Pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up.

BACKGROUND: The success of traditional shoulder hemiarthroplasty (HA) with cobalt-chromium heads is limited by painful glenoid erosion with problematic bone loss. Hemiprostheses with pyrolytic carbon (PyC) heads have shown reduced glenoid erosion in experimental laboratory studies. Few in vivo data are available. METHODS: We performed a single-center consecutive cohort study of 31 of 34 patients (91%) who underwent PyC HA between September 2013 and June 2018. In 11 of these patients, concentric glenoid reaming was additionally performed. The mean follow-up period was 5.5 years (range, 3.5-7 years). Standardized radiographs were taken, and clinical function (Constant score) and pain (visual analog scale score) were recorded. Anteroposterior radiographs were analyzed according to an established method by 2 independent observers: A line parallel to the superior and inferior glenoid rim was translated to the most medial point of the glenoid surface. A further parallel line was placed on the spinoglenoid notch. The distance between these 2 lines was measured. Measurements were scaled using the known diameter of the implanted humeral head component. To assess eccentric erosion, anteroposterior and axial images were classified according to Favard and Walch, respectively. RESULTS: Mean medial glenoid erosion measured 1.4 mm at an average of 5.5 years of follow-up. In the first year, 0.8 mm of erosion was observed, significantly more than the average erosion per year of 0.3 mm (P < .001). Mean erosion per year was 0.4 mm in patients with glenoid reaming vs. 0.2 mm in those without reaming (P = .09). An evolution of glenoid morphology was observed in 6 patients, of whom 4 had a progression of the erosion grade. The prosthesis survival rate was 100%. The Constant score improved from 45.0 preoperatively to 78.0 at 2-3 years postoperatively and 78.8 at latest follow-up (5.5 years postoperatively) (P < .001). The pain score on a visual analog scale decreased from 6.7 (range, 3-9) preoperatively to 2.2 (range, 0-8) at latest follow-up (P < .001). There was a weak correlation (r = 0.37) between erosion and pain improvement (P = .039) and no correlation between erosion and change in Constant score (r = 0.06). CONCLUSION: PyC HA caused little glenoid erosion and a sustained improvement in clinical function in our cohort at mid-term follow-up. PyC demonstrates a biphasic development of glenoid erosion, with a reduced rate after the first year. PyC HA should therefore be considered as an alternative to cobalt-chromium HA and to anatomical total shoulder arthroplasty for patients with a high risk of glenoid component complications.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer.

PURPOSE: Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts. METHODS: A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded. RESULTS: 177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.). CONCLUSION: The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates. LEVEL OF EVIDENCE: Level II.

Reverse Shoulder Arthroplasty for Proximal Humerus Head-Split Fractures-A Retrospective Cohort Study.

Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.

Dislocation Arthropathy of the Shoulder.

Glenohumeral osteoarthrosis (OA) may develop after primary, recurrent shoulder dislocation or instability surgery. The incidence is reported from 12 to 62%, depending on different risk factors. The risk of severe OA of the shoulder following dislocation is 10 to 20 times greater than the average population. Risk factors include the patient's age at the first episode of instability or instability surgery, bony lesions, and rotator cuff tears. For mild stages of OA, arthroscopic removal of intraarticular material, arthroscopic debridement, or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For severe stages, mobilization of the internal rotation contracture and arthroplasty is indicated. With an intact rotator cuff and without a bone graft, results for anatomical shoulder arthroplasty are comparable to those following primary OA. With a bone graft at the glenoidal side, the risk for implant loosening is ten times greater. For the functional outcome, the quality of the rotator cuff is more predictive than the type of the previous surgery or the preoperative external rotation contracture. Reverse shoulder arthroplasty could be justified due to the higher rate of complications and revisions of non-constrained anatomic shoulder arthroplasties reported. Satisfactory clinical and radiological results have been published with mid to long term data now available.

Red Cell Distribution Width Upon Hospital Admission Predicts Short-Term Mortality in Hospitalized Patients With COVID-19: A Single-Center Experience.

