Open Reduction and Stable Internal Fixation Using a 3.5-mm Locking Hook Plate for Isolated Fractures of the Greater Tuberosity of the Humerus: A 2-Year Follow-up Study Using an Innovative Fixation Method

Background@#The best treatment for isolated greater tuberosity (GT) fractures is still controversial. Although previous studies have suggested surgical options, they are either unable to provide firm fixation or present with a variety of complications. @*Methods@#We retrospectively studied the records of patients with isolated GT fractures who underwent open reduction and internal fixation using a 3.5-mm locking hook plate between January 2016 and January 2018. The surgical indication was an at least 5-mm displacement of the GT as observed in either simple radiography or three-dimensional computed tomography. Clinical outcomes were assessed using the following five parameters shortly before implant removal and at the final follow-up: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Shoulder Rating Scale of the University of California, Los Angeles (UCLA), Constant-Murley score, and range of motion. @*Results@#Twenty-one patients with a mean age of 64 years were included. Bone union was achieved within 12–20 weeks of the first surgery in all patients. Implant removal was performed between 13 and 22 weeks after surgery. At the final follow-up, the mean VAS pain score, forward flexion, abduction, external rotation, internal rotation, ASES score, UCLA score, and ConstantMurley score were significantly better when compared to outcomes shortly before implant removal (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively). @*Conclusions@#The 3.5-mm locking hook plate provided sufficient stability and led to satisfactory clinical and radiological outcomes for isolated GT fractures. However, the hook plate may irritate the rotator cuff, and postoperative stiffness may be inevitable.Therefore, second surgery for implant removal is necessary after bone union is achieved.

Open Reduction and Stable Internal Fixation Using a 3.5-mm Locking Hook Plate for Isolated Fractures of the Greater Tuberosity of the Humerus: A 2-Year Follow-up Study Using an Innovative Fixation Method

Background@#The best treatment for isolated greater tuberosity (GT) fractures is still controversial. Although previous studies have suggested surgical options, they are either unable to provide firm fixation or present with a variety of complications. @*Methods@#We retrospectively studied the records of patients with isolated GT fractures who underwent open reduction and internal fixation using a 3.5-mm locking hook plate between January 2016 and January 2018. The surgical indication was an at least 5-mm displacement of the GT as observed in either simple radiography or three-dimensional computed tomography. Clinical outcomes were assessed using the following five parameters shortly before implant removal and at the final follow-up: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Shoulder Rating Scale of the University of California, Los Angeles (UCLA), Constant-Murley score, and range of motion. @*Results@#Twenty-one patients with a mean age of 64 years were included. Bone union was achieved within 12–20 weeks of the first surgery in all patients. Implant removal was performed between 13 and 22 weeks after surgery. At the final follow-up, the mean VAS pain score, forward flexion, abduction, external rotation, internal rotation, ASES score, UCLA score, and ConstantMurley score were significantly better when compared to outcomes shortly before implant removal (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively). @*Conclusions@#The 3.5-mm locking hook plate provided sufficient stability and led to satisfactory clinical and radiological outcomes for isolated GT fractures. However, the hook plate may irritate the rotator cuff, and postoperative stiffness may be inevitable.Therefore, second surgery for implant removal is necessary after bone union is achieved.

Repair Integrity and Functional Outcomes after Arthroscopic Repair of Transtendinous Full-thickness Rotator Cuff Tears Minimum Two-year Follow-up

BACKGROUND: To evaluate the clinical outcomes and associated repair integrity in patients treated with arthroscopic repair for a transtendinous rotator cuff tear followed by resection of the remnant rotator cuff tendon. METHODS: Between July 2007 and July 2011, we retrospectively reviewed patients who were treated for transtendinous full-thickness tears in the tendinous portion of the rotator cuff by arthroscopic repair. Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, the Shoulder Rating Scale of the University of California at Los Angeles (UCLA), the Constant-Murley score, a visual analogue scale (VAS) pain score, and range of motion (ROM). The repair integrity was determined by magnetic resonance imaging or ultrasonography. RESULTS: There were 19 shoulders with transtendinous full-thickness tears in the tendinous portion of the rotator cuff. The ASES, UCLA, Constant-Murley, and VAS pain scores showed significant improvements in function and symptoms (all p<0.001). The active ROM for forward flexion and abduction was also significantly improved (p=0.002 and p<0.001, respectively). The postoperative radiological examination showed cuff integrity without a re-tear in 68.4% of patients. However, the UCLA, ASES, and Constant-Murley scores were not significantly different between healed and re-torn group (p=0.530, p=0.885, and p=0.262, respectively). CONCLUSIONS: Although repair of transtendinous rotator cuff tears followed by resection of the remnant rotator cuff tendon in the footprint has a relatively high re-tear rate, no significant difference was observed in the short-term clinical results between the re-tear and healed groups.

