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1.
Medicine (Baltimore) ; 100(7): e24791, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33607836

RESUMO

RATIONALE: Despite significant advances in surgical techniques and implants, the clinical outcome of high-energy pilon fractures remains unsatisfactory, which continues to represent numerous challenges for orthopedic trauma surgeons. PATIENT CONCERNS: A 62-year-old man injured his right ankle after falling from a 3 m high place. There were no open wounds or other complications. DIAGNOSES: According to the X-ray and CT scans, the patient was diagnosed with pilon fracture (type AO-43-C2) and lateral malleolus fracture of the right limb. INTERVENTIONS: The patient was initially treated with calcaneal traction upon admission to a primary hospital. Five days after the injury, the patient underwent open reduction and internal fixation (ORIF) of the fracture and vacuum sealing drainage (VSD) for wound closure. OUTCOMES: The patient presented to our hospital on the 9th day after the first ORIF operation because of critical ischemia of the affected foot and distal lower leg. Blood circulation did not improve after a series of salvage treatments, and below-knee amputation was ultimately performed. LESSONS: This is a rare case of complete ischemic necrosis following ORIF surgery of a closed pilon fracture due to iatrogenic damage. Standardized treatment that strictly follows the guidelines, instructions, or expert consensus should be promoted in this kind of complicated pilon fracture.


Assuntos
Amputação/métodos , Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas/efeitos adversos , Redução Aberta/efeitos adversos , Fraturas da Tíbia/cirurgia , Angiografia Digital , Fraturas do Tornozelo/complicações , Humanos , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Lesões dos Tecidos Moles/etiologia , Fraturas da Tíbia/complicações , Lesões do Sistema Vascular/etiologia
2.
Medicine (Baltimore) ; 100(3): e24364, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33546072

RESUMO

ABSTRACT: Lower limb amputation (LLA) is still a health issue requiring rehabilitation and long-term care even in industrial societies. Several studies on subjects with LLA have been focused on the efficacy of rehabilitation and factors influencing the use of prosthesis. However, literature data on the recovery of ability to walk outdoors, and thus to participate in social life in this population is limited.To investigate potential correlations between socio-demographic and clinical factors, and the use of the prosthesis for indoor and/or outdoor walking referred to as community ambulation (CA) in subjects with LLA.An observational cohort study on 687 LLA subjects was conducted. Socio-demographic and clinical characteristics of 302 subjects who received similar rehabilitative treatment with respect to the standard protocol were collected by a telephone survey with a structured questionnaire. The CA recovery, in terms of patient's autonomy and participation, assessed by Walking Handicap Scale, was considered as the main outcome.The univariate analysis demonstrated statistical significant positive correlation between CA and gender (χ2 = 3.901, P = .048); amputation level (χ2 = 24.657, P < .001); pre-LLA (χ2 = 6.338, P = .012) and current work activity (χ2 = 25.192, P < .001); prosthesis use (χ2 = 187.037, P < .01); and time from LLA (r = 0.183, P < .001); increasing age was negatively correlated with the outcome (r = -0.329, P < .001), while pain intensity was not significant. Being male (75.4%); trans-tibial (TT) amputation level (9.79%); working before (3.81%) and after LLA (7.68%); and the prosthesis use (24.63%) increased the probability of CA recovery. Multivariate binary logistic regression analysis confirmed that the prosthesis use (P < .001) and TT amputation level (P = .042) are predictors of a positive outcome (Walking Handicap Scale 4-6).These findings highlight the importance of the use of prosthesis in people with LLA for the restoration of a good capacity of participation (CA), especially in subjects with TT amputation level. The identification of predictive factors may help tailor-made rehabilitation approaches addressing an earlier reintegration to social life.


Assuntos
Amputação/reabilitação , Extremidade Inferior/lesões , Caminhada/fisiologia , Idoso , Amputação/métodos , Amputados/reabilitação , Estudos de Coortes , Feminino , Humanos , Extremidade Inferior/fisiopatologia , Masculino , Pessoa de Meia-Idade , Saúde Pública
3.
Isr Med Assoc J ; 23(1): 28-32, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33443339

