1
|
Dragisic MV, Hanlon MK, Merrell GA. Mapping Origins of Tendons on the Medial Epicondyle to Improve Treatment of Medial Epicondylitis: Anatomical Study. J Hand Surg Am 2024:S0363-5023(24)00200-4. [PMID: 38934996 DOI: 10.1016/j.jhsa.2024.04.008] [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: 10/14/2023] [Revised: 03/28/2024] [Accepted: 04/17/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Medial epicondylitis is a tendinosis found commonly in throwing and golfing athletes. Although there are choices for nonsurgical treatments, when these fail, surgical intervention can be considered. When surgical treatment is performed, the objective is to debride the diseased tissue from the epicondyle. The purpose of this study was to clarify the locations and size of the common flexor tendons and medial collateral ligament (MCL) relative to each other and to the posterior ridge of the medial epicondyle. METHODS The common flexor tendons and MCL were dissected and reflected their origin on the medial epicondyle in six cadaver elbows. Measurements were taken from the posterior and distal ridges of the medial epicondyle with respect to the humerus. Each origin was also measured for its height and width. RESULTS The flexor carpi ulnaris origin starts at a mean of 4.2 mm from the posterior ridge of the medial epicondyle and extends anteriorly an average of 4.8 mm. The flexor carpi radialis starts at a mean of 4.2 mm from the posterior ridge and extends anteriorly an average of 7.4 mm. The pronator teres begins at a mean of 4.6 mm from the posterior ridge and extends an average of 5.7 mm anteriorly. The MCL starts at an average of 10.4 mm from the posterior ridge and extends 5.2 mm anteriorly. CONCLUSIONS The measurements found have allowed the creation of a map of the specific common flexor tendon origins and their sizes on the medial epicondyle, as well as their position relative to the MCL. CLINICAL RELEVANCE A surgeon may debride 1 cm anteriorly from the posterior ridge of the medial epicondyle to safely address the affected tissues and ensure the safety and integrity of the MCL.
Collapse
|
2
|
Zhang C, Ma JT, Wang WS. Arthroscopic Medial Bi-portal Extra-articular Debridement for Recalcitrant Medial Epicondylitis. Arthrosc Tech 2024; 13:102876. [PMID: 38584625 PMCID: PMC10995642 DOI: 10.1016/j.eats.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/01/2023] [Indexed: 04/09/2024] Open
Abstract
Medial epicondylitis, or golfer's elbow, is characterized by pain and tenderness at the tendon insertion points of the pronator teres and flexor carpi radialis. Conservative treatment is sufficient for most patients, whereas surgical treatment is the best choice for intractable medial epicondylitis. With open surgery or arthroscopic surgery, good clinical results have been reported. However, there is still no consensus on which surgical technique is more ideal. We describe our technique of arthroscopic medial bi-portal extra-articular debridement, which is a safe and effective technique that allows more accurate debridement and maximum protection of the ulnar nerve while reducing surgical scars, relieving postoperative pain, reducing the probability of elbow infection and ankylosis, and shortening the recovery time.
Collapse
Affiliation(s)
- Chuan Zhang
- Shoulder and Elbow Surgery Center, Luoyang Orthopedic Hospital of Henan Province & Orthopedic Hospital of Henan Province, Zhengzhou, China
| | - Jiang-Tao Ma
- Shoulder and Elbow Surgery Center, Luoyang Orthopedic Hospital of Henan Province & Orthopedic Hospital of Henan Province, Zhengzhou, China
| | - Wen-Sheng Wang
- Shoulder and Elbow Surgery Center, Luoyang Orthopedic Hospital of Henan Province & Orthopedic Hospital of Henan Province, Zhengzhou, China
| |
Collapse
|
3
|
Otoshi K, Kato K, Kaga T. Surgical management for refractory medial epicondylitis based on the anatomical characteristics of flexor pronator origin: surgical results of 8 cases and review of the literature. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:70-74. [PMID: 38323201 PMCID: PMC10840570 DOI: 10.1016/j.xrrt.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Background This case series aimed to introduce surgical management for refractory medial epicondylitis based on the anatomical characteristics of the flexor pronator origin and present the surgical results. Methods Ten elbows from 8 patients (2 males and 6 females; mean age 50.2 years) were included in this case series. All patients underwent resection of the degenerated anterior common tendon and repair using suture anchors. Ulnar neuritis was observed in 9 elbows of 7 patients who underwent the relevant additional surgery. Results Medial elbow pain was resolved in all patients, and pain provocation tests (wrist flexion test and forearm pronation test) were negative postoperatively. The mean Patient-Rated Elbow Evaluation (Japanese version) score was significantly improved from 79.6 ± 7.7 (range, 64.3-92) preoperatively to 8.4 ± 15.2 (range, 0-50) at the final follow-up. Conclusion Angiofibroblastic tendinosis of the anterior common tendon might be an essential pathology of medial epicondylitis, and anterior common tendon resection and repair could be the most appropriate treatment for medial epicondylitis.
