Vol 7, No 4 (2019)

Original studies
A comparative analysis of the surgical treatment of preschool children with congenital spinal deformation and isolated hemivertebra from the combined and dorsal approaches
Vissarionov S.V., Syundyukov A.R., Kokushin D.N., Khusainov N.O., Khardikov M.A.
Abstract

Background. Currently, there are many studies on the evaluation of the results of surgical intervention and the comparative analysis of various surgical techniques for treating children with congenital spinal deformities. However, there is no consensus regarding the choice of surgical access to the abnormal vertebra that considers the duration of surgery, the volume of intraoperative blood loss, the degree of correction achieved during the intervention, the length of metal fixation, and the preservation of the result in the long-term observation period.

Aim. The goal is to identify the advantages and disadvantages of the dorsal and combined approaches to the surgical treatment of preschool children with congenital deformities of the thoracic and lumbar spine against the background of an isolated violation of the vertebral formation.

Materials and methods. A retrospective analysis of 56 patients under the age of five with congenital spinal deformities and a history of an isolated hemivertebra in the thoracic and lumbar regions who underwent one-stage hemivertebral extrusion from a dorsal approach (1st group: n = 30) or from a combined approach (2nd group: n = 26) was conducted.

Results. All patients showed improvement in the sagittal and frontal profiles of the spine. However, during separation in the first group of patients, a progression of the kyphotic component of the deformity in the lumbar spine from −19° to −8° was noted, while the correction value of the curvature of the scoliotic component remained stable. Intraoperative blood loss in the first group of patients was less (234 mL) compared with that in the second group (319 mL), while the duration of surgery was longer (310 min and 185 min, respectively). On average, in the first group, a longer metal structure was used to correct the spinal deformity compared with the second group.

Conclusions. The correction of the patients’ congenital spinal deformities with a single hemivertebra from a combined access approach allows a complete correction of the congenital curvature, the fixation of a smaller number of vertebrae, and the maintenance of a stable result in the long-term observation period compared with the dorsal approach. Isolated dorsal access to the hemivertebral body is characterized by less intraoperative blood loss compared with the combined approach, although the length of surgical intervention is increased.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):5-14
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Broken rods in spinal deformity surgery: an analysis of clinical experience and a literature review
Mikhaylovskiy M.V., Vasujra A.S., Lukinov V.L.
Abstract

Backgrоund. Rod fractures are one of the specific complications of spinal deformity surgery. The number of publications on this topic is small, and the conclusions are often contradictory.

Aim. The aim of this study is to analyze the current situation concerning the problem of fractures of the rods in spinal deformities of various etiologies in terms of frequency and risk factors for this complication.

Materials and methods. The study included 3,833 patients who underwent operations between 1996 and 2018. The inclusion criteria of being over 10 years of age with no history of spinal surgery were applied.

Results. Fractures of metal implant rods were detected in 85 patients out of a total of 3,833 (2.2%). There was a significant difference between the groups of idiopathic and congenital scoliosis patients. A rod fracture in 62 of the 85 patients was the reason for reintervention to restore integrity with a connector or a full replacement. An increase in BMI by one raised the chance of a fracture by 1.07 times (p = 0.019). Increasing the age by one year increased the possibility of a fracture by 1.03 times (p = 0.039). A statistically significant association of the ventral stage of surgical treatment (discectomy and interbody fusion with autologous bone) where no fracture was detected (p = 0.403) was revealed. Being over 15 years old a statistically significant predictor was in the group under 20 years of age (p = 0.048). For BMI, there was no statistically significant threshold for fracture probability in the group under 20 years of age. It was confirmed that a hybrid fixation system produced a significantly lower percentage of complications than a hook system.

A systematic literature review of sources on this topic included international databases (Scopus, Medline, and Google Scholar) as well as investigating the publications contained in the reference list.

