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Malhotra R, Gautam D, Mukherjee K, Mukherjee S, Swamy AM, Rai A, Goyal A, Chawla A. Alternating Layers of Morselized Allograft and Injectable Ceramic Bone Graft Substitute in Acetabular Reconstruction: A Novel 'Sandwich' Technique. Arthroplast Today 2023; 22:101150. [PMID: 37358964 PMCID: PMC10285088 DOI: 10.1016/j.artd.2023.101150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/09/2023] [Accepted: 04/23/2023] [Indexed: 06/28/2023] Open
Abstract
Background Impaction of morselized allograft is an appealing procedure for addressing the bone defects. However, concerns remain about its suitability for massive defects. We used a novel "sandwich" technique by impacting the morselized allograft in layers with an intervening layer of injectable bone graft substitute for restoring bone defects during acetabular reconstruction in total hip arthroplasties. Methods From August 2015 to June 2017, 17 revisions, 4 rerevisions, and 3 complex primary total hip arthroplasties were operated by this novel technique. Postoperatively, serial X-rays were evaluated at regular intervals. Clinical and functional outcomes were assessed by the Harris hip score. To examine if introducing an injectable bone substitute into allograft stock increased its load-bearing capability, simulated mechanical testing using Synbone samples was conducted in the laboratory. Results The mean Harris hip score significantly improved from 54.6 preoperatively to 86.8 at the latest follow-up. Graft incorporation was seen in all the cases. There was no evidence of component migration or loosening as compared to the X-rays at 3 weeks and 3 months in all the cases. With revision of component as end point, the survivorship was 100% at 82 months. The mechanical testing reported a higher capability of allograft samples when compared to those without bone substitutes. Conclusions Our data confirms that the use of the "sandwich" technique is a reliable option for major acetabular reconstruction. Early weight bearing is a significant value addition, and short-term results confirm good clinical and functional outcome. Longer follow-up is necessary to assess the status of the construct in the long term.
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Affiliation(s)
- Rajesh Malhotra
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | | - Kaushik Mukherjee
- Department of Mechanical Engineering, Indian Institute of Technology, Delhi, New Delhi, India
| | - Sudipto Mukherjee
- Department of Mechanical Engineering, Indian Institute of Technology, Delhi, New Delhi, India
| | - Arun Manjunatha Swamy
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Alok Rai
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ajay Goyal
- Department of Mechanical Engineering, Indian Institute of Technology, Delhi, New Delhi, India
- Institute of Design, Nirma University, Ahmedabad, Gujarat, India
| | - Anoop Chawla
- Department of Mechanical Engineering, Indian Institute of Technology, Delhi, New Delhi, India
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2
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Fung A, Fleps I, Cripton PA, Guy P, Ferguson SJ, Helgason B. The efficacy of femoral augmentation for hip fracture prevention using ceramic-based cements: A preliminary experimentally-driven finite element investigation. Front Bioeng Biotechnol 2023; 11:1079644. [PMID: 36777252 PMCID: PMC9909544 DOI: 10.3389/fbioe.2023.1079644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
Femoral fractures due to sideways falls continue to be a major cause of concern for the elderly. Existing approaches for the prevention of these injuries have limited efficacy. Prophylactic femoral augmentation systems, particularly those involving the injection of ceramic-based bone cements, are gaining more attention as a potential alternative preventative approach. We evaluated the mechanical effectiveness of three variations of a bone cement injection pattern (basic ellipsoid, hollow ellipsoid, small ellipsoid) utilizing finite element simulations of sideways fall impacts. The basic augmentation pattern was tested with both high- and low-strength ceramic-based cements. The cement patterns were added to the finite element models (FEMs) of five cadaveric femurs, which were then subject to simulated sideways falls at seven impact velocities ranging from 1.0 m/s to 4.0 m/s. Peak impact forces and peak acetabular forces were examined, and failure was evaluated using a strain-based criterion. We found that the basic HA ellipsoid provided the highest increases in both the force at the acetabulum of the impacted femur ("acetabular force", 55.0% ± 22.0%) and at the force plate ("impact force", 37.4% ± 15.8%). Changing the cement to a weaker material, brushite, resulted in reduced strengthening of the femur (45.2% ± 19.4% acetabular and 30.4% ± 13.0% impact). Using a hollow version of the ellipsoid appeared to have no effect on the fracture outcome and only a minor effect on the other metrics (54.1% ± 22.3% acetabular force increase and 35.3% ± 16.0% impact force increase). However, when the outer two layers of the ellipsoid were removed (small ellipsoid), the force increases that were achieved were only 9.8% ± 5.5% acetabular force and 8.2% ± 4.1% impact force. These results demonstrate the importance of supporting the femoral neck cortex to prevent femoral fractures in a sideways fall, and provide plausible options for prophylactic femoral augmentation. As this is a preliminary study, the surgical technique, the possible effects of trabecular bone damage during the augmentation process, and the effect on the blood supply to the femoral head must be assessed further.