Repair Integrity and Functional Outcomes after Arthroscopic Repair of Transtendinous Full-thickness Rotator Cuff Tears Minimum Two-year Follow-up

BACKGROUND: To evaluate the clinical outcomes and associated repair integrity in patients treated with arthroscopic repair for a transtendinous rotator cuff tear followed by resection of the remnant rotator cuff tendon. METHODS: Between July 2007 and July 2011, we retrospectively reviewed patients who were treated for transtendinous full-thickness tears in the tendinous portion of the rotator cuff by arthroscopic repair. Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, the Shoulder Rating Scale of the University of California at Los Angeles (UCLA), the Constant-Murley score, a visual analogue scale (VAS) pain score, and range of motion (ROM). The repair integrity was determined by magnetic resonance imaging or ultrasonography. RESULTS: There were 19 shoulders with transtendinous full-thickness tears in the tendinous portion of the rotator cuff. The ASES, UCLA, Constant-Murley, and VAS pain scores showed significant improvements in function and symptoms (all p<0.001). The active ROM for forward flexion and abduction was also significantly improved (p=0.002 and p<0.001, respectively). The postoperative radiological examination showed cuff integrity without a re-tear in 68.4% of patients. However, the UCLA, ASES, and Constant-Murley scores were not significantly different between healed and re-torn group (p=0.530, p=0.885, and p=0.262, respectively). CONCLUSIONS: Although repair of transtendinous rotator cuff tears followed by resection of the remnant rotator cuff tendon in the footprint has a relatively high re-tear rate, no significant difference was observed in the short-term clinical results between the re-tear and healed groups.

A Girl with Limping Diagnosed as Burkitt Lymphoma / 대한정형외과학회잡지

A three-year-old girl presented with a right-sided limp and mild fever. Laboratory findings were normal, except for an elevated erythrocyte sedimentation rate (ESR) of 30 mm/h and a C-reactive protein (CRP) level of 1.5 mg/dl. Magnetic resonance imaging showed a periosteal reaction in the distal posteromedial femur with contour bulging and extension of the reaction to the adjacent vastus muscles. Under a working diagnosis of acute suppurative osteomyelitis, she was initially treated with antibiotics and anti-inflammatory agents for one week. However, this did not result in resolution of her problems or normalization of the ESR and CRP. Biopsies of periosteum and muscle revealed Burkitt lymphoma expressing Bcl-6(+). In a child, limping can be the first clinical sign of hematogenous malignancy. In a limping child, if the general clinical course does not show improvement, and empirical treatment is ineffective, a comprehensive evaluation is necessary, including biopsies or bone marrow aspiration.

Acute Tophaceous Gout of the Distal Interphalangeal Joint Misdiagnosed as Cellulitis / 대한정형외과학회잡지

In elderly patients, the first incidence of gout often affects the distal interphalangeal joint (DIP) and usually subsides without specific treatment after about 7 days. A 61-year-old male was presented to our clinic with a 10-day history of tenderness and swelling in his index DIP, which was initially diagnosed as cellulitis. After a skin incision was made to drain the lesion, typical tophaceous deposits were observed around the extensor apparatus, flexor tendons, and joint capsule. The tophi were meticulously removed in order to minimize the injury to its surrounding structures, after which the joint fluid was aspirated. There was no history of gout, laboratory findings suggesting tophaceous gout, or apparent predisposing factors in the patient's history. Pathology confirmed tophaceous deposits and negative birefringent crystals, and the patient has been managed on allopurinol for post-operative six months.

