Analysis of the effect on costochondral graft for TMJ ankylosis with jaw deformities in pediatrics.

OBJECTIVES: To evaluate the effects of costochondral grafting (CCG) used for temporomandibular joint ankylosis (TMJA) in growing patients. MATERIALS AND METHODS: Pediatric patients with TMJA treated by CCG from 2010.5 to 2021.7 were included in the study. CT scans were performed before and after operations with at least 1 year follow-up. The height of the mandibular ramus, menton deviation or retraction, osteotomy gap, etc. were measured by ProPlan CMF1.4 software. CCG growth, resorption, and relapse were evaluated and analyzed with influencing factors such as age, ostectomy gap, etc. by generalized estimating equation. RESULTS: There were 24 patients (29 joints) with an average age of 6.30 ± 3.13 years in the study. After operation, the mandibular ramus was elongated by 5.97 ± 3.53 mm. Mandibular deviation or retrusion was corrected by 4.82 ± 2.84 mm and 3.76 ± 2.97 mm respectively. After a mean follow-up of 38.91 ± 29.20 months, 58.62% CCG grew (4.18 ± 7.70 mm), 20.69% absorbed (2.23 ± 1.16 mm), and 20.69% re-ankylosed. The re-ankylosis was negatively correlated with the osteotomy gap (OR:0.348,0.172-0.702 95%CI, critical value = 6.10 mm). CCG resorption was positively correlated with the distance of CCG ramus elongation (OR:3.353,1.173-9.586 95%CI, critical value = 7.40 mm). CONCLUSIONS: An adequate osteotomy gap and CCG ramus elongation distance are the key factors for successful treatment of TMJA with jaw deformities in growing patients. CLINICAL RELEVANCE: TMJA affects mouth opening and jaw development in pediatric patients. The most common autogenous bone graft for pediatric patients is CCG due to its growth potential, convenient access and easy contouring. Also, it can simultaneously reconstruct the TMJ and improve jaw deformity by lengthening the mandibular ramus. But the growth of CCG is unpredictable. In this study, we explored several factors that may affect the absorption and re-ankylosis of CCG, expecting to provide several suggestions to improve future CCG treatment.

Short-term outcome after treatment of talocrural instability in cats using modified type II transarticular external skeletal fixation.

Transarticular external skeletal fixation (TESF) is repeatedly used for temporary stabilisation of tarsal joint in cats. Hence, this study aimed to evaluate the use of temporary modified type II TESF for management of talocrural instability (TCI) in cats without joint arthrodesis and to rate short-term outcomes and complications. Medical records of all cats treated for TCI between January 2012 and December 2021 were reviewed. Information was collected including signalment, degree of lameness, type of TCI, accompanying soft tissue and bone injuries, and post-operative follow-up assessment including time of frame removal, complications, degree of lameness, range of joint motion and ankylosis. Surgical management didn't involve debridement of the articular cartilage. Eighty-five percent of cats had satisfactory joint stability at the time of frame removal. Eighteen cats exhibited minor complications, six cats had major complications, and 8 cats showed persistent lameness. All cats showed reduction of joint motion range by 20°-30° directly after frame removal while returned to normal in 79% of cats 4 weeks later. Variable degrees of joint ankylosis were reported. In conclusion, this study supports the use of temporary modified type II TESF for management of TCI in cats without joint involvement as an excellent alternative to tarsal arthrodesis.

Sequential surgery for the treatment of type I knee ankylosis: a series of 62 cases.

BACKGROUNDS: The lack of systematic classification and standard treatment principles for knee ankylosis prevents optimal treatments. This study explored treatments for type I (mild) knee joint ankylosis. METHOD: This retrospective study analysed patients with knee joint ankylosis admitted from March 2013 to January 2018 who underwent sequential arthroscopic release. RESULT: The 62 patients had 12-36 (average, 18) months of follow-up. Thirty-eight patients were released; of these, 18 were assisted by limited incision with partial quadriceps femoris expansion myotomy and released according to arthroscopy. Six patients underwent lengthening and release of the quadriceps femoris. All surgeries combined with full-course rehabilitation resulted in improved joint mobility. The range of motion (ROM) of the knee joint recovered to a range of 0° to 85°-140° (mean: 118.32 ± 9.42°) from the preoperative range of 30°-70° (mean: 45° ± 15.50°). The clinical effect was evaluated according to the Judet criteria at the final follow-up. The outcomes at the last follow-up (at least for 1 year) were excellent in 55 cases, good in six cases, and fair in one case. CONCLUSION: Sequential arthroscopic release, minimal selective invasion of limited incision of partial quadriceps femoris expansion myotomy, assisted by pie-crusting technique to release, or quadriceps femoris lengthening, and release surgery for type I knee joint ankylosis, accompanied by early rehabilitation training provided satisfactory results without significant complications.