Background: Coronavirus disease (COVID-19) was first described at the end of 2019 in China and has since spread across the globe. Red cell distribution width (RDW) is a potent prognostic marker in several medical conditions and has recently been suggested to be of prognostic value in COVID-19. Methods: This retrospective, observational study of consecutive patients with COVID-19 was conducted from March 12, 2020 to December 4, 2020 in the Wilhelminenhospital, Vienna, Austria. RDWlevels on admission were collected and tested for their predictive value of 28-day mortality. Results: A total of 423 eligible patients with COVID-19 were included in the final analyses and 15.4% died within 28 days (n = 65). Median levels of RDWwere significantly higher in non-survivors compared to survivors [14.6% (IQR, 13.7-16.3) vs. 13.4% (IQR, 12.7- 14.4), P < 0.001]. Increased RDW was a significant predictor of 28-day mortality [crude odds ratio (OR) 1.717, 95% confidence interval (CI) 1.462-2.017; P = < 0.001], independent of clinical confounders, comorbidities and established prognostic markers of COVID-19 (adjusted OR of the final model 1.368, 95% CI 1.126-1.662; P = 0.002). This association remained consistent upon sub-group analysis. Our study data also demonstrate that RDW levels upon admission for COVID-19 were similar to previously recorded, non-COVID-19 associated RDW levels [14.2% (IQR, 13.3-15.7) vs. 14.0% [IQR, 13.2-15.1]; P = 0.187]. Conclusions: In this population, RDWwas a significant, independent prognostic marker of short-term mortality in patients with COVID-19.

RSA, TSA and PyC hemi-prostheses: comparing indications and clinical outcomes using a second-generation modular short-stem shoulder prosthesis.

INTRODUCTION: The goal of this study was to provide an insight into the clinical results after modular short-stem shoulder arthroplasty for various indications. MATERIALS AND METHODS: A consecutive cohort study of 76 patients followed up for 23-55 (mean 31.4) months. 23 anatomical (TSA), 32 reverse (RSA) and 21 hemi-prostheses with a pyrocarbon head (PyC), using a modular short stem with proximal porous coating were implanted. Range of motion, pain and Constant score (CS) were recorded. Comparisons of pre- vs postoperative outcomes, between prosthesis types and indications, were made. RESULTS: All prosthesis types brought about a significant improvement (p < 0.05) in all measured outcomes. TSA had a significantly higher increase in the CS than PyC and RSA (p = 0.002 and 0.003, respectively). TSA produced superior gains in all ROM compared with RSA (p < 0.02). RSA brought about significantly smaller improvements in internal rotation than TSA and PyC (p = 0.0001 and 0.008, respectively). TSA had greater pain relief than PyC (p = 0.02). TSA with Walch A glenoids seemed to improve more than type B in the CS. PyC patients with Walch B glenoids improved more than Walch A (p = 0.03). When implanted due to Osteoarthritis (OA), PyC had a comparable final outcome to TSA (p = 0.95), although the preoperatively worse TSA patients had a greater improvement in the CS (p = 0.026). The outcome of RSA did not differ between indications, but Walch A glenoids tended to improve more. CONCLUSIONS: Using a second-generation short-stem shoulder prostheses, TSA achieves the best clinical improvements overall, especially for OA with a Walch A glenoid. Despite refixation of the subscapularis tendon in all cases, RSA has inferior internal rotation than TSA and PyC, suggesting a mechanical limitation. OA, a Walch B glenoid and arthritis caused by instability seem to be ideal indications when considering PyC.

Cementless curved short stem shoulder prostheses with a proximal porous coating: ingrowth properties at 2-5 years of radiological follow-up with clinical correlation.

BACKGROUND: Little is known about the way the newest generation of stems integrate into the proximal humerus and their effect on the surrounding bone. Factors that may influence ingrowth have not been investigated. METHODS: A consecutive cohort study was conducted that examined 74 anatomical, reverse, or pyrocarbon hemiprostheses, using a curved modular short stem with a proximal porous coating 2-5 years postoperatively (mean 35 months). X-rays were reviewed by 2 examiners independently. Bone loss was scored with 1 point per zone with partial and 2 points per zone with complete resorption (10 zones). The Constant score was used for clinical correlation. Multiple linear regression was employed to investigate correlations between variables. RESULTS: No subsidence or shift of the stems occurred. Two of 74 patients showed 1 zone of periprosthetic lucency of 1 mm. The filling ratio averaged 0.54 (range: 0.36-0.75). Thirty patients (40.5%) displayed bone resorption, first seen at 16.6 months (range: 3-40 months), commonly in zones 1 and 5. A total of 22 patients had ≥1 zone with partial resorption, and 8 (10.8%) developed full thickness resorption after 32 (range: 10-49) months.One new finding was that female sex and older age accounted for 51% of the variation of the filling ratio. A high filling ratio, especially when >0.55, correlated with bone resorption (P < .001). Age, sex, and prosthesis type did not directly predict bone resorption. Bony sclerosis correlated with a high filling ratio (P = .019) and thereby indirectly with resorption. A direct correlation between sclerosis and resorption was narrowly insignificant (P = .058) once correcting for the filling ratio. Reverse shoulder prosthesis had a higher filling ratio than total shoulder prosthesis patients (P < .001), resulting indirectly in more bone resorption. The preoperative diagnosis did not significantly correlate with the filling ratio (P = .59) or the resorption score (P = .69). A varus or valgus alignment did not predict resorption (P = .21) or the formation of sclerotic lines (P = .93). Bone loss did not correlate with clinical results. CONCLUSIONS: These short stems are firmly anchored 2-5 years postoperatively. However, significant bone loss, linked to a high filling ratio (>0.55), is observed proximally around these stems. The development of sclerotic lines around the stem indicates oversizing. Other factors were not found to have a significant effect on stem ingrowth. The implantation of stems with a large filling ratio is more common in older females and in patients receiving reverse shoulder prosthesis. Autologous impaction bone grafting could downsize the required stem. If adequate hold is not afforded by a suitably small stem, cementation is advisable.