Conclusions. Rod fractures during surgery for spinal deformities of various etiologies are one of the typical complications. Fracture frequency in large study groups is small. The risk of developing this complication rises with both increasing BMI and patient age, although there is no statistically significant threshold for BMI relative to the chances of fracture in the group up to 20 years of age. Modern reticular systems of attachment of the endocorrector to the vertebral structures can dramatically reduce the risk of rod fracture during the postoperative period.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):15-26
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Our experience of the modified Dunn procedure in children with slipped capital femoral epiphysis (preliminary results)
Barsukov D.B., Baindurashvili A.G., Bortulev P.I., Baskov V.E., Pozdnikin I.Y., Krasnov A.I., Poznovich M.S., Asadulaev M.S.
Abstract

Backgrоund. The spatial correlations of the epiphysis and acetabulum during slipped capital femoral epiphysis (SCFE) with acute (at the stage of partial synostosis) and chronic displacement of the epiphysis to a severe degree were restored using different extra-articular corrective hip osteotomy techniques and the standard Dunn procedure. A large number of postoperative ischemic complications and/or the remaining residual displacement of the epiphysis, which is the cause of FAI, was the rationale for improving traditional surgical methods. In 2007, a modified technique of the classic Dunn procedure was proposed using a low traumatic surgical hip dislocation.

Aim. The aim of the study was to evaluate the effectiveness of the modified Dunn procedure in the treatment of children with SCFE.

Materials and methods. The data of preoperative and postoperative clinical and radiological studies of 10 patients (six males and four females) aged 11–15 years who were suffering from SCFE with severe epiphyseal displacement were analyzed. In five cases, the displacement of the epiphysis was chronic, in four cases it was acute associated with chronic, and in one case it was primarily acute. In the joints with acute displacement at the time of surgery, there were signs of partial synostosis at the level of the epiphyseal growth plate. All children underwent a modified Dunn procedure with strict adherence to the author’s technique. The maximum follow-up period was 1.5 years.

Results. Evaluation of the most short-term anatomical and functional treatment results confirmed a satisfactory result in half (5/10) of the observations with the possibility of an additional three. In two cases, a poor treatment result was obtained due to the development of an early complication in the form of aseptic necrosis of the femoral head. The number of early complications of surgical treatment that were recorded is consistent with the literature.

Conclusions. To date, the modified Dunn procedure is the only intervention with a relatively small number of complications that provides a complete and accurate reposition of the epiphysis, thereby eliminating FAI in the above anatomical situations. The modified Dunn procedure can be characterized as an effective intervention for SCFE with severe, acute (at the stage of partial synostosis), and chronic displacements of the epiphysis. The authors intend to continue using the procedure in practice.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):27-36
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Correction of femoral deformities of inflammatory genesis (osteomyelitis sequalae) in children: an analysis of the treatment results of 76 patients
Dolgiev B.H., Garkavenko Y.E., Pozdeev A.P.
Abstract

Backgrоund. In most cases, haematogenic osteomyelitis affects the long bones of the skeleton. Predominantly, the centers of destruction are located in the lower extremities. The orthopedic complications of haematogenic osteomyelitis were observed (according to different data) in 22%–71.2% of childhood cases. In 16.2%–53.7% of cases, the complications can lead to childhood (nascent) disability.

Aim. The purpose of the research is to conduct a retrospective analysis of femoral deformity correction results in children with haematogenic osteomyelitis consequences by applying both an Ortho-SUV Frame™ (based on passive computer navigation) and following the Ilizarov method.

Materials and methods. The study examined 76 patients of both genders aged between 8 and 17 years old who were experiencing the consequences of haematogenic osteomyelitis in the long bones of the lower extremities. A comparative assessment of the parameters reflecting the effectiveness of circular external fixation in combination with an Ortho-SUV Frame™ and the Ilizarov method was conducted. Reference lines and angles before and after surgery, elongation size, distraction time, deformity correction period, external fixation index, number of complications, and the functional result were all considered.

Results. All the children underwent deformity correction surgery, and the length of the afflicted lower extremity segment was reconstructed (restored). The use of the repositioning unit enabled a higher correction accuracy (94.45%) of the femur in comparison with the Ilizarov frame (30%). The frequency of excellent functional results in the first group of patients was more than 1.5 times higher than in the second group, whereas the satisfactory results turned out to be almost twice as low. Fewer complications were observed while using the Ortho-SUV hexapod.