Collapse
Affiliation(s)
- Kenichi Otoshi
- Department of Sports Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
- Otoshi Orthopedic Clinic, Oshu City, Iwate, Japan
| | - Kinshi Kato
- Department of Sports Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Takahiro Kaga
- Department of Sports Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| |
Collapse
|
4
|
de Klerk HH, Verweij LPE, Sierevelt IN, Priester-Vink S, Hilgersom NFJ, Eygendaal D, van den Bekerom MPJ. Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review. Arthroscopy 2023; 39:2363-2387. [PMID: 37146664 DOI: 10.1016/j.arthro.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE To perform a systematic review of complications associated with elbow arthroscopy in adults and children. METHODS A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool. RESULT A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication. CONCLUSIONS Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates. LEVEL OF EVIDENCE Level IV; systematic review of Level I-IV studies.
Collapse
Affiliation(s)
- Huub H de Klerk
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.; Department of Orthopaedic Surgery, University Medical Center Groningen (UMCG) and Groningen University, Groningen, the Netherlands.
| | - Lukas P E Verweij
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam UMC, Amsterdam, the Netherlands; Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - Inger N Sierevelt
- Specialized Centre for Orthopedic Research and Education (SCORE), Xpert Clinics, Orthopedic Department, Amsterdam, the Netherlands; Department of Orthopaedics, Spaarne Gasthuis Academie, Hoofddorp, the Netherlands
| | - Simone Priester-Vink
- Medical Library, Department of Research and Epidemiology, OLVG, Amsterdam, the Netherlands
| | - Nick F J Hilgersom
- Department of Orthopaedic Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michel P J van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands; Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
| |
Collapse
|
5
|
Kim BS, Jung KJ, Lee C. Open procedure vs. arthroscopic débridement for chronic medial epicondylitis. J Shoulder Elbow Surg 2023; 32:340-347. [PMID: 36279988 DOI: 10.1016/j.jse.2022.09.018] [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: 04/04/2022] [Revised: 09/15/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND This retrospective study compared the outcomes after open and arthroscopic treatment of chronic medial epicondylitis (ME). METHODS The study included 44 elbows in 38 patients: 25 (29-72 years) in the open group and 19 (27-70 years) in the arthroscopy group. The indications for ME surgery were failed conservative therapy for more than 3 months, symptom duration exceeding 6 months, and persistent severe pain. We used radiography, ultrasonography, and magnetic resonance imaging assessments. The clinical assessment included operating time, range of motion, grip strength, visual analog scale (VAS) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications. RESULTS The mean follow-up was 20.2 (12-58) months. The mean operating time was significantly longer in the arthroscopy group (32.5 vs. 23.5 minutes; P = .029). In both groups, all outcome measures improved significantly after surgery and there were no significant differences between the DASH scores (preoperative 44.8 vs. 43.9, postoperative 12.5 vs. 13.2), grip strength (preoperative 72.2 vs. 66.8, postoperative 84.8 vs. 83.6), and VAS scores (preoperative 8.5 vs. 8.2, postoperative 1.0 vs. 1.1) in the open and arthroscopy groups. The outcomes were excellent or good in 20 patients (80%) in the open group and 16 (84%) in the arthroscopy group. The only complication was 1 case of transient ulnar neuropathy in the open group. CONCLUSION Open and arthroscopic techniques were very effective and comparable for treating chronic ME. The surgeon can choose either technique for treating chronic ME.