Tendon-derived stem cells from the long head of the biceps tendon: Inflammation does not affect the regenerative potential.

OBJECTIVES: The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration. METHODS: In total, 22 resected LHB tendons were classified into inflamed samples (n = 11) and non-inflamed samples (n = 11). Proliferation potential and specific marker gene expression of primary LHB-derived cell cultures were analyzed. Multipotentiality, including osteogenic, adipogenic, chondrogenic, and tenogenic differentiation potential of both groups were compared under respective lineage-specific culture conditions. RESULTS: Inflammation does not seem to affect the proliferation rate of the isolated tendon-derived stem cells (TDSCs) and the tenogenic marker gene expression. Cells from both groups showed an equivalent osteogenic, adipogenic, chondrogenic and tenogenic differentiation potential in histology and real-time polymerase chain reaction (RT-PCR) analysis. CONCLUSION: These results suggest that the LHB tendon might be a suitable cell source for regenerative approaches, both in inflamed and non-inflamed states. The LHB with and without tendinitis has been characterized as a novel source of TDSCs, which might facilitate treatment of degeneration and induction of regeneration in shoulder surgery.Cite this article: J. Schmalzl, P. Plumhoff, F. Gilbert, F. Gohlke, C. Konrads, U. Brunner, F. Jakob, R. Ebert, A. F. Steinert. Tendon-derived stem cells from the long head of the biceps tendon: Inflammation does not affect the regenerative potential. Bone Joint Res 2019;8:414-424. DOI: 10.1302/2046-3758.89.BJR-2018-0214.R2.

Pyrolytic carbon humeral head in hemi-shoulder arthroplasty: preliminary results at 2-year follow-up.

BACKGROUND: In patients with osteoarthritis (OA) and an intact rotator cuff, hemi-shoulder arthroplasty (HSA) can be a viable option as it offers the advantage of keeping the native glenoid intact. However, glenoid erosion has frequently been reported. The aim of this study was to report preliminary clinical results of HSA with a new pyrolytic carbon (pyrocarbon) humeral head. METHODS: This prospective multicenter study included a continuous series of 65 patients who underwent pyrocarbon HSA in 5 centers. RESULTS: At the time of analysis, 1 patient was lost to follow-up, 3 patients underwent revision, and 61 patients were evaluated at a mean follow-up of 25.9 ± 3.3 months. The mean age at index surgery was 57.9 ± 13.3 years. The indications were primary glenohumeral OA in 37 patients, osteonecrosis in 11, secondary OA in 11, and rheumatoid arthritis in 2. The mean Constant score increased from 31.0 ± 15.8 points at baseline to 74.6 ± 17 points at last follow-up. Radiographic analyses showed that 86% of glenoids remained unchanged whereas 14% evolved slightly. CONCLUSIONS: Pyrocarbon HSA grants improvement in pain and function in patients with primary OA or secondary OA after instability but at a lower level in patients with post-traumatic sequelae (secondary OA or osteonecrosis). These preliminary clinical and radiologic results are encouraging, although they need to be confirmed by longer-term follow-up observations.

Validation of a new classification for periprosthetic shoulder fractures.

