Prognostic factors for return to work in patients affected by chronic low back pain: a systematic review.

Chronic low back pain (LBP) represents a leading cause of absenteeism from work. An accurate knowledge of complex interactions is essential in understanding the difficulties of return to work (RTW) experienced by workers affected by chronic LBP. This study aims to identify factors related to chronic LBP, the worker, and the psycho-social environment that could predict and influence the duration of an episode of sick leave due to chronic LBP.Studies reporting the relation between prognostic factors and absenteeism from work in patients with LBP were included. The selected studies were grouped by prognostic factors. The results were measured in absolute terms, relative terms, survival curve, or duration of sick leave. The level of evidence was defined by examining the quality and the appropriateness of findings across studies in terms of significance and direction of relationship for each prognostic factor.A total of 20 studies were included. Prognostic factors were classified in clinical, psycho-social, and social workplace, reaching a total of 31 constructs. Global conditions with less favorable repercussions on worker's lives resulted in a delay in time to RTW. Older age, female, higher pain or disability, depression, higher physical work demands, and abuse of smoke and alcohol have shown strong level of evidence for negative outcomes.High global health well-being, great socioeconomic status, and good mental health conditions are decisive in RTW outcomes. Interventions that aim at RTW of employee's sick-listed with LBP should focus on psycho-social aspects, health behaviors, and workplace characteristics.

Heterotopic hip ossification resection: monocentric experiences of associated factors, outcomes, and complications.

PURPOSE: The exponential increase in total hip arthroplasty (THA) has led to acute and chronic surgery-related complications. Common chronic and local complications are represented by hip ossification (HO). The aim of our study was to assess the clinical and radiological correlates of patients undergoing surgical removal of heterotopic ossifications after THA and the possible association between HO and prosthetic joint infection. METHODS: Data of 26 patients who underwent surgical removal of periprosthetic calcifications after THA from 2000 to 2022 were analyzed and compared with characteristics of 156 subjects without HO. RESULTS: The preoperative radiographs of patients showed a high-grade Brooker, 3 or 4, later reduced to 1 or 2 in the postoperative radiographs. Ten (38.5%) patients underwent radiotherapy prophylaxis, administered as a single dose 24 h before surgery. In 19 (73%) patients, pharmacological prophylaxis with indomethacin was added in the 30 postoperative days. Only one patient who underwent radiotherapy had a recurrence, while new ossifications were found in three patients without prophylaxis (11.5%). Intraoperative cultures were performed for suspected periprosthetic infection in 8 study group patients. In logistic regression, the presence of HO was significantly and inversely associated with the ASA score (OR = 0.27, 95% CI = 0.09-0.82; P = 0.021) after adjusting. CONCLUSION: Surgical HO removal in symptomatic patients with high-grade disease produces good clinical and radiographic results. Radiotherapy was a good perioperative and preventive strategy for recurrence, also associated with NSAIDs and COX-2 inhibitors.

Validation of a novel smart drilling system to monitor bone impedance during transpedicular screw placement: a pilot study.

Transpedicular screw placement is a high-risk procedure routinely performed in spine surgery. To decrease the rate of complications, it is necessary to find innovative solutions to assist the surgeon during screw insertion so as to avoid the chance of mispositioning. In this study, we developed a new drilling system able to estimate the mechanical properties of drilled tissues. Several investigations show that cortical bone requires a high level of thrust force and torque during drilling compared to trabecular bone. To implement an algorithm for bony breakthrough detection, a new drilling system has been built together with a mechanical support to drill the pedicle along a pre-planned trajectory. The mechanical support is equipped with a smart rotative drill that embeds force and position sensors. Ten human vertebral segments have been used to test the surgical platform, for percutaneous bone drilling. 10 transpedicular holes from L1 to L5 have been performed bilaterally. The holes were further evaluated by computed tomographic scans to measure bone density in the cortical and in the trabecular layers. To compare bone density with the bony mechanical impedance two new parameters (DHU and DPAI) have been introduced. The results show that in 18 out of 20 cases the D values of bone density and mechanical impedance, related to the same bone transition, differ less than 10%. The proposed system is thus able to evaluate the variation of bone density of the cortical and the trabecular layer using impedance. Therefore, it is possible to use the described system to increase the accuracy of transpedicular screw placement.

