Seudoartrosis del escafoides: experiencia con injerto óseo vascularizado del primer metacarpiano. Serie de casos / Scaphoid pseudoarthrosis: experience with vascularized bone graft of the first metacarpal. Case series

Introducción describir los resultados clínicos, funcionales y radiológicos de pacientes con seudoartrosis de fractura del escafoides, sometidos a cirugía con la técnica de Bertelli. en un centro de cuarto nivel de complejidad. Materiales & Métodos Serie de casos en un centro de cuarto nivel de complejidad entre el 2005 y 2016 de pacientes con fractura de escafoides en seudoartrosis sometidos a cirugía de revisión con injerto vascularizado de la primera arteria dorsal metacarpiana según la técnica de Bertelli. Se tomaron datos de historias clínicas, que se analizaron con medidas descriptivas de resumen. Resultados se analizaron 11 pacientes con una edad promedio de 30,1 años. El 72,7% fue llevado a osteosíntesis como manejo inicial. El procedimiento de revisión se realizó en una mediana de 380 días. Se reportaron complicaciones pos-quirúrgicas: necrosis del injerto en un paciente, necesidad de re-intervención en cuatro y no hubo infecciones. En el 72,7% se observó consolidación de la fractura y ocurrió en promedio a los 7,6 meses. La mitad de los pacientes tuvieron un puntaje DASH de 9 o menos y reportaron percepción de dolor leve - moderado el 90,9%. La mediana de seguimiento fue 14 meses. Discusión la ventaja de esta técnica es su reproducibilidad y versatilidad, pues su pedículo vascular constante y de buena longitud, permite utilizarse por un abordaje dorsal o palmar y para no consolidaciones del polo proximal, cintura o polo distal del escafoides. Este estudio mostró buenos resultados clínicos y funcionales, asociados a una baja tasa de complicaciones. Nivel de evidencia IV

Background The aim of study is to describe the clinical, functional, and radiological results in patients with pseudoarthrosis of scaphoid fractures who that underwent surgery using Bertelli's et al. technique. Methods Case series of patients with nonunion of scaphoid fractures in a high complexity care center between 2005 and 2016, who underwent revision surgery with vascularized bone graft of the first metacarpal dorsal artery according to Bertelli's et al. technique. Data were collected from clinical records, and it waswere analyzed using descriptive summary measures. Results The analysis included 11 patients with a mean age of 30,1 years (S.D: 9). 72,7% of the patients underwent conventional osteosynthesis as the initial approach. The revision surgery was performed with a median of 380 days (interquartile range: 194-470); there were no intraoperative complications. Post- surgery complications, such as graft necrosis, were reported in a one patient (9,1%), the need of for re-intervention in four patients and there were no infection related complications. Fracture union was seen in 72,7% patients in a mean of 7,6 months (S.D: 2,9) after the intervention. Half of the patient had a DASH score of 9 points or less. 54,5 reported pain as mild, 36,4% as moderate and without pain 9,1%. The median follow up period was 14 months and only one patient developed carpal arthritis. Discussion The advantage of this surgical technique is its reproducibility and versatility, thanks due to the constant and long vascular pedicle; this allows using dorsal or palmar approaches, as well as for the management of scaphoid nonunions of the proximal pole, waist, or distal pole. This study shows good clinical and functional results outcomes with a low rate of complications. Evidence Level IV

Advantages and disadvantages of repairing large-segment bone defect / 中国组织工程研究

BACKGROUND: The treatment of large-segment bone defect has always been a major problem in clinical orthopedics. The treatment of large-segment bone defect is characterized by long treatment time, high difficulty and high cost. Therefore, it is of great clinical value and significance to study the treatment of large-segment bone defect. OBJECTIVE: To review the current methods of repairing large-segment bone defect and their advantages and disadvantages. METHODS: PubMed, CNKI and Wanfang databases before April 2020 were retrieved by the first author with the keywords of “bone defect, bone repair, bone graft, intramedullary nail technology, Masquelet, bone transport, vascularized bone graft, bone tissue engineering” in English and Chinese, respectively. Forty eligible articles were included to systematically summarize the repair methods and their advantages and disadvantages in the treatment of large-segment bone defect. RESULTS AND CONCLUSION: (1) Currently, the scope of large bone defects is not clearly defined. In clinical practice, long bone defects with poor healing ability and difficult healing by traditional fixation and autogenous bone graft can be regarded as large-segment bone defect according to experience. (2) There are many repair methods, and different methods can play their unique advantages in the treatment process. However, the disadvantages and related complications of different methods should be paid attention to when choosing the treatment method, so as to improve the bone healing rate. (3) It is still necessary to improve and standardize the existing treatment technology of large-segment bone defect to obtain a more satisfactory treatment effect.

