Very early migration of a calcar-guided short stem: a randomized study of early mobilization and the influence of a calcium phosphate coating with 60 patients.

This study analyzed the migration of a calcar-guided short stem to determine the course of very early migration, as well as evaluated the effect of an additional calcium phosphate (CP) coating on a titanium plasma spray (TPS) coating, which has not been analyzed previously. Sixty patients were enrolled in this study and were treated with the A2 calcar-guided short stem. The implant coating was randomized with either the TPS or an additional CP coating, and radiostereometric analysis was performed with the baseline measurement before initial weight-bearing, along with follow-up examinations at 1 week, 6 weeks, 3 months, and 6 months. Implant migrations were 0.27 mm (standard deviation [SD], 0.13 mm) and 0.74 mm (SD, 1.11 mm) at 1 week and 6 months post-surgery, respectively, and 65% and 87% of the implants reached their final position 1 week and 6 weeks after surgery, respectively. After 6 weeks, 3 months, and 6 months, a significant increase was noted in the migration of the CP coating group vs. that of the TPS coating group. Upon the final observation at 6 months, the groups displayed on average a 0.74-mm migration. Most of the analyzed implants ceased migration within the first week post-surgery, but the CP coating demonstrated a higher and more prolonged migration compared to the TPS coating.

[Evaluation of care for slipped capital femoral epiphysis (SCFE) in Germany]. / Analyse der Versorgungssituation bei Epiphyseolysis capitis femoris (ECF) in Deutschland.

INTRODUCTION: The treatment concept for slipped capital femoral epiphysis is still controversial. According to studies, there is currently no recommendation for a universal approach. Therefore, the aim of this study is to analyze the care reality of children with ECF in Germany. METHODS: The evaluation of the study is performed based on a questionnaire sent to physicians tending to ECF in 2021. Data is compared to the literature. RESULTS: 36 of 47 questionnaires sent out were included. Overall, no significant difference in ECF care was proven in terms of annual caseload or the size of hospital. CONCLUSION: A high variance in operative SCFE treatment is reported. According to current literature, the modified Dunn procedure is considered the best therapeutic option to date, especially for patients with severe or chronic ECF. However, compared with alternative care options, this is not feasible in every hospital due to its complicating and challenging nature. Central registration, minimum volume regulation, and expansion of continuing education measures can contribute to optimization.

Solar-driven upgrading of biomass by coupled hydrogenation using in situ (photo)electrochemically generated H2.

With the increasing pressure to decarbonize our society, green hydrogen has been identified as a key element in a future fossil fuel-free energy infrastructure. Solar water splitting through photoelectrochemical approaches is an elegant way to produce green hydrogen, but for low-value products like hydrogen, photoelectrochemical production pathways are difficult to be made economically competitive. A possible solution is to co-produce value-added chemicals. Here, we propose and demonstrate the in situ use of (photo)electrochemically generated H2 for the homogeneous hydrogenation of itaconic acid-a biomass-derived feedstock-to methyl succinic acid. Coupling these two processes offers major advantages in terms of stability and reaction flexibility compared to direct electrochemical hydrogenation, while minimizing the overpotential. An overall conversion of up to ~60% of the produced hydrogen is demonstrated for our coupled process, and a techno-economic assessment of our proposed device further reveals the benefit of coupling solar hydrogen production to a chemical transformation.

Efficient full solar spectrum-driven photocatalytic hydrogen production on low bandgap TiO2/conjugated polymer nanostructures.

The development of photocatalysts that can utilize the entire solar spectrum is crucial to achieving efficient solar energy conversion. The utility of the benchmark photocatalyst, TiO2, is limited only to the UV region due to its large bandgap. Extending the light harvesting properties across the entire spectrum is paramount to enhancing solar photocatalytic performance. In this work, we developed low bandgap TiO2/conjugated polymer nanostructures which exhibit full spectrum activity for efficient H2 production. The highly mesoporous structure of the nanostructures together with the photosensitizing properties of the conjugated polymer enabled efficient solar light activity. The mesoporous TiO2 nanostructures calcined at 550 °C exhibited a defect-free anatase crystalline phase with traces of brookite and high surface area, resulting in the best performance in hydrogen production (5.34 mmol g-1 h-1) under sunlight simulation. This value is higher not only in comparison to other TiO2-based catalysts but also to other semiconductor materials reported in the literature. Thus, this work provides an effective strategy for the construction of full spectrum active nanostructured catalysts for enhanced solar photocatalytic hydrogen production.

