Search

BACKGROUND: Tendon disorders are common problems in sports and are known to be difficult to treat. Only limited information is available concerning treatment of proximal hamstring tendinopathy. To the authors' knowledge, no histopathologic findings of proximal hamstring tendinosis have been published. HYPOTHESIS: Surgery (semimembranosus tenotomy and exploration of the sciatic nerve) is an effective treatment for proximal hamstring tendinopathy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 103 cases of proximal hamstring tendinopathy in athletes (58 men, 32 women; 13 bilateral operations) with surgical treatment were included. The cases were retrospectively analyzed, and a 4-category rating system was used to evaluate the overall result. At the follow-up, the patients were asked about possible symptoms and their return to sports. Biopsy samples from 15 of the operated tendons were taken and analyzed by a pathologist. RESULTS: The average follow-up was 49 months (range, 12-156 months). The result was evaluated to be excellent in 62 cases, good in 30, fair in 5, and poor in 6. After surgery, 80 of the 90 patients were able to return to the same level of sporting activity as before the onset of the symptoms. This took a mean of 5 months (range, 2-12 months). Typical morphologic findings of tendinosis were found in all biopsy specimens. CONCLUSION: Given the good functional outcome and low complication rate, the authors present surgical treatment as a valuable option in proximal hamstring tendinopathy if conservative treatment fails. [ABSTRACT FROM AUTHOR]

BACKGROUND: Complete proximal hamstring avulsions can cause considerable morbidity and are often associated with significant functional loss. HYPOTHESIS: Early surgical treatment leads to better results than does surgery in the chronic phase. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-one patients (21 men and 20 women) with a complete proximal hamstring avulsion were included. The cases were retrospectively analyzed, and a 4-category rating system was used to evaluate the overall result of the surgical treatment. RESULTS: The mean follow-up was 37 months (range, 12-72 months). Nineteen patients were rated as having an excellent result and 10 patients a good result. In 5 patients, the result was classified as moderate and in 7 patients poor. In the patients with an excellent or good result, the delay from the injury to surgery averaged 2.4 months, whereas in patients with a moderate or poor result, the delay averaged 11.7 months. The difference was statistically significant (P < .001). CONCLUSION: Excellent or good results can often be expected with surgery, and considerable improvement of symptoms may be achieved even in chronic cases. According to the results, early operative treatment in complete proximal avulsions of the hamstring muscles gives better results than does late surgery and is therefore recommended. [ABSTRACT FROM AUTHOR]

Proximal stress fractures of the second metatarsal are rare. They have been reported mainly in classical ballet dancers. Non-operative treatment has usually led to good results and rapid return to full activities. We present a series of nine cases with stress fractures of the proximal second metatarsal. The patients were all actively involved in sports. None of them were dancers. In all of these patients non-operative treatment lasting for an average of 13 months had failed. All of the patients were operated on using the same method. In the operation drilling was performed around and through the fracture line. The patients were followed for an average of 38 months. All except one of the patients were able to return to their prior level of activity within 4–6 months. In conclusion if non-operative treatment fails surgery seems to give good results in most patients with a stress fracture of the proximal second metatarsal. [ABSTRACT FROM AUTHOR]

Total proximal avulsions of the quadriceps femoris muscle group are rare injuries. Between the years 2001 and 2004 five patients with a total proximal avulsion of the tendon of the rectus femoris muscle were treated surgically in Mehiläinen Hospital in Turku, Finland. The median age of the patients was 21 years (range, 19–27) and the patients were all men. There were four soccer players and one hurdler. In all cases an avulsion of the proximal tendon of the rectus femoris muscle was confirmed by MRI. All of the patients were operated on and the delay from the injury to surgery ranged from 18 to 102 days. The result of the surgical treatment was rated good in all cases. All of the patients were able to return to their pre-injury level of activity 5–10 months after surgery. The median follow-up time was 20 months (range, 9–38). Surgical treatment of a total proximal avulsion of the tendon of the rectus femoris muscle seems to result in return to the pre-injury activity level in most cases. [ABSTRACT FROM AUTHOR]

