Disability and health after replantation or revascularisation in the upper extremity in a population in southern Sweden – a retrospective long time follow up

DASH

DASH is a region specific instrument [23, 24]. The questionnaire covers daily activities, symptom questions and questions related to self-image and social functioning. The DASH score ranges from 0 to100; 0 indicating no disability and 100 signifying the most severe disability. In this study the Quick-DASH version was used [20].

EQ-5D

To measure health outcome in different groups, the EQ-5D was used [21, 25]. It is composed of five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The reduction in quality of life associated with the health state was taken from the Danish TTO-tariffs [26] and defined as the difference between perfect health and the health state value corresponding to the EQ-5D code. The summary index score of 1 represent the best possible state of health and 0 represent the worst condition. EQ-5D also has a visual analogue scale (EQ-5D VAS). The patient rates his or her current health statues on a VAS scale; a higher score indicates a better health (0–100). The VAS scale generates more general information on the self-perceived health state than the EQ-5DIndex with its five dimensions.

EQ-5D is an international, widely used questionnaire for measuring health related quality of life for different patient categories. EQ-5D has been used to score quality of life for hand injuries, but not for replanted patients [27–29]. It is validated and it is reliability has been tested [30]. It is easy to complete and quick to interpret.

SOC

Sense of coherence (SOC) was assessed with Antonovsky’s short 13-item scale. The scores on each item ranges from 1 to 7 with a total score range from 13–91. High scores indicate a high SOC. The SOC instrument reflects a person’s capacity to respond to a stressful situation and according to Antanovsky a person’s individual environment as being a comprehensible, manageable and meaningful [16, 17]. According to Eriksson and Lindström, SOC seems to be a health promoting resource [31] influencing quality of life [32]. Higher SOC has also been reported to result in a more positive development of life satisfaction [33]. In patients with moderate orthopaedic injuries, it has been shown that low SOC was associated with an increased risk of having less good clinical and functional outcome [18]. Normative data from published studies ranges from mean values 58.5 to 68.7.

CISS

The Swedish version of the CISS questionnaire was used [22]. Question number 1 concerns severity of different symptoms on exposure to cold and is not included in the total CISS score and has a numeric rating scale (0 = no symptoms/trouble at all and 10 = the most severe symptoms/trouble you can possible imagine).

Functional evaluation

A part of the patients (n = 194) had been for an examination to issue a certificate for an insurance company. Information was collected from the certificate, regarding grip power, pinch grip power, range of motion and daily activity. The examination for the certificate was done between one and 10 years after the injury (median 2 years).

Subgroups

The whole group were divided into subgroups with respect to severity of injury (MHISS), cold sensitivity (CISS), return to work and sense of coherence (SOC). The injury severity was classified with MHISS and depending on the score the population was divided into three groups “Moderate”, “Severe” and “Major”. Abnormal cold sensitivity was defined as the cut-off value by Carlsson, CISS score >50 = abnormality and was used to dichotomize the study population [34]. The working group of people was dichotomized into one group who went back to work and one who had to retire early. The median SOC score of 75 was used to dichotomize the study population into low SOC and high SOC.

Data analysis

All variables are presented as median (min-max). Kruskal Wallis test or Mann–Whitney U-test was used to detect differences between subgroups. Fisher’s exact test was used in analysis of contingency tables. The significance level was set at p ≤ 0.05.

General information

The level of injuries is presented in Figure 1. The total number of injured fingers/thumbs was 680 (242 fingers not needing replantation/revascularization) and the numbers of replanted fingers and thumbs were 350 and 88, respectively. When comparing finger and thumb replantation, we found that the patients with a thumb replanted were older (p = 0.0002) and had a higher HISS (p = <0.0001) than the finger replanted. The grip strength (p = 0.001) was lower in the group of finger replanted and the pinch strength (p = 0.004) was lower in the group with thumb replantation. The most frequent replanted finger was index (n = 110) and long finger (n = 103).

Sixty per cent were a replantation and 40% were a revascularisation. The overall survival rate was 90%. The survival rate for fingers was 91% and for thumbs 86%. In 70% of the patients a vein graft was used and in 30% a direct anastomosis was sufficient.

The replanted patients had a higher HISS (p < 0.0001) than those who had a revascularization.

Severity of hand injury

Cold sensitivity

The median CISS was 35 (0–89). Abnormal cold sensitivity (CISS > 50) was seen in 24% (51/209). The predominant problems on exposure to cold among the patients were numbness, stiffness, weakness, skin colour change and pain and aching.

Early retirement

Information regarding the patients work situation at time of injury was available in 268 patients. Most of the patients had a work at the time of injury (n = 206), 40 were school children or students, 6 were preschool children and 16 were retired. Twenty-two per cent of the patients who worked at time of injury had to change work and 10% had to retire early due to the injury.

If the injury took place at work the DASH was worse (p = 0.005) than if the injury were sustained at leisure. Also the grip strength (p = 0.03) and SOC (p = 0.04) was lower in the group injured at work.

