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Li G, Xie Y, Xu B. Three-dimensional reconstruction with dual-source computed tomography for evaluating graft deformation and bone tunnel position following reconstruction of the anterior cruciate ligament. Med Eng Phys 2022; 110:103858. [PMID: 35909023 DOI: 10.1016/j.medengphy.2022.103858] [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: 04/27/2022] [Revised: 06/23/2022] [Accepted: 07/22/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Considering the limitations of MRI and X-ray and few studies on the use of dual-source computed tomography (DSCT) in anterior cruciate ligament (ACL) reconstruction are limited, this study explored the clinical application of DSCT for three-dimensional reconstruction of graft deformation and bone tunnel position images following ACL reconstruction. METHODS The data of 123 patients who underwent single-bundle ACL reconstruction under arthroscopy from January 2017 to October 2021 were retrieved. Two weeks after surgery, DSCT was used to assess graft deformation and tunnel widening. Based on the positions of ACL graft deformation and bone tunnel, the patients were divided into a collision group (n = 35), posterior group (n = 37) and satisfactory group (n = 51). The groups were compared in terms of the relative position of the central point of the femoral tunnel (FX, FY) and tibial tunnel (TX, TY), the straight-line distances of the grafts (L), the sagittal plane angle (∠α), and the coronal plane angle (∠β) between the two bone tunnels. RESULTS Tx, Ty, ∠α and ∠β were significantly different among the three groups, while no difference in Fx, Fy and L were observed. Tx, Ty and ∠α were identified as independent risk factors for collisions between the graft and intercondylar notch. Ty and ∠α were independent risk factors for posterior deviation of tibial tunnel position. CONCLUSION DSCT demonstrated promising clinical applicability to evaluate graft deformation and bone tunnel position after reconstruction of ACL and could guide preoperative positioning and postoperative evaluation.
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Affiliation(s)
- Guangzheng Li
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China; Department of Orthopedics, Maanshan People's Hospital, Ma'anshan, Anhui, 243099, China.
| | - Yang Xie
- Department of Orthopedics, Maanshan People's Hospital, Ma'anshan, Anhui, 243099, China
| | - Bin Xu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China.
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Ogborn D, McRae S, Larose G, Leiter J, Brown H, MacDonald P. Knee flexor strength and symmetry vary by device, body position and angle of assessment following ACL reconstruction with hamstring grafts at long-term follow-up. Knee Surg Sports Traumatol Arthrosc 2021; 31:1658-1664. [PMID: 34477895 DOI: 10.1007/s00167-021-06712-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/16/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Persistent deficits in knee flexor strength following harvest of semitendinosus and gracilis for anterior cruciate ligament reconstruction are inconsistent in the literature. Variation in methodology, including measuring torque at higher knee flexion angles may partially explain these discrepant findings. The objective of this study was to determine whether positioning (seated vs supine), consideration of peak or joint-angle-specific torque or device (Isokinetic Dynamometer vs NordBord Hamstring Dynamometer) impact the magnitude of knee flexor strength differences between limbs. METHODS Participants (n = 31, 44.2 ± 10.7 years,) who were at 14 ± 4.4 years follow-up for unilateral ACL reconstruction with semitendinosus/gracilis grafts completed the ACL Quality of Life outcome and an assessment including isokinetic concentric knee extensor and flexor strength in seated and supine with peak torque and torque at 60° (T60) and 75° (T75) knee flexion measured, followed by an eccentric Nordic Hamstring Curl. RESULTS Isokinetic concentric knee flexor torque was reduced in supine relative to seated, on the reconstructed limb against the unaffected, and at higher degrees of knee flexion relative to peak torque (T60 and T75 against peak torque). Limb symmetry varied by methodology (F(6,204) = 8.506, p = 0.001) with reduced symmetry in supine T75 against all measures (71.1 ± 16.5%, p < 0.05), supine T60 against seated peak torque (82.7 ± 14.2%, p < 0.05), and the NordBord was lower than seated peak torque that was not statistically significant (83.9 ± 12.8%, n.s.). Knee extensor peak (r2 = 0.167 (F(1,27) = 5.3, p = 0.03) and Nordic curl eccentric torque (r2 = 0.267, F(2,26) = 4.736, p = 0.02) were predictors of ACL-QoL score, although a combined model did not improve over Nordic torque alone. CONCLUSION Limb symmetry cannot be assumed in clinical practice across differing assessment methods for knee flexor strength as deficits are greatest in the supine position with torque measured at 75° knee flexion. Isokinetic knee extensor and eccentric knee flexor torque during the Nordic hamstring curl were predictors of ACL-QoL scoring and should be considered alongside patient-reported outcomes for patients following ACL reconstruction with hamstring grafts. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Dan Ogborn
- Pan Am Clinic Foundation, 75 Poseidon Bay, Office 307, Winnipeg, MB, R3M 3E4, Canada. .,College of Rehabilitation Sciences, Rady Faculty of Health Sciences, Winnipeg, MB, Canada.
