Subungual Glomus Tumors Research Articles

Outcomes of the Transungual Approach in 56 Consecutive Digital Subungual Glomus Tumours.

Background: Glomus tumour is a painful small tumour of the glomus body commonly located under the nail bed. The aim of this study is to evaluate the correlation of clinical diagnosis with MRI findings, determine the prevalence of the tumour at different subungual locations and determine the differences in outcomes (if any) between a longitudinal and a transverse nail bed incision for excision of the tumour. Methods: This retrospective study of 56 subungual glomus tumour was conducted from May 2010 to December 2021. Data with regard to gender, age at presentation, digit involved, presenting symptoms, duration of symptoms, clinical signs, need for MRI, anatomical location, surgical approach (longitudinal versus transverse), histopathology result, period of follow-up and complications were recorded. Results: All 56 (100%) patients presented with classic triad of symptoms. The average duration of symptoms was 52.9 months (range: 3-204 months). Eleven (20%) tumours were in the sterile matrix, 38 (68%) at the junction of sterile and germinal matrix and 7 (12%) in the germinal matrix. The tumours were excised through the longitudinal incision in 31 (55.3%) patients and transverse incision in 25 (44.7%). One (1.8%) tumour was intraosseous that was diagnosed intraoperatively and excised successfully. Average follow-up was 35.4 months (range: 6-120 months). There was no difference in outcomes (pain or nail deformity) between the two incisions. One patient (1.8%) has persistent pain that was due to a missed satellite lesion in the same digit. This was excised later with resolution of symptoms. There were no recurrences and all patients were cured after excision of tumour. Conclusions: Diagnosis of glomus tumour is usually clinical, and most are located at junction of sterile and germinal matrix. Tumour can be excised either by longitudinal or transverse nail bed incisions without any change of treatment outcome. Level of Evidence: Level IV (Therapeutic).

Comparing Ultrasound with Magnetic Resonance Imaging in the Evaluation of Subungual Glomus Tumors and Subungual Myxoid Cysts

Introduction: Subungual myxoid cysts and subungual glomus tumors demonstrate characteristic features on magnetic resonance imaging (MRI) and ultrasound (US). It is not yet well-established whether US is congruent to MRI in diagnostic evaluation of these subungual lesions. Methods: Participants with clinical suspicion for subungual glomus tumors or subungual myxoid cysts were recruited. After clinical evaluation, participants underwent radiography, MRI, and US plus biopsy, aspiration, or excision where possible. Differential diagnoses were revised after review of imaging, and imaging findings were compared to definitive diagnosis by pathology, aspiration, or clinical course. Results: All lesions were visible on both US and MRI and size estimates agreed between the two modalities. US and MRI findings of subungual glomus tumors and subungual myxoid cysts agreed with their known respective imaging characteristics. Conclusions: Diagnosis of subungual myxoid cysts and subungual glomus tumors agreed between US and MRI. We provide sample MRI and US imaging parameters for optimal evaluation of subungual myxoid cysts and glomus tumors. We demonstrate that subungual MRI evaluation can be performed without special equipment, allowing for evaluation by most radiology departments. Lastly, US is user-dependent and may be non-inferior for a sonographer familiar with subungual US.

Clinical Characteristics and Results of Transungual Excision of Subungual Glomus Tumor

IntroductionGlomus tumor is rare and subungual location of the distal phalanx is the most common site. Surgical excision is the mainstay of treatment to relieve the symptoms. The objective of this study was to analyze the clinical characteristics and result of transungual excision of the tumor.MethodsA retrospective cross sectional study of was conducted among 15 cases of subungual glomus tumors operated with transungual excision over 8 years period in the department of Orthopedics. The clinical and demographic characteristics were noted from the case record. The outcome variables were assessed from case records, OPD visits, and telephone interviews and the results analyzed were pain relief, postoperative recurrence, nail deformity, and patient satisfaction. Data was analyzed by using descriptive statistical tools in SPSS-20.ResultsThe mean age of the patients was 32.6 years with the mean duration of symptoms 1.8 years. The mean tumor size was 3.4 mm. Pain and pinpoint tenderness were present in all 15 cases and positive cold sensitivity test and positive Hildreth’s test in 13 (86.7%) and 10 (66.7%) cases respectively. All cases had complete relief of pain within 2 weeks of the operation. There was no case of recurrence and nail deformity till a minimum of 1 year of follow up.ConclusionsThe diagnostic clinical triad of pain, point tenderness, and cold sensitivity are the most common findings. The transungual excision of the tumor can give rise to excellent results with complete relief of pain in all cases with no recurrence or nail deformity.