The role of physiotherapy interventions in the management of temporomandibular joint ankylosis: a systematic review and meta-analysis : Running title: Physiotherapy in TMJ ankylosis.

BACKGROUND: The main aim of this systematic review and meta-analysis was to identify peer-reviewed scholarly journal articles reporting the significance of physiotherapy interventions in managing TMJ ankylosis. In addition, this study aimed to critically appraise the existing evidence on the prevalence and clinical presentation, physiotherapy intervention approaches, efficacy of physiotherapy interventions, adverse effects, and safety of physiotherapy interventions in TMJ ankylosis management. METHODS: An all-inclusive literature search was conducted using the PubMed, Google Scholar, and Scopus electronic databases. The researchers screened the potential articles and assessed for eligibility based on the reported inclusion and exclusion criteria. The quality evaluation tool for observational cohort and cross-sectional studies developed by the National Institutes of Health (NIH) and the Cochrane Collaboration's Risk of Bias Tool were used to assess the quality of the included studies. Researchers also comprehensively analyzed the data, reported the results, and discussed them according to the predominant themes. RESULTS: The primary electronic database search yielded 409 articles, of which 25 were included in this review. A secondary search was conducted from citations of the included studies, yielding 74 articles, of which six were included in the study. A significantly higher prevalence of bony ankylosis than fibrous ankylosis, with an overall effect size of p < 0.00001. In addition, there were significantly more unilateral than bilateral presentations with an overall effect size of p < 0.00001. Moreover, there were 78 reported complications out of 245 subjects according to five included studies demonstrating a significant effect size with p = 0.001 following the treatment protocols. CONCLUSION: This study highlighted the prevalence of bony ankylosis in temporomandibular joint ankylosis, emphasizing its impact on patients' well-being. On the other hand, the results show that physiotherapy is essential to optimize postoperative outcomes and minimize adverse events such as re-ankylosis. Practitioners and healthcare professionals must monitor postoperative recovery and ensure strict adherence to physiotherapy protocols for optimal outcomes.

Does distraction osteogenesis improve the airway volume and quality of life of obstructive sleep apnoea patients secondary to temporomandibular joint ankylosis?

Temporomandibular joint (TMJ) ankylosis leads to mandibular micrognathia that severely collapses the upper airway causing obstructive sleep apnoea (OSA), resulting in deterioration and compromise in the quality of life (QoL) of patients. In this study, we aimed to calculate airway volume changes, apnoea-hypopnoea index (AHI), and improvement in quality of life before and after distraction osteogenesis (DO). Fourteen Patients with OSA secondary to TMJ ankylosis at a mean (SD) age of 17.5 (5.43) years were enrolled in this prospective study. Multivector mandibular distractors were used in all patients following the standard Ilizarov distraction protocol with a mean (SD) anteroposterior distraction of 16.21 (4.37) mm and a consolidation period of 116.92 (14.35) days. The patients were followed up for six months. A polysomnography test (PSG) was done to quantify AHI and a low-dose computed tomographic scan was done to calculate airway volume using Dolphin medical imaging software pre and post-DO. The QoL of the patients was calculated using the OSA-18 questionnaire. Results analysis depicted that the mean (SD) preoperative AHI was 51.44 (37.99)/h which was improved to 9.57 (9.74)/h (p = 0.001) after DO. Airway volume was calculated on Dolphin software before and after DO showed a significant improvement in airway volume by 121.12% (98.30)%. Similarly, the OSA-18 questionnaire showed significant improvement in QoL from severe to normal. This study suggested that DO increases the corpus length of the mandible, leading to an increment in airway volume, which improves the QoL.

Assessment of upper airway changes after interpositional arthroplasty: a cephalometric analysis.

