scholarly journals The outcome of a single percutaneous cannulated screw fixation in posterior malleolus fracture accompanied by medial or lateral malleolus fracture

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0037
Author(s):  
Yoo Jung Park ◽  
Yougun Won
Keyword(s):  
Range Of Motion ◽  
Ankle Joint ◽  
Screw Fixation ◽  
Cannulated Screw ◽  
Medial Malleolus ◽  
Posterior Malleolus ◽  
Significant Difference ◽  
Group 2 ◽  
Group 1

Category: Trauma Introduction/Purpose: Posterior malleolus fractures occur most commonly in the setting of a rotational ankle fracture. In the treatment of posterior malleolus fractures, the indications for the surgical procedure are determined by the size of the fragment and the articular congruity of the tibiotalar joint. In general, the size of the bone fragment is known to be an indication of surgery if it involves more than 25% of the joint surface, and if it is less than that, anatomical reduction and fixation of only lateral or medial malleolus was suggested. We evaluate the clinical and radiological results of fixation and early range of motion exercise using a single cannulated screw when the fragment of the posterior malleolus fracture is less than 25%. Methods: Among 60 patients with SER stage 3 or 4 who had undergone surgery from March 2010 to March 2014, percutaneous cannulated screw fixation was performed for posterior malleolus in 30 cases (Group 1). In the other 30 cases (Group 2), we did not perform the fixation for posterior malleolus fracture and only cast immobilization was done after fixation for lateral or medial malleolus. Mean follow-up period was 14.8 weeks(12~18) for the Group 1, 12.9 weeks(12~18) for Group 2. Mean age of patients was 46.6(19~78) for Group 1, 50.2(19~74) for Group 2. The range of motion was checked at week 2, 4, 12, and at last follow-up. Results: There was no significant difference of time to union and union rate between two groups, and AOFAS score between two groups also showed no significant difference(91.94(83~100) vs 90.8(85~100), p = 0.45). The range of motion of ankle joint at the final follow-up showed significant difference (Ankle ROM 52.7’ (45’~65’) vs 45.3’(35’~65’), (p<0.01) and complications between two groups also showed no significant difference. Conclusion: A single percutaneous cannulated screw fixation in posterior malleolus fracture accompanied by medial or lateral malleolus fracture can be performed in fractures with small fragment size and minimal displacement. We found that it can be a effective method to achieve early and wide range of motion of ankle joint after posterior mallolus fracture.

scholarly journals Is transverse screw fixation really necessary in PAO?—A comparative in vivo study

2021 ◽  
Author(s):  
Vincent J Leopold ◽  
Juana Conrad ◽  
Christian Hipfl ◽  
Maximilian Müllner ◽  
Thilo Khakzad ◽  
...  
Keyword(s):  
Screw Fixation ◽  
Periacetabular Osteotomy ◽  
Fixation Technique ◽  
Acetabular Fragment ◽  
Center Edge ◽  
Significant Difference ◽  
Group 2 ◽  
Group 1

Abstract The optimal fixation technique in periacetabular osteotomy (PAO) remains controversial. This study aims to assess the in vivo stability of fixation in PAO with and without the use of a transverse screw. We performed a retrospective study to analyse consecutive patients who underwent PAO between January 2015 and June 2017. Eighty four patients (93 hips) of which 79% were female were included. In 54 cases, no transverse screw was used (group 1) compared with 39 with transverse screw (group 2). Mean age was 26.5 (15–44) in group 1 and 28.4 (16–45) in group 2. Radiological parameters relevant for DDH including lateral center edge angle of Wiberg (LCEA), Tönnis angle (TA) and femoral head extrusion index (FHEI) were measured preoperatively, post-operatively and at 3-months follow-up. All patients were mobilized with the same mobilization regimen. Post-operative LCEA, TA and FHEI were improved significantly in both groups for all parameters (P ≤ 0.0001). Mean initial correction for LCEA (P = 0.753), TA (P = 0.083) and FHEI (P = 0.616) showed no significant difference between the groups. Final correction at follow-up of the respective parameters was also not significantly different between both groups for LCEA (P = 0.447), TA (P = 0.100) and FHEI (P = 0.270). There was no significant difference between initial and final correction for the respective parameters. Accordingly, only minimal loss of correction was measured, showing no difference between the two groups for LCEA (P = 0.227), TA (P = 0.153) and FHEI (P = 0.324). Transverse screw fixation is not associated with increased fragment stability in PAO. This can be taken into account by surgeons when deciding on the fixation technique of the acetabular fragment in PAO.

