Síndrome do túnel do carpo associada à amiloidose / Carpal tunnel syndrome associated with amyloidosis

Introdução: A amiloidose é caracterizada pela deposição de proteínas nos órgãos e tecidos, e tem sido associada à síndrome do túnel do carpo (STC) quando ocorre no punho. O objetivo é descrever uma série de casos de pacientes submetidos à cirurgia para STC associado à amiloidose. Métodos: O estudo incluiu 12 pacientes que se submeteram à cirurgia para tratar a STC cuja biópsia identificou amiloidose; o seguimento foi de cinco anos. Os pacientes foram avaliados por testes clínicos, eletroneuromiografia, imagens radiológicas e biópsia. Resultados: Todos os pacientes apresentaram queixas musculoesqueléticas, sintomas severos de compressão do nervo mediano, alterações nos testes neurofisiológicos. Realizou-se a cirurgia, sinovectomia e biópsia. No pós-operatório, cinco pacientes (41%) desenvolveram dor crônica e distrofia simpático-reflexa. Conclusão: Observou-se maior frequência de dor pós-operatória na amostra, o que revela a necessidade de atenção na abordagem e tratamento dessa associação.

Introduction: Amyloidosis features protein deposition in the organs and tissues and has been associated with carpal tunnel syndrome (CTS) when it occurs in the wrist. The objective is to describe a case series of patients undergoing surgery for CTS associated with amyloidosis. Methods: The study included 12 patients who underwent surgery to treat CTS in whom amyloidosis was proven by biopsy; the follow-up period was 5 years. The patients were evaluated by clinical tests, electroneuromyography, radiological images, and biopsy. Results: All patients presented with musculoskeletal complaints, severe symptoms of median nerve compression, and changes on neurophysiological tests. Surgery, synovectomy, and biopsy were performed. In the postoperative period, five patients (41%) developed chronic pain and reflex sympathetic dystrophy. Conclusion: A higher frequency of postoperative pain was observed in the patients, demonstrating the need for caution in the approach and treatment of this association.

Rabdomiólisis intraoperatoria en cirugía de resección de osteosarcoma de fémur: Reporte de caso y discusión / Case report: Intraoperative rhabdomyolisis after femur osteosarcoma resection

Rhabdomyolysis is a pathology that rarely has causes in the perioperative period, where it has been commonly related as a complication of malignant hyperthermia, prolonged patient positioning with intraoperative muscle compression, in the postoperative period of bariatric surgery and in children. The purpose of this review is to present the case of a 49 year-old male patient, who underwent limb salvage surgery for treatment of a left femur osteosarcoma, with reconstruction via bone transplant and joint prosthesis. During the procedure hyperkalemia and elevation of Creatine-Phosphokinase (CPK) enzyme levels where detected, without changes compatible with renal failure, which required repeated treatment to normalize and that, after ruling out other causes, it was attributed to skeletal muscle destruction during the procedure. Rhabdomyolysis is a phenomenon inherent to this sort of procedures and may manifest initially as laboratory findings and that, if not diagnosed in time, may lead to fatal arrhythmias and acute renal failure.

La rabdomiólisis es una patología que rara vez tiene origen en el período perioperatorio, donde comúnmente se le ha relacionado como complicación de la hipertermia maligna, de decúbitos prolongados con compresión muscular intraoperatoria, del posoperatorio de la cirugía bariátrica y en niños. El objetivo de este trabajo es presentar el caso de un hombre de 49 años, sometido a resección de un osteosarcoma de fémur izquierdo con reconstrucción mediante trasplante óseo y prótesis articular, durante el cual se detectan hiperpotasemia y aumento de la Creatin-Fosfokinasa (CPK), sin alteraciones compatibles con fallo renal, que requirió reiterados tratamientos para la normalización de los valores de kalemia, y que tras descartar otras causas se atribuyó a la destrucción de musculoesquelético durante el procedimiento. La rabdomiólisis es un fenómeno inherente a este tipo de procedimientos y puede manifestarse inicialmente con alteraciones analíticas que, de no ser diagnosticadas en tiempo y forma, pueden llevar a arritmias fatales y fallo renal agudo.

Delirium en el perioperatorio de cirugía de cadera en el adulto mayor / Perioperative delirium in hip surgery in the elderly / Delirum na cirurgia de quadril no idoso

