Distraction as a simple and effective method to reduce pain during local anesthesia: A randomized controlled trial.

BACKGROUND: The administration of local anesthetics is considered the most unpleasant part of office-based surgery. Many procedural and pharmacological strategies have been developed to minimize pain. In children and adolescents, distraction has been demonstrated to be an effective way of minimizing pain during local anesthesia. We present a randomized controlled trial of the effect of distraction on pain during local anesthesia in adults. MATERIAL AND METHODS: We have included 115 patients undergoing small office-based surgery to either the face, wrist, or hand. We randomized these patients between two groups: a control group and an intervention group. The intervention group watched a distractive video during the administration of the local anesthetic; for the rest the surgical procedures were performed in an equal fashion in both groups. Preoperative anxiety was scored from 0 to 10 and pain experienced during the injection of local anesthetic was measured on the visual analogue scale of pain (VAS), ranging from 0 to 10. Patient satisfaction was measured on the Patient Satisfaction Questionnaire (PSQ-18), ranging from 18 to 90. RESULTS: Patients had an equal anticipated pain score in control and intervention group. In the intervention group, a reduction of pain scores of 1 point was observed (p = 0.01). There was no difference in patient satisfaction scores between both groups. DISCUSSION: In this study, we demonstrate the pain minimizing effect of distraction during the administration of local anesthesia. Less experienced pain did not result in improved patient satisfaction in our study. We encourage physicians to seek ways to actively distract patients during unpleasant procedures.

[Sunburn of a reconstructed breast: risk of denervated tissue]. / Zonverbranding van een gereconstrueerde borst.

More and more women opt for breast reconstruction with autologous tissue after breast removal. Reconstruction with a deep inferior epigastric perforator (DIEP) flap is the most common technique. In this operation, the nerves of the DIEP flap are cut. This creates a denervated reconstructed breast which is not only numb, but also lacks autonomic response. This makes the tissue more susceptible to thermal injury. We present a case of a 66-year-old woman who underwent uncomplicated breast reconstruction with a DIEP flap 8 months ago. She recently noticed a second-degree burn on her reconstructed breast after she had been sitting in the sun whilst dressed. She did not feel anything and noticed it by accident. Familiarity with this phenomenon is important for all parties involved in care and aftercare of breast cancer and breast reconstruction, so adequate information can be provided. Reinnervation of the reconstructed breast could be a solution, but more research is needed.

Discrete Pathophysiology is Uncommon in Patients with Nonspecific Arm Pain.

BACKGROUND: Nonspecific symptoms are common in all areas of medicine. Patients and caregivers can be frustrated when an illness cannot be reduced to a discrete pathophysiological process that corresponds with the symptoms. We therefore asked the following questions: 1) Which demographic factors and psychological comorbidities are associated with change from an initial diagnosis of nonspecific arm pain to eventual identification of discrete pathophysiology that corresponds with symptoms? 2) What is the percentage of patients eventually diagnosed with discrete pathophysiology, what are those pathologies, and do they account for the symptoms? METHODS: We evaluated 634 patients with an isolated diagnosis of nonspecific upper extremity pain to see if discrete pathophysiology was diagnosed on subsequent visits to the same hand surgeon, a different hand surgeon, or any physician within our health system for the same pain. RESULTS: There were too few patients with discrete pathophysiology at follow-up to address the primary study question. Definite discrete pathophysiology that corresponded with the symptoms was identified in subsequent evaluations by the index surgeon in one patient (0.16% of all patients) and cured with surgery (nodular fasciitis). Subsequent doctors identified possible discrete pathophysiology in one patient and speculative pathophysiology in four patients and the index surgeon identified possible discrete pathophysiology in four patients, but the five discrete diagnoses accounted for only a fraction of the symptoms. CONCLUSION: Nonspecific diagnoses are not harmful. Prospective randomized research is merited to determine if nonspecific, descriptive diagnoses are better for patients than specific diagnoses that imply pathophysiology in the absence of discrete verifiable pathophysiology.

A threshold disability score corresponds with an estimated diagnosis of clinical depression in patients with upper extremity disease.

BACKGROUND: The purpose of this study was to assess whether there is a threshold Disability of Arm, Shoulder and Hand (DASH) score among patients with common hand diagnoses that corresponds with an estimated diagnosis of clinical depression. METHODS: Two hundred sixty-nine patients with one of five common upper extremity disorders completed a measure of upper extremity-specific disability (QuickDASH or DASH) and a questionnaire assessing depressive symptoms (Patient Health Questionnaire (PHQ) or Center for Epidemiologic Studies Depression scale (CES-D). A receiver operating characteristic (ROC) analysis of the discriminatory value of a threshold DASH score for an estimated diagnosis of clinical depression was assessed. The threshold DASH score with the highest positive predictive value for an estimated diagnosis of clinical depression was selected. In bivariate analysis, the association between demographic factors, disease factors, and an estimated diagnosis of clinical depression was examined. RESULTS: The area under the ROC curve for a threshold DASH value diagnostic of an estimated diagnosis of clinical depression was 0.75, indicating clinical usefulness for a threshold DASH score as a screening test for depression. The highest positive predictive value of 72 % occurred at a threshold QuickDASH/DASH score of 55. In bivariate analysis, only diagnosis and years of education were significantly different between patients with and without an estimated diagnosis of clinical depression. CONCLUSION: A DASH score of 55 or greater in patients with common upper extremity disorders has an acceptable area under the curve and positive predictive value for an estimated diagnosis of clinical depression. LEVEL OF EVIDENCE: Level 3, diagnostic study.

