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As the field of interventional pain management (IPM) grows, the risk of surgical site infections (SSIs) is increasing. SSI is defined as an infection of the incision or organ/space that occurs within one month after operation or three months after implantation. It is also common to find patients with suspected infection in an outpatient clinic. The most frequent IPM procedures are performed in the spine. Even though primary pyogenic spondylodiscitis via hematogenous spread is the most common type among spinal infections, secondary spinal infections from direct inoculation should be monitored after IPM procedures. Various preventive guidelines for SSI have been published. Cefazolin, followed by vancomycin, is the most commonly used surgical antibiotic prophylaxis in IPM. Diagnosis of SSI is confirmed by purulent discharge, isolation of causative organisms, pain/tenderness, swelling, redness, or heat, or diagnosis by a surgeon or attending physician. Inflammatory markers include traditional (C-reactive protein, erythrocyte sedimentation rate, and white blood cell count) and novel (procalcitonin, serum amyloid A, and presepsin) markers. Empirical antibiotic therapy is defined as the initial administration of antibiotics within at least 24 hours prior to the results of blood culture and antibiotic susceptibility testing. Definitive antibiotic therapy is initiated based on the above culture and testing. Combination antibiotic therapy for multidrug-resistant Gramnegative bacteria infections appears to be superior to monotherapy in mortality with the risk of increasing antibiotic resistance rates. The never-ending war between bacterial resistance and new antibiotics is continuing. This article reviews prevention, diagnosis, and treatment of infection in pain medicine.
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Andersen-Tawil syndrome (ATS) is a rare genetic disease characterized by a triad of episodic flaccid muscle weakness, ventricular arrhythmias, and physical anomalies. ATS patients have various cardiac arrhythmias that can cause sudden death. Implantation of an implantable cardioverter-defibrillator (ICD) is required when life-threatening cardiac arrhythmias do not respond to medical treatment. An 11-year-old girl underwent surgery for an ICD implantation. For general anesthesia in ATS patients, anesthesiologists should focus on the potentially difficult airway, serious cardiac arrhythmias, such as ventricular tachycardia (VT), and delayed recovery from neuromuscular blockade. We followed the difficult airway algorithm, avoided drugs that can precipitate QT prolongation and fatal cardiac arrhythmias, and tried to maintain normoxia, normocarbia, normothermia, normoglycemia, and pain control for prevention of sympathetic stimulation. We report the successful application of general anesthesia for ICD implantation in a pediatric patient with ATS and recurrent VT.
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Purpose@#This study was conducted to examine the results of designing and implementing a teaching program for medical education as the elective course for 4th-year students of medical course. @*Methods@#In order to design the teaching program for medical education as an elective course, we conducted literature review, five medical education experts were interviewed, and the literature required in the design process was reviewed. A developing teaching program was implemented as an elective course in a medical school of Korea, and 4th-year students of medical course participated in the program. @*Results@#In the elective course, the medical education program process competencies were derived into three categories: theoretical educational knowledge, teaching competency, and research competency for education. Moreover, instructional materials were developed to help students achieve these competencies. And project-based learning strategy was selected and implemented for 4th-year students in medical course, and positive satisfaction was confirmed. @*Conclusion@#As a study designed and implemented in a medical education program in a medical school in Korea, it is expected to be helpful when introducing medical education to undergraduate students or developing a medical education program to strengthen the teaching capacity of residents.
