Bowel Obstruction as the Initial Presentation of Urothelial Carcinoma.

Bowel obstructions are one of the main causes of hospital admissions for acute abdominal pain. In addition, bladder cancer is one of the most common cancers in the world. This said, bowel obstruction and bladder cancer are very frequent diseases but the same cannot be said about the association between these two pathologies. We report a unique case of an 80-year-old patient admitted to the emergency room with a bowel obstruction caused by a urothelial carcinoma with adrenal metastasis. The patient underwent an urgent laparotomy, and intraoperative inspection of the peritoneal cavity confirmed a large tumorous mass suspected of gastrointestinal etiology. The mass infiltrated the ileum and sigmoid colon and was apparently in contact with the bladder wall. An en-bloc resection of the lesion was performed. An R0 excison was not possible and fragments of the lesion were excised from the bladder wall for separate analysis. Histopathological examination of the resected specimen described a high-grade, undifferentiated urothelial carcinoma that originated in the bladder and invaded the ileum and sigmoid colon. The presence of an invasive urothelial carcinoma presenting with bowel obstruction represents an unexpected diagnosis and, although rare, the surgeon must be aware of this possibility. This case should serve as a reminder that a broad differential diagnosis should be considered when investigating an abdominal tumor.

En bloc resection and reconstruction using a talar prosthesis for malignant talar bone tumor: a surgical technique.

En bloc resection is required for treatment of intermediate-grade talar tumors with extraosseous extension (Enneking stage 3) and malignant talar tumors without intra-articular invasion (Enneking stages IA and IIA). After resection, reconstruction options include tibiocalcaneal fusion, frozen autograft, and talar prosthesis; however, a talar prosthesis is preferable because it preserves ankle range of motion, does not cause leg length discrepancy, and is associated with good long-term outcomes. To the best of our knowledge, en bloc resection and reconstruction of a malignant talar tumor has not been previously reported in detail. We report a detailed surgical technique for en bloc resection of a malignant talar bone tumor using combined anterior and lateral approaches followed by reconstruction using a talar prosthesis.

Efficacy and safety of en-bloc resection versus debulking for spinal tumor: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis aimed to consolidate the existing evidence regarding the comparison between en-bloc resection surgery and debulking surgery for spinal tumors, including both primary and metastatic tumors. MATERIALS AND METHODS: The databases of PubMed, Embase, Cochrane database, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was carried out and included all studies that directly compared en-bloc resection surgery with debulking surgery for spinal tumors in patients through March 2024. The primary outcomes included recurrence rate, postoperative metastasis rate, mortality rate, overall survival (OS), recurrence-free survival (RFS), complication, and so on. The statistical analysis was conducted using Review Manager 5.3. RESULTS: We systematically reviewed 868 articles and included 27 studies involving 1135 patients who underwent either en-bloc resection surgery (37.89%) or debulking surgery (62.11%). Our meta-analysis demonstrated significant advantages of en-bloc resection over debulking surgery. Specifically, the en-bloc resection group had a lower recurrence rate (OR = 0.19, 95%CI: 0.13-0.28, P < 0.00001), lower postoperative metastasis rate (P = 0.002), and lower mortality rate (P < 0.00001). Additionally, en-bloc resection could improve OS and RFS (HR = 0.45, 95%CI: 0.32-0.62, P < 0.00001 and HR = 0.37, 95%CI: 0.17-0.80, P = 0.01, respectively). However, en-bloc resection required longer operative times and was associated with a higher overall complication rate compared to debulking surgery (P = 0.0005 and P < 0.00001, respectively). CONCLUSION: The current evidence indicates that en-bloc surgical resection can effectively control tumor recurrence and mortality, as well as improve RFS and OS for patients with spinal tumors. However, it is crucial not to overlook the potential risks of perioperative complications. Ultimately, these findings should undergo additional validation through multi-center, double-blind, and large-scale randomized controlled trials (RCTs).

Advances in the multidisciplinary surgical approach to primary spinal sarcomas: insights from a retrospective case series on outcomes and survival.

