糖尿病足截肢平面确定及影响因素的研究进展

糖尿病足（DF）是目前非创伤性截肢的主要原因,且有呈逐年上升的趋势。目前有较多的检查手段用于帮助截肢平面的确定,选择一种或几种检查手段来帮助确定一个合适的平面进行截肢手术是临床医师必须要考虑的问题。该文对几种常用于帮助DF截肢平面确定的检查手段及一些影响因素进行综述。     

应用前侧皮瓣的半骨盆截肢术

 目的 探讨应用前方带股血管蒂的股四头肌肌皮瓣覆盖臀后部创面的半骨盆截肢术(前侧皮瓣半骨盆截肢术)的手术适应证、手术方法、患者预后和并发症情况。方法 自2009年4月至2010年10月,北京积水潭医院骨肿瘤科对10例患者采用前侧皮瓣半骨盆截肢术,男9例,女1例;年龄30~62岁,平均45岁。软骨肉瘤7例、上皮样肉瘤1例、多形性脂肪肉瘤1例、梭形细胞肉瘤1例。结果 9例患者获得随访,随访时间12~30个月,平均21.5个月。术后仅1例出现轻度皮缘坏死,无伤口感染者。局部复发3例(33.3%),2例软骨肉瘤、1例上皮样肉瘤。死亡3例(33.3%),包括复发的2例、另1例软组织脂肪肉瘤患者因肺转移死亡;1例复发患者带瘤存活;2例患者肺转移带瘤存活;余3例未见复发和转移。结论 前侧皮瓣半骨盆截肢术适用于：(1)臀后部软组织肿块侵及皮肤皮下或反应区到达皮下;(2)骨盆恶性肿瘤复发需行半骨盆截肢,原手术切口污染臀部软组织,无法使用常规后侧皮瓣;(3)臀部皮肤软组织因放疗等原因影响后侧皮瓣血运。此手术的必要条件是髂外血管到股血管通畅良好,可顺利游离且不在肿瘤反应区内。适应证明确的情况下,前侧皮瓣覆盖较常规后侧半骨盆截肢更便于操作和覆盖,便于获得更好的外科边界,术后并发症少。     

Influence of transfemoral amputation length on resulting loads at the osseointegrated prosthesis fixation during walking and falling

Background

Transfemoral amputation is a surgical measure in which the surgeon typically conserves as much tissue and bone as possible. Osseointegrated fixation of prostheses is a promising alternative to conventional socket-based fixation. However, osseointegrated prostheses pose some risk of possible bone fracture under unexpected high-impact loading scenarios, such as a fall, and this should be protected against by a safety element. The aim of the present study was to determine the effect of amputation height on the forces and moments at the bone–prosthesis interface during normal gait and three falling scenarios.

Methods

Forces and moments at four amputation heights were determined from a multi-body simulation driven by data captured from an able-bodied participant.

Findings

In all three falling scenarios, forces were relatively independent of amputation height, while moments generally displayed considerable increases with shorter residual limb length. Peak moments ranged from 105 Nm (SD 75) (most distal amputation height) to 229 Nm (SD 99) (most proximal amputation height) for a “falling during gait” scenario.

Interpretation

Our findings reveal the dependence of interface loads on amputation height in normal gait and falling. This information may lead to improved prosthesis safety elements against bending moments.     

Individual responses to alignment perturbations in socket reaction moments while walking in transtibial prostheses

Background

The alignment of transtibial prostheses has a systematic effect on the mean socket reaction moments in amputees. However, understanding their individual differences in response to alignment perturbations is also important for prosthetists to fully utilize the socket reaction moments for dynamic alignment in each unique patient. The aim of this study was to investigate individual responses to alignment perturbations in transtibial prostheses with solid-ankle-cushion-heel feet.

Methods

A custom instrumented prosthesis alignment component was used to measure the socket reaction moments while walking in 11 amputees with transtibial prostheses under 17 alignment conditions, including 3° and 6° of flexion, extension, abduction, and adduction of the socket, 5 mm and 10 mm of anterior, posterior, lateral, and medial translation of the socket, and an initial baseline alignment. Coronal moments at 30% of stance and maximum sagittal moments were extracted for comparisons from each amputee.

