Functional outcome and complications after operative treatment of mallet fingers by the Ishiguro technique

Transcription

1 Functional outcome and complications after operative treatment of mallet fingers by the Ishiguro technique Pia Helén Smedsrud Kull V-10 Prosjektoppgave ved Medisinsk fakultet UNIVERSITETET I OSLO Våren 2015

2 Functional outcome and complications after operative treatment of mallet fingers by the Ishiguro technique. Pia Helén Smedsrud, stud.med. (1), Cornelia Juel Lind Eriksen, MD (2), John Williksen, MD (3), Ida Neergård Sletten, MD, PhD (3) 1: Faculty of Medicine, University of Oslo 2: Department of Radiology and Nuclear Medicine, Oslo University Hospital 3: Department of Orthopaedic surgery, Oslo University Hospital

3 Abstract One third of mallet fingers are associated with intra-articular fracture of the distal phalanx. Treatment usually involves splint immobilisation of the distal interphalangeal joint or operative treatment if there is a fracture fragment of more than one third of the articular surface or a palmar subluxation of the distal phalanx. We examined 25 out of 49 consecutive patients treated with the Ishiguro extension block technique in our department to assess the long-term clinical and radiological results. Of the 49 patients with median age of 35 (range 14-74) years, 15 men and 10 women met for a three-year follow up. Scored by Crawford classification we had one excellent, two good, 14 fair and seven poor results. According to relative TAM calculation, we had three excellent, 16 good, five fair and no poor results. The patients reported a median high level of life quality by the Eq-VAS scale, and a median good upper extremity function by the patient-reported outcome QuickDASH, as well as high levels of satisfaction with subjective present hand function and the treatment they received. Despite the small patient sample, we noted two major complications; one case of osteomyelitis and one re-operation due to subluxation, as well as several cases of minor complications. Ten patients had radiological osteoarthritis of at least grade 1 according to the Kellgren and Lawrence grading scale. We question whether operative treatment actually betters the longterm outcome for mallet fractures, and recommend randomised controlled trials comparing conservative splint treatment to extension block pinning in fractures with large fragments.

4 Introduction Mallet finger is the inability to actively extend the distal interphalangeal (DIP) joint caused by injury to the extensor tendon mechanism, one third being associated with an intra-articular fracture of the dorsal lip of the distal phalanx of variable size(1). Most commonly it is caused by direct trauma to an extended fingertip, resulting in forced flexion or hyperextension of the DIP joint (1, 2). Treatment involves either splint immobilisation of the DIP joint or surgery (3), to avoid long term problems such as functional impairment, pain, stiffness, secondary swan neck deformities and premature osteoarthritis (1). Mallet finger injuries are found to affects the ulnar three fingers in 90% of the cases, most commonly the third finger (4). The dominant hand is affected in 74% of the cases (4). The injury is more common in men than in women (2, 3). Most mallet fingers can be treated conservatively, in particular closed rupture of the extensor tendon without an associated fracture of the distal phalanx, or fractures with a small dorsal fragment. The traditional treatment is the use of a Stack splint(5) with the DIP-joint slightly hyperextended and the proximal interphalangeal (PIP) joint left free. The splint has to be of right size, used continuously for 6-8 weeks followed by 2-4 weeks of splinting at night and at risk (sports) activities. Many surgeons agree that a fracture fragment larger than one third of the joint surface, or palmar subluxation of the distal phalanx are indications for surgery, in order to obtain a sufficient reduction of the fracture and to have a large enough fracture fragment to handle a surgical approach (6-8). Different surgical methods exist, such as percutaneous pinning, combinations of pinning and external fixators, pull-out wires, and screw fixation (1, 8). Several of these demand open techniques. A recent review of mallet fingers with fracture and subluxation (1) concludes that operative treatment seems reasonable for mallet fractures with larger displaced fragments and/or subluxation, but that there are no high level evidence to guide treatment since most recommendations are based on level IV studies. In a Cochrane meta-analysis of four randomized clinical trials (3), three of the included trials compared different splints to the Stack splint and the fourth trial compared Kirchner wire (K-wire) fixation to the use of Pryor and Howard splint(9). Including a total of 283 mallet finger injuries, the authors found all trials methodically flawed with inadequate outcome assessment, concluding with insufficient

