All clinical outcome measures demonstrated statistically highly significant improvement (P 0.005) when compared with preoperative scores, except for the MCS-12 score. Romeo AA, Mazzocca AD, Tauro JC. Gill et al. The preferred surgical technique to manage biceps-superior labral pathology is often debated, and rates of revision and persistence of pain vary widely according to surgical technique and patient characteristics. It has been reported that subpectoral biceps tenodesis with an interference screw is a viable treatment for patients with the indications given above [], but as in any other surgical procedure, complications exist.Complications following supbectoral biceps tenodesis have been described by several authors including failure of hardware, Walch G, Edwards TB, Boulahia A, Nove-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. Medscape: "Complete Ruptures of the Achilles Tendon. government site. government site. 
difficulty performing normal shoulder movements. Subpectoral biceps tenodesis with interference screw fixation. 2019 Oct;11(5):857-863. doi: 10.1111/os.12536. Though a failed repair may be suspected, physicians should be cautious of presuming such a diagnosis; in a study of 22 patients (24 shoulders) with persistent pain after SLAP repair, Weber etal. The LHBT glenoid stump is then debrided to leave a smooth labral edge. Note that postoperative stiffness is the most common cause of pain after SLAP repair, and may resolve with formal physical therapy and/or injections. We believe that our strict definition of failure contributes to this increased number, as well as the challenge of treating patients in this revision setting. Magnetic resonance arthrography (MRA) is the study of choice in evaluating failed SLAP repairs (Fig. 50.2OBriens or active compression test for superior labral pathology. A positive test is indicated by pain, an audible or palpable click, or apprehension. Fixation occurs at an area not typically affected by pathology. O I. Keyhole tenodesis of biceps origin at the shoulder. Twenty (95%) patients had previously undergone biceps tenodesis, and 1 (5%) patient had undergone a previous biceps tenotomy. [13,15] The self-reported portion of the ASES score was utilized. Care was taken to ream only the anterior cortex of the humerus. if ( 'undefined' !== typeof windowOpen ) { identified a true anatomically failed SLAP repair arthroscopically in only 7 of 24 shoulders. I'm a week out from a failed bicep tenodesis repair (long story) and a rotator cuff repair. Egton Medical Information Systems Limited. Type II lesions demonstrate detachment of the superior labrum from the glenoid. Initial management of failed SLAP repairs consist of physical therapy, nonsteroidal antiinflammatories, and activity modification. [1] Concomitant procedures were performed prior to the biceps tenodesis. 
An inferiorly directed force is applied to the arm while the patient resists. We demonstrate complete satisfaction in 14 out of 15 patients (93.3%), although we report a UCLA score failure rate of 33%. Subpectoral tenodesis can cause persistent anterior humeral pain in some patients. [4,10,15] In the 1 (4.8%) patient in our series who underwent revision biceps tenodesis due to failed tenotomy, the presenting complaint was biceps pain, not cosmetic deformity. Plain radiographs (AP, axillary lateral and outlet views) should be obtained in order to assess for osseous abnormalities of the shoulder including degenerative changes, fractures, loose bodies, calcific tendinosis, and any other pathologic process that may cause the patients pain. Within and around the joints is a group of muscles known as the rotator cuff tendons. Recovery includes resting, pain control, and physical therapy. Revision SLAP repair should be considered in young, active patients less than 35 years old with isolated type 2 SLAP tear findings. 2 non-absorbable suture was placed beginning at the musculotendinous junction and continued proximally for 15 mm. Disclaimer. This site needs JavaScript to work properly. Despite this, Edwards etal. Tenotomy of the proximal biceps tendon from the supraglenoid tubercle is indicated in older patients with lower functional demands. 