scholarly journals Effects of posterior tibial slope on the mid-term results of medial unicompartmental knee arthroplasty

Arthroplasty ◽  
2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Zhijie Chen ◽  
Kaizhe Chen ◽  
Yufei Yan ◽  
Jianmin Feng ◽  
Yi Wang ◽  
...  
Keyword(s):  
Knee Flexion ◽  
Tibial Slope ◽  
Posterior Tibial ◽  
Significant Difference ◽  
Medial Unicompartmental Knee Arthroplasty ◽  
Group 3 ◽  
Group 2 ◽  
Postoperative Knee ◽  
Group 1

Abstract Objective To evaluate the effect of medial posterior tibial slope (PTS) on mid-term postoperative range of motion (ROM) and functional improvement of the knee after medial unicompartmental knee arthroplasty (UKA). Methods Medical records of 113 patients who had undergone 124 medial UKAs between April 2009 through April 2014 were reviewed retrospectively. The mean follow-up lasted 7.6 years (range, 6.2–11.2 years). Collected were demographic data, including gender, age, height, weight of the patients. Anteroposterior (AP) and lateral knee radiographs of the operated knees were available in all patients. The knee function was evaluated during office follow-up or hospital stay. Meanwhile, postoperative PTS, ROM, maximal knee flexion and Hospital for Special Surgery (HSS) knee score (pre−/postoperative) of the operated side were measured and assessed. According to the size of the PTS, patients were divided into 3 groups: group 1 (<4°), group 2 (4° ~ 7°) and group 3 (>7°). The association between PTS and the knee function was investigated. Results In our cohort, the average PTS was 2.7° ± 0.6° in group 1, 5.6° ± 0.9° in group 2 and 8.7° ± 1.2° in group 3. Pairwise comparisons showed significant differences among them (p < 0.01). The average maximal flexion range of postoperative knees in each group was 112.4° ± 5.6°, 116.4° ± 7.2°, and 117.5° ± 6.1°, respectively, with significant difference found between group 1 and group 2 (p < 0.05), and between group 1 and group 3 (p < 0.05). However, the gender, age, and body mass index (BMI) did not differ between three groups and there was no significant difference between groups in terms of pre−/postoperative HSS scores or postoperative knee ROM. Conclusion A mid-term follow-up showed that an appropriate PTS (4° ~ 7°) can help improve the postoperative flexion of knee. On the other hand, too small a PTS could lead to limited postoperative knee flexion. Therefore, the PTS less than 4° should be avoided during medial UKA.

scholarly journals Percutaneous posteroanterior screw fixation for Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture: Operative technique and randomized clinical results

2021 ◽  
Vol 29 (1) ◽  
pp. 230949902199799
Author(s):  
Tianming Yu ◽  
Jichong Ying ◽  
Jianlei Liu ◽  
Dichao Huang ◽  
Hailin Yan ◽  
...  
Keyword(s):  
Screw Fixation ◽  
Malleolar Fracture ◽  
Malleolar Fractures ◽  
Posterior Malleolar Fracture ◽  
Post Traumatic ◽  
Group 2 ◽  
Traumatic Arthritis ◽  
Group 1

Purpose: The study described a novel surgical treatment of Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture and patient outcomes at intermediate period follow-up. Methods: All patients from January 2015 to December 2017 with tri-malleolar fracture of which posterior malleolar fractures were Haraguchi type 1, were surgically treated in this prospective study. Lateral and medial malleolar fractures were managed by open reduction and internal fixation through dual incision approaches. 36 cases of Haraguchi type 1 posterior malleolar fractures were randomly performed by percutaneous posteroanterior screw fixation with the aid of medial exposure (group 1). And 40 cases were performed by percutaneous anteroposterior screw fixation (group 2). Clinical outcomes, radiographic outcomes and patient-reported outcomes were recorded. Results: Seventy-six patients with mean follow-up of 30 months were included. There were no significant differences in the mean operation time (81.0 ± 11.3 vs. 77.2 ± 12.4), ankle function at different periods of follow-up, range of motions and visual analog scale (VAS) at 24 months between the two groups ( p > 0.05). However, the rate of severe post-traumatic arthritis (Grade 2 and 3) and the rate of step-off rather than gap in radiological evaluation were lower in group 1 than that in group 2 ( p < 0.05). Conclusion: Using our surgical technique, more patients had good outcome with a lower rate of severe post-traumatic arthritis, compared with the group of percutaneous anteroposterior screw fixation. Percutaneous posteroanterior screw fixation can be a convenient and reliable alternative in treating Haraguchi type 1 posterior malleolar fracture.

