Plastic and Reconstructive Surgery • September 2014

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Fig. 1. We can ligate the artery on the opposite side of the digit, mobilize the arch, and
make a transfer for anastomosis to the distal amputated artery (arrows, ligation).

replantation attempt because of the long ischemic
time and should remain optimistic regarding the
outcome.
DOI: 10.1097/PRS.0000000000000444
Yi Poon, M.D.
Department of Plastic Surgery
Changhua Christian Hospital
Changhua, Taiwan
Ching-Yueh Wei, M.D.
Department of Plastic Surgery
Cheng Ching General Hospital
Taichung, Taiwan
Correspondence to Dr. Wei
No. 139, Ping Tien Street
Taichung, Taiwan
ufaf0205@pchome.com.tw
ACKNOWLEDGMENT
The authors gratefully thank Nathan Wei for assistance
with editing this communication.
DISCLOSURE
The authors have no financial interest to declare in rela-
tion to the content of this communication.
REFERENCES
1. Jazayeri L, Klausner JQ, Chang J. Distal digital replantation.
Plast Reconstr Surg. 2013;132:1207–1217.
2. Koshima I, Soeda S, Moriguchi T, Higaki H, Miyakawa
S, Yamasaki M. The use of arteriovenous anastomosis for
replantation of the distal phalanx of the fingers. Plast Recon-
str Surg. 1992;89:710–714.
3. Kamei K, Sinokawa Y, Kishibe M. The venocutaneous fis-
tula: A new technique for reducing venous ­congestion
in replanted fingertips. Plast Reconstr Surg. 1997;99:
1771–1774.
4. Koshima I, Yamashita S, Sugiyama N, Ushio S, Tsutsui T,
Nanba Y. Successful delayed venous drainage in 16 con-
secutive distal phalangeal replantations. Plast Reconstr Surg.
2005;115:149–154.
5. Baek SM, Kim SS. Successful digital replantation after 42
hours of warm ischemia. J Reconstr Microsurg. 1992;8:455–458;
discussion 459.
The Quality of Systematic Reviews in Hand
Surgery: An Analysis Using AMSTAR
Sir:
T he strength of systematic reviews relies inherently
on the methodology of the included studies, which
inevitably to attain a high level of evidence must be reli-
able and transparent. We read with great interest a study
conducted by Momeni et al.,1 in which the authors eval-
uated the methodologic quality of systematic reviews in
the hand surgery literature using the validated critical
appraisal tool AMSTAR.2 The authors concluded that
the median AMSTAR overall score of systematic reviews
in the hand surgery literature was 7 of 11, which cor-
responds to a fair to good score. However, we noted
that the study has two major underlying issues. First, the
authors stated that the majority of the evaluated system-
atic reviews provided only a list of included studies, but
none provided a list of excluded studies. The fifth cri-
terion in the AMSTAR tool states that fulfillment of this
criterion requires “a list of included and excluded stud-
ies should be provided.”2 However, the authors stated
that providing solely a list of included studies was suf-
ficient to satisfy this AMSTAR criterion. Modifying the
original criterion of AMSTAR can potentially negatively

