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PurposeWrist fractures are common, contribute significantly to morbidity in women with postmenopausal osteoporosis, and occur predominantly at the ultradistal radius, a site rich in trabecular bone. This exploratory analysis of the phase 3 ACTIVE study evaluated effects of abaloparatide versus placebo and teriparatide on forearm bone mineral density (BMD) and risk of wrist fracture.MethodsForearm BMD was measured by dual energy X-ray absorptiometry in a subset of 982 women from ACTIVE, evenly distributed across the three treatment groups. Wrist fractures were ascertained in the total cohort (N = 2463).ResultsAfter 18 months, ultradistal radius BMD changes from baseline were 2.25 percentage points greater for abaloparatide compared with placebo (95% confidence interval (CI) 1.38, 3.12, p < 0.001) and 1.54 percentage points greater for abaloparatide compared with teriparatide (95% CI 0.64, 2.45, p < 0.001). At 18 months, 1/3 radius BMD losses (versus baseline) were similar for abaloparatide compared with placebo (−0.42; 95% CI −1.03, 0.20; p = 0.19) but losses with teriparatide exceeded those of placebo (−1.66%; 95% CI −2.27, −1.06; p < 0.001). The decline with abaloparatide was less than that seen with teriparatide (group difference 1.22%; 95% CI 0.57, 1.87; p < 0.001). The radius BMD findings, at both ultradistal and 1/3 sites, are consistent with the numerically lower incidence of wrist fractures observed in women treated with abaloparatide compared with teriparatide (HR = 0.43; 95% CI 0.18, 1.03; p = 0.052) and placebo (HR = 0.49, 95% CI 0.20, 1.19, p = 0.11).ConclusionsCompared with teriparatide, abaloparatide increased BMD at the ultradistal radius (primarily trabecular bone) and decreased BMD to a lesser extent at the 1/3 radius (primarily cortical bone), likely contributing to the numerically lower wrist fracture incidence observed with abaloparatide.

Background Treatment of segmental bone loss remains a major challenge in orthopaedic surgery. Traditional techniques (eg, autograft) and newer techniques (eg, recombinant human bone morphogenetic protein-2 [rhBMP-2]) have well-established performance limitations and safety concerns respectively. Consequently there is an unmet need for osteoinductive bone graft substitutes that may eliminate or reduce the use of rhBMP-2. Questions/purposes Using an established rabbit radius osteotomy defect model with positive (autogenous bone graft) and negative (empty sham) control groups, we asked: (1) whether a collagen-glycosaminoglycan scaffold alone can heal the defect, (2) whether the addition of hydroxyapatite particles to the collagen scaffold promote faster healing, and (3) whether the collagen-glycosaminoglycan and collagen-hydroxyapatite scaffolds are able to promote faster healing (by carrying a low dose rhBMP-2). Methods A 15-mm transosseous radius defect in 4-month-old skeletally mature New Zealand White rabbits were treated with either collagen-hydroxyapatite or collagen-glycosaminoglycan scaffolds with and without rhBMP-2. Autogenous bone graft served as a positive control. Time-series radiographs at four intervals and postmortem micro-CT and histological analysis at 16 weeks were performed. Qualitative histological analysis of postmortem explants, and qualitative and volumetric 3-D analysis of standard radiographs and micro-CT scans enabled direct comparison of healing between test groups. Results Six weeks after implantation the collagen-glycosaminoglycan group had callus occupying greater than ½ the defect, whereas the sham (empty) control defect was still empty and the autogenous bone graft defect was completely filled with unremodeled bone. At 6 weeks, the collagen-hydroxyapatite scaffold groups showed greater defect filling with dense callus compared with the collagen-glycosaminoglycan controls. At 16 weeks, the autogenous bone graft groups showed evidence of early-stage medullary canal formation beginning at the proximal and distal defect borders. The collagen-glycosaminoglycan and collagen-glycosaminoglycan-rhBMP-2 groups had nearly complete medullary canal formation and anatomic healing at 16 weeks. However, collagen-hydroxyapatite-rhBMP-2 scaffolds showed the best levels of healing, exhibiting a dense callus which completely filled the defect. Conclusions The collagen-hydroxyapatite scaffold showed comparable healing to the current gold standard of autogenous bone graft. It also performed comparably to collagen-glycosaminoglycan-rhBMP-2, a representative commercial device in current clinical use, but without the cost and safety concerns. Clinical Relevance The collagen-glycosaminoglycan scaffold may be suitable for a low load-bearing defect. The collagen-hydroxyapatite scaffold may be suitable for a load-bearing defect. The rhBMP-2 containing collagen-glycosaminoglycan and collagen-hydroxyapatite scaffolds may be suitable for established nonunion defects.