INTRODUCTION: The management of spinal sarcomas is complex, given their widespread involvement and high recurrence rates. Despite consensus on the need for a multidisciplinary approach with surgery at its core, there is a lack of definitive guidelines for clinical decision-making. This study examines a case series of primary spinal sarcomas, focusing on the surgical strategies, clinical results, and survival data to inform and guide therapeutic practices. METHODS: We conducted a retrospective analysis of patients who underwent surgical resection for primary spinal sarcomas between 2005 and 2022. The study focused on gathering data on patient demographics, surgical details, postoperative complications, overall hospital stay, and mortality within 90 days post-surgery. RESULTS: The study included 14 patients with a primary diagnosis of spinal sarcoma, with an average age of 48.6 ± 12.6 years. Chondrosarcoma emerged as the most common tumor type, representing 57.1% of cases, followed by Ewing sarcoma at 35.7%, and synovial sarcoma at 7.1%. Patients with chondrosarcoma were treated with en-bloc resection, while the patient with synovial sarcoma underwent intra-lesional excision and those with Ewing sarcoma received decompression and tumor debulking. Postoperative assessments revealed significant improvements in neurological conditions. Notably, functional status as measured by the Karnofski Performance Index (KPI), improved substantially post-surgery (from 61.4 to 80.0%) The mean follow-up was 34.9 ± 9.2 months. During this time period one patient experienced fatal bleeding after en-bloc resection complications involving the vena cava. None of the patient needed further surgery. CONCLUSIONS: Our 16-year study offers vital insights into managing primary spinal sarcomas, showcasing the effectiveness of surgical intervention, particularly en-bloc resection. Despite their rarity and complexity, our multidisciplinary treatment approach yields improved outcomes and highlights the potential for refined surgical strategies to become standardized care in this challenging domain.

Do we need a re-TUR after en bloc resection of T1 stage bladder cancer?

BACKGROUND: A second look trans-urethral resection of the bladder (re-TUR) is recommended after the diagnosis of T1 high grade (T1HG) bladder cancer. Few studies have evaluated the results of re-TUR after a first en bloc resection (EBR) and none of them have specifically reported the pathological results on the field of previous T1 disease. OBJECTIVE: To report the rate of upstaging and the rate of residual disease (RD) on the field of T1HG lesions resected with EBR. MATERIALS AND METHODS: Between 01/2014 and 06/2022, patients from 2 centers who had a re-TUR after an EBR for T1HG urothelial carcinoma were retrospectively included. Primary endpoint was the rate of RD including the rate of upstaging to T2 disease on the scar of the primary resection. Secondary endpoints were the rate of any residual disease outside the field. RESULTS: Seventy-five patients were included. No muscle invasive bladder cancer lesions were found after re-TUR. Among the 16 patients who had a RD, 4 were on the resection scar. All of these lesions were papillary and high grade. RD outside the field of the first EBR was observed in 12 patients. CONCLUSION: After EBR of T1HG disease, none of our patients had an upstaging to MIBC. However, the rate of RD either on and outside the field of the EBR remains quite significant. We suggested that predictive factors of residual papillary disease (number of tumors at the initial TUR and concomitant CIS) might be suitable to select patient who will benefit of the re-TUR.

Biomechanical Effects of Different Prosthesis Types and Fixation Ranges in Multisegmental Total En Bloc Spondylectomy: A Finite Element Study.

OBJECTIVE: Multi-segmental total en bloc spondylectomy (TES) gradually became more commonly used by clinicians. However, the choice of surgical strategy is unclear. This study aims to investigate the biomechanical performance of different prosthesis types and fixation ranges in multisegmental TES. METHODS: In this study, a validated finite element model of T12-L2 post-spondylectomy operations were carried out. The prostheses of these models used either 3D-printed artificial vertebrae or titanium mesh cages. The fixed range was two or three segment levels. Range of motion, stress distribution of the endplate and internal fixation system, intervertebral disc pressure, and facet joint surface force of four postoperative models and intact model in flexion and extension, as well as lateral bending and rotation were analyzed and compared. RESULTS: The type of prosthesis used in the anterior column reconstruction mainly affected the stress of the adjacent endplate and the prosthesis itself. The posterior fixation range had a greater influence on the overall range of motion (ROM), the ROM of the adjacent segment, the stress of the screw-rod system, and adjacent facet joint surface force. For the model of the same prosthesis, the increase of fixed length resulted in an obvious reduction of ROM. The maximal decrease was 70.23% during extension, and the minimal decrease was 30.19% during rotation. CONCLUSION: In three-segment TES, the surgical strategy of using 3D-printed artificial prosthesis for anterior column support and pedicle screws for posterior fixation at both two upper and lower levels respectively can reduce the stress on internal fixation system, endplates, and adjacent intervertebral discs, resulting in a reduced risk of internal fixation failure, and ASD development.

