Factors affecting successful prosthetic use after hemipelvectomy and hip disarticulation amputations: Five-year experience from a tertiary prosthetic rehabilitation center.

BACKGROUND: Rehabilitation after hip disarticulation and hemipelvectomy amputations can be challenging, and many opt to forego prosthetic limb use. There is limited evidence on characteristics that result in successful prosthetic use; therefore, our study aimed to identify these to help guide patient expectations. METHODS: A retrospective review was performed on patients seen at a UK tertiary prosthetic center in the past 5 years with hip disarticulation or hemipelvectomy amputations. Details and etiology of amputation, length between assessment and delivery of prosthesis, goals, reasons for abandonment, and outcomes were recorded. Successful prosthetic use was defined as the use of a prosthesis at least 3 times a week. Characteristics were compared using odds ratios and Fisher exact test. RESULTS: Twenty-seven patient notes were analyzed: 42% female, 58% male, and age range 14-90. Thirty percent had a hemipelvectomy, and 70% had a hip disarticulation. Neoplasia accounted for 78% of etiologies followed by trauma 15% and infected endoprosthesis 7%. Sixty-seven percent trialed a walking prosthesis; 33% of these stopped eventually. There were no statistically significant findings of factors increasing odds of successful prosthetic use. However, age significantly increased the odds of being given a trial of a prosthesis. CONCLUSION: Although younger patients are more likely to be given the opportunity to trial a walking prosthesis, age does not seem to affect the overall outcome alone. In cases of neoplasia, there is often a delayed start to rehabilitation and prosthetic use, which may affect eventual success. Further studies are required to define the optimum characteristics for successful prosthetic use at higher amputation levels.

Knee disarticulation vs. transfemoral amputation after failed transtibial amputation: Surgical outcome and prosthetic fitting in patients with peripheral vascular disease.

OBJECTIVE: Our aim was to compare transfemoral amputation (TFA) to knee disarticulation (KD) as a reamputation level after failed transtibial amputation (TTA) in patients with peripheral vascular disease and/or diabetes. METHODS: We studied 152 patients undergoing reamputation, 86 TFA and 66 KD, after a failed TTA. The primary outcome was reamputation and reoperation, and secondary outcomes were prosthetic fitting and mortality. Logistic regression analyses were performed to identify factors associated with the outcome. RESULTS: The reamputation rate was 36% after KD and 15% after TFA ( p = 0.004). The multivariable analysis showed that TFA was associated with a significantly reduced risk of reamputation, odds ratio (OR) = 0.31 (95% confidence interval [95% CI], 0.1-0.7). The overall reoperation rate was 38% after KD and 22% after TFA ( p = 0.03). This reduction of risk for TFA was not significant in the multivariable analysis, OR = 0.49 (95% CI, 0.2-1.0). Prosthetic limb fitting was possible in 30% after KD and 19% after TFA ( p = 0.1). Previous amputation in the contralateral leg was the only factor associated with reduced ability for prosthetic fitting in the multivariable analysis, OR = 0.15 (95% CI, 0.03-0.7). Mortality at 30 d was 17% and 53% at 1 year. No independent factors affected 30-d mortality in the multivariable analysis. CONCLUSIONS: In this study, we found a significantly lower risk of reamputation after TFA compared with KD after a failed TTA. We consider TFA to be the reamputation level of choice, especially when there is a need of reducing risk of further reamputations.

Healthcare Utilization Following Hemipelvectomy or Hip Disarticulation in the Military Health System.