Positive or Negative Ulnar Variance after Ulnar Shortening for Ulnar Impaction Syndrome: A Retrospective Study

BACKGROUND: The goal of this study was to compare simple radiographic findings and clinical results according to residual ulnar variance following ulnar shortening for ulnar impaction syndrome. METHODS: Forty-five cases of ulnar impaction syndrome, which were treated with ulnar shortening from 2005 to 2008, were studied retrospectively. Group I included 13 cases with positive residual variance after ulnar shortening and group II included 32 cases with negative variance after shortening. The presence of a lunate cystic lesion both preoperatively and at final follow-up and assessments of wrist function based on the modified Mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, as well as the Chun and Palmer score were evaluated. RESULTS: A cystic lesion of the lunate was present in 4 cases preoperatively and the size decreased in 2 cases at final follow-up in group I, and in 10 and 5 cases, respectively, in group II. No statistical difference was observed between the groups. The modified Mayo wrist score, DASH score, as well as the Chun and Palmer score improved significantly in both groups. No significant differences were observed between the two groups in terms of the proportion of positive cystic lesions at final follow-up or the functional scores. CONCLUSIONS: After ulnar shortening, the degree of radiological change in the cystic lunate lesions and clinical improvement did not differ significantly between the groups with unintended residual positive and negative variance after shortening.

A Fusiform Epineural Ganglion Encompassing the Ulnar Nerve in the Cubital Tunnel / 대한정형외과학회잡지

Cubital tunnel syndrome, caused by a ganglion, is rare and most ganglion cysts originate from the medial aspect of the ulnohumeral joint. We present an extremely rare case of a fusiform epineural ganglion, encompassing the ulnar nerve in the cubital tunnel. A 48-year-old man complained of a 6-month history of typical cubital tunnel syndrome symptoms. Electrophysiological studies were compatible with the compressive neuropathy of the ulnar nerve. A fusiform epineural ganglion cyst (1.4 cm in diameter and 7.2 cm in length), which encompasses the ulnar nerve in the cubital tunnel, was found with no connection to the elbow joint. The ganglion cyst was excised and the ulnar nerve anterior transmuscular transposition was performed. Six months postoperatively, the patient was free of pain, tingling sensations, and numbness. In addition, his grip and pinch strength improved, the muscle wasting showed recovery, and an electrophysiological study demonstrated some improvement.

Traumatic Buttonhole Deformity of the Thumb / 대한정형외과학회잡지

Traumatic buttonhole deformity is very rare. In rheumatoid arthritis, synovitis of the metacarpophalangeal joint stretches the dorsal capsule and as a result the extensor pollicis brevis gradually becomes attenuated. Also, the extensor pollicis longus progressively subluxed ulnar and volarward. However, in the cases derived from trauma, combination injuries to the dorsoradial capsule, extensor pollicis insertion and ulnar subluxation of extensor pollicis longus, are essential. Authors experienced the cases of two traumatic buttonhole deformities, and performed operative treatment. In one case, the injured extensor pollicis brevis insertion was detached from the capsule and hood. We advanced and reattached the extensor pollicis brevis to the capsule, after imbricating the capsule and established the normal alignment of the extensor pollicis longus. In the other case, the extensor pollicis brevis insertion was maintained, but the capsule and extensor pollicis longus were severely attenuated. At the 12-month follow-up, the clinical results were satisfactory in both cases.

Outcomes from Treatment of Simple Bone Cyst in the Long Bones with Flexible Intramedullary Nailing in Children and Adolescents: A Retrospective Cases Series / 대한정형외과학회잡지