5 evidence to determine either indications for surgery, or the best conservative treatment for mallet finger injuries. Despite the lack of high-level clinical evidence, the Ishiguro closed percutaneous pinning technique has become increasingly popular the last two decades (6). In Department of Orthopaedic surgery, Oslo University hospital Ullevål, surgical treatment of mallet fractures according to Ishiguro s technique is considered in patients where the fracture fragment affects more than one third of the articular surface, or the distal phalanx is palmarly subluxated. A relative contraindication is 3-5 weeks old fractures, and an absolute contraindication is fractures more than 5 weeks old (6). The objective of our retrospective study was to evaluate the long-term clinical and radiological results after Ishiguro pinning of mallet fractures in Department of Orthopaedic surgery, Oslo University Hospital Ullevål, and compare them to previous reports in the literature.

6 Patients and methods Selection The project was planned in 2012 and conducted in To secure an adequate follow-up time of at least two years, patients were located from the department s operation protocols for 2009 and A total of 49 patients were identified, and invited by mail to participate in the study. The 49 patients were randomized in Microsoft Excel to an individual patient number. A total of 25 out of the 49 invited patients met for a follow-up consultation in the outpatient clinic, which included a radiological examination, an interview and a hand examination. The remaining 24 patients were lost to follow-up, despite repeated attempts to organize a consultation by telephone. The medical records for all 49 subjects were reviewed for data such as date of injury, date of operation, date of wire extraction, number of postoperative controls and early complications such as infection and reoperation where this was possible to retrieve. Treatment protocol in our department The Ishiguro extension block technique (6) involves insertion of two percutaneous K-wires guided by fluoroscopic imaging, under digital block anaesthesia. The first K-wire is inserted through the terminal extensor tendon 1-2 mm proximal and dorsal to the fragment into the middle phalanx while holding the DIP and PIP joints in maximum flexion. The distal phalanx is then pulled distally and the DIP joint is extended for fracture reduction, and a second K- wire transfixing the DIP joint is inserted obliquely, avoiding the fracture line. After satisfactory fracture reduction is achieved under fluoroscopy, the pins protruding the skin are bent and cut, and a proper dressing is applied. All patients are seen one week postoperatively at the outpatient clinic for pin inspection, cleaning and change of dressing. Four weeks later the pins are extracted, and the patients get a custom fitted Stack splint for use during night and while performing risk activities for the next four weeks. Consultant orthopaedic surgeons determine the indication for surgery, and resident doctors perform the procedures and follow-ups. Radiographs are routinely taken when patients first visit the emergency room, postoperatively and after pin removal.

7 Trial follow-up At long-term follow-up all patients were handed the Norwegian versions of the Eq-5D-3L life quality questionnaire (10) and the patient-reported outcome measure (PRO) QuickDASH (11) (short version of the Disabilities of the Arm, Shoulder and Hand Outcome measure (12)), as well as visual analogue scale (VAS) measurements for pain and satisfaction. They completed the two forms, and plotted their VAS-scores unassisted after a short oral and written explanation. The Quick-DASH is an 11-item questionnaire from which a score between can be calculated, where 0 indicates normal hand function. The Eq-VAS part of the Eq-5D-3L measures the overall health-related quality of life on a VAS scale with measurements, with 100 as the best result. The patients reported VAS for pain both at rest and in activity. VAS satisfaction was reported both for present hand function, and for the overall treatment regime. The VAS scale used was a 10 cm long line without any measurements. The reported results were later measured in mm corresponding to a scale between For pain measurement the best result was 0, and for satisfaction the best result was 100. Radiology Imaging was performed using a digital X-ray system. Images were captured in both posteroanterior (PA) and lateral view with small beam collimation. Image analyses were performed on Siemens Radiology Information System and Picture archiving and Communication System (RIS PACS) workstation. One radiologist did all radiological evaluations, including re-examination of the initial radiographs at time of injury, postoperatively and at early routine follow-up. At the late follow-up the corresponding finger of the non-injured hand was also imaged for comparison. The degree of diastase and/or step in the articular surface, the proportion of the articular surface affected, and any evidence of subluxation were evaluated in the primary radiographs. Postoperatively and at the time of removal of the pins, the position of the fracture was described as improved, worsened or unchanged. At the late follow-up, healing of the fracture and possible widening of the articular surface, as well as the degree of osteoarthritis using the Kellgren-Lawrence Grading Scale (0-4) was evaluated (13). Signs of osteoarthritis of other joints of the injured finger, and of the corresponding finger joints of the opposite hand were also described. Interview and examination

