1
|
Li W, Wang Y, Zhou S, Liu S, Di L, Chen W, Lv H. Development and validation of predictive nomogram for postoperative non-union of closed femoral shaft fracture. Sci Rep 2024; 14:3543. [PMID: 38347044 PMCID: PMC10861573 DOI: 10.1038/s41598-024-53356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/31/2024] [Indexed: 02/15/2024] Open
Abstract
Closed femoral shaft fracture is caused by high-energy injuries, and non-union exists after operation, which can significantly damage patients' body and mind. This study aimed to explore the factors influencing postoperative non-union of closed femoral shaft fractures and establish a predictive nomogram. Patients with closed femoral shaft fractures treated at Hebei Medical University Third Hospital between January 2015 and December 2021 were retrospectively enrolled. A total of 729 patients met the inclusion criteria; of them, those treated in 2015-2019 comprised the training cohort (n = 617), while those treated in 2020-2021 comprised the external validation cohort (n = 112). According to multivariate logistic regression analysis, complex fractures, bone defects, smoking, and postoperative infection were independent risk factors. Based on the factors, a predictive nomogram was constructed and validated. The C-indices in training and external validation cohorts were 0.818 and 0.781, respectively; and the C-index of internal validation via bootstrap resampling was 0.804. The Hosmer-Lemeshow test showed good fit of the nomogram (P > 0.05) consistent with the calibration plot results. The clinical effectiveness was best at a threshold probability of 0.10-0.40 in decision curve analysis. The risk prediction for patients with fractures using this nomogram may aid targeted prevention and rehabilitation programs.
Collapse
Affiliation(s)
- Wenjing Li
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Yan Wang
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Shuai Zhou
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Shihang Liu
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Luqin Di
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Wei Chen
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
| | - Hongzhi Lv
- Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Hebei Orthopaedic Research Institute, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
- School of Public Health, Hebei Medical University, No.361 Zhongshan East Road, Shijiazhuang, 050017, China.
- Trauma Emergency Center, Hebei Medical University Third Hospital, No. 139 Ziqiang Road, Shijiazhuang, 050051, China.
| |
Collapse
|
2
|
Patil AR, Patil DS, Jagzape MV. Physiotherapy Rehabilitation in an Infected Non-union Shaft of Femur Repair Patient: A Case Report. Cureus 2023; 15:e50786. [PMID: 38239531 PMCID: PMC10795792 DOI: 10.7759/cureus.50786] [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: 07/21/2023] [Accepted: 12/19/2023] [Indexed: 01/22/2024] Open
Abstract
While definitions may vary, infected non-union is generally described as a condition where a fracture fails to heal due to infection, typically persisting for a duration of six to eight months. Infected non-unions occurring in the shaft of the femur are infrequent and typically result from severe open fractures with deep fragmentation and segmental bone loss or following internal fixation of a severely fragmented closed fracture. Some associated factors contributing to non-union include positive bacterial cultures from deep wounds, histological evidence of bone necrosis, exposed bone without a vascularized periosteum for more than six weeks, and the presence of purulent discharge. Osteomyelitis, stiffness in adjacent joints, smoking, loss of soft tissue resulting in multiple sinus tracts, osteopenia, and deformities leading to limb length discrepancies are all complicating factors that impact treatment and prognosis. Infected non-union of bones, although rare, presents a significant challenge for physiotherapists striving to provide appropriate treatment. The level of stabilization at the fracture site is the most critical factor influencing whether a fracture progresses to non-union or successfully heals. Infection, such as osteomyelitis, also contributes to the development of non-union. Additionally, issues like tissue atrophy, joint stiffness, and muscle contractures can further complicate the non-union of a bone, posing a considerable challenge for physical therapists in helping patients achieve their recovery goals. Top of form this case report reviews the case of a 35-year-old male who was reported to Acharya Vinoba Bhave Rural Hospital (AVBRH) with an infective non-union of the shaft of the femur fracture after two months of repair. This case report highlights the recovery of patients from post-operative complications like non-union, stiffness, and reduced range of motion through tailored physiotherapy rehabilitation and improved quality of life.
