Outcome after modified Putti-Platt procedure for recurrent traumatic anterior shoulder dislocations

Most recent studies on procedures for stabilizing the glenohumeral joint focus on arthroscopic techniques. A relatively simple open procedure is the modified Putti-Platt procedure. The aim of these retrospective case series was to evaluate the functional outcome, patient satisfaction, and quality of life of patients who underwent this procedure. After a median follow-up time of 4.7 (P₂₅–P₇₅ 1.7–6.8) years, fifty-one patients could be enrolled with a mean age of 25 (21–39) years. Five patients (10 %) reported re-dislocations. The median Constant score for the affected side was 84 (P₂₅–P₇₅ 75–91). Median loss of motion in abduction, elevation, external rotation, and external rotation in 90° of abduction did not exceed 10° when compared to the healthy shoulder. A median Rowe score of 92 (P₂₅–P₇₅ 75–95) was measured. The WOSI score and SF-36 showed excellent quality of life. The VAS proved high patient satisfaction with the outcome; 7.9 (6.8–9.5). We concluded that the modified Putti-Platt procedure leads to excellent outcome scores and only marginal restriction in range of motion combined with a high patient satisfaction. Our data prove that excellent results can be obtained with a relatively simple open procedure.     

The Minimum Clinically Important Difference of the Patient-rated Wrist Evaluation Score for Patients With Distal Radius Fractures

Background

The Patient-rated Wrist Evaluation (PRWE) is a commonly used instrument in upper extremity surgery and in research. However, to recognize a treatment effect expressed as a change in PRWE, it is important to be aware of the minimum clinically important difference (MCID) and the minimum detectable change (MDC). The MCID of an outcome tool like the PRWE is defined as the smallest change in a score that is likely to be appreciated by a patient as an important change, while the MDC is defined as the smallest amount of change that can be detected by an outcome measure. A numerical change in score that is less than the MCID, even when statistically significant, does not represent a true clinically relevant change. To our knowledge, the MCID and MDC of the PRWE have not been determined in patients with distal radius fractures.

Questions/Purposes

We asked: (1) What is the MCID of the PRWE score for patients with distal radius fractures? (2) What is the MDC of the PRWE?

Methods

Our prospective cohort study included 102 patients with a distal radius fracture and a median age of 59 years (interquartile range [IQR], 48–66 years). All patients completed the PRWE questionnaire during each of two separate visits. At the second visit, patients were asked to indicate the degree of clinical change they appreciated since the previous visit. Accordingly, patients were categorized in two groups: (1) minimally improved or (2) no change. The groups were used to anchor the changes observed in the PRWE score to patients’ perspectives of what was clinically important. We determined the MCID using an anchor-based receiver operator characteristic method. In this context, the change in the PRWE score was considered a diagnostic test, and the anchor (minimally improved or no change as noted by the patients from visit to visit) was the gold standard. The optimal receiver operator characteristic cutoff point calculated with the Youden index reflected the value of the MCID.

Results

In our study, the MCID of the PRWE was 11.5 points. The area under the curve was 0.54 (95% CI, 0.37–0.70) for the pain subscale and 0.71 (95% CI, 0.57−0.85) for the function subscale. We determined the MDC to be 11.0 points.

Conclusions

We determined the MCID of the PRWE score for patients with distal radius fractures using the anchor-based approach and verified that the MDC of the PRWE was sufficiently small to detect our MCID.

Clinical Relevance

We recommend using an improvement on the PRWE of more than 11.5 points as the smallest clinically relevant difference when evaluating the effects of treatments and when performing sample-size calculations on studies of distal radius fractures.     

Good Functional Recovery of Complex Elbow Dislocations Treated With Hinged External Fixation: A Multicenter Prospective Study

BackgroundAfter a complex dislocation, some elbows remain unstable after closed reduction or fracture treatment. Function after treatment with a hinged external fixator theoretically allows collateral ligaments to heal without surgical reconstruction. However, there is a lack of prospective studies that assess functional outcome, pain, and ROM.Questions/purposesWe asked: (1) In complex elbow fracture-dislocations, does treatment with a hinged external fixator result in reduction of disability and pain, and in improvement in ROM, function, and quality of life? (2) Does delayed treatment (7 days or later) have a negative effect on ROM after 1 year? (3) What are the complications seen after external fixator treatment?MethodsDuring a 2-year period, 11 centers recruited 27 patients 18 years or older who were included and evaluated at 2 and 6 weeks and at 3, 6, and 12 months after surgery as part of this prospective case series. During the study period, the participating centers agreed on general indications for use of the hinged external fixator, which included persistent instability after closed reduction alone or closed reduction combined with surgical treatment of associated fracture(s), when indicated. Functional outcome was evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; primary outcome) score, the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score, and the level of pain (VAS). ROM, adverse events, secondary interventions, and radiographs also were evaluated. A total of 26 of the 27 patients (96%) were available for followup at 1 year.ResultsAll functional and pain scores improved. The median QuickDASH score decreased from 30 (25^th–75^th percentiles [P₂₅–P₇₅], 23–40) at 6 weeks to 7 (P₂₅–P₇₅, 2–12) at 1 year with a median difference of −25 (p < 0.001). The median MEPI score increased from 80 (P₂₅–P₇₅, 64–85) at 6 weeks to 100 (P₂₅–P₇₅, 85–100) at 1 year with a median difference of 15 (p < 0.001). The median Oxford Elbow Score increased from 60 (P₂₅–P₇₅, 44–68) at 6 weeks to 90 (P₂₅–P₇₅, 73–96) at 1 year with a median difference of 29 (p < 0.001). The median VAS decreased from 2.8 (P₂₅–P₇₅, 1.0–5.0) at 2 weeks to 0.5 (P₂₅–P₇₅, 0.0–1.9) at 1 year with a median difference of −2.1 (p = 0.001). ROM also improved. The median flexion-extension arc improved from 50° (P₂₅–P₇₅, 33°–80°) at 2 weeks to 118° (P₂₅–P₇₅, 105°–138°) at 1 year with a median difference of 63° (p < 0.001). Similarly, the median pronation-supination arc improved from 90° (P₂₅–P₇₅, 63°–124°) to 160° (P₂₅–P₇₅, 138°–170°) with a median difference of 75° (p < 0.001). At 1 year, the median residual deficit compared with the uninjured side was 30° (P₂₅–P₇₅, 5°–35°) for the flexion-extension arc, and 3° (P₂₅–P₇₅, 0°–25°) for the pronation-supination arc. Ten patients (37%) experienced a fixator-related complication, and seven patients required secondary surgery (26%). One patient reported recurrent instability.ConclusionsA hinged external elbow fixator provides enough stability to start early mobilization after an acute complex elbow dislocation and residual instability. This was reflected in good functional outcome scores and only slight disability despite a relatively high complication rate.