Findings

In the coronal plane, varus moment at 30% of stance was generally reduced by adduction or medial translation of the socket in all the amputees. In the sagittal plane, extension moment was generally increased by posterior translation or flexion of the socket; however, this was not necessarily the case for all the amputees.

Interpretations

Individual responses to alignment perturbations are not always consistent, and prosthetists would need to be aware of this variance when addressing individual socket reaction moments during dynamic alignment in clinical setting.     

抑郁情绪对Wagner3级糖尿病足溃疡住院患者预后的影响

目的 通过对糖尿病足溃疡住院患者进行心理评估,探讨抑郁情绪对患者预后的影响.方法 对2010年6月至2011年5月因糖尿病足病住院的168例Wagner 3级足溃疡患者应用抑郁自评量表进行评估,按照抑郁程度分为不伴抑郁组和伴抑郁组,采用logistic回归分析抑郁情绪对糖尿病足患者足溃疡愈合以及对足溃疡愈合的患者行截肢手术的影响.结果 Wagner 3级患者中伴抑郁症者95例（56.5％）,不伴抑郁症者73例（43.5％）.卡方检验证实伴抑郁者溃疡不愈合率较不伴抑郁者显著增加（分别为18.9％和6.8％,OR=2.779,95％ CI：1.120 ～9.023）,logistic回归分析发现,在依次调整了与足溃疡预后密切相关的感染程度与动脉病变程度以及年龄、糖化血红蛋白、合并症Charlson评分等因素后,抑郁仍是患者溃疡不愈合的危险因素（OR=3.569,95％CI：1.220～10.442）.进一步对溃疡愈合组患者进行logistic回归发现,在依次调整上述因素后,抑郁情绪的存在也是溃疡愈合组患者截肢的危险因素（OR=2.793,95％ CI：1.361 ～ 5.732）.结论 糖尿病足溃疡患者普遍存在抑郁情绪并对患者预后产生不利影响.对其进行筛查并给予必要的心理治疗,可降低住院糖尿病足溃疡患者的手术风险.     

284例糖尿病足患者的临床分析

目的 了解糖尿病足发生的诱因、危险因素、影响病情严重程度以及截趾/肢预后的因素.方法 对2006年1月至2010年12月在内分泌科住院、符合纳入标准的284例糖尿病足患者的病例资料进行回顾性分析,用二分类Logistic回归分析确定发生重型糖尿病足和截趾/肢的危险因素.结果 284例糖尿病足患者中,男性175例,女性109例,82.4％的患者年龄＞50岁,77.5％的患者糖尿病病程在5年以上,86.5％的患者糖化血红蛋白(HbA1c) ＞6.5％.糖尿病足溃疡好发于足趾,烧/烫伤是最常见诱因,足溃疡分泌物细菌培养阳性率高达94.8％,多并发糖尿病肾病和糖尿病视网膜病变.Wagner 3～5级(重型)患者血清白蛋白(ALB)、总胆固醇(TC)、高密度脂蛋白胆固醇(HDLC)、红细胞计数和血红蛋白(Hb)均低于Wagner 0～2级(轻型)患者(P＜0.05),而其白细胞计数和血小板计数均高于轻型患者(P＜0.05),重型患者更容易发生糖尿病酮症/酮症酸中毒和混合感染,截趾/肢都发生在重型糖尿病足患者中.截趾/肢患者的血清ALB、TC、HDLC均低于非截趾/肢患者(P＜0.05),而HbA1c、白细胞计数和血小板计数均高于非截趾/肢患者(P＜0.05).Logistic回归分析发现,白细胞计数高(OR=1.093,95％ CI为1.012 ～1.180)是发生重型糖尿病足的危险因素,HDLC(OR =0.388,95％CI为0.162～0.931)是其保护性因素;HbA1e(OR=1.411,95％CI为1.077 ～1.849)、下肢动脉闭塞(OR =6.114,95％CI为1.202～31.094)为糖尿病足截趾/肢的危险因素.结论 糖尿病足多发生在血糖控制差、病程长、年龄在50岁以上的糖尿病患者,其发生常有诱因和病原菌感染.感染是重型糖尿病足发生的危险因素.感染、血糖控制差,特别是下肢动脉闭塞增加糖尿病足患者截趾/肢的风险.     