El delirium es una de las complicaciones más frecuentes de la cirugía por fractura de cadera. No hay estudios en Uruguay sobre este tema. El objetivo de este trabajo fue determinar la frecuencia de delirium en el perioperatorio de cirugía por fractura de cadera, describir las características sociodemográficas y clínicas de la población y la asociación entre delirium y variables de interés. Se realizó un estudio observacional, analítico, prospectivo, de cohorte única. Se reclutaron 50 adultos mayores ingresados en el Instituto Nacional de Ortopedia y Traumatología, por fractura de cadera, candidatos a cirugía, durante un período de 4 meses. Se evaluaron previo a la cirugía, y en las 24 y 48 horas del postoperatorio. Se seleccionó una muestra no probabilística. Se contó con la aprobación del Comité de Ética del Hospital de Clínicas de Montevideo. La edad media fue de 83 años. La frecuencia de delirium fue de 42%, 28% previo a la cirugía y 14% en el postoperatorio. La frecuencia de delirium en los de 80 años o más fue del 53,3%. Se encontró una asociación estadísticamente significativa entre la edad mayor de 80 años y el estado funcional basal y el desarrollo de delirium. Esta frecuencia coincide con estudios internacionales. El tamaño y la selección de la muestra pueden haber influido en los resultados secundarios. El delirium es frecuente en este contexto y enfatiza la necesidad de un enfoque multidisciplinario y protocolizado para el abordaje de la población mayor que se somete a cirugía ortopédica.

Delirium is one of the most common complications of hip fracture surgery. There are no studies in Uruguay on this subject. The aim of this study was to determine the frequency of delirium in the perioperative period of hip fracture surgery, to describe the sociodemographic and clinical characteristics of the sample and the association between delirium and variables of interest. An observational, analytical, prospective, single cohort study was conducted. 50 older adults admitted to the National Institute of Orthopedics and Traumatology, for hip fracture, candidates for surgery, were recruited over a period of 4 months. They were evaluated before and after surgery. A non-probabilistic sample was selected. The study was approved by the Ethics Committee of the Hospital de Clínicas of Montevideo. Average age was 83 years. The frequency of delirium was 42%, 28% before surgery and 14% in the postoperative period. The frequency of delirium in those aged 80 years or older was 53.3%. A statistically significant association was found between age over 80 years and baseline functional status and the development of delirium. This frequency is similar to that found in international studies. The size and selection of the sample may have influenced secondary outcomes. Delirium is frequent in this context and highlights the need for a multidisciplinary and protocolized approach to the elderly population undergoing orthopedic surgery.

O delirium é uma das complicações mais comuns da cirurgia de fratura do quadril. Não há estudos no Uruguai em cirurgia ortopédica. O objetivo do estudo foi determinar a freqüência de delirium no peri-operatório da cirurgia ortopédica de fratura do quadril, descrever as características sociodemográficos e clínicas da população, e descrever a associação entre o delirium e as variáveis de interesse. Realizou-se um estudo observacional, analítico, prospectivo e de coorte única. 50 pessoas idosas com fratura de quadril candidatos à cirurgia ortopédica foram recrutados do Instituto Nacional de Ortopedia e Traumatologia, por um período de 4 meses. Foi selecionada uma amostra não-probabilística. A coorte foi avaliada antes e depois da cirurgia. O estudo foi aprovado pelo Comitê de Etica do Hospital de Clinicas. Idade média de 83 anos. A freqüência de delirium foi de 42%, 28% antes da cirurgia e 14% no pós-operatório. O percentual de delírio pré-operatório naqueles de 80 anos ou mais foi de 53,3%. Nós encontramos uma associação estatisticamente significativa entre a idade superior a 80 anos e o estatus funcional no desenvolvimento do delirium. Esta frequência encontrada coincide com estudos internacionais. O tamanho e a seleção da amostra podem ter influenciado os secundários. O delirium é comum neste contexto e enfatiza a necessidade de uma abordagem multidisciplinar e protocolada para os idosos que se someten a uma cirurgia ortopédica.

Adherencia terapéutica a la tromboprofilaxis ortopédica / Adherence compliance to thromboprophylaxis orthopedics

Introducción: En ortopedia una de las peores complicaciones después de un procedimiento quirúrgico es la trombosis venosa, principal causa de morbimortalidad y reingreso hospitalario después de una artroplastia de cadera o de rodilla. Objetivo: Describir el uso de tromboprofilaxis y el riesgo de complicaciones tromboembólicas en cirugía ortopédica. Métodos: Se llevó a cabo una revisión de la literatura en las bases de datos Scielo, ScienceDirect, PubMed y Lilacs, con los descriptores "trombosis", "ortopedia", "prevención y control", en español e inglés. Se seleccionaron 32 artículos relacionados con la tromboprofilaxis en cirugía ortopédica y su adherencia terapéutica. Resultados: El riesgo que presenta un paciente de desarrollar complicaciones tromboembólicas perioperatorias es de 10 por ciento a 50 por ciento. Depende del tipo de cirugía y los factores de riesgo individuales de cada paciente. En el caso de las cirugías ortopédicas, el uso de la tromboprofilaxis evita complicaciones, reintervenciones y una estancia hospitalaria prolongada. Conclusiones: Es fundamental una buena adherencia a los protocolos tromboprofilácticos, entre ellos, la elección del medicamento correcto, la dosis adecuada, el tiempo requerido y los controles necesarios para evitar cualquier evento trombótico(AU)

