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Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting

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Abstract

Background

At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability .

Methods

Forty-six patients were evaluated 6 months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen–Taylor test (JTT), and patient-reported outcomes (PROs)—Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson’s correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes.

Results

MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson’s coefficients all ≥0.33, p ≤ 0.05). In this cohort, mean MHQ score was 79 ± 15 and mean DASH score was 13 ± 15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs 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 job after injury.

Conclusions

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 and may be used to assess post-traumatic disability.

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Acknowledgements

Research reported in this publication was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number 2 K24-AR053120-06. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author information

Authors and Affiliations

  1. Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5340, USA

    Aviram M. Giladi & Kevin C. Chung

  2. Department of Plastic, Hand, and Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, India

    R. Raja Shanmugakrishnan, Hari Venkatramani & S. Raja Sabapathy

  3. Department of Orthopedic Surgery, Ganga Hospital, Coimbatore, India

    S. Raja Sekaran

Authors
  1. Aviram M. Giladi
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  2. R. Raja Shanmugakrishnan
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  3. Hari Venkatramani
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  4. S. Raja Sekaran
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  5. Kevin C. Chung
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  6. S. Raja Sabapathy
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Corresponding author

Correspondence to Kevin C. Chung.

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Electronic supplementary material

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Case Figure 1: Injury resulting from machinery accident (PNG 2348 kb)

Case Figure 2: Injury resulting from a motor vehicle collision (PNG 3295 kb)

268_2017_3902_MOESM3_ESM.jpg

Case Figure 3: Result after repair of humerus, radius, ulna, and radial nerve, and coverage with abdominal flap (JPG 3672 kb)

268_2017_3902_MOESM4_ESM.jpg

Case Figure 4: Result after repair of radial and ulnar artery, radius, ulna, thumb and finger tendons, and placement of skin graft (JPG 1012 kb)

Patient (Case Figures 2 and 4) demonstrating range of motion 13 months after surgery (MPG 13567 kb)

268_2017_3902_MOESM6_ESM.mpg

Patient (Case Figures 1 and 3) demonstrating ADLs with the reconstructed limb nearly 10 years after surgery (MPG 20807 kb)

Appendix

Appendix

See Table 5.

Table 5 Univariate analysis across all variables and the different outcome measures
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Giladi, A.M., Shanmugakrishnan, R.R., Venkatramani, H. et al. Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting. World J Surg 41, 1420–1434 (2017). https://doi.org/10.1007/s00268-017-3902-1

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  • DOI: https://doi.org/10.1007/s00268-017-3902-1

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