| | - Sheila McRae
- Pan Am Clinic Foundation, 75 Poseidon Bay, Office 307, Winnipeg, MB, R3M 3E4, Canada.,College of Rehabilitation Sciences, Rady Faculty of Health Sciences, Winnipeg, MB, Canada.,Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, MB, Canada
| | - Gabriel Larose
- Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, MB, Canada
| | - Jeff Leiter
- Pan Am Clinic Foundation, 75 Poseidon Bay, Office 307, Winnipeg, MB, R3M 3E4, Canada
| | - Holly Brown
- Pan Am Clinic Foundation, 75 Poseidon Bay, Office 307, Winnipeg, MB, R3M 3E4, Canada
| | - Pete MacDonald
- Pan Am Clinic Foundation, 75 Poseidon Bay, Office 307, Winnipeg, MB, R3M 3E4, Canada.,Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, MB, Canada
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Dhillon MS, Rajnish RK, Dhillon S, Kumar P. Is there significant regeneration of the hamstring tendons after harvest for ACL reconstruction? A systematic review of literature. J Clin Orthop Trauma 2021; 16:208-218. [PMID: 33680834 PMCID: PMC7919951 DOI: 10.1016/j.jcot.2021.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/31/2021] [Accepted: 02/10/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Regeneration potential of Hamstring tendons after harvest assumes significant clinical relevance as its use has become widespread today. Methods which best assess the regeneration, extent and type of regeneration, plus issues related to functional loss are important for the surgeon to know. This review looks at the literature to find answers to the above questions. PURPOSE To summarize the evidence in support of hamstring tendon regeneration, and the most appropriate modality for evaluation of regeneration. Additionally, to evaluate the regeneration in terms of complete or partial, extent and its impact on strength deficit and functional outcomes. METHODS We did a systematic review of literature through specified search engines and identified 30 of 285 studies to be relevant (19 prospective and 11 retrospective). RESULTS Evaluation of above data suggests tissue regeneration at harvest sites does occur (78.9% of semitendinosus and 42.7% of gracilis tendons), but this regeneration is variable. No established definition of regeneration exists; MRI is an adequate tool to identify regeneration, while biopsy is confirmative. USG is a cost-effective screening method and can document distal progress of regenerate. Semitendinosus and gracilis tendons regenerate at different rates and extents, and often fuse together, but there is no evidence to state that one regenerates better than the other. Proximal retraction of the muscle-tendon junction occurs, along with some atrophy, which affects function to a variable extent. Strength deficits may persist, but they may not convert to significant functional deficits. CONCLUSION There is variable hamstring regeneration after harvest, with poorly defined definition of "regeneration". Some changes in the muscle itself, abnormal distal insertion and absence of regeneration in some are documented, along with strength deficits. Although overall functional deficits have been reported to be minimal, a definite change in the anatomy of the medial hamstrings is a factor to be kept in consideration. More information is needed about the long-term consequences.
