Effectiveness of intra-articular infiltration of platelet concentrates for the treatment of painful joint disorders in the temporomandibular joint: a systematic review.

BACKGROUND: The role of Platelet-rich Plasma injections as a complementary therapy, together with other minimally invasive procedures, has been analyzed previously, however, there are no articles that evaluate the effects of intra-articular infiltration in the Temporomandibular Joint by itself. The aim of this article is to evaluate the effectiveness of intra-articular infiltration with Platelet-rich Plasma, as a single procedure, to both reduce pain and improve clinical parameters in painful joint disorders. MATERIAL AND METHODS: A systematic search was performed using the terms "Temporomandibular Joint Disorders" and "Platelet-rich plasma" in May 2021. Only the Clinical Trials found in the Pubmed/Medline, Embase, Cochrane Library/Cochrane CENTRAL, Google Scholar, and LILACS databases were selected. RESULTS: Only four articles were selected for full-text review. Statistically significant differences were found in pain reduction Platelet-rich Plasma-based interventions with respect to preoperative measurements up to six months. Only two studies found significant intergroup differences favoring Platelet-rich Plasma over other interventions. In relation to maximum mouth opening, three studies reported an increase compared to the preoperative measurements. CONCLUSIONS: Platelet-rich Plasma might potentially be effective in reducing pain levels and improving clinical parameters such as interincisal distance. However, studies with better methodological quality, larger sample sizes, and lower risk of bias are required to assess the real value of this intervention in the management of painful joint disorders.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Living will, durable power of attorney and legal guardianship in the trauma surgery routine : Data from a geriatric trauma center]. / Patientenverfügung, Vorsorgevollmacht und gesetzliche Betreuung im unfallchirurgischen Alltag : Zahlen aus einem alterstraumatologischen Zentrum.

BACKGROUND: Due to the increasing number of elderly patients, trauma surgeons are often confronted with end-of-life treatment decisions. Advance directives can help reduce the lack of clarity in those situations. OBJECTIVES: The aim of this study was to identify the presence of living wills, durable power of attorney, legal guardianship and appointment of guardianship in the geriatric trauma center of a university hospital. MATERIALS AND METHODS: The data of all patients treated in our geriatric trauma center from 01/01/2013 to 03/31/2014 were analyzed regarding the presence of a living will, durable power of attorney, legal guardianship and appointment of guardianship as well as the procedure of documenting those items. RESULTS: Out of 181 patients, 63 % (n = 114) had one or more of these documents. Most frequently used was the durable power of attorney in 33 % (n = 59), followed by a living will in 27 % (n = 48), legal guardianship in 20 % (n = 37) and appointment of guardianship in 7 % (n = 12). The existence of those documents was recorded in 88 % (n = 100) of patients within 24 h after admission; documentation in the medical records was found in 58 % (n = 66). CONCLUSION: A large proportion of patients had one or more of the documents named above. In this respect, standardized documentation of advance directives in the medical record is an important issue for all persons involved.

[Rehabilitation of multiple injured patients in Germany: Clinic locations, structural and equipment attributes]. / Rehabilitation von Schwerverletzten in Deutschland: Klinikstandorte, Struktur- und Ausstattungsmerkmale.

BACKGROUND: In recent years, there has been an ongoing improvement in the treatment and structural aspects of acute trauma care. Because of the definition of rehabilitation as a post-acute part of the treatment of traumatic injuries, especially in multiple injured patients, there is need to improve the interaction and cooperation between acute care hospitals and rehabilitation clinics. This article gives a survey of the current state of rehabilitation in Germany. MATERIALS AND METHODS: Based on a directory of rehabilitation clinics and an internet search, all rehabilitation clinics were identified and included in the analysis for clinic location, structural and equipment attributes. RESULTS: In total 551 rehabilitation clinics with expertise in the treatment of traumatic and orthopedic injuries were identified. In detail, broad differences between the federal states could be observed. The number of rehabilitation clinics per state ranged from 1 to 136 and the number of beds from 70 to 18040. The average catchment area covered by a rehabilitation clinic is 648 km(2) (range 149-2106 km(2)) with an average of 1584 patients per clinic per year. Of the clinics 68% can treat patients with methicillin-resistant Staphylococcus aureus (MRSA) infections and 62.1% are able to deal with patients who need renal dialyses. Almost all clinics provide an x-ray facility (96.4%) while computed tomography (CT) and magnetic resonance imaging (MRI) are available in 52.6% and 50.3%, respectively. CONCLUSION: The number of rehabilitation clinics available seems to be adequate for all patients with traumatic injuries but there are enormous differences between the federal states. Because rehabilitation is important for the outcome of multiple injured patients, a further improvement of the quality and integration into the regional trauma network seem to be necessary.