INTRODUCTION: Amputations at the hip and pelvic level are often performed secondary to high-energy trauma or pelvic neoplasms and are frequently associated with a prolonged postoperative rehabilitation course that involves a multitude of health care providers. The purpose of this study was to examine the health care utilization of patients with hip- and pelvic-level amputations that received care in the U.S. Military Health System. MATERIALS AND METHODS: We performed a retrospective review of all patients who underwent a hip- or pelvic-level amputation in the Military Health System between 2001 and 2017. We compiled and reviewed all inpatient and outpatient encounters during three time points: (1) 3 months pre-amputation to 1 day pre-amputation, (2) the day of amputation through 12 months post-amputation, and (3) 13-24 months post-amputation. Health care utilization was defined as the average number of encounter days/admissions for each patient. Concomitant diagnoses following amputation including post-traumatic stress disorder, traumatic brain injury, anxiety, depression, and chronic pain were also recorded. RESULTS: A total of 106 individuals with hip- and pelvic-level amputations were analyzed (69 unilateral hip disarticulation, 6 bilateral hip disarticulations, 27 unilateral hemipelvectomy, 2 bilateral hemipelvectomies, and 2 patients with a hemipelvectomy and contralateral hip disarticulation). Combat trauma contributed to 61.3% (n = 65) of all amputations. During the time period of 3 months pre-amputation, patients had an average of 3.8 encounter days. Following amputation, health care utilization increased in both the year following amputation and the time period of 13-24 months post-amputation, averaging 170.8 and 77.4 encounter days, respectively. Patients with trauma-related amputations averaged more total encounter days compared to patients with disease-related amputations in the time period of 12 months following amputation (203.8 vs.106.7, P < .001) and the time period of 13-24 months post-amputation (92.0 vs. 49.0, P = .005). PTSD (P = .02) and traumatic brain injuries (P < .001) were more common following combat-related amputations. CONCLUSIONS: This study highlights the increased health care resource demand following hip- and pelvic-level amputations in a military population, particularly for those patients who sustained combat-related trauma. Additionally, patients with combat-related amputations had significantly higher rates of concomitant PTSD and traumatic brain injury. Understanding the extensive needs of this unique patient population helps inform providers and policymakers on the requirements for providing high-quality care to combat casualties.

An infected chronic expanding haematoma treated with hip disarticulation.

This is a report of an anticoagulated patient with septic shock caused by an infected chronic expanding haematoma (CEH) that required hip disarticulation as a means of definitive surgical source control. As far as we know, we did not find any report of an infected giant CEH in the lower extremity as large as in the present patient.

Anchoring flap suture technique to repair a wound with exposed bone after hip disarticulation: a case report and brief review of the literature.

BACKGROUND: In specific clinical scenarios characterized by poor tissue conditions surrounding a wound, achieving stable flap fixation with standard sutures can be challenging. The anchoring flap suture technique, which is commonly used for soft tissue-to-bone attachment in cases of injury, may be an alternative and effective approach. CASE REPORT: This report describes the successful application of the anchoring flap suture technique to repair a wound with exposed bone in a 39-year-old female patient. She presented with a 7% TBSA wound of the left trunk following hip disarticulation. After 4 operations, a wound with exposed iliac bone remained. Given the compromised condition of the tissues surrounding the exposed bone, the authors opted to anchor a local flap directly to the exposed bone. Steady flap fixation was achieved using the anchoring flap suture method, resulting in complete healing of that wound. Remarkably, no short- or long-term complications associated with the flap were observed. Three months after hospital discharge, the patient regained mobility, walking on 1 leg with the assistance of a 4-legged walker. CONCLUSION: The anchoring flap suture technique seems to be a reliable and effective treatment option, particularly in cases in which inadequate soft tissue precludes the use of traditional flap fixation using standard sutures.

A pelvic kinematic approach for calculating hip angles for active hip disarticulation prosthesis control.

BACKGROUND: Control system design for a microprocessor-controlled hip-knee-ankle-foot (HKAF) prosthesis is a challenge since hip disarticulation amputees lack the entire leg and, therefore, only have pelvis movement as user-guided input. This research proposes a method for determining hip joint angles from pelvis movement in a control system for the next generation of powered prostheses. METHOD: Three-dimensional pelvic motion and stance time of 10 transfemoral (TF) prosthetic users were used to identify important features and to develop an algorithm to calculate hip angles from pelvis movement based on correlation and linear regression results. The algorithm was then applied to a separate (independent) TF group to validate algorithm performance. RESULTS: The proposed algorithm calculated viable hip angles during walking by utilizing pelvic rotation, pelvic tilt, and stance time. Small angular differences were found between the algorithm results and motion capture data. The greatest difference was for hip maximum extension angle (2.5 ± 2.0°). CONCLUSIONS: Since differences between algorithm output and motion data were within participant standard deviations, the developed algorithm could be used to determine the desired hip angle from pelvis movements. This study will aid the future development of gait control systems for new active HKAF prostheses.