Background: Hamstring injuries are common especially in athletes. Partial and complete tears of the proximal origin may cause pain and functional loss. Objective: To evaluate the results of surgical treatment for partial proximal hamstring tears. Methods: Between 1994 and 2005, 47 athletes (48 cases, 1 bilateral) with partial proximal hamstring tears were operated on. The cases were retrospectively analysed. Before surgery, 42 of the patients had undergone conservative treatment with unsatisfactory results, whereas in five patients the operation was performed within four weeks of the injury. Results: The mean length of the follow up was 36 months (range 6-72). The result of the operation was rated excellent in 33 cases, good in nine, fair in four, and poor in two. Forty one patients were able to return to their former level of sport after an average of five months (range 1-12). Conclusion: ~n most cases, excellent or good results can be expected after surgical repair of partial proximal hamstring tears even after conservative treatment has failed. [ABSTRACT FROM AUTHOR]

BACKGROUND: Total or near-total rupture of the pectoralis major muscle is a rare injury. Fewer than 200 cases have been reported in literature, many of them in single case reports. There is discrepancy regarding whether this kind of injury should be treated operatively. HYPOTHESIS: Early surgical treatment is necessary to obtain optimal functional recovery following total or near-total ruptures of the pectoralis major muscle. STUDY DESIGN: A case series of 33 operatively treated pectoralis major ruptures combined with a meta-analysis of the previously published cases in the English literature. METHODS: The authors have retrospectively analyzed 33 operatively treated cases of total or near-total ruptures of the pectoralis major muscle. They have also analyzed the previously published cases and the final outcomes of their treatment. The difference in outcome between groups of acute operation, delayed operation, and conservative treatment in both their own material and meta-analysis was statistically analyzed. RESULTS: Both the case series and the analysis of the cases from the literature showed that early operative treatment is associated with better outcome than delayed treatment. The delayed operation was associated with better outcome than the conservative treatment. CONCLUSION: Early surgical treatment by anatomic repair gives the best results in the treatment of total and near-total ruptures of the pectoralis major muscle. Copyright 2004 American Orthopaedic Society for Sports Medicine [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the events leading to acute traumatic extension deficit of the knee and the arthroscopic findings in these patients. A total of 78 consecutive patients treated in the Turku university hospital during the years 1994–1996 were included. The mean annual incidence of acute traumatic extension deficits of the knee in our study was 1.1 per 10 000 inhabitants. The single most common (33%) event causing the extension deficit was non-sports related twisting of the knee. Various sports related activities accounted for 42% of the extension deficits, and soccer was the most common sport in this group. In conclusion, acute traumatic extension deficit of the knee is usually a sign of serious intra-articular damage, and the most likely finding (in 82% of the patients in our study) is either a meniscal rupture, an anterior cruciate ligament (ACL) rupture, a patellar dislocation, or a combination of these. The lesions in these knees require prompt evaluation by an orthopaedic surgeon mainly because of the high number of bucket-handle and menisco-capsular insertion ruptures of the menisci, which are possibly suitable for repair . [ABSTRACT FROM AUTHOR]

BACKGROUND: The cause, pathogenesis, and appropriate treatment of meniscal cysts remain controversial. PURPOSE: We wanted to evaluate the results of treatment of meniscal cysts with two different operative procedures. STUDY DESIGN: Prospective cohort study. METHODS: Two different operative procedures were compared. Sixteen patients (group 1) had an open excision of the cyst performed in addition to arthroscopic examination of the knee. Nineteen patients (group 2) were treated entirely arthroscopically. The postoperative treatment course was the same for both groups. The mean length of follow-up was 33 months. RESULTS: The results were excellent or good in 86% of the patients (30 of 35) and were equally good for both procedures. Patients with degenerative changes of the knee joint seemed to have a less favorable outcome. CONCLUSIONS: Good or excellent results can be expected from either open or arthroscopic treatment of meniscal cysts. [ABSTRACT FROM AUTHOR]