Enalapril and ASS inhibit tumor growth in a transgenic mouse model of islet cell tumors.

Accumulating evidence suggests a role for angiotensin-converting enzymes involving the angiotensin II-receptor 1 (AT1-R) and the cyclooxygenase pathway in carcinogenesis. The effects of ASS and enalapril were assessed in vitro and in a transgenic mouse model of pancreatic neuroendocrine neoplasms (pNENs). The effects of enalapril and ASS on proliferation and expression of the AGTR1A and its target gene vascular endothelial growth factor (Vegfa) were assessed in the neuroendocrine cell line BON1. Rip1-Tag2 mice were treated daily with either 0.6 mg/kg bodyweight of enalapril i.p., 20 mg/kg bodyweight of ASS i.p., or a vehicle in a prevention (weeks 5-12) and a survival group (week 5 till death). Tumor surface, weight of pancreatic glands, immunostaining for AT1-R and nuclear factor kappa beta (NFKB), and mice survival were analyzed. In addition, sections from human specimens of 20 insulinomas, ten gastrinomas, and 12 non-functional pNENs were evaluated for AT1-R and NFKB (NFKB1) expression and grouped according to the current WHO classification. Proliferation was significantly inhibited by enalapril and ASS in BON1 cells, with the combination being the most effective. Treatment with enalapril and ASS led to significant downregulation of known target genes Vegf and Rela at RNA level. Tumor growth was significantly inhibited by enalapril and ASS in the prevention group displayed by a reduction of tumor size (84%/67%) and number (30%/45%). Furthermore, daily treatment with enalapril and ASS prolonged the overall median survival compared with vehicle-treated Rip1-Tag2 (107 days) mice by 9 and 17 days (P=0.016 and P=0.013). The AT1-R and the inflammatory transcription factor NFKB were abolished completely upon enalapril and ASS treatment. AT1-R and NFKB expressions were observed in 80% of human pNENs. Enalapril and ASS may provide an approach for chemoprevention and treatment of pNENs.

[Rehabilitation of severely injured patients in acute care hospitals: who is doing what? A nationwide survey in the Trauma Network DGU]. / Rehabilitation von schwerverletzten Patienten im Akutkrankenhaus: wer macht was? Eine bundesweite Umfrage im TraumaNetzwerk DGU.

BACKGROUND: During the treatment of severely injured patients, rehabilitation takes an important role. In this study we examined the present structures in acute care hospitals, which influence the process of rehabiliation. MATERIALS AND METHODS: The data was captured in a questionnaire. The questions deal with the personal and structural situation of acute care hospitals in Germany. The questionnaires were sent to all clinics, which are registered in the TraumaNetwork DGU. RESULTS: 424 hospitals answered the questionnaire. This is a response rate of 57.3% regarding 740 acitve clinics in the TraumaNetwork DGU. 58% have no opportunity for rehabilitation. The majority of the hospitals have a physiotherapy, (98.6%) or an occupational therapy (71.0%); 33.3% have a case management. Only 17.0% of the hospitals have rehabilitation teams which take care during the hospital stay. These teams consist mainly of internal rehabilitation physicians and physical therapists. Supraregional Trauma Center have better organized structures, as hospitals with lower level of care. Only 56.6% of all hospitals reported that they were familiar with the cooperating rehabilitation hospitals. There are special cooperations with rehabilita­tion hospitals in 34.4% of all cases. CONCLUSION: The early mobilisation of severely injured patients is an integral part of the postoperative course in German hospitals. While on the one hand a large number of hospitals have good structural conditions on the other hand these structures are little integrated in the daily treamtment. There are major gaps and uncertainties in the cooperation between acute care clincs and rehabilitation hospitals. The integra­tion of rehabilitation hospitals in the TraumaNetwork DGU could be a good chance to improve this collaboration.

Impact of lymphadenectomy on survival after surgery for sporadic gastrinoma.

