Clinics in Shoulder and Elbow最新文献

{"title":"Use of posteroanterior reference guides for bone block or coracoid process transfer in anterior glenohumeral instability: a cadaveric study of the relationship to the suprascapular nerve.","authors":"Musammad Rashida Begum, Rory Cuthbert, Cameron Andrew Joseph Dott, Owen O'Neill, Mohammed Tahir, Adrian Carlos, Livio Di Mascio","doi":"10.5397/cise.2024.00465","DOIUrl":"https://doi.org/10.5397/cise.2024.00465","url":null,"abstract":"<p><strong>Background: </strong>Iatrogenic suprascapular nerve injury secondary to posterior drilling or screw penetration is a recognized complication of bone block or coracoid process transfers for anterior glenohumeral instability. We present the first cadaveric study that assesses the safety of posteroanterior reference guides and quantifies the relationship of the suprascapular nerve to posterior glenoid fixation with suture buttons.</p><p><strong>Methods: </strong>Anterior glenoid bone block reconstruction with suture buttons utilizing a posteroanterior reference guide was performed in 10 fresh frozen cadavers via a posterior portal. Bullets were inserted in predefined superior and inferior guide holes via percutaneous incisions to facilitate posteroanterior drilling. Looped guide wires were used to deliver suture buttons from anterior to posterior positions. The shoulder joint was disarticulated and the infraspinatus sharply elevated until the suprascapular nerve was visualized. Four independent static measures of the shortest distance from the superior drill sleeve to the lateral aspect of the suprascapular nerve were recorded.</p><p><strong>Results: </strong>The suprascapular nerve was not compromised utilizing the posteroanterior guide and suture button fixation technique in any specimen. The mean distance from superior sleeve tunnel to the suprascapular nerve was 5.00 mm (range, 3.25-8.00 mm) in females and 6.80 mm (range, 5.50-8.75 mm) in males. The shortest distance was 3.25 mm and the longest was 8.75 mm.</p><p><strong>Conclusion: </strong>The use of posteroanterior reference guides for suture button fixation was not associated with iatrogenic suprascapular nerve injury in the specimens examined. However, the proximity of the suprascapular nerve underscores the need for caution. Comparative analysis with anteroposterior bone block techniques is required to establish the potential benefits of this procedure. Level of evidence: V.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2024-12-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142883203","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Surgical technique for secondary pectoralis major transfer after reverse total shoulder arthroplasty to treat residual internal rotation dysfunction.","authors":"Chang Hee Baek, Bo Taek Kim, Jung Gon Kim","doi":"10.5397/cise.2024.00542","DOIUrl":"https://doi.org/10.5397/cise.2024.00542","url":null,"abstract":"<p><p>Reverse total shoulder arthroplasty (RSA) has emerged as a promising treatment option for rotator cuff tear arthropathy. However, concerns persist regarding horizontal rotational dysfunction after RSA. While many studies focus on improving external rotation after RSA, limited attention has been paid to internal rotation. In this technical note, we describe how to perform secondary pectoralis major transfer in a patient with residual internal rotation dysfunction after RSA.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142773010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Anterolateral rotatory instability of the elbow: a possible etiology of primary osteoarthritis.","authors":"Young-Bok Kim, James S Fitzsimmons, Enrico Bellato, Shawn W O'Driscoll, Hyo Seok Jang, Dae-Wook Kim","doi":"10.5397/cise.2024.00416","DOIUrl":"10.5397/cise.2024.00416","url":null,"abstract":"<p><strong>Background: </strong>The purpose of this study is to describe anterolateral rotatory instability (ALRI) as a possible etiology of primary osteoarthritis (OA) of the elbow.</p><p><strong>Methods: </strong>We examined 76 fresh frozen cadaveric elbows (male:female, 56:20; mean age, 81 years) for patterns of cartilage erosion that could be due to ALRI. These included erosions on the lateral trochlear ridge (LTR) lesion, crescent rim of the radial head (RC) lesion or the ventral capitellum (VC) lesion. The extent and location of the lesions were mapped by image processing of photographs of the humeral and radial articular surfaces, and the degeneration of the articular surface was graded.</p><p><strong>Results: </strong>Ten of 76 specimens (13%) had one or more lesions consistent with ALRI. LTR lesions were most common and were seen in 10 of 10 specimens (100%), typically involving the distal 30% of the LTR. RC lesions were seen in 9 of 10 and were located on anteromedial crescent of the radial head ranging from 6 to 10 o'clock. VC lesions were seen in 8 of 10 specimens directed anteroinferiorly about 60° to the long axis of the humerus.