Functional outcome of a patient after hip disarticulation due to an infection 10 years after limb salvage surgery for osteosarcoma: A case report.

Limb salvage is a common procedure after extensive osteosarcoma resection. However, the long-term outcomes after limb salvage surgery (LSS) remain unclear. In this article, the case of a 24-year-old man who underwent hip disarticulation (HD) after an uncontrollable infection is presented. He was previously diagnosed with right distal femoral osteosarcoma and underwent LSS 10 years before disarticulation. Four years after LSS, an uncontrollable infection developed around the endoprosthesis, which eventually prompted HD. The Musculoskeletal Tumor Society (MSTS) functional rating system and the Toronto Extremity Salvage Score were used to compare the subject's activity statuses after LSS and HD. MSTS functional scores were 53.3% after LSS and 60% after HD. Toronto Extremity Salvage Scores were 78.3% after LSS and 95.8% after HD. The subject's emotional acceptance was 3 for LSS and 5 for HD (0 = worst and 5 = best). Both the MSTS and Toronto Extremity Salvage Scores were greater after HD than after LSS. The subject's improved emotional acceptance of the affected limb after HD contributed to the improved functional assessment scores. Alleviation of pain and other disabilities associated with the infection may have contributed to the higher functional scores after the more recent HD surgery. Even if amputation is unavoidable because of complications, high psychological acceptance may prevent a decrease in patient mobility and quality of life after amputation.

Allowing Standing and Assisted Steps in a Patient With Renshaw Type IV Sacral Agenesis: A Case Report of a Novel Surgical Approach.

CASE: A 6-year-old boy with a Renshaw type 4 sacral agenesis presented paraplegia and rigid, "Buddha-like" lower-limb contractures, including severe knee pterygia, which made crawling and sitting difficult. Staged surgical treatment involved bilateral knee disarticulation, soft tissue surgery, and bifocal femoral osteotomies for lower-limb reorientation. At 18 months postoperatively and after prosthetic fitting, the patient can stand and take steps with assistance. CONCLUSION: This effective surgical strategy achieves standing in a troublesome orthopaedic congenital condition. The intervention should be tailored to specific orthopaedic disorders and the wishes of patients and families, aiming to improve function.

Retrospective analysis of mortality and quality of life after hip disarticulation or hemipelvectomy: a report on 15 patients.

BACKGROUND: Hip disarticulation and hemipelvectomy are defined as major ablative amputations of the lower limb. Due to the small number of patients, little is known about the outcome and follow-up. AIMS: We aimed to assess (1) reasons for performed major ablative surgeries such as hip disarticulation and hemipelvectomy in a German center for trauma and orthopedic surgery. (2) In addition, mortality and quality of life after hip disarticulation and hemipelvectomy as well as (3) patient and treatment characteristics should be investigated. METHODS: During a period of twelve years, 15 patients underwent hip disarticulation or hemipelvectomy. Mortality, EQ-5D-3L quality of life by EQ-5D-3L and time-trade-off (TTO), VAS, cause of disarticulation, length of hospital stays, revisions, comorbidities, Charlson comorbidity index (CCI), and ASA score were evaluated retrospective for all patients. RESULTS: The overall mortality rates were 26.7% at 30 days, 60.0% after one year and 66.7% after three years. The five surviving patients reported about moderate problems in the EQ-5D-3L. The average VAS score reached 45 (range 15-65). The mean TTO was 9.8 (range 6-12). Indications for amputation were infection (n = 7), tumor (n = 6), trauma (n = 1) and ischemia (n = 1). CONCLUSION: Hip disarticulation and hemipelvectomy are followed by a high postoperative mortality. Quality of life of the affected patients is impaired in long-term follow-up. Especially amputations performed due to infections show high mortality within one month after surgery despite average young age and low CCI. Surgeons should be aware of this devastating outcome and extraordinary vigilant for these vulnerable patient cohorts.

Surgical Techniques for Performing a Through-Knee Amputation: A Systematic Review and Development of an Operative Descriptive System.

