Review of Dohan Eherenfest et al. (2009) on "Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF)".

This classic discusses the original publication of Dohan Eherenfest et al. on "Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF)", in which the authors propose four categories of platelet concentrates depending on their leucocyte and fibrin content (P-PRP, leucocyte- and platelet-rich plasma (L-PRP), pure platelet-rich fibrin (P-PRF), and L-PRF) to group a "jungle" of products in which the term platelet-rich plasma (PRP) was used indistinctly. They were able to identify common factors such as: (1) the use of anticoagulants and immediate centrifugation of the blood after its collection; (2) most preparation techniques allowed platelet concentrate preparation within an hour; (3) the centrifugation aimed to separate the blood in layers that would allow the extraction of specific fractions; and (4) the product was activated with thrombin or calcium chloride. The reviewed manuscript has been listed among the most cited PRP articles in regenerative medicine, with more than 800 citations, driving current scientific research and clinical practise by categorising L-PRP and P-PRP (now, leucocyte-poor PRP). The classification has also opened the door to understanding intrinsic biological mechanisms between platelets, leukocytes, fibrin, and growth factors, which will later be considered for studying the proliferation and differentiation of cells in different tissues affected by PRP. Since the initial classification of platelet concentrates, several other classification systems have been proposed and published in the current literature such as platelet, activation, white blood cell (PAW), Mishra, platelet, leucocyte, red blood cells, and activation (PLRA), dose of platelet, efficiency, purity, and activation (DEPA), method, activation, red blood cells, spin, platelets, image guidance, leukocytes, and light activation (MARSPILL), etc. These classifications have identified important aspects of PRP that affect the biological composition and, ultimately, the indications and outcomes. To date, there is still a lack of standardisation in sample preparation, cohort heterogeneity, and incomplete reporting of sample preparation utilised, leading to a lack of clarity and challenging researchers and clinicians.

Global impact of COVID-19 on surgeons and team members (GlobalCOST): a cross-sectional study.

OBJECTIVES: To investigate the impact of COVID-19 on the well-being of surgeons and allied health professionals as well as the support provided by their institutions. DESIGN: This cross-sectional study involved distributing an online survey through medical organisations, social media platforms and collaborators. SETTING: It included all staff based in an operating theatre environment around the world. PARTICIPANTS: 1590 complete responses were received from 54 countries between 15 July and 15 December 2020. The average age of participants was 30-40 years old, 64.9% were men and 32.5% of a white ethnic background. 79.5% were surgeons with the remainder being nurses, assistants, anaesthetists, operating department practitioners or classified other. MAIN OUTCOME MEASURES: Participants that had experienced any physical illness, changes in mental health, salary or time with family since the start of the pandemic as well as support available based on published recommendations. RESULTS: 32.0% reported becoming physically ill. This was more likely in those with reduced access to personal protective equipment (OR 4.62; CI 2.82 to 7.56; p<0.001) and regular breaks (OR 1.56; CI 1.18 to 2.06; p=0.002). Those with a decrease in salary (29.0%) were more likely to have an increase in anxiety (OR 1.50; CI 1.19 to 1.89; p=0.001) and depression (OR 1.84; CI 1.40 to 2.43; p<0.001) and those who spent less time with family (35.2%) were more likely to have an increase in depression (OR 1.74; CI 1.34 to 2.26; p<0.001). Only 36.0% had easy access to occupational health, 44.0% to mental health services, 16.5% to 24/7 rest facilities and 14.2% to 24/7 food and drink facilities. Fewer measures were available in countries with a low Human Development Index. CONCLUSIONS: This work has highlighted a need and strategies to improve conditions for the healthcare workforce, ultimately benefiting patient care.

The Effect of the COVID-19 Pandemic on Theatre Efficiency, Lessons to be Learned for Subsequent Waves.

