scholarly journals Combined posteromedial or posterolateral PCL injuries: Anatomic repair and ligament bracing as a new treatment option - first results of a multicentre study

2020 ◽  
Vol 8 (5_suppl4) ◽  
pp. 2325967120S0030
Author(s):  
Tobias J. Gensior ◽  
Richard Glaab ◽  
Pierre Hepp ◽  
Johannes Zellner ◽  
Bastian Mester ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Multicentre Study ◽  
Treatment Option ◽  
Lysholm Score ◽  
Anatomic Repair ◽  
One Stage ◽  
Ligament Bracing ◽  
Ikdc Score ◽  
Tegner Score

Aims and Objectives: Acute, isolated PCL injuries can succesfully be managed non-operatively whereas combined PCL injuries usually require surgical management. Currently, there is a lack of evidence regarding the standard of treatment (repair vs. reconstruction, one-stage vs. two-stages procedures). Suture augmented repair leads to good and excellent results in cases of acute knee dislocations. This technique has not been investigated clinically in combined PCL injuries, yet. The aim of this multicentre study was to evaluate the clinical outcome after surgical repair with additional suture augmentation (ligament bracing) of all torn ligaments in acute combined pcl injuries (posteromedial or posterolateral). Materials and Methods: From 2016 to 2018, 25 patients with an acute combined PCL injury were treated with one stage anatomical repair and ligament bracing of the torn ligaments within 14 days at 6 trauma centres (5xGER, 1x SUI). Inclusion criteria: Follow-up min. 6 months, age > 18y. Exclusion criteria: ACL Injury, posteromedial AND posterolateral injury. During the follow-up evaluation, various scores were collected (International Knee Documentation Committee IKDC Score, Tegner Score , KOOS and Lysholm Score). Additional stress radiography was performed (TelosTM) postoperatively. Results: For now 14 combined PCL injuries (posteromedial or -lateral) with a follow-up of 20 months (range 8-33) were evaluated. 10 patients had a posteromedial (PCL + MCL/POL), 4 patients had a posterolateral (PCL + LCL) injury. 10 additional articular lesions were detected (6 meniscus tears, 4 grade IV chondral lesions) and 1 transitional peroneal nerve injury. The average IKDC score was 62.2±18.5, the average Lysholm score was 78±19.2, average KOOS 88.7±7.6. Median loss of activity in the Tegner score was 1 (range 0-5) point. Side-to-side pcl-stress-radiographs showed a difference at a mean of 4.8±3.0mm (range 1-10). 2 cases with symptomatic knee instability, both posterolateral, and 3 patients with knee stiffness needed reoperation. Interestingly, patients with posteromedial injuries showed predominantly good or excellent results according to Lysholm score and were graded as A (4/10) or B (2/10) whereas ligament bracing in posterolateral combined injuries had a high failure rate (Grade D 2/4). Conclusion: Primary anatomic repair and additional suture augmentation predominantly leads to good and excellent clinical results in cases of combined posteromedial PCL injuries. Patients with posterolateral injuries showed inferior clinical outcome and relatively high instability rates following ligament bracing. In conclusion, primary augmented suture repair seems to be a promising treatment option. The overall results of this study have to be evaluated for more exact recommendations.

Cell-Seeded Autologous Chondrocyte Implantation: A Simplified Implantation Technique That Maintains High Clinical Outcomes

2017 ◽  
Vol 45 (5) ◽  
pp. 1028-1036 ◽  
Author(s):  
Andreas H. Gomoll ◽  
Luiz Felipe Ambra ◽  
Amy Phan ◽  
Marissa Mastrocola ◽  
Nehal Shah
Keyword(s):  
Failure Rate ◽  
Autologous Chondrocyte Implantation ◽  
Defect Size ◽  
Lysholm Score ◽  
Collagen Membrane ◽  
Chondrocyte Implantation ◽  
Ikdc Score ◽  
Tegner Score ◽  
Autologous Chondrocyte

