Home Print this page Email this page
Users Online: 779
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 4  |  Page : 282-287

Incidence of postoperative complications of simultaneous bilateral total knee arthroplasty in relation to American Society of Anesthesiologists risk scoring, pilot study


1 Department of Orthopedic Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Anesthesia and Critical Care, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
3 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication12-Oct-2016

Correspondence Address:
Abdullah M Kaki
Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulziz University, P. O. Box: 80215, Jeddah 21589
Saudi Arabia
Login to access the Email id


DOI: 10.4103/2468-6360.191910

Rights and Permissions
  Abstract 

Introduction: As a procedure, simultaneous bilateral total knee arthroplasty (SB-TKA) has not received its acceptance into routine clinical practice yet; perhaps, due to concerns regarding higher rates of perioperative complications associated with it as compared to the conventional unilateral procedure. The objective of the current study is to assess the safety of SB-TKA in relation to the American Society of Anesthesiologists (ASA) score and to assess the incidence of postoperative complications.
Materials and Methods: In a prospective study, 25 patients underwent SB-TKA between January 2011 and April 2014. The inclusion criteria comprised patients with bilateral end-stage primary osteoarthritis of knees interfering with daily activities. A well-defined pre-determined protocol for pre- and postoperative care was adhered.
Results: The study included 8 male and 17 female patients. Mean age of the patients was 66.4 ± 8.3 years. Five cases were classified as ASA-1 (20%), 11 cases as ASA-2 (44%) and 9 cases as ASA-3 (36%). No death, deep venous thrombosis, pulmonary embolism or neurological injury was reported in any of our patients postoperatively. One patient developed chest congestion on day 2 and was treated conservatively. One patient suffered from non-ST-segment elevation myocardial ischaemia on day 3 and was treated uneventfully. Two patients had a minor complication in the form of wound infection. No statistical relation was found between ASA risking score and postoperative complications.
Conclusion: SB-TKA is a safe procedure if done after careful selection of patients in addition to a proper pre- and postoperative management protocol.

Keywords: Perioperative complications, postoperative complications and American Society of Anesthesiologists score, simultaneous bilateral total knee arthroplasty


How to cite this article:
Abbas MM, Habis AA, Alshatri HY, Kaki AM. Incidence of postoperative complications of simultaneous bilateral total knee arthroplasty in relation to American Society of Anesthesiologists risk scoring, pilot study. J Health Spec 2016;4:282-7

How to cite this URL:
Abbas MM, Habis AA, Alshatri HY, Kaki AM. Incidence of postoperative complications of simultaneous bilateral total knee arthroplasty in relation to American Society of Anesthesiologists risk scoring, pilot study. J Health Spec [serial online] 2016 [cited 2019 Dec 10];4:282-7. Available from: http://www.thejhs.org/text.asp?2016/4/4/282/191910


  Introduction Top


Knee osteoarthritis (OA) is one of the most commonly encountered complaints in orthopaedic clinical practice, worldwide. Currently, the lifetime risk of developing symptomatic knee OA is approximately 50%. [1] The final solution for patients with severely advanced disease is total knee arthroplasty (TKA), especially after conservative treatment fails. [2] Symptoms of knee OA begin to manifest in 13% of women and 10% of men by the age of 60 years and above. [3] The prevalence of bilateral knee OA is about 5% [4] and the osteoarthritic process can cause debility in as many as two-thirds of affected patients. [5] However, the clinical practice at the King Abdulaziz University Hospital reveals that the majority of the cases have bilateral disease, which warrants bilateral knee surgery. In 2007, 611,000 TKAs were done in the United States, 7% of which were simultaneous bilateral (SB) while 15% were staged unilateral. It has been predicted that this number could reach up to 3.4 million TKAs by 2030; this implies a projected increase of a whopping 450% in TKAs [6] Offering the SB-TKA procedure to patients who need bilateral knee arthroplasty offers multiple advantages. Such as reduced duration of hospitalisation and increased affordability of treatment. Moreover, surgery for both knees is possible in a single session of anaesthesia with a shorter functional rehabilitation time. Hence, SB-TKA offers better feasibility as compared to unilateral or staged knee arthroplasty.

