Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 4 appraisals
The Cochrane database of systematic reviews
Surgery for thumb (trapeziometacarpal joint) osteoarthritis
RATIONALE: Surgery is used to treat persistent pain and dysfunction due to osteoarthritis at the base of the thumb, when conservative management is no longer effective. This is an update of a Cochrane review first published in 2005. OBJECTIVES: To evaluate the benefits and harms of different surgeries for people with thumb (trapeziometacarpal) osteoarthritis. SEARCH METHODS: We searched CENTRAL, MEDLINE and Embase up to 19 May 2025. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that compared at least two surgical techniques for trapeziometacarpal osteoarthritis. We excluded studies that used non-surgical interventions as the sole comparator (e.g. splinting). OUTCOMES: Pain, physical function, quality of life, patient global assessment, adverse events, treatment failure and trapeziometacarpal joint imaging. RISK OF BIAS: We assessed risk of bias using the Cochrane Risk of bias 1.0 tool (RoB 1). SYNTHESIS METHODS: Two authors screened studies, extracted data, assessed risk of bias, and judged the certainty of evidence using the GRADE criteria. We synthesised effect estimates for both dichotomous (risk ratio (RR) using Mantel-Haenszel method) and continuous outcomes (standardised mean difference (SMD) or MD using the inverse-variance method) using a random-effects meta-analysis model. INCLUDED STUDIES: We included 25 studies with 1591 participants. We identified 11 surgical procedures: trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint implant, arthrodesis, trapeziometacarpal joint replacement, trapeziectomy and haematoma distraction arthroplasty, trapeziectomy with interpositional arthroplasty with allograft, arthroscopic hemitrapeziectomy, and suture tape suspensionplasty. Other than arthrodesis, no studies compared surgeries that did not involve at least partial trapeziectomy (e.g. first carpometacarpal joint denervation). We found no studies with placebo or non-surgical comparators. SYNTHESIS OF RESULTS: More than 90% of the included studies were at high or unclear risk of performance, detection and selective reporting biases. Below, we summarise the evidence for trapeziectomy with LRTI, the most widely utilised technique. We did not summarise single-study comparisons for trapeziectomy with LRTI. Quality of life, patient global assessment and treatment failure were not reported. Pain was measured on a 100-point visual analogue scale (mm); physical function on a relevant scale (typically the Disabilities of the Arm, Shoulder and Hand questionnaire) presented as a mean difference; adverse events as the proportion of participants who experienced any adverse events; trapeziometacarpal joint imaging as the scapho-metacarpal distance at rest reported in mm. Trapeziectomy with LRTI versus trapeziectomy: compared to trapeziectomy, trapeziectomy with LRTI may make little to no difference to pain (MD -2.80 mm, 95% CI -9.82 to 4.21; I2 = 0%; 3 studies, 162 participants), physical function (SMD 0.01, 95% CI -0.70 to 0.72 translated to an MD of 0.03 points (95% CI -1.95 to 1.98); I2 = 19%; 3 studies, 211 participants), adverse events (RR 1.89, 95% CI 0.96 to 3.73; I2 = 0%; 4 studies, 328 participants) or scapho-metacarpal distance (MD -0.10 mm, 95% CI -0.81 to 0.61; 1 study, 42 participants); all low-certainty evidence. Trapeziectomy with LRTI versus trapeziometacarpal joint replacement: we are uncertain of the effects of trapeziectomy with LRTI compared to trapeziometacarpal joint replacement on pain (MD 1.38 cm, 95% CI 0.7 to 2.07; 2 studies, 206 participants) and physical function (MD 12.53, 95% CI 3.71 to 21.35; I2 = 78%; 2 studies, 207 participants); both very low-certainty evidence. There may be little to no difference in adverse events (RR 0.36, 95% CI 0.12 to 1.06; I2 = 0%; 3 studies, 261 participants; low-certainty evidence). Trapeziectomy with LRTI versus haematoma distraction arthroplasty: compared to haematoma distraction arthroplasty, we are uncertain of the effects of trapeziectomy with LRTI on pain (MD 0.34 cm, 95% CI -1.19 to 1.87; I2 = 97%; 2 studies, 172 participants) and physical function (MD 1.96 points, 95% CI -0.40 to 4.32; I2 = 55%; 2 studies, 172 participants); both very low-certainty evidence). LRTI may make little to no difference to adverse events (RR 16.66, 95% CI 0.99 to 279.94; 1 study, 120 participants) or scapho-metacarpal distance (MD 0.0 mm, 95% CI -2.12 to 2.12; 1 study, 