Structured Effectiveness Quality Evaluation Scale Research Articles

Comparative Outcomes Between Surgical and Conservative Management of Mallet Thumb: A Systematic Review and Pooled Analysis.

While mallet finger remains a relatively common injury of the hand, mallet thumb is much rarer in occurrence. Mallet thumb management has been noted infrequently within the literature and reliable evidence regarding the most effective method of management remains absent. The aim of this review is to assess the quality of literature that exists pertaining to mallet thumb to determine whether conservative or surgical management is superior. A search was completed in February 2023 of Ovid Medline, Embase, CINAHL, and SPORTDiscus with no limitation on study type, and date of publication. Comparative outcomes of thumb interphalangeal (IP) joint range of motion, tip, lateral pinch and grip strength, complications, outcome measure scores, and follow-up period were recorded. We assessed 103 mallet thumbs (51 surgically and 52 conservatively managed) across the 23 studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. While recommendations remain weak due to low quality of evidence, our review found a lower complication rate and higher IP joint flexion in thumbs managed conservatively. These findings demonstrate a need for future research to shift toward ensuring standardized patient-rated outcome measures are utilized and functional outcomes are included in research planning and operationalization in order to contextualize clinical outcomes.

Outcomes Following Surgical Interventions for Isolated Lunotriquetral Interosseous Ligament Injuries: A Systematic Review.

Ulnar-sided wrist pain can be attributed to various bony and ligamentous structures. The purpose of this review is to compare outcomes following surgical interventions for isolated lunotriquetral (LT) interosseous ligament injuries in adults. We assessed 202 procedures from 9 retrospective case series studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The comparative outcomes (ie, range of motion, pain, strength, quality of life, complications, return to work, and patient satisfaction) were aggregated and categorized under arthrodesis, capsulodesis, ligament repairs and reconstruction, and ulna shortening osteotomy procedures. Although the comparison of outcomes was largely inconclusive due to the heterogeneity and the omission of preoperative characteristic data, we did observe higher complications and reoperation rates post LT arthrodesis. It is recommended that all outcomes be standardized and presented uniformly with best practices developed to better characterize the injury's severity and integrity in future studies.

Systematic review: Zone IV extensor tendon early active mobilization programs

Study DesignSystematic review IntroductionEarly active mobilization (EAM) of tendon repairs is preferred to immobilization or passive mobilization. Several EAM approaches are available to therapists; however, the most efficacious for use after zone IV extensor tendon repairs has not been established. Purpose of the StudyTo determine if an optimal EAM approach can be identified for use after zone IV extensor tendon repairs based on current available evidence. MethodsDatabase searching was undertaken on May 25, 2022 using MEDLINE, Embase, and Emcare with further citation searching of published systematic/scoping reviews and searching of the Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Studies involving adults with repaired finger zone IV extensor tendons, managed with an EAM program, were included. Critical appraisal using the Structured Effectiveness Quality Evaluation Scale was performed. ResultsEleven studies were included, two were of moderate methodological quality, and the remainder was low. Two studies reported results specific to zone IV repairs. Most studies utilized relative motion extension (RME) programs; two utilized a Norwich program, and two other programs were described. High proportions of “good” and “excellent” range of motion (ROM) outcomes were reported. There were no tendon ruptures in the RME or Norwich programs; small numbers of ruptures were reported in other programs. ConclusionsThe included studies reported minimal data on outcomes specific to zone IV extensor tendon repairs. Most studies reported on the outcomes for RME programs which appeared to provide good ROM outcomes with low levels of complications. The evidence obtained in this review was insufficient to determine the optimal EAM program after zone IV extensor tendon repair. It is recommended that future research focus specifically on outcomes of zone IV extensor tendon repairs. Level of EvidenceI.

Rehabilitation of children with cochlear implant in Iran: A scoping review.

