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JRPMS 2018

Mini Review Article JRPMS, Vol 2, No 1, March 2018, p.2-6
Hypophosphatasia in adults
Antonia A. Kountouri, Anna Papadopoulou
Keywords: ALPL gene, PEA, PLP, Alkaline phosphatase, Asfotase alfa
Hypophosphatasia (HPP) is a sporadic inheritable disease. Patients suffer from defective bone and teeth mineralization, due to low levels of alkaline phosphatase (ALP). It is caused by mutations in the ALPL gene which encodes the tissue-nonspecific isoenzyme (TNAP or TRANSALP) of alkaline phosphatase. Hypophosphatasia is classified into six forms: lethal perinatal, benign prenatal, infantile, childhood, adult and odontohypophosphatasia. The adult form is the rarest and the mildest of all types characterized by low levels of alkaline phosphatase, increased levels of pyridoxal-5'-phosphate (PLP) in serum and increased levels of phosphoethanolamine (PEA) in urine. ALPL mutations associated with adult hypophosphatasia are either autosomal recessive or autosomal dominant. Patients' phenotype depends on the site of the enzyme these mutations affect. Although, there is not a treatment for this disease actually, enzyme replacement treatment (ERT) with asfotase alfa promises a lot to patients.
Case Report Article JRPMS, Vol 2, No 1, March 2018, p.7-11
Misdiagnosis of alkaptonuria in an elderly patient
Georgia C. Tseliou, Mayra P. Giannelou, Evangelos A. Boulios, Anastasia K. Klangou, George N. Katsoulis, George D. Bailas, Athanasios I. Georgountzos
Keywords: Alkaptonuria, Ochronosis, Homogentisic acid (HGA), Low back pain, Degenarative arthropathy
Alkaptonuria is a rare hereditary metabolic disorder, resulting from deficiency of enzyme homogentisate 1,2-dioxygenase (HGD). Its features include spine and peripheral joint arthritis, as well as bluish discoloration of cartilage tissues. We report a case of an 81 year old male with a 5 year history of low back pain and progressively increasing stiffness of the spine, incorrectly diagnosed as ankylosing spondylitis and treated with non steroid anti-inflammatory drugs (NSAIDs) and sulfasalazine. Diagnosis of alkaptonuria was based on the characteristic ochronotic pigmentation of ears and eyes cartilage and typical radiographic findings of the spine-narrowed intervertebral spaces and intervertebral disc calcification, combined with the presence of homogentisic acid in the patient’s urine. Complete history,physical and radiological examinations revealed severe degenerative arthropathy of knee, hip and shoulder joints, which had led to bilateral total hip and knee arthroplasty in the last 7 years. Due to the patient’s cardiovascular comorbidity and advanced age, surgical treatment of ochronotic spine arthropathy was not considered. Management of the patient was based on analgesic treatment and vitamin C. Although alkaptonuria is a rare disease it should be considered in patients, even the elderly ones, who present with low back pain and severe degenerative arthropathy.
Review Article JRPMS, Vol 2, No 1, March 2018, p.12-17
The role of CT and MRI in imaging of Paget bone disease
Spyridon G. Adamopoulos, Glykeria M. Petrocheilou
Keywords: Paget, Bone, Computed tomography, Magnetic resonance imaging
Paget disease (PD) is a common bone disease characterized by abnormal bone turnover that follows a disorderly osteoclastic overactivity. In typical PD, imaging assessment is accomplished with conventional radiography and bone scintigraphy. CT and MRI may have complementary roles in the imaging workflow of PD preventing inappropriate investigation and helping the management planning at an early stage. Apart from discovering incidental findings, CT and MRI contribute substantially to the diagnosis of less typical cases, the delineation of PD pathology in complex anatomic areas, the differential diagnosis from sinister causes and the accurate assessment of specific complications.
Case Report Article JRPMS, Vol 2, No 1, March 2018, p.18-21
Bilateral transient osteoporosis of the knees during pregnancy. A case report and review of the literature
Nikolaos Milonas, Panagiotis Touzopoulos, Christos P. Zafeiris, Nikolaos Papantoniou, Eufrosini Koutsoubeli, Athanasios Chatzigiannakis
Keywords: Transient osteoporosis, Knee, Pregnancy
Transient osteoporosis is a rare self-limited condition that affects mostly middle-aged men or women in the third trimester of pregnancy. The most commonly affected joint is the hip, while bilateral involvement of the knees is extremely rare. Complete resolution of symptoms and MRI findings occurs over 8 to 10 months after clinical onset. We present a case of a 40-year-old woman diagnosed with bilateral transient osteoporosis of the knees, in the early postpartum period treated for 6 months with calcitonin, analgesics and physiotherapy.
