RESUMO
Circular saw injuries may cause severe damage to the soft tissue of the hand, including destruction of skin, tendons and bone. We report the use of an osteotendocutaneous radial forearm flap for hand reconstruction following circular saw injury. This flap allowed simultaneous reconstruction of skin, tendon and osseous defect of the metacarpal bone.
Assuntos
Transplante Ósseo/métodos , Fraturas Expostas/cirurgia , Traumatismos da Mão/cirurgia , Ossos Metacarpais/lesões , Lesões dos Tecidos Moles/cirurgia , Retalhos Cirúrgicos , Traumatismos dos Tendões/cirurgia , Idoso , Desbridamento , Fixação Interna de Fraturas/métodos , Fraturas Expostas/diagnóstico por imagem , Traumatismos da Mão/diagnóstico por imagem , Humanos , Masculino , Ossos Metacarpais/diagnóstico por imagem , Ossos Metacarpais/cirurgia , Microcirurgia/métodos , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/cirurgia , Radiografia , Lesões dos Tecidos Moles/diagnóstico por imagem , Retalhos Cirúrgicos/irrigação sanguínea , Infecção da Ferida Cirúrgica/diagnóstico por imagem , Infecção da Ferida Cirúrgica/cirurgia , Traumatismos dos Tendões/diagnóstico por imagem , Transferência Tendinosa/métodosRESUMO
The transverse rectus abdominis muscle flap is widely used in free microvascular tissue transfer for breast reconstruction following mastectomy. Flap survival may be compromised by failure at the microsurgical anastomosis due to both venous and arterial thrombosis. It is unclear, whether hereditary thrombophilia represents a risk factor for early thrombotic occlusion following free flap procedures. We present a case of a patient with previously diagnosed activated protein C resistance caused by heterozygous factor V (position 1691 G-->A) Leiden mutation in whom a free transverse rectus abdominis muscle flap was performed. The postoperative course was complicated by repeated thrombosis of both the venous and arterial part of the anastomosis. Immediate thrombectomy and repeated arteriography allowed for partial flap salvage. More data are needed to analyze the impact of hereditary thrombophilia on microvascular anastomosis failure.
Assuntos
Resistência à Proteína C Ativada/genética , Arteriopatias Oclusivas/etiologia , Fator V/genética , Mamoplastia , Complicações Pós-Operatórias/etiologia , Retalhos Cirúrgicos , Trombose Venosa/etiologia , Adulto , Anastomose Cirúrgica , Anticoagulantes/uso terapêutico , Arteriopatias Oclusivas/tratamento farmacológico , Neoplasias da Mama/complicações , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Feminino , Humanos , Mastectomia , Complicações Pós-Operatórias/tratamento farmacológico , Radioterapia Adjuvante/efeitos adversos , Reoperação , Terapia Trombolítica , Trombofilia/complicações , Trombofilia/tratamento farmacológico , Trombofilia/genética , Ativador de Plasminogênio Tipo Uroquinase/uso terapêutico , Trombose Venosa/tratamento farmacológicoRESUMO
INTRODUCTION: In adipose tissue-derived osteogenic cells (ADOC), osteoblast markers and surface proteins were determined and compared with osteoblasts harvested from cancellous bone (OB). METHOD: Osteocalcin (OC), core binding factor 1 (CBFA1), collagen type 1 (Coll1), alkaline phosphatase (ALP), nucleostemin (NS), and surface proteins CD 10, CD44, CD 59 and CD 105 were analyzed using RT-PCR, immunofluorescence and Western blot. RESULTS: Osteocalcin expression was more distinct in OB than in ADOC, but the other markers and surface proteins showed no differences. CONCLUSION: These data support the use of adipose tissue for future regenerative medicine; however, further studies are necessary to establish the role of long-term differentiation.
RESUMO
The clinical appearance of septic disorders is characterized by an enormous dynamic. The sepsis-induced dysbalance of the immune system necessitates immediate and aggressive therapeutic interventions to prevent further damage progression of the disease to septic shock and multiple organ failure. This includes supportive therapy to normalize and maintain organ and tissue perfusion as well as the identification of the infection focus. In cases where an infectious focus is identified, surgical source control frequently is a key element of the treatment strategy besides pharmacologic and supportive measures. The integrative approach of the management of septic patients requires rapid communication between the involved medical disciplines and the nursing personnel. Therefore, this article outlines current therapeutic concepts of septic diseases as well as central nursing aspects.
