Quantifying the Burden of Unmet Upper Extremity Care Need in Low-Middle Income Countries: A Four-Country, Cluster-Randomized Study.

PURPOSE: Currently, no nationally implementable survey exists to identify the burden of hand and upper extremity conditions at the household level in low-middle income countries (LMICs). This study describes a randomized cluster survey approach to estimating the burden of hand and upper extremity conditions in four LMICs using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey. Additionally, this study identifies factors associated with responses of unmet surgical need at the multinational level. METHODS: The SOSAS instrument is a cluster-randomized, cross-sectional, countrywide survey of households administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. We identified nationwide trends for sociodemographic, anatomic, condition type, mechanism, prevalence, subjective disability, and barriers to care for upper extremity survey responses. A multivariable model identified factors associated with unmet upper extremity need across the four nations. RESULTS: Across the four countries, 13,763 individuals participated in the survey, with 883 conditions of the upper extremity identified (7.4% of all surgical conditions surveyed). Fractures accompanied many of the injuries (32.3%). Although most conditions were acquired, congenital conditions comprised 11% of all etiologies. Overall, open fire/explosion was the most common mechanism (22.9%). Rwandans had the highest proportion of individuals seeking care (91.0%) and receiving care (88.6%). Sierra Leone indicated the fewest seeking and receiving care (71% and 63%, respectively). Chronic injuries were significantly associated with receiving care, whereas illiteracy and worsening subjective disability were barriers to receiving care. CONCLUSIONS: In this survey of upper extremity conditions from four LMICs, upper extremity conditions primarily resulted from fire/explosions, and many reported sustaining a fracture. Illiteracy and more disabling conditions decreased the odds of receiving care by 30% to 40%, respectively. CLINICAL RELEVANCE: The SOSAS survey may provide a reproducible means to evaluate the unmet need for upper extremity care across similar LMICs.

Treatment and outcomes of arthrogryposis in the upper extremity.

Upper extremity involvement in patients with arthrogryposis multiplex congentia is quite frequent. Treatment initially consists of stretching and splinting as significant gains can be seen in the first years of life. The goal of any surgical procedure is to improve upper extremity function and performance of daily living activities, yet it is important to treat each patient individually and understand that areas do not always need to be addressed surgically. Despite overall lower functioning scores in this patient population, quality of life scores are comparable to the general aged adjusted population. This article will discuss the clinical presentation, treatment procedures and outcomes when addressing the upper extremities of patients presenting with arthrogryposis.

Femoral lengthening over a pediatric femoral nail: results and complications.

BACKGROUND: Limb lengthening by callotasis as described by Ilizarov has become the standard method of lower extremity lengthening. Lengthening over an intramedullary nail to allow early removal of the external fixator has also become common in adults but few studies have addressed the efficacy in children. METHODS: A retrospective review of 37 consecutive children who had undergone femoral lengthening with external fixator over an intramedullary nail was performed. Charts were reviewed for demographics, surgical details, and complications. Radiographs were examined to determine magnitude of lengthening and to calculate lengthening index. RESULTS: The average age of the 37 patients was 11.6 years (range, 8.1 to 17.0). The amount of lengthening averaged 7.0 cm (range, 3.0 to 11.4 cm), which represented a mean 20.4% increase in length. The mean time in the fixator was 81 days. The lengthening index was 1.21 days/mm. Thirteen patients developed major complications (37.8%) including 4 limbs that failed to lengthen initially, 3 fractures (1 before fixator removal and 3 after fixator removal), 2 nail failures, 4 deep infections, and 2 joint subluxations requiring operative care. The 3 fractures after fixator removal were treated with exchange nailing as were the 2 intramedullary nail failures. Four patients (10.8%) developed deep infections requiring irrigation, debridement, and IV antibiotics. One patient developed a late hip subluxation, which was treated with a shelf osteotomy but resulted in pain and limitation of motion. One patient developed knee subluxation during lengthening requiring operative intervention. The technique was successful in obtaining a good result with a functional lengthened femur without unresolved problems in 94% of the patients despite a significant rate of major complications, particularly in those with a congenital etiology. Only 2 of the 37 patients ultimately had results that were ultimately compromised by complications. CONCLUSIONS: Femoral lengthening over an intramedullary nail with the aid of an external fixator has shown to be an effective method for correcting limb length discrepancy. The technique has a high complication rate similar to other methods of lengthening. LEVEL OF EVIDENCE: Level IV-Case Series.