1. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Carpal Tunnel Decompression: A Systematic Review and Meta-analysis of Absorbable versus Non-absorbable Sutures for Skin Closure
Ryckie G Wade, Justin CR Wormald, Andrea Figus
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

2. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Introduction
Carpal Tunnel Syndrome is common
Annual incidence: 1-2 per 10 (UK) 1
Surgical decompression
The definitive treatment 2
The most common surgery on the hand 3
72,000 operations annually
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

3. Carpal Tunnel Decompression
Leeds Teaching Hospitals Trust
Carpal Tunnel Decompression
Absorbable
Non-Absorbable
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

4. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Absorbable
Non-Absorbable
Cost of suture = £3.67
Doesn’t require removal
= £0 per annum
“Risk of infection & scarring”
Cost of suture = £2.80
Removal at GP/Hospital
= £3 million annually
“Better scar”
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

5. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Why does this matter?
£3 million annually (£41 per Nurse appointment) 5
3750 cataract operations (£800)
1000 total hip replacements (£3k)
300 CABGs (£10k)
100 kidney transplants (£30k)
Complications are rare 6
Telephone follow-up
Adverse events managed de-novo
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

6. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Methods
Eligibility = RCTs and quasi-RCTs of adult elective CTD comparing absorbable vs. non-absorbable sutures
Exclusion:
Children
Simultaneous other surgery
Revision surgery
Outcomes:
1o = pain (VAS)
2o = hand function, scar satisfaction and complications
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

7. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Methods: Search
Information Scientist
Search terms
P = carpal tunnel syndrome
I = absorbable sutures
C = non-absorbable sutures
O = pain
S = randomised controlled trial
Electronic database searches (Jan May 2015)
Cochrane Library, CENTRAL, MEDLINE, EMBASE, USNIH Clinical Trials Registry, ClinicalTrials.gov, WHO Clinical Trials Registry Portal, Reference tracing
Here are our search terms according to the PICOS model
Relevant databases, grey literature, unpublished works and reference tracking
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

8. Methods: Study Selection
Leeds Teaching Hospitals Trust
Methods: Study Selection
Two independent authors (RGW, JCRW):
Title & abstract screening
Duplicate removal
Full article  In/Out form
Discussion
PRIMSA flowchart
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

9. Methods: Data Extraction
Leeds Teaching Hospitals Trust
Methods: Data Extraction
Double independent data extraction (RGW, JCRW)
Missing data actions (RGW, JCRW)
Independent risk of bias assessments (RGW, JCRW, AF)
Ris of bias – internal (rigor) and external validity
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

10. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Results
Article
Random-isation
Allocation
Blinding
Data
Selective
Other
Erel (2001)
Hansen (2009)
Kharwadkar (2005)
Menosky (2004)
Theopold (2012)
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

11. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Results
Article
Intervention
Summary Risk of Bias
Erel (2001)
32 absorbable
32 non-absorbable
High risk
Hansen (2009)
25 absorbable
17 non-absorbable
Kharwadkar (2005)
18 absorbable
18 non-absorbable
Low risk
Menosky (2004)
28 absorbable
26 non-absorbable
Theopold (2012)
20 non-absorbable
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

12. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Results
Postoperative Pain at 10 days
Favours Absorbable sutures
Favours non-absorbable sutures
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

13. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Results
Postoperative Pain at 6 weeks
Favours Absorbable sutures
Favours non-absorbable sutures
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

14. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Results
Wound inflammation at 10 days
Favours Absorbable sutures
Favours non-absorbable sutures
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

15. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Conclusions
Larger, better designed, executed and reported non-inferiority RCTs required
Cost utility analysis
Use absorbable sutures
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

16. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
References
Latinovic, R., Gulliford, M. C. & Hughes, R. A. C. Incidence of common compressive neuropathies in primary care. J. Neurol. Neurosurg. Psychiatry 77, 263–5 (2006).
Verdugo, R., Salinas, R., Castillo, J. & Cea, J. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst. Rev. (2002).
Wildin, C., Dias, J. J., Heras-Palou, C., Bradley, M. J. & Burke, F. D. Trends in elective hand surgery referrals from primary care. Ann R Coll Surg Engl 88, 543–546 (2006).
Cochrane handbook for Systematic Reviews of Interventions v5.1.0 (2011) Available at
Unit Costs of Health and Social Care. PSSRU 2016;171–92. Available from: pages/unit-costs/2014/
Williams M, Amin A, Getgood A, Hallam P, Chojnowski AJ, Chapman PG. Telephone clinic follow-up following carpal tunnel decompression. J Hand Surg Eur Vol [Internet]. 2008;33(5):641–4.
With thanks to Dr Ruth Brassington and co-editors of the NIHR and MRC funded Centre for Neuromuscular Disease), and Professors Richard Wormald and Felix Freshwater for their peer reviews
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)

17. Wade RG, et al. Cochrane Database of Systematic Reviews (2016)
Leeds Teaching Hospitals Trust
Questions?
Wade RG, et al. Cochrane Database of Systematic Reviews (2016)