Assuntos
Cuidados Críticos/métodos , Sepse/cirurgia , Acidose/diagnóstico , Acidose/terapia , Temperatura Corporal , Encefalopatias/diagnóstico , Encefalopatias/prevenção & controle , Cortisona/fisiologia , Frequência Cardíaca , Humanos , Hidrocortisona/uso terapêutico , Hipotensão/diagnóstico , Hipóxia/diagnóstico , Controle de Infecções , Contagem de Leucócitos , Transtornos Mentais/etiologia , Transtornos Mentais/terapia , Insuficiência de Múltiplos Órgãos/prevenção & controle , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Insuficiência Renal/diagnóstico , Insuficiência Renal/terapia , Sepse/imunologia , Sepse/enfermagem , Sepse/fisiopatologia , Choque Séptico/imunologia , Choque Séptico/enfermagem , Choque Séptico/fisiopatologiaRESUMO
AIM: Two clinically established PMMA bone cements (Refobacin Palacos R and Palacos R + G) and two newer cements not yet in widespread clinical use (Refobacin Bone Cement R and SmartSet GHV) were tested in vitro for practically relevant differences. METHODS: The tests included chemical analyses, handling properties and testing according to the ISO standard for PMMA bone cements. RESULTS: The results obtained indicate clearly that the copolymers used in Refobacin Bone Cement R and SmartSet GHV differ from those used in the Palacos cements. There were also significant differences in viscosity behaviour and waiting time (p < 0.01 for Palacos cements versus Refobacin Bone Cement R) as an expression of different handling properties. The hardening times under ISO 5833 conditions also differed significantly (p < 0.01 and p < 0.05 for Palacos cements compared with Refobacin Bone Cement R and p < 0.01 for Refobacin Bone Cement R compared with SmartSet GHV). CONCLUSION: In view of these differences in material properties, the clinical data from long-term use of the bone cements Refobacin Palacos R and Palacos R + G cannot be extrapolated to the newly developed PMMA cements Refobacin Bone Cement R and Smart GHV. Before broad clinical use of these cements, prospective clinical studies using RSA or DEXA and, as a second step, statistically powerful prospective comparative studies should be performed. Until these data are available, patients in whom Refobacin Bone Cement R and SmartSet GHV are used should be informed that the material employed deviates from the standard procedures for cemented joint replacement in the Scandinavian arthroplasty registers and that the long-term consequences cannot, in the final instance, be foreseen. This is essential in order to avoid later malpractice claims on the grounds of inadequate information.
Assuntos
Artroplastia de Substituição , Cimentos Ósseos/química , Gentamicinas/química , Metilmetacrilatos/química , Polimetil Metacrilato/química , Estresse Mecânico , Suporte de Carga/fisiologia , Testes de Dureza , Humanos , Técnicas In Vitro , ViscosidadeRESUMO
BACKGROUND: Gynecomastia is defined as the benign enlargement of the male breast. Most studies on surgical treatment of gynecomastia show only small series and lack histopathology results. The aim of this study was to analyze the surgical approach in the treatment of gynecomastia and the related outcome over a 10-year period. PATIENTS AND METHODS: All patients undergoing surgical gynecomastia corrections in our department between 1996 and 2006 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and histological results. RESULTS: A total of 100 patients with 160 operations were included. Techniques included subcutaneous mastectomy alone or with additional hand-assisted liposuction, isolated liposuction, and formal breast reduction. Atypical histological findings were found in 3% of the patients (spindle-cell hemangioendothelioma, papilloma). The surgical revision rate among all patients was 7%. Body mass index and a weight of the resected specimen higher than 40 g were identified as significant risk factors for complications (p < 0.05). CONCLUSIONS: The treatment of gynecomastia requires an individualized approach. Caution must be taken in performing large resections, which are associated with increased complication rates. Histological tissue analysis should be routinely performed in all true gynecomastia corrections, because histological results may reveal atypical cellular pathology.
