A 24-year-old female with high-grade dysplastic spondylolisthesis, underwent posterior decompression, L4 to S2-ilium instrumentation, and in situ fusion with two fibular strut grafts. Subfascial closed suction drains were placed to prevent hematoma formation. On post-operative Day 2, the drain tube snapped during removal, leaving a retained portion in the wound. Removal of the retained drain tube was performed using a minimally invasive tubular microscopic technique. The drain tube was found to be entangled with the cross-link. This case highlights the possible entrapment of deep fascial drain over the cross-link and feasibility of removal using a minimally invasive technique.
Superior patellar dislocation is a rare condition and is often misdiagnosed as patellar tendon rupture because of similar clinical features. We report the case of a 60-year-old woman with known left knee osteoarthritis who presented acutely with the left knee locked in extension, associated with pain and effusion. Examination revealed an infrapatellar dimple, and plain radiographs demonstrated patella alta with tilting of the patella. Magnetic resonance imaging (MRI) confirmed superior patellar dislocation caused by an inferior patellar osteophyte locked against the superior trochlea. The patellar tendon was intact. Closed manipulation and reduction under sedation were successfully performed. A review of the literature identified hyperextension and direct trauma as the most common mechanisms of injury, with osteoarthritis recognised as an important risk factor. Closed reduction, performed under various forms of anaesthesia, was successful in the vast majority of cases. Rare recurrences were managed either by open surgery or arthroscopic intervention.
Phalanx fractures are among the most frequently encountered hand injuries, with fractures at the base of the proximal phalanx presenting unique management challenges due to their diverse presentations. We present a case of a 47-year-old male with a complex fracture at the base of the proximal phalanx following a motorcycle accident. Radiology revealed severe comminution with apex volar angulation. Treatment involved open reduction and internal fixation with a miniplate using the distraction plating method; the hardware was removed at six weeks. Physical therapy was then initiated, and after one year, the patient achieved an excellent range of motion post-operatively (metacarpophalangeal joint of 45 – 90°, proximal interphalangeal joint and distal interphalangeal joint were 0 –90°) comparable to pre-injury function. Radiographs showed union of the fracture and proper alignment. The successful application of distraction plating in complex comminuted distal radius fractures inspires further research and application in other challenging fractures. Distraction plating can effectively maintain proper fracture alignment while minimising strain on surrounding soft tissues. This supports bone healing and allows good radiological and functional outcomes. The favourable outcome in this case supports the use of distraction plating in situations where traditional fixation methods, such as Kirschner wire fixation, may be insufficient. Distraction plating may be an alternative to Kirschner wire fixation to maintain the proper alignment and avoid the risk of pin-track infections, and allow an early return to daily activities. The successful application of distraction plating in complex comminuted distal radius fractures has inspired further research and its application in other challenging fractures. Distraction plating can effectively maintain proper fracture alignment while minimising strain on surrounding soft tissues, thereby supporting bone healing and enabling favourable radiological and functional outcomes. Distraction plating may serve as a viable alternative to Kirschner wire fixation by maintaining proper alignment, reducing the risk of pin-track infections, and allowing an earlier return to daily activities.
Anterior cruciate ligament (ACL) revision surgeries remain challenging, with higher failure rates than primary reconstructions. This case report aims to demonstrate the clinical outcomes of revision ACL reconstruction using the Modified UKM Internal Bracing (MUIB) technique and evaluate its protective role in maintaining graft integrity after high-impact trauma. This case report describes a 37-year-old male with recurrent ACL graft failure who underwent revision reconstruction using the MUIB technique. Post-operatively, the patient achieved excellent knee stability with no functional limitations at the post-operative nine month. Following a high-energy motorcycle accident, a second-look arthroscopy after one year from the last reconstruction revealed only a small tear of the ACL graft and just one of the strands of MUIB ruptured. There was also no evidence of tunnel widening, a common complication in revision cases. These findings demonstrate that MUIB effectively protected the graft from complete failure despite significant trauma. Additionally, suture tape reinforcement using the MUIB technique improves outcomes in revision ACL reconstructions by preventing graft elongation, tunnel widening, and stress shielding while also providing protective reinforcement.