Background: Recovery of children does not appear on its own after cochlear implantation. Coherent, thoughtful, and comprehensive rehabilitation is needed to achieve complete success. The purpose of this study was to identify the types of rehabilitation interventions for children with cochlear implants that have been performed in Iran. Methods: A scoping review study was conducted. An electronic search was carried out both in English and Persian. In English, the following keywords were used: cochlear implantation, child, cochlear implants, auditory rehabilitation, deaf, hearing loss, comprehensive, interventions, rehabilitation, and telerehabilitation and a combination of them in ProQuest, PubMed, Science Direct, and Scopus databases, Web of Sciences, Medline and Embase. Persian electronic search was conducted in the Scientific Information Database (SID) of Jihad Daneshgahi, Iran Journals Database (MagIran), and Islamic World Science Citation Database (ISC). Searches were done using articles published until September 25, 2020, and a total of 902 articles were found, of which 14 were directly related to the purpose of the study. Interventional studies were included in the study, and the quality of studies was measured using the Structured Effectiveness Quality Evaluation Scale. Results: The results showed that using music and rehabilitation equipment, different methods of speech therapy and auditory training, story-based instruction, creative play, family-centered instruction, and occupational therapy are interventions in cochlear implant rehabilitation. Speech therapy accounts for 54% of the rehabilitation share. The mean number of rehabilitation sessions was 26. These interventions were all somehow effective in children with cochlear implantation; the longer the training duration, the better the results. Conclusion: The process of cochlear implant rehabilitation in children is multi-professional; auditory training and speech therapy possesses the highest share of rehabilitation. Therefore, it is recommended to develop speech therapy centers in Iran.

Treatment of Stages IIIA and IIIB in Kienbock's Disease: A Systematic Review.

Background Despite numerous proposed surgical interventions, there is a lack of consensus in the optimal treatment of advanced Kienbock's disease. Purpose This study aims to perform a systematic review of the current evidence in the management of Lichtman's stages IIIA and IIIB of the disease. Methods A literature search was performed using the MEDLINE, EMBASE, and COCHRANE databases to identify studies between 2008 and 2018 evaluating stage-specific outcomes in Lichtman's stages IIIA and IIIB. The quality of each included paper was evaluated using the Structured Effectiveness Quality Evaluation Scale (SEQES). Data extracted were stage-specificity, clinical and functional outcomes, and radiographic progression of Lichtman's staging. Results A total of 1,489 titles were identified. Eighty-three papers were fully reviewed, and 30 articles met eligibility criteria for inclusion. There were 3 low-quality and 27 moderate-quality papers. Surgical techniques reported included decompression surgeries, joint-levelling, and radial wedge osteotomies, revascularization techniques, intracarpal arthrodesis, proximal row carpectomy, arthroplasty, and balloon kyphoplasty. All treatment modalities offered pain relief and improvement in functional outcomes. Compared with proximal row carpectomy, intracarpal arthrodesis, and arthroplasty, nonsalvage procedures provided similar clinical and functional outcomes in both stages, with joint-levelling and radial wedge osteotomies preserving greater range of motion. Conclusion In this systematic review of Kienbock's disease stages IIIA and IIIB, all treatment modalities provided positive outcomes. In stage IIIB, there is evidence to support nonsalvage procedures, as they produced similar clinical outcomes to salvage procedures that have the advantage of not precluding future treatment options if needed and preserving greater range of motion.

Treatment of Sagittal Band Injuries and Extensor Tendon Subluxation: A Systematic Review.