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Ginecomastia/cirurgia , Adolescente , Adulto , Idoso , Humanos , Lipectomia , Masculino , Mamoplastia , Mastectomia Subcutânea , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE/BACKGROUND: High-voltage burns represent a challenging surgical entity. Compared to conventional burns, these injuries are characterized by an increased morbidity and worse potential for rehabilitation. The aim of the present study was to analyse the management of high-voltage injuries during the early posttraumatic period with special emphasis on the surgical procedures. PATIENTS/MATERIAL AND METHOD: We retrospectively evaluated the medical records of patients with electrical injuries treated from 1995 - 2007. A total of 61 patients (57 men, 4 females, mean age: 34 +/- 13 years) with high-voltage burns was included for analysis. RESULTS: The majority of high-voltage burns was work-related (75 %). The mean total burn area was 35 % of the total body surface, with a mean of 29 % deep burns. An average of 4.8 +/- 4 operations were performed per patient (range: 1 - 23 operations). Surgical procedures included repeated debridement/necrectomy (100 % of all patients), early escharotomy/fasciotomy (47.5 %), and amputations (18 %). 14 patients (23 %) underwent reconstructive surgery using either local or free flaps. The mortality rate was 15 %. CONCLUSION: The surgical management of high-voltage burns is characterised by repetitive debridements and necrectomies. Despite an aggressive approach to remove necrotic tissue, the mortality in this type of injury is considerably high. Limb salvage may be achieved with the use of free microvascular flaps. However, an amputation of necrotic extremities must be considered in the copresence of septic complications.
Assuntos
Amputação Cirúrgica , Traumatismos do Braço/cirurgia , Queimaduras por Corrente Elétrica/cirurgia , Desbridamento , Traumatismos da Mão/cirurgia , Traumatismos da Perna/cirurgia , Salvamento de Membro , Adolescente , Adulto , Traumatismos do Braço/mortalidade , Queimaduras por Corrente Elétrica/mortalidade , Traumatismos Faciais/mortalidade , Traumatismos Faciais/cirurgia , Feminino , Alemanha , Traumatismos da Mão/mortalidade , Mortalidade Hospitalar , Humanos , Queratinócitos/transplante , Traumatismos da Perna/mortalidade , Masculino , Microcirurgia , Pessoa de Meia-Idade , Traumatismo Múltiplo/mortalidade , Traumatismo Múltiplo/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Reoperação , Estudos Retrospectivos , Retalhos Cirúrgicos , Análise de SobrevidaRESUMO
BACKGROUND: Low molecular weight heparins (LMWHs) are currently used as a standard for anti-thrombotic therapy. Skin necrosis caused by LMWH is a rare and probably under-reported complication. The aim of our systematic review is to analyse the present literature for cases of LMWH-induced skin necrosis, emphasising the pathogenesis, clinical pattern, and management of this rare side effect. METHODS: We performed a Medline literature search (PubMed database) and manual cross-referencing to identify all articles related to LMWH-induced skin necrosis. Data were analysed for type of LMWH used, time until skin necrosis occurred, localisation, size, laboratory findings, switch anticoagulant, complications, and outcome. Additionally, the case of a patient from our hospital is presented. RESULTS: We included a total of 20 articles (21 cases) reporting on LMWH-induced skin necrosis. Skin necrosis occurred locally and distant from the injection site. Heparin-induced antibodies were frequently observed (positive 9/11 articles, negative 2/11). However, severe thrombocytopenia (platelet count <100,000 cells/ml) occurred in only four cases, while platelet count remained normal in 50% of the cases. After patients had been switched to other anti-thrombotic drugs, the clinical course was usually benign; however, reconstructive surgery was necessary in two cases. CONCLUSION: LMWH-induced skin necrosis may occur as part of the heparin-induced thrombocytopenia (HIT) syndrome, but other pathomechanisms, including allergic reactions and local trauma, may also be involved. When HIT is excluded, unfractionated heparin is a safe switch anticoagulant. Otherwise, non-heparin preparations such as hirudin or fondaparinux should be preferred.