Collapse
Affiliation(s)
- Anushri R Patil
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Deepali S Patil
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Medhavi V Jagzape
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| |
Collapse
|
3
|
Concha JM, Osma JL, Fantín E, Concha C, Caicedo AJ. Augmentative lag screws as a treatment for aseptic hypertrophic nonunion after internal fracture fixation. Injury 2023; 54 Suppl 6:110805. [PMID: 38143134 DOI: 10.1016/j.injury.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Hypertrophic nonunion after intramedullary (IM) nailing and plating is Uncommon and the treatment remained controversial. The aim of this study was to show the result of a simple augmentative lag screws technique for vital non-unions after internal fixation PATIENTS AND METHODS: We retrospectively reviewed the patients with nonunion after internal fixation between January 2016 to August 2022. Patients with unacceptable shortening or deformity were excluded as well as nonunion septic cases. All the patients were followed up for at least 6 months. RESULTS Seven patients achieved bony union in a median time of 12 weeks (IRQ 12-16). There was a failure case with persistent non-union and brokerage of the screws. DISCUSSION Various techniques have been described to treat non-union after intramedullary nailing or plating. The existing nail is frequently removed, and the non-union site is either re-reamed and re-nailed or fixed with a plate or external fixation devices or rechanged by a nail in the case of plates. In our study of non-union, augmentative lag screws were successfully applied to treat eight patients with aseptic nonunion, resulting in the healing of non-union in all cases except one. CONCLUSION Augmentative lag screws represent a simple technique for the management of aseptic hypertrophic nonunion after internal fixation with a significantly shorter operating time.
Collapse
Affiliation(s)
- Juan Manuel Concha
- Departamento de Ciencias Quirúrgicas, Universidad del Cauca, Popayán Colombia; Hospital Susana López de Valencia, Popayán, Colombia.
| | - Jose Luis Osma
- Universidad Industrial de Santander, Bucaramanga, Colombia.
| | - Emilio Fantín
- IUCBC Instituto Universitario de Ciencias Biomédicas, Cordoba, Argentina.
| | - Carolina Concha
- Department Facultad de Medicina, Institution Pontificia, Universidad Javeriana, Bogotá, Colombia.
| | - Alvaro Jose Caicedo
- Department Facultad de Medicina, Institution Pontificia, Universidad Javeriana, Cali, Colombia.
| |
Collapse
|
4
|
Marshall WG, Filliquist B, Tzimtzimis E, Fracka A, Miquel J, Garcia J, Fontana MD. Delayed union, non-union and mal-union in 442 dogs. Vet Surg 2022; 51:1087-1095. [PMID: 36053918 PMCID: PMC9804201 DOI: 10.1111/vsu.13880] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/23/2022] [Accepted: 08/08/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES (1) To estimate the prevalence of delayed union, non-union and mal-union in canine fractures; (2) to describe fracture, demographic, and treatment characteristics for these outcomes; (3) to identify risk factors for delayed or non-union. STUDY DESIGN Retrospective study. SAMPLE POPULATION Four hundred and forty two dogs (461 fractures). METHODS A review was conducted of clinical records and radiographs from 2 teaching hospitals. "Union," "delayed union," "non-union" and "mal-union" were defined, and fracture, demographic, treatment, and outcome variables described. Differences in proportions or medians between "union," "delayed union" and "non-union" were tested using χ2 and Mann-Whitney U-tests for categorical and continuous variables respectively. Potential explanatory variables for "delayed or non-union" were tested using logistic regression to identify risk factors. RESULTS Median radiographic follow up was 53 days (14-282). Delayed union occurred in 13.9% of fractures (64/461), non-union in 4.6% (21/461), and mal-union in 0.7% (3/461). Risk factors for delayed or non-union were age (OR 1.21, 95% CI 1.12-1.31); comminuted fracture (OR 4.24, 95% CI 2.4-7.5); treatment with bone graft (all types) (OR 3.32, 95% CI 1.3-8.5); surgical site infection (OR 3.24, 95% CI 1.17-8.97), and major implant failure (OR 12.94, 95% CI 5.06-33.1). CONCLUSION Older dogs, dogs with comminuted fractures, surgical site infection, or major implant failure were at increased odds of delayed or non-union. Radius and ulna fractures in toy breed dogs were not at increased odds of delayed or non-union. CLINICAL SIGNIFICANCE The identified risk factors should inform fracture planning and prognosticating. The prognosis for radial fractures in toy breeds appears better than historically believed.
