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BACKGROUND: Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM. METHODS: A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists). RESULTS: Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained. CONCLUSION: Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.
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Queimaduras , Médicos , Humanos , Deambulação Precoce , Estado Terminal , Queimaduras/terapia , Inquéritos e QuestionáriosRESUMO
Background Closed reduction and cast immobilization of displaced distal radius fractures carries the risk of secondary displacement, which could result in a symptomatic malunion. In patients with a symptomatic malunion, a corrective osteotomy can be performed to improve pain and functional impairment of the wrist joint. Objective The aim of this study was to assess the functional outcomes of children who underwent a corrective osteotomy due to a symptomatic malunion of the distal radius. Methods Between 2009 and 2016, all consecutive corrective osteotomies of the distal radius of patients younger than 18 years were reviewed. The primary outcome was functional outcome assessed with the ABILHAND-Kids score. Secondary outcomes were QuickDASH (Quick Disabilities of Arm, Shoulder, and Hand) score, range of motion, complications, and radiological outcomes. Results A total of 13 patients with a median age of 13 years (interquartile range [IQR]: 12.5-16) were included. The median time to follow-up was 31 months (IQR: 26-51). The median ABILHAND-Kids score was 42 (range: 37-42), and the median QuickDASH was 0 (range: 0-39). Range of motion did not differ significantly between the injured and the uninjured sides for all parameters. One patient had a nonunion requiring additional operative treatment. The postoperative radiological parameters showed an improvement of radial inclination, radial height, ulnar variance, dorsal tilt, and dorsal tilt. Conclusion Corrective osteotomy for children is an effective method for treating symptomatic malunions of the distal radius. Level of Evidence This is a Level IV study.
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INTRODUCTION: Malunion occurs in approximately 23% of non-operatively treated and 11% of operatively treated distal radius fractures. The decision whether to correct a malunion is primarily based on functional impairment and wrist pain. The purpose of this study was to assess the long-term functional outcomes of corrective osteotomies for symptomatic malunited distal radius fractures. METHODS: All consecutive corrective osteotomies of the distal radius performed in one centre between January 2009 and January 2016 were included. The primary outcome was the functional outcome assessed with the Disability of the Arm, Shoulder and Hand (DASH) and the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes were range of motion, grip strength, pain as indicated on the Visual Analogue Scale (VAS) before and after corrective osteotomy, radiological parameters, time to union and complications. Additionally, we aimed to determine if there were any difference in graft versus no graft usage. RESULTS: A total of 48 patients were included. The median age was 54.5 years (IQR 39-66) and 71% was female. The median time to follow-up was 27 months. The median DASH and PRWE score were respectively 10.0 (IQR 5.8-23.3) and 18.5. (6.5-37.0). Except for pronation and supination, range of motion and grip strength of the injured wrist were significantly less compared to the uninjured side. Palmar and dorsal flexion and radial and ulnar deviation of the injured wrist were significantly less compared with the uninjured side. VAS pain scores decreased significantly from 6.5 preoperative to 1.0 postoperative. The median time to union was 23 weeks (IQR 12-29.5). Eighteen patients (38%) had a complication for which additional treatment was required. Except for a significant difference in radial inclination and length after the corrective osteotomy in favour of graft usage, there were no significant differences between graft an no graft usage. CONCLUSIONS: Corrective osteotomy is an effective method of treating symptomatic distal radius malunions with good long-term functional results, measured with the DASH and PRWE score, and improvement in radiographic parameters and pain scores. Additionally, no differences in functional outcomes were found between graft and no graft usage.