RESUMO

BACKGROUND: Patients with critical limb ischemia (CLI) involving the below-the-knee (BTK) arteries are at increased risk of limb loss. Despite improvement in endovascular modalities, it is still unclear whether an aggressive approach results in improved limb salvage. OBJECTIVES: To assess whether an aggressive approach to BTK arterial disease results in improved limb salvage. METHODS: A comparative study of two groups was conducted. Group 1 included patients treated between 2012 and 2014, primarily with transfemoral angioplasty of the tibial arteries. Group 2 included patients treated between 2015-2019 with a wide array of endovascular modalities (stents, multiple tibial artery and pedal angioplasty, retrograde access). Primary endpoint was freedom from amputation at 4 years. RESULTS: A total of 529 BTK interventions were performed. Mean age was 71 ± 10.6 years, 382 (79%) were male. Patients in group 1 were less likely to be taking clopidogrel (66% vs. 83%, P < 0.01) and statins (72 % vs. 87%, P < 0.01). Several therapeutic modalities were used more often in group 2 than in group 1, including pedal angioplasty (24 vs. 43 %, P = 0.01), tibial and pedal retrograde access (0 vs. 10%, P = 0.01), and tibial stenting (3% vs. 25%, P = 0.01). Revascularization of two or more tibial arteries was performed at a higher rate in group 2 (54% vs. 50%, P = 0.45). Estimated freedom from amputation at 40 months follow-up was higher in group 2 (53% vs. 63%, P = 0.05). CONCLUSIONS: An aggressive, multimodality approach in treating BTK arteries results in improved limb salvage.


Assuntos
Amputação , Angioplastia , Procedimentos Endovasculares , Isquemia , Perna (Membro) , Salvamento de Membro , Doença Arterial Periférica , Complicações Pós-Operatórias , Artérias da Tíbia , Idoso , Amputação/métodos , Amputação/estatística & dados numéricos , Angioplastia/efeitos adversos , Angioplastia/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/cirurgia , Israel , Perna (Membro)/irrigação sanguínea , Perna (Membro)/cirurgia , Salvamento de Membro/instrumentação , Salvamento de Membro/métodos , Salvamento de Membro/estatística & dados numéricos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Doença Arterial Periférica/complicações , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Stents , Artérias da Tíbia/diagnóstico por imagem , Artérias da Tíbia/fisiopatologia , Artérias da Tíbia/cirurgia , Grau de Desobstrução Vascular
4.
Clin Podiatr Med Surg ; 38(1): 17-29, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33220742

RESUMO

In the diabetic and peripheral vascular disease population there is a high risk of further amputation following a primary amputation. Amputation surgery is often approached negating the biomechanics of the lower extremity leading to complications or additional surgery. Implementing appropriate tendon balancing of stump and applying orthoplastic techniques will improve outcomes. This article introduces the basic techniques to a wider audience of foot and ankle surgeons. Specifically, this article is intended to be a descriptive guide for the use of tendon balancing and intrinsic muscle advancements in the various levels of foot amputations.


Assuntos
Amputação/métodos , Pé/cirurgia , Hallux/cirurgia , Humanos , Ossos do Metatarso/cirurgia , Músculo Esquelético/cirurgia , Retalhos Cirúrgicos , Transferência Tendinosa
5.
Am J Case Rep ; 21: e926886, 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-32999267

RESUMO

BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, China, in late 2019 and has led to an ongoing pandemic. COVID-19 typically affects the respiratory tract and mucous membranes, leading to pathological involvement of various organ systems. Although patients usually present with fever, cough, and fatigue, less common manifestations have been reported including symptoms arising from thrombosis and thromboembolism. A spectrum of dermatologic changes is becoming recognized in patients with COVID-19 who initially present with respiratory symptoms. The mechanism behind these manifestations remains unclear. This report presents the case of a 47-year-old Hispanic man who developed cutaneous vasculitic lesions and gangrene of the toes following admission to hospital with COVID-19 pneumonia. CASE REPORT COVID-19 has been associated with cardiovascular disease entities including stroke, acute coronary syndrome, venous thromboembolism, and peripheral vascular disease. We present a case in which a 47-year-old Hispanic man arrived at the Emergency Department with COVID-19 and was admitted for respiratory failure. Despite anticoagulation initiated on admission in the presence of an elevated D-dimer, the patient developed gangrene of all his toes, which required bilateral transmetatarsal amputation. CONCLUSIONS This case shows that dermatologic manifestations may develop in patients who initially present with COVID-19 pneumonia. These symptoms may be due to venous thrombosis following SARS-CoV-2 vasculitis, leading to challenging decisions regarding anticoagulation therapy. Randomized controlled trials are needed to evaluate the efficacy of anticoagulation, to choose appropriate anticoagulants and dosing, and to assess bleeding risk.


