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Shih CA, Huang MT, Chern TC, Shao CJ, Wu KC, Lin CJ, Jou IM, Wu PT. The use of ultrasound for monitoring reduction and ulnar nerve subluxation in pediatric humeral supracondylar fractures. Eur J Radiol 2024; 170:111201. [PMID: 38042022 DOI: 10.1016/j.ejrad.2023.111201] [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: 06/09/2023] [Revised: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Traditional treatment for displaced humeral supracondylar fractures (SCFs) in children involves closed reduction (CR) under fluoroscopic guidance, percutaneous pinning, and immobilization with a long-arm cast. This study aims to explore the viability of using radiation-free ultrasound (US) for guiding CR and tracking ulnar nerve dynamics during medial pinning, contrasting the US method with the conventional cross pinning technique. MATERIALS AND METHODS We assessed 70 children with acute displaced SCFs. The US group (n = 30) underwent US-guided reduction, whereas the traditional group (n = 40) underwent fluoroscopy-guided reduction. Both groups received percutaneous cross pinning and subsequent cast immobilization. Postoperative outcomes were compared between the two methods after a 6-month follow-up. In the US group, ultrasonography assessed fracture displacement distances before and after CR. The angle at which the ulnar nerve relocated to the cubital tunnel during elbow extension was documented using real-time US monitoring during medial pinning. RESULTS The US group demonstrated improved reduction accuracy, increased range of motion, superior restoration of both Baumann and Humeroulnar angles, and a decreased incidence of malunions compared to the traditional group (all p < 0.05). The ultrasonographic measurement of fracture displacement was comparable with that of fluoroscopy (intraclass correlation coefficient > 0.90). In the US group, no ulnar nerve injury was noted, compared to 2.5 % in the traditional group, and real-time US observations revealed ulnar nerve hypermobility, with 53.3 % of patients exhibiting anterior ulnar nerve subluxation at 120° elbow flexion, 40 % at 90°, 16.7 % at 60°, and none at 30° flexion. CONCLUSION Ultrasound is as reliable as fluoroscopy for evaluating fracture reductions. The use of intra-operative ultrasound significantly improves reduction accuracy and radiographic outcomes while reducing the risk of ulnar nerve injury.
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Affiliation(s)
- Chien-An Shih
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Tung Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Great East Gate Orthopedic Clinic, Tainan, Taiwan
| | | | - Chung-Jung Shao
- Department of Orthopedic Surgery, Tainan Municipal Hospital, Tainan, Taiwan
| | - Kuo-Chen Wu
- Department of Orthopedic Surgery, Kuo General Hospital, Tainan, Taiwan
| | - Chii-Jeng Lin
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan; President Office, Joint Commission of Taiwan, New Taipei City, Taiwan, ROC
| | - I-Ming Jou
- Great East Gate Orthopedic Clinic, Tainan, Taiwan; Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
| | - Po-Ting Wu
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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Dresing K, Kraus R, Fernandez F, Schmittenbecher P, Dresing K, Strohm P, Spering C. [Imaging after trauma in clinics and practice for children and adolescents : Part 1 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:34-41. [PMID: 34918189 PMCID: PMC9842554 DOI: 10.1007/s00113-021-01115-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND The indication for radiography should strictly follow the ALARA (as low as reasonably achievable) principle in pediatric and adolescent trauma patients. The effect of radiation on the growing sensitive tissue of these patients should not be disregarded. QUESTION The Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) wanted to clarify how the principle is followed in trauma care. METHODS An online survey was open for 10 weeks. Target groups were trauma surgeons, pediatric surgeons, general surgeons, and orthopedic surgeons. RESULTS From Nov. 15, 2019, to Feb. 29, 2020, 788 physicians participated: branch office 20.56%, MVZ 4.31%, hospital 75.13%; resident 16.62%, senior 38.07%, chief 22.59%. By specialist qualification, the distribution was: 38.34% surgery, 33.16% trauma surgery, 36.66% special trauma surgery, 70.34% orthopedics and trauma surgery, 18.78% pediatric surgery. Frequency of contact with fractures in the above age group was reported as 37% < 10/month, 27% < 20/M, 36% > 20/M. About 52% always request radiographs in 2 planes after acute trauma. X-ray of the opposite side for unclear findings was rejected by 70%. 23% use sonography regularly in fracture diagnosis. In polytrauma children and adolescents, whole-body CT is never used in 18%, rarely in 50%, and standard in 14%. DISCUSSION The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. CONCLUSION Comparing the results of the survey with the consensus findings of the SKT recently published in this journal, persuasion is still needed to change the use of radiography in primary diagnosis.
