Adnexal torsion during pregnancy: report of four cases and review of the literature

Intraoperative Utilization of Indocyanine Green (ICG) Dye for the Assessment of Ovarian Perfusion-Case Report and Review of the Literature

The assessment of ovarian perfusion after detorsion is crucial in the surgical management of patients with ovarian torsion. In current routine clinical practice, the surgical decision (preservation of the ovary versus oophorectomy) is based on the subjective impression of the surgeon. Intraoperative indocyanine green (ICG) angiography has been shown to sufficiently reflect tissue perfusion with a potential impact on the surgical procedure. Currently, there are only sparse data available on the utilization of ICG in the surgical treatment of ovarian torsion. Here, we describe the successful intraoperative use of ICG in a 17-year-old female patient with ovarian torsion who underwent ovary-preserving surgery. Further, a systematic literature review was performed. Based on the data available to date, the use of ICG in the surgical treatment of ovarian torsion is feasible and safe. The extent to which this might reduce the necessity for oophorectomy has to be evaluated in further investigations.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications

Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.

Adnexal torsion in pregnancy: A systematic review of case reports and case series

OBJECTIVES

This study aimed to investigate clinical presentations, surgical procedures and findings, complications, and predisposing factors of adnexal torsion in pregnant women.

METHODS

We searched PubMed/Medline, Embase, and Web of Science from January 2000 to March 2022. All case reports and case series with full-text English language reporting adnexal torsion in pregnant women were included. Medical history, clinical presentations, surgical procedures and findings, complications related to adnexal torsion, and predisposing factors were independently extracted by two investigators.

RESULTS

A total of 182 articles reporting 662 pregnant women with adnexal torsion were included. Most of the adnexal torsions occurred during the first trimester (54.63%), while others occurred during the second (26.36%) and third (19.00%) trimesters. The most common symptom of adnexal torsion was sudden-onset pain (80.60%). Enlargement of the adnexa was the most prevalent ultrasound finding in a twisted adnexa (95.20%). Additionally, about half of the patients had decreased blood flow in Doppler ultrasound (53.80%). Laparoscopic surgery was the favorite option (56.88%), while cystectomy and detorsion were the most commonly performed procedure (29.06%). Expectant management was reported in only 2.99% of the patients. In addition, the most common complications were preterm labor (27.58%) and emergent cesarean sections (25.28%).

CONCLUSIONS

Clinicians should think of adnexal torsion when pregnant women complain of sudden-onset pain. Then, using ultrasound, adnexal enlargement or masses should be explored seriously. They should take invasive and urgent therapy to preserve ovaries and prevent complications.

Is Ultrasound a Reliable and Reproducible Method for Assessing Adnexal Masses in Pregnancy? A Systematic Review

In this study, we aimed to systematicallyreview the current evidence regarding the diagnostic accuracy of ultrasound in assessing adnexal masses in pregnancy. The Cochrane Register of Controlled Trials, PubMed, and EMBASE databases were searched for all types of clinical studies that utilised ultrasound for the diagnosis of adnexal masses in pregnancy. Only studies that used outcome measures of either histological diagnosis or significant regression of the adnexal mass on imaging follow-up were included. The quality of each study was assessed for risk of bias. The diagnostic performance of ultrasound in each study type was calculated, along with the pooled diagnostic performance of ultrasound in differentiating benign from malignant masses. The initial search yielded 4,915 articles, of which 2,547 qualified for abstract screening. A total of 83 articles were included in this review, including one prospective cohort study, six retrospective observational studies, seven case series, and 69 case reports. In the included studies, the total number of adnexal masses was 559. The mean patient age was 29.2 years (95% confidence interval [CI]: 28.7-29.7), with a mean gestational age at diagnosis of 13.8 weeks (95% CI: 13.2-14.4). The mean quality assessment score was 75%. The International Ovarian Tumour Analysis Simple Rules were used in two articles, whereas subjective impression was used in the remaining 81 articles. The most frequently diagnosed mass was a simple or physiological cyst (35%). The prevalence of malignancy in the entire sample was 46/559 (8%; 95% CI: 34-61%). The overall pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of ultrasound in detecting ovarian malignancy were 64% (95% CI: 30-88%), 88% (95% CI: 64-97%), 5.6 (95% CI: 1.2-25.4), and 0.4 (95% CI: 0.15-1), respectively. In conclusion, currently, there is a lack of high-quality prospective studies to guide the management of adnexal masses in pregnancy. Ultrasound appears to have an adequate accuracy in differentiating benign from malignant masses; however, more research is required to assess the role of ultrasound models, rules, and subjective assessment in pregnancy compared to non-pregnant women.