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Affiliation(s)
- Mandeep S. Dhillon
- Department of Orthopaedics, Post Graduate Institue of Medical Eduacation and Research, Chandigarh, India
| | - Rajesh Kumar Rajnish
- Department of Orthopaedics, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, PIN-174001, India
| | | | - Prasoon Kumar
- Department of Orthopaedics, Post Graduate Institue of Medical Eduacation and Research, Chandigarh, India
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Perumal S, Thiyagarajan KA, Prakash A, Arumugam S. Evaluation of regeneration of semitendinosus tendon using ultrasound imaging and isokinetic strength testing after graft harvest for arthroscopic anterior cruciate ligament reconstruction. J Orthop 2020; 21:340-344. [PMID: 32773984 DOI: 10.1016/j.jor.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/05/2020] [Accepted: 07/12/2020] [Indexed: 11/18/2022] Open
Abstract
Background A lot of the research has been done worldwide evaluating the capacity of the semitendinosus tendon to regenerate which has not been conducted in the Indian population. Study design 31 patients who underwent unilateral ACL reconstruction with hamstrings were taken into study. All patients underwent ultrasonography imaging of both knees and bilateral isokinetic flexion strength assessment at a one-year postoperative period. Images were obtained at three levels and their dimensions are compared with normal side. Isokinetic testing of the knee is done to evaluate the flexion deficit and is compared to the uninvolved knee. Results Out of a total of 31 patients, 14 patients showed no regeneration, 17 showed regeneration at various levels. On isokinetic testing patients with no regeneration showed the highest mean flexion deficit. Conclusion The semitendinosus tendon and its regeneration can be visualized well using ultrasonography. After semitendinosus harvesting, the flexion strength will be decreased as compared to the normal knee. The flexion strength in patients who have a regenerated tendon will be higher as compared to those who have no regeneration.
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Affiliation(s)
- Suresh Perumal
- Department of Arthroscopy and Sports Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - K A Thiyagarajan
- Department of Arthroscopy and Sports Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - A Prakash
- Department of Arthroscopy and Sports Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - S Arumugam
- Department of Arthroscopy and Sports Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Lyle MA, Nichols TR, Kajtaz E, Maas H. Musculotendon adaptations and preservation of spinal reflex pathways following agonist-to-antagonist tendon transfer. Physiol Rep 2018; 5:5/9/e13201. [PMID: 28468849 PMCID: PMC5430118 DOI: 10.14814/phy2.13201] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/17/2017] [Indexed: 01/05/2023] Open
Abstract
Tendon transfer surgeries are performed to restore lost motor function, but outcomes are variable, particularly those involving agonist‐to‐antagonist muscles. Here, we evaluated the possibility that lack of proprioceptive feedback reorganization and musculotendon adaptations could influence outcomes. Plantaris‐to‐tibialis anterior tendon transfer along with resection of the distal third of the tibialis anterior muscle belly was performed in eight cats. Four cats had concurrent transection of the deep peroneal nerve. After 15–20 weeks, intermuscular length and force‐dependent sensory feedback were examined between hindlimb muscles, and the integrity of the tendon‐to‐tendon connection and musculotendon adaptations were evaluated. Three of the transferred tendons tore. A common finding was the formation of new tendinous connections, which often inserted near the original location of insertion on the skeleton (e.g., connections from plantaris toward calcaneus and from tibialis anterior toward first metatarsal). The newly formed tissue connections are expected to compromise the mechanical action of the transferred muscle. We found no evidence of changes in intermuscular reflexes between transferred plantaris muscle and synergists/antagonists whether the tendon‐to‐tendon connection remained intact or tore, indicating no spinal reflex reorganization. We propose the lack of spinal reflex reorganization could contribute the transferred muscle not adopting the activation patterns of the host muscle. Taken together, these findings suggest that musculotendon plasticity and lack of spinal reflex circuitry reorganization could limit functional outcomes after tendon transfer surgery. Surgical planning and outcomes assessments after tendon transfer surgery should consider potential consequences of the transferred muscle's intermuscular spinal circuit actions.