Review Article JRPMS, Vol 2, No 1, March 2018, p.22-30
The multiple roles of steroids and anabolic steroids and its relations to cardiovasular and musculoskeletal pathology: a brief review
Margarita Theodorakidou, Olti-Alexandra Nikola, George I. Lambrou
Keywords: Corticosteroids, Anabolic steroids, Cardiovascular, Musculoskeletal
Steroids are defined as compounds included in the family of terpenoid lipids. Specifically, anabolic steroids are synthetic steroids of the androgen steroids. Since the beginning of the 20th century, anabolic steroids have proven influence on physical strength, endurance and muscle tissue synthesis. They have been used both for military purposes as well as for athletic achievements. Their use has been expended thereafter up to the point that side-effects began to become apparent. To date, it is well documented that anabolic steroids have adverse side effects on the primary and secondary sex characteristics. Steroids attribute male characteristics to females, and, at the same time, sterility and erection dysfunctions to males. Several studies have shown that the use of anabolic steroids is connected to dysfunctions of the cardiovascular system. No direct adverse effects have been reported on the function of cardiovascular system during the use of anabolic steroids, however, it has been shown that there is an indirect connection between anabolic steroids and cardiovascular disease. Steroids elevate levels of cholesterol and triglycerides which both are related to high risk of cardiovascular disease. The present work reviews the hitherto known connections between steroids in general, both synthetic and naturally occurring to the risk or not of cardiovascular disease.
Οriginal Article JRPMS, Vol 2, No 2, June 2018, p.39-45
Femoral stem sagittal balance - Do we need a new entry point?
Meletis Rozis, Mathaios Bakalakos, Vasilios D Polyzois, John Vlamis, Spyros Pneumaticos
Keywords: Femoral stem, Entry point, THA, Sagittal balance
Objectives: Femoral stem positioning is of great importance in hip arthroplasty. Straight stem sagittal balance gains recently more attention in the literature. Methods: We performed a both clinical and cadaveric study in order to identify a possible ideal stem entry point at the level of the proximal femur, that ensures an optimal sagittal stem centering. We compared the sagittal tilt of 52 patients with femoral stem implantation in post-operative x-rays, dividing them in two groups depending on posterior neck cortex perforation. Subsequently, femoral neck osteotomy was performed in 40 cadaveric femurs. After placing an average straight stem, measurements of stem axis and femoral neck were made, in order to identify a possible area that could be used as a landmark, through which an optimal sagittal centering could be achieved. Results: Based on our results, stem sagittal tilt differed significantly when posterior neck was spared. In cadaveric evaluation, when posterior neck cortex was not perforated, the tip of stem was in contact with the posterior diaphysis cortex, thus malpositioned in the sagittal plane. We additionally found a statistically significant difference between neck centre and a) stem posterior boarder and b) neck posterior cortex distance. Conclusions: We conclude that placing the femoral stem just posteriorly to the posterior neck cortex, seems to be a good technique in order to achieve optimal sagittal balance of the femoral component.
Mini Review JRPMS, Vol 2, No 2, June 2018, p.46-52
Prevention of orthopaedic infection in spine surgery
Effrosyni Koutsoumpeli, Nikolaos Koutsoumpelis
Keywords: Prevention, Spine surgery, Surgical site infection
Surgical site infection (SSI) in spine surgery is a complication that increases not only the time of patient-recovery and the mortality but also the duration of hospitalization and subsequently the total hospital costs. The objective of this review is to identify the preventable risk factors, to reduce SSI in spine surgery. There are several factors that are associated with an increased risk of postoperative SSI. Some of them are associated with the health status of patient (ASA score >2, diabetes, obesity, smoking, urinary tract infection or incontinence, hypertension), while others with the surgical procedure (hand and instrument antisepsis, revision surgery, invasiveness, CSF leak, dural tear, blood loss, transfusion) and the compliance of the patient. Preoperative patient optimization and perioperative strategies can minimize the risk of SSI. Understanding the pathogenesis is essential to develop prevention strategies and improve surgical outcomes.