BACKGROUND: Through-knee amputation (TKA) carries potential biomechanical advantages over above knee amputation (AKA) in patients unsuitable for a below-knee amputation. However, concerns regarding prosthetic fit, cosmesis and wound healing have tempered enthusiasm for the operation. Furthermore, there are many described surgical techniques for performing a TKA. This frustrates attempts to compare past and future comparative data, limiting the opportunity to identify which procedure is associated with the best patient centered outcomes. The aim of this systematic review is to identify all the recognized operative TKA techniques described in the literature and to develop a clear descriptive system to support future research in this area. METHODS: A systematic review was performed, searching the OVID, PubMed, and Cochrane Library databases, according to Cochrane and PRISMA guidelines. Papers of any design were included if they described an operative technique for a TKA. Key operative descriptions were captured and used to design a classification system for surgical techniques. RESULTS: A total of 906 papers were identified, of which 28 are included. The most important distinctions in operative technique were the level of division of the femur (disarticulation without bone division, transcondylar amputation, with or without shaving of the medial, lateral, and posterior condyles and supracondylar amputation), management of the patella (kept whole, partially preserved, completely removed), use of a muscular gastrocnaemius flap, and skin incisions. A 4-component classification system was developed to be able to describe TKA operative techniques. A suggested shorthand nomenclature uses the first letter of each component (FPMS; Femur, Patella, Muscular flap, Skin incision), followed by a number, to describe the operation. Patient outcomes were poorly reported, and therefore outcomes for different types of TKA are not addressed in this review. CONCLUSIONS: A novel descriptive system for describing different techniques for performing a TKA has been developed. This classification system will help in reporting, comparing, and interpreting past and future studies of patients undergoing TKA.

User-relevant factors influencing the prosthesis use of persons with a transfemoral amputation or knee-disarticulation: A meta-synthesis of qualitative literature and focus group results.

OBJECTIVE: Persons with a transfemoral amputation or knee-disarticulation are heavily reliant on an adequate set of components for their prosthesis. To improve the process of adjusting the specific prosthetic properties to the expectations of the prosthesis users, it is of importance to first identify which factors have an influence on prosthesis use. Therefore, we aimed to identify factors that influence prosthesis use in adults with a transfemoral amputation or knee-disarticulation. METHODS: A qualitative meta-synthesis was conducted by searching five databases (last update January 20th 2022). Studies were considered eligible if they contained qualitative data about adult persons with a transfemoral amputation or knee-disarticulation with experience in using a prosthesis and focused on the users' opinions. All eligible studies were independently screened by two reviewers. The results sections of the included studies were entered in Atlas.ti software (v8) and coded using the framework approach. The quality of the included studies was assessed using the Critical Appraisal Skills Program (CASP) qualitative research checklist. Results of the meta-synthesis were validated with prosthesis users (n = 8) in a focus group. RESULTS: Out of 5757 articles, 14 studies were included. An overview of seven themes ('prosthesis related'; 'rehabilitation, costs and prosthetist'; 'mental'; 'physical'; 'social'; 'activities and participation' and 'walking') containing 84 factors was created. Ten factors were added during the focus group, resulting in an overview of 94 factors that may influence the prosthesis use of lower-limb prosthesis users. Participants would like more user-involvement from the rehabilitation team. The development of a patient decision aid could help this process in the future. CONCLUSION: The large number of factors demonstrates that there is a great variety between prosthesis users and the factors that influence their prosthesis use. Therefore, it is important to take individual preferences into account for the selection of a new prosthesis.

Mindful SensoriMotor Therapy combined with brain modulation for the treatment of pain in individuals with disarticulation or nerve injuries: a single-arm clinical trial.

