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Poulsen M, Stødle AH, Nordsletten L, Röhrl SM. Does temporary bridge plate fixation preserve joint motion after an unstable Lisfranc injury? Foot Ankle Surg 2023; 29:151-157. [PMID: 36529589 DOI: 10.1016/j.fas.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recently, temporary bridge plate fixation has gained popularity in the treatment of unstable Lisfranc injuries. The technique aims to reduce the risk of posttraumatic osteoarthritis, and after plate removal, the goal is to regain joint mobility. Here we explore marker-based radiostereometric analysis (RSA) to measure motion in the 1st tarsometatarsal (TMT) joint and asses the radiological outcome in patients treated with this surgical technique. METHOD Ten patients with an unstable Lisfranc injury were included. All were treated with a dorsal bridge plate over the 1st TMT joint and primary arthrodesis of the 2nd and 3rd TMT joints. The plate was removed four months postoperatively. Non- and weight-bearing RSA images were obtained one and five years postinjury to assess joint mobility and signs of osteoarthritis. RESULTS Detectable 1st TMT joint motion was observed in 2/10 patients after one year, and 6/9 patients after five years. At the final follow-up, mean 1st TMT dorsiflexion was 2.0°. Radiologically, the incidence of posttraumatic osteoarthritis was present in 4/10 patients after one year, and 5/9 patients after five years. All patients had observed TMT joint stability throughout the follow-up period. CONCLUSION Preservation of joint motion can be achieved with a temporary bridge plate fixation over the 1st TMT joint. TYPE OF STUDY/LEVEL OF EVIDENCE Prospective cohort study/Therapeutically level IV.
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Affiliation(s)
- Magnus Poulsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway.
| | - Are H Stødle
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Lars Nordsletten
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Stephan M Röhrl
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
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Rammelt S, Murillo PAC. Lisfranc Arthrodesis in Posttraumatic Chronic Injuries. Foot Ankle Clin 2022; 27:745-767. [PMID: 36368795 DOI: 10.1016/j.fcl.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic injuries at the tarsometatarsal joint represent a wide array of painful malunions ranging from isolated instability to complex three-dimensional deformities with rapid development of posttraumatic arthritis. Deformity correction and arthrodesis of the symptomatic joints leads to significant pain reduction and functional improvement provided that realignment of the anatomic axes is achieved. Arthrodesis should be limited to the first to third tarsometatarsal joints, whereas interposition arthroplasty is preferred for symptomatic arthritis of the fourth to fifth tarsometatarsal joints. For complex deformities and instability, the intercuneiform and naviculocuneiform joints may need to be included into corrective fusion.
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Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl-Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Pablo Andrés Cárdenas Murillo
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl-Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany
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Engelmann EWM, Roelofs A, Posthuma J, Schepers T. Evaluation of Functional Outcome and Complications in Bridge Plating Compared to Transarticular Screws for Lisfranc Injuries: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2022; 61:1267-1274. [PMID: 35459613 DOI: 10.1053/j.jfas.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023]
Abstract
The optimal treatment strategy of Lisfranc injury is still in debate. This study aimed to compare the functional outcome and complications of dorsal bridge plating (BP) and transarticular screws (TAS). A systematic review and meta-analysis of the present literature was performed. PubMed, EMBASE, and Cochrane databases were searched using set search criteria and date range January 2000 to July 26, 2021. Randomized controlled trials (RCTs) and observational comparative studies concerning the outcome of dorsal BP and TAS for the fixation of Lisfranc injuries were eligible for inclusion. Random effect models were used to analyze pooled data. Forest plots using 95% confidence intervals (CI) were created to illustrate mean differences and odds ratios. Four observational studies were eligible for inclusion, including 111 patients in the BP group and 87 patients in the TAS group. American Orthopaedic Foot & Ankle Society (AOFAS) score was significantly higher in the BP group (mean difference 7.08, 95% CI 1.50-12.66, p = .01). Osteoarthritis was significantly less common in the BP group compared to the TAS group (odds ratio 0.45, 95% CI 0.22-0.94, p = .03). No significant difference was found between the groups in terms of postoperative infection, hardware removal, chronic pain, and secondary arthrodesis. Dorsal bridge plating of fractures in the Lisfranc joint may lead to better functional outcome and a lower incidence of post-traumatic arthritis when compared to transarticular screws. A larger body of high-quality evidence is required to independently analyze the severity of fractures in the different columns involved and subsequent outcomes of operative management.