Osseointegration for lower and upper-limb amputation a systematic review of clinical outcomes and complications.

The conventional use of prosthetic custom-design socket is affected by discomfort related to wellknown problems: sweating, sores or skin irritation, excessive weight and harness, impaired body image, that lead to a high rate of abandonment. Osseointegrated prosthetic implants for limb amputation are progressively evolving to overcome limitations of socket. The aim of this article is to present a systematic review of the use, safety in terms of rate of infection and complications, and reported outcomes of upper and lower limb osseointegrated prosthetic implants. A systematic search was carried out for studies that evaluated outcomes of osseointegration technique in case of upper and lower limb amputees according to the PRISMA guidelines with a PRISMA checklist and algorithm. MINORS score was used for methodologic assessment. 17 articles about the treatment of patients with upper or lower limb amputation treated with an osseointegrated prostesis were included. The overall rate of infections was 32%. All the clinical outcomes reported were related to lower limb. No clinical data for upper limb was found. The postoperative mean value of MCS and PCS SF-36 and Q-TFA was 55.1, 45.4 and 73.8 respectively, while six minute walk test (6MWT) and the timed up and go (TUG) test scored an average value of 388 meters and 11.5 seconds respectively. MINORS score ranged from 5 to 13, with a median of 11 [interquartile range (IQR), 9-11]. The osseointegration is associated to a high rate of postoperative complications but, significant improvement in clinical outcomes compared to preoperative time are shown. The data available from the literature are limited but suggest good clinical outcomes and significant survivorship of the implants. Further clinical studies are needed to establish which kind of implant is associated to higher clinical performance and lower rate of postoperative complications and infections.

Frailty of the elderly in orthopaedic surgery and body composition changes: the musculoskeletal crosstalk through irisin.

In recent years, scientific interest has been developed towards irisin, a novel molecule of the family of myokines, which is directly involved in body mass composition balance, chronic diseases susceptibility and physiologic resilience to stressful events, including surgery. In the context of musculoskeletal disease, the role of this molecule has been associated to the balance of lean and fatty mass, and the production of irisin is subordinated to a healthy lifestyle and exercise. The mechanism of action of irisin on tissues is complex, and several studies described the molecular pathways in animal model and human subjects. In particular, in adipose cells, the key-role of irisin is to stimulate the differentiation of white adipose tissue to brown adipose tissue, through the action on the uncoupling protein 1. Furthermore, in the bony tissue, irisin stimulates osteogenesis through expression of Sost and Opn genes. These features make irisin a suitable molecule to use as a biomarker of the overall musculoskeletal health of the elderly, before undergoing orthopaedic surgery. Further research on this topic should be carried out to highlight the possible clinical role and predictive value of irisin in a multidisciplinary approach to the elderly before musculoskeletal surgery.

Adipose-derived stromal vascular fraction processed with different systems for the treatment of knee osteoarthritis: a pilot study on cell proliferation and clinical results.

In recent years, the interest in stromal vascular fraction (SVF) therapy for conservative treatment of osteoarthritis has grown significantly. This study aims to assess three different processing systems (micro-fragmentation, filtration, or slow centrifugation) in terms of cell proliferation in vitro and clinical results of intraarticular injections for the treatment of knee OA. From December 2017 to June 2018, 25 procedures were performed using three different systems. A considerable improvement of the clinical condition in almost all patients already one month after the treatment with a stable effect at 6 and 12 months was recorded. Patients treated with SVF, obtained by the micro-fragmentation system, had better outcomes one month after the treatment with a mean improvement of the symptomatology higher than that found in patients treated with the filtration or slow centrifugation system. The SVF product from the same system had a higher cell proliferation capacity in vitro.

Targeting VEGF-A in cartilage repair and regeneration: state of the art and perspectives.