Management of Large Mandibular Ameloblastoma Crossing Midline: Reconstructed by Bilateral Iliac Crest Graft: A Rare Entity.

Ameloblastoma is a true neoplasm of odontogenic epithelial origin. It is the second most common odontogenic neoplasm. It’s incidence approximately 1% of all oral tumors and 18% of all odontogenic tumors. More than 80% of cases of ameloblastoma occur in mandible. The ameloblastoma occurs in three variants solid or multicystic, unicystic, and peripheral. A painless expansion of the jaws is the most common clinical presentation. The correct diagnosis can be easily made with the help of plain X-rays and tissue biopsy. The standard management of ameloblastoma is marginal resection but sometimes a large tumor requires complete resection of affected part. Untreated tumors may lead to tremendous facial disfigurement, a severe malocclusion and pathological fractures of the jaw. Here we present a case of a young man with the chief complaint of facial asymmetry. The orthopantomogram of the patient was showing a multilocular radiolucency with Buccal and lingual cortical expansion. A diagnosis was made on the basis of the biopsy as multicystic ameloblastoma, and resection of the mandible was carried out. The mandibular primary reconstruction was done with avascular bilateral iliac crest bone graft. Long term prognosis showed satisfactory healing and good facial esthetics.

Modified free vascularized fibular grafting for the osteonecrosis of the femoral head / 中华显微外科杂志

Objective To evaluate the short term results of repairing osteonecrosis of the femoral head by modified free vascularized fibular grafting through Smith-Peterson approach without cutting the rectus femoris.Methods Between January,2009 and September,2012,14 osteonecrotic hips of 14 patients who underwent free vascularized fibular grafting were retrospectively studied including 10 male and 4 female.The follow up period was 24 months.The preoperative and postoperative symptoms relief,recovery of hip function (Harris score),radiographic assessment (X-ray).Results All patients got postoperative ipsilateral hip pain relief.Average Harris hip score improved significantly (68.47 ± 5.33,86.80 ± 4.72 points in preoperation and postoperation,respectively; paired t test,t =18.724,P ＜ 0.01).Postoperative X-ray results showed there were no progresses of osteonecrosis and no collapse in the operative side within 2 years follow-up.Conclusion The short term treatment results of femoral head avascular necrosis were satisfactory by using free vascularized fibular graft through Smith-Peterson approach without cutting off the rectus femoris and it may be a relatively practical option of surgical approach.

Scaphoid Nonunions Treated with 1, 2-Intercompartment Supraretinacular Artery Pedicled Vascularized Bone Graft and Headless Compression Screw Fixation

PURPOSE: The purpose of this study was to evaluate the clinical results of scaphoid nonunions treated with 1, 2-intercompartment supraretinacular artery (ICSRA) pedicled vascularized bone grafting (VBG) and headless compression screw fixation. METHODS: Since August 1, 2005, 11 scaphoid nonunions with avascular necrosis or bone marrow edema of proximal fragments were managed with 1, 2-ICSRA pedicled VBG combined with headless compression screw fixation. The mean age was 37.1 years (range, 21-66 years). 8 patients had avascular necrosis (AVN) of proximal fragments and 3 patients had bone marrow edema in proximal fragments. Serial radiographic evaluations were performed in every 4-8 weeks for bone union and follow up computed tomography scanning were checked in 8 patients. RESULTS: Bone unions were obtained in all 11 patients at 4.9 months (range, 3-9 months) after operation. At last follow up, the average range of motion was 82.5% and the grip power was 84.1% compared to the contralateral side. The mean New York Orthopaedic Hospital wrist score at last follow up was 83.2 (range, 58.1-93.3). CONCLUSION: Combined 1, 2-ICSRA pedicled VBG and headless compression screw fixation were reliable methods for managements of scaphoid nonunions even with AVN at proximal fragments.

