The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale; translation and validation of the Dutch language version for ankle fractures.

OBJECTIVES: The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale is among the most commonly used instruments for measuring outcome of treatment in patients who sustained a complex ankle or hindfoot injury. It consists of a patient-reported and a physician-reported part. A validated, Dutch version of this instrument is currently not available. The aim of this study was to translate the instrument into Dutch and to determine the measurement properties of the AOFAS Ankle-Hindfoot Scale Dutch language version (DLV) in patients with a unilateral ankle fracture. SETTING: Multicentre (two Dutch hospitals), prospective observational study. PARTICIPANTS: In total, 142 patients with a unilateral ankle fracture were included. Ten patients were lost to follow-up. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients completed the subjective (patient-reported) part of the AOFAS Ankle-Hindfoot Scale-DLV. A physician or trained physician-assistant completed the physician-reported part. For comparison and evaluation of the measuring characteristics, the Foot Function Index and the Short Form-36 were completed by the patient. Descriptive statistics (including floor and ceiling effects), reliability (ie, internal consistency), construct validity, reproducibility (ie, test-retest reliability, agreement and smallest detectable change) and responsiveness were determined. RESULTS: The AOFAS-DLV and its subscales showed good internal consistency (Cronbach's α >0.90). Construct validity and longitudinal validity were proven to be adequate (76.5% of predefined hypotheses were confirmed). Floor effects were not present. Ceiling effects were present from 6 months onwards, as expected. Responsiveness was adequate, with a smallest detectable change of 12.0 points. CONCLUSIONS: The AOFAS-DLV is a reliable, valid and responsive measurement instrument for evaluating functional outcome in patients with a unilateral ankle fracture. This implies that the questionnaire is suitable to compare different treatment modalities within this population or to compare outcome across hospitals. TRIAL REGISTRATION: The Netherlands Trial Register (NTR5613; 05-jan-2016).

Impact of the European Working Time Directive (EWTD) on the operative experience of surgery residents.

BACKGROUND: In Europe and the United States, work hour restrictions are considered to be particularly burdensome for residents in surgery specialties. The aim of this study was to examine whether reduction of the work week to 48 hours resulting from the implementation of the European Working Time Directive has affected the operative experience of surgery residents. METHODS: This study was conducted in a general surgery training region in the Netherlands, consisting of 1 university hospital and 6 district training hospitals. Operating records summarizing the surgical procedures performed as "primary surgeon" in the operating theater for different grades of surgeons were retrospectively analyzed for the period 2005-2012 by the use of linear regression models. Operative procedures performed by residents were considered the main outcome measure. RESULTS: In total, 235,357 operative procedures were performed, including 47,458 (20.2%) in the university hospital and 187,899 (79.8%) in the district training hospitals (n = 5). For residents in the university hospital, the mean number of operative procedures performed per 1.0 full-time equivalent increased from 128 operations in 2005 to 204 operations in 2012 (P = .001), whereas for residents in district training hospitals, no substantial differences were found over time. The mean (±SD) operative caseload of 64 residents who completed the 6-year training program between 2005 and 2012 was 1,391 ± 226 (range, 768-1856). A comparison of the operative caseload according to year of board-certification showed no difference. CONCLUSION: Implementation of the European Working Time Directive has not affected adversely the number of surgical procedures performed by residents within a general surgical training region in the Netherlands.

Assessment of surgery residents' operative skills in the operating theater using a modified Objective Structured Assessment of Technical Skills (OSATS): a prospective multicenter study.

