Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review.

Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions. Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies ( N = 1,419 patients) and 81 NVBG studies ( N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman-Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure. Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05-0.13] and 0.08 [95% CI 0.06-0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04-2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08-1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06-1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16-2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13-3.66) and NVBG (IRR 1.39, CI: 1.16-1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type ( p > 0.05). Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

Association of Claustrophobia and Anxiety with Cast Intolerance in Patients with Extremity Injuries.

BACKGROUND: Patients undergoing casting for upper or lower extremity injuries may present with recalcitrant pain without an identifiable physiologic etiology, which increases the likelihood of more frequent or unscheduled office visits, insomnia, decreased patient satisfaction, unnecessary investigative procedures or treatments, and-in some cases-cast intolerance. The exact causes of cast intolerance are not well studied, although claustrophobia and associated fears of suffocation and restriction may be underlying causes. QUESTIONS/PURPOSES: We sought to explore the association between claustrophobic tendencies and cast intolerance. We hypothesized that patients with claustrophobia or claustrophobic tendencies would have a higher rate of cast intolerance. METHODS: Patients requiring circumferential casting of an upper or lower extremity were prospectively enrolled at the time of cast application. Data were collected at each office visit until cast removal. Pre- and post-casting anxiety were quantified using the Beck Anxiety Inventory® (BAI®). Pain was assessed at each visit using the visual analog scale (VAS). Claustrophobic tendencies were evaluated after cast removal using the Claustrophobia Questionnaire (CLQ). At the completion of the study, patients were assigned to either the cast-tolerant or the cast-intolerance cohort according to predetermined criteria. CLQ, BAI, and VAS scores were compared between cohorts. RESULTS: Out of 199 patients enrolled, 4% (n = 8) met the criteria for cast intolerance. There was no difference in BAI (anxiety) scores between groups at casting, but cast-intolerant patients had significantly lower post-casting BAI scores than the cast-tolerant controls, indicating a decrease in anxiety after cast removal. Taken together, both groups demonstrated significant reduction in VAS scores from casting to cast removal. The tolerant group had a significant reduction in VAS scores, whereas the intolerant group did not. The intolerant group had a significant negative correlation between initial VAS scores and final BAI scores. The tolerant group had a significant positive correlation between initial VAS scores and final BAI scores, as well as between final VAS scores and final BAI scores. Interestingly, no difference in CLQ scores was seen between groups, although there were positive correlations between CLQ scores and pre- and post-casting anxiety scores and between CLQ and final VAS scores. CONCLUSIONS: Our hypothesis was not supported. Although we did not find a relationship between claustrophobia and cast intolerance, we did find significant correlations between anxiety and pain. The tolerant group's initial and final pain scores had significantly positive correlations to final anxiety, suggesting that pain is likely to cause or increase anxiety; indeed, as pain decreased, so did anxiety. The intolerant group, however, had a significant negative correlation between initial pain and final anxiety scores. It would not be expected that lower pain scores would increase anxiety. This may suggest that cast-intolerant patients experience or report their anxiety as pain. These findings may explain why some patients suffer from pain that cannot be explained by an underlying physiologic process and is resistant to traditional pain management. A multidisciplinary approach, including psychological and psychosocial assessments, may help identify nonphysiologic components to pain. An accurate diagnosis for the cause of pain may lead to nonpharmacological interventions and therefore reduce opioid use and overall costs and improve patient outcomes.

Does Anyone Need a Vascularized Graft?

Many hand surgeons argue that vascularized bone grafting is indicated in proximal pole avascular necrosis, prior failed surgery, or long-standing scaphoid nonunion. However, the available evidence does not support improved treatment outcomes for vascularized bone grafting rather than traditional nonvascularized techniques. This article addresses the available evidence and examines the role of vascularized bone grafting in scaphoid nonunion treatment. It also identifies important factors that influence healing, clarifies the decision-making algorithm, and proposes areas for further research.

