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Trikha R, Greig DE, Olson TE, Kendal JK, Geiger EJ, Wessel LE, Eckardt JJ, Bernthal NM. Proximal Femur Replacements for an Oncologic Indication Offer a Durable Endoprosthetic Reconstruction Option: A 40-year Experience. Clin Orthop Relat Res 2023; 481:2236-2243. [PMID: 37458708 PMCID: PMC10566928 DOI: 10.1097/corr.0000000000002765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/22/2023] [Accepted: 06/08/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Proximal femur replacements (PFRs) are an effective surgical option to treat primary and metastatic tumors causing large bony defects in the proximal femur. Given the relative rarity of these indications, current studies on PFR for oncologic indications are generally limited by patient volume or relatively short-term follow-up. Because recent advances in systemic therapy have improved the prognosis of patients who undergo limb salvage surgery for musculoskeletal tumors, data on the long-term durability of endoprosthetic reconstructions have become increasingly important. QUESTIONS/PURPOSES (1) How does the long-term survival of cemented bipolar PFRs compare with patient survival in patients who underwent PFR for benign, aggressive, and metastatic tumors? (2) What are common reasons for revisions of primary PFRs? (3) Which factors are associated with survival of primary PFRs? (4) What is the survivorship free from conversion of bipolar PFRs to THA? METHODS Between January 1, 1980, and December 31, 2020, we treated 812 patients with an endoprosthetic reconstruction for an oncologic indication. All patients who underwent a primary PFR for an oncologic indication were included in this study. The study cohort consisted of 122 patients receiving a primary PFR. Eighteen patients did not reach a censored endpoint such as death, revision, or amputation within 2 years. Thirty-three patients died within 2 years of their surgery. Of the 122 patients with primary PFRs, 39 did not reach a censored endpoint and have not been seen within the past 5 years. However, the mean follow-up time for these patients was longer than 10 years. The Social Security Death Index was queried to identify any patients who may have died but might not have been captured by our database To allow for adequate follow-up, endoprosthetic reconstructions performed after December 31, 2020 were excluded. The mean age at the time of the index surgery was 48 ± 22 years. The mean follow-up time of surviving patients was 7 ± 8 years. All PFRs were performed using a bipolar hemiarthroplasty with a cemented stem, and all implants were considered comparable. Demographic, oncologic, procedural, and outcome data including prosthesis survival, patient survival, complication rates, and rates of conversion to THA were analyzed. Patient, prosthesis, and limb salvage survival rates were generated, with implant revision as the endpoint and death as a competing risk. Statistical significance was defined as p < 0.05. RESULTS Generally, patients with benign or low-grade (Stage I) disease outlived their implants (100% patient survival through 30 years; p = 0.02), whereas the opposite was true in patients with high-grade, localized Stage II disease (64% patient survival at 5 years [95% CI 49% to 76%]; p = 0.001) or widespread Stage III metastatic disease (6.2% patient survival at 5 years [95% CI 0.5% to 24%]; p < 0.001). Primary PFR implant survival at 5, 10, 20, and 30 years was 97% (95% CI 90% to 99%), 81% (95% CI 67% to 90%), 69% (95% CI 46% to 84%), and 51% (95% CI 24% to 73%), respectively. Eight percent (10 of 122) of primary PFRs were revised for any reason. The most common causes of revision were aseptic loosening (3% [four of 122]), infection (3% [three of 122]), breakage of the implant (2% [two of 122]), and tumor progression (1% [one of 122]). Follow-up time was the only factor that was associated with revision of primary PFRs. Neither segment length nor stem length were associated with revision of primary. Six percent (seven of 122) of PFRs were converted to THA at a mean 15 ± 8 years from the index procedure. Survivorship free from conversion to THA (accounting for death as a competing risk) was 94% (95% CI 85% to 99%), 86% (95% CI 68% to 94%). and 77% (95% CI 51% to 91%) at 10, 20, and 30 years, respectively. CONCLUSION Cemented bipolar PFRs for an oncologic indication are a relatively durable reconstruction technique. Given the relative longevity and efficacy of PFRs demonstrated in our study, especially in patients with high-grade or metastatic disease where implant survival until all-cause revision was longer than patient survival, surgeons should continue to seriously consider PFRs in appropriate patients. The relative rarity of these reconstructions limits the number of patients in this study as well as in current research; thus, further multi-institutional collaborations are needed to provide the most accurate prognostic data for our patients. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Rishi Trikha
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Danielle E. Greig
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Thomas E. Olson
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Joseph K. Kendal
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Erik J. Geiger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren E. Wessel
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Jeffrey J. Eckardt
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