Background While good results have been reported with both nonoperative and operative treatment of isolated displaced partial radial head fractures, there remains considerable disagreement about the role of surgery in the management of these injuries. Questions/purposes We (1) compared isolated displaced partial articular radial head fractures treated nonoperatively with open reduction internal fixation (ORIF) in terms of validated outcomes scores, ROM, and strength; (2) assessed whether there were any predictor variables for outcomes; and (3) compared complications between groups. Methods We retrospectively compared patients with isolated partial articular radial head fractures displaced greater than 2 mm but less than 5 mm who received either nonoperative treatment (30 patients) or ORIF (30 patients). We reviewed the nonoperative and ORIF groups at a mean of 3 and 4.5 years, respectively. The nonoperative and ORIF groups were similar except for age (51 ± 17 years versus 39 ± 10 years, respectively) and fracture displacement (2.3 ± 0.3 mm versus 2.8 ± 0.6 mm, respectively). As there were no definitive guidelines on which treatment represented best management, treatment type was decided by the attending surgeon in conjunction with the patient on a case-by-case basis. Patients were evaluated using the Patient-rated Elbow Evaluation (PREE) (primary outcome measure), Mayo Elbow Performance Score (MEPS), QuickDASH, SF-12, clinical examination, and radiographic evaluation (14 and 28 in the nonoperative and ORIF groups, respectively). Elbow ROM was assessed with a goniometer and hand grip strength with calibrated strength testing. We assessed possible predictive variables (age, displacement, energy of injury) for clinical outcome scores and recorded complications. Results PREE scores were not different between groups, but the MEPS favored the nonoperative group (93 versus 86; p = 0.012). ROM and grip strength were similar between groups. Younger age was associated with worse outcome, but displacement and energy were not. More complications occurred in the ORIF group (eight cases of mild heterotopic ossification, two cases of hardware failure) than in the nonoperative group (one case of mild heterotopic ossification, one case of complex regional pain syndrome). Conclusions No clinical benefit with ORIF could be found compared to nonoperative management of isolated partial articular radial head fractures with displacement of greater than 2 mm but less than 5 mm at short-term followup. A well-designed randomized trial and followup at longer term are required to provide better information about how to treat these common fractures. Level of Evidence Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Summary Metaphyseal comminution in distal radius fracture (DRF) cases might indicate severe osteoporosis. The patients with DRFs and metaphyseal comminution showed 5.2-fold increased secondary fractures compared with those receiving combination osteoporosis therapy. High-risk DRF patients require aggressive osteoporosis management and fracture risk stratification. Purpose Distal radius fractures (DRFs) are common in patients with osteoporosis and associated with increased risks for subsequent fractures. Metaphyseal comminution in patients with DRFs may indicate severe osteoporosis and heightened bone fragility. However, its relationship with the risk of secondary fragility fractures remains unclear. This study aimed to evaluate the incidence of secondary fractures in patients with DRFs involving metaphyseal comminution and assess the effectiveness of osteoporosis treatment in reducing this risk. Methods In this retrospective cohort study, 134 patients aged ≥ 50 years underwent DRF surgery at a single institution from July 2018 to December 2022. The patients were allocated into groups by the presence ( n  = 45) or absence ( n  = 89) of metaphyseal comminution. The primary outcome was secondary fracture incidence. A multivariate Cox model was used, adjusting for age, sex, body mass index, bone mineral density, osteoporosis treatment type, and dementia. Results Secondary fractures were significantly more frequent in the comminution group (17.8%) than in the non-comminution group (3.4%) ( p  = 0.004). Metaphyseal comminution was associated with 5.2-fold increased secondary fracture risk (hazards ratio: 5.2, 95% confidence interval: 1.4–10.7, p  = 0.004). The patients administered combination therapy (active vitamin D plus bisphosphonates or anabolic agents) had notably lower secondary fracture rate than did those receiving vitamin D alone (5.6% vs. 15.4%, p  = 0.046). Conclusions Metaphyseal comminution in patient with DRFs significantly elevated secondary fracture risk; combination osteoporosis therapy might mitigate this risk. These findings underscore the need for robust osteoporosis management in high-risk patients, suggesting metaphyseal comminution should be crucial for fracture risk stratification.

