|Year : 2019 | Volume
| Issue : 2 | Page : 73-76
Does the patient satisfaction correlate with sensorial recovery after primary repair of digital nerves and flexor tendons?
Egemen Ayhan1, Abdurrahman Ciftaslan2, Melih Bagir3, Metin M Eskandari4
1 Department of Orthopaedics and Traumatology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara, Turkey
2 Department of Orthopaedics and Traumatology, Faculty of Medicine, Mersin University, Mersin, Turkey
3 Department of Orthopedics and Traumatology, Division of Hand Surgery, Faculty of Medicine, Cukurova University, Adana, Turkey
4 Department of Orthopedics and Traumatology, Division of Hand Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
|Date of Web Publication||27-Mar-2019|
Dr. Egemen Ayhan
Mutlukent Mh. Angora Evleri, No: 2/6, Cankaya, Ankara
Source of Support: None, Conflict of Interest: None
Background: We aimed to evaluate the correlation of patients' satisfaction with sensorial evaluation results after primary repair of digital nerves and flexor tendons. Materials and Methods: In total, 31 fingers of 25 patients that underwent primary repair for clear-cut digital nerve and flexor tendon injuries were included in this retrospective study. The mean age of the patients was 34.8 ± 9.4 years. Patients' gender, age at admission, trauma date, and injured finger were obtained from patients' folders. We called the patients for the last follow-up and used two-point discrimination (2PD) and Semmes–Weinstein monofilament (SWM) tests to evaluate sensorial recovery. Patients were interviewed for hand dominance, cold intolerance, and if they were satisfied. Visual analog scale (VAS) was used to evaluate the satisfaction of patients related to the injured finger. We analyzed correlations between VAS score and age, follow-up period, 2PD score, SWM score, cold intolerance score, gender, hand dominance, and the injured finger. Results: Patients' satisfaction was significantly correlated only with cold intolerance score. There was no significant correlation between patients' satisfaction and age, follow-up period, gender, hand dominance, injured finger, 2PD score, and SWM score. Conclusion: Our study revealed that patients' satisfaction was not only correlated with sensorial recovery scores but also significantly negatively correlated only with cold intolerance, and novel modalities to treat this phenomenon are required. Moreover, patients' satisfaction was not related to age, gender, hand dominance, and the injured finger; hence, surgeons should focus on meticulous repair of digital nerves in any age, for any gender, and any finger of patients.
Keywords: Cold intolerance, digital nerve injury, flexor tendon laceration, patients' satisfaction, sensorial recovery
|How to cite this article:|
Ayhan E, Ciftaslan A, Bagir M, Eskandari MM. Does the patient satisfaction correlate with sensorial recovery after primary repair of digital nerves and flexor tendons?. Turk J Plast Surg 2019;27:73-6
|How to cite this URL:|
Ayhan E, Ciftaslan A, Bagir M, Eskandari MM. Does the patient satisfaction correlate with sensorial recovery after primary repair of digital nerves and flexor tendons?. Turk J Plast Surg [serial online] 2019 [cited 2019 Nov 14];27:73-6. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/2/73/255009
| Introduction|| |
In 1834, Bell reported, “We find every organ of sense, with the exception of that of touch, more perfect in brutes than in man. But in the sense of touch, seated in the hand, man claims the superiority; and it is of consequence to our conclusion that we should observe why it is so.” Today, we can undoubtedly conclude that daily activities of civilized humans are endowed with this incomparable sensation of the hand, through its tiny digital nerves. As a matter of course, digital nerves have arisen as the most frequently injured peripheral nerve with simultaneous tendon, bone, and vascular injuries.,,
Despite developments in microsurgical techniques, patients' satisfaction after digital nerve repair have not been consistently satisfactory, and the concomitant injuries probably play a role.,,,,,,,, In isolated proper digital nerve injuries, it is expected that patients' satisfaction would correlate with objective test results of sensorial recovery (e.g., two-point discrimination [2PD] and Semmes–Weinstein monofilament [SWM] tests). But, what about if there is an accompanying flexor tendon zone 2 injury with a proper digital nerve injury? In such patients, it is possible that the patients would not care about their recovery of sensation when their fingers' motion is the matter. Therefore, we hypothesized that patients' satisfaction was not correlated with sensorial recovery when there was an accompanying flexor tendon injury to digital nerve injury. Hence, our aim was to evaluate the correlation of patients' satisfaction with sensorial evaluation results after primary repair of digital nerves and flexor tendons.
