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American Association for Hand Surgery

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The Role of Amputation and Myoelectric Prosthetic Fitting in Patients with Traumatic Brachial Plexus Injuries
Sean R. Cantwell, MD, Nicholas A. Pulos, MD, Robert J. Spinner, MD, Allen T Bishop, MD and Alexander Y. Shin, MD, Mayo Clinic, Rochester, MN

Introduction
Advancements over the past 20 years have led surgeons to consider amputation a failure of treatment for patients with traumatic brachial plexus injures (BPIs). Despite this, a cohort of patients exists who have either failed surgical reconstruction or are unsatisfied with their outcomes, are burdened by paralyzed and insensate limbs, and have sought elective amputation. With lighter weight myoelectric prosthetics (MEPs) using nonintuitive control mechanisms, some of these patients have demonstrated great improvement of their function. We sought to determine the role and outcome of amputation in this patient population, as well as determine if prosthetic fitting with nonintuitive myoelectric control mechanisms was feasible and functionally useful.

Materials & Methods
A retrospective review of patients with BPIs who underwent elective upper extremity amputation at a single BPI clinic between 2001 and 2020 was performed. Medical records were reviewed for demographics, injury details, reconstruction attempts, amputation characteristics, outcomes, and complications. Patients' use of MEPs was determined, as well as their functional benefit from the device. Primary outcomes included post-amputation visual analog scale (VAS) pain scores and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores.

Results
Thirty-two patients with BPIs underwent elective amputation. Seventeen patients (53%) underwent prosthetic fitting and 10 patients (31%) were fit for MEP devices. Transradial amputees were more likely to undergo prosthetic fitting and MEP fitting. Patients who experienced spontaneous nonfunctional recovery or improvements after surgery tended to undergo MEP fitting. Post-amputation VAS scores decreased for all patients regardless of amputation level or prosthetic fitting. DASH scores were not significantly different before and after amputation, reflecting the severity of the BPI disability. Patients were more likely to be employed following amputation regardless of prosthetic fitting. No patient expressed regret about undergoing amputation. All patients fit for MEPs reported regular use of their prosthetic compared to 29% of patients fit for traditional prosthetics. 100% of patients fit with MEPs demonstrated functional terminal grasp/release. No major complications occurred as a result of amputation.

Conclusions
Amputation is a safe, effective treatment for patients with severe BPIs who fail attempts at surgical reconstruction or are ineligible for reconstruction due to the severity of their injuries. In amputees with sufficient nonintuitive myoelectric signals, MEP fitting allows for dramatically increased function, resulting in high rates of prosthetic use with grasp and release. Amputation is associated with decreased mechanical pain, increased rates of employment, and high levels of patient satisfaction.


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