Background: This study aims to demonstrate the impact of the COVID-19 pandemic on providing trauma services at our district general hospital. We aim to identify the impact on specific areas of theatre delay to help optimize theatre efficiency and generate better protocols and improve patient flow for future pandemic waves. Methods: Patients who underwent orthopaedic trauma surgery at our hospital between July-August 2019 (pre-COVID-19) and 2020 (first UK wave of COVID-19) were identified retrospectively and grouped by year of operation. Type of operation was recorded, including time for sending, anaesthetic induction, surgical preparation, operating time, and time for transfer to recovery. The two groups were compared for analysis. Results: Case numbers were similar in both 2019 and 2020 (215vs.213 operations), with a similar proportion being hip fractures (39.1% and 36.6%), respectively. Median sending time (40vs.23 minutes, P <0.00001) and induction time (13vs.8 minutes, P<0.00001) were increased in 2020, a 74% and 63% increase compared to 2019, respectively. Median surgical preparation time (35vs.37 minutes, P=0.06) and operating time (56vs.50 minutes, P=0.16) were not statistically significant. Transfer time in 2020 (16vs.13 minutes, P<0.00001) was significantly increased. Overall case time increased in 2020 (2:40vs.2:11, P<0.00001) by 29 minutes. Conclusion: COVID-19 had a significant impact on theatre efficiency in our hospital, causing multiple points of delay. As hospitals across the UK restart crucial elective services, focus should be given to maximizing theatre efficiency by providing rapid access COVID-19 testing for patients undergoing emergency surgery. We have proposed and implemented several steps for better theatre utilization.

Lunotriquetral Ligament Repair Using Augmented Internal Brace.

Lunotriquetral (LT) ligament tear, usually in combination with an adjacent carpal ligament injury, can result in complete LT dissociation and VISI (Volarflexed Intercalated Segment Instability). Operative techniques for the management of instability are highly variable with many described in literature, although there is little evidence to demonstrate the superiority of one definitive therapeutic technique of repair and reconstruction. In this paper, we discuss our proposed technique for performing LT ligament repair using an augmented internal brace, which addresses triquetral extension and lunate flexion. The internal brace construct also provides biomechanical superiority as it includes the augmentation of the ligament and capsule repair. We use figures and references from our case example to demonstrate this technique.

Prospective multicentre mid-term clinical and radiological outcomes of 159 reverse total shoulder replacements and assessment of the influence of post-operative complications.

Background: The aim of our prospective multicentre study is to evaluate the five-year follow-up outcomes of primary reverse shoulder replacement utilizing two different designs of glenoid baseplates. Methods: There were 159 reverse shoulder replacements (91 cemented and 68 uncemented stems, 67 Trabecular Metal baseplates and 92 Anatomical Shoulder baseplates in 152 patients (99 women) with a mean age of 74.5 (58-90) years. The principal diagnosis was rotator cuff arthropathy in 108 shoulders. Results: Clinical and functional results improved significantly overall; the adjusted Constant Murley score improved from 28.2 ± 13.3 pre-operatively to 75.5 ± 22.8 (p < 0.0001) and the mean Subjective Shoulder Value improved from 27.5 ± 20 to 73.8 ± 21.3 points (p < 0.0001). Radiologically, there was good bony stability in 88% and 86% of cemented and uncemented stems without significant impact on the Constant Murley score and Subjective Shoulder Value at one, two and five years post-surgery. There were no significant clinical differences between Trabecular Metal and Anatomical Shoulder baseplates at five years. There were four cases of intraoperative shaft fractures that were managed with cables. Although the Trabecular Metal baseplates showed better integration radiologically, there was no significant difference in the mean of Constant Murley, Subjective Shoulder Value and the range of motion depending on the grade of inferior scapular notching at one-, two- and five-year intervals. Conclusions: Reverse total shoulder arthroplasty restores the function in shoulder with significant improvements in function and moderate complications with minor differences between both designs of baseplates that were not reflected clinically.

Clinical and Radiological Outcomes of Rotator Cuff Repairs Using All-Suture Anchors as Medial Row Anchors.