Introduction: In orthopedics, one of the worst complications after a surgical procedure is venous thrombosis, being the main cause of morbidity and mortality and hospital readmission after a hip or knee arthroplasty. Objective: To synthesize and describe information on the use of thromboprophylaxis and the risk of thromboembolic complications in orthopedic surgery. Methods: A review of the literature was carried out in the databases Scielo, ScienceDirect, PubMed and Lilacs with the descriptors: thrombosis, orthopedics, prevention & control, in Spanish and English. We included 32 articles with a review focused on thromboprophylaxis in orthopedic surgery and adherence compliance. Results: The risk that a patient presents or develops perioperative thromboembolic complications is about 10 to 50 % according to the literature, which depends on the type of surgery and the individual risk factors. In the case of orthopedic surgeries, the use of this treatment avoids complications, reinterventions and a long hospital stay. Conclusions: A good adherence to the thromboprophylactic protocols is important, including the choice of the correct medication, the appropriate dose, the time required and the necessary controls to avoid any thrombotic event(AU)

Tratamiento quirúrgico de las dismetrías y deformidades angulares de miembros inferiores mediante epifisiodesis con tornillos transfisarios (técnica de Metaizeau) / Surgical treatment of lower limb length discrepancy and angular deformity by epiphysiodesis with transphyseal screw (Metaizeau technique) / Tratamento cirúrgico das dismetrias e deformidades angulares de membros inferiores mediante epifisiodese com parafusos transfisários (técnica de Metaizeau)

Evaluamos los niños con dismetrías y deformidades angulares operados mediante la Técnica de Metaizeau en el período 2010-2014, mediante un estudio retrospectivo de 11 pacientes, analizados en 2 Grupos. Grupo 1 (Dismetrías), formado por 5 pacientes, de los cuales 3 fueron operados solamente mediante esta técnica, mientras que 2 requirieron adicionalmente procedimientos de alargamiento femoral, valoramos dismetría inicial, dismetría por predicción para el último control y para el final de la madurez, y dismetría final. Grupo 2 (Deformidades Angulares), formado por 6 pacientes, de los cuales 1 presentaba genu varo, 4 genu valgo y 1 valgo de tobillo, valoramos el ángulo femorotibial anatómico, ángulo femoral distal lateral anatómico, ángulo tibial proximal medial, y ángulo tibioastragalino. En ambos Grupos se valoraron las complicaciones. El seguimiento promedio fue de 2 años y 5 meses. En el Grupo 1 obtuvimos dismetría promedio inicial 7,64 cm., dismetría promedio por predicción para el último control 8,54 cm., dismetría promedio final 7,62 cm., corrección promedio lograda 0,91 cm. En el Grupo 2 el promedio de corrección del ángulo femorotibial anatómico 16,85˚, promedio de corrección del ángulo femoral distal lateral anatómico 16,85˚, promedio de corrección del ángulo tibial proximal medial 7,62˚. No detectamos complicaciones en ningún paciente. En 8 (72,72%) pacientes la Técnica fue efectiva, mientras que en 3 (27,27%) los resultados fueron malos por errores técnicos o error en la predicción. La Técnica de Metaizeau, respetando los detalles quirúrgicos y realizando una adecuada predicción, es una buena opción para el tratamiento de dismetrías y deformidades angulares.

We evaluated children with lower limb length discrepancy and angular deformity operated by the Metaizeau technique in the 2010-2014 period through a retrospective study of 11 patients analyzed in 2 groups. Group 1 (Lower limb length discrepancy), consisted of 5 patients, among whom 3 were operated only by Metaizeau technique, whereas the other 2 additionally required procedures for femoral elongation. We evaluated initial discrepancy, predicted discrepancy for ultimate control and at maturity, and final discrepancy. Group 2 (Angular deformity), consisted of 6 patients, among whom 1 had genu varum, 4 genu valgum and, 1 ankle valgus. We evaluated anatomic femorotibial angle, anatomic lateral distal femoral angle, medial proximal tibial angle, and tibio talar angle. In both groups the complications were assessed. The average follow-up was 2 years and 5 months. In Group 1 we obtained the following values: average initial discrepancy, 7.64 cm; average discrepancy predicted for ultimate control, 8.54 cm; average final discrepancy, 7.62 cm and average correction achieved, 0.91 cm. In Group 2 the values were: average correction anatomic femorotibial angle, 16.85˚; average correction anatomic lateral distal femoral angle, 16.85˚ and average correction medial proximal tibial angle, 7.62˚. We found no complications in any patient. In 8 patients (72.72%) the technique was effective, while in 3 (27.27%) the results were poor due to technical errors or prediction errors . Metaizeau Technique, respecting the surgical details and making an accurate prediction is an effective, simple and uncomplicated procedure.

