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Viitanen J, Quinn R, Allen M, Broeckx BJG, Bartkowiak T, Haimel G. Do locking plugs improve implant strength? Biomechanical comparison of polyaxial locking constructs with and without locking plugs in a fracture gap model. BMC Vet Res 2023; 19:104. [PMID: 37528435 PMCID: PMC10394762 DOI: 10.1186/s12917-023-03660-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/14/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND The objective of this study was to investigate the effects of locking plugs and the biomechanical properties of a 3.5 mm 8-hole polyaxial locking plate in a fracture gap model. Our hypothesis was that locking plugs would increase the strength and stiffness of the construct. Twelve 3.5 mm 8-hole plates were used to evaluate two different construct designs (with locking plugs vs. without locking plugs) with validated bone substitutes in a 25 mm bridging osteosynthesis gap model. Each construct was subjected to a single cycle four-point bending load to failure using a servo-hydraulic testing machine. Bending stiffness, bending strength, and bending structural stiffness were calculated and compared using an unpaired Student´s t-test. RESULTS The plating construct with locking plugs did not show any significant increase in terms of bending stiffness, bending strength, and bending structural stiffness compared to plating construct without locking plugs in a 25 mm gap fracture model during a single cycle four-point bending. CONCLUSIONS Under the conditions tested, filling empty plate holes with locking plugs in bridging osteosynthesis does not increase stiffness or strength of the plate-bone construct.
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Affiliation(s)
- Joni Viitanen
- Veterinary Specialists Scotland, part of Linnaeus veterinary limited, Livingston, EH54 8AG, United Kingdom.
| | - Robert Quinn
- Anderson Moores Veterinary Specialists, part of Linnaeus veterinary limited, Hampshire, S021 2LL, United Kingdom
| | - Matthew Allen
- Department of Veterinary Medicine, Surgical Discovery Centrum, University of Cambridge, Cambridge, CB3 0ES, United Kingdom
| | - Bart J G Broeckx
- Department of Nutrition, Genetics and Ethology, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
| | - Tomasz Bartkowiak
- Institute of Mechanical Technology, Poznan University of Technology, 60-965, Poznań, Poland
| | - Georg Haimel
- Tierarztpraxis Am Stadtpark, Reisnerstrasse7, 1030, Vienna, Austria
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Yuan D, Wu Z, Luo S, Zhou Y, Teng J, Ye C. Improve biomechanical stability using intramedullary nails with femoral neck protection in femoral shaft fractures. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 225:107078. [PMID: 36037604 DOI: 10.1016/j.cmpb.2022.107078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/02/2022] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Elderly patients treated for femoral shaft fractures have a higher risk of hip fracture. We hypothesized that intramedullary nails protecting the femoral neck can improve mechanical strength and reduce the risk of subsequent hip fracture. This study aims to analyze the biomechanical stability using intramedullary nails with or without femoral neck protection through finite element analysis. METHODS Thirty finite element models (FEMs) were established, including five different conditions of femoral shaft fracture: Fracture healing, Proximal fractures (Transverse and oblique), Distal fractures (Transverse and oblique), and five different fixation methods. Femoral neck protection groups: cephalomedullary nail (CN), reconstruction nail (RN); No femoral neck protection groups: type-1 of antegrade intramedullary nail (AIN-1), type-2 of antegrade intramedullary nail (AIN-2), and retrograde intramedullary nail (RIN). The maximum stress of bone and internal fixation in the femoral neck region for all type of fixation were calculated to evaluate the biomechanical stability. RESULTS Maximum equivalent stress values of bone in the femoral neck region for five different conditions of femoral shaft fracture: AIN-2 (77.23 MPa) >RIN (77.15 MPa) > AIN-1 (76.71 MPa) > CN (60.74 MPa) > RN (57.66 MPa) for the fracture healing; RIN (80.05 MPa) > AIN-1 (79.15 MPa) > AIN-2(78.77 MPa) > RN (65.16 MPa) > CN (65.03 MPa) for the proximal transverse fracture; RIN (80.10 MPa) > AIN-2 (79.36 MPa) > AIN-1 (79.18 MPa) > RN (65.09 MPa) > CN (64.96 MPa) for the proximal oblique fracture; RIN (80.24 MPa) > AIN-2 (79.68 MPa) > AIN-1 (79.33 MPa) > CN (65.02 MPa) > RN (64.76 MPa) for the distal transverse fracture; RIN (80.23 MPa) > AIN-2 (79.61 MPa) > AIN-1 (79.35 MPa) > CN (65.06 MPa) > RN (64.76 MPa) for the distal oblique fracture. Maximum equivalent stress of internal fixation in the femoral neck region is greater than the maximum stress of bone and avoids stress concentration of bone for the femoral neck protection groups (CN and RN). CONCLUSIONS Intramedullary nails with femoral neck protection in the treatment of femoral shaft fractures improve mechanical strength and prevent secondary hip fractures and decrease the overall risk of reoperation postoperatively.