The Relationship between Serum Ferritin Levels and 5-Year All-Cause Mortality in Hemodialysis Patients

2021 ◽  
pp. 1-7
Author(s):  
Emre Erdem ◽  
Ahmet Karatas ◽  
Tevfik Ecder
Keyword(s):  
Serum Ferritin ◽  
Hemodialysis Patients ◽  
Rank Test ◽  
Significant Difference ◽  
All Cause Mortality ◽  
Group 3 ◽  
Group 2 ◽  
The Relationship ◽  
Group 1

<b><i>Introduction:</i></b> The effect of high serum ferritin levels on long-term mortality in hemodialysis patients is unknown. The relationship between serum ferritin levels and 5-year all-cause mortality in hemodialysis patients was investigated in this study. <b><i>Methods:</i></b> A total of 173 prevalent hemodialysis patients were included in this study. The patients were followed for up to 5 years and divided into 3 groups according to time-averaged serum ferritin levels (group 1: serum ferritin &#x3c;800 ng/mL, group 2: serum ferritin 800–1,500 ng/mL, and group 3: serum ferritin &#x3e;1,500 ng/mL). Along with the serum ferritin levels, other clinical and laboratory variables that may affect mortality were also included in the Cox proportional-hazards regression analysis. <b><i>Results:</i></b> Eighty-one (47%) patients died during the 5-year follow-up period. The median follow-up time was 38 (17.5–60) months. The 5-year survival rates of groups 1, 2, and 3 were 44, 64, and 27%, respectively. In group 3, the survival was lower than in groups 1 and 2 (log-rank test, <i>p</i> = 0.002). In group 1, the mortality was significantly lower than in group 3 (HR [95% CI]: 0.16 [0.05–0.49]; <i>p</i> = 0.001). In group 2, the mortality was also lower than in group 3 (HR [95% CI]: 0.32 [0.12–0.88]; <i>p</i> = 0.026). No significant difference in mortality between groups 1 and 2 was found (HR [95% CI]: 0.49 [0.23–1.04]; <i>p</i> = 0.063). <b><i>Conclusion:</i></b> Time-averaged serum ferritin levels &#x3e;1,500 ng/mL in hemodialysis patients are associated with an increased 5-year all-cause mortality risk.

scholarly journals Impact of percutaneous embolization versus subinguinal microsurgical ligation on semen parameters in primary varicocele patients: comparative study

2020 ◽  
Vol 51 (1) ◽  
Author(s):  
Haytham M. Nasser ◽  
Ahmed Hussein ◽  
Gad M. Behairy ◽  
Mostafa Abdo
Keyword(s):  
Sperm Count ◽  
Semen Analysis ◽  
Statistical Significance ◽  
Semen Parameters ◽  
Male Factor ◽  
Percutaneous Embolization ◽  
Significant Difference ◽  
Group 2 ◽  
Group 1

