Outcomes following Lower Extremity Amputation in Patients with Diabetes Mellitus and Peripheral Arterial Disease.
- 作者列表："Pourghaderi P","Yuquimpo KM","Roginski Guetter C","Mansfield L","Park HS
BACKGROUND:Lower extremity amputations (LEAs) are projected to increase drastically in the United States. The potential effects of diabetes mellitus (DM) and peripheral arterial disease (PAD) on LEA outcomes have not been well-explored. We sought to investigate the clinical outcomes of LEA in patients with DM alone, PAD alone, and patients with concurrent DM and PAD (DM + PAD) from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. METHODS:Adult patients (≥18 years) undergoing LEA in 2007-2011 based on ICD-9 procedure codes were selected. Patient morbidity, and mortality were assessed utilizing logistic and linear regression. Multivariable analyses adjusted for additional patient and hospital characteristics. RESULTS:A total of 62,291 LEAs were identified between 2007 and 2011. The mean (SD) age was 66.4 (13.7) years. Patients were predominantly Caucasian (56.4%), male (62.9%), and admitted as an emergency admission (44.1%). A higher incidence of LEA was observed in patients with DM + PAD (47.3%) than those with either DM alone (26.4%) or PAD alone (26.3%). On adjustment for patient characteristics, PAD alone was associated with significantly higher mortality and complications postoperatively (OR 1.71; P < 0.001, and 1.28; P < 0.001, respectively), but concurrent DM + PAD was not associated with these outcomes. CONCLUSION:Outcomes were significantly affected by presence of PAD as a comorbidity in patients undergoing LEA. It is imperative to understand and enhance preventive measures and screening guidelines for such comorbidities to optimize postoperative outcomes to ensure best-practice care in this patient population.
背景: 下肢截肢 (LEAs) 预计在美国将急剧增加。糖尿病 (DM) 和外周动脉疾病 (PAD) 对LEA结局的潜在影响尚未得到很好的探讨。我们试图研究LEA在单纯DM、单纯PAD和合并DM和PAD (DM + PAD) 患者中的临床结局来自全国住院患者样本的医疗成本和利用项目。 方法: 选择在 2007-2011 接受LEA的成人患者 (≥ 18 岁)，根据ICD-9 程序代码。采用logistic和线性回归评估患者发病率和死亡率。调整额外患者和医院特征的多变量分析。 结果: 在 2007 年至 62,291 年间共鉴定了 2011 个lea。平均 (SD) 年龄为 66.4 (13.7) 岁。患者主要为白种人 (56.4%)，男性 (62.9%)，作为急诊入院 (44.1%)。DM + PAD患者的LEA发生率 (47.3%) 高于单纯DM (26.4%) 或PAD (26.3%)。调整患者特征后，仅PAD与术后死亡率和并发症显著较高相关 (OR 1.71; P < 0.001 和 1.28; P <0.001)，但并发DM + PAD与这些结局无关。 结论: 在接受LEA的患者中，PAD作为合并症的存在显著影响结局。必须了解和加强此类合并症的预防措施和筛查指南，以优化术后结局，确保该患者人群的最佳实践护理。
METHODS:BACKGROUND:Postoperative cognitive dysfunction (POCD) is a common complication after orthopedic surgery, which is not conducive to the prognosis of the elderly. AIMS:We performed this study to investigate the effects of oxycodone applied for patient-controlled intravenous analgesia (PCIA) on postoperative cognitive function in elderly patients after total hip arthroplasty (THA). METHODS:Ninety-nine participants were enrolled and allocated into two groups: oxycodone group (group O) and sufentanil group (group S). The primary outcome was the incidence of POCD, diagnosed according to the changes in the Mini-mental status examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores. The secondary outcomes included the plasma levels of S-100B protein and neuron-specific enolase (NSE), the amount of postoperative analgesic consumption and the incidence of adverse reactions. RESULTS:The incidence of POCD was significantly lower in patients receiving oxycodone up to the 3rd postoperative day (POD, 1st POD 27.3% vs. 51.1%, P = 0.021; 3rd POD 20.5% vs. 40.0%, P = 0.045), as compared to patients receiving sufentanil. The MMSE and MoCA scores of both groups decreased to varying degrees. However, compared with group S, the MMSE scores at 1st POD, 3rd POD, 5th POD and 7st POD in group O were higher than that in group S, while MoCA scores at 1st POD, 3rd POD and 5th POD in group O were higher. Compared with group S, the plasma levels of S-100B protein in group O at 4 h, 8 h, 12 h post-surgery were lower. While the plasma levels of NSE in group O at 4 h, 8 h, 12 h, 24 h post-surgery were lower. Number of PCIA boluses and consumption of analgesic drug during the first two POD were similar between two groups. However, postoperative incidence of nausea, vomiting and pruritus was significantly lower in patients receiving oxycodone. CONCLUSION:Oxycodone applied for PCIA in elderly patients after THA could reduce the incidence of POCD, improve postoperative cognitive function and decrease the adverse reactions.
METHODS:BACKGROUND:Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. METHODS:We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. RESULTS:In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. CONCLUSIONS:Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. LEVEL OF EVIDENCE:Level III-retrospective comparative study with a systematic review.
METHODS:INTRODUCTION:As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA. METHODS:Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded. RESULTS:Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed. CONCLUSION:Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.