Assuntos
Infecções por Coronavirus/complicações , Gangrena/etiologia , Gangrena/cirurgia , Pneumonia Viral/complicações , Síndrome Respiratória Aguda Grave/complicações , Dedos do Pé/cirurgia , Vasculite/etiologia , Amputação/métodos , Infecções por Coronavirus/diagnóstico , Serviço Hospitalar de Emergência , Seguimentos , Gangrena/fisiopatologia , Hispano-Americanos , Humanos , Masculino , Ossos do Metatarso/cirurgia , Pessoa de Meia-Idade , Multimorbidade , Pandemias , Admissão do Paciente , Pneumonia Viral/diagnóstico , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/etnologia , Insuficiência Respiratória/etiologia , Medição de Risco , Síndrome Respiratória Aguda Grave/diagnóstico , Dedos do Pé/irrigação sanguínea , Dedos do Pé/fisiopatologia , Resultado do Tratamento , Vasculite/fisiopatologia
7.
Plast Reconstr Surg ; 146(4): 819-829, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32970003

RESUMO

BACKGROUND: Multilevel dysvascular injury of the hand can be treated with replantation or revision amputation. The authors compared both modalities regarding functional outcomes, patient-reported outcomes, and required resources, as relevant studies are scarce. METHODS: In this retrospective review of consecutive case series (replantation, n = 8; revision amputation, n = 11), clinical results and functional outcomes (including grip strength, range of motion, sensory recovery, and grip or pinch ability) were assessed. Patient-reported outcomes, required hospital resources, and treatment cost until 1 year after surgery were compared between both groups. RESULTS: Six patients used passive prostheses, two used body-powered prostheses, and three did not use a prosthesis in the revision amputation group. All patients in the replantation group could grip objects and had restored hands, with protective sensory recovery and substantial wrist motion, whereas six patients in the revision amputation group were unable to grip or pinch objects. Replantation was associated with superior patient-reported outcomes, but required more hospital resources and treatment costs. CONCLUSIONS: This study suggests that in the treatment of multilevel dysvascular injury of the hand, the surgical method should be chosen on a case-by-case basis. For better functional and patient-reported outcomes, replantation is preferred. Revision amputation can be performed in the absence of sufficient hospital resources and to reduce treatment cost. These findings can aid in the preoperative counseling of patients with multilevel dysvascular injury of the hand. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Traumatismos da Mão/cirurgia , Mãos/irrigação sanguínea , Mãos/cirurgia , Reoperação , Reimplante/métodos , Adulto , Idoso , Amputação/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
8.
Foot Ankle Spec ; 13(5): 415-419, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32924585

RESUMO

Skin cancer is the most common cancer within the United States. Reports estimate that 1 in 5 Americans will develop some form of skin cancer. Eccrine porocarcinoma is a rare type of skin cancer of sweat gland origin. Eccrine porocarcinoma is most commonly found on the lower extremities. Clinically it may appear similar to benign skin lesions and it has significant metastatic potential. The authors present a case report with 22 months' follow-up. It describes a multiyear delay in diagnosis involving 3 specialties, including primary care, dermatology, and wound physical therapy. Information is given on techniques when high-risk cutaneous cancers are suspected or encountered. A multispecialty treatment plan is discussed.Levels of Evidence: Level V.


Assuntos
Diagnóstico Tardio/prevenção & controle , Porocarcinoma Écrino/diagnóstico , Porocarcinoma Écrino/cirurgia , Hallux/cirurgia , Procedimentos Ortopédicos/métodos , Neoplasias das Glândulas Sudoríparas/diagnóstico , Neoplasias das Glândulas Sudoríparas/cirurgia , Idoso , Amputação/métodos , Porocarcinoma Écrino/diagnóstico por imagem , Porocarcinoma Écrino/patologia , Humanos , Comunicação Interdisciplinar , Extremidade Inferior , Masculino , Equipe de Assistência ao Paciente , Doenças Raras , Biópsia de Linfonodo Sentinela , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton Único , Neoplasias das Glândulas Sudoríparas/diagnóstico por imagem , Neoplasias das Glândulas Sudoríparas/patologia , Resultado do Tratamento
9.
PLoS One ; 15(9): e0239236, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32936828

