跟骨结节骨赘对足跟部压力的影响及其与跟痛症的相关性

目的 探讨跟骨结节骨赘对足跟部压力的影响程度及其与跟痛症的相关性.方法 2005年2月至2007年4月,32例(48足)跟痛症伴跟骨结节骨赘患者、24例(33足)跟痛症无跟骨结节骨赘患者、18例(28足)跟骨结节骨赘无跟痛症患者及40名健康志愿者,分为病例1～3组及对照组.经站立和行走规范训练后,应用计算机化的足底压力分析系统(F-Scan Mobile,Tekscan,USA)测量分析比较四组间足跟部的静态峰值压力、动态平均峰值压力及动态最大峰值压力差异.结果 在足跟部静态、动态平均及最大峰值压力测量中,四组间差异均有统计学意义(P＜0.05).不同测量状态下,组间两两比较结果近似,即跟痛症伴跟骨结节骨赘组、跟骨结节骨赘无跟痛症组足跟部峰值压力较跟痛症无跟骨结节骨赘组和对照组明显增高,但增加的程度不同,增幅最大是动态最大的峰值压力,跟痛症伴跟骨结节骨赘组和跟骨结节骨赘无跟痛症组分别达到(638.8±172.3)kPa和(510.2±85.6)kPa,而跟痛症无跟骨结节骨赘组和对照组仅为(382.5±61.3)kPa和(395.6±62.3)kPa.结论 跟骨结节骨赘可明显增加足跟部压力,跟骨结节骨赘伴跟痛症时压力增高更为显著,而跟痛症无跟骨结节骨赘时,足跟部压力并未明显增高.     

Outcomes of partial and total calcanectomies for the treatment of diabetic heel ulcers complicated with osteomyelitis. A systematic review and meta-analysis

BackgroundInfected diabetic foot ulcers (DFU) complicated with calcaneal osteomyelitis are a real challenge for limb preservation. Very few alternatives to amputation are available, mainly the resection of a part or the totality of the calcaneal bone. Calcanectomies were advanced as limb-sparing procedures in patients with heel osteomyelitis. However, there is a lack of pooled quantitative evidence on their efficacy and complications.ObjectivesThe present systematic review and meta-analysis was conducted to determine the primary outcome of healing rates following partial (PC) and total calcanectomies (TC) in treating calcaneal osteomyelitis due to diabetic heel ulcers. Additionally, secondary outcomes such as secondary TC following PC, secondary below knee amputation (BKA), mortality and the change in the ambulation status were analyzed.MethodsMedline, Scopus, Web of science, Cochrane Library and Google Scholar were searched since inception. All types of study design were included. Single case report studies and studies reporting osteomyelitis due to other etiologies than DFU were excluded.ResultsTwenty studies met the inclusion criteria comprising 295 patients with 300 calcanectomies (270 PC and 30 TC). With a mean follow-up period of 29.3 ± 17.7 months, the weighted results were as follows: a) the osteomyelitis healing rate was of 80% (95% CI = 0.728 to 0.861, I² = 48.3%), b) the rate of secondary total calcanectomy was of 5.4% (95% CI = 0.022 to 0.097, I² = 7.5%), c) the rate of secondary BKA was of 17.1% (95% CI = 0.111 to 0.241, I² = 50.6%) with no difference between subgroups of TC and PC, and d) the combined mortality rate of both calcanectomies was of 13.4% (95% CI = 0.064 to 0.224, I² = 73.6%); however, significant higher mortality was found following TC compared to PC (p < 0.0001).ConclusionPartial and total calcanectomies were found to yield very good healing rates with acceptable complication frequencies. When compared to the reported outcomes of below and above-knee amputations in the literature, calcanectomies could be fairly considered as good alternatives to above ankle amputations.     