Objective: To prospectively assess the early results of surgical treatment of chronic Achilles tendinopathy. Methods: This seven month prospective follow up study assessed the short term results of surgical treatment of chronic Achilles tendinopathy and compared the subjective and functional outcome of patients with Achilles tendinopathy without a local intratendinous lesion (group A) with that of similar patients with such a lesion (group B). Forty two of the initial 50 patients were examined before surgery and after the seven month follow up. Evaluation included an interview, subjective evaluation, clinical tests, and a performance test. Results: At the follow up, physical activity was fully restored in 28 of the 42 patients (67%), and 35 patients (83%) were asymptomatic or had only mild pain during strenuous exercise. In clinical tests, significant improvements were observed in climbing up and down stairs and the rising on the toes test. Surgical treatment also seemed to be successful from the total test score, which was excellent or good in 35 patients, compared with before surgery when it was excellent or good in one patient only. Patients in group A fared better than those in group B, whether evaluated by recovery of physical activity after surgery (88% v 54%) or the complication rate (6% v 27%). Conclusions: Surgical treatment of chronic Achilles tendinopathy gives good and acceptable short term results. A lower complication rate and a trend to better recovery was observed in patients with peritendinous adhesions only than in those with peritendinous adhesions combined with an intratendinous lesion. [ABSTRACT FROM AUTHOR]

We analyzed the complications after surgical treatment of Achilles tendon overuse injuries in 432 consecutive patients. The patients underwent a clinical examination 2 weeks, and 1, 2, and 5 months after the surgery. If a complication appeared, the patient was followed up clinically for at least 1 year. There were 46 (11%) complications in the 432 patients: 14 skin edge necroses, 11 superficial wound infections, 5 seroma formations, 5 hematomas, 5 fibrotic reactions or scar formations, 4 sural nerve irritations, 1 new partial rupture, and 1 deep vein thrombosis. Fourteen patients with a complication had reoperations: four patients for skin edge necrosis, two for superficial wound infection, two for seroma formation, one for hematoma formation, two for fibrotic reaction or scar formation, two for sural nerve irritation, and one for a new partial rupture. About every 10th patient treated surgically for chronic Achilles tendon overuse injury suffered from a postoperative complication that clearly delayed recovery. However, the majority of patients with a complication healed and returned to their preinjury levels of activity. To reduce this morbidity, it is essential that the surgeon be continuously aware of the possibility of postoperative complications and use proper surgical techniques. [ABSTRACT FROM AUTHOR]

We investigated the prognosis of low-back pain and the association of clinical symptoms and anatomic findings among young athletes. Consecutive patients, aged between 12 and 18 years, who had low-back pain that had interfered with their training for at least 4 weeks were included in the case series. All the patients participated in a standardized interview and clinical examination, and plain radiographs and magnetic resonance images were also obtained. Most patients also participated in technetium bone scan examination. In 15 out of 19 subjects there were anatomic abnormalities that corresponded with the location and type of clinical symptoms. Twelve subjects had changes in the disk-vertebral end plate complex and eight had a positive bone scan indicative of posterior vertebral arch stress reaction. Six out of eight boys and two out of 11 girls had stress reaction (P = 0.043). Restriction of painful activities was recommended to all subjects, restriction of activities and the use of a dynamic low-back brace for the first 3 months was recommended to patients with posterior vertebral arch stress reaction. The self-reported intensity of low-back pain (scale 0-100) among all the patients was 69 +/- 16 (mean +/- SD) at baseline and 18 +/- 21 at the 1-year follow-up (P < 0.0001). In conclusion, the reasons for prolonged back pain among young athletes are usually established by imaging studies. A knowledge of anatomic abnormalities may help in tailoring training programmes and avoiding the progression of changes during growth. Simple restriction of painful activities usually leads to good recovery. [ABSTRACT FROM AUTHOR]

Five cases of stress fracture of the patella in athletes are presented. Four of these occurred transversally in the lower part and one longitudinally in the lateral part of the patella. Three of the patients were females (endurance runner, high jumper, and orienteerer) and two males (volleyball and soccer player). The diagnosis was made 2-8 months from the onset of the symptoms. Conservative treatment was successful in only one patient; all others were treated surgically, with good end result. Drilling of the fracture line was performed twice with metal wire cerclage fixation, excision of the lateral fragment was carried out once, and a bone graft with K wires and cerclage compression (tension band) was performed once. In all cases the patellar retinaculum was intact, indicating a stress injury. Stress fracture of the patella is a rare overuse injury, and therefore difficulties and delays in the diagnosis and treatment may occur. In cases with delayed diagnosis we recommend operative treatment. [ABSTRACT FROM AUTHOR]