A Case of Glomus Tumor; Missed Diagnosis as Enchondroma For Previous 13 Years

Rare benign tumors called subungual glomus tumors that develop from the glomus body can cause sharp discomfort under the nail. This case involves a 38-year-old female patient who has been complaining of severe pain above her left thumbnail for 13 years. Under general anesthesia, a transungular technique was used to remove the tumor mass, and histology revealed a subungual glomus tumor. To lessen the damage and deformity to the nail bed, the tumor mass must be completely removed. To get the right diagnosis, it's crucial to consider specific clinical traits such as intense pain, regional soreness, and cold sensitivity. The diagnosis can be verified, and the tumor mass can be located with the use of a physical examination and imageology.

High-resolution ultrasonography is a more useful primary diagnostic tool than magnetic resonance imaging for subungual glomus tumors: a single-center retrospective study

Purpose: Ultrasonography (US) and magnetic resonance imaging (MRI), which has better resolution, have been suggested as appropriate diagnostic tools for digits; however, comparative studies of both modalities are scarce. This study compared the diagnostic performance of high-resolution US and MRI in characterizing subungual glomus tumors. Methods: We retrospectively analyzed the data of consecutive patients who were examined with high-resolution US and MRI before surgical exploration for subungual tumors from January 2017 to April 2020. The patients’ clinical data and radiological findings were collected. Historical reports for diagnostic confirmation and measurements of mass size were reviewed. We conducted the McNemar test and evaluated the degree of agreement between the size measurements made using both techniques.Results: Overall, 22 patients (age range, 19–72 years) underwent surgical exploration and had subungual glomus tumors. The mean duration from initial symptom presentation to diagnosis was 7 years (range, 5–30) years. Only nine patients (40.9%) presented with the symptomatic triad of pain, cold sensitivity, and tenderness. MRI detected lesions in 19 cases (86.4%); three cases (13.6%) were undetected. Contrastingly, US was able to detect all lesions. Nine patients (40.9%) had visibly rich blood flow in tumor tissues on Doppler US. MRI and US showed bone erosion in eight and 15 cases, respectively. Conclusion: The detection rate of high-resolution US for subungual glomus tumors was as high as that of MRI. US can be applied easily and quickly and can be more useful as a primary diagnostic tool.

Clinico-epidemiological profile and management outcome of subungual digital glomus tumor-Indian experience.

Glomus tumors are rare tumors arising from the mesenchymal smooth muscle cells of the glomus body. They are extremely painful tumors but because of their subungual location, remain mostly underdiagnosed. To characterize the demographic, clinical, onychoscopic, radiological features and management outcome of subungual glomus tumor. Material & methods- 15 patients with a total of 16 subungual glomus tumors were evaluated and their demographic data, history, clinical features, investigations, treatment, and follow-up were analyzed. Glomus tumors had a female preponderance (11/15) with thumb being the commonest site. All patients presented with intractable pain. Nail discoloration was observed in 11/16 (68.8%) lesions and nail plate deformity in 6/16 (37.5%) lesions. Common features on onychosocpy were pink glow and linear vascular structures. Doppler sonography and/or magnetic resonance imaging confirmed the diagnosis of glomus tumor in all the lesions. Surgical excision was done under local anesthesia using a trans-ungual approach and no recurrence was seen. High index of suspicion, meticulous clinical assessment along with radiological investigations can help in the early diagnosis. Complete surgical excision is the treatment of choice to prevent recurrence.

