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Harrison DE, Haas JW, Moustafa IM, Betz JW, Oakley PA. Can the Mismatch of Measured Pelvic Morphology vs. Lumbar Lordosis Predict Chronic Low Back Pain Patients? J Clin Med 2024; 13:2178. [PMID: 38673450 PMCID: PMC11050312 DOI: 10.3390/jcm13082178] [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: 02/24/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Measures of lumbar lordosis (LL) and elliptical modeling variables have been shown to discriminate between normal and chronic low back pain (CLBP) patients. Pelvic morphology influences an individual's sagittal lumbar alignment. Our purpose is to investigate the sensitivity and specificity of lumbar sagittal radiographic alignment and modeling variables to identify if these can discriminate between normal controls and CLBP patients. Methods: We conducted a computer analysis of digitized vertebral body corners on lateral lumbar radiographs of normal controls and CLBP patients. Fifty normal controls were attained from a required pre-employment physical examination (29 men; 21 women; mean age of 27.7 ± 8.5 years), with no history of low back pain, a normal spinal examination, no pathologies, anomalies, or instability. Additionally, 50 CLBP patients (29 men; 29.5 ± 8 years of age) were randomly chosen and matched to the characteristics of the controls. The inclusion criteria required no abnormalities on lumbar spine radiographs. The parameters included the following: ARA L1-L5 lordosis, ARA T12-S1 lordosis, Cobb T12-S1, b/a elliptical modelling ratio, sacral base angle (SBA), and S1 posterior tangent to vertical (PTS1). Two measures of pelvic morphology were determined for each person-the angle of pelvic incidence (API) and posterior tangent pelvic incidence angle (PTPIA)-and the relationships between API - ARA T12-S1, API - Cobb T12-S1, and API - ARA L1-5 was determined. Descriptive statistics and correlations among the primary variables were determined. The receiver operating characteristic curves (ROC curves) for primary variables were analyzed. Results: The mean values of LL were statistically different between the normal and CLBP groups (p < 0.001), indicating a hypo-lordotic lumbar spine for the CLBP group. The mean b/a ratio was lower in the chronic pain group (p = 0.0066). The pelvic morphology variables were similar between the groups (p > 0.05). API had a stronger correlation to the SBA and Cobb T12-S1 than PTPIA did, while PTPIA had a stronger correlation to the S1 tangent and ARA T12-S1 than API did. While CLBP patients had a stronger correlation of ARA T12-S1 and Cobb T12-S1 relative to the pelvic morphology, they also had a reduced correlation of ARA L1-L5 lordosis relative to their SBA and pelvic morphology measures. API - T12-S1, API - L1-L5, and API - Cobb T12-S1 were statistically different between the groups, p < 0.001. Using ROC curve analyses, it was identified that ARA L1-L5 lordosis of 36° and ARA T12-S1 of 68° have a good sensitivity and specificity to discriminate between normal and CLBP patients. ROC curve analyses identified that lordosis ARAT12-S1 < 68° (AUC = 0.83), lordosis ARAL1-L5 < 36° (AUC = 0.78), API - ARA T12-S1 < -18° (AUC = 0.75), API - ARAL1-L5 > 35° (AUC = 0.71), and API - Cobb T12-S1 < -5° (AUC = 0.69) had moderate to good discrimination between groups (AUC = 0.83, 0.78, 0.75, and 0.72). Conclusions: Pelvic morphology is similar between normal and CLBP patients. CLBP patients have an abnormal 'fit' of their API - ARAT12-S1 and L1-L5 lumbar lordosis relative to their pelvic morphology and sacral tilt shown as a hypolordosis.