120 participants); both low-certainty evidence. Trapeziectomy with LRTI versus trapeziectomy with interpositional arthroplasty: compared to trapeziectomy with interpositional arthroplasty, trapeziectomy with LRTI may slightly reduce pain (MD -0.57cm, 95% CI -1.10 to -0.04; I2 = 0%; 2 studies, 98 participants), and may make little to no difference to adverse events (RR 1.29, 95% CI 0.49 to 3.44; 2 studies, 146 participants) and scapho-metacarpal distance (MD -0.70 mm, 95% CI -1.44 to 0.04; 1 study, 46 participants); all low-certainty evidence. We are uncertain of the effects of trapeziectomy with LRTI on physical function (MD -6.75 points, 95% CI -15.88 to 2.39; I2 = 70%; 2 studies, 98 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: There are no placebo-controlled trials or studies comparing surgery with non-operative treatment. Low-certainty evidence showed that compared to trapeziectomy, trapeziectomy with LRTI for people with thumb osteoarthritis, may result in little to no difference in pain, function or scapho-metacarpal distance. Compared to trapeziectomy with interpositional arthroplasty, trapeziectomy with LRTI may slightly reduce pain. Trapeziectomy with LRTI may make little to no difference to scapho-metacarpal distance compared to haematoma distraction arthroplasty or trapeziectomy with interpositional arthroplasty. Very low-certainty evidence showed that we are uncertain of the effects of trapeziectomy with LRTI on pain and function compared to trapeziometacarpal joint replacement or haematoma distraction arthroplasty. We are uncertain of the effects of trapeziectomy with LRTI on function compared to trapeziectomy with interpositional arthroplasty. Overall, low-certainty evidence showed that trapeziectomy with LRTI may make little to no difference to adverse events. Low- to very low-certainty evidence from small studies limits our ability to draw conclusions on the benefits and harms of surgical procedures for thumb osteoarthritis. FUNDING: None. REGISTRATION: Protocol (2004) DOI: 10.1002/14651858.CD004631 Original review (2005) DOI: 10.1002/14651858.CD004631.pub2. Review update (2009) DOI: 10.1002/14651858.CD004631.pub3 Review update (2015) DOI: 10.1002/14651858.CD004631.pub4 Review update (2017) DOI: 10.1002/14651858.CD004631.pub5.
30 May 2026
Read appraisal →Medicine
Predicting poor wrist function recovery after internal fixation of distal radius fractures: A retrospective study based on multivariate analysis and machine learning models
This study aimed to identify independent risk factors associated with poor wrist function recovery 6 months after internal fixation of distal radius fractures (DRF) and develop machine learning models for early risk prediction. This retrospective study included 328 patients who underwent internal fixation for DRF at our hospital between January 2022 and June 2025. Wrist function was evaluated using the Cooney Wrist Score at 6 months postoperatively. Poor recovery was defined as a Cooney score <75. The overall incidence of poor wrist function recovery was 21.56% (71/328). Clinical variables including demographic characteristics, comorbidities, laboratory indicators, fracture type, postoperative pain scores, and rehabilitation compliance were collected. Rehabilitation compliance referred to patients' adherence to prescribed postoperative functional training and follow-up plans. Variables with P <.05 in univariate analysis were entered into multivariate logistic regression to identify independent risk factors. These variables were subsequently used to construct random forest (RF), XGBoost, and backpropagation (BP) neural network models. Model performance was evaluated using ROC curves and classification metrics. Multivariate analysis identified low rehabilitation compliance, age ≥65 years, AO type C fractures, postoperative visual analogue scale scores >3 at 1 week, and decreased serum albumin levels as independent predictors of poor wrist function recovery. Among the machine learning models, the RF model demonstrated the best performance (AUC = 0.939, accuracy = 0.946), followed by the BP neural network (AUC = 0.924). The XGBoost model showed comparatively lower predictive performance (AUC = 0.876). Poor wrist function recovery after internal fixation of DRF is influenced by multiple clinical factors. Machine learning models based on identified independent risk factors, particularly the RF model, show strong predictive ability and may assist clinicians in early risk stratification and individualized rehabilitation planning.
