Journal of Clinical Orthopaedics and Trauma最新文献

{"title":"Chronic reactive synovitis in patients undergoing ACL reconstruction and augmentation with tape-type sutures","authors":"Anant Joshi ,&nbsp;Aashiket Sable ,&nbsp;Sajeer Usman ,&nbsp;Bhushan Sabnis ,&nbsp;Vaibhav Bagaria","doi":"10.1016/j.jcot.2024.102884","DOIUrl":"10.1016/j.jcot.2024.102884","url":null,"abstract":"<div><h3>Introduction</h3><div>Arthroscopic Anterior Cruciate Ligament Reconstruction (ACLR) with internal bracing and augmentation using tape-type sutures (TTS) has gained popularity due to its biomechanical advantages. However, concerns have emerged regarding chronic reactive synovitis, which can lead to graft failure and the need for revision surgery. The purpose of this research is to determine the prevalence of chronic reactive synovitis after TTS-reinforced ACLR.</div></div><div><h3>Materials and methods</h3><div>A retrospective review was conducted on a series of 84 patients who underwent arthroscopic ACL reconstruction with FiberTape or SutureTape augmentation, performed by a single surgeon in the year 2019.</div></div><div><h3>Results</h3><div>Of the 84 patients analyzed, 17 presented with at least two or more symptoms, including persistent instability, knee pain, swelling, stiffness, and local rise in temperature, within 3–45 months post-surgery. All required secondary surgery, either for synovectomy, and tape removal (8 cases) or revision ACLR (9 cases). Intraoperative histopathological analysis confirmed the diagnosis of reactive synovitis due to foreign body reaction. One year after the secondary surgery, all 17 knees showed satisfactory results. None of the patients experienced the pain, swelling, or instability that they had before the secondary surgery.</div></div><div><h3>Conclusion</h3><div>Foreign body synovitis was found in 17 symptomatic patients out of 84 (20.2 %) who underwent ACLR with TTS reinforcement one year. While this study does not establish a direct causal link between tape-type sutures and the development of synovitis, it emphasizes the significance of remaining vigilant for impending reactive synovitis as a complication, given the potential exposure of the knee to foreign body material.</div></div><div><h3>Level of evidence</h3><div>Level IV (Retrospective case series without a comparison group)</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102884"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016250","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":"A survey of Scottish Committee for Orthopaedics and Trauma members on lower limb joint replacement practices in morbidly obese patients","authors":"Alexis Panzures ,&nbsp;Nick D. Clement ,&nbsp;Paul Jenkins ,&nbsp;Muhammad Adeel Akhtar","doi":"10.1016/j.jcot.2024.102855","DOIUrl":"10.1016/j.jcot.2024.102855","url":null,"abstract":"<div><h3>Background</h3><div>Scotland has one of the highest rates of obesity in the developed world which increases risk of lower limb osteoarthritis resulting in total joint arthroplasty (TJA). This paper aimed to investigate (1) current practice of orthopaedic consultants in Scotland in managing end-stage hip and knee osteoarthritis in obese patients, (2) adherence to National guidelines, and (3) understanding of complication risks in lower limb TJA for BMI≥40.</div></div><div><h3>Methods</h3><div>A 15-question online survey was sent to all active members of Scottish Committee for Orthopaedics and Trauma (SCOT) between February and March 2023 to understand the current practices for managing obese patients with lower limb arthritis requiring joint replacement surgery.</div></div><div><h3>Results</h3><div>The survey received 62 responses from members of SCOT. The experience ranges from 1 to 44 years (mean 15 years) at consultant level. 61 % of respondents were aware of the SCOT National Guidelines for lower limb TJA in obese patients. 72 % would offer TJA to patients with a BMI&gt;40.35 % would get a second opinion and 22 % discuss these cases in a multidisciplinary team meeting. 71 % were aware of the local weight management guidelines. 77 % quoted risk of deep infection to be between 1 and 30 %, and 40 % quoted risk of amputation between .002 % and 10 % in morbidly obese patients.</div></div><div><h3>Conclusion</h3><div>Surgical management of obese patients with lower limb osteoarthritis in Scotland is variable. A standardised approach would be beneficial in obtaining informed consent.