This prospective cohort study examined the changes in airway area and soft tissue parameters following interpositional arthroplasty for temporomandibular joint (TMJ) ankylosis. Ten patients with TMJ ankylosis underwent surgery, and preoperative and postoperative skeletal and soft tissue measurements were obtained. A significant rise in soft tissue parameters was observed following surgery, although only minor changes in skeletal parameters were seen. The nasoropharyngeal area, oral area, soft palate area, and tongue area were examined. After the surgery, increases in values were observed in the nasoropharyngeal area (from 3482.4 mm2 to 3618.7 mm2), the oral area (from 2731.8 mm2 to 2840.8 mm2), the soft palate area (from 204.9 mm2 to 217.3 mm2), and the tongue area (from 2577.5 mm2 to 2600.8 mm2). These findings suggest that interpositional arthroplasty can improve airway area and soft tissue dimensions, affecting the stomatognathic system's aesthetic and functional aspects. Further research is needed to validate these results and assess long-term stability.

Did temporomandibular gap arthroplasty with temporalis interpositional flap improve function and pain in patients with end-stage joint disease? A 5-year retrospective follow-up.

The primary aim of this study was to investigate whether patients with end-stage temporomandibular joint (TMJ) disease treated with gap arthroplasty with temporalis interpositional flap (GAT) had improved maximal interincisal opening (MIO) and TMJ pain in a long-term perspective. All patients with severe osteoarthritis, or fibrous or bony ankyloses, and subjected to GAT between 2008 and 2015 were included. The criteria of treatment success were TMJ pain VAS score ≤4 and MIO ≥30 mm. Reoperation was considered as a failure. Forty-four patients (mean age 47 years) were included in this retrospective descriptive case series and followed up for up to 7 years (mean 4.5). Comorbidities were frequent (n = 34) and most commonly rheumatic disease (n = 17). The indications for surgery were ankylosis (n = 32) or severe osteoarthritis (n = 12). Of the 44 included patients, 84% (n = 37) had a history of earlier TMJ surgery. The preoperative mean values for TMJ pain and MIO (VAS 7 and 23 mm, respectively) changed significantly (p < 0.001) to postoperative means of VAS 3 and 34 mm, respecitvely. The success rate was 59% (n = 26). When compared with a previous 2-year follow-up, the success rate was found to have decreased over time (p = 0.0097). The rate of successful treatment outcome in terms of MIO alone was 82% (n = 36). The most common reason for treatment failure was residual pain. In conclusion, the success-rate after GAT did not show long-term stability and continued to drop over time in this patient cohort. TMJ pain seems to be the main reason for failure.

Simultaneous standard total joint prosthesis reconstruction with SSRO and Le Fort I osteotomy in the treatment of unilateral temporomandibular joint ankylosis with jaw deformity: a case cohort study.

OBJECTIVE: Unilateral temporomandibular joint ankylosis with jaw deformity (UTMJAJD) may require simultaneous total joint prosthesis (TJP) reconstruction, sagittal split ramus (SSRO), and Le Fort I osteotomies. The purpose of this study was to evaluate outcomes in patients treated with these procedures. METHODS: Patients diagnosed UTMJAJD between 2016 and 2018 were selected for the study. Mandible-first procedure was performed after ankylosis release with TJP on the ankylosed side and SSRO on the contralateral side. Le Fort I osteotomy with and without genioplasty was lastly performed. Maximal incisor opening (MIO), facial symmetry, and jaw and condyle stability were compared before, after operation, and during follow-ups. RESULTS: Seven patients were included in the study. Their average chin deviation was 9.5 ± 4.2 mm, and maxillary cant was 5.1 ± 3.0°. After operation, jaw deformity significantly improved, with chin deviation corrected 7.6 ± 4.1 mm (p = 0.015) and advanced 5.9 ± 2.5 mm (p = 0.006). After an average follow-up of 26.6 ± 17.1 months, MIO significantly increased from 11.4 ± 9.3 to 35.7 ± 2.6 mm (p = 0.000). The occlusion was stable with no significant positional or rotational changes of the jaw (p > 0.05). There was no obvious condylar resorption during follow-ups. CONCLUSION: Simultaneous TJP reconstruction, SSRO, and Le Fort I osteotomy are reliable and effective methods for the treatment of UTMJAJD.

Role of buccal fat pad to reduce the chances of re-ankylosis-A systematic review of literature.

