RESUMEN
INTRODUCTION: Extracorporeal membrane oxygenation (ECMO)-associated compartment syndrome (CS) is a rare complication seen in critically ill patients. The epidemiology and management of ECMO-associated CS in the upper extremity (UE) and lower extremity (LE) are poorly defined in the literature. We sought to determine the epidemiology and characterize treatment and outcomes of UE-CS compared to LE-CS in the setting of ECMO therapy. METHODS: Adult patients undergoing ECMO therapy were identified in the Nationwide Readmission Database (2015-2019) and followed up for 6 months. Patients were stratified based on UE-CS versus LE-CS. Primary outcomes were fasciotomy and amputation. All-cause mortality and length of stay were also collected. Risk-adjusted modeling was performed to determine patient- and hospital-level factors associated with differences in the management UE-CS versus LE-CS while controlling for confounders. RESULTS: A total of 24,047 cases of ECMO during hospitalization were identified of which 598 were complicated by CS. Of this population, 507 cases were in the LE (84.8%), while 91 (15.5%) were in the UE. After multivariate analysis, UE-CS patients were less likely to undergo fasciotomy (50.5 vs. 70.9; P = 0.013) and were less likely to undergo amputation of the extremity (3.3 vs. 23.7; P = 0.001) although there was no difference in mortality (58.4 vs. 65.4; P = 0.330). CONCLUSIONS: ECMO patients with CS experience high mortality and morbidity. UE-CS has lower rates of fasciotomy and amputations, compared to LE-CS, with similar mortality. Further studies are needed to elucidate the reasons for these differences.
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Síndromes Compartimentales , Bases de Datos Factuales , Oxigenación por Membrana Extracorpórea , Fasciotomía , Humanos , Oxigenación por Membrana Extracorpórea/estadística & datos numéricos , Oxigenación por Membrana Extracorpórea/efectos adversos , Masculino , Síndromes Compartimentales/etiología , Síndromes Compartimentales/epidemiología , Síndromes Compartimentales/terapia , Síndromes Compartimentales/mortalidad , Síndromes Compartimentales/cirugía , Femenino , Persona de Mediana Edad , Bases de Datos Factuales/estadística & datos numéricos , Fasciotomía/estadística & datos numéricos , Adulto , Anciano , Amputación Quirúrgica/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos/epidemiología , Extremidad Inferior/irrigación sanguínea , Extremidad Superior , Tiempo de Internación/estadística & datos numéricos , Resultado del TratamientoRESUMEN
INTRODUCTION: The primary aim of this randomized controlled trial was to assess if a head-mounted display (HMD) providing telemedicine support improves performance of a two-incision lower leg fasciotomy by a NATO special operations combat medic (combat medic). MATERIALS AND METHODS: Thirty-six combat medics were randomized into two groups: One group performed a two-incision lower leg fasciotomy with the assistance of an HMD, while the control group completed the procedure without guidance. A Mann-Whitney U test was used to determine the possible differences in release of compartments and performance scores, as assessed by a supervising medical specialist. A Fisher's exact test was used to compare the proportions of collateral damage between groups. An independent-samples t-test was used to interpret total procedure times. The usability and technical factors involving HMD utilization were also assessed. RESULTS: Combat medics in the HMD group released the anterior compartment (P ≤ .001) and deep posterior compartment (P = .008) significantly better. There was significantly more iatrogenic muscle (P ≤ .001) and venous damage (P ≤ .001) in the control group. The overall performance of combat medics in the HMD group was significantly better than that of the control group (P < .001). Combat medics in the control group were significantly faster (P = .012). The combat medics were very satisfied with the HMD. The HMD showed no major technical errors. CONCLUSIONS: This randomized controlled trial shows that a HMD providing telemedicine support leads to significantly better performance of a two-incision lower leg fasciotomy by a combat medic with less iatrogenic muscle and venous damage.