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Affiliation(s)
| | - Anne Roelofs
- Trauma Unit, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Jelle Posthuma
- Trauma Unit, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Tim Schepers
- Trauma Unit, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
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Stødle AH, Hvaal KH, Brøgger H, Madsen JE, Husebye EE. Outcome after nonoperative treatment of stable Lisfranc injuries. A prospective cohort study. Foot Ankle Surg 2022; 28:245-250. [PMID: 33832813 DOI: 10.1016/j.fas.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/15/2021] [Accepted: 03/23/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the outcome after nondisplaced and stable Lisfranc injuries. METHODS 26 patients with injuries to the Lisfranc joint complex detected on CT scans, but without displacement were tested to be stable using a fluoroscopic stress test. The patients were immobilized in a non-weightbearing short leg cast for 6 weeks. The final follow-up was 55 (IQR 53-60) months after injury. RESULTS All the Lisfranc injuries were confirmed to be stable on follow-up weightbearing radiographs at a minimum of 3 months after injury. Median American Foot and Ankle Society (AOFAS) midfoot score at 1-year follow-up was 89 (IQR 84-97) and at final follow-up 100 (IQR 90-100); The AOFAS score continued to improve after 1-year (P=.005). The median visual analog scale (VAS) for pain was 0 (IQR 0-0) at the final follow-up. One patient had radiological signs of osteoarthritis at 1-year follow-up. CONCLUSION Stable Lisfranc injuries treated nonoperatively had an excellent outcome in this study with a median follow-up of 55 months. The AOFAS score continued to improve after 1 year.
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Affiliation(s)
- Are H Stødle
- Division of Orthopaedic Surgery, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway.
| | - Kjetil H Hvaal
- Division of Orthopaedic Surgery, Oslo University Hospital, Norway
| | - Helga Brøgger
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway
| | - Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway
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Bušková K, Bartoníček J, Rammelt S. Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202110000-00004. [PMID: 34673663 DOI: 10.2106/jbjs.rvw.21.00010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
» Fractures of the proximal fifth metatarsal (PFMT) are one of the most common foot injuries, accounting for 61% to 78% of all foot fractures, but full consensus on their classification, diagnosis, and treatment has not yet been reached. » The most commonly accepted classification is that of Lawrence and Botte, who divided the location of PFMT fractures into 3 zones with respect to their healing potential. » Avulsion fractures of the tuberosity of the base (zone 1) generally heal well, and nonoperative treatment is commonly recommended. » Internal fixation may be considered for displaced fractures that extend into the fourth-fifth intermetatarsal joint (zone 2) as well as for nondisplaced fractures in athletes or high-demand patients, with the aims of reducing the healing time and expediting return to sport or work. » Stress fractures of the proximal diaphysis (zone 3) are preferably treated operatively, particularly in the presence of signs of delayed union. With nonoperative treatment, supportive measures such as ultrasonography or external/extracorporeal shockwave therapy have been demonstrated to have limited potential for the enhancement of fracture-healing.
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Affiliation(s)
- Kamila Bušková
- Department of Orthopaedics, First Faculty of Medicine Charles University and Military University Hospital Prague, Prague, Czech Republic
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine Charles University and Military University Hospital Prague, Prague, Czech Republic
- Department of Anatomy, First Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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Ponkilainen VT, Partio N, Salonen EE, Laine HJ, Mäenpää HM, Mattila VM, Haapasalo HH. Outcomes after nonoperatively treated non-displaced Lisfranc injury: a retrospective case series of 55 patients. Arch Orthop Trauma Surg 2021; 141:1311-1317. [PMID: 32960309 PMCID: PMC8295070 DOI: 10.1007/s00402-020-03599-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 09/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current knowledge of the role of the nonoperative treatment of Lisfranc injuries is based on a few retrospective case series. Hence, consensus on which patients can be treated nonoperatively does not exist. The aim of this study was to investigate outcomes after nonoperative treatment of Lisfranc injuries. METHODS In this study, patients were collected by recruiting all computer tomography-confirmed Lisfranc injuries treated during a 5-year period at a major trauma hospital. Between 2 and 6 years after suffering the injury, patients completed the visual analogue scale foot and ankle questionnaire. RESULTS In total, 55 patients returned adequately completed questionnaires and were included in the study. Of those, 22 patients had avulsion fractures and 33 had simple non-displaced intra-articular fractures. Of these patients, 30 (55%) scored over 90 points in both the pain and function subscales of the VAS-FA, and 35 (64%) scored over 90 points overall. In addition, three (5%) patients scored under 60 points in both the pain and function subscales of the VAS-FA, and four (7%) scored under 60 points overall. Only one patient with avulsion fractures underwent secondary surgery. CONCLUSION Nonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of our study support the view that avulsion and simple intra-articular fractures with < 2 mm of displacement can be treated nonoperatively with high functional outcomes. The results of nonoperative and operative treatment should be compared in a prospective randomized controlled study setting in future studies. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Ville T Ponkilainen
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland.
- University of Tampere, School of Medicine, 33520, Tampere, Finland.
| | - Nikke Partio
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
| | - Essi E Salonen
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
| | | | - Heikki M Mäenpää
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
| | - Ville M Mattila
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
- COXA Hospital for Joint Replacement, Biokatu 6, 33520, Tampere, Finland
| | - Heidi H Haapasalo
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
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Joannas G, Filippi J. How to Identify Unstable Lisfranc Injuries? Review of Diagnostic Strategies and Algorithm Proposal. Foot Ankle Clin 2020; 25:697-710. [PMID: 33543724 DOI: 10.1016/j.fcl.2020.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
"Misdiagnosed Lisfranc injuries can be as high as 50%, leading to chronic pain, functional impairment, and posttraumatic arthritis. Subtle or incomplete lesions are the most problematic group for an adequate diagnosis. Conventional non-weight-bearing radiographs can overlook up to 30% of unstable cases. Abduction stress radiographs and anteroposterior monopodial comparative weight-bearing radiographic views are very useful to identify instability. Computed tomography gives detailed information about fracture patterns and comminution. MRI can predict instability but it is expensive and not readily available in the acute setting."
