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Guizzi A, Collin P, Zbinden J, Hurtado JA, Amiri A, Lädermann A. Calcaneum-Achilles Tendon Allograft for Massive Posterosuperior Rotator Cuff Lesion With Bony Deficiency. Arthrosc Tech 2024; 13:102919. [PMID: 38690347 PMCID: PMC11056741 DOI: 10.1016/j.eats.2024.102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/10/2023] [Indexed: 05/02/2024] Open
Abstract
Dealing with massive and irreparable rotator cuff tears presents intricate challenges. Concerning elder patients, either conservative management or reverse shoulder arthroplasty could be the most appropriate treatment. On the other hand, in younger patients, there is a wide spectrum of solutions, most of them being under evaluation and not completely validated. The complexity increases when a greater tuberosity avulsion occurs at the same time. Regardless of whether surgical fixation is performed, there is a risk for bone resorption, which would result in the posterosuperior cuff's insertion spot loss. In this case, the surgeon is expected to simultaneously manage the bone loss and the tendon tear. The Calcaneum-Achilles Tendon Allograft (CalATA) therefore appears to play an interesting role due to its solid bone-tendon structure. This Technical Note aims to present the CalATA technique, which consists in both tendon and bone deficiency restoration in massive rotator cuff tears with greater tuberosity resorption.
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Affiliation(s)
- Alberto Guizzi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Philippe Collin
- CHP Saint-Gregoire, Saint-Grégoire, France
- Clinique Victor Hugo, Paris, France
- American Hospital of Paris, Neuilly-sur-Seine, France
| | - Jeanni Zbinden
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Meyrin, Switzerland
| | - Juan Arturo Hurtado
- Clínica San Pablo Surco, Lima, Perú
- Clínica San Gabriel, Lima, Perú
- Clínica Providencia, Lima, Perú
| | - Arash Amiri
- Trauma Research Center, Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Meyrin, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Miyamura S, Shiode R, Lans J, Oka K, Tanaka H, Okada S, Murase T, Chen NC. Quantitative 3-D CT Demonstrates Distal Row Pronation and Translation and Radiolunate Arthritis in the SNAC Wrist. J Bone Joint Surg Am 2023; 105:1329-1337. [PMID: 37471563 DOI: 10.2106/jbjs.22.01350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
BACKGROUND In scaphoid nonunion advanced collapse (SNAC) wrist arthritis, we analyzed the 3-dimensional (3-D) deformity patterns of carpal alignment secondary to scaphoid nonunion and quantified subchondral arthritis by investigating alterations in bone density. METHODS We constructed 3-D models of the carpal bones and radius from 51 patients with scaphoid nonunion (nonunion group) and 50 healthy controls (control group). We quantified the differences in 3-D geometric position of the distal carpal row relative to the distal radius in SNAC wrists versus controls. In addition, we assessed the bone density of anatomic regions of interest in the radiocarpal and capitolunate joints relative to the pisiform bone density to characterize degenerative changes in SNAC wrists. RESULTS The distal carpal row pronated by a difference of 14° (7.2° versus -6.7°; p < 0.001), deviated ulnarly by a difference of 19° (7.7° versus -11.2°; p < 0.001), shifted dorsally by a difference of 17% of the dorsovolar width of the distal radius (21.0% versus 4.4%; p < 0.001), shifted radially by a difference of 8% of the radioulnar width of the distal radius (13.2% versus 5.3%; p < 0.001), and migrated proximally by a difference of 12% of the lunate height (96.3% versus 108.8%; p < 0.001) in the nonunion group compared with the control group. Additionally, it was found that bone density was greater at the capitolunate joint (capitate head: 140.4% versus 123.7%; p < 0.001; distal lunate: 159.9% versus 146.3%; p < 0.001), the radial styloid (157.0% versus 136.3%; p < 0.001), and the radiolunate joint (proximal lunate: 134.8% versus 122.7%; p < 0.001; lunate fossa: 158.6% versus 148.1%; p = 0.005) in the nonunion group compared with the control group. CONCLUSIONS Scaphoid nonunion exhibited a unique deformity pattern and alteration in bone-density distributions. The distal carpal row not only shifted dorsally and migrated proximally but also pronated, deviated ulnarly, and shifted radially. Bone density was greater at the capitolunate joint, the radial styloid, and surprisingly, the radiolunate joint. Our findings give insight into the natural history and progression of arthritis of the SNAC wrist. Additionally, future studies may give insight into whether successful treatment of scaphoid nonunion arrests the progression of arthritis. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Satoshi Miyamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Ryoya Shiode
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Jonathan Lans
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kunihiro Oka
- Department of Orthopaedic Biomaterial Science, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hiroyuki Tanaka
- Department of Sports Medical Science, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Tsuyoshi Murase
- Department of Orthopaedic Surgery, Bell Land General Hospital, Sakai, Osaka, Japan
| | - Neal C Chen