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Affiliation(s)
- Anita Fung
- Laboratory for Orthopaedic Technology, Institute for Biomechanics, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland,*Correspondence: Anita Fung,
| | - Ingmar Fleps
- Orthopaedic and Developmental Biomechanics Laboratory, Department of Mechanical Engineering, Boston University, Boston, MA, United States
| | - Peter A. Cripton
- Orthopaedic and Injury Biomechanics Group, School of Biomedical Engineering and Departments of Mechanical Engineering and Orthopaedics, University of British Columbia, Vancouver, BC, Canada,Centre for Hip Health and Mobility, University of British Columbia, Vancouver, BC, Canada
| | - Pierre Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, BC, Canada,Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Stephen J. Ferguson
- Laboratory for Orthopaedic Technology, Institute for Biomechanics, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Benedikt Helgason
- Laboratory for Orthopaedic Technology, Institute for Biomechanics, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
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3
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Xu H, Liu Y, Sezgin EA, Tarasevičius Š, Christensen R, Raina DB, Tägil M, Lidgren L. Comparative effectiveness research on proximal femoral nail versus dynamic hip screw in patients with trochanteric fractures: a systematic review and meta-analysis of randomized trials. J Orthop Surg Res 2022; 17:292. [PMID: 35658909 PMCID: PMC9164432 DOI: 10.1186/s13018-022-03189-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/18/2022] [Indexed: 11/28/2022] Open
Abstract
Background The treatments for trochanteric fractures try to regain early mobility and limit morbidity and risk of reoperations. The most currently used dynamic hip screw (DHS) and the proximal femoral nail (PFN) are both with pros and cons. We aimed to assess the comparative effectiveness of these interventions for trochanteric fractures by evaluating the surgical performance and postoperative outcomes.
Methods PubMed, Web of Science and Cochrane Central Register were searched for RCTs comparing DHS and PFN for trochanteric fractures. All selected studies and the risk of bias were assessed. Clinical data including operative time, intraoperative blood loss, intraoperative fluoroscopy time, successful closed reduction and complications like nonunion, implant failure and reoperation were recorded. Random-effects models were used in Review Manager software, and GRADE was applied for the interpretation of the evidence. Results From 286 identified trials, twelve RCTs including 1889 patients were eligible for inclusion; six RCTs directly comparing DHS with PFN, while other six compared DHS with proximal femoral nail antirotation (PFNA). Compared to DHS, PFN had shorter operative time and led to less intraoperative blood loss. However, DHS need less intraoperative fluoroscopy time than PFN. No difference was seen for the achievement of closed reduction. For risk of postoperative complications, no difference was seen between PFN and DHS for non-union, risk of implant failure and revision surgery. Conclusions PFN(A) resulted in a shorter operative time and less intraoperative blood loss compared to DHS. However, no difference was seen for postoperative complications. Trial registration PROSPERO: CRD42021239974. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03189-z.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, China.