Ovarian Cystic Teratoma in Pregnant Women: Conservative Management or Prophylactic Oophorectomy?

Acute abdominal pain in pregnancy is common and the differential diagnosis is vast. Mature cystic teratomas are rarely the cause of adnexal torsion during pregnancy and can be difficult to diagnose. Timely surgical intervention is required to avoid ovarian infarction. We report a 22-year-old patient presenting with sudden right lower abdominal pain. Imaging including bedside Doppler ultrasonography and MRI were negative for signs of acute ovarian torsion. Despite no definitive imaging findings, due to severe pain, we made the decision for diagnostic multi-port laparoscopic examination with possible oophorectomy. The right cystic ovary was noted to be torsed three times around the utero-ovarian ligament. A right oophorectomy was performed. Grossly, cystic teratoma was confirmed with a large amount of hair and sebum, and pathological analysis also confirmed a benign mature teratoma. The patient recovered well and delivered without any complications. Bedside ultrasonography is a highly accessible tool; however, imaging can be uncertain. Despite the rarity of ovarian torsion due to mature teratomas in second- and third-trimester pregnancies, physicians should be aware of the possibility of acute ovarian torsion in a pregnant patient even with uncertain imaging results, especially those with a documented ovarian mass. Early prophylactic surgical intervention preferably with laparoscopy should be pursued for ovarian masses between 5 cm and 10 cm.

Adnexal torsion in pregnancy after in vitro fertilization: Case report and literature review

RATIONALE

Torsion is the most common gynecologic emergency of the adnexal mass occurring during pregnancy. We report the clinical data of a case of twin pregnancy with adnexal torsion after in vitro fertilization (IVF) and embryo transfer, in which the patient underwent surgery for adnexal detorsion and experienced preterm delivery. One child died as a neonate, and the other child was diagnosed with hematological disease, which, to our knowledge, has not been reported previously. We also performed a systematic literature review to increase knowledge of the need for prompt surgical intervention.

PATIENT CONCERNS

The patient was a 32-year-old pregnant woman, who presented to our center with acute onset of stabbing and non-radiating continuous lower left abdominal pain after urination, of 6 hours duration.

DIAGNOSIS

Physical examination revealed that the lower abdominal tenderness was worse on the left side, and there were no signs of peritonitis. Transvaginal ultrasonographic examination indicated a multiloculated left ovary measuring 12.1 × 7.1 cm with sparse blood flow. The size of the largest cyst was 7.2 × 6.6 cm, the right ovary appeared normal, and two live fetuses were seen.

INTERVENTIONS

laparoscopy was performed 1.5 hours later, which revealed a cystic and multilocular left ovary with a black purplish surface and thin wall. The left ovary and left fallopian tube had undergone 720° torsion (3 rotations), and detorsion was performed laparoscopy.

OUTCOMES

The left adnexa recovered to near normal appearance 20 minutes postoperatively. The patient was discharged from hospital 5 days postsurgery, without complications. Unfortunately, the patient delivered two preterm babies at 30 weeks of gestation.

CONCLUSIONS

We should be alert to the possible risk of adnexal torsion in pregnant women after IVF. Adnexal torsion necessitates prompt surgical intervention, detorsion and preserving ovarian function are the main treatment methods. Furthermore, the possibility of recurrence, and pregnancy outcomes for the patient, as well as newborn health, should be considered.

Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion

OBJECTIVES

To describe the clinical and ultrasound characteristics of adnexal torsion.

METHODS

This was a retrospective study. From the operative records of the eight participating gynecological ultrasound centers, we identified patients with a surgically confirmed diagnosis of adnexal torsion, defined as surgical evidence of ovarian pedicle, paraovarian cyst and/or Fallopian tube twisted on its own axis, who had undergone preoperative ultrasound examination by an experienced examiner, between 2008 and 2018. Only cases with at least two available ultrasound images and/or videoclips (one grayscale and one with Doppler evaluation) were included. Clinical, ultrasound, surgical and histological information was retrieved from each patient's medical record and entered into an Excel file by the principal investigator at each center. In addition, two authors reviewed all available ultrasound images and videoclips of the twisted adnexa, with regard to the presence of four predefined ultrasound features reported to be characteristic of adnexal torsion: (1) ovarian stromal edema with or without peripherally displaced antral follicles, (2) the follicular ring sign, (3) the whirlpool sign and (4) absence of vascularization in the twisted organ.