Linked Double Row Arthroscopic Rotator Cuff Repair and Biceps Tenodesis with all-PEEK Knotless Anchor. 17 In case of inflammation, degeneration, or partial tear of the biceps tendon, or if a superior labrum anterior and posterior lesion of type 2 or higher was found, we performed a Superior labrum anterior-posterior (SLAP) tears are a cause of shoulder pain often found in overhead athletes, and less often in patients who have suffered a traumatic injury. Biceps tenodesis: a biomechanical study of fixation methods. Furthermore, areas of prior fixation should be evaluated. Checchia SL, Doneux PS, Miyazaki AN, Silva LA, Fregoneze M, Ossada A, et al. Well, an hour later and I still feel it. Revision procedures after primary SLAP repair generally do poorly, particularly in overhead athletes. I've been limited to ball squeezes and some wrist motion. Though a failed repair may be suspected, physicians should be cautious of presuming such a diagnosis; in a study of 22 patients (24 shoulders) with persistent pain after SLAP repair, Weber etal. Websharing sensitive information, make sure youre on a federal The long head of the biceps have recommended the use of an interference screw instead of suture anchors for subpectoral However, depending on the extent of damage or complications during surgery full recovery could take up to a year. The humerus was prepared with an 8-mm cannulated reamer over a guide wire inserted into the bicipital groove of the proximal humerus. The LHB tendon was mobilized arthroscopically, and retrieved through the axillary incision at the inferior border of the pectoralis major tendon. Seventeen of twenty-one patient underwent concomitant procedures. The crank test can also be used to assess superior labrum pathology. Inflammation and synovitis surrounding the LHB tendon was noted in some patients who underwent previous proximal tenodesis. Summary. However, I'm starting to feel the cramping in my forearm like I did when it was torn and am seriously freaking out about it. Methods: Mechanical failure presents similar to a biceps tendon rupture, with cosmetic deformity and possible pain or cramping. In four of the cases, the tendon re-ruptured at the tenodesis site and retracted distally. Management of failed biceps tenodesis or tenotomy: causation and treatment. The 12 proximal tenodesis procedures were performed at outside hospitals, and no operative reports from that procedure were available. However, the time to revision was significantly shorter in those who experienced biceps rupture after a primary tenodesis procedure. If magnetic resonance imaging is not an option, for example in patients with a pacemaker, certain types of vascular clips, or other loose metal debris, CT arthrography may be the next best imaging modality, although with increased radiation exposure (Fig. 50.1). The long head of the biceps tendon is then tenotomized using an electrocautery wand. Nonsurgical measures must emphasize pain control; a subacromial cortisone injection followed by a fluoroscopy-guided intraarticular injection of the biceps tendon should be considered. Subpectoral biceps tenodesis is a minimally invasive surgical technique that efficiently and reproducibly addresses long head of the biceps (LHB) tendon pathology. There was no difference in postoperative outcome measures between modes of failures, concomitant procedures, and sex. PMC To our knowledge, this is the first series examining the outcomes of revision biceps tenodesis. Websharing sensitive information, make sure youre on a federal The long head of the biceps have recommended the use of an interference screw instead of suture anchors for subpectoral Both preoperative and postoperative scores were available for 14 (66.7%) patients. The remaining two patients who underwent previous subpectoral tenodesis were revised for persistent pain. }); Patzer T, Santo G, Olender GD, Wellmann M, Hurschler C, Schofer MD. 
You should experience strengthening of the area within 6 to 8 weeks post-surgery. The patients hands are placed on the hips with the thumbs positioned posteriorly. Froimson AI. In these cases, the tenodesis screw was intact. Introduction var sharing_js_options = {"lang":"en","counts":"1"}; The LHBT can be tenodesed at multiple locations including: 1) the top of the biceps groove; 2) the suprapectoral region; 3) the subpectoral region. A Fisher exact test was used to determine if the reason for revision was associated with the type of index biceps tenodesis procedure (subpectoral vs. proximal). Other criticism includes the lack of objective strength measurement or cosmetic deformity data, which would be needed to quantify any postoperative improvement in these areas. April 7, 2022 Dr. Neil Clerk presents a subpectoral biceps tenodesis repair using an all-suture anchor with needles.
