Browsing by Author "Kadija, Marko (16063920000)"

Introduction/Objective The objective of the paper is an analysis of clinical outcomes of non-surgical conservative and operative management of patients with posterior acetabular wall fractures. Methods We investigated 88 fractures of the acetabular joint, 31 of which were treated surgically and 57 non-surgically. Only screws or reconstruction plates and screws were used for surgical treatment and traction in patients who underwent nonsurgical treatment. The study period lasted at least three years. The measures used to assess the outcome of operative, surgical and non-operative, conservative approach were Merle d’Aubigné modified score, Harris hip score, and Matta’s radiometric criteria. Results Matta’s evaluation criteria showed an excellent score of 40.4% in conservatively treated patients; 19.4% in patients who underwent surgery; a good score of 49.1% in conservatively treated patients; and 48.4% in patients who underwent surgery. Comparation between two patient groups differently treated, by Merle d’Aubigné tool, showed excellent results for 56.1% conservatively treated patients and 25.8% in those patients who underwent surgery, and good results in 29.8% conservatively treated patients and 38.7% in patients who underwent surgery. Harris hip score (excellent results were showed in 54.4% for non-operative-treated patients) also showed statistical significance, p < 0.005. Conclusion Proper diagnostics and a proper definitive diagnosis can help avoid surgical treatment if the fracture cannot be treated surgically, making the postoperative period more comfortable for the patient. © 2023, Serbia Medical Society. All rights reserved.

Purpose: The anterolateral ligament, a structure that has been known for 130 years, has again attracted the attention both of orthopaedic doctors and anatomists. Since its initial description until now, this structure has had different names. Whether labelled as the mid-third lateral capsular ligament, the anterior oblique band of the fibular collateral ligament or the anterolateral ligament of the knee, this structure has been responsible for the so-called Segond avulsion fractures. The aim of this study was to determine the precise position and layer of the lateral knee compartment within which the anterolateral ligament is located, as well as its type. Methods: In this study, the anatomical dissection of the lateral segment of 14 cadaveric knees (six male, eight female; seven right, seven left; average age of subjects: 78 years) was performed. The dissection was carried out in keeping with Seebacher, layer by layer. Results: The anterolateral ligament was identified in seven out of 14 cadaveric knee joints (50 %). The length of the ligament was 41 ± 3 mm, while the width was 4 ± 1 mm and the thickness 1 mm (in the middle section). In 14 % of the cases, the anterior oblique band was identified as a part of the FCL. In all of the knee joints, a part of the fibres of the ITT with the same insertions and direction as the ALL was found, located, however, at a much more superficial level than the ALL. Conclusion: Analysis of the current scientific literature related to the anterolateral ligament and layer-by-layer dissection of the lateral region of 14 cadaveric knees has led to the conclusion that the anterolateral ligament is a thickening of the knee joint capsule located in the third layer of the lateral region of the knee (according to Seebacher) which is not always clearly morphologically differentiated from the remainder of the joint capsule. The anterolateral ligament is unequivocally a part of the joint capsule, which is why any damage to it should be treated in the same way as any other damage to the joint capsule. © 2014, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).

Introduction: Peripheral nerve blocks are an efficient method of pain control after total knee arthroplasty (TKA), but there is no report of their impact on chronic post-surgical pain (CPSP). Methods: This prospective observational study aimed to assess adductor canal block (ACB) and IPACK block (blocks vs. no blocks) on opioid consumption, postoperative pain score, chronic post-surgical pain 2 years after TKA. Results: 166 patients (82 vs. 84) were analyzed. Opioid consumption was less in the group with blocks (9.74 ± 3.87 mg vs. 30.63 ± 11.52 mg) (p < 0.001). CPSP was present in 20.24% of patients in the group without blocks and 6.1% of patients with blocks (p = 0.011). Predictor variables of CPSP included pain before surgery (cut-off of 5.5), pain at rest (cut-off of 2.35), pain during active movement (cut-off: 2.5), and opioid consumption (cut-off: 8 mg). Conclusion: Peripheral nerve blocks provide adequate analgesia, significantly decrease opioid consumption, improve functional outcomes, and reduce CPSP 2 years after surgery. Copyright © 2024 Sreckovic, Ladjevic, Milicic, Tulic, Milovanovic, Djukanovic and Kadija.