Systematic review of the use of prophylactic dressings in the prevention of pressure ulcers

This systematic review considers the evidence supporting the use of prophylactic dressings for the prevention of pressure ulcer. Electronic database searches were conducted on 25 July 2013. The searches found 3026 titles and after removal of duplicate records 2819 titles were scanned against the inclusion and exclusion criteria. Of these, 2777 were excluded based on their title and abstract primarily because they discussed pressure ulcer healing, the prevention and treatment of other chronic and acute wounds or where the intervention was not a prophylactic dressing (e.g. underpads, heel protectors and cushions). Finally, the full text of 42 papers were retrieved. When these 42 papers were reviewed, 21 were excluded and 21 were included in the review. The single high‐quality randomised controlled trial (RCT) and the growing number of cohort, weak RCT and case series all suggest that the introduction of a dressing as part of pressure ulcer prevention may help reduce pressure ulcer incidence associated with medical devices especially in immobile intensive care unit patients. There is no firm clinical evidence at this time to suggest that one dressing type is more effective than other dressings.     

Management of heel ulcers in insensate foot by using free prefabricated radial fascial flap — a new flap

Heel ulcers are common in insensate foot. The management of such ulcers require tissue not only to resurface the skin defect, which is small in most of the cases; but also well vascularised tissue to fill the cavity which results after excision of the ulcer. We have described a new flap prefabricated radial fascial flap, by which both aims are achieved easily.     

Comprehensive management of pressure ulcers in spinal cord injury: Current concepts and future trends

Abstract

Pressure ulcers in spinal cord injury represent a challenging problem for patients, their caregivers, and their physicians. They often lead to recurrent hospitalizations, multiple surgeries, and potentially devastating complications. They present a significant cost to the healthcare system, they require a multidisciplinary team approach to manage well, and outcomes directly depend on patients' education, prevention, and compliance with conservative and surgical protocols. With so many factors involved in the successful treatment of pressure ulcers, an update on their comprehensive management in spinal cord injury is warranted. Current concepts of local wound care, surgical options, as well as future trends from the latest wound healing research are reviewed to aid medical professionals in treating patients with this difficult problem.     

Slow to heel: a literature review on the management of diabetic calcaneal ulceration

The diabetic heel ulcer (DHU) represents a reconstructive challenge to clinicians and the multidisciplinary team alike. It is traditionally viewed as a condition that is inherently difficult to treat due to the intrinsic anatomical vulnerabilities of the heel. In addition to this, several factors are associated with poorer end outcomes – namely, that of major amputation. These include peripheral vascular disease, infection/osteomyelitis and the size of the ulcer itself. In light of the significant morbidity, economic burden and mortality seen in this cohort of patients, this review aims to explore current treatment modalities that have been undertaken. Literature in this field has mostly been confined to a handful of small case studies, some of which reflect novel, multimodal approaches, and promising results. Management with osteotomy, flap reconstruction and acellular dermal matrices, amongst other options, is covered within this review.     

A comparative assessment of interface pressures generated by four surgical theatre heel pressure ulcer prophylactics

Current heel protection devices used in the operating room do not comply with the consensus document of the European and National (North American) Pressure Ulcer Advisory Panels. A complying prototype has been tested. Prospective cohort study comparing interface pressures. While using the prototype device, the heel interface pressure is significantly [mean 0·0 mmHg, standard deviation (SD) 0·0] less than the viscose elastic gel (VEG) mat (mean 174·8 mmHg, SD 64·5), the Action^® heel block (mean 182·3 mmHg, SD 70·8) and the theatre table (mean 193·2 mmHg, SD 57·1). At the Achilles tendon, the prototype device (mean 16·2 mmHg, SD 19·0) is significantly superior to the Oasis (mean 183·7 mmHg, SD 67·4) and Action^® heel blocks (mean 112·3 mmHg, SD 64·7). At the lateral malleolus, the prototype device (mean 0·0, SD 0·0) is better than the Action^® (mean 24·3 mmHg, SD 53·4) and Oasis heel blocks (mean 20·9 mmHg, SD 49·2). At the calf, the prototype (mean 53·7 mmHg, SD 23·0) imposed more pressure than all other devices tested but was not statistically significant compared with the theatre table or the VEG mat. It is possible to design a device that protects the heel, lateral malleolus and Achilles tendon without causing hyperextension of the knee and consequent popliteal vein compression, thereby complying with the above guidelines.     