There are only a few epidemiological studies on the incidence of Achilles tendon (AT) ruptures. These show an increase in incidence in the West during the past few decades. The main reason is probably the increased popularity of recreational sports among middle-aged people. Ball games constitute the cause of over 60% of AT ruptures in many series. The 2 most frequently discussed pathophysiological theories involve chronic degeneration of the tendon and failure of the inhibitory mechanism of the musculotendinous unit. There are reports of AT ruptures related to the use of corticosteroids, either systemically or locally, but the role of corticosteroids in large patient series is marginal. In addition, recent studies do not confirm earlier findings of blood group O dominance in patients with AT rupture. Comparable series have been published with surgical versus nonsurgical treatment and postoperative cast immobilisation versus early functional treatment. Although conservative treatment has its own supporters, surgical treatment seems to have been the method of choice in the late 1980s and the 1990s in athletes and young people and in cases of delayed ruptures. Early ruptures in non-athletes can also be treated conservatively. In small series of compliant, well motivated patients, functional postoperative treatment has been reported to be well tolerated, safe and effective. The lack of a universal, consistent protocol for subjective and objective evaluation of AT ruptures has prevented any direct comparison of the results. The results have been often assessed according to the criteria of Lindholm or Percy and Conochie, but no scoring is available for the analysis. We assessed a new scoring method and analysed the prognostic factors related to the results. There is also no single, uniformly accepted surgical technique. Although early ruptures have been treated successfully with simple end-to-end suture, many authors have combined simple tendon suture with plastic procedures of various types. No randomised study comparing simple suture technique and repair with augmentation could be found in the literature. The major complaint against surgical treatment has been the high rate of complications. Most are minor wound complications, which delay improvement but do not influence the final outcome. Major complications are rare, but often difficult to treat with minor procedures. For instance, large postoperative skin and soft tissue defects in the Achilles region can be treated successfully with a microvascular free flap reconstruction. The complications of conservative treatment include mostly reruptures and residual lengthening of the tendon, which may result in significant calf muscle weakness. It has been postulated that a physically inactive lifestyle leads to a decrease in tendon vascularisation, while maintenance of a continuous level of activity counteracts the structural changes within the musculotendinous unit induced by inactivity and aging. Proper warm-up and stretching are essential for preventing musculotendinous injuries, but improper or excessive stretching or warming-up can predispose to these injuries. [ABSTRACT FROM AUTHOR]

We present a series of 19 avulsions of the distal tendon of the biceps brachii muscle after a follow-up of 2 to 11 years. Ten patients with delayed diagnosis and treatment (3 weeks to 5 months) were compared with nine patients treated early (within 8 days after injury). Excellent or good results at follow-up were obtained in 9 of 10 patients in the delayed-treatment group and in all 9 patients in the early-treatment group. Nine of 10 patients in the delayed-treatment group and all patients in the early-treatment group had been able to return to their preinjury levels of activity. For reference, a meta-analysis of 147 cases reported previously was performed. Ninety percent of the patients treated with an anatomic reinsertion had excellent or good results after an average follow-up of 3 years, while similar results after 3 years were seen in 60% of the patients who had nonanatomic tendon reinsertion and in 14% of the patients who were treated nonoperatively. The delay of up to 3 years between injury and anatomic reinsertion had not compromised the result. From these data we concluded that anatomic reinsertion of the avulsed distal biceps tendon to the radius is the preferred treatment in acute as well as chronic injuries. [ABSTRACT FROM AUTHOR]

We report nine cases of stress-related avulsion fracture of the tarsal navicular in athletes. This uncommon overuse injury is thought to occur following repetitive cyclic compressive loading secondary to an impingement of the tarsal navicular. The small dorsal triangular fragment is best seen in weightbearing lateral view radiographs and isotope scan and/or tomography help confirm the diagnosis. We feel that operative treatment is the method of choice in highly symptomatic cases and among top athletes because of the shorter recovery time. [ABSTRACT FROM AUTHOR]