The 4+5th Extensor Compartmental Artery- Pedicled Vascularized Bone Graft in Lichtman Stage III Kienbock's Disease

PURPOSE: The purpose of this study was to evaluate the clinical results of the 4+5th extensor compartmental artery pedicled vascularized bone graft in advanced Lichtman stage III Kienbock's disease. MATERIALS AND METHODS: Eight patients with advanced Lichtman stage III Kienbock's disease who underwent the 4+5th extensor compartmental artery pedicled vascularized bone graft and followed up more than 1 year were analyzed retrospectively. There were 3 men and 5 women. The mean age was 43.6 years old. Two patients were Lichtman stage IIIA and six patients were IIIB. The clinical outcomes were evaluated with radiocarpal joint pain, range of motion, grip strength, carpal-height ratio, radioscaphoid angle, return to daily living activity and/or work. The mean follow up period was 38.5 months (range from 12 to 86 months). RESULTS: On last follow up, the pain was disappeared in 6 patients, and mild occasional pain was remained in 2 patients. Mean radiocarpal joint flexion and extension were 55 degrees and 60 degrees, 87% and 88% of the normal side, respectively. The carpal-height ratio was maintained or improved in 6 patients and slightly decreased in 2 patients. Radioscaphoid angle were improved or maintained in 7 patients. Mean grip strength was 67 lb, 93% of the normal side. All 8 patients returned to daily living activities and/or their previous works. CONCLUSION: The 4+5th extensor compartmental artery pedicled vascularized bone graft prevented the progression of disease and provided clinical improvement even in advanced Lichtman stage III Kienbock's disease.

The Treatment for Kienbock's Disease using the Fourth Extensor Compartment Artery Vascularized Bone Graft: Preliminary Results

Lunate revascularization with the vascularized bone grafts is a current concept in the treatment of Kienbock disease. The aim of this study is to present our experience and preliminary results of the treatment using the fourth extensor compartment artery (4 ECA) vascularized bone graft for Kienbock disease. Between May 2009 and June 2010, five patients (3 men and 2 women) with Kienbock disease were treated with 4 ECA vascularized bone grafts. The mean age was 32.8 years and mean follow-up time was 13 months. The patients were composed of two patients in stage II and three patients in stage IIIa according to Lichtman's classification. Modified Mayo wrist score including pain, grip strength, range of motion and functional status and radiographic parameters such as carpal height ratio and radioscaphoid angle were evaluated at a final follow-up. Pain was markedly diminished and modified Mayo wrist score was 82 at last follow up period. There were no or little changes in carpal height ratio and radioscaphoid angle. All patients showed satisfactory bony union and no further lunate collapse on follow-up radiographs. The 4 ECA vascularized bone graft is a reliable alternative procedures among revascularization procedures for treatment of Kienbock's disease. It is less invasive and has low risk of kinking of pedicle compared to the 4+5 ECA vascularized bone graft. However, long term follow-up and MRI evaluation at follow up period should be needed for the future.

Treatment of Kienbock's Disease Using the 4+5 Extensor Compartmental Vascularized Bone Grafting Procedure: Early Experience / 대한정형외과학회잡지

PURPOSE: Kienbock's disease can be treated with a vascularized bone graft to provide relief of wrist joint symptoms and prevent collapse of the lunate. We evaluated the functional outcome and subjective satisfaction in patients with Kienbock's disease treated with the 4+5 extensor compartmental vascularized bone graft. MATERIALS AND METHODS: We included 6 patients in the study. 3 males and 3 females with an average age of 37.5 years (range 21-49). Kienbock's disease was staged by Lichtman classifi cation based on plain radiography. Three patients were in stage II and three in stage IIIA. Cooney's wrist function score was used to evaluate changes in severity of pain, functional status, range of motion, and grip strength. We also assessed subjective patient satisfaction, carpal height ratio and bone union on the radiographs, and the occurence of complications. The mean follow-up period was 30 months. RESULTS: Four patients had excellent and two had good outcomes of wrist function. Three patients showed excellent subjective satisfaction, and three were good. All patients showed radiographic bone union and no further progression of lunate necrosis. The presurgical carpal height ratio was similar to the value at last follow-up, and there was no radiographic carpal bone collapse. For two cases of Lichtman stage IIIA, the slight degenerative arthritis at the lunocapitate joint observed preoperatively did not change. Skin necrosis and pin track infection were not observed. CONCLUSION: The 4+5 extensor compartmental vascularized bone graft is a reliable procedure for Lichtman stage II and IIIA patients with Kienbock's disease, as it achieved not only pain relief and improvement of range of motion but also maintenance of the intercarpal bone relationship on radiographs, with relatively few complications.