8 All subjects were interviewed and examined by the author. The interview consisted of questions concerning self-assessment of present hand function compared to the hand function before the injury occurred (Table 1), and postoperative complications such as nail deformity, pain, subjectively impaired skin sensation and cold intolerance. Examination of the hand consisted of active and passive finger range of motion (ROM) using a goniometer in the metacarpophalangeal (MCP), PIP and DIP joints. Measurements were performed both in the injured finger and in the contralateral corresponding finger for comparison. Grip strength measurement was performed in both hands as the best of three attempts using the Jamar dynamometer (Patterson Medical Holdings, Inc., Bolingbrook, Illinois, US) with the elbows held close to the body in 90 flexion and a neutral wrist. Pinch power was measured using a pinch dynamometer with the injured finger against the thumb, or thumb against the index finger in the cases of thumb injury. Pinching was performed finger pulp to finger pulp without flexion of the DIP or PIP joints, and the other fingers were isolated in full flexion. From these results, total active motion (TAM) and total passive motion (TPM) of the finger joints were calculated. TAM and TPM are defined by American Society for Surgery of the Hand (ASSH) as the sum of the active or passive MCP, PIP and DIP joint flexion, minus any extension deficits (14). The respective TAM and TPM of the injured finger was then divided by the TAM and TPM of the contralateral finger, calculating the relative TAM and TPM. ASSH categorizes the relative TAM as poor (<50%), fair (>50%), good (>75%) or excellent (100%). The overall outcome was also described according to outcome criteria given by Crawford (15), which ranges from excellent to poor, and involves review of extension deficit, flexion loss and persistent pain (Table 2). We considered pain as significant when reported as 10 on the VAS scale. The author did all interviews and hand examinations. Ethics The local ethical committee at Oslo University Hospital approved the research protocol. The 25 patients who met at follow-up signed a written consent of participation. Statistics All data from interviews, examinations and patient records were analysed by the use of

9 Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY, US). As the continuous outcome variables did not follow the normal distribution, average values are given as medians and the variability is described by total and interquartile range.

10 Results Demographics The patients were median 35 (range 14-74) years old at operation. Of all the 49 operated patients 32 were men, while 15 of the 25 who came to late follow-up were men. 25 of all patients had injured their left hand, 33 had injured their fifth finger, and 11 of the 25 patients at late follow-up had injured their dominant hand. Time from injury to operation was median 8 (range 1-40) days, and the time from operation to pin removal was median 33 (25-43) days. Time from injury to long-term follow-up was median 38 (range 27-48) months. The number of postoperative controls in the outpatient clinic was median 3 (1-8) in the late follow-up group. Indication for surgery was a dorsal fragment size of more than one third of the joint surface in 23 of the 25 patients who met for the late follow-up. One of the two patients with a smaller fragment size had a clinical rotational deformity of the fingertip at presentation according to the patient record, while indication for surgery was not clearly stated in the other patient s record. There were no palmar subluxations of the distal phalanges, nor any open fractures. The most common mechanism of injury was ball games (n=7), four of these sports injuries involved the third finger. Five patients reported crush injury, five patients suffered a low-injury fall, four patients reported an axial trauma to the finger, and four patients reported unknown or other mechanism of injury. Sixteen of the 25 patients who came for a late follow-up reported to be non-smokers and healthy, two were regular smokers, three had diabetes, one had rheumatoid arthritis, while five reported to have other chronic diseases such as chronic obstructive pulmonary disease or cancer. Clinical outcome The patients had low median scores for Quick-DASH and VAS pain at rest and in activity at final follow-up (Table 3). They reported high levels of satisfaction with both hand function and the overall treatment, and they had high Eq-VAS health-related life quality scores (Table 3). The patients responses to questions regarding subjective hand function (Table 1) demonstrated than only 16/25 considered themselves as strong as before the injury, and only 15/25 reported to have the same hand function as before the injury. Only 8/25 reported that they had the same finger ROM as before the injury. On the other hand; only two patients