PURPOSE: A retrospective review of cases series about the outcomes of treatment for simple bone cyst in the long bones with flexible intramedullary nailing in children and adolescents. MATERIALS AND METHODS: Eighty-five cases with a simple bone cyst in the long bones diagnosed between April 2002 and December 2007 were enrolled in the study. The mean age of the patients was 10.8 years. Thirteen cases were accompanied by a pathological fracture, and 72 cases were not. Thirty-three cases had a simple bone cyst on the proximal humerus, 41 cases on the shaft of the humerus, and 11 cases on the proximal femur. Steroid injections were performed in 21 cases (group 1), curettage and a synthetic bone graft in 18 cases (group 2), and decompression and fixation using flexible intramedullary nailing in 46 cases (group 3). We followed up all cases for at least 24 months and evaluated the results according to the Capanna classification. RESULTS: The mean duration for absorption and healing of bone cysts was 18.4 months in group 1, 10.6 months in group 2, and 5.8 months in group 3. The complete cure rate according to the Capanna classification was 67% in group 1, 56% in group 2, and 78% in group 3. There was one case of recurrence in group 1 (5%), one case in group 2 (6%), and one case in group 3 (2%), as well as two cases of "no response to treatment" in group 1 (9%) and one case in group 2 (6%). CONCLUSION: Flexible intramedullary nailing for simple bone cysts in children and adolescents is effective for healing cystic lesions with a short healing duration and for mechanical stability.

Hematoma Distraction Arthroplasty after Trapeziectomy in Advanced Osteoarthritis of the Trapeziometacarpal Joint / 대한정형외과학회잡지

PURPOSE: To investigate the clinical usefulness of hematoma distraction arthroplasty to treat advanced trapeoziometacarpal osteoarthritis of the thumb. MATERIALS AND METHODS: We studied 12 cases (1 male, 11 females) with osteoarthritis of the thumb that was managed with hematoma distraction arthroplasty using K-wire fixation. Of the 12 cases, 7 were Littler-Eaton stage III and 5 were Littler-Eaton stage IV. We investigated operation time, preoperative and postoperative visual analogue scale (VAS) score, preoperative and postoperative range of motion, grip power and radiologic changes. RESULTS: The mean patient age was 53.2 (39-61) years and the mean duration of follow-up was 19.5 (14-27) months. The average operation time was 52 minutes. The mean VAS scores at 6 and 12 months after the operation were 1.3 and 0.7, respectively. The range of motion and grip power of the finger improved postoperatively (15% in abduction, 18% in adduction, 25% in flexion, 14% in extension, 66% in grip power of the finger). On a simple 12-month postoperative radiologic exam, the interval between the scaphoid and first metacarpal bone had decreased 6.5 mm compared with the preoperative interval. CONCLUSION: The surgical treatment using hematoma distraction arthroplasty for trapeziometacarpal osteoarthritis is an effective method for pain relief, improvement of motion range and finger-grip power.

The Relationship between the Pedicle Screw Loosening and Bone Mineral Density after Transpedicular Spinal Instrumentation / 대한골다공증학회지

OBJECTIVES: We have analyzed relationship between pedicle screw loosening and bone mineral densitiy (BMD) after spinal arthrodesis with pedicle screw. MATERIALS AND METHODS: We have chosen 31 cases that had screw loosening radiologically on the follow up X-ray among the patients who underwent spinal arthrodesis with pedicle screws, and compared Saville's index that was measured by lateral view of preoperative X-ray with Dual energy X-ray absortiometry (DEXA) score.

Four Cases of Vitamin D Deficiency Rickets with Lower Extremity Deformities / 대한정형외과학회잡지

Since the overall nutritional status of the general population has improved nowadays and manufactured formulas contain vitamin D, the prevalence of vitamin D deficiency rickets has significantly decreased. Recently, however, 4 cases with lower extremity deformities came to the outpatient department. Among them, 1 case consumed only Sunsik (a powder mixture of several grains and fruits) instead of the manufactured formula, to control atopic dermatitis, 2 cases stopped eating due to diarrhea from milk feeds, and to control atopic dermatitis. 1 case was on a normal diet without any specific allergic reaction to foods, but had very less exposure to sunlight. Providing sufficient vitamin D and calcium, along with increasing the time of sunlight exposure have significantly improved the hematologic and radiologic findings, and the bone growth. The authors will explain the necessity of adequate supplementation of vitamin D and calcium, especially in cases which control or restrict their diet due to food allergies.