| Materials and Methods|| |
Between January 01, 2009, and January 01, 2017, the patients who underwent primary repair for clear-cut digital nerve and flexor tendon injuries were included in this retrospective study. The study was approved by Mersin University clinical researches ethical committee. The inclusion criteria for patients were as follows: being between 18 and 65 years of age, willing to cooperate for final evaluation, and having at least 6 months of postoperative follow-up period. Exclusion criteria were as follows: patients with insufficient preoperative data, crush or saw injuries of fingers, both digital nerve injuries in a single finger, digital nerve injuries occurring with phalanx fractures, amputation injuries, and bilateral hand injuries. In total, 31 fingers of 25 patients were included in this study. Primary epineural repair for proper digital nerve lacerations was performed under the surgical microscope with 8:0 or 9:0 polypropylene suture at the same day of emergency service admission. Simultaneous flexor tendon lacerations were repaired with 3:0 polypropylene (modified Kessler or four-strand core suture technique) and with 4:0 or 5:0 polypropylene (circumferential epitendinous suture technique). Surgeons working in Mersin University, faculty of medicine Orthopedics and Traumatology Department, Hand Surgery Division, performed all procedures. A postoperative 3 or 4 weeks of protective dorsal splinting regimen was applied regarding the quality of tendon repair. No specific sensory re-education program was prescribed. Patients' gender, age at admission, trauma date, and injured finger were obtained from patients' computerized data, hospital charts, and folders.
We called the patients for the last follow-up evaluation, and the patients gave written informed consent. We used static 2PD and SWM tests to evaluate the recovered sensibility of the innervated area of the injured nerve. We used the Dellon 2-Point Disk-Criminator in a longitudinal direction of the related autonomous zone of injured digital nerve to measure the distance. The 2PD distances (mm) were then converted to a single number using an ordinal scale (≤6 mm = 4, 7–10 mm = 3, 11–15 mm = 2, and ≥16 mm = 1). A 20-piece full kit of SWM (Touch-Test®, North Coast Medical, Inc., Gilroy, CA, USA) was used to evaluate the cutaneous pressure threshold. Each monofilament was vertically pressed for 2 s onto the skin until it slightly bent, while the patients were holding her eyes closed. We converted the results to a five-point numerical ordinal scale according to the procedure described by Bell-Krotoski [Table 1]. Patients were interviewed for hand dominance, cold intolerance, and if they were satisfied. Cold intolerance were categorized as none = 4, mild = 3, moderate = 2, and severe = 1. Visual analog scale (VAS) was used to evaluate the satisfaction of patients related to the injured finger. Each patient was requested to quantify their satisfaction from 0 to 100 in a decimal order for their every finger individually. Finally, we questioned the patients scored ≤50 if they would wish revision operation. Throughout the follow-up evaluations, we used the uninjured contralateral finger as controls.
|Table 1: Semmes-Weinstein monofilaments five-point numerical ordinal scale|
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We analyzed patients for correlations between VAS score and age, follow-up period, 2PD score, SWM score, cold intolerance score, gender, hand dominance, and the injured finger. Finally, we analyzed all of the cases (31 fingers) for correlations between hand dominance, gender, and the injured finger.
The correlation statistics were analyzed with Spearman's rank correlation for nonparametric variables and with Pearson correlation for parametric variables. Statistical significance was accepted at P < 0.05.
| Results|| |
There were 25 patients who underwent primary epineural repair for 31 proper digital nerve and flexor tendon zone 2 lacerations (18 fingers of 13 men and 13 fingers of 12 women). The mean follow-up period was 31.7 ± 21.1 months. The baseline characteristics were shown in [Table 2].
The median score for VAS was 60 (0–100), and there were 12 fingers with VAS scores of ≤50. The median score of 2PD was 3 (7–10 mm) and of SWM was 3 (0.6–2.0 g). When the correlation statistics were analyzed, patients' satisfaction was significantly correlated only with cold intolerance score (r = 0.396, P = 0.027). There was no significant correlation between patients' satisfaction and age, follow-up period, gender, hand dominance, injured finger, 2PD score, and SWM score [Table 3].