Dermoscopy of glomus tumour: a cross‐sectional study of 86 cases

Glomus tumours (GTs) are benign cutaneous neoplasms derived from the neuromyoarterial apparatus with a strong predilection for acral sites, especially the subungual space. Current data regarding dermoscopy of these lesions are very limited. To analyse the dermoscopic structures and patterns seen in a large series of subungual (SUGTs) and extraungual glomus tumours (EUGTs) and to determine their diagnostic significance. Clinical and dermoscopic images of 86 histopathologically proven cases of GTs (47 SUGTs and 39 EUGTs) collected from 9 hospitals in Spain, France, Italy, and Brazil were evaluated for the presence of dermoscopic structures and patterns. Similarly, 189 and 185 dermoscopic images of other ungual tumours and other extraungual non-pigmented tumours, respectively, were evaluated for the same structures and patterns. Finally, we evaluate diagnostic testing accuracy calculating sensitivity (S), specificity (Sp), and positive and negative predictive values of the different patterns for the diagnosis of GT. Regarding SUGTs, four patterns were built from the combination of different structures. The pattern composed of a structureless purplish/red subungual spot with or without vessels reached the highest S (S1, 78.8%). The combination of a structureless purplish/red subungual spot and longitudinal erythronychia (LE) (S2) is highly specific (96.3%). Patterns S3 (proximal purplish/red subungual spot, LE, and distal notch) and S4 (bed subungual spot and onycholysis) are the most specific and exclusive of matrix and bed tumours, respectively. The most consistent pattern in EUGTs is composed of a structureless purplish-white to reddish-white homogeneous area and linear unfocused vessels (E) (S: 61.5%, Sp: 95.7%). EUGTs did not show lacunae, unlike other vascular tumours. Dermoscopy is helpful in improving the diagnostic accuracy of GTs, not only in SUGTs but also when these lesions arise out of the ungual apparatus.

Nail sparing and sub-nail bed approach for the excision of subungual glomus tumors

Purpose: The excision of subungual glomus tumors on the distal phalanx may cause nail deformities. Herein, we report our nail-sparing and sub-nail bed approach for the excision of subungual glomus tumors, which enables subungual glomus tumor excision without removal of the nail plate and further allows access to the tumor mass by dissecting beneath the nail bed and germinal matrix to minimize postoperative pain and nail bed injury. Therefore, the present article describes this operative approach and reports surgical outcomes with respect to patient satisfaction, pain, and the final postoperative nail shape.Methods: Thirty-two cases of clinically diagnosed subungual glomus tumors treated with this approach were retrospectively evaluated. Mean pain scores were measured at 1 week postoperatively and at the last follow-up. Patients were asked for their subjective opinion regarding the final nail shape, and their responses were assessed as “satisfied” or “unsatisfied.” The objective results for the final nail shape were graded as “excellent,” “good,” or “poor” by two orthopedic hand surgeons.Results: The mean postoperative pain score (visual analog scale) at 1 week was 1.8. No patients reported pain at the last follow-up. Subjectively, 96.6% of patients were satisfied with the operation. Objectively, the postoperative nail shape was excellent in 9.3% of cases, good in 87.5%, and poor in 3.1%.Conclusion: This approach provides minimal postoperative pain, high patient satisfaction, and favorable cosmetic outcomes with respect to the nail shape by avoiding removal of the nail plate and incision of the nail bed and germinal matrix.

The role of dermoscopy in the diagnosis of subungual glomus tumors.

The dermoscopic features of glomus tumors have only been described in a few case reports. The aim of this research was to define the clinical and dermoscopic features of subungual glomus tumors. Thirty-two patients with subungual glomus tumors were evaluated retrospectively. On the photographs, longitudinal erythronychia, longitudinal leukonychia, punctate leukonychia, splinter hemorrhage, isolated capillaries, distal notching, distal subungual hyperkeratosis, onycholysis, and onychoschizia were found. There was no statistical difference between the rates of detection of these findings by evaluation from clinical photographs alone and from both clinical and dermoscopic photographs. While ramified vessels with bluish spots could be detected in only five of 26 cases with bluish spots in their clinical photographs, these ramified vessels were seen in 14 cases in bluish spots in dermoscopic photographs (P = 0.004). Compared to clinical examination, dermoscopy was able to detect blue spots in three more cases. Lesion duration was higher in the cases with ramified vessels (P = 0.018). Dermoscopy seems to contribute to the clinical examination in displaying only ramified vessels located in bluish spots and in determining the localization of the subungual tumors. The presence of ramified vessel in the bluish spots is strongly related to lesion duration.