Stable surgical fixation of the distal femur relies significantly on accurate restoration of the lower limb mechanical axis. Methods previously described such as the cable method, axis board method, and alignment rod method require assessment to be performed with the lower limb in extension. We describe a novel technique – which utilises simple and easily accessible components such as an Ilizarov half-ring, connecting rod, and two nuts – that permits intra-operative assessment of the lower limb mechanical axis with the knee in both flexion or extension. Allowing the knee to remain in flexion also facilitates fracture reduction, as the flexed position reduces the pull of the gastrocnemius muscle on the distal fragment. Intra-operatively, the Ilizarov half-ring is attached to the connecting rod in at the perpendicular and secured with two nuts. Fluoroscopy is used to confirm that the ring is placed parallel to the knee joint, and the tip of the rod centred on the femoral head; when both of these landmarks are aligned, it indicates the lower limb mechanical axis has been restored. This technique has proven accurate and reproducible in our institution but will require further evaluation with more detailed studies in a larger patient sample.
Introduction: The Ponseti technique (PT) is widely used for managing idiopathic congenital talipes equinovarus (CTEV), but it can lead to talar dome distortion and reduced ankle range of motion (ROM), resulting in compromise functional outcomes. This study aimed to evaluate talar distortion in children treated with the Ponseti method and explore the relationship between static ankle movement and talar distortion, using the radius-to-length (R/L) ratio. Materials and methods: A prospective observational study was conducted involving 25 children aged 5 to 15 years with unilateral idiopathic CTEV, all of whom had achieved correction with the Ponseti method by the age of one. Detailed clinical histories, functional assessments, and radiographic evaluations were performed. The R/L ratio of the talus was calculated and correlated with ankle ROM, number of casts, number of tenotomies, and the Ponseti and Laaveg score. Results: Talar dome distortion was observed in 64% of cases. A significant negative correlation was found between the treated foot's R/L ratio and its ankle ROM (Spearman’s ρ = -0.634, p = 0.001), as well as with the Ponseti and Laaveg scores (Spearman’s ρ = -0.533, p = 0.006). A positive correlation was identified between the R/L ratio and the number of casts applied (Spearman’s = 0.417, p = 0.038). A statistically significant difference in both ROM and R/L ratio was noted between the treated and unaffected feet. Conclusion: Talar Dome distortion is present in conservatively managed CTEV feet. There is also a significant negative correlation between R/L ratio, ankle ROM and Ponseti and Laaveg score.
Introduction: Management of quadrilateral plate (QLP) fractures is challenging. Current QLP implants are suboptimal in terms of plate positioning and risk of intra-articular screw penetration, which requires detailed anatomical knowledge. There are limited morphometric data on the acetabulum among Malaysian patients. This study aimed to determine the safe zones for implant placement in QLP fractures among a Malaysian Malay cohort. Materials and methods: In this retrospective CT-based study, 3D pelvic models were reconstructed using MIMICS v21.0, and measurements of acetabular roof length from pubic tubercle (point A) and safe angles (beyond X-Y angle), area without the risk of intra-articular screw penetration, were recorded. Means ± SD were reported, and sex comparisons were analysed by using independent t tests (α = 0.05). Results: Out of 56 patients, 82.1% were male. The mean age was 37 years old. All measurements were longer in males. Mean acetabular length or danger zone (B–C) was 58.38mm (SD 4.04) in males and 53.22 (SD 4.55) in females. Statistically significant sex differences were observed for two measurements, A-C and B-C, with p=0.018 and 0.001, respectively. No other measurements showed significant sex differences. Conclusion: These morphometric data provide population-specific parameters that may inform safer implant placement and screw trajectory planning for QLP fractures in Malay patients. Further multiethnic studies are needed before generalising these findings to the wider Malaysian population.