RESULTS

A total of 315 cases of adnexal torsion were identified. The median age of the patients was 30 (range, 1-88) years. Most patients were premenopausal (284/314; 90.4%) and presented with acute or subacute pelvic pain (305/315; 96.8%). The surgical approach was laparoscopic in 239/312 (76.6%) patients and conservative surgery (untwisting with or without excision of a lesion) was performed in 149/315 (47.3%) cases. According to the original ultrasound reports, the median largest diameter of the twisted organ was 83 (range, 30-349) mm. Free fluid in the pouch of Douglas was detected in 196/275 (71.3%) patients. Ovarian stromal edema with or without peripherally displaced antral follicles was reported in the original ultrasound report in 167/241 (69.3%) patients, the whirlpool sign in 178/226 (78.8%) patients, absent color Doppler signals in the twisted organ in 119/269 (44.2%) patients and the follicular ring sign in 51/134 (38.1%) patients. On retrospective review of images and videoclips, ovarian stromal edema with or without peripherally displaced antral follicles (201/254; 79.1%) and the whirlpool sign (139/153; 90.8%) were the most commonly detected features of adnexal torsion.

CONCLUSION

Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Common ultrasound signs are an enlarged adnexa, the whirlpool sign, ovarian stromal edema with or without peripherally displaced antral follicles and free fluid in the pelvis. The follicular ring sign and absence of Doppler signals in the twisted organ are slightly less common signs. Recognizing ultrasound signs of adnexal torsion is important so that the correct treatment, i.e. surgery without delay, can be offered. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Emergent complication of assisted reproductive technology: Clinical analysis of 17 pregnant women with adnexal torsion

BACKGROUND

The purpose of this study was to evaluate the clinical symptoms, surgical management, and outcomes of pregnant women with adnexal torsion due to assisted reproductive technology.

METHODS

It was a retrospective study that include 17 pregnant women with adnexal torsion, in which the maternal age, type of fertilization, gestational age, clinical symptoms, ultrasonic findings, side affected by the disease, surgical method, and pregnancy outcomes were evaluated.

RESULTS

A total of 17 patients with adnexal torsion were included in this study, of which 8 patients conceived by in vitro fertilization-embryo transfer (IVF-ET), 1 by artificial insemination (AIH), and the other 8 conceived naturally after ovulation induction. About 14 were reported to have occurred in the first trimester of pregnancy, 1 case in the second trimester, and the other 2 in the third trimester. Clinical symptoms were abdominal pain with or without nausea and vomiting. 14 cases occurred in the right adnexa and the other 3 in the left. 5 of the patients underwent laparoscopy, and the other 12 underwent laparotomy. 8 cases were of full- term delivery, 6 twins gave birth prematurely, and 3 patients had inevitable abortion.

CONCLUSIONS

Adnexal torsion is an acute onset of lower abdominal pain in women, which seldom occurs during pregnancy. However, because of the wide application of assisted reproductive technology (ART), its incidence has increased. Early diagnosis and treatment can lead to better results.

Ovarian torsion of a term pregnancy – a new twist: review of the literature and management

Background

Ovarian and adnexal torsions are gynecologic emergencies [Li Q, Li X, Zhang P. Ovarian torsion caused by hyperreactio luteinalis in the third trimester of pregnancy: a case report. Int J Clin Exp Med. 2015;8:19612–5; Ssi-Yan-Kai G, Rivain AL, Trichot C, Morcelet MC, Prevot S, Deffieux X. What every radiologist should know about adnexal torsion. Emerg Radiol. 2018;25:51–9; Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150:8–12].

Case presentation

Though rare in pregnancy, this case report describes a 32-year-old G0 at 39 + 3/7 weeks with a history of kidney stones and a simple ovarian cyst that presented to the labor floor with left lower quadrant pain. She underwent an induction of labor for persistent pain and had a subsequent primary section for a category II tracing.

Conclusion

During the section, a torsion x3 of the left infundibular ligament was noted. The pathology indicated an acute infarct – only one other case of a full-term torsion was found in the literature (Li Q, Li X, Zhang P. Ovarian torsion caused by hyperreactio luteinalis in the third trimester of pregnancy: a case report. Int J Clin Exp Med. 2015;8:19612–5).

Potential therapeutic effect of pomegranate seed oil on ovarian ischemia/reperfusion injury in rats

Objective(s):

The aim of this study is to determine the therapeutic effects of pomegranate seed oil, which is a powerful antioxidant and anti-inflammatory agent, on ovarian-ischemia and reperfusion injury in rats.