| | - Yang Liu
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Erdem Aras Sezgin
- Department of Orthopaedics&Traumatology, Faculty of Medicine, Aksaray University, Aksaray, Turkey
| | - Šarūnas Tarasevičius
- Department of Orthopedics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Research Unit of Rheumatology, Department of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Deepak Bushan Raina
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Magnus Tägil
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
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The Effect of Humanized Nursing Intervention Guided by Computed Tomography Images on Elderly Patients Undergoing Anesthesia for Femur Intertrochanteric Fractures under Intelligent Reconstruction Algorithm. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5070518. [PMID: 35655860 PMCID: PMC9155936 DOI: 10.1155/2022/5070518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 11/18/2022]
Abstract
This research was aimed at analyzing the effect of humanized nursing intervention combined with computed tomography (CT) imaging in the surgical anesthesia of femur intertrochanteric fractures (FIF) in the elderly. An image reconstruction algorithm was proposed based on nonlocal mean (NLM) algorithm, which was named as ONLM, and its performance was analyzed. A total of 114 elderly patients with FIF were equally and randomly divided into a humanized nursing group (57 cases) and a routine nursing group (57 cases). They were performed with CT imaging scan based on the ONLM algorithm, and the clinical indicators of the two groups of patients were recorded. The root mean square error (RMSE) and mean absolute error (MAE) of the CT images constructed using the ONLM algorithm were significantly lower than those using NLM algorithm, edge filtering algorithm, and total variation model, while the peak signal-to-noise ratio (PSNR) was the opposite (P < 0.05). The operation time, hospitalization days, intraoperative blood loss, postoperative drainage, and anesthesia preparation time of patients in the humanized nursing group were significantly lower than those in the routine nursing group. The number of patients with excellent Harris scores in the humanized nursing group was higher than that in the routine nursing group, and the number of patients with poor Harris scores was lower (P < 0.05). The language pain score, facial pain score, and visual analog simulation (VAS) scores of patients in the humanized nursing group were significantly lower than those in the routine nursing group. The numbers of postoperative hip varus and fracture nonunion cases in the humanized nursing group were significantly more than those in the routine nursing group. In short, CT images constructed by the ONLM showed higher performance than those by the traditional algorithm. In addition, CT images constructed by ONLM combined with humanized nursing intervention could more effectively improve the cooperation of patients with surgical anesthesia, reduce surgical pain and fear of patients, improve the prognosis of patients, and lower the occurrence of adverse events.
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5
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Sas A, Sermon A, van Lenthe GH. Experimental validation of a voxel-based finite element model simulating femoroplasty of lytic lesions in the proximal femur. Sci Rep 2022; 12:7602. [PMID: 35534595 PMCID: PMC9085891 DOI: 10.1038/s41598-022-11667-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/15/2022] [Indexed: 11/09/2022] Open
Abstract
Femoroplasty is a procedure where bone cement is injected percutaneously into a weakened proximal femur. Uncertainty exists whether femoroplasty provides sufficient mechanical strengthening to prevent fractures in patients with femoral bone metastases. Finite element models are promising tools to evaluate the mechanical effectiveness of femoroplasty, but a thorough validation is required. This study validated a voxel-based finite element model against experimental data from eight pairs of human cadaver femurs with artificial metastatic lesions. One femur from each pair was left untreated, while the contralateral femur was augmented with bone cement. Finite element models accurately predicted the femoral strength in the defect (R2 = 0.96) and augmented (R2 = 0.93) femurs. The modelled surface strain distributions showed a good qualitative match with results from digital image correlation; yet, quantitatively, only moderate correlation coefficients were found for the defect (mean R2 = 0.78) and augmented (mean R2 = 0.76) femurs. This was attributed to the presence of vessel holes in the femurs and the jagged surface representation of our voxel-based models. Despite some inaccuracies in the surface measurements, the FE models accurately predicted the global bone strength and qualitative deformation behavior, both before and after femoroplasty. Hence, they can offer a useful biomechanical tool to assist clinicians in assessing the need for prophylactic augmentation in patients with metastatic bone disease, as well as in identifying suitable patients for femoroplasty.
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Affiliation(s)
- Amelie Sas
- Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Celestijnenlaan 300C, 3001, Leuven, Belgium
| | - An Sermon
- Department of Traumatology, University Hospitals Gasthuisberg, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - G Harry van Lenthe
- Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Celestijnenlaan 300C, 3001, Leuven, Belgium.