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Affiliation(s)
- Daizhu Yuan
- Department of Orthopaedics, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; Center for Tissue Engineering and Stem Cells, Guizhou Medical University, Guiyang 550004, China; Sports Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China
| | - Zhanyu Wu
- Department of Orthopaedics, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; Center for Tissue Engineering and Stem Cells, Guizhou Medical University, Guiyang 550004, China
| | - Siwei Luo
- Department of Orthopaedics, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; Center for Tissue Engineering and Stem Cells, Guizhou Medical University, Guiyang 550004, China
| | - Yuhu Zhou
- Department of Orthopaedics, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China
| | - Jianxiang Teng
- Department of Orthopaedics, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; Center for Tissue Engineering and Stem Cells, Guizhou Medical University, Guiyang 550004, China
| | - Chuan Ye
- Department of Orthopaedics, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; Center for Tissue Engineering and Stem Cells, Guizhou Medical University, Guiyang 550004, China.
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Muthusamy B, Chao CK, Su SJ, Cheng CW, Lin J. Effects of merged holes, partial thread removal, and offset holes on fatigue strengths of titanium locking plates. Clin Biomech (Bristol, Avon) 2022; 96:105663. [PMID: 35550943 DOI: 10.1016/j.clinbiomech.2022.105663] [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: 01/06/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study investigated the effects of screw hole merging, thread removal, and screw hole offset on the mechanical properties of locking plates. METHODS Finite element models were used to develop the optimal design of the merged holes. Four titanium locking plates with different hole designs were analyzed. Type I had threaded round holes. Type II had merged holes. Type III had merged holes with partial thread removal. Type IV had threaded offset holes. Mechanical experiments similar to finite element analyses were conducted and compared. Screw bending tests were used to assess the screw holding power. FINDINGS Finite element analyses showed the optimal merging distance between two round screw holes was 3.5 mm with 2/3 circumferences in each hole. The stresses of types II and III were respectively 6.42% and 7.33%, lower than that of type I. The stress of type IV was 1.66% higher than that of type I. In the mechanical tests, the fatigue lives of types II and III were respectively 3.86 and 7.16 times higher than that of type I. The fatigue life of type IV was 37% lower than that of type I. The differences in the bending strengths of screws were insignificant. INTERPRETATION Merging holes could mitigate screw hole stress and increase the fatigue lives of the plates significantly. Partial thread removal could further improve the fatigue life. Merging holes and thread removal did not decrease the screw holding power significantly. The fatigue lives were significantly decreased in plates with offset holes.
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Affiliation(s)
- Balraj Muthusamy
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Ching-Kong Chao
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Shinyen Jason Su
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Cheng-Wen Cheng
- Department of Orthopedic Surgery, Sijhih Cathay General Hospital, No. 2, Ln. 59, Jiancheng Rd., Xizhi Dist., New Taipei 221037, Taiwan
| | - Jinn Lin
- Department of Orthopedic Surgery, Sijhih Cathay General Hospital, No. 2, Ln. 59, Jiancheng Rd., Xizhi Dist., New Taipei 221037, Taiwan.
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Wang Q, Sheng N, Rui B, Chen Y. The neck-shaft angle is the key factor for the positioning of calcar screw when treating proximal humeral fractures with a locking plate. Bone Joint J 2020; 102-B:1629-1635. [PMID: 33249912 PMCID: PMC7954146 DOI: 10.1302/0301-620x.102b12.bjj-2020-0070.r1] [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] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to explore why some calcar screws are malpositioned when a proximal humeral fracture is treated by internal fixation with a locking plate, and to identify risk factors for this phenomenon. Some suggestions can be made of ways to avoid this error. Methods We retrospectively identified all proximal humeral fractures treated in our institution between October 2016 and October 2018 using the hospital information system. The patients’ medical and radiological data were collected, and we divided potential risk factors into two groups: preoperative factors and intraoperative factors. Preoperative factors included age, sex, height, weight, body mass index, proximal humeral bone mineral density, type of fracture, the condition of the medial hinge, and medial metaphyseal head extension. Intraoperative factors included the grade of surgeon, neck-shaft angle after reduction, humeral head height, restoration of medial support, and quality of reduction. Adjusted binary logistic regression and multivariate logistic regression models were used to identify pre- and intraoperative risk factors. Area under the curve (AUC) analysis was used to evaluate the discriminative ability of the multivariable model. Results Data from 203 patients (63 males and 140 females) with a mean age of 62 years (22 to 89) were analyzed. In 49 fractures, the calcar screw was considered to be malpositioned; in 154 it was in the optimal position. The rate of malpositioning was therefore 24% (49/203). No preoperative risk factor was found for malpositioning of the calcar screws. Only the neck-shaft angle was found to be related to the risk of screw malpositioning in a multivariate model (with an AUC of 0.72). For the fractures in which the neck-shaft angle was reduced to between 130° and 150°, 91% (133/46) of calcar screws were in the optimal position. Conclusion The neck-shaft angle is the key factor for the appropriate positioning of calcar screws when treating a proximal humeral fracture with a locking plate. We recommend reducing the angle to between 130° and 150°. Cite this article: Bone Joint J 2020;102-B(12):1629–1635.
