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Lymphedema: A Significant Risk Factor for Infection and Implant Failure After Total Knee Arthroplasty. J Am Acad Orthop Surg 2020; 28:996-1002. [PMID: 32235243 DOI: 10.5435/jaaos-d-20-00005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/07/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Lymphedema is characterized by fluid buildup and swelling, leading to skin fibrosis and recurring soft-tissue infections. There is a paucity of data examining the impact of lymphedema in total knee arthroplasty (TKA). The purpose of this study was to review the outcomes of TKA in patients with lymphedema compared with a matched cohort with primary osteoarthritis. METHODS One hundred forty-four knees underwent primary TKA with a preceding diagnosis of ipsilateral lymphedema. The mean follow-up was 7 years. A blinded 1:2 match of knees with lymphedema to a group of knees without lymphedema undergoing primary TKA was performed. Matching criteria included sex, age, date of surgery, and body mass index. The mean follow-up for the comparison cohort was 8 years. RESULTS Lymphedema increased revision hazard ratio [HR] 7.60; P < 0.001), reoperation (HR, 2.87; P < 0.001), and infection (HR, 6.19; P < 0.001) in addition to periprosthetic fracture (P = 0.04) and tibial component loosening (P = 0.01). The mean time to infection trended toward later time points in knees with lymphedema (19 versus 2 months, P = 0.25). DISCUSSION Lymphedema increased the risk of revision, reoperation, and infection. These data highlight the need for appropriate patient counseling and the need for further investigation into the effects of preoperative and postoperative optimization of lymphedema management in the TKA setting. LEVEL OF EVIDENCE Therapeutic Level III.
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Henderson ER, Keeney BJ, Husson EG, Bernthal NM, Ji T, Pala E, Funovics PT, Groundland JS, Lozano-Calderon S, Puchner S, Zoller SD, Ruggieri P, Windhager R, Guo W, Hornicek FJ, Letson GD, Temple HT. Nonmechanical Revision Indications Portend Repeat Limb-Salvage Failure Following Total Femoral Replacement. J Bone Joint Surg Am 2020; 102:1511-1520. [PMID: 32453111 DOI: 10.2106/jbjs.19.01022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is scant evidence to guide decision-making for patients considering total femoral replacement (TFR). We aimed to identify the indication, patient, disease, and surgical technique-related factors associated with failure. We hypothesized that failure occurs more frequently in the setting of revision surgical procedures, with infection as the predominant failure mode. METHODS We performed a retrospective cohort study of patients receiving total femoral endoprostheses for oncological and revision arthroplasty indications; 166 patients met these criteria. Our primary independent variable of interest was TFR for a revision indication (arthroplasty or limb salvage); the primary outcome was failure. Analyses were performed for patient variables (age, sex, diagnosis group, indication), implant variables (model, decade, length, materials), and treatment variables. We analyzed TFR failures with respect to patient factors, operative technique, and time to failure. We conducted bivariate logistic regressions predicting failure and used a multivariate model containing variables showing bivariate associations with failure. RESULTS Forty-four patients (27%) had treatment failure. Failure occurred in 24 (23%) of 105 primary TFRs and in 20 (33%) of 61 revision TFRs; the difference was not significant (p = 0.134) in bivariate analysis but was significant (p = 0.044) in multivariate analysis. The mean age at the time of TFR was 37 years in the primary group and 51 years in the revision group (p = 0.0006). Of the patients who had mechanical failure, none had reoccurrence of their original failure mode, whereas all 8 patients from the nonmechanical cohort had reoccurrence of the original failure mode; this difference was significant (p = 0.0001). CONCLUSIONS TFR has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection. All failed TFRs performed for revision indications for infection or local recurrence failed by reoccurrence of the original failure mode and resulted in amputation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eric R Henderson
- Department of Orthopaedics and the Sarcoma & Connective Tissue Oncology Program, Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire
| | - Benjamin J Keeney
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire.,Berkley Medical Management Solutions, Overland Park, Kansas
| | - Emily G Husson
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire
| | - Nicholas M Bernthal
- University of California at Los Angeles Sarcoma Program, Los Angeles, California
| | - Tao Ji
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Elisa Pala
