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Bionic Upper Limb Reconstruction: A Valuable Alternative in Global Brachial Plexus Avulsion Injuries-A Case Series.

ABSTRACT: Global brachial plexopathies including multiple nerve root avulsions may result in complete upper limb paralysis despite surgical treatment. Bionic reconstruction, which includes the elective amputation of the functionless hand and its replacement with a mechatronic device, has been described for the transradial level. Here, we present for the first time that patients with global brachial plexus avulsion injuries and lack of biological shoulder and elbow function benefit from above-elbow amputation and prosthetic rehabilitation. Between 2012 and 2017, forty-five patients with global brachial plexus injuries approached our centre, of which nineteen (42.2%) were treated with bionic reconstruction. While fourteen patients were amputated at the transradial level, the entire upper limb was replaced with a prosthetic arm in a total of five patients. Global upper extremity function before and after bionic arm substitution was assessed using two objective hand function tests, the action research arm test (ARAT), and the Southampton hand assessment procedure (SHAP). Other outcome measures included the DASH questionnaire, VAS to assess deafferentation pain and the SF-36 health survey to evaluate changes in quality of life. Using a hybrid prosthetic arm mean ARAT scores improved from 0.6 ± 1.3 to 11.0 ± 6.7 (p = 0.042) and mean SHAP scores increased from 4.0 ± 3.7 to 13.8 ± 9.2 (p = 0.058). After prosthetic arm replacement mean DASH scores improved from 52.5 ± 9.4 to 31.2 ± 9.8 (p = 0.003). Deafferentation pain decreased from mean VAS 8.5 ± 1.0 to 6.7 ± 2.1 (p = 0.055), while the physical and mental component summary scale as part of the SF-36 health survey improved from 32.9 ± 6.4 to 40.4 ± 9.4 (p = 0.058) and 43.6 ± 8.9 to 57.3 ± 5.5 (p = 0.021), respectively. Bionic reconstruction can restore simple but robust arm and hand function in longstanding brachial plexus patients with lack of treatment alternatives.

SUBMITTER: Hruby LA

PROVIDER: S-EPMC7019829 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Bionic Upper Limb Reconstruction: A Valuable Alternative in Global Brachial Plexus Avulsion Injuries-A Case Series.

Hruby Laura A LA Gstoettner Clemens C Sturma Agnes A Salminger Stefan S Mayer Johannes A JA Aszmann Oskar C OC

Journal of clinical medicine 20191220 1

Global brachial plexopathies including multiple nerve root avulsions may result in complete upper limb paralysis despite surgical treatment. Bionic reconstruction, which includes the elective amputation of the functionless hand and its replacement with a mechatronic device, has been described for the transradial level. Here, we present for the first time that patients with global brachial plexus avulsion injuries and lack of biological shoulder and elbow function benefit from above-elbow amputat ...[more]

PMID: 31861941

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Project description:Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand. Many patients report of psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation and prosthetic replacement of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. In this paper we describe a psychosocial assessment procedure for bionic reconstruction in patients with complete brachial plexopathies and present psychosocial outcome variables associated with bionic reconstruction.Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted semi-structured interviews exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. During the interview patients were asked to respond freely. Their answers were transcribed verbatim by the interviewer and analyzed afterwards on the basis of a pre-defined item scoring system. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning (SF-36 Health Survey), body image (FKB-20) and deafferentation pain (VAS). Additionally, psychosocial outcome variables were presented for seven patients before and after bionic reconstruction.Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. 88% of patients felt functionally limited to a great extent due to their disability, and all of them reported constant, debilitating pain in the deafferented hand. After bionic reconstruction the physical component summary scale increased from 30.80 ± 5.31 to 37.37 ± 8.41 (p-value = 0.028), the mental component summary scale improved from 43.19 ± 8.32 to 54.76 ± 6.78 (p-value = 0.018). VAS scores indicative of deafferentation pain improved from 7.8 to 5.6 after prosthetic hand replacement (p-value = 0.018). Negative body evaluation improved from 60.71 ± 12.12 to 53.29 ± 11.03 (p-value = 0.075). Vital body dynamics increased from 38.57 ± 13.44 to 44.43 ± 16.15 (p-value = 0.109).Bionic reconstruction provides hope for patients with complete brachial plexopathies who have lived without hand function for years or even decades. Critical patient selection is crucial and the psychosocial assessment procedure including a semi-structured interview helps identify unresolved psychological issues, which could preclude or delay bionic reconstruction. Bionic reconstruction improves overall quality of life, restores an intact self-image and reduces deafferentation pain.