A Comparative Study of Three Different Bone Grafting Methods for Treatment of Scaphoid Nonunion / 대한정형외과학회잡지

PURPOSE: Bone graft is a widely accepted surgical treatment for scaphoid nonunion. The purpose of this study was to analyze and compare the clinical outcomes of the three different bone graft techniques, Matti-Russe technique, Fisk-Fernandez technique and vascularized bone grafting. MATERIALS AND METHODS: This study involved 20 cases in 20 patients of established scaphoid nonunion who were treated with three different bone graft techniques and followed up for at least 1 year. We measured preoperative and postoperative pain, Mayo Modified Wrist Score (MMWS) and range of motion of the affected and normal side. For radiological evaluation we assessed bone union, avascular necrosis, and dorsal intercalated segment instability (DISI). RESULTS: There were no significant differences among the three groups with respect to the pain, MMWS, and range of motion. The union rate and correction of DISI also made no significant difference. The time to achieve bone union, which averaged 2.6 months was significantly decreased in the vascularized bone graft group than in the other two groups. CONCLUSION: All three methods were proper surgical procedures for treatment of scaphoid nonunion because there was no statistically significant difference in clinical and radiological outcomes. Among these three methods the vascularized bone grafting had the shortest time to achieve bone union so it could result in the fast functional recovery of the patient.

4+5 Extensor Compartmental Vascularized Bone Graft for Stage III Kienbock's Disease : Preliminary Results

PURPOSE: The aim of this study was to evaluate the preliminary results using the 4+5 extensor compartmental vascularized bone graft for the treatment of stage III Kienbock's disease and to report the usefulness of this procedure. METHODS: A retrospective study was carried out on five patients who had undergone 4+5 extensor compartmental vascularized bone graft for stage III Kienbock's disease between Jan. 2005 and Aug. 2006. All patients were composed of two patients in stage IIIA and three patients in stage IIIB according to Lichtman classification. The radiographic findings were evaluated by carpal height ratio, Stahl's index, ulnar variance and scapholunate angle. The clinical outcome was assessed using the Mayo wrist score. RESULTS: The mean age of 43.4 years(range, 21-61) and the mean follow up of 23.6 months(range, 14-31) were presented. All patients were satisfied and the mean Mayo wrist score was 78(range, 70-85). Two patients showed further lunate collapse on follow-up radiographs. Four patients had no pain in the activity of daily living, one patient had a mild occasional pain. CONCLUSION: The 4+5 extensor compartmental vascularized bone graft for the surgical treatment of stage III Kienbock's disease is the effective treatment showing satisfactory clinical results, but a lunate collapse proceeds. Before this operation, the possibility of lunate collapse should be considered.

Treatment of Scaphoid Nonunionusing a Pedicled Vascularized Bone Graft / 대한정형외과학회잡지

PURPOSE: This study examined the clinical usefulness of a pedicled vascularized bone graft for the treatment of a scaphoid nonunion. MATERIALS AND METHODS: Twenty-one patients with a scaphoid nonunion were treated with a pedicled vascularized bone graft using the 1, 2 intercompartmental supraretinacular branch of the radial artery. The average age of the patients was 29.3 years (range, 16-47) and the mean follow-up period was 19.6 months (range, 12-36). Punctate bleeding of the proximal fragment was evaluated intraoperatively and complete avascular necrosis was observed in 10 patients (47.5%). RESULTS: Radiographic union was observed in 19 patients (90%). The other 2 patients were considered to have clinical union although it was unclear radiographically. The average union time was 10.7 weeks (range, 6-16). Eight of the ten patients with an avascular proximal pole showed radiographic union. Sixteen patients (76%) showed satisfactory subjective results at the time of the last follow up based on the scaphoid score. CONCLUSION: Pedicled vascularized bone graft is a good method for treating a scaphoid nonunion and is strongly recommended in cases of scaphoid nonunion with proximal pole avascular necrosis.