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Background and Objectives@#Epidemiological investigations have shown positive correlations between increased diesel exhaust particles (DEP) in ambient air and adverse health outcomes. DEP are the major constituent of particulate atmospheric pollution and have been shown to induce proinflammatory responses both in the lung and systemically. Here, we report the effects of DEP exposure on the properties of human Wharton’s jelly-derived mesenchymal stem cells (WJ-MSCs), including stemness, regeneration, and immunomodulation. @*Methods@#and Results: Non-apoptotic concentrations of DEP (10 μg/ml) inhibited the migration and osteogenic differentiation capacity of WJ-MSCs. Gene expression profiling showed that DEP increased intracellular reactive oxygen species (ROS) and expression of pro-inflammatory and metabolic-process-related genes including cFos. Furthermore, WJ-MSCs cultured with DEP showed impaired suppression of T cell proliferation that was reversed by inhibition of ROS or knockdown of cFos. ERK inhibition assay revealed that DEP-induced ROS regulated cFos through activation of ERK but not NF-κB signaling. Overall, low concentrations of DEP (10 μg/ml) significantly suppressed the stemness and immunomodulatory properties of WJ-MSCs through ROS/ERK/cFos signaling pathways. Furthermore, WJ-MSCs cultured with DEP impaired the therapeutic effect of WJ-MSCs in experimental colitis mice, but was partly reversed by inhibition of ROS. @*Conclusions@#Taken together, these results indicate that exposure to DEP enhances the expression of pro-inflammatory cytokines and immune responses through a mechanism involving the ROS/ERK/cFos pathway in WJ-MSCs, and that DEP-induced ROS damage impairs the therapeutic effect of WJ-MSCs in colitis. Our results suggest that modulation of ROS/ERK/cFos signaling pathways in WJ-MSCs might be a novel therapeutic strategy for DEP-induced diseases.
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Background@#Hypoxia causes oxidative stress and affects cardiovascular function and the programming of cardiovascular disease. Melatonin promotes antioxidant enzymes such as superoxide dismutase, glutathione reductase, glutathione peroxidase, and catalase. @*Objectives@#This study aims to investigate the correlation between melatonin and hypoxia induction in cardiomyocytes differentiation. @*Methods@#Mouse embryonic stem cells (mESCs) were induced to myocardial differentiation.To demonstrate the influence of melatonin under hypoxia, mESC was pretreated with melatonin and then cultured in hypoxic condition. The cardiac beating ratio of the mESCderived cardiomyocytes, mRNA and protein expression levels were investigated. @*Results@#Under hypoxic condition, the mRNA expression of cardiac-lineage markers (Brachyury, Tbx20, and cTn1) and melatonin receptor (Mtnr1a) was reduced. The mRNA expression of cTn1 and the beating ratio of mESCs increased when melatonin was treated simultaneously with hypoxia, compared to when only exposed to hypoxia. Hypoxia-inducible factor (HIF)-1α protein decreased with melatonin treatment under hypoxia, and Mtnr1a mRNA expression increased. When the cells were exposed to hypoxia with melatonin treatment, the protein expressions of phospho-extracellular signal-related kinase (p-ERK) and Bcl-2-associated X proteins (Bax) decreased, however, the levels of phospho-protein kinase B (p-Akt), phosphatidylinositol 3-kinase (PI3K), B-cell lymphoma 2 (Bcl-2) proteins, and antioxidant enzymes including Cu/Zn-SOD, Mn-SOD, and catalase were increased.Competitive melatonin receptor antagonist luzindole blocked the melatonin-induced effects. @*Conclusions@#This study demonstrates that hypoxia inhibits cardiomyocytes differentiation and melatonin partially mitigates the adverse effect of hypoxia in myocardial differentiation by regulating apoptosis and oxidative stress through the p-AKT and PI3K pathway.
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While there is a high prevalence of patent foramen ovale in adults, paradoxical embolism via a patent foramen ovale is rare. Previous echocardiographic studies indicated that paradoxical embolism might only occur in patients with high-risk features of patent foramen ovale (i.e., large defect size, presence of a Eustachian valve, and high right atrial pressure). Here, we present a case of patent foramen ovale with high-risk CT features for paradoxical embolism.
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Background@#This study aimed to assess the clinical characteristics of patients with major depressive disorder who were rehospitalized within 1 year and to determine whether the 1-year rehospitalization rate varied depending on the type of medication and treatment method. @*Methods@#Clinical characteristics of 531 patients hospitalized for major depressive disorder were assessed. The use and type of antidepressants, antipsychotics, mood stabilizers, and hypnotics were also evaluated. @*Results@#Of the 531 subjects, 68 (12.8%) were rehospitalized within a year. The number of past depressive episodes (1.56±2.67 vs. 0.90±1.18) (p=0.048) and the number of previous psychiatric hospitalizations (0.82±1.93 vs. 0.29±0.83 times) (p=0.029) were high in the 1-year rehospitalization group. The rate of family history of mood disorder (25.0% vs. 13.6%) (p=0.014) and the rate of comorbid personality disorder (16.2% vs. 8.6%) (p=0.049) were also high in the 1-year rehospitalization group. Multiple logistic regression analysis showed that the number of previous psychiatric hospitalizations affected the rate of 1-year rehospitalization (p=0.003). @*Conclusion@#The number of previous psychiatric hospitalizations could be used to predict rehospitalizations of patients with major depressive disorder within 1 year. In addition, family history of mood disorders and comorbidity of personality disorders may affect rehospitalization of such patients.