BACKGROUND: With the implementation of competency-based curricula, Objective Structured Assessment of Technical Skills (OSATS) increasingly is being used for the assessment of operative skills. Although evidence for its usefulness has been demonstrated in experimental study designs, data supporting OSATS application in the operating room are limited. This study evaluates the validity and reliability of the OSATS instrument to assess the operative skills of surgery residents in the operating theater. METHODS: Twenty-four residents were recruited from seven hospitals within a general surgical training region and classified equally into three groups according to postgraduate training year (PGY). Each resident had to perform five different types of operations. Surgical performance was measured using a modified OSATS consisting of three scales: Global Rating Scale, Overall Performance Scale, and Alphabetic Summary Scale. Validity and reliability metrics included construct validity (Kruskal-Wallis test) and internal consistency reliability (Cronbach's α coefficient). Spearman's correlation coefficients were calculated to determine correlations between the different scales. RESULTS: Eighteen residents (PGY 1-2 [n = 7]; PGY 3-4 [n = 8]; PGY 5-6 [n = 3]) performed 249 operations. Comparisons of the performance scores revealed that evidence for construct validity depended on the difficulty level of the selected procedures. For individual operations, internal consistency reliability of the Global Rating Scale ranged from 0.93 to 0.95. Scores on the different scales correlated strongly (r = 0.62-0.76, P < .001). CONCLUSION: Assessment of operative skills in the operating theater using this modified OSATS instrument has the potential to establish learning curves, allowing adequate monitoring of residents' progress in achieving operative competence. The Alphabetic Summary Scale seems to be of additional value. Use of the Overall Performance Scale should be reconsidered.

Surgeons' attitude toward a competency-based training and assessment program: results of a multicenter survey.

BACKGROUND: Currently, most surgical training programs are focused on the development and evaluation of professional competencies. Also in the Netherlands, competency-based training and assessment programs were introduced to restructure postgraduate medical training. The current surgical residency program is based on the Canadian Medical Education Directives for Specialists (CanMEDS) competencies and uses assessment tools to evaluate residents' competence progression. In this study, we examined the attitude of surgical residents and attending surgeons toward a competency-based training and assessment program used to restructure general surgical training in the Netherlands in 2009. METHODS: In 2011, all residents (n = 51) and attending surgeons (n = 108) in 1 training region, consisting of 7 hospitals, were surveyed. Participants were asked to rate the importance of the CanMEDS competencies and the suitability of the adopted assessment tools. Items were rated on a 5-point Likert scale and considered relevant when at least 80% of the respondents rated an item with a score of 4 or 5 (indicating a positive attitude). Reliability was evaluated by calculating the Cronbach's α, and the Mann-Whitney test was applied to assess differences between groups. RESULTS: The response rate was 88% (n = 140). The CanMEDS framework demonstrated good reliability (Cronbach's α = 0.87). However, the importance of the competencies 'Manager' (78%) and 'Health Advocate' (70%) was undervalued. The assessment tools failed to achieve an acceptable reliability (Cronbach's α = 0.55), and individual tools were predominantly considered unsuitable for assessment. Exceptions were the tools 'in-training evaluation report' (91%) and 'objective structured assessment of technical skill' (82%). No significant differences were found between the residents and the attending surgeons. CONCLUSION: This study has demonstrated that, 2 years after the reform of the general surgical residency program, residents and attending surgeons in a large training region in the Netherlands do not acknowledge the importance of all CanMEDS competencies and consider the assessment tools generally unsuitable for competence evaluation.

Long-term effects of structured home-based exercise program on functional capacity and quality of life in patients with intermittent claudication.

OBJECTIVES: To evaluate effects of a structured home-based exercise program on functional capacity and quality of life (QoL) in patients with intermittent claudication (IC) after 1-year follow-up, and to compare these results with those from a concurrent control group who received supervised exercise training (SET). DESIGN: Comparative longitudinal cohort study. SETTING: Referral center. PARTICIPANTS: Patients (N=142) with IC. INTERVENTIONS: Structured home-based exercise training or SET. MAIN OUTCOME MEASURES: The maximum (pain-free) walking distance and the ankle-brachial index (ABI) (at rest and postexercise) were measured at baseline and after 6 and 12 months' follow-up. Additionally, QoL was evaluated using a self-administered questionnaire consisting of the Euroqol-5D (scale 0-1), rating scale (scale 0-100), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; scale 0-100), and the Vascular Quality of Life Questionnaire (VascuQol; scale 1-7). Comparison of the groups was performed with adjustment for the nonrandomized setting using propensity scoring. RESULTS: One hundred forty-two patients with IC started the structured home-based exercise program, of whom 95 (67%) completed 12 months' follow-up. The mean relative improvement compared with baseline was statistically significant after 12 months' follow-up for the maximum and pain-free walking distance (342%, 95% confidence interval [CI], 169-516; P<.01 and 338%, 95% CI, 42-635; P=.03, respectively) and for the ABI postexercise (mean change, .06; 95% CI, .01-.10; P=.02). For the QoL outcomes, the improvement compared with baseline was statistically significant after 12 months for the VascuQol (mean change, .42; 95% CI, .20-.65; P<.01) and for the SF-36 physical functioning (mean change, 5.17; 95% CI, .77-9.56; P=.02). Compared with the structured home-based exercise program, patients in the control group showed significantly better results in the mean relative improvement of maximum and pain-free walking distance and change in the ABI at rest after 12 months' follow-up. CONCLUSIONS: Structured home-based exercise training is effective in improving both functional capacity and QoL in patients with IC and may be considered as a feasible and valuable alternative toSET, since supervised exercise programs are not often available.