Collapse
Affiliation(s)
- Byung-Sung Kim
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Bucheon-si, Gyeonggi-do, South Korea.
| | - Ki Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Bucheon-si, Gyeonggi-do, South Korea
| | - Changeui Lee
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Bucheon-si, Gyeonggi-do, South Korea
| |
Collapse
|
6
|
Arevalo A, Rao S, Willier DP, Schrock CI, Erickson BJ, Jack RA, Cohen SB, Ciccotti MG. Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review. Am J Sports Med 2022:3635465221095565. [PMID: 35658623 DOI: 10.1177/03635465221095565] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial epicondylitis (ME) is a pathological condition that arises in laborers and athletes secondary to repetitive wrist flexion and forearm pronation causing degeneration of the common flexor tendon. Although nonoperative management has demonstrated high rates of success, no standardized surgical technique has been established for situations when operative management is indicated. PURPOSE/HYPOTHESIS The purpose of this study was to perform a systematic review of the surgical treatment options for ME and evaluate the associated patient-reported outcomes (PROs). We hypothesized that surgical management of ME would vary across studies but no technique would prove to be superior. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS Searches were conducted using PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature (CINAHL), SPORTDiscus, and Cochrane databases between 1980 and April 2020. All level 1 to 4 studies were identified that focused on surgical management and PROs in the setting of ME. Description of surgical technique and PROs were required for inclusion. Investigators independently dually abstracted and reviewed the studies for eligibility. Weighted means were calculated for demographic characteristics and available PROs. RESULTS Overall, 851 studies were identified according to the search criteria. A total of 16 studies met the inclusion and exclusion criteria and therefore were evaluated. Three surgical techniques were found: open (13 studies), arthroscopic (2 studies), and percutaneous (1 study). Descriptions of the open technique were subdivided into those with (7 studies) and without (6 studies) common flexor tendon repair. Analysis included 479 elbows; patients were primarily male (58.3%) with a weighted mean age of 47.2 years. Weighted mean follow-up was 4.6 years. Tennis and manual laborer were the most common sport and occupation, respectively. Surgical success ranged from 63% to 100%, with a low complication rate of 4.3%. Success rates for return to sports and work were 81%-100% and 66.7%-100%, respectively, and only 1 study reported a return to work rate <90%. CONCLUSION This systematic review demonstrates that surgical intervention for refractory ME often has a high success rate. Regardless of surgical technique performed, patients generally demonstrated an improvement in PROs, and an encouraging number returned to work with limited complications. Further investigation is necessary to determine superiority among open, arthroscopic, and percutaneous techniques.
Collapse
Affiliation(s)
- Alfonso Arevalo
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Donald P Willier
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Robert A Jack
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Steven B Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|
7
|
Kheiran A, Pandey A, Pandey R. Common tendinopathies around the elbow; what does current evidence say? J Clin Orthop Trauma 2021; 19:216-223. [PMID: 34150494 PMCID: PMC8190485 DOI: 10.1016/j.jcot.2021.05.021] [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: 05/02/2021] [Revised: 05/15/2021] [Accepted: 05/16/2021] [Indexed: 01/21/2023] Open
Abstract
Tendinopathies are common causes of pain around the elbow resulting in significant functional impairment in athletes or the working-age population. Patients complain of a gradual onset pain with or without any specific trauma. Tissue histology shows chronic fibroblast and vascular proliferation, with a disorganized collagen pattern and absence of inflammatory mediators. Currently, numerous treatment options are described, but many of these are only supported by a heterogenous evidence base. Thus, management guidelines are difficult to define. Surgery is mostly indicated in selected cases that have failed non-operative management. This article reviews the pathophysiology and natural history of lateral and medial elbow tendinopathies, as well as distal biceps and triceps tendinopathies, and their current treatment options.