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Objective@#The optimum chest compression point during cardiopulmonary resuscitation (CPR) associated with a good neurological outcome is unestablished. We aimed to suggest the association between the point and a simple index measured on anteroposterior chest radiography (chest_AP). @*Methods@#This retrospective, cross-sectional study included all adults with available chest_AP who arrived at a university hospital from January 2014 to June 2019 for non-traumatic out-of-hospital cardiac arrest (OHCA). Distances from the vertical midsternum to the farthest right and left cardiac borders were defined as RB and LB, respectively. Their sum provided cardiac diameter (CD). Assuming the universality of cardiac anatomy, the cardiac structure immediately beneath the midsternum was compressed most forcefully during CPR. The influencing outcome of CPR was determined using the RB:CD ratio. We investigated the association of RB:CD ratio with a good neurological outcome at discharge using multiple logistic regression analysis, adjusting for the core Utstein elements and comorbidities. @*Results@#Among 429 patients (63.2±14.5 years; 121 [28.2%] female), return of spontaneous circulation, survival-to-discharge and good neurological outcome at discharge were achieved in 259 (60.4%), 121 (28.2%) and 84 (19.6%) cases, respectively. The RB:CD ratio (0.279±0.072) was divided into semi-tertiles to enhance clinical usage: 0.30 (n=161). The second group was associated with good neurological outcome (odds ratio, 6.00 [95% confidence interval, 1.58-22.8], P=0.010). @*Conclusion@#An RB:CD ratio of 0.25-0.30 measured on chest_AP is associated with good neurological outcomes in OHCA victims receiving CPR.
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Background@#Hypoxia causes oxidative stress and affects cardiovascular function and the programming of cardiovascular disease. Melatonin promotes antioxidant enzymes such as superoxide dismutase, glutathione reductase, glutathione peroxidase, and catalase. @*Objectives@#This study aims to investigate the correlation between melatonin and hypoxia induction in cardiomyocytes differentiation. @*Methods@#Mouse embryonic stem cells (mESCs) were induced to myocardial differentiation.To demonstrate the influence of melatonin under hypoxia, mESC was pretreated with melatonin and then cultured in hypoxic condition. The cardiac beating ratio of the mESCderived cardiomyocytes, mRNA and protein expression levels were investigated. @*Results@#Under hypoxic condition, the mRNA expression of cardiac-lineage markers (Brachyury, Tbx20, and cTn1) and melatonin receptor (Mtnr1a) was reduced. The mRNA expression of cTn1 and the beating ratio of mESCs increased when melatonin was treated simultaneously with hypoxia, compared to when only exposed to hypoxia. Hypoxia-inducible factor (HIF)-1α protein decreased with melatonin treatment under hypoxia, and Mtnr1a mRNA expression increased. When the cells were exposed to hypoxia with melatonin treatment, the protein expressions of phospho-extracellular signal-related kinase (p-ERK) and Bcl-2-associated X proteins (Bax) decreased, however, the levels of phospho-protein kinase B (p-Akt), phosphatidylinositol 3-kinase (PI3K), B-cell lymphoma 2 (Bcl-2) proteins, and antioxidant enzymes including Cu/Zn-SOD, Mn-SOD, and catalase were increased.Competitive melatonin receptor antagonist luzindole blocked the melatonin-induced effects. @*Conclusions@#This study demonstrates that hypoxia inhibits cardiomyocytes differentiation and melatonin partially mitigates the adverse effect of hypoxia in myocardial differentiation by regulating apoptosis and oxidative stress through the p-AKT and PI3K pathway.
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While there is a high prevalence of patent foramen ovale in adults, paradoxical embolism via a patent foramen ovale is rare. Previous echocardiographic studies indicated that paradoxical embolism might only occur in patients with high-risk features of patent foramen ovale (i.e., large defect size, presence of a Eustachian valve, and high right atrial pressure). Here, we present a case of patent foramen ovale with high-risk CT features for paradoxical embolism.