Background: Hip fractures in the elderly are followed by increased mortality, which is highest in the period immediately after the fracture. Predictors for early mortality have neither been well identified nor summarized. Identification of early postoperative mortality predictors enables the stratification of high-risk patients and can help in the development of strategies aimed at reducing risk and improving outcome after hip fracture. The primary aim of this study was to investigate the incidence of 30-day mortality. The secondary aim was to investigate factors related to early mortality. Methods: We examined 384 elderly patients with hip fracture. Multivariate logistic regression analysis was used to explore independent prognostic factors for 30-day mortality. Results: By the end of the 30-day follow-up period, 22 patients (6.4%) had died. Postoperative delirium was the only variable independently related to 30-day mortality after hip fracture. Older, male patients with a lower cognitive status had a higher chance of developing postoperative delirium. Discussion: Postoperative delirium is a strong independent marker of high risk for 30-day mortality. Older, male patients with more severe cognitive impairment are at increased risk of developing postoperative delirium. Identifying patients at risk for developing postoperative delirium upon admission and early detection of delirium enable the development of targeted prevention and intervention strategies in older patients with hip fracture. Psychogeriatrics © 2014 Japanese Psychogeriatric Society.

Background: Hip fractures in the elderly are followed by increased mortality, which is highest in the period immediately after the fracture. Predictors for early mortality have neither been well identified nor summarized. Identification of early postoperative mortality predictors enables the stratification of high-risk patients and can help in the development of strategies aimed at reducing risk and improving outcome after hip fracture. The primary aim of this study was to investigate the incidence of 30-day mortality. The secondary aim was to investigate factors related to early mortality. Methods: We examined 384 elderly patients with hip fracture. Multivariate logistic regression analysis was used to explore independent prognostic factors for 30-day mortality. Results: By the end of the 30-day follow-up period, 22 patients (6.4%) had died. Postoperative delirium was the only variable independently related to 30-day mortality after hip fracture. Older, male patients with a lower cognitive status had a higher chance of developing postoperative delirium. Discussion: Postoperative delirium is a strong independent marker of high risk for 30-day mortality. Older, male patients with more severe cognitive impairment are at increased risk of developing postoperative delirium. Identifying patients at risk for developing postoperative delirium upon admission and early detection of delirium enable the development of targeted prevention and intervention strategies in older patients with hip fracture. Psychogeriatrics © 2014 Japanese Psychogeriatric Society.

Introduction Osteomyelitis of the radius resulting in the radial clubhand is a very rare condition and few studies have been published about its prognosis and treatment. Case Outline This is a case report of hematogenous osteomyelitis of the radius with a complete loss of the radius leaving only the distal radial metaphysis to carry the carpus. In order to achieve best functional results, four-step operative protocol was performed for reconstruction; lengthening of the forearm by external fixator, radioulnar transposition to create a one-bone forearm, plate removal and transposition of brachioradialis to the extensor pollicis longus as well as proximal row carpectomy. After nine years of the last operation, the function of the elbow and hands is good with acceptable cosmetic result. The forearm is 5 cm shorter and there has been a persistent mild limitation of palmar flexion. Conclusion Creation of the one-bone forearm normalizes the elbow and wrist function, corrects forearm malalignment, and improves forearm growth potential.

Giovanni Battista Monteggia was born in Laverne on the 8th of August 1762. Monteggia started his education in the School of Surgery at the Hospital Maggiore in Milano in 1779. This hospital was called “Big House” and it is one of the oldest medical institutions in Italy. He passed exam in surgery in 1781. Monteggia was promoted to assistant at surgery in Maggiore hospital in 1790. He was among the first who gave a complete clinical description of polio. He described traumatic hip dislocation and special forearm fracture which was named after him. Strictly speaking, a Monteggia fracture is a fracture of the proximal third of the ulna with an anterior dislocation of the radial head. Monteggia became a member of the renewed Institute of Science, Literature and Art in Milano in 1813.

