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ContributorsAdnan PRSICDepartment of Plastic Surgery, Rhode IslandHospital, Providence RI, USA; Division ofPlastic Surgery, The Alpert Medical School,Brown University, Providence RI, USA.adnan prsic@brown.eduPratik RASTOGIDepartment of Hand Surgery & Peripheral NerveSurgery, Royal North Shore Hospital, The Children’sHospital at Westmead, University of Sydney,Sydney, Australia.pratikrastogi88@gmail.comJeremy N. RODRIGUESNIHR Academic Clinical Fellow inPlastic Surgery, Nuffield Departmentof Orthopaedics, Rheumatology andMusculoskeletal Sciences (NDORMS),University of Oxford, UK.j.n.rodrigues@doctors.org.ukRobert SAVAGEConsultant Orthopaedic andHand Surgeon, Newport, UK.robsavager@gmail.comXXIV

David SHEWRINGConsultant Hand Surgeon, Cardiff, UK.davidshewring@me.comİlkem Ceren SIĞIRTMAÇHacettepe Üniversitesi, Sağlık BilimleriFakültesi, Ergoterapi Bölümü 06100Samanpazarı/Ankara, Turkey.ilkemceren@hacettepe.edu.trBranavan SIVAKUMARDepartment of Plastic Surgery, GreatOrmond St Hospital for Children, London,United Kingdom; The Portland Hospitalfor Women & Children, London, UK.kim.davies@hje.org.ukGill SMITHDepartment of Plastic Surgery, GreatOrmond St Hospital for Children,London, United Kingdom; ThePortland Hospital for Women &Children, London, UK.gill.smith@gosh.nhs.ukXXV

ContributorsPaul SMITHDepartment of Plastic Surgery, Great Ormond St Hospitalfor Children, London, United Kingdom; The Portland Hospitalfor Women & Children, London, UK.Bishops Wood Hospital, Rickmansworth RoadNorthwood, Middlesex, UK. HA6 2JWpaul@paulsmithfrcs.co.ukFrancisco SOLDADOHospital Sant Joan de Deu. PasseigSant Joan de Deu, 2. 08950 Espluguesde Llobregat, Barcelona, Spain.drsoldado@cirugiamanoinfantil.comDavid A. STEWARDDepartment of Hand Surgery & Peripheral Nerve Surgery,Royal North Shore Hospital, The Children’s Hospital atWestmead, University of Sydney, Sydney, Australia.Sydney Hand Surgery AssociatesSuite 1, Level 4 North Shore Private HospitalWestbourne Street St Leonards NSW 2061, Australia.dave@drdavidstewart.comJose A. SUURMEIJERDepartment of Hand Surgery & Peripheral Nerve Surgery,Royal North Shore Hospital, The Children’s Hospital atWestmead, University of Sydney, Sydney, AustraliaAcute Services Building, Clinical Admin 3ERoyal North Shore HospitalSt Leonards NSW 2065, Sydney, Australia.annelie.suurmeijer@gmail.comXXVI

Jin Bo TANGThe Department of Hand Surgery, HandSurgery Research Center, NantongUniversity, Nantong, Jiangsu, China.jinbotang@yahoo.comKrzysztof A. TOMASZEWSKIDepartment of Anatomy, JagiellonianUniversity Medical College, Krakow, Poland.International Evidence-Based AnatomyWorking Group, Krakow, Poland.krtomaszewski@gmail.comMichael A. TONKINMy postal address is:PO Box 632 Milsons Point 1565Australia.mtonkin@med.usyd.edu.auRyan TRICKETTConsultant Hand Surgeon, Cardiff, UK.ryantrickett@gmail.comXXVII

ContributorsChristianne Van NIEUWENHOVENDepartment of Plastic and Reconstructive Surgery, andHand SurgeryErasmus MC Rotterdam. Postbox 20603000 CB Rotterdam, The Netherlands.cvannieuwenhoven@icloud.comGianni VIRGILIDepartment of Translational Surgery and Medicine,University of Florence, AOUC, Florence, Italy.Alessandro VIVIANIStatistics, Computer Science, Applications "G. Parenti"(DISIA), University of Florence, Florence, Italy.David WARWICKConsultant Hand Surgeon, UniversityHospital Southampton, UK.davidwarwick@handsurgery.co.ukXXVIII