Background: This systematic review assesses the current literature and reviews the clinical outcomes of treatment for sagittal band injuries and extensor tendon instability. Materials: A systematic search of MEDLINE, EMBASE, and the Cochrane databases was performed for English-language articles on the treatment of nonrheumatoid adult sagittal band injuries between 1969 and 2019. Two independent reviewers were involved in screening, data extraction, and critical appraisal. The level of evidence was assigned using the Sackett scale, and the methodological quality of the studies was evaluated using the Structured Effectiveness Quality Evaluation Scale (SEQES). Outcome measures were persistent pain, extensor lag, and recurrent tendon subluxation. Results: In all, 1653 abstracts were identified, with 43 articles reviewed in full text and 17 articles (429 treated digits) included in the final systematic review. There were 10 studies on surgical management, 3 on nonoperative management, and 4 on both. There were 4 retrospective case series and 13 retrospective case reports (Sackett level 4) with an average SEQES score of 15 (low quality). Studies on nonoperative management had on average more digits per study and higher SEQES scores (n = 27.7, SEQES = 19) compared with studies on surgical management (n = 11.8, SEQES = 13.8). Variability in reported outcome measures precluded meta-analysis. Conclusion: Qualitative synthesis of available literature suggests that acute sagittal band injuries can be successfully treated by splinting the injured digit in neutral or hyperextension. Patients with chronic injuries or those failing nonoperative management may benefit from surgical exploration. A lack of consistent outcome measures precluded comparison of surgical techniques.

Flexor tendon rehabilitation in the 21st century: A systematic review

Study DesignSystematic review. IntroductionThe rehabilitation of patients following flexor tendon injury has progressed from immobilization to true active flexion with the addition of wrist motion over the last 75 years. Purpose of the StudyThis review specifically intended to determine whether there is evidence to support one type of exercise regimen, early passive, place and hold, or true active, as superior for producing safe and maximal range of motion following flexor tendon repair. MethodsThe preferred reporting items for systematic review and meta-analysis (PRISMA-P 2015) checklist was utilized to format the review. Both reviewers collaborated on all aspects of the research, including identifying inclusion/exclusion factors, search terms, reading and scoring articles, and authoring the paper. Articles were independently scored by each reviewer using the Structured Effectiveness Quality Evaluation Scale (SEQES). ResultsA total of nine intervention studies that included a rehabilitative comparison group were systematically reviewed: one pediatric, four comparing passive flexion protocols to place and hold flexion, and four comparing true active flexion to passive and/or place and hold flexion. DiscussionThis review provides moderate to strong evidence that place and hold exercises provide better outcomes than passive flexion protocols for patients with two to six-strand repairs. The studies included in this review suffered from methodological limitations including short timeframes for follow-up, unequal group distribution, and limited attention to repair site strength. ConclusionsBased on a lack of superior benefits following true active motion regimens, there is not sufficient evidence to support true active motion as an effective or preferable choice for flexor tendon rehabilitation at this time.

Triangular Fibrocartilage Complex Repair and Ulna Variance: A Systematic Review.

This purpose of the study was to conduct a systematic review of available literature regarding the association between ulnar variance and outcomes after repair of peripheral traumatic tears of the triangular fibrocartilage complex (TFCC). A systematic literature search of the medical literature about peripheral tears of the TFCC was performed. We selected seven studies comparing clinical outcome and ulnar variance in patients with peripheral TFCC tears. We evaluated quality of the articles using both the Structured Effectiveness Quality Evaluation Scale (SEQES) and Sackett's Level of Evidence (LOE). The outcomes were objective or self-assessment scoring systems for the function of the hand, wrist, or upper extremity. Seven articles were evaluated. The SEQES scores varied from 19 to 28, with a mean of 23. Five studies reported no association between ulnar variance and clinical outcome, and 2 studies reported an association. The studies reporting no association either excluded or did not mention the cases of unstable distal radioulnar joint (DRUJ). This systematic review did not demonstrate strong evidence regarding the association between ulnar variance and outcomes after TFCC repair. As most of the studies did not distinguish between capsular and foveal tears which can affect DRUJ stability, further studies looking at this point are necessary to determine whether ulnar shortening osteotomy has an added value for better outcomes after TFCC repair.

The Effect of Socioeconomic Factors on Outcomes of Distal Radius Fractures: A Systematic Review.