The data about the incidence and risk factors for surgical site infections (SSIs) following total joint arthroplasty (TJA) in middle-income countries are still scant. The aim of this study was to assess the incidence and risk factors associated with 30-day SSIs following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The study was conducted at the Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia (CCS) in Belgrade, from May 2016 to April 2018. All patients undergoing THA or TKA were followed throughout hospitalization until day 30 after discharge. Of the 1073 admitted patients, 459 had THA and 230 had TKA. The incidence rate of surgical site infections (SSIs) among the patients who underwent THA was 5.4%, which is 3.8 per 1000 postoperative patient-days, while the rate among those who had TKA was 4.8%, i.e., 3.4 per 1000 postoperative patient-days. Out of the 36 SSIs, 15 were deep and 21 were superficial incisional ones. Among the variables examined, the independent risk factors for SSIs after THA were the American Society of Anesthesiologists (ASA) score > 2 (RR = 3.17; 95% CI—1.26–8.02), smoking (RR = 3.14; 95% CI—1.26–7.82) and peripheral vascular disease (PVD) (RR = 6.09; 95% CI—2.35–15.77), and after TKA, only PVD (RR = 3.87; 95% CI—1.09–13.76) was the risk factor. Incidence rates of SSIs after arthroplasty are higher compared to reports from developed countries. Therefore, it is necessary to enhance infection prevention and control measures with strict control of modifiable risk factors. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

The data about the incidence and risk factors for surgical site infections (SSIs) following total joint arthroplasty (TJA) in middle-income countries are still scant. The aim of this study was to assess the incidence and risk factors associated with 30-day SSIs following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The study was conducted at the Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia (CCS) in Belgrade, from May 2016 to April 2018. All patients undergoing THA or TKA were followed throughout hospitalization until day 30 after discharge. Of the 1073 admitted patients, 459 had THA and 230 had TKA. The incidence rate of surgical site infections (SSIs) among the patients who underwent THA was 5.4%, which is 3.8 per 1000 postoperative patient-days, while the rate among those who had TKA was 4.8%, i.e., 3.4 per 1000 postoperative patient-days. Out of the 36 SSIs, 15 were deep and 21 were superficial incisional ones. Among the variables examined, the independent risk factors for SSIs after THA were the American Society of Anesthesiologists (ASA) score > 2 (RR = 3.17; 95% CI—1.26–8.02), smoking (RR = 3.14; 95% CI—1.26–7.82) and peripheral vascular disease (PVD) (RR = 6.09; 95% CI—2.35–15.77), and after TKA, only PVD (RR = 3.87; 95% CI—1.09–13.76) was the risk factor. Incidence rates of SSIs after arthroplasty are higher compared to reports from developed countries. Therefore, it is necessary to enhance infection prevention and control measures with strict control of modifiable risk factors. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

The aim of this study was to determine the outcome for patients who sustain a second hip fracture compared with those who sustain a first fracture, and to define the optimal measure to evaluate functional outcome after second hip fracture. Methods: 343 patients with acute hip fractures who presented during a 12 month period were included in the study. Patients with a first (318 patients, 78.10 +/− 7.53 years) and second (25 patients, 78.96 +/− 6.02) hip fracture were compared regarding all baseline variables. Regression analysis was also performed to assess the independent relationship between the presence of a second hip fracture and observed outcome variables at discharge (physical disability, complications, length of stay, and mortality) and one-year after surgery (physical disability and mortality). Results: Disability when performing instrumentalized activities of daily living (IADL) at one-year follow-up is independently related to the presence of a second hip fracture. There were no other statistically significant relationships between the presence of a second hip fracture and other observed outcome variables. Conclusions: Patients with a second hip fracture showed worse functional outcome at one-year follow-up when measured with the IADL scale. No increased short-nor long-term mortality rates were found in patients with a secondary hip fracture. IADL is a good tool to assess disability after a second hip fracture and could be thus a more reliable outcome measure when investigating differences in functional recovery in patients with a second hip fracture compared to conventionally used ADL scales. © 2020 by the authors. Licensee MDPI, Basel, Switzerland.