Review Article JRPMS, Vol 2, No 2, June 2018, p.53-57
Clinical consequences of pseudotumors in hip arthroplasty
Georgios I. Karagiannis
Keywords: Total hip arthroplasty, Metal-on-metal, Pseudotumor, Hip revision, Metal ions
The occurrence of pseudotumors currently constitutes an important topic of interest among orthopaedic surgeons who prefer metal on metal arthroplasty and especially hip resurfacing arthroplasty. Adverse reactions to metal ions are associated with the formation of such lesions and the orientation of implants has also been implicated in their pathogenesis. The diagnosis of pseudotumors is as difficult as complex. There is a variety of symptoms and patients with mild or tolerable pain may not seek medical attention. Revision surgeries may be the only solution in some cases. The goal of this article is to review the clinical presentation, prognosis of pseudotumors and associated complications, based on evidence published in the literature.
Οriginal Article JRPMS, Vol 2, No 2, June 2018, p.58-61
Incidence and anatomic location of fractures resulting from static line parachuting in the Greek Army Forces: A retrospective study
Filippos Zigras, Spilios Dellis
Keywords: Parachute, Paratrooper, Parachuting fracture, Ankle brace
Objectives: The incidence and patterns of parachuting fractures were investigated in Greek Armed Forces and compared to those of other studies in an attempt to assess the safety of parachuting. Methods: Data of 26.429 military static line parachute (SLP) jumps on 4019 paratroopers were collected by the official archive of the Greek parachuting military school during a 2 year period. Results: The total number of fractures was 55 in 26.429 SLP jumps. The overall rate was 2,1 fractures per 1000 descents. The fracture rate for the recruits, within the 18-30 year old group (5,3 fractures per 1000 jumps) was significantly higher (P<0,0005) than for the officers, the 30-60 year old group (1,1 fractures per 1000 jumps). Ankle fractures were the most common, accounted for 47,3% of the cases. Fracture - dislocation of the shoulder might be the new “paratroopers’s fracture”, which was encountered in 14,5% of the cases. Conclusion: We conclude that our data compares favorably with other studies except for higher rate of ankle fracture. It is recommended that a parachute ankle brace (PAB) should be worn by all paratroopers, especially those with lack of experience.
Case Report JRPMS, Vol 2, No 2, June 2018, p.62-66
Bilateral iliac stress fracture in a young male Military cadet: report of an unusual case
Christos Apergis, Georgios Bekas, Christos Zafeiris, Terpsithea Koureta, Konstantinos Raptis
Keywords: Bilateral fractures, Iliac fractures, Stress fractures, Fractures in military population
Stress fractures are common in highly active people, such as athletes or the military population and occur more frequently in the tibia and especially the tarsal and metatarsal bones. Concomitant bilateral presentation is rare and especially bilateral iliac bone stress fracture has never been reported in the current English literature. We present a case of a young Air Force cadet with acute onset of bilateral hip pain, while participating in the routine military training program. Clinical examination, radiologic evaluation and MRI established the diagnosis of bilateral iliac bone stress fracture. The patient followed conservative treatment with partial weight bearing using crutches and the symptoms disappeared after a 3 month period.
Case Report JRPMS, Vol 2, No 2, June 2018, p.67-71
Acute compartment syndrome of the foot after an ankle sprain: a case report
Christos Christoforidis, Panagiotis Lepetsos, Stamatios Papadakis, Anastasios Gketsos, Theodoros Balfousias, George Macheras
Keywords: Acute compartment syndrome, Ankle sprain,Fasciotomy, Muscle necrosis, Intracompartmental pressure
The aim of this study is to report the case of a patient with an acute foot compartment syndrome after an ankle sprain, discussing the diagnostic challenges and rarity of such an uncommon complication of a very common and low-trauma event. A 19-year old young man presented at the emergency department for a twisting injury of his left ankle. Physical and radiological evaluation revealed a 2nd degree lateral ankle sprain and the patient was treated conservatively. Two days later, the patient returned to the emergency department, late at night, with worsening and excruciating pain of his left foot and inability to walk. Physical evaluation showed severe swelling of the left foot and decreased range of active and passive motion. X-rays and CT scan were negative for fractures. An emergency fasciotomy of the lateral and medial compartment of the foot was performed and necrotic muscle parts were removed. Postoperatively, patient’s symptoms were controlled and a week later he was discharged from the hospital. Twelve months later, the patient is pain-free with full range of motion of his left ankle and foot.