11 reported that there were activities they could no longer perform; write with a pen and play the cornet. TAM in the injured finger compared to the contralateral, uninjured finger leaves three of the patients with excellent results, sixteen with good results, five with fair results and none with poor results. The grip strength of the injured hand equalled the opposite hand, and the pinch power of the injured finger was only slightly reduced compared to the contralateral finger (Table 3). Judged by the Crawford classification(15), many of our patients outcomes were poor, and these results correlated relatively well to their Quick-DASH outcomes (Table 4). We did not find worse Crawford scores for patients operated later than 14 days after injury; in fact all patients with poor outcome were operated within 14 days. Complications One patient suffered osteomyelitis postoperatively and was treated with antibiotics. This patient reported no risk factors and was previously healthy, and presented at late follow-up with radiological ankylosis of the DIP-joint, measured to 45 of permanent flexion. The patient reported a QuickDASH score of 16, and presented with a poor Crawford score and a relative TAM of 72% at late follow-up. Another patient was re-operated due to subluxation of the distal phalanx at the four-week post-operative control, although the trial s radiologist noted no subluxation retrospectively either before or after surgery, and the postoperative radiographs showed good position and no step or diastasis. This patient reported a QuickDASH score of 2 at late follow-up, and presented with a fair Crawford score and relative TAM of 93%. Of the 25 patients at late follow-up four reported present nail deformities, such as shorter or more bulky nail, or slower nail growth. Several other patients reported that they had noticed nail deformities postoperatively which had resolved by the time of follow-up. Three patients had their pins removed prematurely either by accident or because of infection. Two of the 25 patients received oral antibiotics postoperatively, due to signs of superficial skin infection. Nine patients reported cold intolerance in the operated finger. Four patients reported impaired sensation in the finger pulp. One patient of the 24 lost to follow-up suffered a new injury to the same finger one year after his mallet fracture, and underwent a subsequent arthrodesis of the DIP joint. Three of the patients lost to follow-up also received oral antibiotics for superficial infection according to their patient records.

12 Radiological outcome Postoperatively, twenty-two patients had improved radiological position of the fracture compared to primary radiographs. The initial position was unchanged in one patient, and worsened in another. One patient lacked initial radiographs at time of injury. After pin removal, nineteen patients had unchanged fracture position compared to postoperative radiographs, while in four patients the position was described as worsened. One patient was re-operated, and one patient had their pins removed in Spain. All fractures were healed at late follow-up, in five patients with a minor articular step of 1mm. The articular surface of the basis of the distal phalanx was widened compared to the contralateral finger in 20 of the 25 patients. While 10 of the operated DIP joints had osteoarthritis of at least grade 1 according to the Kellgren-Lawrence Grading Scale (0-4) (13), another five were graded as 0-1. There were no signs of osteoarthritis in nine patients. Thirteen of the 15 patients with osteoarthritis at late follow-up had no signs of osteoarthritis in the initial radiographs. One patient lacked initial radiographs, and in one patient the quality of the primary radiographs was too low to exclude osteoarthritis. None of the patients had osteoarthritis in the PIP- or MCP-joints of the injured finger, or in any of the contralateral finger joints. Patients lost to follow-up Seven women and 17 men were lost to follow up. Two had moved out of Oslo, ten were impossible to locate both by telephone and mail, and the remaining 12 did not find time to come to follow up even after several attempts. Five of the 15 women we were able to locate were lost to follow-up, while of the located men 9 out of 24 were lost to follow-up. Median age in the lost to follow-up group was 33 (15-74) years, compared to 35 (14-68) years in the group that met for the late follow-up. Among the 24 patients lost to follow-up 18 had injured their fifth finger, while 12 of the 25 who met at follow-up had injured their fifth finger.