BACKGROUND: The study was undertaken to determine prognostic factors and the value of systematic lymphadenectomy on survival in sporadic gastrinoma. METHODS: Patients with sporadic gastrinoma who underwent initial surgery during a 21-year period in two tertiary referral centres were analysed retrospectively with respect to clinical characteristics, operative procedures and outcome. RESULTS: Forty-eight patients with a median age of 52 (range 22-73) years were analysed. Some 18 patients had pancreatic and 26 had duodenal gastrinomas, whereas the primary tumour remained unidentified in four patients. After a median postoperative follow-up of 83 (range 3-296) months, 20 patients had no evidence of disease, 13 patients were alive with disease, 11 patients had died from the disease and four had died from unrelated causes. In 41 patients who underwent potentially curative surgery, systematic lymphadenectomy with excision of more than ten lymph nodes resulted in a higher rate of biochemical cure after surgery than no or selective lymphadenectomy (13 of 13 versus 18 of 28 patients; P = 0·017), with a trend towards prolonged disease specific survival (P = 0·062) and disease-free survival (P = 0·120), and a reduced risk of death (0 of 13 versus 7 of 24 patients; P = 0·037). Negative prognostic factors for disease specific survival were pancreatic location (P = 0·029), tumour size equal to or larger than 25 mm (P = 0·003), Ki-67 index more than 5 per cent (P < 0·001), preoperative gastrin level 3000 pg/ml or more (P = 0·003) and liver metastases (P < 0·001). Sex, age, type of surgery and presence of lymph node metastases had no influence on disease free or disease specific survival. CONCLUSION: In sporadic gastrinoma, systematic lymphadenectomy during initial surgery may reduce the risk of persistent disease and improve survival.

Use of sugarcane molasses "B" as an alternative for ethanol production with wild-type yeast Saccharomyces cerevisiae ITV-01 at high sugar concentrations.

Molasses "B" is a rich co-product of the sugarcane process. It is obtained from the second step of crystallization and is richer in fermentable sugars (50-65%) than the final molasses, with a lower non-sugar solid content (18-33%); this co-product also contains good vitamin and mineral levels. The use of molasses "B" for ethanol production could be a good option for the sugarcane industry when cane sugar prices diminish in the market. In a complex medium like molasses, osmotolerance is a desirable characteristic for ethanol producing strains. The aim of this work was to evaluate the use of molasses "B" for ethanol production using Saccharomyces cerevisiae ITV-01 (a wild-type yeast isolated from sugarcane molasses) using different initial sugar concentrations (70-291 g L(-1)), two inoculum sizes and the addition of nutrients such as yeast extract, urea, and ammonium sulphate to the culture medium. The results obtained showed that the strain was able to grow at 291 g L(-1) total sugars in molasses "B" medium; the addition of nutrients to the culture medium did not produce a statistically significant difference. This yeast exhibits high osmotolerance in this medium, producing high ethanol yields (0.41 g g(-1)). The best conditions for ethanol production were 220 g L(-1) initial total sugars in molasses "B" medium, pH 5.5, using an inoculum size of 6 × 10(6) cell mL(-1); ethanol production was 85 g L(-1), productivity 3.8 g L(-1 )h(-1) with 90% preserved cell viability.

[Nitrogen and protein content analysis of human milk, diurnality vs nocturnality]. / Análisis del contenido en nitrógeno y proteínas de leche materna, día vs noche.

Breast milk is changing with the progression of lactation and during a 24-h period. To determine the effect of diurnality or nocturnality on total nitrogen and protein content of the breast milk. We collected human milk samples from health mothers living throughout Community of Extremadura (Spain) from January 2008 to December 2008 with less than two months of lactation. We divided the samples in three groups: calostral group (1-5 days postpartum), transitional group (6-15 days postpartum) and mature group (> 15 days postpartum). All samples were stored in a freezer at -80 ºC. We considered as day period between 08:00-20:00 h and night period 20:00-08:00 h. Analysis of the human milk samples was based on the Kjeldahl method. Protein contents were calculated from total nitrogen x 6,25. The statistical analysis of the data was descriptive (mean ± standard deviation) and inferential (T-Student test). No differences (P > 0,05) were found to exist among the contents of individual human milk samples. The mean contents of each component were as follows: Total nitrogen of calostral, transitional and mature group was 0,30 ± 0,06 g/dL (night period), 0,29 ± 0,05 g/dL (day period); 0,26 ± 0,04 g/dL (night period), 0,25 ± 0,04 g/dL (day period); 0,22 ± 0,05 g/dL (night period), 0,20 ± 0,04 g/dL (day period) respectively, in this mature group with a statistical variation (P < 0,05). Protein content of calostral, transitional and mature group was 1,88 ± 0,4 g/dL (night period), 1,81 ± 0,3 g/dL (day period); 1,62 ± 0,3 g/dL (night period), 1,59 ± 0,3 g/dL (day period); 1,35 ± 0,3 g/dL (night period), 1,26 ± 0,3 g/dL (day period) respectively, in this mature group with a statistical variation (P < 0,05). Although we observed differences in the nitrogen and protein content during the individual stages of lactation, it is just in the population of mature lactating women, where the components analyzed varied significantly between day and night.