Collapse
Affiliation(s)
| | - Barbro Filliquist
- Department of Surgical and Radiological Sciences, School of Veterinary MedicineUniversity of California DavisDavisCaliforniaUSA
| | - Emmanouil Tzimtzimis
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Agnieszka Fracka
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Jose Miquel
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Javier Garcia
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| | - Maria Dalla Fontana
- Small Animal Hospital, School of Veterinary MedicineUniversity of GlasgowGlasgowUK
| |
Collapse
|
5
|
Bakshi AS, Singh A, Kaur H, Kaur G, Singh J. A Comparative Study of Treatment With External Fixator Versus Antibiotic Coated Intramedullary Nail in Infected Non-union Long Bones. Cureus 2022; 14:e29659. [PMID: 36320998 PMCID: PMC9612901 DOI: 10.7759/cureus.29659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction: Infected non-union of bones shows problems in providing stability and controlling the infection. The treatment comprises debridement with or without the use of antibiotic cement and achieving stability by either external or internal fixation with or without bone grafting. The use of antibiotic-impregnated cement-coated intramedullary nailing gives stability and treats the infection, thereby permitting early mobilization. External fixation is a definitive mode of fracture stabilization indicated in cases of infected non-unions of the humerus, tibia, and juxta-articular bone. The present study was conducted to compare the results of management of infected non-union long bones treated with an external fixator (Ilizarov and Limb Reconstruction System (LRS)) and vancomycin-coated intramedullary nail. Materials and method: The present prospective study was conducted on 40 study subjects aged >18 years, and were randomly divided using the alternative method into two groups. Group A: 20 Patients were treated with antibiotic-coated intramedullary interlocking nail (ACIIN). Group B: 20 patients were treated with the external fixator (LRS/Ilizarov). All patients were then evaluated post-operatively using laboratory investigations, and for any sign of inflammation or infection. Results were evaluated using association for the study and application of methods of Ilizarov (ASAMI) scoring system. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA). Results: It was observed that 80.0% of patients in Group A, and 70% of subjects in Group B showed bony union, revealing a statistically significant (p-value<0.05) difference. Infection control, limb length discrepancy, and deformity were also assessed in both groups. Bone and functional outcomes were assessed using the ASAMI score in both groups. In LRS/Ilizarov, it was observed that 55% of subjects had no infection, 15% showed loosening, and 30% had an infection. Conclusion: The ACIIN should not be used for bone defects more than 4 cm as it does not achieve stability and for these cases, procedures like external fixators (Ilizarov and LRS) should be used. Antibiotic-coated nail eliminated the complications of the external fixators like pin loosening, and pin infections and was technically less demanding. In our study, stiffness of adjacent joints was more in external fixators (LRS/Ilizarov) than ACIIN.
Collapse
|
6
|
You DZ, Krzyzaniak H, Kendal JK, Martin CR, Schneider PS. Outcomes and complications after dual plate vs. single plate fixation of displaced mid-shaft clavicle fractures: A systematic review and meta-analysis. J Clin Orthop Trauma 2021; 17:261-266. [PMID: 33936947 PMCID: PMC8079453 DOI: 10.1016/j.jcot.2021.03.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Open reduction and internal fixation (ORIF) of displaced midshaft clavicle fractures is associated with higher union rates and earlier functional recovery. However, ORIF with plate fixation is associated with complications including implant irritation and implant failure. Dual plate fixation provides fixation in orthogonal planes, and uses a lower profile fixation technique in comparison to pre-contoured and surgeon-contoured small-fragment locking plates, which may be more prominent. The objective of this study was to conduct a systematic review to summarize outcomes and complications associated with surgical fixation of displaced acute midshaft clavicle fractures with dual plate fixation. METHODS Using a predetermined study protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the databases MEDLINE, EMBASE, and CENTRAL were searched from inception to 2020 to identify studies reporting outcomes in acute midshaft clavicle fractures treated with dual plate fixation. All clinical studies which reported on outcomes of dual plating in patients with acute midshaft clavicle fractures were included. Baseline demographics, plate fixation constructs, fracture union rates, implant removal rates, maintenance of reduction, symptomatic implant rates, wound complications, and functional outcomes were extracted. All extracted data were recorded, and descriptive statistics were summarized. Meta-analysis was performed on fracture union rates and implant removal rates using random-effects modeling using Mantel-Haenszel weighting. RESULTS Our literature search identified 2226 unique abstracts, of which eight studies met our study inclusion criteria following review. A total of 278 patients made up of 79.8% male with an average age of 36.0 years were included. The overall dual plate implant removal rate was 4.2% with excellent rates of union reported. Moreover, single plate fixation was associated with a 3.9-fold increased implant removal rate compared to dual plate fixation. CONCLUSION Results from this systematic review demonstrate that ORIF of displaced midshaft clavicle fractures using a dual plate fixation technique is a viable option to reduce the incidence of implant removal, without negatively impacting the rate of fracture union. LEVEL OF EVIDENCE Therapeutic Level III.