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Affiliation(s)
- Klaus Dresing
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland.
| | - Ralf Kraus
- Klinik für Unfallchirurgie und Orthopädie, Klinikum Bad Hersfeld, Bad Hersfeld, Deutschland
| | - Francisco Fernandez
- Kindertraumatologie, Klinikum Stuttgart Olgahospital, Stuttgart, Deutschland
| | | | - Kaya Dresing
- Darmstädter Kinderkliniken Prinzessin Margaret, Darmstadt, Deutschland
| | - Peter Strohm
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Bamberg, Bamberg, Deutschland
| | - Christopher Spering
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland
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[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:42-54. [PMID: 34918188 PMCID: PMC9842560 DOI: 10.1007/s00113-021-01114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/27/2023]
Abstract
The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair. METHODS An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons. RESULTS Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks. DISCUSSION The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed. CONCLUSION Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.
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[X-ray diagnostics of fractures in childhood and adolescence-Consensus report of the scientific working group of the pediatric traumatology section of the German Society for Trauma Surgery (DGU)]. Unfallchirurg 2021; 124:427-430. [PMID: 33754172 PMCID: PMC8099802 DOI: 10.1007/s00113-021-00994-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/23/2022]
Abstract
Seit Jahrzehnten ist die Projektionsradiographie Standard in der Diagnostik von Frakturen und Verletzungen auch bei Patienten im Kindes- und Jugendalter. Bei jeder Untersuchung mit Röntgenstrahlen sollen aber auch individuell Nutzen und Risiko gegeneinander abgewogen werden. Die Sektion Kindertraumatologie der DGU hat zu verschiedenen Aspekten der Bildgebung zu Diagnostik und Verlaufsbeurteilung, zu Einstellungsmöglichkeiten der intraoperativen Bildgebung, zum Röntgen der Gegenseite, zu Polytrauma und CT, zu postoperativen radiologischen Kontrollen und dem Einsatz der Sonographie ein Konsenspapier erarbeitet.
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Qiao F, Jiang F. Closed reduction of severely displaced radial neck fractures in children. BMC Musculoskelet Disord 2019; 20:567. [PMID: 31775704 PMCID: PMC6882240 DOI: 10.1186/s12891-019-2947-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/14/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Severely displaced radial neck fractures in skeletally immature children are rare and can be difficult to reduce. The purpose of this study is to evaluate the results using our reduction maneuver. METHODS From October 2011 to December 2015, 26 children with radial neck fractures(O'Brien type II, III and Judet type III, IV) were treated at our institute. All patients underwent percutaneous K-wire leverage and radial intramedullary pinning in an average surgery time of 35 mins (15-80 min). The injured arm was immobilized at the functional position with plaster for 4-6 weeks, evaluated clinically and radiologically. The Metaizeau classification and Mayo elbow performance score were used to evaluate the radiological and clinical results, respectively. Percutaneous K-wire leverage and radial intramedullary pinning were performed for 26 patients. No patients were treated with open reduction. Twenty four patients were followed up for a mean of 33 (range 12-53 months) months. RESULTS There were 15 girls and 9 boys with ages ranging from 1.5 to 12 years and an average age of 7.2 years. Percutaneous K-wire leverage reduction and intramedullary pinning were successfully used in an average total surgery time of 35 mins (range 15-80 min). In total, 2 cases (O'Brien type III and Judet type IVb, angulation = 90°) needed the additional maneuver. Bone union was achieved in all patients within a mean time of 4.2 weeks. The clinical results were evaluated basing on the Mayo elbow performance score, and there were 23 excellent results and one good result. There were no refractures and no incidences of nonunion, suture infection, iatrogenic radial nerve injury, asymptomatic enlargements of the radial head or growth arrest in the proximal radial epiphysis. CONCLUSION Our modified percutaneous leverage technique with radial intramedullary fixation may be successfully used to avoid open reduction.
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Affiliation(s)
- Fei Qiao
- Department of Pediatric Orthopaedic, Dalian Children's Hospital, 154 Zhongshan Road, Dalian, 116012, China
| | - Fei Jiang
- Department of Pediatric Orthopaedic, Dalian Children's Hospital, 154 Zhongshan Road, Dalian, 116012, China.