Abstract Background Varicocele is an abnormally dilated pampiniform plexus of the veins within the spermatic cord and is considered the most common correctable cause of male factor infertility. Many approaches are described for treatment either surgical (tradition inguinal, subinguinal, and laparoscopic) or non-surgical percutaneous embolization. During the period from August 2017 to December 2018, we prospectively analyzed the preoperative and post-operative alteration of semen parameters (at 3 and 9 months) of the data collected from 63 patients with clinically evident varicocele referred to our tertiary hospital. Patients were divided into two groups: group 1, thirty-three patients who underwent subinguinal microsurgical ligation, and group 2, thirty patients who underwent percutaneous embolization. Results Sixty-three patients enrolled in this study were divided in two groups: group 1, patients who underwent surgery, and group 2, patients who underwent embolization; the mean age is 24.6 ± 1.27 years in group 1 and 23.7 ± 2 years in group 2; there was no statistically significant difference between the two groups as regards BMI, diabetes, hypertension, and smoking. Bilaterality was present in 15.2% of group 1 patients and 10% in group 2 patients (P value 0.06). Most of the patients were classified as grades 2 and 3 with no statistical significance regarding severity of the disease. Preoperative semen parameters for patients including sperm count, motility, and abnormal forms showed no statistically significant difference between the two groups. Post-intervention semen analysis was done twice during follow-up after 3 months and 9 months from the date of intervention. After 3 months, the semen parameters were improved in both groups in spite of the higher sperm count in group 2 but with no statistical significance. After 9 months follow-up, semen analysis showed persistent increase in sperm mobility in group 1 patients in comparison to group 2 patients. Both groups had better improvement in count of normal form with no statistical significant change. Conclusion Improvement of semen parameters while treating primary varicocele by either subinguinal microsurgery approach or percutaneous embolization shows equivalent outcomes.

COMPARATIVE EVALUATION OF RESTORATIVE TREATMENTS ON NON-CARIOUS CERVICAL LESIONS OF COMPOSITE AND GLASS IONOMER CEMENT

2020 ◽  
pp. 38-45
Author(s):  
Duong Nguyen Thi Thuy ◽  
Huong Nguyen Thi Kim
Keyword(s):  
Glass Ionomer Cement ◽  
Glass Ionomer ◽  
Cervical Lesions ◽  
Composite Restorations ◽  
Significant Difference ◽  
Composite Glass ◽  
Group 2 ◽  
Ionomer Cement ◽  
Group 1

Background: Composite and Glass ionomer cement (GIC) are common restorative materials of non carious cervical lesions (NCCLs), which effects are controverisial. The aim of the present study was to compare the result of restorations on NCCLs between Composite and GIC. Materials and Methods: follow-up clinical trial with split-mouth design. Thirty-six patients with 96 NCCLs were divided into 2 groups (n=48/group): Group 1 restored by Composite, Group 2 restored by GIC. The restorations were evaluated at baseline, 1 and 3 months for pulpal sensitivity, restoration morphology and overall success grade. Results: GIC restorations gained 100% Good results for all parameters at 3 time points. Composite showed 87.5%, 93.8% and 97.9% Good results at baseline, 1 and 3 months, sequentially. At 3 weeks recall, 1 Composite restorations (2.1%) showed Moderate results of Retention and 2 Composite restorations (4.2%) changed colour. Conclusions: There was no statistically significant difference seen among the three groups for 3 parameters. Key words: non-carious cervical lesion, Composite, Glass ionomer cement

scholarly journals Comparison of Changes in Number of Hyperreflective Dots After İntravitreal Ranibizumab or Dexamethasone İmplant in Patients with Branch Retinal Vein Occlusion

2021 ◽  
Author(s):  
Aylin Karalezli ◽  
Sema Kaderli ◽  
Ahmet Kaderli ◽  
Cansu Kaya ◽  
Sabahattin Sul
Keyword(s):  
First Year ◽  
Intravitreal Ranibizumab ◽  
Retinal Layers ◽  
Vein Occlusion ◽  
Significant Difference ◽  
Group 3 ◽  
The Mean ◽  
Group 2 ◽  
Group 1