Socioeconomic factors are known to affect outcomes for both medical and surgical conditions. The purpose of this systematic review was to assess the current evidence regarding the effect of socioeconomic factors such as income, geographic location, educational level, and occupation on clinical outcomes after distal radius fractures. A systematic search strategy was performed to identify studies commenting on the effect of socioeconomic factors on clinical outcomes following open or closed distal radius fracture repair. Abstract and full-text screening was performed by 2 independent reviewers, and articles were evaluated by Structured Effectiveness Quality Evaluation Scale (SEQES). Treatment outcomes of interest included, but were not limited to, pain, function, range of motion, and grip strength. There were 1745 studies that met our inclusion and exclusion criteria for abstract screening. Of these, 48 studies met our inclusion criteria for full-text screening and 20 studies met our criteria for quality analysis with the SEQES score. There were 3 studies of high quality, 16 of moderate quality, and 1 of low quality. Meta-analyses were not possible due to the variability in outcomes of interest across papers. Patient factors indicative of socioeconomic status are relevant predictors of functional outcome after distal radius fractures. There is currently limited evidence in this area of research, and further examination should be considered to improve outcomes from a patient and system standpoint.

Optimal early active mobilisation protocol after extensor tendon repairs in zones V and VI: A systematic review of literature.

IntroductionEarly mobilisation protocols after repair of extensor tendons in zone V and VI provide better outcomes than immobilisation protocols. This systematic review investigated different early active mobilisation protocols used after extensor tendon repair in zone V and VI. The purpose was to determine whether any one early active mobilisation protocol provides superior results.MethodsAn extensive literature search was conducted to identify articles investigating the outcomes of early active mobilisation protocols after extensor tendon repair in zone V and VI. Databases searched were AMED, Embase, Medline, Cochrane and CINAHL. Studies were included if they involved participants with extensor tendon repairs in zone V and VI in digits 2–5 and described a post-operative rehabilitation protocol which allowed early active metacarpophalangeal joint extension. Study designs included were randomised controlled trials, observational studies, cohort studies and case series. The Structured Effectiveness Quality Evaluation Scale was used to evaluate the methodological quality of the included studies.ResultsTwelve articles met the inclusion criteria. Two types of early active mobilisation protocols were identified: controlled active motion protocols and relative motion extension splinting protocols. Articles describing relative motion extension splinting protocols were more recent but of lower methodological quality than those describing controlled active motion protocols. Participants treated with controlled active motion and relative motion extension splinting protocols had similar range of motion outcomes, but those in relative motion extension splinting groups returned to work earlier.DiscussionThe evidence reviewed suggested that relative motion extension splinting protocols may allow an earlier return to function than controlled active motion protocols without a greater risk of complication.

Complications of Distal Radius Fractures in the Elderly: A Systematic Review and Meta-analysis

There is no financial information to disclose. Optimal treatment for elderly patients with distal radius fractures has remained controversial as the benefits and risks of surgical fixation are less clear than for a younger patient. Since complication rates can be unstable in small studies, synthesis may provide more accurate risk estimates. The purpose of this review was to assess the complications associated with the treatment of distal radius fractures in elderly patients through a systematic review and meta-analysis of the literature. A systematic review of the literature was conducted using the PubMed, Medline, and Cochrane databases to search for studies that satisfied predetermined inclusion and exclusion criteria. We compared the complications associated with each specified DRF treatment option. A validated complication checklist was used to grade the severity of each reported complication. The Structured Effectiveness Quality Evaluation Scale (SEQES) and the Sackett level of evidence scale was used to critically appraise the included studies. We identified 1,229 articles in the primary search, and 33 studies for full text evaluation. Based on our inclusion/exclusion criteria 20 studies were included for analysis. Sackett level of evidence (LOE) studies included were: 3 level one, 6 level two, 2 level three and 9 level four studies. There were 6 randomized control trials, 3 prospective cohorts, 2 case controls and 9 retrospective case series studies identified. The incidence of complications (i.e. requiring intervention) was significantly higher in the operative group (129/1095, 11.8%) versus the non-operative group (40/483, 8.3%) (P = 0.008). External fixation (51/227, 22.5%) had significantly higher complication rates when compared to other fixation methods except dorsal plating (3/15, 20%). Percutaneous pinning (1/83, 1.2%) had significantly lower major complications compared to volar locked plating (VLP) (14/86, 16.3%). Furthermore, percutaneous pinning (0/83, 0%) had significantly less reoperation rates when compared to the VLP group (11/86, 12.8%) (P = 0.006). •Elderly patients who underwent surgery had higher major complications than those treated conservatively.•Given that complication rates are less with percutaneous pinning than plating, this minimally invasive fixation may have advantages for fixation of fractures in older adults.•With equivocal outcomes shown among different treatment strategies, complication profiles should be considered when making treatment decisions in this population.

