Treatment Of Pelvic Fractures Research Articles

PMD101 - Health Care Resource Utilization and Direct Medical Costs Among Patients Receiving Treatment for Pelvic Fractures

To estimate the healthcare resource utilization and direct medical costs among patients receiving treatment for pelvic fractures in the United States. This retrospective longitudinal cohort study included Truven Health MarketScan Commercial Claims and Encounters and the Medicare Supplemental and Coordination of Benefits databases. Patients that received open or closed treatment (index event) for pelvic fractures from 2012 to 2016 were identified using Current Procedural Terminology (CPT) code series 272xx (15-18, 20, 22, 26-28) or 27130. Analyses were performed at the index and at 12-month follow up after the index. The outcome measures included length of stay and costs during the index hospitalization and readmission rates and all-cause direct medical costs for both inpatient and outpatient services during the 12-month follow-up period. A total of 4,994 patients in the commercial and 1,735 patients in Medicare databases were identified that underwent procedures for pelvic fractures from 2012-2016. A majority was male, 65.5% in commercial with age between 46-64 years and 54.4% in Medicare with age greater than equal to 65 years. The mean (SD) length of stay were 9.34 (±10.69) days and 5.16 (± 6.57) days and the mean costs for index hospitalization were $79,961(±123,887) and $22,099 (±57,737) for commercial and Medicare populations respectively. During the 12-month follow-up the rates of readmission were 39.3% and 40.2% and the mean (SD) total all-cause direct costs were $ 36,371 (±75,037) and $41,128 (±61,912) for commercial and Medicare populations respectively. The results show that patients receiving treatment for pelvic fractures not only have long length of stay and burdensome costs for index pelvic procedures but also have high 12-month readmission rates and post-index costs. Better cost efficient medical procedures are warranted to successfully treat patients and address the current economic burden.

A Case Report of Korean Rehabilitation Treatment and Analysis of Conservative Treatment of Pelvic Fracture in Korea

The objective of this study is to investigate conservative treatment of pelvic fracture, and report that Korean rehabilitation treatment is effective for pelvic fracture. We reported a case about pelvic fracture treated with Korean rehabilitation treatment. We searched 10 domestic electronic databas...

3D printing-based minimally invasive cannulated screw treatment of unstable pelvic fracture

BackgroundOpen reduction and internal fixation of pelvic fractures could restore the stability of the pelvic ring, but there were several problems. Minimally invasive closed reduction cannulated screw treatment of pelvic fractures has lots advantages. However, how to insert the cannulated screw safely and effectively to achieve a reliable fixation were still hard for orthopedist. Our aim was to explore the significance of 3D printing technology as a new method for minimally invasive cannulated screw treatment of unstable pelvic fracture.MethodsOne hundred thirty-seven patients with unstable pelvic fractures from 2014 to 2016 were retrospectively analyzed. Based on the usage of 3D printing technology for preoperative simulation surgery, they were assigned to 3D printing group (n = 65) and control group (n = 72), respectively. These two groups were assessed in terms of operative time, intraoperative fluoroscopy, postoperative reduction effect, fracture healing time, and follow-up function. The effect of 3D printing technology was evaluated through minimally invasive cannulated screw treatment.ResultsThere was no significant difference in these two groups with respect to general conditions, such as age, gender, fracture type, time from injury to operation, injury cause, and combined injury. Length of surgery and average number of fluoroscopies were statistically different for 3D printing group and the control group (p < 0.01), i.e., 58.6 vs. 72.3 min and 29.3 vs. 37 min, respectively. Using the Matta radiological scoring systems, the reduction was scored excellent in 21/65 cases (32.3%) and good in 30/65 cases (46.2%) for the 3D printing group, versus 22/72 cases (30.6%) scored as excellent and 36/72 cases (50%) as good for the control group. On the other hand, using the Majeed functional scoring criteria, there were 27/65 (41.5%) excellent and 26/65 (40%) good cases for the 3D printing group in comparison to 30/72 (41.7%) and 28/72 (38.9%) cases for the control group, respectively. This suggests no significant difference between these two groups about the function outcomes.ConclusionFull reduction and proper fixation of the pelvic ring and reconstruction of anatomical morphology are of great significance to patients’ early functional exercise and for the reduction of long-term complications. This retrospective study has demonstrated the 3D printing technology as a potential approach for improving the diagnosis and treatment of pelvic fractures.Trial registrationThe study was retrospectively registered at the Chinese Clinical Trial Registry, number: ChiCTR-TRC-17012798, trial registration date: 26 Sept. 2017.