Abstract Purpose: To compare the effect of intravitreal ranibizumab (IVR) or intravitreal dexamethasone implants (IVD) on regression of hyperreflective dots (HRDs) on optical coherence tomography (OCT) B-scan in patients with branch retinal vein occlusion (BRVO). Methods: 37 eyes of 37 patients with cystoid macular edema who received IVR or IVD and followed up for at least 12 months were included in this study. The patients were divided into three groups according to intravitreal treatment. Group 1 consisted of 12 eyes who received only IVD, group 2 consisted of 10 eyes who received only IVR on a pro re nata and group 3 consisted of 15 eyes who received both IVD and IVR. OCT parameters (CMT, number of HRDs, status of external limiting membrane (ELM) and ellipsoid zone (EZ)) and best-corrected visual acuity (BCVA) were compared between the groups over the follow-up time. HRDs were categorized as HRD in inner retinal layers (from the internal limiting membrane to the inner nuclear layer) or HRD in outer retinal layers (from the outer plexiform layer to the outer border of the photoreceptor layer).Results: There was no significant difference between groups in terms of BCVA, CMT, HRDs in the inner and the outer retinal layers at baseline visit. (p˃0.05 for all) Comparing the baseline values in all groups, a significant decrease was observed in CMT in the first year. (For group 1; p=0.013, group 2; p=0.010; group 3, p<0.001) The BCVA was significantly increased after 1 year in all groups. (p=0.001, p=0.006, p<0.001) The mean number of HRDs in inner and outer retinal layers were significantly decreased in group 1 and group 3. (For group 1; p<0.001, p=0.001, for group 3; p<0.001, p<0.001) However, there was no significant difference in terms of the mean number of HRDs in inner and outer retinal layers for group 2. (p=0.134, p=0.477) At the first year, the number of HRDs in inner and outer retinal layers was significantly lower in group 1 and group 3 than group 2. (For inner HRDs; group 1 vs. group 2 p=0.007, group 2 vs. group 3 p<0.001. For outer HRDs group 1 vs. group 2 p<0.001, group 2 vs. group 3 p<0.001.) The BCVA was higher in group 3 than group 2 at 1year. (p=0.048). There was no significant difference in terms of post-treatment CMT and the number of HRDs between group 1 and group3 in posthoc tests (p=0.621, p=0.876, and p=0.632).Conclusion: The reduction in HRDs at 12 months and better BCVA after IVD intimates that the HRDs should be considered as inflammatory markers in the follow-up of CME in BRVO. Thus, IVD injection could be more appropriate for patients with higher HRDs after BRVO.

scholarly journals MULLIGAN BENT LEG RAISE LEBIH MENINGKATKAN LINGKUP GERAK SENDI LUMBOSAKRAL DAN MENURUNKAN DISABILITAS DIBANDINGKAN DENGAN SLUMP STRETCHING PADA PENGRAJIN GENTENG DENGAN MECHANICAL LOW BACK PAIN DI DESA DARMASABA

2017 ◽  
Author(s):  
I Made Dhita Prianthara ◽  
I Made Jawi ◽  
Wahyuddin ◽  
I Nengah Sandi ◽  
I Putu Adiartha Griadhi ◽  
...  
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Range Of Motion ◽  
Control Group ◽  
Low Back ◽  
Control Group Design ◽  
Significant Difference ◽  
Group 2 ◽  
Lumbar Range Of Motion ◽  
Group 1

Background: Mechanical low back pain is pain that resulting from poor posture which cause decreased disability and limitation of lumbar range of motion. Purpose: The purpose of this study was to prove mulligan bent leg raise more effective to increase lumbosacral range of motion and decreased disability than slump stretching among tile craftsman with Mechanical low back pain in Darmasaba village. Methods: This research was an experimental study with pre and post test control group design. Sample of this study is tile craftsman with mechanical low back pain with 20 samples aged 30-55. Samples were divided into two groups, which the first group (n = 10) was given Mulligan bent leg raise, while the second group was given slump stretching. Do exercise 3 times a week for 4 weeks. Lumbar range of motion was measured with modified-modified schober test while level of disability was measured with modified oswestry disability index. Result: Paired Sample T-test in Group 1 and Group 2 obtained p=0,000 that showed in each Group 1 and Group 2 there is significant difference. Independent Samples Test of Group 1 and Group 2 showed the result p=0,000 which mean that there is significant difference in increased lumbar range of motion and decreased disability. Conclusion: Mulligan bent leg raise more effective to increase lumbosacral range of motion and decreased disability than slump stretching to tile craftsman with mechanical low back pain in Darmasaba village.

The prognostic value of mid-treatment prostate-specific antigen level in patients receiving salvage radiotherapy.