Assuntos
Anticoagulantes/efeitos adversos , Heparina de Baixo Peso Molecular/efeitos adversos , Pele/patologia , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/cirurgia , Necrose , Fraturas da Coluna Vertebral/cirurgia , Tromboembolia/prevenção & controle , Fatores de TempoRESUMO
BACKGROUND: The prolonged administration of heparin for prevention and treatment of venous thromboembolism has been associated with a risk of heparin-induced osteoporosis. Fondaparinux is a new antithrombotic drug that specifically inhibits factor Xa. Because of the known interactions of other antithrombotic agents with bone remodelling, the effects of fondaparinux on human osteoblasts were analysed in vitro. METHODS: Primary human osteoblast cell cultures were incubated with either the low molecular weight heparin dalteparin at concentrations of 30, 300 and 900 microg/ml or with fondaparinux at concentrations of 25, 50, 100, 150, 200 and 250 microg/ml. Cellular proliferation rate and protein synthesis were measured. Expression of genes encoding osteocalcin, collagen type I and alkaline phosphatase was examined by reverse transcriptase-polymerase chain reaction. RESULTS: Incubation with dalteparin led to a significant, dose-dependent inhibition of osteoblast proliferation, inhibition of protein synthesis, and inhibited expression of phenotype markers (osteocalcin and alkaline phosphatase genes) after 3 and 7 days. No inhibitory effects were observed in the fondaparinux-treated cells. CONCLUSION: Fondaparinux did not inhibit osteoblast proliferation in vitro and may reduce the risk of heparin-induced osteoporosis associated with long-term heparin administration.
Assuntos
Anticoagulantes , Dalteparina/efeitos adversos , Osteoblastos/efeitos dos fármacos , Osteoporose/induzido quimicamente , Polissacarídeos/uso terapêutico , Tromboembolia/prevenção & controle , Fosfatase Alcalina/metabolismo , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Células Cultivadas , Fluoresceínas , Fondaparinux , Expressão Gênica , Humanos , Osteoblastos/metabolismo , Osteocalcina/metabolismo , Osteoporose/prevenção & controle , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Fatores de RiscoRESUMO
BACKGROUND: Living kidney donation represents an important source of organs for patients with end-stage renal failure. Over the past decade, laparoscopic donor nephrectomy has replaced the conventional open procedure in many transplant centres. Using evidence-based methods, this study examines the current status of laparoscopic donor nephrectomy. METHOD: A Medline literature search (PubMed database, 1999-2002) and manual cross-referencing were performed to identify all articles relating to laparoscopic donor nephrectomy. Safety and efficacy criteria were analysed systematically for each study. Studies included were categorized using an evidence-based level grading system. RESULTS: Of 687 publications, 20 studies with level I-II evidence and 12 with level III evidence were analysed. Only one level I study could be identified. Level I and level II evidence suggests superiority of the laparoscopic approach in regard to postoperative analgesic consumption, hospital stay and return to work. Other safety and efficacy criteria, including donor and recipient outcomes, were similar between the two techniques. CONCLUSION: Laparoscopic donor nephrectomy has gained community acceptance by physicians and patients over the past decade. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the 'gold standard' for donor nephrectomy in the near future.
Assuntos
Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Laparoscopia/métodos , Doadores Vivos , Nefrectomia/métodos , Analgésicos/uso terapêutico , Perda Sanguínea Cirúrgica , Análise Custo-Benefício , Humanos , Falência Renal Crônica/economia , Transplante de Rim/efeitos adversos , Transplante de Rim/economia , Laparoscopia/efeitos adversos , Laparoscopia/economia , Tempo de Internação , Nefrectomia/efeitos adversos , Nefrectomia/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Obtenção de Tecidos e Órgãos/economia , Obtenção de Tecidos e Órgãos/métodos , Resultado do TratamentoRESUMO
Osteoporosis is a rare but potentially severe complication under high-dose, long-term unfractionated heparin therapy. Low-molecular-weight heparins (LMWHs) have gained increased importance in antithrombotic therapy over the past decade. Whether this heterogeneous group of drugs carries a comparable risk of osteoporosis in long-term application is unknown. In a standardized in vitro model, the effects of 4 different low-molecular-weight heparins (nadroparin, enoxaparin, dalteparin, certoparin) on osteoblast growth were studied at the same dose (50 microg/mL). As control, the effect of unfractionated heparin (Liquemin) was tested on human osteoblasts in vitro at an equal dose. Human osteoblast cell cultures were incubated with equal doses of the heparins, and cell concentrations were measured after 48 and 96 hours. In addition, a fluorescence assay was performed to detect potential cytotoxic effect of heparins on bone cells. In comparison to control groups of non-incubated cell cultures, LMWHs caused a significant inhibition of osteoblast growth (p<0.05). Therefore, the risk of osteoporosis under long-term therapy with high doses of LMWHs cannot be excluded and should be further evaluated in clinical trials.