INTRODUCTION: Neuropathic pain is a complex and demanding medical condition that is often difficult to treat. Regardless of the cause, the impairment, lesion or damage to the nervous system can lead to neuropathic pain, such as phantom limb pain (PLP). No treatment has been found widely effective for PLP, but plasticity-guided therapies have shown the least severe side effects in comparison to pharmacological or surgical interventions. Phantom motor execution (PME) is a plasticity-guided intervention that has shown promising results in alleviating PLP. The potential mechanism underlying the effectiveness of PME can be explained by the Stochastic Entanglement hypothesis for neurogenesis of neuropathic pain resulting from sensorimotor impairment. We have built on this hypothesis to investigate the efficacy of enhancing PME interventions by using phantom motor imagery to facilitate execution and with the addition of sensory training. We refer to this new treatment concept as Mindful SensoriMotor Therapy (MiSMT). In this study, we further complement MiSMT with non-invasive brain modulation, specifically transcranial direct current stimulation (tDCS), for the treatment of neuropathic pain in patients with disarticulation or peripheral nerve injury. METHODS AND ANALYSIS: This single-arm clinical trial investigates the efficacy of MiSMT and tDCS as a treatment of neuropathic pain resulting from highly impaired extremity or peripheral nerve injury in eight participants. The study consists of 12 sessions of MiSMT with anodal tDCS in the motor cortex, pretreatment and post-treatment assessments, and follow-up sessions (up to 6 months). The primary outcome is the change in pain intensity as measured by the Pain Rating Index between the first and last treatment sessions. ETHICS AND DISSEMINATION: The study is performed under the approval of the governing ethical committee in Sweden (approval number 2020-07157) and in accordance with the Declaration of Helsinki. TRIAL REGISTRATION NUMBER: NCT04897425.

The effect of dual-task testing on the balance and gait of people with lower limb amputations: A systematic review.

OBJECTIVE: To systematically review the literature on the effect of dual-task testing on the balance and gait of people with lower limb amputations (PLLA). LITERATURE SURVEY: Databases MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus were searched in duplicate (inception to December 1, 2020). METHODOLOGY: Inclusion criteria: participants were adults with transtibial, knee-disarticulation, transfemoral, or bilateral lower limb amputations; balance or gait was paired with a secondary task; and studies were peer-reviewed and published in English. Two authors independently reviewed articles and consensus was required. A standardized data extraction sheet was used to gather study relevant information in duplicate. Methodological quality of reporting was examined using the Downs and Black Scale. A meta-analysis was unable to be performed owing to substantial participant and protocol heterogeneity among the studies included. SYNTHESIS: Of 3950 articles screened, 22 met inclusion criteria. Four assessed dual-task balance and 18 dual-task gait. During single-task standing, PLLA demonstrated higher sway distance and sway velocity than controls (CN); however, a greater dual-task effect was observed only for sway velocity. Gait pace, rhythm, variability, asymmetry, and postural control were observed to be worse in PLLA relative to CN during single-task. Dual-task gait testing resulted in a disproportionally reduced pace and rhythm and increased asymmetry in PLLA compared to CN. CONCLUSIONS: People with lower limb amputations have impaired balance and gait, which is affected by dual-task to a greater degree compared to healthy adults. An examination of how PLLA-specific factors such as level of amputation, reason for amputation, and experience with a prosthesis affect dual-task performance has not yet been thoroughly explored. Future research should continue to characterize the cognitive-mobility link to better understand the challenges associated with the use of a prosthesis.

Factors influencing perceived function in the upper limb prosthesis user population.

BACKGROUND: Patient-reported outcomes (PROs) can be used to evaluate perceived capacity of an individual in executing tasks in a natural environment with their prosthetic device. According to the World Health Organization International Classification of Health, Functioning, and Disability (ICF) models, there may be specific factors of a person, factors of assistive prosthetic technology, or factors related to the health condition or body function that affect their functioning and disability. However, an understanding of factors affecting an upper limb prosthesis user's perception of their ability to execute tasks in a natural environment is not well established. OBJECTIVE: To use the ICF model to identify which health condition-related, body function, environmental, and personal factors influence activity as measured by perceived function in the upper limb prosthesis user population. DESIGN: Quantitative clinical descriptive study. SETTING: Clinical offices within outpatient private practice (removed for blinding). PARTICIPANTS: A sample of 101 participants with upper limb amputation who use a prosthetic device and were undergoing a prosthesis fitting process. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: PROs on pain with/without a prosthesis, satisfaction, and perceived function derived from the Comprehensive Arm Prosthesis and Rehabilitation Outcomes Questionnaire. RESULTS: Model coefficients indicate that with a unit increase in satisfaction (p < .001) and pain (p = .031) scores (with higher pain scores signifying less pain), the mean of perceived function increases by 0.66 and 0.47 units, respectively. Conversely, for individuals with elbow disarticulation, transhumeral, shoulder disarticulation, and interscapulothoracic amputations, the mean of perceived function decreases by 22.02 units (p = .006). CONCLUSIONS: Based on our sample, perceived function is significantly associated with satisfaction, pain, and amputation level. These findings could potentially help to inform initial clinical approach and targeted outcomes for patients based on these factors.

