Frequency and reporting of complications after Dupuytren's contracture interventions: A systematic review and meta-analysis.

INTRODUCTION: Numerous complications are reported following interventions for Dupuytren's contracture; however, their incidence, management, and outcomes remain poorly reported. The aims of this review were to report the proportions of complications, compare likelihood of complications between interventions, and evaluate reporting of complications, including assessment, grading, management, and subsequent reporting of their impact on patient outcomes. METHODS: Extracted data included patient demographics, intervention details, complications, their management, and final outcomes. Analysis of descriptive data enabled review of complications reporting. Meta-analysis(MA) of non-comparative datasets enabled estimation of proportions of patients experiencing complications. Network meta-analysis(NMA) of comparative studies estimated the relative occurrence of complications between interventions. Risk of bias analysis was performed. RESULTS: 26 studies, comprising 10,831 patients, were included. Interventions included collagenase injection, percutaneous needle fasciotomy(PNF), limited fasciectomy(LF), open fasciotomy(OF), and dermofasciectomy(DF). Overall quality and consistency of outcomes reporting was poor. MA enabled estimates of probabilities for three common complications(infection, nerve injury, complex regional pain syndrome(CRPS)) across all interventions; the reported rates for LF were 4.5% for infection, 3% for nerve injury, and 3.3% for CRPS. As the commonest intervention, LF was used as the reference intervention for comparison of the commonest complications via NMA, including haematoma [OF OR 0.450(0.277, 0.695); PNF OR 0.245(0.114, 0.457)], infection [PNF OR 0.2(0.0287, 0.690); DF OR 2.02(1.02, 3.74)], and neuropraxia [PNF OR 0.0926(0.00553, 0.737)]. We noted that the complication incidence was higher the more invasive the intervention. CONCLUSIONS: There was limited reporting of complication occurrence, management, and outcomes following interventions, contributing to a gap in information for informed patient consent. MA was possible for reporting of proportions for infection, nerve injury, and CRPS across interventions. NMA enabled direct comparison of the six commonest complications between interventions. These findings can guide intervention selection. Improving consistency and quality in complications reporting is essential to aid counselling of patients regarding the true rates and consequences of the risks of interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: 2.

Unconstrained metacarpophalangeal joint arthroplasties: a systematic review.

AIMS: We performed a systematic review of the current literature regarding the outcomes of unconstrained metacarpophalangeal joint (MCPJ) arthroplasty. MATERIALS AND METHODS: We initially identified 1305 studies, and 406 were found to be duplicates. After exclusion criteria were applied, seven studies were included. Outcomes extracted included pre- and post-operative pain visual analogue scores, range of movement (ROM), strength of pinch and grip, satisfaction and patient reported outcome measures (PROMs). Clinical and radiological complications were recorded. The results are presented in three groups based on the design of the arthroplasty and the aetiology (pyrocarbon-osteoarthritis (pyro-OA), pyrocarbon-inflammatory arthritis (pyro-IA), metal-on-polyethylene (MoP)). RESULTS: Results show that pyrocarbon implants provide an 85% reduction in pain, 144% increase of pinch grip and 13° improvements in ROM for both OA and IA combined. Patients receiving MoP arthroplasties had a reduction in pinch strength. Satisfaction rates were 91% and 92% for pyrocarbon-OA and pyrocarbon-IA groups, respectively. There were nine failures in 87 joints (10.3%) over a mean follow-up of 5.5 years (1.0 to 14.3) for pyro-OA. There were 18 failures in 149 joints (12.1%) over a mean period of 6.6 years (1.0 to 16.0) for pyro-IA. Meta-analysis was not possible due to the heterogeneity of the studies and the limited presentation of data. CONCLUSION: We would recommend prospective data collection for small joint arthroplasties of the hand consisting of PROMs that would allow clinicians to come to stronger conclusions about the impact on function of replacing the MCPJs. A national joint registry may be the best way to achieve this. Cite this article: Bone Joint J 2017;99-B:100-6.

Risk of hip fracture following a wrist fracture-A meta-analysis.

AIMS: This purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture. METHOD: Studies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included. Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool. A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies. RESULTS: 12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93-4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used. CONCLUSION: Risk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43). Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture. This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.

Screening for cervical neoplasia in a developing country utilizing cytology, cervicography and the acetic acid test.

OBJECTIVE: To compare three screening tests for cervical neoplasia. METHOD: Women (6301) were screened simultaneously with cytology, cervicography and the acetic acid test (AAT). Biopsies were taken from the acetowhite lesions and every fifth seemingly normal cervix. Positive cases (both at screening and histology) were referred for colposcopy. The histology results served as the golden standard. RESULTS: Cytology was positive in 1.7% of cases, cervicography in 10.7% and the AAT in 17.8%. The sensitivity of cytology was 19.3%, of cervicography 41.8% and the AAT 49.4%. Corresponding specificities were 99.3%, 78.8% and 48.5%. In 23% of biopsies showing cervical intraepithelial neoplasia (grade I--III), all three screening tests were negative. By combining the three tests, a sensitivity of 76.9% was achieved. CONCLUSION: The sensitivity of cytology alone is not great enough for implementing as a screening test in a developing country where screening programs are often inadequate. Screening with a combination of tests, once or a few times per woman's life, is a more acceptable alternative since it allows for less screening events without sacrifying sensitivity.

Screening for cervical neoplasia during pregnancy.