Case Report JRPMS, Vol 2, No 3, September 2018, p.75-80
A new COL1A1 mutation in a Greek patient with osteogenesis imperfecta: Response to a low-dose protocol of zoledronic acid and two-year follow-up
Michail Sarantis, Panagoula Kollia, Stavroula Samara, Helen Athanasopoulou, Yolanda Gyftodimou, Dimitra Lianou, Evdoxia Mpourazani, Artemis Doulgeraki
Keywords: Osteogenesis imperfecta, Collagen, Zoledronic acid, Mutation
Osteogenesis Imperfecta is a severe metabolic bone disorder, mainly caused by mutations of COL1A1 and COL1A2 genes that encode type I procollagen. We report a case of a 7-year-old boy with OI phenotype (recurrent, low-energy fractures, blue sclerae), whose DNA analysis revealed a new mutation of the COL1A1 gene. Herein, his two-year follow-up and his response to current treatment is described (low-dose protocol of zoledronic acid). Also, an insight is given on his metabolic bone profile, unfolding the biochemical response of bone turnover to this bisphosphonate.
Mini Review JRPMS, Vol 2, No 3, September 2018, p.81-84
Pin site infections in pediatric population, microbiology, treatment and long-term functional disability
Sophia A. Syngouna, Pantelis K. Mitsikostas, Emmanouil Fandridis, Ioannis K. Triantafyllopoulos
Keywords: Pediatric, Hand, Upper extremity, Infections, Osteomyelitis
Pin site or pin track infection (PTI) is the most common complication when applying external fixation. In case of failure of proper treatment, PTI will progress to soft tissue infection and osteomyelitis and cause mechanical loosening of the osteosynthesis and instability. Thus pin site infection remains a clinical challenge in deformity corrections, limb lengthening, and pediatric fracture osteosynthesis. This article discusses the pathophysiology, microbiology, and epidemiology of pin site infection in pediatric populations, as well as treatment and long-term functional outcomes.
Review Article JRPMS, Vol 2, No 3, September 2018, p.85-88
Radiofrequency kyphoplasty for the treatment of osteoporotic vertebral fractures: A review of the literature
Stylianos S. Pernientakis, Panagiotis T. Masouros, Christos P. Margiannis, Aristomenis Vasilopoulos
Keywords: RF Kyphoplasty, Radiofrequency kyphoplasty, Osteoportic vertebral fractures, Balloon kyphoplasty
Vertebral fractures are a leading cause of disability among the elderly people. While conservative treatment remains the mainstay of treatment, other techniques such as kyphoplasty are reserved for cases of lasting pain. However, cement extravasation has traditionally been a relatively common complication of all vertebra augmentation procedures. Radiofrequency kyphoplasty (RF-VTA) is a relatively new method, which relies on the targeted creation of minimally destructive paths, thus preserving the microarchitecture of the trabeculae. In addition, it yields comparable or superior outcomes than compatible techniques. The aim of this project is to review all the studies concerning this novel technique and provide the reader with its results and potential adverse effects.
Original Article JRPMS, Vol 2, No 3, September 2018, p.89-94
Meniscal repair using fibrin clot from autologous blood: description of the surgical technique
Chrysanthos Chrysanthou, Nikolaos Laliotis, Nikiforos Galanis, George Paraskevas, Michael Potoupnis, Fares Sayegh, George Kapetanos
Keywords: Meniscus, Meniscus repair, Biological augmentation techniques, Surgical technique, Fibrin clot
The crucial role of the menisci in function and biomechanics of the knee has been increasingly recognized and well described during the past several years. Meniscectomy was a gold standard treatment for a torn meniscus. Reviewing the literature, shows that this procedure is deleterious for the chondral surface. In the last decades, orthopaedic surgeons give a battle to salvaging and repair a torn meniscus, when this is possible. Clinical studies have shown that the introduction of biological augmentation techniques has the potential to enhance meniscus repair especially in young active individuals. Fibrin clot is relative quick to reproduce and easy to use technique which promises encouraging results in repairing the torn meniscus and in the same time is considered one of the most cost effective solutions comparing with others. In this paper our aim is to present the surgical technique of preparation and use of the fibrin clot form autologous blood step-by-step in case series of 24 patients. However, despite the relative ease preparation of fibrin clot from autologous blood, the placement and stabilizing it into the gap of the meniscal rupture arthroscopically is challenging.