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Volume 134, Number 3 • Letters
influence the validity of the AMSTAR tool and thus lead
to misleading results. Second, the last criterion of the
AMSTAR tool, which consists of evaluating conflict of
interest, was reported in 81 percent of the included
systematic reviews. This criterion states that “potential
sources of support should be clearly acknowledged in
both the systematic review and the included studies.”2
However, the authors consider acknowledgment of
source of support in systematic reviews only and not
the included studies. Popovich et al. found that more
than half of Cochrane reviews did not assess conflicts
of interest in their included studies, which resulted in
a downshift of final score.3 Although we acknowledge
this is a difficult criterion to achieve, we feel that this
criterion should not be counted as “yes” if not fully met,
as it could result in a misleadingly high-quality score.
We conducted a pilot systematic search, which
involved a MEDLINE search of all hand surgery sys-
tematic reviews from 2003 to 2013 published in Plastic
and Reconstructive Surgery. The search identified a total
of 90 articles. After screening titles and abstracts, 76
articles were excluded. Eventually, 14 hand surgery sys-
tematic reviews were identified. We applied the same
quality assessment tool, AMSTAR, on these studies,
focusing on the two aforementioned criteria discussed
previously. We found that only 21.4 percent (versus
88.1 percent) of studies provided a list of included and
excluded studies and none of the studies (­versus 81
percent) provided a clear acknowledgment of poten-
tial source of support in the systematic review and the
included studies.
Researchers and clinicians have the responsibil-
ity of providing the highest possible level of evidence,
given the significant implications on clinical and policy
decision-making. When we assess the literature, the aim
is to ensure that the best quality and highest level of evi-
dence is being used. We should avoid overstating any
results, as this could affect the progress of the improve-
ment of quality in our surgical specialty by giving a false
encouraging image. We find that this unjustified modi-
fication of the two AMSTAR criteria has led to inflated
results that may have influenced the final conclusion
of the study in a misleading manner. Although we feel
that these modifications will not help in the improve-
ment of the quality of systematic reviews in the hand
surgery literature, the authors may have a reasonable
justification for modifying these two AMSTAR criteria.
DOI: 10.1097/PRS.0000000000000473
Osama A. Samargandi, M.D., M.H.Sc.
School of Population and Public Health
Faculty of Medicine
University of British Columbia
Vancouver, British Columbia, Canada
Haroon Hasan, B.Sc., M.P.H.
Department of Radiation Oncology
British Columbia Cancer Agency
Vancouver, British Columbia, Canada and
Pediatric Oncology Group of Ontario
Toronto, Ontario, Canada
Correspondence to Dr. Samargandi
School of Population and Public Health
University of British Columbia
2206 East Mall
Vancouver, British Columbia V6T 1Z4, Canada
osama.samargandi@alumni.ubc.ca
DISCLOSURE
The authors have no financial interest to declare in rela-
tion to the content of this communication. This letter did not
require any funding.
REFERENCES
1. Momeni A, Lee GK, Talley JR. The quality of systematic
reviews in hand surgery: An analysis using AMSTAR. Plast
Reconstr Surg. 2013;131:831–837.
2. Shea BJ, Grimshaw JM, Wells GA, et al. Development of
AMSTAR: A measurement tool to assess the methodologi-
cal quality of systematic reviews. BMC Med Res Methodol.
2007;7:10.
3. Popovich I, Windsor B, Jordan V, Showell M, Shea B, Far-
quhar CM. Methodological quality of systematic reviews in
subfertility: A comparison of two different approaches. PLoS
One 2012;7:e50403.
Reply: The Quality of Systematic Reviews in
Hand Surgery: An Analysis Using AMSTAR
Sir:
We thank Samargandi and Hasan for their interest
in our work and appreciate the opportunity to further
clarify our analysis. We agree that “researchers and cli-
nicians have the responsibility of providing the highest
possible level of evidence” and to “ensure that the best
quality and highest level of evidence is being used.”
However, we disagree with their conclusion that we
provided a “false encouraging image” or a “misleading”
conclusion regarding the quality of research within our
specialty.1
The importance of transparent reporting cannot
be overstated and represents a key element of qual-
ity. With respect to criterion 5 (i.e., list of included
and excluded studies), we reported that providing a
list of included studies was deemed sufficient to meet
this criterion. It is true that we deviated from the strict
definition that AMSTAR uses.2 The reader, however,
is informed about this modification in a transparent
manner, thus honoring an important principle of sci-
entific reporting.3 An essential component facilitat-
ing critical appraisal is transparent reporting, and we
feel we have adhered to this principle. We certainly
welcome any discussion of our decision to modify this
criterion, particularly as quality assessment tools, such
as AMSTAR, should not be regarded as static instru-
ments. A constructive discussion regarding design and
content is a prerequisite for improvement of any qual-
ity assessment instrument. AMSTAR is no exception as
it, despite all its strengths, represents an instrument
that was originally designed and tested on systematic
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