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Affiliation(s)
- German Joannas
- Foot and Ankle Division "CEPP", Instituto Dupuytren, Av. Belgrano 3402, Ciudad Autónoma de Buenos Aires CP 1078, Argentina; Foot and Ankle Division, Orthopaedics Department, Centro Artroscópico Jorge Batista SA, Pueyrredón 2446 1er piso, Ciudad Autónoma de Buenos Aires (CABA) CP 1119, Argentina; Instituto Barrancas, Hipolito Yrigoyen 902, Quilmes, CP 1878, Buenos Aires, Argentina
| | - Jorge Filippi
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes, Estoril 450, Las Condes, Santiago 7591047, Chile; Department of Orthopedic Surgery, Foot and Ankle Unit, Hospital del Trabajador, Ramon Carnicer 185, Providencia, Santiago 7501239, Chile.
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Engelmann EWM, Rammelt S, Schepers T. Fractures of the Cuboid Bone: A Critical Analysis Review. JBJS Rev 2020; 8:e0173. [PMID: 32304497 DOI: 10.2106/jbjs.rvw.19.00173] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cuboid fractures rarely occur in isolation, and a high index of suspicion for the presence of Chopart, Lisfranc, or complex midfoot injuries should be raised. The cuboid is the cornerstone of the lateral column and acts as a bridge between the lateral column and the transverse plantar arch. Its most important role is maintenance of lateral column length and associated motion in the midtarsal and tarsometatarsal joints. To date, a classification system that is validated for clinical practice (i.e., guidance for management and prediction of outcome and prognosis) is lacking. The principles of operative treatment are restoration of articular congruity, lateral column length, and stability of the Chopart and Lisfranc joints. Nonoperative management is reserved for nondisplaced articular fractures (<1 mm) or avulsion fractures that are caused by low-energy trauma.
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Affiliation(s)
- Esmee W M Engelmann
- Trauma Unit, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Stefan Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Tim Schepers
- Trauma Unit, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries. Arch Orthop Trauma Surg 2020; 140:1423-1429. [PMID: 32140830 PMCID: PMC7505866 DOI: 10.1007/s00402-020-03391-w] [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: 10/25/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury. METHODS One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents. RESULTS Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003). CONCLUSIONS Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle. LEVEL OF EVIDENCE III.
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Mason L, Jayatilaka MLT, Fisher A, Fisher L, Swanton E, Molloy A. Anatomy of the Lateral Plantar Ligaments of the Transverse Metatarsal Arch. Foot Ankle Int 2020; 41:109-114. [PMID: 31502882 DOI: 10.1177/1071100719873971] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While the anatomy of the Lisfranc complex is well understood, the lateral tarsometatarsal ligamentous structures, in contrast, are less well studied. Our aim in this study was to identify an anatomical explanation as to why the second to fifth metatarsals function as a unit in homolateral and divergent midfoot injuries. METHODS Eleven cadaveric lower limbs, preserved in formaldehyde, were examined at the University of Liverpool Human Anatomy and Resource Centre. Each of the lower limbs was dissected to identify the plantar aspect of the transverse metatarsal arch. RESULTS On removal of the long plantar ligament, the peroneal longus tendon was visible, as was its insertion onto the first metatarsal base. A lateral Lisfranc ligament (which was a transverse suspensory metatarsal ligament) spanned between the bases of the second and fifth metatarsals in all specimens with an average length of 33.7 mm and width of 4.6 mm. This ligament has not previously been described. It was noted that in all specimens, the long plantar ligament blended with the lateral Lisfranc ligament. In addition to the lateral Lisfranc ligament, separate intermetatarsal ligaments were identifiable connecting each metatarsal. The long plantar ligament provided a connection through the lateral Lisfranc ligament connecting the transverse and longitudinal arches of the foot. CONCLUSION We found a plantar ligament that provided connection through the long plantar ligament of both the transverse and the longitudinal arches. It spanned from the second to the fifth metatarsal, which we believe may explain that in some cases, lateral instability can be overcome when the middle column is stabilized. CLINICAL RELEVANCE We suspect that in the majority of homolateral and divergent types of tarsometatarsal injuries that the lateral Lisfranc ligament remains intact and thus it has significant clinical ramifications.
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Affiliation(s)
- Lyndon Mason
- Aintree University Hospital, Liverpool, UK.,Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
| | | | - Andrew Fisher
- Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
| | - Lauren Fisher
- Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
| | | | - Andrew Molloy
- Aintree University Hospital, Liverpool, UK.,Human Anatomy and Resource Centre, University of Liverpool, Liverpool, UK
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