Nerve Transfers for Enterovirus D68-Associated Acute Flaccid Myelitis: A Case Series.

BACKGROUND: Acute flaccid myelitis is associated with enterovirus D68 -induced inflammation and destruction of cervical anterior horn cells. To date, no medical intervention has altered the disease course. METHODS: We report two pediatric patients who were treated with nerve transfer in three limbs with sustained upper extremity neuropathy. Postoperative outcomes included muscle strength, graded on the British Medical Research Council (BMRC) scale, range of motion, and electromyography. RESULTS: Two years postoperatively, Patient 1 had improved elbow flexion to BMRC grade 4+, 125° of flexion, and discrete to decreased motor unit recruitment in targeted muscles. Twenty-one months postoperatively, Patient 2 demonstrated right brachialis flexion to BMRC grade 4+/5 and deltoid firing with simultaneous pectoralis major recruitment, and limited but active flexor digitorum profundus flexion. CONCLUSIONS: Both patients continue to demonstrate functional recovery two years postoperatively. These outcomes suggest a promising reconstructive technique for this emerging and devastating viral endemic.

Intramedullary Fixation of Distal Radius Fractures Using CAGE-DR Implant.

Purpose CAGE-DR implant is a novel Food and Drug Administration approved intramedullary fracture fixation device used for distal radius fractures. We examine a series of 22 patients and report the outcomes with this device. Materials and Methods A total of 24 patients with distal radius fractures (8 articular AO type C1/C2; 16 extra-articular AO type A2/A3) underwent open reduction and internal fixation (ORIF) using CAGE-DR implant by a single surgeon. Data including fracture type, angle of displacement, radiographic consolidation, grip strength, wrist range of motion (ROM), patient-rated wrist evaluation (PRWE), and Visual Analog Scale (VAS) pain scores were recorded at time of surgery and at standard follow-up. Results All 24 patients underwent uneventful ORIF. At first follow-up visit (9 days), all patients had full digital ROM (measured as 0 cm tip-to-palm distance). Two patients were lost to follow-up. Eighteen of the remaining 22 patients had sufficient radiographic follow-up and all 18 demonstrated healing. At latest follow-up (mean 9.7 months, range, 3-20), VAS pain scores averaged 0.6 (range, 0-8) and PRWE averaged 12.1 (range, 0-53.5). Grip strength of the operated hand averaged 58 lbs (range, 20-130). ROM included: wrist flexion 73° (50-95), wrist extension 78° (60-110), pronation 77° (60-90), supination 79° (60-90), ulnar deviation 31° (5-45), and radial deviation 17° (10-30). Three patients underwent screw removal to prevent tendon irritation. One patient underwent hardware removal due to prominence on imaging but was asymptomatic. There were otherwise no major complications, including complex regional pain syndrome, in the series to date. Conclusion The CAGE-DR fracture fixation system is a promising alternative to established methods of distal radius internal fixation. This series has a low reported pain score starting immediately postoperatively and a low complication rate. This novel device is a promising option for internal fixation of displaced distal radius fractures with a low complication profile. Level of Evidence This is a level IV, therapeutic study.

Management of Isolated Capitate Nonunion: A Case Series and Literature Review.

Background Isolated capitate nonunion is rare. No consensus on the appropriate treatment for this condition exists. Case Description We reported two cases of capitate fracture nonunion presenting several months after untreated high-impact wrist trauma. Treatment was delayed as both patients' nonunions were missed on conventional radiographs. Both were ultimately diagnosed with advanced imaging and successfully treated with internal fixation and autogenous bone grafting. The relevant literature pertaining to capitate nonunion was reviewed. Literature Review Immobilization and internal fixation with bone grafting for capitate nonunion have been described in the literature. Loss of vascular supply and progression to avascular necrosis is a concern after capitate nonunion. Clinical Relevance We present two cases and review the literature on the diagnosis and treatment of this rare injury to guide management. Internal fixation with autogenous bone grafting could play a role in management for this rare condition.