Background: The use of autologous chondrocyte implantation (ACI) remains limited, even though multiple studies have demonstrated success rates exceeding 75%. The procedure is perceived as invasive and technically challenging, presenting barriers to more widespread adoption. Purpose/Hypothesis: The objective of this study was to investigate whether outcomes and the failure rate of a simplified ACI technique (cs-ACI) were comparable with those of the more complicated traditional technique of a chondrocyte suspension injected under a collagen membrane (cACI). We hypothesized that the change in technique would not negatively affect outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Thirty-nine patients treated with the cs-ACI technique fulfilled the inclusion requirements. A group of 45 patients treated previously with standard cACI was used as a comparison. The functional outcomes were prospectively collected both preoperatively and postoperatively at the last follow-up. Failure was defined as any graft removal of more than 25% of the original defect size. Magnetic resonance imaging was performed postoperatively, and scans were assessed using a modified MOCART (magnetic resonance observation of cartilage repair tissue) scoring system. Results: Group demographics were not significantly different, except for the defect size and mean follow-up: 4.09 years in the cACI group and 2.46 years in the cs-ACI group. Significant improvements were seen in all outcome measures except the Tegner score from the preoperative baseline to the latest follow-up for both the cACI group (International Knee Documentation Committee [IKDC] score, from 42.0 to 63.4; Knee injury and Osteoarthritis Outcome Score [KOOS]–Pain subscore, from 58.7 to 77.1; Lysholm score, from 57.2 to 69.7; and Tegner score, from 3.5 to 4.2) and the cs-ACI group (IKDC score, from 45.6 to 68.0; KOOS-Pain subscore, from 66.6 to 84.7; Lysholm score, from 53.7 to 75.4; and Tegner score, from 3.2 to 3.8). No significant difference was found between the groups at the latest follow-up. The failure rate at 2 years was not significantly different, while the total failure rate over the entire study period was significantly lower in the cs-ACI group than the cACI group (5% vs 24%, respectively). The overall MOCART score was not significantly different between the groups. Conclusion: The treatment of full-thickness articular cartilage defects with a simplified cell-seeded ACI technique demonstrated no significant differences in the failure rate and patient-reported outcomes when compared with a standard technique utilizing interrupted sutures and the injection of a cell suspension under a collagen membrane.

scholarly journals Is it worth to perform initial non-operative treatment for patients with acute ACL injury?: a prospective cohort prognostic study

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Yong-Geun Park ◽  
Chul-Won Ha ◽  
Yong-Beom Park ◽  
Sang-Eun Na ◽  
Manyoung Kim ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Operative Treatment ◽  
Prospective Cohort ◽  
Acl Injury ◽  
Lysholm Score ◽  
Viable Option ◽  
Lachman Test ◽  
Clinical Evaluations ◽  
Tegner Score

Abstract Purpose To evaluate the result of implementing an initial non-operative treatment program for an acute ACL injury and to find if the timing of initiating the non-operative treatment is significant. Methods This study included a prospective cohort of 85 consecutive patients with acute ACL injury who were treated according to the above strategy for the initial 3 months with 1-year follow-up. Clinical evaluations were made by Lysholm score, Tegner activity score, Lachman test (LT), pivot-shit test (PST), and the side to side difference (SSD) by KT-2000 arthrometer. The results were analyzed according to the timing of initiating the non-operative treatment. Results Initially, 84% of the patients showed LT and PST ≤ grade 1, and 16% with ≥grade 2. At 1-year follow-up, 77 patients (91%) with LT and PST ≤ grade 1 did not receive reconstruction as copers and 8 patients with LT or PST ≥ grade 2 required reconstruction (six patients received the operation and two refused). The patients with LT and PST ≤ grade 1 showed average Lysholm score 91.2, average SSD 2.5 mm, and mean Tegner score decreased from 6.9 (pre-injury) to 6.2. Patients who started the non-operative treatment within 2 weeks after injury revealed superior rates of grade 0 or 1 instability than those who commenced the treatment later than 2 weeks after injury (P = 0.043). Conclusions Implementing a non-operative treatment with brace in acute phase of ACL injury appears to be an effective and viable option to achieve a reasonable clinical outcome. We recommend earlier initiation of the non-operative treatment to obtain a better result in patients with acute ACL injury.

scholarly journals The Effect of Irreducible Dislocation on Functional Outcomes in Knees With Multiligament Injuries: A Matched-Cohort Analysis