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Lu KY, Tai TH, Liu YH, Chiang CJ, Loh EW, Wong CC, Wu JJ. Post-Operative Greater Tuberosity Resorption or Malreduction Is Associated with Poor Prognostic Outcomes in Patients with Proximal Humeral Fractures Treated Operatively-A Single-Center Retrospective Cohort Study. Diagnostics (Basel) 2023; 13:2789. [PMID: 37685327 PMCID: PMC10486750 DOI: 10.3390/diagnostics13172789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: Proximal humerus fractures can be a debilitating condition if not properly treated. These fracture patterns are varied and differ in every patient. Functional outcomes may be determined by the integrity of the shoulder girdle involving the rotator cuff insertion. The post-operative resorption or malreduction of the greater tuberosity (GT) is an important factor contributing to the poor functional outcome of a patient. Thus, we intend to evaluate the cause-and-effect relationship between GT complications and clinical prognosis and outcomes. (2) Methods: A single-center retrospective comparative study was performed to evaluate the functional outcomes of patients undergoing operative fixation for this injury. A total of 387 consecutive cases treated operatively from 2019-2021 were included for analysis. (3) Results: 94 cases fulfilled our criteria for analysis. A matched-group comparison of 19 patients each was performed to compare demographics, post-operative fracture characteristics and clinical outcomes. (4) Conclusions: The resorption or malreduction of the GT contributes greatly to the prognostic outcome in patients treated with open reduction and internal fixation (ORIF) surgery. In our demographic study, obesity is another contributing factor affecting the parameters of post-operative reduction in proximal humerus fractures. Appropriate surgical planning and post-operative multidisciplinary care must be taken into consideration to attain a satisfactory prognostic outcome.
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Affiliation(s)
- Kuan-Yu Lu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Ting-Han Tai
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Yu-Hsin Liu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Chang-Jung Chiang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - El-Wui Loh
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- Center for Evidence-Based Health Care, Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei 11031, Taiwan
- Department of Medical Imaging, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Chin-Chean Wong
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei 11031, Taiwan
| | - Jeffrey J. Wu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
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Wu RJ, Zhang W, Lin YZ, Fang ZL, Wang KN, Wang CX, Yu DS. Influence of preoperative simulation on the reduction quality and clinical outcomes of open reduction and internal fixation for complex proximal humerus fractures. BMC Musculoskelet Disord 2023; 24:243. [PMID: 36997961 PMCID: PMC10061994 DOI: 10.1186/s12891-023-06348-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE Proximal humerus fractures (PHFs) are common. With the development of locking plates, open reduction and internal fixation (ORIF) of the proximal humerus can provide excellent clinical outcomes. The quality of fracture reduction is crucial in the locking plate fixation of proximal humeral fractures. The purpose of this study was to determine the impact of 3-dimensional (3D) printing technology and computer virtual technology assisted preoperative simulation on the reduction quality and clinical outcomes of 3-part and 4-part proximal humeral fractures. METHOD A retrospective comparative analysis of 3-part and 4-part PHFs undergoing open reduction internal fixation was performed. Patients were divided into 2 groups according to whether computer virtual technology and 3D printed technology were used for preoperative simulation: the simulation group and the conventional group. Operative time, intraoperative bleeding, hospital stay, quality of fracture reduction, Constant scores, American Society for Shoulder and Elbow Surgery (ASES) scores, shoulder range of motion, complications, and revision surgeries were assessed. RESULTS This study included 67 patients (58.3%) in the conventional group and 48 patients (41.7%) in the simulation group. The patient demographics and fracture characteristics were comparable in these groups. Compared with the conventional group, the simulation group had shorter operation time and less intraoperative bleeding (P < 0.001, both). Immediate postoperative assessment of fracture reduction showed a higher incidence of greater tuberosity cranialization of < 5 mm, neck-shaft angle of 120° to 150°, and head shaft displacement of < 5 mm in the simulation group. The incidence of good reduction was 2.6 times higher in the simulation group than in the conventional group (95% CI, 1.2-5.8). At the final follow-up, the chance of forward flexion > 120° (OR 5.8, 95% CI 1.8-18.0) and mean constant score of > 65 (OR 3.4, 95% CI 1.5-7.4) was higher in the simulation group than the conventional group, as well as a lower incidence of complications in the simulation group was obtained (OR 0.2, 95% CI 0.1-0.6). CONCLUSIONS This study identified that preoperative simulation assisted by computer virtual technology and 3D printed technology can improve reduction quality and clinical outcomes in treatment of 3-part and 4-part PHFs.