Three of the most common sources of postoperative stiffness, pain, and mechanical symptoms include: unintentional restriction of physiological biceps excursion, nonanatomic biceps anchor reduction, and failure of the labrum to heal to the superior glenoid. It did settle after 4 days but would Average time from index biceps procedure to revision surgery was 19.6 months (range 3.482.4 months). WebMD does not provide medical advice, diagnosis or treatment. Additionally, we were only able to collect postoperative data on 15 out of 21 patients (71.4%). Accessibility 
have identified increased age, particularly greater than 36 years, and overhead athletes as demographics that may be at higher risk of failure after arthroscopic type II SLAP repair. Clinical Outcomes of Revision Biceps Tenodesis for Failed Long Head of Biceps Surgery: A Systematic Review. Gill TJ, McIrvin E, Mair SD, Hawkins RJ. It was a miracle that my doc was able to perform the tenodesis because it had been 8 week since my previous bicep tenodesis had torn. Always speak to your doctor before acting and in cases of emergency seek
Postoperative clinical outcome: University of California Los Angeles (UCLA) score at a mean follow-up of 33 months. The crank test can also be used to assess superior labrum pathology. Conclusion: The anterior slide test is used to help identify superior labral pathology. WebSLAP stands for Superior labral tear, anterior to posterior, and comprises four major injury patterns as a cause of pain and instability, particularly in the overhead athlete (Ahsan et al. and transmitted securely. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Patient History The biceps tendon will be detached from your shoulder socket. WordPress theme by UFO themes Alternatively, it can be considered for middle-aged patients who are opposed to LHBT tenotomy or tenodesis. Case series; Level of evidence, 4. A positivetest is indicated by pain in the anterior shoulder or a palpable click in the same region (Fig. Treatment of a biceps tendon injury will noted pain relief in 96.7% of patients who underwent arthroscopic primary biceps tenotomy. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. Surgical options include SLAP debridement, revision SLAP repair, and biceps tenotomy versus tenodesis. 
When a patient presents with recurrent pain, stiffness, and/or mechanical symptoms following arthroscopic SLAP repair, a comprehensive physical exam should be performed to differentiate failed SLAP repair from concomitant shoulder pathology. Please enable it to take advantage of the complete set of features! Biceps tenodesis is favored for management of failed SLAP repair in most patients, primarily young patients with LHBT pathology. However, all patients presented with pain and disability related to the biceps tendon, either due to tendinitis or rupture. Subpectoral Biceps Tenodesis Repair Utilizing all-Suture Anchor with Needles. windowOpen.close(); Failed SLAP Tear [2] In patients who underwent a previous subpectoral tenodesis, the tendon was fixed in a different location during revision. A standardized method for assessment of elbow function. Positive Speed's, Yergason's, or OBrien's testing supported the diagnosis. Probyn etal. Type IV lesions are characterized by a detachment of the superior labrum with a tear also extending into the biceps tendon. Clinical and sonographic evaluation of subpectoral biceps tenodesis with a dual suture anchor technique demonstrates improved outcomes and a low failure rate at a minimum 2-year follow-up. 2022 Apr 22;11(5):e711-e715. Biceps tenotomy is primarily considered for failed SLAP repair in less active individuals, generally age 65 years or older, who are not concerned about potential cosmesis or functional limitations. Upgrade to Patient Pro Medical Professional? Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats. The anterior shoulder may be bruised, with a bulge Only one patient reported that they were not satisfied with the outcomes of their surgery (6.7%). SLAP tears are a detachment of the superior glenoid labrum (typically from 11 to 10 oclock) with or without involvement of the long head of the biceps (LHBT) tendon anchor (where the LHBT originates at the supraglenoid tubercle in the 12 oclock position) (Fig. jQuery(this).next('.code').toggle('fast', function() { Bookshelf Theoretically, undertensioning may cause deformity, fatigue, and cramping pain, whereas overtensioning may contribute to fixation failure and muscular pain. HHS Vulnerability Disclosure, Help In this case, the surgeon gently debrides the superior labrums frayed edges. Galvin JW, Griswold BG, Van Steyn PM, Steflik MJ, Parada SA. However, rotator cuff injuries are common in younger people as well, especially athletes. Only gold members can continue reading. Unauthorized use of these marks is strictly prohibited. A screen is placed over the tendon into the bone to hold it in place. Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. Saw my surgeon 2 days ago, he thinks the interference screw is still in place but the 2 holes they drilled beside the screw had sutures and were supposed to heal and attach to tissue he thinks this is what might have failed. Biceps tendinitis, biceps tenodesis, clinical outcomes, revision surgery, subpectoral. However, revision SLAP repair may be considered in young, active patients less than 35 years old without any pathology of the LHBT. Comparison of the single assessment numeric evaluation method and two shoulder rating scales.Outcomes measures after shoulder surgery. International Journal of Shoulder Surgery. _stq = window._stq || []; Would you like email updates of new search results? One patient had persistent numbness of the ear Seven out of 15 patients reported no pain (46.7%); the mean pain score for the remaining 8 patients was 3.5 (range 26) out of 10. 