RESUMO

PURPOSE: A considerable number of diabetic foot ulcer (DFU) patients require amputation every year, which worsens their quality of life, aggravates the social burden, and shortens their life expectancy. Considering these negative effects, it is important to explore the relative risk factors affecting amputation in DFU patients. METHODS: The PubMed, SCIE and Embase databases were comprehensively searched for prospective or retrospective studies published before October 31, 2019. All English language studies involving DFU patients were included, and RevMan 5.3 software was used to analyse the data. RESULTS: This meta-analysis includes 21 studies involving 6505 participants, including 2006 patients who required a lower limb amputation. The following variables were associated with an increased risk of amputation: male sex (odds ratios (OR) = 1.30, 95% confidence interval (CI) = 1.16~1.46, P<0.00001), smoking history (OR = 1.19, 95% CI = 1.04~1.35, P = 0.009), a history of foot ulcers (OR = 2.48, 95% CI = 2.00~3.07, P<0.00001), osteomyelitis (OR = 3.70, 95% CI = 3.02~4.53, P<0.00001), gangrene (OR = 10.90, 95% CI = 5.73~20.8, P<0.00001), a lower body mass index (mean difference IV (MD) = -0.88, 95% CI = -1.30~-0.47, P<0.0001), and a higher white blood cell count (MD = 2.42, 95% CI = 2.02~2.82, P<0.00001). However, age (MD = 1.24, 95% CI = -0.45~2.93, P = 0.15), type of diabetes (OR = 0.96, 95% CI = 0.61~1.52, P = 0.86), hypertension (OR = 1.19, 95% CI = 0.96~1.47, P = 0.12), and HbA1c level (MD = 0.02, 95% CI = -0.28~0.33, P = 0.87) were not associated with amputation in patients with DFU. CONCLUSIONS: Our meta-analysis identified several risk factors for amputation in DFU patients, including the male sex, a smoking history, a history of foot ulcers, osteomyelitis, gangrene, a lower body mass index, and a higher white blood cell count. Once gangrene occurs, the risk of amputation rapidly increases.


Assuntos
Diabetes Mellitus Tipo 2/cirurgia , Pé Diabético/cirurgia , Úlcera do Pé/cirurgia , Extremidade Inferior/cirurgia , Amputação/métodos , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/fisiopatologia , Pé Diabético/etiologia , Pé Diabético/fisiopatologia , Úlcera do Pé/fisiopatologia , Humanos , Extremidade Inferior/fisiopatologia , Qualidade de Vida , Fatores de Risco
10.
Surgery ; 168(5): 904-908, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32736868

RESUMO

BACKGROUND: Forefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation. METHODS: We queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation. RESULTS: In the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2-3.6) were independent predictors of more proximal amputation. CONCLUSION: Early below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.


Assuntos
Amputação/efeitos adversos , Antepé Humano/cirurgia , Adulto , Idoso , Amputação/métodos , Amputação/mortalidade , Feminino , Humanos , Modelos Logísticos , Masculino , Ossos do Metatarso/cirurgia , Pessoa de Meia-Idade , Falha de Tratamento
11.
J Am Acad Orthop Surg ; 28(16): 684-691, 2020 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-32769724

RESUMO

BACKGROUND: Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers. METHODS: We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded. RESULTS: Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average. DISCUSSION: In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation. LEVEL OF EVIDENCE: IV, Case Series.


Assuntos
Amputação/métodos , Pé Diabético/cirurgia , Adulto , Idoso , Amputação/efeitos adversos , Pé Diabético/complicações , Feminino , Humanos , Infecções/etiologia , Masculino , Pessoa de Meia-Idade , Osteomielite/etiologia , Avaliação de Resultados da Assistência ao Paciente , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia , Ajuste de Prótese , Transferência Tendinosa , Resultado do Tratamento , Cicatrização
12.
Fisioterapia (Madr., Ed. impr.) ; 42(4): 218-223, jul.-ago. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-193509