Osteoarthritis (OA) is the most common joint disorders in western populations, and is characterized by a progressive degradation of articular cartilage (AC) leading to loss of joint function. Methods to cure, delay or prevent the onset of OA and/or improve AC repair strategies have high clinical and socioeconomic impact. Possible innovative strategies envisioned for early OA treatments or cartilage repair include the implantation/injection of mesenchymal progenitors (MPs)-based constructs or cell-free bioactive scaffolds/hydrogel coupled with the controlled recruitment and instruction of resident MPs or AC. However, these tissue engineering-based strategies still suffer from unreliable outcomes with poor fibro-cartilaginous repair and blood vessel invasion. In such conditions Vascular Endothelial Growth Factor (VEGF) family has been shown to play a key role in controlling AC catabolism on one hand and angiogenesis on the other as a crucial step for endochondral ossification of MPs, ultimately leading to progressive breakdown of the neo-formed matrix. This review aims to provide a summary of relevant relationships between impaired angiogenesis, OA and cartilage regeneration highlighting how VEGF might play a paramount role in the pathophysiology of cartilage aging or degeneration as well as in cartilage repair.

A new surgical positioning system for robotic assisted minimally invasive spine surgery and transpedicular approach to the disc.

Minimally Invasive Spine Surgery (MISS) procedures for the treatment of spinal pathologies have experienced exponential growth due to improved techniques and decreased trauma to the patient. Several MISS procedures that require the use of a trans-pedicular cannula as a guiding tool for pedicle screw placement, delivery of biomaterials to the vertebral body or injection of biologics to the disc space have been described. Although these are clear advantages of MISS, the limited dissection and exposure may reduce the accuracy and stability of operation and make spine surgeons rely heavily on intraoperative fluoroscopy, raising concerns over the level of radiation exposure. Robot-assisted minimal invasive surgery has aroused more attention for its high precision and stability, minimizing risks of damage to neurovascular structures and diminishing harmful exposure to ionizing radiation. The aim of this paper is to describe and characterize a new surgical positioning system for for robotic assisted MISS. The system is conceived to be integrated in a surgical platform capable of supporting the surgeon in a new procedure to treat degenerative intervertebral disc disease. For this purpose, it is necessary to orientate a cannula in order to guide the bone drill along a planned route, to access the intervertebral disc through the pedicle and endplate. In particular, we describe a mechanism that percutaneously guides a cannula towards the intervertebral disc based on the acquisition of few fluoroscopic images. The design of the positioning system, with its features and constrains imposed by the presence of instrumentation and medical staff in the operating room, as well as the software for trajectory planning during surgery, are here described.

Targeted muscle reinnervation for improved control of myoelectric upper limb prostheses.

Targeted muscle reinnervation (TMR) is a novel surgical technique developed to improve the control of myoelectric upper limb prostheses. Nerves transected by the amputation, which retain their original motor pathways even after being severed, are redirected to residual denervated muscles that serve as target for consequent reinnervation. Once the process is complete, reinnervated muscles will contract upon voluntary activation of transferred nerves while attempting to move missing regions of the amputated limb, generating EMG signals that can be recorded and used to control a prosthetic device. This allows creating new control sites that can overcome major drawbacks of conventional myoelectric prostheses by offering a more natural and intuitive control of prosthetic arms. TMR has been widely performed in individuals who underwent shoulder disarticulation amputation and transhumeral amputation since proximal amputations do not leave enough functional muscles exploitable to control independent degree of freedoms of multi-articulated prostheses. TMR application is currently under investigation in patients suffering further distal amputations, as well as for treating and preventing painful post-amputation neuromas. The purpose of this paper is to describe the physiologic basis and the surgical technique of TMR, reporting current knowledge on the clinical results.

The cytokinome in osteoarthritis, a new paradigm in diagnosis and prognosis of cartilage disease.

At present, diagnosis and progression monitoring of osteoarthritis (OA) is made through radiological and clinical assessment. Several studies investigated the role of synovial fluid analysis, to find out whether joint disease could be characterized by the pattern of cytokines, which acts during the pathogenic process or in specific stages of it. Online PubMed-Medline search was performed in order to retrieve evidence concerning synovial fluid analysis of cytokines involved in OA degenerative process. Concerning pro-inflammatory cytokines, it has been shown that interleukin (IL)-6, TNF-α and IL-17 are mainly over-expressed in the synovial fluid of OA joints, as well as anti-inflammatory cytokine IL-10. Variations of cytokines levels occur with radiological and clinical progression. It was also reported that metalloproteinases are involved. Synovial fluid analysis may be helpful in defining stage and type of OA, but more research is needed, especially focusing on the variation of sets of cytokines during OA stages and correlating these patterns with clinical features.

Bone marrow concentrated cells and stromal vascular fraction cells injections for osteoarthritis treatment: a systematic review.