2020 ◽  
Vol 8 (8) ◽  
pp. 232596712094020
Author(s):  
Zhong Zhang ◽  
Kai-Bo Zhang ◽  
Bei-Ni Mao ◽  
Si-Ke Lai ◽  
Jian Li ◽  
...  
Keyword(s):  
Cohort Study ◽  
Soft Tissue ◽  
Functional Outcomes ◽  
Lysholm Score ◽  
Control Group ◽  
Irreducible Group ◽  
Ikdc Score ◽  
The Mean ◽  
Tegner Score

Background: Most cases of bicruciate knee dislocation (KD) with associated posteromedial disruption (KD-IIIM) are reducible, but some cannot be reduced by closed reduction because of soft tissue incarceration. Purpose: To compare the clinical characteristics and functional outcomes of KD-IIIM injuries in patients with or without incarceration of soft tissue requiring open or arthroscopic reduction. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective cohort study of patients with KD was conducted between January 2013 and December 2017 at a single large institution. We applied a 1:2 matching ratio between patients with irreducible KD-IIIM injuries (irreducible group; n = 14) and those with reducible KD-IIIM injuries (control group; n = 28). There were 13 patients in the irreducible group and 25 in the control group who completed follow-up (≥2 years) and were included in our analysis. The efficacy of treatment in patients with KD was evaluated based on range of motion, the Tegner score, the Lysholm score, and the International Knee Documentation Committee (IKDC) score. Results: At the end of follow-up, the mean Tegner score was 4.5 (range, 4-6), the mean Lysholm score was 79.2 (range, 60-95), and the mean IKDC score was 78.6 (range, 60.9-95.4) in the irreducible group. The respective results in the control group were 4.6 (range, 3-8), 83.1 (range, 39-100), and 80.6 (range, 42.5-96.6). These scores did not differ significantly between the 2 groups. Similarly, mean range of motion was similar between groups (irreducible, 118.1°; control, 124.8°). In the irreducible group, the acute subgroup showed significantly higher Lysholm and IKDC scores than the chronic subgroup, while the acute and chronic subgroups in the control group showed no significant differences in these respective outcome scores. Conclusion: In the present study, the treatment of irreducible KD led to similar functional outcomes compared with reducible KD. However, the treatment of chronic irreducible KD led to worse outcomes compared with acute irreducible KD, and therefore, urgent reduction is recommended in these patients.

CLINICAL OUTCOME OF ARTHROSCOPIC REDUCTION AND FIXATION BY PULL THROUGH SUTURE TECHNIQUE IN TIBIAL SPINE FRACTURES

2021 ◽  
pp. 17-20
Author(s):  
Ravi Shankar ◽  
Arunim Swarup ◽  
Rahul Kumar Gupta ◽  
Sunil Malhotra ◽  
Sparsh Jaiswal
Keyword(s):  
Clinical Outcome ◽  
Range Of Motion ◽  
Suture Technique ◽  
Lysholm Score ◽  
Spine Fractures ◽  
Lachman Test ◽  
Tibial Spine ◽  
Ikdc Score ◽  
Pull Through

Background -Tibial spine avulsion fracture is bony avulsions of anterior cruciate Ligament (ACL) from its attachment on the anteromedial portion of the intercondylartibial eminence. If not treated well, Tibial spine fractures can lead to non-union or malunion, which can lead to signicant disability in the form of exion deformity,loss of extension, or instability. Aims And Objectives: This study was conducted with the aim of evaluating clinical outcome of arthroscopic reduction and xation of fractures by pull through suture technique and complications associated with the procedure. Thi Material And Method: s prospective with retrospective study analyzed 20 patients (16 males and 4 females), with mean age of 28.6 ± 9.8 years (range, 15-55). Patients were classied by Meyers and Mckeever type III (n=16) and IV (n=4) and were operated arthroscopically by pull through suture technique. They were followed over a mean period of 10±2.8 months. Postoperative assessment was done by using Lachman test, Lysholm knee score and international knee documentation Committee (IKDC) score. Objective assessment of anterior translation of tibia was done by using indigenously developed device named Laxometer. At the end of follow up,17 of 20 patient had no or minimal anterior transl Results: ation of tibia by Lachman test. The mean preoperative Lysholm score in 20 knees was 38 (range 29 to 55) and mean post-operative Lysholm score was 96 (range 83-100). At the end of follow up 17 of 20 (85%) patients accessed by IKDC score were normal/ nearly normal grade A/B and 3 patients were abnormal (grade C). All patients achieved union within 3 months (range 8 to 17 weeks). 20% patients had restricted range of motion. Arthroscopic pull Conclusion: through suture technique has good clinical outcomes in both type III and type IV fractures, and in all age groups (open and closed physis) with minimal complications. This was evidenced by no instability and residual ACL deciency, postoperatively at 1 year. Most patients have excellent recovery with full return of knee range of motion.