What middle phalanx base fracture characteristics are most reliable and useful for surgical decision-making?

BACKGROUND: Fracture-dislocations of the proximal interphalangeal joint are vexing because subluxation and articular damage can lead to arthrosis and the treatments are imperfect. Ideally, a surgeon could advise a patient, based on radiographs, when the risk of problems merits operative intervention, but it is unclear if middle phalanx base fracture characteristics are sufficiently reliable to be useful for surgical decision making. QUESTIONS/PURPOSES: We evaluated (1) the degree of interobserver agreement as a function of fracture characteristics, (2) the differences in interobserver agreement between experienced and less-experienced hand surgeons, and (3) what fracture characteristics and surgeon characteristics were associated with the decision for operative treatment. METHODS: Ninety-nine (33%) of 296 hand surgeons evaluated 21 intraarticular middle phalanx base fractures on lateral radiographs. Eighty-one surgeons (82%) were in academic practice and 57 (58%) had less than 10 years experience. Participants assessed six fracture characteristics and recommended treatment (nonoperative or operative: extension block pinning, external fixation, open reduction and internal fixation, volar plate arthroplasty, or hemihamate autograft arthroplasty) for all cases. RESULTS: With all surgeons pooled together, the interobserver agreement for fracture characteristics was substantial for assessment of a 2-mm articular step or gap (kappa, 0.73; 95% CI, 0.60-0.86; p < 0.001), subluxation or dislocation (kappa, 0.72; 95% CI, 0.58-0.86; p < 0.001), and percentage of articular surface involved (intraclass correlation coefficient [ICC], 0.67; 95% CI, 0.54-0.81; p < 0.001); moderate for comminution (kappa, 0.55; 95% CI, 0.39-0.70; p < 0.001) and stability (kappa, 0.54; 95% CI, 0.39-0.69; p < 0.001); and fair for the number of fracture fragments (ICC, 0.39; 95% CI, 0.27-0.57; p < 0.001). When recommending treatment, interobserver agreement was substantial (kappa, 0.69; 95% CI, 0.50-0.88; p < 0.001) for the recommendation to operate or not to operate, but only fair (kappa, 0.34; 95% CI, 0.21-0.47; p < 0.001) for the specific type of treatment, indicating variation in operative techniques. There were no differences in agreement for any of the fracture characteristics or treatment preference between less-experienced and more-experienced surgeons, although statistical power on this comparison was low. None of the surgeon characteristics was associated with the decision for operative treatment, whereas all fracture characteristics were, except for stable and uncertain joint stability. Articular step or gap (ß, 0.90; R-squared, 0.89; 95% CI, 0.75-1.05; p < 0.001), likelihood of subluxation or dislocation (ß, 0.80; R-squared, 0.76; 95% CI, 0.59-1.02; p < 0.001), and unstable fractures (ß, 0.88; R-squared, 0.81; 95% CI, 0.67-1.1; p < 0.001), are most strongly associated with the decision for operative treatment. CONCLUSIONS: We found that assessment of a step or gap and likelihood of subluxation were most reliable and are strongly associated with the decision for operative treatment. Surgeons largely agree on which fractures might benefit from surgery, and the variation seems to be with the operative technique. Efforts at improving the care of these fractures should focus on the comparative effectiveness of the various operative treatment options. LEVEL OF EVIDENCE: Level III, diagnostic study.

Revision rate after short-stem total hip arthroplasty: a systematic review of 49 studies.

BACKGROUND AND PURPOSE: The aim of short-stem total hip arthroplasty is to preserve proximal bone stock for future revisions, to improve biomechanical reconstruction, and to make minimally invasive approaches easier. It is therefore being increasingly considered to be a sound alternative to conventional total hip arthroplasty, especially for young and active patients. However, it is still unknown whether survival rates of short-stem hips match current standards. We made a systematic summary of reported overall survival after short-stem total hip arthroplasty. MATERIALS AND METHODS: We conducted a systematic review of English, French, German, and Dutch literature. 2 assessors independently identified clinical studies on short-stem hip arthroplasty. After recalculating reported revision rates, we determined whether each implant had a projected revision rate of 10% or less at 10 years of follow-up or a revision rate per 100 observed component years of 1 or less. Stems were classified as "collum", "partial collum", or "trochanter-sparing". RESULTS AND INTERPRETATION: We found 49 studies, or 51 cohorts, involving 19 different stems. There was a large increase in recent publications. The majority of studies included had a follow-up of less than 5 years. We found a large number of observational studies on "partial collum" and "trochanter-sparing" stems, demonstrating adequate survival rates at medium-term follow-up. Clinical evidence from "collum stem" studies was limited to a small number of studies with a medium-term follow-up period. These studies did not show a satisfactory overall survival rate.