Plastic Surgery clinical outcomes

Clinical outcomes are measurable changes in health, function 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 can also be isolated, with no other anomalies affecting the upper limb present. 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 maximize the movement, strength, function, and appearance of their new thumb.

1. Patient-Reported Outcome Measure of thumb function and appearance

The Patient-Reported Outcome Measure (PROM) provides an insight into the parent and patient’s perspective of surgical outcome. It asks about 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 it themselves. The PROM results below include all thumb hypoplasias, including isolated thumb hypoplasia and those associated with RRD.

Table 1.1 Patient reported thumb use (N=14), 2018/19

Do you use your thumb?

I use my thumb spontaneously in daily tasks

79%

I use my thumb in daily tasks only when prompted / reminded

14%

I never use my thumb

7%

How often do you use your thumb to pick up large objects (eg a bottle)?

Often

64%

Sometimes

36%

Never

0%

How often do you use your thumb to pick up small objects (eg a pea)?
Often 50%
Sometimes 36%
Never 14%
How often do you use your thumb to manipulate small objects (eg doing up a button)?
Often 50%
Sometimes 17%
Never 33%

The majority of patients (79%) report to use their thumb spontaneously in daily tasks, 14% when prompted or reminded and 7% reported never to use their thumb.

We asked how frequently patients use their thumb to pick up large objects and all reported to do this with 64% reporting to do this often, 36% reporting to do this sometimes.

We asked how frequently patients use their thumb to pick up small objects and 50% reported often, 36% reported sometimes and 14% reported never.

When we asked how frequently patients use their thumb to manipulate small objects, 50% reported often, 17% reported sometimes and 33% reported never.

Table 1.2 Patient reported satisfaction (N=14), 2018/19 

Following your surgery, how satisfied are you with…

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%

7%

93%

The movement of your thumb?

8%

21%

71%

The function of your thumb (how it works)?

8%

21%

71%

The strength of your thumb?

8%

28%

64%

The majority of patients report to be satisfied with the appearance of their thumb (93%), their movement (71%) and function (71%). Thumb strength was reported to have the lowest level of satisfaction (64%).

2. Occupational Therapist assessment of strength

In addition to the PROM, the 6 to 18 year olds were also assessed for grip and pinch strength, and the results were compared to the normal population, matched for sex and age. 

Fig 2.1 Average of grip and pinch strength, 6-18 year olds with isolated hypoplasia (N=4), 2018/19

Fig 2.1 Average of grip and pinch strength, 6-18 year olds with isolated hypoplasia, 2018/19

Fig 2.2 Average of grip and pinch strength, 6-18 year olds, with all types of radial ray dysplasia and/or syndrome affecting hands (N=7), 2018/19

Fig 2.2 Average of grip and pinch strength 6-18 year olds with all type of radial ray dysplasia and / or syndrome affecting hands 2018/19

The results displayed are compared with normal population data, matched for sex and age. They demonstrate that following pollicisation surgery, grasp and pinch strength is always significantly less than normal, and the more severe the associated condition of RRD the weaker the grip and pinch will be. For isolated thumb hypoplasia, grip strength is 26% of normal person and pinch strength is 33%. When there is an associated syndrome or anomaly, grip strength is 11% of normal and pinch is 13%.

Conclusion

The results of our PROM suggest pollicisation surgery is an effective treatment to improve the movement, function and appearance of the hand in children and young people with thumb hypoplasia. The pollicised thumb is always significantly weaker when compared to normal thumb strength and has the lowest level of satisfaction. Patients report to using their thumb to pick up large objects more frequently than to pick up and manipulate small objects. Overall, the patients and families who have undergone pollicisation are satisfied with the outcome of their surgery.

This information was published in July 2019 and will be updated in July 2020.

References

McQuiddy, V. A. et al. Normative Values for Grip and Pinch Strength for 6- to 19-Year-Olds, Archives of Physical Medicine and Rehabilitation, 96:1627-33 (2015)

Netscher, D. T. et al. Functional Outcomes of Children With Index Pollicizations for Thumb Deficiency, The Journal of Hand Surgery, 38:250-257 (2013)

de Kraker M. et al. Outcome after pollicization: comparison of patients with mild and severe longitudinal radial deficiency, Plastic and Reconstructive Surgery, 131:544e-551e (2013)