13 Discussion The 25 patients at late follow-up had overall good upper extremity function according to QuickDASH. Most reported no pain at rest, and little pain in activity. When evaluated according to relative TAM, 19 patients had an excellent or good result. Nevertheless, our patients scored low on the Crawford scale, with only three patients having good or excellent results. QuickDASH is an outcome measure for shoulder, arm and hand, and may not be fit to detect minor changes in one finger joint function (16). The Crawford classification system focuses solely on the DIP joint function, and may therefore be better suited for measuring long-term results after mallet finger injuries. The risk of complications after surgical treatment for mallet fingers is well known, and include infection, nail deformity due to nail bed injury and limited ROM of the DIP joint (3). In our study we recorded one case of osteomyelitis, one early re-operation, and one case of secondary arthrodesis, in addition to several cases of minor complications such as nail deformities, cold intolerance and subjectively impaired sensation. A majority of the patients at late follow-up showed signs of osteoarthritis, and a surveillance of further development of the osteoarthritis and possible clinical implication would be of interest. The follow-up rate was 51%, with no major differences between the two groups regarding sex, age or early complications. As in previous studies, our patients were relatively young and previously healthy, having few risk factors for post-operative complications (8, 17). In our study, the author recruited the patients and performed all interviews and examinations. One radiologist has evaluated all radiographs. Although being inexperienced with hand examinations, the author was prior to the study thoroughly instructed by a skilled hand therapist. The interview and examination situation was well planned and standardized to avoid bias. Our study included all patients operated for mallet fracture in our department during a two-year interval. We do not know, however, how many patients who visited the emergency department with the same injury but ended with conservative treatment even though satisfying our described indications for surgery. It would be interesting to investigate whether all patients satisfying operation indications actually were operated. If not, comparison of our results to long-term follow-up results of similar patients treated conservatively with a splint would be of great interest.

14 To our knowledge there has so far not been conducted any randomised controlled trials comparing the Ishiguro extension block technique to conservative treatment with the Stack splint in patients with a dorsal fragment of >1/3 of the joint surface. Kalainov and coworkers (18) recommended conservative treatment for mallet finger fractures with greater than one-third articular surface involvement, based on good results in a 21 patients cohort. The results from at least three retrospective studies focusing on hand function after extension block with Kirchner wires have been published the past fifteen years (1). In two of these, modified versions of the technique was used (17, 19), while the Ishiguro extension block technique was used in the third (8). In the latter the mean (?) follow-up time was 69 weeks for 65 patients with a large bone fragment with subluxation or loss of joint congruity. The patients finger function was rated after the Crawford classification system (15) where 51 (78 %) had excellent or good results. They found 13 fair results reportedly caused by poor initial reduction, and three complications including pin track infection and nail deformity. The two studies using modified techniques also used Crawford classification system. One found that 22 out of 24 patients had good or excellent results, and there were no major and five minor complications after more than one year (19). The other study found that 21 out of 22 patients had good or excellent results at 25 month follow-up (17). A patient-reported outcome measure (PRO) such as DASH or QuickDASH was not used in any of these four studies. Compared to these four studies, we had more complications and substantially worse DIP joint-specific outcome according to the Crawford classification. On the other hand, our patients had low QuickDASH scores and only two patients reported on activities they could no longer perform. A possible reason for our results might be lower quality of the surgeries performed in our department. Possibly, the resident doctors should be better instructed and closer supervised in the operation theatre. Another possibility is that we have reported more meticulously the clinical outcomes and the complications than previous authors, including the assessment of radiological grading of osteoarthritis. As our study was retrospective, it does not have a high enough level of evidence to serve as a foundation for treatment recommendations. Nevertheless, our findings make us question whether operative treatment actually yields the long-term results we seek regarding improvement of DIP joint function, and avoidance of persisting pain and premature osteoarthritis. We therefore recommend the conduction of randomised controlled trials comparing extension block pinning and conservative splint treatment for mallet fractures that involve more than one third of the joint surface.