Background Distal radius fractures are the most common of all fractures. Optimal treatment is still debated. Previous studies report substantial changes in treatment trends in recent decades. Few nation-wide studies on distal radius fracture epidemiology and treatment exist, none of which provide detailed data on patient and injury characteristics, fracture pattern and mortality. The aim of this study was to describe the epidemiology, fracture classification, current treatment regimens and mortality of distal radius fractures in adults within the context of a large national register study. Methods We performed a descriptive study using prospectively registered data from the Swedish fracture register. Included were all non-pathological distal radius fractures registered between January 1st 2015 and December 31st 2017 in patients aged 18 years and above. Nominal variables were presented as proportions of all registered fractures. Results A total of 23,394 distal radius fractures in 22,962 patients were identified. The mean age was 62.7 ± 17.6 years for all, 65.4 ± 16.0 for women and 53.6 ± 20.0 for men. A simple fall was the most common cause of injury (75%, n  = 17,643/23,394). One third (33%, n  = 7783/21,723) of all fractures occurred at the patients’ residence. 65% ( n  = 15,178/23,394) of all fractures were classified as extra-articular AO-23-A, 12% ( n  = 2770/23,394) as partially intra-articular AO-23-B and 23% ( n  = 5446/23,394) as intra-articular AO-23-C. The primary treatment was non-surgical for 74% ( n  = 17,358/23,369) and surgical for 26% ( n  = 6011/23,369) of all fractures. Only 18% of the AO-23-A fractures were treated surgically, compared to 48% of the AO-23-C fractures. The most frequently used surgical method was plate fixation (82%, n  = 4954/5972), followed by pin/wire fixation (8.2%, n  = 490/5972), external fixation (4.8%, n  = 289/5972) and other methods (4.0%, n  = 239/5972). The overall 30-day mortality was 0.4% ( n  = 98/23,394) and the 1-year mortality 2.9% ( n  = 679/23,394). Conclusion This nation-wide observational study provides comprehensive data on the epidemiology, fracture classification and current treatment regimens of distal radius fractures in a western European setting. The most common patient was an eldery woman who sustained a distal radius fracture through a simple fall in her own residence, and whose fracture was extra-articluar and treated non-surgically.