Osteoporosis in patients with a low-energy fracture: 3 years of screening in an osteoporosis outpatient clinic.

BACKGROUND: The prevalence of osteoporosis in the Netherlands is 52 per 1,000 men and 166 per 1,000 women (age >55 years). Previous results of an osteoporosis screening program showed that 55%, 41%, and 37.1% had osteoporosis. This study aims to evaluate the incidence of osteoporosis after low-energy fractures and to describe the care program for osteoporosis screening. The second endpoint was to investigate the incidence of risk factors in the whole study population and a subgroup analysis from the three major groups with osteoporotic fractures. METHODS: All female and male patients older than 50 years with a low-energy fracture were included for the osteoporosis screening program. Patients with a fracture of the vertebrae were also included if the age was less than 50 years. All patients underwent a bone mineral density measurement by means of dual-energy X-ray film absorptiometry. All obtained data were registered by a nurse specialist in osteoporosis, in a computerized database. RESULTS: The incidence of osteoporosis in patients with low-energy fractures is high, 46.4%. At the time of fracture presentation, there were 33.2% of the patients with a low body weight (<67 kg), almost all osteoporotic patients (96%) had a low-energy fracture occurred after their 50th year. In patients diagnosed with osteoporosis, the hip fracture is the most common fracture site (34%), followed by the humerus (20.1%). CONCLUSIONS: In conclusion, a screening program for osteoporosis is necessary and should be a tool in the armamentarium of every traumatology department.

Intermittent claudication: clinical effectiveness of endovascular revascularization versus supervised hospital-based exercise training--randomized controlled trial.

PURPOSE: To compare clinical success, functional capacity, and quality of life during 12 months after revascularization or supervised exercise training in patients with intermittent claudication. MATERIALS AND METHODS: This study had institutional review board approval, and all patients gave written informed consent. Between September 2002 and September 2005, 151 consecutive patients who presented with symptoms of intermittent claudication were randomly assigned to undergo either endovascular revascularization (angioplasty-first approach) (n = 76) or hospital-based supervised exercise (n = 75). The outcome measures were clinical success, functional capacity, and quality of life after 6 and 12 months. Clinical success was defined as improvement in at least one category in the Rutherford scale above the pretreatment level. Significance of differences between the groups was assessed with the unpaired t test, chi(2) test, or Mann-Whitney U test. To adjust outcomes for imbalances of baseline values, multivariable regression analysis was performed. RESULTS: Immediately after the start of treatment, patients who underwent revascularization improved more than patients who performed exercise in terms of clinical success (adjusted odds ratio [OR], 39; 99% confidence interval [CI]: 11, 131; P < .001), but this advantage was lost after 6 (adjusted OR, 0.9; 99% CI: 0.3, 2.3; P = .70) and 12 (adjusted OR, 1.1; 99% CI: 0.5, 2.8; P = .73) months. After revascularization, fewer patients showed signs of ipsilateral symptoms at 6 months compared with patients in the exercise group (adjusted OR, 0.4; 99% CI: 0.2, 0.9; P < .001), but no significant differences were demonstrated at 12 months. After both treatments, functional capacity and quality of life scores increased after 6 and 12 months, but no significant differences between the groups were demonstrated. CONCLUSION: After 6 and 12 months, patients with intermittent claudication benefited equally from either endovascular revascularization or supervised exercise. Improvement was, however, more immediate after revascularization.

Cost-effectiveness of endovascular revascularization compared to supervised hospital-based exercise training in patients with intermittent claudication: a randomized controlled trial.

