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Hunt KJ, Hewitt MA, Buckley SE, Bartolomei J, Myerson MS, Hogan MV, Laf Committee ISAKOS. Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons. J ISAKOS 2023; 8:239-245. [PMID: 37100118 DOI: 10.1016/j.jisako.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/30/2022] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR. METHODS We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence. RESULTS Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p = 0.005). CONCLUSION LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Kenneth J Hunt
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA.
| | - Michael A Hewitt
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Sara E Buckley
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Jonathan Bartolomei
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - Mark S Myerson
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - MaCalus V Hogan
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
| | - I S A K O S Laf Committee
- Department of Orthopedic Surgery, University of Colorado School of Medicine, 1635 Aurora Ct., 4th Floor, Aurora, CO, 80045, USA
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Tan A, Chan M, Kon Kam King C, Chandrakumara D, Socklingam R. The Outcome of Modified Mini-Open Brostrom Gould Ankle Surgery on Chronic Ankle Instability. Cureus 2023; 15:e40656. [PMID: 37476148 PMCID: PMC10356182 DOI: 10.7759/cureus.40656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction Modified Brostrom-Gould surgery (MBG) aims to repair the lateral ligaments of the ankle in patients with ligamentous laxity and chronic instability. Brostrom-Gould surgery-the Brostrom technique associated with Gould augmentation-is currently the gold standard surgical option for chronic ankle instability worldwide. Chronic lateral ankle instability caused by lateral ankle sprains is one of the most common sports-related injuries, and Brostrom-Gould surgery is commonly recommended as the operative treatment. While arthroscopic surgery is becoming the more heavily favored approach of choice, open Brostrom-Gould surgery is still pertinent for patients for whom arthroscopic repair is unsuitable. Aim This paper discusses a modified mini-open approach of the open Brostrom-Gould surgery with a smaller incision (1.5 cm) and aims to study the outcomes of this modified approach on patients' post-operative pain, stability, and functional outcome. Methods Forty-two patients were followed up for a mean of 2.6 years after undergoing modified mini-open Brostrom-Gould surgery. The Visual Analog Scale (VAS), the Foot and Ankle Outcome Score (FAOS), and Karlsson scores were used to monitor their post-operative recovery. The Wilcoxon signed-rank test and the SPSS Statistics (v.28.0.1) software were used for data management and analytics. Results The results showed a mean Karlsson score of 83.4, a mean FAOS score of 69.7, and a mean VAS score of 1.33. These results are comparable to studies conducted on conventional open Brostrom-Gould repair. Conclusion The modified mini-open Brostrom Gould provides a favorable functional outcome with a reduction in pain and suggests no decrease in efficacy with the modified approach. This is coupled with the added advantages of a smaller wound, better wound healing outcomes, and availability to patients not suited to arthroscopic repair.
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Affiliation(s)
- Amarinda Tan
- Orthopedic Surgery, Yong Loo Lin School of Medicine, Singapore, SGP
| | - Mark Chan
- Orthopedic Surgery, Yong Loo Lin School of Medicine, Singapore, SGP
| | | | | | - Raj Socklingam
- Orthopaedic Surgery, Changi General Hospital, Singapore, SGP
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Dallman J, Wolf MR, Campbell T, Herda T, White J, Tarakemeh A, Vopat BG. Current Definitions of Failure in Lateral Ankle Instability Surgery: A Systematic Review. Am J Sports Med 2023:3635465231153165. [PMID: 36917833 DOI: 10.1177/03635465231153165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND "Failure" is a term that is frequently used to describe an unfavorable outcome for patients who undergo surgical treatment for lateral ankle instability (LAI). A standard definition of failure for the surgical treatment of ankle instability has not been established by clinicians and researchers. PURPOSE To identify the definitions of ankle instability treatment failure that are currently in the literature and to work toward the standardization of the definition. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic search of MEDLINE, SPORTDiscus, CINAHL, Embase, and Web of Science was conducted to identify clinical studies that included patients who underwent surgical treatment for LAI and included information about surgical failure. Studies with level of evidence 1 to 4 were included in this review. Animal studies, biomechanical studies, cadaveric studies, review articles, and expert opinions were excluded. The included studies were then reviewed for definitions of failure of any surgical procedure that was performed to correct LAI. RESULTS Of the 1200 studies found, 3.5% (42/1200) published between 1984 and 2021 met the inclusion criteria and were analyzed. After reviewing the data, we found numerous definitions were reported in the literature for LAI surgical failure. The most common was recurrent instability (40% [17/42]), followed by rerupture (19% [8/42]). For the original surgical procedure, the anatomic Broström-Gould technique was used most frequently (57% [24/42]). The failure rate of the Broström-Gould technique ranged from 1.1% to 45.2% depending on the definition of failure. CONCLUSION There were multiple definitions of failure for the surgical treatment of LAI, which is one of the reasons why the rate of failure can vary greatly. The literature would benefit greatly from the standardization of the definition of ankle instability treatment failure. This definition should include specific, objective physical examination findings that eliminate the ambiguity surrounding failure.