</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102855"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11732070/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016263","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 use of three-dimensional printing and virtual reality technologies in orthopaedics-with a focus on orthopaedic trauma","authors":"Thomas J. Policicchio ,&nbsp;Kishore Konar ,&nbsp;Devon T. Brameier ,&nbsp;Patrick Sadoghi ,&nbsp;Nishant Suneja ,&nbsp;Derek Stenquist ,&nbsp;Michael J. Weaver ,&nbsp;Arvind von Keudell","doi":"10.1016/j.jcot.2025.102930","DOIUrl":"10.1016/j.jcot.2025.102930","url":null,"abstract":"<div><div>Although the use of three-dimensional printing in orthopaedics is relatively new, many benefits of this technology to both patients and providers have already been observed. Printing models of fractured bone based upon segmented CT imaging allows for improved surgical planning as surgeons are able to view and physically manipulate accurate representations of fracture patterns prior to surgery, increasing both speed and accuracy of fixation in the operating room. The use of three-dimensional models by surgeons prior to surgery has been shown to reduce blood loss, intraoperative time, and fluoroscopy use. These models also have incredible potential in orthopaedic resident and patient education. Among residents, these models significantly improve recognition of fracture patterns, while patients benefit from the use of these models through increased trust and satisfaction with their surgeon's care, as well as decreased anxiety about their injury. Currently, the imaging segmentation and model generation process are prohibitively costly both in terms of time and money; however, in the future, three-dimensional printing may become a point-of-care technology in the orthopaedic field as technology improves and costs decrease. This article aims to illustrate the value of three-dimensional printing and virtual reality technologies in preoperative planning and intraoperative precision, resident education, and patient understanding and satisfaction. The benefits and challenges of the technologies are discussed, as well as current limitations.</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"63 ","pages":"Article 102930"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143349604","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":"Cementless fixation in total joint arthroplasty: Factors impacting osseointegration","authors":"Sravya P. Vajapey ,&nbsp;Vivek M. Shah ,&nbsp;Mengnai Li ,&nbsp;Daniel M. Estok II","doi":"10.1016/j.jcot.2024.102871","DOIUrl":"10.1016/j.jcot.2024.102871","url":null,"abstract":"<div><div><ul><li><span>•</span><span><div>The success of cementless fixation in TJA depends on a multitude of factors including biological, mechanical, implant, surgical, and material properties.</div></span></li><li><span>•</span><span><div>Biologic fixation has become the primary mode of fixation for the majority of primary total hip arthroplasty (THA) surgeries done today in the United States (US) due to its low complication rate and superior longevity compared to cemented fixation.</div></span></li><li><span>•</span><span><div>Cementless fixation has yet to gain wider acceptance in total knee arthroplasty (TKA) and hip hemiarthroplasty due to several factors including host bone quality, implant design, and surgical technique.</div></span></li><li><span>•</span><span><div>Understanding a) the properties of the different biomaterials, b) the bone-implant interface characteristics of the different ingrowth and ongrowth surfaces, and c) the various factors that affect osseointegration can lead to:<ul><li><span>i)</span><span><div>appropriate choice of implants for individual patients with consequent increase in revision-free survival, and</div></span></li><li><span>ii)</span><span><div>the development of new techniques that can reduce the risk of aseptic loosening.</div></span></li></ul></div></span></li></ul></div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102871"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016267","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":"Public perceptions of meniscus tears: Evaluating knowledge gaps and the role of education","authors":"Beshoy A. William ,&nbsp;Claudia Davidson ,&nbsp;Eric N. Bowman","doi":"10.1016/j.jcot.2024.102853","DOIUrl":"10.1016/j.jcot.2024.102853","url":null,"abstract":"<div><h3>Background</h3><div>Meniscus tears are common, occurring acutely during sports or as degenerative tears with aging. Limited information exists about the public’s understanding of these injuries and their management.</div></div><div><h3>Hypothesis/Purpose</h3><div>This study aimed to evaluate the public’s baseline understanding of meniscus tear management and assess the effectiveness of an educational intervention to improve their understanding.</div></div><div><h3>Study design</h3><div>Level III, Cross-Sectional Study.</div></div><div><h3>Methods</h3><div>A 33-question survey on meniscus anatomy, injury risk, diagnosis, treatment, and surgical expectations was distributed online to adults aged 18+ over 5 months from the beginning of July. An educational video and handout were provided to improve baseline knowledge. Data analysis included descriptive statistics, ANOVA, McNemar’s test, and a paired <em>t</em>-test to measure pre- and post-intervention changes.</div></div><div><h3>Results</h3><div>Baseline surveys from 245 participants showed 66.9% were women, 69.4% were aged 18–29, and 63.7% were white. 46.1% held a bachelor’s degree, and 90.2% had limited knowledge of meniscus tears. 