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Fasciotomía , Telemedicina , Humanos , Fasciotomía/métodos , Fasciotomía/estadística & datos numéricos , Fasciotomía/normas , Telemedicina/normas , Masculino , Adulto , Femenino , Pierna , Personal Militar/estadística & datos numéricos , Médicos de CombateRESUMEN
BACKGROUND: The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease. METHODS: A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool. RESULTS: This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome. CONCLUSIONS: This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence.
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Aponeurosis/cirugía , Contractura de Dupuytren/etiología , Fasciotomía/métodos , Aponeurosis/efectos de los fármacos , Aponeurosis/patología , Progresión de la Enfermedad , Contractura de Dupuytren/epidemiología , Contractura de Dupuytren/patología , Contractura de Dupuytren/cirugía , Fascia/efectos de los fármacos , Fascia/patología , Fasciotomía/estadística & datos numéricos , Humanos , Inyecciones Intralesiones , Colagenasa Microbiana/administración & dosificación , Pronóstico , Recurrencia , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Return to work is potentially an important factor in assessing the success of treatment. However, little is known about the return to work after treatment for Dupuytren's contracture. Therefore, the primary aim of this study was to assess return to work after limited fasciectomy and percutaneous needle fasciotomy. METHODS: Patients who underwent either a limited fasciectomy or percutaneous needle fasciotomy were invited to complete a return-to-work questionnaire at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Median time to return to work was assessed using inverted Kaplan-Meier curves, and hazard ratios were calculated with Cox regression models. Finally, a cost analysis was carried out using the human capital method to determine indirect costs associated with loss of productivity. RESULTS: The authors included 2698 patients in the study, of which 53 percent were employed at intake and included in the follow-up. After 1 year of follow-up, 90 percent of the patients had returned to work. Median time to return to work was 2 weeks after limited fasciectomy and within days after percutaneous needle fasciotomy. Furthermore, physically strenuous work, female sex, and higher age were associated with a longer time to return to work. Lost productivity per patient was estimated at 2614.43. CONCLUSIONS: The majority of patients returned to work after treatment for Dupuytren's disease. Return to work is much faster after percutaneous needle fasciotomy compared to limited fasciectomy. These findings can be used for more evidence-based preoperative counseling with patients with Dupuytren's disease.
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Costo de Enfermedad , Contractura de Dupuytren/cirugía , Fasciotomía/economía , Costos de la Atención en Salud/estadística & datos numéricos , Reinserción al Trabajo/estadística & datos numéricos , Contractura de Dupuytren/economía , Fasciotomía/instrumentación , Fasciotomía/métodos , Fasciotomía/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Agujas , Estudios Prospectivos , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Inflammation is an early feature of acute limb ischaemia (ALI), hence the potential prognostic significance of inflammatory biomarkers. This study aimed to assess the value of pre-operative inflammatory biomarkers, specifically the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR), for predicting an adverse outcome after revascularisation for ALI. METHODS: All patients submitted to lower limb revascularisation for Rutherford IIa or IIb ALI at the authors' institution between 2009 and 2019 were screened retrospectively. Pre-operative NLR and PLR were analysed, along with other known prognostic factors. Primary outcome was the composite endpoint of 30 day death or amputation. RESULTS: A total of 345 patients were included, 84 of whom suffered the primary outcome (24.3%). The median follow up was 23.1 months (3.1 - 52.2). Higher age (OR 1.05 per year increase, 95% CI 1.01 - 1.09), diabetes (OR 2.63, 95% CI 1.14 - 6.06), Rutherford grade IIb vs. IIa (OR 5.51, 95% CI 2.11 - 14.42), higher NLR (OR 1.28 per unit increase, 95% CI 1.12 - 1.47), and fasciotomy need (OR 3.44, 95% CI 1.14 - 10.34) were independently associated with 30 day death or amputation, whereas pre-operative statin or anticoagulant medication were associated with a risk reduction (OR 0.23, 95% CI 0.53 - 0.96 and OR 0.20, 95% CI 0.05 - 0.84, respectively). PLR did not show an independent effect on this population. Pre-operative NLR presented a good discriminative ability (AUC 0.86, 95% CI 0.82 - 0.90). A cut off NLR level ≥ 5.4 demonstrated a 90.5% sensitivity and 73.6% specificity for 30 day death or amputation. Kaplan-Meier analysis showed that patients with pre-operative NLR ≥ 5.4 had significantly lower 30 day, six month and one year amputation free survival when compared with those with NLR < 5.4 (64.8 ± 4.0%, 44.1 ± 4.1%, and 37.5 ± 4.1% vs. 98.5 ± 0.9%, 91.9 ± 2.0%, and 85.9 ± 2.5%, log rank p < .001). CONCLUSION: In this study, higher pre-operative NLR was associated with 30 day death or amputation following intervention for Rutherford grade IIa or IIb ALI. NLR potentially stands as a simple, widely available and inexpensive biomarker that can refine decision making and possibly contribute to ALI morbidity and mortality reduction.