Conclusions. The application of the Ortho-SUV Frame™ at the long-bone-deformity-correction stage facilitates an increase in the efficiency of the circular external fixation method.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):37-48
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Change in the severity of congenital clubfoot in the first week of life
Kruglov I.Y., Rumyantsev N.Y., Omarov G.G., Rumiantceva N.N.
Abstract

Backgrоund. Congenital clubfoot or congenital equino-cava-varus deformity of the feet is one of the most common pathologies of the musculoskeletal system in children. Numerous articles in global literature have been published about changes in clubfoot severity during treatment; however, there are very few reports on how the severity of foot deformities with congenital clubfoot changes during the first week of life in the absence of deformity correction.

Aim. To analyze changes in the severity of congenital clubfoot in the first week of life without any treatment.

Materials and methods. The study group included 28 newborns with idiopathic congenital clubfoot (a total of 40 feet). The severity of clubfoot was evaluated on days one and seven after birth using the Dimeglio and Pirani scores.

Results. During the initial examination of the newborns on the first day of life, the clubfoot severity recorded on the Pirani score was between 2 to 3 points and between 9 to 15 points on the Dimeglio score. Thus, in the first seven days of life in all patients who did not receive treatment, there was a significant increase in the severity of the equino-cava-varus deformity of the feet (p < 0.05). The results of this study confirm that the severity of congenital clubfoot increases in the first week of life. This necessitates the beginning of the correction of severe idiopathic clubfoot in the first days after birth.

Conclusions. The severity of congenital clubfoot during the first week of life significantly increased in all feet studied (p < 0.05: χ2 higher than in the table). If left untreated in the first week after birth, the equinus deformity progresses followed by varus deformity, anterior forefoot reduction, and, to a lesser extent, rotation.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):49-56
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Lengthening of the ulna by external fixation in children with congenital radial club hand
Avdeychik N.V., Golyana S.I., Grankin D.Y., Safonov A.V.
Abstract

Background. Congenital radial club hand is characterized by the radial deviation of the hand, the longitudinal underdevelopment of the forearm, and the dysfunction of the upper limb. The shortening of the ulna is observed in all types of congenital radial club hand. The average shortening of the ulna surgical treatment was 33.3% compared to the intact contralateral side.

Aim. This study aimed to evaluate the results of ulna elongation by the method of external fixation, depending on the level of osteotomy, in patients with congenital radial club hand type III–IV.

Materials and methods. The treatment results of 36 patients with congenital radial club hand type III–IV from 1998 to 2018 were analyzed. The average age of the patients was 7.4 years ± 3.5 years. The patients were divided into three groups, depending on the level of ulnar osteotomy. Shortening of the ulna, correction of the angle of deformity of the ulna, radial deviation of the hand, period of correction, elongation obtained, index of fixation and osteosynthesis, and associated complications were analyzed.

Results. The observation period was an average of 5.8 years. Before surgical treatment, the ulna was 33.3% shorter, while after surgery, it was 16%. Before surgery, the angle of deformation was 20.5° ± 14.8°, while after surgery, it was 7.4° ± 5.6°; this gives an angle of deformity correction of 63.9%. The elongation of the ulna was 3.2 ± 1.1 cm. In patients who underwent proximal osteotomy, the resulting elongation was 32% and 18.4% more, respectively, than in patients who underwent an osteotomy in the middle and distal sections of the ulna. In group 1, the correction period was 24.4% and 28.9% more than in groups 2 and 3, respectively. The index of fixation in group 1 was 53.6%, which was 45.7% less than in groups 1 and 3. Postoperative complications included a false joint (15%), inflammation (10%), and forearm deformities (7.5%).

Conclusions. In patients with congenital radial club hand type III–IV, the optimal part of an ulna osteotomy is the proximal section. With a hand deviation of more than 20°, osteotomy is performed in the distal section with simultaneous correction of the deformity.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):57-66
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Algorithm of medical care for children with polytrauma
Yunusov D.I., Aleksandrovich V.Y., Mironov P.I., Pshenisnov K.V., Ulrich G.E., Pastukhova N.K., Nezabudkin S.N., Kupatadze D.D.
Abstract

Backgrоund. Polytrauma is the main reason for incapacitation and death in children of all ages. The appropriate timing of specialized medical care plays a crucial role for the outcomes of the polytrauma.