Management and outcome of subungual glomus tumours: A series of 21 cases

Introduction: Glomus Tumour are vascular neoplasm that arise from glomus body. They are benign hamartomas most commonly occurring at subungual region of digits. They can cause recurrent episodes of intense lancinating pain and disability. Patients often undergo undiagnosed or misdiagnosed for many years because the tumours are small. The purpose of our study was to assess pain relief and recurrence rate after complete excision of tumour. Material and Methods: Twenty one patients were included in the study. All cases were assessed clinically and on MRI. Glomus tumour excision was done under microscope and the diagnosis was confirmed post-operatively by HPE. Pre- and Post-operative VAS scores were compared to evaluate the symptomatic outcome. Recurrence was assessed by recurrence of pain and MRI changes. Results: Out of 21 patients 18 were females and 3 were males. The mean age was 35 years. All patients showed dramatic relief of pain after surgical excision. Early diagnosis and surgical excision decreases patient's sufferings from severe pain and disability. The average improvement in VAS score was from 7.952 (pre-op) to 1.048 (post-op). No recurrence observed at 24 months follow-up. Conclusion: Glomus tumour is a rare disease, one should have a high index of suspicion for Glomus tumour in intractable chronic fingertip pain. Excision of Glomus tumour under microscope allows better tissue clearance and hence low recurrence rate.

454 Efficacy of ultrasound and MR in diagnosis of subungual glomus tumors and subungual myxoid cysts: A case series

454 Efficacy of ultrasound and MR in diagnosis of subungual glomus tumors and subungual myxoid cysts: A case series

Minimally Invasive Transungual Tumors Enucleation With Nail Preservation for Subungual Glomus Tumors

Glomus tumors are benign neurovascular neoplasms, most commonly located in the subungual region. These subcutaneous nodules are characterized by intense pain and temperature sensitivity. Although surgical excision is the curative treatment, permanent nail deformity and recurrence are not uncommon after conventional surgery. This study evaluated the long-term efficacy of a modified transungual approach with nail preservation for removing subungual glomus tumors. Thirty-nine patients with clinically diagnosed and histopathologically proven glomus tumors treated at a medical center over a 13-year period (2007-2019) were retrospectively evaluated. The 39 patients included 28 women and 11 men (ratio, 2.5:1), with a mean age of 48.9 years. Thirty-four tumors were located in the fingers and 5 in the toes. All patients returned to normal activity soon after the surgery. At a mean follow-up of 28.8 months, all were pain free or experienced minimal pain and were satisfied with treatment outcomes. One patient (2.6%) experienced recurrence. No nail deformity was observed. The transungual approach with nail plate preservation is a novel and effective method for removing subungual glomus tumors with reduced postoperative pain and rapid healing, while preserving or improving the configuration of the nail.

Clinical and onychoscopic characteristics of subungual glomus tumor: a cross-sectional study.

Subungual glomus tumor is a relatively uncommon entity with varied clinical presentations which may lead to diagnostic delays. Onychoscopy can be used as an evaluation tool in routine evaluation of glomus tumors. With an aim to characterize the onychoscopic features of subungual glomus tumors, we analyzed 15 cases presenting over 3years, in this observational study. The clinical, onychoscopic, radiological, and operative findings in these patients were evaluated and correlated depending on the location and extent of the lesions. All 15 patients (11 female and 4 male) had pain as the presenting symptom and fulfilled the classic triad of paroxysmal pain, cold sensitivity, and positive Love's pin test. Clinical nail plate findings included onycholysis, onychorrhexis with distal splitting, and onychoschizia, while nail bed and matrix findings included localized erythematous and bluish patches, longitudinal erythema, and altered lunula. Onychoscopy corroborated the clinical findings and revealed a more extensive area of involvement in five cases. Definitive onychoscopy findings included a localized structureless erythema interspersed with bluish and patchy whitish areas (five cases of nail bed and six nail matrix tumors) and a "candy-cane appearance" (six cases, all large and lobulated nail matrix tumors). MRI reported the tumor in 13 cases, while two nail matrix tumors were missed. Transungual excision revealed tumors larger in size than predicted by MRI. The presence of candy-cane appearance was consistent with lobulated matrix tumors. Onychoscopy improves the intraoperative detection of location and extent of subungual glomus tumors. Nail bed and nail matrix glomus tumors can have distinctive onychoscopic features that may help in better surgical planning.

