1
|
Wei S, Li Q, Wu H, Kong C, Xu F, Cai X. All-inside endoscopic semiautomatic running locked stitch technique shows favourable outcomes for acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2024; 32:1615-1621. [PMID: 38578228 DOI: 10.1002/ksa.12177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE The safety and reliability of endoscopic Achilles tendon rupture repair are still concerning aspects. This study's aim is to evaluate an all-inside endoscopic semiautomatic running locked stitch (Endo-SARLS) technique. METHODS Forty cases with acute Achilles tendon rupture were treated with the all-inside Endo-SARLS technique between 2020 and 2021. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semiautomatic flexible suture passer. The threads of the high-strength suture were grasped through the paratenon subspace and then fixed into calcaneal insertion with a knotless anchor. Magnetic resonance imaging (MRI), surgical time and complications were assessed. Achilles Tendon Total Rupture Score (ATRS), Achilles Tendon Resting Angle (ATRA) and Heel Rise Height Scale (HRHS) were utilised to evaluate final outcomes. RESULTS The average follow-up time was 25.4 ± 0.4 (range: 24-32) months. Appropriate tendon regeneration was observed on MRI after 12 months. At the final follow-up, the median value of ATRS score was 95 (interquartile range: 94, 98). Furthermore, there is no significant difference between the injured and contralateral side in the average ATRA (18.2 ± 1.8 vs. 18.3 ± 1.9°, ns) and median value of HRHS [14.5 (13.3, 15.5) vs. 14.8 (13.5, 15.6) cm, ns]. No infection and nerve injuries were encountered. Thirty-nine patients reported that they resumed casual sports activity after 6 months. One patient had a slight anchor cut-out, due to an addition injury, which was removed after 5 months. CONCLUSIONS An all-inside Endo-SARLS technique showed promising clinical results for acute Achilles tendon ruptures. This procedure reduces the risk of sural nerve injuries while establishing a reliable connection between the tendon stumps. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Shijun Wei
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Qing Li
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
| | - Helin Wu
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Changwang Kong
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
| | - Feng Xu
- Department of Orthopaedics, General Hospital of Central Theater Command, Wuhan, China
- The First Clinical Medical School, Southern Medical University, Guangzhou, China
| | - Xianhua Cai
- Department of Orthopaedics, South China Hospital of Shenzhen University, Shenzhen, China
| |
Collapse
|
2
|
DiIorio SE, Young B, Parker JB, Griffin MF, Longaker MT. Understanding Tendon Fibroblast Biology and Heterogeneity. Biomedicines 2024; 12:859. [PMID: 38672213 PMCID: PMC11048404 DOI: 10.3390/biomedicines12040859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Tendon regeneration has emerged as an area of interest due to the challenging healing process of avascular tendon tissue. During tendon healing after injury, the formation of a fibrous scar can limit tendon strength and lead to subsequent complications. The specific biological mechanisms that cause fibrosis across different cellular subtypes within the tendon and across different tendons in the body continue to remain unknown. Herein, we review the current understanding of tendon healing, fibrosis mechanisms, and future directions for treatments. We summarize recent research on the role of fibroblasts throughout tendon healing and describe the functional and cellular heterogeneity of fibroblasts and tendons. The review notes gaps in tendon fibrosis research, with a focus on characterizing distinct fibroblast subpopulations in the tendon. We highlight new techniques in the field that can be used to enhance our understanding of complex tendon pathologies such as fibrosis. Finally, we explore bioengineering tools for tendon regeneration and discuss future areas for innovation. Exploring the heterogeneity of tendon fibroblasts on the cellular level can inform therapeutic strategies for addressing tendon fibrosis and ultimately reduce its clinical burden.
Collapse
Affiliation(s)
- Sarah E. DiIorio
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.E.D.); (B.Y.); (J.B.P.); (M.F.G.)
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Bill Young
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.E.D.); (B.Y.); (J.B.P.); (M.F.G.)
| | - Jennifer B. Parker
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.E.D.); (B.Y.); (J.B.P.); (M.F.G.)
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Michelle F. Griffin
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.E.D.); (B.Y.); (J.B.P.); (M.F.G.)
| | - Michael T. Longaker
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.E.D.); (B.Y.); (J.B.P.); (M.F.G.)