The aim of this study was to determine the outcome for patients who sustain a second hip fracture compared with those who sustain a first fracture, and to define the optimal measure to evaluate functional outcome after second hip fracture. Methods: 343 patients with acute hip fractures who presented during a 12 month period were included in the study. Patients with a first (318 patients, 78.10 +/− 7.53 years) and second (25 patients, 78.96 +/− 6.02) hip fracture were compared regarding all baseline variables. Regression analysis was also performed to assess the independent relationship between the presence of a second hip fracture and observed outcome variables at discharge (physical disability, complications, length of stay, and mortality) and one-year after surgery (physical disability and mortality). Results: Disability when performing instrumentalized activities of daily living (IADL) at one-year follow-up is independently related to the presence of a second hip fracture. There were no other statistically significant relationships between the presence of a second hip fracture and other observed outcome variables. Conclusions: Patients with a second hip fracture showed worse functional outcome at one-year follow-up when measured with the IADL scale. No increased short-nor long-term mortality rates were found in patients with a secondary hip fracture. IADL is a good tool to assess disability after a second hip fracture and could be thus a more reliable outcome measure when investigating differences in functional recovery in patients with a second hip fracture compared to conventionally used ADL scales. © 2020 by the authors. Licensee MDPI, Basel, Switzerland.

Hip fracture in elderly people is associated with high morbidity and mortality. Therefore, it is important to identify risk factors that potentially influence outcomes after hip surgery. The main purpose of this study was to evaluate the relationship of anemia at admission and short-term outcomes after hip fracture. We studied 343 community-dwelling patients who underwent surgery for hip fracture from March 2009 to March 2010. Functional mobility at discharge, postoperative complications, hospital length of stay and in-hospital mortality were analyzed in respect to presence and severity of anemia at admission. Anemia (defined as hemoglobin levels < 13.0 g/dl for men and < 12.0g/dl for women) was present in 185 (53.9%) patients, of whom 54 (29.2%) were severely anemic (defined as hemoglobin level 10.0g/dl or below). In multivariate analysis anemia was associated with age, gender (female), type of fracture (intertrochanteric) and American Society of Anesthesiologists (ASA) classification (3 or 4), while severity of anemia was associated with recovery of ambulatory ability at discharge. There was no difference in the incidence of postoperative complication, in-hospital mortality and length of hospital stay between the groups at discharge. Overall anemia at admission is an indicator of poor general health status. Ambulatory recovery in hip fracture patients is independently related to severity of anemia at admission. © Versita Sp. z o.o.

Purpose: The aim of this paper was to determine whether the change in the position of the patient’s leg as well as the use of flexible reamers may help in obtaining a longer femoral tunnel with minimal risk of perforating the posterior cortex. Methods: One hundred and twenty-five patients who had undergone anatomic ACL reconstruction between 2010 and 2013 were included in this prospective cohort study. The first group was composed of patients whose femoral tunnel had been drilled with rigid reamers, while the leg being operated on was positioned on an arthroscopic leg holder (82 patients). In the second group of patients, the femoral tunnel was also drilled with rigid reamers, but the leg was positioned on the table (25 patients), while the third group was composed of patients whose femoral tunnel was drilled with flexible reamers, and the leg was positioned on a leg holder (18 patients). The length of the femoral tunnel was measured intraoperationally, while the site of femoral insertion and the position of the tunnel were read from native radiographic images. Results: When the femoral tunnel was drilled on the medial aspect of the lateral condyle, the centre of the tunnel was located at 31.4 % from the most proximal point of the femoral condyle and 34.7 % from the Blumensaat line. The length of the tunnel drilled with rigid reamers on the operating table (36.1 mm) was statistically significantly greater (p < 0.05) than the length of the tunnel drilled with the same reamers, but with the leg positioned on the leg holder (32.5 mm). The length of the tunnel drilled with flexible reamers with the leg positioned on the leg holder (42.5 mm) was highly statistically significantly greater than the length of the tunnel drilled with rigid reamers (p < 0.01), and it was statistically significantly greater than the length of the tunnel drilled with rigid reamers with the leg placed on the operating table (p < 0.05). Conclusion: The drilling of the femoral tunnel during anatomic ACL reconstruction with the use of flexible reamers provides a longer femoral tunnel than when it is drilled with rigid reamers, without any danger of perforation of the posterior cortex. Level of evidence: III. © 2015, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).