RESUMO

ANTECEDENTES Y OBJETIVO: La amputación de miembros inferiores genera ajustes en los sistemas somato sensorial y musculoesquelético modificando la manera como se mantiene la estabilidad, parámetro sensible y clínicamente relevante en la evaluación clínica. El objetivo de este trabajo fue determinar las características de la estabilidad en personas con amputación transtibial unilateral (ATU) en fase posprotésica. MATERIALES Y MÉTODOS: Estudio descriptivo de serie de casos que incluyó 5 varones con ATU con marcha independiente y que no usaran dispositivos de asistencia. Se evaluó la estabilidad estática y dinámica con ojos abiertos (OA) y ojos cerrados (OC). RESULTADOS: La estabilometría estática mostró una superficie de elipse de baricentro corporal mayor con OC y en el miembro inferior sano (MIS) respecto al miembro inferior protetizado (MIP), la media del índice de Romberg se ubicó en el rango de referencia; la estabilometría dinámica mostró límites de estabilidad menores en sentido anterior y hacia el MIS, y aún más reducidos con OC. CONCLUSIÓN: Las personas con ATU tienden a generar mayor apoyo y oscilaciones en el MIS y menores límites de estabilidad en el MIP para mantener el control de la estabilidad estática y dinámica


BACKGROUND AND OBJECTIVE: The amputation of lower limbs leads to adjustments in somatosensory and musculoskeletal systems to modify the way that stability is maintained. This is a sensitive and relevant parameter within clinical evaluation. The objective of this study was to determine the characteristics of stability in patients with a unilateral transtibial amputation (TTA) in the post-prosthetic phase. MATERIALS AND METHODS: A descriptive study of a case series including five men with TTA and an independent gait, and who did not use assistive devices. Static and dynamic stability was evaluated with open eyes (OE) and closed eyes (CE). RESULTS: Static stabilometry displayed a greater elliptical surface area of body centre of gravity with CE and in the Healthy Lower Limb (HLL) compared to the Prosthetic Lower Limb (PLL). The mean Romberg ratio (EC/EO) was within the reference range. Dynamic stabilometry showed lower limits of stability in the anterior direction and towards the HLL, and even more reduced stability with CE. CONCLUSION: People with TTA tend to generate more support and oscillations in the HLL and lower stability limits in the PLL to maintain static and dynamic stability control


Assuntos
Humanos , Adulto , Pessoa de Meia-Idade , Amputação/métodos , Amputação/reabilitação , Cotos de Amputação , Amputados , Desenho de Prótese , Membros Artificiais , Marcha/fisiologia , Equilíbrio Postural/fisiologia
13.
Cochrane Database Syst Rev ; 7: CD010525, 2020 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692430

RESUMO

BACKGROUND: People undergoing major amputation of the lower limb are at increased risk of venous thromboembolism (VTE). Risk factors for VTE in amputees include advanced age, sedentary lifestyle, longstanding arterial disease and an identifiable hypercoagulable condition. Evidence suggests that pharmacological prophylaxis (e.g. heparin, factor Xa inhibitors, vitamin K antagonists, direct thrombin inhibitors, antiplatelets) is effective in preventing deep vein thrombosis (DVT), but is associated with an increased risk of bleeding. Mechanical prophylaxis (e.g. antiembolism stockings, intermittent pneumatic compression and foot impulse devices), on the other hand, is non-invasive and has minimal side effects. However, mechanical prophylaxis is not always appropriate for people with contraindications such as peripheral arterial disease (PAD), arteriosclerosis or bilateral lower limb amputations. It is important to determine the most effective thromboprophylaxis for people undergoing major amputation and whether this is one treatment alone or in combination with another. This is an update of the review first published in 2013. OBJECTIVES: To determine the effectiveness of thromboprophylaxis in preventing VTE in people undergoing major amputation of the lower extremity. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2019. We planned to undertake reference checking of identified trials to identify additional studies. We did not apply any language restrictions. SELECTION CRITERIA: We included randomised controlled trials and quasi-randomised controlled trials which allocated people undergoing a major unilateral or bilateral amputation (e.g. hip disarticulation, transfemoral, knee disarticulation and transtibial) of the lower extremity to different types or regimens of thromboprophylaxis (including pharmacological or mechanical prophylaxis) or placebo. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed risk of bias. We resolved any disagreements by discussion. Outcomes of interest were VTE (DVT and pulmonary embolism (PE)), mortality, adverse events and bleeding. We used GRADE criteria to assess the certainty of the evidence. The two included studies compared different treatments, so we could not pool the data in a meta-analysis. MAIN RESULTS: We did not identify any eligible new studies for this update. Two studies with a combined total of 288 participants met the inclusion criteria for this review. Unfractionated heparin compared to low molecular weight heparin One study compared unfractionated heparin with low molecular weight heparin and found no evidence of a difference between the treatments in the prevention of DVT (odds ratio (OR) 1.23, 95% confidence interval (CI) 0.28 to 5.35; 75 participants; very low-certainty evidence). No bleeding events occurred in either group. Deaths and adverse events were not reported. This study was open-label and therefore at a high risk of performance bias. Additionally, the study did not report the method of randomisation, so the risk of selection bias was unclear. Heparin compared to placebo In the second study, there was no evidence of a benefit from heparin use in preventing PE when compared to placebo (OR 0.84, 95% CI 0.35 to 2.01; 134 participants; low-certainty evidence). Similarly, no evidence of improvement was detected when the level of amputation was considered, with a similar incidence of PE between the two treatment groups: above knee amputation (OR 0.79, 95% CI 0.31 to 1.97; 94 participants; low-certainty evidence); and below knee amputation (OR 1.53, 95% CI 0.09 to 26.43; 40 participants; low-certainty evidence). Ten participants died during the study; five underwent a post-mortem and three were found to have had a recent PE, all of whom had been on placebo (low-certainty evidence). Bleeding events were reported in less than 10% of participants in both treatment groups, but the study did not present specific data (low-certainty evidence). There were no reports of other adverse events. This study did not report the methods used to conceal allocation of treatment, so it was unclear whether selection bias occurred. However, this study appeared to be free from all other sources of bias. No study looked at mechanical prophylaxis. AUTHORS' CONCLUSIONS: We did not identify any eligible new studies for this update. As we only included two studies in this review, each comparing different interventions, there is insufficient evidence to make any conclusions regarding the most effective thromboprophylaxis regimen in people undergoing lower limb amputation. Further large-scale studies of good quality are required.


