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American Association for Hand Surgery

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Early Active Range of Motion Protocol Following Upper Extremity Tendon Transfers Does Not Increase the Risk of Postoperative Complications: A Propensity Score Analysis from a Retrospective Cohort Study
Moaath Saggaf, MD, University of Toronto, Toronto, ON, Canada, Justin Haas, BSc, Toronto Western Hospital, Toronto, ON, Canada, Christine B Novak, PT, PhD, Toronto Western Hospital Hand Program, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada, Steve McCabe, MD, MSc, Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada and Dimitri J Anastakis, MD, Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, ON, Canada

Introduction
The study aim was to compare the postoperative complication rates between patients started on early active range of motion (EAROM) protocols and patients on delayed mobilization. Our hypothesis was EAROM is not strongly associated with increased postoperative complications.

Methods
A retrospective cohort study design was used to evaluate adult patients treated with a tendon transfer from January 2004 to December 2019. Cases were patients who started EAROM protocols within 7 days following a tendon transfer surgery, and controls were patients who started active range of motion after 7 days following surgery. Exclusion criteria were a prior tendon transfer, pediatric patients, upper motor neuron lesions, and a major psychiatric diagnosis. The primary outcome measure was the composite postoperative complications variable, which includes tendon rupture, reoperation to readjust tension or tendon adhesions requiring tenolysis. The propensity scores were derived from a logistic regression model using the average of treatment effect on the treated (ATT) trimmed weights. After achieving balance, the inverse probability of treatment weighting (IPTW) was used to estimate the relative risk for major postoperative complications after adjusting for age, sex, medical comorbidities, occupation, smoking status, traumatic injuries, nerve injuries, type of tendon transfer performed and method of repair. Based on the power analysis, a sample size of 80 per group would be required to detect a medium effect size.

Results
A total of 141 patients were included in the study: EAROM group (n=74) and delayed mobilization group (n=67). The overall median postoperative follow-up duration was 7 months (IQR=14.9 months). The mean age of the participants was 49 years (SD=17.3), and 92 patients (64.8%) were males. Sixty-nine cases (48.9%) were associated with nerve injuries, 47 cases (33.3%) were associated with tendon injuries, and 25 cases (17.7%) had combined injuries. The incidence of postoperative complications was 8.1% (n=6) in the EAROM group and 6% (n=4) in the delayed mobilization group. The relative risk of postoperative complications in patients with EAROM was 1.38 (95% CI: 0.4 - 4.6, p=0.75). In the adjusted analysis using IPTW from the propensity scores, the relative risk for major postoperative complications in the EAROM group was 2.65 (95% CI: 0.7 - 10.1, p=0.15).

Conclusions
The overall incidence of postoperative complications was low in this large series. EAROM is a safe approach following upper extremity tendon transfers, and in this study was not largely associated with an increased risk of major postoperative complications.


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