A Retrospective Comparative Study of Internal Fixation with Contoured Plate Using Bicortical Screw Versus a Double Plate in Comminuted Olecranon Fractures / 대한정형외과학회잡지

PURPOSE: To analyze the clinical result of a contoured plate fixation using a bicortical screw and a double plate fixation in the surgical treatment of an adult's comminuted olecranon fracture. MATERIALS AND METHODS: A total of 22 patients were classified by Mayo classification as Type IIB (17) and Type IIIB (5). All patients enrolled in the study were treated between July 2002 and September 2009. Twelve patients were operated on using the contoured plate internal fixation using a bicortical screw procedure classified as group 'A'. The 10 patients operated on by a double plate fixation were classified as group 'B'. The Mayo elbow performance score was used to compare postoperative clinical results based on total points in 4 categories: pain, range of motion, articular stability, and articular function. RESULTS: The clinical results of using the Mayo elbow performance score of group 'A' were that 10 scored in the 'excellent' range and 2 scored in the 'good' range the following: in group 'B' were in the excellent range and 3 were in the good range. Both groups showed satisfactory results. Postoperative elbow exercises in group 'A' commenced 7.8 (5-14) days on average, postoperatively. For 'B' group, post-operative elbow exercises began 4.5 (3-7) days following the operation. With regard to the exercise and the range of elbow motion, group 'A' averaged 113.5 degrees and group 'B' averaged 112 degrees. After surgery, the average durations until the bone union were 3.8 (2.4-5.6) months for group 'A' and 4 (2.5-5) months for group 'B', respectively. CONCLUSION: There was no significant difference in the clinical results between patients treated with the contoured plate internal fixation using a bicortical screw or the internal fixation using a double plate in the surgical treatment of adults with comminuted olecranon fracture or dislocation. Therefore, both types of operative approach are acceptable.

Simple Subperiosteal Hematoma with a Periosteal Reaction Mimicking a Malignancy / 대한정형외과학회잡지

A benign periosteal reaction, which can occur after trauma or stress, has a solid and uninterrupted appearance on radiography. In contrast, an aggressive periosteal reaction, which may indicate a malignancy, appears as a Codman's triangle or with a spiculated and sunburst pattern. In the present case, an 11-year-old boy with a previous injury to the distal radial growth plate presented with diffuse osteolysis on the distal radial metaphysis and decreased opacity of the lateral side cortex on plain radiograph. A Codman's triangle-like lesion was seen on the lateral side of the distal radius, and a few spicules were observed on the medial side of the distal radius. A T2-weighted coronal magnetic resonance image revealed a mass that had stripped the periosteum; the mass had heterogeneous signal intensity and a fl uid-fluid level on axial views. The margins of the mass were unclear, but enhanced. Suspecting a primary malignancy, we performed a biopsy. The pathology revealed that the mass was a simple hematoma.

Separate Vertical Wirings for the Extra-articular Fractures of the Distal Pole of the Patella

PURPOSE: To evaluate the usefulness of separate vertical wirings for extra-articular fracture of distal pole of patella. MATERIALS AND METHODS: We have analyzed the clinical results of 18 cases that underwent separate vertical wirings for extra-articular fracture of distal pole of the patella from March 2005 to March 2010, by using the range of motion and Bostman score. Occurrence of complication was also evaluated. Additionally, by taking simple radiographs, the correlation between the postoperative degree of anterior transposition of bone fragment and the time of bone fusion, preoperative length of bone fragment, and occurrence of comminuted fracture were investigated. RESULTS: It took an average of 13.8 weeks for radiological bone union after separate vertical wiring fixation. Flexion contracture was an average of 0.8 degrees and further flexion was an average of 127.6degrees, and Bostman score was an average of 27.5 points (excellent in 12 cases, and good in 6 cases). On the first postoperative year, average flexion contracture was 0.6 degrees and further flexion was an average of 136.3degrees, which exhibited increased joint motion and recovery to normal range of motion, and Bostman score was an average of 28.7 points (excellent in 16 cases, and good in 2 cases). There was no statistically significant difference between the preoperative bone fragment length and presence of comminution, and degree of anterior transposition of bone fragment after fracture union on simple radiograph (p=0.175, p=0.146). CONCLUSIONS: We were able to obtain satisfactory clinical results, while preserving the bone fragment by separate vertical wiring fixation for extra-articular fracture of distal pole of patella. Moreover, the method is easy to perform, which is also considered as a useful surgical method for extra-articular fracture of distal pole of patella.