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Affiliation(s)
- Mark A Lyle
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia
| | - T Richard Nichols
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia
| | - Elma Kajtaz
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia
| | - Huub Maas
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands
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Suijkerbuijk MAM, Reijman M, Lodewijks SJM, Punt J, Meuffels DE. Hamstring Tendon Regeneration After Harvesting: A Systematic Review. Am J Sports Med 2015; 43:2591-8. [PMID: 25548149 DOI: 10.1177/0363546514562169] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hamstring tendons are often used as autografts for anterior cruciate ligament (ACL) reconstruction. However, no systematic review has been performed describing consequences such as hamstring tendon regeneration rate and determinants of hamstring tendon regeneration. PURPOSE To summarize the current literature regarding hamstring tendon rate regeneration, the time course of regeneration, and determinants of hamstring regeneration. STUDY DESIGN Systematic review. METHODS A search was performed in the Embase, Medline (OvidSP), Web of Science, Cochrane, PubMed, and Google Scholar databases up to June 2014 to identify relevant articles. A study was eligible if it met the following inclusion criteria: tendons were harvested, regeneration at harvest site was assessed, population size was at least 10 human subjects, full-text article was available, and the study design was either a randomized controlled trial, prospective cohort study, retrospective cohort study, or case control study. A risk of bias assessment of the eligible articles was determined. Data describing hamstring tendon regeneration rates were pooled per time period. RESULTS A total of 18 publications met the inclusion criteria. The mean regeneration rate for the semitendinosus and gracilis tendons was, in all cases, 70% or higher. More than 1 year after harvesting, 79% (median [IQR], 80 [75.5-90]) of the semitendinosus tendons and 72% (median [IQR], 80 [61-88.5]) of the gracilis tendons were regenerated. No significant differences in regeneration rate could be found considering patient sex, age, height, weight, or duration of immobilization. Results did not clearly show whether absence of regeneration disadvantages the subsequent hamstring function. Five studies measured the regeneration rate at different moments in time. CONCLUSION Hamstring tendons regenerated in the majority of patients after ACL reconstruction. The majority of the hamstring tendon regeneration was found to occur between 1 month and 1 year after harvest. No significant determinants for hamstring tendon regeneration could be identified because of a lack of research. The function and strength of the regenerated hamstring remained unclear.
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Affiliation(s)
- Mathijs A M Suijkerbuijk
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Max Reijman
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Susanne J M Lodewijks
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jorien Punt
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Duncan E Meuffels
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Papalia R, Franceschi F, D'Adamio S, Diaz Balzani L, Maffulli N, Denaro V. Hamstring Tendon Regeneration After Harvest for Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2015; 31:1169-83. [PMID: 25557918 DOI: 10.1016/j.arthro.2014.11.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/11/2014] [Accepted: 11/07/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess whether the portions of the semitendinosus and gracilis tendons harvested for anterior cruciate ligament reconstruction have the potential to regenerate and, if so, to evaluate the histologic properties and actual function of this newly formed tissue. METHODS We performed a comprehensive search of CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, Medline, the Cochrane Central Registry of Controlled Trials, and SPORTDiscus from inception of the databases to July 2014, using various combinations of keywords. Studies focusing on hamstring tendon and muscle regeneration through imaging and histology, as well as on the related functional outcomes, were selected. We included studies assessing evidence of tissue regeneration with imaging (magnetic resonance imaging, 3-dimensional computed tomography, ultrasonography) or with histologic examination of biopsy samples (or a combination thereof). RESULTS Nineteen articles were included in this review, with a total of 400 patients observed. The overall rate of tissue regeneration was 86.0%, with similar values shown in most studies regardless of the methodology of the assessment. Biopsy confirmed that the tissue found at the site in 74% of the cases showed typical histologic features of the tendon. The mean modified Coleman Methodology Score of the studies included was 52.7 points, showing a modest methodologic quality for the studies published to date. CONCLUSIONS In over 85% of the cases analyzed, regeneration signs of the harvested tendon were found through different imaging and histologic methodologies. A torque deficit in deep knee flexion is always present postoperatively, but the cause for this is still unclear. There is a need for better-designed trials featuring a higher level of evidence to further investigate this matter, and the effects of postoperative care and the surgical approach used on the regeneration process should be analyzed in the future. LEVEL OF EVIDENCE Level IV, systematic review of Level II, III, and IV studies.
