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Cross WW, Tomov MN, Hung MY, Muir JM. Patient-Reported Outcomes and Computed Tomography Review After Minimally Invasive Fusion of the Sacroiliac Joint With Aggressive Joint Decortication and Joint Compression. Orthopedics 2024; 47:101-107. [PMID: 37672779 DOI: 10.3928/01477447-20230901-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
The sacroiliac joint (SIJ) is a common, underrecognized source of low back pain. We evaluated outcomes in patients undergoing sacroiliac joint fusion (SIJF) using a novel, minimally invasive SIJF system emphasizing compressive forces across an aggressively debrided SIJ. We retrospectively reviewed data from a continuous set of patients presenting to a large, tertiary care hospital from September 2017 to August 2019. All patients received the novel SIJF device. Outcomes were assessed at 8 weeks, 6 months, and 12 months using the Oswestry Disability Index (ODI) score, Numerical Rating Scale (NRS) score, Single Assessment Numerical Evaluation (SANE) score, and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, plus radiographic evaluation of fusion status. Data from 75 patients were analyzed. At 8 weeks, 6 months, and 12 months, the ODI score improved by 10.5 points (P=.002), 17.4 points (P<.0001), and 23.6 points (P<.0001), respectively, while the NRS score improved by 4.6 points (P<.0001), 4.4 points (P<.0001), and 4.6 points (P<.0001), respectively. SANE scores indicated high levels of patient satisfaction (81.0%, 92.18%, and 89.2%, respectively). PROMIS physical function scores improved by 2.65 points, 3.30 points, and 3.63 points, respectively, while PROMIS mental health scores showed changes of -1.93 points, 1.57 points, and -0.47 points, respectively. A review of computed tomography scans demonstrated grade 3 fusion (complete) in 81% of cases at a mean of 371 days postoperatively. There was one revision case for a malpositioned implant. The use of a novel SIJF device emphasizing compressive forces provided early, durable improvements in patient-reported outcomes and extremely high patient satisfaction. [Orthopedics. 2024;47(2):101-107.].
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Broida SE, Kemble JP, Wahlig BD, Cross WW, Viers BR, Houdek MT. Sacral insufficiency fractures are a frequent and painful consequence of pubic symphysis osteomyelitis. Eur J Orthop Surg Traumatol 2024; 34:647-652. [PMID: 37673832 DOI: 10.1007/s00590-023-03707-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Pubic symphysis osteomyelitis can result from urosymphyseal fistula formation. High rates of sacropelvic insufficiency fractures have been reported in this population. The aim of this study was to describe the presentation and risk factors for sacral insufficiency fractures (SIF) associated with surgical treatment of pubic symphysis osteomyelitis. METHODS A retrospective review was performed for 54 patients who underwent surgery for pubic symphysis osteomyelitis associated with a urosymphyseal fistula at a single institution from 2009 to 2022. Average age was 71 years and 53 patients (98%) were male. All patients underwent debridement or partial resection of the pubic symphysis at the time of fistula treatment. Average width of the symphyseal defect was 65 mm (range 9-122) after treatment. RESULTS Twenty patients (37%) developed SIF at a mean time of 4 months from osteomyelitis diagnosis. Rate of sacral fracture on Kaplan-Meier analysis was 31% at 6 months, 39% at 12 months, and 41% at 2 years. Eleven patients developed SIF prior to pubic debridement and 12 patients developed new or worsening of pre-existing SIF following surgery. Width of pubic resection was higher in patients who developed SIF (76 mm vs. 62 mm), but this did not meet statistical significance (p = 0.18). CONCLUSION Sacral insufficiency fracture is a common sequela of pubic symphysis osteomyelitis. These fractures are often multifocal within the pelvis and can occur even prior to pubic resection. Pubectomy further predisposes these patients to fracture. Clinicians should maintain a high index of suspicion for these injuries in patients with symphyseal osteomyelitis.
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Affiliation(s)
- Samuel E Broida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
| | | | - Brian D Wahlig
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - William W Cross
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Cancio-Bello AM, Owen AR, Kuttner NP, Hidden KA, Cross WW, Yuan BJ, Sems SA. Patella Fracture Fixation With Novel Wagon Wheel Construct Versus Tension-Band Construct: A Technical Trick. J Orthop Trauma 2023; 37:e452-e458. [PMID: 36788110 DOI: 10.1097/bot.0000000000002579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
SUMMARY Internal fixation of patella fractures remains technically challenging. Cannulated screws with an anterior tension band have been associated with high rates of implant prominence, and fracture comminution can make appropriate application of a tension band impractical. We present the results of a novel technique using a transtendinous/transligamentous mini-fragment plate positioned peripherally around the patella with radially directed screws: termed the wagon-wheel (WW) construct. Compared with a cohort of fractures treated with cannulated screws with an anterior tension band, there was no difference in final range of motion and rate of nonunion. The WW construct had a significantly decreased incidence of symptomatic implants (5% vs. 32%, P = 0.02), rate of reoperation (9% vs. 38%, P = 0.018), dependency on gait aids (10% vs. 38%, P = 0.031), and a faster time to union (HR: 2.2; 95% CI, 1.28-3.95, P = 0.005). In summary, the WW was designed with the goal of obtaining peripheral plate fixation to maximize fragment-specific fixation while minimizing implant prominence. Patients treated with the WW demonstrated reduced rates of implant prominence and reoperation.