Materials and Methods:

Fifty-six female albino Wistar rats were divided into 7 equal groups. Group 1; Sham Operation, Group 2; Ischemia, Group 3; Ischemia + Reperfusion, Group 4; Ischemia + Pomegranate 0,32 ml / kg (IP), Group 5; Ischemia + Pomegranate 0.64 ml / kg, Group 6; Ischemia + Pomegranate 0,32 ml / kg + reperfusion, Group 7; Ischemia + Pomegranate 0,64 ml / kg + reperfusion. Three hours after ischemia and 3 hours after reperfusion, the study was terminated.

Results:

While NADPH oxidase activity, MDA and TNF-α levels were significantly increased, SOD activity and GSH levels were reduced in ischemia and I/R groups. Low dose pomegranate seed oil application reduced significantly oxidative stress and NADPH oxidase activity in both ischemic and ischemic/reperfusion groups. At the same time, low-dose pomegranate seed oil extract reduced TNF-α levels and significantly increased antioxidant activity.

Conclusion:

PSO demonstrated an important therapeutic effect in the treatment of ovarian ischemia and reperfusion injury.

Acute abdomen in early pregnancy due to ovarian torsion following successful in vitro fertilization treatment

OBJECTIVE

Ovarian torsion is an acute abdomen requiring prompt intervention. Ovarian torsion seldom occurs during pregnancy. However, with in vitro fertilization (IVF) treatments, ovarian hyperstimulation may increase the size of the ovaries and result in the occurrence of adnexal torsion. Here, we report two cases of ovarian torsion after IVF and discuss the optimal management of this emergency medical condition.

CASE REPORT

The first case was a 23-year-old woman who received IVF-embryo transfer due to tubal factor infertility. Sudden-onset, lower abdominal pain developed at the 6th week of pregnancy. Conservative treatment with antibiotics was the initial approach, but a right oophorectomy had to be performed due to right ovarian torsion with hemorrhagic and gangrenous changes. The second case was a 38-year-old woman diagnosed with bilateral ovarian torsion at 8 weeks' gestation due to the sudden onset of low abdominal pain. Laparoscopy was arranged immediately after the diagnosis was confirmed. The left ovary was successfully preserved due to prompt intervention. Both pregnancies continued without problems after surgery.

CONCLUSION

Ovarian hyperstimulation during IVF-embryo transfer treatment is a risk factor for developing adnexal torsion. Early diagnosis and prompt surgical intervention is the only way to protect the ovary and preserve the pregnancy. Laparoscopic surgery in early pregnancy causes no harm to the fetus and should be encouraged once the diagnosis is confirmed. Delaying surgery may induce serious infection and jeopardize the lives of both the fetus and mother.

Association between pregnancy and adnexal torsion: A population-based, matched case-control study

The purpose of this study was to determine the effect of pregnancy on adnexal torsion (AT). We conducted a matched case-control study using the Korean Health Insurance Review and Assessment Service-National Inpatients Sample (HIRA-NIS) from 2009 to 2011. AT patients were defined as women with both a diagnostic code (N835) and a surgical code for AT. The AT patients were randomly matched 1:4 with women without AT by age and year of claim. In total, 545 AT cases and 2180 controls were enrolled from a total of 1,843,451 women. After adjustment for such covariates as age, pregnancy was found to be associated with a lower rate of AT (adjusted odds ratio 0.314, 95% confidence interval [CI] 0.237-0.416, P value <0.01) and ovarian hyperstimulation syndrome was associated with a higher rate of AT (adjusted odds ratio 20.091, 95% CI 3.607-111.908, P value <0.01). We found that pregnancy is a negative risk factor for AT. However, a further study is needed to elucidate the mechanisms underlying these results.

Investigation and Management of Adnexal Masses in Pregnancy

Adnexal masses can be found in 0.19 to 8.8% of all pregnancies. Most masses are functional and asymptomatic and up to 70% resolve spontaneously in the second trimester. The main predictors of persistence are the size (>5 cm) and the imagiological morphocomplexity. Those that persist carry a low risk of malignancy (0 to 10%). Most malignant masses are diagnosed at early stages and more than 50% are borderline epithelial neoplasms. Ultrasound is the preferred method to stratify the risk of complications and malignancy, allowing medical approach planning. Pregnancy and some gestational disorders may modify the levels of tumor markers, whereby their interpretation during pregnancy should be cautious. Large masses are at increased risk of torsion, rupture, and dystocia. When surgery is indicated, laparoscopy is a safe technique and should ideally be carried out in the second trimester of pregnancy.