Effectiveness of edema management techniques for subacute hand edema: A systematic review

Study DesignSystematic review. IntroductionProlonged hand edema can have detrimental effects on range of motion and function. There is no consensus on how best to manage traumatic subacute edema. This is the first systematic review which examines the clinical effectiveness of edema treatments on hand volume. Purpose of the StudyThe purpose of this systematic review was to examine the evidence of effectiveness of treatments for sub-acute hand edema. MethodsA literature search of AMED, CINAHL, Embase, and OVID MEDLINE (from inception to August 2015) was undertaken. Studies were selected if they met the following inclusion criteria: randomized controlled or controlled trials in adults who have subacute swelling after a recent upper limb musculoskeletal trauma or cerebral vascular attack or after surgery. Two independent assessors rated study quality and risk of bias using the 24-point MacDermid Structured Effectiveness Quality Evaluation Scale (SEQES). ResultsTen studies met the inclusion criteria. Study quality ranged from 23 to 41 out of 48 points on the SEQES. A total of 16 edema interventions were evaluated across the studies. Due to heterogeneity of the patient characteristics, interventions, and outcomes assessed, it was not possible to pool the results from all studies. Therefore, a narrative best evidence synthesis was undertaken. There is low to moderate quality evidence with limited confidence in the effect estimate to support the use of manual edema mobilization methods in conjunction with standard therapy to reduce problematic hand edema. ConclusionManual edema mobilization techniques should be considered in conjunction with conventional therapies, in cases of excessive edema or when the edema has not responded to conventional treatment alone; however, manual edema mobilization is not advocated as a routine intervention. Level of Evidence2b.

Relative motion orthoses in the management of various hand conditions: A scoping review

Study DesignScoping review. IntroductionThe relative motion (RM) concept and immediate controlled active motion (ICAM) program, originally applied after zones IV-VII extensor tendon repairs, have been modified and extended to a variety of hand conditions, such as sagittal band injury, boutonniere deformity, and extensor lag. Purpose of the StudyTo scope the published and unpublished literature to review ICAM modifications, hand conditions for which the RM concept is used, and describe the preferred degree of relative metacarpophalangeal joint extension/flexion reported and spectrum of orthosis design. MethodsElectronic and manual searches of scientific and gray literature and expert consultation were conducted. Documents with quantitative data were assessed with Oxford Levels of Evidence and the Structured Effectiveness Quality Evaluation Scale. ResultsFifteen references met the inclusion criteria; 1 was level III evidence, and others were level IV evidence. RM-ICAM modifications, preferred degree of relative extension/flexion, orthotic design, management of other hand conditions and knowledge gaps were identified. ConclusionRM orthoses may improve outcomes in a variety of hand conditions; however, high-quality studies that contribute to the evidence base for its use are needed. Level of EvidenceNot applicable.

Functional outcomes post-radial head arthroplasty: a systematic review of literature.