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Somasundaram V, Owen AR, Hidden KA, Barlow JD, Cross WW, Sems SA, Yuan BJ. Cephalomedullary Nailing of Unstable Geriatric Intertrochanteric Fractures on a Traction Table Combined With Percutaneous Reduction Techniques Is Safe and Results in a Low Rate of Cutout. J Orthop Trauma 2023; 37:323-329. [PMID: 36750432 DOI: 10.1097/bot.0000000000002577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To describe a reproducible technique for reduction assessment and percutaneous reduction of unstable intertrochanteric fractures treated with a cephalomedullary nail on a traction table. DESIGN Retrospective cohort study. SETTING Level-1 trauma center. PATIENTS Two-hundred 20 consecutive patients with intertrochanteric fractures. INTERVENTION Initial closed reduction performed on a traction table. Accessory incisions were used to facilitate a reduction in 77 patients (35%). All fractures were stabilized with a cephalomedullary nail. MAIN OUTCOME MEASUREMENTS Radiographic outcome including union, cutout, and fracture collapse (FC). Surgical outcomes including infection and hematoma were also reported. RESULTS Mechanical complications (nonunion, cutout, and varus collapse) occurred in 8.8% of patients at 1 year. Eleven of 13 patients who developed these complications had either suboptimal implant placement (tip-to-apex distance >25 mm) or a varus reduction. There was no difference in the incidence of reoperation, nonunion, lag screw cutout, or posttraumatic arthritis based on the use of an accessory incision for fracture reduction. There was a significant increase in FC in patients who received an accessory incision (6.8 mm vs. 5.4 mm, P = 0.04). One patient (1%) developed a hematoma in the accessory incision cohort, and 1 patient (0.7%) who did not have an accessory incision developed a postoperative infection. CONCLUSIONS The current study suggests utilization of accessory incisions assist in reduction is safe and is associated with a low rate of complications. The surgeon should prioritize fracture reduction and optimal implant placement and not hesitate to use an accessory incision to assist with fracture reduction. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
| | | | | | | | - Stephen A Sems
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
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Abstract
BACKGROUND Sacroiliac joint fusion (SIJF) has been established as an effective treatment for sacroiliac joint dysfunction. However, failure necessitating revision has been reported in up to 30% of cases. Little is known regarding outcomes of revision SIJF. METHODS We retrospectively reviewed all revision SIJF at a single academic center between 2017 and 2020. Revision surgery was performed using the principles of joint decortication, bone grafting, compression, and rigid internal fixation. Outcomes were assessed at 6 months and 1 year after surgery using the Oswestry Disability Index (ODI), Numeric Pain Rating Scale (NPRS), and Single Assessment Numeric Evaluation (SANE) scale. Fusion was assessed using computed tomography at 12 months postoperatively. RESULTS Eighteen revision SIJFs in 13 patients were included. The mean age was 55.8 years (range 35-75). Mean body mass index was 27.9 (range 21.7-36.7). Sixty-two percent of the patients were women. The indications for revision were pseudarthrosis without fixation failure in 14 cases (77.8%), hardware failure (loosening) in 3 cases (16.7%), and continued pain after partial fusion in 1 case (5.6%). ODI and NPRS scores demonstrated significant statistical and clinical improvements at all timepoints. Mean (SD) ODI scores improved from 53.8 (19.9) preoperative to 37.5 (19.8) at 6 months and 32.9 (21.7) at 12 months. Improvement in ODI was found in 15 joints (83.3%), and the minimal clinically important difference (MCID) was achieved in 12 joints (66.7%). Mean (SD) NPRS scores improved from 6.5 (1.4) preoperative to 3.2 (2.8) at 6 months and 3.4 (2.6) at 12 months. Improvement in NPRS was also identified in 17 joints (94.4%), and 10 joints (55.6%) achieved MCID for NPRS. Mean (SD) SANE score was 72.0% (30.8) at 6 months and 70.0% (33.8) at 12 months. There were no radiographic lucencies, implant subsidence, or implant fractures at final follow-up. We identified an 88.9% fusion rate with definitive bridging bone across the sacroiliac joint. CONCLUSION Utilizing a principles-based technique of joint decortication, compression, and rigid internal fixation, revision SIJF showed an improvement in patient-reported outcomes as well as high rate of fusion at 12 months. The most common indications for revision SIJF are symptomatic pseudarthrosis and implant loosening. This is the largest series of revision SIJF to date. LEVEL OF EVIDENCE: 4
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Affiliation(s)
| | - Erick Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA
| | - William W Cross
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA
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Cancio-Bello AM, Karam MD, Jahangir AA, Templeman D, Cross WW. Winquist View of the Femoral Neck: Ideal Visualization of Femoral Neck Fixation. Iowa Orthop J 2023; 43:191-194. [PMID: 37383865 PMCID: PMC10296462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Background Despite the increased frequency of cephalomedullary fixation for unstable intertrochanteric hip fractures, failure with screw cut-out and varus collapse remains a significant failure mode. Proper positioning of implants into the femoral neck and head directly influences the stability of fracture fixation. Visualization of the femoral neck and head can be challenging and failure to do so may lead to poor results; Obstacles include patient positioning, body habitus, and implant application tools. We present the "Winquist View," an oblique fluoroscopic projection that shows the femoral neck in profile, aligns the implant and cephalic component, and assists in implant placement. Methods With the patient in the lateral position, the legs are scissored when possible. Following standard reduction techniques, the Winquist view is used to check reduction prior to surgical draping. Intraoperatively, we rely on a perfect image to place implants in the ideal portion of the femoral neck, with a trajectory that achieves the center-center or center-low position of the femoral neck. This is achieved by incorporating the anterior-posterior, lateral, and Winquist view. Results We present 3 patients who underwent fixation with a cephalomedullary nail for intertrochanteric hip fractures. The Winquist view facilitated excellent visualization and positioning in all cases. All postoperative courses were uneventful, without failures or complications. Conclusion While standard intraoperative imaging may be adequate in many cases, the Winquist view facilitates optimal implant positioning and fracture reduction. With lateral imaging, implant insertion guides may obscure visualization of the femoral neck during which Winquist view is the most helpful. Level of Evidence: V.
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Affiliation(s)
| | - Matthew D. Karam
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - A. Alex Jahangir
- Department of Orthopaedic Surgery, Division of Orthopedic Trauma, Vanderbilt University Medical School, Nashville, Tennessee, USA
| | - David Templeman
- Department of Orthopedic Surgery, University of Minnesota, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - William W. Cross
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Goodnough LH, Salazar BP, Furness J, Feng JE, DeBaun MR, Campbell ST, Lucas JF, Cross WW, Leucht P, Grant KD, Gardner MJ, Bishop JA. How are peri-implant fractures below short versus long cephalomedullary nails different? Eur J Orthop Surg Traumatol 2020; 31:421-427. [PMID: 32909108 DOI: 10.1007/s00590-020-02785-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/01/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cephalomedullary nails are a commonly used implant for the treatment of many pertrochanteric femur fractures and are available in short and long configurations. There is no consensus on ideal nail length. Relative advantages can be ascribed to short and long intramedullary nails, yet both implant styles share the potentially devastating complication of peri-implant fracture. Determining the clinical sequelae after fractures below nails of different lengths would provide valuable information for surgeons choosing between short or long nails. Thus, the purpose of the study was to compare injury patterns and treatment outcomes following peri-implant fractures below short or long cephalomedullary nails. METHODS This was a multicenter retrospective cohort study that identified 33 patients referred for treatment of peri-implant fractures below short and long cephalomedullary nails (n = 19 short, n = 14 long). We compared fracture pattern, treatment strategy, complications, and outcomes between these two groups. RESULTS Short nails were associated with more diaphyseal fractures (odds ratio [OR] 13.75, CI 2.2-57.9, p 0.002), which were treated more commonly with revision intramedullary nailing (OR, infinity; p 0.01), while long nails were associated with distal metaphyseal fractures (OR 13.75, CI 2.2-57.9, p 0.002), which were treated with plate and screw fixation (p 0.002). After peri-implant fracture, there were no differences in blood loss, operative time, weight bearing status, or complication rates based on the length of the initial nail. In patients treated with revision nailing, there was greater estimated blood loss (EBL, median 300 cc, interquartile range [IQR] 250-1200 vs median 200 cc, IQR 100-300, p 0.03), blood product utilization and complication rates (OR 11.1, CI 1.1-135.7, p 0.03), but a trend toward unrestricted post-operative weight-bearing compared to patients treated with plate and screw constructs. CONCLUSION Understanding fracture patterns and patient outcomes after fractures below nails of different lengths will help surgeons make more informed implant choices when treating intertrochanteric hip fractures. Revision to a long nail for the treatment of fractures at the tip of a short nail may be associated with increased patient morbidity.