Anna WATSONDepartment of Hand Surgery & Peripheral Nerve Surgery,Royal North Shore Hospital, The Children’s Hospital atWestmead, University of Sydney, Sydney, Australia45/93 Elizabeth Bay Road, Elizabeth Bay,Sydney, NSW, Australia.watson.anna@hotmail.comAdam WATTSConsultant Upper Limb Surgeon, Wrightington Hospital.Visiting Professor, Department of Materials, University ofManchester, UK.James WHITESpeciality Registrar, Northwest Thames Deanery, St Mary’sHospital, Paddington, London, UK.Daniel M.G. WINSONSpecialist Registrar in Trauma &Orthopaedic Surgery, Cardiff, UK.danwinson@doctors.org.ukXXIX

ContributorsTakae YOSHIZUNiigata Hand Surgery Foundation,Suwayama 997, Seiro-machi, Niigata957-0117, Japan.home@tenogeka.comAndrzej ŻYLUKDepartment of General and Hand SurgeryPomeranian Medical University in Szczecin, Poland.71-252 Szczecin, ul. Unii Lubelskiej, Poland.zyluk@hotmail.comXXX

FOREWORDThis FESSH instructional course book is unique amongstFESSH instructional books in concentrating on EvidenceBased Medicine through systematic reviews. It was conceived by Zsolt Szabo the Chairman of the 2017 FESSH organising committee. We were asked to chair the instructional courseand edit the instructional book. A systematic review of every topicin Hand Surgery was plainly impossible. We have commissioneda range of topics outlining Evidence Based Medicine and how itworks, and a range of Elective and Trauma topics in Hand surgery. We have tried to cover a broad range of subjects. Not everyone who was approached could deliver their work in time so thereare common conditions that we treat which we have not covered.This was inevitable given how much work there is in writing asystematic review especially in some parts of Hand Surgery wherethere is extensive published literature. In other sections there isvery little published work making the chapters rather sparse. Thatreflects the work we as Hand Surgeons need to do, not the workof the authors.Editing the chapters has been very instructive. Some have confirmed what we already know. Others have challenged our beliefsusually showing that what we believed we knew is not so clear-cut.For a few sub-topics we can be clear we have achieved a reasonablydefinitive position, e.g. endoscopic carpal tunnel release does notgive better results than open surgery; in most we have highlightedhow little we know. This may seem a disappointment and in someways it is; many dedicated, often brilliant, surgeons, therapists andXXXI

Forewordothers have worked incredibly hard to advance our speciality, butwhat we know definitively is surprisingly small. Science moves onand what was good science 20 or more years ago is often (but notalways) inadequate. It is important that we highlight this ratherthan perpetuating errors.That does not mean that what we are doing is wrong (althoughsometimes it will be), but that we cannot be sure enough that whatwe are doing is right. We hope this work, combined with othersystematic reviews and Cochrane reviews will provide a basis fromwhich to develop our speciality along more scientific lines to tryto ensure what we do is right. Read these chapters, learn what weknow and where you see what we do not know set out to answerthose many questions. However young you are you will still haveplenty of work left to complete by the end of your career.We want this work available to anyone working to advancethe care of patients with hand problems. This electronic book willbe given to everyone attending the FESSH meeting in Budapestand can be distributed widely from there to help all clinicians andscientists in interested in advancing Hand care through EvidenceBased Medicine.We have been honoured to do this work for FESSH. We are tremendously grateful to the editors and authors of the chapters whohave done an enormous amount of work to produce this book.We hope we have made a small contribution to the advancementof Hand Surgery by throwing some light on what we know andespecially on what we do not know.Grey Giddins, Bath, UKGürsel Leblebicioğlu, Ankara, TurkeyXXXII

1CHAPTERGENERAL TOPICS

1. GENERAL TOPICS2

1.1 Basic ConceptsGürsel LEBLEBİCİOĞLUEgemen AYHANCorresponding AuthorGürsel LEBLEBİCİOĞLUProfessor of Orthopaedic Surgery and TraumatologyWilly Brandt Sokak ¾, Çankaya, Ankara, Turkey. 06680gurselleblebicioglu@yandex.comIntroductionWhy do we read? Any of us will answer this question similarly: Iam curious, I am looking for answers, or I am working on a research project. But, how much do you read per patient? Seconds,or minutes? What do you read? Textbooks, or journals?Traditionally, if our clinical experience is sufficient to solve theproblem of the patient, we used to rely on that only. If we are notsufficiently experienced, acting upon the well-known motto -medical teaching is a kind of master and apprentice model-, our nextstep may be to consult an expert. Finally, we read textbooks andmedical journals. However, these are conflicted: as we grow older,our experience expands but our up-to-date knowledge weakens;the research evidence behind our (or the expert’s) treatment weakens; and it is not possible to keep up with all the published knowledge even in hand surgery. We all need an easily available sourceof valid, up-to-date information in a short time.This has led to emergence of “evidence-based medicine” (EBM)leading to a paradigm shift in medicine, trivializing the expertopinion and case studies and emphasizing randomized clinical trials and systemic researches (Hoppe and Bhandari, 2008).3

