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Stofferin H, Pfitscher K, Hörmann R, Gmeiner R, Thaler M. The Anatomical Course of the Femoral Nerve with Regard to the Direct Anterior Approach for Total Hip Arthroplasty. J Arthroplasty 2024; 39:1341-1347. [PMID: 38043744 DOI: 10.1016/j.arth.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Femoral nerve (FN) injury is noted as a serious neurological complication following total hip arthroplasty performed via a direct anterior approach (DAA). Therefore, we aimed to clarify the anatomical course of the FN around the acetabular rim and in relation to retractor placement during DAA. METHODS According to standard protocol, a DAA for total hip arthroplasty was performed on 69 hemipelves from formalin-preserved full-body donors. The surgery was halted after retractor placement at the anterior part of the acetabulum. Then dissection was performed to expose the FN and the iliopsoas muscle. Various measurements were taken using a reference line from the anterior superior iliac spine to the acetabulum's center. A total of 6 measurement points, one every 30° from 0° to 150° along the reference line were used to determine the association between the FN and the retractor tip (RT) and the anterior acetabular rim. RESULTS The mean distance from the RT to the FN was 22.5 millimeters (mm). The distance from the FN to the anterior acetabular rim decreased from 0 to 90°, where it was 18.8 mm, before increasing again to 27.3 mm at 150°. CONCLUSIONS In our cadaveric study, the FN was within 11 to 36 mm of the RT. Second, we found the FN to be closest to the anterior acetabular rim at 90° and 120°. Accordingly, special care should be taken during retractor placement, and if possible, placement at 90° and 120° avoided.
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Affiliation(s)
- Hannes Stofferin
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Pfitscher
- Department of Obstetrics and Gynecology, Schwaz County Hospital, Schwaz, Austria
| | - Romed Hörmann
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raphael Gmeiner
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria; Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Thaler
- Arthroplasty Center, Helios Klinikum Munich West, Munich, Germany; Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University of Greifswald, Greifswald, Germany
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Rossetto G, Lopomo NF, Shaikh SZ. Longitudinal Movements and Stiffness of Lower Extremity Nerves Measured by Ultrasonography and Ultrasound Elastography in Symptomatic and Asymptomatic Populations: A Systematic Review With Meta-analysis. Ultrasound Med Biol 2023:S0301-5629(23)00140-0. [PMID: 37331920 DOI: 10.1016/j.ultrasmedbio.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/07/2023] [Accepted: 04/24/2023] [Indexed: 06/20/2023]
Abstract
This study was aimed at analyzing the effectiveness of ultrasonography (US) and ultrasound elastography (UE) in evaluating longitudinal sliding and stiffness of nerves. In line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, we analyzed 1112 publications (range: 2010-2021) extracted from MEDLINE, Scopus and Web of Science focusing on specific outcomes, including shear wave velocity (m/s), shear modulus (kPa), strain ratio (SR) and excursion (mm). Thirty-three papers were included and evaluated for overall quality and risk of bias. From the analysis of data concerning 1435 participants, mean shear wave velocity (SWV) in the sciatic nerve was 6.70 ± 1.26 m/s in controls and 7.51 ± 1.73 m/s in participants presenting with leg pain; in the tibial nerve, mean SWV was 3.83 ± 0.33 m/s in controls and 3.42 ± 3.53 m/s in participants presenting with diabetic peripheral neuropathy (DPN). The mean shear modulus (SM) was 20.9 ± 9.33 kPa for sciatic nerve, whereas it was an average of 23.3 ± 7.20 kPa for the tibial nerve. Considering 146 subjects (78 experimental, 68 controls) no significant difference was observed in SWV when comparing participants with DPN with controls (standard mean difference [SMD]: 1.26, 95% confidence interval [CI]: 0.54, 1.97), whereas a significant difference was observed in the SM (SMD: 1.78, 95% CI: 1.32, 2.25); furthermore, we found significant differences between left and right extremity nerves (SMD:1.14. 95% CI: 0.45, 1.83) among 458 participants (270 with DPN and 188 controls). No descriptive statistics are available for excursion because of the variability in participants and limb positions, whereas SR is considered only a semiquantitative outcome and therefore not comparable among different studies. Despite the presence of some limitations in study designs and methodological biases, on the basis of our findings, we can conclude that US and UE are effective methods in assessing longitudinal sliding and stiffness of lower extremity nerves in both symptomatic and asymptomatic subjects.
