ABSTRACT
AIM: To develop pathogenetically justified surgical treatment of diabetic neuroosteoarthropathy (DNOAP). MATERIAL AND METHODS: 52 patients were operated and long-term results were studied in 36 of them. 2 groups were assessed depending on completeness of surgical treatment including changed synovial structures removal. Tarso-metatarsal arthrodesis was created after synovectomy in median foot to restore longitudinal arch. Cruro-calcaneal neoarthrosis was performed after elimination of posterior focus of DNOAP. Excision of large, deep plantar ulcer (or osteomyelitic fistula) was completed by tissues tension with needles for primary wound healing. RESULTS: DNOAP patients are tolerant against surgical infection that is decreased in patients with neuropathic form of diabetic foot syndrome. Skin plasty is followed by rejection in DNOAP that was cured with prednisolone. Deep suppurations complicating foot skeleton fragmentation have subacute course and do not lead to sepsis. Infected wounds heal by primary intention in 98% after closure with primary suture. It was empirically found that synovectomy and osteochondral detritus removal discontinue DNOAP course. Reconstructive surgical stage is aimed to restoring the shape and function of the foot. Analysis of long-term outcomes showed absence of DNOAP signs in 76.2±9.2% of cases after radical surgery and positive results of treatment in 97.2±2.7% of patients. CONCLUSION: Our data conceptually assume the possibility of autoimmune mechanism in DNOAP pathogenesis. On this basis pathogenetically reasonable surgical procedures are established to interrupt pathological process. These interventions differ by technological aspects only depending on middle or rear foot destruction.
Subject(s)
Arthrodesis/methods , Diabetic Foot , Dissection/methods , Long Term Adverse Effects , Surgical Wound Infection , Adult , Diabetic Foot/diagnostic imaging , Diabetic Foot/surgery , Female , Follow-Up Studies , Humans , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/etiology , Male , Middle Aged , Outcome and Process Assessment, Health Care , Radiography/methods , Plastic Surgery Procedures/methods , Russia , Surgical Wound Infection/diagnosis , Surgical Wound Infection/prevention & control , Wound Closure TechniquesABSTRACT
AIM: to improve the results of advanced peritonitis management. MATERIAL AND METHODS: 743 patients with advanced peritonitis were studied. Patients were divided into 2 groups depending on treatment strategy. RESULTS: Programmed relaparotomy combined with removable draining musculoaponeurotic seams during laparotomy closure decreased mortality from 47.8±2.7% to 24.1±2.3% (p<0.001) and provided 4-fold reduction of postoperative suppuration incidence (p<0.001). Refusal from removable draining musculoaponeurotic seams and use of only cutaneous seams in persistent abdominal hypertension were associated with further decrease of mortality to 15.8±2.7% (p<0.05). CONCLUSION: Programmed relaparotomy combined with removable draining musculoaponeurotic seams are advisable for advanced peritonitis management. Laparotomy closure with only cutaneous seams is indicated in case of persistent abdominal hypertension. Large eventration always requires abdominal wall repair. APACHE-III scale scores have significant prognostic value in patients with advanced peritonitis.
