Do Patient- and Parent-reported Outcomes Measures for Children With Congenital Hand Differences Capture WHO-ICF Domains?

Parent Perspectives for Type B Ulnar Polydactyly Management

BACKGROUND

Type B ulnar polydactyly is one of the most commonly encountered congenital hand differences and can be treated with ligation or excision. The purpose of this study was to determine what factors families consider in selecting treatment for their child with type B ulnar polydactyly.

METHODS

We reviewed treatment outcomes and administered a survey by telephone to parents of children with type B ulnar polydactyly treated at a pediatric hospital between 2015 and 2020. We assessed satisfaction, reasons for choosing treatment, and post-management complications.

RESULTS

The families of 70 of the 156 consecutive treated patients were successfully contacted and agreed to participate (45% response rate). The mean follow-up was 27 months. Twenty-eight chose in-office suture ligation and 42 chose excision. Rapid treatment was prioritized by those who opted for in-office ligation (P = .044). The complication rate for suture ligation was significantly higher than excision (P < .0001), with the most common complication being a residual remnant (nubbin or neuroma stump) (64%). Respondents with residual remnant reported significantly less satisfaction with the appearance of their child's hand (P < .001) and with treatment outcomes (P = .028) compared to those without residual remnants.

CONCLUSIONS

Factors considered by parents in choosing type of treatment for type B ulnar polydactyly vary and may be significantly influenced by the surgeon. Although the majority of parents remain extremely satisfied with their child's outcome regardless of management type, time to treatment plays a determinative role in parents opting for ligation rather than excision in the operating room.

Long-Term Outcomes After Treatment for Type B Ulnar Polydactyly

BACKGROUND

Type B ulnar polydactyly is a common congenital hand difference and can be treated with either ligation or surgical excision. There is a paucity of literature, however, evaluating long-term patient reported outcomes of these treatments. The purpose of this study was to compare the long-term outcomes after ligation and excision for the management of type B ulnar polydactyly.

METHODS

We created a database of patients who underwent treatment for type B ulnar polydactyly at a single pediatric health system from 2005 to 2014. We administered the Patient Reported Outcomes Measurement Information System (PROMIS) Pediatric Upper Extremity survey to patients through telephone and assessed for their satisfaction.

RESULTS

We successfully collected outcomes from 69 of 173 eligible patients treated in infancy (40% response rate). The mean follow-up was 11.1±2.5 years, and the average age of the participant at the time of the survey was 11.7±2.6 years of age. Twenty-four patients were treated with in-office ligation and 45 underwent formal surgical excision. Ten patients who were initially treated with ligation required future treatment with surgery because of symptomatic neuroma stump or persistent polydactyly (42%). Patients who were treated with surgical excision rated significantly higher satisfaction with their treatment than those who underwent ligation (P=0.003). Patients in both cohorts rated similar satisfaction with the esthetic appearance of their hand (P=0.07). There was no significant difference in PROMIS-rated hand function between the ligation and surgical cohort (P=0.765) and treated adolescents PROMIS scores were not statistically different than age-matched controls without polydactyly.

CONCLUSION

While ligation and surgical excision result in similar function and esthetics, patient satisfaction is higher after surgery. Furthermore, a significant number of patients fail ligation and ultimately undergo surgery for symptomatic neuroma or persistent polydactyly. Counseling parents of patients with type B ulnar polydactyly should include these considerations to assist them in selecting the best treatment for their child.

LEVEL OF EVIDENCE

Level III.

A systematic review of the use of psychological assessment tools in congenital upper limb anomaly management

STUDY DESIGN

This study is a systematic review.

INTRODUCTION

Congenital upper limb anomalies (CULAs) are often associated with psychosocial difficulties including negative body image, low self-esteem, and withdrawal from social activities.

PURPOSE OF THE STUDY

The purpose of the study was to identify, describe, and evaluate all published psychosocial assessment tools used in the assessment and management of CULAs, to direct the use of these tools in clinical practice, and to identify areas requiring development.

METHODS

A systematic search of Medline, EMBASE, Pubmed, and PsychInfo databases was performed. In total, 23 studies were included for analysis. Data extracted included study and population characteristics, psychosocial measures utilized, psychosocial outcomes reported, and the reliability and validity of measures.

RESULTS

Seventeen patient-reported measures were identified. The most commonly used tool was a Likert scale (n =7) with satisfaction with appearance and function, the most commonly evaluated outcome (n = 18). Other evaluated domains included quality of life or psychosocial functioning (n = 9), self-image (n = 2), and psychological well-being (n = 5).