Patient-special screw template 3D printed based on external fixation for treatment of pelvic fractures

Objective To investigate the feasibility and accuracy of a patient-special template for antegrade pubic branch screwing and sacroiliac screwing which is 3D printed and based on the external fixation for treatment of pelvic fractures. Methods From January to April 2017, 5 patients with Tile B fracture of the pelvis were treated by external fixation for damage control and closed reduction of the fracture at the first stage. They were 4 males and one female, aged from 42 to 65 years(average, 54.8 years). By the Tile classification, there were one case of type B1 and 4 cases of type B2. After the CT scan data following external fixation were reconstructed and the screw trajectories were designed in 3D format, an individual template for the pelvic model was 3D printed. After the feasibility was confirmed by the preoperative operation, the patient-special template was used to insert antegrade pubic branch screws and sacroiliac screws in the surgery. The accuracy and safety of the actual screwing aided by the template were evaluated by comparing postoperative CT scans and preplanned trajectories of the screws. Results The individualized 3D printing templates based on external fixation led to precise screw placements into the superior ramus of the pubis and the sacroiliac joint. All the patient-special templates matched the external fixation well. Screw placement time ranged from 5.1 to 17.5 min, averaging 10.3 min. The fluoroscopy frequency ranged from 6 to 16 times, averaging 9 times. The wound healed primarily. There was no damage to the vessels or nerves. Verification of preoperative and postoperative CT scans showed an axial displacement deviation of 1.60+0.21 mm and an angle deviation of 2.0°±0.3°. The screws were basically in the bone channel without penetrating the cortex of important parts. Conclusion In the treatment of pelvic fractures, a patient-special screw template 3D printed based on external fixation can help accurate and safe insertion of the screws in a minimally invasive manner, significantly reducing the operation time and radiation exposure. Key words: Pelvis; Fractures, bone; External fixator; 3D print technology; Template

Progress in and reflections on treatment of pelvic and acetabular fractures

Progress in and reflections on treatment of pelvic and acetabular fractures

Comparative study on clinical results of pertacuneous sacroiliac screw combined with retrograde anterior column screw fixation or with external fixation stent for 3D navigation aided treatment of Tilt pelvic fractures

Objective To evaluate the clinical effects of pertacuneous sacroiliac screw combined with retrograde anterior column screw fixation and that with external fixation stent for 3D navigation aided treatment of Tilt pelvic fractures. Methods A retrospective case control review was conducted on 49 cases of Tilt pelvic fractures admitted to our hospital from June 2015 to February 2017. There were 27 males and 22 females, aged 21-68 years (mean, 44.6 years). Twenty eight cases were treated with the pertacuneous sacroiliac screw combined with retrograde anterior column screw fixation (Group A), and twenty one cases were treated with pertacuneous sacroiliac screw combined with external fixation stent (Group B). Operation duration, blood loss, time for exercise, postoperative complications, Majeed pelvic fractures function score and visual analogue scale(VAS) at the last follow-up were compared between the two groups. Results All patients were followed up for 6-16 months (mean, 12.7 months). No significant difference was found for operation duration, intraoperative blood loss and Majeed pelvic fractures functional scores at the last follow-up (P>0.05). Time for exercise in Group A[(9.71±0.49)weeks]was earlier than that in Group B[(17.05±0.73)weeks](P<0.05). The incidence of postoperative complications was 4% in Group A, significantly lower than 29% in Group B (P<0.05). Significant difference was observed for VAS between the two groups at postoperative 1, 4 and 12 weeks (P<0.05). Conclusion Pertacuneous sacroiliac screw combined with retrograde anterior column screw fixation aided by 3D navigation has advantages of early time for exercise, pain relief, few complications, which serves as a favorable treatment for Tilt pelvic fractures. Key words: Pelvis; Fracture fixation, internal; Surgical procedures, minimally invasive; Navigation technology

Preliminary application of 3D printing individualized plastic guide plate in the treatment of pelvic and acetabular fracture