The available medical literature raises concerns of a greater risk of perioperative complications with SB-TKA as compared to unilateral or staged bilateral procedure. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] Previous clinical studies have shown divergent findings with large variations in the estimated risk of perioperative complications associated with SB-TKA. Hence, it has not been possible to reach any clinical consensus yet. A few studies have described the main advantages of SB procedure in comparison to unilateral or staged procedures. [25],[26],[27]

Although SB-TKA offers multiple advantages, as stated earlier, in comparison to unilateral staged knee arthroplasty; the acceptance of SB-TKA among the medical fraternity has been somewhat impeded by doubts and concerns regarding its safety. The greater risk of perioperative complications associated with SB-TKA has been repeatedly cited as a drawback. In lieu of this, the current study was intended to assess the safety of SB-TKA and to investigate whether the risk of associated complications can be reduced with appropriate patient selection; and with a clear postoperative protocol. In addition, we intended to correlate the postoperative complications with the American Society of Anesthesiologists (ASA) risk scoring [28] to assess the safety of our procedure between different ASA score-based subgroups of patients.


  Materials and methods Top


This study was approved by our institutional research and ethics committee and was conducted at a tertiary care university hospital in the period from January 2011 to April 2014. All ambulatory patients who were mentally healthy were booked for SB-TKA and were considered 'study eligible' if they were ASA physical Class I-III, diagnosed with bilateral end-stage primary OA interfering with their daily activities, and causing night time pain. Patients with a history of septic arthritis and rheumatoid arthritis were excluded from the study. Demographic data were collected, and ASA scoring was decided according to the history taking and physical examination performed by a senior anaesthesiologist. ASA classifies patients as follows: ASA-1: Healthy patients with no comorbidities, ASA-2: Patients with controlled medical disease, ASA-3: Patients suffering from non-controlled medical disease, ASA-4: Patients with life-threatening disease, ASA-5: Patients who are deemed ineligible to survive any kind of surgical procedure and finally ASA-6: Brain dead patients. Types of administered anaesthesia were left to the discretion of the attending anaesthesiologist. Prophylactic antibiotic in form 1 - 2 g of cefazolin depending on the patients' weight was initiated in the holding area which was to be continued postoperatively every 8 h until the epidural and Foley's catheters were removed on day 3 postoperatively. Pneumatic tourniquet was applied to surgical site at 250 mmHg. Anteromedial standard knee approach was used for surgery. Implants used were P.F.C. sigma with Cruciate-Sacrificing (Depuy Johnson and Johnson) and no drains were inserted. Clexane (low-molecular-weight heparin) 40 - 60 mg subcutaneously once daily was used according to patients' weight, initiated 6 h postoperatively and continued for 3 weeks. Postoperatively a knee immobilizer was applied most of the time for the first 3 days. After completion of day 3, the immobilizer was worn only at night time for 2 weeks. Early mobilisation with full weight bearing through a walker as well as physiotherapy was initiated from day 1 postoperatively. Clinical variables such as patients' medical history, ASA score, type of anaesthesia, operation and tourniquet time, estimated blood loss, intraoperative complications, recovery room time, antithrombotic protocol and postoperative systemic and local complications, length of hospital stay were recorded and data were analysed statistically with Statistical Science for Social Package (SPSS, Inc., Somers, NY, USA, software computer program version 20).

Descriptive statistics were used for the majority of results that showed frequency distributions with counts and percentages, central tendency using the mean, ranges and standard deviation. Finally, we used cross tabulation to check for the association of ASA score with different complications applying exact-Fisher's test or Chi-square test correspondingly. P < 0.05 was considered statistically significant.


  Results Top


The study included 8 male and 17 female patients. Mean age was 66.4 ± 8.3 years. Epidural anaesthesia was administered to 18 patients and was maintained for 3 days postoperatively for pain control. General anaesthesia was given only to one patient due to a previous history of back surgery. Five patients received combined general and epidural anaesthesia while two cases were performed under combined epidural and spinal anaesthesia [Table 1].

The mean surgical procedure time was 380.4 ± 41.9 min. Tourniquet time was 123.7 ± 24.1 min. Estimated mean volume of blood loss was 504 ml for both knees. Ninety-two per cent of patients were transfused packed red blood cells (PRBCs) postoperatively, with mean of 2.2 ± 1 units; with each PRBC unit containing a volume of 250 ml. There were no death reports, reports of deep venous thrombosis (DVT), pulmonary embolism (PE) or neurological deficit in any of the patients. None of the patients developed pneumonia; however, one patient developed desaturation on day 2 postoperatively, due to chest congestion which resolved with medical treatment. None of the patients needed Intensive Care Unit (ICU) admission post SB-TKA. One patient developed chest pain on day 3 postoperatively. The patient was diagnosed to have non-ST-segment elevation myocardial infarction (MI). The patient received therapy for MI and the outcome was uneventful. One of the patients had a wound infection while another developed superficial wound blisters and localised skin sloughing. Finally, 3 female patients developed urinary tract infection (UTIs). Patients were classified according to their ages and body mass index (BMI) into different subgroups with no statistical significance [Table 1].
Table 1: Demographic data and characteristics changes of all patients