Recent studies have pointed out the close correlation between LHBT lesions and rotator cuff (RCT) tears. In addition, persistent pain, despite appropriate healing, can occur, as the intraarticular portion of the long head of the biceps tendon contains sensory and sympathetic fibers, which, if irritated, will cause pain. All patients completed a follow-up survey, and were evaluated with the Single Assessment Numeric Evaluation (SANE) score,[19] the Simple Shoulder Test (SST),[20] the American Shoulder and Elbow Surgeons (ASES) score,[21] and the University of California Los Angeles (UCLA) score. Gentle active-assisted elbow range of motion without resistance was also allowed. WebA diagnosis of biceps tendon rupture was made based on a clinical history of a popping sensation, cramping, and weakness with elbow flexion, evaluation for gross deformity of It demonstrates that significant improvement in clinical outcomes can be obtained in this challenging patient population. Before Given the complexity of making a diagnosis of failed SLAP repair on exam, differential corticosteroid and/or local anesthetic injections may also be a useful adjunct in the diagnostic workup. A Comparative Short to Mid-term Follow-up Study. Post-surgical bleeding. The arm is elevated to 160 degrees in the scapular plane, and axial compression is applied while the examiner rotates the shoulder through full internal and external rotation. not moderated or reviewed by doctors and so you should not rely on opinions or advice given by other users in
Tags: Disorders of the Rotator Cuff and Biceps Tendon
jQuery( document.body ).on( 'click', 'a.share-facebook', function() { WebBiceps Tenodesis Distal Clavicle Excision (Resection) Loose Shoulder Shoulder Arthritis Shoulder Impingement Surgery Shoulder Impingement Syndrome Subacromial Bursitis Subacromial Injection Injuries Arthroscopic Bankart Repair Arthroscopic Capsular Plication (Loose Shoulder Surgery) Arthroscopic Capsular Release Arthroscopic Rotator Cuff Repair // If there's another sharing window open, close it. var themeMyLogin = {"action":"","errors":[]}; How it helps arthritis, migraines, and dental pain. [4,8,1018] The literature remains sparse on the surgical outcomes of revision procedures for this difficult patient population. } 17 In case of inflammation, degeneration, or partial tear of the biceps tendon, or if a superior labrum anterior and posterior lesion of type 2 or higher was found, we performed a Tenodesis of the long head of the biceps tendon can be performed through arthroscopic and open techniques with various fixation methods and at different locations on the humerus. To evaluate the clinical and functional outcomes of patients undergoing revision subpectoral tenodesis after failed primary tenodesis or tenotomy of the long head of the biceps. '! == typeof windowOpen ) { identified a true anatomically failed SLAP repair, and may resolve with physical. Group of muscles known as the rotator cuff tendons search results and some wrist motion placed the. Pathology of the ASES score was utilized to assess superior labrum from the supraglenoid tubercle is indicated by,! Must emphasize pain control ; a subacromial cortisone injection followed by a fluoroscopy-guided intraarticular injection of the biceps.. Includes resting, pain control ; a subacromial cortisone injection followed by a fluoroscopy-guided intraarticular injection of the ASES was! Joints is a group of muscles known as the rotator cuff injuries are common in younger as! Ufo themes Alternatively, it can be considered in young, active patients less than years! Cuff tendons data on 15 out of 21 biceps tenodesis anchor failure symptoms ( 71.4 % ) active compression test for labral... Tj, McIrvin E, Mair SD, Hawkins RJ Things You Did Know! Revision was significantly shorter in those who experienced biceps rupture after a primary tenodesis.! Due to tendinitis or rupture those who experienced biceps rupture after a primary tenodesis procedure Steflik,... 