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Isquemia/mortalidad , Linfocitos , Neutrófilos , Enfermedades Vasculares Periféricas/mortalidad , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica/estadística & datos numéricos , Anticoagulantes/uso terapéutico , Biomarcadores/sangre , Plaquetas , Toma de Decisiones Clínicas , Terapia Combinada/métodos , Terapia Combinada/estadística & datos numéricos , Extremidades/irrigación sanguínea , Extremidades/cirugía , Fasciotomía/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Inflamación/diagnóstico , Inflamación/inmunología , Isquemia/sangre , Isquemia/inmunología , Isquemia/terapia , Estimación de Kaplan-Meier , Recuento de Linfocitos , Masculino , Persona de Mediana Edad , Enfermedades Vasculares Periféricas/sangre , Enfermedades Vasculares Periféricas/inmunología , Enfermedades Vasculares Periféricas/terapia , Recuento de Plaquetas , Periodo Preoperatorio , Pronóstico , Estudios Retrospectivos , Medición de Riesgo/estadística & datos numéricos , Resultado del TratamientoAsunto(s)
Analgésicos Opioides/envenenamiento , Síndromes Compartimentales/inducido químicamente , Síndromes Compartimentales/mortalidad , Extremidades/irrigación sanguínea , Adulto , Amputación Quirúrgica , Codificación Clínica , Síndromes Compartimentales/cirugía , Bases de Datos Factuales , Sobredosis de Droga/complicaciones , Fasciotomía/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Epidemia de Opioides/tendencias , Estados Unidos/epidemiologíaRESUMEN
The aim of this nonrandomized cohort study was to compare the clinical effectiveness of an elective fasciotomy with conservative treatment for chronic exertional compartment syndrome of the leg. Patients diagnosed with chronic exertional compartment syndrome who opted for surgery (n=188) completed a preoperative questionnaire and a 12-month postoperative questionnaire. Patients who continued conservative treatments (n=23) served as controls. Gender, age, sports activity or affected compartments were comparable, but intensity of pain was higher in the surgical group (at rest: 2.5±0.1 vs. 2.0±0.2, during exercise: 4.2±0.1 vs. 3.8±0.2; both p<0.05). Following treatment, surgical patients demonstrated a larger drop in intensity levels of pain (surgery 1.6±0.1, conservative 0.9±0.2, p=0.01) and tightness (surgery 1.4±0.1, conservative 0.4±0.3, p=0.00) during exercise. Success (good or excellent treatment effect) was attained in 42% of the surgical group compared to only 17% in the conservatively treated group (p=0.02). However, previous activity level was achieved in a mere 26% in the surgical treatment group and 35% in the conservative treatment group (p=0.33). A fasciotomy for chronic exertional compartment syndrome in the leg results in significantly decreased levels of pain and tightness and better satisfaction compared to patients who continued a conservative treatment regimen.