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Affiliation(s)
| | - Megan R Wolf
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.,Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Tanner Campbell
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Trent Herda
- Neuromechanics Laboratory, Department of Health, Sport & Exercise Sciences, University of Kansas, Lawrence, Kansas, USA
| | - Jacob White
- Dykes Library, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Armin Tarakemeh
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Bryan G Vopat
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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Kim SW, Cho BK, Kang C, Choi SM, Bang SM. Anatomic anterior talofibular ligament repair augmented with suture-tape for chronic ankle instability with poor quality of remnant ligamentous tissue. J Orthop Surg (Hong Kong) 2022; 30:10225536221141477. [PMID: 36420544 DOI: 10.1177/10225536221141477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Because modified Broström procedure provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue is considered as a prognostic factor for ligament repair surgery. The purpose of this study was to assess the intermediate-term clinical results after anatomic anterior talofibular ligament repair augmented with suture-tape for chronic lateral ankle instability (CLAI) with poor quality of ligament remnants. METHODS 64 patients with the insufficient anterior talofibular ligament confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for ≥3 years after the augmented anterior talofibular ligament repair. The clinical outcomes were assessed with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Measurements on stress radiographs were performed to assess the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was analysed with single leg stance test. RESULT Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved from preoperative mean 58.3 and 53.6 points to 90.2 and 88.7 points at final followup, respectively (p < 0.001). Talar tilt angle and anterior talar translation improved from preoperative mean 16.5° and 13.4 mm to 3.2° and 4.4 mm at final followup, respectively (p < .001). Two patients (3.1%) showed a recurrence of instability. Although balance retention time improved from preoperative mean 3.9-6.2 seconds at final followup (p < .001), a significant side-to-side difference was found. CONCLUSION Anatomic anterior talofibular ligament repair augmented with suture-tape appears to be a useful surgical option for CLAI with poor quality of ligament remnants at intermediate-term followup. Through anatomic repair of attenuated ligaments and suture-tape augmentation, this combined procedure can provide the reliable restoration of mechanical stability and advantages of the anatomic ligament repair. Postural control deficit compared to the uninjured ankle supports a necessity of continuous proprioceptive-oriented rehabilitation.
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Affiliation(s)
- Seok-Won Kim
- Department of Orthopaedic Surgery, College of Medicine, 58928Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Byung-Ki Cho
- Department of Orthopaedic Surgery, College of Medicine, 58928Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Chan Kang
- Department of Orthopaedic Surgery, College of Medicine, 26715Chungnam National University, Daejeon, Republic of Korea
| | - Seung-Myung Choi
- Department of Orthopaedic Surgery, 587171Uijeongbu Eulji University Hospital, Chungju, Republic of Korea
| | - Seung-Min Bang
- Department of Orthopaedic Surgery, College of Medicine, 58928Chungbuk National University Hospital, Cheongju, Republic of Korea
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Choi SM, Cho BK, Kim SH. The Influence of Suture-Tape Augmentation on Biological Healing of the Anterior Talofibular Ligament in Chronic Ankle Instability: A Quantitative Analysis Using MRI. J Foot Ankle Surg 2022; 61:957-963. [PMID: 35016831 DOI: 10.1053/j.jfas.2021.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
While the effectiveness of suture-tape augmentation for chronic ankle instability has been supported biomechanically and clinically, little information is available regarding biological changes of the lateral ligaments postoperatively. This study aims to quantitatively evaluate ligament regeneration with MRI after suture-tape augmentation. Forty-six patients underwent MRI scan at follow-up of a minimum of 1 year after lateral ligaments augmentation using suture-tape. The signal-to-noise ratio (SNR) and width of anterior talofibular ligament (ATFL) were measured on preoperative and postoperative MRI by 3 researchers. The degree of biological healing of ATFL was analyzed based on the change of SNR and comparison with normal contralateral ankle. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Mean Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved significantly from 63.1 to 92.7, and 59.6 to 91.5 points at final follow-up, respectively (p < .001). Mean SNR and width of ATFL were changed insignificantly from 8.24 to 7.96, and 1.88 mm to 2.05 mm at final follow-up, respectively (p = .391, .509). As compared to contralateral side, there were significant differences in both mean SNR and width of the ATFL, respectively (p < .001, p = .0012). Spearman's correlation analysis revealed no significant association between clinical outcomes and degree of biological healing of ATFL based on MRI. Despite significant improvement in patient-reported clinical outcomes, the influence on ligament regeneration of suture-tape augmentation for chronic ankle instability was insignificant. In addition, there was no significant correlation between clinical outcomes and degree of biological healing of the ATFL.