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Affiliation(s)
- Rui-Ji Wu
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Wei Zhang
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Yan-Ze Lin
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Zhang-Lu Fang
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Kang-Nan Wang
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Chang-Xing Wang
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Dong-Sheng Yu
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China.
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Garofalo R, Fontanarosa A, Lassandro N, De Crescenzo A. Reverse Total Shoulder Arthroplasty with a Cementless and Metaphyseal Stem Fixation Is a Viable Option for the Treatment of Proximal Humeral Fractures with Calcar Involvement. J Clin Med 2023; 12:jcm12041443. [PMID: 36835978 PMCID: PMC9958614 DOI: 10.3390/jcm12041443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/24/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with a steel wire cerclage. Clinical and radiographic outcomes were compared with the same RTSA for PHFs without a calcar fragment at a minimum of five-year follow-up. METHODS A retrospective analysis was performed on acute PHFs "with a medial calcar fragment" (group A) and "without a calcar fragment" (group B) treated with a RTSA and cementless metaphyseal stem fixation. RESULTS At an average follow-up of 6.7 years (5-7.8 years), no statistical difference was observed comparing group A (18 patients) to group B (50 patients) for active anterior elevation (141 ± 15° vs. 145 ± 10°, p = 0.67), active external rotation ER1 (49 ± 15° vs. 53 ± 13°, p = 0.55), and active internal rotation (5 ± 2 vs. 6 ± 2, p = 0.97). Similarly, a comparison of ASES score (89.2 ± 10 vs. 91.6 ± 9, p = 0.23) and Simple Shoulder Test score (91.1 ± 11 vs. 90.4 ± 10, p = 0.49) revealed no significant difference. CONCLUSION RTSA with a cementless and metaphyseal stem fixation represents a safe and feasible treatment for complex PHFs with a medial calcar fragment when this may be fixed with a steel wire cerclage.
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Chen H, Chang Z, Zhu Z, Tang P. Treatment of elderly comminuted proximal humeral fracture using endosteal anatomical support system: A case report. Int J Surg Case Rep 2022; 102:107823. [PMID: 36473269 PMCID: PMC9720443 DOI: 10.1016/j.ijscr.2022.107823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/26/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Intramedullary anatomical medial strut with allograft bone (IAMSAB), which accommodates the shape of the proximal humeral cavity and provides rotational stability and direct support to the medial column, was successfully introduced to augment Lateral locking plate (LLP) in the treatment of elderly comminuted proximal humeral fractures. Based on the LLP-IAMSAB construct, a newly titanium endosteal anatomical support system (EASS) was developed. CASE PRESENTATION Reported here is a single case of a highly comminuted proximal humeral fracture. The fractures were treated with EASS. The patient's fracture healed properly. The 24-month follow-up demonstrated no pain and a good functional outcome, with no signs of reduction loss, absorption of greater tuberosity, varus displacement and avascular necrosis of humeral head. CLINICAL DISCUSSION The newly developed EASS had several special considerations contributing to satisfactory surgical outcome. The flat plane construct of the proximal end of the EASS directly support humeral head to prevent varus displacement of the humeral head, instead of the purchase between the screw thread and the cancellous bone inside the humeral head in the nail or plate fixation. Medial anatomical shape of proximal end helps to reduce medial cortex reduction. Greater tuberosity support block with rotator cuff suture fixation might promote greater tuberosity healing and prevent its absorption. However, there is no similar construct in the nail or plate fixation. CONCLUSION The newly developed endosteal anatomical support system might be a promising option in the treatment of elderly comminuted proximal humeral fractures. Although the effectiveness of this system requires additional evaluation upon more patients being treated with this surgical method, the newly developed EASS may serve as a humeral head-preserving method for elderly patients with comminuted proximal humeral fractures.