Relation Between Aerobic Capacity and Walking Ability in Older Adults With a Lower-Limb Amputation

Objectives

To determine the relative aerobic load, walking speed, and walking economy of older adults with a lower-limb prosthesis, and to predict the effect of an increased aerobic capacity on their walking ability.

Design

Cross-sectional.

Setting

Human motion laboratory at a rehabilitation center.

Participants

Convenience sample of older adults (n=36) who underwent lower-limb amputation because of vascular deficiency or trauma and able-bodied controls (n=21).

Interventions

Not applicable.

Main Outcome Measures

Peak aerobic capacity and oxygen consumption while walking were determined. The relative aerobic load and walking economy were assessed as a function of walking speed, and a data-based model was constructed to predict the effect of an increased aerobic capacity on walking ability.

Results

People with a vascular amputation walked at a substantially higher (45.2%) relative aerobic load than people with an amputation because of trauma. The preferred walking speed in both groups of amputees was slower than that of able-bodied controls and below their most economical walking speed. We predicted that a 10% increase in peak aerobic capacity could potentially result in a reduction in the relative aerobic load of 9.1%, an increase in walking speed of 17.3% and 13.9%, and an improvement in the walking economy of 6.8% and 2.9%, for people after a vascular or traumatic amputation, respectively.

Conclusions

Current findings corroborate the notion that, especially in people with a vascular amputation, the peak aerobic capacity is an important determinant for walking ability. The data provide quantitative predictions on the effect of aerobic training; however, future research is needed to experimentally confirm these predictions.     

Resilience in patients with amputation because of Complex Regional Pain Syndrome type I

Abstract

Purpose: Although controversial, an amputation for longstanding and therapy-resistant Complex Regional Pain Syndrome Type I (CRPS-I) may improve quality of life and pain intensity. Resilience, the way people deal with adversity in a positive way may be related to these positive outcomes. This study focused on the relationship between resilience and post-amputation outcomes, i.e. quality of life, pain and recurrence of CRPS-I and psychological distress. Method: Twenty-six patients with an amputation related to CRPS-I filled in the Connor-Davidson Resilience Scale (CD-RISC), World Health Organisation -- Quality of life Assessment (WHOQOL-Bref) and the Symptom Checklist-90 Revised (SCL-90-R). An interview was conducted and a physical examination performed. Results were compared with reference groups from literature and a control group from the outpatient rehabilitation clinic at our medical center. Results: Resilience correlated significantly with all domains of the WHOQOL-Bref (ρ ranged from 0.41 to 0.72) and negatively with all domains of the SCL-90-R (ρ ranged from ?0.39 to ?0.68). Patients with an amputation because of CRPS-I have higher scores on resilience and quality of life than the control group. Resilience was lower in patients who reported CRPS-I symptoms compared to those who did not. Conclusions: The results confirmed our hypothesis that patients with an amputation because of CRPS-I who have a higher resilience also have a higher quality of life and experience lower psychological distress. The prognostic value of resilience in this patient group requires further research.

• Implications for Rehabilitation

• Until characteristics of patients with positive quality of life outcome have been further unraveled, amputation for CRPS-I should only be performed in expertise centers.

• Resilience, the process of adapting well in the face of adversity, should be further explored in Rehabilitation Medicine research in general.

• Measurement of resilience should be a standard procedure when patients with CRPS-I request an amputation.

• Improving resilience of patients in in- and outpatient rehabilitation clinics might be an additional treatment in rehabilitation care.