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Affiliation(s)
| | - Jason W. Haas
- Chiropractic Biophysics NonProfit, Inc., Eagle, ID 83616, USA
| | - Ibrahim M. Moustafa
- Department of Physiotherapy, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates;
- Neuromusculoskeletal Rehabilitation Research Group, RIMHS–Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates
| | | | - Paul A. Oakley
- Kinesiology and Health Science, York University, Toronto, ON M3J 1P3, Canada;
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Noureldine MHA, McBride P, Liaw D, Coughlin E, Mhaskar R, Alikhani P. Pelvic Incidence as a Predictor of Proximal Junctional Failure in Patients Undergoing Anterior Column Realignment with Anterior Longitudinal Ligament Release to Restore Lordosis in Adult Spinal Deformity: A Retrospective Cohort Study. World Neurosurg 2024; 182:e772-e779. [PMID: 38092350 DOI: 10.1016/j.wneu.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE To identify variables that may contribute to the development of proximal junctional failure (PJF) in patients with long lumbo-sacral and thoraco-lumbo-pelvic constructs undergoing anterior column realignment (ACR) with anterior longitudinal ligament release (ALLR). METHODS Data of patients with adult spinal deformity who underwent ACR with ALLR at L3-4 were collected retrospectively from medical records and a prospectively maintained spine research database between 2016 and 2022. RESULTS Eleven (41%) developed PJF at a mean of 24 ± 21 months from the index surgery. The cohort was then divided into 2 groups for analysis, 13 subjects in the high pelvic incidence (PI) group (defined as PI ≥ 55°) and 14 subjects in the low PI group (defined as PI < 55°). Visual Analog Scale for back pain and Oswestry Disability Index decreased from 9.5 to 2.1 and 61 to 10 in the high PI group, and from 8.9 to 2.4 and 60.9 to 10.3 in the low PI group, respectively. PI (P = 0.004), sacral slope (P = 0.005), and postoperative PI-lumbar lordosis mismatch (P = 0.02) were found to be significant predictors of PJF. The receiver operator curve revealed a cutoff PI value ≤ 53° (95% confidence interval: 52°-64°), below which the risk of PJF becomes significantly higher in patients undergoing ACR with ALLR at L3-4. CONCLUSIONS PI may be a predictor of PJF and highly correlates with ACR-ALLR levels. In patients undergoing L3-4 ACR-ALLR, a PI value of ≤53° is associated with a significantly elevated risk of PJF. Preoperative planning of ACR-ALLR level based on normal sagittal alignment in otherwise healthy individuals may mitigate the risk of PJF development in patients with adult spinal deformity treated with ACR-ALLR.
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Affiliation(s)
- Mohammad Hassan A Noureldine
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Paul McBride
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Deborah Liaw
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Emily Coughlin
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
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Vitale JA, Borghi S, Bassani T, Messina C, Sconfienza LM, Galbusera F. Effect of a mattress on lumbar spine alignment in supine position in healthy subjects: an MRI study. Eur Radiol Exp 2023; 7:47. [PMID: 37661237 PMCID: PMC10475448 DOI: 10.1186/s41747-023-00361-w] [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: 03/02/2023] [Accepted: 06/06/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Humans should sleep for about a third of their lifetime and the choice of the mattress is very important from a quality-of-life perspective. Therefore, the primary aim of this study was to assess the changes of lumbar angles, evaluated in a supine position using magnetic resonance imaging (MRI), on a mattress versus a rigid surface. METHODS Twenty healthy subjects (10 females, 10 males), aged 32.3 ± 6.5 (mean ± standard deviation), with body mass index 22.4 ± 2.9, completed three evaluations: (i) spine MRI in supine position on a mattress (MAT); (ii) spine MRI in supine position on rigid surface (CON); and (iii) biplanar radiographic imaging in standing position. The following indexes were calculated for both MAT and CON: lumbar lordosis angles L1-L5, L1-S1, L5-S1, and the sacral slope (SS). Further, pelvic incidence (PI) was calculated from the biplanar radiographic images. RESULTS Main findings were (i) L1-L5 and SS were greater in MAT than CON (L1:L5: +2.9°; SS: +2.0°); (ii) L5-S1 was lower in MAT than CON (-1.6°); (iii) L1-S1 was greater in MAT than CON only for male subjects (+2.0°); (iv) significant and positive correlations between PI and L1-L5, L1-S1 and SS were observed in both CON and MAT. CONCLUSIONS The use of a mattress determined small but statistically significant changes in lumbar angles. RELEVANCE STATEMENT The use of a mattress determines small but statistically significant changes in radiological angles describing the sagittal alignment of the lumbar spine when lying in the supine position. KEY POINTS • Lordosis angle L1-L5 was greater in MAT than in CON condition (+2.9°). • Sacral slope was greater in MAT than in CON condition (+2.0°). • Lordosis angle L5-S1 was lower in MAT than in CON condition (-1.6°).
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Affiliation(s)
| | - Stefano Borghi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Tito Bassani
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Carmelo Messina
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Luca Maria Sconfienza
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Ge T, Xie L, Li J, Ao J, Wu J, Sun Y. Lumbar Lordosis Distribution in Asymptomatic Adult Volunteers: A Systematic Review. HSS J 2023; 19:223-233. [PMID: 37065105 PMCID: PMC10090846 DOI: 10.1177/15563316221145156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/02/2022] [Indexed: 01/05/2023]
Abstract
Background Restoring lumbar lordosis is important for adult spinal deformity surgery. Several reports have suggested that lumbar lordosis distribution has a significant impact on the outcome of surgery, including lumbar distribution index (LDI), proximal lumbar lordosis (PLL), and distal lumbar lordosis (DLL). The features of lumbar lordosis distribution are inconclusive in asymptomatic adults. Questions/Purposes We sought to evaluate the variation of lumbar lordosis distribution (LDI, PLL, and DLL) and to identify associated factors in asymptomatic adult volunteers. Methods We performed a systematic review of the Embase and Medline databases to identify studies in asymptomatic adult volunteers to evaluate lumbar lordosis distribution including LDI, PLL, and DLL. Results Twelve articles met eligibility criteria and were included in our review. The respective pooled estimates of mean and variance, respectively, were 65.10% (95% confidence interval [CI]: 62.61-67.58) and 13.70% in LDI, 16.51° (95% CI: 5.54-27.49) and 11.46° in PLL, and 35.47° (95% CI: 32.79-38.18) and 9.10° in DLL. Lumbar lordosis distribution was associated with race, age, sex, body mass index, pelvic incidence, and Roussouly classification. Conclusions This systematic review found that despite a wide variation in LDI and PLL, DLL is maintained in a narrower range in asymptomatic adult volunteers, especially in white populations. Distal lumbar lordosis may be a more reliable radiographic parameter to restore the lumbar lordosis distribution in preoperative planning.