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Tsukushi S, Nishida Y, Hirose T, Nakata E, Nakagawa R, Nakamura T, Imanishi J, Nagano A, Tamiya H, Ueda T. Short-term clinical outcomes of Kyocera Modular Limb Salvage System designed cementless stems for the endoprosthetic reconstruction of lower extremities: a Japanese Musculoskeletal Oncology Group multi-institutional study. BMC Cancer 2022; 22:781. [PMID: 35842696 PMCID: PMC9288729 DOI: 10.1186/s12885-022-09873-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The high rate of aseptic loosening of cemented stems has led to their frequent use in endoprosthetic reconstruction. However, problems, such as stem breakage and stress shielding at the insertion site, remain. The Japanese Musculoskeletal Oncology Group (JMOG) has developed Kyocera Modular Limb Salvage System (KMLS) cementless stems with a unique tapered press-fit and short fixation design. This study aimed to clarify the short-term postoperative outcomes of this prosthesis and validate the stem design. METHODS One hundred cases of KMLS cementless stems (51 male patients; median age, 49 years; mean follow-up period, 35 months), with a minimum follow-up of 2 years, for the proximal femur (PF), distal femur (DF), and proximal tibia were prospectively registered for use. Prosthesis survival, complication rates, postoperative functional, and radiographical evaluation were analyzed. Complications or failures after insertion of the KMLS endoprostheses were classified into five types and functional results were analyzed according to the MSTS scoring system at postoperative 1 year. The diaphyseal interface and anchorage were graded by the ISOLS system at postoperative 2 years. RESULTS The overall prosthesis survival rates at 2 and 4 years were 88.2 and 79.6%, respectively. The prosthesis-specific survival rate excluding infection and tumor recurrence was 90.2 and 87.9%, respectively. Younger age (p = 0.045) and primary tumor (p = 0.057) were associated with poor prognosis of prosthesis-specific survival excluding infection and tumor recurrence. Complications were observed in 31 patients, 13 patients underwent revision surgery. The mean MSTS functional score at 1 year postoperatively was 68%. Early implant loosening was significantly more common in the DF (p = 0.006) and PF/DF straight stem (p = 0.038). The ISOLS radiographic evaluation at 2 years after surgery revealed good bone remodeling and anchorage in most cases (bone remodeling: 90% / excellent and good, anchorage: 97% / excellent and good). CONCLUSIONS Tumor endoprosthesis long-term fixation to the diaphysis of the lower extremity remains challenging. The KMLS cementless stem with a unique tapered press fit design showed good short-term results in maintaining bone stock. To prevent early loosening, a curved stem should be used in PF and DF, but long-term follow-up is necessary.
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Affiliation(s)
- Satoshi Tsukushi
- Department of Orthopaedic Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku Nagoya, 464-8681, Japan.
| | - Yoshihiro Nishida
- Department of Rehabilitation Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Takeshi Hirose
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Eiji Nakata
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Rumi Nakagawa
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoki Nakamura
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Jungo Imanishi
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Akihito Nagano
- Department of Orthopaedic Surgery, Gifu University School of Medicine, Gifu, Japan
| | - Hironari Tamiya
- Department of Orthopedic Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takafumi Ueda
- Department of Orthopaedic Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
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Li JJ, Tian DM, Yang L, Zhang JY, Hu YC. Influence of a metaphyseal sleeve on the stress-strain state of a bone-tumor implant system in the distal femur: an experimental and finite element analysis. J Orthop Surg Res 2020; 15:589. [PMID: 33298115 PMCID: PMC7724731 DOI: 10.1186/s13018-020-02025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/14/2020] [Indexed: 12/03/2022] Open
Abstract
Background Aseptic loosening of distal femoral tumor implants significantly correlates with the resection length. We designed a new “sleeve” that is specially engaged in the metaphysis at least 5 cm proximal to the knee joint line to preserve as much bone stock as possible. This study investigates the influence of a metaphyseal sleeve on the stress-strain state of a bone tumor implant system in the distal femur. Methods Cortex strains in intact and implanted femurs were predicted with finite element (FE) models. Moreover strains were experimentally measured in a cadaveric femur with and without a sleeve and stem under an axial compressive load of 1000 N. The FE models, which were validated by linear regression, were used to investigate the maximal von Mises stress and the implanted-to-intact (ITI) ratios of strain in the femur with single-legged stance loading under immediate postoperative and osseointegration conditions. Results Good agreement was noted between the experimental measurements and numerical predictions of the femoral strains (coefficient of determination (R2) ≥ 0.95; root-mean-square error (RMSE%) ≈ 10%). The ITI ratios for the metaphysis were between 13 and 28% and between 10 and 21% under the immediate postoperative and osseointegration conditions, respectively, while the ITI ratios for the posterior and lateral cortices around the tip of the stem were 110% and 119% under the immediate-postoperative condition, respectively, and 114% and 101% under the osseointegration condition, respectively. The maximal von Mises stresses for the implanted femur were 113.8 MPa and 43.41 MPa under the immediate postoperative and osseointegration conditions, which were 284% and 47% higher than those in the intact femur (29.6 MPa), respectively. Conclusions This study reveals that a metaphyseal sleeve may cause stress shielding relative to the intact femur, especially in the distal metaphysis. Stress concentrations might mainly occur in the posterior cortex around the tip of the stem. However, stress concentrations may not be accompanied by periprosthetic fracture under the single-legged stance condition.