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Affiliation(s)
- L Henry Goodnough
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA.
| | - Brett P Salazar
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Jamie Furness
- Department of Orthopaedic Surgery, Beaumont Hospital, Royal Oak, MI, USA
| | - James E Feng
- Department of Orthopaedic Surgery, Beaumont Hospital, Royal Oak, MI, USA
| | - Malcolm R DeBaun
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Sean T Campbell
- Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA, USA
| | - Justin F Lucas
- Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - William W Cross
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Philipp Leucht
- Department of Orthopaedic Surgery, New York University Langone Health, New York, NY, USA
| | - Kevin D Grant
- Department of Orthopaedic Surgery, Beaumont Hospital, Royal Oak, MI, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA
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Yuan BJ, Shamaa MT, Aibinder WR, Parry JA, Cross WW, Barlow JD, Sems SA. High incidence of "in-out-in" posterosuperior screws after cannulated screw fixation of femoral neck fractures. Eur J Orthop Surg Traumatol 2020; 30:1417-1420. [PMID: 32556582 DOI: 10.1007/s00590-020-02717-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/05/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Cadaveric models have demonstrated a high incidence of extraosseous "in-out-in" (IOI) posterosuperior screws after cannulated screw fixation of femoral neck fractures. The purpose of this study was to determine the incidence of IOI screws in vivo and to evaluate their association with osteonecrosis and revision surgery. METHODS A total of 104 patients with 107 hips with a pelvis computed tomography (CT) scan after cannulated screw fixation of a femoral neck fractures were included. Screw position was evaluated on postoperative radiographs and CT scan to determine if screws were IOI or all-in. Osteonecrosis and revision surgeries were documented. RESULTS IOI posterosuperior screws were identified on CT scan in 58 (54%) hips. On postoperative AP and lateral radiographs, IOI screws were a median (interquartile range) of 10 mm (7-11 mm) and 3 mm (0-4 mm) from the cortex, respectively. The sensitivity and specificity of radiographs to detect IOI screws was 39% and 92%, respectively. The incidence of osteonecrosis and revision surgeries in hips, with and without IOI screws, was 6% versus 6% [Odds ratio (OR) 1.1, 95% confidence interval (CI) 0.2-5.3] and 10% versus 10% (OR 1.0, CI 0.3-3.1), respectively; a true clinical difference cannot be excluded due to the width of the confidence intervals. CONCLUSIONS There was a high incidence of IOI posterosuperior screws on CT scans. Postoperative radiographs had a poor sensitivity for detecting IOI screws. A larger sample size is necessary to evaluate the association of IOI screws with osteonecrosis and revision surgery. LEVEL OF EVIDENCE Level III, comparative cohort study.
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Affiliation(s)
- Brandon J Yuan
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - William R Aibinder
- Department of Orthopaedic Surgery, State University of New York Downstate Health Sciences University, New York City, NY, USA
| | - Joshua A Parry
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
| | - William W Cross
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Stephen A Sems
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
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Aibinder WR, Yuan BJ, Cross WW, Parry JA. Sequential fluoroscopic rollover images reliably identify "in-out-in" posterosuperior screws during percutaneous fixation of femoral neck fractures. Eur J Orthop Surg Traumatol 2020; 30:1061-1065. [PMID: 32306104 DOI: 10.1007/s00590-020-02668-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/04/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Percutaneous screws placed into the posterosuperior femoral neck are frequently extraosseous or "in-out-in" (IOI). These IOI screws are not readily identifiable on anteroposterior (AP) and lateral fluoroscopic images. The purpose of this study was to examine the ability of surgeons to identify IOI guide pins using sequential fluoroscopic rollover images. MATERIALS AND METHODS A 3.2-mm guide pin was placed into the posterosuperior quadrant of eleven synthetic femur models. Five samples were "all-in" (AI), and six were IOI. Sequential fluoroscopic rollover images were obtained starting with an AP image, then images at 10-degree rollover intervals ending with a direct lateral image. Images were reviewed in a blinded fashion by five attending orthopedic trauma surgeons and 20 resident surgeons to determine whether guide pins were AI or IOI. Accuracy, interobserver reliability, sensitivity, and specificity were assessed. RESULTS The overall accuracy of responses was 86% with no difference between attending trauma surgeons and residents (p = 0.5). The sensitivity and specificity for an IOI guide pin were 98.0% and 71.2%, respectively. Interobserver reliability among surgeons was good (κ = 0.703). CONCLUSION The use of the sequential fluoroscopic rollover images after placement of the posterosuperior guide pin into the femoral neck was highly sensitive for detecting an IOI position. The 40-degree rollover image was the best view to evaluate the proximity of the guide pin to the posterior cortex.
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Affiliation(s)
- William R Aibinder
- Department of Orthopaedic Surgery, State University of New York Downstate Health Sciences University, New York City, NY, USA
| | - Brandon J Yuan
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - William W Cross
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joshua A Parry
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA.
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Bishop JA, Dalstrom DJ, Githens MF, Schultz BJ, Cross WW. The Not-So-Simple Ankle Fracture: Avoiding Problems and Pitfalls to Improve Patient Outcome. Instr Course Lect 2020; 69:477-488. [PMID: 32017747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Ankle fractures are among the most common fractures encountered by orthopaedic surgeons and, in the setting of tibiotalar instability, are usually treated surgically. Although orthopaedic surgeons from diverse educational backgrounds often feel comfortable treating such fractures, many controversies and clinical challenges remain. A detailed understanding of the unique issues presented by each patient as well as the best available treatments are required to optimize outcome. Given the unforgiving soft-tissue envelope and the particular importance of both precise reduction and absolute stability, poorly conceived and executed surgery will predictably end in compromised patient outcomes. The purpose of this manuscript is to update practicing surgeons on the best strategies for improving patient outcome after ankle fracture. The focus will be on some of the more nuanced, controversial, and complex ankle fracture-related topics, both in terms of decision making and technical execution. These will include the optimal management of posterior malleolus fractures and syndesmosis injuries as well as the best strategies to minimizing risks in poor hosts such as diabetics, obese patients, and the frail elderly. We will also provide a framework with which surgeons can approach the salvage of patients in whom the initial management has failed.
