Journal Article Review, February 2017

How do patients rate forearm replantation vs. prosthesis?

Pet MA et al: Comparison of patient-reported outcomes after traumatic upper extremity amputation: Replantation versus prosthetic rehabilitation. Injury. 2016 Oct 19. [Epub ahead of print]

It is generally understood that patients with amputations through the forearm have better function (task completion, return to work) after replantation than comparable patients with amputation stump closure and prosthetic fitting. What is not known, however, is how patients accept these two treatments with respect to appearance, psychological concerns, and pain.
Great emphasis is presently being made on shared decision making and patient-centric treatment, so viability and function of a replanted part are only two measures of success. Patients, providers, and payers would benefit from an assessment from that patients’ perspective: patient-reported outcomes (PROs).
Investigators at University of Washington, University of Michigan, and Union Memorial Hospital in Baltimore pooled their 20 year experience of managing amputations through the forearm and have provided some answers.
They contacted all patients previously treated for unilateral forearm amputations and asked them to complete DASH and Michigan Hand Questionnaire outcomes measures and asked those with prostheses to describe the type(s) of prostheses used. A total of 187 patients met inclusion criteria, but only 31 could be contacted and agreed to participate.
There were 9 patients in the replantation group and 22 in the prosthetic rehabilitation group. The groups were evenly matched for sex, age at injury, current age, income, race, tobacco use, alcohol abuse, and medical and psychiatric comorbidities. Mean follow-up from time of amputation to completion of the questionnaires was 9.1 years for the replantation group and 10.4 years for the prosthetic group.

Seven of the 9 patients receiving replantation had sustained electric saw injuries, and these were mainly through the distal forearm. The prosthetic group had a wide spectrum of injury mechanisms, and most of the amputations were through the mid-forearm.

Fourteen of the prosthetic patients used body-powered prostheses, nine used myoelectric prostheses, and two used passive prostheses at least some of the time. Nine patients reported using multiple types of prostheses. Five patients had been fitted with prostheses but quit using them because of pain, awkwardness, or expense.

RESULTS:

For the MHQ domains, overall function and patient satisfaction  were significantly better in the replantation group. The MHQ scores for pain, ability to work, and performance of ADLS with two hands were not significantly different between the groups.  The mean DASH scores between the groups were not significantly different.

DISCUSSION:

Limb replantation is an expensive and time consuming endeavor, both for the surgery itself and for the subsequent rehabilitation. In order to recommend it and justify it, not only should the functional results be better, but also the PROs should be better. This study is largest to compare replantation vs. prosthetic fit in a relatively large number of patients with injuries restricted to the forearm. The authors note that the group sizes were different and that the levels of amputation in the forearm were different. None-the-less they conclude that amputations through the forearm should be replanted when possible.

COMMENT:

These injuries are relatively rare, so combining the experience from three large centers was appropriate. The follow-up period was long, which gives a better view of outcome but reduced the number of patients who the investigators could find and query.

This study serves as a baseline for future studies comparing PROs for prostheses, replantation, and transplantation. Another helpful comparison would be studying PROs between patients with body-powered prostheses (the main type used in this study) with modern myoelectric prostheses, which may offer superior function that would result in improved patient-rated outcomes.