Click here to view


The incidence of complications in relation to age, gender, BMI and ASA risk scoring system was presented in [Table 2] and [Table 3] (P ≥ 0.05). None of them had statistically significant correlation with increased risk for complications.
Table 2: Incidence of post-operative complications in relation to age, gender and body mass index

Click here to view
Table 3: Correlation of American Society of Anesthesiologists risking score, age, gender and body mass index and incidence of complications

Click here to view



  Discussion Top


The main results of this study showed that SB-TKA was not associated with a higher incidence of serious complications, for patients up to the score of ASA-3. At this juncture, it would be interesting to have a closer look at those patients who developed postoperative complications. Two patients developed local wound complications; the first got localised blister formation around the incision site, which was resolved within a span of 2 weeks. He was a diabetic, hypertensive patient and had an ASA-3 score with a history of cardiac stenting 3 years before this procedure. The second patient developed a superficial wound infection in one of her knee incisions, and she underwent operative irrigation and debridement and was treated with intravenous antibiotics. The patient who sustained a cardiac event presented with chest pain on day 3 postoperatively and was diagnosed to have a non-ST segment elevation MI. Spiral computed tomography of the chest ruled out PE. This patient was diabetic, hypertensive, and classified as an ASA-3 class patient, in whom preoperative echocardiogram examination revealed normal left ventricular systolic function with grade 1 diastolic dysfunction and an ejection fraction of 71%. This was the only patient who had the procedure under general anaesthesia due to previous history of multiple lumbar spinal surgeries. Although the event did not warrant an ICU admission, the patient was treated conservatively and discharged 13 days later. Three female patients developed UTI. One patient developed oxygen desaturation on day 2 postoperatively due to chest congestion and recovered after conservative therapy. She has a history of diabetes, hypertension and hypercholesterolaemia; her ASA score was 2 and the procedure was performed under epidural anaesthesia.

The available medical literature presents divergent views regarding SB-TKA. [7],[8],[9],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] Past studies have indicated that SB-TKA increases the risk of perioperative complications as compared to the unilateral staged arthroplasties, and hence does not seem to be a safe approach. On the other hand, the existing evidence supports the proposition that SB-TKA is a safe procedure with no increased risk of complications in comparison to the unilateral procedure. In fact, evidence favouring SB-TKA highlights other advantages of this procedure as compared to unilateral surgery such as reduced hospitalisation time, better affordability, faster recovery, and the opportunity to operate on both affected knees in a single session of anaesthesia with better patient compliance. Faster rehabilitation is in favour of SB-TKA when compared with unilateral knee arthroplasty, as the unoperated side in the staged procedure can impede quick gain of function. [25],[26],[27] In a systematic review, Noble et al., compared different research studies in this regard to arrive to a consensus. It seems a daunting task due to significant interstudy variation seen with respect to reported morbidity and mortality figures put forth by these studies. [11] However, a noteworthy commonality was the fact that most research studies included in this systematic review favoured the maxim which states that a thorough preoperative assessment, appropriate patient selection and strict protocols for postoperative care; hold the key to improving the safety of SB-TKA. In 2010, Yoon et al., divided his sample of patients according to ASA classification into low risk (ASA-1 and 2) and high risk (ASA-3 and 4) subgroups. [25] The study compared the risk of complications between SB-TKA and unilateral staged arthroplasties. Yoon et al., findings seem quite similar to the results obtained in this study. In Yoon et al., study, the high-risk subgroup with an ASA score of 3 did not experience any thromboembolic events or mortality related to the bilateral surgical procedure. In this study, 9 patients scored as ASA-3 underwent SB-TKA without any notable rise in serious complications. Trojani et al., [8] demonstrated that with appropriate patient selection, SB-TKA is a safe approach, particularly for patients with ASA scores 1 - 2. They conducted the study in 30 patients. Three of them were diagnosed with postoperative DVT while one patient had a cardiopulmonary event and requested ICU admission for 1 day. No death, MI, PE or early infection was reported in their study. In 2013 Jenny et al., conducted a retrospective study [9] including 123 patients to compare SB-TKA with unilateral surgery. The researchers reported that the safety profile of both surgical approaches was comparable in their patient cohort. Bolognesi et al., compared 4,519 SB cases with 3,788 staged procedures. It was reported that the risk of infection and the need of revision surgeries were similar between the two groups. There was a marginal increase in serious complications with SB-TKA as compared to the unilateral staged procedure. However, the differences were neither clinically meaningful nor statistically significant. [29]