The aim of this systematic review is to examine current clinical evidences supporting the intraarticular injection of bone marrow concentrate cells (BMC) and adipose-derived stromal vascular fraction cells (SVF) for the treatment of osteoarthritis (OA). The research was performed on PubMed (Medline), EMBASE and Cochrane Library considering the English literature. Only clinical trials have been included. The systematic research identified twelve clinical trials. Articles included in the study, were one of level II, four of level III, six of level IV and one level V. Among clinical trials, none were randomized, four were comparative, seven were case series, and one was a case report. Seven studies were focused on the use of SVF (1332 patients) and five on the use of BMC (963 patients), with preliminary interesting findings in the OA treatment. Despite the growing interest in this biological approach for OA, knowledge on this topic is still preliminary. Randomized controlled trials are needed to support the potential of BMC and SVF injections and to evaluate advantages and disadvantages with respect to the available treatments.

Autologous bone marrow concentrate combined with platelet-rich plasma enhance bone allograft potential to induce spinal fusion.

Bone marrow cells concentrate (BMCs) is a source of osteoprogenitor cells and platelet-rich plasma (PRP) is a source of growth factors. The objective of the study was to determine whether BMC and PRP could increase the potential of bone allograft to induce posterolateral-lumbar spinal fusion compared to the bone allograft alone. A prospective nonrandomized radiographic study has been conduced on 10 patients with posterolateral instrumented fusion for degenerative lumbar disease with 1-year follow-up using CT scan. A fresh frozen bone allograft alone and bone allograft with a mixture of autologous BMC and PRP blended with thrombin were apposed in the right and left posterolateral side, respectively. CT showed good right fusion masses (allograft alone) in 4 patients and poor in 6; good left masses (BMC and PRP plus allograft) in 9 patients and poor in 1. The differences detected between right-side and left-side masses show an advantage in adding BMC and PRP to the bone allograft to increase spinal fusion rate.

Mesenchymal stem cells for intervertebral disc regeneration.

Low back pain (LBP) is one of the most common disabling symptoms affecting the adult population throughout the industrialized world. The main cause underlying this condition is intervertebral disc degeneration (IDD), which is characterized by progressive decrease of the proteoglycan content within the nucleus pulposus (NP), leading to disc dehydration and loss of its morpho-functional and biomechanical properties. To date, LBP treatment is based upon conservative and invasive procedures which are not capable of restoring the degenerative alterations of the disc, as they only help relieve the symptoms and/or slow down disc degeneration and are, nonetheless, characterized by significant comorbidities, costs and secondary risks. The potential use of different mesenchymal stem/stromal cells (MSCs) for treating IDD has been promisingly tested in vitro and in vivo. The combination of different cell types, preconditioning culture conditions, engineered scaffolds and delivery systems have yielded proof of disc matrix reconstitution, increased cell viability and tissue regeneration in several experimental settings. This article reviews the current literature on stem cell-based therapy for IDD and the outcomes that diverse approaches have achieved.

BIOTECHNOLOGIES AND BIOMATERIALS IN SPINE SURGERY.

Over the past few decades, spine disorders have become a major health concern and the number of spinal surgical procedures has been rising significantly. Several biotechnologies and biomaterials are often used in spine surgery to increase the effectiveness of the treatment. In the degenerative spine, when conservative treatment is ineffective the most recommended surgical procedure is decompression followed by spinal fusion. Success rates of spine fusion extensively rely on bone grafts peculiar properties. Autograft has been considered the gold standard to achieve a solid fusion but current research is focused on the development of new biomaterials. Osteoporosis is the main cause of vertebral compression fractures that are significantly associated with pain and disability, especially in the aging population. Vertebral augmentation is a minimally invasive approach in which cement is injected into the vertebral body to stabilize the fracture. New cements are being developed in the clinical scenario with reabsorbable properties and biomechanical features more similar to the native bone. The development of disc regeneration strategies such as nucleus pulposus restoration and annulus fibrosus repair may represent a minimally invasive procedure towards regeneration rather than fusion. Therefore, biomaterials and tissue engineering are fields of growing interest among both surgeons and manufacturing companies, with a major involvement in spine surgery. This review discusses current and novel biotechnologies and biomaterial used in spine surgery employing fusion, augmentation and regeneration.