</p><p><strong>Conclusions: </strong>ALRI is a possible mechanism initiating primary OA of the elbow. It has a characteristic pattern of triple lesions involving the LTR, the RC, and the VC. Level of evidence: IV.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":"27 4","pages":"419-427"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615464/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142773014","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Persistent lateral elbow pain from overlooked posterolateral impingement of the elbow: a literature review and guidance for treatment.","authors":"Gur-Aziz Singh Sidhu, Niyam Amanullah, Harjot Kaur, Saphalya Pattnaik, Neil Ashwood, Andrew Peter Dekker, Harpal Singh Selhi","doi":"10.5397/cise.2023.01081","DOIUrl":"10.5397/cise.2023.01081","url":null,"abstract":"<p><p>Posterolateral impingement is sometimes diagnosed as a cause of refractory elbow pain, often after other treatments have been tried for common conditions such as lateral epicondylitis (tennis elbow) or subtly different conditions common in throwing athletes, such as valgus extension overload syndrome. Arthroscopic surgical treatment is effective when targeting abnormal anatomy such as plical folds. Partial excision of the olecranon must be undertaken with caution because it can lead to instability. This systematic review of the current literature uses a narrative synthesis to identify anatomical morphological variations of the olecranon, humeral and capitellar geometry, and overloading of the lateral part of the elbow as causative factors for this condition and discusses how arthroscopic techniques can resolve symptoms. Further understanding of the static and dynamic anatomy of the lateral part of the elbow will help to develop future treatment and preventive strategies.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":"487-495"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615467/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141976820","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is partial excision of the radial head safe and effective in all-arthroscopic treatment of terrible triad fractures?","authors":"Hyung Gyu Cho, Gyeong Hoon Lim, Min Su Joo, Jae Won Kim, Jun Ho Park, Jeong Woo Kim","doi":"10.5397/cise.2024.00703","DOIUrl":"10.5397/cise.2024.00703","url":null,"abstract":"<p><strong>Background: </strong>Our study aimed to evaluate the clinical and radiologic results of all-arthroscopic treatment of terrible triad injuries followed-up for a minimum of 5 years and investigate how arthroscopic partial excision for radial head fractures affects the results at the final follow-up.</p><p><strong>Methods: </strong>We retrospectively reviewed consecutive patients with terrible triad injuries who underwent all-arthroscopic treatment between January 2011 and June 2018. In group I, we performed conservative or arthroscopic fixation of stable radial head fractures, while in group II, arthroscopic partial excision of unstable radial head fractures involving <30%-50% of the articular surface area was performed. Clinical outcomes were measured by visual analog scale score and assessment of instability, range of motion (ROM), and Mayo Elbow Performance Score. Radiological outcomes were evaluated using x-rays, and the integrity of the repaired lateral collateral ligament complex was confirmed through magnetic resonance imaging.</p><p><strong>Results: </strong>Thirty-two patients with an average age of 49.5±16.2 years met the inclusion criteria and were followed-up for a mean of 82.7±22.2 months. Twenty patients were assigned to group I and 12 patients to group II. Clinical outcomes showed no significant differences between the two groups at the final follow-up (P>0.05). On radiological evaluation, more heterotopic ossifications were found in the radial head excision group (group II, 66.7% vs. group I, 35%; P=0.02); however, there was no significant difference in ROM between the two groups (P>0.05).</p><p><strong>Conclusions: </strong>In all-arthroscopic treatment of terrible triad injuries, arthroscopic partial excision of the radial head did not seem to have a significant impact on elbow joint stability. Level of evidence: III.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":"454-463"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615460/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142629620","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The impact of supraspinatus tear on subscapularis muscle atrophy and fatty infiltration.","authors":"Su Cheol Kim, Seung Jin Yoo, Je Hyeong Jo, Jong Hyun Lee, Eugene Baek, Sang Min Lee, Jae Chul Yoo","doi":"10.5397/cise.2024.00521","DOIUrl":"10.5397/cise.2024.00521","url":null,"abstract":"<p><strong>Background: </strong>Aimed to report the prevalence and predisposing factors affecting subscapularis muscle atrophy and fatty infiltration (MAFI) in patients without a subscapularis tear, and to analyze the effect of this condition on surgical outcomes.