The Hand: A Second Face?
EARL R. BOGOCH, MD, Msc, FRCSC,
Address reprint requests to Dr. Bogoch.
Die Hand ist sowie das zweite Gesicht der Frau [The hand is like a woman's second face.]
The patient with rheumatoid arthritis (RA) who has severe, advanced involvement in the upper and lower limb joints may require a hierarchy of reconstruction procedures, selected according to the patient's greatest needs. Maintenance of ambulation (lower limb) and maintenance of independence in self-care (upper limb) take priority in the surgical management of these patients1. The suggestion that improvement of the appearance of the hand is an important goal in this context is likely to be dismissed. Add into the decision making process a consideration of escalating health care costs in Canada, with limited surgical resources and long waiting lists, and esthetic considerations in the rheumatoid hand may seem even less significant.
In the RA hand, the primary goals for metacarpophalangeal (MCP) arthroplasty include improvement of hand function, relief of pain, and correction of deformity. For the most part, surgeons that address correction of deformity do so in the context of functional improvement, rather than improvement of appearance. Nevertheless, there is reason to believe that the appearance of the deformed rheumatoid hand is an important issue to many patients, that correction of deformity to improve appearance is a valued benefit of hand surgery, and that therefore it is incumbent upon caregivers to give systematic consideration to this issue.
Surgery is currently considered to be indicated in the RA hand with significant flexion contractures in order to open the hand for grip, in a joint stiff in extension to permit flexion, in progressive and persistent ulnar drift to place the fingers in a position of function, and in destroyed joints to relieve pain and provide stability or mobility2-8. Indications for surgery are strengthened where both hands are involved and in cases where improved hand function will permit use of a cane for ambulation8.
The pain pattern is different in the RA patient, who experiences pain and stiffness during intermittent active periods of the disease. Late in the disease, despite extensive joint destruction, pain is often not severe in RA and is typically not the primary indication for surgery.
After MCP reconstruction, ulnar drift deformity is substantially reduced, and the index finger is placed in a position that improves pinch function. However, objectively measured improvement in grip function is not highly consistent or predictable, and improvement in the mean active range of MCP motion is modest or minimal, although the shift in the arc of motion usually permits greater functionality3,5-11. Improvement in function is also dependent on the condition of the proximal interphalangeal joints and the thumb12.
Despite modest or no improvement in objectively measured functional outcomes, 68% to 100% of patients subjectively indicated a substantial improvement in function following surgery, which may be partially attributed to improved performance of activities of daily living, elimination of pain, and improved stability through the joint2,4,5,8-10,13-16. Further, several studies report that the majority of RA patients (86%-100%) indicated satisfaction with improved appearance of the hand almost immediately following surgery8,13-16. Finally, 84% to 100% of patients report overall satisfaction with MCP reconstruction3,6,7,9,14. A retrospective study of 26 patients by Mandl, et al in this issue17 reports that 69% of patients expressed overall satisfaction with MCP reconstruction, and postoperative hand appearance and pain were the outcome measures most highly correlated with overall patient satisfaction.
Why does a patient express high satisfaction with an operation where improvement in grip function is not highly consistent or predictable and range of motion may remain limited? To what degree might the esthetic appearance of the hand be an element of patient satisfaction with this procedure? Some studies acknowledge that patients appreciated the esthetic improvement of their hands following surgery5,8,9,14. Mandl, et al17 reported a Spearman correlation of 0.6 to 0.7 between postoperative hand appearance and overall patient satisfaction with surgery. Swanson, et al18 emphasized assessment of both the passive and active elements in relation to general appearance, rotational deformity, scarring, coordination, stiffness, and residual joint imbalance, where both the examiner and patient rate the cosmetic improvement after surgery on a 3 point scale of minimum (1), moderate (2), and marked (3). However, no systematic or standardized attempt has been made to specifically measure patient satisfaction with surgical change in the appearance of the hand or to compare it with satisfaction with other aspects of the results of the surgery.
If visible improvement of the deformity and appearance of the RA hand following surgery is to be systematically considered, it could be reviewed under 3 criteria: (1) patient motivation and indications for surgery; (2) patient rating of the quality of the outcome; and (3) patient satisfaction with the outcome.
In a pilot study to determine the relative role of esthetics versus function and pain in patients' motivations for surgery and in patients' perception of and satisfaction with the outcome, we conducted a retrospective review of 22 patients with RA (95% female; mean age 66 yrs; mean disease duration 18.5 yrs, mean followup period 5 yrs), who had undergone MCP reconstruction for digits 2-5 inclusive, performed by one of the authors (ERB). Patient views were collected through interview, using the esthetics subscale of the Michigan Hand Outcomes Questionnaire19,20, and a purpose written questionnaire using 7-point Likert scale questions specifically developed to assess patients' reasons to undergo MCP reconstruction (motivation), rating of outcome, and satisfaction with outcome, separately for hand appearance, function, and pain (Appendix I). Means were determined for each question, and a chi-square test was used to compare means and determine a statistically significant difference at p = 0.05. Median differences in patient agreement were also compared by Mann-Whitney test.
A desire for improvement in hand appearance was found to be as strong a patient motivator in the decision to have hand surgery as relief of pain, but less strong than a desire for improvement in hand function (p < 0.05) (Figure 1, Motivation). When patients were asked to rate the outcomes of the surgery, there was no median significant difference between improved appearance and improved function outcome ratings, and improved appearance outcome was rated superior to pain relief outcome after surgery (p < 0.05) (Figure 1, Outcome).
Figure 1: Median patient response (n = 22) on a 7-point Likert agreement scale, where 1 represents strong agreement and 7 represents strong disagreement, with statements that function, hand appearance, and pain were: a strong motivator for hand surgery (Motivation); improved following surgery (Outcome); and were satisfactory after surgery (Satisfaction).