Avaliamos as crianças com dismetrias e deformidades angulares operadas pela técnica de Metaizeau no período de 2010 até 2014, mediante um estudo retrospectivo de 11 pacientes analisados em dois grupos. Grupo 1 (Dismetrias), constituído por cinco pacientes, dos quais 3 foram operados apenas por esta técnica, enquanto que os outros dois precisaram de procedimentos adicionais de alongamento femoral. Avaliamos a dismetria inicial, a dismetria por predição para o último controle e para o final da maturação, e a dismetria final. Grupo 2 (deformidades angulares), constituído por 6 pacientes, entre os quais um apresentava genu varo, 4 genu valgo e um, valgo do tornozelo. Avaliamos o ângulo femorotibial anatômico, o ângulo femoral distal anatômico o ângulo femoral distal lateral anatômico, o ângulo tibial proximal medial, e o ângulo tibioastragalino. Em ambos os grupos foram avaliadas as complicações. O seguimento médio foi de 2 anos e 5 meses. No Grupo 1, obtivemos dismetría inicial média de 7,64 cm, dismetria média por previsão para o último controle de 8,54 cm, dismetría final média de 7,62 cm e correcção média atingida de 0,91 cm. No Grupo 2, a correção de ângulo tibiofemoral anatómica média 16,85˚, correção média do ângulo femoral distal lateral anatómico 16,85˚, e correção média de ângulo tibial proximal medial de 7,62˚. Não detectamos complicações em nenhum paciente. A técnica foi efetiva em 8 (72,72%) pacientes, mas em 3 (27,27%) os resultados foram insatisfatórios por erros técnicos ou na predicção. A técnica de Metaizeau, desde que sejam respeitados os detalhes cirúrgicos e seja feita uma predicção adequada, é uma boa escolha para o tratamento de dismetrías e deformidades angulares.

Applicability of the surgical site infection risk index to patients undergoing cardiac, neurologic and orthopedic surgery

Introduction: The surgical site infection risk index (SSIRI) includes three risk factors for surgical site infection (SSI): potential for surgical contamination, duration of surgery, and patient's ASA score. A patient having a preoperative American Society of Anesthesiologists (ASA) score of III, IV or IV; a surgery classified as either contaminated or dirty-infected; an operation with duration of surgery more than T hours, where T depends on the surgical procedure being performed are considered in risk of SSI. The SSIRI can be used as a method of postoperative surveillance. The aim of this study is to analyze the applicability of the SSIRI to patients undergoing cardiac, neurologic and orthopedic surgery. Methods: A retrospective cohort study including patients undergoing cardiac, neurological and orthopedic surgeries considered major, from January to December 2014, evaluated through review of medical charts of patients admitted to a university hospital in southern Brazil. Values of p <0.05 were considered significant. Results: A total of 761 patients were included in the study; of these, 122 (16%) developed SSI. The SSIRI did not demonstrate statistical significance to distinguish the patients most likely to develop SSI between the four levels of the ASA score. Black and brown patients, patients who underwent intraoperative blood transfusion, and patients who underwent surgical reintervention were more susceptible to SSI. Conclusions: The SSIRI could not be used as a method of postoperative surveillance for patients in the present study. The other risk factors found may serve as a guide to articulate SSI prevention strategies and, thus, minimize chances of development of serious infections (AU)

Pain after major elective orthopedic surgery of the lower limb and type of anesthesia: does it matter? / Dor após cirurgia eletiva ortopédica de grande porte em membro inferior e o tipo de anestesia: isso importa?

Abstract Background and objectives: Total knee arthroplasty and total hip arthroplasty are associated with chronic pain development. Of the studies focusing on perioperative factors for chronic pain, few have focused on the differences that might arise from the anesthesia type performed during surgery. Methods: This was a prospective observational study performed between July 2014 and March 2015 with patients undergoing unilateral elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) for osteoarthritis. Data collection and pain evaluation questionnaires were performed in three different moments: preoperatively, 24 hours postoperatively and at 6 months after surgery. To characterize pain, Brief Pain Inventory (BPI) was used and SF-12v2 Health survey was used to further evaluate the sample's health status. Results: Forty and three patients were enrolled: 25.6% men and 74.4% women, 51,2% for total knee arthroplasty and48.8% for total hip arthroplasty, with a mean age of 68 years. Surgeries were performed in 25.6% of patients under general anesthesia, 55.8% under neuraxial anesthesia and 18.6% under combined anesthesia. Postoperatively, neuraxial anesthesia had a better pain control. Comparing pain evolution between anesthesia groups, neuraxial anesthesia was associated with a decrease in “worst”, “medium” and “now” pain at six months. Combined anesthesia was associated with a decrease of “medium” pain scores at six months. Of the three groups, only those in neuraxial group showed a decrease in level of pain interference in “walking ability”. TKA, “worst” pain preoperatively and general were predictors of pain development at six months. Conclusions: Patients with gonarthrosis and severe pain preoperatively may benefit from individualized pre- and intraoperative care, particularly preoperative analgesia and neuraxial anesthesia.