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Affiliation(s)
- Tenghui Ge
- Department of Spine Surgery, Peking
University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing,
People’s Republic of China
| | - Linzhen Xie
- Department of Spine Surgery, Peking
University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing,
People’s Republic of China
| | - Jianing Li
- Department of Spine Surgery, Peking
University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing,
People’s Republic of China
| | - Jintao Ao
- Department of Spine Surgery, Peking
University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing,
People’s Republic of China
| | - Jingye Wu
- Department of Spine Surgery, Peking
University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing,
People’s Republic of China
| | - Yuqing Sun
- Department of Spine Surgery, Peking
University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing,
People’s Republic of China
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Quantitative evaluation of correlation between lumbosacral lordosis and pelvic incidence in standing position among asymptomatic Asian adults: a prospective study. Sci Rep 2022; 12:18965. [PMID: 36347920 PMCID: PMC9643535 DOI: 10.1038/s41598-022-21840-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022] Open
Abstract
The determination of lumbopelvic alignment is essential for planning adult spinal deformity surgery and for ensuring favorable surgical outcomes. This prospective study investigated the correlation between the lumbar section of lumbar spine lordosis and increasing pelvic incidence in 324 Asian adults with a mean age of 55 ± 13 years (range: 20-80 years), comprising 115 male and 209 female volunteers. Participants were divided into three groups based on pelvic incidence (G1, G2, and G3 had pelvic incidence of < 45°, 45-55°, and ≥ 55°, respectively). We determined that distal and proximal lumbar lordosis contributed differentially to the increase in pelvic incidence, whereas the lordosis ratio of the L3-L4 and L4-L5 segments mostly remained constant. The mean contribution ratio of the segmental lordosis from L1 to S1 was as follows: L1-L2, 2.3%; L2-L3, 11.7%; L3-L4, 18.1%; L4-L5, 25.2%; and L5-S1, 42.7%. Pelvic incidence had a stronger correlation with proximal lumbar lordosis than did distal lumbar lordosis. The ratios of proximal lumbar lordosis to distal lumbar lordosis were 37.8% in G1, 45.8% in G2, and 55.9% in G3. These findings serve as a reference for future lumbar spine correction or fusion surgery for Asian adults.
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Chu ECP, Wong AYL. Change in Pelvic Incidence Associated With Sacroiliac Joint Dysfunction: A Case Report. J Med Cases 2022; 13:31-35. [PMID: 35211233 PMCID: PMC8827249 DOI: 10.14740/jmc3816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/23/2021] [Indexed: 11/25/2022] Open
Abstract
The sacroiliac joint (SIJ) is designed primarily for stability with minute motions. SIJ dysfunction refers to improper movement of the SIJs. Diagnosis and evaluation of SIJ dysfunction are difficult, with use of physical maneuvers and image-guided anesthetic injection. This case report describes a 47-year-old female who experienced right buttock pain and painful limp for approximately 2 months. Standing radiographs revealed inflammatory sclerosis surrounding the right SIJ. Physical examination found tenderness over the right SIJ and positive results in provocation (the distraction, compression, and thigh thrust) tests, compatible with right SIJ dysfunction. Her pain was resolved and gait performance was retrieved following 6-month program of combined thoracolumbar manipulation and rehabilitation exercises. Unexpectedly, change in pelvic incidence (PI) angles was noticed on follow-up radiograph. PI remains more or less fixed throughout adult life since the mobility of the SIJs is considered negligible. The current presentation is designed to explore the significance of PI change. The PI disparity unfolds the possibility of recognizing SIJ dysfunction based on consecutive radiographs.
