RESUMO
BACKGROUND: Implant removal is a common procedure in orthopedic surgery which can be associated with many complications such as scar formation, hematoma, nerve injury, infection, and refracture. Indications for orthopedic implant removal have declined in recent years. Most studies have considered orthopedic hardware removal as an unnecessary procedure in the absence of severe complications such as nonunion. Some studies have reported the complications of orthopedic hardware removal to be 24% to 50% dependent on their types and locations as well as on other factors such as patient's condition and the orthopedist's experience. OBJECTIVES: The present study surveyed possible mental and psychological causes among patients who asked for removal procedures in spite of orthopedic surgeons' advice and being aware of complications. PATIENTS AND METHODS: Patients who had undergone plating for the treatment of radius and ulna fractures from 2011 to 2013, were told that it is not necessary to remove the plate and they were warned of all the risks of removal surgery, such as anesthesia, possible nerve or vascular damage, and the cost of surgery. Then, their tendency to remove the plate was examined based on evaluation criteria scores. Patients were divided into two groups: patients who insisted on surgery despite all the risks and patients who had little tendency or gave up after explanations. Both groups were given visual analog pain scale (VAS), symptom checklist-90 (SCL-90), and pain catastrophizing scale (PCS) questionnaires. The questions were explained for patients by an expert trained in the clinic and in case of ambiguity further explanations were given to the patients. The data were then entered into statistical package for the social science (SPSS) version 20 for analysis. RESULTS: A total of 29 patients with plates were enrolled. The first group consisted of 16 male and 13 female patients. In the control group (group II), there were 30 patients with no tendency for plate removal. In this group, 15 patients were male and 15 were female. The mean age of the first group was 38.25 ± 11.12 years and for the second group it was 36.82 ± 12.01 years. There was no significant difference between the two groups in terms of age and gender. Mean discomfort of patients was 7.75 ± 1.74 in the first and 3.96 ± 1.90 in the second group, indicating a statistically significant difference (P = 0.000). Mean VAS score was 3.96 ± 1.20 in the first group and 3.80 ± 1.15 in the second group, which was not statistically significant (P = 0.593). Mean daily pain and discomfort was 10.62 ± 3.09 hours in the first and 4.86 ± 2.23 hours in the control group, indicating a statistically significant difference (P = 0.000). Linear regression analysis results demonstrated a significant correlation between increased VAS scores in the first group (P = 0.000), but it was not significant in the second group (P = 0.083). The results also showed that increase in time of daily pain and discomfort had a linear relationship with increased discomfort score in both groups (P = 0.00). Mean pain catastrophizing scale (PCS) score was 10.13 ± 3.62 in the first and 9.56 ± 3.07 in the second group, which was not statistically significant. Mean somatization score was 52% ± 6.53% and 47.96% ± 7.17% in the first and second groups, respectively, which showed no significant differences (P = 0.013). Obsessive compulsive score was 54.63 ± 5.34 in the first and 46.63 ± 4.49 in the second group, which was statistically significant (P = 0.000). CONCLUSIONS: Mental and psychological backgrounds can affect the severity of discomfort of the implant. Given that so far the present study is the only study investigating the relationship between mental criteria and tendency of patients for implant removal, further studies with larger sample sizes seem warranted.
RESUMO
BACKGROUND: Reflex sympathetic dystrophy (RSD) syndrome is a multifactorial disorder with clinical features of neurogenic inflammation that causes hypersensitivity to pain or severe allodynia as well as blood flow problems, swelling, skin discoloration and maladaptive neuroplasticity due to vasomotor disorders. Patients with major trauma are prone to homeostasis leading to inflammatory response syndrome and multiple organ distress syndrome. Several studies have investigated the etiology of this condition, but the cause remains unknown. The role of associated factors such as the limb immobilization technique and genetics has been reported in the development of this complication, but, so far, there is no information regarding the effect of trauma severity on the risk of RSD occurrence. OBJECTIVES: Given the importance of diagnosing and treating this condition, we aimed to study the effect of trauma severity on the prevalence of RSD. PATIENTS AND METHODS: In this cross-sectional study, we examined patients with distal tibial fracture who visited Rasht Poursina hospital from 2010 to 2013. Exclusion criteria included associated fractures, underlying musculoskeletal diseases and mental and cognitive problems. To assess the severity of the initial injury in patients, the Hannover Fracture Scale 98 (HFS98) scoring checklist was used. The diagnosis of RSD was made on the basis of the IASP criterion. Demographic data, HFS98 scores, and information regarding RSD prevalence were analyzed using SPSS version 20. The Mann Whitney U nonparametric test was used for variables that were not normally distributed; the chi-square test was used to compare the qualitative variables. RESULTS: Among the 488 patients, 292 (59.83%) were male. The mean age of the study population was 44 ± 9.82 years. During the 6-month follow-up, RSD occurred in 45 patients, of whom 28 (62.22%) were female and 17 (37.77%) were male; there was thus a significant difference in the prevalence of RSD in terms of gender (P = 0.00; chi square test). The mean HFS98 score in patients without and with RSD was 3.081 ± 4.083 and 4.080 ± 4.622, respectively, and the difference was not statistically significant (P = 0.363; Mann Whitney U test). Analyses of the eight items of HFS98 shows that local circulation in patients with RSD is significantly better than that in patients without RDS (0.683 ± 0.822 vs. 0.528 ± 0.629, respectively). Statistical analysis showed that the odds ratio for RSD for patients with HFS95 score > 0 was 1.079 (confidence interval [CI]: 0.898 - 1.333). Moreover, the odds ratio for RSD was 1.100 (CI: 795 - 1.531) in patients with an injury severity score higher than the calculated mean score in patients without RSD (> 4.083). CONCLUSIONS: The results suggest no significant relationship between the severity of injury and risk of RSD occurrence, although the mean injury severity score was higher in patients with RSD than in those without RSD in this study population. The lower score of local circulation in patients with RSD than in those without RSD is a statistically significant finding and can be attributed to changes in the antioxidant levels at the injury site, which is one of the main mechanisms for the onset of RSD. Wound contamination was also justifiably higher in patients with RSD, although the difference was not statistically significant. In summary, the severity of injury alone cannot be a determining factor for predicting the probability of RSD.