1. GENERAL TOPICSSUBTOPICSHistory and Evolution of Evidence-Based MedicinePractice of EBM Asking a Focused Question Finding the Best Evidence Critical Appraisal of the Evidence Integration of the best evidence with clinical expertise and patient values Self-evaluation (of the previous steps)PRISMA MethodologyIndustrial ConsiderationsHistory and Evolution of Evidence-Based MedicineIn the early 1980s, as the seeds of the paradigm shift, Dr. DavidSackett used the term “critical appraisal” to describe the systematic examination of the medical literature to extract best evidenceat McMaster University (Hoppe and Bhandari, 2008; Sackett etal., 2000). In 1992 the term Evidence Based Medicine (EBM) wasused to describe a new approach to medical practice, by a groupled by Gordon Guyatt (Guyatt et al., 1992). The Oxford Centrefor Evidence-Based Medicine (CEBM) was established in 1995 bythe efforts of Dr. Muir Gray, who invited Dr. David Sackett to bedirector of CEBM. The CEBM is now an internationally renownednot-for-profit organization for practice, teaching and dissemination of high quality evidence based medicine to improve healthcarein everyday clinical practice. In 1996, Sackett et al., (1996) defined EBM:“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisionsabout the care of individual patients.” The same year, Haynes et al(1996) described the “conscientious use” phrase as the evidence isapplied consistently to each patient for whom it is relevant. Theydescribed the “judicious use” phrase as the clinical application tothe patient’s unique clinical circumstances and preferences. Theseconcepts were schematized (Figure 1).4

Figure 1Clinical expertiseResearchevidencePatientpreferencesIn 2000, Sackett et al., refined their definition: “EBM is the integration of current best research evidence with clinical expertiseand patient values.” Based on this revised definition, Haynes et al.,(2002) offered an advanced diagram for evidence-based decisions(Fig 2). As an alternative definition of EBM, Trisha Greenhalghand Anna Donald pointed to the use of mathematics for an evidence-based approach (Greenhalgh, 2014): “Evidence based medicine is the use of mathematical estimates of the risk of benefit andharm, derived from high-quality research on population samples,to inform clinical decision-making in the diagnosis, investigationor management of individual patients.”Figure 2Clinical state and circumstancesClinical statesand circumstancesClinical expertisePatient preferencesand actionsResearch evidence5

1. GENERAL TOPICSThe Cochrane library is one of the most important results of theparadigm shift to evidence-based medicine (Sheridan and Julian,2016). The Cochrane Centre was established in 1992 under themanagement of Iain Chalmers (Chalmers et al., 1992). It originated from Archie Cochrane’s idea about the value of randomized controlled trials in improving the UK National Health Service (NHS) (Cochrane, 1972). It is an independent, international,non-profit scientific organization, consisting of more than 37,000volunteers over 130 countries (Cochrane, 2016). The contributors work together to prepare over 400 systematic reviews of randomized controlled trials a year along strict guidelines. They arepublished in the Cochrane Library (The Cochrane Library Oversight Committee, 2012). Some authors claim that Cochrane andevidence-based approach is not as ideal as is suggested (Sheridanand Julian, 2016). A major criticism since the introduction of theevidence-based approach is the decline of original science research(Sheridan and Julian, 2016). Because evidence-based approach isbased on comparative research, it is criticized as being evaluationof what is known. Original science, which explores what is unknown, seems to lose its importance. Moreover, relegation of clinical judgment and over-reliance on the reliability of clinical trialsand statistics, are other criticisms for EBM (Sheridan and Julian,2016).It is now widely accepted that the evidence-based decisions depend on three critical elements: clinical state and circumstances;patient preferences and actions; and research evidence, integratedby clinical expertise (Haynes et al., 2002; Tilburt, 2008). The clinical state and circumstances are of paramount importance, becausea patient with chest pain admitted to a primary care center or atertiary care center will face different approaches to diagnosis ortreatment. Patient preferences that may affect their choices includetheir wish and ability to cooperate with treatment, their toleranceof risk, personal beliefs and even health care insurance. Like thetraditional approach, the EBM paradigm assumes that clinical experience and the development of clinical instincts are crucial elements of physician competence. Overall EBM has two important6

