Reduction of Acute Shoulder Dislocations in a Remote Environment: A Prospective Multicenter Observational Study.

OBJECTIVE: Acute dislocations of the glenohumeral joint are common in wilderness activities. Emergent reduction should take place at the site of trauma to reduce the patient's pain and the risk of vascular and neurological complications. A limited number of reduction methods are applicable in remote areas. The aim of this study is to present our method of reduction of anterior shoulder luxation that is easily applicable in remote areas without medication, adjuncts, and assistants and is well tolerated by patients. METHODS: A prospective observational study was conducted during a 5-year period. The patients included underwent closed manual reduction with our technique. After each reduction, the physician who performed the reduction completed a standardized detailed history, and reexamined the patient (for acute complications). The patients were contacted 6 months after the trauma to investigate long-term postreduction complications. RESULTS: Reduction was achieved with our method in 39 (100.0%) of 39 patients. The mean pain felt during our reduction procedure was rated 1.7 ± 1.4 (on a scale of 10) using the visual analog scale scoring system. No complications were noted before or after the reduction attempts. We did not find any long-term complications. CONCLUSIONS: The reduction method presented in the present study is an effective method for the reduction of acute shoulder luxations in remote places. Our data suggest that this method could be applied for safe and effective reduction of shoulder dislocation.

Minimal-access video-assisted thyroidectomy for benign disease: a retrospective analysis of risk factors for postoperative complications.

BACKGROUND: Minimal-access video-assisted thyroidectomy (MIVAT) has now become a widespread technique in the treatment of benign thyroid disease. No studies systematically investigate risk factors for postoperative complications. The aim of our study was to investigate possible risk factors for postoperative complications in MIVAT in patients with benign disease. METHODS: One-hundred eighty-nine patients who underwent MIVAT for benign disease were retrospectively identified in a prospectively-maintained institutional register of thyroid surgery. Exclusion criteria were: (1) thyroid volume>45 mL; (2) malignant disease; (3) prior neck surgery; (4) prior neck irradiation; (5) nodule size>3 cm; (6) intrathoracic component; (7) follow-up<1 year. Age, sex, comorbidities, body mass index, existence of symptoms, duration of disease evolution, thyroid volume, hyperthyroidism, thyroiditis, and the duration of surgery were analyzed as risk factors for complications. We applied both bivariate and multivariate logistic regression analyses in order to identify risk factors associated with postoperative complications. RESULTS: Complications were presented by 28 patients (14.8%). The variables associated as independent risk factors with these complications were hyperthyroidism (OR = 4.31; P = 0.003) and thyroiditis (OR = 3.59; P = 0.035). Age, sex and thyroid volume up to 45 mL do not seem to be independent risk factors. CONCLUSIONS: In endocrine surgery units, two independent risk factors for postoperative complications could be identified in MIVAT patients: hyperthyroidism and thyroiditis. Surgeons operating on patients presenting these factors should be aware of the potential augmented risk in order to correctly adapt intraoperative and postoperative care.

Postoperative ulnar neuropathy is not necessarily iatrogenic: a prospective study on dynamic ulnar nerve dislocation at the elbow.

BACKGROUND: Patients who undergo surgery may develop ulnar neuropathy. Although the mechanism of ulnar neuropathy is still not clear, ulnar neuropathies are common causes of successful lawsuits against surgeons. Recently, the concept developed that endogenous patient factors can lead to postoperative peripheral neuropathies. We hypothesize that dynamic ulnar nerve dislocation at the elbow (DUNDE) may be a predisposing factor for ulnar irritation (i.e., neuropathy) in normal subjects. METHODS: In a prospective investigation, patients aged 20 years and older presenting in our emergency department were asked to participate. Three physicians examined both elbows of subjects included in our study for evidence of DUNDE (through clinical and sonographic examination) and for clinical symptoms related to ulnar neuropathy. RESULTS: Dynamic ulnar nerve dislocation was observed in 29.3% of examined subjects. No significant difference in its occurrence was observed in relation to gender or dominant side. Physical examination with provocation tests demonstrated significantly more positive Tinel tests and spontaneous signs of neuropathy in patients with dynamic dislocating ulnar nerves (14.7 vs. 1.1%). CONCLUSION: Dynamic ulnar nerve dislocation may be linked to ulnar nerve irritability (i.e., ulnar neuropathy) in normal subjects without history of trauma, surgical procedure, or anesthesia. Considering the high incidence of this variant in the general population, our study supports previous investigations suggesting that many postoperative ulnar nerve deficits are traceable to chronic patient conditions. Our study suggests that dynamic ulnar nerve dislocation is a predisposing factor in the development of ulnar neuropathy in the postoperative period. NOTES: (1) neuropathy should be viewed as a broad definition as signs of nerve irritation/inflammation, and independently of the pathophysiology and etiology; (2) because no specific term exists in the international anatomic nomenclature (Nomina Anatomica) to designate this variant, several synonyms have been used in the literature, leading to confusion and misleading conclusions concerning its traumatic etiologies and their consequences: (a) recurrent or habitual ulnar nerve luxation (or subluxation); (b) recurrent or habitual ulnar nerve dislocation; (c) ulnar nerve instability; (d) laxity of the ulnar nerve; and (e) ulnar nerve hypermobility.