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Síndrome Compartimental Crónico de Esfuerzo/terapia , Tratamiento Conservador , Procedimientos Quirúrgicos Electivos/métodos , Fasciotomía/métodos , Pierna , Adulto , Síndrome Compartimental Crónico de Esfuerzo/cirugía , Estudios de Cohortes , Tratamiento Conservador/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Ejercicio Físico/fisiología , Fasciotomía/estadística & datos numéricos , Femenino , Encuestas Epidemiológicas , Humanos , Masculino , Dimensión del Dolor , Satisfacción del Paciente , Recuperación de la Función , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Background: Management of Dupuytren Disease is variable, and influenced by multiple factors including location, extent of disease, surgical preference and familiarity with different treatment techniques. The objective of this study was to determine current Dupuytren Disease management trends in Australia. Methods: A questionnaire was sent through The Australian Hand Surgery Society to all members. In addition to demographic data, indications and preferences for different management interventions were surveyed on location of disease, age and activity level of the patient. Results: 99 (48%) of the Australian Hand Surgery Society members completed the survey. Respondents were primarily Orthopaedic (50%) or Plastic (49%) Surgeons, and most worked in private (99%) and public (71%) practice. Surgeon's believed that Tubiana's treatment goals to correct deformity was the most important (60%) and to shorten post-operative recovery (60%) was the least important. Only 42% of respondents perform needle aponeurotomy for Dupuytren Disease. In contrast 70% of respondents perform collagenase injections, with manipulation most commonly undertaken on the second day (46%) and skin tears (52%) the most common complication. Seventy-five percent of the respondents feel there is sufficient evidence to support the treatment of Dupuytren disease with collagenase injections. Ninety nine percent of all respondents perform fasciectomes for Dupuytren Disease, with Limited (without graft) (76%) the most routine performed. Conclusions: Several procedural options for the treatment of Dupuytren Disease exist within Australia. This study shows current Australian practice trends and highlights the increasing use of collagenase.
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Contractura de Dupuytren/terapia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cirujanos , Adulto , Anciano , Australia , Clostridium histolyticum , Fasciotomía/estadística & datos numéricos , Humanos , Inyecciones/estadística & datos numéricos , Colagenasa Microbiana/uso terapéutico , Persona de Mediana Edad , Agujas , Encuestas y CuestionariosRESUMEN
INTRODUCTION: Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed. METHODS: A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution. RESULTS: The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome-including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair. CONCLUSIONS: While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons' opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.
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Arterias/lesiones , Síndromes Compartimentales/cirugía , Fasciotomía/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cirujanos/estadística & datos numéricos , Procedimientos Quirúrgicos Vasculares , Lesiones del Sistema Vascular/complicaciones , Arterias/cirugía , Síndromes Compartimentales/etiología , Síndromes Compartimentales/prevención & control , Fasciotomía/métodos , Humanos , Encuestas y Cuestionarios , Traumatología , Estados Unidos , Lesiones del Sistema Vascular/cirugíaRESUMEN
INTRODUCTION: The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome. METHODS: A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy. RESULTS: Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001). CONCLUSIONS: Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling.
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Síndromes Compartimentales , Creatina Quinasa/sangre , Diabetes Mellitus/epidemiología , Fasciotomía , Traumatismos de la Pierna , Músculo Esquelético/patología , Factores de Edad , Síndromes Compartimentales/sangre , Síndromes Compartimentales/diagnóstico , Síndromes Compartimentales/epidemiología , Síndromes Compartimentales/cirugía , Fasciotomía/métodos , Fasciotomía/estadística & datos numéricos , Femenino , Humanos , Cuidados Intraoperatorios/métodos , Traumatismos de la Pierna/patología , Traumatismos de la Pierna/cirugía , Masculino , Persona de Mediana Edad , Necrosis/diagnóstico , Necrosis/etiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The open abdomen or laparostomy is a great advance of surgery based on the concept of damage control surgery. Aim of the study is to review the laparostomy outcomes of non-trauma emergency surgery patients in a district general hospital and identify parameters affecting early definite primary fascial closure. METHODS: The records of all non-trauma emergency surgical patients who underwent laparostomy in a three-year period in a single institute were studied retrospectively. Outcomes included length of stay, morbidity, mortality, readmission rates, number of re-look operations, rate of definite primary fascial closure and time to closure. RESULTS: Thirty-two patients were included. Morbidity was 84.4% and mortality rates were 21.9% (in-hospital), 18.8% (30-day) and 46.9% (overall). Median length of hospital stay was 22 days. Rate of primary fascial closure was 87.5% and median time to closure was two days. The number of relook operations was the only independent prognostic factor of definite early primary fascial closure, with higher rates of closure in patients with 1-2 relooks. CONCLUSIONS: Although the open abdomen has been demonstrated to improve survival, the precise role in abdominal sepsis has not been elucidated. Current consensus does not support use of open abdomen routinely, however in selected situations it becomes unavoidable. Laparostomy is a valid option in non-trauma emergency surgery and can be managed safely in a district hospital. High closure rates can be achieved if one or two re-look operations are performed with an early attempt for closure.