Treatment of Nonunion of Proximal Scaphoid Fractures Using Vascularized Bone Graft / 대한정형외과학회잡지

PURPOSE: To evaluate the radiographic and clinical results of the treatment of nonunion of scaphoid proximal fractures using vascularized bone graft and internal fixation, and to present the surgical procedures in detail. MATERIALS AND METHODS: Six patients with established nonunion of scaphoid proximal fractures who had been treated by vascularized bone graft and internal fixation from the year of 2000 to 2003 were analyzed retrospectively. The mean ages were 27.8 years old (18-45) and all the patients were male. The average follow up period was 13 months (8-18), and the causes of injuries were fall down in 4 cases, and motor vehicle accident in 2 cases. The 1, 2-intercomparmental supraretinacular artery was used as a vascular pedicle for the bone graft and fixed with a Herbert screw. RESULTS: All the non-unions had united at a mean period of 8.7 weeks (7-11). According to the Maudsley and Chen's criteria, 4 and 2 cases showed excellent and good results, respectively. There was one case of dysesthesia on the superficial branch of the radial nerve after surgery, which was resolved in 2 months. CONCLUSION: A vascularized bone graft is an useful method for treating a nonunion of scaphoid proximal fractures without severe arthritic changes, and can achieve a shorter immobilization and improved bone healing.

Treatment of talar neck fractures with external fixators combined with vascularized bone graft / 中华创伤骨科杂志

Objective To evaluate the effects of external fixators combined with vascularized bone graft in treatment of talar neck fractures. Methods We retrospectively reviewed the records of seven patients who were treated for fractures of talar neck from January 2004 to March 2005 in our department. Of them, six were type Ⅱ and one was type Ⅲ according to the Hawkin s classification. One case was managed with closed reduction and six with open reduction and internal fixation with percutaneous cannulated screws. In addition, all the patients were treated with transarticular external fixators combined with vascularized bone graft. Bone healing, osteonecrosis and hindfoot functional recovery were documented. Results All the patients were followed up for 13 to 24 months (average, 17 months). All of them achieved bony union. According to the Maryland hindfoot scoring system, five cases were excellent and two were good. No avascular necrosis was found. One patient complicated with talar body fracture developed posttraumatic arthritis that was later managed by tibiotalar fusion. Conclusions External fixators combined with vascularized bone graft can effectively prevent avascular necrosis of the talus, but the long-term effects of this method need further observation.

Reconstruction of Composite Tissue Defect of the Hand using the Osteofasciocutaneous Lateral Arm Free Flap

There are severe soft tissue defects associated with intercalary segmental or distal loss of bone in the crushing injury of the hand by high-energy machine such as presser, electrical saw, and agricultural machine. Bone grafting to restore the skeletal scaffold is essential for reconstruction of the soft tissue and preservation of the digit function. However, non-vascularized free bone grafts are not desirable, because recipient sites often have a poorly vascularized bed. We described 12 cases, which were reconstructed by the lateral arm osteofasciocutaneous or osteofascial free flap from 1997 to 2001. The bone was harvested from the distal humeral bone as an osteofasciocutaneous lateral arm flap that has constant osseous branches from the main pedicle of the posterior radial collateral artery along the lateral intermuscular septum. Lateral arm osteofasciocutaneous flap is able to provide well vascularized bone and soft tissue for hand reconstruction. All flaps survived and had acceptable shape and function without bone resorption. We consider that lateral arm osteofasciocutaneous flap is a useful method for reconstruction of the composite tissue defect containing the bone in one-stage operation of the hand.

Vascularized Bone Graft for Spine and Limb Reconstruction / 대한정형외과학회잡지

We analysed the thirty three cases of the free vascularized bone graft performed in the Department of Orthopaedic Surgery, Yonsei University College of Medicine from February 1982 to December 1989 and would like to report the results as follows. 1. There were 27 cases in men and 6 cases in women and the mean age was 27.3 years. 2. We have performed the procedure for the reconstruction of the large bony defects developed after massive trauma in 13 cases, core decompression of the avascular necrosis of the femoral head in 8 cases, tumoral resection in 6 cases, treatment of congenital pseudoarthrosis in 3 cases, and bone infection in 3 cases. 3. The most common recipient site was tibial shaft (18 cases, 54%) and the most common donor site was fibular shaft (23 cases, 69%). 4. The average length of bone defect (or grafted bone) in 23 cases of vascularized fibular graft was 9.8 cm and in 9 cases of vascularized osteocutaneous iliac bone graft, it was 5.8 cm. 5. The follow-up period was ranged from 13 months to 5 years 8 months (mean, 2 years 2 months). 6. All patients were evaluated clinically and roentgenographycally on the basis of fuctional recovery and bony union. Of the 33 cases, 31 cases (93%) showed satisfactory functional recovery with sound bony union. 7. It is highly expected that the vascularized bone graft is a one of the better alternatives for the reconstruction of the large bone defect and prevention of the early state of the avascular necrosis of the femoral head from progession.