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6
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Kok J, Törnquist E, Raina DB, Le Cann S, Novak V, Širka A, Lidgren L, Grassi L, Isaksson H. Fracture behavior of a composite of bone and calcium sulfate/hydroxyapatite. J Mech Behav Biomed Mater 2022; 130:105201. [DOI: 10.1016/j.jmbbm.2022.105201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 03/19/2022] [Accepted: 03/25/2022] [Indexed: 12/12/2022]
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7
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Sezgin EA, Tor AT, Markevičiūtė V, Širka A, Tarasevičius Š, Raina DB, Liu Y, Isaksson H, Tägil M, Lidgren L. A combined fracture and mortality risk index useful for treatment stratification in hip fragility fractures. Jt Dis Relat Surg 2021; 32:583-589. [PMID: 34842088 PMCID: PMC8650669 DOI: 10.52312/jdrs.2021.382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/20/2021] [Indexed: 02/06/2023] Open
Abstract
Objectives
In this study, we aimed to assess the stratification ability of the Fracture and Mortality Risk Evaluation (FAME) index for reoperation, new fragility fracture, and mortality during one-year follow-up. Patients and methods
Between November 2018 and July 2019, a total of 94 consecutive hip fragility fracture patients from two centers (20 males, 74 females; mean age: 79.3±8.9 years; range, 57 to 100 years) were retrospectively analyzed. The patients were classified into high, intermediate, and low fracture and mortality risk groups according to the Fracture Risk Assessment Tool (FRAX) score and Sernbo score, respectively, as well as nine combined categories according to the FAME index. Hospital records were reviewed to identify re-fractures (reoperations, implant failure, new fragility fractures on any site) and mortality at one year following the FAME index classification. Results
Overall re-fracture and mortality rates were 20.2% and 33%, respectively. High fracture risk category (FRAX-H) was significantly associated with higher re-fracture (odds ratio [OR]: 2.9, 95% confidence interval [CI]: 1-8.2, p=0.037) and mortality rates compared to others (OR: 3.7, 95% CI: 1.5-9.3, p=0.003). The patients classified within the FRAX-H category (n=35) had different mortality rates according to their Sernbo classification; i.e., patients classified as low mortality risk (Sernbo-L) (n=17) had lower mortality rates compared to others in this group (n=18) (35.3% and 66.7%, respectively), indicating a low statistical significance (OR: 0.3, 95% CI: 0.1-1.1, p=0.063). Similarly, within patients classified in Sernbo-L category (n=64), those classified as high fracture risk (FRAX-H) (n=17) had significantly higher re-fracture rates compared to others in this group (n=47) (35.3% and 8.5%, respectively), (OR: 5.9; 95% CI: 1.4-24.5), (p=0.017). Multivariate logistic regression analyses adjusting for covariates (age, sex, length of hospital stay and BMI) yielded similar results. Conclusion
The FAME index appears to be a useful stratification tool for allocating patients in a randomized-controlled trial for augmentation of hip fragility fractures.
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Affiliation(s)
- Erdem Aras Sezgin
- Aksaray Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, 68200 Aksaray, Türkiye.
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8
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Prophylactic augmentation implants in the proximal femur for hip fracture prevention: An in silico investigation of simulated sideways fall impacts. J Mech Behav Biomed Mater 2021; 126:104957. [PMID: 34861519 DOI: 10.1016/j.jmbbm.2021.104957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 12/26/2022]
Abstract
Femoral fractures from sideways falls in the elderly are associated with significant rates of morbidity and mortality. Approaches to prevent these catastrophic injuries include pharmacological treatments, which have limited efficacy. Prophylactic femoral augmentation systems are a promising alternative that are gaining prominence by addressing the most debilitating osteoporosis-related fracture. We have developed finite element models (FEMs) of a novel experimental sideways fall simulator for cadavers. By virtue of the range of specimens and injury outcomes, these FEMs are well-suited to the evaluation of such implants. The purpose of this study was to use the FEMs to evaluate the mechanical effectiveness of three different prophylactic femoral augmentation systems. Models of the Y-Strut® (Hyprevention®, Pessac, France), Gamma Nail® (Stryker, Kalamazoo, USA), and a simple lag screw femoral fracture implant systems were placed into FEMs of five cadaveric pelvis-femur constructs embedded in a soft tissue surrogate, which were then subject to simulated sideways falls at seven impact velocities. Femur-only FEMs were also evaluated. Peak impact forces and peak acetabular forces were examined, and failure was evaluated using a strain-based criterion. We found that the femoral augmentation systems increased the peak forces prior to fracture, but were unable to prevent fracture for severe impacts. The Gamma Nail® system consistently produced the largest strength increases relative to the unaugmented femur for all five specimens in both the pendulum-drop FEMs and the femur-only simulations. In some cases, the same implant appeared to cause fractures in the acetabulum. The femur-only FEMs showed larger force increases than the pendulum-drop simulations, which suggests that the results of the femur-only simulations may not represent sideways falls as accurately as the soft tissue-embedded pendulum-drop simulations. The results from this study demonstrate the ability to simulate a high energy phenomenon and the effect of implants in an in silico environment. The results also suggest that implants could increase the force applied to the proximal femur during impact. Fracture outcomes from the tested implants can be used to inform the design of future devices, which reaffirms the value of modelling with biofidelic considerations in the implant design process. To the authors' knowledge, this is the first paper to use more complex biofidelic FEMs to assess prophylactic femoral augmentation methods.