scholarly journals Outcomes of one-stage reconstruction for chronic multiligament injuries of knee

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Tarun Goyal ◽  
Souvik Paul ◽  
Sushovan Banerjee ◽  
Lakshmana Das
Keyword(s):  
Cruciate Ligament ◽  
Lysholm Score ◽  
Activity Level ◽  
Type Ii ◽  
Hamstring Tendons ◽  
Peroneus Longus ◽  
Type Iii ◽  
Type Iv ◽  
Ikdc Score

Abstract Purpose This article aims to evaluate patterns of chronic multiligament injuries and outcomes of treatment with single-stage reconstruction using autografts. Methods All patients with clinicoradiologically diagnosed multiligament knee injury (MKI) were included in this prospective observational study. As the time since injury was more than 6 weeks in all of the patients, they were categorized as having chronic MKI. Patients were assessed clinically for laxity, and the diagnosis was confirmed radiologically. Ipsilateral hamstring tendons were used for medial collateral ligament (MCL) or posterolateral corner reconstruction in a patient with Schenck knee dislocation (KD) type III. In these cases, the posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) were reconstructed by using the peroneus longus and contralateral hamstring tendons respectively. Ipsilateral hamstring tendons were used for ACL reconstruction and an ipsilateral peroneus longus tendon graft was used for reconstruction of the PCL in a KD type II injury. In two cases of KD type IV injury, the lateral laxity was only grade II and was managed conservatively; the rest of the ligaments were addressed like a KD type III injury. Outcome evaluation was done using a visual analogue scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity level, preoperatively and postoperatively at 2 years’ follow-up. Results A total of 27 patients of mean age 33.48 ± 9.9 years with MKI were included in the study. The patients were classified as eight KD type II, 17 KD type III, and two KD type IV. The majority of the patients had associated meniscal (59.2%) or chondral (40.7%) injuries. At the 2 years’ follow-up visit, there were significant improvements in VAS score (p = 0.0001) IKDC score (p = 0.0001), Lysholm score (p = 0.0001), and range of motion (p = 0.001). None of the patients had residual laxity on clinical examination of the knee joint at the 2 years’ follow-up. All but two of the patients went back to their previous activity level. These two patients had progressive knee arthritis and needed knee arthroplasty. Conclusion Single-stage surgical reconstruction for chronic MKI has favourable functional outcomes. Level of evidence Level IV, case series.

scholarly journals Revision Meniscal Repair - Failure rates, clinical outcome and patient satisfaction

2019 ◽  
Vol 7 (6_suppl4) ◽  
pp. 2325967119S0022
Author(s):  
Andreas Fuchs ◽  
Ferdinand Kloos ◽  
Gerrit Bode ◽  
Kaywan Izadpanah ◽  
Norbert Südkamp ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Clinical Outcome ◽  
Revision Surgery ◽  
Meniscal Repair ◽  
Sports Participation ◽  
Lysholm Score ◽  
Failure Rates ◽  
The Mean ◽  
High Level