Occurrence and significance of odontoid lateral mass interspace asymmetry in trauma patients.

BACKGROUND: The odontoid lateral mass interspace (OLMI) is the space between the lateral aspect of the dens axis and the medial circumference of the massa lateralis atlantis. The position of OLMI asymmetry as a normal variant or pathologic finding is an area of debate and clinical interest in trauma patients. We designed this prospective study to lay a framework for proposing strategies for the appropriate use of OLMI. METHODS: A total of 301 adult patients admitted for trauma were included. Computed tomography (CT) and magnetic resonance imaging (MRI) of the cervical spine were performed and examined for the presence OLMI asymmetry and bony/ligamentous lesions of the occipitoatlantoaxial complex. RESULTS: Head rotation is linked to the occurrence of OLMI asymmetry. Reliable OLMI asymmetry evaluation is limited by observer agreement under a threshold value of 1.0 mm. In all, 86 patients (28.6 %) were found to have OLMI asymmetry on CT after trauma. Among these patients, 17.4 % had a bony/ligamentous lesion of the occipitoatlantoaxial complex. Among the patients without OLMI asymmetry, 8.8 % were found to have such lesions. CONCLUSIONS: OLMI asymmetry should only be investigated by CT scans of the head in optimal position and with the threshold value of 1.0 mm. OLMI asymmetry should not be used alone as a sign of a cervical spine lesion. MRI should be performed if: (1) the physician has a high degree of suspicion of a cervical spine lesion; (2) OLMI asymmetry was demonstrated on a technically adequate CT scan; (3) clinical symptoms persist in patients with OLMI asymmetry when no acute MRI was performed.

Effects of a cost-effective surgical workflow on cosmesis and patient's satisfaction in open thyroid surgery.

PURPOSE: In thyroid surgery, minimally invasive procedures are thought to improve cosmesis and patient's satisfaction. However, studies using standardized tools are scarce, and results are controversial. Moreover, minimally invasive techniques raise the question of material costs in a context of health spending cuts. The aim of the present study is to test a cost-effective surgical workflow to improve cosmesis in conventional open thyroid surgery. METHODS: Our study ran between January 2009 and November 2010, and was based on a prospectively maintained thyroid surgery register. Patients operated for benign thyroid diseases were included. Since January 2010, a standardized surgical workflow was used in addition to the reference open procedure to improve the outcome. Two groups were created: (1) G1 group (patients operated with the reference technique), (2) G2 group (patients operated with our workflow in addition to reference technique). Patients were investigated for postoperative outcomes, self-evaluated body image, cosmetic and self-confidence scores. RESULTS: 820 patients were included in the present study. The overall body image and cosmetic scores were significantly better in the G2 group (P < 0.05). No significant difference was noted in terms of surgical outcomes, scar length, and self-confidence. CONCLUSIONS: Our surgical workflow in conjunction with the reference technique is safe and shows significant better results in terms of body image and cosmesis than do the reference technique alone. Thus, we recommend its implementation in order to improve outcomes in a cost-effective way. The limitations of the present study should be kept in mind in the elaboration of future studies.

Cosmesis and body image after minimally invasive or open thyroid surgery.

BACKGROUND: Minimally invasive techniques, such as laparoscopic appendectomy or minimally invasive thyroid surgery, are thought to produce better cosmetic results. However, cosmesis in thyroid surgery was rarely investigated using a standardized approach. The objectives of this study were to evaluate body image and cosmesis in patients who had either minimally invasive (MI) or conventional open (CO) thyroid surgery. METHODS: Two hundred fifty patients of 540 participated (46.3 %): 50 patients (20.0 %) had MI thyroid surgery and 200 (80.0 %) had CO thyroid surgery. The patients filled out a body image questionnaire that investigated body image, cosmesis, and self-confidence. SPSS 19.0 software was used for statistical analysis. RESULTS: Although the mean incision size was significantly shorter in the MI group than in the CO group (2.8 vs. 3.5 cm), the mean scores from the body image questionnaire (body image score, cosmetic score, and self-confidence score) were similar for both groups (p > 0.05). No significant differences in postoperative complications were observed in these groups (p > 0.05). CONCLUSIONS: Studies in the literature that evaluate body image and cosmesis in thyroid surgery using standardized methods are scarce. In our department, the results of a questionnaire showed that the MI approach has no advantage for body image and cosmesis over the CO approach. Further prospective randomized studies using different tools with a larger sample size are needed to investigate the use of MI procedures for thyroid surgery.