Pressure sensing mat as an objective and sensitive tool for the evaluation of lameness in rabbits.

In orthopaedic research, the analysis of the gait pattern is an often-used evaluation method. It allows an assessment of changes in motion sequence and pain level during postoperative follow up periods. Visual assessments are highly subjective and dependent on the circumstances. Particular challenge in rabbits is their hopping gait pattern. The aim of the present study was to establish a more objective and sensitive lameness evaluation using a pressure sensing mat. Twelve NZW rabbits were implemented in the study. They got an artificial anterior cruciate ligament transection of the right knee in connection with an experimental study, which investigated PTOA treatment. Rabbits were examined by a visual lameness score. Additionally, load of the hindlimbs was measured by the use of a pressure sensing mat and a video was recorded. Peak pressure and time force integral, defined as cumulated integral of all sensors associated to a hind paw, were evaluated. Preoperative data were collected on three independent days. As postoperative measurement time points, week 1 and week 12 after surgery were chosen. The subjective visual scoring was compared to the objective data of the pressure sensing mat. Following the visual score, lameness in week one was mild to moderate. In week twelve, rabbits were evaluated as lame free bar one. Contrary, following the values of the sensor mat, lameness in week one appeared to be more pronounced and almost all rabbits still showed low-grade lameness in week twelve. Consequently, the pressure sensing mat is more sensitive than the visual score and captures the grade of lameness much more accurately. For specific orthopaedic issues, where subtle differences in lameness are important to detect, the used system is a good supplementary evaluation method.

Is Micellar Catalysis Green Chemistry?

Many years ago, twelve principles were defined for carrying out chemical reactions and processes from a green chemistry perspective. It is everyone's endeavor to take these points into account as far as possible when developing new processes or improving existing ones. Especially in the field of organic synthesis, a new area of research has thus been established: micellar catalysis. This review article addresses the question of whether micellar catalysis is green chemistry by applying the twelve principles to micellar reaction media. The review shows that many reactions can be transferred from an organic solvent to a micellar medium, but that the surfactant also has a crucial role as a solubilizer. Thus, the reactions can be carried out in a much more environmentally friendly manner and with less risk. Moreover, surfactants are being reformulated in their design, synthesis, and degradation to add extra advantages to micellar catalysis to match all the twelve principles of green chemistry.

Degradation of Phenol via an Advanced Oxidation Process (AOP) with Immobilized Commercial Titanium Dioxide (TiO2) Photocatalysts.

Four commercial titanium dioxide (TiO2) photocatalysts, namely P25, P90, PC105, and PC500, were immobilized onto steel plates using a sol-gel binder and investigated for phenol degradation under 365 nm UV-LED irradiation. High-performance liquid chromatography (HPLC) and total organic carbon (TOC) analyses were performed to study the impact of three types of oxygen sources (air, dispersed synthetic air, and hydrogen peroxide) on the photocatalytic performance. The photocatalyst films were stable and there were significant differences in their performance. The best result was obtained with the P90/UV/H2O2 system with 100% degradation and about 70% mineralization within 3 h of irradiation. The operating conditions varied, showing that water quality is crucial for the performance. A wastewater treatment plant was developed based on the lab-scale results and water treatment costs were estimated for two cases of irradiation: UV-LED (about 600 EUR/m3) and sunlight (about 60 EUR/m3). The data show the high potential of immobilized photocatalysts for pollutant degradation under advanced oxidation process (AOP) conditions, but there is still a need for optimization to further reduce treatment costs.

Comparison of conventional socket attachment and bone-anchored prosthesis for persons living with transfemoral amputation - mobility and quality of life.

