Commentary and Perspective
This paper addresses a topic that is probably not of great interest to the general orthopaedist who reads The Journal of Bone and Joint Surgery. Many readers will glance at this paper and dismiss it with a disparaging remark about another hand surgery tempest in a teapot. But, in this era of reporting outcomes for science and business, there are a few points that all of us can take from this article that apply to all outcome rating systems.
Point 1: Define what it is that you are reporting, and correlate the findings with the severity of the starting point. The proverbial “sow’s ear” must be described.
The authors looked at a number of outcome measures that are in use to assess how good a result can be following reconstruction of Flatt type-II and IV thumbs. While we all know what a good result is when we see it, it is not so easy to quantify how much less than a good result our efforts produce.
Point 2: Give proper attribution to coauthors and mentors.
The authors of this paper chose to limit their evaluation to the two most common types of radial polydactyly. Wassel classified Adrian E. Flatt’s Iowa series of duplicated thumbs with a seven-part system1. The paper was published in 1969 without Flatt’s name. Later, in The Care of Congenital Hand Anomalies, 2nd edition (1994), Flatt recommended that type VII be separated from the more common forms of thumb anomaly2. I agree with using Flatt’s name to describe types-I through VI forms of typically unilateral and non-hereditary “split” thumbs.
Point 3: Choose the right assessment tool.
In this paper, the authors point out that the desired outcomes may be skewed by the choice of the assessment measure. In other words, you can make your results look better or worse by selecting how to assess them. The sensitivity of the scoring will also be affected by the number of potential items to be graded, and the number of scoring options.
Point 4: Try not to leave out important information.
None of the children examined had difficulty using the reconstructed thumbs, and this implies intact sensation in the tips of the digits. While we do not routinely use Semmes-Weinstein or two-point discrimination testing for these young children, we assume that sensation has been preserved.
Point 5: How do you know if something is really a problem if you don’t ask?
It is interesting to note that the patients reported an ability to perform all tasks requested of them in the evaluations. Is this a “ceiling effect” as the children adapt and grow? Or is it that we are not asking the right questions? The activities do not include some of today’s common daily activities such as using cell phones for texting or typing on computer keyboards. Use of these devices may require some adaptive positioning but, when asked, none of my patients have reported an inability to communicate in this way. We tend to ask what the patient can do, and focus less on what they cannot do.
Point 6: Don’t forget the psychosocial ramifications of surgery, however large or small.
While a visual analog scale (VAS) for rating aesthetic results is not the best way to assess what is in the “eye of the beholder,” it does give some idea of the level of satisfaction. Children are extremely sensitive to the comments of their peers, and this is not assessed by any measurement system. A “peer” assessment might be an interesting study to find out what classmates and friends think about a child’s hand. Although it was not the purpose of the study to correlate the ratings with psychological or emotional factors, it would be useful for questionnaires to have some free space to allow the children to describe other concerns.
This paper teaches us to be a bit skeptical of the excellent results that we like to report, and explains the difficulty in reproducing those results. One of my mentors defined a good result as occurring when “the patient and the doctor are happy to see each other.”3
*The author received no payments or services, either directly or indirectly (i.e., via her institution), from a third party in support of any aspect of this work. Neither the author nor her institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
1. Wassel HD. The results of surgery for polydactyly of the thumb. A review. Clin Orthop Relat Res. 1969 May-Jun;64:175-93.
2. Flatt AE. The care of congenital hand anomalies. 2nd ed. St. Louis: Quality Medical Publishers; 1994.
3. Carter PR. Personal communication.