</p><p><strong>Methods: </strong>Between 2020 and 2022, 153 patients (mean age 58.1 ± 10.2 years; 84 men and 69 women) who underwent repair of posterosuperior cuff tears, with no subscapularis tears identified during arthroscopy were retrospectively analyzed. Baseline characteristics, preoperative and follow-up (6 months) magnetic resonance imaging findings, arthroscopic findings, and clinical outcomes (>1 year) were recorded.</p><p><strong>Results: </strong>The prevalence of subscapularis MAFI (Goutallier grade 1 or 2) was 73.9% (113/153), of which the prevalence of Goutallier grade 2 was 23.5% (36/153). From multivariable logistic regression analysis, female sex (odds ratio [OR], 5.6; 95% CI, 1.7-18.6; P=0.005), older age (OR, 1.1; 95% CI, 1.0-1.1; P=0.052), advanced supraspinatus MAFI by Goutallier grade (OR, 3.2; 95% CI, 1.5-6.9; P=0.004), and synovitis (OR, 2.8; 95% CI, 1.1-7.9; P=0.030) were identified as independent predisposing factors for subscapularis MAFI. However, patients with preoperative subscapularis MAFI exhibited similar final range of motion, pain and function, and belly press strength compared to those without preoperative subscapularis MAFI.</p><p><strong>Conclusions: </strong>Subscapularis MAFI is frequently observed conditions even in the absence of subscapularis tears, and this condition could be affected by supraspinatus MAFI, female sex, older age, and synovitis. However, because subscapularis MAFI does not affect the surgical outcome, surgeons need not be concerned about this condition when repairing posterosuperior rotator cuff tear. Level of evidence: IV.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":"437-446"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615468/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142669207","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Glenohumeral internal rotation deficit: insights into pathologic, clinical, diagnostic, and therapeutic characteristics.","authors":"Mohamad Y Fares, Jad Lawand, Mohammad Daher, Joyce D Suarez, Theodore Kayepkian, Jonathan Koa, Eddie Geagea, Joseph A Abboud","doi":"10.5397/cise.2023.00885","DOIUrl":"10.5397/cise.2023.00885","url":null,"abstract":"<p><p>Overhead throwing athletes undergo significant biomechanical adaptations due to repetitive overhead movements, primarily affecting the glenohumeral joint. These adaptations can lead to glenohumeral internal rotation deficit (GIRD), which is characterized by posterior capsule stiffness that results in glenohumeral joint translation and a shift in the center of gravity. The severity of GIRD is dependent upon the presence of asymmetry between gained external and lost internal rotation, which is defined clinically as an asymmetry exceeding 20º; this reduces the total range of motion compared to the unaffected limb or baseline measurements. Diagnosis is challenging, as it can be mistaken for chronic scapular adaptations. To mitigate misdiagnosis, a high clinical suspicion is crucial in overhead athletes, especially those who began performing forceful overhead movements before closure of growth plates. Periodic physical examinations should establish baseline values for glenohumeral rotation and track changes in glenohumeral motion to aid in diagnosis. Symptoms of GIRD include shoulder pain, stiffness, and decreased force exertion. Magnetic resonance imaging is the preferred imaging method for evaluating GIRD and assessing concomitant soft tissue pathologies. Untreated GIRD can lead to rotator cuff strength imbalances. Treatment mainly involves conservative measures, such as physical therapy, to improve internal rotation and alleviate posterior tightness. Surgical interventions.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":"505-513"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615455/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140913022","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcomes of lateralized reverse total shoulder arthroplasty versus latissimus dorsi transfer for external rotation deficit: a systematic review and meta-analysis.","authors":"Keegan M Hones, Caroline T Gutowski, Taylor R Rakauskas, Victoria E Bindi, Trevor Simcox, Jonathan O Wright, Bradley S Schoch, Thomas W Wright, Jean-David Werthel, Joseph J King, Kevin A Hao","doi":"10.5397/cise.2024.00304","DOIUrl":"10.5397/cise.2024.00304","url":null,"abstract":"<p><strong>Background: </strong>To compare clinical outcomes following lateralized reverse shoulder arthroplasty (RSA) versus RSA with latissimus dorsi transfer (LDT) in patients with poor preoperative active external rotation (ER).</p><p><strong>Methods: </strong>We performed a systematic review per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We queried PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of RSA with LDT or lateralized RSA alone performed in patients with preoperative ER ≤0°. Our primary outcomes were active ER, active forward elevation (FE), Constant score, and the incidence of complications.