Aim. The aim of the study is to analyze the results of the treatment of musculoskeletal injuries with the use of a decision-making algorithm in pediatric patients with polytrauma.

Materials and methods. This is a prospective, observational, controlled, single-center study. The research included 130 children who were divided into two groups. In the main group, the children were provided with specialized medical care by a multidisciplinary team. After stabilization, the patients were transferred to a specialized center for final surgical treatment by minimally invasive fracture osteosynthesis. After the elimination of existing life-threatening conditions and the fitting of skeletal traction, the patients in the control group received surgical treatment only after transferal to a specialized center.

Results. In the main group, pain regressed significantly earlier (1.7 ± 0.6 vs 3.2 ± 0.4, p < 0.05), and the duration of the postoperative ICU stay was significantly reduced (1.5 ± 0.9 vs 2.4 ± 1.4 days, p < 0.05). The optimization of the surgical treatment of injuries facilitated a reduction in the duration of the ICU stay of patients in the main group (5.6 ± 0.3 vs 6.5 ± 0.4 days), in the surgical department (21.5 ± 0.7 vs 25 ± 0.9 days), and the overall hospital stay (up to 27.5 days).

Conclusions. This study developed a decision-making algorithm for administering medical care to children with polytrauma based on the principle of stabilization of the condition and early low-trauma surgery in the hours following injury.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):67-78
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Bone metabolism biomarkers in walking children with cerebral palsy
Kenis V.M., Bogdanova S.L., Prokopenko T.N., Sapogovskiy A.V., Kiseleva T.I.
Abstract

Backgrоund. Osteoporosis is an important factor in the pathogenesis of orthopedic manifestations in children with cerebral palsy. It was previously demonstrated that children with cerebral palsy have specific changes in bone metabolism, which can cause changes in laboratory parameters compared with other orthopedic patients without neurological backgrounds.

Aim. The aim of this study was to assess bone metabolism biomarkers in children with cerebral palsy, identifying distinguishing characteristic patterns in comparison with patients with orthopedic pathology without neurological backgrounds.

Materials and methods. This study evaluated the concentrations of calcium, phosphorus, β-cross laps, osteocalcin, vitamin D, CICP, and alkaline phosphatase in the blood serum of 50 children with cerebral palsy aged between 6 to 12 years with GMFCS levels I–III. The control group consisted of 50 patients with plano-valgus deformities of the feet.

Results. The alkaline phosphatase activity in the group of children with cerebral palsy was 170.25 ± 59.35 u/L, while in the control group it was 145.58 ± 46.29 u/L; the CICP concentration in the study group was higher than in the control group (324.01 ± 174.10 and 269.68 ± 240.98, respectively). The concentration of β-cross laps, osteocalcin, calcium, and vitamin D in the study group was lower than in children with flat feet.

Conclusions. This study demonstrated multidirectional changes in the biomarkers of bone metabolism that are characteristic of walking children with cerebral palsy. These changes are characterized by a corresponding increase in the activity of osteoresorption and osteoreparation. This makes it possible to justify the combined use of metabolites and metabolic activators (calcium and vitamin D) and drugs that suppress osteoresorption (bisphosphonates) for the prevention and treatment of osteoporosis in children with cerebral palsy.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):79-86
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Exchange of experience
Long-term treatment results of congenital hip disease in adolescents
Abakarov A.A., Abakarov A.A.
Abstract

Backgrоund. An analysis of modern literature reveals that presently, there are no algorithms for determining the correct method of surgical treatment for adolescents with high congenital hip dislocation; few publications are devoted to the treatment of adolescents with this pathology. Children are treated by podiatrists until the age of 18 before transferring to adult specialists. There remain debatable issues of total hip replacement in adolescents because there are time limits for hip preservation. The search for improved treatment methods for adolescents with this pathology by preserving their own bone structures continues to be relevant.