BACKGROUND: The optimal first-line treatment for intermittent claudication is currently unclear. OBJECTIVE: To compare the cost-effectiveness of endovascular revascularization vs supervised hospital-based exercise in patients with intermittent claudication during a 12-month follow-up period. DESIGN: Randomized controlled trial with patient recruitment between September 2002-September 2006 and a 12-month follow-up per patient. SETTING: A large community hospital. PARTICIPANTS: Patients with symptoms of intermittent claudication due to an iliac or femoro-popliteal arterial lesion (293) who fulfilled the inclusion criteria (151) were recruited. Excluded were, for example, patients with lesions unsuitable for revascularization (iliac or femoropopliteal TASC-type D and some TASC type-B/C. INTERVENTION: Participants were randomly assigned to endovascular revascularization (76 patients) or supervised hospital-based exercise (75 patients). MEASUREMENTS: Mean improvement of health-related quality-of-life and functional capacity over a 12-month period, cumulative 12-month costs, and incremental costs per quality-adjusted life year (QALY) were assessed from the societal perspective. RESULTS: In the endovascular revascularization group, 73% (55 patients) had iliac disease vs 27% (20 patients) femoral disease. Stents were used in 46/71 iliac lesions (34 patients) and in 20/40 femoral lesions (16 patients). In the supervised hospital-based exercise group, 68% (51 patients) had iliac disease vs 32% (24 patients) with femoral disease. There was a non-significant difference in the adjusted 6- and 12-month EuroQol, rating scale, and SF36-physical functioning values between the treatment groups. The gain in total mean QALYs accumulated during 12 months, adjusted for baseline values, was not statistically different between the groups (mean difference revascularization versus exercise 0.01; 99% CI -0.05, 0.07; P = .73). The total mean cumulative costs per patient was significantly higher in the revascularization group (mean difference euro2318; 99% CI 2130 euros, 2506 euros; P < .001) and the incremental cost per QALY was 231 800 euro/QALY adjusted for the baseline variables. One-way sensitivity analysis demonstrated improved effectiveness after revascularization (mean difference 0.03; CI 0.02, 0.05; P < .001), making the incremental costs 75 208 euro/QALY. CONCLUSION: In conclusion, there was no significant difference in effectiveness between endovascular revascularization compared to supervised hospital-based exercise during 12-months follow-up, any gains with endovascular revascularization found were non-significant, and endovascular revascularization costs more than the generally accepted threshold willingness-to-pay value, which favors exercise.

Reference value of transcutaneous oxygen measurement in diabetic patients compared with nondiabetic patients.

PURPOSE: This study evaluated the values of transcutaneous oxygen tension (TcPo(2)) measurement in diabetic patients compared with nondiabetic patients and assessed its reproducibility. METHODS: In 60 diabetic patients (type 1 and type 2 diabetes mellitus) without signs of peripheral arterial disease or neuropathy, we measured TcPo(2) at the chest and foot and compared these measurements with 60 age- and sex-matched nondiabetic patients in a cross-sectional fashion. The reproducibility of TcPo(2) in terms of interobserver variability was also assessed. RESULTS: Diabetic patients had a mean +/- SD TcPo(2) value at the foot of 50.02 +/- 8.92 mm Hg, which was significantly lower compared with 56.04 +/- 8.80 mm Hg in nondiabetic patients (P < .001). At the chest wall, values for TcPo(2) were 51.77 +/- 11.15 mm Hg, and 58.22 +/- 12.47 mm Hg for diabetic patients and nondiabetic patients, respectively (P = .003). Regression analysis showed that TcPo(2)was significantly associated with diabetes mellitus (coefficient = -0.258; P = .004), and with having a first-degree relative with diabetes mellitus (coefficient = -0.265; P = .003). Furthermore, the interobserver variability showed a substantial correlation for both measurements at the chest (P < .001; r = 0.654; intraclass correlation coefficient [ICC] = 0.79) and at the dorsum of the foot (P < .001; r = 0.426; ICC = 0.60). CONCLUSION: Diabetic patients without signs of peripheral disease or neuropathy had significantly lower TcPo(2) values compared with age- and sex-matched nondiabetic patients. The influence of the examiner on the variance in TcPo(2) measurements was relatively small. We advocate the use of TcPo(2) measurement in diabetic patients to detect subclinical microvascular impairment as an additional tool to assess peripheral vascular disease.