Biomechanical and neural changes evaluation induced by prolonged use of non-stable footwear: a systematic review.

The aim of this review is to collect and discuss the current best evidence published in literature about the effect of the Masai Barefoot Technology(MBT) shoes on gait and muscle activation and try to draw conclusions on the possible benefits. We searched Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials. The reference lists of the previously selected articles were then examined by hand. Only studies comparing biomechanical and clinical outcomes were selected. Review, anatomical studies, letter to editor and instructional course were excluded. Finally, all the resulting articles were reviewed and discussed by all the authors to further confirm their suitability for this review: in the end, 22 articles were included. A total of 532 patients presenting a mean age of 34.3 years were studied. All patients evaluated were healthy or amateur sports except in two studies where only obese subjects and knee osteoarthritis patients were involved. Seven studies evaluated only male subjects, whereas four studies evaluated only female. Twelve of twenty-two studies performed electromyographic analyses. Weight was reported in 19 studies, whereas body mass index were reported only in a five studies. All studies reported kinematic analysis of shoe effects and compared the relationship between muscle recruitment and electromyographic activity. Unstable footwears were shown to immediately alter the stability in gait during daily-life activities. The center of body pressure is moved posteriorly with a consequent posterior displacement of the upper part of body in order to regain an appropriate body balance, and these postural changes are associated with an overall increase in the activity of lumbar erector spine muscles, as well as certain lower limb muscles. Current literature provides enough cues to conclude for a beneficial role of MBT shoes in the postural and proprioceptive recovery, but from the same literature cannot be drown clear and appropriate guidance to determine more in detail their indication for specific pathological conditions or for particular phases of the musculoskeletal recovery process.

Endothelial dysfunction and tendinopathy: how far have we come?

Symptomatic tendon tears are one of the most important causes of pain and joint dysfunction. Among the intrinsic causes, vascularization recently gained a major role. Endothelial function is indeed a key factor, as well as vascular tone and thrombotic factors, in the regulation of vascular homeostasis and the composition of vascular wall. In this review, we studied systematically whether there is a relationship between endothelial dysfunction and tendinopathy. A literature search was performed using the isolated or combined keywords endothelial dysfunction and tendon,' 'nitric oxide (NO) and tendinopathy,' and 'endothelial dysfunction in tendon healing.' We identified 21 published studies. Of the selected studies, 9 were in vivo studies, 2 focusing on animals and 7 on humans, while 12 reported about in vitro evaluations, where 7 were carried out on humans and 5 on animals. The evidence about a direct relationship between tendinopathy and endothelial dysfunction is still poor. As recent studies have shown, there is no significant improvement in clinical and functional assessments after treatment with NO in patients suffering from tendinopathy in different locations. No significant differences were identified in the outcomes reported for experiment group when compared with controls treated with conventional surgical procedures or rehabilitation programs. Nitric oxide could be a marker to quantify the response of the endothelium to mechanical stress or hypoxia indicating the final balance between vasodilatating and vasoconstricting factors and their effects, but more ad stronger evidence is still needed to fully support this practice.

Update on the TURBO BOOSTER spectranetics laser for lower extremity occlusive disease.

In the last two decades the endovascular treatment of peripheral arterial occlusive disease (PAOD) has gained a widespread and predominant role. New technologies have developed in the last years as atherectomy devices, self expandible nitinol stents, drug eluting devices (stent and balloons), absorbable stents. In recent years, growing interest has been dedicated to laser technology due to device improvements and literature data reporting safety and efficacy of excimer laser. The role of this new endovascular technique for the treatment of atherosclerotic arterial diseases should be considered with regard to two fields of interest: the claudicatio intermittens (CI) and the critical limb ischemia (CLI). A 20-year history with medical lasers has proven that not all lasers are equal. Lasers used and studied in the late 1980s and 1990s had poor outcomes due to inappropriate laser selection and undefined laser techniques. Over the last 10 years, multicenter studies with the excimer laser confirm that case selection, appropriate utilization of equipment, application of safe lasing techniques, and knowledge of indications and contraindications, all contribute to the successful application of laser-assisted angioplasty in complex coronary and peripheral artery disease. If applied properly, the Excimer Laser is a useful technique to transform complex obstructive arterial disease into more treatable lesions, improving the results of endovascular treatment and lowering the threshold of intervention for ''untreatable'' patients. New larger studies are requested to assess the definitive role of this technique in PAD treatment and limb salvage. This review will discuss the Laser Phisics and application in PAD along with the clinical data available to support the Excimer Laser as a reliable technology for endovascular intervention.