characteristics: the definition of the problem of the unique patient;and the selection of the best diagnostic and treatment options forthat unique patient.The paradigm shift affected all of the medical disciplines andthe evidence-based medicine term became a popular icon. In arecent analysis of four major hand surgery journals, Mei et al.,(2016) reported a 2.1-fold increase in the number of publishedarticles each year between 2005 and 2014. Although a tendencytowards randomized controlled trials is appearing in recent years,hand surgery has fallen behind other medical fields in being evidence based; most of the evidence in hand surgery is level III - IVstudies (Hammert et al., 2013; Post et al., 2014).Practice of EBMEBM is a structured approach with five discrete steps (Sackett etal., 2000):Step 1: Convert the problem (information needed) into a focusedquestionStep 2: Find the best evidence to answer that question (explore theliterature)Step 3: Critically appraise that evidence for its validity and applicabilityStep 4: Integrate the results with clinical expertise, patient valuesand circumstances, and apply the results in clinical practiceStep 5: Evaluate the efficiency of all of the steps to improve themfor the next timeAsking a Focused Question (O’Keefe et al., 2013; Szabo andMacDermid, 2009)This is the groundwork for EBM. Clinical expertise is necessaryto define the specific question. An erroneous question will wastetime and effort and lead to the wrong answer. A focused and answerable clinical question facilitates the task of finding the bestevidence. This is most easily done with the PICO(T) approach.7

1. GENERAL TOPICS“P” describes the patient/population characteristics. The characteristic must be specified. This may be the disease, their age,their gender or some key prognostic feature e.g. a 35-year-old basketball player with an extraarticular radius distal fracture.“I” describes the intervention (diagnostic test, medication, surgical treatment) that might potentially be used.“C” describes the comparison i.e. compared with nonsurgicaltreatment“O” describes the outcome of interest e.g. resolution of pain orincreased movement. Patient priorities must be considered carefully.“T” refers to time. “T” can be added to the acronym becauseoutcomes are often time-dependent e.g. early return to work.Finding the Best EvidenceAs noted above the traditional paper based repositories of knowledge e.g. textbooks, or journal articles are already out of date bythe time they are published (Haynes et al., 2002) and are frequently biased, relying on expert opinion (Tilburt, 2008), and there aretoo many publications for any individual to assess thoroughly(Hoppe and Bhandari, 2008).Critical Appraisal of the Evidence (Karlsson et al., 2011; MacDermid et al., 2009; O’Keefe et al., 2013; Sackett et al., 2000; Szaboand MacDermid, 2009)The highest quality evidence that applies to a given clinicalquestion is sought. The question is “What is a high level study?” Ahigh level study comprises five components (Groves, 2010):Eligibility High level studies need to design strict and clearly outlined inclusion and exclusion criteria in order to gain homogeneity andto minimize confounding factors. But, to recruit enough number of eligible patients will be difficult. Rarity of the subject (e.g. brachial plexus surgery) is another obstacle to recruit sufficient number of patients for a high level study.8

Number of subjects In order to detect subtle differences the study population mustbe sufficient. The sample size required can be calculated statistically in the beginning of the study. The risk of losing follow-upof the patients must be kept in mind.Follow-up time Patients must be followed for an adequate time period to observe the outcome. Any patients that are lost to follow-up mustbe recorded. But, long follow-up periods are needed for manyinterventions of the hand surgery. This may be longer than asurgeon’s life.Generalizability The external validity (i.e., generalizability) of the study must bestrong. It describes the applicability of the study findings to other patients. The individual patient characteristics play importantrole for the outcomes, and those mu

Visiting Professor University of Bath Editor-in-Chief Journal of Hand Surgery (European) (2012 -2016) President of the British Society for Surgery of the Hand The Hayes Newton St Loe Bath BA2 9BU 07828 149967 The Hand to Elbow Clinic 29a James St West Bath BA1 2BT 01225 316895 greygiddins@thehandclinic.co.uk Gürsel LEBLEBİCİOĞLU Professor of Orthopaedic Surgery and Traumatology Council .