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Cross WW, Berven SH, Slater N, Lehrman JN, Newcomb AGUS, Kelly BP. In Vitro Biomechanical Evaluation of a Novel, Minimally Invasive, Sacroiliac Joint Fixation Device. Int J Spine Surg 2018; 12:587-594. [PMID: 30364882 DOI: 10.14444/5072] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Sacroiliac (SI) joint pathology may result in low-back pain, which causes substantial disability. Treatment failure with operative management of SI pain may be related to incomplete fusion of the joint and to fixation failure. The objective of this study was to evaluate the initial biomechanical stability of SI joint fixation with a novel implantable device in an in vitro human cadaveric model. Methods The right and left sides of 3 cadaveric L4-pelvis specimens were tested (1) intact, (2) destabilized, and (3) instrumented with an implantable SI joint fixation device using a simulated single-stance load condition. Right-leg and left-leg stance data were grouped together for a sample size of 6, and angular range of motion (ROM) was determined during application of flexion-extension, lateral bending, and axial rotation bending moments to a limit of 7.5 Nm. Results Following intact testing, destabilization by severing the posterior SI joint capsule and ligaments and the pubic symphysis reliably produced a significantly destabilized joint with the mean angular ROM more than doubling in flexion-extension and lateral bending and more than tripling in axial rotation (P ≤ .003) compared to the intact condition. Instrumentation with the SI screw fixation device significantly reduced mean joint ROM compared to the destabilized condition in all 3 anatomic planes tested (P < .001). When compared to the intact condition, the SI-instrumented condition significantly reduced lateral bending (P = .01) and had a similar ROM in flexion-extension (P = .14) and axial rotation (P = .85). Conclusions Instrumentation with the SI screw fixation device significantly reduced mean joint ROM compared to the destabilized condition, with similar ROM in flexion-extension and axial rotation, and it significantly reduced ROM in lateral bending compared to that for the intact joint. The ROM values observed with the instrumented condition were comparable to levels of mobility considered favorable for spinal fusion.
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Affiliation(s)
- William W Cross
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sigurd H Berven
- Department of Orthopedic Surgery, University of California at San Francisco, San Francisco, California
| | | | - Jennifer N Lehrman
- Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Anna G U S Newcomb
- Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Brian P Kelly
- Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Hernandez MC, Reisenauer JS, Aho JM, Zeb M, Thiels CA, Cross WW, Schiller HJ, Kim BD. Bone Autograft Coupled with Locking Plates Repairs Symptomatic Rib Fracture Nonunions. Am Surg 2018; 84:844-850. [PMID: 29981613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010-2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (±6.1) months. A median of 3 [1-3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.
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Hernandez MC, Reisenauer JS, Aho JM, Zeb M, Thiels CA, Cross WW, Schiller HJ, Kim BD. Bone Autograft Coupled with Locking Plates Repairs Symptomatic Rib Fracture Nonunions. Am Surg 2018. [DOI: 10.1177/000313481808400630] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010–2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (66.1) months. A median of 3 [1–3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.
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Affiliation(s)
| | | | | | - Muhammad Zeb
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cornelius A. Thiels
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - William W. Cross
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Brian D. Kim
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Cross WW, Delbridge A, Hales D, Fielding LC. Minimally Invasive Sacroiliac Joint Fusion: 2-Year Radiographic and Clinical Outcomes with a Principles-Based SIJ Fusion System. Open Orthop J 2018; 12:7-16. [PMID: 29430266 PMCID: PMC5791206 DOI: 10.2174/1874325001812010007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/29/2017] [Accepted: 12/29/2017] [Indexed: 11/29/2022] Open
Abstract
Background: Sacroiliac joint (SIJ) degeneration is a common source of low back pain (LBP). Minimally invasive (MI) SIJ fusion procedures have demonstrated meaningful clinical improvement. A recently developed MI SIJ fusion system incorporates decortication, placement of bone graft and fixation with threaded implants (DC/BG/TF). Patients and Methods: Nineteen patients who had MI SIJ fusion with DC/BG/TF were enrolled at three centers. Fusion was assessed in CT images obtained 12 and 24 months postoperatively by an independent radiographic core laboratory. LBP was assessed using a 0-10 numerical pain scale (NPS) preoperatively and at 12 and 24 months postoperatively. Results: At 12 months, 15/19 patients (79%) had bridging bone across the SIJ, and at 24 months 17/18 patients (94%) available for follow-up had SIJ fusion. Of the patients with bridging bone 88% had fusion within the decorticated area, with solid fusion in 83%. A significant reduction in NPS scores was demonstrated, representing a 73% reduction in average low back pain. Conclusion: The patients in this series demonstrated significant improvement in LBP. Fusion rates at 24 months demonstrate promise for this system, which utilizes the established orthopedic principles of DC/BG/TF to achieve arthrodesis. Further study is warranted to demonstrate comparative fusion rates for different implant systems.
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Affiliation(s)
| | - Arnold Delbridge
- Cedar Valley Medical Specialists PC Waterloo, Iowa, IA 50704, United States
| | - Donald Hales
- Northern Arizona Orthopaedics Flagstaff, Arizona, AZ 86001, United States
| | - Louis C Fielding
- Tahoe Labs, LLC 1057 Montgomery St., San Carlos, California, 94070, United States
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15
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Firoozabadi R, Cross WW, Krieg JC, Routt MLC. Acetabular Fractures in the Senior Population- Epidemiology, Mortality and Treatments. Arch Bone Jt Surg 2017; 5:96-102. [PMID: 28497099 PMCID: PMC5410751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/21/2016] [Indexed: 06/07/2023]
Abstract
BACKGROUND Management of acetabular fractures in the senior population can be one of the most challenging injuries to manage. Furthermore, treating surgeons have a paucity of information to guide the treatment in this patient population. THE PURPOSE OF THIS STUDY WAS TO DETERMINE (1) demographic and epidemiologic data, (2) mortality rates for nonoperative compared to operative management at different time points, (3) common fracture configurations, and (4) fracture fixation strategies in senior patients treated with acetabular fractures. METHODS Retrospective review of prospectively gathered data at a Level I trauma center over a five-year period. 1123 acetabular fractures were identified. 156 of them were for patients over the age of 65 (average age of 78). RESULTS Falls and motor vehicle accidents accounted for the two most common mechanisms of injury. 82% of patients had significant medical comorbidities. 51 patients (33%) died within one year, in which 75% of them died within 90 days of their acetabular fracture. 84% of the deceased patients, i.e. from the group of 51 patients, had non-operative treatment. For patients treated with traction alone, there was a 79% one-year mortality and 50% mortality rate within 90 days. Within the entire cohort, 70% had either an associated both-column (ABC) or anterior column/posterior hemitransverse (AC/PHT) fracture pattern. Fifty-seven patients (36.5%) underwent open reduction and internal fixation using standard reduction techniques and surgical implants via two main surgical exposures of ilioinguinal (69%) and Kocher-Langenbeck (29%). CONCLUSION Geriatric patients with acetabular fractures are uncommon accounting for only 14% of all acetabular fractures. Patients who undergo surgery show lower mortality rates. ABC and AC/PHT fracture patterns are the two most common fracture patterns. Routine fixation constructs and implants can be used to manage these challenging fractures. Most patients are unable to return to their homes and instead require skilled nursing facility during their convalescence.