Objective To introduce the application of 3D printing individualized plastic guide plate in the treatment of pelvic and acetabular fracture and to evaluate its application value. Methods From June 2016 to April 2017, the clinical data of eleven adult patients with pelvic and acetabular fracture was analyzed retrospectively.The pelvic CT scan was performed before operation to obtain the original data.Three-dimensional reconstruction performed by mimics 17.0 software with the data and the fracture reduction performed on the software.3D printing individualized plastic guide plate was designed and made to guide the pre-implantation plate bending and shaping.The pre implantation plate bending was completed according to the plastic guide.Postoperative Matta imaging score was used to evaluate fracture reduction, while the function of the hip joint was assessed by the Harris scores. Results All the operations were successfully completed.There were no adverse complications during or after the operation.Anatomical reduction was performed in 10 cases and functional reduction in 1 case.The excellent and good rate of Matta scores was 90.9%, excellent in 7 cases, good in 3 cases, fair in 1 case and no poor case.The excellent rate of Harris scores was 81.8%, excellent in 6 cases, good in 3 cases, fair in 2 cases and no poor case. Conclusion In the treatment of pelvic and acetabular fracture, the application of 3D printing individualized plastic guide plate may not only make mode simple and feasible and save time and materials, but also simplify the operation, reduce the difficulty of operation and hold satisfactory clinical effect. Key words: Retrospective analysis; 3D printing technology; Individualized plastic guide plate; Pelvic and acetabular fracture

Surgical treatment of pelvic fracture using multi-axis system for interventional imaging: A report of 2 cases

Surgical treatment of pelvic fracture using multi-axis system for interventional imaging: A report of 2 cases

Geriatric pelvic fractures (2)--management, conservative treatment, surgery and drug therapy at acute phase

There are difficulties in the treatment of geriatric pelvic fractures. In current clinical practice in China, many geriatric pelvic fractures are managed by strict bed rest. However, more and more epidemiological data and studies have shown that long-term bed rest for geriatric pelvic fractures can bring about various complications, leading to a high long-term mortality. For unstable geriatric pelvic fractures, early fixation using minimally invasive techniques should be implemented to facilitate early mobilization. It is to be further explored whether early fixation is needed for relatively stable pelvic fractures. Special attention should be paid to the aged patients undergoing conservative treatment as complications are likely to happen in them and their fragile vessels are likely to get injured during fracture. At acute phase we should pay special attention to the hemodynamic situation of the patients, for timely intervention is essential for those with suspected arterial injury. It is important to understand the concept of holistic management of geriatric pelvic fractures in which anti-osteoporosis treatment and rehabilitation are indispensable. This article reviews the literature, home and abroad, regarding the treatment of osteoporotic pelvic fractures in the past decade, providing reference points for the Chinese doctors concerned. Key words: Pelvis; Fractures, bone; Osteoporosis; Treatment; Aged

Biomechanical study of pelvic discontinuity in failed total hip arthroplasty. Lessons learnt from the treatment of pelvic fractures

Pelvic discontinuity is a rare but serious problem in orthopedic surgery. Acetabular reconstruction in case of severe bone loss after failed total hip arthroplasty is technically difficult, especially in segmental loss type III (anterior or posterior) or pelvic discontinuity (type IV). Acetabular reinforcement devices are frequently used as load-sharing devices to allow allograft incorporation and in order to serve as support of acetabular implants. This study tries to show, by means of biomechanic work, the efficiency of reinforced plate in anterior column in a segmental pelvic loss, illustrated with a clinical case, which shows the socket stability of hip prosthesis.

Interval versus external fixation for the treatment of pelvic fractures: a comparative study.

This retrospective study evaluated the efficacy and safety of internal fixation (IF) in the treatment of pelvic fractures (PF). A total of 263 unstable PF patients were treated from February 2009 to April 2015. Patients were divided into two groups according to type of fixation used to treat their PF: 136 cases received IF surgery (IF group); and, 127 cases received external fixation (EF) surgery (EF group). Postoperative follow-ups were conducted to record the clinical data, perioperative clinical indicators, Matta scores for fracture displacements, Majeed scores for hip functions and postoperative complications. Operation time, blood loss, the total length of the wound, postoperative fever rate, hospitalization time and complication rate for the IF group were significantly decreased in comparison with the EF group, while the ratings of pain, working and sitting ability and Matta and Majeed scores of the IF group were significantly higher than those of the EF group. IF was found to be associated with shorter operation times, less blood loss and better postoperative rehabilitation in comparison with EF, suggesting that it is an effective therapy for the treatment of unstable PF and will lead to restoration of normal pelvis functions.