The present study was conducted to determine the quality and content of research on the functional outcomes and complications post-metal radial head arthroplasty (RHAP). A comprehensive search of medical databases for studies reporting on functional outcomes of patients undergoing metallic RHAP was conducted. The Structured Effectiveness Quality Evaluation Scale (SEQES) was used to evaluate quality of the studies. We identified 21 Sackett's Level IV studies reporting on 391 radial heads. The mean duration of follow-up was 47.2 months and the mean (SD) age of patients was 48.4 years (6.9 years). The male to female ratio was found to be 1.05 : 1 and the dominant arm was involved in 54% of patients. When functional outcomes achieved post-RHAP were compared with normative scores, the comparison suggested that RHAP has good to excellent functional outcomes in short- to mid-term follow-up. The weighted mean (SD) Mayo Elbow Performance Score was 85.8 (4.1) (95% confidence interval 85.3 to 86.3). Incidences of implant removal (3.06%) and revision (2.22%) were found to be low. There is consistent low-quality evidence of positive functional outcomes following RHAP. The heterogeneity of type of implant, patient characteristics and outcome measures used, along with an inadequate reporting of study details, restrict any definitive conclusions being made.

The effectiveness of early mobilization after tendon transfers in the hand: A systematic review

Study DesignSystematic review. IntroductionOver the past decade, early mobilization (initiated within a week) has become an increasing trend in postoperative rehabilitation after tendon transfer surgery in the hand. However, there are no published reviews summarizing the effectiveness of early mobilization protocols in comparison with conventional immobilization in tendon transfer rehabilitation. PurposeTo systematically review available evidence on the effectiveness of early mobilization protocols to conventional immobilization protocol after tendon transfers in the hand. MethodsA literature search of the Cochrane Library, PubMed, PEDro, EMBASE, and CINAHL databases was conducted (1980 to date). Randomized controlled trials (RCTs), case–control, and other study designs were included. Six articles were eligible for inclusion in the analysis (five RCTs and one retrospective study) and 260 articles that did not meet inclusion criteria were excluded. Level of evidence (Center for Evidence-based Medicine) and methodological quality (Structured Effectiveness Quality Evaluation Scale [SEQES] score) of each study were assessed by two independent reviewers. ResultsThis review found three high quality trials (SEQES score: 35–43 of 48), with level 1b and 2b evidence, supporting early mobilization of tendon transfers. The literature reports reduced total cost, total rehabilitation time, and demonstrates that early mobilization is a safe approach with no incidence of tendon ruptures or insertion pull out. In the initial phase of rehabilitation, outcomes like range of motion, grip strength, pinch strength, total active motion of digits, deformity correction, and tendon transfer integration were significantly superior with early mobilization compared with immobilization. However, in the long term, these outcomes were similar in both the groups, suggesting that early mobilization protocol improves hand function in the initial phase of rehabilitation (four weeks) and the long-term results (two months to one year) are equivalent to immobilization. ConclusionsBased on a limited number of small studies, there is evidence of short-term benefit for early mobilization, but inconclusive findings for longer-term outcomes. Until the body of evidence increases, clinicians should consider the clinical context, their experience in optimizing patient outcomes after surgery, and the patient's preferences when selecting between early and late mobilization after tendon transfer. Level of Evidence2a.

Efficacy of Knee Braces and Foot Orthoses in Conservative Management of Knee Osteoarthritis

A systematic analysis was conducted on the effectiveness of knee braces and foot orthoses in conservative management of knee osteoarthritis. The methodologic quality of the randomized clinical trials, controlled clinical trials, and observational studies were systematically reviewed using the Structured Effectiveness Quality Evaluation Scale. Twenty-five studies met the inclusion criteria. The orthoses used in the studies included Generation II osteoarthritis knee brace, valgus knee braces, functional off-loading knee braces, knee sleeves, lateral-wedged insoles with subtalar strapping, medial-wedged insoles, and specialized footwear. Results suggest that knee braces and foot orthoses are effective in decreasing pain, joint stiffness, and drug dosage. They also improve proprioception, balance, Kellgren/Lawrence grading, and physical function scores in subjects with varus and valgus knee osteoarthritis. Knee braces and foot orthoses could be cautiously considered as conservative management for relief of pain and stiffness and improving physical function for persons with knee osteoarthritis. The conclusions of this review are limited by methodologic considerations like poor quality of trials and heterogeneity of interventions.