The optimal management of distal radius fractures (DRFs) in older patients remains debatable. A knowledge gap exists concerning how to manage fractures with early malalignment during nonoperative treatment. We conducted a prospective, multicenter, and randomized controlled trial to compare nonoperative treatment to operative treatment with volar locking plating (VLP) in the management of primarily malaligned DRFs and DRFs that exhibit early malalignment during nonoperative treatment. The DRIFT trial was conducted at five trauma centers in Finland, Sweden, and Denmark. Patients aged 65 years or older with a dorsally displaced AO-type A or C DRF were included in the trial. Patients with DRF who did not maintain alignment after closed reduction (CR) were randomized in 1:1 ratio to nonoperative treatment or VLP. Patients with acceptable alignment after CR visited the outpatient clinic 5-10 days after CR. If the alignment was lost, the patients were randomized in 1:1 ratio to either continue nonoperative treatment or to VLP. The primary outcome measure was Patient Rated Wrist Evaluation (PRWE) at 12 months. The primary analysis method for PRWE was a linear mixed model. In the linear mixed model, patient was a random factor and age and intra/extra articularity of the fracture were fixed. Participants and orthopedic investigators were not blinded. The statisticians and investigators responsible for the analysis remained blinded to the treatment groups during data analysis and the drawing of conclusions. Between March 15, 2018 and June 6, 2023, 291 patients aged 65 years or older (mean age 73 years (standard deviation (SD) 5.8), 258 women, 33 men) who had sustained a DRF were included in the trial. The 12-month follow-up was completed on June 11, 2024. One hundred twenty-four DRFs did not maintain acceptable fracture alignment after CR; 66 were randomized to nonoperative treatment and 58 to VLP. These patients are referred to as primarily malaligned DRFs. Eighty-six patients lost fracture alignment during the first 5-10 days of follow-up; 44 patients were randomized to continue nonoperative treatment, and 42 patients to VLP. These patients are referred to as early malaligned DRFs. In primarily malaligned DRFs, the estimated mean effect for PRWE at 12 months was -9.6 points (95% confidence interval (CI) [-17.4, -1.7]; p = 0.0178) in favor of VLP, which is smaller than the predefined minimal clinically important difference (MCID) of the PRWE (11 points). In early malaligned DRFs, the mean effect for PRWE at 12 months was -6.2 points (95% CI [-15.4, 3.0]; p = 0.1816). At 12-month follow-up, we found 25 treatment-related adverse events (AE) (10/66, 15% in primarily malaligned DRFs nonoperative; 5/58, 8.6% in primarily malaligned DRFs operative; 2/44, 4.5% in early malaligned DRFs nonoperative; 3/42, 7.1% in early malaligned DRFs operative; 5/63, 7.9% in well-aligned DRFs) and 11 other AE. The trial recruitment period was longer than expected due to the restrictions caused by the global COVID-19 pandemic. Due to the decreased inclusion rate, we had to cease the recruitment of patients with early malaligned DRF before reaching the predefined 57 patients per Arm, which was the main limitation of the trial. Operative treatment of primarily malaligned DRF with VLP may slightly improve wrist function at 12 months. The estimated mean difference between the groups was, however, smaller than the predefined MCID of the PRWE (11 points). In DRFs with early loss of alignment, operative treatment does not appear to provide benefit. Our results suggest that the choice of treatment modality should be made following primary fracture reduction because subsequent monitoring of fracture alignment does not offer any additional benefit in terms of expected wrist function. This questions the need for early radiographic follow-up during the nonoperative treatment. The trial was registered at ClinicalTrials.gov (Identifier: NCT02879656, registration date 08/17/2016).

Background Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Specifically, the question of whether to repair or replace the radial head remains controversial. Questions/purposes We compared patients with terrible triad injuries of the elbow whose radial head fracture was treated with either internal fixation and internal fixation (ORIF) or radial head arthroplasty in terms of (1) clinical outcome measures (DASH and Broberg-Morrey scores, ROM), (2) elbow stability and radiographic signs of arthrosis, and (3) complications and reoperation rates. Methods Retrospective review identified 39 patients with terrible triad injuries and minimum 18-month complete clinical and radiographic followup (mean, 24 months; range, 18–53 months). Patients were managed with a standard algorithm consisting of (1) repair (n = 9) or replacement (n = 30) of the radial head, (2) repair of the lateral ulnar collateral ligament, and (3) repair of the coronoid fracture. During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. Evaluation included the DASH score, the Broberg-Morrey index, measurements of elbow stability and motion, and radiographic assessment for signs of arthrosis; chart review was performed for complications and reoperations. Complete followup was available on 87% (39 of 45 patients). Results There were no differences between groups