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No abstract available.
Subject(s)
Diagnosis , Ductus Arteriosus, Patent , Endarteritis , Pulmonary EmbolismABSTRACT
In approximately 10% of patients with acute myocardial infarction (MI), angiography does not reveal an obstructive coronary stenosis. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA), which has complex and multifactorial causes. However, this term can be confusing and open to dual interpretation, because MINOCA is also used to describe patients with acute myocardial injury caused by ischemia-related myocardial necrosis. Therefore, with regards to this specific context of MINOCA, the generic term for MINOCA should be replaced with troponin-positive with non-obstructive coronary arteries (TpNOCA). The causes of TpNOCA can be subcategorized into epicardial coronary (causes of MINOCA), myocardial, and extracardiac disorders. Cardiac magnetic resonance imaging can confirm MI and differentiate various myocardial causes, while cardiac computed tomography is useful to diagnose the extracardiac causes.
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In approximately 10% of patients with acute myocardial infarction (MI), angiography does not reveal an obstructive coronary stenosis. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA), which has complex and multifactorial causes. However, this term can be confusing and open to dual interpretation, because MINOCA is also used to describe patients with acute myocardial injury caused by ischemia-related myocardial necrosis. Therefore, with regards to this specific context of MINOCA, the generic term for MINOCA should be replaced with troponin-positive with non-obstructive coronary arteries (TpNOCA). The causes of TpNOCA can be subcategorized into epicardial coronary (causes of MINOCA), myocardial, and extracardiac disorders. Cardiac magnetic resonance imaging can confirm MI and differentiate various myocardial causes, while cardiac computed tomography is useful to diagnose the extracardiac causes.
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We performed a point seroprevalence survey of measles among healthcare workers (HCWs) at two Korean teaching hospitals in 2019. A total of 2,830 HCWs underwent an antibody test.The overall seropositivity of measles was 93.1%. The seroprevalence of measles was lowest in HCWs aged 20 - 24 years (81.2%), followed by those aged 25 - 29 years (90.1%). The rates of anti-measles IgG positivity were significantly different between the two hospitals (97.0% vs.89.4%, P <0.001). These results suggest that the seropositivity of measles in HCWs may differ depending on the hospital's vaccination policy.
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Objective@#To assess the incremental prognostic value of coronary computed tomography angiography (CCTA) in comparison toa clinical risk model (Framingham risk score, FRS) and coronary artery calcium score (CACS) for future cardiac events in ischemicstroke patients without chest pain. @*Materials and Methods@#This retrospective study included 1418 patients with acute stroke who had no previous cardiac diseaseand underwent CCTA, including CACS. Stenosis degree and plaque types (high-risk, non-calcified, mixed, or calcified plaques) wereassessed as CCTA variables. High-risk plaque was defined when at least two of the following characteristics were observed:low-density plaque, positive remodeling, spotty calcification, or napkin-ring sign. We compared the incremental prognosticvalue of CCTA for major adverse cardiovascular events (MACE) over CACS and FRS. @*Results@#The prevalence of any plaque and obstructive coronary artery disease (CAD) (stenosis ≥ 50%) were 70.7% and 30.2%,respectively. During the median follow-up period of 48 months, 108 patients (7.6%) experienced MACE. Increasing FRS, CACS,and stenosis degree were positively associated with MACE (all p 0.05). @*Conclusion@#Assessment of stenosis degree and plaque type using CCTA provided additional prognostic value over CACS andFRS to risk stratify stroke patients without prior history of CAD better.