Resumo Justificativa e objetivos: A artroplastia total de joelho e a artroplastia total de quadril estão associadas ao desenvolvimento de dor crônica. Dentre os estudos que avaliam os fatores perioperatórios para a dor crônica, poucos abordam as diferenças que podem surgir do tipo de anestesia feita durante a cirurgia. Métodos: Estudo observacional, prospectivo, feito entre julho de 2014 e março 2015 com pacientes submetidos à ATJ unilateral eletiva ou ATQ para a osteoartrite. A coleta de dados e a avaliação da dor por meio de questionários foram feitas em três momentos distintos: no pré-operatório, em 24 horas de pós-operatório e aos seis meses após a cirurgia. O Inventário Breve da Dor (IBD) foi usado para caracterizar a dor o e o Questionário SF-12v2 foi usado para avaliar melhor o estado de saúde da amostra. Resultados: Foram inscritos 43 pacientes: 25,6% homens e 74,4% mulheres, 51,2% para ATJ e 48,8% ATQ, com média de 68 anos. A cirurgia foi feita em 25,6% dos pacientes sob anestesia geral, em 55,8% sob anestesia neuroaxial e em 18,6% sob anestesia combinada. No pós-operatório, a anestesia neuraxial apresentou melhor controle da dor. Na comparação da evolução da dor entre os grupos, a anestesia neuraxial foi associada a uma diminuição de “pior”, “médio” e “sem” dor em seis meses. A anestesia combinada foi associada a uma diminuição do escore “médio” de dor em seis meses. Dos três grupos, apenas aqueles no grupo neuraxial apresentaram uma diminuição do nível de interferência da dor na “capacidade de caminhar”. ATJ, “pior” dor no pré-operatório e anestesia geral foram preditivos de desenvolvimento de dor aos seis meses. Conclusões: Os pacientes com gonartrose e dor intensa no pré-operatório podem obter benefício de cuidados individualizados no pré e intraoperatório, particularmente de analgesia no pré-operatório e anestesia neuraxial.

Is Antegrade Transmalleolar Drilling Method for Osteochondral Lesion of Talus Necessary? Iatrogenic Cystic Formation at the Tibia: A Report of Five Cases

Antegrade transmalleolar drilling method is one of the options for the treatment of osteochondral lesion of talus (OLT). We present five patients who underwent tibial drilling for treatment of OLT and later developed distal tibial cystic formation induced by cartilage opening or heat necrosis during drilling. Antegrade transmalleolar drilling can be a possible option for the treatment of OLT if the lesion is not easily reachable; however, other viable treatment should be considered due to its possibility of distal tibial pathologic change.

Readmission from orthopedic surgical site infections: an integrative review / Reingreso por infección del sitio quirúrgico ortopédico: una revisión integradora / Readmissão por infecção do sítio cirúrgico ortopédico: uma revisão integrativa

Abstract OBJECTIVE Characterizing readmissions from orthopedic surgical site infections. METHOD An integrative review of literature in the LILACS, IBECS, MEDLINE, Cochrane, SciELO and PUBMED databases, using the descriptors Patient readmission, Wound infection, Cross infection, Orthopedic procedures, Orthopedics. RESULTS 78 studies were identified and 10 publications were selected. Surgical site infections are the most common cause of unplanned orthopedic readmissions, representing long periods of hospitalization, new surgical procedures and high costs, and greater possibility of subsequent hospitalizations. Most significant predictors have indicated average length of hospitalization, need for intensive care, emergency status at admission, risk of death, age > 65 years, males and higher body mass index. CONCLUSION Readmission rates have increasingly become measures of quality and concerns about costs. New studies could involve issues related to indirect costs, specifically social and psychological costs.

Resumen OBJETIVO Caracterizar los reingresos por infección del sitio quirúrgico ortopédico. MÉTODO Revisión integradora de la literatura, en las bases de datos LILACS, IBECS, MEDLINE, Cochrane, SciELO y PUBMED, por medio de los descriptores Reingreso del paciente, Infección de la herida operatoria, Infección hospitalaria, Procedimientos ortopédicos, Ortopedia. RESULTADOS Fueron identificados 78 estudios y seleccionadas 10 publicaciones. La infección del sitio quirúrgico es la causa más frecuente entre los reingresos ortopédicos no planificados, que representan largas estancias hospitalarias, nuevas intervenciones quirúrgicas y costos elevados, además de mayor posibilidad de ingresos subsiguientes. Los factores predictivos más significativos señalaron tiempo de estancia media, necesidad de cuidados intensivos, status de urgencia en el ingreso, riesgo de muerte, edad > 65 años, sexo masculino y mayor índice de masa corpórea. CONCLUSIÓN Las tasas de reingreso se hacen cada vez más medidas de cualidad y preocupación con relación a los costos. Nuevos estudios podrían involucrar cuestiones relacionadas con costos indirectos, especialmente los sociales y psicológicos.