INTRODUCTION: Successful treatment of periprosthetic shoulder fractures depends on the right strategy, starting with a well-structured classification of the fracture. Unfortunately, clinically relevant factors for treatment planning are missing in the pre-existing classifications. Therefore, the aim of the present study was to describe a new specific classification system for periprosthetic shoulder fractures including a structured treatment algorithm for this important fragility fracture issue. METHODS: The classification was established, focussing on five relevant items, naming the prosthesis type, the fracture localisation, the rotator cuff status, the anatomical fracture region and the stability of the implant. After considering each single item, the individual treatment concept can be assessed in one last step. To evaluate the introduced classification, a retrospective analysis of pre- and post-operative data of patients, treated with periprosthetic shoulder fractures, was conducted by two board certified trauma surgery consultants. RESULTS: The data of 19 patients (8 male, 11 female) with a mean age of 74 ± five years have been analysed in our study. The suggested treatment algorithm was proven to be reliable, detected by good clinical outcome in 15 of 16 (94%) cases, where the suggested treatment was maintained. Only one case resulted in poor outcome due to post-operative wound infection and had to be revised. CONCLUSIONS: The newly developed six-step classification is easy to utilise and extends the pre-existing classification systems in terms of clinically-relevant information. This classification should serve as a simple tool for the surgeon to consider the optimal treatment for his patients.

Impingement Syndrome of the Shoulder.

BACKGROUND: Shoulder pain is the third most common musculoskeletal complaint in orthopedic practice. It is usually due to a defect of the rotator cuff and/or an impingement syndrome. METHODS: This review is based on pertinent literature retrieved by a selective search of the Medline database. RESULTS: Patients with shoulder impingement syndrome suffer from painful entrapment of soft tissue whenever they elevate the arm. The pathological mechanism is a structural narrowing in the subacromial space. A multiplicity of potential etiologies makes the diagnosis more difficult; it is established by the history and physical examination and can be confirmed with x-ray, ultra - sonography, and magnetic resonance imaging. The initial treatment is conservative, e.g., with nonsteroidal antiinflammatory drugs, infiltrations, and patient exercises. Conservative treatment yields satisfactory results within 2 years in 60% of cases. If symptoms persist, decompressive surgery is performed as long as the continuity of the rotator cuff is preserved and there is a pathological abnormality of the bursa. The correct etiologic diagnosis and choice of treatment are essential for a good outcome. The formal evidence level regarding the best treatment strategy is low, and it has not yet been determined whether surgical or conservative treatment is better. CONCLUSION: Randomized controlled therapeutic trials are needed so that a standardized treatment regimen can be established.

Is the humeral stem useful in anatomic total shoulder arthroplasty?

PURPOSE: Traditionally and since Neer, the humeral side of shoulder arthroplasty consisted of a stemmed component but the real need for stem fixation in total shoulder arthroplasty (TSA) has barely been investigated. The current study evaluated the clinical and radiological outcomes with a stemless TSA. METHODS: Forty-seven patients, 20 female and 27 male patients with an average age of 63, were selected in four orthopaedic centres during a four year period, and implanted with a humeral head prosthesis with a three-fin design and titanium coating. Aetiologies were: primary osteoarthritis (29), fracture sequelae (12) and avascular osteonecrosis (6). Minimum follow-up was two years (range 24-51 months). The patients were evaluated with the Constant score (CS) and radiological exams. RESULTS: Two patients had revision of the implants, one for persistent pain and one for secondary massive rotator cuff tear. At the final follow-up, the mean CS was 69, with an average gain of 36. All parameters improved with a foremost in pain relief. Mean satisfaction rate was 87%. Average anterior active elevation was 131° with a gain of 48. Radiologic evaluations showed stable implants in all cases. However, 17 cases demonstrated radiolucent areas, particularly superior and lateral to the implant, which neither decreased nor increased with time. No revisions were related to humeral component loosening. CONCLUSIONS: Stemless TSA provides the same results as compared to TSA with a humeral stem. We are still unsure as to the nature of the lucent zones and we are continuing our investigation to better understand this radiological phenomenon.

Gorham-Stout syndrome of the shoulder.

INTRODUCTION: Gorham-Stout syndrome (GSS) is a rare but severe subtype of idiopathic osteolysis. There are no guidelines for the treatment of GSS. We analysed different diagnostic and therapeutic regimes and we describe the sucessful treatment of GSS considering individual patient factors. METHODS: We diagnosed three patients with shoulder-specific GSS using clinical, radiological and histopathological examinations. Two out of three patients with similar clinical appearances were treated non-operatively. One patient was treated by reverse shoulder arthroplasty. All patients were analysed retrospectively using clinical and radiological evaluation with a mean follow-up of 42 (range 30-50) months. RESULTS: Two patients had few symptoms of GSS and were treated conservatively. One patient underwent arthroplasty, with a good clinical result. No additional therapy, such as radiation or anti-resorptive medications, was needed for the stable fixation of the prosthesis and the termination of osteolysis. In all patients we found good clinical outcomes with high patient satisfaction. DISCUSSION: GSS is diagnosed after exclusion of infectious, malignant, and systemic disorders. The diagnosis should be supported by clinical, radiological, and histopathological characteristics of patients. Different humoral and cellular changes have been reported in GSS, but lack sufficient supporting evidence. GSS is associated with angiomatous and lymphatic malformations. The changes in GSS and the theories of its pathophysiology may reveal.