BACKGROUND: The aim of our study is to report the clinical and radiological outcomes of a series of prospectively enrolled patients who have had double-row transosseous equivalent rotator cuff repairs, where all-suture anchors were used as medial-row anchors, with a minimum follow-up of 1 year. METHODS: Twenty-two consecutive patients underwent arthroscopic transosseous equivalent double-row rotator cuff repair using all-suture anchors as medial-row anchors. Oxford Shoulder Score, Constant Score and Visual Analogue Scale pain score, together with shoulder range of motion, were used preoperatively and at 3 months, 6 months and final follow-up. Radiological evaluation was performed with magnetic resonance imaging at one-year post surgery to assess the structural integrity of the repair and the rate of cyst formation in greater tuberosity. RESULTS: The patient mean age was 61 years (range 46-75). Minimum follow-up was 1 year, and the mean final follow-up was 15 months (range 12-24). Healing failure in our patients was less than 5% (1/22 patients). There were significant improvements in shoulder function outcome scores at final follow-up. The Constant and Oxford scores were 78 and 44 at final follow-up respectively. There were similar magnitudes of improvement in range of motion (combined abduction and rotation), pain score and supraspinatus strength at final follow up. The improvements in outcome scores were already statistically significant at 3 months (P<.001). Using Kim's classification for cyst formation on T2-weighted MRI images, we observed no fluid or minimal fluid collection in 85% of the patients (17/22 patients). There were no correlations between the grade of bone changes and the clinical outcomes. CONCLUSION: It is safe to use all-suture anchors as medial-row anchors when performing double-row anchor transosseous equivalent rotator cuff repairs. The purported advantages of all-suture anchors may outweigh their perceived disadvantages in rotator cuff repair surgery.

Aerosol generating procedures in trauma and orthopaedics in the era of the Covid-19 pandemic; What do we know?

PURPOSE: COVID-19 pandemic has created havoc all over the globe and spared no one regardless of status, gender, location and ethnicity. There were questions raised if trauma and orthopaedic (T&O) procedures actually generated aerosols? The need for a review of literature highlighting the nature and impact of aerosol generation within T&O surgery was noted. METHODS: A comprehensive online search was performed for all published articles in the English language, evaluating AGPs in T&O surgery and the relevant personal protection equipment used. RESULTS: The search strategy populated 43 studies. Six studies were identified as duplicates. The shortlisted 37 studies were screened and nine studies were included in the review. An additional four studies were included from the bibliography review. CONCLUSION: Most orthopaedic procedures are high-risk aerosol generating procedures (AGPs). Conventional surgical masks do not offer protection against high-risk AGPs. In the current era of COVID-19 pandemic, there is a significant risk to the transmission of infection to the theatre staff. For protection against airborne transmission, appropriate masks should be used. These need proper fitting and sizing to ensure full protection when used.

Bankart Repair Versus Latarjet Procedure for Recurrent Anterior Shoulder Instability: A Systematic Review and Meta-analysis of 3275 Shoulders.

BACKGROUND: Little consensus is available regarding the standard treatment for recurrent anterior instability of the shoulder. Typically, treatment selection has been based on training and tradition rather than the available evidence. PURPOSE: This study aimed to compare the clinical outcomes between arthroscopic Bankart procedure and the Latarjet procedure in the treatment of recurrent anterior shoulder instability with emphasis on follow-up time. STUDY DESIGN: Systematic review and meta-analysis. METHODS: We searched PubMed, Cochrane Central Register of Controlled Trials, Scopus, Ovid, and Web of Science up to January 2018 and included studies that compared arthroscopic Bankart versus Latarjet for treatment of anterior shoulder instability. Continuous data, such as operative time and patient-reported outcomes, were pooled as mean differences (MDs), whereas dichotomous data, such as recurrence, revision, redislocation, arthropathy, infection, and hematoma, were pooled as risk ratios (RRs), with 95% CIs. RESULTS: Pooling data from 7 cohort studies (3275 patients) showed that arthroscopic Bankart was associated with a higher risk of redislocation (RR, 2.74; 95% CI, 1.48-5.06; P = .03), a higher risk of recurrence (RR, 2.87; 95% CI, 1.91-4.30; P < .0001), and a lower risk of infection (RR, 0.16; 95% CI, 0.06-0.43; P = .0002) compared with Latarjet, while the effect size did not favor arthroscopic Bankart or Latarjet in terms of Rowe score (MD, 0.22; 95% CI, -5.64 to 6.08; P = .94), revision (RR, 0.34; 95% CI, 0.08-1.39; P = .13), and hematoma (RR, 0.20; 95% CI, 0.03-1.19; P = .07). The effect estimate showed a pronounced advantage for Latarjet from 6 to 10 years postoperatively in terms of recurrence and redislocation (RR, 3.00; 95% CI, 1.98-4.56 and RR, 2.85; 95% CI, 1.51-5.38, respectively). CONCLUSION: Our results showed that Latarjet had less risk of recurrence and redislocation with longer follow-up time. Both procedures were comparable in terms of Rowe score, the need for revision, and postoperative hematoma formation, whereas Bankart repair was associated with a lower risk of infection.