15240 Modified transungual approach with nail preservation for subungual glomus tumor: A 13-year evaluation and experience in a medical center in Taiwan

Background: Glomus tumors are benign neurovascular neoplasms, commonly in subungual region. The clinical presentation appears as intense pain, cold sensitivity, and severe tenderness of the involved digits or toes. The permanent nail deformity and recurrence is not uncommon after conventional surgery Objective: This study was designed to evaluate the long-term efficacy of the modified transungual approach with nail-preservation for removing subungual glomus tumors.

Diagnosis of Subungual Glomus Tumors with 18\xa0MHz Ultrasound and CDFI

To evaluate the imaging features of subungual glomus tumors using 18 MHz high-frequency ultrasound with CDFI (Color Doppler Flow Imaging). 20 patients treated by surgical resection and examined by ultrasound between January 2008 and December 2019. All eligible cases are divided into two groups: Group A used the probe frequency of 9–14 MHz from January 2008 to December 2014, and Group B used the probe frequency of 18 MHz from January 2015 to December 2019. Patient demographics, clinical records, pathologic specimens and sonography features were reviewed. 50% of tumors in Group A and 100% of tumors in Group B showed clear boundary and regular shape. Blood flow signals were identified inside 50% tumors in Group A (3 in 6), all 14 cases with blood flow signals detected in Group B (14 in 14,100%). 2 cases were misdiagnosed and 1 case escaped diagnosis in Group A, no case was misdiagnosed in Group B. The accuracy of diagnosis rate of Group B is significantly higher than that of Group A. 18-MHz ultrasound combined with CDFI may be a practical useful tool for detecting subungual glomus tumors. More importantly 18-MHz ultrasound can obviously improve the diagnostic accuracy.

Eponychial flap elevation method for surgical excision of a subungual glomus tumor.

The clinical symptoms of glomus tumors are pain, tenderness, nail discoloration, and cold intolerance. The only treatment for subungual glomus tumors is surgical removal. In this clinical study, we present an eponychium preserving method as a new innovative surgical approach for subungual glomus tumor. We retrospectively reviewed the data of 27 patients with subungual glomus tumors who underwent tumor resection using the eponychial flap elevation method between March 2010 and 2019. After the excision of the subungual glomus tumor using the eponychial flap elevation method, wound problems, severe pain, and nail deformity other than a minimal scar were not noted. The innovative eponychial flap elevation method is a simple and straightforward method for the management of subungual glomus tumors; the tumors can be sufficiently exposed and completely excised using this method while avoiding secondary nail dystrophy. This method can be another option among several methods of subungual glomus tumor removal.

Outcome of transungual surgical approach with synthetic nail shield in the treatment of digital glomus tumors: A retrospective study

Glomus tumor is a benign neuromyoarterial tumor commonly found in the hand, particularly in the subungual region, that is removed only by surgery. Surgical excision leaves postoperative nail deformity and may cause a recurrence of subungual glomus tumors. A retrospective chart review was performed to assess the role of a synthetic nail shield in the prevention of postoperative nail deformity after transungual glomus tumor excision; the review was performed at a minimum of one year of follow-up of proven diagnosed 19 patients with digital glomus tumor between May 2011 and April 2016 in the orthopedic department in the university hospitals. All patients underwent surgical excision using transungual approach with a synthetic nail shield under digital nerve block anesthesia. Pain, cold intolerance, and complications were examined before and after surgery, and data were recorded. All patients had pain, tenderness, and cold intolerance, 12 patients (63.2%) had nail discoloration, and 3 patients (15.8%) had dystrophic changes. The tumors detached from surrounding tissues had an ovoid or round shape of 2–10 mm in size. Diagnosis was confirmed after pathological examination. In all patients, pain and cold sensitivity diminished. The mean follow-up period was 20.6 months, with no recurrences detected and improved nail appearance. No patient had postoperative nail deformity. Transungual approach followed by artificial coverage was an effective method for the treatment of glomus tumors without complications to the nail bed.