Collapse
Affiliation(s)
- Daniel Z. You
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Halli Krzyzaniak
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Joseph K. Kendal
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - C. Ryan Martin
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Prism S. Schneider
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Canada,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada,Corresponding author. Division of Orthopaedic Trauma, McCaig Tower, 3134 Hospital Drive NW, Calgary, Alberta, T2N 5A1, Canada.
| |
Collapse
|
7
|
Periosteal and endosteal microcirculatory injury following excessive osteosynthesis. Injury 2021; 52 Suppl 1:S3-S6. [PMID: 33280891 DOI: 10.1016/j.injury.2020.11.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We examined the endosteal and periosteal circulations in a patient with fracture non-union who had undergone excessive osteosynthesis applications (two long plates had been placed medially and laterally on the left tibia extending from the proximal 2/7 to the distal 6/7 parts of the bone, while a tibial component of a total knee prosthesis with a long stem had been inserted at the same time). METHODS Concomitant perfusion changes were determined in the anterolateral and anteromedial periosteal sheath of the non-united bone ends and intramedullary nearest the osteosynthesis materials during their surgical removal on re-operation. The blood flow in the periosteum and endosteum was recorded by a laser-Doppler flowmetric device using a novel approach. Control measurements were made at identical points of the right tibia. RESULTS Considerably lower blood flow values were measured along the tibial periosteal region of the re-operated limb than on the contralateral side (the average perfusion unit (PU) was 76 vs. 106 PU, respectively). Perfusion values were markedly lower in the endosteal region (average values of approx. 30 PU) in the control tibia and were even more diminished in the re-operated tibial endosteum (average 9 PU). CONCLUSIONS Our study was conducted to characterize the microcirculatory changes of a long bone in response to intramedullary implantation and to provide quantitative data on the insufficiency of local perfusion in a patient with fracture non-union. Our results highlight the association between local perfusion failure and the unfavorable outcome (i.e. fracture non-union), confirming that the vital aspects of the microcirculation should not be disregarded when aiming for mechanical stability. Microcirculatory measurements constitute a new area of improvement in planning the adequate treatment for fracture non-unions with an unclear aetiology. Further refinement of the laser-Doppler technique could have potential benefits for bone surgery and postoperative trauma care in the future.
Collapse
|
8
|
Abstract
The reported levels of non-union in the lateral locking plate differ widely, with some early studies showing rates of less than 6% and up to 17%-21% in more recent studies. We report a case where better results were shown by a non-union treated with distal femoral nailing with allogenic grafting.
Collapse
Affiliation(s)
- Kishore Vellingiri
- Orthopaedics, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Nagakumar J S
- Orthopaedics, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| |
Collapse
|
9
|
Simpson AHRW, Robiati L, Jalal MMK, Tsang STJ. Non-union: Indications for external fixation. Injury 2019; 50 Suppl 1:S73-S78. [PMID: 30955871 DOI: 10.1016/j.injury.2019.03.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 03/28/2019] [Indexed: 02/02/2023]
Abstract
External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.
Collapse
Affiliation(s)
- A H R W Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom.
| | - L Robiati
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - M M K Jalal
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - S T J Tsang
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| |
Collapse
|