76% believed surgery was necessary, 84% thought degenerative tears were repairable, and 65% didn’t understand the link to osteoarthritis. Most expected over 3 months for recovery. Higher scores were associated with male gender, healthcare experience, and prior knowledge (p &lt; 0.05). Post-intervention, correct responses rose from 45.3% to 75% (p &lt; 0.001) among 118 participants.</div></div><div><h3>Conclusion</h3><div>Significant misconceptions about meniscus tears were identified. An educational intervention notably improved knowledge of meniscus anatomy, its link to osteoarthritis, and treatment options. This underscores the importance of education in aligning patient expectations with current medical practices to enhance care quality.</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102853"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016392","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":"AI in scientific publishing: Revolutionizing research with caution","authors":"Madhan Jeyaraman ,&nbsp;Vijay Kumar Jain","doi":"10.1016/j.jcot.2024.102904","DOIUrl":"10.1016/j.jcot.2024.102904","url":null,"abstract":"","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102904"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143069486","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":"Midfoot fractures: Patterns of injury and predictors of stability","authors":"Serena Patel,&nbsp;Danielle Piper,&nbsp;Paul Fenton","doi":"10.1016/j.jcot.2024.102874","DOIUrl":"10.1016/j.jcot.2024.102874","url":null,"abstract":"<div><h3>Background</h3><div>Lisfranc injuries describe a spectrum of midfoot and tarsometatarsal joint (TMTJ) trauma ranging from purely ligamentous to multiple fracture-dislocations. Lisfranc injuries represent 0.2 % of all fractures and are seen predictably, with mechanisms involving a fall from height, crushing, or torsion. Diagnosis can be challenging, with approximately 20 % of cases being missed, and relies upon clinical acumen and proficient image interpretation. Whilst multiple classification systems have described Lisfranc injuries using a 3-column concept, these add zero prognostic value and are therefore rarely used clinically. Furthermore, existing literature on diagnosis and management is limited to retrospective small series.</div></div><div><h3>Methods</h3><div>We present a review of 161 midfoot injuries, with the aim of highlighting characteristics of radiological instability and indication for operative management. CT scans and weight-bearing and non-weight-bearing X-rays were reviewed for features of joint instability. These features included metatarsal base, cuneiform and cuboid fractures, tarsometatarsal joint subluxation or dislocation and C1-MT2 diastasis. The subsequent “stable” and “unstable” injury groups were then compared to identify statistically significant indicators for instability.</div></div><div><h3>Results</h3><div>Avulsion and intra-articular fractures of the medial, middle, or lateral column were all suggestive of instability. Although these appeared in multiple combinations, 95 % involved the middle column. Concomitant inter-cuneiform and cuboid fractures were additional indicators of instability. In cases of uncertain midfoot instability, weight-bearing radiographs were of value with 14.2 % demonstrating a diastasis of C1-MT2 &gt;2 mm.</div></div><div><h3>Conclusion</h3><div>We propose the need for a new classification of midfoot injuries which emphasises the diagnosis of instability and guides surgical management. We propose that, based on non-weight-bearing X-ray and CT scans, these injuries can be initially classified as “stable”, “unstable”, or “stability uncertain”. Weight-bearing X-rays are a safe and reliable method of detecting instability in the “stability uncertain” group. Fractures of the medial column and cuneiform on initial imaging were suggestive of midfoot instability.</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102874"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016303","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":"Mid-term outcomes of elbow hemiarthroplasty using the triceps-on approach for comminuted distal humerus fractures","authors":"Siddharth Virani ,&nbsp;Karim M. Abdelghafour ,&nbsp;Angelos Assiotis ,&nbsp;Clarence Yeoh ,&nbsp;Adam Rumian ,&nbsp;Harpal Uppal","doi":"10.1016/j.jcot.2024.102886","DOIUrl":"10.1016/j.jcot.2024.102886","url":null,"abstract":"<div><h3>Background</h3><div>There has been an increasing interest in elbow hemiarthroplasty to circumvent the problems with total elbow arthroplasty for comminuted distal humerus fractures in the elderly. The primary aim of the study is to assess the mid-term clinical and radiological outcomes of patients undergoing TEA and hemiarthroplasty for distal humerus fractures.</div></div><div><h3>Methods</h3><div>Retrospective analysis of data for patients undergoing hemiarthroplasty for distal humerus fractures (OTA- C3 Comminuted total articular fractures) was done. This is a non-randomized consecutive series from a single centre. A minimum follow-up of 3 years was required for inclusion. Patients with delayed/neglected presentation (&gt;3 weeks), those needing total elbow arthroplasty and conservatively managed fractures needing delayed arthroplasty were excluded.