DISCUSSION AND CONCLUSIONS

There is no well-established, validated assessment tool in regular use to effectively address psychosocial outcomes for children with CULAs. Although the majority of children born with a CULA appear to adjust well, this is by no means the case for all children. There is a need for routine psychosocial evaluation preoperatively and postoperatively with long-term follow-up data to help direct patient-orientated management. A clear understanding of these, and how to measure them, is needed to help for a patient-centred, multidisciplinary, evidence-driven approach to CULA management.

The psychosocial impact of congenital hand and upper limb differences on children: a qualitative study

This qualitative study explored the psychosocial concerns of children born with congenital hand and upper limb differences (CHULDs) from the point of view of these children and their parents. Qualitative, in-depth, semi-structured interviews were conducted face-to-face with eight parent-child dyads. Open format questions allowed spontaneous emergence of relevant themes, followed by guided questioning. Thematic analysis of audio-recorded and transcribed interviews found that children as young as 5 years old had unique and meaningful opinions about their CHULD, of which parents were sometimes unaware. Children reported that unsolicited questions from peers caused significant stress, and this increased around the time of surgery. All children used planned responses to peers as an effective coping mechanism. Children also identified positive aspects of their difference, including an increased sense of determination and an appreciation for being unique. Strategies that may improve psychosocial outcomes for children with CHULDs are discussed.Level of evidence: IV.

Correction of Thumb Duplication: A Systematic Review of Surgical Techniques

Surgical intervention for thumb duplication can be divided into three categories: simple excision of the accessory thumb, excision of the accessory thumb with reconstruction from available "spare parts," and combining the two thumbs into one, as described by Bilhaut. This prospectively PROSPERO registered systematic review evaluates the overall, aesthetic and functional outcomes for the latter two options (reconstruction from spare parts vs. combining two thumbs into one), aiming to facilitate evidence-based decision making when addressing thumb duplication and direct future research. The review was performed in accordance with the Cochrane Handbook of Systematic Reviews and PRISMA statement. Embase, PubMed, Medline, and Cochrane databases were systematically searched. Studies offering comparisons of techniques were included. Risk of bias was assessed using the Risk of Bias In Non-randomized Studies-of Intervention tool. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation. Ten retrospective observational studies were included. Data did not consistently allow analysis by procedure type. Four studies reported similar overall outcomes between techniques, while two specifically reported poor overall outcomes for the Bilhaut procedure. Two studies reported comparatively worse aesthetic outcomes for the Bilhaut procedure with four studies reporting comparatively improved functional outcomes for this procedure. Overall, interpretation of outcomes was challenging with no patient-reported outcome measures used. The quality of the evidence was universally "very low" due to all studies being at risk of methodological bias. Based on the available evidence, surgical techniques for thumb duplication correction appear comparable regarding overall outcome. There is limited evidence suggesting reconstruction with spare parts offers superior aesthetic outcomes at the expense of stability. The level of evidence is III.

Convergent Validity of PODCI and PROMIS Domains in Congenital Upper Limb Anomalies

PURPOSE

This study evaluates the perceived functional and psychosocial impact of upper limb congenital anomalies prior to surgical intervention, utilizing the Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measure Information System (PROMIS) domains. We hypothesized that scores will be in the normal range and that the 2 outcomes measures will have strong convergent validity.

METHODS

A multicenter prospectively collected database of congenital upper limb patients, the CoULD (Congenital Upper Limb Differences) study group, was utilized. Demographic information was collected, and anomalies were classified by the Oberg-Manske-Tonkin (OMT) classification. Scores for PODCI subscales of Upper Extremity (UE) function, Pain/comfort, and Happiness and PROMIS domain of UE function, Pain, Depression, Anxiety, and Peer relations were collected. Ceiling and floor effects and convergent validity for PODCI and PROMIS domains were calculated.

RESULTS

Three hundred fifty-nine patients, average age 10 years and 55% male, were included. Two hundred forty-one patients had a malformation of the entire limb and 231 had a hand plate malformation. Four patients had a deformation, 118 dysplasia, and 45 a syndrome. There was no difference between the PODCI and the PROMIS ceiling or floor effects for the UE domains. The ceiling effect for PROMIS Pain domain (46%) was similar to the floor effect of the PODCI Pain subscale and no difference was seen between the floor effect of PODCI Happiness and PROMIS Depression domains. Convergent validity was obtained for the UE and Pain domains, and also between PODCI Happiness and PROMIS Depression subscales.