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PURPOSE: This study evaluated differences in bone healing and remodeling among 3 implants with different surfaces: sandblasting and large-grit acid etching (SLA; IS-III Active®), SLA with hydroxyapatite nanocoating (IS-III Bioactive®), and SLA stored in sodium chloride solution (SLActive®). METHODS: The mandibular second, third, and fourth premolars of 9 dogs were extracted. After 4 weeks, 9 dogs with edentulous alveolar ridges underwent surgical placement of 3 implants bilaterally and were allowed to heal for 2, 4, or 12 weeks. Histologic and histomorphometric analyses were performed on 54 stained slides based on the following parameters: vertical marginal bone loss at the buccal and lingual aspects of the implant (b-MBL and l-MBL, respectively), mineralized bone-to-implant contact (mBIC), osteoid-to-implant contact (OIC), total bone-to-implant contact (tBIC), mineralized bone area fraction occupied (mBAFO), osteoid area fraction occupied (OAFO), and total bone area fraction occupied (tBAFO) in the threads of the region of interest. Two-way analysis of variance (3 types of implant surface×3 healing time periods) and additional analyses for simple effects were performed. RESULTS: Statistically significant differences were observed across the implant surfaces for OIC, mBIC, tBIC, OAFO, and tBAFO. Statistically significant differences were observed over time for l-MBL, mBIC, tBIC, mBAFO, and tBAFO. In addition, an interaction effect between the implant surface and the healing time period was observed for mBIC, tBIC, and mBAFO. CONCLUSIONS: Our results suggest that implant surface wettability facilitates bone healing dynamics, which could be attributed to the improvement of early osseointegration. In addition, osteoblasts might become more activated with the use of HA-coated surface implants than with hydrophobic surface implants in the remodeling phase.
Subject(s)
Animals , Dogs , Bicuspid , Bone Remodeling , Bone-Implant Interface , Durapatite , Miners , Osseointegration , Osteoblasts , Sodium Chloride , WettabilityABSTRACT
PURPOSE: The purpose of this study was to investigate the radiologic and serologic factors related to postoperative union using intramedullary (IM) internal fixation in atypical femoral fractures (AFF), which are closely related to bisphosphonates (BPs) for osteoporosis. MATERIALS AND METHODS: From February 2008 to December 2016, 65 patients (71 cases) who had undergone IM nail fixation after diagnosis of AFF were enrolled in this study. Patients were divided into group A, who experienced union within 6 months and group B, who did not experience union within 6 months. They were evaluated for duration of BPs use, radiologic factors and serological factors. RESULTS: The mean duration of BPs use was 6.17 years in group A and 8.24 years in group B (p=0.039). In the subtrochanteric area, there were 14 cases (27.5%) in group A and 14 cases (70.0%) in group B. In the femoral shaft, there were 37 cases (72.5%) in group A and 6 cases (30.0%) in group B (p=0.001). On the preoperative, the flexion in the coronal plane was 5.9° (2.1°–9.2°) in group A and 8.0° (3.1°–12.1°) in group B (p=0.041). On the postoperative, conversion to valgus was 15 cases (29.4%), 8 cases (40.0%); conversion to neutral was 34 cases (66.7%) and 8 cases (40.0%); conversion to varus was 2 cases (3.9%) and 4 cases (20.0%), each (p=0.037). The fracture site gap was 1.5 mm (0–2.9 mm) on the front side and 1.2 mm (0–2.2 mm) on lateral side and 2.2 mm (0.9–4.7 mm) and 1.9 mm (0.5–3.5 mm), each (p=0.042, p=0.049). Among serological factors, there was no significant difference between the two groups. CONCLUSION: Factors adversely affecting the union should be recognized before surgery, such as longterm BPs use or a severe degree of bending of the femur in the coronal plane. During surgery, proper reduction and spacing of the fracture site on the coronal plane should allow adequate reduction of the anterior and posterior surfaces. Obtaining anatomic reduction would be most beneficial for union, but if that is not possible, obtaining congenital valgus rather than varus on the coronal plane may be helpful for union.
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Humans , Diagnosis , Diphosphonates , Femoral Fractures , Femur , OsteoporosisABSTRACT
BACKGROUND: It is uncommon for patients who have received a permanent implant to remove the spinal cord stimulator (SCS) after discontinuation of medication in complex regional pain syndrome (CRPS) due to their completely painless state. This study evaluated CRPS patients who successfully removed their SCSs. METHODS: This 10-year retrospective study was performed on patients who had received the permanent implantation of an SCS and had removed it 6 months after discontinuation of stimulation, while halting all medications for neuropathic pain. Age, sex, duration of implantation, site and type of CRPS, and their return to work were compared between the removal and non-removal groups. RESULTS: Five (12.5%, M/F = 4/1) of 40 patients (M/F = 33/7) successfully removed the permanent implant. The mean age was younger in the removal group (27.2 ± 6.4 vs. 43.5 ± 10.7 years, P < 0.01). The mean duration of implantation in the removal group was 34.4 ± 18.2 months. Two of 15 patients (13.3%) and 3 of 25 patients (12%) who had upper and lower extremity pain, respectively, had removed the implant. The implants could be removed in 5 of 27 patients (18.5%) with CRPS type 1 (P < 0.01). All 5 patients (100%) who removed their SCS returned to work, while only 5 of 35 (14.3%) in the non-removal group did (P < 0.01). CONCLUSIONS: Even though this study had limited data, younger patients with CRPS type 1 could remove their SCSs within a 5-year period and return to work with complete pain relief.