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Affiliation(s)
- Qiuke Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ning Sheng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Biyu Rui
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yunfeng Chen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Chao CK, Chen YL, Wu JM, Lin CH, Chuang TY, Lin J. Contradictory working length effects in locked plating of the distal and middle femoral fractures-a biomechanical study. Clin Biomech (Bristol, Avon) 2020; 80:105198. [PMID: 33121831 DOI: 10.1016/j.clinbiomech.2020.105198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/11/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Working length have been reported to affect the plate stress and fixation stiffness. However, the results of previous studies have been controversial. The present study was to determine working length effects on different locations of femoral bone gap. METHODS Five composite femurs with wide bone gaps at five levels (G1, 2, 3, 5, and 7), were fixed with locking plates. G1-3, G5 and G7 represented gaps at distal femur, distal-middle femur and middle femur respectively. Strain gauges were applied near the screw holes. The plate-bone constructs were loaded through a hemicylinder on the femoral head with total constraints at the distal femur. The micro-strains, axial stiffness and interfragmentary motions were recorded. Then the locking screws were removed one by one and the tests were re-run. The working length effects were compared and correlated. FINDINGS In distal femurs (G1-3), long working length was negatively correlated with the highest strains (r = -0.97, -0.95 and - 0.95, p < 0.01) and axial stiffness (r = -1, -0.96 and -0.99, p < 0.01). In distal-middle femurs (G5), as the working length increased, the highest strain decreased initially and then increased (r = 0.81, p = 0.026) and the axial stiffness decreased (r = -0.98, p < 0.01). In middle femurs (G7), the highest strain and gap motions were much higher than that in the other groups and not significantly correlated with the working length change. INTERPRETATION Long working length could reduce the highest plate strain in distal femurs, but had no significant effects in middle femurs. The working length effects were markedly affected by the loading and boundary conditions.
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Affiliation(s)
- Ching-Kong Chao
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - You-Lin Chen
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Jian-Ming Wu
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Chen-Huei Lin
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Ting-Yu Chuang
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Jinn Lin
- Department of Orthopedic Surgery, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd., Taipei, Taiwan.
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Chao CK, Chen YL, Lin J. Half-threaded holes markedly increase the fatigue life of locking plates without compromising screw stability. Bone Joint Res 2020; 9:645-652. [PMID: 33101654 PMCID: PMC7547639 DOI: 10.1302/2046-3758.910.bjr-2019-0237.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims To determine whether half-threaded screw holes in a new titanium locking plate design can substantially decrease the notch effects of the threads and increase the plate fatigue life. Methods Three types (I to III) of titanium locking plates were fabricated to simulate plates used in the femur, tibia, and forearm. Two copies of each were fabricated using full- and half-threaded screw holes (called A and B, respectively). The mechanical strengths of the plates were evaluated according to the American Society for Testing and Materials (ASTM) F382-14, and the screw stability was assessed by measuring the screw removal torque and bending strength. Results The B plates had fatigue lives 11- to 16-times higher than those of the A plates. Before cyclic loading, the screw removal torques were all higher than the insertion torques. However, after cyclic loading, the removal torques were similar to or slightly lower than the insertion torques (0% to 17.3%), although those of the B plates were higher than those of the A plates for all except the type III plates (101%, 109.8%, and 93.8% for types I, II, and III, respectively). The bending strengths of the screws were not significantly different between the A and B plates for any of the types. Conclusion Removing half of the threads from the screw holes markedly increased the fatigue life of the locking plates while preserving the tightness of the screw heads and the bending strength of the locking screws. However, future work is necessary to determine the relationship between the notch sensitivity properties and titanium plate design.Cite this article: Bone Joint Res 2020;9(10):645-652.