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Affiliation(s)
- Gianluca Rossetto
- Department of Information Engineering, University of Brescia, Brescia, Italy
| | | | - Summaiva Zareen Shaikh
- Department of Neuro-physiotherapy, SIA College of Health Sciences, College of Physiotherapy, Thane, India.
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Perka C, Ascherl R. [Pitfalls in revision hip arthroplasty]. Orthopadie (Heidelb) 2023; 52:35-47. [PMID: 35841403 DOI: 10.1007/s00132-022-04282-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 01/19/2023]
Abstract
Significant key points for a successful revision surgery in hip arthroplasty are as follows: identification of the implants, preoperative clinical diagnoses, planning (including alternatives) as well as establishing a surgical strategy, selection of revision implants and provision with special tools, secure fixation of acetabular and femoral components and the reconstruction of a stable joint without risk of dislocation or impingement. It seems to be obvious that most problems can be avoided by clear and concise decision-making. Some tips and tricks are also presented.
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Brodt S, Boersch V, Strube P, Wassilew G, Matziolis G. Defining the canal for ischial and pubic screws in cup revision surgery. International Orthopaedics (SICOT) 2022; 46:2547-2552. [PMID: 35994066 PMCID: PMC9556370 DOI: 10.1007/s00264-022-05552-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/11/2022] [Indexed: 12/03/2022]
Abstract
Purpose When revising acetabular cups, it is often necessary to provide additional stabilisation with screws. In extensive defect situations, the placement of screws caudally in the ischium and/or pubis is biomechanically advantageous. Especially after multiple revision operations, the surgeon is confronted with a reduced bone stock and unclear or altered anatomy. In addition, screw placement caudally is associated with greater risk. Therefore, the present study aims to identify and define safe zones for the placement of caudal acetabular screws. Methods Forty-three complete CT datasets were used for the evaluation. Sixty-three distinctive 3D points representing bone landmark of interests were defined. The coordinates of these points were then used to calculate all the parameters. For simplified visualisation and intra-operative reproducibility, an analogue clock was used, with 12 o’clock indicating cranial and 6 o’clock caudal. Results A consistent accumulation was found at around 4.5 ± 0.3 hours for the ischium and 7.9 ± 0.3 hours for the pubic bone. Conclusions The anatomy of the ischium and pubis is sufficiently constant to allow the positioning of screws in a standardised way. The interindividual variation is low — regardless of gender — so that the values determined can be used to position screws safely in the ischium and pubis. The values determined can provide the surgeon with additional orientation intra-operatively when placing caudal acetabular screws.
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Affiliation(s)
- Steffen Brodt
- German Center for Orthopaedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Vincent Boersch
- Clinic for Traumatology and Orthopedic Surgery, Klinikum Kassel, Kassel, Germany
| | - Patrick Strube
- German Center for Orthopaedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Georgi Wassilew
- Clinic for Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Georg Matziolis
- German Center for Orthopaedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
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Ni S, Luo P, Guo L, Jiang T. Are additional screws required for press-fit fixation of cementless acetabular cups? A systematic review and meta-analysis. J Orthop Traumatol 2022; 23:9. [PMID: 35142933 DOI: 10.1186/s10195-022-00629-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/25/2022] [Indexed: 01/10/2023] Open
Abstract
Background Press-fit cementless acetabular cup is widely used in total hip arthroplasty (THA). However, the use of additional screws for the acetabular cup has been extensively debated. The purpose of this review is to compare the stability, revision rate, wear rate, and clinical scores of cementless acetabular cups with and without screws in THA. Materials and Methods Comprehensive literature searches of the following databases were performed: Cochrane Library, Pubmed, Web of Science, OVID, Elsevier ClinicalKey, Clinicaltrials.gov, and EMBASE. We searched for trials that compared cementless acetabular cups with screws or without screws, and were published in the English language. We evaluated the stability of the prosthesis by osteolysis and migration. The clinical scores included Harris hip scores (HHS) and pain scores. Results Nineteen articles involving 4046 THAs met the inclusion criteria. Our analysis revealed that additional screws did not increase the stability of acetabular cups, and there was no statistical significance between the groups with and without screws in osteolysis and clinically relevant migration. Revision rates showed no significant difference between the groups with and without screws. There was no difference in wear between the two groups. Our analysis showed no difference in pain scores and HHS between groups. Conclusion Press-fit without screws could achieve sufficient acetabular cup stability. Acetabular cups without screws showed no difference from acetabular cups with screws in many outcomes. Additional screws are not required for cementless acetabular cups. Level of evidence: Level III.
