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Comparison of Patient-Reported Outcomes after Traumatic Upper Extremity Amputation: Replantation versus Prosthetic Rehabilitation
Mitchell A Pet, MD1; Shane D Morrison, MD, MS1; Jacob S Mack, BS2; Erika D Sears, MD, MS2; Thomas Wright, MD1; Kenneth R Means Jr, MD3; James P Higgins, MD4; Jason H Ko, MD5; Paul S Cederna, MD2; Theodore A Kung, MD2; Alisha Lussiez, BS2
1University of Washington, Seattle, WA, 2The University of Michigan, Ann Arbor, MI, 3Union Memorial Hospital, Baltimore, MD; 4Curtis National Hand Center, Baltimore, MD; 5Northwestern University, Chicago, IL

Purpose: After major upper extremity amputation, replantation is generally attempted based upon the assumption that patient outcomes for a successfully replanted limb exceed those for revision amputation and prosthetic rehabilitation. There is sparse data demonstrating superior task-based functional outcomes for patients undergoing replantation, but to our knowledge there are no studies directly comparing patient-reported outcomes. It increasingly apparent that a patient's perception of his or her function is an important measure of outcome after loss of an upper extremity, and that functional testing and physician assessment may not align with the patient experience. It is the goal of this study to compare upper extremity replantation versus revision amputation with prosthetic rehabilitation using the DASH and MHQ instruments, two validated measures of patient-reported upper extremity outcomes.

Methods: At each of three collaborating major replantation centers, patients with a history of traumatic, unilateral, upper extremity amputation between the radiocarpal and elbow joint (inclusive) were identified. This included patients who underwent successful replantation, and those who underwent revision amputation and attempted prosthetic rehabilitation. Those who could be contacted and agreed to participate completed the DASH and MHQ instruments. Intergroup comparison was completed for aggregate DASH score, aggregate MHQ score on the injured side, and each of the MHQ component sub-scales including overall function, ADLs, pain, appearance, and patient satisfaction.

Results: 22 amputees who underwent prosthetic rehabilitation and 9 patients who had successful replantation were included. Aggregate MHQ score for the affected extremity was significantly better for the Replantation group compared to the Prosthetic Rehabilitation group (47.2 vs. 35.1, p<0.05). Amongst the component MHQ sub-scales, significant advantages to replantation were demonstrated with respect to overall function (41.1 vs. 19.7, p=0.03), ADLs (28.3 vs. 6.0, p=0.03), and patient satisfaction (46.0 vs. 24.4, p=0.03). DASH score was more favorable in Replantation patients (24.6 vs. 39.8), though this difference fell short of statistical significance (p=0.08).

Conclusions: After upper extremity amputation, patients who underwent successful replantation reported superior outcomes with respect to overall function, ADLs, and patient satisfaction, compared to patients who underwent revision amputation followed by prosthetic rehabilitation. This offers some justification for the considerable effort and expenditure required on the part of the patient, surgeon, and payer to complete this heroic reconstruction. Assessment of patient reported outcomes is a critical part of evaluating the success of surgical treatment, and future outcomes studies should include the DASH and MHQ.

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