Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations
Authors: Kevin C. Chung, Alfred P. Yoon, Sunitha Malay, Melissa J. Shauver, Lu Wang, Surinder Kaur
Journal: JAMA Surgery (2019)

<h3>Importance</h3> Optimal treatment for traumatic digit amputation is unknown. <h3>Objective</h3> To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations. <h3>Design, Setting, and Participants</h3> Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018. <h3>Exposures</h3> Revision amputation or replantation of traumatic digit amputations. <h3>Main Outcomes and Measures</h3> The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes. <h3>Results</h3> Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82;<i>P</i> = .02), DASH (−4.29; 95% CI, −8.45 to −0.12;<i>P</i> = .04), and PROMIS (3.44; 95% CI, 0.60 to 6.28;<i>P</i> = .02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9,<i>P</i> = .05), indicating less disability and pain, and PROMIS scores higher (78 vs 75,<i>P</i> = .04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42,<i>P</i> = .03 for DASH and 61 vs 36,<i>P</i> = .01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65,<i>P</i> = .06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm,<i>P</i> = .05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds,<i>P</i> = .001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g,<i>P</i> = .008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg,<i>P</i> = .03). <h3>Conclusions and Relevance</h3> When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.