Surgery for multiple endocrine neoplasia type 1-associated primary hyperparathyroidism.

BACKGROUND: Surgery in patients with multiple endocrine neoplasia type 1 (MEN1)-associated primary hyperparathyroidism (pHPT) is difficult as the condition it is caused by asymmetrical multiple gland hyperplasia. It is uncertain which operative procedure provides the best outcome with regard to long-term normocalcaemia. METHODS: All patients who had surgery for genetically confirmed MEN1-associated pHPT between 1987 and 2009 were identified from a prospective database. Clinical data, operative procedures and outcome were analysed retrospectively. RESULTS: A total of 47 patients were identified. Twenty-three patients underwent total parathyroidectomy with thymectomy and autotransplantation (TPTX + AT), 11 patients subtotal parathyroidectomy (3-3.5 glands, SPTX) with thymectomy, and 13 patients selective gland excision (fewer than 3 glands, SGE). Rates of persistent disease, recurrent disease and permanent hypoparathyroidism after TPTX + AT were 4 per cent (1 patient), 4 per cent (1 patient) and 22 per cent (5 patients) respectively. Respective rates after SPTX were 0 per cent, 18 per cent (2 patients) and 45 per cent (5 patients), which were not statistically different from those following TPTX + AT. SGE resulted in persistent disease in 23 per cent (3 patients) and a significantly higher rate of recurrent disease (46 per cent, 6 patients; P = 0.004 versus TPTX, P = 0.210 versus SPTX), but permanent hypoparathyroidism did not occur. CONCLUSION: TPTX + AT and SPTX both seem adequate surgical procedures for the treatment of MEN1-associated pHPT and are associated with fewer recurrences than SGE.

Effects of oral administration of L-methionine on activity/rest rhythm.

We describe a chronobiological study of the effects of the oral administration of the essential amino acid L-methionine to common quail ( Coturnix coturnix ). This amino acid is a precursor of the neurotransmitter acetylcholine which is responsible for controlling and maintaining wakefulness through the ventrolateral pre-optic area of the hypothalamus and controlling the REM sleep in the nucleus reticularis pontinus oralis (NRPO). The quail model was chosen as these birds are monophasic and active by day, as are humans. The animals were kept under a constant 12h:12h light/dark cycle, fed ad libitum and housed in separate cages equipped for activity recording. Methionine was administered daily (1 h before lights off) for 1 week (chronic treatment), with the birds divided into 4 groups: a capsule with 15 mg of L-methionine (Met15 treatment group); a capsule with 30 mg of L-methionine (Met30 treatment group); a capsule with methylcellulose as excipient (control group); no capsule (basal group). In addition, we compared the first day of treatment (acute experiment) with the basal and control results. Actimetry (DAS24) was used to quantify the activity data, and the sleep/wake rhythm was analyzed using the Ritme software package. The statistical analysis of the activity data was descriptive (+/- SD) and inferential (Tukey test). The data showed increased (p<0.05) mean diurnal activity pulses in the Met30 group versus the other groups in both the acute and the chronic experiments. No changes were found in nocturnal activity. The chronobiological analysis showed a significant increase in the MESOR parameter of the Met30 group in both chronic and acute experiments versus the other groups. The acrophase showed no significant changes, in all groups being at around 13:45 h. In conclusion, the oral administration of L-methionine increased diurnal activity; probably due to the stimulating neuromodulatory action of acetylcholine.

[The risk of defects in the neural tube caused by valproic acid and carbamazepine]. / Riesgo de defectos del tubo neural con ácido valproico y carbamacepina.

OBJECTIVE: To determine the risk, if any, of carbamazepine and valproic acid use on the foetus with respect to neural tube defects. MATERIALS AND METHODS: Databases such as MEDLINE, EMBASE, SCISEARCH, The Cochrane Library and LILACS were consulted to have access to published literature from January 1966 to September 2004. All articles published in English and Spanish were considered. A manual review of the references presented in each produced article was done in order to identify the articles that the electronic search may have not found itself. However, articles which seemed ambiguous as to the title and/or abstract were completely analyzed to establish their relevance. Studies that examined the effects of systematic exposure to carbamazepine or valproic acid during pregnancy and that assessed neural tube defects in the infants were eligible. The data was extracted in the form of 2 x 2 tables. The odds ratio (OR), relative risk (RR) and 95% confidence interval (CI) was calculated for each of the studies. RESULTS: The pooled relative risk of neural tube defects among the exposed to valproic acid was 0.61 (95% CI: 0.06-6.72). The risk among the exposed to carbamazepine was 1.10 (95% CI: 0.16-7-75). CONCLUSIONS: Due to the methodologic limitations of most of the studies where the data was insufficient, only three studies could be included in the meta-analysis. There is not enough evidence to establish the risk raised in the objective of the study.