In our study, 21 of 31 fingers (67.7%) had cold intolerance and 14 of them (45.1%) reported to have moderate or severe cold intolerance. When all of the fingers were considered [Table 4], there was a highly significant tendency to be injured for the ulnar fingers (e.g., ring and small) of dominant hands and for the radial fingers (e.g., thumb and index) of nondominant hands (r = −0.550, P < 0.001). Furthermore, nondominant hands of the women and dominant hands of the men were significantly correlated to be injured (r = 0.392, P < 0.05). None of the patients wished revision operation for his/her numbness (digital nerve exploration and revision surgery).
|Table 4: Correlation analysis of hand dominance, gender, and injured finger in all of the fingers|
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| Discussion|| |
Our rationale was that the patients would not care about their recovery of sensation after primary repair of digital nerve when there was a simultaneous flexor tendon injury. We assessed correlation of patients' satisfaction with results of the sensorial evaluation after primary repair of digital nerves and flexor tendons.
This study has several limitations. First, this was a retrospective study and digital nerve repairs were not performed by the same surgeon. Second, the small number of cases was an important limitation. However, this was due to our strict inclusion and exclusion criteria. We only included the unilateral proper digital nerve sharp lacerations. To impede confounders, we excluded fingers with high-energy injuries, both digital nerve injuries of single finger, digital nerve injuries with phalanx fractures, amputations, and bilateral hand injuries. Most of the studies above included one or more of those confounders.,,,,,,,, Finally, not to include the concomitant unilateral digital arterial injury as an independent variable was the last limitation. Although Fakin et al. found no correlation between sensory outcome and digital artery injury in their recent study, the concomitant arterial injury might have affected the cold intolerance of our patients. Our approach to unilateral digital artery injury was surgeon dependent, and some of us would not repair the digital artery if there was no circulatory compromise. Therefore, the documentation of vascular injuries in surgical notes was not trustable and that was why we obliged to ignore it.
Our results demonstrated that most of the injured fingers (67.7%) developed cold intolerance and almost half of them (45.1%) were moderate or severe. Cold intolerance was a well-known sequel following nerve injury.,,, However, the pathophysiology of cold intolerance stays uncertain. Apart from hand injuries, cold intolerance occurs in various vasospastic disorders, such as systemic lupus erythematosus and Raynaud's phenomenon. Several studies reported that cold sensitivity was not purely vascular phenomena and neurogenic pathways probably have role., In our study, there was no correlation between cold intolerance and sensorial recovery, similar to studies of Collins et al. and Freedlander. Although the pathophysiology of cold intolerance is a matter of debate, there is a general agreement that cold intolerance is an important negatively affecting factor on patients' activity of daily living.,,, Supporting this fact, in our series, there was no significant correlation between patients' satisfaction and age, gender, follow-up period, 2PD score, SWM score, hand dominance, and the injured finger, but the cold intolerance was the only factor associated with patients' satisfaction.
We found that after primary repair of proper digital nerves, patients' satisfaction was not correlated with objective evaluation tests of sensorial recovery when there was a concomitant flexor tendon injury. Both 2PD and SWM tests were reported to be valid and reliable measurement tests for functional sensibility., However, how did the discordance appear between objective outcomes and patients' satisfaction? The answer might be related to the concomitant flexor tendon injury. The patients did not care about their recovery of sensation when their fingers' motion was the matter of subject. In other words, the patients' satisfaction was probably based on the motion of the finger, not on the recovery of sensation for these injuries. To impede bias, we did not ask any question and did not perform any measurement about patients' fingers range of motion; nevertheless, patients probably focused on the range of motion of their fingers during the simple question of patients' satisfaction.
None of the patients wished revision surgery for his numbness. We think that this is due to socioeconomic status. Our patients were generally heavy workers and did not care about the fine sensibility. Certainly, the best way is to raise the awareness of hand injury prevention in this high-risk group.
We found a tendency of the ulnar fingers (e.g., ring and small) to be injured in dominant hands of men and of the radial fingers (e.g., thumb and index) in nondominant hands of women. This finding was probably because of the more used grasping action of dominant hand of men (e.g., grasping a sharp material), and the more used supportive action of nondominant hand of women (e.g., holding the vegetable while cutting).
| Conclusion|| |
Patient satisfaction was not related to age, gender, hand dominance, and the injured finger; hence, surgeons should focus on meticulous repair of digital nerves in any age, for any gender, and for any finger of the patients. Cold intolerance was the only factor associated with patients' satisfaction and novel modalities to avoid this phenomenon is a good subject for future researches.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bell C, editor. Of sensibility and touch. 3rd
ed. The Hand: Its Mechanisms and Vital Endowments as Evincing Design. London: William Pickering; 1834. p. 170.