Collapse
Affiliation(s)
- Amin Kheiran
- Shoulder & Elbow Unit, University Hospitals of Leicester, Leicester, UK
| | - Aditi Pandey
- University College of London Hospital, London, UK
| | - Radhakant Pandey
- Shoulder & Elbow Unit, University Hospitals of Leicester, Leicester, UK,Corresponding author. University Hospitals of Leicester Leicester, LE5 4PW, UK
| |
Collapse
|
8
|
Park H, Hahn S, Yi J, Bang JY, Kim Y, Jung HK, Baik J. Clinical Assessments and MRI Findings Suggesting Early Surgical Treatment for Patients with Medial Epicondylitis. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:613-625. [PMID: 36238785 PMCID: PMC9432437 DOI: 10.3348/jksr.2020.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/04/2020] [Indexed: 06/16/2023]
Abstract
Purpose To evaluate the MRI findings and clinical factors that are characteristic of patients who ultimately undergo surgery for medial epicondylitis. Materials and Methods Fifty-two consecutive patients who were diagnosed with medial epicondylitis and underwent an elbow MRI between March 2010 and December 2018 were included in this retrospective study. The patients' demographic information, clinical data, and MRI findings were evaluated. All variables were compared between the conservative treatment and surgical treatment groups. Logistic regression analyses were conducted to identify which factors were associated with surgical treatment. Results Common flexor tear (CFT) tear size showed a statistically significant difference in both the transverse and longitudinal planes (p < 0.001, p = 0.013). The CFT abnormality grade significantly differed in both the transverse and longitudinal planes (p = 0.022, p = 0.003). A significant difference was also found in the medial collateral ligament abnormality (p = 0.025). Logistic regression analyses showed that only the transverse diameter of the CFT tear size (odds ratio: 1.864; 95% confidence interval: 1.264-2.750) was correlated with surgical treatment. Conclusion Of patients diagnosed with medial epicondylitis, patients with a larger transverse CFT tear size tend to undergo surgical treatment ultimately.
Collapse
|
9
|
Alrabaa RG, Dantzker N, Ahmad CS. Injuries and Conditions Affecting the Elbow Flexor/Pronator Tendons. Clin Sports Med 2020; 39:549-563. [PMID: 32446574 DOI: 10.1016/j.csm.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Common flexor-pronator tendon injuries and medial epicondylitis can be successfully treated nonoperatively in most cases. Operative treatment is reserved for patients with continued symptoms despite adequate nonoperative treatment or in high-level athletes with complete rupture of the common flexor-pronator tendon. The physical examination and workup of patients with flexor-pronator tendon injuries should focus on related or concomitant pathologies of the medial elbow. The gold standard for surgical treatment of flexor-pronator tendon ruptures or medial epicondylitis includes tendon debridement and reattachment.
Collapse
Affiliation(s)
- Rami George Alrabaa
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY 10032, USA.
| | - Nicholas Dantzker
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY 10032, USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY 10032, USA
| |
Collapse
|
10
|
Tennisellenbogen. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-0295-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
Shin M, Hahn S, Yi J, Lim YJ, Bang JY. Clinical Application of Real-Time Sonoelastography for Evaluation of Medial Epicondylitis: A Pilot Study. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:246-254. [PMID: 30352727 DOI: 10.1016/j.ultrasmedbio.2018.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 06/08/2023]
Abstract
The aim of this study was to evaluate the diagnostic potential of real-time sonoelastography (RSE) in medial epicondylitis by comparing clinically diagnosed patients and patients without medial elbow pain. From July 2016 to December 2017, gray-scale sonographic findings (swelling, cortical irregularity, hypo-echogenicity, calcification and tear), color Doppler findings (hyperemia) and sonoelastographic findings (elastographic grade on a 3-point visual scale and strain ratio from two regions of interest) for 63 elbows of 56 patients were compared. Twenty-four patients with 29 imaged elbows were clinically diagnosed with medial epicondylitis, and 32 patients with 34 imaged elbows had no medial elbow pain. Cortical irregularity, hypo-echogenicity, calcification, elastographic grade and strain ratio revealed significant differences (p < 0.05). Among these, strain ratio had the highest diagnostic performance (area under the curve: 0.985). Real-time sonoelastography, which can obtain both elastographic grade and strain ratio, is valuable as a supplementary tool in the diagnosis of medial epicondylitis.
Collapse
Affiliation(s)
- Minwoo Shin
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Seok Hahn
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea.
| | - Jisook Yi
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Yun-Jung Lim
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Jin-Young Bang
- Department of Orthopaedic Surgery, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| |
Collapse
|