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Fasciotomía , Técnicas de Abdomen Abierto , Adulto , Anciano , Anciano de 80 o más Años , Urgencias Médicas , Fascia , Fasciotomía/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Hospitales de Distrito , Hospitales Generales , Humanos , Laparotomía/efectos adversos , Laparotomía/mortalidad , Tiempo de Internación , Masculino , Persona de Mediana Edad , Técnicas de Abdomen Abierto/mortalidad , Técnicas de Abdomen Abierto/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Segunda Cirugía/estadística & datos numéricos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: Point-of-injury (POI) care requires immediate specialized assistance but delays and expertise lapses can lead to complications. In such scenarios, telementoring can benefit health practitioners by transmitting guidance from remote specialists. However, current telementoring systems are not appropriate for POI care. This article clinically evaluates our System for Telementoring with Augmented Reality (STAR), a novel telementoring system based on an augmented reality head-mounted display. The system is portable, self-contained, and displays virtual surgical guidance onto the operating field. These capabilities can facilitate telementoring in POI scenarios while mitigating limitations of conventional telementoring systems. METHODS: Twenty participants performed leg fasciotomies on cadaveric specimens under either one of two experimental conditions: telementoring using STAR; or without telementoring but reviewing the procedure beforehand. An expert surgeon evaluated the participants' performance in terms of completion time, number of errors, and procedure-related scores. Additional metrics included a self-reported confidence score and postexperiment questionnaires. RESULTS: STAR effectively delivered surgical guidance to nonspecialist health practitioners: participants using STAR performed fewer errors and obtained higher procedure-related scores. CONCLUSIONS: This work validates STAR as a viable surgical telementoring platform, which could be further explored to aid in scenarios where life-saving care must be delivered in a prehospital setting.
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Educación Médica Continua/normas , Fasciotomía/métodos , Tutoría/normas , Telemedicina/normas , Realidad Aumentada , Cadáver , Educación Médica Continua/métodos , Educación Médica Continua/estadística & datos numéricos , Fasciotomía/estadística & datos numéricos , Humanos , Indiana , Tutoría/métodos , Tutoría/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud/métodos , Telemedicina/métodos , Telemedicina/estadística & datos numéricosRESUMEN
INTRODUCTION: Chronic exertional compartment syndrome (CECS) presents with pain during exercise, most commonly within the anterior compartment of the lower limb. A diagnosis is classically made from a typical history and the measurement of intramuscular compartmental pressure (IMCP) testing. Improved, more specific diagnostic criteria for IMCP testing allow clinicians to now be more certain of a diagnosis of CECS. Outcomes following surgical treatment in patients diagnosed using these more robust criteria are unknown. METHODS: All patients undergoing fasciectomy for anterior compartment CECS at a single rehabilitation unit were identified between 2014 and 2017. Wilcoxen signed-rank test was used to compare military fitness grading and paired t-test was used to compare Foot and Ankle Ability Measure, FAAM Sport Specific and Exercise-Induced LimbPain-G outcome measures, presurgery and postsurgery. RESULTS: There was a significant difference in fitness grading between presurgical and postsurgical intervention (Z = -2.68, p < 0.01) with 46 % of patients improving their occupational medical grading. All secondary measures of outcome, looking at clinical symptoms, also improved. CONCLUSION: Almost half of the patients undergoing fasciectomy, following diagnosis using more specific criteria, will have an improvement in occupational medical grading. These outcomes represent the lower end of those reported in civilian populations. This is likely a result of a combination of factors, most notably the different diagnostic criteria followed and the more stringent criteria applied to military occupational grading, compared with civilian practice. Further work is now required to evaluate the impact of differing rehabilitation regimes on postoperative patients identified through this more specific diagnostic testing.