Heterotophic Ossification in the Thenar Eminence and the Thumb: A Case Report

Heterotopic ossification is defined as a reactive disease with mature lamellar bone formation in soft tissue. We experienced a case of heterotopicc ossification occurred on the thenar eminence and the thumb without trauma. We report this rare case with a review of the relevant literature.

The Effect of Rotational Deformities on Cubitus Varus for Supracondylar Humerus Fractures in Children / 대한정형외과학회잡지

PURPOSE: To analyze the relationship between cubitus varus deformities and rotatory abnormalities after bone union. MATERIALS AND METHODS: A total of 263 patients were diagnosed with Gartland type II supracondylar humerus fractures between May 1996 and May 2003 and underwent surgery. The Gartland method was used to classify the fractures. Of the 263 cases, 141 were type II, and 122 were type III. All patients underwent subcutaneous K-wire fixation after manual reduction except one that showed open radial nerve damage at the time of trauma. A mathematical method was used to evaluate rotation abnormalities in the axial plane. RESULTS: There was no postoperative nonunion or iatrogenic ulnar nerve palsy in 8 cases of cubitus varus deformity. Cubitus varus deformities failed to show a statistically significant correlation with malrotation in the axial plane. CONCLUSION: There was no relationship between rotatory abnormalities after union and cubitus varus deformities.

Staged Management of High Energy Proximal Tibia Fractures with Severe Soft Tissue Damage

PURPOSE: To find out the efficiency of two staged operation of patients with high energy proximal tibia fracture with severe soft tissue damage, the first step being external fixation, and the second, internal fixation with plates. MATERIALS AND METHODS: The study group was the 42 patients who had followed for one year out of a group of 56, performed the first step external fixation and the second step internal fixation with plates retrospectively, from March 2003 to March 2007. The average age of the study group was 51.4, 26 men, and 16 women participating in this study. The average time of follow up was 32 months. In the final follow up, investigations of the radiological assessments and functional abilities of the bony fusion were carried out along with the complications of the soft tissue. RESULTS: The duration after the first step external fixation until second step internal fixation to be performed was 14.9 (6~40) days in average. The final bone fusion took about 15 weeks, and according to the final follow up, the range of motion of the knee was around 110.8 degrees (6.2~117 degrees). In 31 cases, only the internal fixation was performed, while in 11 cases, soft tissue reconstruction was carried out with the internal fixations. As for the complications there were 2 cases of deep soft tissue infection, 2 cases of nonunion, 1 case of malunion and 1 case of knee joint stiffness. CONCLUSION: In cases of proximal tibia fracture with severe soft tissue damage, external fixation was important to secure the safety of the fracture, carry forward the anatomical alignment, plan the soft tissue safety and manage the wound to decrease the number of microbial in the next operation, which is the internal fixation with plates.

Clinical Results of Carpal Tunnel Release with Open Minimal Incision

PURPOSE: To find out the clinical usefulness of carpal tunnel release with open minimal incision MATERIALS AND METHODS: We studied 149 patients (152 carpal tunnel) who were able to follow up for more than 6 months after being treated with carpal tunnel release with open minimal incision from January 2000 to January 2006. We compared the clinical results of this procedure using recovery time, the disappearance of symptoms, the presence of the kelloid and the scar tenderness and analyzed preoperative and postoperative VAS score of tingling sensation, dull sensation, inappropriate hand movement, muscle weakness, edema, palmar pain as subjective satisfaction. We used the independent t-test for the statistical significance. RESULTS: All cases had complete disappearance or marked improvement in symptoms, and there was no kelloid formation. Residual symptoms and tenderness of the scar was found in 8 cases (5.4%), but gradually disappeared. In last follow up, tingling sensation decreased from 7.8 to 1.0 and dull sensation from 7.0 to 1.5, inappropriate hand movement from 4.8 to 1.1, muscle weakness from 5.9 to 0.8, edema from 2.0 to 0.5, palmar pain from 2.1 to 0.2 in preoperative and postoperative VAS score, all were significantly improved statistically (P<0.05). CONCLUSIONS: We think that carpal tunnel release with open minimal incision has little complication and is a safe and effective operation method having similar effect with endoscopic surgery or conventional open surgery.