Aim. To evaluate the long-term results of the treatment of adolescents with complete congenital hip dislocation after intertrochanteric osteotomy using the authors’ technique.

Materials and methods. From 1990–2006, in the Republican Orthopedic and Traumatological Center of the Republic of Dagestan and the clinic of the Department of Traumatology and Orthopedics of the Dagestan State Medical University, 37 patients with high congenital dislocation of the hip underwent 49 operations using the method developed by the authors. The surgeries were performed by a single orthopedist and were presented as an angulatory lengthening by transtrochantiс osteotomy of the femur by fixation with a fingered plate. All patients underwent clinical, radiographical, biomechanical, and statistical evaluation before and after surgery using the Harris and VAS scales. The results of the study were processed using the Student, Pearson, and Kolmogorov coefficients and confidence intervals.

Results. Over a long-term treatment period of up to 10 years, the average Harris score increased from 44.2 (95% CI 38.7–47.9) to 80.5 (95% CI 77.1–85.3). After the 10-year follow-up period (10–15 years after surgery), the scores gradually dropped to 72.4 (95% CI 70.1–78.3). Unsatisfactory treatment results were found in 13.5% of cases and were mainly associated with an unsuccessful choice of support point under the pelvis and the preservation of uncompensated shortening of the limb. The alignment of the created degree of angulation of the hip in terms of adolescent age groups was not established. Differences in treatment results (depending on the inter-operation time for the bilateral dislocation of the hip) were not established. At follow-up periods of 10–15 years after surgery, total hip replacement was performed in 21 joints (56.7%).

Conclusions. The proposed method of surgical treatment of congenital hip dislocation in adolescents improves the static–dynamic capabilities of the hip joint and remains effective over the following 15 years of life. The duration of inpatient treatment is reduced and does not interfere with subsequent total hip arthroplasty.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):87-96
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Clinical cases
Treatment of complex regional pain syndrome after filling a single bone-cyst cavity with beta-tricalcium phosphate granules
Aminova L.R., Lobashov V.V., Akhtiamov I.F.
Abstract

Backgrоund. Сomplex regional pain syndrome is a condition associated with a multitude of clinical factors. Its characteristic feature is persistent pain caused by injuries and is not anatomically limited to the location of a particular peripheral nerve.

Clinical case. This article describes a case involving the treatment of complex regional pain syndrome in a thirteen-year-old patient, which resulted in a simple bone cyst surgical treatment of the lower-third of the fibula. Diagnostics were based on clinical, laboratorial, histological, radiological, and instrumental methods of research. The treatment methods included medication (nonsteroidal anti-inflammatory drugs, antidepressants, antipsychotics, anticonvulsants, non-opioid analgesics of central action, and bisphosphonates), cold plasma ablation, neurolysis of the sural nerve, prolonged regional anesthesia, tunneling of the bone marrow cavity (filled by substitutional filler), and marginal bone resection.

Discussion. Сomplex regional pain syndrome is a poorly studied condition, which contributes to the complexity of its diagnosis. In this case, the presence of complex regional pain syndrome can be characterized by tissue injury during surgical intervention as well as by intraoperative injury of the nerve fibers. The stages of complex regional pain syndrome detected in studies may not appear in all patients, and in this case, no staging was observed. By eliminating the obliteration of the medullary canal after segmental resection of the sclerosed portion of the bone, it was possible to reduce the severity of pain, which resulted in the subsequent disappearance of the manifestations of complex regional pain syndrome.

Conclusions. This case testifies to the effectiveness of various methods of treating complex regional pain syndrome. The etiology of the specific patient’s pain syndrome should be considered when treating complex regional pain syndrome.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):97-104
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Superior mesenteric artery syndrome following spinal deformity correction
Strelnikova A.S., Kozyrev A.S., Vissarionov S.V., Kartavenko K.A., Murashko V.V.
Abstract

Background. Superior mesenteric artery syndrome is a rare pathological condition caused by an abnormal transposition of the superior mesenteric artery from the abdominal part of the aorta. It results in compression of the distal part of the duodenum between the aorta and the superior mesenteric artery. It is clinically manifested by signs of acute intestinal obstruction, including pain in the epigastric region, nausea, and profuse vomiting. In the absence of timely treatment, patients may experience electrolyte disturbance, severe nutritional deficiency, the risk of perforation of the stomach, aspiration pneumonia, bezoar formation, thromboembolism, and the development of other life-threatening complications that can lead to death.