Lower Extremity Reconstruction by Vascularized Bone Graft Transfer / 대한정형외과학회잡지

Eleven cases of the free vascularized bone graft have been performed in the Department of Orthopaedic Surgery, Yonsei University Hospital during the period of 30.9 months from February 1981 to December 1985. Follow up ranges from 8 to 62 months. The indication for the procedure was reconstruction of extensive bony defect after acute trauma in 3 cases, osteomyelitis in 3 cases, chronic nonunion 3 cases, bone tumor in one case and congenital pseudoarthrosis in one case. The results were obtained as follows; 1. To reconstruct the lower extremity the vascularzed bone graft has much more advantages than the other conventional method and the technique may be very useful in the management of certain difficult reconstructive problem of the lower extremity. 2. In the defects of bone and skin, even infected, composite bone and soft tissue transfer can be filled by one stage operation and made the infection heal more rapidly. 3. In children the vacularized fibular graft was hypertrophied and similar to thickness of tibia.

Treatment of Bone Tumor with Free Vascularized Bone Graft / 대한정형외과학회잡지

In certain low-grade malignant tumors such as chondrosarcoma and giant cell tumor, radical treatments may provide a good chance for cure. And large bony defect after the radical treatment can be filled with the massive bone graft. Recent advances in clinical microsurgery have made free tissue transfer a clinical reality, and Taylor in 1975, first reported the technique of free vascularized fibula graft for the reconstruction of large tibial defects with excellent clinical results. We tried wide excision and free vascularized bone graft in 6 patients with malignant or aggressive bone tumor from April 1981 to November 1985 and followed up for more one year. Mean follow up of free vascularized bone graft is 26.4 months and that of devascularized bone graft is 22.6 months. The results of the free vascularized bone graft were compared with 10 patients who were treated with the wide excision and the devascularized bone graft. In this analysis, free vascularized bone graft is superior to devascularized bone graft in bony union, complications and functional results.

Tibia Shaft Fractures Treated with the Hoffmann External Fixation / 대한정형외과학회잡지

The anatomical characteristics of the tibia, which is covered by subcutaneous tissue anteriorly, emphasize the vulnerability of the tibia to trauma and frequently result in open comminuted fracture. Open fractures add to the risk of infection and nonunion and require treatment that prevent infection, provide skin coverage, and maintaine reasonable fixation during the early healing phase. 50 cases of tibia shaft fractures were reviewed from May 1978 to December 1983, managed with the modified Vidal-Adrey frame of Hoffmann extemal fixator, at the Orthopaedic Department of Kyung Hee University Hospital. The results obtained were as follows; 1. In 50 cases of tibia fractures, 46 cases are open injuries and 43 cases (86.0%) among them were Grade II and IU open fractures. 2. 31 operative procedures were performed for the coverage of soft tissue injury; 13 cases of rotation and cross-leg pedicle flaps were effective aids, but futher good results could be expected with the micmvascular free flap. 3. 17 operative procedures for acceleration of bony union and reconstruction of bone defect were performed. In cases of massive bone defect, vascularized fibular transplantation and free vascularized fibular graft should be employed, and additional bone shortening and electric stimulation would contribute to the enhancement of the bony union process. 4. The mean period of extemal immobilization with the frame was 15.4 weeks and that of bone union was 31.7 weeks. The periods of bone union were markedly delayed in cases of Grade II andIII open fracture than those of closed and Grade I open fractures. 5. Nonunion developed in 17 cases (34.0%); 4 cases in Grade II and 13 cases in Grade III injury. 6. 12 cases of wound infection developed. 7. 12 cases of pin tract infection happened. More careful pin tract management could diminish this troublesome complication.