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 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 below include all types of RRD and isolated thumb hypoplasia.

Table 1.1 PROM for all assessed hands (N=26), 2017-18

PROM all assessed hands (N=26)

How do you use your thumb?

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

89%

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

8%

I do not use my thumb

4%

 

How often do you use your thumb?

Often

65%

Sometimes

35%

I do not use my thumb

0%

Table 1.2 PROM for all assessed hands (N=26), 2017-18

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%

15%

85%

the movement of your thumb?

0%

27%

73%

the function of your thumb (how it works)?

8%

31%

62%

the strength of your thumb?

12%

15%

73%

2. Occupational Therapist assessment of strength

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

Grip and pinch strength

Grip and pinch strength was measured and 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=5), 2017-18 

Fig 2.1 Average of grip and pinch strength, 6-18 year olds, with isolated thumb hypoplasia (N=5), 2017-18

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=10), 2017-18

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=10), 2017-18

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 November 2018 and will be updated in November 2019.

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)