Posterior Shoulder Instability: The Augmented McLaughlin Procedure.

Posterior shoulder dislocation, whilst uncommon, is frequently missed and often associated with a significant defect on the antero-medial aspect of the humeral head (the reverse Hill-Sachs lesion). Several techniques for stabilisation have been described, depending on the size of the lesion. We describe an additional technique for stabilising the shoulder following posterior dislocation by augmenting the reverse Hill-Sachs lesion with layers of extracellular matrix, thus further filling the defect.

Hamburger Technique: Augmented Rotator Cuff Repair With Biological Superior Capsular Reconstruction.

Despite profound advancements in arthroscopic rotator cuff repair (RCR) techniques, radiologic failure rates may be in excess of 60% with repairs of large and massive tears in the elderly population. One of the strategies to improve these healing rates has been "patch" augmentation of the cuff repair. At the same time, superior capsular reconstruction (SCR) has gained significant popularity as an option for irreparable rotator cuff (RC) tears. Some have also advocated performing SCR in addition to arthroscopic RCR to reinforce the repair and improve healing rates. Techniques involving the use of fascia lata, ECM patches, and long head of the biceps (LHB) for SCR to reinforce the cuff repair have all been elegantly described. In this article, we propose a technique that enables a combination of the aforementioned procedures and involves performing RCR with patch augmentation, as well as SCR using LHB. In doing so, the repaired RC is bordered by the patch over its bursal surface and the LHB on the articular surface (functioning as the superior capsule), thus giving us the name "Hamburger technique" (a 3-layered construct).

Normal Wrist Development in Children and Adolescents: A Geometrical Observational Analysis Based on Plain Radiographs.

BACKGROUND: To investigate the geometric development of the wrist in relation to the changes in its ossification pattern. This study will help the treating surgeon to identify early deviations from normal in children with musculoskeletal disorders and provide a template for anatomic reduction after trauma scenarios. METHODS: A retrospective multicenter analysis was carried out of radiographs of 896 children (896 posteroanterior and 896 lateral views) with normal wrists from January 1996 till April 2016. We stratified patients into different yearly age groups; these included 16 age groups from 1 to 16 years, and 2 sex groups: males and females. We evaluated, depending on the wrist ossification pattern, the ulnar variance, radial and carpal heights, carpal height ratio, radial inclination, volar tilt, together with radiocarpal, scapholunate, and capitate-lunate angles and scapholunate distance. RESULTS: Our analysis showed that the ulna minus variance predominates in children. Radial height, radial inclination, and radiocarpal angle increase steadily during growth and reach their respective expected values at the beginning of the pubertal growth spurt. The scapholunate and capitolunate angles showed a downward trend with growth till reaching the adult values at puberty. Carpal height increased constantly, whereas the carpal height ratio was similar to that in adults. Volar tilt was not developed until the age of 12 years, when it started to increase gradually to reach the adult values by puberty. Both sexes have similar measurements. CONCLUSIONS: Most radiologic parameters showed reproducible anatomic changes till the 12-year-old time-point. After that, there are minimal changes till adulthood. CLINICAL RELEVANCE: The study findings offer a template of pediatric normal values guiding hand and pediatric surgeons in treatment of children with wrist pathology.

The unicortical sternoclavicular joint reconstruction using synthetic graft.

Sternoclavicular joint injuries represent 5% of all injuries to the shoulder complex. We report a safe and reproducible technique for reconstruction of anterior sternoclavicular joint dislocations, employing a synthetic graft using a unicortical technique with minimal dissection anterior to the joint.