in terms of ROM or elbow scores. All patients who underwent radial head arthroplasty at the index procedure had a stable elbow at final followup whereas three of nine patients who underwent ORIF were unstable (p = 0.009). However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45). Conclusions For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. As these injuries commonly occur in younger patients, longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. Level of Evidence Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Background Distal radius fractures are very common injuries and surgical treatment for them can be painful. Achieving early pain control may help improve patient satisfaction and improve functional outcomes. Little is known about which anesthesia technique (general anesthesia versus brachial plexus blockade) is most beneficial for pain control after distal radius fixation which could significantly affect patients’ postoperative course and experience. Questions/Purposes We asked: (1) Did patients receiving general anesthesia or brachial plexus blockade have worse pain scores at 2, 12, and 24 hours after surgery? (2) Was there a difference in operative suite time between patients who had general anesthesia or brachial plexus blockade, and was there a difference in recovery room time? (3) Did patients receiving general anesthesia or brachial plexus blockade have higher narcotic use after surgery? (4) Do patients receiving general anesthesia or brachial plexus blockade have higher functional assessment scores after distal radius fracture repair at 6 weeks and 12 weeks after surgery? Methods A randomized controlled study was performed between February, 2013 and April, 2014 at a multicenter metropolitan tertiary-care referral center. Patients who presented with acute closed distal radius fractures (Orthopaedic Trauma Association 23A-C) were potentially eligible for inclusion. During the study period, 40 patients with closed, displaced, and unstable distal radius fractures were identified as meeting inclusion criteria and offered enrollment and randomization. Three patients (7.5%), all with concomitant injuries, declined to participate at the time of randomization as did one additional patient (2.5%) who chose not to participate, leaving a final sample of 36 participants. There were no dropouts after randomization, and analyses were performed according to an intention-to-treat model. Patients were randomly assigned to one of two groups, general anesthesia or brachial plexus blockade, and among the 36 patients included, 18 were randomized to each group. Medications administered in the postanesthesia care unit were recorded. Patients were discharged receiving oxycodone and acetaminophen 5/325 mg for pain control, and VAS forms were provided. Patients were called at predetermined intervals postoperatively (2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours) to gather pain scores, using the VAS, and to document the doses of analgesics consumed. In addition, patients had regular followups at 2 weeks, 6 weeks, and 12 weeks. Pain scores were again recorded using the VAS at these visits. Results Patients who received general anesthesia had worse pain scores at 2 hours postoperatively (general anesthesia 6.7 ± 2.3 vs brachial plexus blockade 1.4 ± 2.3; mean difference, 5.381; 95% CI, 3.850–6.913; p < 0.001); whereas reported pain was worse for patients who received a brachial plexus blockade at 12 hours (general anesthesia 3.8 ± 1.9 vs brachial plexus blockade 6.3 ± 2.4; mean difference, −2.535; 95% CI, −4.028 to −1.040; p = 0.002) and 24 hours (general anesthesia 3.8 ± 2.2 vs brachial plexus blockade 5.3 ± 2.5; mean difference, −1.492; 95% CI, −3.105 to 0.120; p = 0.031).There was no difference in operative suite time (general anesthesia 119 ± 16 minutes vs brachial plexus blockade 125 ± 23 minutes; p = 0.432), but time in the recovery room was greater for patients who received general anesthesia (284 ± 137 minutes vs 197 ± 90; p = 0.0398). Patients who received general anesthesia consumed more fentanyl (64 μg ± 93 μg vs 6.9 μg ± 14 μg; p < 0.001) and morphine (2.9 μg ± 3.6 μg vs 0.0 μg; p < 0.001) than patients who received brachial plexus blockade. Functional outcome scores did not differ at 6 weeks (data, with mean and SD for both groups, and p value) or 12 weeks postoperatively (data, with mean and SD for both groups, and p value). Conclusions Brachial plexus blockade pain control during the immediate perioperative period was not significantly different from that of general anesthesia in patients undergoing operative fixation of distal radius fractures. However, patients who received a brachial plexus blockade experienced an increase in pain between 12 to 24 hours after surgery. Acknowledging “rebound pain” after the use of regional anesthesia coupled with patient counseling regarding early narcotic administration may allow patients to have more effective postoperative pain control. It is important to have a conversation with patients preoperatively about what to expect regarding rebound pain, postoperative pain control, and to advise them about being aggressive with taking pain medication before the waning of regional anesthesia to keep one step ahead in their pain control management. Level of Evidence Level 1, therapeutic study.