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Brodt S, Bischoff K, Schulze M, Nowack D, Roth A, Matziolis G. The use of acetabular screws in total hip arthroplasty and its influence on wear and periacetabular osteolysis in the long-term follow-up. Int Orthop 2021; 46:717-722. [PMID: 34581866 PMCID: PMC8930858 DOI: 10.1007/s00264-021-05219-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
Purpose The cementless implantation of hip replacement cups may be performed with and without the additional use of acetabular screws. If the surgeon uses screws or not depends on variable factors. In general, the use of screws is intended to increase the primary stability of the cup. Whether screws increase the initial stability of the cup construct, or even reduce it in part, is the subject of considerable debate in the literature. It is also unclear whether the additional screws lead to increased wear or increased periacetabular osteolysis over the long-term course. Methods Two hundred eleven patients from a previous study with a minimum follow-up of 10.7 years were included. Of these, 68 patients with 82 total hip arthroplasties (THA) were given clinical and radiological follow-up examinations. Of these, 52 had been fitted without screws and 30 with screws. On the basis of radiographs, annual wear and osteolysis were quantified. The clinical results were recorded by means of VAS, HHS, and WOMAC scores. Results Significantly more periacetabular osteolysis was found if additive acetabular screws had been used. No difference was found in relation to the volumetric wear per year. Likewise, no difference was found with regard to the clinical scores. Conclusions The use of additive acetabular screws leads to increased osteolysis in the periacetabular bone stock. Insofar as the primary stability of the cementless cup construct allows it, no additional acetabular screws should be used. Supplementary Information The online version contains supplementary material available at 10.1007/s00264-021-05219-7.
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Affiliation(s)
- Steffen Brodt
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany.
| | - Kathleen Bischoff
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Marcel Schulze
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Dimitri Nowack
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Andreas Roth
- Department Endoprosthesis/Orthopedics, Clinic of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Georg Matziolis
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
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Vajapey SP, Morris J, Lynch D, Spitzer A, Li M, Glassman AH. Nerve Injuries with the Direct Anterior Approach to Total Hip Arthroplasty. JBJS Rev 2020; 8:e0109. [DOI: 10.2106/jbjs.rvw.19.00109] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Stubbs T, Moon AS, Dahlgren N, Patel HA, Jha AJ, Shah A, Naranje SM. Anterior acetabular retractors and the femoral neurovascular bundle in anterior total hip arthroplasty: a cadaveric study. Eur J Orthop Surg Traumatol 2020; 30:617-20. [PMID: 31863272 DOI: 10.1007/s00590-019-02611-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/13/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The direct anterior approach for primary total hip arthroplasty (THA) has become increasingly popular in recent years. Nerve compression or traction with a retractor is a common cause of nerve injury in this approach. The purpose of this cadaveric study was to evaluate the anatomic relationship of the femoral neurovascular bundle to the anterior acetabular retractor during direct anterior approach THA. METHODS Eleven fresh-frozen cadavers underwent a standard direct anterior THA, with placement of an anterior acetabular retractor in the usual fashion between the iliopsoas and acetabulum for visualization during acetabular preparation. Careful dissection of the femoral triangle was performed, and the distances from the anterior retractor tip to the femoral nerve, artery, and vein were recorded and analyzed as mean distance ± standard deviation. RESULTS In all 11 cadavers, the retractor tip was medial to the femoral nerve. The mean distance from retractor tip to femoral artery and vein was 5.9 mm (SD = 5.5, range 0-20) and 12.6 mm (SD 0.7, range 0-35), respectively. CONCLUSIONS Surgeons should be aware of the proximity of the neurovascular structures in relation to the anterior acetabular retractor in the direct anterior approach, taking care to avoid perforating the iliopsoas muscle during retractor insertion and limit excessive traction to prevent nerve injury.