Radical Oophorectomy for Advanced Ovarian Cancer: A Feasibility Study from Tertiary Care Cancer Centre in Eastern India.

Background: Radical oophorectomy was first performed by Hudson in order to remove an "intact ovarian tumour lodged in the pelvis, with the entire peritoneum remaining attached". We report 16 cases of radical oophorectomy done at our institute in the past 3 years and have analysed the perioperative morbidity as well as feasibility of performing the surgery without much of perioperative complication. Methods: Twenty-three patients with advanced ovarian cancer who underwent modified en bloc pelvic resection at our institute, between November 2018 and October 2021, were initially enrolled. Patients below 70 years, resectable disease on CT scan and no significant comorbidities were included. Exclusion criteria were extra-abdominal metastasis, secondary cancers or complete intestinal obstruction. Initially, 23 patients were enrolled out of which seven patients were excluded. Hence, a total of 16 patients with ovarian cancer extensively infiltrating into nearby pelvic organs and peritoneum were included. In Type 1 radical oophorectomy, retrograde modified radical hysterectomy alongwith in toto removal of the bilateral adnexae, pelvic cul-de-sac and affected pelvic peritoneum is done. Type 2 radical oophorectomy includes total parietal and visceral pelvic peritonectomy as well as an en bloc resection of the rectosigmoid colon below the peritoneal reflection. Results: Radical oophorectomy is feasible with acceptable complication rate. In our study, only one patient had burst abdomen that too due to the poor nutritional status of the patient. There was no surgery-related deaths, but one patient succumbed to pulmonary embolism 5 days after the operation. Conclusion: Hence, radical oophorectomy proves to be an effective, feasible and secure surgical technique in cases of advanced ovarian malignancies with extensive involvement of peritoneum, pelvis and visceras.

Revision total en bloc spondylectomy for a recurrent aggressive vertebral haemangioma of the thoracic spine causing progressive thoracic myelopathy with segmental kyphosis.

Vertebral haemangiomas are common amongst primary benign tumours of the spine, usually asymptomatic and discovered incidentally, whereby symptomatic cases are rare. Aggressive vertebral haemangiomas, occurring even less frequently, are characterized by their expansion, resulting in pain and neural compression symptoms. Depending on presentation and severity, several treatment options exist, and when causing progressive neurological deficit, surgical decompression and resection is warranted. Despite local recurrence being rare, regular follow-ups to detect recurrence are advised. In case of recurrent aggressive vertebral haemangiomas, however, subsequent treatment strategy usually depends on a case-by-case consideration, whereby reports in the literature are lacking. We describe a case of a recurrent aggressive vertebral haemangiomas of the thoracic spine in a 20-year-old male causing progressive thoracic myelopathy with segmental kyphosis, treated with a revision total en bloc spondylectomy and a multilevel fixation with vertebral column reconstruction using radiolucent instrumentation.

Epithelioid Hemangioma of the Spine: A Case Series and Treatment Flow Chart-Experience from a Single Centre.

Epithelioid hemangioma is recognized by the World Health Organization as a distinct benign neoplasm; however, it is characterized by locally aggressive and rarely metastasizing behavior. Epithelioid vascular tumors are rare bony vascular lesions with varying degrees of malignant potential that remain controversial because of their rarity, unusual morphological features, and unpredictable biological behavior. The application of new molecular tools, such as massive parallel sequencing technologies, have provided new diagnostic markers and an opportunity to further refine the classification of bone vascular neoplasms. Very few cases of EH of the spine have been reported in the literature; therefore, it is difficult to make evidence-based therapeutic decisions for these patients. We report herein our experience with eleven patients suffering from EH of the spine. The study population included three males and eight females treated in our center from 2016 to the present; the average age was 44.8 years (range 14-75 years). The surgical, clinical, and radiographic data were retrospectively analyzed. The mean follow-up was 34.8 months. All patients presented lytic vertebral body lesions, six of them with pathological fracture. The majority of patients (80%) presented myelo-radicular compression. All patients were surgically treated, and preoperative embolization was performed in all cases. In light of the literature review and the clinical experience of our center, we can consider EH a locally aggressive tumor that requires surgical treatment in case of symptoms. Here, we propose a treatment algorithm that could be useful in the management of patients with this rare disease.