Resumo OBJETIVO Caracterizar as readmissões por infecção do sítio cirúrgico ortopédico. MÉTODO Revisão integrativa da literatura, nas bases de dados LILACS, IBECS, MEDLINE, Cochrane, SciELO e PUBMED, por meio dos descritores Readmissão do paciente, Infecção da ferida operatória, Infecção hospitalar, Procedimentos ortopédicos, Ortopedia. RESULTADOS Identificados 78 estudos e selecionadas 10 publicações. A infecção do sítio cirúrgico é a causa mais frequente entre as readmissões ortopédicas não planejadas, que representam longos períodos de internação, novas intervenções cirúrgicas e custos elevados, além de maior possibilidade de internações subsequentes. Fatores preditivos mais significantes apontaram tempo médio de internação, necessidade de cuidados intensivos,status de urgência na admissão, risco de morte, idade > 65 anos, sexo masculino e maior índice de massa corporal. CONCLUSÃO Taxas de readmissão tornam-se cada vez mais medidas de qualidade e preocupação em relação a custos. Novos estudos poderiam envolver questões relacionadas a custos indiretos, especificamente os sociais e psicológicos.

Incidence of Deep Vein Thrombosis after Major Lower Limb Orthopedic Surgery: Analysis of a Nationwide Claim Registry

PURPOSE: We aimed to evaluate the nationwide incidence and risk factors for symptomatic deep vein thrombosis (DVT) after major lower limb orthopedic surgeries. MATERIALS AND METHODS: The Korean Health Insurance Review and Assessment Service database was used to retrospectively identify International Classification of Disease-10 codes for DVT and operation codes representing hip arthroplasty, knee arthroplasty, and hip fracture surgeries. The age- and gender-adjusted annual incidence of DVT, rates of major lower limb orthopedic surgeries, and the postoperative incidence of DVT according to the surgical procedure were assessed. RESULTS: The age- and gender-adjusted annual incidence of DVT was 70.67 per 100000 persons/year. Compared to patients aged 70 years (p<0.001). Females showed a greater relative risk for DVT than males (1.08; p<0.001). The incidence of postoperative DVT, according to the type of surgery, was significantly greater for knee replacement arthroplasty than for other forms of surgery (p<0.002). The relative risk of postoperative DVT was higher in females in knee replacement arthroplasty (1.47) and hip fracture surgery (2.25) groups, although relatively lower in those who underwent hip replacement arthroplasty (0.97). CONCLUSION: Among major lower limb surgeries, advanced age, female gender, and undergoing a knee replacement arthroplasty were found to be risk factors for developing postoperative DVT. These findings further emphasize the need for orthopedic surgeons to consider the development of DVT after surgery in high-risk patients.

Perioperative Complications of Orthopedic Surgery for Lower Extremity in Patients with Cerebral Palsy

Because complications are more common in patients with cerebral palsy (CP), surgeons and anesthesiologists must be aware of perioperative morbidity and be prepared to recognize and treat perioperative complications. This study aimed to determine the incidence of and risk factors for perioperative complications of orthopedic surgery on the lower extremities in patients with CP. We reviewed the medical records of consecutive CP patients undergoing orthopedic surgery. Medical history, anesthesia emergence time, intraoperative body temperature, heart rate, blood pressure, immediate postoperative complications, Gross Motor Function Classification System (GMFCS) level, Cormack-Lehane classification, and American Society of Anesthesiologists physical status classification were analyzed. A total of 868 patients was included. Mean age at first surgery was 11.8 (7.6) yr. The incidences of intraoperative hypothermia, absolute hypotension, and absolute bradycardia were 26.2%, 4.4%, and 20.0%, respectively. Twenty (2.3%) patients had major complications, and 35 (4.0%) patients had minor complications postoperatively. The incidences of intraoperative hypothermia, absolute hypotension, and major postoperative complications were significantly higher in patients at GMFCS levels IV and V compared with patients at GMFCS levels I to III (P<0.001). History of pneumonia was associated with intraoperative absolute hypotension and major postoperative complications (P<0.001). These results revealed that GMFCS level, patient age, hip reconstructive surgery, and history of pneumonia are associated with adverse effects on intraoperative body temperature, the cardiovascular system, and immediate postoperative complications.

Acute right heart failure caused by iatrogenic brachiocephalic arteriovenous fistula following orthopedic surgery

No abstract available.

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina / Venous thromboembolic prophylaxis: Guidelines for adults in Argentina

La enfermedad tromboembólica venosa (ETV) en adultos posee elevada morbimortalidad y puede asociarse a complicaciones crónicas invalidantes. Sin embargo, la adherencia a estándares de cuidado no es óptima. Se analizó la evidencia disponible en tromboprofilaxis y se generaron recomendaciones (1) o sugerencias (2) con diferentes grados de evidencia (A, B o C) para diferentes escenarios y métodos de tromboprofilaxis. En cirugías ortopédicas mayores se recomienda la profilaxis farmacológica con heparinas de bajo peso molecular, HBPM (1B), fondaparinux, dabigatrán y rivaroxaban (1B) que deben iniciarse durante la internación y mantenerse hasta 35 días después de la cirugía de cadera y hasta 10 días posteriores a la artroplastia de rodilla. La artroscopia de rodilla y la cirugía de columna programada no requieren profilaxis farmacológica (2B) salvo que posean factores de riesgo adicionales, en cuyo caso se recomiendan las HBPM. En pacientes con internación clínica y movilidad reducida esperable mayor a tres días, que posean factores de riesgo adicionales, se recomienda tromboprofilaxis con HBPM, HNF o fondaparinux (1B) hasta el alta. Aquellos pacientes neuroquirúrgicos o con HIC deberán recibir inicialmente tromboprofilaxis mecánica (2C) y dependiendo del caso, iniciar HBPM o HNF entre las 24-72 horas posteriores (2C). Estas últimas dos drogas son recomendadas para pacientes críticos. Los pacientes sometidos a cirugías no ortopédicas con bajo riesgo de ETV deberán realizar deambulación precoz (2C) y tromboprofilaxis mecánica (2C), mientras que aquellos en los que el riesgo de ETV sea elevado deberán recibir HBPM y HNF (1B o 2C según su riesgo de sangrado).