The fulcrum axis: a new method for determining glenoid version.

Previously applied methods for the evaluation of glenoid version did not use body-surface landmarks; therefore, it is not possible to get information about glenoid version from the outside. The tip of the coracoid and the posterolateral corner of the acromion can easily be found on the body surface. These 2 landmarks were connected by a line called the fulcrum axis. After using an experimental x-ray technique in 143 human cadaver scapulae, 5 independent observers identified the fulcrum axis and the glenoid fossa twice. The resulting overall angle between the fulcrum axis and the glenoid fossa was 1.8 degrees (SD 4.5). The fulcrum axis may be used for the preoperative planning and the intraoperative evaluation of glenoid version while performing total shoulder arthroplasties. As the fulcrum axis and the plane of the glenoid fossa are approximately parallel, the fulcrum axis can be used to position patients for performing a true antero-posterior x-ray.

Hemiarthroplasty for Humeral Head Fractures.

OBJECTIVE: Replacement of the fractured humeral head with a modular prosthesis. The procedure aims at an adequate reconstruction of shape and function of the shoulder. INDICATIONS: Displaced three- and four-part fractures of the proximal humerus that cannot be reduced and internally fixed. CONTRAINDICATIONS: Fracture can be reduced and adequately internally fixated. Noncompliant patient. SURGICAL TECHNIQUE: In beach-chair position, the fractured humeral head is removed via a deltopectoral approach. The Aequalis modular fracture prosthesis can be positioned by two methods: (i) a fracture jig optimizing height and retroversion of the prosthesis, (ii) under additional intraoperative fluoroscopy. Healing of the tuberosities can be promoted by cancellous grafts taken from the fractured head. These are fixed by four heavy sutures running horizontally and two sutures running vertically. RESULTS: 13 out of 22 patients treated by primary hemiarthroplasty (within 10 days after the fracture) and 34 out of 50 patients treated by secondary arthroplasty could be assessed after a mean follow-up of 40 (15-70) and 44 (8-98) months, respectively. The absolute Constant score amounted to 45 and 50 points, respectively, and the relative score to 56% in both groups. The majority of patients was free of pain or suffered less pain than before the operation (secondary arthroplasty; p < 0.001). In contrast to these, only satisfactory, objective results, self-assessment was good or better than before (secondary prostheses; p < 0.001). In both groups, prognostic factors were the size and position of the tuberosities (p < 0.001).

Classification of calcaneal fractures by spiral computed tomography: implications for surgical treatment.

The purpose of this study was to evaluate spiral computed tomography and multislice CT (SCT/MSCT) with multiplanar reconstructions (MPR) in the classification of calcaneal fractures according to a modified CT classification and to quantify fragment displacement to guide surgical treatment. Forty-eight calcaneal fractures were examined by spiral CT (1- to 2-mm slice thickness, pitch=1.5) with multiplanar reconstructions (MPR). Fractures were grouped according to a modified Munich classification scheme, differentiating six categories of fractures by joint involvement, number of fragments in the posterior facet, and the presence and extent of displacement. A qualitative and quantitative statement was made for the presence of clinical relevant displacement of the posterior articular facet (A: >2 mm), widening of the heel (B: crossing fibular reference line), reduction in calcaneal height (C: >10%), and axis shift of the calcaneocuboid angle (D: >10 degrees ). Treatment recommendations resulting from the CT classification were retrospectively compared with the treatment given by examining the patients' files. There were 10 extra-articular and 38 intra-articular fractures; 8 were in class I (extra-articular, nondisplaced), 2 in class II (extra-articular, displaced), 1 in class III (intra-articular, nondisplaced), 20 in class IV (two fragments), 9 in class V (three fragments), and 8 in class VI (>4 fragments), one of the latter being uncertain; 34 showed displacement of the articular facet, 35 widening of the heel, 35 reduction in calcaneal height, and 20 a shift of the axis. In 94% of the cases the procedure recommended by the Munich system of classification was followed; there was disagreement in 1 case in class I and 1 in class IV. Spiral CT allowed fracture classification and quantification of relevant displacement of fragments by radiologists. The implemented recommendations for treatment were adopted by surgeons in most cases.