Ultrasonographic appearance of glomus tumors: A retrospective study

Background: The glomus tumor is a rare neoplasm and can be easily misdiagnosed. Patients with glomus tumor may present nonspecific symptoms such as long-term pain, temperature intolerance, and history of injury. It is common for such patients to be examined by physicians from various specialties such as orthopedics, family medicine or plastic surgery. They may undergo multiple imaging studies such as plain film X-ray, ultrasonography, or magnetic resonance imaging depending on the location of the nodule. Objective: In this paper we present the first study in the Gulf Cooperation Council (GCC) region to address a retrospective institutional review of all ultrasonography studies of glomus tumors in a single medical center in the Kingdom of Bahrain between January 2013 and December 2018. Results: Out of 31 patients with glomus tumors, 11 patients underwent an ultrasonography imaging study. The sex ratio (male: female) in the group of 11 patients was 0.56:1. 63.63% (7/11) of the ultrasonography requests were done by orthopedic surgeons, whereas 27.27% (3/11) were requested by a primary care physician (PCP), and 9.09% (1/11) of the patients were referred by an emergency physician. Glomus tumors were more common in patients aged 30–39 years and 50-54 years with a mean age of (mean ± SD, 47.818 ± 12.408) years. Ultrasonography results showed that 100% (11/11) were hypoechoic. The majority of the studies showed 90.90% (10/11) with a well-defined border. Doppler US showed that 72.72% (8/11) had visible hypervascularization in the tumor, 18.18% (2/11) had moderate visible blood in the tumor, and 9.09% (1/11) had no comments on vascularity in the report. The tumor size ranged from 2.2 to 6.5 mm (mean ± SD, 4.081 ± 1.470 mm) x 1 to 4 mm (mean ± SD, 2.690 ± 1.135 mm). 90.90 % (10/11) of glomus tumors were located in the fingers. 90.90% (10/11) of the lesions were located in the left hand, whereas 9.09% (1/11) were located in the right hand and 9.09% (1/11) in the left toe. Conclusion: The results of this study were similar to those of other studies described in the literature. A well-defined, hypoechoic lesion with a hypervascular mass in the nail bed were the most common ultrasonography findings associated with subungual glomus tumors.

Glomus tumors of the nail bed: topographic anatomy and an algorithmic approach based on the topography.

Glomus tumors are rare vascular pathologies characterized by a triad of symptoms: tenderness, pain and cold intolerance. In the hand they are highly concentrated under the nail bed. In this retrospective study, we aimed to present a topographic map of the location of glomus tumors in the nail bed and a map-based surgical approach algorithm to the subungual glomus tumors. We prepared a nail bed map with 6 zones and named these zones as ulnar distal, ulnar proximal, central distal, central proximal, radial distal and radial proximal. With respect to the tumor location and the used surgical approach we retrospectively evaluated the intraoperative photos and the hospital records of patients who were operated between 2008-2019 and had the pathological diagnosis of glomus tumor. The examination records of the postoperative first year were evaluated for each patient retrospectively. A descriptive statistical analysis was performed. In addition we analyzed the described surgical approaches to excise a glomus tumor in the nail bed. The described approaches and the approaches used by us were matched with the localisation of the tumors in this study developing an algorithm for the surgical approach depending on the localisation of the nail bed glomus tumor. Finally 44 patients had inclusion criteria. The distribution of the glomus tumor was as follows: 2 were on ulnar distal (4.5 %), 9 on ulnar proximal (20.5 %), 1 on central distal (2.3 %), 18 on central proximal (40.9 %), 4 on radial distal (9.1 %) and 10 were on the radial proximal zones (22.7 %). 4 lateral approaches, 1 nail sparing and 39 transungual approaches were performed. We had one recurrence in a male patient operated by transungual approach. Glomus tumors are mostly located on the central proximal part of the nail bed. Our glomus map and the algorithm we described might be helpful for the selection of the surgical approach for the glomus tumor.

The 'shark mouth' flap approach for digital glomus tumours in 24 patients: technique and clinical outcomes.

This retrospective, single-centre study was carried out on patients with digital subungual glomus tumours. We describe a subperiosteal approach with a 'shark mouth' flap containing the nail plate and nail bed as a single unit, providing ideal exposure and easy access to the tumour. It combines the advantages of the transungual and lateral approaches, whether the subungual tumours are located centrally, peripherally or under the germinal matrix. The 'shark mouth' flap approach was used by the same surgeon in 24 patients with solitary glomus tumours of the fingers. Clinical outcomes at the early postoperative phase and at the last follow-up were satisfactory. Pain relief and wound healing were quickly achieved. No complications, such as fingertip numbness or nail deformities, were observed, and there was only one recurrence. This approach is reliable, nail-sparing and less time-consuming than other techniques. Level of evidence: IV.