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| |
Collapse
|
3
|
Carmont MR, Gunnarsson B, Brorsson A, Nilsson-Helander K. Musculotendinous ruptures of the achilles tendon had greater heel-rise height index compared with mid-substance rupture with non-operative management: A retrospective cohort study. J ISAKOS 2024; 9:148-152. [PMID: 38154754 DOI: 10.1016/j.jisako.2023.12.006] [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: 09/04/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Achilles tendon ruptures (ATRs) may occur at varying locations with ruptures at the mid-substance (MS) of the tendon most common, followed tears at the musculotendinous (MT) junction. There is scant literature about the outcome of MT ATR. This study compared the outcome of patients with a MT ATR with patients following a MS ATR. METHODS The diagnostic features and clinical outcome of 37 patients with a MT ATR were compared with a cohort of 19 patients with a MS ATR. Patients in both groups were managed non-operatively and received the same rehabilitation protocol with weight-bearing rehabilitation in protective functional brace. RESULTS From February 2009 to August 2023, 556 patients presented with an ATR. Of these, 37 (6.7 %) patients were diagnosed with a MT tear. At final follow-up, at 12 months following injury, the MT group reported an Achilles tendon total rupture score (ATRS) of mean (standard deviation (SD)) of 83.6 (3.5) (95 % confidence interval (CI) 81.8, 85.4) and median (inter-quartile range (IQR)) ATRS of 86 points (78-95.5) and the MS group mean (SD) of 80.3 (8.5) (95%CI) 76.1, 80.5) and median (IQR) of 87 points (59-95) (p = 0.673). Functional evaluation, however, revealed statistically significant differences in mean (SD) heel-rise height index MT group 79 % (25) (95%CI 65.9, 92.1) and MS group 59 % (13) (95%CI 51.9, 67.1) (p = 0.019). In the MT rupture group, there were considerably less complications than the MS rupture group. CONCLUSIONS When managed non-operatively, with only a 6 weeks period of brace protection, patients have little limitation although have some residual reduction of single heel-rise at the one-year following MT ATR. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Michael R Carmont
- Department of Trauma & Orthopaedic Surgery, Shrewsbury & Telford Hospital NHS Trust, Shropshire, TF1 6TF, United Kingdom; University of Keele, Staffordshire, ST5 5BG, United Kingdom; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden.
| | - Baldvin Gunnarsson
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
| | - Annelie Brorsson
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
| |
Collapse
|
4
|
Mashimo S, Nozaki T, Amaha K, Tanaka K, Kubota J, Sato H, Kitamura N. Quantitative Assessment of Calf Muscle Volume, Strength, and Quality After Achilles Tendon Rupture Repair: A 1-Year Prospective Follow-up Study. Am J Sports Med 2023; 51:3781-3789. [PMID: 37960840 DOI: 10.1177/03635465231206391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND A number of studies have reported that calf muscle atrophy is a common long-term problem after Achilles tendon repair; however, there is still a lack of data concerning early postoperative morphological changes in the calf muscle after surgery. PURPOSE To investigate changes over time in calf muscle volume and fatty degeneration during 1 year after Achilles tendon repair. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A prospective 1-year serial magnetic resonance imaging study was carried out with 20 patients who underwent tendon repair for unilateral acute Achilles tendon rupture. The magnetic resonance imaging assessment in addition to clinical and functional evaluations was performed at 1, 3, 6, and 12 months after surgery. The muscle volume of the medial and lateral gastrocnemius, soleus, and flexor hallucis longus (FHL) and fatty degeneration of the medial and lateral gastrocnemius and soleus were measured for the calf muscles, and the relative volume and fatty degeneration changes in the affected leg compared with the healthy contralateral leg were calculated as a percentage ([injured/healthy control] × 100) to assess structural changes over time. RESULTS Muscle volumes of the medial gastrocnemius, lateral gastrocnemius, soleus, and FHL were 92.3%, 92.8%, 84.6%, and 95.9% at 12 months after surgery, respectively. Medial and lateral gastrocnemius and FHL muscle volumes improved over time and recovered to almost equal to that of the healthy side at 12 months after surgery. The soleus muscle volume did not recover significantly over time and was statistically significantly smaller than that of the healthy side at 12 months (P = .029). Fatty degeneration rates of the medial gastrocnemius, lateral gastrocnemius, and soleus were 118.2%, 113.9% and 121.1% at 12 months after surgery, respectively. Fatty degeneration of the medial and lateral gastrocnemius did not change significantly, but there was a statistically significant increase in fatty degeneration of the soleus over time (P < .001). CONCLUSION Within the triceps surae muscle, the soleus was the most negatively affected by injury and repair for both muscle volume and fatty degeneration. Postoperative management to recover the soleus muscle function before a return to sporting activities should be considered in the future.