- Orthopaedic Oncology Unit, University of Padua, Padua, Italy
| | - Philipp T Funovics
- Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Stephan Puchner
- Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stephen D Zoller
- University of California at Los Angeles Sarcoma Program, Los Angeles, California
| | - Pietro Ruggieri
- Orthopaedic Oncology Unit, University of Padua, Padua, Italy
| | - Reinhard Windhager
- Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China
| | - Francis J Hornicek
- University of California at Los Angeles Sarcoma Program, Los Angeles, California
| | - G Douglas Letson
- Sarcoma Program, H. Lee Moffitt Cancer and Research Institute, Tampa, Florida
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DeRogatis MJ, Issack PS. Total Femoral Replacement as a Salvage Operation for the Treatment of Massive Femoral Bone Loss During Revision Total Hip Arthroplasty. JBJS Rev 2019; 6:e9. [PMID: 29847442 DOI: 10.2106/jbjs.rvw.17.00195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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King SW, Lamb JN, Cage ES, Pandit H. Periprosthetic femoral fractures following total hip and total knee arthroplasty. Maturitas 2018; 117:1-5. [PMID: 30314554 DOI: 10.1016/j.maturitas.2018.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 11/25/2022]
Abstract
Total joint arthroplasties are increasing worldwide in both frequency and prevalence. When successful, they offer great improvements in quality of life. However, fractures around implants are often difficult to manage and require prolonged inpatient stays in tertiary hospitals. Management may differ between surgeons, but most patients will be managed surgically if mobility or joint stability is threatened. Those affected are often at higher risk from surgery, are frailer and at higher risk of mortality and a lifelong reduction in mobility. The incidence of these fractures is increasing, and patients should appreciate the risk and implications of this recognised complication of joint arthroplasty.
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Affiliation(s)
- Samuel W King
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK
| | - Jonathan N Lamb
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK; Leeds Institutes of Rheumatology and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Rd, Leeds, LS7 4SA, UK.
| | - Emily S Cage
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK; Indiana University School of Medicine, 340 West 10th Street, Indianapolis, IN 46202, USA
| | - Hemant Pandit
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK; Leeds Institutes of Rheumatology and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Chapeltown Rd, Leeds, LS7 4SA, UK
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Amanatullah DF, Trousdale RT, Hanssen AD, Lewallen DG, Taunton MJ. Non-oncologic total femoral arthroplasty: retrospective review. J Arthroplasty 2014; 29:2013-5. [PMID: 25041874 DOI: 10.1016/j.arth.2014.05.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/12/2014] [Accepted: 05/20/2014] [Indexed: 02/08/2023] Open
Abstract
Total femoral arthroplasty (TFA) is an option to amputation in the setting of excessive bones loss during revision total hip and knee arthroplasty. Twenty non-oncologic TFAs with a minimum of 2years follow-up were retrospectively reviewed. The average clinical follow-up was 73±49months. The incidence of new infection was 25% (5/20), while the overall infection rate was 35% (7/20). The incidence of primary hip instability was 10% (2/20), while the overall instability rate was 25% (5/20). Six patients (30%) required revision. The average pre-operative HHS was 30.2±13.1. The average post-operative HHS was 65.3±16.9. TFA is a viable alternative to amputation in non-oncologic patients with massive femoral bone deficiency. However, TFA performed poorly in the setting of infection and instability.
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Affiliation(s)
| | | | - Arlen D Hanssen
- Dept of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
Knee replacement is an effective treatment for pain and functional impairment secondary to degenerative joint conditions. The number of knee replacements performed continues to rise. Periprosthetic fractures around total knee arthroplasties are a relatively rare complication but are complex injuries that require the treating surgeon to be familiar with and proficient at arthroplasty and trauma reconstructive techniques. An increase in life expectancy and in the functional demands of elderly patients may lead to an increased incidence of periprosthetic fractures. Supracondylar fractures of the femur are the most common type and this review will focus on the incidence, risk factors, classification, investigation, and treatment options for periprosthetic fractures around total knee arthroplasties.