Assuntos
Amputação/efeitos adversos , Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Extremidade Inferior/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Embolia Pulmonar/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Amputação/métodos , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Tromboembolia Venosa/etiologia
14.
BMJ Case Rep ; 13(7)2020 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-32641312

RESUMO

A 17-year-old man with osteosarcoma of the proximal humerus was planned for possible limb salvage surgery after standard neoadjuvant chemotherapy. However, during the surgical phase of treatment, the COVID-19 or SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) outbreak occurred changing the healthcare landscape due to uncertainty regarding the virus, risk of COVID-19 infection and complications, and implementation of an enhanced community quarantine restricting movement of people within cities. Instead of limb salvage surgery, the patient underwent a forequarter amputation. Exposure to the virus in a high-risk hospital setting was minimised with patient discharge after a short hospital stay and home convalescence monitored by video conferencing. Multidisciplinary sarcoma team meetings with family members and a sarcoma navigator nurse were crucial in managing expectations and deciding on appropriate treatment in the setting of a novel infectious disease causing a pandemic.


Assuntos
Amputação/métodos , Neoplasias Ósseas , Cisplatino/administração & dosagem , Infecções por Coronavirus , Doxorrubicina/administração & dosagem , Úmero , Salvamento de Membro/métodos , Osteossarcoma , Pandemias , Pneumonia Viral , Adolescente , Antineoplásicos , Betacoronavirus , Neoplasias Ósseas/patologia , Neoplasias Ósseas/terapia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Humanos , Úmero/diagnóstico por imagem , Úmero/cirurgia , Imagem por Ressonância Magnética/métodos , Masculino , Estadiamento de Neoplasias , Osteossarcoma/patologia , Osteossarcoma/terapia , Pandemias/prevenção & controle , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle
15.
J Pediatr Orthop ; 40(6): e532-e536, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32501929