OBJECTIVE: To evaluate cytology as a screening method for cervical neoplasia in pregnancy and to compare it with cervicography and the acetic acid test (AAT). METHODS: In a large antenatal clinic in South Africa, 842 women were screened utilizing cytology, cervicography and the acetic acid test simultaneously. The proportion of positive results of the different tests were compared and the agreement calculated by the kappa statistic. RESULTS: The mean age of the women was 27 years, and 12.5% smoked. Cytological smears were abnormal (low-grade squamous intra-epithelial lesion and higher degrees of abnormality) in 1.4% of cases, cervicography in 6.3% and the AAT in 14.3% (P = 0.5400). Kappa values were as follows: cytology vs. cervicography 0.01, cytology vs. AAT 0.0 and cervicography vs. AAT 0.2. CONCLUSIONS: As a result of cytology's rather low yield and the small measure of agreement between the tests, cytology should be supplemented by an additional screening test in pregnancy.

Effects of dilute acetic acid on the cervical smear.

OBJECTIVE: To evaluate the effect of 5% acetic acid on the cells and cellular content of cervical smears. STUDY DESIGN: A randomized, controlled trial was performed with 42 patients in each group. The study group received acetic acid application to the cervix followed by a smear, while the sequence was reversed in the control group. Cytologic evaluation of the smears was done without knowledge of the group allocation in each case. RESULTS: The group in which acetic acid was applied before the smear was taken showed significantly poorer staining properties of the smear (P < .0001) and also significantly lower cellular content (P = .0006). CONCLUSION: Acetic acid has adverse effects on the cervical smear and should be applied after the smear is taken.

Prevalence of vaginitis, syphilis and HIV infection in women in the Orange Free State.

OBJECTIVE: To determine the prevalence of vaginitis, syphilis and HIV infection in women in the Orange Free State. METHOD: By cluster sampling, 120 rural (farm) and 120 urban (local authority) clusters, each containing 4 women, were selected. Women aged 18-49 years who were included in the study had a cervical smear taken for cytological evaluation and blood specimens drawn for syphilis and HIV testing; they were questioned on their knowledge of AIDS. RESULTS: Trichomonas vaginalis vaginitis was present in 27.4% of the rural women and 29.6% of the urban women, Gardnerella vaginalis in 7.2% and 8.4% and Candida spp. in 2.6% and 6.7% respectively. Syphilis serology was positive in 12% of rural and 16% of urban women. HIV was present in 0.4% of rural and 1.5% of urban women. Ninety per cent of urban women and 74% of rural women knew AIDS was a sexually transmitted disease. CONCLUSIONS: The prevalences of trichomonas vaginitis and syphilis were unusually high, while HIV positivity was similar to that in other reports in South Africa.

The role of mammography to evaluate palpable breast tumours.

Mammography is the best screening tool at present available to detect early breast cancer in asymptomatic women. Its diagnostic ability to clarify the true nature of a palpable tumour in symptomatic breast disease remains controversial. To investigate this, case records of 115 women over 35 years, who presented clinically with a palpable and solid breast tumour over a 5 1/2-year period at Universitas Hospital, Bloemfontein, were retrospectively reviewed. All women were pre-operatively evaluated by clinical examination, mammography and fine-needle aspiration cytology and all patients subsequently underwent open surgical biopsy. Results of this triple diagnostic regimen were correlated to the final histopathological diagnosis. No differences in diagnostic accuracy could be found between mammography and either clinical or cytological diagnosis alone. Combining the clinical finding with that of either mammography or cytology significantly improved the diagnostic ability of both. Malignant disease diagnosed by cytology alone negated the additional diagnostic role of mammography in this context. However, to enable confirmation of a benign tumour, mammography proved to be an essential addition to clinical and cytological evaluation. Mammography correctly detected multicentricity in 7% of malignant tumours, proving it to be essential before breast-conserving surgery could be carried out for malignant tumours.

Pre-operative evaluation of palpable breast tumours.

The diagnostic accuracy of clinical examination, mammography and fine-needle aspiration cytology in identifying malignancy was retrospectively assessed in 207 women with palpable breast masses undergoing breast biopsy for histological examination. Clinical examination was more sensitive (96%) than mammography (81%) or cytology (69%). Cytological examination was totally specific for malignancy. The combined evaluation of clinical examination, mammography and cytological examination revealed a 100% diagnostic accuracy for concordant triplet results. Where discordant triplet results were recorded, 75% of tumours were malignant. Biopsy and frozen section are thus recommended if the 'triplet' provides conflicting results. Preliminary biopsy and frozen section may be unnecessary when the diagnostic triplet unequivocally demonstrates malignancy, or when cytological examination reliably reveals the presence of malignancy. Where the components of the triplet all point to benignity, the patient may be confidently followed up without the necessity of biopsy. The adoption of these guidelines may safely reduce the number of open breast biopsies by about 50-60%.

Cervical cytological services in the Orange Free State. Demographic characteristics.

In the Bloemfontein academic hospitals the incidence of infiltrating cervical cancer is four times that of severe cervical intra-epithelial neoplasia (CIN III). A cross-sectional survey was therefore conducted to identify the extent of cervical cytological services in the Orange Free State. From the four major laboratories dealing with the population of the OFS all cytological reports of one randomly chosen working day per month in 1985 were analysed for three demographic variables: age, race, and locality according to census district. As a control, similar demographic variables were identified from national census figures for 1980, limited to females aged 15-65 years. The follow-up of patients with CIN III diagnosed cytologically in the academic hospitals in Bloemfontein was determined. Results showed significant differences (P less than 0.001) in age, race and locality between the census population and that submitted to cytological screening. Acceptable figures were virtually limited to Bloemfontein, predominantly in white patients, while three-quarters of the population of the OFS is black. The peak frequency in the age distribution in the screened population was 25-35 years and 15-24 years for the census population. Follow-up for patients with CIN III was 65.5%. The conclusion is that the female population of the OFS is not representatively reached by existing cytological services.