Partial bladder transplantation with en bloc kidney transplant-long-term, 17 years, the outcome of a "bladder patch technique".

A transplant of a portion of the bladder with an en bloc kidney from a 2-year-old donor was previously reported in a 12-month-old girl due to her extremely small bladder. Bilateral kidneys were transplanted en bloc with their ureters connected to a patch of the donor bladder (bladder patch technique). The long-term outcomes and complications of this technique have not been documented. Here, we report a long-term, 17-year follow-up of this patient with an evaluation of whole bladder functions at 18 years of age. The patient has had no episodes of urinary tract infections. Cystoscopy showed a viable transplanted bladder with a well-perfused mucosa. We observed that the native bladder has stretched over time, forming more than half of the bladder wall. Urodynamic studies showed preserved bladder compliance at 43 mL/cmH2O, and native bladder contractility was preserved. Prolonged voiding time and postvoid residual urine were also observed. These findings were suggestive of detrusor underactivity. No reflux across the donor ureterovesical junctions was observed. The recipient was instructed to continue timed voiding and double voiding to empty the bladder. In conclusion, en bloc kidney transplantation with a bladder patch is a feasible and safe option for kidney transplant recipients with a small bladder capacity.

The long-term learning curve of holmium laser enucleation of the prostate (HoLEP) in the en-bloc technique: a single surgeon series of 500 consecutive cases.

PURPOSE: To evaluate perioperative parameters, clinical outcomes, and the learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon in 500 consecutive cases. METHODS: Demographic parameters, outcomes, and adverse events were evaluated. The learning curve for HoLEP in en-bloc technique of the first 500 consecutive patients was analyzed in clusters of 100 (clusters 1-5) using the Wilcoxen rank test, Chi² test and Kruskal Wallis test. RESULTS: Enucleation weight was similar in the clusters 1,2,3, and 5 (62 g, 63 g, 61 g, 61 g), in cluster 4 it was slightly higher at 73 g. There was a significant reduction in operating time from 67 min (cluster 1) to 57 min (cluster 2), 46 min (cluster 3), 53 min (cluster 4), and 43 min (cluster 5), p < 0.001. Enucleation efficiency (g/min) showed a steady increase (1.72, 2.24, 2.79, 2.92 vs. 2.99, p < 0.001). Laser energy efficiency also improved (2.17 vs. 2.12 vs. 1.71 vs. 1.65 vs. 1.55; p < 0.001). There was no measurable learning curve regarding the length of hospital stay (mean 2.5 days), catheterization time (1.9 days), hemoglobin drop (approx. 1 g/dl) or complications (p > 0.1). CONCLUSIONS: HoLEP using the en-bloc technique is a safe and highly effective method. Over time, a slight but steady learning curve and improvement in operation time, enucleation efficiency and laser energy efficiency were shown even for an experienced surgeon - after 500 cases, still no plateau was reached. There was no measurable learning curve regarding blood loss, complications, length of hospital stay, and catheterization time.

Refining surgical strategies in ThuLEP for BPH: a propensity score matched comparison of En-bloc, three lobes, and two lobes techniques.

