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Management of Severe Extended Burn Axillary Contracture in a Low-resource Setting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4893. [PMID: 36923714 PMCID: PMC10010848 DOI: 10.1097/gox.0000000000004893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/03/2023] [Indexed: 03/14/2023]
Abstract
Contracture is a common complication of deep burn injury, affecting up to one-third of patients. Although some degree of contracture occurs in any setting, severe extended axillary contractures are more often due to unavailable or inappropriate care. Very few cases have been described in the literature. Their management can be especially challenging in a low-resource environment. The purpose of this article is to present two cases in which severe postburn axillary contractures were effectively managed in a low resource setting, using an island perforator flap coupled with a skin graft or advancement flap. In severe extended axillary contracture, more than one technique is often required to cover the large defect created after contracture release.
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Botman M, Hendriks TCC, de Haas L, Mtui G, Binnerts J, Nuwass E, Niemeijer AS, Jaspers MEH, Winters HAH, Nieuwenhuis MK, van Zuijlen PPM. Access to burn care in low-and middle-income countries: An assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania. J Burn Care Res 2021; 43:657-664. [PMID: 34643726 PMCID: PMC9113785 DOI: 10.1093/jbcr/irab191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study investigates patients' access to surgical care for burns in a low-and-middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50 percent reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within three weeks for 74 percent in this group. Of contracture patients, seventy four percent, had sought healthcare after the acute burn injury. Of the same group, only 4 percent had been treated with skin grafts beforehand, and 70 percent never received surgical care or a referral. Combined, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively impacting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socio-economic factors that determine patient mortality and disability.
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Affiliation(s)
- Matthijs Botman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC (location VUmc), Amsterdam, the Netherlands.,Global Surgery Amsterdam, the Netherlands.,Amsterdam Public Health Research Institute
| | - Thom C C Hendriks
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC (location VUmc), Amsterdam, the Netherlands.,Global Surgery Amsterdam, the Netherlands.,Amsterdam Public Health Research Institute.,Haydom Lutheran Hospital, Department of Surgery, Haydom, Tanzania
| | - Louise de Haas
- Global Surgery Amsterdam, the Netherlands.,Haydom Lutheran Hospital, Department of Surgery, Haydom, Tanzania
| | - Grayson Mtui
- Global Surgery Amsterdam, the Netherlands.,Haydom Lutheran Hospital, Department of Surgery, Haydom, Tanzania
| | - Joost Binnerts
- Global Surgery Amsterdam, the Netherlands.,Haydom Lutheran Hospital, Department of Surgery, Haydom, Tanzania
| | - Emanuel Nuwass
- Global Surgery Amsterdam, the Netherlands.,Haydom Lutheran Hospital, Department of Surgery, Haydom, Tanzania
| | - Anuschka S Niemeijer
- Association of Dutch Burn Centers, Burn Centre Martini Hospital, Groningen, the Netherlands
| | - Mariëlle E H Jaspers
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC (location VUmc), Amsterdam, the Netherlands.,Global Surgery Amsterdam, the Netherlands
| | - Hay A H Winters
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC (location VUmc), Amsterdam, the Netherlands.,Global Surgery Amsterdam, the Netherlands
| | - Marianne K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Centre Martini Hospital, Groningen, the Netherlands.,Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen, the Netherlands
| | - Paul P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC (location VUmc), Amsterdam, the Netherlands.,Global Surgery Amsterdam, the Netherlands.,Burn Center and Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, the Netherlands.,Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, the Netherlands
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Hendriks TCC, Botman M, Binnerts JJ, Mtui GS, Nuwass EQ, Niemeijer AS, Mullender MG, Winters HAH, Nieuwenhuis MK, van Zuijlen PPM. The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up. Burns 2021; 48:215-227. [PMID: 34716045 DOI: 10.1016/j.burns.2021.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/04/2021] [Accepted: 04/23/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country. METHODS Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury. RESULTS Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns. CONCLUSION The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.
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Affiliation(s)
- T C C Hendriks
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands.
| | - M Botman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Doctors of the World, The Netherlands
| | | | - G S Mtui
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - E Q Nuwass
- Haydom Lutheran Hospital, Haydom, Tanzania; Global Surgery Amsterdam, The Netherlands
| | - A S Niemeijer
- Association of Dutch Burn Centers, Burn Center, The Netherlands; Burn Center, Martini Hospital, Groningen, The Netherlands
| | - M G Mullender
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands
| | - H A H Winters
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands
| | - M K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Center, The Netherlands; Burn Center, Martini Hospital, Groningen, The Netherlands
| | - P P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC (Location VU), Amsterdam, The Netherlands; Global Surgery Amsterdam, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, Location AMC and VUmc, Amsterdam, The Netherlands
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Luan A, Mghase AE, Meyers N, Chang J. Are we curing by cutting? A call for long-term follow up and outcomes research in global surgery interventions - perspective. Int J Surg 2021; 87:105885. [PMID: 33513453 DOI: 10.1016/j.ijsu.2021.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 01/06/2023]
Abstract
Success in global surgery interventions cannot be claimed until consistent long-term follow up is achieved and corresponding outcomes are studied. However, post-operative outcomes remain inconsistently collected and analyzed in the setting of global surgery, with current efforts largely focused on the delivery of surgical care. Barriers in low- and middle-income countries include patient cost and distance, low surgical workforce capacity, poor patient health literacy, lack of affordable technology availability, inconsistent documentation, and structural deficiencies. Here, we suggest that future work can be focused on (1) enhancing systems to facilitate long-term follow up and care, (2) expanding availability and adoption of electronic medical record systems, and (3) collaboration with local surgeons in the development of international cross-organizational registries and standardized quality measures. Long-term collaborations between local healthcare administrators and providers, policymakers, international bodies, nonprofit organizations, patients, and the private sector are necessary to build and sustain processes to achieve reliable long-term follow up and rigorous data collection, with the goal of ultimately ensuring better patient outcomes.
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Affiliation(s)
- Anna Luan
- Department of Surgery, Plastic and Reconstructive Surgery Division, Stanford University School of Medicine, Stanford, CA, USA; ReSurge International, Sunnyvale, CA, USA.
| | - Adelaida E Mghase
- Department of Surgery, Plastic and Reconstructive Surgery Unit, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | | | - James Chang
- Department of Surgery, Plastic and Reconstructive Surgery Division, Stanford University School of Medicine, Stanford, CA, USA; ReSurge International, Sunnyvale, CA, USA
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