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Affiliation(s)
- Reza Firoozabadi
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - William W Cross
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - James C Krieg
- Harborview Medical Center, University of Washington, Seattle, WA, USA
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16
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Shannon SF, Wagner ER, Houdek MT, Cross WW, Sánchez-Sotelo J. Reverse shoulder arthroplasty for proximal humeral fractures: outcomes comparing primary reverse arthroplasty for fracture versus reverse arthroplasty after failed osteosynthesis. J Shoulder Elbow Surg 2016; 25:1655-60. [PMID: 27101774 DOI: 10.1016/j.jse.2016.02.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical treatment of proximal humeral fractures in the elderly pose challenges in decision making. Reverse total shoulder arthroplasty (RTSA) has been established as a reliable option for salvage of failed hemiarthroplasty, although few studies have analyzed RTSA after failed open reduction with internal fixation (ORIF). This study evaluated the outcomes of patients with failed osteosynthesis who undergo salvage RTSA compared with patients undergoing primary RTSA for proximal humeral fractures. METHODS We retrospectively reviewed 18 patients who underwent primary RTSA for acute proximal humeral fractures and 26 patients who underwent arthroplasty after failed ORIF at our institution between 2003 and 2013. Minimum follow-up was 2 years, with a mean follow-up 3 years (range, 2.0-6.0 years). RESULTS There are no statistically significant differences in clinical outcomes between the two cohorts in the American Shoulder and Elbow Surgeons scores and in the most recent forward flexion or external rotation. The salvage RTSA cohort experienced a higher complication rate (8%), including dislocation and aseptic loosening. The primary RTSA cohort had a 5% complication rate, with 1 late prosthetic joint infection requiring reoperation. CONCLUSION Although RTSA after failed ORIF has a higher rate of complications compared with acute RTSA, the revision and reoperation rate as well as clinical outcomes and shoulder function remained comparable. When a surgeon approaches these complex fractures in patients with poor underlying bone stock, this study supports acute arthroplasty or ORIF with the knowledge that salvage RTSA still has the potential to achieve good outcomes if osteosynthesis fails.
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Affiliation(s)
- Steven F Shannon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Eric R Wagner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - William W Cross
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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17
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Sawan TG, Nickerson TP, Thiels CA, Aho JM, Cross WW, Schiller HJ, Kim BD. Load Sharing, not Load Bearing Plates: Lessons Learned from Failure of Rib Fracture Stabilization. Am Surg 2016. [DOI: 10.1177/000313481608200109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | - Henry J. Schiller
- Division of Trauma, Critical Care, and General Surgery Mayo Clinic Rochester, MN
| | - Brian D. Kim
- Division of Trauma, Critical Care, and General Surgery Mayo Clinic Rochester, MN
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18
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Sawan TG, Nickerson TP, Thiels CA, Aho JM, Cross WW, Schiller HJ, Kim BD. Load Sharing, not Load Bearing Plates: Lessons Learned from Failure of Rib Fracture Stabilization. Am Surg 2016; 82:E15-E17. [PMID: 26802843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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19
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Reisenauer JS, Kim BD, Cassivi SD, Cross WW, Morris DS, Schiller HJ. Repair of symptomatic non-union rib fractures: outcomes from a contemporary thoracic surgical series. J Cardiothorac Surg 2015. [PMCID: PMC4693821 DOI: 10.1186/1749-8090-10-s1-a205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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20
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Burgers PTPW, Poolman RW, Van Bakel TMJ, Tuinebreijer WE, Zielinski SM, Bhandari M, Patka P, Van Lieshout EMM, Devereaux PJ, Guyatt GH, Einhorn TA, Thabane L, Schemitsch EH, Koval KJ, Frihagen F, Poolman RW, Tetsworth K, Guerra-Farfan E, Walter SD, Sprague S, Swinton M, Scott T, McKay P, Madden K, Heels-Ansdell D, Buckingham L, Duraikannan A, Silva H, Heetveld MJ, Van Lieshout EMM, Burgers PT, Zura RD, Avram V, Manjoo A, Williams D, Antoniou J, Ramsay T, Bogoch ER, Trenholm A, Lyman S, Mazumdar M, Bozic KJ, Luborsky M, Goodman S, Muray S, Korley R, Buckley R, Duffy P, Puloski S, Carcary K, Lorenzo M, McKee MD, Hall JA, Nauth A, Whelan D, Daniels TR, Waddell JP, Ahn H, Vicente MR, Hidy JT, MacNevin MT, Kreder H, Axelrod T, Jenkinson R, Nousiainen M, Stephen D, Wadey V, Kunz M, Milner K, Cagaanan R, MacNevin M, O’Brien PJ, Blachut PA, Broekhuyse HM, Guy P, Lefaivre KA, Slobogean GP, Johal R, Leung I, Coles C, Leighton R, Richardson CG, Biddulph M, Gross M, Dunbar M, Amirault JD, Alexander D, Coady C, Glazebrook M, Johnston D, Oxner W, Reardon G, Wong I, Trask K, MacDonald S, Furey A, Stone C, Parsons M, Stone T, Zomar M, McCormack R, Apostle K, Boyer D, Moola F, Perey B, Viskontas D, Moon K, Moon R, Laflamme Y, Benoit B, Ranger P, Malo M, Fernandes J, Tardif K, Fournier J, Vendittoli PA, Massé V, Roy AG, Lavigne M, Lusignan D, Davis C, Stull P, Weinerman S, Weingarten P, Lindenbaum S, Hewitt M, Danielwicz R, Baker J, Mont M, Delanois DE, Kapadia B, Issa K, Mullen M, Sems A, Foreman B, Parvizi J, Morrison T, Lewis C, Caminiti S, Tornetta P, Creevy WR, Lespasio MJ, Carlisle H, Marcantonio A, Kain M, Specht L, Tilzey J, Garfi J, Mehta S, Esterhai JL, Ahn J, Donegan D, Horan A, McGinnis K, Roberson J, Bradbury T, Erens G, Webb K, Mullis B, Shively K, Parr A, Ertl J, Worman R, Webster M, Cummings J, Frizzell V, Moore M, Jones CB, Ringler JR, Sietsema DL, Walker JE, Kanlic E, Abdelgawad A, Shunia J, DePaolo C, Sutherland S, Alosky R, Zura R, Manson M, Strathy G, Peter K, Johnson P, Morton M, Shaer J, Schrickel T, Hileman B, Hanes M, Chance E, Heinrich EM, Dodgin D, LaBadie