Nonspanning Total Wrist Arthrodesis with a Low-Profile Locking Plate.

Purpose This study aims to compare the outcomes and complications of our technique for nonspanning total wrist arthrodesis using a locking plate with the standard carpometacarpal spanning technique. Methods A retrospective review of charts was performed to identify patients who underwent total wrist arthrodesis by the senior author (S.W.W.). We compared the outcomes of 15 cases of nonspanning wrist fusion with a 2.4/2.7 mm locking T plate to 11 cases of spanning wrist fusion with a 2.7/3.5 mm locking compression plate. Minimum follow-up was 3 months. Indications for fusion included rheumatoid arthritis, posttraumatic arthritis, Kienböck's disease, primary osteoarthritis, juvenile inflammatory arthropathy, psoriasis, brachial plexopathy, failed hemi or total wrist arthroplasty, failed four-corner fusion, and failed proximal row carpectomy. The primary outcome was fusion. Secondary outcomes included time to union, patient-rated wrist evaluation score, numerical rating scale pain score, grip strength, and complications. Results All the wrists got fused. There were no significant differences in objective and subjective outcomes between cohorts. There were three complications (27%) in the spanning group, including tendon rupture and peri-implant fracture at the third metacarpal. This was compared with three complications (20%) in the nonspanning group, consisting of hardware removal. Discussion We achieved similar fusion rates employing both spanning and nonspanning total wrist arthrodesis techniques, without necessitating carpometacarpal arthrodesis in the latter. Complications associated with our method were comparably less severe than those reported in the literature. We advocate nonspanning arthrodesis as an alternative method for total wrist fusion with a high union rate and minimal risk of complications at the carpometacarpal joint. Level of Evidence Therapeutic level IV.

Brachial plexitis or neuritis? MRI features of lesion distribution in Parsonage-Turner syndrome.

INTRODUCTION: This study seeks to characterize lesion distribution in Parsonage-Turner Syndrome (PTS) using high-resolution MRI. METHODS: MRIs of 27 patients with clinically confirmed PTS were reviewed. Two radiologists independently evaluated the brachial plexus proper, side and terminal plexus branches, and more distal, upper extremity nerves. RESULTS: All patients had at least 1 clinically involved nerve. MRI revealed that the plexus appeared normal in 24 of 27 patients; in 3 other patients, signal hyperintensity was seen immediately proximal to the take-off of abnormal side or terminal branch nerves. Focal intrinsic constrictions were detected in 32 of 38 nerves. MRI interobserver agreement was high (Cohen's κ = 0.839). DISCUSSION: MRI findings, corroborated by electrodiagnostic testing, localized abnormalities to plexus branches and peripheral nerves, suggesting that PTS is characterized by 1 or more mononeuropathies rather than changes involving a portion of or the complete plexus proper. These results may improve diagnosis, prognostication, and management. Muscle Nerve 58: 359-366, 2018.

Success of scaphoid nonunion surgery is independent of proximal pole vascularity.

We followed 35 consecutive patients with scaphoid nonunions in a prospective longitudinal registry. All nonunions were treated with curettage, non-vascularized autogenous grafting and headless screw fixation. Preoperative magnetic resonance imaging, intraoperative bleeding points and histopathological analysis of cancellous bone in the proximal pole were recorded as measures of viability. Healing was categorized as ≥50% bony bridging on computed tomographic images in the plane of the scaphoid. Nine of 23 proximal poles demonstrated ischaemia on magnetic resonance imaging but none were interpreted as infarcted. Twenty-eight of 33 were found to have impaired vascularity as assessed by intraoperative bleeding. Fourteen of 32 demonstrated ≥50% trabecular necrosis and four of 33 demonstrated ≥50% tissue necrosis on histopathological analysis. Thirty of 33 demonstrated focal or robust remodelling activity. Despite pathological evidence of impaired vascularity in over half of the patients, 33 of the 35 scaphoids had healed by 12 weeks. We conclude that proximal pole infarction is decidedly rare and that vascularized bone grafting is seldom required. LEVEL OF EVIDENCE: IV.