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Singh JA, Jensen M, Lewallen D. Predictors of periprosthetic fracture after total knee replacement: an analysis of 21,723 cases. Acta Orthop 2013; 84:170-7. [PMID: 23530873 PMCID: PMC3639338 DOI: 10.3109/17453674.2013.788436] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Periprosthetic fracture is a devastating complication of total knee replacement (TKR). Most published studies have not comprehensively assessed clinical and demographic predictors. We wanted to determine the incidence and predictors of postoperative periprosthetic fracture after primary and revision TKR. PATIENTS AND METHODS We used prospectively collected data in the Mayo Clinic Total Joint Registry on all patients who underwent primary or revision TKR at the Mayo Clinic, Rochester, from 1989 through 2008. We assessed incidence of postoperative periprosthetic fractures and modifiable (comorbidity, body mass index) and unmodifiable factors (age, sex, operative diagnosis, ASA class, previous cardiac disease, and previous thromboembolic disease) as predictors of postoperative periprosthetic fractures. We used multivariable-adjusted Cox regression analyses separately for primary and revision TKR. RESULTS 12,914 patients underwent 17,633 primary TKRs and 3,286 patients underwent 4,090 revision TKRs during the period 1989-2008. 1.1% of patients (188/17,633) after primary TKR and 2.5% of patients (104/4,090) after revision TKR sustained a postoperative periprosthetic fracture on or after postoperative day 1. Older age was associated with lower risk of periprosthetic fractures after primary TKR (p < 0.001). Compared to ≤ 60 years, risk was lower for ages 61-70 years (hazard ratio (HR) = 0.5, 95% confidence interval (CI): 0.3-0.7)) and 71-80 years (HR = 0.6, CI: 0.4-0.8), but not for age > 80 years (HR = 0.9, CI: 0.5-1.6). In revision TKR cohort, a diagnosis of non-union (HR = 4.9, CI: 1.2-20), infection (HR = 2.9, CI: 1.3-6.4) or previous surgery with components removed (HR = 2.1, CI: 1.3-3.4) increased the risk of postoperative periprosthetic fracture, compared to a diagnosis of loosening/wear/osteolysis. INTERPRETATION We identified significant risk factors for periprosthetic fracture after primary and revision TKR. Patients with these risk factors can be informed by their surgeons of increased risk of this uncommon, but serious complication of TKR.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL,Department of Medicine, University of Alabama, and Division of Epidemiology, School of Public Health, University of Alabama, Birmingham, AL,Department of Orthopedic Surgery
| | - Matthew Jensen
- Department of Health Sciences Research, Mayo Clinic School of Medicine, Rochester, MN
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Sherman SL, Cunneen KP, Walcott-Sapp S, Brause B, Westrich GH. Custom total femur spacer and second-stage total femur arthroplasty as a novel approach to infection and periprosthetic fracture. J Arthroplasty 2008; 23:781-6. [PMID: 18534389 DOI: 10.1016/j.arth.2007.05.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 05/18/2007] [Indexed: 02/08/2023] Open
Abstract
Total femur arthroplasty procedures have previously been used after tumor excision and as a last resort for failed revision arthroplasty. The patient in this case presented with massive loss of femoral bone stock, a periprosthetic fracture, and recurrent Staphylococcus epidermidis infection. A specially designed total femoral spacer impregnated with antibiotics was created for a 2-stage revision procedure that successfully restored functional ability and eradicated the infection. Although 2-stage protocols with spacers have been used to treat persistent infections after hip and knee arthroplasty, this is the first reported instance of the creation of a total femur antibiotic-impregnated cement spacer and subsequent total femoral arthroplasty as a 2-stage protocol at our institution.
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Affiliation(s)
- Seth L Sherman
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA
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Holley K, Zelken J, Padgett D, Chimento G, Yun A, Buly R. Periprosthetic fractures of the femur after hip arthroplasty: an analysis of 99 patients. HSS J 2007; 3:190-7. [PMID: 18751793 PMCID: PMC2504263 DOI: 10.1007/s11420-007-9045-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The medical records and radiographs of 99 patients treated for a periprosthetic femur fracture after total hip arthroplasty over a 17-year period at a single institution were prospectively reviewed. Fractures were classified according to the Vancouver system and stratified as to treatment method. Sixty-six patients had complete records available and a minimum of 12 months follow-up. Overall, 86% of the patients achieved fracture union. The success rate of cemented revision in the B2 and B3 groups was 84%, whereas cement-less revision was 86% successful. The complication rate of surgical treatment was 29%. Fracture union with a stable implant was possible in the majority of cases. Our results support the use of the Vancouver classification as a treatment algorithm.
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Affiliation(s)
- Keith Holley
- Naval Medical Center San Diego Department of Orthopaedic Surgery, San Diego, CA USA
| | - Jonathan Zelken
- Hospital for Special Surgery, Cornell University Medical Center, 535 E 70th St, New York, NY 10021 USA
| | - Douglas Padgett
- Hospital for Special Surgery, Cornell University Medical Center, 535 E 70th St, New York, NY 10021 USA
| | - George Chimento
- Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121 USA
| | - Andrew Yun
- The Arthritis Institute, John F. Kennedy Hospital, Dr Carreon Blvd, Indio, CA 92201 USA
| | - Robert Buly
- Hospital for Special Surgery, Cornell University Medical Center, 535 E 70th St, New York, NY 10021 USA
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Abstract
Postoperative periprosthetic fracture is a rare but serious complication after joint replacement surgery. Due to poor bone quality, multiple joint involvement with the replacement of different joints and considerable comorbidity, the presence of rheumatoid arthritis is associated with a high risk of periprosthetic fractures. For the same reasons, periprosthetic fractures in patients with rheumatoid arthritis can be very difficult to treat, and their management often requires an interdisciplinary approach. On the basis of the current literature, the present work describes different aspects of the epidemiology of periprosthetic fractures, principles of their classification, different treatment options and the results of treatment of these fractures. Special attention is paid to the situation of patients with rheumatoid arthritis.
