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Discussion: Measuring Outcomes and Determining Long-Term Disability after Revision Amputation for Treatment of Traumatic Finger and Thumb Amputation Injuries

756e T appropriate assessment of disability after a hand injury has many implications, affecting not only prognosis of function for individuals with newly acquired injuries, but also financial, occupational, and social factors. Given two patients, one with an amputation at the distal interphalangeal joint of the ring finger and one with an amputation at the metacarpophalangeal joint of the thumb, all hand surgeons would likely agree that the thumb amputation results in higher disability than the distal ring finger amputation. However, the article, “Measuring Outcomes and Determining Long-Term Disability after Revision Amputation for Treatment of Traumatic Finger and Thumb Amputation Injuries,” suggests that the American Medical Association guidelines currently used to determine impairment (and possibly disability, by proxy) are an inadequate measurement system, with a lack of measurement of other dimensions of disability such as pain and psychosocial factors. The authors propose that the addition of patient-rated outcomes would improve the American Medical Association metric to clarify a patient’s disability as opposed to simply the impairment. In the context of this article, we respectfully disagree. The authors’ main hypothesis in this article was that patient-rated outcomes would “outperform” functional tests in measuring hand function and disability, including health-related quality of life. However, there were several issues from both a sample and a methodologic perspective that we feel compromise the conclusions drawn in this study. There were also several glaring reporting issues that we feel should have been included in the article. THE JEBSEN-TAYLOR HAND FUNCTION TEST The Jebsen-Taylor Hand Function Test is a functional test that measures seven tasks: writing, card turning, picking up small objects, stacking checkers, simulated feeding, moving light objects, and moving heavy objects.1 Of these tasks, the authors did not include the writing component, as it was felt to be too dependent on hand dominance and therefore difficult to interpret. We do not feel this was adequate justification for eliminating this portion of the scale, as finger amputations on nondominant hands do result in lower impairment (and therefore lower disability) than amputations in dominant hands, and this should be reflected as a part of the evaluation. Elimination of the handwriting component lends the Jebsen-Taylor test to bias toward greater disability if there was a substantial proportion of amputations affecting the nondominant hand, as those scores would have been lower. This bias is not ascertainable in this study, as the proportion of dominant versus nondominant hands was not reported. In addition, the Jebsen-Taylor, though a timed test (technically, a maximum of 14 minutes, as the maximum allowed time for any task is 120 seconds), was primarily validated as a seven-task test, with the writing component as the first task. The removal of the writing component calls into question whether the validity of the Jebsen-Taylor would remain intact, and whether the scores would be affected by not beginning with the writing component in cases where hand fatigue might play a role in the performance of the subsequent tasks. In addition, as the writing component has been shown to have “less” test-retest reliability even in the dominant hand, feeding and moving large, light objects have also been associated with lower test-retest reliability in the nondominant