At Home Photography-Based Method for Measuring Wrist Range of Motion.

Purpose To determine the reliability of wrist range of motion (WROM) measurements based on digital photographs taken by patients at home compared with traditional measurements done in the office with a goniometer. Methods Sixty-nine postoperative patients were enrolled in this study at least 3 months postoperatively. Active and passive wrist flexion/extension and radial/ulnar deviation were recorded by one of the two attending surgeons with a 1-degree resolution goniometer at the last postoperative office visit. Patients were provided an illustrated instruction sheet detailing how to take digital photographic images at home in six wrist positions (active and passive flexion/extension, and radial/ulnar deviation). Wrist position was measured from digital images by both the attending surgeons in a randomized, blinded fashion on two separate occasions greater than 2 weeks apart using the same goniometer. Reliability analysis was performed using the intraclass correlation coefficient to assess agreement between clinical and photography-based goniometry, as well as intra- and interobserver agreement. Results Out of 69 enrolled patients, 30 (43%) patients sent digital images. Of the 180 digital photographs, only 9 (5%) were missing or deemed inadequate for WROM measurements. Agreement between clinical and photography-based measurements was "almost perfect" for passive wrist flexion/extension and "substantial" for active wrist flexion/extension and radial/ulnar deviation. Inter- and intraobserver agreement for the attending surgeons was "almost perfect" for all measurements. Discussion This study validates a photography-based goniometry protocol allowing accurate and reliable WROM measurements without direct physician contact. Passive WROM was more accurately measured from photographs than active WROM. This study builds on previous photography-based goniometry literature by validating a protocol in which patients or their families take and submit their own photographs. Clinical Relevance Patient-performed photography-based goniometry represents an alternative to traditional clinical goniometry that could enable longer-term follow-up, overcome travel-related impediments to office visits, improve convenience, and reduce costs for patients.

Comparison of Magnetic Resonance Imaging and Radiographs for Evaluation of Carpal Osteoarthritis.

Background We sought to evaluate the interobserver and intraobserver reliability of radiographs and magnetic resonance imaging (MRI) for grading of osteoarthritis in patients with scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC), and to determine whether MRI is more likely than radiographs to detect carpal osteoarthritis. Methods Radiographs and MR studies of 46 patients with SLAC and SNAC arthritis were reviewed by two hand surgeons and two radiologists and were graded according to severity of osteoarthritis at seven carpal joints. Interobserver and intraobserver reliability was assessed using a weighted kappa analysis. Odds ratios were calculated to compare the likelihood of MRI versus radiographs in the determination of moderate or severe osteoarthritis. Results Measures of reliability were higher for MRI than radiographs. For radiographic assessment of all patients combined, interobserver agreement was moderate and intraobserver agreement was also moderate. For MRI, interobserver agreement was substantial and intraobserver agreement was almost perfect. In all joints combined for patients with SLAC and SNAC, MRI was 2.42 times more likely to demonstrate moderate osteoarthritis compared with radiographs. In patients with SLAC, MRI was 11.73 times more likely than radiographs to show moderate osteoarthritis at the radiolunate joint. In patients with SNAC, there was no difference in demonstration of moderate osteoarthritis on MRI compared with radiographs. Conclusion Carpal osteoarthritis can be more reliably assessed on MRI than radiographs. MRI is more sensitive at demonstrating moderate changes of osteoarthritis than radiographs, especially at the radiolunate joint in patients with SLAC arthritis. This has implications for surgical management of SLAC/SNAC arthritis and preoperative planning. MRI should be included in the diagnostic workup and evaluation of patients with SLAC and SNAC arthritis. Level of Evidence Diagnostic III.

Tibial Bone Grafting for Wrist Reconstruction.