M, Zamorano D, Tynan M, Schwarzkopf R, Scolaro JA, Gupta R, Bederman S, Bhatia N, Hoang B, Kiester D, Jones N, Rafijah G, Alavekios D, Lee J, Mehta A, Schroder S, Chao T, Colin V, Dang P(P, Heng SK, Lopez G, Galle S, Pahlavan S, Phan DL, Tapadia M, Bui C, Jain N, Moore T, Moroski N, Pourmand D, Kubiak EN, Gililland J, Rothberg D, Peters C, Pelt C, Stuart AR, Corbey K, Shuler FD, Day J, Garabekyan T, Cheung F, Oliashirazi A, Salava J, Morgan L, Wilson-Byrne T, Cordle MB, Elmans LH, van den Hout JA, Joosten AJP, van Beurden AFA, Bolder SBT, Eygendaal D, Moonen AF, van Geenen RCI, Hoebink EA, Wagenmakers R, van Helden W, van Jonbergen HPW, Roerdink H, Reuver JM, Barnaart AFW, Flikweert ER, Krips R, Mullers JB, Schüller H, Falke MLM, Kurek FJ, Slingerland ACH, van Dijk JP, van Helden WH, Bolhuis HW, Bullens PHJ, Hogervorst M, de Kroon KE, Jansen RH, Steenstra F, Raven EEJ, Fontijne WPJ, Wiersma SC, Boetes B, ten Holder EJT, van der Heide HJL, Nagels J, van der Linden-van der Zwaag EH, Keizer SB, Swen JWA, den Hollander PHC, Thomassen BJW, Molekamp WJK, de Meulemeester FR, Kleipool AEB, Haverlag R, Simons MP, Mutsaerts EL, Kooijman R, Postema RR, Bleker RJ, Lampe HIH, Schuman L, Cheung J, van Bommel F, Winia WP, Haverkamp D, van der Vis H, Nolte PA, van den Bekerom MPJ, de Jong T, van Noort A, Vergroesen DA, Schutte BG, van der Vis HM, Beimers L, de Vries J, Zurcher AW, Albers GR, Rademakers M, Breugem S, van der Haven I, Jan Damen P, Bulstra GH, Campo MM, Somford MP, Haverkamp D, Liew S, Bedi H, Carr A, Chia A, Csongvay S, Donohue C, Doig S, Edwards E, Esser M, Freeman R, Gong A, Li D, Miller R, Ton L, Wang O, Young I, Dowrick A, Murdoch Z, Sage C, Page R, Bainbridge D, Angliss R, Miller B, Thomson A, Brown G, Williams S, Eng K, Bowyer D, Skelley J, Goyal C, Beattie S, Guerado E, Cruz E, Cano JR, Froufe MA, Serra LM, Al-dirra S, Martinez C, Tarazona Santabalbina FJ, Serra JT, Hernandez JT, Garcia MA, Garcia VM, Barrera S, Garrido M, Nordsletten L, Clarke-Jenssen J, Hjorthaug G, Brekke AC, Vesterhus EB, Skaugrud I, Tripathi P, Katiyar S, Shukla P, Swiontkowski M, Guyatt G, Jeray K, Walter S, Viveiros H, Truong V, Koo K, Zhou Q, Maddock D, Simunovic N, Agel J, Zielinski SM, Rangan A, Hanusch BC, Kottam L, Clarkson R, Della Rocca GJ, Slobogean G, Katz J, Gillespie B, Greendale GA, Hartman C, Rubin C, Waddell J, Lemke HM, Oatt A, Buckley RE, Korley R, Johnston K, Powell J, Sanders D, Lawendy A, Tieszer C, Murnaghan J, Nam D, Yee A, Whelan DB, Wild LM, Khan RM, Coady C, Amirault D, Richardson G, Dobbin G, Bicknell R, Yach J, Bardana D, Wood G, Harrison M, Yen D, Lambert S, Howells F, Ward A, Zalzal P, Brien H, Naumetz V, Weening B, Wai EK, Papp S, Gofton WT, Kingwell SP, Johnson G, O’Neil J, Roffey DM, Borsella V, Oliver TM, Jones V, Endres TJ, Agnew SG, Jeray KJ, Broderick JS, Goetz DR, Pace TB, Schaller TM, Porter SE, Tanner SL, Snider RG, Nastoff LA, Bielby SA, Switzer JA, Cole PA, Anderson SA, Lafferty PM, Li M, Ly TV, Marston SB, Foley AL, Vang S, Wright DM, Marcantonio AJ, Kain MSH, Iorio R, Specht LM, Tilzey JF, Lobo MJ, Garfi JS, Vallier HA, Dolenc A, Robinson C, Prayson MJ, Laughlin R, Rubino LJ, May J, Rieser GR, Dulaney-Cripe L, Gayton C, Gorczyca JT, Gross JM, Humphrey CA, Kates S, Noble K, McIntyre AW, Pecorella K, Davis CA, Lindenbaum S, Schwappach J, Baker JK, Rutherford T, Newman H, Lieberman S, Finn E, Robbins K, Hurley M, Lyle L, Mitchell K, Browner K, Whatley E, Payton K, Reeves C, Cannada LK, Karges D, Hill L, Esterhai J, Horan AD, Kaminski CA, Kowalski BN, Keeve JP, Anderson CG, McDonald MD, Hoffman JM, Tarkin I, Siska P, Gruen G, Evans A, Farrell DJ, Irrgang J, Luther A, Cross WW, Cass JR, Sems SA, Torchia ME, Scrabeck T, Jenkins M, Dumais J, Romero AW, Sagebien CA, Butler MS, Monica JT, Seuffert P, Hsu JR, Ficke J, Charlton M, Napierala M, Fan M, Tannoury C, Archdeacon M, Finnan R, Le T, Wyrick J, Hess S, Brennan ML, Probe R, Kile E, Mills K, Clipper L, Yu M, Erwin K, Horwitz D, Strohecker K, Swenson TK, Schmidt AH, Westberg JR, Aurang K, Zohman G, Peterson B, Huff RB, Baele J, Weber T, Edison M, McBeth J, Ertl JP, Parr JA, Moore MM, Tobias E, Thomas E, DePaolo CJ, Shell LE, Hampton L, Shepard S, Nanney T, Cuento C, Cantu RV, Henderson ER, Eickhoff LS, Hammerberg EM, Stahel P, Hak D, Mauffrey C, Gibula D, Gissel H, Henderson C, Zamorano DP, Tynan MC, Lawson D, Crist BD, Murtha YM, Anderson LK, Linehan C, Pilling L, Lewis CG, Sullivan RJ, Roper E, Obremskey W, Kregor P, Richards JE, Stringfellow K, Dohm MP, Zellar A, Segers MJM, Zijl JAC, Verhoeven B, Smits AB, de Vries JPPM, Fioole B, van der Hoeven H, Theunissen EBM, de Vries Reilingh TS, Govaert L, Wittich P, de Brauw M, Wille J, Go PM, Ritchie ED, Wessel RN, Hammacher ER, Visser GA, Stockmann H, Silvis R, Snellen JP, Rijbroek B, Scheepers JJG, Vermeulen EGJ, Siroen MPC, Vuylsteke R, Brom HLF, Rijna H, de Rijcke PAR, Koppert CL, Buijk SE, Groenendijk RPR, Dawson I, Tetteroo GWM, Bruijninckx MMM, Doornebosch PG, de Graaf EJR, van der Elst M, van der Pol CC, van’t Riet M, Karsten TM, de Vries MR, Stassen LPS, Schep NWL, Ben Schmidt G, Hoffman WH, van der Heijden FH, Willems WJ, van der Hart CP, Turckan K, Festen S, de Nies F, Out NJM, Bosma J, van Kampen A, Biert J, van Vugt AB, Edwards MJR, Blokhuis TJ, Frölke JPM, Geeraedts LMG, Gardeniers JWM, Tan ET, Poelhekke LM, de Waal Malefijt MC, Schreurs B, Roukema GR, Josaputra HA, Keller P, de Rooij PD, Kuiken H, Boxma H, Cleffken BI, Liem R, Rhemrev SJ, Bosman CHR, de Mol van Otterloo A, Hoogendoorn J, de Vries AC, Meylaerts SAG, Verhofstad MHJ, Meijer J, van Egmond T, van der Brand I, Patka P, Eversdijk MG, Peters R, Den Hartog D, Van Waes OJF, Oprel P, Campo M, Verhagen R, Albers GR, Simmermacher RKJ, van Mulken J, van Wessem K, van Gaalen SM, Leenen LPH, Bronkhorst MW, Guicherit OR, Goslings JC, Ponsen KJ, Bhatia M, Arora V, Tyagi V, Gupta A, Jain N, Khan F, Sharma A, Sanghavi A, Trivedi M, Rai A, Subash, Rai K, Yadav V, Singh S, Prasad AS, Mishra V, Sundaresh DC, Khanna A, Cherian JJ, Olakkengil DJ, Sharma G, Dadi A, Palla N, Ganguly U, Rai BS, Rajakumar J, Hull P, Lewis S, Evans S, Nanda R, Logishetty R, Anand S, Bowler C, Jennings A, Chuter G, Rose G, Horner G, Clark C, Eke K, Reed M, Herriott C, Dobb C, Curry H, Etherington G, Jain A, Moaveni A, Russ M, Donald G, Weinrauch P, Pincus P, Yang S, Halliday B, Gervais T, Holt M, Flynn A, Pirpiris M, Love D, Bucknill A, Farrugia RJ, Ianssen T, Amundsen A, Brattgjerd JE, Borch T, Bøe B, Flatøy B, Hasselund S, Haug KJ, Hemlock K, Hoseth TM, Jomaas G, Kibsgård T, Lona T, Moatshe G, Müller O, Molund M, Nicolaisen T, Nilsen F, Rydinge J, Smedsrud M, Stødle A, Trommer A, Ugland S, Karlsten A, Ekås G, Pape HC, Knobe M, Pfeifer R. Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture. J Bone Joint Surg Am 2015; 97:751-7. [PMID: 25948522 DOI: 10.2106/jbjs.n.00542] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.