Posterior percutaneous fixation of lumbo-ilium with rod/screw system for sacral fractures of Denis type II

Objective To investigate the clinical efficacy of anterior pelvic plating plus percutaneous lumbo-iliac rod/screw fixation in the treatment of pelvic fractures which are vertically and rotationally unstable and combined with unilateral sacral fracture of Denis type Ⅱ. Methods From January 2008 to November 2012, 19 patients were treated for compound injury to the anterior and posterior pelvic rings complicated with sacral fracture of unilateral Denis type Ⅱ using anterior pelvic plating plus posterior percutaneous fixation of lumbo-ilium with screws. Their improvement in neurological function, reduction outcome and clinical effectiveness were evaluated by comparing preoperation and 2 years postoperation in terms of visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) score for lower back pain, MOS Item Short-form health survey (SF-36 comprehensive scale), modified Roland-Morris Disability questionnaire (RDQ), Oswestry disability index (ODI), Gibbons overall scale, Majeed total score, sacral kyphosis abnormity, bias of sagit-tal/coronal vertical axis (SVA/CVA), pelvic incidence, pelvic tilt, lumbar lordosis, vertical displace, and leg length discrepancy. Results The differences respectively reached statistical significance for the aforementioned clinical and imaging parameters between preoperation and 2 years postoperation (P< 0.05). By Majeed scoring, 13 cases were rated as excellent, 4 as good and 2 as fair. By Tometta/Matto scoring postoperatively, the fracture reduction was rated as excellent in 12 cases, as good in 6 and as fair in one. The complications of incision infection or necrosis, secondary neurovascular damage, implant failure or mal-union was not observed. Perfect nerve functional recovery and sufficient imaging reduction were achieved in all but one patient who had to receive decompression and release for sacral canals or foramens. According to Mo-hammad criteria, 15 patients were engaged in the jobs with the same intensity and property as their pre-injury ones. Conclusions The simultaneous hybrid performance of anterior reconstruction plating combined with unilateral lumbar/sacral pedicle and iliac screwing may be a safe, reliable and satisfactory treatment for pelvic fractures of AO/Tile C1 type which involve unilateral sacral Denis type Ⅱ. Key words: Sacrum; Fractures,bone; Fracture fixation, internal

Effectiveness of percutaneous iliosacral screwing versus reconstruction plating for treatment of pelvic posterior ring fractures of Tile C: a Meta analysis

Objective To assess the clinical efficacy of percutaneous iliosacral screwing versus re-construction plating in the treatment of pelvic posterior ring fractures of Tile C. Methods The authors retrieved the randomized controlled trials (RCTs) and clinical controlled trials (CCTs) comparing percuta-neous iliosacral screwing versus reconstruction plating for Tile C pelvic posterior ring fractures from the Cochrane library, Medline, Embase, CNKI, Wanfang Data and Chinese Biomedical Database by computer and from major Chinese orthopedic journals by hand. Qualified data were extracted by statistical software Revman 5.2 for meta-analysis. Results 334 cases were included in this Meta-analysis from one RCT and 3 CCTs. Of them, 162 underwent percutaneous iliosacral screwing and 172 reconstruction plating (including 66 cases of percutaneous reconstruction plating and 106 ones of anterior reconstruction plating). There was no significant difference between percutaneous iliosacral screwing and reconstruction plating in operation time (P=0.16). Percutaneous reconstruction plating consumed significantly less operation time than anterior re-construction plating (P 0.05), but percutaneous iliosacral screwing performed significantly better than anterior reconstruction plating (P< 0.001). Percutaneous reconstruction plating led to significantly fewer postoperative complications than anterior reconstruction plating (P< 0.001) but similar incidence of postoperative pain at the sacroiliac joint compared with percutaneous reconstruction plating (P=0.30). Conclusion Compared with anterior reconstruction plating, pereutaneous iliosacral screwing and percutaneous reconstruction plating may lead to better clinical efficacy and fewer complications. Percutaneous iliosacral screwing may be superior in incision length and intraoperative blood loss, but it requires more in-traoperative X-ray exposure and more demanding technical skills. Key words: Pelvis; Fractures, bone; Fracture fixation, internal; Systematic review