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Síndrome Compartimental Crónico de Esfuerzo/clasificación , Síndrome Compartimental Crónico de Esfuerzo/cirugía , Codificación Clínica/normas , Resultado del Tratamiento , Adulto , Síndrome Compartimental Crónico de Esfuerzo/diagnóstico , Codificación Clínica/métodos , Codificación Clínica/tendencias , Fasciotomía/métodos , Fasciotomía/normas , Fasciotomía/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
INTRODUCTION: The primary objective of this study is to determine whether time from injury to fasciotomy is associated with increased risk for death or limb amputation in patients with acute leg compartment syndrome. The secondary objective of this study is to identify other risk factors for death or limb amputation in patients with acute leg compartment syndrome. METHODS: In an institutional review board approved retrospective study, we identified 546 patients with acute compartment syndrome of 558 legs treated with fasciotomies from January 2000 to June 2015 at two Level I trauma centers. Our primary outcome measures were death and limb amputation during inpatient hospital admission. Electronic medical records were analyzed for patient-related factors and treatment-related factors. Bivariate analyses were used to screen for variables associated with our primary outcome measures, and explanatory variables with a p value below 0.05 were included in our multivariable logistic regression analyses. RESULTS: In-hospital death occurred in 6.6% and in-hospital limb amputation occurred in 9.5% of acute leg compartment syndrome patients. Neither death nor limb amputation was found to be associated with time from injury to fasciotomy. Multivariable logistic regression analyses showed that older age (p = 0.03), higher modified Charlson Comorbidity Index (p = 0.009), higher potassium (p = 0.02), lower hemoglobin (p = 0.002), and higher lactate (p < 0.001) were associated with death, and diabetes mellitus (p = 0.05), no compartment pressure measurement (p = 0.009), higher PTT (p = 0.03), and lower albumin (p = 0.01) were associated with limb amputation. CONCLUSIONS: Time to fasciotomy is not found to be associated with death or limb amputation in acute leg compartment syndrome. Death and limb amputation are associated with patient-related factors and injury severity. LEVEL OF EVIDENCE: Level III Prognostic.
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Amputación Quirúrgica/estadística & datos numéricos , Síndromes Compartimentales/mortalidad , Pierna/irrigación sanguínea , Enfermedad Aguda , Síndromes Compartimentales/etiología , Síndromes Compartimentales/patología , Síndromes Compartimentales/cirugía , Fasciotomía/estadística & datos numéricos , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Pierna/cirugía , Traumatismos de la Pierna/complicaciones , Traumatismos de la Pierna/mortalidad , Traumatismos de la Pierna/patología , Traumatismos de la Pierna/cirugía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
The best method for fascial closure during hernia repair remains unknown. This study evaluates the impact of fascial closure techniques on short-term outcomes. All patients undergoing open ventral hernia repair were queried using the Americas Hernia Society Quality Collaborative database. Analysis was stratified by suture type (absorbable and permanent) and technique (figure-of-eight, running, and interrupted). Outcome measures included SSI, surgical site occurrence (SSO), SSO requiring intervention, recurrence rate, and quality of life. Descriptive statistics and logistic regression were used. The study included 6544 patients. Two-thirds of surgeons closed fascia during ventral hernia repair with absorbable suture and one-third with permanent suture. In the absorbable group, 17 per cent used figure-of-eight, 46 per cent running, and 4 per cent interrupted suture. In the permanent group, 13 per cent used figure-of-eight, 8 per cent running, and 11 per cent interrupted suture. There was no significant association between SSO and closure technique (P = 0.2). However, SSO and suture type were significant (P < 0.001) with the odds of SSO for closure with absorbable suture being 62 per cent higher than the odds of permanent. Fascial closure technique and suture type had no significant association (P > 0.5) with SSI, SSO requiring intervention, hernia recurrence rate, or HerQLes or NIH PROMIS 3a scores at 30 days or 6 months. Fascial closure technique and suture material do not have a major impact on outcomes in ventral hernia repair. Despite a significantly higher rate of SSO for absorbable sutures than permanent, this did not increase the rate of interventions.