Special Issue: Current concepts in ACL reconstruction

Guest Editor: Christos K. Yiannakopoulos

Ass. Professor National & Kapodistrian University of Athens. School of Physical Education & Sport Science. Sports Medicine & Excercise Biology Section

Original Article JRPMS, Vol 2, No 4, December 2018, p.98-112
MRI and arthroscopic findings in acute and chronic ACL injuries. A pictorial essay
Christos K. Yiannakopoulos, Iakovos E. Vlastos, Natali Sideri, Olympia Papakonstantinou
Keywords: ACL, Arthroscopy, Cartilage, Knee, Meniscus, MRI
Objectives: The purpose of this paper is to present the various forms that an ACL injury may acquire on MRI and knee arthroscopy. Methods: The MR imaging studies and arthroscopy files of 192 patients with an acute or chronic ACL injury were reviewed by an independent musculoskeletal radiologist and the imaging finding were confirmed or disapproved during knee arthroscopy. Results: MR imaging findings in regard to ACL tears were confirmed in 186 cases (96,87%), in meniscal injuries in 106/122 (86.88%) cases and in full thickness articular cartilage defect in 33/36 (91.6%) cases. The main source of error was an inadequately performed MRI from a technical point of view. Conclusion: High resolution 3T MRI is very reliable in detecting ACL, meniscus and articular cartilage lesions in acute and chronic injuries. Level of evidence: Level IV, Case series.
Original Article JRPMS, Vol 2, No 4, December 2018, p.113-117
Flat anatomy of ACL and “ribbon like” ACL reconstruction
Lazaros Kostretzis, Kaori Nakamura, Maja Siebold, Christian Fink, Robert Smigielski, Rainer Siebold
Keywords: Ribbon-like ACL reconstruction, Flat ACL anatomy, Anterior cruciate ligament, Flat graft, C-shape
Recent anatomical studies show clear evidence that the anterior cruciate ligament (ACL) has a ribbon like structure from its femoral origin to its tibial attachment. The femoral bony origin of the ACL is half-moon like and the tibial attachment is duck-foot like. On the femoral side the flat midsubstance raise from its origin in a straight line and on the tibial side in a “C”-shaped way. Twisting of the flat ACL from extension to flexion gives the impression of separate bundles. However, no bundles could be found in recent studies. Based on above findings this article introduce a new technique for a flat ACL reconstruction. It was developed to reproduce the native “ribbon like” morphology of the ACL, with a rectangular femoral- and a C-shaped tibial socket.
Original Article JRPMS, Vol 2, No 4, December 2018, p.118-123
Quantitative ultrasound densitometry of the calcaneus in acute and chronic anterior cruciate ligament deficiency
Christos K. Yiannakopoulos, Iakovos Vlastos, Theodoros Zekis, Georgios Theotokatos, Elissavet Rousanoglou
Keywords: Anterior Cruciate Ligament Deficiency, Bone Mineral Density, BUA, Calcaneus, SOS, Quantitative Ultrasound
Purpose: To evaluate the effect of acute and chronic knee instability secondary to anterior cruciate ligament (ACL) deficiency on the ultrasound-measured density and bone quality of the calcaneus, implementing quantitative ultrasound densitometry. Methods: Bilateral measurements of the speed of sound (SOS) and broadband ultrasound attenuation (BUA) of the calcaneus were performed on a cohort of 97 male patients with acute (n=38) or chronic (n=57) unilateral ACL deficiency. Results: In the acute ACL tear group, BUA was 56.181±3.731 dB/ MHz on the affected extremity calcaneus and 57.030±6.564 dB/MHz on the uninjured side, whilst the SOS was 1577.265±14.04 m/sec and 1584.675±11.484 m/sec respectively. The difference between the two sides was not significant. In the chronic ACL deficiency group, however, there was significant difference between both calcanei for both BUA (p<0.01) and SOS (p<0.001). BUA was 47.307±3.786 dB/MHz on the affected extremity calcaneus and 59.011±3.64 dB/MHz on the uninjured extremity calcaneus, whilst the SOS was 1457.873±9.467 m/sec and 1579.413±8.404 m/sec respectively. Conclusion: Chronic ACL deficiency adversely affects the structural properties and the bone quality of the calcaneus. Level of evidence: Level II, prospective comparative study.