The role of buccal fat pad (BFP) as interpositional material in the temporomandibular joint ankylosis (TMJA) have been well documented. The purpose of the present systematic review is to reinforce the role of buccal fat pad as interpositional material in preventing re-ankylosis. A systematic search was conducted in PubMed, Google Scholar, Semantic scholar and Cochrane library database from 1980 to 2022 following the PRISMA guidelines. The studies using BFP as interpositional material in TMJA with more than 10 patients with atleast a follow-up of 6-months were included. All the human studies {prospective, retrospective, case reports/series (with more than 10 subjects), randomized or non-randomized trial) reporting the outcome of BFP as interpositional material were included. The present systematic review included 11 studies (prospective=7, Retrospective=3 and ambispective=1) using BFP as interpositional material. The total number of patients were 205. The number of unilateral TMJA and bilateral TMJA were 153 and 52 respectively, making a number of joint to 257. The distribution of gender was almost equal (few studies did not report the gender distribution). The minimum follow-up was 6-months and extended up to 5.3 years. Out of 205 patients, no re-ankylosis was reported in patients. The authors concluded that the BFP is nearly ideal and a preferred interpositional material to prevent re-ankylosis in temporomandibular joint ankylosis. Its vicinity to TMJ, ease of harvesting through the same surgical site and avoiding other scar makes it a preferred interpositional material in TMJA cases.

A screw and wire assisted coronoidectomy procedure: A technical note.

Temporomandibular joint (TMJ) ankylosis and oral submucous fibrosis (OSMF) often exhibit elongated hyperplastic coronoid processes with fibrous attachments to the temporalis muscle. In managing this condition, a vital step involves performing a coronoidotomy or coronoidectomy alongside the primary surgical procedure. While coronoidectomy is preferable due to reattachment issues, its complexity arises from the thickened and elongated coronoid process. Our technical note introduces a screw and wire assisted coronoidectomy method, found to be efficient, replicable, and time-saving.

Peri-articular bone formation involving the temporomandibular joint: a narrative summary and Delphi consensus of a new classification system.

Heterotopic ossification (HO) is defined as 'bone where it does not belong'. Given the historical variety of nomenclature and eponyms, there is significant confusion about the etiology, pathogenesis, classification, and treatment of HO related to the temporomandibular joint (TMJ). The existing classifications for TMJ HO have shortcomings: they relate to specific populations, use differing imaging studies and demographic data, do not universally include alloplastic/autologous replacements, are based variously on radiological and/or clinical presentations that cannot always be combined, and were largely developed to assist oral and maxillofacial surgeons in surgical management. These deficiencies make it problematic to compare studies, draw valid conclusions, and pursue research. The aim of this study was to develop a new, more inclusive classification for TMJ HO. Currently available classifications were evaluated and a Delphi-type system used to build consensus from clinicians and researchers to develop a new system. Fourteen unique classifications for TMJ ankylosis/HO were identified. In light of the biological specifics related to heterotopic calcification of extracellular matrix versus heterotopic formation of actual bone, the group recommends a more unambiguous term - peri-articular bone formation - and proposes a new classification. This will help clinicians and researchers to study, describe, and manage various types of ectopic bone associated with the TMJ.

Surgical correction of neonatal obstructive sleep apnea due to a temporomandibular joint ankylosis.

In growing children, temporomandibular joint (TMJ) ankylosis and septic arthritis are uncommon. Retrognathia and micrognathia affect airway patency and can cause obstructive sleep apnea (OSA). No unified diagnostic criteria have been established for the management of this pathology. We describe the first case of treatment for pediatric TMJ ankylosis and severe OSA due to neonatal group B streptococcal septic TMJ arthritis. Untreated pathological changes in the TMJ will eventually lead to ankylosis. Among children, this will include facial growth disturbances leading to mandibular retrognathia, reduction in the oropharyngeal spaces, and OSA. Our patient had severe OSA with an apnea-hypopnea index of 24.9 events/h and oxygen saturation nadir of 73% as measured by polysomnography. She was treated successfully according to Andrade protocol. This is the first report of pediatric OSA due to TMJ ankylosis following neonatal group B streptococcal septic arthritis. CITATION: Pesis M, Goldbart A, Givol N. Surgical correction of neonatal obstructive sleep apnea due to a temporomandibular joint ankylosis. J Clin Sleep Med. 2024;20(1):173-179.

