1. Intra-patient controlled outcome measures of Zone 1/2 EPL repairs post 4-weeks immobilisation and cost analysis
Ali Arnaout (1), Paul Caine* (1), Elizabeth Mawby (2), Christopher Powell (1)
Department of Plastic, Burns and Reconstructive Surgery, Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Aylesbury, UK;
*Presenting author
(2) Department of Physiotherapy, Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Aylesbury, UK
Aims & Objectives
RESULTS
DISCUSSION
Extensor Pollicis Longus (EPL) division is a commonly encountered injury seen in hand trauma units. Despite this, the literature on the subject regarding management, is limited and rarely discussed in isolation from other finger extensors injuries.
There are two accepted rehabilitation regimes for EPL mobilisation after surgical repair and these include;
The utilisation of early active movement (EAM) regimes
Splinting
European units is immobilising the repair in a cast or early active mobilisation, with or without dynamic outrigger for 4 to 6 weeks followed by active mobilisation for further 2-4 weeks.
We decided to assess the outcome of our EPL repairs in zone 1 and 2, through an intra-patient controlled range of movement outcome measures, following 4 weeks static regime and analysed the associated physiotherapy cost .
Over half of the patients regained >75% of the ROM of the unoperated thumb within only 2 or 3 physiotherapy sessions.
Literature published previously by Stuart el al 1965, and Mowlavi et al 2005 both reported no long-term superiority of mobilisation protocols over immobilisation.
The reported NHS tariff for a physiotherapy session is £81(€91.37) for the initial session followed by £40(€45)/session.
Extrapolating this data, immobilising post EPL repair and discharging in 3 session (66%) will cost £161(€181.61) , while for early active movement it is suggested a patient will have between 8-12 weeks of physiotherapy, every 2 weeks which is postulated to cost between £281
This leads an increased cost of 76% per patient without any likely long-term benefit.
Although greater ROM represents restoration closer to pre-injury movement, it does not necessarily reflect the restoration of function.
The thumb is very versatile in adapting to a reduced ROM in one joint by increasing the ROM in another joint and thus preventing or minimising functional loss.
In future projects, we will assess the outcome using functional measures, such as the time of returning to work post-injury, any difficulty with function or pain, using a variety of Patient reported Outcome Measures (PROMS) ideally with a larger sample size.
Total sample size N=20 patients
Followed up to discharge.
ROM started days after surgery 90% (N=18).
Over half (55%) of cases therefore, achieved 75% ROM of the control thumb on discharge, 95% achieved over >50% ROM on discharge.
66% of patients required less than 3 sessions, and 80% of patients were discharged after fewer than 8 treatment sessions.
METHOD
Prospective data was collected by the departmental hand specialist physiotherapists, between February 2013 and September Any patient identified as having a complete Zone 1 or Zone 2 EPL who underwent surgical repair of the tendon was selected for inclusion.
Total Active Movement (TAM), which calculates the active range of movement as a percentage of movement of the unoperated thumb at the metacarpophalangeal joint (MCPJ) and the interphalangeal joint (IPJ) and White’s criteria (1956) was used to analyse the range of movement outcome post repair.
All therapists within the department were taught how to measure thumb range of movement (ROM) according to department guidelines using standardised positioning and equipment.
Conclusion
REFERENCES .
White, WL (1956). Secondary restoration of finger flexion by digital tendon grafts. An evaluation of 76 cases, The American Journal of Surgery 91: 662–668
Khandawala et al. Immediate repair and early mobilisation of Extensor Pollicus Longus Tendon in zones 1-4. British Journal of Hand Surgery 2004, 29:B
Mowlavi, A, Burns, M, Brown, RE. Dynamic versus static splinting of simple zone V and zone VI extensor tendon repairs: a prospective, randomized, controlled study. Plast Reconstr Surgery 2005; 115: 482–487.
Stuart D, Duration of spliting after repair of extensor tendons in the hand. The Journal of Bone and Joint surgery : 72-79