Case study. In the presented case study, superior mesenteric artery syndrome developed in a 17-year-old girl after surgical correction of a spinal deformity in the treatment of idiopathic scoliosis. This was due to postoperative loss of body weight, as well as a rapid change in the patient’s ratio of growth to body weight.

Discussion. Significant clinical improvement was achieved as a result of an integrated approach to the treatment of this complication. However, despite the successful result from conservative therapy, the patient remains at risk of developing chronic duodenal obstruction of varying severity, which may require surgical treatment.

Conclusion. With the untimely and incomplete treatment of superior mesenteric artery syndrome, the risk of developing chronic intestinal obstruction increases. Treatment of this complication begins with conservative therapy. In the absence of the effect of conservative therapy, and in the case of disease progression, the development of life-threatening conditions (such as bleeding and perforation) requires surgical treatment.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):105-112
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Review
Current views on radial head subluxation
Petrushin A.L., Bragina S.V., Berezin P.A.
Abstract

Backgrоund. Radial head subluxation is the most common injury in young children and accounts for 2.6% of the total population in this age group. In 39%–82% of cases, the mechanism of injury is the traction of the arm, but subluxation can occur during a fall and in other circumstances; in 19%–51% of cases, the mechanism of injury is unknown.

Aim. The purpose of this study is to generalize and arrange the available literature and data and present current views on the prevalence, etiology, pathogenesis, diagnosis, and treatment of radial head subluxation in children.

Materials and methods. A literature search was performed using the PubMed, PubMed Central, Google Scholar, CNKI-Scholar, Cyberleninka, and eLibrary databases. The sample of sources was mainly limited to 2000–2019.

Results. The cause of subluxation is the displacement of the annular ligament and its interposition in the humeroradial joint. It is determined by a number of features of the elbow joint anatomy in young children. Diagnosis of radial head subluxation is based on history and clinical data; radiography and ultrasonography are used to obtain a clear clinical picture and to exclude fractures. The mainstay of treatment is a closed reduction, which is conducted via two methods as follows: supination–flexion and hyperpronation. According to modern research data, preference is given to the hyperpronation method; it is more effective in terms of number of reduction attempts, is technically simpler and, possibly, less painful. Generally, immobilization after effective reduction is not required as the function of the elbow joint is fully restored. A consequence of radial head subluxation is recurrence, which occurs in 5%–46% of cases. A factor associated with recurrence is being less than two years of age. The prophylaxis of radial head subluxation is aimed at preventing forceful arm traction in children under three years of age and involves educating the parents or caregivers in the symptoms of subluxation to prevent late admission.

Conclusions. Radial head subluxation is found in young children and is mainly diagnosed clinically. The treatment consists of a closed reposition, and the prognosis for restoring limb function is favorable.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):113-124
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Conference ProceedIngs
Scientific and practical conference: Turner readings
Baindurashvili A.G., Zaletina A.V., Solovyova K.S.
Abstract

The article is dedicated to the organization and presentation of the scientific and practical conference, Turner Readings, which addressed the current issues in trauma surgery and childhood orthopedics between October 3 and 4, 2019 in St. Petersburg. The subjects discussed at the plenary and section meetings are covered, and the reports on the current level of trauma surgery and pediatric orthopedics and the prospects for the development of scientific and clinical research are analyzed. A total of 104 reports were presented. They were devoted to the diagnosis, treatment, and rehabilitation of injuries and their sequelae and the congenital and acquired diseases of the musculoskeletal system in children. A total of 386 people from 52 regions of Russia, Belarus, Moldova, Ukraine, Uzbekistan, Estonia, Germany, Switzerland, and Egypt registered to participate in the conference.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(4):125-132
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