</div></div><div><h3>Results</h3><div>A total of 12 patients were operated in the period between 2016 and 2021(mean follow-up-59.4 months). The mean age of the patients undergoing hemiarthroplasty was 68.4 years. The mean arc of flexion extension was 21–115°. The mean range of supination was 75° while pronation was 86° (p &gt; 0.05). The mean QuickDASH score was 8.7. There were no cases of infection, dislocations, intra-operative fractures or revision surgery. Two patients had transient weakness in the ulnar nerve distribution that recovered on follow-up.</div><div>Evidence of heterotrophic ossification was seen in 8 patients. None of the patients showed radiological evidence of loosening but trochlear cartilage wear was seen in 2 patients. None of the radiographs showed migration of the condyles. There were 5 cases where the medial condyle though approximated had not healed.</div></div><div><h3>Conclusions</h3><div>Elbow hemiarthroplasty provides predictably good clinical and radiological outcomes on mid-term follow-up. Longer follow-up is necessary to determine the survival of these prostheses in the long term.</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102886"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143030000","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":"Magnetic resonance imaging of knee arthropathies: A pictorial review","authors":"Shayeri Roy Choudhury ,&nbsp;Mahesh Prakash ,&nbsp;Madhurima Sharma ,&nbsp;Anindita Sinha ,&nbsp;Devendra Kumar Chouhan","doi":"10.1016/j.jcot.2024.102872","DOIUrl":"10.1016/j.jcot.2024.102872","url":null,"abstract":"<div><div>A wide variety of degenerative, inflammatory and infective arthropathies with overlapping clinical features can involve the knee joint. Due to its excellent soft tissue contrast resolution and multiplanar capability, magnetic resonance imaging (MRI) plays a significant role in early and accurate diagnosis of various arthropathies. In this article, we have provided a brief review of MRI features of various arthropathies involving the knee joint.</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102872"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016285","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":"Medial patellofemoral ligament reconstruction using synthetic suture tape: A systematic review of biomechanical and clinical outcomes","authors":"Muzammil Akhtar ,&nbsp;Sonia Aamer ,&nbsp;Mohammad Asad ,&nbsp;Daniel Razick ,&nbsp;Mustafa Jundi ,&nbsp;Trevor Shelton","doi":"10.1016/j.jcot.2024.102883","DOIUrl":"10.1016/j.jcot.2024.102883","url":null,"abstract":"<div><h3>Purpose</h3><div>To review outcomes of medial patellofemoral ligament reconstruction (MPFLR) using synthetic suture tape in biomechanical and clinical studies.</div></div><div><h3>Methods</h3><div>A comprehensive literature search was performed in three databases. Studies reporting biomechanical and/or clinical outcomes of MPFLR using synthetic suture tape were included. For clinical studies, the primary outcome measures included patient-reported outcomes (PROs) and adverse events.</div></div><div><h3>Results</h3><div>Three biomechanical studies were included. One study reported stronger integrity of fixation with suture tape versus semitendinosus autografts. One study reported similar integrity of MPFLR with knotless anchor versus soft tissue fixation. Another study found suture tape fixation between 60° and 90° of knee flexion to avoid excessive medial patellofemoral joint contact pressure after MPFLR. Eight clinical studies with 287 patients and 317 knees (36.1 % male, pooled mean age: 23.2 years old, pooled mean follow-up: 41.6 months) were included. All studies reported significant preoperative to postoperative improvement for all PROs except for the Tegner score in one study. The range of PROs were as follows (preoperative and postoperative): Lysholm (32.8–72.0 and 78.0 to 96.7), Kujala (36.0–75.2 and 78.8 to 97.7), International Knee Documentation Committee (IKDC) (48.6–69.8 and 71.3 to 91.3), and Tegner (1.0–4.6 and 4.0 to 6.5). Two studies comparing suture tape with autografts (quadriceps and gracillis tendons) reported similar postoperative PROs. The pooled rate of adverse postoperative events was 8.2 %. The pooled rate of positive patellar apprehension tests at follow-up was 3.2 %.</div></div><div><h3>Conclusions</h3><div>Patients undergoing MPFLR with suture tape fixation achieved significant improvements in PROs and demonstrated low rates of postoperative complications. Compared to autograft fixation, suture tape fixation provided comparable or superior clinical and biomechanical outcomes.</div></div>","PeriodicalId":53594,"journal":{"name":"Journal of Clinical Orthopaedics and Trauma","volume":"61 ","pages":"Article 102883"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016289","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}