McAllister RM, Gilbert SE, Calder JS, Smith PJ. The epidemiology and management of upper limb peripheral nerve injuries in modern practice. J Hand Surg Br 1996;21:4-13.
Thorsén F, Rosberg HE, Steen Carlsson K, Dahlin LB. Digital nerve injuries: Epidemiology, results, costs, and impact on daily life. J Plast Surg Hand Surg 2012;46:184-90.
Weinzweig N, Chin G, Mead M, Stone A, Nagle D, Gonzalez M, et al.
Recovery of sensibility after digital neurorrhaphy: A clinical investigation of prognostic factors. Ann Plast Surg 2000;44:610-7.
al-Ghazal SK, McKiernan M, Khan K, McCann J. Results of clinical assessment after primary digital nerve repair. J Hand Surg Br 1994;19:255-7.
Bulut T, Akgün U, Çıtlak A, Aslan C, Şener U, Şener M, et al.
Prognostic factors in sensory recovery after digital nerve repair. Acta Orthop Traumatol Turc 2016;50:157-61.
Efstathopoulos D, Gerostathopoulos N, Misitzis D, Bouchlis G, Anagnostou S, Daoutis NK, et al.
Clinical assessment of primary digital nerve repair. Acta Orthop Scand Suppl 1995;264:45-7.
Mailänder P, Berger A, Schaller E, Ruhe K. Results of primary nerve repair in the upper extremity. Microsurgery 1989;10:147-50.
Poppen NK, McCarroll HR Jr., Doyle JR, Niebauer JJ. Recovery of sensibility after suture of digital nerves. J Hand Surg Am 1979;4:212-25.
Slutsky DJ. The management of digital nerve injuries. J Hand Surg Am 2014;39:1208-15.
Sullivan DJ. Results of digital neurorrhaphy in adults. J Hand Surg Br 1985;10:41-4.
Tadjalli HE, McIntyre FH, Dolynchuk KN, Murray KA. Digital nerve repair: Relationship between severity of injury and sensibility recovery. Ann Plast Surg 1995;35:36-40.
Rosén B. Recovery of sensory and motor function after nerve repair. A rationale for evaluation. J Hand Ther 1996;9:315-27.
Bell-Krotoski J. Light touch-deep pressure testing using the Semmes-Weinstein monofilaments. In: Hunter J, Schneider L, Mackin E, Callahan A, editors. Rehabilitation of the Hand: Surgery and Therapy. 3rd
ed. St. Louis: Mosby; 1990. p. 585-93.
Gift AG. Visual analogue scales: Measurement of subjective phenomena. Nurs Res 1989;38:286-8.
Fakin RM, Calcagni M, Klein HJ, Giovanoli P. Long-term clinical outcome after epineural coaptation of digital nerves. J Hand Surg Eur Vol 2016;41:148-54.
Collins ED, Novak CB, Mackinnon SE, Weisenborn SA. Long-term follow-up evaluation of cold sensitivity following nerve injury. J Hand Surg Am 1996;21:1078-85.
Engkvist O, Wahren LK, Wallin G, Torebjrk E, Nystrom B. Effects of regional intravenous guanethidine block in posttraumatic cold intolerance in hand amputees. J Hand Surg Br 1985;10:145-50.
Irwin MS, Gilbert SE, Terenghi G, Smith RW, Green CJ. Cold intolerance following peripheral nerve injury. Natural history and factors predicting severity of symptoms. J Hand Surg Br 1997;22:308-16.
Naidu S, Baskerville PA, Goss DE, Roberts VC. Raynaud's phenomenon and cold stress testing: A new approach. Eur J Vasc Surg 1994;8:567-73.
Backman C, Nyström A, Backman C, Bjerle P. Arterial spasticity and cold intolerance in relation to time after digital replantation. J Hand Surg Br 1993;18:551-5.
Freedlander E. The relationship between cold intolerance and cutaneous blood flow in digital replantation patients. J Hand Surg Br 1986;11:15-9.
Koman LA, Slone SA, Smith BP, Ruch DS, Poehling GG. Significance of cold intolerance in upper extremity disorders. J South Orthop Assoc 1998;7:192-7.
Bell-Krotoski J. Pocket filaments and specifications for the Semmes-Weinstein monofilaments. J Hand Ther 1990;3:26-31.
Dellon AL, Mackinnon SE, Crosby PM. Reliability of two-point discrimination measurements. J Hand Surg Am 1987;12:693-6.
[Table 1], [Table 2], [Table 3], [Table 4]