CONCLUSIONS

The PROMIS domains for UE function, Pain, and Depression are comparable with PODCI scores in congenital upper extremity anomalies.

CLINICAL RELEVANCE

Given the large burden placed on patients with the lengthy PODCI questionnaire, consideration of replacing the PODCI with the more quickly obtained PROMIS scores may reduce patient burden and provide similar information in this population.

Long-Term Results of Surgically Treated Radial Polydactyly - An Outcome Correlation Study

Background: Thumb polydactyly is one of the commonest congenital hand differences. Traditional surgeon-based outcome scores capture outcomes mainly on bodily structure and function. Outcomes on the long-term well-being of the patients in the domains of activity and participation are not fully studied. Methods: Forty-eight thumbs in forty-five Chinese patients with radial polydactyly underwent surgical treatment at or before 3 years old were recruited. Mean follow-up was 11.6 years. Surgical outcomes were collected and compared to the normal opposite thumb. The results were compiled into the Japanese Society for Surgery of the Hand (JSSH) score, Cheng score and Tada score. Patients' activity involving hands were assessed by both objective tools and patient-reported outcome measure while their health-related quality of life (HRQoL) was assessed by Patient- and Parent-reported Pediatric Quality of Life Inventory (PedsQL). Correlations between outcomes were analysed. Results: Overall, both parents and patients themselves reported good quality of life with mean score of 86.6% and 92.1% respectively in PedsQL. The combined surgical scores ranged from 52% good or excellent results using JSSH score to 100% good result using Cheng score. None of the outcomes on bodily structure and function showed positive correlation with patient's well-being. Negative correlation was noted in total passive range of movement, active movement and Cheng score. All patients reported no activity restriction. Writing test did not show significant slowing. The operated hands had significantly poorer fine motor dexterity than normal. No significant correlation is noted between activity outcomes and PedsQL. Conclusions: Outcomes on bodily structure, function and activity showed little correlation with patients' well-being after thumb polydactyly correction. It should be careful in using or analysing patient/parent-reported outcome measures on HRQoL as outcome assessment of surgical treatment of radial polydactyly.

Functional Impact of Congenital Hand Differences: Early Results From the Congenital Upper Limb Differences (CoULD) Registry

PURPOSE

To characterize the functional, emotional, and social impact of congenital upper limb differences on affected children and families before treatment, using validated functional outcome instruments.

METHODS

From June 2014 to March 2016, 586 children with congenital upper limb differences from 2 pediatric hospitals were enrolled in the Congenital Upper Limb Differences registry. Demographic, clinical, and radiographic data were collected, and diagnoses categorized according to the Oberg-Manske-Tonkin classification. Functional outcomes were assessed in 301 patients using the Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) function, pain, anxiety, depression, and peer relationships modules.

RESULTS

The cohort had high median PODCI scores in all domains, ranging from 83 to 100 in children and adolescents. Patients had decreased PROMIS UE scores compared with population norms; however, they showed low scores for pain, anxiety, depression and higher scores in the peer relationship domain, respectively. Patients with entire limb involvement had higher PROMIS pain scores and lower PODCI UE and global functioning than those with differences limited only to the hand. Compared with those with bilateral involvement, patients with unilateral differences reported higher scores for PODCI sports global functioning, better PROMIS UE function, and lower pain scores. Additional orthopedic conditions and medical comorbidities negatively influenced all PODCI scores and PROMIS pain and UE function domains.

CONCLUSIONS

Children with congenital hand differences report decreased upper limb function but better peer relationships and positive emotional states compared with population norms.

CLINICAL RELEVANCE

The Congenital Upper Limb Differences registry is a valid source of information related to congenital upper limb differences in clinical practice. With continuous enrollment and longitudinal follow-up, the registry will increase the understanding of UE function and psychosocial aspects of health in pediatric population.

Outcomes Assessment After Hand Burns

Accurately assessing function and disability after hand burns is imperative to improving the management of patients. The biological, social, and psychological impact of these injuries should be considered. The International Classification of Functioning Disability (ICF) and Health Core Sets for Hand Conditions provides a guide to what should be measured and reported. Although many outcomes measures instruments are available to assess patients with hand or burn injuries, few are validated in the subpopulation of hand burns. Further efforts are required to investigate the ability of current assessment instruments to evaluate hand burn outcomes within the ICF framework.