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Fasciotomía/métodos , Hernia Ventral/cirugía , Hernia Incisional/cirugía , Técnicas de Sutura/estadística & datos numéricos , Técnicas de Cierre de Heridas , Adulto , Anciano , Fascia , Fasciotomía/estadística & datos numéricos , Femenino , Herniorrafia/métodos , Herniorrafia/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Pautas de la Práctica en Medicina , Calidad de Vida , Recurrencia , Suturas/estadística & datos numéricos , Técnicas de Cierre de Heridas/estadística & datos numéricosRESUMEN
BACKGROUND: With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS: We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS: Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS: Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Analgésicos Opioides/envenenamiento , Síndromes Compartimentales/inducido químicamente , Adulto , Alcoholismo/complicaciones , Nalgas/irrigación sanguínea , Síndromes Compartimentales/cirugía , Lesiones por Aplastamiento/inducido químicamente , Desbridamiento/estadística & datos numéricos , Sobredosis de Droga/complicaciones , Fasciotomía/estadística & datos numéricos , Femenino , Antebrazo/irrigación sanguínea , Heroína/envenenamiento , Humanos , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Epidemia de Opioides/estadística & datos numéricos , Factores de Tiempo , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: There are multiple studies about the effectiveness of primary treatment in Dupuytren's disease. However, such studies concerning treatment effectiveness of recurrent disease are scarce. Therefore, the primary aim of this study was to compare treatment effectiveness of initial and repeated surgery in patients with Dupuytren's disease. METHODS: Patients who underwent both initial and repeated treatment were selected from a prospectively maintained database. Outcome measurements consisted of finger goniometry, the Michigan Hand Outcomes Questionnaire, and complications. Treatment effectiveness was defined as improvement in extension deficit and patient-reported hand function. In addition, measurements at intake of both treatments were compared. Subgroup analyses were performed to evaluate influence of type of surgery of initial treatment on outcomes of repeated treatment. RESULTS: One hundred fourteen patients were included in the analyses. Improvement in extension deficit and Michigan Hand Outcomes Questionnaire outcomes was equal for initial and repeated treatments. Extension deficit and Michigan Hand Outcomes Questionnaire scores were worse at intake of repeated treatment compared to these outcomes at intake of initial treatment. In addition, patients who initially underwent needle fasciotomy achieved a better contracture reduction after repeated treatment. CONCLUSIONS: This study demonstrates that treatment of recurrent Dupuytren's disease is as effective as initial treatment, despite larger extension deficit and worse self-assessed hand function before undergoing repeated treatment. Complication rates were similar for initial and repeated treatments. Furthermore, needle fasciotomy for initial treatment results in better outcomes of repeated treatment compared to patients who initially underwent limited fasciectomy. These findings can be used for a more evidence-based preoperative counseling with patients with recurrent Dupuytren's disease. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Contractura de Dupuytren/diagnóstico , Contractura de Dupuytren/cirugía , Terapia por Ejercicio/métodos , Fasciotomía/métodos , Articulaciones de los Dedos/fisiopatología , Anciano , Artrometría Articular/métodos , Estudios de Cohortes , Bases de Datos Factuales , Contractura de Dupuytren/rehabilitación , Fasciotomía/efectos adversos , Fasciotomía/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Cuidados Posoperatorios/métodos , Rango del Movimiento Articular/fisiología , Recuperación de la Función , Reoperación/métodos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Resultado del TratamientoRESUMEN
BACKGROUND: Critical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors. METHODS: In a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts. RESULTS: Resident trauma readiness index increased with training (P < .001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P < .05). Expert trauma readiness index was higher than residents (P < .004) and practicing surgeons (P < .001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index <0.60 or <6 decile in their cohort, predicts a surgeon will make a critical error. CONCLUSION: Low trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.