Primary surgical repair of prostatic urethral rupture following multiple pelvic fracture in a dog

Abdominal urethral rupture commonly occurs in male dogs after traumatic pelvic fractures and can lead to uroperitoneum, causing peritonitis and azotemia. The primary complications of urethral damage include strictures, incontinence and innervation injury. Here, we describe a case report of prostatic urethral rupture, treated by primary suture repair, that yielded early healing and recovery in a ten-year-old, male, mixed-breed dog who visited our facility within 24 hours of being struck by a car. Positive contrast urethrocystography resulted in leakage of the contrast medium into the abdominal cavity in a point caudal to the urinary bladder. Additional radiography revealed multiple pelvic fractures. During surgery, we found a laceration of the right prostatic lobe causing urethral rupture. We performed a full thickness simple continue suture with 7-0 polyglactin 910 to reestablish urethral continuity. The prostate capsule was also sutured in a simple continue pattern. A previously placed indwelling urinary catheter was kept inside to divert urine flow. On the third postoperative day, the animal withdrew the urinary catheter and started to urinate by himself. The conservative treatment of pelvic fractures enabled complete return to function on the 55th day. One hundred and fifty days after the trauma, no evidence of urinary stricture or another clinical sign was observed. Urethral wounds can be treated surgically by primary suturing and urinary diversion. A short healing time was experienced, and the indwelling urinary catheter was removed three days after surgery since there was no more urine leakage and the animal began voiding normally.

Concept of damage control and the choice of operative methods in the treatment of pelvic fractures

Concept of damage control and the choice of operative methods in the treatment of pelvic fractures

Application of early total care in treatment of unstable pelvic fractures

Objective To evaluate the clinical effect of early total care (ETC) for treatment of unstable pelvic fractures. Methods This retrospective case series study included eighteen patients with unstable pelvic fractures treated surgically from May 2013 to May 2015. There were 11 male and 7 female patients, aged (45.1±13.1)years. Eleven patients were injured due to road traffic accidents and 7 due to fall from height. Tile B type pelvic fractures were seen in 8 patients and Tile C type in 10 patients. All patients were treated with ETC method and received open reduction and internal fixation within 24 to 48 hours after the primary treatment. Data were collected, such as operation time, intraoperative blood loss, hospital length of stay and perioperative complications. Majeed score and EuroQol 5 dimension (EQ-5D) were used for evaluation of clinical outcome and quality of life respectively. Excellent and good rate of operation was assessed using the Matta clinical evaluation standard. Results Three patients died and fifteen patients survived. Operation time was (120.1±22.2)minutes, amount of intraoperative blood loss was (355.9±56.4)ml, and hospitalization was (8.5±1.6)days. Incidence of perioperative complications was 56%, including 3 patients with acute respiratory distress syndrome, 1 pneumonia, 2 acute lung injury, 1 incisional wound infection, 2 multiple organ failure and 1 diffuse intravascular coagulation. All patients were followed up for (15.1±2.4)months (range, 12-21 months). Majeed score was decreased from preoperative (93.7±6.1)points to final follow-up of (74.1±9.2)points, and the EQ-5D index was decreased from preoperative 0.96±0.04 to final follow-up of 0.74±0.19 (both P<0.05). Excellent and good rate of operation was 80%. Conclusions ECT provides satisfactory short-term outcome for treatment of unstable pelvic fractures, but the incidence of complications is high. Doctors should choose reasonable treatment plan according to the surgical indications. Key words: Pelvis; Fracture fixation, internal; Postoperative complications

Современные способы и методы лечения переломов костей таза

Современные способы и методы лечения переломов костей таза

Long-term follow-up study of 3D printing model-aided treatment of complicated pelvic fractures