RESUMO

BACKGROUND: Syme amputation (SA) is a term used to describe an amputation at the level of the ankle joint in which the heel pad is preserved. It is performed for a number of indications in a pediatric population. SA is purported to hold the advantage of allowing weight bearing without a prosthesis. A limb length discrepancy (LLD) is useful for ambulation without a prosthesis but can be restrictive with regards to the fitting of modern prostheses. METHODS: A voluntary survey was distributed to persons living with SA. Recruitment occurred through hospital electronic database and electronic advertising. Data collected included baseline demographic information, data pertaining to weight bearing in different environments, as well as 2 validated outcome measures: the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R activity restriction scale) and the Locomotor Capabilities Index-5 (LCI-5). An illustration was designed to allow participants to classify their LLD by zone in relation to their nonamputated limb. RESULTS: At total of 47 persons living with SA participated. The average age at amputation was 3.7 years (range, 0.5 to 14.1 y), and at survey completion 15.8 years (1.7 to 60.3). Five of the described "zones" of LLD were represented. Average LCI-5 score was 52.6. Mean TAPES-R activity restriction scale was 0.59, the lowest mean being achieved by zone E participants, indicating the least restriction. Ability to walk without a prosthesis was lower in those participants over 11 years, when compared with those under, as well as being dependent on the walking environment. CONCLUSIONS: Our study found no trend indicating that a very low LLD was functionally optimal, and indeed found participants with a moderate LLD (zone E) to have the least mean restriction with regard to their prosthesis. Our study demonstrates that ambulation without a prosthesis depends on the environment (ie, flooring), and rates decrease significantly into adulthood. Optimal care should not focus simply "preserving length," but rather functional optimization and length modulation in parallel with a nuanced understanding of actual daily activities and prosthetic options. LEVEL OF EVIDENCE: Level III-retrospective comparative study.


Assuntos
Amputação/métodos , Articulação do Tornozelo/cirurgia , Membros Artificiais , Adolescente , Membros Artificiais/efeitos adversos , Membros Artificiais/psicologia , Membros Artificiais/normas , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Satisfação Pessoal , Desempenho Físico Funcional , Estudos Retrospectivos , Inquéritos e Questionários , Caminhada
17.
Sanid. mil ; 76(2): 71-73, abr.-jun. 2020. ilus
Artigo em Espanhol | IBECS | ID: ibc-197386

RESUMO

La infección por el nuevo coronavirus SARS-COV-2 (COVID-19) y declarada pandemia mundial por la OMS, ha demostrado en algunos pacientes ser una enfermedad altamente trombogénica, tanto venosa como arterial, generando trombosis venosa profunda, embolismo pulmonar y cuadros de isquemia aguda, tanto en pacientes sin patología previa como con ellas. Se presentan cuatro casos de pacientes atendidos en el Hospital Gómez Ulla de Madrid durante la pandemia. Se compara su presentación clínica y evolución con otras series similares


The infection caused by the novel coronavirus SARS-COV-2 (COVID-19) which was declared global pandemic by the WHO has showed to be a highly thrombotic disease in some patients, presenting with venous and arterial complications such as deep vein thrombosis, pulmonary embolism and acute ischemia affecting patients with and without previous diseases. We describe four cases of COVID-19 patients treated in Gomez Ulla Hospital of Madrid during the pandemic. Clinical manifestations and outcome are compared with other similar series


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Isquemia , Arteriopatias Oclusivas/complicações , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Arteriopatias Oclusivas/cirurgia , Betacoronavirus/isolamento & purificação , Unidades de Terapia Intensiva , Amputação/métodos
18.
Fertil Steril ; 113(4): 885-887, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32228882

RESUMO

OBJECTIVE: To describe the diagnosis and the management of hematometra in a patient with unicornuate uterus with noncommunicating functional horn (hemi uterus and rudimentary uterine hemicavity). DESIGN: Video case report. SETTING: Minimally invasive gynaecology unit. PATIENT(S): Sixteen-year-old nulliparous woman admitted to the gynaecologic emergency department with pelvic pain during menses. INTERVENTION(S): Two-dimensional transvaginal ultrasound, magnetic resonance imaging, and laparoscopic rudimentary horn resection. MAIN OUTCOME MEASURE(S): Description of a case of anomaly of the female reproductive tract treated by laparoscopy. RESULT(S): After pain reduction and stabilization of clinical condition, ultrasound and magnetic resonance were performed, which detected a hemi uterus with a right rudimentary uterine hemicavity and a hematosalpinx. The removal of the right rudimentary uterine horn was successfully performed. The patient was in good health at the 3-month follow-up visit. CONCLUSION(S): Laparoscopic amputation of a functional rudimentary horn is considered the basic and traditional surgical option for women with hemiuterus. A detailed diagnostic evaluation should be performed to avoid misdiagnoses of other anomalies with blind hemicavity, which may be treated by hysteroscopy. Laparoscopic surgery with minimally invasive approach could be an essential tool to treat these cases, achieving optimal results with low postsurgical pain and a short hospital stay.