BACKGROUND: For patients with transfemoral amputation experiencing issues with their sockets, bone-anchored prosthesis systems are an alternative and sometimes the only way to be mobile and independent. The present cross-sectional study aimed to investigate the gait performance and quality of life of a group of patients treated with bone-anchored systems compared to those of participants treated with a conventional socket-suspended prosthesis. METHODS: A total of 17 participants with a socket-suspended and 20 with a bone-anchored prosthesis were included. Gait patterns were examined for symmetry, and performance was assessed using the six-minute walk test and the timed "Up & Go" test. Magnetic resonance imaging was performed to detect signs of osteoarthritis in both hips. Mobility in everyday life and quality of life were assessed using questionnaires. FINDINGS: There were no differences between the groups regarding the quality of life, daily mobility, and gait performance. The step width was significantly higher for the patients using socket-suspended prosthesis. The socket-suspended group showed a significant asymmetry regarding the step length. In the socket-suspended group, the prosthetic leg showed significantly higher cartilage abrasion than the contralateral leg did. INTERPRETATION: Large differences in the measured outcomes in both groups illustrate the very different capabilities of the individual participants, which is apparently not primarily determined by the type of treatment. For patients who are satisfied with the socket treatment and perform well, bone-anchored prosthesis systems may not necessarily improve their functional capabilities and perceived quality of life.

Life cycle net energy assessment of sustainable H2 production and hydrogenation of chemicals in a coupled photoelectrochemical device.

Green hydrogen has been identified as a critical enabler in the global transition to sustainable energy and decarbonized society, but it is still not economically competitive compared to fossil-fuel-based hydrogen. To overcome this limitation, we propose to couple photoelectrochemical (PEC) water splitting with the hydrogenation of chemicals. Here, we evaluate the potential of co-producing hydrogen and methyl succinic acid (MSA) by coupling the hydrogenation of itaconic acid (IA) inside a PEC water splitting device. A negative net energy balance is predicted to be achieved when the device generates only hydrogen, but energy breakeven can already be achieved when a small ratio (~2%) of the generated hydrogen is used in situ for IA-to-MSA conversion. Moreover, the simulated coupled device produces MSA with much lower cumulative energy demand than conventional hydrogenation. Overall, the coupled hydrogenation concept offers an attractive approach to increase the viability of PEC water splitting while at the same time decarbonizing valuable chemical production.

Why Is There a Range in Time Returning to Preoperative Activity Habits After Femoroacetabular Impingement Treatment in Recreational Athletes?

CONTEXT: Professional athletes showed excellent results after hip preserving procedures. However, there is still a lack of knowledge regarding the rate of return to activity and the rehabilitation time of recreational athletes. Thus, the aim of this study was to investigate factors that were associated with an extended return-to-activity time in nonprofessional athletes. DESIGN: Retrospective, quantitative case-control study. METHODS: This study included 47 cases (45 nonprofessional athletes), which were divided according to return-to-activity time (short term: 0.0-7.0 mo vs long term: >7.0 mo). The clinical outcome were evaluated with the modified Harris hip score, the nonarthritic hip score, the Western Ontario and McMaster Universities Osteoarthritis Index, and the University of California, Los Angeles activity score. For statistical analysis between both groups, an unpaired student t test and a paired Wilcoxon test were used. In addition, the sports behavior, intraoperative findings, and surgical procedures were also assessed. RESULTS: After a mean follow-up of 4.3 years (±0.6; 3.4-5.6), the overall postoperative modified Harris hip score was 81.8 points, the nonarthritic hip score was 75.8 points, the Western Ontario and McMaster Universities Osteoarthritis Index was 36.7 points, and the University of California, Los Angeles activity score was 7.9. Compared with the preoperative results, all scores improved significantly (P < .001). Patients of the short-term return-to-activity group showed a higher preoperative activity diversity and, postoperatively, a higher rate in high-impact sports (P = .024). CONCLUSIONS: After mini-open arthrotomy for femoroacetabular impingement syndrome treatment, 92.5% of the recreational athletes returned to sports activity. The findings did not detect factors influencing the return-to-activity time. However, a higher preoperative diversity of activities and a shift to high-level impact sport activities might support a shorter rehabilitation.

Analysis of factors affecting the time for implantation of a total hip arthroplasty in patients with symptomatic primary and secondary hip osteoarthritis.