25 May 2026
Read appraisal →PloS one
A remote monitoring system based on deep learning for real-time assessment of free flaps
PURPOSE: Venous congestion is a major cause of postoperative free flap compromise, and early detection is crucial for improving flap salvage rates and patient outcomes. This study aimed to develop and validate a deep learning (DL)-integrated remote monitoring system with a smartphone application for real-time, quantitative assessment of free flaps, with a specific focus on the early detection of venous congestion. METHODS: This diagnostic study was conducted at our institution. Patients aged 18-60 years who underwent free flap reconstruction between January 2019 and June 2025 were included. The study was divided into three phases: a 5-month model training phase for DL model development and internal validation, a 5-month external validation and clinical application phase, and a 4-month clinical comparison phase. The DL model was developed using TensorFlow Lite and a Flap Segmentation Network (FS-Net). Performance was evaluated through accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and clinical outcomes including time to detection and flap survival. RESULTS: A total of 1649 photographs from 615 patients were analyzed in the development and validation of the DL classification model between January 2019 and February 2025. During model development, the model achieved an accuracy of 86.8%, sensitivity of 92.4%, specificity of 79.7%, and AUC of 0.88. Internal validation improved these metrics to 87.6%, 95.0%, 81.1%, and 0.92, respectively. External validation demonstrated the model's generalizability, with an accuracy of 89.3%, sensitivity of 96.2%, specificity of 84.9%, and AUC of 0.93. The clinical application phase showed that the system had an overall accuracy of 92.16%, sensitivity of 95.18%, false-positive rate of 2.62%, and false-negative rate of 4.82%. A total of 113 patients were included in clinical comparison between March 2025 and June 2025. The remote monitoring group exhibited a trend towards a shorter mean time to congestion detection, higher flap survival rate, and shorter mean time to re-exploration, although these differences were not statistically significant. CONCLUSIONS: The DL-integrated remote monitoring system demonstrated high accuracy and reliability in detecting venous congestion. It provided an objective and real-time tool that may help reduce clinical burden and support timely intervention in free flap management. However, its impact on definitive clinical outcomes required further validation in larger studies.
13 May 2026
Read appraisal →JBJS reviews
Treatment Outcomes for Distal Radius Fractures: A Meta-Analysis
BACKGROUND: Distal radius fractures (DRFs) are among the most prevalent in upper-extremity injuries, particularly in older adults and individuals with osteoporosis. The common treatment options include surgical interventions such as volar locking plate (VLP) fixation and percutaneous pinning, as well as conservative strategies like splinting and bracing. However, the comparative effectiveness of these modalities remains unclear. This study aims to compare the functional outcomes and complication rates associated with VLP, percutaneous pinning, bracing, and splinting in the treatment of DRFs. METHODS: A systematic search of PubMed, Google Scholar, and the Cochrane Library (September 2001-February 2025) identified randomized controlled trials, prospective cohort studies, and retrospective cohort studies comparing DRF treatments. Functional outcomes and complication rates (superficial infection, malunion, nonunion, delayed union) were analyzed. Data were analyzed using Review Manager Web with significance set at p ≤ 0.05. RESULTS: Twenty-seven studies involving 3,200 patients met inclusion criteria: VLP fixation (n = 896), percutaneous pinning (n = 666), splinting (n = 718), and bracing (n = 903). No significant differences were observed between VLP and splinting or between bracing and splinting for Disabilities of the Arm, Shoulder, and Hand (DASH); Patient-Rated Wrist Evaluation (PRWE); or grip strength. Compared with VLP, percutaneous pinning demonstrated better PRWE scores but a higher infection rate. Compared with bracing, percutaneous pinning showed significantly better DASH, PRWE, and grip strength outcomes, although with substantial heterogeneity. Compared with bracing, VLP fixation yielded significantly better DASH, PRWE, and grip strength outcomes and a lower malunion rate. CONCLUSION: All 4 treatments achieved acceptable outcomes, but with key trade-offs: Percutaneous Pinning had the best functional results but a higher infection risk. VLP provided better function and lower malunion rates than bracing. Splinting and bracing were effective conservative options, often yielding results similar to VLP, but were inferior in some specific measures. The findings suggest that a perfect anatomic repair is not always necessary for a good recovery. Ultimately, the choice of treatment must be individualized, weighing the functional benefits against the risks of complications, while considering patient health factors and preferences. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
8 Apr 2026
Read appraisal →