Introduction: Atypical clubfoot forms a small subset of idiopathic clubfoot, features of which are more severe, is difficult to treat using normal Ponseti casting, and treatment often requires modifications. We therefore undertook this study to evaluate the role of modified Ponseti method of manipulation in management of atypical clubfoot. Materials and methods: We evaluated 30 atypical clubfeet in a prospective, descriptive study conducted at a tertiary care centre in central India and used modified Ponseti casting for its management. Achilles tenotomy was performed in all patients, followed using a foot abduction brace. All children of age less than three years, presenting with features of atypical clubfoot were included in the study. Children with typical or having secondary clubfoot or with history of previous surgical treatment were excluded from the study. Children were followed-up for minimum of six months after tenotomy. Severity assessment was done using Pirani score. Results: Our study included 30 feet in 18 children (12 bilateral and 6 unilateral) and Male to Female ratio was 2:1 (12:6). On an average 9.44 casts were required for correction in each foot and mean treatment duration was 11.44 weeks. Three patients had excellent results, 25 had good and 2 had poor results. Second tenotomy was required in two cases. Complications included pressure sores in 8 patients, cast slippage in 13/267 casts and relapses in 2 patients. Conclusion: Management of Atypical Clubfoot is a challenge for orthopaedic surgeon, early identification and treatment with modified Ponseti technique provides good to excellent results in most of the patients and reduces the need for major surgical intervention.
Introduction: The fifth metacarpal bone (5th MCB) fracture is common particularly among the young adults. Treatment options for 5th MCB neck fractures can be treated surgically. Studies suggest non-surgical treatment also yields good outcomes No established guideline on optimal treatment strategy exists. This study was performed to measure functional outcomes of 5th MCB neck fracture treated conservatively. Materials and methods: A retrospective cross-sectional study was done to assess hand function in patients with 5th MCB neck fractures treated non-operatively from January 2015 to September 2023 at HPUSM. Grip strength in both injured and contralateral hands were measured and QuickDASH questionnaire was utilised to evaluate function. Flexion gap measurements was also analysed. Results: There were total of 43 patients, [35 males (81.4%) and 8 females (18.6%)] included in this study. There was a significant drop in mean grip strength compared injured to the contralateral normal hand with percentage loss is averaging 11.5%. QuickDASH points accumulated showed 36 patients (83.7%) with ‘Good’ outcome while 7 patients (16.3%) having ‘Satisfactory’ outcomes. Most common complication was cosmetic (30.2%), followed by reduced ROM in 8 patients. Residual pain was present in five patients. Out of 43 patients, 3 patients had flexion gap deformity. Conclusion: The overall scores from the QuickDASH questionnaire showed no significant drop in functional outcome. There was significant decline in mean grip strength. Most patients had favourable outcomes. Conservative treatment for 5th MCB neck fracture is still a good option of treatment. Further evaluation comparing outcome with operated cases will be worthwhile.
Introduction: Cerclage wiring remains a popular reduction tool in managing complex fractures of the femur. We propose that the direction in which the minimally-invasive wire passer (MI-WP) is inserted should be considered distinct from that of the conventional wire passer to minimise vessel injury. Materials and methods: The computed-tomographic angiograms of 101 limbs from 78 unique patients from 2010 to 2017 were reviewed. We identified three common levels of wiring: the lesser trochanter (LT), midshaft of the femur, and the adductor tubercle. The position of and the shortest distance from the outer cortex of the femur to the superficial femoral artery (SFA) and the profunda femoris artery (PFA) at these levels were recorded. Results: The mean distance of the SFA to the LT and femur midshaft was 6.8mm further in a male compared to a female (p<0.001). Males showed a significantly further distance from the PFA to the LT and femur midshaft (p<0.001 and p=0.009, respectively). There was a significantly shorter distance from the SFA and PFA to the femur at the LT of 0.2mm (95% CI: 0.1-0.2) and 0.1mm (95% CI: 0.1-0.2), respectively, for each 1-year increase in age (p<0.001). Conclusion: Responsible use of the MI-WP requires that the surgeon is aware of its differences from other wire passers; in particular, one of the jaws of one forceps-half extends forward by approximately 5mm during assembly. To minimise the risk of vessel injury, safe usage of the MI-WP should consider both the position of the extending forceps-jaw and the angle of insertion with respect to the surrounding vessels.
