Journal Club Article, February 2019

February, 2019

Does toe-to-hand transfer impair foot function? The patient’s perspective.

Tsai TY et al: Patient Reported Outcome Measures for Toe-to-Hand Transfer: a Prospective Longitudinal Study. Plast Reconstr Surg. 2019 Jan 21. doi: 10.1097/PRS.0000000000005422. [Epub ahead of print]

Last week, doctors in Taiwan published the results of pre- and postoperative outcome questionnaires obtained from 23 patients undergoing toe-to-hand transfers following traumatic loss. In the past, objective measures (eg, strength, sensation measurements) or only postoperative outcomes have been reported. Thus the current study is unique and valuable in that it studied patient-rated outcome measures (PROMs) both before and after the free tissue transfers.

Forty-one patients received toe(s)-to-hand transfers at the investigators’ hospital between 2012 and 2015. Twenty-three completed all of the questionnaires and are the subject of this study. Average age was 39, mean duration of follow-up was 2.7 years. In total, 34 toes (9 great toes, 20 second toes, and 5 third toes) were transferred. The recipient hand was dominant for 10 patients and nondominant for 13. A thumb or a combination of thumb and fingers were reconstructed in 9 patients, and only finger(s) were reconstructed in 14. The surgeons reconstructed one digit in 15 patients, two digits in 5 patients, and 3 digits in 2 patients. Every patient required secondary surgeries for appearance, function, or both. This usually consisted of tenolysis and/or reshaping of the pulp.

The 3 Chinese-language-validated PROMs used were the Michigan Hand Outcome Questionnaire (MHQ), the 36-Item Short Form Survey (SF-36), and the Lower Limb Outcomes Questionnaire (LLOQ). The MHQ measures the patient’s perception of hand function and appearance. The SF-36 evaluates the patient’s physical, psychological, and mental status. The LLOQ enquires about the status of the donor foot/feet.

RESULTS: In general, patients with thumb reconstructions and those with reconstructions of their dominant hand scored better than the group as a whole, but not significantly greater.

The MHQ scores were statistically higher post-operatively for the domains of activities of daily living, work, aesthetics, and satisfaction. Scores for hand function and pain improved but did not reach statistical significance.

Although the SF-36 scores improved for all domains (physical function, physical role, emotional role, vitality, mental health index, social function, pain, and general health), only for the domains of physical and emotional roles did the results achieve statistical significance.

The LLOQ showed no statistically significant difference between pre- and postoperative foot function.

DISCUSSION: The authors note that PROMs focus on the patient’s symptoms and life quality and are useful in helping the patient’s and providers’ decision-making process. Past studies have either neglected PROMs in favor of measures such as two-point discrimination, pulp-to-pulp function, and strength measurements or they did not collect PROMs pre-operatively to establish a baseline level of satisfaction.

COMMENT: The investigators were able to collect complete data on 23 of 41 patients. Were the ones who completed the study more or less inclined to do so? Nonetheless, this is an impressive series of patients who underwent toe(s)-to-hand transfer. Satisfaction was high, improvement in function and appearance was generally obtained, and donor site morbidity was nil.

Hand therapists often see patients with digital amputations before any reconstruction is performed. This paper will help guide conversations and improve expectations if toe-to-hand transfer is under consideration.