[Treatment of serious hepatic lacerations with Ton That Tung's technique]. / Trattamento delle gravi lacerazioni epatiche secondo la tecnica di Ton That Tung.

BACKGROUND: Serious hepatic lacerations are associated with an elevated mortality which depends on the consequent haemorrhage. The hepatic resection in emergency, according to Ton That Tung, seems to be the more appropriate operation for the rapidity of execution and the low mortality associated (11% out of 1000 operations). METHOD: According to Ton That Tung' technique, 12 operations of hepatic lobe and segment resections were executed after trauma caused by road accidents, firearm lesions, sidearm lesions and bleeding neoplasms. RESULTS: Among 12 patients operated on, 9 healed (75%) and 3 died (25%). CONCLUSIONS: The high mortality in the hepatic resections depends on the technique used. The anatomic resection, according to Bismuth, has an operative time longer than the time described by Ton That Tung, time that in emergency is important because the mortality depends not only from the blood lost, but, also the time in which the blood is lost. Hepatic resection according to Ton That Tung is the gold standard for the treatment of serious lacerations and hepatic bleeding neoplasms.

[Tension-free hernioplasty in the aged. A report of 94 cases]. / Ernioplastica secondo Lichtenstein nell'anziano. Contributo clinico.

BACKGROUND: Tension free inguinal hernioplasty has become the procedure of choice in the elderly. The operation of originally popularized by Lichtenstein and Shulman gives the best early result with low complication rates. METHODS: Between January 1991 and December 1996, 94 subjects over 70 with inguinal hernia were submitted to hernioplasty. The tension-free technique was adopted utilizing a polypropylene mesh. Peridural anesthesia was the method used in 67 procedures, local anesthesia in 27 procedures. RESULTS: The mean hospital stay was 48 hours (short stay surgery). Noteworthy general complications were not observed. Superficial wound infection occurred in 2 patients; superficial skin hematoma in 4 patients. No recurrences were observed (mean follow-up 60 months). The primary inguinal hernias in the aged is due to a progressive deterioration of the inguinal floor (collagenolylis, overpowers net collagen synthesis and deposition in the floor of the inguinal canal). CONCLUSIONS: Tension-free inguinal hernioplasty, originally popularized by Lichtenstein and Shulman, is simple to perform and gives excellent results with low complication rates. Current evidence suggests it as operation of choice in the elderly.

[Laparoscopic surgery of perforated duodenal ulcer]. / Trattamento laparoscopico dell'ulcera duodenale perforata.

BACKGROUND AND AIM: Endoscopic diagnostic and therapeutic possibilities have been increased by videolaparoscopy. The method enables an immediate reliable diagnosis to be made, associated with possible surgical treatment. METHODS: The authors report their laparoscopic experience relating to the treatment of perforated duodenal ulcer from 1972 to 1995 in 8 patients divided into two groups. Jacob Palmer's laparoscopic operator was used in the first group together with Menghini's needle for the aspiration of peritoneal effusion; the operation was performed under local anesthesia with nitrogen monoxide insufflation using Taylor's technique number I. The second group underwent ulcorrhaphy with omentopexy, again using a laparoscopic route, together with abundant lavage and accurate aspiration of fibrin. RESULTS: The patients in the first group made a prompt recovery in terms of their general conditions following the remission of fever, pain, diminished leukocytes and an early renewal of canalisation; cicatrisation of the ulcer was confirmed by the endoscopic control on day 15. Patients in the second group showed early deambulation approximately 4 hours after surgery; canalisation occurred after about 6 hours and all patients were discharged on day 3. The eradication of Helicobacter pylori led to complete resolution, as was confirmed by subsequent follow-ups. CONCLUSIONS: Laparoscopy was found to be extremely useful both in the immediate diagnosis of acute abdomen following perforated ulcer and in its surgical treatment as a result of the introduction of operating laparoscopes and in particular videolaparoscopes, together with surgical instruments that allow careful abdominal cleansing and ulcorrhaphy. In the authors' opinion, the latter procedure is the most suitable for managing this pathology.