Subfascial ligation at three different levels versus partial exeresis of the incompetent short saphenous vein: a randomized clinical trial.

OBJECTIVE: The study's objective was to compare subfascial ligation at three different levels and partial exeresis of the short saphenous vein for persistence of a reflux route and patients' subjective improvement of symptoms. DESIGN: A prospective randomized clinical trial was conducted. MATERIALS AND METHODS: Eighty-four limbs with incompetent short saphenous veins were randomized for subfascial ligation at three different levels (n = 44) or partial exeresis (n = 40). Duplex ultrasound was performed preoperatively and postoperatively. The short saphenous vein was mapped before surgery. The patients' symptoms were documented before and after surgery. The Student t test and chi(2) test were used to calculate differences between the two treatment groups. Logistic regression analyses were performed to determine predictive values for the primary outcome measures: persisting reflux route and patients' subjective improvement after surgery. RESULTS: Patients' characteristics and previous and additional surgical intervention were not significantly different between the two treatment groups (chi(2) test). Postoperative duplex sonography showed reflux in 64 limbs (76%). Improvement of symptoms was demonstrated in 57 cases (68%). There was no significant difference in the persistence of reflux or patients' improvement of symptoms between the two treatment groups. CONCLUSIONS: Our study showed poor technical results after subfascial ligation at three different levels or partial exeresis of the short saphenous vein. No significant differences in the persistence of a reflux route and patients' subjective improvement of symptoms between both treatments were demonstrated. Routine postoperative monitoring with duplex ultrasound would facilitate the surgical techniques, and anatomic knowledge of all variations of the saphenopopliteal junction is needed.

Value of the duplex waveform at the common femoral artery for diagnosing obstructive aortoiliac disease.

PURPOSE: To evaluate the accuracy, predictive value, and observer agreement of the duplex ultrasound waveform at the common femoral artery as a marker of significant aortoiliac disease in a large group of consecutive patients who underwent a diagnostic workup for peripheral arterial disease in a vascular unit. METHODS: In 191 consecutive patients (381 aortoiliac segments), we classified the duplex ultrasound waveform at the common femoral artery as triphasic, biphasic, sharp monophasic, or poor monophasic. The waveforms were then compared with the findings of magnetic resonance angiography of the aortoiliac segment and peripheral runoff vessels. We calculated the diagnostic accuracy of the duplex waveform for detecting >50% obstructive disease of the aortoiliac segment and determined the observer agreement for classifying the duplex waveforms done by two independent observers. RESULTS: Magnetic resonance angiography showed obstruction in 152 (39.9%) of 381 aortoiliac segments in 191 patients. The presence of a poor monophasic waveform, encountered in 91 (24.3%) of 375 segments, was a reliable sign of significant aortoiliac disease, with a positive predictive value of 92%. Other waveforms were nondiagnostic for aortoiliac obstructive disease. The sharp monophasic waveform reliably predicted occlusive disease of the superficial femoral artery that was seen in 17 of 23 instances. There was good observer agreement for classifying duplex waveforms (kappa(w)= 0.85; 95% confidence interval, 0.80 to 0.89). CONCLUSION: The poor monophasic duplex waveform at the common femoral artery is in itself an accurate marker of aortoiliac obstructive disease. Other waveforms are nondiagnostic for aortoiliac disease.

Intermittent claudication: functional capacity and quality of life after exercise training or percutaneous transluminal angioplasty--systematic review.