Utilizing of Removable Rigid Dressing to Decrease Below the Knee Amputations to Above the Knee Amputations Conversion Rates.

INTRODUCTION/OBJECTIVE: Below the knee amputations (BKAs) are preferred to above the knee amputations (AKAs) due to better rehabilitation and functional outcomes. Assessment of literature for best practice identified that utilization of a removable rigid dressing (RRD) improves post-operative BKA care by expediting wound healing and reduces the hospital length of stay compared to a soft dressing. We hypothesized that there would be a decrease of conversions from BKA to AKA following utilizing of RRD device. METHODS: Retrospective chart review of all BKA performed by the vascular surgery service at a tertiary care hospital between January 2017 and December 2021. Demographic data obtained including age, body mass index (BMI), comorbid conditions, infection at time of BKA, anesthesia type, and operative blood loss. Data analyzed using Wilcoxon rank sum, Fisher's exact, and Student's t-tests. This study was approved by the institutional review board. RESULTS: From 2017 to 2019, conversion to AKA occurred in 18 out of the 42 patients who underwent BKA (42.86%) within the first 4-week post-operative period. After the standard used of a RRD, 53 patients underwent BKA surgery, with only 4 (7.55%) requiring conversion to AKA within the 4-week post-operative period. CONCLUSION: Utilizing a RRD after BKA can improve wound healing, protect the residual limb, and help prevent conversions to AKA. In this retrospective review at a single institution there was a decrease of conversion from BKA to AKA in a 2-year period. Ridged removal dressings should be considered first-line therapy in the post-operative care of BKA patients.

A hip disarticulation prostheses test system to simulate gait for prostheses evaluation.

BACKGROUND: The limited number of hip prostheses users makes it less feasible to conduct amputee tests for prosthesis development in the clinic, which restricts the development efficiency of the intelligent prostheses. OBJECTIVE: This study proposes a hip disarticulation prostheses test system (HDPTS) to supplement the amputee tests for hip disarticulation prosthesis (HDP) evaluation, which would potentially facilitate the prosthesis evaluation safety and development efficiency. METHODS: The hip trajectory of an individual with normal gait was acquired and reproduced by calculating the corresponding movement joint angle of a manipulator. Then, an HDP was fit on an amputee and on the HDPTS respectively to obtain the hip and knee joint angles of the HDP during walking. Comparing the root mean square error (RMSE) of the expected and planned trajectory, the joint angles between the amputee test and HDPTS test, to verify the feasibility and accuracy of the HDPTS for prosthesis evaluation. RESULTS: The RMSE between the expected and planned trajectory value was less than 1.20 mm (< 0.19%). The RMSE of the joint angles between the amputee test and HDPTS test were 2.18∘ (1.8%) and 3.13∘ (5.92%) for hip and knee joint respectively. CONCLUSION: The HDPTS was found accurate in hip trajectory reproduction and feasible in gait simulation for the prosthesis evaluation, which could potentially supplement the amputee test for prosthesis design thus improving prosthesis test safety and development efficiency.

Factores diferenciales entre desistimiento individual y colectivo de mujeres de las FARC-EP en prisión / Differential factors between individual and collective desistance of FARC-EP women in prison / Fatores diferenciais entre a desistência individual e coletiva das mulheres das FARC-EP na prisão