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Iwanaga J, Simonds E, Vetter M, Patel M, Oskouian RJ, Tubbs RS. The inferior gluteal nerve often has a cutaneous branch: A discovery with application to hip surgery and targeting gluteal pain syndromes. Clin Anat 2018; 31:937-941. [DOI: 10.1002/ca.23232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Joe Iwanaga
- Seattle Science Foundation; Seattle, Seattle Washington
- Division of Gross and Clinical Anatomy, Department of Anatomy; Kurume University School of Medicine; Kurume Fukuoka Japan
| | - Emily Simonds
- Seattle Science Foundation; Seattle, Seattle Washington
| | - Marc Vetter
- Seattle Science Foundation; Seattle, Seattle Washington
| | - Mayank Patel
- Seattle Science Foundation; Seattle, Seattle Washington
| | | | - R. Shane Tubbs
- Seattle Science Foundation; Seattle, Seattle Washington
- Department of Anatomical Sciences; St. George's University; St. George's Grenada West Indies
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Abstract
BACKGROUND Vascular injury during minimally invasive total hip arthroplasty (THA) is uncommon, yet a well-recognized and serious issue. It emerges because of non-visibility of vascular structures proximal to the pelvic bone during reaming, drilling holes, and fixing of screws. Numerous studies have found that screw fixation during cementless THA is beneficial for the initial stability of cup; yet, no anatomical guidelines support angular eccentric screw fixation. MATERIALS AND METHODS In this study, we obtained the pelvic arterial-phase computed tomographic data of thirty eight humans and reconstructed the three-dimensional models of osseous and vessel structures. We performed the surgical simulation to fix these structures with cementless cups and screws with angular eccentricities. RESULTS The effect of screw eccentricities (angular eccentricities of ±17° and ±34°) on the vascular injury was determined. Measurement between screw and adjoining vessels was performed and analyzed statistically to ascertain a comparative risk study for blood vessels that are not visible during surgery. CONCLUSION Authors similarly discussed the significant absence of appreciation of quadrant systems proposed by Wasielewski et al. on eccentric screws. Adjustment of quadrant systems provided by Wasielewski et al. is required for acetabular implants with eccentric holes for fixation of acetabular screws.
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Affiliation(s)
- Nishant Kumar Singh
- School of Biomedical Engineering, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh, India
| | - Sanjay Kumar Rai
- School of Biomedical Engineering, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh, India,Address for correspondence: Dr. Sanjay Kumar Rai, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, Uttar Pradesh, India. E-mail:
| | - Amit Rastogi
- Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Primadi A, Xu HX, Yoon TR, Ryu JH, Lee KB. Neurologic injuries after primary total ankle arthroplasty: prevalence and effect on outcomes. J Foot Ankle Res 2015; 8:55. [PMID: 26435751 PMCID: PMC4592541 DOI: 10.1186/s13047-015-0112-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 09/23/2015] [Indexed: 11/10/2022] Open
Abstract
Background Neurologic injuries are complications that can arise after total joint arthroplasty. However, no comprehensive study has been conducted on peripheral nerve injuries after total ankle arthroplasty. The purpose of the present study was to identify the prevalence of neurologic injury following primary total ankle arthroplasty, the predisposing factors, and evaluate the effect on clinical outcomes. Methods We retrospectively analyzed 150 consecutive primary total ankle arthroplasty using the mobile-bearing prosthesis between January 2005 and December 2011, in 150 patients with symptomatic ankle end-stage arthritis. All the patients were divided into groups according to whether they had postoperative peripheral neuropathy (23 patients) or not (127 patients). We investigated the prevalence, predisposing factors, and effect on clinical outcomes of neurologic injuries. The mean age was 61.3 years, and the mean follow-up period was 41.8 months. Results There were 23 nerve injuries (15.3 %), including nine in posterior tibial nerves, six superficial peroneal nerves, six deep peroneal nerves, one saphenous nerve, and one sural nerve. Neurologic injury was significantly associated with the development of posttraumatic osteoarthritis, but it was not significantly associated with other predisposing factors, such as age, gender, body mass index, and symptom duration. Of the 23 nerve injuries, 13 (56.5 %) presented a complete, spontaneous recovery, 9 (39.1 %) presented an incomplete recovery, and 1 (4.3 %) presented no recovery. The patients with neurologic injury had significantly lower American Orthopaedic Foot and Ankle Society scores and lower levels of patient satisfaction. Conclusions The results of this study suggest that the prevalence of neurologic injury after total ankle arthroplasty is considerable, and that neurologic injury is associated with low levels of patient satisfaction and poor clinical outcomes at mean of 3 years, postoperatively. Care is needed to reduce the occurrence of neurologic injuries.
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Affiliation(s)
- Andri Primadi
- Department of Orthopaedics and Traumatology, Universitas Padjadjaran Medical School/Hasan Sadikin Hospital, Bandung, Indonesia
| | - He-Xing Xu
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 42 Jebongro, Donggu Gwangju, 501-757 Republic of Korea
| | - Taek-Rim Yoon
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 42 Jebongro, Donggu Gwangju, 501-757 Republic of Korea
| | - Je-Hwang Ryu
- Department of Pharmacology and Dental Therapeutics, School of Dentistry, Chonnam National University, Gwangju, Republic of Korea
| | - Keun-Bae Lee
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 42 Jebongro, Donggu Gwangju, 501-757 Republic of Korea
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