PURPOSE: This study compares the peri-operative and functional outcomes of three distinct surgical techniques in Thulium Laser Enucleation of the Prostate (ThuLEP) for benign prostatic hyperplasia (BPH). The main aim is to assess whether the En-bloc, Three-lobe, and Two-lobe techniques have differential effects on surgical efficacy and patient outcomes. METHODS: A retrospective analysis was conducted on patients undergoing ThuLEP for BPH between January 2019 and January 2024 at two tertiary centers. Propensity score matching was utilized to balance baseline characteristics among patients undergoing the different techniques. Surgical parameters, including operative time, enucleation time, morcellation time, energy consumption, and postoperative outcomes, were compared among the groups. RESULTS: Following propensity score matching, 213 patients were included in the analysis. Intraoperative analysis revealed significantly shorter enucleation, laser enucleation, morcellation and operative times and total energy delivered in the En-bloc and Two-lobe groups compared to the Three-lobe group. No significant differences were observed among the groups in terms of intraoperative and postoperative complications. There were no significant differences in functional outcomes at the 3-month follow-up among the groups. CONCLUSION: The findings of this study suggest that while the En-bloc and Two-lobe techniques may offer efficiency benefits and could be considered safe alternatives in ThuLEP procedures, the reduction in laser enucleation time and energy delivered did not necessarily translate into improvements in post operative storage symptoms or other functional outcomes for the patients. Surgeon preference and proficiency may play a crucial role in selecting the most suitable technique for individual patients. Future research should focus on larger-scale prospective studies to further validate these findings and explore potential factors influencing surgical outcomes.

Combined Urinary Reconstruction During en Bloc Kidney Transplantation From a Pediatric Donor to an Adult Recipient: A Case Report.

Urinary reconstruction during en bloc kidney transplantation is challenging, with different techniques described. Here, we report a case of combined urinary reconstruction using modified Lich ureteroneocystostomy and ureteroureterostomy.

A novel laser resection approach: efficacy of rotatable bi-channel en bloc resection of bladder tumor in a pilot in-vivo study.

En bloc resection of bladder tumor (ERBT) involves removing bladder tumors and their base. Laser resection has been used to reduce complications including bleeding and obturator nerve reflex (ONR). We developed a novel approach (rotatable bi-channel en bloc resection of bladder tumor (RBC-ERBT)) and assessed its efficacy in a pilot in-vivo study to enhance laser ERBT's applicability in challenging bladder regions. In the laser RBC-ERBT procedure, lesions were excised by inserting a holmium laser through the rotating external working channel, while forceps were inserted through the internal working channel provided traction on the tissue. Fifteen laser RBC-ERBT procedures were performed in five different bladder areas of three live pigs. The technical success rate (TSR), procedure time, lesion size, occurrence of complications (bleeding, perforation, ONR), and detrusor muscle (DM) presence rate and DM thickness were evaluated. All 15 procedures were performed with a 100% TSR. The resections were successful in all bladder regions (posterior, left, right and anterior walls and dome). Median procedure time was 20 min. The resected specimen size was 10 mm × 7 mm to 17 mm × 13 mm. Mild bleeding occurred in two procedures (13.3%) but was effectively managed. No incidents of ONR or perforation were observed. Histological examination confirmed presence of DM in all specimens with a median DM thickness of 1.26 mm. Our pilot in-vivo study suggested the feasibility and effectiveness of laser RBC-ERBT for bladder tumors in various locations. This technique offers effective traction, improved visualization, and enhanced laser accessibility. Further studies are required to validate its effectiveness in humans.

Thoracic giant cell tumor after two total en bloc spondylectomies including one emergency surgery: A case report.

BACKGROUND: For patients with acute paraplegia caused by spinal giant cell tumor (GCT) who require emergency decompressive surgery, there is still a lack of relevant reports on surgical options. This study is the first to present the case of an acute paraplegic patient with a thoracic spinal GCT who underwent an emergency total en bloc spondylectomy (TES). Despite tumor recurrence, three-level TES was repeated after denosumab therapy. CASE SUMMARY: A 27-year-old female patient who underwent single-level TES in an emergency presented with sudden severe back pain and acute paraplegia due to a thoracic spinal tumor. After emergency TES, the patient's spinal cord function recovered, and permanent paralysis was avoided. The postoperative histopathological examination revealed that the excised neoplasm was a rare GCT. Unfortunately, the tumor recurred 9 months after the first surgery. After 12 months of denosumab therapy, the tumor size was reduced, and tumor calcification. To prevent recurrent tumor progression and provide a possible cure, a three-level TES was performed again. The patient returned to an active lifestyle 1 month after the second surgery, and no recurrence of GCT was found at the last follow-up. CONCLUSION: This patient with acute paraplegia underwent TES twice, including once in an emergency, and achieved good therapeutic results. TES in emergency surgery is feasible and safe when conditions permit; however, it may increase the risk of tumor recurrence.

Sagittal en bloc resection of thoracolumbar tumours: a report of thirty one cases.