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Affiliation(s)
- Paul T P W Burgers
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail address for P.T.P.W. Burgers: . E-mail address for T.M.J. Van Bakel: . E-mail address for W.E. Tuinebreijer: . E-mail address for S.M. Zielinski: . E-mail address for E.M.M. Van Lieshout:
| | - Rudolf W Poolman
- Joint Research, Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, 1090 HM Amsterdam, the Netherlands. E-mail address:
| | - Theodorus M J Van Bakel
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail address for P.T.P.W. Burgers: . E-mail address for T.M.J. Van Bakel: . E-mail address for W.E. Tuinebreijer: . E-mail address for S.M. Zielinski: . E-mail address for E.M.M. Van Lieshout:
| | - Wim E Tuinebreijer
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail address for P.T.P.W. Burgers: . E-mail address for T.M.J. Van Bakel: . E-mail address for W.E. Tuinebreijer: . E-mail address for S.M. Zielinski: . E-mail address for E.M.M. Van Lieshout:
| | - Stephanie M Zielinski
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail address for P.T.P.W. Burgers: . E-mail address for T.M.J. Van Bakel: . E-mail address for W.E. Tuinebreijer: . E-mail address for S.M. Zielinski: . E-mail address for E.M.M. Van Lieshout:
| | - Mohit Bhandari
- Department of Clinical Epidemiology and Biostatistics, McMaster University, HSC 2C, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada. E-mail address:
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail address:
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail address for P.T.P.W. Burgers: . E-mail address for T.M.J. Van Bakel: . E-mail address for W.E. Tuinebreijer: . E-mail address for S.M. Zielinski: . E-mail address for E.M.M. Van Lieshout:
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Okike K, O'Toole RV, Pollak AN, Bishop JA, McAndrew CM, Mehta S, Cross WW, Garrigues GE, Harris MB, Lebrun CT. Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Aff (Millwood) 2015; 33:103-9. [PMID: 24395941 DOI: 10.1377/hlthaff.2013.0453] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures' costs. Physicians have been encouraged to consider cost in the selection of devices, but several factors make acquiring cost information difficult. To assess physicians' levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs "below average" or "poor." However, more than 80 percent of all respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost containment efforts.
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Kralovec ME, Houdek MT, Martin JR, Morrey ME, Cross WW. Atypical presentation of fat embolism syndrome after gunshot wound to the foot. Am J Orthop (Belle Mead NJ) 2015; 44:E71-E74. [PMID: 25750954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 42-year-old man sustained a gunshot wound to the foot, which caused multiple fractures of the tarsal bones. Over the course of 6 hours, he became obtunded and began to experience respiratory compromise and neurologic symptoms. On magnetic resonance imaging, he was found to have innumerable tiny infarcts consistent with fat embolism syndrome. He was placed in a spanning external fixator. The patient remained in a coma for 6 weeks after injury but gradually regained function. Fat embolism syndrome is classically described as resulting from injury to the diaphysis of a long bone, but it can occur secondary to trauma of the foot. Neurovascular status must be continually evaluated in the setting of any bony trauma, and index of suspicion should remain high when neurologic deficits are encountered.
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Affiliation(s)
| | | | | | | | - William W Cross
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN.
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Abstract
Surgical treatment has been advocated for ischial tuberosity avulsion fractures in athletes. This article presents the case of an elite rower with a large avulsion fracture involving the entire inferior obturator ring with a novel technique for open reduction using a limited Kocher-Langenbeck approach and percutaneous fixation using posterior column lag screws. The fracture healed anatomically, and at 1 year follow-up the patient had full range of motion, normal gait and had returned to high-level sporting activities.
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Affiliation(s)
- Chad D Watts
- Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert U Hartzler
- Department of Orthopedic Surgery, The San Antonio Orthopaedic Group, San Antonio, Texas, USA
| | - William W Cross
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Posterior depression of the lateral articular surface of the tibial plateau can be difficult to elevate and support with morselized bone graft and internal fixation. Progressive collapse after open reduction and internal fixation has been described and can lead to failure in treatment. A standard anterolateral approach to the tibia may not allow direct reduction and stabilization of posterolateral joint depression given the anatomic barriers of the fibular collateral ligament and the proximal tibiofibular articulation. Posterolateral approaches to the tibial plateau have been described and may allow direct reduction of the articular depression. These approaches, however, require dissection close to the common peroneal nerve, and some approaches also require a proximal fibular osteotomy. The use of an intraosseous fibular shaft allograft as an adjunct to open reduction and internal fixation in select cases of depressed posterolateral tibial plateau fractures allows both reduction of the joint and stabilization of the articular segment through a single approach familiar to many orthopaedic surgeons.