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Farvardin A, Bakhtiarinejad M, Murphy RJ, Basafa E, Khanuja H, Oni JK, Armand M. A biomechanically-guided planning and execution paradigm for osteoporotic hip augmentation: Experimental evaluation of the biomechanics and temperature-rise. Clin Biomech (Bristol, Avon) 2021; 87:105392. [PMID: 34174676 PMCID: PMC8550980 DOI: 10.1016/j.clinbiomech.2021.105392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Augmentation of the proximal femur with bone cement (femoroplasty) has been identified as a potential preventive approach to reduce the risk of fracture. Femoroplasty, however, is associated with a risk of thermal damage as well as the leakage of bone cement or blockage of blood supply when large volumes of cement are introduced inside the bone. METHODS Six pairs of cadaveric femora were augmented using a newly proposed planning paradigm and an in-house navigation system to control the location and volume of the injected cement. To evaluate the risk of thermal damage, we recorded the peak temperature of bone at three regions of interest as well as the exposure time for temperature rise of 8 °C, 10 °C, and 12 °C in these regions. Augmentation was followed by mechanical testing to failure resembling a sideway fall on the greater trochanter. FINDINGS Results of the fracture tests correlated with those of simulations for the yield load (R2 = 0.77) and showed that femoroplasty can significantly improve the yield load (42%, P < 0.001) and yield energy (139%, P = 0.062) of the specimens. Meanwhile, temperature recordings of the bone surface showed that the areas close to the greater trochanter will be exposed to more critical temperature rise than the trochanteric crest and femoral neck areas. INTERPRETATION The new planning paradigm offers a more efficient injection strategy with injection volume of 9.1 ml on average. Meanwhile, temperature recordings of bone surfaces suggest that risk of thermal necrosis remains as a concern with femoroplasty using Polymethylmethacrylate.
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Affiliation(s)
- Amirhossein Farvardin
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA.
| | - Mahsan Bakhtiarinejad
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Ryan J Murphy
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Ehsan Basafa
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Harpal Khanuja
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Juluis K Oni
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Mehran Armand
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Rd, Laurel, MD 20723, USA; Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
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10
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Kok J, Širka A, Liu Y, Tarasevičius Š, Belickas J, Tägil M, Lidgren L, Isaksson H, Raina DB. Augmenting a dynamic hip screw with a calcium sulfate/hydroxyapatite biomaterial. Med Eng Phys 2021; 92:102-109. [PMID: 34167704 DOI: 10.1016/j.medengphy.2021.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/30/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022]
Abstract
Internal fixation failure in hip fractures can lead to reoperation. Calcium sulfate/hydroxyapatite (CaS/HA) is a biomaterial that can be used for augmenting fracture fixation. We aimed to determine whether an injection of 2 ml CaS/HA increases the fixation of a dynamic hip screw inserted in synthetic and human trabecular bone. The study consists of two parts: 1) synthetic bone blocks (n = 74), with three subgroups: empty (cannulated screw, no injection), cannulated, and fenestrated; and 2) osteoporotic human femoral heads (n = 29), with the same subgroups. The heads were imaged using µCT. Bone volume fraction, insertion angle, and head diameter were measured. Pullout tests were performed and peak force, stiffness, and work were measured. The fenestrated group showed increases in pullout strength compared to no injection in the synthetic blocks. The cannulated group showed a higher pullout strength in low-density blocks. In the femoral heads, the variation was larger and there were no significant differences between groups. The bone volume fraction correlated with the peak force and work, and the insertion angle correlated with the stiffness. CaS/HA can improve the fixation of a dynamic hip screw. For clinical use, spreading of the material around the threads of the screw must be ensured.