Medical device related pressure ulcers in hospitalized patients

Most pressure ulcers occur over bony prominences such as heels and the sacrum. However, the National Pressure Ulcer Advisory Panel recognises that pressure ulcers can also occur on any tissue under pressure and thereby can develop beneath medical devices. This article reports on results from a secondary analysis of existing data collected by The Nebraska Medical Center on pressure ulcer quality improvement initiatives and outcomes. The purpose of this study was to quantify the extent of the problem and identify risk factors for medical device related (MDR) pressure ulcer development in hospitalised patients. A subset of data collected during eight quarterly pressure ulcer incidence and prevalence studies (N = 2178) was created and analysed. The overall rate of hospital‐acquired pressure ulcers was 5·4% (113 of 2079). The proportion of patients with hospital‐acquired ulcers related to medical devices was 34·5% (39 of 113). Findings indicate that if a patient had a medical device, they were 2·4 times more likely to develop a pressure ulcer of any kind. Numerous risk factors for pressure ulcer development were identified; however, none differentiated between those with MDR and traditional pressure ulcers.     

Surgical therapy of peptic ulcers in the 21st century: more common than you think

BACKGROUND: The frequency of surgery for peptic ulcer disease (PUD) has decreased dramatically during the last 3 decades. The purpose of this study was to characterize the Veteran patients undergoing surgery for peptic ulcer disease in a modern series and to examine the effect of H. pylori status on surgical outcome and recurrence of PUD. METHODS: An Institutional Review Board-approved retrospective review of all patients undergoing operations for peptic ulcer disease during a 66-month period at a single Veterans Administration medical center was performed. Patient records were examined for demographics, medication use, Helicobacter pylori status, operative details, and surgical outcomes. RESULTS: From January 1999 to July 2004, 43 of 128 upper gastrointestinal operations were performed for PUD. Thirty-five operations (81%) were performed for bleeding or perforated ulcers, and 26 (60%) patients had no history of PUD. The mean age was 60 years, and 66% of patients were American Society of Anesthesiologists (ASA) class 3 or 4; 47% were Helicobacter pylori positive, and 54% used nonsteroidal anti-inflammatory (NSAID) medication. Hospital mortality was 23%. By univariate analysis, emergent surgery, higher ASA status, H. pylori status, and absence of a history of ulcer disease were risk factors for mortality (P <.05). Only 36% underwent definitive ulcer surgery. With a median follow-up of 18 months, there has been only 1 single recurrence (3%). CONCLUSIONS: PUD still accounts for 33% of all gastroduodenal surgery performed in a Veterans Administration medical center. The majority of these operations are emergent operations in high-risk patients. In this era of effective acid suppression and H. pylori treatment, definitive ulcer surgery in the emergent setting may not be necessary.     

High cost of stage IV pressure ulcers

Background

The aim of this study was to calculate and analyze the cost of treatment for stage IV pressure ulcers.

Methods

A retrospective chart analysis of patients with stage IV pressure ulcers was conducted. Hospital records and treatment outcomes of these patients were followed up for a maximum of 29 months and analyzed. Costs directly related to the treatment of pressure ulcers and their associated complications were calculated.

Results

Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts were reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during 1 admission, and $124,327 for community-acquired ulcers over an average of 4 admissions.

Conclusions

The costs incurred from stage IV pressure ulcers are much greater than previously estimated. Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce health care expenditures by millions of dollars.     

The risk of pressure ulcers in a proned COVID population

The utilisation of prone positioning has been vital during the COVID-19 pandemic, however risks the development of anterior pressure ulcers. An observational study was performed to examine the prevalence of pressure ulcers in this population and define risk factors. Eighty-seven patients admitted to critical care were studied. Of 62 patients with >1 day in prone position, 55 (88.7%) developed anterior pressure ulcers, 91% of which were anterior. The most commonly affected site were the oral commisures (34.6%), related to endotracheal tube placement. Prone positioning (p < .001) and the number of days prone (OR 3.11, 95% CI 1.46–6.62, p = 0.003) were a significant risk factors in development of an anterior ulcer. Prone positioning is therefore a significant cause of anterior pressure ulcers in this population.     