Inactivation of glutathione S-transferases by nitric oxide-derived oxidants: exploring a role for tyrosine nitration.

Reactive intermediates derived from nitric oxide ((*)NO) are thought to play a contributing role in disease states associated with inflammation and infection. We show here that glutathione S-transferases (GSTs), principal enzymes responsible for detoxification of endogenous and exogenous electrophiles, are susceptible to inactivation by reactive nitrogen species (RNS). Treatment of isolated GSTs or rat liver homogenates with either peroxynitrite, the myeloperoxidase/hydrogen peroxide/nitrite system, or tetranitromethane, resulted in loss of GST activity with a concomitant increase in the formation of protein-associated 3-nitrotyrosine (NO(2)Tyr). This inactivation was only partially (<25%) reversible by dithiothreitol, and exposure of GSTs to hydrogen peroxide or S-nitrosoglutathione was only partially inhibitory (<25%) and did not result in protein nitration. Thus, irreversible modifications such as tyrosine nitration may have contributed to GST inactivation by RNS. Since all GSTs contain a critical, highly conserved, active-site tyrosine residue, we postulated that this Tyr residue might present a primary target for nitration by RNS, thus leading to enzyme inactivation. To directly investigate this possibility, we analyzed purified mouse liver GST-mu, following nitration by several RNS, by trypsin digestion, HPLC separation, and matrix-assisted laser desorption/ionization-time of flight analysis, to determine the degree of tyrosine nitration of individual Tyr residues. Indeed, nitration was found to occur preferentially on several tyrosine residues located in and around the GST active site. However, RNS concentrations that resulted in near complete GST inactivation only caused up to 25% nitration of even preferentially targeted tyrosine residues. Hence, nitration of active-site tyrosine residues may contribute to GST inactivation by RNS, but is unlikely to fully account for enzyme inactivation. Overall, our studies illustrate a potential mechanism by which RNS may promote (oxidative) injury by environmental pollutants in association with inflammation.

Comparative thermodynamic study of the interaction of some antifolates with dihydrofolate reductase.

The thermodynamic parameters of the binding of antifolate drugs to bovine liver dihydrofolate reductase (EC 1.5.1.3., 5,6,7,8-tetrahydrofolate: NADP+ oxidoreductase) have been measured with a flow microcalorimetric method. These parameters are greatly influenced by the structure of the inhibitor and/or by the presence of NADPH and above all by temperature. For all the compounds studied, binding at 37 degrees C is driven by favourable enthalpy variations, whereas entropy variations are unfavourable. At 10 degrees C, reactions are both enthalpically and entropically driven. These effects can be explained by a partial thermal denaturation of dihydrofolate reductase at 37 degrees C, which is restructured by NADPH and/or the antifolate. The refolding induced by the antifolate trimetrexate may explain its high association constant in the binary system (without NADPH), and the weaker cooperative effect of NADPH in the ternary system, as compared to methotrexate. In contrast, the poor affinity of trimethoprim for mammalian dihydrofolate reductase in binary and ternary systems at 37 degrees C is the result of a weaker stabilizing effect of this compound as regards temperature increase. Heat capacity variation linked to the complex formation reaction showed that this conformational transition is more pronounced between 25 and 37 degrees C than between 10 and 25 degrees C. Thus, the ability of the inhibitors to give to dihydrofolate reductase a more stable thermal behaviour at 37 degrees C is determinant in their binding.

Attitudes of nonsecluded patients toward seclusion rooms.

This study investigated the attitudes toward seclusion rooms of a group of hospitalized psychiatric patients who were not at the time secluded. Those patients who had never been secluded endorsed more negative feelings about seclusion room use than did those who had actually been secluded during prior hospitalizations. Women were more critical of the seclusion process than were men.

Isolated metachronous metastases to soft tissues of the buttock from a colonic adenocarcinoma.

The more common patterns of dissemination and recurrence of colonic cancer are known and well-documented. In contrast, extravisceral, distant soft tissue metastases are comparatively rare. Therefore, these metastases are not subject to meaningful generalizations, with the exception that they are often associated with widespread metastatic disease. This report describes the first case of carcinoma of the colon metastatic to the skeletal muscle of the contralateral buttock and the sciatic nerve without concurrent evidence of pelvic or distant metastases. Curative resection was not possible because of involvement of the proximal sciatic nerve.