Collapse
Affiliation(s)
- Shota Mashimo
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Taiki Nozaki
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Kentaro Amaha
- Department of Orthopaedic Surgery, St Luke's International Hospital, Tokyo, Japan
| | - Keita Tanaka
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Junya Kubota
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Hiroyuki Sato
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
| | - Nobuto Kitamura
- Department of Rehabilitation, St Luke's International Hospital, Tokyo, Japan
- Department of Orthopaedic Surgery, St Luke's International Hospital, Tokyo, Japan
| |
Collapse
|
5
|
Yu YH, Lee CH, Hsu YH, Chou YC, Yu PC, Huang CT, Liu SJ. Anti-Adhesive Resorbable Indomethacin/Bupivacaine-Eluting Nanofibers for Tendon Rupture Repair: In Vitro and In Vivo Studies. Int J Mol Sci 2023; 24:16235. [PMID: 38003425 PMCID: PMC10671766 DOI: 10.3390/ijms242216235] [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: 10/20/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
The treatment and surgical repair of torn Achilles tendons seldom return the wounded tendon to its original elasticity and stiffness. This study explored the in vitro and in vivo simultaneous release of indomethacin and bupivacaine from electrospun polylactide-polyglycolide composite membranes for their capacity to repair torn Achilles tendons. These membranes were fabricated by mixing polylactide-polyglycolide/indomethacin, polylactide-polyglycolide/collagen, and polylactide-polyglycolide/bupivacaine with 1,1,1,3,3,3-hexafluoro-2-propanol into sandwich-structured composites. Subsequently, the in vitro pharmaceutic release rates over 30 days were determined, and the in vivo release behavior and effectiveness of the loaded drugs were assessed using an animal surgical model. High concentrations of indomethacin and bupivacaine were released for over four weeks. The released pharmaceutics resulted in complete recovery of rat tendons, and the nanofibrous composite membranes exhibited exceptional mechanical strength. Additionally, the anti-adhesion capacity of the developed membrane was confirmed. Using the electrospinning technique developed in this study, we plan on manufacturing degradable composite membranes for tendon healing, which can deliver sustained pharmaceutical release and provide a collagenous habitat.
Collapse
Affiliation(s)
- Yi-Hsun Yu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan; (Y.-H.Y.)
| | - Chen-Hung Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan; (Y.-H.Y.)
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan; (Y.-H.Y.)
| | - Ping-Chun Yu
- Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chao-Tsai Huang
- Department of Chemical and Materials Engineering, Tamkang University, New Taipei City 25137, Taiwan;
| | - Shih-Jung Liu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan; (Y.-H.Y.)
- Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan
| |
Collapse
|
6
|
Schnabel LV, Koch DW. Use of mesenchymal stem cells for tendon healing in veterinary and human medicine: getting to the "core" of the problem through a one health approach. J Am Vet Med Assoc 2023; 261:1435-1442. [PMID: 37643722 PMCID: PMC11027114 DOI: 10.2460/javma.23.07.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023]
Abstract
The purpose of this manuscript, which is part of the Currents in One Health series, is to take a comparative approach to stem cell treatment for tendon injury and consider how the horse might inform treatment in other veterinary species and humans. There is increasing experimental and clinical evidence for the use of bone marrow-derived mesenchymal stem cells to treat tendon injuries in the horse. The same evidence does not currently exist for other species. This manuscript will review why the equine superficial digital flexor tendon core lesion might be considered optimal for stem cell delivery and stem cell interaction with the injury environment and will also introduce the concept of stem cell licensing for future evaluation. The companion Currents in One Health by Koch and Schnabel, AJVR, October 2023, addresses in detail what is known about stem cell licensing for the treatment of other diseases using rodent models and how this information can potentially be applied to tendon healing.