The Ellipse modification of the Friedman method for measuring glenoid version.

AIMS: Accurate measurement of the glenoid version is important in performing total shoulder arthroplasty (TSA). Our aim was to evaluate the Ellipse method, which involves formally defining the vertical mid-point of the glenoid prior to measuring the glenoid version and comparing it with the 'classic' Friedman method. METHODS: This was a retrospective study which evaluated 100 CT scans for patients who underwent a primary TSA. The glenoid version was measured using the Friedman and Ellipse methods by two senior observers. Statistical analyses were performed using the paired t-test for significance and the Bland-Altman plot for agreement. RESULTS: The mean glenoid version was -3.11° (-23.8° to 17.9°) using the Friedman method and -1.95° (-29.8° to 24.6°) using the Ellipse method (p = 0.002). In 16 patients the difference between methods was greater than 5°, which we considered to be clinically significant. There was poor agreement between methods with relatively large 95% limits of agreement. There was excellent inter-rater agreement between the observers for the Ellipse method and similarly, the intrarater agreement was excellent with a repeatability coefficient of 0.94. CONCLUSION: We recommend the use of the Ellipse modification to define the mid glenoid point prior to measuring the glenoid version in patients undergoing TSA. Cite this article: Bone Joint J 2020;102-B(2):232-238.

A simple reproducible technique for the retrieval of broken proximal femoral blades, a technical note and review of literature.

Despite advances in metallurgy, fatigue failure of hardware in orthopaedics is common especially when a fracture fails to heal. Revision procedures can be difficult, usually requiring removal of intact or broken hardware. Several different methods are usually used to successfully remove the intact or broken hardware. The proximal blade fracture is rare and under-reported in the literature. In our tertiary non-union and limb reconstruction unit, we have developed a technique for an easy and quick removal of a broken proximal femoral blades.

Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results.

HYPOTHESIS: Is salvage reverse total shoulder arthroplasty (RTSA) a justifiable treatment for failed operative treatment (open reduction-internal fixation [ORIF] or primary and secondary hemiarthroplasty) of proximal humeral fractures in patients younger than 60 years? METHODS: Thirty patients (mean age, 52 years; age range, 30-59 years) were reviewed after a mean follow-up period of 11 years (range, 8-18 years). Of the patients, 7 (23%) underwent RTSA for failed ORIF and 23 (77%) for failed hemiarthroplasty. Clinical and radiographic outcomes were assessed longitudinally. RESULTS: At final follow-up, the mean relative Constant score had improved from 25% (±12%) to 58% (±21%, P < .001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45° to 106°), abduction (42° to 99°), pain scores, and strength (P < .001). Clinical outcomes did not significantly deteriorate over a period of 10 years. Patients with salvage RTSA for failed secondary hemiarthroplasty (n = 8) vs. those for failed ORIF (n = 6) showed significantly inferior active abduction (77° vs. 116°, P = .023). Patients with a healed greater tuberosity (n = 9) showed significantly better external rotation than patients with a resorbed/resected greater tuberosity (n = 13, 21° vs. 3°, P = .025). One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA. CONCLUSIONS: Salvage RTSA in patients younger than 60 years is associated with a high complication rate. It leads nonetheless to substantial and durable improvement beyond 10 years, provided the complications can be handled with implant retention. Inferior shoulder function is associated with greater tuberosity resorption or resection and inferior overhead elevation with the diagnosis of failed hemiarthroplasty.

Posterior Acromial Morphology Is Significantly Associated with Posterior Shoulder Instability.