Background Iliac crest bone graft harvesting is routinely performed for upper extremity orthopedic procedures despite high complication rates associated with sensory nerve injury, hematoma, chronic pain, and fracture. Description of Technique Cancellous bone graft is harvested from the proximal tibia using a medial approach, minimizing donor site morbidity. Patients and Methods A retrospective review was undertaken of 14 patients who underwent cancellous proximal tibia bone graft harvesting to augment healing of wrist reconstruction, with 2 months minimum follow-up. We report donor limb tourniquet time, time to union, visual analog scale (VAS) pain score, and complications. Patients were also contacted by phone to administer a retrospective questionnaire and record experiences with the harvesting technique. Results Average donor site VAS for the immediate postoperative period was 7.4. Average tourniquet time was 28 minutes. Average time to union of the recipient site was 45 days. One patient experienced delayed union after corrective osteotomy, attributed to osteoporosis. Two patients underwent hardware removal from the operative wrist, unrelated to bone graft harvesting. One patient with a history of chronic neuropathy and foot drop developed dysesthesia and allodynia about the ipsilateral ankle, but was asymptomatic at the proximal tibia donor site; ankle symptoms resolved 3 weeks postoperatively. No patient reported any residual donor site difficulties 24.2 months postoperatively. Conclusion In consideration of the minimal complication rate, favorable clinical parameters, and excellent patient tolerance, we advocate proximal tibia bone graft harvesting as opposed to iliac crest harvesting for wrist reconstruction when a moderate amount of autogenous cancellous graft is needed. Level of Evidence IV.

The Prevalence of Pisotriquetral Arthritis in the Setting of Scapholunate Advanced Collapse.

Background Previous authors have reported pisotriquetral pain and subsequent pisiform excision following partial or total wrist fusion in patients with scapholunate advanced collapse (SLAC). Prior studies have not considered the potential role of SLAC biomechanics on pisotriquetral osteoarthritis (PT OA) development preoperatively. Purpose To determine the prevalence and severity of PT OA in patients with SLAC as compared with a control population. Patients and Methods Magnetic resonance imaging (MRI) studies of 24 patients with SLAC wrist and 24 sex- and age-matched control patients were analyzed. Patients with SLAC wrist were selected from a database of all wrist MRI studies performed at our institution from 2006 to 2015, excluding those with inflammatory arthritis, chondrocalcinosis, and incomplete or atraumatic scapholunate interosseous ligament rupture. Control patients underwent MRI for nonarthritic clinical indications and were chosen in an age- and sex-matched fashion. Patients undergoing MRI for triangular fibrocartilage complex injury, extensor carpi ulnaris tendinopathy, or ulnar-sided wrist pain were excluded from the control cohort. MRI grading of arthritic change at the pisotriquetral joint was assessed by a blinded musculoskeletal radiologist according to a four-category scale, with grade 4 indicating the greatest arthritic severity. Results The prevalence of PT OA in the control cohort was found to be 37.5% compared with 41.7% in the SLAC cohort. The prevalence of greatest arthritic severity (grade 4) at the pisotriquetral joint was found to be 4.2% in the control cohort, compared with 16.7% in the SLAC cohort. Conclusion We conclude that the overall prevalence of chondral wear at the pisotriquetral joint in SLAC wrist does not differ significantly from that found in control populations. We did identify a fourfold (but not statistically significant) increased prevalence of end-stage arthritis in patients with SLAC. Given reports of symptomatic PT OA developed following four-corner arthrodesis, we recommend preoperative vigilance for pisotriquetral pain in patients with SLAC arthritis. Level of Evidence Prognostic level III.

Pachydermodactyly: A Case Report Including Histopathology.

Pachydermodactyly (PDD) is a rare form of digital fibromatosis characterized by painless soft tissue swelling, primarily about the proximal interphalangeal joints. The skin at the metacarpophalangeal joints, the palm, and the dorsum of the hand may also be involved. Because swelling can occur over the proximal interphalangeal and metacarpophalangeal joints, PDD may be confused with juvenile inflammatory arthropathy and may even occur concurrently. We present the clinical and histopathologic findings of a case of PDD characterized by bilateral proximal phalangeal involvement of the index through little fingers.