PURPOSE: To systematically review published data about the short- and long-term effects of exercise training and angioplasty on functional capacity and quality of life of patients with intermittent claudication. MATERIALS AND METHODS: Articles published between January 1980 and February 2003 were included if patients had intermittent claudication treated with exercise training or angioplasty and if both functional capacity and quality-of-life scores from Medical Outcomes Study 36-Item Short Form health survey were reported for at least 3 months of follow-up. Data were pooled by using a random effects model and weighted means. Pooled results were compared between the treatment groups by using the chi2 test and the Student t test (alpha = .05, two sided). RESULTS: In the analyses, five studies (202 patients) were included in the exercise group, and three studies (470 patients), in the angioplasty group. At 3 months of follow-up, the ankle-brachial index was significantly improved in the angioplasty group (mean change, 0.18; P < .01) but not in the exercise group (mean change, 0.01; P = .29). At 3 months, quality of life was significantly improved with regard to ratings of physical functioning and bodily pain in the exercise group (mean change, 18 and 10, respectively; P < .01) and physical role functioning in the angioplasty group (mean change, 30; P = .03). Mean change in ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months (P < .01); mean change in quality-of-life scores did not. CONCLUSION: Improvement in quality of life was demonstrated after both exercise training and angioplasty, whereas functional capacity showed significant improvement after angioplasty. The ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months, whereas the quality-of-life scores did not.

Endoscopic evaluation and treatment of groin pain in the athlete.

BACKGROUND: Chronic groin pain in athletes forms a major diagnostic and therapeutic challenge. HYPOTHESIS: Evaluate and treat undiagnosed groin pain in the athlete by endoscopy. STUDY DESIGN: Prospective cohort study. METHODS: Athletes who were referred to the Ikazia Hospital with undiagnosed chronic groin pain between January 1998 and August 2001 were included. Radiography, bone scintigraphy, and ultrasonography were performed. In 14 athletes, groin pain remained undiagnosed. Ten patients complained of unilateral, 4 of bilateral groin pain. Patients underwent a transabdominal or extraperitoneal diagnostic endoscopy. RESULTS: All patients were operated ambulatory without significant difficulties. Pathology found by endoscopy was hernia inguinalis (n = 9), hernia femoralis (n = 4), preperitoneal lipoma (n = 3), and hernia obturatoria (n = 1). Only once was there no pathology. In 17 groins, a Prolene mesh was placed preperitoneally. Thirteen patients (93%) returned to full activity within 3 months of surgery. One year after surgery, one patient had minor symptoms and one patient had persistent symptoms. All other patients had no complaints. CONCLUSIONS: An occult hernia should be high on the list of differential diagnoses in undiagnosed chronic groin pain in athletes. Operative treatment can return the patient to his sport within 3 months.

The vascular nurse in practice: Results of prescribed exercise training in patients with intermittent claudication.

Intermittent claudication (IC) is a mild stage of peripheral arterial disease that affects between 3% and 7% of the population and up to 1 in 5 patients over the age of 75 years. Risk factors such as hypertension, hyperlipidemia, diabetes, smoking, and genetics increase the incidence of peripheral arterial disease. Patients with IC have limitations in functional capacity and can benefit from regular exercise. Walking is the preferred mode of exercise and improves the symptoms of claudication in several ways. Vascular nurses can play an important role during exercise therapy. A personalized, home-based exercise program can be developed, and nurses can assist and motivate patients during follow-up periods. Helping patients to quit smoking and control other risk-factor modifications (ie, high blood pressure and lipid levels) also has high priority in daily practice of the vascular nurse. This prospective study will illustrate the results of prescribed home-based exercise training by a vascular nurse on the maximum painless walking distance for patients with IC and will be applied to subgroups of vascular pathology.

Subfascial ligation of the incompetent short saphenous vein: technical success measured by duplex sonography.

The aim of this prospective study was to assess the technical success of subfascial ligation of the short saphenous vein (SSV) in patients with SSV varices by postoperative duplex sonography. From January 1997 to October 2000, 28 patients (9 men and 19 women; mean age 56 years, range 32-72) underwent sapheno-popliteal ligation for incompetence of the sapheno-popliteal junction (SPJ). Four patients had operations on both limbs. Follow-up took place 3 months after the operation by using duplex sonography. In only 5 cases, the SSV was occluded completely. In 14 cases, there was no communication with the deep venous system, but a venous reflux via collaterals and epifascial veins still existed. In 13 cases, the SPJ still existed with tortuous development of the SPJ and sometimes with partial thrombosis. Postoperative duplex sonography showed that subfascial ligation of the SSV alone is not effective for the treatment of sapheno-popliteal reflux. Further prospective studies are necessary to find the best treatment for sapheno-popliteal reflux. Because of the immense progress in this treatment and the increased responsibility of nurses caring for these patients, the nurse must be thoroughly aware of the multifaceted problems of SSV varices.