Introduction: With increasing popularity of rock-climbing, both recreationally and competitively, its related injuries are increasing, leading to greater healthcare demands. This study aims to evaluate orthopaedic injury patterns and associated inpatient and outpatient costs from rock-climbing accidents. Materials and methods: A retrospective review was conducted on patients admitted to the department of orthopaedic surgery between January 2017 and December 2023 for rock-climbing-related injuries. Data on demographics, injury patterns, outcomes, and costs were analysed. Results: A total of 21 patients were included, with a mean age of 27.4 years and 76.2% female. Injuries occurred during bouldering (47.6%) and sport climbing (52.4%), with 90.5% resulting from falls. Fractures occurred in 95.2% of cases; 60% sustained multiple fractures, and 10% had open fractures. Lower limb injuries predominated. Surgery was required in 90.5% of patients, of whom 36.8% underwent a second procedure. The mean hospital stay was 11.0 days, and average hospitalisation leave lasted 78.5 days. Median inpatient and outpatient costs were S$7,056.92 and S$710.78, respectively. Higher inpatient costs were associated with multiple injuries, open fractures, and high-dependency admissions, while outpatient costs were influenced by gender, fall height, injury severity, and multiple surgeries. Conclusion: Rock-climbing injuries impose substantial financial and healthcare burdens, costing patients nearly 1.5 months’ wages for inpatient care. Although 11% lower than PMD- and motorcycle-related injuries, its total expenses, including rehabilitation and societal costs, are likely higher. These findings highlight the need to emphasise on preventive measures and enhanced safety protocols to reduce injury rates and mitigate economic impact.
We read with great interest the article by Kumar et al, “A Prospective Study Assessing Functional Outcomes of Arthroscopic Subacromial Decompression with Platelet-Rich Plasma Augmentation in Shoulder Impingement Syndrome” published in the Malaysian Orthopaedic Journal (2025; 19: 114-121). The authors are to be commended for presenting prospective data evaluating biologic augmentation in the management of shoulder impingement syndrome (SIS).
Introduction: The innominate tubercle (IT), a bony prominence at the anterior inter-trochanteric line of the femur, plays a crucial role as a surgical and radiological landmark in orthopaedics. Despite its clinical importance in intertrochanteric fracture classification and femoral osteotomy during hip arthroplasty, limited literature exists on its detailed anatomy. Materials and methods: This study investigated the morphometric and relational characteristics of the IT in 47 adult dry femora (25 right, 22 left). Measurements included IT dimensions, distances from the IT to proximal femoral landmarks, and their correlations with femoral parameters. Pearson correlation coefficient and multivariate regression tests were utilised to find the relationship between these measurements. Results: Revealed significant correlations between the IT length and width with key proximal femoral dimensions such as femoral head diameter, neck length, and femoral axis length. The IT height, however, showed no notable associations. The intersection of the anatomical axis of femur and the line in between the centre of head (COH) to the lateral-most point of vastus lateralis (VL) ridge was most consistent landmark for topographic localisation of the IT. Conclusion: These findings underscore the IT’s anatomical consistency and reliability as a surgical landmark, particularly in the direct anterior approach to hip arthroplasty. Our study highlights the need for broader, population-specific research to enhance localisation and clinical applications of the IT.
Introduction: Pectoralis major muscle rupture is one of the most infrequently occurring sports/exercise injuries. Among the various techniques described for its repair, three are most commonly used: transosseous (TOS) through drill hole or bone tunnel, suture anchor (SA), and unicortical or bicortical button (UCB and BCB, respectively). Materials and methods: In this retrospective observational study, we studied the results of ten cases with complete pectoralis major muscle tears from January 2021 to January 2023. All of them underwent repair using suture anchors in a double-row configuration to get a better anatomical footprint at the insertion site on the humerus, along with box-suture bites through the muscle-tendinous unit to provide a better bulk of muscle available for repair in chronic cases. Functional outcomes were assessed over a one-year follow-up period using the ASES score, Penn score, and Bak’s criteria. Results: At one-year follow-up, the American Shoulder and Elbow Surgery score (ASES) improved from 46.33±9.83 pre-operative to 97.5±2.73 post-op for acute cases (p – 0.0001), while for chronic cases it went from 52.33±12.31 to 95.77±3.53 (p – 0.0001). According to the ASES score and Bak’s criteria, patients had excellent results with good shoulder ROM without any functional impairment at 12 months post-surgery. Conclusion: The double row suture anchor technique provides a practical, transosseous equivalent method for repairing pectoralis major ruptures, demonstrating favourable outcomes even in chronic cases. By adapting principles from the familiar rotator cuff repair approach, this technique is particularly relevant in regions where such injuries are infrequently encountered. Nevertheless, the small sample size and lack of objective strength testing in this study highlight the need for further research to validate its efficacy and generalisability.
