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Figure 1
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Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.1 Change in sensory score after one year.
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Figure 2

Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.1 Change in sensory score after one year.

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Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.2 Proportion of ulnar nerves with sensory improvement after one year.
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Figure 3

Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.2 Proportion of ulnar nerves with sensory improvement after one year.

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Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.3 Change in motor score after one year.
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Figure 4

Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.3 Change in motor score after one year.

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Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.4 Proportion of ulnar nerves with motor improvement after one year.
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Figure 5

Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.4 Proportion of ulnar nerves with motor improvement after one year.

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Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.5 Change in sensory score after two years.
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Figure 6

Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.5 Change in sensory score after two years.

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Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.6 Change in motor score after two years.
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Figure 7

Forest plot of comparison: 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, outcome: 1.6 Change in motor score after two years.

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Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 1 Change in sensory score after one year.
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Analysis 1.1

Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 1 Change in sensory score after one year.

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Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 2 Proportion of ulnar nerves with sensory improvement after one year.
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Analysis 1.2

Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 2 Proportion of ulnar nerves with sensory improvement after one year.

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Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 3 Change in motor score after one year.
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Analysis 1.3

Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 3 Change in motor score after one year.

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Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 4 Proportion of ulnar nerves with motor improvement after one year.
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Analysis 1.4

Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 4 Proportion of ulnar nerves with motor improvement after one year.

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Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 5 Change in sensory score after two years.
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Analysis 1.5

Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 5 Change in sensory score after two years.

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Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 6 Change in motor score after two years.
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Analysis 1.6

Comparison 1 Medial epicondylectomy plus oral steroids versus oral steroids alone, Outcome 6 Change in motor score after two years.

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Study

Surgery plus oral steroid group

Steroid alone group

Test

Outcome

Boucher 1999

25% median improvement

20% median improvement

Tukey box plot test

No significant difference at 5% level

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Analysis 2.1

Comparison 2 Longitudinal epineurotomy plus oral steroids versus oral steroids alone, Outcome 1 Median sensory improvement after two years.

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Study

Surgery plus oral steroid group

Steroid alone group

Test

Outcome

Boucher 1999

30% median improvement

20% median improvement

Tukey box plot test

No significant difference at 5% level

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Analysis 2.2

Comparison 2 Longitudinal epineurotomy plus oral steroids versus oral steroids alone, Outcome 2 Median motor improvement after two years.

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Study

Surgery plus oral steroid group

Steroid alone group

Test

Outcome

Boucher 1999

11% median improvement

0% median improvement

Tukey box plot test

Significant difference at 5% level

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Analysis 2.3

Comparison 2 Longitudinal epineurotomy plus oral steroids versus oral steroids alone, Outcome 3 Median improvement in nerve pain and tenderness after two years.

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Summary of findings for the main comparison. Medial epicondylectomy plus oral steroids versus oral steroids alone for treating nerve damage in leprosy

Medial epicondylectomy plus oral steroids versus oral steroids alone for treating nerve damage in leprosy

Patient or population: patients with nerve damage in leprosy
Settings: hospital
Intervention: medial epicondylectomy plus oral steroids versus oral steroids alone

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

medial epicondylectomy plus oral steroids versus oral steroids alone

Change in sensory score after one year

The mean change in sensory score after one year ranged across control groups from
0.06‐3.94 points

The mean change in sensory score after one year in the intervention groups was
0.08 higher
(2.45 lower to 2.61 higher)

57
(1 study)

⊕⊝⊝⊝
very low1,2,3

Proportion of ulnar nerves with sensory improvement after one year

516 per 1000

578 per 1000
(366 to 913)

RR 1.12
(0.71 to 1.77)

62
(1 study)

⊕⊝⊝⊝
very low1,2,3

Change in motor score after one year

The mean change in motor score after one year ranged across control groups from
0.21‐4.31 points

The mean change in motor score after one year in the intervention groups was
0.82 higher
(1.34 lower to 2.98 higher)

57
(1 study)

⊕⊝⊝⊝
very low1,2,3

Proportion of ulnar nerves with motor improvement after one year

710 per 1000

646 per 1000
(454 to 909)

RR 0.91
(0.64 to 1.28)

62
(1 study)

⊕⊝⊝⊝
very low1,2,3

Change in sensory score after two years

The mean change in sensory score after two years ranged across control groups from
0.73‐5.09 points

The mean change in sensory score after two years in the intervention groups was
0.02 lower
(2.82 lower to 2.78 higher)

57
(1 study)

⊕⊝⊝⊝
very low1,2,3

Change in motor score after two years

The mean change in motor score after two years ranged across control groups from
0.49‐4.65 points

The mean change in motor score after two years in the intervention groups was
0.22 higher
(2.39 lower to 2.83 higher)

57
(1 study)

⊕⊝⊝⊝
very low1,2,3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Randomisation by alternation. Blinding of patients and clinicians not possible; blinding of outcome assessor not reported. 17% loss to follow‐up of nerves; no intention to treat analysis was performed.
2 Data from only one trial available.
3 No separate analysis was done using only one independent outcome from each patient (results from a patient contributing outcomes from more than one nerve will be treated, in the analysis, as having more weight as a patient contributing only one nerve).

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Summary of findings for the main comparison. Medial epicondylectomy plus oral steroids versus oral steroids alone for treating nerve damage in leprosy
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Comparison 1. Medial epicondylectomy plus oral steroids versus oral steroids alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Change in sensory score after one year Show forest plot

1

57

Mean Difference (IV, Fixed, 95% CI)

0.08 [‐2.45, 2.61]

2 Proportion of ulnar nerves with sensory improvement after one year Show forest plot

1

62

Risk Ratio (M‐H, Fixed, 95% CI)

1.13 [0.71, 1.77]

3 Change in motor score after one year Show forest plot

1

57

Mean Difference (IV, Fixed, 95% CI)

0.82 [‐1.34, 2.98]

4 Proportion of ulnar nerves with motor improvement after one year Show forest plot

1

62

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.64, 1.28]

5 Change in sensory score after two years Show forest plot

1

57

Mean Difference (IV, Fixed, 95% CI)

‐0.02 [‐2.82, 2.78]

6 Change in motor score after two years Show forest plot

1

57

Mean Difference (IV, Fixed, 95% CI)

0.22 [‐2.39, 2.83]
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Comparison 1. Medial epicondylectomy plus oral steroids versus oral steroids alone
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Comparison 2. Longitudinal epineurotomy plus oral steroids versus oral steroids alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Median sensory improvement after two years Show forest plot

Other data

No numeric data

2 Median motor improvement after two years Show forest plot

Other data

No numeric data

3 Median improvement in nerve pain and tenderness after two years Show forest plot

Other data

No numeric data
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Comparison 2. Longitudinal epineurotomy plus oral steroids versus oral steroids alone
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