Background/Aim. Osteoporotic fractures are a major cause of morbidity in the population. Therefore, fracture prevention strategies should be a major concern, and one of the priorities in the primary health care system. The aim of the study was to assess fracture and fall risk factors, and fracture risk level in patients with acute hip fracture, and to evaluate if there had been adequate osteoporosis treatment prior to fracture in this group of patients. Methods. Fracture and fall risk factors were assessed in 342 patients, > 65 years old, hospitalized due to acute hip fracture at the Clinic for Orthopedic Surgery and Traumatology, Clinical Centre of Serbia in a 12-month period. Fall risk factors were assessed with the Fracture Risk Assessment (FRAX®) algorithm, and patients were classified in respect to fracture risk level. Results. Hip fracture occurred in the majority of the patients in the high risk group (74.2%), where no additional bone mineral density testing was needed. Less than 10% of the patients had a diagnosis of osteoporosis before injury, while less than 2% were treated. Cognitive impairment (95.3%), visual impairment (58.2%), lower index of daily activities (51.8%), and depression (47.1%) were the most frequently observed fall risk factors. Conclusion. The results of our investigation reveal insufficient identification of clinical fracture risk factors in the primary care setting, inadequate treatment of osteoporosis and, consequently, ineffective prevention of hip fractures in the geriatric population. The introduction of FRAX® into clinical practice enables more effective acknowledgment of patients with elevated fracture risk, even if bone density measurement is not available. The results of this study have a special significance for everyday clinical practice, because they impose a need for reviewing the existing approaches to osteoporosis prevention, and precise definiment of hip prevention strategies.

Background and Objectives: Total knee arthroplasty (TKA) has become the treatment of choice for advanced osteoarthritis. The aim of this paper was to show the possibilities of optimizing the Perth CT protocol, which is highly effective for preoperative planning and postoperative assessment of alignment. Materials and Methods: The cross-sectional study comprised 16 patients for preoperative planning or postoperative evaluation of TKA. All patients were examined with the standard and optimized Perth CT protocol using advance techniques, including automatic exposure control (AEC), iterative image reconstruction (IR), as well as a single-energy projection-based metal artifact reduction algorithm for eliminating prosthesis artifacts. The effective radiation dose (E) was determined based on the dose report. Imaging quality is determined according to subjective and objective (values of signal to noise ratio (SdNR) and figure of merit (FOM)) criteria. Results: The effective radiation dose with the optimized protocol was significantly lower compared to the standard protocol (p < 0.001), while in patients with the knee prosthesis, E increased significantly less with the optimized protocol compared to the standard protocol. No significant difference was observed in the subjective evaluation of image quality between protocols (p > 0.05). Analyzing the objective criteria for image quality optimized protocols resulted in lower SdNR values and higher FOM values. No significant difference of image quality was determined using the SdNR and FOM as per the specified protocols and parts of extremities, and for the presence of prothesis. Conclusions: Retrospecting the ALARA (‘As Low As Reasonably Achievable’) principles, it is possible to optimize the Perth CT protocol by reducing the kV and mAs values and by changing the collimation and increasing the pitch factor. Advanced IR techniques were used in both protocols, and AEC was used in the optimized protocol. The effective dose of radiation can be reduced five times, and the image quality will be satisfactory. © 2024 by the authors.

Periprosthetic joint infection (PJI) after total knee arthroplasty remains a challenging complication. The treatment options for PJI include different procedures; however, regardless of the strategy, antibiotics are required. The combination of different antibiotics increased the rates of PJI eradication. For almost 3 decades, rifampicin has been used as part of antibiotic therapy for PJI. Drug fever, a febrile response that coincides with the onset of drug administration and disappears after drug discontinuation in the absence of other underlying conditions that could cause fever, is frequently misdiagnosed. We present the case of a 72-year-old man with PJI 6 months after total knee arthroplasty. Two-stage revision surgery was followed by culture-directed antibiotic treatment (ciprofloxacin and rifampicin) against Staphylococcus aureus isolated from the periprosthetic tissue. On the fifth day of antibiotic treatment, the patient became febrile and, in the next 5 days, he had an intermittent fever of up to 40°C, although he showed clinical improvement. The patient was normotensive without a maculopapular rash, urticaria or clotting abnormalities. A drug fever was suspected, and rifampicin was discontinued. A re-challenge test was performed, and the fever recurred. Antibiotic treatment with ciprofloxacin was continued and, after 12 months of follow-up, the patient was doing well. Clinicians should be aware that fever could be a clinical presentation of drug fever. If it occurs during an infection, drug fever could necessitate additional diagnostic procedures for further evaluation, inadequate antibiotic therapy and prolonged hospitalisation. © 2022 British Pharmacological Society.

