Outcomes of Massive Proximal Upper Extremity Reconstruction in the Resource-Poor Setting: Level 4 Evidence

Abstract

There is no financial information to disclose. Considering current limitations in prosthetics and hand transplantation, limb salvage remains the dominant reconstructive option for proximal upper extremity trauma. This is especially true in countries where social services are not available to support the disabled. At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries.1Sabapathy S.R. Venkatramani H. Bharathi R.R. Dheenadhayalan J. Bhat V.R. Rajasekaran S. Technical considerations and functional outcome of 22 major replantations (The BSSH Douglas Lamb Lecture, 2005).J Hand Surg Eur Vol. 2007; 32: 488-501Crossref PubMed Scopus (41) Google Scholar However, long-term outcomes of complex reconstruction performed in this resource-limited setting are not known. We hypothesize that patient-reported outcome questionnaires (PROs) can measure functional and health-related quality-of-life (QoL) outcomes after upper extremity salvage, and determine what injury components and outcomes predict long-term success. Forty-six patients were evaluated 6 months or more after massive upper extremity reconstruction at Ganga Hospital. Demographic and employment data were collected. Patients completed isolated functional tests, Jebsen-Taylor composite functional test (JTT), and PROs – Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between outcomes metrics were assessed with Pearson’s correlation coefficients. Linear regression modeling evaluated associations between injury severity, reconstruction required, and outcomes. MHQ and DASH had significant correlations with functional tests, JTT, and SF-36 (Figure 1). Mean MHQ score was 79 +/- 15 and mean DASH score was 13 +/- 15, not significantly different than long-term outcomes after other upper extremity procedures.2Shauver M.J. Chung K.C. The Michigan Hand Outcomes Questionnaire after 15 Years of field trial.Plast Reconstr Surg. 2013; 131: 779e-787eCrossref PubMed Scopus (70) Google Scholar Injury severity score, as well as most fractures and vessel injuries, did not predict outcomes; however, the following factors did predict patient-reported outcomes and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their current job after injury (Table 1). •Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes.•PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing.•Extent of soft tissue reconstruction and need for median nerve repair are more predictive of outcomes and satisfaction than other elements of reconstruction.•Facilitating return to work is critical in improving outcomes and satisfaction for patients in the developing world.View Large Image Figure ViewerDownload Hi-res image Download (PPT)