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Affiliation(s)
- Joeri Kok
- Department of Biomedical Engineering, Lund University, Box 118, 22100 Lund, Sweden.
| | - Aurimas Širka
- Department of Orthopedics and Traumatology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu ave.2, Kaunas, Lithuania.
| | - Yang Liu
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Šarūnas Tarasevičius
- Department of Orthopedics and Traumatology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu ave.2, Kaunas, Lithuania.
| | - Juozas Belickas
- Department of Orthopedics and Traumatology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu ave.2, Kaunas, Lithuania.
| | - Magnus Tägil
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Lars Lidgren
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Box 118, 22100 Lund, Sweden; Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Deepak Bushan Raina
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
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11
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Magri AMP, Parisi JR, de Andrade ALM, Rennó ACM. Bone substitutes and photobiomodulation in bone regeneration: A systematic review in animal experimental studies. J Biomed Mater Res A 2021; 109:1765-1775. [PMID: 33733598 DOI: 10.1002/jbm.a.37170] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 11/08/2022]
Abstract
In general, bone fractures are able of healing by itself. However, in critical situations such as large bone defects, poor blood supply or even infections, the biological capacity of repair can be impaired, resulting in a delay of the consolidation process or even in non-union fractures. Thus, technologies able of improving the process of bone regeneration are of high demand. In this context, ceramic biomaterials-based bone substitutes and photobiomodulation (PBM) have been emerging as promising alternatives. Thus, the present study performed a systematic review targeting to analyze studies in the literature which investigated the effects of the association of ceramic based bone substitutes and PBM in the process of bone healing using animal models of bone defects. The search was conducted from March and April of 2019 in PubMed, Web of Science and Scopus databases. After the eligibility analyses, 16 studies were included in this review. The results showed that the most common material used was hydroxyapatite (HA) followed by Biosilicate associated with infrared PBM. Furthermore, 75% of the studies demonstrated positive effects to stimulate bone regeneration from association of ceramic biomaterials and PBM. All studies used low-level laser therapy (LLLT) device and the most studies used LLLT infrared. The evidence synthesis was moderate for all experimental studies for the variable histological analysis demonstrating the efficacy of techniques on the process of bone repair stimulation. In conclusion, this review demonstrates that the association of ceramic biomaterials and PBM presented positive effects for bone repair in experimental models of bone defects.
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Affiliation(s)
- Angela Maria Paiva Magri
- Department of Biosciences, Federal University of São Paulo (UNIFESP), Santos, São Paulo, Brazil.,University Center of the Guaxupé Education Foundation (UNIFEG), Guaxupé, Minas Gerais, Brazil
| | - Júlia Risso Parisi
- Department of Biosciences, Federal University of São Paulo (UNIFESP), Santos, São Paulo, Brazil.,Department of Physical Therapy, Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil
| | | | - Ana Claudia Muniz Rennó
- Department of Biosciences, Federal University of São Paulo (UNIFESP), Santos, São Paulo, Brazil.,Department of Physical Therapy, Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil
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12
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Hockett SA, Sherrill JT, Self M, Mears SC, Barnes CL, Mannen EM. Augmentation of core decompression with synthetic bone graft does not improve mechanical properties of the proximal femur. J Mech Behav Biomed Mater 2020; 115:104263. [PMID: 33385950 DOI: 10.1016/j.jmbbm.2020.104263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/25/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
Core decompression is a minimally invasive surgical technique used to treat patients with avascular necrosis of the femoral head. The procedure requires an entry hole in the lateral cortex of the femur which potentially leaves patients susceptible to subtrochanteric fractures. The purpose of this study was to determine if filling the core decompression tract with synthetic bone-graft mechanically strengthens the proximal femur. Twenty composite synthetic femurs underwent a core decompression procedure; ten were augmented with synthetic bone-graft (PRO-DENSE™, Wright Medical) and ten femurs were left unfilled as a control group. Compressive testing to failure was performed using a mechanical testing machine. Stiffness, fracture load, and toughness did not significantly differ between groups. More subtrochanteric fractures were seen in the control group (6 of 10 specimens) compared to the bone-graft augmented group (2 of 10 specimens). In conclusion, augmentation of a core decompression tract does not improve mechanical properties in a synthetic bone model but may be protective of subtrochanteric fracture.
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Affiliation(s)
- Samuel A Hockett
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Engineering and Physics, Harding University, Searcy, AR, USA
| | - John T Sherrill
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Micah Self
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Erin M Mannen
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Mechanical and Biomedical Engineering Department, Boise State University, Boise, ID, USA.