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Affiliation(s)
- Jian-Jun Li
- Tianjin Medical University, 22 Qixiangtai Road, Tianjin, People's Republic of China.,Department of Bone Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, People's Republic of China.,Department of Bone Trauma, Second Hospital of Tangshan, 22 Jianshe North Road, Tangshan, Hebei, People's Republic of China
| | - Dong-Mu Tian
- Beijing Weigao Yahua Artificial Joint Development Company, 7 Niuhui Street, Shunyi, Beijing, People's Republic of China
| | - Li Yang
- Tianjin Medical University, 22 Qixiangtai Road, Tianjin, People's Republic of China
| | - Jing-Yu Zhang
- Department of Bone Oncology, Second Hospital of Tangshan, 22 Jianshe North Road, Tangshan, Hebei, People's Republic of China
| | - Yong-Cheng Hu
- Department of Bone Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, People's Republic of China.
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Guttowski D, Polster V, Huber G, Morlock MM, Püschel K, Nüchtern J. Comparative Biomechanical In Vitro Study of Different Modular Total Knee Arthroplasty Revision Stems With Bone Defects. J Arthroplasty 2020; 35:3318-3325. [PMID: 32654944 DOI: 10.1016/j.arth.2020.06.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/19/2020] [Accepted: 06/14/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study is to investigate the effects of different stem lengths and types including cones on primary stability in revision total knee arthroplasty with different femoral bone defects and fixation methods in order to maximize bone preservation. It is hypothesized that longer stems provide little additional mechanical stability. METHODS Thirty-five human femurs were investigated. A distal bone defect, Anderson Orthopedic Research Institute classification (s. 33) type-F2a, was created in group 1-3 and type-F3 in group 4-6. A cemented, rotating hinge femoral component was combined with different stems (100 and 160 mm total or hybrid cemented cones, or a 100-mm custom-made anatomical cone stem). The femora were loaded according to in vivo loading during gait. Relative movements were measured to investigate primary stability. Pull-out testing was used to obtain a parameter for the primary stability of the construct. RESULTS Relative movements were small and similar in all groups (<40 μm). For small defect, the pull-out forces of cemented long (4583 N) and short stems (4650 N) were similar and about twice as high as those of uncemented stems (2221 N). For large defects, short cemented stems with cones showed the highest pull-out forces (5500 N). Long uncemented stems (3324 N) and anatomical cone stems (3990 N) showed similar pull-out forces. CONCLUSION All tested stems showed small relative movements. Long cemented stems show no advantages to short cemented stems in small bone defects. The use of cones or an anatomical cone stem with hybrid cementation seems to offer good stability even for larger bone defects. The use of a short cemented stem (with or without cone) may be a suitable choice with a high potential for bone preservation in total knee arthroplasty revision with respective bone defects.
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Affiliation(s)
- Dario Guttowski
- Department for Trauma Surgery and Orthopaedics, UKE University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valerie Polster
- Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany
| | - Gerd Huber
- Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany
| | - Michael M Morlock
- Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany
| | - Klaus Püschel
- Department of Forensic Medicine, UKE University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Nüchtern
- Department for Trauma Surgery and Orthopaedics, UKE University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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The effects of length of femoral stem on aseptic loosening following cemented distal femoral endoprosthetic replacement in tumour surgery. INTERNATIONAL ORTHOPAEDICS 2020; 44:1427-1433. [PMID: 32435955 DOI: 10.1007/s00264-020-04629-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Aseptic loosening is a common prosthetic failure mode. The purpose of this study was to identify dose-response relationship between length of femoral stem and aseptic loosening. METHODS We collected data of patients who underwent distal femoral prosthetic replacements at our institution from 2001 to 2017. Cox regression and two-piecewise regression model were used to analyze the associations between stem length and aseptic loosening. RESULTS Significant association of length of femoral stem with aseptic loosening was observed in multivariate model and a non-linear relationship could be found from the smoothed curve. In two-piecewise model, an inflection point was calculated to be 143 mm. On the left of the inflection point, every 1 mm increase in the length of stem indicated that the risk of aseptic loosening could be reduced by 6%. CONCLUSION There was a significant non-linear relationship between the length of femoral stem and aseptic loosening, and the inflection point was 143 mm.