Aims and Objectives: Failure of isolated primary meniscal repair must be expected in 14% - 28%. Patients requiring revision surgery may benefit from revision meniscal repair, however, the results of revision meniscal repair remain unclear. The purpose of this study was therefore to evaluate the clinical outcome and failure rates of revision meniscal repair in patients with re-tears or failed healing after previous isolated meniscal repair in stable knee joints. Materials and Methods: A chart review was performed to identify all patients undergoing revision meniscal repair between 08/2010 and 02/2016. Only patients without concomitant procedures, without ligamentous insufficiency, and a minimum follow-up of 24 months were included. The records of all patients were reviewed to collect patient demographics, injury patterns of the meniscus, and details about primary and revision surgery. Follow-up evaluation included failure rates, clinical outcome scores (Lysholm Score, KOOS Score), sporting activity (Tegner scale), and patient satisfaction. Results: A total of 12 patients with a mean age of 22 ± 5 years were included. The mean time between primary repair and revision repair was 27 ± 21 months. Reasons for failed primary repairs were traumatic re-tears in 10 patients (83%) and failed healing in two patients (17%). The mean follow-up period after revision meniscal repair was 43 months. Failure of revision meniscal repair occurred in 3 patients (25%). In two of these patients, re-revision repair was performed. At final follow-up, the mean Lysholm Score was 95.2 with a range of 90-100, representing a good to excellent result in all patients. The final assessment of the KOOS subscores also showed good to excellent results. The mean Tegner scale was 6.8 ± 1.8, indicating a relatively high level of sports participation. Ten patients (83%) were either very satisfied or satisfied with the outcome. Conclusion: In patients with re-tears or failed healing after previous isolated meniscal repair, revision meniscal repair results in good to excellent knee function, high level of sports participation, and high patient satisfaction. The failure rate is comparable to isolated meniscal repair. Therefore, revision meniscal repair is worthwhile in order to save as much meniscal tissue as possible.

scholarly journals Arthroscopic Transphyseal Anterior Cruciate Ligament Reconstruction in Adolescent Athletes

2016 ◽  
Vol 24 (3) ◽  
pp. 307-311 ◽  
Author(s):  
Luca Dei Giudici ◽  
Roberto Fabbrini ◽  
Luca Garro ◽  
Serena Arima ◽  
Antonio Gigante ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Lysholm Score ◽  
Leg Length ◽  
Adolescent Athletes ◽  
Ikdc Score ◽  
The Mean ◽  
Anterior Cruciate ◽  
Tegner Activity Scale

Purpose To evaluate the 5-year outcome of arthroscopic transphyseal anterior cruciate ligament (ACL) reconstruction in 19 adolescent athletes. Methods 14 male and 5 female adolescent athletes aged 12 to 16 (mean, 13.9) years with Tanner stage 2 or 3 open physes underwent arthroscopic transphyseal ACL reconstruction by a single surgeon and were followed up for 5 years. Patients were evaluated using the numerical rating score (NRS) for pain, knee osteoarthritis outcome score (KOOS), International Knee Documentation Committee (IKDC) score, Tegner Activity Scale, and Lysholm Score, as well as the leg length discrepancy, femorotibial alignment, varus or valgus deformities, active and passive knee range of motion. Results At 5-year follow-up, physes were closed in all patients. The mean NRS for pain improved from 7.2 to 1.6; the KOOS improved from 55.3 to 88; the mean IKDC score improved from 34.5 to 84; the mean Tegner Activity Scale improved from 2.7 to 8.2 and was comparable with that before injury (8.4); and the mean Lysholm score improved from 36.3 to 84.6. All except 2 patients returned to their pre-injury level of sports activity after a mean of 25 weeks. The 2 exceptions had a 2+ Jerk test and a 3+ Lachman test; one of them also had positive signs for a lateral meniscal lesion. Both had sustained a second trauma not long before the 5-year follow-up. Two patients had reduced sensitivity in the anteromedial aspect of the proximal third of the tibia. One patient had leg length discrepancy of +1.5 cm owing to overgrowth response of the physis. Conclusion Transphyseal ACL reconstruction is a viable option for skeletally immature patients, with high reproducibility, a high rate of return to sport, and a low incidence of growth disturbance. Early surgery can prevent the onset of meniscal lesions and early osteoarthritis.