A series of 59 patients was treated and operated on for pain felt over the area of the ischial tuberosity and radiating down the back of the thigh. This condition was labeled as the "hamstring syndrome." Pain was typically incurred by assuming a sitting position, stretch ing the affected posterior thigh, and running fast. The patients usually had a history of recurrent hamstring "tears." Their symptoms were caused by the tight, tendinous structures of the lateral insertion area of the hamstring muscles to the ischial tuberosity. Upon divi sion of these structures, complete relief was obtained in 52 of the 59 patients. [ABSTRACT FROM PUBLISHER]

From 1971 to 1985, 369 athletes presented to us with stress fractures. Of these patients, 10% (37) were treated for development of delayed unions or non unions. Twenty-seven of the patients were male and 10 were female. Their mean age was 23.1 years (range, 17 to 39). About half of the athletes were involved in endurance sports. The diagnostic criteria for a delayed union or nonunion were clinical and radiological evi dence. There was a diagnostic delay of about 3.5 months in the series. Plain radiographs, tomography, and isotope scans were used in the diagnosis. Special radiographic views were also used. In 15 cases (10 hallux sesamoid bone fractures, 1 midtibial shaft frac ture, 1 metatarsal V base fracture, 1 tarsal navicular fracture, 1 olecranon fracture, and 1 proximal tibial shaft fracture) nonoperative treatment was used. Operative treatment was used 22 times (5 sesamoid fractures, 5 midtibial fractures, 5 metatarsal V base fractures, 3 tarsal navicular fractures, 3 olecranon fractures, and 1 proximal tibial shaft fracture). Results were good or excellent in 32 cases (86.5%), moderate in 4 cases, and poor in 1 case. [ABSTRACT FROM PUBLISHER]

Three cases of the antebrachial-palmar hammer syndrome are described in volley ball players. They all suffered from a decreased blood perfusion of their right hand and fingers due to the repeated ball and floor impacts during the volley ball training and playing. The vascular lesions of the radial and ulnar arteries were reversible. The patients recovered spontaneously during the rest from excessive physical activity by their hands. The vascular lesions of this kind are rare but seem to be typical to volley ball players. [ABSTRACT FROM AUTHOR]

Osteochondroses are disorders of primary and secondary growth centres, or lesions at the apophyseal or epiphyseal growth areas of bones. Although there are many types of osteochondroses, the history, clinical symptoms and findings as well as radiological findings are typical. Physical exercise is one of the factors that provokes symptoms. In a series of 185 osteochondroses in active young athletes, there were 18 different disorders. The commonest were Osgood-Schlatter's disease, Sever's disease, osteochondritis dissecans of the femoral condyles, various other patellar osteochondroses and Scheuermann's disease. Most of the athletes were from individual events; track and field sports (53.5%), cross-country skiing (8.1%), gymnastics (3.2%) and power events (2.7%). Of the team sports soccer produced the most (20.0%). The treatment was conservative in 84.3% and operative in 15.7%. The duration of symptoms in these athletes persisted in about 43% for less than one year and in 57% for more. The late changes of osteodhondroses do not cause serious risks for a normal life, if the treatment is active and the follow-up efficient. [ABSTRACT FROM AUTHOR]

Because sports injuries in men form most of the available statistics, the reportage of injuries in female athletes is sparse. We describe exertion injuries and disorders in 281 women athletes, all of which hampered athletic training or performances. Sixty per cent of the injuries occurred to girls ages between 12-19 years, and about forty-eight per cent were track and field athletes. The most common sites of injury were the ankle, foot, heel and leg. Osteochondritic disorders were the most typical injuries in the series, and the chronic medical tibial syndrome was the injury that needed surgical treatment most frequently. Overuse injuries seem to differ very little from each other in the events included in this survey. [ABSTRACT FROM PUBLISHER]