BACKGROUND: Many studies have identified factors associated with an unfavourable clinical outcome or an early conversion to total hip arthroplasty (THA) after joint-preserving treatment. We analysed the effect and reliability of different factors on the age at which THA becomes necessary. METHODS: Hip joint radiographs of 2485 cases were evaluated using the lateral centre-edge angle (LCEA) and acetabulum angle (ACA) as well as the alpha angle to describe the femoral head shapes. Regressions were performed using patient's age at the time of THA and body mass index (BMI) as well as LCEA and ACA. Multiple linear regressions were used to create a formula comprising factors that significantly correlated with patient age at the time of joint replacement surgery. RESULTS: The BMI, LCEA, and ACA showed significant correlations with the age of THA implantation (p < 0.001). Multiple linear regressions produced the following formula: age (THA) = 72.40-0.40 × BMI + 0.20 × LCEA-0.18 × ACA. BMI showed a stronger impact on the age of end-stage osteoarthritis than the ACA. The formula explained 12.1% of the distributing data (r2). Surprisingly, the alpha angle did not show an impact on the age of THA surgery. CONCLUSIONS: BMI had the greatest impact on patient's age at the time of THA, followed by the characteristic radiological angles for hip dysplasia. The resulting formula could emphasise and visualise the significant impact of these factors. However, despite the calculation being based on 2485 cases, the calculated validity of 12.1% was limited.

Noise exposure during robot-assisted total knee arthroplasty.

The aim of the study was to examine the noise exposure for operating theater staff during total knee arthroplasty (TKA) with three different robot systems. There is already evidence that noise exposure during TKA performed manually exceeds recommended guidelines for occupational noise. Therefore, if surgical staff is exposed to it for several years, the development of noise-inducing hearing loss (NIHL) is significantly increased. To investigate the noise exposure during robot-assisted TKA, the study measured the average noise and the peak sound pressure during TKA with MAKO robot (Stryker, Kalamazoo, Michigan, United States), NAVIO robot (Smith and Nephew, London, Great Britain), and CORI robot (Smith and Nephew, London, Great Britain) using a class 1 sound level meter. Each robot system exceeds the recommended guidelines from the national institute for occupational safety and health. While the MAKO robot had the highest average sound level (93.18 dB(A)) of the three robot systems (NAVIO: 88.88 dB(A), CORI: 89.38 dB(A)), the peak sound level was the highest with the NAVIO Robot (134.48 dB(C)) compared to the MAKO Robot (128.98 dB(C)) and CORI robot (126.48 dB(C)). Robot-assisted TKA is a risk factor for NIHL, like manually performed TKA. Further research for decreasing the noise exposure during TKA is needed to minimize the hearing loss in operating theater staff.

Efficient preparation of nanocatalysts. Case study: green synthesis of supported Pt nanoparticles by using microemulsions and mangosteen peel extract.

Greener nanocatalyst synthesis is growing in importance, especially when using scarce noble metals such as platinum (Pt) as the active metal. In the synthesis process presented herein, we utilized extract of mangosteen peel as a green reductant and found that it produces Pt nanoparticles (NPs) with high activity. The supported Pt NPs were synthesized via thermos-destabilization of a mangosteen extract microemulsion and subsequently tested with α-methyl styrene (AMS) hydrogenation at SATP. Additionally, we optimized the green synthesis of the supported Pt nanocatalyst (NPs) in terms of their synthesis yield and catalytic activity using the approaches of full factorial design (FFD), central composite design (CCD), and response surface methodology (RSM). In comparing the results of single and multiple optimization, it was found that for the single optimization, the synthesis yield of supported Pt NPs could be increased from their average value of 78.9% to 99.75%, and their activity from 2136 to 15 600 µmol s-1 gPt -1. The results of multiple response optimization to the yield and activity are 81.71% and 8255 µmol s-1 gPt -1, respectively. The optimization approach presented in this study is suitable for similar catalyst synthesis procedures where multivariate responses are sensitive to a number of experimental factors.

Influence of Cocatalysts (Ni, Co, and Cu) and Synthesis Method on the Photocatalytic Activity of Exfoliated Graphitic Carbon Nitride for Hydrogen Production.