Treatment of Acute Scaphoid Fractures: A Systematic Review and Meta-Analysis

The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review and meta-analysis of the literature. Our search yielded 59 articles that met our inclusion criteria with five studies achieving high, 22 moderate, and 32 low Structured Effectiveness Quality Evaluation Scale scores. Pooled results of the four Sackett level 1 evidence studies showed no significant difference between the operative (114/115, 99%) versus non-operative group (106/112, 95%) (p = 0.07) when the definition of nonunion was based on more definitive criterion versus plain radiographs that may be insufficient to assess bony union. Similar results were found for the Sackett level 2 and 4 articles. This systematic review reveals that significant weaknesses exist in the literature with respect to the level of evidence and quality of published studies on this topic. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures.

Treatment of proximal humerus fractures with locking plates: A systematic review

Locking plates with special configuration for the anatomic region of the proximal humerus have been introduced recently to address the difficulties of stabilizing proximal humeral fractures. The purpose of this study was to carry out a systematic review of the literature on the efficacy and early to medium term functional results of locking plates for stabilization of proximal humeral fractures. Using the PubMed database, a systematic review of the English and German literature was carried out in order to assess the efficacy and complications related to the use of these plates and the patients' functional outcome, using the key words "locking plates proximal humeral fractures," "angular stability plates proximal humeral fractures," "PHILOS plate," and "LPHP plate." Our criteria for eligibility were clinical studies with more than ten cases followed-up, adult patients, and adequate data provided at least in terms of implant related complications. Articles written in English and German language were included. Exclusion criteria were: studies dealing exclusively with 2-part fractures (since this category has a more favorable outcome); experimental studies; case reports; and, literature other than English or German. Each one of the articles was evaluated for quality of the study using the Structured Effectiveness Quality Evaluation Scale (SEQES). Twelve studies including 791 patients met the inclusion criteria. Patients in these studies continued to improve up to one year, achieving a mean Constant score of 74.3. The incidence of the reported complications was: avascular necrosis 7.9%, screw cut-out 11.6% and re-operation rate 13.7%. The high incidence of cut-out may be secondary to the rigidity of the implant in combination with medial inadequate support, in cases compromised by severe underlying osteoporotic bone. Definition of indications for the use of locking plates and attention on technical aspects of applying them would help optimization of the results. Systematic Review.

Proximal humeral fractures: A systematic review of treatment modalities

A systematic review was conducted of primary intervention of proximal humeral fracture, which is a common injury with significant morbidity. Keywords of proximal humeral fracture were entered into PubMed and Embase databases. Two evaluators reviewed abstracts from 1985 to 2004 for inclusion and exclusion criteria yielding 66 articles. These articles were evaluated independently for outcomes and quality of evidence using the Structured Effectiveness Quality Evaluation Scale and Sackett's Levels of Evidence. Patient characteristics and outcomes were recorded. The 66 studies included 2155 patients grouped by fracture types according to the Neer classification system. Studies differed by intervention, methods, outcome measures and results. Quality scores averaged 15/48; only 2 articles included randomized groups. Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. Further research comparing primary treatment methods in a properly designed and controlled fashion is required, ideally using randomized controlled trials.

Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review

The purpose of this study was to determine the effectiveness of hand therapy interventions for carpal tunnel syndrome (CTS) based on the best available evidence. A qualitative systematic review was conducted. A literature search using 40 key terms was conducted from the earliest available date to January 2003 using seven databases. Articles were randomly assigned to two of five reviewers and evaluated according to predetermined criteria for inclusion at each of the title, abstract, and article levels. Included studies were independently scored by two reviewers using a structured effectiveness quality evaluation scale and also graded according to Sackett's Levels of Evidence. There were 2027 articles identified from the literature search, of which 345 met the inclusion criteria. Twenty-four studies were used to formulate 30 recommendations. Current evidence demonstrates a significant benefit (grade B recommendations) from splinting, ultrasound, nerve gliding exercises, carpal bone mobilization, magnetic therapy, and yoga for people with CTS.