Background The “terrible triad” of the elbow is a complex injury that can lead to pain, stiffness, and posttraumatic arthritis if not appropriately treated. The primary goal of surgery for these injuries is to restore stability of the joint sufficient to permit early motion. Although most reports recommend repair and/or replacement of all coronoid and radial head fractures when possible, a recent cadaveric study demonstrated that type II coronoid fractures are stable unless the radial head is removed and not replaced. Questions/purposes The purposes of this study were to determine the (1) range of motion; (2) clinical scores using the Disabilities of the Arm, Shoulder and Hand (DASH) and the Broberg-Morrey questionnaires; and (3) rate of arthritic changes, heterotopic ossification (HO), or elbow instability postoperatively in patients whose terrible triad injuries of the elbow included Reagan-Morrey type I or II coronoid fractures that were treated without fixation. Methods Between April 2008 and December 2010, 14 consecutive patients were treated for acute terrible triad injuries that included two Regan-Morrey type I and 12 Regan-Morrey type II coronoid fractures. Based on the senior author’s (DGS) clinical experience that coronoid fractures classified as such do not require fixation to restore intraoperative stability to the posterolaterally dislocated elbow, all injuries were treated by the senior author with a surgical protocol that included radial head repair or prosthetic replacement and repair of the lateral ulnar collateral ligament (LUCL) followed by intraoperative fluoroscopic examination through a range of 20° to 130° of elbow flexion to confirm concentric reduction of the ulnohumeral joint. Using this protocol, intraoperative stability was confirmed in all cases without any attempt at coronoid or anterior capsular repair. Repair of the medial collateral ligament or application of external fixation was not performed in any case. All patients were available for followup at a minimum of 24 months (mean, 41 months; range, 24–56 months). The mean patient age was 52 years (range, 32–58 years). At the followup all patients were evaluated clinically and radiographically by the senior author. Outcome measures included elbow range of motion, forearm rotation, elbow stability, and radiographic evidence of HO or arthritic changes using the Broberg and Morrey scale. Elbow instability was defined as clinical or radiographic evidence of recurrent ulnohumeral dislocation or subluxation at final followup. Clinical outcomes were assessed with the patient-reported DASH questionnaire and the physician-administered Broberg-Morrey elbow rating system. Results The mean arc of ulnohumeral motion at final followup was 123° (range, 75°–140°) and mean forearm rotation was 145° (range, 70°–170°). The mean Broberg and Morrey score was 90 of 100 (range, 70–100, higher scores reflecting better results) and the average DASH score was 14 of 100 (range, 0–38, higher scores reflecting poorer results). Radiographs revealed mild arthritic changes in one patient. One patient developed radiographically apparent but asymptomatic HO. None of the patients demonstrated instability postoperatively. Conclusions These findings demonstrate that terrible triad injuries with type I and II coronoid process fractures can be effectively treated without fixation of coronoid fractures when repair or replacement of the radial head fracture and reconstruction of the LUCL complex sufficiently restores intraoperative stability of the elbow through a functional range of motion. Level of Evidence Level IV, therapeutic study. See Guidelines to Authors for a complete description of levels of evidence.

Mechanical and biochemical bone properties are influenced by muscles. However, the muscle-bone interaction has not been fully elucidated regarding the upper extremities. The objective of the present study was to evaluate the mechanical muscle-bone interaction at the forearm by evaluating the relationship between the properties of three-dimensional (3D) forearm cortical bone models derived from conventional computed tomography (CT) images and handgrip strength (HGS). A total of 108 women (mean age, 75.2 ± 9.4 years; range, 62-101 years) with a distal radius fracture who took conventional CT scans for the assessment of the fracture were included in this study. Distal radius 3D models were reconstructed and the average cortical bone density (Cd) and thickness (Ct) of the region of interest (ROI), which might be affected by the forearm flexor muscles, were calculated using a 3D modeling software. Clinical parameters including HGS, lumbar and hip bone mineral densities (BMDs), and other demographic factors were also obtained. A multivariate linear regression analysis was performed to identify relevant factors associated with HGS. HGS was found to be independently associated with height and Cd, but no significant difference was found between HGS and Ct, age, weight, as well as lumber and hip BMDs. Cortical bone density might be associated with HGS, which is generated by the forearm flexor muscles. Hence, the mechanical muscle-bone interaction in the upper extremities could be supported by the present study.