Review Article JRPMS, Vol 2, No 4, December 2018, p.124-130
Fear of re-injury following ACL reconstruction: an overview
Stavros D. Papadopoulos, Maksim Tishukov, Konstantinos Stamou, Trifon Totlis, Konstantinos Natsis
Keywords: ACL reconstruction, Kinesiophobia, Sports injuries, Rehabilitation, Return to sports
Patients undergo ACL reconstruction not only to avoid subsequent meniscal or chondral injuries and early osteoarthritis, but especially to return to the pre-injury level of activity. Yet, this level of activity is achieved in only 40 to 70% of the cases. This inability to return to the pre-injury level of activity, even when functional tests allow medical clearance to continue sports, is mainly attributed to fear of re-injury or kinesiophobia. This fear affects the athlete’s physical abilities, function and return to sports. Thus, it should be considered as a real risk factor undermining the patients’ knee movement and should be one of the core targets for the rehabilitation programme. Healthcare professionals have to assess the athletes that present with fear of re-injury and implement into their rehabilitation programme the appropriate adjunctive interventions, such as the “graded exposure”.
Original Article JRPMS, Vol 2, No 4, December 2018, p.131-135
Posterior semitendinosus tendon harvesting minimizes the risk of injury to the infrapatellar and sartorial branches of the saphenous nerve
Panagiotis Kouloumentas, Efstratios Kavroudakis, Ioannis Tsekouras, Efstathios Charalampidis, Georgios Triantafyllopoulos, Dimitris Kavroudakis
Keywords: Saphenous nerve, Short grafts, All-inside, ACL reconstruction, Posterior ST harvest
There are several reports of iatrogenic injury to the saphenous nerve branches during anterior cruciate ligament (ACL) reconstruction attributed to tendon harvesting through an anterior approach. Other investigators advocate that there is virtually no nerve damage when the tendons are harvested through a posteromedial knee incision. The aim of the present study was to compare the incidence of iatrogenic injury to the infrapatellar and sartorial branches of the saphenous nerve with anterior and posterior tendon harvesting. A prospective, randomized clinical study was conducted comparing patients treated with ACL reconstruction employing the conventional technique with a semitendinosus/gracilis autograft versus the all-inside technique with a short, quadrupled semitendinosus autograft. Tendon harvesting for these two groups was performed through the anterior and the posterior approach, respectively. Skin sensation of the anterior aspect of the operated knee and tibia was assessed by the pin prick test and was compared to the contralateral side. No sensory alterations were noted on the anteromedial aspect of the operated knee and tibia in patients of the posterior harvest group.
Original Article JRPMS, Vol 2, No 4, December 2018, p.136-143
Atlas of complications in anterior Cruciate Ligament Reconstruction
Stergios G. Papastergiou, Nikolaos E. Koukoulias, Theophilos D. Dimitriadis, Efstathios I. Kalivas, Athanasios V. Papavasileiou, Evangelos C. Ziogas
Keywords: Anterior cruciate ligament, Complications, Reconstruction, Intraoperative, Postoperative
Objectives: The aim of this study was to investigate the incidence of anterior cruciate ligament reconstruction complications. Methods: One thousand nine hundred and seventy two (1972) anterior cruciate ligament reconstructions, performed in a single Orthopaedic Department the last 27 years, were studied and followed for up to two years postoperatively. In 1244 cases (one thousand two hundred and forty four) hamstrings autograft was used for the reconstruction and in the rest 728 (seven hundred and twenty eight) cases bone patella tendon bone autograft was used for the reconstruction. Results: In total, 467, 23.68% complications were found in our patient population. 431, 21,85% complications occurred intraoperatively and 36, 1,82% complications occurred postoperatively. Conclusions: The variety and frequency of complications in anterior cruciate ligament reconstruction underline the importance of accurate surgical technique and close postoperative follow-up.