</p><p><strong>Results: </strong>We included 12 RSA with LDT studies with 188 shoulders and 4 lateralized RSA without transfer studies with 250 shoulders. Mean preoperative ER in RSA with LDT was -14°, while mean preoperative ER in lateralized RSA alone was -11°. Lateralized RSA alone was associated with superior postoperative ER (28° vs. 22°, P=0.010) and Constant score (69 vs. 65, P=0.014), but similar postoperative FE (P=0.590). Pre- to postoperative improvement in ER and FE was similar between cohorts. RSA with LDT had a higher incidence of nerve-related complications (2.1% vs. 0%) and dislocation (2.8% vs. 0.8%) compared to lateralized RSA alone.</p><p><strong>Conclusions: </strong>Both RSA with LDT and lateralized RSA are reliable options to restore ER in patients with significantly limited preoperative ER. Our analysis suggests that lateralized RSA alone is superior to RSA with LDT in patients with either a medialized or lateralized implant design and confers a lower risk of complications, particularly nerve injury and dislocation. However, the addition of an LDT may still be indicated in certain patient populations with very severe ER loss. Level of evidence: IV.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":"464-478"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615459/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142669203","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors affecting healing of rotator cuff repairs: microfracture of the greater tuberosity.","authors":"Gwan Kyu Son, Myung Seo Kim","doi":"10.5397/cise.2024.00290","DOIUrl":"10.5397/cise.2024.00290","url":null,"abstract":"<p><strong>Background: </strong>This study aimed to investigate the impact of microfractures generated within the footprint of the greater tuberosity (GT) on postoperative cuff healing following arthroscopic rotator cuff repair (ARCR).</p><p><strong>Methods: </strong>A retrospective analysis was conducted on patients who underwent ARCR for full-thickness rotator cuff tear (FTRCT) between April 2020 and October 2023 at our institution. A total of 73 patients was categorized into two groups based on the presence of microfractures: a microfracture group (group M, n=33) and a non-microfracture group (group N, n=40). Six months post-surgery, magnetic resonance imaging was performed to assess cuff healing and retear rates between the two groups. Furthermore, patients were stratified into retear and healing groups based on cuff integrity to analyze the factors influencing retear.</p><p><strong>Results: </strong>There was no significant difference in retear rates between groups M and N (18.2% vs. 10.0%, P=0.332). Among demographic factors, age showed a significant difference between the retear and healing groups (67.4±8.5 vs. 61.6±6.1, P=0.044). ML tear size (3.1±1.7 vs. 2.0±1.1, P=0.015), AP tear size (2.4±1.2 vs. 1.6±1.0, P=0.332), FI of the supraspinatus (2.3±1.3 vs. 1.4±1.0, P=0.029), and FI of the infraspinatus (1.6±1.3 vs. 0.9±0.8, P=0.015) exhibited significant differences between the retear and healing groups.</p><p><strong>Conclusions: </strong>ARCR with concurrent microfracture of the GT footprint did not significantly impact cuff healing in patients with FTRCT. However, older age and larger ML tear size were associated with an increased risk of retear. Level of evidence: III.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":"412-418"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615469/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142629617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Epithelioid hemangioma of the acromion causing shoulder pain: a case report.","authors":"Whanyong Jung, Suil Jung, Seung-Yong Sung","doi":"10.5397/cise.2023.00941","DOIUrl":"10.5397/cise.2023.00941","url":null,"abstract":"<p><p>Epithelioid hemangioma of bone is a rare benign vascular tumor. Because of the locally destructive clinical presentation and the presence of atypical histologic features with increased mitotic activity and necrosis, it is often misdiagnosed as low-grade malignant epithelioid hemangioendothelioma or high-grade malignant epithelioid angiosarcoma. Correct diagnosis through imaging studies and histopathological examination is mandatory to determine the appropriate course of treatment, as the prognosis differs from that of other malignant hemangioma tumors. A 69-year-old male who presented with intractable shoulder pain caused by epithelioid hemangioma in the acromion of the scapula was treated with tumor curettage. This paper reports a good result with a review of the relevant literature.</p>","PeriodicalId":33981,"journal":{"name":"Clinics in Shoulder and Elbow","volume":" ","pages":"519-523"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11615465/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140913015","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}