Sense of coherence

General information

The most frequent causes of injury were by saw, woodcutter or a machine, except if the injury was at the wrist level or more proximal. In these cases, it was still from a woodcutter, but also from farmer, machine or crush (Table 1). In this study, 50% of the injuries were work-related, which is lower than have been reported earlier [36].

The overall success rate was 90%, which has been reported by others [8, 12, 37], indicating that the present material is valid. Survival rates for digital replantation have been analyzed in a meta-analysis and a clear difference exists between a clean-cut injury (91%) and crush (68%) or avulsion (66%) injuries [37]. Also, the level of amputation has been found to influence the survival rate [12, 14, 38]. The high success rate might depend on our preoperative selection of patients suitable for replantation.

Injury severity

Patients needing replantation is a very heterogeneous group from an almost surgical clean cut amputation of a thumb to a patient with multiple injured fingers, but only the thumb needs revascularisation. To be able to reflect this situation, the MHISS was used to score the total severity of the injury. Not only the finger(s) needing revascularization, but the complexity of the total injury influence the outcome and how the patients deal with daily living, work and leisure. MHISS correlated with QuickDASH, which is in accordance with earlier studies [39, 40]. It may indicate that a more severe injury needs more rehabilitation resources to gain a more useful hand function. Tamai’s score system, which is often used in replantation studies, has also been found to correlate with HISS [40].

Cold intolerance

Cold intolerance is a common problem after replantation and known to be a longstanding problem [28]. However, different classification systems have been used and therefore different degrees of cold intolerance are reported [2, 9, 14]. We used the Swedish CISS questionnaire, which is reliable and validated [22].

All patients in the present study reported some type of cold intolerance. Abnormal cold sensitivity influences the patient’s daily life, work and leisure. When using the cut of value by Carlson et al. [34] for defining an abnormal cold sensitivity 24% had an abnormal cold sensitivity which is in accordance with others [41]. A high correlation between CISS and hand disability, quality of life and functional outcome was also found. They also had a low SOC. This is information is important to the rehabilitation team in helping the patient with protection and rehabilitation strategies for handling this difficult problem.

Disability

The DASH and also Quick-DASH was designed to assess upper extremity disability and symptoms and could be helpful in evaluating the effect of a treatment on the upper limb and serves as a value with which other outcomes can be composed. DASH or Quick-DASH have been used in other replantation studies and reported values are the same as in this study [2, 13]. However, other reported higher DASH scores, which might reflect different follow up times and different patient selection [11, 42].

Quality of life

Only in one previous study [15] quality of life has been investigated in replanted patients. However, the EQ-5D has not before been used in this patient group. Hand function has been evaluated previously by different types of scores [2, 8, 11, 13, 14, 42]. Quality of life is more than hand function. Both EQ-5DIndex and EQ-5D VAS correlated with QuickDASH, but not with the severity of injury. The EQ-5D Index and EQ-5D VAS scales have been shown to be age dependent [43, 44], which was not confirmed.

Return to work

One third of the injured patients, who had a work, had to change work or retire early due to the injury. They were older and had a more severe injury, indicated by a higher HISS, and were more often injured at work. They also had more problems with daily activities and a worse quality of life. Also, functional variables, as grip- and pinch strength, were worse. No difference was found between men and women. Almost comparable figures for return to work have been shown by others [11, 13, 14].

Return to work in a group of patients with a serious hand injury was not related to the severity of the hand injury (HISS) [45]. However, it seemed that factors more dependent on the person’s own ability and motivation was important. This may indicate that SOC could play an important role for how a patient will be able to rehabilitate after a hand injury.

In contradiction, other has reported that HISS could adequately be used to predict return to work [40]. In this study, also age and the place of injury might have influenced return to work. An impaired hand function, such as cold sensitivity [46], pain [47] and reduced grip strength [48, 49], can greatly hinder recovery and reduce successful functional outcome and return to work, which was confirmed. The ability to return to work is probably not only dependent on the above factors, but also on the socioeconomic benefits of the given society.

Sense of coherence

Several differences in outcome between patients with a high or low SOC were found. The relationship between the SOC and outcomes after amputation injuries in the upper extremity, needing replantation or revascularisation, has not been previously studied. In a recently published study, patients with a severe or major hand injury and a low SOC showed significantly lower satisfaction in daily occupation, higher DASH scores, lower mental QoL, more sleep disturbances and bodily pain [35]. Also, after moderate orthopaedic injuries, a low SOC were associated with an increased risk of having a less good clinical and functional outcome [18]. There are some problems with SOC, such as the influence of age [17], different life situations effect [33, 50] and the interpretation of healthy/unhealthy [35]. Another possible limitation with SOC might be that no preinjury value is available. As a cut point the median value of SOC could not be considered a generalized recommended cut point for screening individuals. The findings, like others [35], suggest that SOC need to be considered further when planning rehabilitation of patients with severe hand injuries.