Collapse
Affiliation(s)
- Lauren V. Schnabel
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC
| | - Drew W. Koch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC
| |
Collapse
|
7
|
Diniz P, Abreu M, Lacerda D, Martins A, Pereira H, Ferreira FC, Kerkhoffs GMMJ, Fred A. Pre-injury performance is most important for predicting the level of match participation after Achilles tendon ruptures in elite soccer players: a study using a machine learning classifier. Knee Surg Sports Traumatol Arthrosc 2022; 30:4225-4237. [PMID: 35941323 PMCID: PMC9360634 DOI: 10.1007/s00167-022-07082-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE Achilles tendon ruptures (ATR) are career-threatening injuries in elite soccer players due to the decreased sports performance they commonly inflict. This study presents an exploratory data analysis of match participation before and after ATRs and an evaluation of the performance of a machine learning (ML) model based on pre-injury features to predict whether a player will return to a previous level of match participation. METHODS The website transfermarkt.com was mined, between January and March of 2021, for relevant entries regarding soccer players who suffered an ATR while playing in first or second leagues. The difference between average minutes played per match (MPM) 1 year before injury and between 1 and 2 years after the injury was used to identify patterns in match participation after injury. Clustering analysis was performed using k-means clustering. Predictions of post-injury match participation were made using the XGBoost classification algorithm. The performance of this model was evaluated using the area under the receiver operating characteristic curve (AUROC) and Brier score loss (BSL). RESULTS Two hundred and nine players were included in the study. Data from 32,853 matches was analysed. Exploratory data analysis revealed that forwards, midfielders and defenders increased match participation during the first year after injury, with goalkeepers still improving at 2 years. Players were grouped into four clusters regarding the difference between MPMs 1 year before injury and between 1 and 2 years after the injury. These groups ranged between a severe decrease (n = 34; - 59 ± 13 MPM), moderate decrease (n = 75; - 25 ± 8 MPM), maintenance (n = 70; 0 ± 8 MPM), or increase (n = 30; 32 ± 13 MPM). Regarding the predictive model, the average AUROC after cross-validation was 0.81 ± 0.10, and the BSL was 0.12, with the most important features relating to pre-injury match participation. CONCLUSION Most players take 1 year to reach peak match participation after an ATR. Good performance was attained using a ML classifier to predict the level of match participation following an ATR, with features related to pre-injury match participation displaying the highest importance. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Pedro Diniz
- Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela, 501, 2775-028, Parede, Portugal. .,Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. .,Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. .,Fisiogaspar, Lisbon, Portugal.
| | - Mariana Abreu
- grid.9983.b0000 0001 2181 4263Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal ,grid.421174.50000 0004 0393 4941Instituto de Telecomunicações, Lisbon, Portugal
| | - Diogo Lacerda
- Department of Orthopaedic Surgery, Hospital de Sant’Ana, Rua de Benguela, 501, 2775-028 Parede, Portugal
| | - António Martins
- Department of Orthopaedic Surgery, Hospital de Sant’Ana, Rua de Benguela, 501, 2775-028 Parede, Portugal ,Fisiogaspar, Lisbon, Portugal
| | - Hélder Pereira
- Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila do Conde, Portugal ,Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia-Madrid, Spain ,grid.10328.380000 0001 2159 175XUniversity of Minho ICVS/3B’s-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Frederico Castelo Ferreira
- grid.9983.b0000 0001 2181 4263Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal ,grid.9983.b0000 0001 2181 4263Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Gino MMJ Kerkhoffs
- grid.509540.d0000 0004 6880 3010Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands ,grid.491090.5Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands ,grid.512724.7Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
| | - Ana Fred
- grid.9983.b0000 0001 2181 4263Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal ,grid.421174.50000 0004 0393 4941Instituto de Telecomunicações, Lisbon, Portugal
| |
Collapse
|