Journal of surgical orthopaedic advances
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Review Practice Guideline
Resuscitation and blood utilization guidelines for the multiply injured, multiple amputee.
Given the current tempo of overseas contingency operations, military orthopaedic surgeons are increasingly performing their duties in an austere environment. At Level 1 trauma centers and combat support hospitals, resources tend to be more abundant than in less "metropolitan'' locations. ⋯ Early involvement of orthopaedic surgeons in damage control surgery, as well as resuscitation, are critical to the survival of patients with high amputations, multiple amputations, open pelvic injuries, and mangled extremities common in high-energy penetrating and blast-induced trauma. This article introduces the concept of Damage Control Resuscitation to the orthopaedic surgeon, and also presents a treatment guideline for use as appropriate.
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The magnitude of recent combat blast injuries sustained by forces fighting in Afghanistan has escalated to new levels with more troops surviving higher-energy trauma. The most complex and challenging injury pattern is the emerging frequency of high-energy IED casualties presenting in extremis with traumatic bilateral lower extremity amputations with and without pelvic and perineal blast involvement. These patients require a coordinated effort of advanced trauma and surgical care from the point of injury through definitive management. ⋯ Emergent operative intervention is critical with timely surgical hemostasis, adequate wound decontamination, revision amputations, and pelvic fracture stabilization. Efficient index surgical management is paramount to prevent further physiologic insult, and a team of orthopaedic and general surgeons operating concurrently may effectively achieve this. Despite the extent and complexity, these are survivable injuries but long-term followup is necessary.
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Traumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are the mainstays of initial treatment. ⋯ A multidisciplinary team is necessary in order to treat associated injuries as well assist with eventual rehabilitation. Adherence to specific treatment tenants outlined herein may minimize mortality and secondary morbidity, improving patient outcomes following these devastating injuries.
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Comparative Study
Role of diabetes type in perioperative outcomes after hip and knee arthroplasty in the United States.
The objective of this study was to determine whether the type of diabetes mellitus (DM) affected the incidence of immediate perioperative complications following joint replacement. From 1988 to 2003, the Nationwide Inpatient Sample recognized 65,769 patients with DM who underwent total hip and knee arthroplasty in the United States. ⋯ Type 1 patients also had significant increases in the incidence of myocardial infarction, pneumonia, urinary tract infection, postoperative hemorrhage, wound infection, and death (p < .02). Perhaps because of the differences in the duration of disease and their underlying pathologies, patients with type 1 diabetes carry more significant overall perioperative risks and require more health care resources compared with patients with type 2 diabetes following hip and knee arthroplasty.
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Chronic pain and gait disturbance are possible complications of subtalar arthroereisis. Despite literature indicating a considerably high rate of such complications, subtalar arthroereisis continues to be commonly performed for children with pes planus. The goals of this study are to identify common presenting features and an approach to the treatment of foot pain after subtalar arthroereisis. ⋯ After failing conservative management for chronic postoperative pain, all patients had their implants removed resulting in relief of pain. The expedited removal of subtalar implants in cases of chronic foot pain after arthroereisis is encouraged. The authors do not recommend the use of subtalar arthroereisis in pes planus given its potential complications and literature review indicating a paucity of cases with improved function and activity level as a result of the procedure.