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13
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Sas A, Helgason B, Ferguson SJ, van Lenthe GH. Mechanical and morphological characterization of PMMA/bone composites in human femoral heads. J Mech Behav Biomed Mater 2020; 115:104247. [PMID: 33310683 DOI: 10.1016/j.jmbbm.2020.104247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/23/2020] [Accepted: 11/28/2020] [Indexed: 11/16/2022]
Abstract
PMMA bone cement has gained an important place in a variety of orthopaedic applications in the femur. However, appropriate data on the mechanical properties of bone-cement composites from the human femur are lacking. Therefore, the goal of this study was to determine the morphological and quasi-static compressive properties of proximal femoral bone-cement composites. Thirty trabecular bone specimens were extracted from fifteen pairs of human femoral heads using specimen-specific cutting guides to ensure an accurate alignment with the main trabecular direction (MTD). One specimen from each pair was augmented with PMMA bone cement, while the other one was left untreated. Specimens were scanned with μCT to determine morphological parameters and tested in quasi-static compression until failure. We found that the long axis of the specimens was highly aligned with the MTD (mean error < 5°). A higher compressive modulus and ultimate strength were observed for the bone-cement composite specimens (E = 5.7 ± 0.4 GPa; σu = 77.9 ± 5.1 MPa) compared to the bone only specimens (E = 2.9 ± 0.7 GPa; σu = 19.0 ± 5.8 MPa). Furthermore, the composites had a higher modulus, but lower strength than cement itself (E = 5.0 ± 0.3 GPa; σu = 85.9 ± 2.7 MPa) and the composite modulus was significantly correlated with the bone volume fraction (BV/TV). These results are in contrast to previous findings on human vertebral bone, where the composite was more compliant than cement and no correlation was found between BV/TV and the composite modulus. Thus, properties of bone-cement composites cannot simply be applied across different anatomical sites; the site-specific differences in bone density and trabecular alignment should be taken into account. Collectively, the present results suggest that at low BV/TV, cement dominates the composite properties, while at high BV/TV, the contribution of bone becomes apparent, revealing a positive relationship between BV/TV and the on-axis modulus.
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Affiliation(s)
- Amelie Sas
- Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | | | | | - G Harry van Lenthe
- Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium.
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14
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Raina DB, Širka A, Qayoom I, Teotia AK, Liu Y, Tarasevicius S, Tanner KE, Isaksson H, Kumar A, Tägil M, Lidgren L. Long-Term Response to a Bioactive Biphasic Biomaterial in the Femoral Neck of Osteoporotic Rats. Tissue Eng Part A 2020; 26:1042-1051. [PMID: 32242474 PMCID: PMC7580608 DOI: 10.1089/ten.tea.2020.0018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/27/2020] [Indexed: 11/13/2022] Open
Abstract
Osteoporosis often leads to fragility fractures of the hip, resulting in impaired quality of life and increased mortality. Augmenting the proximal femur could be an attractive option for prevention of fracture or fixation device failure. We describe a tissue engineering based strategy to enhance long-term bone formation in the femoral neck of osteoporotic rats by locally delivering bioactive molecules; recombinant human bone morphogenic protein-2 (rhBMP-2), and zoledronic acid (ZA) by using a calcium sulfate/hydroxyapatite (CaS/HA) biomaterial. A defect was created by reaming the femoral neck canal of osteoporotic (OVX) rats and they were treated as follows: G1. Empty, G2. CaS/HA, G3. CaS/HA+Systemic ZA, G4. CaS/HA+Local ZA, and G5. CaS/HA+Local ZA+rhBMP-2. Bone formation was evaluated 6 months after treatment. Further, radioactively labeled 14C-ZA was used to study the bioavailability of ZA at the defect location, which was determined by using scintillation counting. Micro-CT indicated significantly higher bone volume in groups G4 and G5 compared with the other treatment groups. This was confirmed qualitatively by histological assessment. Addition of rhBMP-2 gave no additional benefit in this model. Local delivery of ZA performed better than systemic administration of ZA. Mechanical testing showed no differences between the groups, likely reflecting that the addition of bioactive molecules had limited effect on cortical bone or the choice of mechanical testing setup was not optimal. Scintillation counting revealed higher amounts of 14C-ZA present in the treated leg of G4 compared with its contralateral control and compared with G3, indicating that local ZA delivery can be used to achieve high local concentrations without causing a systemic effect. This long-term study shows that local delivery of ZA using a CaS/HA carrier can regenerate cancellous bone in the femoral neck canal and has clear implications for enhancing implant integration and fixation in fragile bone.