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Affiliation(s)
- Hua Chen
- The Department of Orthopaedic Surgery, Fourth Medical Center of Chinese PLA General Hospital, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, China,Corresponding authors at: The Department of Orthopaedic Surgery, Fourth Medical Center of Chinese PLA General Hospital, Beijing 100048, China.
| | - Zuhao Chang
- The Department of Orthopaedic Surgery, Fourth Medical Center of Chinese PLA General Hospital, China
| | - Zhengguo Zhu
- The Department of Orthopaedic Surgery, Fourth Medical Center of Chinese PLA General Hospital, China
| | - Peifu Tang
- The Department of Orthopaedic Surgery, Fourth Medical Center of Chinese PLA General Hospital, China,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, China,Corresponding authors at: The Department of Orthopaedic Surgery, Fourth Medical Center of Chinese PLA General Hospital, Beijing 100048, China.
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Ho SW, Denard PJ, Chong XL, Collin P, Wang S, Lädermann A. Achilles Tendon–Bone Block Allograft for Massive Rotator Cuff Tears With Bony Deficiency of the Greater Tuberosity: A Minimum 2-Year Follow-up Study. Orthop J Sports Med 2022; 10:23259671211073719. [PMID: 35224116 PMCID: PMC8873559 DOI: 10.1177/23259671211073719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Massive rotator cuff tears associated with greater tuberosity bone loss are challenging to treat. Repairing the rotator cuff without addressing the greater tuberosity deficiency may result in poorer clinical outcomes. Hypothesis: Utilizing an Achilles tendon–bone block allograft to address both the massive rotator cuff tear and greater tuberosity bone loss concurrently can result in improved clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: The authors performed a retrospective study of patients treated between January 2011 and December 2018 with Achilles tendon–bone block allograft for massive rotator cuff tears associated with greater tuberosity bone loss. The inclusion criteria were massive rotator cuff tear and bony deficiency of the greater tuberosity; patients with a history of bony metabolism disease, connective tissue disease, and previous surgery to the wrist or elbow of the affected limb were excluded. Range of motion, visual analog scale for pain, Constant score, and Single Numeric Assessment Evaluation score were assessed preoperatively and at a minimum of 2 years postoperatively. Radiographs and ultrasound images were evaluated to assess allograft union and rotator cuff integrity. Results: Five patients (3 male and 2 female; mean age, 54.0 ± 12.2 years) were included in the study. The mean follow-up was 80.6 ± 33.7 months. Preoperative to postoperative values improved significantly on the visual analog scale (from 45.8 ± 25.5 to 14.5 ± 14.1; P = .04), Constant score (from 36.8 ± 7.9 to 73.5 ± 3.1; P < .001), and Single Numeric Assessment Evaluation score (from 42.5 ± 26.3 to 82.5 ± 10.4; P = .04). Forward flexion improved significantly from 53° ± 47° to 149° ± 17° (P = .03). Four of the 5 patients achieved bony union. One patient required removal of symptomatic hardware at 6 months postoperatively, and 1 patient required revision surgery at 1 year postoperatively because of progressive osteonecrosis of the humeral head. Conclusion: In patients with massive rotator cuff tears and a greater tuberosity bony deficiency, utilizing an Achilles tendon–bone block allograft to restore the bony defect and reinforce the rotator cuff repair was safe and effective. At a minimum of 2 years postoperatively, most patients demonstrated improved clinical outcomes, tendon healing, and graft incorporation.
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Affiliation(s)
- Sean W.L. Ho
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Xue Ling Chong
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint-Grégoire, France
| | - Sidi Wang
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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