On the other hand, Memtsoudis et al., [26] in a nationally representative dataset, reported a statistically significantly higher risk of perioperative complications with SB-TKA, when compared to unilateral procedure. Complications rate in general was 9.45% for the simultaneous group versus 7.07% for the unilateral group, PE rate was 0.82% versus 0.39%, venous thromboembolism rate was 1.21% versus 0.72% and mortality rate was 0.3% versus 0.14%. Fu et al., published a systematic review that included 18 retrospective comparative studies on this topic spanning a total of 107,318 patients. Of these, 28,760 underwent SB surgery while 78,760 had unilateral staged procedure. [4] The results did not show any statistically significant difference in terms of DVT, cardiac complications, superficial infection or neurological complications postoperatively. In addition, the simultaneous procedure was associated with lower risk of deep infection and the need for revision surgery; however, they found that 30 days mortality, PE and the need for blood transfusion were significantly higher in this group. Perhaps the higher mortality rate in the bilateral surgery group was attributable to the higher PE seen in this subgroup. It is essential to mention the postoperative care in form of adequate anticoagulation programs, mobilisation, physiotherapy protocols and usage of pneumatic compression devices; however, unfortunately, they were not mentioned in the published paper. Meehan et al., [6] in a retrospective study compared 11,445 simultaneous procedures with 23,715 staged procedures. This study revealed that patients with higher risk of cardiovascular diseases were unsuitable for SB-TKA as it could predispose them to an increased risk of MI or PE postoperatively. Recently, Niki et al., compared 60 cases of SB procedure with equal numbers of stage one procedures and stage two procedures. [30] The study favoured the multiple benefits of simultaneous procedure, if preventive measures were applied. In another study by Odum and Springer, the risk of minor and major complications was compared among 24,574 cases of SB and 382,496 cases of unilateral procedures. [7] The study revealed that both SB and unilateral procedures have a low rate of complications. African-American and Asian-Pacific ethnicity, male gender, hospitals with low volume of knee arthroplasty cases and advancing age (≥75 years); were identified as risk factors for minor complications. This study, however, did not comment on the risk factors for major complications.

Fabi et al., found that bilateral surgery was the procedure of choice after proper patient selection. This study emphasised the need for proper patients' selection as patient's age above 75 years and a BMI >30 are significantly associated with greater risk of complications after bilateral surgery. [27] In this study, age, gender and BMI did not seem to have statistically significant correlation with the increased risk for complications. However, further studies with larger sample sizes are needed to validate a possible correlation between these variables and the risk of postoperative complications with bilateral surgeries as the subject numbers were limited in this study due to the difficulty in recruiting patients.


  Conclusion Top


This study reveals that SB-TKA is a safe procedure if done after careful selection of patients in addition to a proper preoperative preparation and strict postoperative management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 2008;59:1207-13.  Back to cited text no. 1
    
2.
Sabari Girish R, Gopalakrishnan KC, Sugath S, Anoop S. Simultaneous bilateral total knee arthroplasty - Is it the final answer. Kerala J Orthop 2011;24:15-22.  Back to cited text no. 2
    
3.
Heidari B. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian J Intern Med 2011;2:205-12.  Back to cited text no. 3
    
4.
Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z. Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: A systematic review of retrospective studies. J Arthroplasty 2013;28:1141-7.  Back to cited text no. 4
    
5.
Leonard L, Williamson DM, Ivory JP, Jennison C. An evaluation of the safety and efficacy of simultaneous bilateral total knee arthroplasty. J Arthroplasty 2003;18:972-8.  Back to cited text no. 5
    
6.
Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH. A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Joint Surg Am 2011;93:2203-13.  Back to cited text no. 6
    
7.
Odum SM, Springer BD. In-hospital complication rates and associated factors after simultaneous bilateral versus unilateral total knee arthroplasty. J Bone Joint Surg Am 2014;96:1058-1065.  Back to cited text no. 7
    
8.
Trojani C, Bugnas B, Blay M, Carles M, Boileau P. Bilateral total knee arthroplasty in a one-stage surgical procedure. Orthop Traumatol Surg Res 2012;98:857-62.  Back to cited text no. 8
    
9.
Jenny JY, Trojani C, Prudhon JL, Vielpeau C, Saragaglia D, Houillon C, et al. Simultaneous bilateral total knee arthroplasty. A multicenter feasibility study. Orthop Traumatol Surg Res 2013;99:191-5.  Back to cited text no. 9
    