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).

Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery? / A tromboprofilaxia evita o tromboembolismo venoso após cirurgia ortopédica de grande porte?

OBJECTIVE: Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital. METHODS: Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities. RESULTS: We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the patients presented with PE and DVT (61.5% and 72.4%, respectively) within the first 72 h after surgery. Patients undergoing femur fracture repair, those aged ≥ 65 years, and bedridden patients were at a higher risk for developing VTE. CONCLUSIONS: Our results show that VTE was a significant complication of major orthopedic surgery, despite the use of thromboprophylaxis. Clinicians should be aware of VTE, especially during the perioperative period and in bedridden, elderly patients (≥ 65 years of age). .

OBJETIVO: A embolia pulmonar (EP) é uma complicação importante de cirurgia ortopédica de grande porte. Este estudo visou avaliar a incidência de tromboembolismo venoso (TEV) e os fatores que influenciam o desenvolvimento de TEV em pacientes submetidos a cirurgia ortopédica de grande porte em um hospital universitário. MÉTODOS: Pacientes submetidos a cirurgia ortopédica de grande porte (artroplastia de quadril, artroplastia do joelho ou reparação de fratura de fêmur) entre fevereiro de 2006 e junho de 2012 foram incluídos retrospectivamente no estudo. As incidências de EP e de trombose venosa profunda (TVP) foram avaliadas, assim como os fatores que influenciaram sua ocorrência, tais como o tipo de cirurgia, idade e comorbidades. RESULTADOS: Foram revisados os prontuários médicos de 1.306 pacientes. As proporções de artroplastia do joelho, artroplastia de quadril e reparação de fratura de fêmur foram, respectivamente, de 63,4%, 29,9% e 6,7%. A incidência cumulativa de EP e TVP nos pacientes submetidos a cirurgia ortopédica de grande porte foi, respectivamente, de 1,99% e 2,22%. A maioria dos pacientes apresentou EP e TVP (61,5% e 72,4 %, respectivamente) nas primeiras 72 h após a cirurgia. Pacientes submetidos à reparação de fratura de fêmur, aqueles com idade ≥ 65 anos, e pacientes acamados tinham um risco maior de desenvolver TVP. CONCLUSÕES: Nossos resultados demonstram que o TEV foi uma complicação importante de cirurgia ortopédica de grande porte, apesar da utilização de tromboprofilaxia. Os médicos clínicos devem estar alerta para a ocorrência ...

Infecção de sítio cirúrgico em pacientes submetidos a procedimentos ortopédicos com implante, em um hospital público de Belo Horizonte, Minas Gerais / Surgical site infection in patients undergoing orthopedic surgeries with implants, a public hospital in Belo Horizonte-MG

A infecção de sítio cirúrgico (ISC) decorrente do ato operatório com o uso de implante é considerada evento grave, causando prejuízo para o paciente, instituição de saúde, família e sociedade. A vigilância sistemática desses pacientes no pós-operatório torna-se imprescindível para o reconhecimento de forma confiável dos fatores de riscos que causam as ISCs e para direcionar medidas de prevenção e controle. O método de vigilância por telefone tem sido uma prática com boa taxa de retorno. Este estudo é uma coorte concorrente de 222 pacientes submetidos à cirurgia ortopédica com implante, no período de maio a setembro de 2011, com o acompanhamento pós-alta hospitalar durante um ano, por contato telefônico. O objetivo geral foi avaliar os aspectos epidemiológicos das ISCs nos pacientes submetidos a cirurgias ortopédicas com implantes, de um hospital público de Minas Gerais. Os objetivos específicos foram caracterizar a população do estudo; estimar a incidência de ISC global, por procedimentos e por topografias; identificar, entre as variáveis coletadas, quais constituem fatores de risco para a ISC; estimar o tempo de manifestação da ISC; identificar o tipo de implante mais usado nas cirurgias ortopédicas e sua natureza; identificar os agentes etiológicos responsáveis pelas ISCs e perfil de resistência desses microrganismos; estimar a taxa de mortalidade, o número de eventos não infecciosos e as incapacidades funcionais dos pacientes nas atividades diárias após um ano de cirurgia. Utilizou-se metodologia do NHSN⁄CDC. Para a análise descritiva foi usada frequência simples e medidas de tendência central como média, mediana e de variabilidade como desvio-padrão. Para verificar a associação entre fatores de risco e ISC foi realizada a análise de sobrevida empregando Kaplan Meier na análise univariada e regressão de Cox na análise multivariada. A população foi caracterizada por pacientes do gênero feminino, idosos (>60 anos) e acima do peso corporal...