PURPOSE: To develop a novel classification of sagittal en bloc resection (SEBR) based on anatomical locations for thoracolumbar spine tumors and assess the clinical outcomes of this surgical procedure. METHODS: 31 patients with thoracolumbar tumours treated with SEBR were enrolled in this study. The individualized surgical strategy was adopted based on our surgical classification. Demographics, perioperative outcomes, complications and postoperative outcomes were assessed. RESULTS: Based on our surgical classifications, patients were divided into four types. All bony resection margins were negative, wide resection was achieved in 25 patients, marginal resection in four, and intralesional resection in two. 18 patients underwent anterior reconstruction. Complications were encountered in five patients, and instrumentation failure occurred in one patient. The median follow-up was 24 (range, 6-72) months and recurrence was found in only one patient. CONCLUSION: SEBR is a safe and effective surgical procedure for patients with thoracolumbar spinal tumours in specific anatomical locations. The proposed surgical classification covers all SEBR types and is easy to apply, it may assist surgical decision-making in patients with spinal tumours.

Preoperative embolization and en bloc resection of a metastatic pheochromocytoma of the cervical spine.

This is a unique case of metastatic pheochromocytoma of the cervical spine treated with preoperative embolization and subsequent en bloc resection. A 65-year-old man with metastatic pheochromocytoma presented with two weeks of worsening neck pain, left arm and leg weakness and paresthesia, and urinary incontinence. Magnetic resonance imaging showed a metastatic osseous lesion at C6 with severe stenosis and spinal cord compression. The patient underwent successful preoperative angiographic embolization with a liquid embolic agent followed by C5-C7 laminectomy, en bloc tumor resection, and C3-T2 posterior spinal fusion. Six weeks postoperatively, the patient reported improving strength and resolving neck pain and paresthesias. While there is no standard paradigm for the treatment of metastatic pheochromocytomas of the cervical spine, preoperative embolization may minimize intraoperative blood loss and hemodynamic instability during subsequent surgical resection.

A Unique Presentation of Vertebral Body Osteochondroma of Sixth Cervical Spine Causing Myelopathic Symptoms: Management with En bloc Excision and Cervical Fusion.

Introduction: Vertebral body osteochondroma presenting with myelopathic symptoms is exceptionally rare entity of spinal osteochondroma which arises from the posterior surface of vertebral body and leading to spinal canal stenosis and cord compression. Early definitive diagnosis and subsequent successful treatment is necessary in such cases to prevent life threatening complications. Case Report: In this context, we report a case of a 20-years old female presented with mechanical neck pain, unsteady gait, giddiness with neurological deficit for the past 3 months. An MRI of the cervical spine revealed a mass growing from the posterior aspect of the C6 vertebral body and extending toward the vertebral canal, causing marked spinal cord compression. Conclusion: The following case report not only describes the rare presentations of vertebral body osteochondroma but also emphasizes on surgical management by en bloc resection of tumor and anterior cervical fusion, resulting in a favorable outcome without any recurrence.

Huge Distal Ulna Giant Cell Tumor Treated with Wide Local Excision and Extensor Carpi Ulnaris Tenodesis - A Rare Case Report.

Introduction: Giant cell tumors (GCT) are a relatively uncommon type of non-cancerous bone growth, representing around 4-10% of all bone tumors. These tumors tend to exhibit local aggressiveness and are typically prevalent in individuals between 20 and 40 years old. Commonly observed locations for GCT include the distal femur, proximal tibia, and the distal end of the radius. However, occurrences at the distal end of the ulna are rare, accounting for only 0.45-3.2% of cases. Case Report: In this instance, we present the case of a 36-year-old male diagnosed with a GCT specifically located in the left distal ulna. Our approach involved managing the patient through the complete removal (en-bloc resection) of the distal ulna. Following this, we performed an extensor carpi ulnaris (ECU) tenodesis to stabilize the proximal stump. After 2-year follow-up, the patient exhibited positive outcomes, displaying satisfactory wrist joint mobility and functionality without any signs of tumor recurrence. Conclusion: This case emphasizes the effectiveness of wide resection as a viable treatment for huge GCTs in the distal ulna. Utilizing tenodesis with the tendon of ECU significantly contributes to stabilizing the ulnar stump, leading to improved wrist function.