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Improving patient and staff safety by minimising radiation exposure during trauma surgery: A simple and validated predictive model. Surgeon 2019; 18:95-99. [PMID: 31420252 DOI: 10.1016/j.surge.2019.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/14/2019] [Accepted: 07/22/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Minimising radiation exposure, from fluoroscopic equipment during trauma surgery is crucial to safe-guarding patients and staff. This aim of this study was to identify variables associated with increased radiation exposure for 3 of the most common trauma procedures. Secondly, we aimed to derive an internally and externally validated mathematical model for predicting radiation exposure for these procedures. MATERIALS AND METHODS We prospectively recorded radiation exposure from 270 sliding hip screw (SHS), ankle and wrist fixation procedures. Patient demographics, fracture severity, surgeon and radiographer grade were assessed using univariate and multivariate analyses. A mathematical model was then created and externally assessed for validity from another unit. RESULTS With regards to the analysis of radiation exposure when fixing wrist fractures, a significant regression equation was found (F (3, 86) = 62.2, p < 0.001), with an adjusted R2 of 0.69. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 81.916(Fracture severity) + 43.426(Surgical grade) + 23.490 (radiographer grade)-203.89.With regards to the analysis of radiation exposure when fixing ankle fractures, a significant regression equation was found, (F (3, 83) = 15.49, p < 0.001), with an adjusted R2 of 0.34. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 39.541(Fracture severity) + 51.937(Surgical grade) + 37.702 (radiographer grade)-124.558 SHS (F (3, 89) = 25.29, p < 0.001), R2 of 0.44.61.338(Fracture severity) + 60.945(Surgical grade) + 35.491 (radiographer grade)-105.501. These predictive models were successfully externally validated. CONCLUSION This study has demonstrated a workable and externally validated model for accurately predicting the likely radiation exposure using common and easily collectable variables. These models could be used to modify practuce and minimise the radiation exposure to patients and staff.
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Malik AT, Rai HH, Lakdawala RH, Noordin S. Does surgeon experience influence the amount of radiation exposure during orthopedic procedures? A systematic review. Orthop Rev (Pavia) 2019; 11:7667. [PMID: 30996838 PMCID: PMC6452094 DOI: 10.4081/or.2019.7667] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/02/2018] [Indexed: 01/09/2023] Open
Abstract
With an increasing use of intraoperative fluoroscopy in operating rooms worldwide, the topic of radiation exposure has become a major concern among hospital staff, doctors and patients alike. Since fluoroscopy has become an integral part in orthopedic intraoperative management, we sought to identify whether surgeon grade or experience plays a role in the amount of radiation used and consequently exposed. We performed a systematic review examining the association between surgeon experience and radiation exposure using primary outcome measures (radiation dose and total screening time/fluoroscopy time). To be included in the review, the study population had to compare varying surgeon experience levels and their effect on the primary outcomes. A total of eighteen studies were included in the review. The studies were a mix of prospective and retrospective studies with low to moderate quality as evaluated by the MINORs criteria. Studies were variable in defining surgeon experience levels and in the type of operations being performed. Majority of the studies showed that inexperienced surgeons/trainees had a higher total fluoroscopy time and a higher mean radiation exposure as compared to experienced surgeons. We conclude that higher surgeon experience significantly reduces usage of fluoroscopy and the consequent radiation exposure in orthopedic procedures. Introduction of strict radiation guidelines involving limited usage of fluoroscopy and supervision of trainees may be beneficial in controlling radiation exposure in the future.