Applying negative pressure therapy to deep pressure ulcers covered by soft necrotic tissue

Negative pressure therapy was applied to 39 deep pressure ulcers covered by soft necrotic tissue. All of the wounds were so deep that there were bones or ligaments just beneath the soft necrotic tissue. They had already received several types of conservative therapy including a necrotomy for periods ranging from 1 to 72 months. The wounds were minimally debrided and put in an adequately wet environment with negative pressure. This environment was established by the application of a suction‐dressing. All of these wounds showed clear wound beds within only 1 month. All of the wounds were successfully cured, either with or without a musculocutaneous flap. Negative pressure wound therapy is thus considered to be one of the choices for the management of non healing deep pressure ulcers covered by soft necrotic tissue.     

Surgical and reconstructive management of pressure ulcers

Despite significant advances in therapeutic options, pressure ulcers continue to pose a challenge to physicians and surgeons and frequently require multidisciplinary input. In addition, they place huge financial burdens on health care providers. Generally classified as grades I to IV depending on the extent and severity of the ulcer, grades I and II are usually amenable to conservative management. Grades III and IV may require surgical intervention, which could either be simple debridement or complex reconstructive microsurgery. Direct closure or skin grafting is useful in only a small number of early pressure ulcers. For non-healing and advanced pressure ulcers, reconstructive surgery is indicated, which consists of soft tissue flap coverage such as fasciocutaneous, musculocutaneous, perforator, or free flaps. The selection of a particular flap depends on a variety of factors, for instance, the location and grade of the ulcer, vascularity of the surrounding tissue, mobility of the patient, and the experience and expertise of the surgeon. There are no clear guidelines at present regarding the suitability of a particular flap in the management of pressure ulcers at different stages. This article aims to provide an overview of the etiology, pathophysiology, and management of pressure ulcers in various anatomical locations, with particular emphasis on current advances in reconstructive surgical procedures.     

Research priorities in surgical simulation for the 21st century

BackgroundLaryngeal complications occur in thyroidectomies as a result of several factors, but especially because of nerve damage. We compared intraoperative stimulation neuromonitoring (IONM) with intraoperative continuous electromyographic neuromonitoring (IEM) to evaluate their ability to identify postoperative laryngeal complications.MethodsThis prospective clinical trial included 174 patients (348 nerves) who had both IONM and IEM. We recorded age, sex, pathology, vocal fold motility, and complications.ResultsIONM identified 334 nerves, whereas IEM identified 348. Five patients had transient laryngeal complications, 2 bilateral, and 3 unilateral recurrent laryngeal nerve paresis. In addition, in 2 patients IEM showed placement of the tracheal tube balloon on the vocal folds, which led to correction. Sensitivity and specificity were 96.48% and 100% for IONM and 100% and 100% for IEM, respectively. IONM had a positive predictive value of 100% and a negative predictive value of 36.84%. The positive and negative predictive values of IEM were 100%.ConclusionsBoth techniques identify recurrent laryngeal nerve injuries; however, IEM seems to have an advantage concerning the nonsurgical laryngeal complications and may play a role in preventing morbidity.     

Combined use of super‐oxidised solution with negative pressure for the treatment of pressure ulcers: case report

A 61‐year‐old patient was affected by flaccid paraplegia for 20 years because of post‐traumatic medullar injury caused by an accidental fall, with stage IV sacral pressure ulcer for 3 years. The patient later developed stage IV sacral pressure ulcer. After 6 months, a new granulation tissue formation appeared in the wound and a reduction of its diameter was observed (length 20 cm, width 15 cm, depth 5 cm). We therefore treated the wound with PRP (platelet rich plasma) intra‐lesion and peri‐lesional injections. The wounds were covered with three‐dimensional polymerised hyaluronic acid medicated biologic dressing. After the surgery, a moderate reduction in diameter and the depth was observed. Super‐oxidised solution (SOS‐Dermacyn) was applied to control infection locally together with negative pressure to control the exudate and the local bacteremia, to avoid infectious complications without application of systematic antibiotic therapy.