Plastic Surgery clinical outcomes

Clinical outcomes are broadly agreed, measurable changes in health or quality of life that result from our care. Constant review of our clinical outcomes establishes standards against which to continuously improve all aspects of our practice.

About the Plastic and Reconstructive Surgery Service

We see children with a wide range of conditions, both present at birth (congenital) or developed in childhood. Children who need plastic or reconstructive surgery are seen as outpatients, day case patients or inpatients.

As well as our five consultants, the surgical team consists of two specialist registrars, fellows in hand, cleft and craniofacial surgery, and two Trust doctors. Eight clinical nurse specialists, two occupational therapists and our departmental secretary complete the Plastic and Reconstructive Surgery Department.

Our special areas of expertise include:

  • craniofacial surgery
  • cleft lip and palate repair
  • congenital hand anomalies
  • ear surgery
  • vascular anomalies and birthmarks
  • general plastic and reconstructive surgery

Clinical outcome measures

Functional and cosmetic outcome measure following pollicisation surgery

The Congenital Hand Anomalies Service at Great Ormond Street Hospital (GOSH) is one of the largest in the UK, offering reconstructive hand surgery and therapy to children with a variety of conditions.

Thumb hypoplasia is a congenital condition where the child is born with a small or absent thumb. It is often associated with radial ray dysplasia (RRD), also known as radial club hand. This condition affects the development of the whole arm, and is classified from mild (Type I) to severe (Type IV). Thumb hypoplasia is frequently treated by pollicisation surgery. This complex surgery constructs a new thumb using the index finger. Following surgery, hand therapy is provided by the occupational therapists to help children maximise the movement, strength, function, and appearance of their new thumb.

1. Patient-Reported Outcome Measure of functional and aesthetic results

The Patient-Reported Outcome Measure (PROM) measures the outcome from the parent and patient’s perspective. It asks about type and frequency of thumb use, movement, strength, function and appearance. Parents or carers completed the PROM for children under 6 years of age. Children and young people aged 6 to 18 completed the PROM themselves. The PROM results are for all patients, and does not differentiate between those with no or mild RRD and those with severe RRD. 

Table 1.1 PROM for Under 6 (parent-reported), 2016-17

Under 6 (parent-reported) (N=11)

How do you use your thumb?

I use my thumb actively in daily tasks (e.g. to dress, eat, use a phone/toy)

91%

I use my thumb passively in daily tasks (e.g. to hold objects placed in my hand)

9%

I do not use my thumb

0%

 

How often do you use your thumb?

Often

36%

Sometimes

55%

I do not use my thumb

9%

Table 1.2 PROM for under 6 (parent-reported), 2016-17

Following your surgery, how do you feel about…

Dissatisfied

Dissatisfied smiley picture

Neither satisfied nor dissatisfied

Neither satisfied or dissatisfied smiley face picture

Satisfied

Satisfied smiley face picture

the appearance of your thumb (how it looks)?

0%

9%

91%

the movement of your thumb?

0%

27%

73%

the function of your thumb (how it works)?

0%

36%

64%

the strength of your thumb?

18%

36%

46%

Table 1.3 PROM for 6-18 year olds, 2016-17

6-18 (self-report) (N=18)

How do you use your thumb?

I use my thumb actively in daily tasks (e.g. to dress, eat, use a phone/toy)

100%

I use my thumb passively in daily tasks (e.g. to hold objects placed in my hand)

0%

I do not use my thumb

0%

 

How often do you use your thumb?

Often

59%

Sometimes

41%

I do not use my thumb

0%

Table 1.4 PROM for 6-18 year olds, 2016-17

Following your surgery, how do you feel about…

Dissatisfied

Dissatisfied smiley picture

Neither satisfied nor dissatisfied

Neither satisfied or dissatisfied smiley face picture

Satisfied

Satisfied smiley face picture

the appearance of your thumb (how it looks)?

0%

18%

82%

the movement of your thumb?

0%

35%

65%

the function of your thumb (how it works)?

0%

18%

82%

the strength of your thumb?

12%

35%

53%

2. Occupational Therapist assessment of function

In addition to the PROM, the 6 to 18 year olds were also assessed by the occupational therapists for grip and pinch strength and manual dexterity.

a. Grip and pinch strength

Grip and pinch strength was measured and compared to the normal population, matched for sex and age. 

Fig 2.1 Range of grip and pinch strength, 6-18 year olds, 2016-17 with no or mild RRD

Fig 2.1 Range of grip and pinch strength with no or mild RRD, 6-18 year olds, 2016-17

Fig 2.2 Range of grip and pinch strength, 6-18 year olds, 2016-17 with severe RRD

Fig 2.2 Range of grip and pinch strength with severe RRD, 6-18 year olds, 2016-17

All children and young people who had pollicisation surgery have the ability to grip and pinch using their new thumb. The grip strength of children with no or mild RRD ranges from 8% to 57% of the normal population, while the pinch strength ranges from 18-37%. The grip strength of children with severe RRD ranges from 10% to 30% while the pinch strength ranges from 7-29%. These results suggest the more severe the RRD before surgery, the weaker the grip and pinch post-pollicisation.

b. Manual dexterity

Manual dexterity was assessed using the Box and Blocks Test, where wooden blocks are transferred from one compartment to another as fast as possible. The score achieved is the number of blocks transferred in one minute and is compared to a normal population matched for sex and age.

Fig 2.3 Manual dexterity, 6-18 year olds, 2016-17

Fig 2.3 Manual dexterity, 6-18 year olds, 2016-17

These results show that 71% of those with no or mild RRD who had pollicisation surgery have manual dexterity within the normal range for their age and sex. This is compared with children and young people with severe RRD who had the surgery, where only 14% score within the normal range.

Conclusion

These results suggest that pollicisation surgery is an effective treatment to improve the movement, function and appearance of the hand in children and young people with thumb hypoplasia. Grasp and pinch strength is always less than normal, and the more severe the associated condition of RRD before surgery, the weaker the grip and pinch will be. However, following surgery, most patients use their thumb actively for function and are happy with the appearance.

This information was published in July 2017.