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Affiliation(s)
- Seung-Myung Choi
- Department of Orthopaedic Surgery, Eulji University School of Medicine, Uijeongbu Hospital, Uijeongbu, South Korea
| | - Byung-Ki Cho
- Department of Orthopaedic Surgery, College of Medicine Chungbuk National University, Cheongju, South Korea; Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, South Korea.
| | - Seong-Hyeon Kim
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, South Korea
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Mercer NP, Kanakamedala AC, Azam MT, Hurley ET, Samsonov AP, Walls RJ, Kennedy JG. Clinical Outcomes After Suture Tape Augmentation for Ankle Instability: A Systematic Review. Orthop J Sports Med 2022; 10:23259671221095791. [PMID: 35647213 PMCID: PMC9134450 DOI: 10.1177/23259671221095791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background: There is minimal literature on the use of suture tape augmentation in the
treatment of chronic lateral ankle instability (CLAI), prompting an
investigation on its use and effect during surgery of the lateral ankle. Purpose: To evaluate the evidence for the use of suture tape augmentation in the
treatment of CLAI and the outcomes after this procedure. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed using the PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) guidelines. Studies were included
if they evaluated the use of suture tape for CLAI. Outcome measures included
the Foot and Ankle Ability Measure, American Orthopaedic Foot and Ankle
Society (AOFAS) score, return to play, and radiological improvement in
anterior talar translation and talar tilt angle. Quantitative and
qualitative analyses were performed. Results: There were 11 studies (2 with level 2 evidence, 1 with level 3, and 8 with
level 4) including 334 patients (334 ankles) that underwent suture-tape
augmentation. The mean age was 27.3 years, 67.3% were women, and the mean
follow-up was 27.6 months (range, 11.5-38.5 months). The mean weighted
postoperative AOFAS score was 95, and 87.7% were able to return to sports.
Overall, 9 recurrent instability events (4.1%) were reported. In 3 studies
that compared Broström repair and suture tape augmentation, there were no
significant differences between the procedures in recurrent instability
(mean difference [MD], 0.81 [95% CI, 0.19 to 3.50]; I2 = 0%; P = .78), Foot and Ankle Ability Measure
(MD, 1.24 [95% CI, –3.73 to 6.21]; I2 = 66%; P = .63), talar tilt angle improvement
(MD, –0.07 [95% CI, –0.68 to 0.54]; I2 = 0%; P = .42), or anterior talar translation
improvement (MD, –0.06 [95% CI, –0.69 to 0.56]; I2 = 0%; P = .77). Conclusion: Suture tape augmentation did not significantly improve clinical or
radiological outcomes in the setting of modified Broström repair for CLAI.
There is currently insufficient evidence to recommend suture tape
augmentation for all patients at this time.
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Affiliation(s)
- Nathaniel P. Mercer
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | | | - Mohammad T. Azam
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | - Eoghan T. Hurley
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Alan P. Samsonov
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | - Raymond J. Walls
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | - John G. Kennedy
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
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Piscoya AS, Bedrin MD, Lundy AE, Eckel TT. Modified Broström With and Without Suture Tape Augmentation: A Systematic Review. J Foot Ankle Surg 2022; 61:390-395. [PMID: 34862125 DOI: 10.1053/j.jfas.2021.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/16/2021] [Accepted: 09/26/2021] [Indexed: 02/03/2023]
Abstract
The Modified Broström has become the gold standard for operative management of chronic lateral ankle instability. Despite overall good clinical outcomes with this procedure, recent biomechanical data have called into question the strength and durability of this technique. Accordingly, the addition of suture tape to the Modified Broström construct has been described in an attempt to more closely recreate the natural biomechanical properties of the ankle lateral ligament complex. We performed a systematic review of the literature was using PubMed, Embase, and CINAHL to identify English-language articles from 2009 to present discussing outcomes with the augmented Modified Broström technique. A total of 4 studies (2 retrospective cohort studies, 2 case series) involving 156 patients with Modified Broström with augmentation met inclusion criteria. Average follow-up time was 13.8 months. Of the 3 studies reporting patient-reported outcome measures both pre- and postoperatively, there was a significant improvement in all measures (p < .05). Two studies compared the Modified Broström directly with and without augmentation, one of which found a statistically significant difference in the Foot and Ankle Ability Measure in favor of the augmentation group (93.1 vs 90.5, p = .027), while American Orthopaedic Foot and Ankle Society score was not significantly different (p > .05) between the 2 procedures across studies. There were no significant differences in complications between techniques. Modified Broström with suture tape augmentation for chronic lateral ankle instability can produce good short-term clinical outcomes with few complications, comparable to the Modified Broström alone.
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Affiliation(s)
- Andres S Piscoya
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Michael D Bedrin
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD.
| | - Alexander E Lundy
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Tobin T Eckel
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD
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Lan R, Piatt ET, Bolia IK, Haratian A, Hasan L, Peterson AB, Howard M, Korber S, Weber AE, Petrigliano FA, Tan EW. Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211045978. [PMID: 35097476 PMCID: PMC8532228 DOI: 10.1177/24730114211045978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.
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Affiliation(s)
- Rae Lan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric T. Piatt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander B. Peterson
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Mark Howard
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Shane Korber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A. Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric W. Tan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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