15 1. Wada T, Oda T. Mallet fingers with bone avulsion and DIP joint subluxation. The Journal of hand surgery, European volume. 2015;40(1): Geyman JP, Fink K, Sullivan SD. Conservative versus surgical treatment of mallet finger: a pooled quantitative literature evaluation. The Journal of the American Board of Family Practice / American Board of Family Practice. 1998;11(5): Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries. The Cochrane database of systematic reviews. 2004(3):CD Wehbe MA, Schneider LH. Mallet fractures. The Journal of bone and joint surgery American volume. 1984;66(5): Stack HG. A modified splint for mallet finger. Journal of hand surgery. 1986;11(2): Ishiguro T, Itoh Y, Yabe Y, Hashizume N. Extension block with Kirschner wire for fracture dislocation of the distal interphalangeal joint. Techniques in hand & upper extremity surgery. 1997;1(2): Hamas RS, Horrell ED, Pierret GP. Treatment of mallet finger due to intra- articular fracture of the distal phalanx. The Journal of hand surgery. 1978;3(4): Pegoli L, Toh S, Arai K, Fukuda A, Nishikawa S, Vallejo IG. The Ishiguro extension block technique for the treatment of mallet finger fracture: indications and clinical results. Journal of hand surgery. 2003;28(1): Auchincloss JM. Mallet- finger injuries: a prospective, controlled trial of internal and external splintage. The Hand. 1982;14(2): EuroQol G. EuroQol- - a new facility for the measurement of health- related quality of life. Health policy. 1990;16(3): Beaton DE, Wright JG, Katz JN, Upper Extremity Collaborative G. Development of the QuickDASH: comparison of three item- reduction approaches. The Journal of bone and joint surgery American volume. 2005;87(5): Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). American journal of industrial medicine. 1996;29(6): Kellgren JH, Lawrence JS. Radiological assessment of osteo- arthrosis. Annals of the rheumatic diseases. 1957;16(4): American Society for Surgery of the Hand. The Hand, examination and diagnosis. 3nd ed. New York: Churchill Livingstone; Crawford GP. The molded polythene splint for mallet finger deformities. The Journal of hand surgery. 1984;9(2): Kennedy CA; Beaton DE SS, McConnell S, Bombardier C. The DASH and QuickDASH Outcome Measure User's Manual,. Third ed. Toronto, Ontario: Institute for Work & Health; Darder- Prats A, Fernandez- Garcia E, Fernandez- Gabarda R, Darder- Garcia A. Treatment of mallet finger fractures by the extension- block K- wire technique. Journal of hand surgery. 1998;23(6): Kalainov DM, Hoepfner PE, Hartigan BJ, Carroll Ct, Genuario J. Nonsurgical treatment of closed mallet finger fractures. The Journal of hand surgery. 2005;30(3): Hofmeister EP, Mazurek MT, Shin AY, Bishop AT. Extension block pinning for large mallet fractures. The Journal of hand surgery. 2003;28(3):453-9.

16 Table 1. Questionnaire Self-assessment questions 1. Do you experience that your hand function is as good as prior to the injury? 2. Do you experience that the range of motion in your hand is as good as prior to the injury? 3. Do you experience that your hand is as strong as prior to the injury? 4. Are there any activities that you can no longer perform due to this injury? If so, specify: 5. Do you do any activities that require especially fine motoric skills? If so, specify: Table 2. Crawford Classification Outcome Description Excellent Full distal joint extension, full flexion, and no pain Good 0-10 of extension deficit with full flexion and no pain Fair of extension deficit, any flexion loss, and no pain Poor >25 of extension deficit or persistent pain Table 3. Clinical outcome Median Range Interquartile range Follow-up interval (months) Quick-DASH (0-100, 0 best) Eq-VAS (0-100, 100 best) VAS pain at rest (0-100, 0 best) VAS pain in activity (0-100, 0 best) VAS satisfaction hand function (0-100, 100 best) VAS satisfaction treatment (0-100, 100 best) Grip strength (kg) Relative grip strength (%) Pinch power (kg) 3,3 2,0-7,5 2,9-5,0 Relative pinch power (%) DIP extension deficit ( ) DIP flexion lag ( ) TAM ( ) Relative TAM (%) TPM ( ) Relative TPM (%) Quick-DASH: Quick-Disability of arm, shoulder and hand Outcome Measure Eq-VAS: EuroQol Visual Analogue Scale (self-evaluation of health-related quality of life) TAM and TPM: Total active/passive finger motion

17 Table 4. Outcome according to Crawford s classification compared to QuickDASH Patient number DIP extension lag ( ) DIP flexion loss ( ) VAS pain at rest (0-100) VAS pain in activity (0-100) Crawford score Time from injuryoperation (days) Quick- DASH (0-100) Excellent Good Good Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair Poor Poor Poor Poor Poor Poor Poor 0