The frequency and nature of exertion pains of the leg in athletes were studied in 2,750 cases of overuse injuries treated at the Sports Clinic of the Deaconess Institute of Oulu, Finland, during the years 1972-1977. 465 cases of exertion pain (18%) were located in the shin. The medial tibial syndrome was the most common overuse injury among these athletes, comprising 9.5% of all exertion injuries and 60% of the leg exertion pains. Together with stress fracture of the tibia, the second most common exertion pain of the leg, it accounted for 75% of the total leg pains. There are certain difficulties in differentiating between the medial tibial syndrome and stress fracture of the tibia. They both occur at the same site with similar symptoms. Radiological examination and isotope scanning are needed. The medial tibial syndrome is an overuse injury at the medial tibial border caused by running exercises. The pain is elicited by exertional ischaemia. The pathogenesis is explained by increased pressure in the fascial compartment of the deep flexor muscles due to prolonged exercise. Similar chronic ischaemic pains from exercise are also found in other fascial compartments of the leg, especially in the anterior compartment. The only treatment needed for stress fractures is rest from training. Fascial compartment pains also usually subside. If chronic fascial syndromes prevent training, fasciotomy is recommended as a reliable method to restore the athlete to normal training without pains. [ABSTRACT FROM PUBLISHER]

An uncommon exertion pain on the lateral side of the knee is described in 88 patients, in four of whom it was bilateral. The disorder is a result of the friction of the iliotibial tract over the lateral femoral epicondyle. The syndrome is the iliotibial tract friction syndrome of ITFS. All the patients in the material were active athletes or middle-aged joggers in regular training. The cases were seen over four years and four months. The mean age of them was approximately 25 years, and there were only nine women in the series. Th pain appeared usually after running and was localised on the outer femoral condyle, and often radiated downwards along the iliotibial tract. Conservative treatment and changes in training habits cured most cases. The disorder has not often been described in the literature, and seems to appear only in physically very active people, such as athletes or military recruits. [ABSTRACT FROM PUBLISHER]

A series of 147 cases of exertion injuries in less than or equal to 15 years old athletes is presented. All injuries occurred during training or athletic performances without trauma and caused symptoms that prevented athletic exercises. There were 67 girls (46%) and 80 boys (54%) in the material. About 90% of them had been training for more than one year before the onset of the symptoms; 65% were interested in track and field athletics, 13% in ball games, 11% in skiing, 4% in swimming, and 3% in orienteering. The rest were interested in other sports. About 33% of the injuries were growth disturbances or osteochondroses seen also in other children. About 15% were anomalies, deformities or earlier osteochondritic changes, which caused first symptoms during the physical exercise; 50% were typical overuse injuries that may bother adult athletes, too; 43% of the injuries were localized in ankle, foot and heel, 31% in knee, 8% in back and trunk, 7% in pelvic and hip region, and the rest in other parts of the body. The injuries were generally slight, no permanent disability was noticed. Rest and conservation therapy cured most cases; operative treatment was used in only eight cases. [ABSTRACT FROM PUBLISHER]

34 cases of avulsion fractures are described. Each fracture took place during athletic training or competition. Excepting six sportsmen participating in a general fitness programme, every patient was an active competitive athlete. There were six women and 28 men; their average age was 20.1 years, raised by a few middle-aged "fitness sportsmen". Most avulsion fractures took place in sprinters and hurdlers; next were middle and long distance renner, footballers, fitness joggers, skiers and ice-hockey players. The most usual location of a fracture was the anterior pelvic spines; avulsion fractures were also detected in various parts of lower limbs. There were fewer avulsion fractures in the area of the trunk and upper extremities. Roetgenologically, the diagnosis of an avulsion fracture is generally easy to make. However, the diagnosis is facilitated by knowing the mechanism of the injury, the technique of the athletic event, and some of the training methods. Generally, a fracture heals well, even if it requires both sufficient immobilisation and some delay in resuming physical exertion. [ABSTRACT FROM PUBLISHER]

Copyright of Archives of Orthopaedic & Traumatic Surgery / Archiv für Orthopädie, Mechanotherapie und Unfallchirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A series of surgically treated patellar tendon lesions among athletes is presented. The material was collected during 5 years from three sports injury clinics and from two hospitals. During this period the authors treated about 150 cases of jumper's knee, of which 34 cases were treated by operation. The athletes were mostly volley ball players, jumpers or runners. The operation revealed a necrotic focus of the patellar tendon in 21 cases, the retinaculum was thick and adherent in 16 patients and an exostosis of the patellar insertion was seen in two cases. The necrotic areas were excised, the thick and adherent retinaculum was divided and the exostoses were excised and drilled. Surgical treatment of chronic patellar tendon pains may give good results in selected cases. [ABSTRACT FROM PUBLISHER]