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Affiliation(s)
- Adam A Sassoon
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN
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Abstract
Ipsilateral displaced acetabular and femoral shaft fractures represent a dilemma for orthopedic surgeons because antegrade femoral nailing may complicate a Kocher-Langenbeck acetabular exposure. The goals of this study were to review the results of ipsilateral femoral and acetabular fractures treated with antegrade femoral nailing and a Kocher-Langenbeck approach and to evaluate the assertion that this treatment strategy is associated with increased morbidity. This was a retrospective cohort study at a regional Level I trauma center. Sixteen patients with a femoral fracture treated with antegrade nailing and an ipsilateral acetabular fracture treated with a Kocher-Langenbeck approach were identified. One patient died as a result of his injuries, and 2 were not available for long-term follow-up. One had a deep infection requiring irrigation, debridement, and intraveonous antibiotics. One patient developed a hematoma requiring irrigation and debridement. At final follow-up, 2 patients had no heterotopic ossification about the hip, 4 had Brooker class I heterotopic ossification, 3 had Brooker class II heterotopic ossification, 2 had Brooker class III heterotopic ossification, and 2 patients had Brooker class IV heterotopic ossification requiring excision. Ipsilateral femoral and acetabular fractures represent a rare and severe injury constellation. Antegrade nailing of the femur with ipsilateral Kocher-Langenbeck exposure for fixation of the acetabulum was not associated with excessive rates of wound-healing complications, but the incidence of heterotopic ossification was increased.
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Cross WW, Levy BA, Morgan JA, Armitage BM, Cole PA. Periarticular raft constructs and fracture stability in split-depression tibial plateau fractures. Injury 2013; 44:796-801. [PMID: 23433659 DOI: 10.1016/j.injury.2012.12.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 12/03/2012] [Accepted: 12/22/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate relative fracture stability yielded by screws placed above a lateral plate, as well as locking and non-locking screws placed through a plate in a split depression tibia plateau fracture model. METHODS Cadaver tibia specimens (mean age 74.1 years) were randomised across 3 groups: Groups 1: raft-construct outside the plate, 2: non-locking raft screws through the plate, and 3: locking raft screws through the plate. Displacement of the depressed fragment was recorded with force values from 400N to 1600N in increasing 400N increments. The force required to elicit lateral plateau fragment displacement of 5mm, 10mm, and 15mm was also recorded. RESULTS None of the mechanical testing results demonstrated statistical significance with p-values of <0.05. Cyclic testing of Groups 1, 2, and 3 at 400N revealed displacements of 0.54mm, 0.64mm, and 0.48mm, respectively. At 800N, displacements were 1.36mm, 1.4mm, and 1.4mm, respectively. At 1200N, displacements were 2.4mm, 1.9mm, and 2.1mm, respectively. At 1600N, displacements were 2.8mm, 2.5mm, and 2mm, respectively. Resistance to displacement data demonstrated the mean force required to displace the fracture 5mm in Groups 1, 2, and 3 were 250N, 330N, and 318N, respectively. For 10mm of displacement, forces required were 394N, 515N, and 556N, respectively. For 15mm of displacement, forces required were 681N, 853N, and 963N, respectively. Compared to combined groups using screws through the plate, Group 1 demonstrated lower displacement ≤800N, but demonstrated greater displacement >800N. Group 2 demonstrated greatest resistance to plateau displacement of 5mm compared to Group 1 or 3, while Group 3 was most resistant to greater displacement. The combined group using screws through the plate (Groups 2+3) was consistently more resistant than Group 1 at all levels of displacement. CONCLUSIONS Designs utilising screws through the plate trended towards statistically significant improved stability against plateau displacement relative to utilising screws outside the plate. Our study also suggests that there is no significant benefit of locking screws over non-locking screws in this unicondylar tibia plateau fracture model.
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Affiliation(s)
- William W Cross
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
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Abstract
The management of open fractures continues to provide challenges for the orthopedic surgeon. Despite the improvements in technology and surgical techniques, rates of infection and nonunion are still troublesome. Principles important in the treatment of open fractures are reviewed in this article. Early antibiotic administration is of paramount importance in these cases, and when coupled with early and meticulous irrigation and debridement, the rates of infection can be dramatically decreased. Initial surgical intervention should be conducted as soon as possible, but the classic 6 h rule does not seem to be supported in the literature. All open fractures should be addressed for the risk of contamination from Clostridium tetani. When possible, early closure of open fracture wounds, either by primary means or by flaps, can also decrease the rate of infection, especially from nosocomial organisms. Early skeletal stabilization is necessary, which can be accomplished easily with temporary external fixation. Adhering to these principles can help surgeons provide optimal care to their patients and assist them in an early return to function.
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Affiliation(s)
- William W Cross
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave., Ste R 200, Minneapolis, MN 55454, USA
| | - Marc F Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave., Ste R 200, Minneapolis, MN 55454, USA,Address for correspondence: Dr. Marc F. Swiontkowski, Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave., Suite R200, Minneapolis, MN 55454, USA. E-mail:
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Abstract
UNLABELLED Total knee arthroplasty is an effective and cost efficient procedure that improves the quality of life for patients with end stage knee arthritis. With the prevalence of arthritis expected to increase with the aging of the population, the demand for total knee arthroplasty will increase substantially. We examined current indications for total knee arthroplasty by reviewing articles extracted from a comprehensive Med-line search. We studied the indications for proceeding with a total knee arthroplasty, the indications for referring a patient for a total knee arthroplasty, and the contraindications among orthopaedic surgeons, rheumatologists, and primary care providers. We evaluated 27-42 different patient factors. "Pain not responsive to drug therapy" was the only factor with consensus for total knee arthroplasty. "Major psychiatric disorder, including dementia" was the only contraindication to total knee arthroplasty that had a consensus. The lack of consensus within orthopaedics and across specialties likely represents a limitation in empirical data associated with total knee arthroplasty outcomes. Achieving better consensus will require conducting and disseminating better research on patient characteristics that predict the success of total knee arthroplasty. LEVEL OF EVIDENCE Economic and decision analyses, level IV (analyses with no sensitivity analyses). See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William W Cross
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Kane RL, Saleh KJ, Wilt TJ, Bershadsky B, Cross WW, MacDonald RM, Rutks I. Total knee replacement. Evid Rep Technol Assess (Summ) 2003:1-8. [PMID: 15160414 PMCID: PMC4781011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Cross WW. DEATH FOLLOWING CAUTERIZATION OF THE CERVIX. Cal West Med 1925; 23:1178. [PMID: 18739752 PMCID: PMC1654841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Cross WW. Practical Value of State Medical Law. Cal State J Med 1903; 1:363-365. [PMID: 18732942 PMCID: PMC1649384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Cross WW. Scamp and Criminal. Cal State J Med 1903; 1:276-277. [PMID: 18732881 PMCID: PMC1649321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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