Subject(s)
Humans , Age Factors , Device Removal , Extremities , Lower Extremity , Neuralgia , Retrospective Studies , Return to Work , Spinal Cord Stimulation , Spinal CordABSTRACT
PURPOSE: To determine whether the swelling and mechanical properties of osmotic self-inflating expanders allow or not the induction of intraoral soft tissue expansion in dogs. METHODS: Three different volumes (0.15, 0.25, and 0.42 mL; referred to respectively as the S, M, and L groups) of soft tissue expanders (STEs) consisting of a hydrogel core coated with a silicone-perforated membrane were investigated in vitro to assess their swelling behavior (volume swelling ratio) and mechanical properties (tensile strength, tensile strain). For in vivo investigations, the STEs were subperiosteally inserted for 4 weeks in dogs (n=5). Soft tissue expansion was clinically monitored. Histological analyses included the examination of alveolar bone underneath the expanders and thickness measurements of the surrounding fibrous capsule. RESULTS: The volume swelling ratio of all STEs did not exceed 5.2. In tensile mode, the highest mean strain was registered for the L group (98.03±0.3 g/cm), whereas the lowest mean value was obtained in the S group (81.3±0.1 g/cm), which was a statistically significant difference (P < 0.05). In addition, the S and L groups were significantly different in terms of tensile strength (1.5±0.1 g/cm for the S group and 2.2±0.1 g/cm for the L group, P < 0.05). Clinical monitoring showed successful dilatation of the soft tissues without signs of inflammation up to 28 days. The STEs remained volumetrically stable, with a mean diameter in vivo of 6.98 mm, close to the in vitro post-expansion findings (6.69 mm). Significant histological effects included highly vascularized collagen-rich fibrous encapsulation of the STEs, with a mean thickness of 0.67±0.12 mm. The bone reaction consisted of resorption underneath the STEs, while apposition was observed at their edges. CONCLUSIONS: The swelling and mechanical properties of the STEs enabled clinically successful soft tissue expansion. A tissue reaction consisting of fibrous capsule formation and bone loss were the main histological events.
Subject(s)
Animals , Dogs , Alveolar Ridge Augmentation , Dilatation , Hydrogels , In Vitro Techniques , Inflammation , Membranes , Tensile Strength , Tissue Expansion , Tissue Expansion DevicesABSTRACT
BACKGROUND: In elbow fracture-dislocation, partial excision of the comminuted radial head fracture that is not amenable to fixation remains controversial considering the accompanying symptoms. This study was undertaken to evaluate the results of radial head partial excision when the comminuted radial head fracture involved < 50% of the articular surface in all-arthroscopic repair of elbow fracture-dislocation. METHODS: Patients were divided into two groups based on the condition of the radial head fracture. In Group A, the patients had a radial head comminuted fracture involving < 50% of the articular surface, and underwent arthroscopic partial excision. Group B was the non-excision group comprising patients with stable and non-displacement fractures. Follow-up consultations were conducted at 6 weeks and at 3, 6, 12, and 24 months after surgery. RESULTS: In all, 19 patients (Group A: 11; Group B: 8) met the inclusion criteria and were enrolled in the study. At the final follow-up, all 19 patients showed complete resolution of elbow instability. No significant differences were observed in the range of motion, visual analogue scale score, and Mayo elbow performance score between groups. Radiological findings did not show any complications of the radiocapitellar joint. However, nonunion of the coracoid fracture was observed in 3 patients (Group A: 1; Group B: 2), without any accompanying instability and clinical symptoms. CONCLUSIONS: Considering that the final outcome is coronoid fracture fixation and lateral collateral ligament complex repair for restoring elbow stability, arthroscopic partial excision for radial head comminuted fractures involving < 50% of articular surface is an effective and acceptable treatment for elbow fracture-dislocation.