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Affiliation(s)
- G Pap
- Orthopädische Universitäitsklinik Magdeburg.
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12
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Abstract
Fractures around total knee arthroplasties are challenging clinical problems and include the following: stress fractures of the pelvis and femoral neck, supracondylar femur fractures, fractures of the proximal tibial metaphysis and diaphysis, and patellar fractures. Treatment focuses on restoration of the patient's prefracture functional status. The etiology of supracondylar femur fractures is multifactorial and treatment includes immobilization, retrograde intramedullary nailing, open reduction and internal fixation, and revision arthroplasty. The "Less Invasive Stabilization System" plate has recently been added to the list of viable fixation options. Tibial metaphyseal and diaphyseal fractures are less common and usually treated with revision arthroplasty. In the absence of maltracking or component loosening, vertical patellar fractures often respond to immobilization. Disruption of the extensor mechanism may require cerclage wiring or even extensor mechanism allografting if chronic. Conventional tension band wiring usually fails. Patellar fractures are controversial and problematic.
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Affiliation(s)
- Ravi Tharani
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Los Angeles, CA 90033, USA
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Eichinger S, Forst R. [Femoral neck prosthesis in the case of femoral neck fracture and ipsilateral long stem-knee tumour prosthesis]. Unfallchirurg 2005; 108:679-83. [PMID: 15798919 DOI: 10.1007/s00113-005-0919-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Femoral neck fracture in the case of a previously implanted ipsilateral tumour knee-prosthesis represents a challenging situation because of the long proximal stem of the knee implant. Avoiding total femur replacement, we implanted a femoral neck prosthesis (Eska Cut 2000) in a 65 year old patient to preserve as much of the femur free of implant as possible, minimizing the risk of a periprosthetic or interprosthetic fracture. At 2.5 years postoperatively, there were no signs of loosening, migration or periprosthetic fracture with a good functional result. In our case, the femoral neck prosthesis avoided the implantation of a total femur replacement. Nevertheless, this prosthesis must be considered critically and cannot be recommended as the standard implant for femoral neck fracture in the case of an ipsilateral long stem-knee prosthesis.
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Affiliation(s)
- S Eichinger
- Orthopädische Universitätsklinik Erlangen-Nürnberg, Erlangen.
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Westrich GH, Mollano AV, Sculco TP, Buly RL, Laskin RS, Windsor R. Rotating hinge total knee arthroplasty in severly affected knees. Clin Orthop Relat Res 2000:195-208. [PMID: 11039807 DOI: 10.1097/00003086-200010000-00023] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A consecutive series of 24 knees in 21 patients who received a Finn rotating hinge for primary (nine knees) or revision (15 knees) total knee arthroplasty between August 1993 and January 1997 was reviewed. The average followup was 33 months (range, 21-62 months) for all patients in the study. Seventeen patients (20 knees) were followed up for more than 2 years. Twenty-four knees (21 patients) were categorized according to Knee Society scoring criteria: 37.5% (nine knees) were Category A, 25% (six knees) were Category B, and 37.5% (nine knees) were Category C. Using the Knee Society knee and function scores, clinical and radiographic results were assessed and outcome analysis was determined. The average Knee Society knee score improved from 44 points (range, 5-64 points) before surgery to 83 points (range, 45-95 points) after surgery; the average functional score according to the Knee Society system improved from 10 points (range, 0-35 points) before surgery to 45 points (range, 0-100 points) after surgery. Pain and function markedly improved after surgery. For treatment of the most severely affected knees with compromised bone and ligamentous instability, the Finn total knee replacement appears to be an acceptable option. As a rotating hinge design, the prosthesis at early followup provides excellent pain relief, restoration of walking capacity, and stabilization, without evidence of early mechanical failure.
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Affiliation(s)
- G H Westrich
- Hospital for Special Surgery-Cornell University Medical Center, New York, NY 10021, USA
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