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Affiliation(s)
- Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Stefano D'Adamio
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Lorenzo Diaz Balzani
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy; Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, England.
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
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Altintas AA, Vogt PM, Altintas MA. Acute effects of splint immobilization of the forearm on in vivo microcirculation and histomorphology of the human skin. Microsc Res Tech 2014; 77:99-103. [PMID: 24738150 DOI: 10.1002/jemt.22317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Splint immobilization of the forearm is often performed in clinical practice. Previous studies investigated the effect of immobilization on bone, cartilage, muscle, and tendon, however, the acute effects on human skin microcirculation and histomorphology remains elusive. METHODS In 12 healthy, nonsmoking individuals (aged 29.7 ± 9.1 years) a randomly selected forearm was immobilized by splinting for 72 h, whereas the other forearm served as control. In vivo Reflectance-Mode Confocal-Microscopy (RMCM) was performed prior (baseline value) and postimmobilization to evaluate: quantitative blood cell flow; density of functional dermal capillaries; epidermal thickness; and granular cell size. RESULTS At 72h forearm immobilization, quantitative blood cell flow was significantly reduced (42.86 ± 3.68 cells/min) compared to the control blood flow (53.11 ± 3.68 cells/min, P < 0.05) and dermal capillaries indicates less functional density (5.73 ± 0.63 capillaries/mm2) compared to the controls (7.04 ± 0.81 capillaries/mm2, P < 0.05). Histometric assessment reveals significantly thinner epidermis following immobilization compared to the control site (40.02 ± 2.91 vs. 46.64±3.09 µm, P < 0.05). Granular cell size was significantly altered at 72 h splinting (730.1 ± 42.53 µm2) compared to the control cell size at 770.2 ± 38.21 µm2. Comparison of baseline values of both forearms indicate statistically insignificance (P > 0.05) for each parameter. CONCLUSION At 72 h splint immobilization, for the first time, significant adaptive mechanisms were evaluated on human skin microcirculation and histomorphology using in vivo RMCM. These adaptations may be considered as an incipient atrophy of the human skin. Long-term effects of immobilization including the regenerative potential should be evaluated in further RMCM studies.
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Nakamae A, Ochi M, Deie M, Adachi N. Unsuccessful regeneration of the semitendinosus tendon harvested for anterior cruciate ligament reconstruction: report of two cases. Orthop Traumatol Surg Res 2012; 98:932-5. [PMID: 23123037 DOI: 10.1016/j.otsr.2012.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 06/10/2012] [Accepted: 07/02/2012] [Indexed: 02/02/2023]
Abstract
Recent magnetic resonance imaging (MRI) and three-dimensional (3D) computed tomography (CT) analyses have demonstrated that semitendinosus tendon can regenerate at a high rate following harvesting the tendon for anterior cruciate ligament (ACL) reconstruction. Although it is known that the regeneration of the semitendinosus tendon does not occur in all the patients, the reason for this unsuccessful regeneration of the tendon in certain patients remains unknown. We recently encountered two cases in which regeneration of the semitendinosus tendon was unsuccessful because of apparent reasons. These patients experienced a sudden sharp pain in the posterior aspect of their thighs when their hamstring muscles were subjected to aggressive load at 3 and 4 weeks after surgery. At the follow-up examination conducted after 12 months, 3D CT imaging revealed unsuccessful regeneration of the semitendinosus tendons in both cases. Severe proximal retraction of the semitendinosus muscle belly was also confirmed.
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Affiliation(s)
- A Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan.
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