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Affiliation(s)
- Eric Chun Pu Chu
- New York Chiropractic and Physiotherapy Centre, Hong Kong, China,Corresponding Author: Eric Chun Pu Chu, New York Chiropractic and Physiotherapy Centre, Hong Kong, China.
| | - Arnold Yu Lok Wong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
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Kodsy MM, Freitag HE, Winkelman RD, Rabah NM, Lee BS, Honomichl R, Thompson N, Savage JW, Orr RD, Benzel EC, Kalfas IH. A Retrospective Analysis of the L3-4 Disc and Spinopelvic Parameters on Outcomes in Thoracolumbar Fusion: Was Art Steffee Right? World Neurosurg 2021; 159:e399-e406. [PMID: 34954442 DOI: 10.1016/j.wneu.2021.12.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine if the L3-4 disc angle may be a surrogate marker for global lumbar alignment in thoracolumbar fusion surgery. To explore the relationship between radiographic and patient-reported outcomes (PROs) after thoracolumbar fusion surgery. METHODS Retrospective chart review was conducted on patients who had undergone a lumbar fusion involving levels from T9 to pelvis. EuroQol-Five Dimension (EQ-5D) scores and adverse events including adjacent segment disease and degeneration, pseudoarthrosis, proximal junctional kyphosis, stenosis, and reoperation were collected. Pre- and postoperative spinopelvic parameters were measured on weight-bearing radiographs, with the L3-4 disc angle of novel interest. Univariate logistic and linear regression were performed to assess the associations of radiographic parameters with adverse event incidence and improvement in EQ-5D, respectively. RESULTS 182 patients met inclusion criteria. Univariable analysis revealed that increased magnitude of L3-4 disc angle, anterior pelvic tilt, and pelvic incidence measures are associated with increased likelihood of developing postoperative adverse events. Conversely, increased lumbar lordosis demonstrated a decreased incidence of developing a postoperative adverse event. Linear regression showed that radiographic parameters did not significantly correlate with postoperative EQ-5D scores although scores were significantly improved post-fusion in all dimensions except Self-care (P = 0.51). CONCLUSIONS L3-4 disc angle magnitude may serve as a surrogate marker of global lumbar alignment. Degree of spinopelvic alignment did not correlate to improvement in EQ-5D score in the present study, suggesting that quality of life metric change may not be a sensitive or specific marker of post-fusion alignment.
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Affiliation(s)
- Mark M Kodsy
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA.
| | - Harvey E Freitag
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Robert D Winkelman
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nicholas M Rabah
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Bryan S Lee
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ryan Honomichl
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas Thompson
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jason W Savage
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Douglas Orr
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward C Benzel
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Iain H Kalfas
- Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Nakashima H, Ito K, Katayama Y, Tsushima M, Ando K, Kobayashi K, Machino M, Ito S, Koshimizu H, Segi N, Tomita H, Imagama S. The Level of Conus Medullaris in 629 Healthy Japanese Individuals. J Clin Med 2021; 10:jcm10143182. [PMID: 34300348 PMCID: PMC8305241 DOI: 10.3390/jcm10143182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/01/2021] [Accepted: 07/17/2021] [Indexed: 11/16/2022] Open
Abstract
The conus medullaris typically terminates at the L1 level; however, variations in its level and the factors associated with the conus medullaris level are unclear. We investigated the level of conus medullaris on magnetic resonance imaging in healthy volunteers. In total, 629 healthy adult volunteers (≥50 individuals of each sex and in each decade of age from 20 to 70) were enrolled. The level of the conus medullaris was assessed based on the T2-weighted sagittal magnetic resonance images, and factors affecting its level were investigated employing multivariate regression analysis including the participants' background and radiographical parameters. L1 was the most common conus medullaris level. Participant height was significantly shorter in the caudally placed conus medullaris (p = 0.013). With respect to the radiographical parameters, pelvic incidence (p = 0.003), and pelvic tilt (p = 0.03) were significantly smaller in participants with a caudally placed conus medullaris. Multiple regression analysis showed that the pelvic incidence (p < 0.0001) and height (p < 0.0001) were significant factors affecting the conus medullaris level. These results indicated that the length of the spinal cord varies little among individuals and that skeletal differences affect the level of the conus medullaris.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
- Correspondence:
| | - Keigo Ito
- Department of Orthopedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya 455-8530, Japan; (K.I.); (Y.K.); (M.T.)
| | - Yoshito Katayama
- Department of Orthopedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya 455-8530, Japan; (K.I.); (Y.K.); (M.T.)
| | - Mikito Tsushima
- Department of Orthopedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya 455-8530, Japan; (K.I.); (Y.K.); (M.T.)
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
| | - Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
| | - Masaaki Machino
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
| | - Sadayuki Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
| | - Hiroyuki Koshimizu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
| | - Naoki Segi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
| | - Hiroyuki Tomita
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan; (K.A.); (K.K.); (M.M.); (S.I.); (H.K.); (N.S.); (H.T.); (S.I.)
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