Periprosthetic joint infection (PJI) after total knee arthroplasty remains a challenging complication. The treatment options for PJI include different procedures; however, regardless of the strategy, antibiotics are required. The combination of different antibiotics increased the rates of PJI eradication. For almost 3 decades, rifampicin has been used as part of antibiotic therapy for PJI. Drug fever, a febrile response that coincides with the onset of drug administration and disappears after drug discontinuation in the absence of other underlying conditions that could cause fever, is frequently misdiagnosed. We present the case of a 72-year-old man with PJI 6 months after total knee arthroplasty. Two-stage revision surgery was followed by culture-directed antibiotic treatment (ciprofloxacin and rifampicin) against Staphylococcus aureus isolated from the periprosthetic tissue. On the fifth day of antibiotic treatment, the patient became febrile and, in the next 5 days, he had an intermittent fever of up to 40°C, although he showed clinical improvement. The patient was normotensive without a maculopapular rash, urticaria or clotting abnormalities. A drug fever was suspected, and rifampicin was discontinued. A re-challenge test was performed, and the fever recurred. Antibiotic treatment with ciprofloxacin was continued and, after 12 months of follow-up, the patient was doing well. Clinicians should be aware that fever could be a clinical presentation of drug fever. If it occurs during an infection, drug fever could necessitate additional diagnostic procedures for further evaluation, inadequate antibiotic therapy and prolonged hospitalisation. © 2022 British Pharmacological Society.

Introduction: A minority of patients with hip fractures sustain concomitant wrist fractures. Little is known about the rehabilitation outcome in this group of patients. Aim of study: Prospective investigation of functional outcome and survival in patients with combined hip and wrist fractures compared with patients who sustain an isolated hip fracture. Methods: 341 patients who presented with an acute hip fracture during a 12 month period were included in the study. Outcome at discharge and 4 months follow-up was compared between patients with isolated hip fractures and those patients who sustained simultaneous distal wrist fractures. Results: The actual incidence of concurrent hip and wrist fractures in our cohort was 4.7%. Patients who sustained a concurrent hip and wrist fracture showed no differences regarding short- and long-term functional outcome and survival. Conclusion: Our results imply that patients with simultaneous hip and wrist fractures have no difference in rehabilitative outcome. Future studies should further investigate the distinctive characteristics of this patient subgroup. © 2019 by the authors.

Introduction: A minority of patients with hip fractures sustain concomitant wrist fractures. Little is known about the rehabilitation outcome in this group of patients. Aim of study: Prospective investigation of functional outcome and survival in patients with combined hip and wrist fractures compared with patients who sustain an isolated hip fracture. Methods: 341 patients who presented with an acute hip fracture during a 12 month period were included in the study. Outcome at discharge and 4 months follow-up was compared between patients with isolated hip fractures and those patients who sustained simultaneous distal wrist fractures. Results: The actual incidence of concurrent hip and wrist fractures in our cohort was 4.7%. Patients who sustained a concurrent hip and wrist fracture showed no differences regarding short- and long-term functional outcome and survival. Conclusion: Our results imply that patients with simultaneous hip and wrist fractures have no difference in rehabilitative outcome. Future studies should further investigate the distinctive characteristics of this patient subgroup. © 2019 by the authors.

Eggerthia catenaformis has been reported as a human pathogen. We present the first case of the primary knee infection caused by Eggerthia catenaformis in a 23-year-old male patient with a knee infection, after primary anterior cruciate ligament reconstruction. Eggerthia catenaformis was confirmed by MALDI-TOF mass spectrometry from synovial fluid. The dental focus was excluded. The isolated bacterial strain showed sensitivity to all of the tested antimicrobials. However, for successful management of knee infection, besides culture-directed antibiotics therapy, arthroscopic debridement and lavage were necessary. © 2021 Elsevier Ltd