Exfoliated graphitic carbon nitride (ex-g-CN) was synthesized and loaded with non-noble metals (Ni, Cu, and Co). The synthesized catalysts were tested for hydrogen production using a 300-W Xe lamp equipped with a 395 nm cutoff filter. A noncommercial double-walled quartz-glass reactor irradiated from the side was used with a 1 g/L catalyst in 20 mL of a 10 vol% triethanolamine aqueous solution. For preliminary screening, the metal-loaded ex-g-CN was synthesized using the incipient wetness impregnation method. The highest hydrogen production was observed on the Ni-loaded ex-g-CN, which was selected to assess the impact of the synthesis method on hydrogen production. Ni-loaded ex-g-CN was synthesized using different synthesis methods: incipient wetness impregnation, colloidal deposition, and precipitation deposition. The catalysts were characterized by X-ray powder diffraction, X-ray photoelectron spectroscopy, nitrogen adsorption using the Brunauer-Emmett-Teller method, and transmission electron microscopy. The Ni-loaded ex-g-CN synthesized using the colloidal method performed best with a hydrogen production rate of 43.6 µmol h-1 g-1. By contrast, the catalysts synthesized using the impregnation and precipitation methods were less active, with 28.2 and 10.1 µmol h-1 g-1, respectively. The hydrogen production performance of the suspended catalyst (440 µmol m-2 g-1) showed to be superior to that of the corresponding immobilized catalyst (236 µmol m-2 g-1).

Influence of microsurgical decompression on segmental stability of the lumbar spine - One-year results in a prospective, consecutive case series using upright, kinetic-positional MRI.

BACKGROUND: Standard procedure in patients with lumbar spinal canal stenosis is decompression to relieve the neural structures. Clinical results generally show superiority compared to nonoperative therapy after an observation period of several years. However, there is still a question of postsurgical segmental stability and correlation to clinical findings. Therefore, the aim of this prospective study was to evaluate the clinical outcome in patients who underwent microsurgical decompression in lumbar spine and particularly to analyze intervertebral movement by use of upright, kinetic-positional magnetic resonance imaging (MRI) over a period of 12 months and then to correlate the clinical and imaging data with each other. METHODS: Complete clinical data of 24 consecutive participants with microsurgical decompression of the lumbar spine were obtained by questionnaires including visual analogue scale (VAS) for back and leg, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), Short-Form-36 (SF-36), walking distance and use of analgesics with assessment preoperatively and after 6 weeks and 12 months. At the same points of time all patients underwent upright, kinetic-positional MRI to measure intersegmental motion of the operated levels with determination of intervertebral angles and translation and to correlate the clinical and imaging data with each other. RESULTS: VAS for leg, ODI, RMDQ and physical component scale of SF-36 improved statistically significantly without statistically significant differences regarding intersegmental motion and horizontal displacement 6 weeks and 12 months after operation. Regression analysis did not find any linear dependencies between the clinical scores and imaging parameters. CONCLUSIONS: In awareness of some limitations of the study, our results demonstrate no increase of intersegmental movement or even instability after microsurgical decompression of the lumbar spine over a follow-up period of 12 months, which is equivalent to preservation of intervertebral stability. Furthermore, the magnitude of intervertebral range of motion showed no correlation to the clinical score parameters at all three examination points of time.

Photocatalytic hydrogenation of acetophenone on a titanium dioxide cellulose film.

A previously developed sustainable immobilization concept for photocatalysts based on cellulose as a renewable support material was applied for the photocatalytic hydrogenation of acetophenone (ACP) to 1-phenyl ethanol (PE). Four different TiO2 modifications (P25, P90, PC105, and PC500) were screened for the reaction showing good performance for PC25 and PC500. PC500 was selected for a detailed kinetic study to find the optimal operating conditions, and to obtain a better understanding of the photocatalytic pathway in relation to conventional and transfer hydrogenation. The kinetic data were analyzed using the pseudo-first-order reaction rate law. A complete conversion was obtained for ACP concentrations below 1 mM using a 360 nm filter and argon as the purge gas within 2-3 hours. High oxygen concentrations slow down or prevent the reaction, and wavelengths below 300 nm lead to side-products. By investigating the temperature dependency, an activation energy of 22 kJ mol-1 was determined which is lower than the activation energies for conventional and transfer hydrogenation, because the light activation of the photocatalyst turns the endothermic to an exothermic reaction. PC500 was immobilized onto the cellulose film showing a 37% lower activity that remains almost constant after multiple use.

Foot and Ankle Surgical Incision Closure With Three Different Materials.