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Transplante Ósseo/métodos , Consolidação da Fratura/fisiologia , Fraturas Mal-Unidas/cirurgia , Osteotomia , Satisfação do Paciente/estatística & dados numéricos , Fraturas do Rádio/cirurgia , Articulação do Punho/fisiopatologia , Adulto , Avaliação da Deficiência , Feminino , Seguimentos , Fraturas Mal-Unidas/epidemiologia , Fraturas Mal-Unidas/fisiopatologia , Fraturas Mal-Unidas/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Osteotomia/métodos , Medição da Dor , Radiografia , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/fisiopatologia , Fraturas do Rádio/psicologia , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The treatment of choice for elderly with a displaced intra-capsular femoral neck fractures is prosthetic replacement. This is however a major surgical procedure for geriatric patients with multiple co-morbidities which can threaten hemodynamic stability and lead to death. In this study we compared the outcome of internal fixation (IF) versus hemiarthroplasty (HA) for the management of intra-capsular femoral neck fractures in the elderly with severe co-morbidities. METHODS: We conducted a retrospective cohort study of all the patients who were admitted to our Level-II trauma centre with a femoral neck fracture between January 2009 and June 2011. Inclusion criteria were: 70 years or older, ASA 3 or higher, a displaced femoral neck fracture and treatment with either internal fixation or a cemented hemiprosthesis. The primary outcome was 6-month mortality rate. Secondary outcomes were 30-day mortality, post-operative complications, re-operation rate and length of hospital stay. RESULTS: 80 patients met our inclusion criteria. The mean age of the IF group was 81.6 years and in the HA group it was 84.5 years (P=0.07). The medical records were retrieved 34-64 months after surgery. Two intra-operative deaths due to cement implantation syndrome were found in the HA group and none in the IF group. Twelve patients (21.8%) in the HA group died within 30 days after surgery and 2 (8.0%) in the IF group (P=0.21). The mean operating time was 83 min. for the HA group and 51 min. for the IF group (P=0.000). There were more implant-related complications in the IF than in the HA group (36% vs 9.1% respectively, P=0.008). The 6-month mortality rates didn't differ between the IF and the HA groups (respectively 28.0% vs 34.5%, P=0.62). CONCLUSION: The post-operative mortality rates did not differ between the IF and the HA groups in elderly patients with a displaced femoral neck fracture and ASA 3 to 5. However, the HA associated with less implant-related complications than the IF in this group and it is therefore the treatment of choice.
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A 62-year-old man had tenderness in the neck due to cervicothoracic dislocation after a fall from his bicycle.
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Acidentes por Quedas , Ciclismo , Vértebras Cervicais/lesões , Luxações Articulares/diagnóstico , Vértebras Torácicas/lesões , Vértebras Cervicais/cirurgia , Humanos , Luxações Articulares/cirurgia , Masculino , Pessoa de Meia-Idade , Fusão Vertebral/métodos , Vértebras Torácicas/cirurgia , Resultado do TratamentoRESUMO
Although cochlear implantation is considered a safe method of rehabilitation for profoundly deaf individuals, a number of these patients suffer complications after surgery. To evaluate post-operative complications after cochlear implantation, a retrospective chart review was performed for 112 patients who had undergone implantation in the Maastricht Academic Hospital. Minor complications were defined as those that could be overcome by medical or audiological management. These occurred in 36 patients (32 per cent) and all were managed successfully. Major complications were defined as device extrusion and those requiring further surgery, and these were identified in four patients (3.6 per cent). These complications included wound infection and device failure mediated by middle-ear pathology. In cases of chronic otitis media, we recommend performance of cochlear implantation as a staged procedure. In order to reduce the post-operative incidence of acute otitis media, we recommend adenoidectomy, placement of ventilation tubes and early antibiotic treatment.
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Implante Coclear/efeitos adversos , Surdez/cirurgia , Otite Média/prevenção & controle , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Implante Coclear/métodos , Implantes Cocleares , Surdez/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação da Orelha Média , Falha de Prótese , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/prevenção & controleRESUMO
Combined chemotherapy and radiation therapy is the standard treatment for epidermoid carcinoma of the anal canal. Failures are often not associated with distant recurrence and are therefore potentially amenable to salvage abdominoperineal resection. The aim of this study was to review our experience with abdominoperineal resection following failure of chemoradiation therapy for epidermoid carcinoma of the anus. Between 1980 and 1998, 17 patients underwent salvage abdominoperineal resection following failure of chemoradiation therapy. Four patients were excluded from survival analysis because resection was performed with palliative intent. Survival curves were based on the method of Kaplan and Meier, and univariate analysis of predictive variables was performed using the log-rank test. Twelve patients underwent abdominoperineal resection for persistent disease and five patients for recurrent disease. No operative deaths occurred, but local complications including perineal wound infection and wound breakdown was seen in 8 of 17 patients and 6 of 17 patients, respectively. Patients undergoing omental flap reconstruction (n = 3) or no pelvic reconstruction (n = 5) had a higher incidence of perineal breakdown compared to those undergoing muscle flap reconstruction (n = 9) (P <0.05). The median follow-up time for the patients operated on with curative intent was 53 months. The 5-year actuarial survival was 47%. Potential prognostic factors that were not found to have an impact on survival included margin status of resection, sphincter invasion, and degree of differentiation. Only pathologic tumor size greater than 5.0 cm (P <0.001) and age over 55 years (P <0.05) adversely affected survival. Selected patients with recurrent or persistent anal carcinoma following chemoradiation therapy can be offered salvage abdominoperineal resection. This operation is associated with a high incidence of local wound complications, and muscle flap reconstruction should be considered when possible. Prolonged survival can be achieved in some patients following salvage resection for epidermoid carcinoma of the anal canal.