2019 ◽  
Vol 37 (7_suppl) ◽  
pp. 289-289
Author(s):  
Jason Homza ◽  
John T. Nawrocki ◽  
Harmar D. Brereton ◽  
Christopher A. Peters
Keyword(s):  
Prostate Cancer ◽  
Prostate Specific Antigen ◽  
Specific Antigen ◽  
Salvage Radiotherapy ◽  
Clinical Failure ◽  
Treatment Intensification ◽  
Significant Difference ◽  
Group 2 ◽  
Group 1

289 Background: Salvage radiotherapy (SRT) may be employed as a potentially curative intervention for patients experiencing biochemical failure (serum prostate-specific antigen [PSA] ≥ 0.2 ng/mL) after prostatectomy for localized prostate cancer. Patients not showing a favorable response to SRT alone may require additional therapies and may benefit from earlier identification of this need. Methods: 131 consecutive patients received SRT during the timeframe of this study. 76 were deemed eligible based on the following criteria: prostatic adenocarcinoma diagnosis receiving SRT, no clinical evidence of metastasis, no hormone use prior to/during SRT, serum PSA measurement halfway through SRT, and minimum follow-up time of 3 months. Median follow-up time was 51.6 months. Eligible patients were divided into three groups based on PSA response by the midpoint of treatment: no change, decrease, or increase in PSA. The primary endpoint of the study was clinical failure (measured from SRT completion), defined as serum PSA value ≥0.2ng/mL above the post-radiotherapy nadir, initiation of androgen deprivation therapy, development of bone metastasis, or death from prostate cancer. Results: 13.1% experienced no change in PSA halfway through SRT (group 0), 68.4% of patients experienced a decrease (group 1), 18.4% experienced an increase (group 2). Four-year freedom from clinical failure was 60.0% for group 0, 58.3% for group 1, and 41.7% for group 2. Median time to clinical failure was 71.7 months for group 1, 26.8 months for group 2, and was not reached for group 0. Pairwise multiple comparison demonstrated a significant difference in four-year freedom from clinical failure between groups 1 and 2 (p = 0.036). Conclusions: These data strongly suggest that changes in PSA are apparent midway through SRT and are associated with 4-year freedom from clinical failure. Further study is warranted to determine whether mid-treatment PSA during SRT may be used to identify a subset of patients that may benefit from treatment intensification.

scholarly journals Medical management in locally advanced and metastatic prostate cancer: Does changes in treatment policy have any specific effect on PSA levels?

2017 ◽  
Vol 89 (4) ◽  
pp. 282 ◽  
Author(s):  
Murat Bagcioglu ◽  
Cristian Surcel ◽  
Serkan Ozcan ◽  
Cristian Mirvald ◽  
Mehmet Ali Karagoz ◽  
...  
Keyword(s):  
Medical Treatment ◽  
Medical Management ◽  
Locally Advanced ◽  
Androgen Deprivation ◽  
Testosterone Levels ◽  
Management Protocol ◽  
Significant Difference ◽  
Group 2 ◽  
Group 1

Objective: Androgen deprivation therapy (ADT) is commonly used as a first-line treatment for locally advanced and metastatic prostatic cancer (Pca). There is no consensus about which alternative treatment should be used after the failure of initial ADT. We aimed to investigate the effect of changes in treatment on PSA and testosterone levels. Material and methods: A total of 120 patients with an established diagnosis of either locally advanced or metastatic Pca in two different centers. Depending on the type of medical and/or surgical management protocol planned at initial presentation, all cases were divided into three main groups as follows. Group 1 (n: 80) included the patients who underwent medical management during whole follow-up period in whom the initial management protocol was later on switched to another medical treatment with different agents, Group 2 (n: 20) included patients who were initially treated with a medical management protocol and switched to surgical castration during follow-up evaluation and lastly Group 3 (n: 20) included the patients undergoing treated surgical castration as initial treatment modality without any further medical management protocol. Results: Evaluation of our data did clearly demonstrate a statistically significant difference between the initial and final PSA as well as testosterone levels in Group 1 cases. Mean PSA and testosterone levels increased significantly in these cases despite a change in hormonal therapy by using another agent for androgen deprivation. Cases in Group 2 and 3 cases did not show any statistically significant difference with respect to the mean PSA as well as testosterone values during the same follow-up period. Conclusions: Our data clearly indicated that in case of a biochemical progression, switching into another alternative medical treatment was not effective enough in limiting the rising PSA levels in a statistically significant manner when compared with the approaches of switching to surgical castration after initial medical treatment or continuing with regular and close follow-up after initial surgical castration alone.

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