10.
Bullock DP, Sporer SM, Shirreffs TG Jr. Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications. J Bone Joint Surg Am 2003;85-A: 1981-6.  Back to cited text no. 10
    
11.
Noble J, Goodall JR, Noble DJ. Simultaneous bilateral total knee replacement: A persistent controversy. Knee 2009;16:420-6.  Back to cited text no. 11
    
12.
Adili A, Bhandari M, Petruccelli D, De Beer J. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients > or = 75 years old: Complications and functional outcomes. J Arthroplasty 2001;16:271-8.  Back to cited text no. 12
    
13.
Ansari S, Warwick D, Ackroyd CE, Newman JH. Incidence of fatal pulmonary embolism after 1,390 knee arthroplasties without routine prophylactic anticoagulation, except in high-risk cases. J Arthroplasty 1997;12:599-602.  Back to cited text no. 13
    
14.
Cohen RG, Forrest CJ, Benjamin JB. Safety and efficacy of bilateral total knee arthroplasty. J Arthroplasty 1997;12:497-502.  Back to cited text no. 14
    
15.
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81:2-10.  Back to cited text no. 15
    
16.
Bottner F, Pavone V, Johnson T, Heitkemper S, Sculco TP. Blood management after bilateral total knee arthroplasty. Clin Orthop 2003; 410:254-61.  Back to cited text no. 16
    
17.
Lane GJ, Hozack WJ, Shah S, Rothman RH, Booth RE Jr, Eng K, et al. Simultaneous bilateral versus unilateral total knee arthroplasty. Outcomes analysis. Clin Orthop 1997;345:106-12.  Back to cited text no. 17
    
18.
Lombardi AV, Mallory TH, Fada RA, Hartman JF, Capps SG, Kefauver CA, et al. Simultaneous bilateral total knee arthroplasties: who decides? Clin Orthop 2001;392:319-29.  Back to cited text no. 18
    
19.
Lynch NM, Trousdale RT, Ilstrup DM. Complications after concomitant bilateral total knee arthroplasty in elderly patients. Mayo Clin Proc 1997;72:799-805.  Back to cited text no. 19
    
20.
Ritter MA, Harty LD, Davis KE, Meding JB, Berend M. Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Joint Surg Am 2003;85-A: 1532-7.  Back to cited text no. 20
    
21.
Ritter M, Mamlin LA, Melfi CA, Katz BP, Freund DA, Arthur DS. Outcome implications for the timing of bilateral total knee arthroplasties. Clin Orthop Relat Res 1997;345:99-105.  Back to cited text no. 21
    
22.
Williams-Russo P, Urquhart BL, Sharrock NE, Charlson ME. Post-operative delirium: Predictors and prognosis in elderly orthopedic patients. J Am Geriatr Soc 1992;40:759-67.  Back to cited text no. 22
    
23.
Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG. Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am 2001;83-A: 1157-61.  Back to cited text no. 23
    
24.
Mangaleshkar SR, Prasad PS, Chugh S, Thomas AP. Staged bilateral total knee replacement - A safer approach in older patients. Knee 2001;8:207-11.  Back to cited text no. 24
    
25.
Yoon HS, Han CD, Yang IH. Comparison of simultaneous bilateral and staged bilateral total knee arthroplasty in terms of perioperative complications. J Arthroplasty 2010;25:179-85.  Back to cited text no. 25
    
26.
Memtsoudis SG, Ma Y, González Della Valle A, Mazumdar M, Gaber-Baylis LK, MacKenzie CR, et al. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology 2009;111:1206-16.  Back to cited text no. 26
    
27.
Fabi DW, Mohan V, Goldstein WM, Dunn JH, Murphy BP. Unilateral vs bilateral total knee arthroplasty risk factors increasing morbidity. J Arthroplasty 2011;26:668-73.  Back to cited text no. 27
    
28.
Saklad M. Grading of patients for surgical procedure. Anesthesiology 1941;2:281.  Back to cited text no. 28
    
29.
Bolognesi MP, Watters TS, Attarian DE, Wellman SS, Setoguchi S. Simultaneous vs staged bilateral total knee arthroplasty among Medicare beneficiaries, 2000-2009. J Arthroplasty 2013;28 8 Suppl: 87-91.  Back to cited text no. 29
    
30.
Niki Y, Katsuyama E, Takeda Y, Enomoto H, Toyama Y, Suda Y. Comparison of postoperative morbidity between simultaneous bilateral and staged bilateral total knee arthroplasties: Serological perspective and clinical consequences. J Arthroplasty 2014;29:504-9.  Back to cited text no. 30
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed1886    
    Printed34    
    Emailed0    
    PDF Downloaded136    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]