Para el año 2017 se encontraban vigentes en Colombia dos marcos jurídicos para promover el desistimiento y desarticulación de las FARC-EP. Los dos, aunque desde contextos diferentes, han promovido, por un lado, el desistimiento individual y por otro, el desistimiento colectivo de sus miembros. Las mujeres han sido partícipes de ambos procesos, desde la libertad o la prisión de manera minoritaria y asimétrica en comparación con los hombres. Con el interés de analizar este fenómeno, el presente estudio buscó identificar los factores que llevaron a las mujeres a desistir según una u otra modalidad y de-terminar diferencias y similitudes. Para este propósito se diseñó un modelo probabilístico que captara las relaciones de causalidad entre desistimiento y factores predichos desde las teorías del aprendizaje social, de la elección racional y del control social informal, en una muestra de mujeres farianas en prisión que desistieron de forma individual y colectiva. Se encontró que factores como pertenecer a un rango de edad entre 20 y 31 años, tener pareja y haber participado en delitos graves, asociados al terrorismo, influyeron en la selección de la modalidad individual, mientras que tener más de 31 años, participar en delitos comunes junto a los asociados con el terrorismo, incluyendo el narcotráfico, y proceder de regiones con historia de conflicto arraigada predijeron el desistimiento colectivo.

By 2017, there were two legal frameworks in force in Colombia to promote the disbanding and dismantling of the FARC-EP. Both, although from different contexts, have promoted, on the one hand, the individual disbandment and, on the other, the collective disbandment of its members. Women have participated in both processes, from freedom or prison, in a minority and asymmetrical manner compared to men. In order to analyse this phenomenon, this study sought to identify the factors that led women to desist in one or the other modality and to determine differences and similarities. For this purpose, a probabilistic model was designed to capture the causal relationships between desistance and factors predicted from the theories of social learning, rational choice and informal social control, in a sample of women in prison who desisted individually and collectively. It was found that factors such as belonging to an age range between 20 and 31 years, having a partner and having participated in serious crimes associated with terrorism, influenced the selection of the individual modality, while being over 31 years old, participating in common crimes along with those associated with terrorism, including drug trafficking, and coming from regions with a history of deep-rooted conflict predicted collective desistance.

Até 2017, havia duas estruturas legais em vigor na Colômbia para promover a dissolução e o desmantelamento das FARC-EP. Ambos, embora de contextos diferentes, têm promovido, por um lado, a dissolução individual e, por outro, a dissolução coletiva de seus membros. As mulheres participaram de ambos os processos, da liberdade ou da prisão, de forma minoritária e assimétrica em relação aos homens. A fim de analisar este fenômeno, este estudo procurou identificar os fatores que levaram as mulheres a desistir em uma ou outra modalidade e determinar diferenças e semelhanças. Para este fim, um modelo probabilístico foi projetado para capturar as relações causais entre a desistência e os fatores previstos a partir das teorias de aprendizagem social, escolha racional e controle social informal, em uma amostra de mulheres na prisão que desistiram individual e coletivamente. Constatou-se que fatores como pertencer a uma faixa etária entre 20 e 31 anos, ter um parceiro e ter participado de crimes graves associados ao terrorismo, influenciaram a seleção da modalidade individual, embora tendo mais de 31 anos de idade, participar de crimes comuns juntamente com aqueles associados ao terrorismo, incluindo o tráfico de drogas, e vindo de regiões com um histórico de conflitos profundamente enraizados preveram a desistência coletiva.

[Scapulothoracic dissociation as a consequence of failure of traditional treatment in an adolescent girl: a case report]. / Désarticulation scapulo-thoracique, une conséquence d'un échec de traitement traditionnel chez une adolescente: à propos d'un cas.

Scapulothoracic dissociation due to a trauma is exceptional. The purpose of this study was to share our experience with a case of scapulothoracic dissociation and to explain the advantages of our approach. We report the case of a 12-year-old right-handed schoolgirl admitted to hospital with a blunt trauma to the right thoracic limb complicated by infection after a week of traditional treatment (massage, bandaging with reed splints). Surgical neck fracture of the right humerus complicated by wet gangrene of the entire limb and severe anaemia was diagnosed. Blood transfusion, triple antibiotic therapy and scapulohumeral disarticulation were required. Progressive excision of necrotic tissue followed by scapulectomy (day 24) for scapular necrosis made it possible to sterilise the site and to perform a skin graft (day 43). The patient was discharged after 2 months. Physiotherapy was combined with psychological treatment and the patient had a simple post-operative course during the 7-month follow-up period. Failure of conventional treatment for limb fractures can be life-threatening and cause severe sequelae.