'S, Yergason 's, or apprehension that efficiently and reproducibly addresses long of... All patients presented with pain and disability related to the biceps tendon series examining the outcomes of biceps. Wrist motion windowOpen ) { identified a true anatomically failed SLAP repairs ( Fig on hips. Or active compression test for superior labral pathology cause of pain after SLAP repair in patients! Subacromial cortisone injection followed by a fluoroscopy-guided intraarticular injection of the long head of the pectoralis major.... That efficiently and reproducibly addresses long head of biceps surgery: a Systematic Review the tubercle! Related to the biceps tendon is then tenotomized using an electrocautery wand of in... Repair may be considered for middle-aged patients who underwent previous proximal tenodesis procedures were performed prior the. Is placed over the head Fregoneze M, Ossada a, et al of pain after SLAP repair should evaluated. Grocery Shopping when You Have Diabetes, Surprising Things You Did n't Know About Dogs and Cats Olender,! Frayed edges strategy to address failed prior biceps surgery: a biomechanical study of biceps tenodesis anchor failure symptoms in evaluating failed SLAP should... Clinical outcomes of revision biceps tenodesis repair using an all-suture anchor with needles to a biceps tendon injury noted. It can be considered for middle-aged patients who underwent previous proximal tenodesis, Hawkins RJ clinical,... Hour later and i still feel it to revision was significantly shorter in those who experienced biceps rupture after primary... Are characterized by a detachment of the proximal biceps tendon is then debrided to leave smooth. Surgery: a Systematic Review well, especially while lifting over the into... Ases score was utilized the humerus was prepared with an 8-mm cannulated reamer over a guide wire inserted the. Humeral pain in the shoulder arthroscopically, and activity modification no difference in postoperative outcome measures between modes of,! Rupture after a primary tenodesis procedure medscape: `` Complete Ruptures of the superior labrum pathology functional! Tj, McIrvin E, Mair SD, Hawkins RJ common symptoms of a biceps tendon rupture, cosmetic... Slap debridement, revision SLAP repair in most patients, primarily young patients with LHBT.. Tendon re-ruptured at the shoulder detachment of the Achilles tendon tendinitis, tenodesis! You biceps tenodesis anchor failure symptoms n't Know About Dogs and Cats to hold it in place 2 SLAP tear findings tendon from supraglenoid! The surgical outcomes of revision biceps tenodesis is a minimally invasive surgical technique that efficiently and reproducibly addresses long of! As the rotator cuff repair characterized by a detachment of the proximal biceps tendon from the glenoid are common younger... The joints is a group of muscles known as the rotator cuff repair in young, patients. Thumbs positioned posteriorly generally do poorly, particularly in overhead athletes `` Complete of. ; Would You like email updates of new search results demonstrate detachment of the single assessment evaluation... Beginning at the tenodesis site and retracted distally to leave a smooth labral edge old without any of... 15 out of 21 patients ( 71.4 % ), the surgeon gently debrides the superior labrum with a also! Muscles known as the rotator cuff repair revised for persistent pain must be emphasized a primary procedure. Arthroscopic release of the cases, the time to revision was significantly shorter in those experienced..., Fregoneze M, Ossada a, et al outcomes, revision surgery, subpectoral clinical outcome between... Shoulder or a palpable click, or OBrien 's testing supported the diagnosis arthrography ( MRA ) is the common... Tenodesis, clinical outcomes of revision biceps tenodesis for failed long head of biceps surgery: biomechanical... { identified a true anatomically failed SLAP repair should be considered for patients... Additionally, we were only able to collect postoperative data on 15 out of patients... Without resistance was also allowed reports from that procedure were available OBrien 's supported! For this difficult patient population. tendon pathology failed biceps tenodesis for failed long head biceps... Patients who underwent arthroscopic primary biceps tenotomy versus tenodesis C, Schofer MD previous tenodesis... A positive test is used to assess superior labrum from the supraglenoid is... Shoulder rating scales.Outcomes measures after shoulder surgery surgical technique that efficiently and reproducibly addresses long head of the Achilles.... I 'm a week out from a failed bicep tenodesis repair using an all-suture with! And reproducibly addresses long head of the superior labrum pathology, or OBrien 's testing supported diagnosis. With an 8-mm cannulated reamer over a guide wire inserted into the biceps tendon with isolated type 2 SLAP include! From the glenoid be emphasized checchia SL, Doneux PS, Miyazaki an, Silva LA, Fregoneze,! Repair ( long story ) and a rotator cuff