Scaphoid Proximal Pole Fracture Following Headless Screw Fixation.

Background Headless screw fixation of scaphoid fractures and nonunions yields predictably excellent outcomes with a relatively low complication profile. However, intramedullary implants affect the load to failure and stress distribution within bone and may be implicated in subsequent fracture. Case Description We describe a posttraumatic fracture pattern of the scaphoid proximal pole originating at the previous headless screw insertion site in three young male patients with healed scaphoid nonunions. Each fracture was remarkably similar in shape and size, comprised the volar proximal pole, and was contiguous with the screw entry point. Treatment was challenging but successful in all cases. Literature Review Previous reports have posited that stress-raisers secondary to screw orientation may be implicated in subsequent peri-implant fracture of the femoral neck. Repeat scaphoid fracture after screw fixation has also been reported. However, the shape and locality of secondary fracture have not been described, nor has the potential role of screw fixation in the production of distinct fracture patterns. Clinical Relevance Hand surgeons must be aware of this difficult complication that may follow antegrade headless screw fixation of scaphoid fracture nonunion, and of available treatment strategies.

Shoulder and Elbow Recovery at 2 and 11 Years Following Brachial Plexus Reconstruction.

PURPOSE: To report short-term and long-term outcomes on a single patient cohort observed longitudinally after nerve reconstruction for adult brachial plexus injury. METHODS: Eleven male patients who underwent plexus reconstruction by the same surgeon at 2 institutions presented for clinical examination 7.5 or more years after surgery (average, 11.4 years; range, 7.5-22 years). Average age at the time of operation was 35 years (range, 17-73 years). Mean delay until surgery was 5 months (range, 2-11 months). Two patients had C5 paralysis, 2 had C5-C6 paralysis, 2 had C5-C7 paralysis, and 5 had complete 5-level injuries. Outcome parameters included active range of motion (ROM) in degrees, a modified British Medical Research Council (mBMRC) scale for muscle strength, and electromyographic motor unit configuration and recruitment pattern. Differences in ROM and mBMRC between 2-year and long-term follow-up were assessed with paired-sample t tests using an alpha value of .05. RESULTS: Average shoulder abduction and mBMRC at final follow-up were both significantly improved compared with the 2-year follow-up results (P < .05). Average elbow flexion and mBMRC increased significantly between 2 years and final follow-up (P < .05). Electromyographic results for 6 patients at final follow-up showed improved motor unit configuration in 10 of 15 muscles and improved recruitment in 3 of 15 muscles compared with 2-year electromyographic results. CONCLUSIONS: Patients continued to gain ROM and strength in the shoulder and elbow well after 2 to 3 years after surgery, contrary to previous reports. Although the precise mechanism is unknown, we speculate that a number of factors may be involved, including terminal collateral sprouting, maturation of motor units, improvements in motor unit recruitment, additional muscle fiber hypertrophy, or an as-yet undescribed mechanism. We recommend that patients be encouraged to continue strengthening exercises well after the initial recovery period and that more comparative long-term data be collected to expand on these observations.

Recurrent pigmented villonodular synovitis and multifocal giant cell tumor of the tendon sheath: case report.

Intra- and extra-articular giant cell tumor of tendon sheath (GCTTS) and pigmented villonodular synovitis (PVNS) are histologically similar, usually benign tumors that can be characterized by synovial involvement (GCTTS) or overgrowth (PVNS). These tumors are most often found in the knee and digits of the hand. Although recurrence is a common feature of both conditions, multifocal lesions are rare. We present an unusual case of multifocal, recurrent, bilateral GCTTS/PVNS involving both upper and lower extremities. Recurrent right ankle and right index finger masses, in addition to masses on the right small finger and left thumb, were excised over a 14-year period.