Hybrid total alloplastic temporomandibular joint replacement prosthesis: a pilot study to evaluate feasibility, functional performance and impact on post-operative quality of life.

PURPOSE: The aim of the present study was to investigate the clinical efficiency of hybrid alloplastic temporomandibular joint (TMJ) prosthesis in patients undergoing TMJ total alloplastic joint replacement (TMJR). The prosthesis utilized for this study for TMJR is a hybrid variant with combination of stock prototype design and a partial customization of components. MATERIALS AND METHODS: A prospective clinical study was conducted involving five patients with unilateral TMJ ankylosis or end-stage joint disease (ESJD) indicated for and requiring TMJR. The patients underwent resection of the joint or gap arthroplasty followed by TMJR using the hybrid alloplastic TMJ prosthesis. The subjective and objective variables that included the jaw function (JF), inter-incisal opening (IO), diet intake (DI) and quality of life (QoL) were assessed using the psychometric modified Likert scale. The nutritional status of the patients was evaluated using the mid-upper arm circumference (MUAC) as reference. RESULTS: The assessed study variables demonstrated functional and observational improvement in the post-operative follow-up when compared to the pre-operative period. The patients showed an improvement in overall QoL and nutritional status post-operatively. The follow-up period showed subjective and objective improvement in the parameters assessed among the study population. CONCLUSION: There is a technical and clinical feasibility to utilize the hybrid alloplastic TMJ prosthesis as a reliable alloplastic option for treating patients requiring TMJR, with prudent indications.

[Management of traumatic temporomandibular joint ankylosis: a perspective].

Traumatic injury to the temporomandibular joint (TMJ) was the most common cause of TMJ ankylosis (85%), while sagittal fracture of the mandibular condyle was identified as the high risk fracture pattern. TMJ disc displacement is one of the prerequisite factors of TMJ ankylosis. The severe damage and close contacts of both the articular surface of glenoid fossa and condyle were also crucial pathogenic factors in the development of TMJ ankylosis. The mechanism and development of TMJ ankylosis may be similar to hypertrophic non-union, and the persistence of radiolucent zone within the ankylotic callus governs the clinical and pathological process of TMJ ankylosis. In type Ⅰ traumatic TMJ ankylosis, repositioning of the displaced disk is required, while the preservation of pseudo-joint is essential in the management of the type Ⅱ traumatic TMJ ankylosis. Nevertheless, the rate of TMJ reankylosis still remains high. Higher rate of TMJ reankylosis was observed in paediatric population, bilateral involvement of TMJ ankylosis, and in cases with reconstruction of mandibular condyle with coronoid process.

Congenital Ankylosis of the Knee Treated with Van Nes Rotationplasty: A Case Report.

CASE: This is a case of a female patient born with thrombocytopenia-absent radius syndrome, with bilateral upper extremity phocomelia, bilateral hip dislocations, and congenital fusion of the right knee with progressively worsening flexion contracture. At age 3 years and 5 months, the patient was treated with excision of the knee ankylosis and Van Nes rotationplasty. This proved durable at age 20 years (final follow-up) without any need for further surgery and without complication. CONCLUSION: This is the first known report of Van Nes rotationplasty as a durable treatment option in the management of congenital knee ankylosis, which may avoid reoperation and eliminate risk of recurrence.

Rehabilitation of Dentofacial Asymmetry Secondary to Unilateral Temporomandibular Joint Ankylosis with Dual Distraction and Fixed Orthodontics - Stability at Three-year Follow-up.

Optimal rehabilitation of asymmetric dentofacial deformity secondary to unilateral temporomandibular joint (TMJ) ankylosis is often a challenge. The purpose of this case series is to present an insight into esthetic, occlusal and functional rehabilitation of two patients with varying degree of asymmetric Class II dentofacial deformities secondary to long-standing unilateral TMJ ankylosis. The patients were treated with one-stage surgical protocol employing simultaneous dual distraction technique along with interpositional arthroplasty. Dual distraction technique entailed the simultaneous use of two distractors which allowed for proper control of proximal condylar segment during the course of distraction and lowering the risk of ankylosis recurrence. Thereafter, comprehensive fixed orthodontic mechanotherapy involving the use of temporary anchorage devices was instituted to align and level the compensated dentition. Post-treatment records showed significant improvements in skeletal disharmony and functional stability with good functional occlusion. At the three-year follow-up, the morphological and functionally acceptable results were reasonably well-maintained, with no signs of relapse. Through the two cases reported here, we would like to highlight that one-stage concurrent arthroplasty and dual distraction technique is a safe, stable, and reliable approach for surgical and functional rehabilitation of an adult asymmetric dentofacial deformity secondary to unilateral TMJ ankylosis. Meticulously executed comprehensive orthodontic manipulations involving use of acrylic bite-blocks, elastic traction, and temporary skeletal anchorage device play a crucial role in enhancing the final occlusal outcomes.

