Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations: The FRANCHISE Multicenter International Retrospective Cohort Study

IMPORTANCE Optimal treatment for traumatic digit amputation is unknown. OBJECTIVE To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018. EXPOSURES Revision amputation or replantation of traumatic digit amputations. MAIN OUTCOMES AND MEASURES The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes. RESULTS Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82; P=.02), DASH (-4.29; 95% CI, -8.45 to -0.12; P=.04), and PROMIS (3.44; 95% CI, 0.60 to 6.28; P=.02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9, P=.05), indicating less disability and pain, and PROMIS scores higher (78 vs 75, P=.04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42, P=.03 for DASH and 61 vs 36, P=.01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65, P=.06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm, P=.05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds, P=.001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g, P=.008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg, P=.03). CONCLUSIONS AND RELEVANCE When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.