Introduction: Understanding knee alignment development in early childhood is essential to differentiate normal growth from pathology. However, local normative data are lacking. This study investigates knee development patterns in healthy Malaysian children aged three years and below. Materials and methods: Three hundred healthy children were randomly selected from clinics, daycare centres, and screening programs in Klang Valley and equally divided into three age groups (0–12, 13–24, 25–36 months). Clinical assessments included intercondylar distance (ICD), tibiofemoral angle (TFA), mid-arm, and head circumference. One-way ANOVA, Kruskal-Wallis test, Pearson correlation, and multiple linear regression were used for analysis. Results: Significant age-related changes were observed in ICD and TFA. Median ICD decreased from 5.00cm (0 – 12 months) to 1.00cm (13 – 24 months) and 0.00cm (25–36 months) (p<0.05). TFA shifted from varus (8.74°) to neutral (0.23°) and then to valgus (-4.91°) (p<0.05). No gender differences were found, but at 0 – 12 months, Malay children had greater varus angulation (9.55°) compared to Chinese (7.44°) and Indian (7.67°) children (p<0.05). ICD and TFA were negatively correlated with anthropometric measures (p<0.01). Multiple regression analysis revealed that ICD and height were independent predictors of TFA (p<0.001). Conclusion: This study presents normative data on knee alignment in Malaysian children under three. Knee angulation progresses from varus in infancy to neutral by age two and valgus by age three. Clinicians can utilise population-specific normative data to track physiological bowing and identify cases requiring specialist referral when knee varus persists beyond the age of two.
Introduction: Many arthroscopic fixation techniques have been described for PCL avulsion fractures, amongst which suture bridge (SBF) and TightRope [Arthrex,Naples,US] fixation (TRF) techniques are commonly employed. However, there is no consensus on the optimal method of fixation. Our study aimed to assess the functional outcome of displaced isolated tibial side PCL avulsion fractures treated with either an arthroscopic suture bridge or TightRope technique. Materials and methods: Our institution assessed the functional outcome in 34 patients diagnosed with bony PCL avulsion and treated arthroscopically between Jan 1, 2015, and Jun 1, 2021. We used the Modified Lysholm and IKDC scores to assess the functional outcome. Scoring was carried out pre-operatively and post-operatively at 3 months, 6 months, and 12 months. Results: The study population had a mean age of 34.6 years, with a predominant male (82.6%) patient population. Twenty patients (58.8%) underwent fixation using the suture bridge technique, while the remaining 14 had undergone TightRope-aided fixation. Significant functional outcome improvement in modified Lysholm and IKDC scores was seen after 6 months and 12 months of arthroscopic fixation, irrespective of the technique used. Both techniques led to comparable functional outcomes, suggesting that achieving stable fixation is more critical than the choice of method. Conclusion: Both techniques are effective for PCL avulsion fractures. In our study, outcomes were independent of patient age, sex, and mechanism of injury; therefore, the choice of fixation was primarily determined by surgeon expertise. This suggests that either technique can be applied across patient groups with comparable results.
Introduction: ACL Reconstruction (ACLR) with various autografts is associated with several complications. Autograft diameter is an important factor contributing to ACLR failure. In this study, we evaluated the long-term functional outcome of the peroneus longus tendon (PLT) graft in primary ACLR and donor site morbidity, and evaluated the correlation of PLT dimensions (length and diameter) with various anthropometric parameters. Materials and methods: The patient’s pre-operative anthropometric data were recorded. Ipsilateral PLT graft was harvested, and the distal part tenodesis done with the peroneus brevis. Graft diameter and length were noted intra-operatively. The Lachmann test, Pivot Shift test, Lysholm II knee score, and AOFAS were recorded at pre-operative, six months, one year, and two years post-operatively. Results with p-values <0.05 were considered significant. Results: During this study 51 patients were enrolled. Mean graft diameter and length were 7.93mm and 25.71cm, respectively. Mean Lysholm Score was 97.07, and AOFAS was 98.07 at 2 years follow-up. Six patients showed Lachman Grade 1+, and 3 had Pivot shift test positive 1+ at 2 years. A strong positive correlation of graft diameter and length with both patient height (cm) and weight (kg) was observed. But neither graft diameter nor length was significantly correlated with either age or BMI. Conclusion: PLT autograft demonstrate favourable long-term functional outcome at the knee, minimal donor site morbidity at the ankle. Among anthropometric parameters, height and weight are associated with PLT diameter and length prediction. No association of patient’s age and BMI was found with graft diameter and length.