scholarly journals Arthroscopic-assisted Treatment of Popliteus Tendinitis

2020 ◽  
Author(s):  
Biao Chen ◽  
Hankun Liu ◽  
Haitao Chen ◽  
Liaobin Chen ◽  
Hua Wang
Keyword(s):  
Clinical Outcomes ◽  
International Knee Documentation Committee ◽  
Lateral Approach ◽  
Popliteus Tendon ◽  
Ikdc Score ◽  
The Mean ◽  
Improved Function ◽  
Tegner Score ◽  
Lost To Follow Up

Abstract Background: Popliteus tendinitis is an unusual factor to cause pain of the knee joint in its posterolateral compartment. There are few reports that the arthroscopy used for the treatment of refractory and symptomatic popliteus tendinitis. This study aimed to evaluate the effect of arthroscopic treatment of popliteus tendinitis via an auxiliary extreme lateral approach and to investigate the pathogenesis and treatment of popliteus tendinitis.Methods: From 2014 to 2018, arthroscopic popliteus tendon ablation was performed in 15 patients (15 knees) with popliteus tendinitis via an auxiliary extreme lateral approach. Clinical outcomes were assessed using the Lysholm knee scoring scale, the Tegner score, the International Knee Documentation Committee (IKDC) score and the visual analogue scale (VAS) pain score at the 24-month follow-up after surgery.Results: A total of 15 patients (mean age, 51.1 ± 7.1 years) were included; they had a mean body mass index of 23.8 ± 2.1. The minimum follow-up period was 24 months. Comparing the postoperative state to the preoperative state, the mean postoperative Lysholm score, Tegner score, and IKDC score improved significantly from 70.0 ± 5.0, 3.0 ± 0.9, and 62.3 ± 5.5 to 89.3 ± 4.2, 4.6 ± 0.61, and 80.5 ± 4.4, respectively (p < 0.01). The preoperative VAS score for pain improved from 4.3 ± 0.7 to 0.9 ± 0.6 (p < 0.01). No patients were lost to follow-up.Conclusion: Following arthroscopic-assisted treatment, all the patients with popliteus tendinitis achieved satisfactory clinical outcomes in terms of pain relief and improved function.

scholarly journals Surgical Treatment for Avulsion Fractures of the Anterolateral Ligament Associated with Periarticular Fractures of the Knee

2021 ◽  
Author(s):  
Xuelei Wei ◽  
Zengliang Wang ◽  
Yandong Lu ◽  
Jie Sun ◽  
John Riehl
Keyword(s):  
Avulsion Fracture ◽  
Pivot Shift ◽  
Anterolateral Ligament ◽  
Lysholm Score ◽  
Pivot Shift Test ◽  
X Rays ◽  
Avulsion Fractures ◽  
Ikdc Score ◽  
The Mean

AbstractThe existence and anatomy of the anterolateral ligament (ALL) of the knee are a somewhat controversial topic in orthopaedic surgery. The fixation of the avulsion fracture of the ALL (Segond fracture), associated with periarticular knee fractures, is rarely given much consideration while the major fracture fragments are reconstructed. This study aims to confirm the existence of ALL and evaluate the clinical outcomes of surgical management for avulsion fractures, involving its insertion, when associated with periarticular knee fractures. Twenty-three patients (16 males and 7 females) with avulsion fractures of the ALL associated with periarticular knee fractures were fixed with a spider plate, cannulated screw, or suture anchor. Eight patients were diagnosed with distal femoral fracture, 10 with tibial plateau fracture, and 5 with tibial eminence avulsion fracture. All patients underwent X-rays at follow-up. Clinical and functional outcomes were assessed with the pivot-shift test, objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. The ALL was found and identified as a distinct ligamentous structure in all patients. Prior to Segond repair, patients had significantly more instability, as determined by pivot-shift test, than seen postoperatively (p < 0.0001). At final follow-up, the mean subjective IKDC score was 83.2 ± 10.3. Fourteen patients were graded A, 6 were graded B, and 3 was graded C on the IKDC objective score. The mean Lysholm score was 85.4 ± 12.2. The mean Tegner score was 7.5 ± 1.2. This study confirmed that the ALL is a distinct structure in the anterolateral portion of the knee. The fixation of the avulsion fracture of the ALL associated with periarticular knee fractures can be an effective procedure without specific complications. Long-term and comparative follow-up studies are necessary to confirm the effects.

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