Static mechanical analysis of the vertebral body after modified anterior cervical discectomy and fusion (partial vertebral osteotomy): a finite element model.

BACKGROUND: Modified anterior cervical discectomy and fusion (Mod ACDF) can effectively address ossification of the posterior longitudinal ligament (OPLL), which is difficult to remove directly from the posterior edge of the vertebral body, with considerably lesser damage as compared to anterior cervical corpectomy and fusion (ACCF). We compared the static mechanics of different anterior approaches by using an ideal finite element model. METHODS: A complete finite element model was established and classified into the following three surgical models according to different model cutting operations: ACDF, ACCF, and Mod ACDF. Three different bone volume situations (normal bone mineral density, osteopenia, and osteoporosis) were simulated. After fixing the lower surface of C5 or C6, a load was applied to the upper surface of C4, and the stress distribution and displacement of the upper surface of C5 or C6 were observed and the related values were recorded. RESULTS: The average Von Mises Stress and displacement levels of Mod ACDF were between those of ACDF and ACCF; with the peak Von Mises Stress occurring on the posterior side of the vertebral body (Points 1-4). The change in Von Mises Stress of the vertebral body is not significant during bone loss. However, the degree of displacement of the vertebral body surface and risk of vertebral collapse are increased (100 N: 13.91 vs. 19.47 vs. 21.62 µm; 150 N: 19.60 vs. 29.30 vs. 31.64 µm; 200 N: 28.53 vs. 38.65 vs. 44.83 µm). CONCLUSIONS: The static biomechanical effects caused by Mod ACDF are intermediate between ACDF and ACCF, and the risk of vertebral body collapse is lower than that by ACCF. Therefore, Mod ACDF may be an effective solution when targeting OPLL with poorly positioned posterior vertebral body edges.

Temporomandibular Joint Replacement Using Stock Alloplastic Graft in the Treatment of Ankylosis: A Case Report.

INTRODUCTION: This paper aims to assess the suitability and effectiveness of temporomandibular joint replacement (TMJR) devices to treat a case of re-ankylosis and association of tuberculosis (TB) with reduced mouth opening. Traditional protocols for the treatment of temporomandibular joint (TMJ) ankylosis have preferred autologous grafts for reconstruction. Usage of TMJR devices have been reserved for very specific conditions. CASE DESCRIPTION: We present a case of a patient previously treated for ankylosis using a sternoclavicular graft, who came with a chief complaint of progressive decrease in mouth opening. She also gave a history of pulmonary TB a year back. Investigations revealed no active TB. Images and clinical presentation were consistent with bilateral ankylosis. The treatment plan consisted of resection of ankylotic mass on the left side and removal of the failed graft and reconstruction with Biomet stock TMJR prosthesis on the left side. DISCUSSION: Stock device has proven to be reliable option in planned TMJR procedures. Osteoarticular TB should be ruled out in patients with a history and features of TB. CONCLUSION: Stock TMJR devices are an effective and viable option for the treatment of re-ankylosis. This ensures almost immediate possibility of physiotherapy and long-term results including maintenance of mouth opening and function. Osteoarticular TB can cause trismus and painful joints which may be misdiagnosed. Any patient with reduced mouth opening with a history of TB should be investigated for possible extrapulmonary TB.

Complications of Mandibular Fracture Repair.

Mandible fracture management has evolved dramatically. Therefore, the variety of surgical complications associated with mandibular fractures, and their incidences, have continued to change as well. This article aims to assess the most common and most concerning complications that can occur secondary to management of mandibular fractures by examining categories of complication types. This article also explores factors and techniques associated with reduced rates of complications as well as the management of complications.