Introduction: Osteoarthritic patients who undergo index total hip or knee replacement have higher likelihood of receiving subsequent arthroplasties. This study hypothesises that patients who receive THR first have better functional outcomes than patients who receive TKR before ipsilateral THR. Materials and methods: This retrospective study analysed 60 patients with ipsilateral THR and TKR from January 1999 to December 2014. Group 1 underwent THR before TKR (n=27, interval between surgeries 50.4±37.8 months) while Group 2 underwent TKR first (n=33, interval between surgeries 42.1±34.4 months). Functional outcome scores – Short Form Health Survey (SF-36), Oxford Knee Score (OKS), Knee Society Score (KSSFS), Oxford Hip Score (OHS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) – were recorded pre-operatively, six-months and two-years post-operatively. Results: Pre-operatively, Group 1 patients had superior SF-36 physical component scores (33.8±10.4 vs 28.3±8.0, P=0.028) compared to Group 2. Group 1 patients had superior 6-month OKS (20.7±5.2 vs 26.8±10.9, P=0.035) and 2-year KSSFS (66.8±13.3 vs 56.2±24.1, P=0.020) post-TKR. Both groups demonstrated improvements in SF-36 scores after the 2nd surgery. Group 1 patients had superior satisfaction rates (1.9±0.6 vs 2.8±1.5, P=0.019) and expectations met (1.9±0.8 vs 2.8±1.8, P=0.04). Conclusion: In patients with ipsilateral THR and TKR, those with THR first had superior early functional outcomes. This may be due to technical disease factors such as altered kinematics of the arthritic hip, or knee pain resulting from referred hip pain as a cognate joint. Further studies to evaluate long term outcomes of patients with ipsilateral TKR and THR is recommended.
Distal Radioulnar Joint (DRUJ) Dislocation is a common underdiagnosed wrist injury, with 50% of cases missed in the acute phase. Delayed diagnosis and suboptimal management can result in chronic instability, pain, and functional impairment. The endobutton technique has emerged as a minimally invasive alternative for DRUJ stabilisation compared to conventional methods. We shared a case of a 33-year-old woman with DRUJ dislocation with ulna subluxation posteriorly without any fractures, fixed with minimally invasive surgery using the endobutton technique, resulting in a Disabilities of the Arm, Shoulder, and Hand (DASH) score of 0 three weeks post-surgery. Successful restoration of DRUJ function in daily activities suggests the endobutton technique could become a preferred therapy option in the future.
Tuberculous osteomyelitis is an uncommon manifestation of extrapulmonary tuberculosis in children, with diaphyseal involvement being particularly rare. Its insidious course and nonspecific imaging often lead to misdiagnosis as pyogenic osteomyelitis or Brodie’s abscess, resulting in delayed treatment. This report highlights a diagnostically challenging case of paediatric tibial tuberculosis osteomyelitis mimicking Brodie’s abscess. A 15-year-old girl presented with an 18-month history of chronic pain, swelling, and a draining sinus on her left lower leg. Despite undergoing multiple surgeries and a prolonged course of anti-tuberculous therapy, symptoms persisted. Radiographic and MRI findings suggested Brodie’s abscess with diaphyseal and metaphyseal involvement. However, biopsy revealed granulomatous inflammation, and polymerase chain reaction (PCR) testing confirmed Mycobacterium tuberculosis. Subsequent treatment led to clinical improvement and radiological bone union at six-month follow-up. The case underscores the diagnostic difficulty in distinguishing TB osteomyelitis from subacute pyogenic infections, especially in children. Classical radiologic features such as sclerotic rims, lytic lesions, and periosteal reaction are often indistinguishable. FNAB and pus cultures may yield inconclusive results. In this case, PCR was pivotal for definitive diagnosis. Misdiagnosis can lead to inappropriate treatment and unnecessary surgical interventions. Tuberculosis should be considered in the differential diagnosis of chronic osteomyelitis, particularly in TB-endemic regions. Early use of molecular diagnostics such as PCR, along with histopathology, is critical for accurate diagnosis. A multidisciplinary approach facilitates timely intervention, prevents complications, and improves outcomes.