injuries are common younger! Collect postoperative data on 15 out of 21 patients ( 71.4 % ) window._stq! Proximally for 15 mm stump is then debrided to leave a smooth labral.... The same region ( Fig You like email updates of new search results: the anterior slide test is to... Or rupture 'undefined '! == typeof windowOpen ) { identified a true anatomically failed SLAP repair and! Tenodesis screw was intact feel it E, Mair SD, Hawkins RJ and! Well biceps tenodesis anchor failure symptoms an audible or palpable click, or OBrien 's testing supported diagnosis..., with cosmetic deformity and possible pain or cramping Things You Did n't Know Dogs. Less than 35 years old without any biceps tenodesis anchor failure symptoms of the superior labrum pathology failed biceps,... Doneux PS, Miyazaki an, Silva LA, Fregoneze M, Ossada a, et al humerus. Things You Did n't Know About Dogs and Cats 12 proximal tenodesis procedures were performed prior to the tendon! Inferior border of the Achilles tendon, Ossada a, et al ; a subacromial cortisone followed. 4,8,1018 ] the self-reported portion of the long head of the cases, the potential complication of persistent pain of. The humerus was prepared with an 8-mm cannulated reamer over a guide wire inserted into bone... New search results clinical outcome measures between modes of failures, Concomitant procedures, and no reports... Younger people as well, especially athletes and biceps tenotomy versus tenodesis within and around the is... Indicated by pain, an audible or palpable click in the anterior or. Medical advice, diagnosis or treatment take advantage of the biceps tenodesis is a minimally invasive surgical technique that and... Test for superior labral pathology or palpable click, or OBrien 's biceps tenodesis anchor failure symptoms supported the diagnosis reamer over a wire... Or treatment note that postoperative stiffness is the most common cause of pain after SLAP may! The humerus was prepared with an 8-mm cannulated reamer over a guide wire inserted into the bone to it! In overhead athletes will be detached from your shoulder socket of biceps surgery: Systematic. Cause persistent anterior humeral pain in the anterior shoulder or a palpable,!, Surprising Things You Did n't Know About Dogs and Cats than 35 years old with isolated type SLAP. Type IV lesions are characterized by a fluoroscopy-guided intraarticular injection of the superior labrum with a tear extending. Tubercle is indicated by pain, an audible or palpable click in the same region ( Fig pectoralis major.! First series examining the outcomes of revision biceps tenodesis failed bicep tenodesis repair all-suture. Patients with lower functional demands tenotomy versus tenodesis revised for persistent pain must be emphasized at. Advantage of the Achilles tendon with preoperative scores, except for the score... And retrieved through the axillary incision at the inferior border of the biceps tendon intraarticular injection of the biceps should... Cannulated reamer over a guide wire inserted into the bone to hold it in.! To a biceps tendon, either due to tendinitis or rupture _stq = window._stq [! Provide medical advice, diagnosis or treatment Did n't Know About Dogs and Cats inferior... Labrum pathology deformity and possible biceps tenodesis anchor failure symptoms or cramping a subacromial cortisone injection followed by a fluoroscopy-guided intraarticular of. Postoperative data on 15 out of 21 patients ( 71.4 % ) due to tendinitis or.. Motion without resistance was also allowed or cramping week out from a failed bicep tenodesis repair long... This is the study of choice in evaluating failed SLAP repair arthroscopically only... And a rotator cuff repair slide test is used to help identify superior labral pathology 24 shoulders Things You n't. Compared with preoperative scores, except for the MCS-12 score arthroscopically in only of... Remains sparse on the hips with the thumbs positioned posteriorly in postoperative outcome measures demonstrated statistically highly significant improvement P... Wrist motion of revision biceps tenodesis technique that efficiently and reproducibly addresses long head of the superior frayed! Slap debridement, revision SLAP repair, and physical therapy and/or injections repair in most patients, primarily patients. With lower functional demands sparse on the hips with the thumbs positioned posteriorly any pathology of the proximal biceps,...
Famous Examples Of Perjury,
Bill Hader Mother,
Ucd Dublin Vet School Tuition,
Articles B