BACKGROUND: The purpose of this paper was to determine whether acromial morphology influences anteroposterior shoulder stability. We hypothesized that a more horizontal and higher position of the acromion in the sagittal plane would be associated with posterior instability. METHODS: In this retrospective study, patients with unidirectional posterior instability were age and sex-matched to a cohort of patients with unidirectional anterior instability. Both cohorts were compared with a control group of patients with no instability and no degenerative glenohumeral (rotator cuff and/or joint surface) or acromial changes. Measurements on radiographs included posterior acromial tilt, anterior and posterior acromial coverage (AAC and PAC), posterior acromial height (PAH), and the critical shoulder angle (CSA). RESULTS: The number of patients enrolled in each instability group was 41, based on a priori power analysis. The control group consisted of 53 shoulders. Of the measured anatomic factors, PAH showed the most significant association with posterior instability (odds ratio [OR] = 1.8; p < 0.001) in the logistic regression model. PAH was significantly greater in the posterior instability group compared with the anterior instability group (30.9 versus 19.5 mm; p < 0.001). With a cutoff value of PAH of 23 mm, the OR for posterior instability was 39. Shoulders with posterior instability were also significantly different from normal shoulders with regard to PAH (p < 0.001), AAC (p < 0.001), and PAC (p < 0.001) whereas, in the shoulders with anterior instability, all of these values except the AAC (p = 0.011) did not differ from those of normal shoulders. CONCLUSIONS: Specific acromial morphology is significantly associated with the direction of glenohumeral instability. In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability; this acromial position may provide less osseous restraint against posterior humeral head translation. A steep "Swiss chalet roof-type" acromion virtually excluded recurrent posterior instability in an albeit relatively small cohort of patients. Additional investigation is needed to determine the relevance of these findings for future treatment. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sliding hip screws versus cancellous screws for femoral neck fractures: a systematic review and meta-analysis.

PURPOSE: Both sliding hip screws (SHS) and cancellous screws are used in the surgical management of intracapsular femoral neck fracture. However, there is paucity of information as to which is the superior treatment modality. We performed this systematic review and meta-analysis study to compare the clinical outcomes of SHS and cancellous screws for the treatment of femoral neck fractures in adult patients. METHODS: We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL, up to December 2017. Randomized controlled trials (RCTs) directly comparing the clinical outcomes of SHS and cancellous screws for femoral neck fractures were retrieved with no language or publication year restrictions. Data retrieved included operative details, nonunion rate, avascular necrosis, reoperation, infection and mortality, hip pain, functional hip scores, and medical complications. These were pooled as risk ratio or mean difference (MD) with their corresponding 95% confidence interval (CI). Heterogeneity was assessed by Chi-square test. RESULTS: Ten RCTs involving 1934 patients were included in the final analysis. The pooled estimate showed that the SHS group was associated with more intraoperative blood loss (MD = 110.01 ml, 95% CI [52.42, 167.60], p = 0.00002) than the cancellous screws. There was no significant difference in terms of operative time, postoperative hip function, nonunion, avascular necrosis, reoperation rate, infection, fracture healing, hip pain, medical complications, and mortality rate. CONCLUSION: Based on our study, the cancellous screws group was associated with less intraoperative blood loss in comparison with the SHS group. No other significant differences were found between the two interventions.

Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: A pooled analysis of 30,250 participants data.

PURPOSE: To assess the clinical outcomes of unipolar versus bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures in older patients and to report whether bipolar implants yield better long-term functional results. METHODS: We searched PubMed, Scopus, EBSCO, and Cochrane Library for relevant randomized clinical trials (RCTs) and observational studies, comparing unipolar and bipolar hemiarthroplasty. Data were extracted from eligible studies and pooled as relative risk (RR) or mean difference (MD) with corresponding 95% confidence intervals (CI) using RevMan software for Windows. RESULTS: A total of 30 studies were included (13 RCTs and 17 observational studies). Analyses included 30,250 patients with a mean age of 79 years and mean follow-up time of 24.6 months. The overall pooled estimates showed that bipolar was superior to unipolar hemiarthroplasty in terms of hip function, range of motion and reoperation rate, but at the expense of longer operative time. In the longer term the unipolar group had higher rates of acetabular erosion compared to the bipolar group. There was no significant difference in terms of hip pain, implant related complications, intraoperative blood loss, mortality, six-minute walk times, medical outcomes, and hospital stay and subsequently cost. CONCLUSIONS: Bipolar hemiarthroplasty is associated with better range of motion, lower rates of acetabular erosion and lower reoperation rates compared to the unipolar hemiarthroplasty but at the expense of longer operative time. Both were similar in terms of mortality, and surgical or medical outcomes. Future large studies are recommended to compare both methods regarding the quality of life.