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Bischel OE, Nadorf J, Klein SB, Gantz S, Jakubowitz E, Kretzer JP, Arnholdt J, Seeger JB. Modular tumor prostheses: are current stem designs suitable for distal femoral reconstruction? A biomechanical implant stability analysis in Sawbones. Arch Orthop Trauma Surg 2019; 139:843-849. [PMID: 30887123 DOI: 10.1007/s00402-019-03158-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION High loosening rates after distal femoral replacement may be due to implant design not adapted to specific anatomic and biomechanical conditions. MATERIALS AND METHODS A modular tumor system (MUTARS®, Implantcast GmbH) was implanted with either a curved hexagonal or a straight tapered stems in eight Sawbones® in two consecutively generated bone defect (10 cm and 20 cm proximal to knee joint level). Implant-bone-interface micromotions were measured to analyze main fixation areas and to characterize the fixation pattern. RESULTS Although areas of highest relative micromotions were measured distally in all groups, areas and lengths of main fixation differed with respect to stem design and bone defect size. Regardless of these changes, overall micromotions could only be reduced with extending bone defects in case of tapered stems. CONCLUSIONS The tapered design may be favorable in larger defects whereas the hexagonal may be advantageous in defects located more distally.
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Affiliation(s)
- Oliver E Bischel
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany. .,BG Trauma Center, Ludwigshafen am Rhein, Germany.
| | - J Nadorf
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM), Klinikstrasse 33, 35392, Giessen, Germany.,Project Solutions GmbH, Ludwigshafen am Rhein, Germany
| | - S B Klein
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - S Gantz
- Biometrics Consulting and Project Management, University Heidelberg, Heidelberg, Germany
| | - E Jakubowitz
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic Surgery, Hannover Medical School, Hannover, Germany
| | - J P Kretzer
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - J Arnholdt
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University, Brettreichstr. 11, 97074, Würzburg, Germany
| | - J B Seeger
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM), Klinikstrasse 33, 35392, Giessen, Germany
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Min L, Yao K, Lu M, Zhou Y, Wang J, Tang F, Zhang W, Luo Y, Duan H, Tu C. First application of 3D design custom-made uncemented prosthetic stem for distal femoral cemented megaprosthesis revision. PRECISION CLINICAL MEDICINE 2018; 1:88-96. [PMID: 35693199 PMCID: PMC8985771 DOI: 10.1093/pcmedi/pby008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/10/2018] [Accepted: 08/05/2018] [Indexed: 02/05/2023] Open
Abstract
Objectives 3D design, which is widely used in orthopedics, can be applied for precise distal femoral megaprosthetic revision. This research aimed to present and evaluate the design, perioperative management, and mid-term clinical outcomes of a 3D design custom-made uncemented prosthetic stem. Methods Between January 2014 and January 2016, seven patients received 3D design custom-made uncemented prosthetic stem revision at our institution. Clinical records and radiographs were evaluated retrospectively. Results There were no hardware-related complications during the follow-up (average 24.3 months; range 24–48 months). The average Musculoskeletal Tumor Society (MSTS) score at the last follow-up after revision (27.7 points, range 25–28 points) was significantly higher than that before (16.0 points, range 13–18 points). In addition, the range of motion (ROM) of the affected knee, and the scores of pain, function, emotional acceptance, support, walking and gait all improved significantly. The antecurvature radian of the revision stem averaged at 3.6°. Of the seven patients, three received femoral stem revision and four received revision of the femoral stem and the femoral component; three of them used longer prostheses than the others. There were no significant differences in function between these two groups at the last follow-up after revision. Conclusion The 3D design custom-made prosthesis is a typical precision medicine technology in oncologic orthopedics. Characterized by its individually and precisely designed uncemented stem, it offers an alternative option for distal femoral cemented prosthesis revision. Besides the 3D design itself, the perioperative management, especially the techniques for stem implantation, and long-term follow-up are also crucial.
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Affiliation(s)
- Li Min
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Kai Yao
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Minxun Lu
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Yong Zhou
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Jie Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Fan Tang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Wenli Zhang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Yi Luo
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Hong Duan
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
| | - Chongqi Tu
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Xiang #37, Chengdu, Sichuan, People's Republic of China
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