There is no clear recommendation for wound closure material in foot and ankle surgery. Thus, we hypothesized that there was no difference in clinical outcomes among 3 suture materials, namely, absorbable sutures, nonabsorbable sutures, and metallic staples. This study compared the 3 materials for wound closure in foot and ankle surgery. In this prospective randomized study, 124 patients were randomly divided into the nonabsorbable suture group, absorbable suture group, and staple group. ASEPSIS score, Hollander Wound Evaluation Scale, and numerical rating scale (regarding pain and satisfaction) were collected at first dressing changes, suture removal, and 6 weeks after surgery. Suture time and incision length were recorded. No significant differences were detected for the ASEPSIS and Hollander Wound Evaluation Scale scores. There was significantly more pain after 6 weeks in the nonabsorbable suture group. The closure time (13 s/cm) with staples was significantly lower in the nonabsorbable suture group than in the other groups. Regardless of wound closure material, male sex and obesity appeared to be associated with a higher risk for the occurrence of wound complications. The 3 suture materials showed no significant differences regarding the frequency of wound complications. Staples and absorbable sutures should therefore be considered in the repertoire of suture materials used in foot and ankle surgery.

The lateral joint space width is essential for the outcome after arthroscopically assisted mini-open arthrotomy for treatment of a femoroacetabular impingement: an analysis of prognostic factors for the success of this hip-preserving technique.

PURPOSE: The purpose of this study was to analyze predicting factors for a conversion to a total hip replacement (THR) after mini-open arthrotomy for treatment of femoroacetabular impingement (FAI). METHODS: Between 2011 and 2016, we identified 32 patients, who were treated for FAI with a mini-open arthrotomy and received after mean time of 2.1 ± 1.4 years a THR. These patients were compared to 47 cases who did not receive a THR (mean follow-up: 4.3 ± 0.7 years) to explore pre- and intra-operative factors associated with a conversion to THR. The results were presented in separated Kaplan-Meier curves with log rank test for significance and hazard ratios. RESULTS: A lateral joint space width of > 4 mm showed a higher THR-free survival rate compared to < 4 mm (p = 0.001); analogously one-sided (acetabular/femoral) 3-4° cartilage damage had a comparable THR-free survival rate than 1-2° kissing lesions (p = 0.001). Furthermore, an intact labrum without treatment and good cartilage status, a refixed labrum after rim resection in case of a pincer type FAI, or a refixed teared labrum were associated with a longer THR-free time than an untreated labrum accompanied by a poor cartilage status or an ossified labrum (p = 0.002). The strongest independent factor for a conversion to THR was femoral cartilage damage grade 1 and higher (p = 0.046). However, the rate of available patients was 53.0%. CONCLUSION: The success of a joint-preserving mini-open arthrotomy seems to be dependent on the status of the radiological joint space width and the intra-operative cartilage status of the lateral edge.

Cementless total hip arthroplasty with anatomic-shaped implants. Does the minimal invasive anterolateral technique influence the stem position or subsidence in contrast to the standard lateral approach?

INTRODUCTION: Using cementless stems in total hip arthroplasty (THA) has revealed variable results. The risk for early aseptic loosening has been associated to certain surgical approaches and implant designs. This study determines misalignment of collared/collarless stems and the rate of subsidence using the anterolateral approach (ALA) compared to implantations via the direct lateral approach (DLA). MATERIALS AND METHODS: One hundred consecutive patients underwent primary unilateral THA using the minimal invasive ALA in the lateral decubitus position and were compared to another cohort of 100 patients, treated trough the DLA. Clinical results were noted preoperatively and after 1 year using the WOMAC score. The radiographic evaluation included the stem alignment and subsidence. RESULTS: Overall, all patients improved in WOMAC from 48.9 points (± 11.4; 21.0-82.0) to 3.1 (± 3.2; 0.0-22.0) (p < 0.001). For DLA and ALA, the stem was placed on average 2.5° in varus to the femoral axis. The mean alignment was about 0.5° more valgus for collarless stems. The mean subsidence in the DLA group was about 0.3 mm higher compared to the ALA group. With collarless implants, the subsidence was about 1.0 mm higher compared to collared implants (p < 0.05), especially in patients with Dorr type B femurs. CONCLUSIONS: Changing from the DLA to the minimal invasive ALA did not significantly affect the implant position. Misalignment and a potential risk for early aseptic loosening could not be seen. The use of a collared cementless stem seems safe and is likely to prevent a relevant subsidence, even more so in Dorr type B femurs. LEVEL OF EVIDENCE: III.