Surgical site infection (SSI), resulting from the surgery with the use of implant, is considered a severe event causing injury to the patient, health institution, family and society. The systematic surveillance of these patients in the postoperative period it becomes essential for the recognition of reliably risk factors that cause the SSI and guide prevention and control measures. The method of surveillance by telephone has been identified as a practice with good return rate. This study was prospective cohort of 222 patients undergoing orthopaedic surgery with implantation, in the period May to September 2011, with follow-up post-hospital discharge, during a year, by telephone contact. Its general objective was to evaluate the epidemiologic aspects The SSI in patients undergoing orthopedic surgery with implants, a public hospital in Minas Gerais. Specific objectives were to characterize the study population; estimate the incidence of SSI global, by procedures and by topographies; identify, among the collected variables, which are risk factors for the SSI; estimate the time of the manifestation of SSI; identify the type of implant used in orthopedic surgery and its nature; identify the etiologic agents responsible for SSI and resistance profile of these microorganisms; estimate the rate of mortality, the number of events not infectious and the functional disability of patients daily activities one year after surgery. We used methodology NHSN⁄CDC. For the descriptive analysis was used to simple frequency and measures of central tendency as mean, median and of variability as standard deviation.To check the association between the risk factors and the occurrence of SSI was held in the survival analysis using Kaplan Meier in the univariate analysis and Cox regression for the multivariate analysis. The population was characterized by female patients, the elderly (>60 years) and above the body weight (BMI >25 kg⁄m2). Were notified 28 ISC with...

Modified Combined Approach for Distal Humerus Shaft Fracture: Anterolateral and Lateral Bimodal Approach

BACKGROUND: Due to the anatomical nature of the radial nerve, dissection and attainment of an adequate operative field in mid to distal humerus fracture is dangerous and limited. We devised a combined anterolateral and lateral approach that ensures protection of the radial nerve. This is achieved by performing bimodal dissection of the proximal humerus anteriorly and the distal humerus laterally. METHODS: Thirty-five consecutive patients were treated using a combined anterolateral and lateral approach for a minimum follow-up period of 24 months. We analyzed time to bony union, time to return to daily work, range of motion, elbow joint function as assessed by the Mayo elbow performance index and complications. RESULTS: Radiologic bony union was observed at 11.2 weeks (range, 8 to 20 weeks) on average. Four cases of incomplete radial nerve palsy before surgery all recovered. Time to return to work was 10.2 weeks (range, 2 to 32 weeks) on average. The average range of motion of the elbow was 3.3degrees (range, 0degrees to 10degrees) of extension and 135.9degrees (range, 125degrees to 145degrees) of flexion. There were 21 cases of excellent and 13 cases of good or better recovery, comprising over 97.1% on the Mayo elbow performance index. There were no complications of radial nerve palsy, non-union, mal-union, or infection. CONCLUSIONS: Our a modified combined anterolateral and lateral approach is a clinically effective surgical method of achieving protection of the radial nerve and securing easy and firm internal fixation.

Guía de recomendaciones para la profilaxis de la enfermedad tromboembólica venosa en adultos en la Argentina / [Venous thromboembolic prophylaxis. Guidelines for adults in Argentina].

The venous thromboembolic disease (VTD) in adults has a high morbidity and mortality. It can be also associated to disabling chronic conditions. In spite of this, prophylaxis in healthcare assistance is still underused. In this article, the available evidence in thromboprophylaxis was analyzed to offer recommendations (1) or suggestions (2) classified according to different levels of evidence (A, B or C). Different medical scenarios and types of thromboprophylaxis were analyzed. In major orthopedic surgeries low molecular weight heparins, LMWH, inhibitors of the Xa and IIa factors are recommended (1B) to be started during hospitalization and continued for 35 days in hip replacement surgery and for 10 days in total knee replacement surgery. Knee arthroscopy and spine surgery do not require pharmacologic treatment (2B) unless the patient has other risks factors for thrombosis. In such cases, LMWH are recommended. Non-surgical patients who have at least one risk factor should receive LMWH, NFH or fondaparinux (1B) if they are to be bedridden or unable to walk for three or more days. Patients undergoing neurosurgery or with intracranial hemorrhage should receive mechanic prophylaxis (2C), and accordingly they should start LMWH or NFH 24 to 72 hours afterwards (2C). The latter two drugs are recommended for critically ill patients. Patients with low risk for VTD undergoing other type of surgeries should be prescribed with mechanical prophylaxis (2C) and encouraged to walk promptly (2C), while those with high risk should be prescribed with LMWH or NFH (1B or 2C according to bleeding risk factors).