Assuntos
Amputação/métodos , Laparoscopia/métodos , Anormalidades Urogenitais/diagnóstico , Anormalidades Urogenitais/cirurgia , Útero/anormalidades , Adolescente , Feminino , Humanos , Histeroscopia/métodos , Útero/cirurgia
19.
Arch Phys Med Rehabil ; 101(7): 1183-1189, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32272105

RESUMO

OBJECTIVES: To establish reference values for the 2-minute walk test (2-MWT) distance and gait speed in people with a lower limb amputation (LLA) who are prosthetic ambulators. Also, to describe the differences in distance and gait speed between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups. DESIGN: Cross-sectional study. SETTING: National meeting for people with lower limb amputation. PARTICIPANTS: A convenience sample of unilateral people (N=101; 47 men, 54 women; mean age ± SD, 50.9±14.3 y) with an LLA; 48 had a transtibial amputation and 53 had a transfemoral amputation. Participants were classified as either limited community ambulators, community ambulators, or those who exceed basic ambulation skills (K2, n=7; K3, n=70; K4, n=24). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: 2-MWT performance (ie, distance and gait speed). RESULTS: The mean ± SD 2-MWT distance and gait speed for the entire sample was 143.8±37.5 meters (range, 49-259 m) and 72.1±18.8 meters per minute (range, 25-130 m/min), respectively. Men walked farther (distance: men, 154.2±34.2 m; women, 134.4±38.1 m) and faster (gait speed: men, 77.3±17.1 m/min; women, 67.4±19.1 m/min) than women (P<.05). The mean ± SD 2-MWT distance for K4, K3, and K2 level participants was 177.9±31.1 meters, 138.4±28.5 meters, and 81.7±26.9 meters, respectively. Functional level K4 participants performed better than K3 participants (P<.05), and K3 participants performed better than K2 participants (P<.05). People with transtibial amputation walked farther than those with transfemoral amputation (152.9±43.0 m vs 135.6±43.0 m) (P<.05). The distance and speed ambulated by those participants classified in the very high health risk group was worse than those categorized as being at an increased high health risk group (P<.05) and the no increase health risk group (P<.05). The performance of participants older than 70 years old was inferior to the performance of all younger age groups. CONCLUSIONS: Reference values for the 2-MWT distance and gait speed were established in people with LLA who are prosthetic ambulators. Significant differences in the 2-MWT performance were found between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups.


Assuntos
Amputação/reabilitação , Amputados/reabilitação , Membros Artificiais , Extremidade Inferior/cirurgia , Teste de Caminhada/estatística & dados numéricos , Velocidade de Caminhada/fisiologia , Adulto , Idoso , Amputação/métodos , Estudos Transversais , Feminino , Fêmur/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Equilíbrio Postural/fisiologia , Ajuste de Prótese/métodos , Qualidade de Vida , Tíbia/cirurgia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Teste de Caminhada/métodos , Caminhada/fisiologia
20.
Diabetes Res Clin Pract ; 163: 108136, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32272190

RESUMO

Amputation has been known to be a rare adverse event of sodium glucose co-transporter-2 (SGLT2) inhibitors. It remains unclear whether the SGLT2 inhibitor as a class or specific categories of the SGLT2 inhibitors are linked with an increased risk of amputation. The objective of this meta-analysis was to investigate the association between the amputation risk and the use of SGLT2 inhibitors. The main outcome measure was the risk of amputation. Multiple databases were searched up to February 2020 and data extraction was performed. Inclusion criteria were randomized controlled trials (RCTs) which reported risk of amputation with SGLT2 inhibitors over non-SGLT2 inhibitors or placebo. The risk of bias was assessed by Cochrane bias tool. The initial search yielded 1,873 citations and a total of five RCTs were included in the meta-analysis. The five included studies evaluated a total of 39,067 patients with diabetes mellitus, including 21,395 patients on SGLT2 inhibitors. The incidence rate of amputation ranged from 0.36 to 3.18% in the SGLT2 inhibitor group and from 0% to 2.87% in the control group. Follow up duration ranged from 24 weeks to 4.2 years. Use of SGLT2 inhibitors was not associated with significant increase in the risk of amputation as compared with controls (OR: 1.31, 95% CI: 0.92-1.87, I2 = 75%). Subgroup analysis showed that neither canagliflozin, empagliflozin, nor dapagliflozin was associated with increased risk of amputation. In conclusion, our meta-analysis showed that neither canagliflozin nor other SGLT2 inhibitors increase the risk of amputation.


Assuntos
Amputação/métodos , Diabetes Mellitus Tipo 2/complicações , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
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