Objective To discuss the application and long-term effect of the 3D printing model in the treatment of complicated pelvic fractures. Methods Thirty-two patients with Tile C pelvic fractures treated between June 2004 and June 2006 were reviewed retrospectively. Operation was guided by the pelvic-3D printing model in experimental group (nine males and five females; 19-47 years, mean 38 years), while operation was performed based on the traditional CT data in control group (14 males and four females; 16-59 years, mean 36 years). Reconstruction plates and lag screws were used for the fracture internal fixation. Operation time and blood loss were compared between the two groups. Quality of reduction was evaluated using the Matta standard. Pelvic function was evaluated using the Majeed score at postoperative 1 year and 10 years. Results Operation time, intraoperative blood loss and intraoperative transfusion in experimental group were 120(60-186)min, 400(300-650)ml and 315(150-600)ml respectively, which were significant lower than those in control group [185(119-270)min, 740(500-850)ml and 700(400-1 085)ml] (P 0.05). Incidence of complications were comparable between experimental group (14%) and control group (11%) (P<0.05). Conclusions Application of 3D printing models can shorten operation time, reduce surgical trauma, decrease blood loss, and increase reduction rate in the treatment of complicated pelvic fractures. The technique is of great significance in guiding the treatment of complicated pelvic fractures, improving long-term efficacy and reducing long-term complications. Key words: Pelvis; Imaging, three-dimensional; Fracture fixation, internal; Rapid prototyping

Surgical treatment for unstable pelvic fractures in pre-school children

Surgical treatment for unstable pelvic fractures in pre-school children

Effects of internal iliac artery embolization on systemic inflammatory response syndrome in dogs with simulated-pelvic-fracture combined with massive bleeding.

BackgroundPelvic fracture combined with massive bleeding (PFCMB) is a complex issue in clinical practice. Currently, the use of angiography and embolization for the treatment of PFCMB obtains good results. The aim of this study is to observe the effects of early internal iliac artery embolization on the SIRS in dogs with simulated-pelvic-fracture combined with massive bleeding.MethodsTwenty adult dogs were randomly divided into an embolization group (EG) and a control group (CG). For the two groups, heart rate, respiratory rate and body temperature and other physiological variables were measured, and IL-6, TNF-α and arterial blood gas levels were monitored. These variables were assayed every 30 min until death in the CG, while dogs in the EG underwent arterial angiography after 60 min of modeling. The internal iliac artery was embolized on the injured side.ResultsThe average time to SIRS in the CG was 3.56 h, occurring at a rate of 90 % (9/10) within 24 h, with a mortality rate of 50 % (5/10); the average time to SIRS for the EG was 5.33 h, occurring at a rate of 30 % (3/10) within 24 h, with a mortality rate of 10 % (1/10). When SIRS occurred in the EG, the mean plasma IL-6 level was 52.66 ± 7.38 pg/ml and the TNF-α level was 11.45 ± 2.72 ng/ml, showing a significant difference with those of the CG (P < 0.05). In the two groups, the respiratory rate and leukocyte levels were higher at each monitored time after modeling than those before modeling; the mean arterial pressure, levels of hemoglobin and oxygen partial pressure were significantly lower at each time point after modeling than those before modeling except for the mean arterial pressure at 0 h in EG; the platelet levels at 4 and 8 h were higher than those before modeling; and the differences were statistically significant (P < 0.05). In the EG, the mean arterial pressure, heart rate, respiratory rate and hemoglobin levels at 2 , 4 and 8 h were lower than those at 0 h; the levels of leukocytes, platelets and carbon dioxide partial pressure at 4 and 8 h after modeling were higher than those at 0 h, and the differences were statistically significant (P < 0.05, P < 0.01); in the CG after modeling, the mean arterial pressure, levels of hemoglobin and carbon dioxide partial pressure at 2, 4 and 8 h were lower than those at 0 h; the levels of heart rate and leukocytes were higher than those before modeling; the respiratory rate and platelet levels at 4 and 8 h were higher than those at 0 h; and the differences were statistically significant (P < 0.05). The levels of the mean arterial pressure and hemoglobin at 4 and 8 h and the pH values at 8 h after modeling in the EG were significantly higher than those in the CG, while the heart rate and respiratory rate at 4 and 8 h were significantly lower than those in the CG. The pH values at 8 h after modeling were significantly lower than those of the other monitored times in the CG (P < 0.05, P < 0.01). The two groups had elevated levels of alkaline phosphatase after injury induction.ConclusionThrough the use of an on-spot interventional treatment cabin, early internal iliac artery embolization can control bleeding associated with pelvic fractures, delay the occurrence of SIRS, and improve the success rate of the treatment of pelvic fracture combined with bleeding.