Evaluation of the Diagnostic Accuracy of Serum D-Dimer Levels in Pregnant Women with Adnexal Torsion

We aimed to evaluate the diagnostic accuracy of serum D-dimer levels in pregnant women with adnexal torsion (AT). The pregnant women with ovarian cysts who suffered from pelvic pain were divided into two groups; the first group consisted of the cases with surgically proven as AT (n = 17) and the second group consisted of the cases whose pain were resolved in the course of follow-up period without required surgery (n = 34). The clinical characteristics and serum D-dimer levels were compared between the groups. Patients with AT had a higher rate of elevated serum white blood cell (WBC) count (57% vs. 16%, p = 0.04) and serum D-dimer levels (77% vs. 21%, p < 0.01) on admission in the study group than in the control group. Elevated D-dimer and cyst diameter larger than 5 cm yielded highest sensitivity (82% for each); whereas the presence of nausea and vomiting and elevated CRP had the highest specificity (85% and 88%, respectively). This is the first study that evaluates the serum D-dimer levels in humans in the diagnosis of AT, and our findings supported the use of D-dimer for the early diagnosis of AT in pregnant women.

Fetal ovarian cyst: 2- and 3-dimensional ultrasound as a new diagnostic method to rule out ovarian torsion

Owing to the improvement in obstetric ultrasound imaging, prenatal diagnosis of ovarian masses has increased considerably. Fetal ovarian cysts can be suspected when an ultrasound scan shows intra-abdominal structures in female fetuses in the presence of normal bowel and urinary structures. The most common complication is the adnexal torsion, causing partial or complete strangulation of blood supply via ovarian vessels, leading ovarian ischemia, or necrosis. Current information regarding the treatment of fetal ovarian cysts is based on personal experiences and some case series. The management is controversial, characterized by dissimilar approaches, such as “wait and see”, prenatal or postnatal aspiration, or neonatal surgery. In more than half of the cases, spontaneous regression occurs in the prenatal or postnatal period, probably due to the small size and simple aspect. Large cysts may cause both local effects (adnexal torsion, ovarian autoamputation), and distant effects (intestinal and urinary obstruction, adhesion with adjacent organs, abdominal and thoracic mass effect, pulmonary hypoplasia, hemoperitoneum, ascites, polyhyramniosis). In the absence of accurate guidelines for management, we must start with the development of more accurate methods for diagnosing associated complications such as torsion. This case report describes the role of three-dimensional (3-D) ultrasonography as potential diagnostic method for ruling out adnexal torsion when an ovarian cyst is present.

[Torsion of uterine appendages during pregnancy: report of a case at Yaoundé Central Hospital, Cameroon]

Les kystes ovariens sont dans la majorité des cas asymptomatiques et peuvent être de découverte fortuite lors d'une échographie. Ils ne deviennent symptomatiques que lorsque survient une complication. Nous présentons un cas de torsion d'annexe gauche diagnostiqué à 8 semaines et 4 jours de grossesse. Nous avons réalisé une annexectomie Suivie de l'administration de progestérone retard à la dose 500 mg par jour. L'évolution a été marquée par la survenue d'un avortement au cinquième jour post opératoire. L'analyse anatomopathologique de la masse chirurgicale a conclu à une apoplexie ovarienne. L'ablation chirurgicale du corps jaune au premier trimestre de la grossesse pose le problème du maintien de celle - ci et devrait être présente à l'esprit des praticiens avant toute chirurgie pelvienne pendant cette période.

Differences between adnexal torsion in pregnant and nonpregnant women

STUDY OBJECTIVE

To compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women.

DESIGN

Retrospective case-control study (Canadian Task Force classification II-3).

SETTING

Tertiary care university hospital.

PATIENTS

Sixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion.

INTERVENTIONS

Surgery to treat proved adnexal torsion.

MEASUREMENTS AND MAIN RESULTS

The mean (SD) gestational age in the pregnant group was 11.5 (7.7) weeks. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Sonographic demonstration of multicystic ovaries was more common in pregnant women with recurrent torsion than in women with a single episode of torsion (86% vs 31%; p = .009). Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001).

CONCLUSION

Pregnancy after treatment for infertility is a risk factor for adnexal torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries.

Comparison of adnexal torsion between pregnant and nonpregnant women

OBJECTIVE

The purpose of this study was to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women.

STUDY DESIGN

We conducted a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed.

RESULTS

Recurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women; 83.3% of pregnant women delivered at term. Laparoscopic detorsion was the main surgical procedure.

CONCLUSION

Presentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.