Challenges in Measuring Outcomes Following Digital Replantation

Abstract

A right-handed 20-year-old construction worker sustained a crush amputation of his right middle finger at work. He has no other associated injuries and is in good health. He was seen at the hospital 1 hour after his injury and underwent a successful replantation procedure. He eventually developed a stiff insensate digit, which prevented him from returning to work. One year later and following two secondary procedures, much therapy, and use of significant health care resources, he still had not returned to work. Eventually, he underwent a ray amputation of the digit. Although the replantation was successful, it worsened the patient's existing function.The common tendency to equate digit survival with success is erroneous. Success must be measured in terms of the contribution of the replanted digit to subsequent overall performance of the patient.1 Mortality in digital replantation is rarely an issue, so the end result of the interventions should be functional gain. 2 In the presented case, success is attained at the cost of the patient's functional outcome. In today's consumer-driven medical environment, patients and payers demand reliable data that can help them make informed medical decisions that lead to cost-effective medical practices. The literature regarding digital replantation surgery is full of personal case series and anecdotal experience, which is no longer an acceptable platform for making medical decisions. Patients want more information not only about surgical outcomes and functional recovery, but also about the delivery of care, psychological and social wellbeing, and the aesthetic appearance.3 Outcomes research provides patients with this information. In this article, we will summarize the challenges in assessing outcomes of digital replantation and suggest measures to improve the reporting of outcomes. Keywords► digital replantation ► outcome of replantation ► research design ► health-related quality of life instruments ► cost effectiveness AbstractIn the early period of replantation surgery, the emphasis was on digit survival. Subsequently, with better microsurgical techniques and instrumentation, the focus has shifted to function and in recent years to consideration of cost-effectiveness. Despite over 40 years of effort in refining digital replantation surgery, a rigorous evaluation of the outcomes of digital replantation has not been performed. This is because of the many confounding variables that influence outcome comparisons. These variables include the mechanism of injury (guillotine, crush, avulsion), the injury itself (total, near total, subtotal, partial amputation), and the surgical procedure (replantation, revascularization). In addition, the traditional outcome measures (two-point discrimination, range of motion, grip strength, or the ability to return to work) are reported inconsistently and vary widely among publications. All these factors make meaningful comparison of outcomes difficult. The recent emphasis on outcome research and cost-effectiveness necessitates a rethinking in t...

Long-term functional, subjective and psychological results after single digit replantation

“… 1 However, several discrepancies can be observed between subjective satisfaction and objective results, including the range of motion of digits, sense perception, and power of the hand. To date, a rigorous and comprehensive evaluation system of the functional outcomes of replantation has not been applied and accepted widely 2 because many confounding variables affect the comparison of functional outcomes, such as the mechanism of injury (guillotine, crush, and avulsion), types of amputation (total or partial), different injured digits or multiple-digit amputation (thumb or index, middle, ring, or little finger), different planes of amputation, and different evaluation methods.…”

“…Sebastin et al 2 summarised the challenges in assessing the outcomes of digital replantation and advised that the comprehensive evaluation of the hand function should include objective assessments, health-related quality of life, and psychological status. Truly successful replantation is achieved when the mind and body of the patient return to a functional state.…”

Trans-metacarpal hand replantation – case report

“…Long-term outcomes can be estimated based on HISS or Tamai classification [11,12]. They can be applied to predict the probability of going back to work after severe hand trauma.…”

Reporting Outcomes and Outcome Measures in Digital Replantation: A Systematic Review

“…Although a complete list of outcomes and respective outcome measures has not yet been compiled, the heterogeneity of these items has been identified as problematic. 2,3 The variability in outcome measurement and reporting in the digital replantation literature is, most likely, because of the number of confounding variables that can influence the success of replantation. 2 Although these extraneous factors can make drawing conclusions about replantation success a challenge, the subjective and inconsistent reporting of outcomes and outcome measures further complicates this task.…”

“…Additionally, multiple discrepant measures for the same outcome (e.g., two-point discrimination vs. monofilament testing for sensation) are being used to assess interventions. 3 This lack of regulation results in a variety of outcomes and outcome measures across the replantation literature. This heterogeneity introduces biases, impedes clinical decision-making, and obstructs the ability to compare results.…”