When asked to rate their satisfaction with the surgery, patients expressed higher satisfaction with improved appearance and improved function outcomes than with pain relief outcome. Patients were at least as satisfied with improved appearance outcome as with improved function outcome, with a trend towards higher satisfaction with appearance than function (Figure 1, Satisfaction). In a subset of 6 patients, the reconstructed hand was less functional than the non-operated hand, as defined by Jamar grip strength, Jamar pinch strength, active range of motion, and the Jebsen hand function test. All 6 patients reported high satisfaction with their reconstructed hands and expressed the desire to have their second hand reconstructed to correct deformity, even though measured function was superior in the non-operated hand.
This simple examination of surgical patients' motivations and satisfaction with outcomes of surgery, while not conclusive, suggests that these patients were strongly motivated to have their hand deformity or appearance corrected, that they considered their hand appearance improved by surgery, and that their satisfaction with surgery was partly predicated on the improvement with the esthetics of their hand.
A patient with RA who has a MCP flexion deformity that prevents opening of the hand, complicating the simple act of shaking hands, faces a physical, psychological, and social barrier when greeting another person. Rheumatologists may recognize the look of anxiety that passes across a patient's face when the physician offers to shake hands and, subsequently, the look of relief when the hand is grasped in a manner that conveys understanding of the deformity and minimizes discomfort and embarrassment (Figure 2).
Figure 2. The hand a second face?
Correction of disfigurement and improvement of appearance are widely accepted primary indications for surgery in other fields, particularly with respect to reconstructive or esthetic surgery of the face and the breast. As defined by the American Society of Plastic Surgeons21, reconstructive surgery is performed "on abnormal structures to improve function," but also, and one could argue, more frequently, "to approximate a more normal appearance." Common reconstructive surgical procedures with a substantial cosmetic component include breast reduction, correction of breast asymmetry, burn scar revision, and improvement of congenital deformities and keloid formations of the face. These are mainstream surgical activities supported by publicly funded billing criteria and listed in the International Classification of Disorders (ICD), reflecting their legitimacy. Esthetic surgery is performed to "reshape normal structures of the body to improve the patient appearance and self-esteem"21.
Attempts to examine patient motivations, define surgical goals, assess outcome measures, and ascertain patient satisfaction for reconstructive and esthetic surgical procedures of the face and breast have been limited22. Appearance outcome measures are often highly subjective, consisting of panels of surgeons, medical staff, and patients that rank pre and postoperative photographs on a simple ordinal scale, where each grade is generally poorly defined, if at all, or using a visual analog scale22-26. Other outcome measure studies have applied quality of life measures such as the Medical Outcome Study Short Form-3627-29, and psychological questionnaires to evaluate patient anxiety, self-esteem and depression, such as the Crown-Crisp Experiential Index23,30,31. Recently, several new objective grading systems have been developed for esthetic outcome evaluation of cosmetic breast and facial surgery32-35. These provide a standardized evaluation of the efficacy of these treatments in achieving specific goals. However, we have found no report that systematically assessed the esthetic outcome of the rheumatoid hand following surgical procedures.
We conducted an informal survey of 25 hand surgeons active in rheumatoid hand reconstruction in 4 countries by mail questionnaire, utilizing Likert scales, to elucidate the reasons for performing surgery (Appendix II). Thirty-five per cent of the 23 respondents agreed that hand deformity is a primary indication, 25% neither agreed nor disagreed, and 40% disagreed (responding that hand deformity was not in their view a primary reason for MCP reconstruction). While some surgeons acknowledge that esthetic improvement of the hand may be a consideration that influences the patient's satisfaction with the surgery, they tend to emphasize that it should only be a secondary indication for surgery9.
Outcome analysis of rheumatoid hand surgery usually includes clinician-focused objective tests that evaluate functional outcome (grip strength, pinch strength, active range of motion). However, a search of the literature has found only one study utilizing the patient-focused Arthritis Impact Measurement Scale for evaluation of MCP arthroplasty36. Since our preliminary data indicate that appearance may be a motivating factor for a patient to have surgery, and since patient satisfaction is high despite moderate functional outcomes, it would be valuable to introduce more patient-focused assessments. These might include patient specific indices that allow patients to choose the outcome measures that are important prior to their surgery, which may include esthetic appearance.
This issue could be better clarified with a prospective study that follows patients from their first visit with the surgeon to one or more years postoperatively. The study would utilize patient specific indices to define their motivation for the surgery and their feelings regarding the deformity, in order to establish what is important, not only to the doctor, but also to the patient.
Our working hypothesis is the following: there is unmeasured motivation for patients who choose to have corrective surgery for a deformity of the rheumatoid hand and an unmeasured source of satisfaction after the surgery. This hypothesis is currently being tested in a prospective study. We seek to determine if esthetic considerations are important to the patients. The ultimate goal of this and other studies is to help us refine indications for surgery and to determine which operations are best received by patients. Ultimately, we want surgery to be evidence based, utilizing, among other factors, the determinants of patient motivation and satisfaction. There is no intention to recommend that esthetic appearance replace functional outcome as the primary indication for surgery. We do, however, believe that rheumatologists and orthopedic surgeons need to evaluate to what degree improvement of appearance is a legitimate and perhaps equally important indication for surgery of the hand in the RA patient, and to what degree esthetic improvement after surgery is valued by the patient.
The authors thank Nancy De Boni for creating the illustration, and Dagmar Gross for assistance with preparation of this manuscript.
Appendix I. Patient survey questionnaire.
Appendix II. Surgeon survey questionnaire.
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