Project description:BACKGROUND:Regional anaesthesia for upper limb surgery is routinely performed with brachial plexus blocks. A retroclavicular brachial plexus block has recently been described, but has not been adequately compared with another approach. This randomised controlled single-blinded trial tested the hypothesis that the retroclavicular approach, when compared with the supraclavicular approach, would increase the success rate. METHODS:One hundred and twenty ASA physical status 1-3 patients undergoing distal upper limb surgery were randomised to receive an ultrasound-guided retroclavicular or supraclavicular brachial plexus block with 30 mL of a 1:1 mixture of mepivacaine 1% and ropivacaine 0.5%, using a single-injection technique without needle tip repositioning. The primary outcome was block success rate 30 min after local anaesthetic injection, defined as a composite score of 14 of 16 points, inclusive of sensory and motor components. Secondary outcomes included needling time, time to first opioid request, oxycodone consumption, and pain scores (numeric rating scale, 0-10) at 24 h postoperatively. RESULTS:Success rates were 98.3% [95% confidence interval (CI): 90.8%, 99.9%] and 98.3% [95% CI: 90.9%, 99.9%] in the supraclavicular and retroclavicular groups, respectively (P=0.99). The mean needling time was reduced in the supraclavicular group [supraclavicular: 5.0 (95% CI: 4.7, 5.4) min; retroclavicular: 6.0 (95% CI: 5.4, 6.6) min; P=0.006]. The mean time to first opioid request was similar between groups [supraclavicular: 439 (95% CI: 399, 479) min; retroclavicular: 447 (95% CI: 397, 498) min; P=0.19] as were oxycodone consumption [supraclavicular: 10.0 (95% CI: 6.5, 13.5 mg; retroclavicular: 7.9 (95% CI: 4.8, 11.0) mg; P=0.80] and pain scores at 24 h postoperatively [supraclavicular: 1.2 (95% CI: 2.1, 2.7); retroclavicular: 1.5 (95% CI: 1.6, 2.4); P=0.09]. CONCLUSIONS:Ultrasound-guided retroclavicular and supraclavicular brachial plexus blocks share identical success rates, while providing similar pain relief. Reduced needling time in the supraclavicular approach is not clinically relevant. CLINICAL TRIAL REGISTRATION:NCT02641613.

Project description:BackgroundTraumatic brachial plexus injuries (BPIs) disproportionately affect young, able-bodied individuals. Beyond direct costs associated with medical treatment, there are far-reaching indirect costs related to disability and lost productivity. Our objective was to estimate per-patient indirect cost associated with BPI.MethodsWe estimated indirect costs as the sum of (1) short-term wage loss, (2) long-term wage loss, and (3) disability payments. Short-term (6-month) wage loss was the product of missed work days and the average earnings per day. The probability of return to work was derived from a systematic review of the literature, and long-term wage loss and disability payments were estimated. Monte Carlo simulation was used to perform a sensitivity analysis of long-term wage loss by varying age, sex, and return to work simultaneously. Disability benefits were estimated from U.S. Social Security Administration data. All cost estimates are in 2018 U.S. dollars.ResultsA systematic review of the literature demonstrated that the patients with BPI had a mean age of 26.4 years, 90.5% were male, and manual labor was the most represented occupation. On the basis on these demographics, our base case was a 26-year-old American man working as a manual laborer prior to BPI, with an annual wage of $36,590. Monte Carlo simulation estimated a short-term wage loss of $22,740, a long-term wage loss of $737,551, and disability benefits of $353,671. The mean total indirect cost of traumatic BPI in the Monte Carlo simulations was $1,113,962 per patient over the post-injury lifetime (median: $801,723, interquartile range: $22,740 to $2,350,979). If the probability of the patient returning to work at a different, lower-paying job was doubled, the per-patient total indirect cost was $867,987.ConclusionsBPI can have a far-reaching economic impact on both individuals and society. If surgical reconstruction enables patients with a BPI to return to work, the indirect cost of this injury decreases.Level of evidenceEconomic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Project description:BackgroundPrevious studies of factors associated with prolonged duration of ultrasound-guided brachial plexus block have included multiple surgical procedures or multiple anesthetic approaches, all of which are important confounders, and there is no study based on a single method of anesthesia exploring the factors affecting the resolution of brachial plexus block during upper limb surgery, especially in Asians. This study aimed to identify the risk factors affecting the prolonged duration of US-guided brachial plexus block in American Society of Anesthesiologists (ASA) I-II grade patients to improve postoperative analgesia.MethodsThis study enrolled patients scheduled to undergo surgery for upper limb fracture in Anting Hospital, Shanghai from May 2021 to September 2021. Inclusion criteria: (I) patients aged 18 years and above; (II) ASA I-II grade patients; (III) success of US-guided brachial plexus block. Based on the median duration of brachial plexus block, patients were divided into a <5-hour group and a ≥5-hour group. The factors were selected base on previous studies conclution and clinical demographic characteristics of patients. Multivariable logistic regression was used to estimate relevant influencing factors.ResultsA total of 129 patients (51.2% males; 51.01±16.54 years old) were analyzed. The duration of brachial plexus block was 2-12 hours, with a median duration of 5.09 hours. Multivariable analysis suggested that age 40-49 years [odds ratio (OR): 4.841; 95% confidence interval (CI): 1.033 to 22.695; P=0.045], 50-59 years (OR: 4.730, 95% CI: 1.149 to 19.474; P=0.031), 60 years (OR: 8.540; 95% CI: 1.605 to 45.449; P=0.012), gender (OR: 3.314; 95% CI: 1.330 to 8.257; P=0.010), alanine aminotransferase (ALT; OR: 5.817, 95% CI: 1.509 to 22.472; P=0.011), and glomerular filtration rate (GFR) <60 (OR: 22.700; 95% CI: 1.994 to 198.386; P=0.012) were the risk factors for the duration of brachial plexus block.ConclusionsIt is advisable to use the lowest effective dose for the shortest possible time when using ropivacaine in upper limb fracture surgery patients with elevated ALT (≥40 U/L) and lower GFR (<60 mL/min) in male patients aged ≥60 years.

Dataset Information

Bionic Upper Limb Reconstruction: A Valuable Alternative in Global Brachial Plexus Avulsion Injuries-A Case Series.

Publications

Bionic Upper Limb Reconstruction: A Valuable Alternative in Global Brachial Plexus Avulsion Injuries-A Case Series.

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