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Affiliation(s)
- Deepak Bushan Raina
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Aurimas Širka
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Irfan Qayoom
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Arun Kumar Teotia
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Yang Liu
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Sarunas Tarasevicius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kathleen Elizabeth Tanner
- Queen Mary University of London, School of Engineering and Materials Science and Institute of Bioengineering, London, United Kingdom
| | - Hanna Isaksson
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Ashok Kumar
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Magnus Tägil
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
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15
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Sas A, Tanck E, Sermon A, van Lenthe GH. Finite element models for fracture prevention in patients with metastatic bone disease. A literature review. Bone Rep 2020; 12:100286. [PMID: 32551337 PMCID: PMC7292864 DOI: 10.1016/j.bonr.2020.100286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/04/2020] [Accepted: 05/25/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with bone metastases have an increased risk to sustain a pathological fracture as lytic metastatic lesions damage and weaken the bone. In order to prevent fractures, prophylactic treatment is advised for patients with a high fracture risk. Mechanical stabilization of the femur can be provided through femoroplasty, a minimally invasive procedure where bone cement is injected into the lesion, or through internal fixation with intra- or extramedullary implants. Clinicians face the task of determining whether or not prophylactic treatment is required and which treatment would be the most optimal. Finite element (FE) models are promising tools that could support this decision process. The aim of this paper is to provide an overview of the state-of-the-art in FE modeling for the treatment decision of metastatic bone lesions in the femur. First, we will summarize the clinical and mechanical results of femoroplasty as a prophylactic treatment method. Secondly, current FE models for fracture risk assessment of metastatic femurs will be reviewed and the remaining challenges for clinical implementation will be discussed. Thirdly, we will elaborate on the simulation of femoroplasty in FE models and discuss future opportunities. Femoroplasty has already proven to effectively relieve pain and improve functionality, but there remains uncertainty whether it provides sufficient mechanical strengthening to prevent pathological fractures. FE models could help to select appropriate candidates for whom femoroplasty provides sufficient increase in strength and to further improve the mechanical benefit by optimizing the locations for cement augmentation.
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Affiliation(s)
- Amelie Sas
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - An Sermon
- Department of Traumatology, University Hospitals Gasthuisberg, Leuven, Belgium and Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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16
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Combined fracture and mortality risk evaluation for stratifying treatment in hip fracture patients: A feasibility study. Jt Dis Relat Surg 2020; 31:163-168. [PMID: 32315279 PMCID: PMC7489183 DOI: 10.5606/ehc.2020.73458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/18/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES This study aims to test the feasibility of the Fracture and Mortality Risk Evaluation (FAME) Index. PATIENTS AND METHODS Two academic centers in Lithuania and Turkey participated in this retrospective study conducted between November 2018 and July 2019. A total of 100 consecutive patients (22 males, 78 females; mean age 78.9 years; range, 45 to 100 years) with low energy proximal femur fractures admitted for surgery were included in the study. Fracture Risk Assessment tool (FRAX) and the Sernbo scores were calculated and patients were classified into one of the nine subcategories of the FAME Index. RESULTS Demographics and FAME Index classifications were similar between centers. Patients with high risk of fracture and low risk of mortality accounted for 18% of all patients, which is the FAME Index subcategory to theoretically benefit from cancellous bone augmentation during internal fixation of a fragility hip fracture the most. CONCLUSION The FAME Index was successfully applied in clinical emergency setting utilizing a simple form, and demonstrated promising potential in stratification of hip fractures most suitable for screw and device augmentation. Larger studies with at least one-year of follow-up are warranted to verify the validity of FAME Index.
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17
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Sas A, Van Camp D, Lauwers B, Sermon A, van Lenthe GH. Cement augmentation of metastatic lesions in the proximal femur can improve bone strength. J Mech Behav Biomed Mater 2020; 104:103648. [DOI: 10.1016/j.jmbbm.2020.103648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/15/2020] [Accepted: 01/18/2020] [Indexed: 12/16/2022]
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