Level of Evidence

Level IV, therapeutic study.     

Full Recovery from a Potentially Lethal Dose of Mercuric Chloride

Introduction

Mercuric chloride poisoning is rare yet potentially life-threatening. We report a case of poisoning with a potentially significant amount of mercuric chloride which responded to aggressive management.

Case Report

A 19-year-old female presented to the Emergency Department with nausea, abdominal discomfort, vomiting of blood-stained fluid, and diarrhea following suicidal ingestion of 2–4 g of mercuric chloride powder. An abdominal radiograph showed radio-opaque material within the gastric antrum and the patient’s initial blood mercury concentration was 17.9 μmol/L (or 3.58 mg/L) at 3 h post-ingestion. Given the potential toxicity of inorganic mercury, the patient was admitted to the intensive care unit and chelation with dimercaprol was undertaken. Further clinical effects included mild hemodynamic instability, acidosis, hypokalemia, leukocytosis, and fever. The patient’s symptoms began to improve 48 h after admission and resolved fully within a week.

Discussion

Mercuric chloride has an estimated human fatal dose of between 1 and 4 g. Despite a reported ingestion of a potentially lethal dose and a high blood concentration, this patient experienced mild to moderate poisoning only and she responded to early and appropriate intervention. Mercuric chloride can produce a range of toxic effects including corrosive injury, severe gastrointestinal disturbances, acute renal failure, circulatory collapse, and eventual death. Treatment includes close observation and aggressive supportive care along with chelation, preferably with 2,3-dimercapto-1-propane sulfonate or 2,3-meso-dimercaptosuccinic acid.     

Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach

Purpose

Post-operative wound infections (PWI) following calcaneal fracture surgery can lead to prolonged hospital stay and additional treatment with antibiotics, surgical debridement or implant removal. Our aim was to determine the incidence of superficial and deep PWI and to identify risk factors (RF).

Methods

This study is a retrospective case series. All consecutive patients from 2000 to 2010 with a closed unilateral calcaneal fracture treated with open reduction and internal fixation (ORIF) by an extended lateral approach were included. Patient, fracture, trauma and peri-operative characteristics were collected, including RF such as smoking, diabetes mellitus, time to operation, pre-operative in- or outpatient management and wound closure technique. The primary end point was a PWI as defined by the US Centers for Disease Control and Prevention.

Results

A total of 191 patients were included of which 47 patients (24.6 %) had a PWI; 21 (11.0 %) and 26 (13.6 %) patients had a superficial and deep wound infection, respectively. American Society of Anesthesiologists (ASA) classification higher than ASA 1 was associated with an increased risk. Placement of a closed suction drain at the end of surgery was associated with less PWI (35 % vs 15 %, p = 0.002). In this study, none of the previously reported RF were associated with an increased risk for PWI.

Conclusions

ORIF of displaced calcaneal fractures is associated with a high rate of PWI of 25 %. Factors that were associated with an increased risk were ASA classification other than 1 and absence of a closed suction drain placement. A closed suction drain may be a protective measure to avoid wound complications.     

Recognising vascular causes of leg complaints in endurance athletes. Part 2: the value of patient history,physical examination,cycling exercise test and echo-Doppler examination

Leg complaints at maximal exercise in endurance athletes may have many causes, including arterial flow limitations in the iliac arteries. Such flow limitations can evolve into serious health problems due to increasing intravascular obstruction or even complete obstruction as a result of dissection or thrombosis. Early detection is therefore of clinical importance, but conventional diagnostic tools often prove inadequate. In the current study simple sports-specific tests are examined for their diagnostic power. Test variables derived from patient history, physical examination, cycling exercise testing followed by arterial pressure measurements at the ankle, and echo-Doppler examination with provocative manoeuvres were tested in 92 symptomatic legs (80 patients). A validated clinical classification acted as a reference. Several test variables proved useful. However, no single test variable combined a high sensitivity with a high specificity. Multivariate testing resulted in the correct classification of 91 % of patients, reaching a sensitivity of 0.90 and specificity of 0.93 (kappa 0.76). Four patients wrongly classified as non-vascular suffered from kinking in the common iliac artery that could not be visualised using the diagnostic tools currently available in this study. In conclusion: simple sports-specific tests accurately diagnose iliac artery obstruction in endurance athletes.