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Evaluación Educacional/estadística & datos numéricos , Internado y Residencia/organización & administración , Errores Médicos/prevención & control , Heridas y Lesiones/cirugía , Arteria Axilar/lesiones , Arteria Axilar/cirugía , Benchmarking/métodos , Benchmarking/estadística & datos numéricos , Arteria Braquial/lesiones , Arteria Braquial/cirugía , Cadáver , Competencia Clínica/estadística & datos numéricos , Evaluación Educacional/métodos , Fasciotomía/efectos adversos , Fasciotomía/estadística & datos numéricos , Arteria Femoral/lesiones , Arteria Femoral/cirugía , Humanos , Internado y Residencia/estadística & datos numéricos , Errores Médicos/estadística & datos numéricos , Estudios Prospectivos , Cirujanos/educación , Cirujanos/estadística & datos numéricos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/educación , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricosRESUMEN
INTRODUCTION: Orthopedic surgery constitutes 27% of procedures performed for combat injuries. General surgeons may deploy far forward without orthopedic surgeon support. This study examines the type and volume of orthopedic procedures during 15 years of combat operations in Iraq and Afghanistan. MATERIALS AND METHODS: Retrospective analysis of the US Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 and Role 3 facilities, from January 2002 to May 2016. The 342 ICD-9-CM orthopedic surgical procedure codes identified were stratified into fifteen categories, with upper and lower extremity subgroups. Data analysis used Stata Version 14 (College Station, TX). RESULTS: A total of 51,159 orthopedic procedures were identified. Most (43,611, 85.2%) were reported at Role 3 s. More procedures were reported on lower extremities (21,688, 57.9%). Orthopedic caseload was extremely variable throughout the 15-year study period. CONCLUSIONS: Orthopedic surgical procedures are common on the battlefield. Current dispersed military operations can occur without orthopedic surgeon support; general surgeons therefore become responsible for initial management of all injuries. Debridement of open fracture, fasciotomy, amputation and external fixation account for 2/3 of combat orthopedic volume; these procedures are no longer a significant part of general surgery training, and uncommonly performed by general/trauma surgeons at US hospitals. Given their frequency in war, expertise in orthopedic procedures by military general surgeons is imperative.
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Procedimientos Ortopédicos/estadística & datos numéricos , Guerra/estadística & datos numéricos , Campaña Afgana 2001- , Amputación Quirúrgica/métodos , Amputación Quirúrgica/estadística & datos numéricos , Desbridamiento/métodos , Desbridamiento/estadística & datos numéricos , Fasciotomía/métodos , Fasciotomía/estadística & datos numéricos , Fracturas Abiertas/epidemiología , Fracturas Abiertas/cirugía , Humanos , Guerra de Irak 2003-2011 , Medicina Militar/métodos , Medicina Militar/estadística & datos numéricos , Procedimientos Ortopédicos/métodos , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Compartment syndrome of the thigh (CST) is a rare condition, and its delayed diagnosis and therapy may lead to devastating adverse effects. Thus, the aim of this study was to present the amassed clinical experiences, regarding diagnosis and treatment of CST at a level I trauma centre. MATERIALS AND METHODS: The database was reviewed for all patients with a manifest CST treated surgically between 1995 and 2014. RESULTS: 69 patients (61 males and 8 females) met the inclusion criteria, with a mean age of 42.9 years (range: 11-87 years). Forty-four patients (64%) presented with an isolated CST. There was a significant association between complication rates and high impact vs. blunt trauma (12/32, 38% vs. 0/20, 0%; p = 0.0022; Fisher's exact test). The number of surgeries in patients with a concomitant femur fracture was significantly increased (in mean: 2.8 vs. 4.9 surgical interventions; p < 0.001; U test). CONCLUSION: Patients after high impact trauma showed the highest complication rate. Concomitant femur fractures were associated with an increased number of surgical interventions. The synopsis of trauma mechanism, clinical presentation, age, anticoagulation status and clinical experience of the trauma surgeon seem to be the best tools to correctly diagnose CST.