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Affiliation(s)
- Ching-Kong Chao
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan
| | - You-Lin Chen
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan
| | - Jinn Lin
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Fletcher JWA, Zderic I, Gueorguiev B, Richards RG, Gill HS, Whitehouse MR, Preatoni E. Stripping torques in human bone can be reliably predicted prior to screw insertion with optimum tightness being found between 70% and 80% of the maximum. Bone Joint Res 2020; 9:493-500. [PMID: 32922757 PMCID: PMC7469512 DOI: 10.1302/2046-3758.98.bjr-2019-0318.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIMS To devise a method to quantify and optimize tightness when inserting cortical screws, based on bone characterization and screw geometry. METHODS Cortical human cadaveric diaphyseal tibiae screw holes (n = 20) underwent destructive testing to firstly establish the relationship between cortical thickness and experimental stripping torque (Tstr), and secondly to calibrate an equation to predict Tstr. Using the equation's predictions, 3.5 mm screws were inserted (n = 66) to targeted torques representing 40% to 100% of Tstr, with recording of compression generated during tightening. Once the target torque had been achieved, immediate pullout testing was performed. RESULTS Cortical thickness predicted Tstr (R2 = 0.862; p < 0.001) as did an equation based on tensile yield stress, bone-screw friction coefficient, and screw geometries (R2 = 0.894; p < 0.001). Compression increased with screw tightness up to 80% of the maximum (R2 = 0.495; p < 0.001). Beyond 80%, further tightening generated no increase in compression. Pullout force did not change with variations in submaximal tightness beyond 40% of Tstr (R2 = 0.014; p = 0.175). CONCLUSION Screw tightening between 70% and 80% of the predicted maximum generated optimum compression and pullout forces. Further tightening did not considerably increase compression, made no difference to pullout, and increased the risk of the screw holes being stripped. While further work is needed for development of intraoperative methods for accurate and reliable prediction of the maximum tightness for a screw, this work justifies insertion torque being considerably below the maximum.Cite this article: Bone Joint Res 2020;9(8):493-500.
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Affiliation(s)
- James W. A. Fletcher
- Department for Health, University of Bath, Bath, UK
- AO Research Institute Davos, Davos, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | | | | | - Michael R. Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Pengrung N, Lakdee N, Puncreobutr C, Lohwongwatana B, Sa-Ngasoongsong P. Finite element analysis comparison between superior clavicle locking plate with and without screw holes above fracture zone in midshaft clavicular fracture. BMC Musculoskelet Disord 2019; 20:465. [PMID: 31640668 PMCID: PMC6806505 DOI: 10.1186/s12891-019-2847-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/23/2019] [Indexed: 11/30/2022] Open
Abstract
Background Midshaft clavicular fractures are common fractures and generally treated conservatively. Among the surgical options, plate fixation is the most popular and has been biomechanically and clinically proven in numerous studies. However, implant failures caused by plate deformations or breakage still occur in up to 16.7% of cases, and recent studies showed that screw holes above fracture zone (SHFZ) might be the at-risk location. Using finite element analysis, this study aimed to test the biomechanical property of the superior clavicle locking plate (SCLP) with and without SHFZ in comminuted midshaft clavicular fracture. Methods Finite element models of comminuted midshaft clavicular fracture fixed with standard 8-hole titanium SCLP with screw holes (SHFZ plate) and without screw holes above fracture zone (No-SHFZ plate) were built. Both groups were tested under three different loading models (100-N cantilever bending, 100-N axial compression, and 1-Nm torsion). The average peak stress on medial clavicle, fracture zone, and lateral clavicle, and the peak stress on each screw hole (or the same position in the No-SHFZ plate) were measured and compared. Results The highest average peak stress on the fracture zone was higher than those on medial and lateral clavicles under all loading conditions in both plates. However, the No-SHFZ plate significantly reduced the average peak stress value on the fracture zone, compared to the SHFZ plate (45.0% reduction in cantilever bending, 52.2% reduction in axial compression, and 54.9% reduction in axial torsion). The peak stress value on the maximal stress point in the SHFZ and No-SHFZ plates with cantilever bending, axial compression, and torsion loads were 1257.10 MPa vs. 647.21 MPa, 186.42 MPa vs. 131.63 MPa, and 111.86 MPa vs. 82.41 MPa, respectively. Conclusion The weakest link of the SCLP construct in comminuted midshaft clavicular fracture fixation is the SHFZ, especially in the cantilever bending load. Additionally, the biomechanical property of the SCLP without SHFZ model (No-SHFZ plate) is superior to the standard SCLP model (SHFZ plate), with a significantly lower peak stress on the SHFZ location in all loading conditions. We recommend a new SCLP design with SHFZ to prevent implant failure and improve surgical outcomes.
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Affiliation(s)
- Nachapan Pengrung
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Natthaphop Lakdee
- Biomechanic Research Center, Meticuly Co. Ltd., Chulalongkorn University, Bangkok, Thailand
| | - Chedtha Puncreobutr
- Biomedical Engineering Research Center, Chulalongkorn University, Bangkok, Thailand.,Department of Metallurgy Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Boonrat Lohwongwatana
- Biomedical Engineering Research Center, Chulalongkorn University, Bangkok, Thailand.,Department of Metallurgy Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Paphon Sa-Ngasoongsong
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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