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Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopedics, the Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Riaz Hussain Lakdawala
- Section of Orthopedic Surgery, Department of Surgery, Aga Khan University, Karachi, Sindh, Pakistan
| | - Shahryar Noordin
- Section of Orthopedic Surgery, Department of Surgery, Aga Khan University, Karachi, Sindh, Pakistan
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Need for Higher Quality Evidence to Determine the Utility of Postoperative Radiography. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e026. [PMID: 30631828 PMCID: PMC6286900 DOI: 10.5435/jaaosglobal-d-18-00026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Rashid MS, Aziz S, Haydar S, Fleming SS, Datta A. Intra-operative fluoroscopic radiation exposure in orthopaedic trauma theatre. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2018; 28:9-14. [PMID: 28798994 PMCID: PMC5754436 DOI: 10.1007/s00590-017-2020-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/19/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Radiation exposure from intra-operative fluoroscopy in orthopaedic trauma surgery is a common occupational hazard. References for fluoroscopy use in the operating room for commonly performed operations have not been reported adequately. This study aimed to report appropriate intra-operative fluoroscopy use in orthopaedic trauma and compare the effect of surgery type and surgeon grade on radiation exposure. METHODS Data on 849 cases over an 18-month period were analysed retrospectively. Median and 75th centile values for dose area product (DAP), screening time (ST), and number of fluoroscopy images were calculated for procedures where n > 9 (n = 808). RESULTS Median DAP for dynamic hip screws for extracapsular femoral neck fractures was 668 mGy/cm2 (ST 36 s), 1040 mGy/cm2 (ST 49 s) for short proximal femoral nail, 1720 mGy/cm2 (ST 2 m 36 s) for long femoral nail for diaphyseal fractures, 25 mGy/cm2 (ST 25 s) for manipulation and Kirschner wire fixation in distal radius fractures, and 27 mGy/cm2 (ST 23 s) for volar locking plate fixation in distal radius fractures. These represented the five commonest procedures performed in the trauma operating room in our hospital. Experienced surgeons utilized less radiation in the operating room than junior surgeons (DAP 90.55 vs. 366.5 mGy/cm2, p = 0.001) and took fewer fluoroscopic images (49 vs. 66, p = 0.008) overall. CONCLUSIONS This study reports reference values for common trauma operations. These can be utilized by surgeons in the operating room to raise awareness and perform clinical audits of appropriate fluoroscopy use for orthopaedic trauma, using this study as guidance for standards. We demonstrated a significant reduction in fluoroscopy usage with increasing surgeon experience.
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Lee JE, Kim JB, Choi ES. Ultrasonography-guided reduction of pediatric radial neck fractures. BMC Musculoskelet Disord 2017; 18:516. [PMID: 29216921 PMCID: PMC5721654 DOI: 10.1186/s12891-017-1891-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/04/2017] [Indexed: 12/20/2022] Open
Abstract
Background Treatment of displaced and angulated radial neck fractures in children is controversial and challenging. Numerous studies have been conducted regarding treatment algorithms and surgical techniques that use fluoroscopy. However, ultrasonography (US)-guided reduction of pediatric radial neck fractures has not been reported yet. We aimed to determine the safety and efficacy of US-guided reduction and fixation of radial neck fractures in children. Methods Among 28 cases of radial neck fracture from 2014 to 2016, 12 were classified as type III or IV according to the Judet classification. All 12 patients underwent US-guided reduction and percutaneous fixation with Kirschner wire and follow-up for more than 6 months. US was used primarily to monitor the angulation and reduction of the radial neck. Fluoroscopy was applied to confirm the fixation with Kirschner wire. Dose area product (DAP; mGy/cm2) was measured to assess per-procedure radiation dose. Radiological and clinical results were evaluated at 6 months after the surgery by using the Metaizeau criteria. Results Of the patients, 4 were boys and 8 were girls, with a mean age of 7.7 years (range, 5–11 years). Judet type III fractures accounted for 83% of all injuries. The mean preoperative radial angulation was 62.5° (range: 46°–76°). The mean postoperative radial angulation was 5.6° (range: 2°–9°). The mean fluoroscopy time was 31 s (range: 10–73 s), and the mean DAP was 10.7 mGy/cm2 (range: 7.2–18.7 mGy/cm2). The mean follow-up period was 18.3 months (range, 8–24 months). According to the Metaizeau criteria, 10 cases were excellent and 2 cases were good at the last follow-up. Conclusions US-guided reduction and percutaneous fixation is safe and reliable option to treat displaced radial neck fractures in children.
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Affiliation(s)
- Jung Eun Lee
- Department of Orthopaedic Surgery, Gachon University Gil Hospital, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, South Korea
| | - Jung Bong Kim
- Department of Orthopaedic Surgery, Gachon University Gil Hospital, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, South Korea
| | - Eun Seok Choi
- Department of Orthopaedic Surgery, Gachon University Gil Hospital, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, South Korea.
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Spence R. Radiation - friend or foe? Presidential address to Ulster Medical Society 4th October 2012. THE ULSTER MEDICAL JOURNAL 2014; 83:158-70. [PMID: 25484465 PMCID: PMC4255836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/04/2014] [Indexed: 12/04/2022]
Affiliation(s)
- Roy Spence
- Professor of Surgery and Consultant Surgeon, Belfast Trust, Centre for Medical Education, Queen's University Belfast, Mulhouse BuildingGrosvenor Road, Belfast BT12 6BA
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