstructive Surgery most frequently reported confidence intervals. The quality of the studies had a median Jadad score of 2 of 5. Bivariate analysis revealed that higher Jadad score and involvement of an individual with formal research training were associated with reporting of confidence intervals. Multivariate analysis revealed similar findings, whereas journal impact factor, year of publication, and statistical significance were not correlated with confidence interval reporting. CONCLUSIONS: Confidence intervals are underreported in the plastic surgery literature. To improve reporting quality of clinical trials, results should always include the confidence intervals to avoid misinterpretation of the effect size of a statistically significant result.

What Are Your Patients Reading Online About Soft-tissue Fillers? An Analysis of Internet Information.

BACKGROUND: Soft-tissue fillers are increasingly being used for noninvasive facial rejuvenation. They generally offer minimal downtime and reliable results. However, significant complications are reported and patients need to be aware of these as part of informed consent. The Internet serves as a vital resource to inform patients of the risks and benefits of this procedure. METHODS: Three independent reviewers performed a structured analysis of 65 Websites providing information on soft-tissue fillers. Validated instruments were used to analyze each site across multiple domains, including readability, accessibility, reliability, usability, quality, and accuracy. Associations between the endpoints and Website characteristics were assessed using linear regression and proportional odds modeling. RESULTS: The majority of Websites were physician private practice sites (36.9%) and authored by board-certified plastic surgeons or dermatologists (35.4%) or nonphysicians (27.7%). Sites had a mean Flesch-Kincaid grade level of 11.9 ± 2.6, which is well above the recommended average of 6 to 7 grade level. Physician private practice sites had the lowest scores across all domains with a notable lack of information on complications. Conversely, Websites of professional societies focused in plastic surgery and dermatology, as well as academic centers scored highest overall. CONCLUSIONS: As the use of soft-tissue fillers is rising, patients should be guided toward appropriate sources of information such as Websites sponsored by professional societies. Medical professionals should be aware that patients may be accessing poor information online and strive to improve the overall quality of information available on soft-tissue fillers.