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Murphy J, Pak S, Shteynman L, Winkeler I, Jin Z, Kaczocha M, Bergese SD. Mechanisms and Preventative Strategies for Persistent Pain following Knee and Hip Joint Replacement Surgery: A Narrative Review. Int J Mol Sci 2024; 25:4722. [PMID: 38731944 PMCID: PMC11083264 DOI: 10.3390/ijms25094722] [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: 03/01/2024] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Chronic postsurgical pain (CPSP) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is a prevalent complication of joint replacement surgery which has the potential to decrease patient satisfaction, increase financial burden, and lead to long-term disability. The identification of risk factors for CPSP following TKA and THA is challenging but essential for targeted preventative therapy. Recent meta-analyses and individual studies highlight associations between elevated state anxiety, depression scores, preoperative pain, diabetes, sleep disturbances, and various other factors with an increased risk of CPSP, with differences observed in prevalence between TKA and THA. While the etiology of CPSP is not fully understood, several factors such as chronic inflammation and preoperative central sensitization have been identified. Other potential mechanisms include genetic factors (e.g., catechol-O-methyltransferase (COMT) and potassium inwardly rectifying channel subfamily J member 6 (KCNJ6) genes), lipid markers, and psychological risk factors (anxiety and depression). With regards to therapeutics and prevention, multimodal pharmacological analgesia, emphasizing nonopioid analgesics like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), has gained prominence over epidural analgesia. Nerve blocks and local infiltrative anesthesia have shown mixed results in preventing CPSP. Ketamine, an N-methyl-D-aspartate (NMDA)-receptor antagonist, exhibits antihyperalgesic properties, but its efficacy in reducing CPSP is inconclusive. Lidocaine, an amide-type local anesthetic, shows tentative positive effects on CPSP. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have mixed results, while gabapentinoids, like gabapentin and pregabalin, present hopeful data but require further research, especially in the context of TKA and THA, to justify their use for CPSP prevention.
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Affiliation(s)
- Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Sery Pak
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Lana Shteynman
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Ian Winkeler
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11794, USA; (M.K.); (S.D.B.)
| | - Martin Kaczocha
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11794, USA; (M.K.); (S.D.B.)
| | - Sergio D. Bergese
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11794, USA; (M.K.); (S.D.B.)
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Sreckovic S, Ladjevic N, Milicic B, Tulic G, Milovanovic D, Djukanovic M, Kadija M. Chronic post-surgical pain after knee arthroplasty: a role of peripheral nerve blocks. Front Med (Lausanne) 2024; 10:1335405. [PMID: 38274441 PMCID: PMC10810136 DOI: 10.3389/fmed.2023.1335405] [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: 11/15/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Peripheral nerve blocks are an efficient method of pain control after total knee arthroplasty (TKA), but there is no report of their impact on chronic post-surgical pain (CPSP). Methods This prospective observational study aimed to assess adductor canal block (ACB) and IPACK block (blocks vs. no blocks) on opioid consumption, postoperative pain score, chronic post-surgical pain 2 years after TKA. Results 166 patients (82 vs. 84) were analyzed. Opioid consumption was less in the group with blocks (9.74 ± 3.87 mg vs. 30.63 ± 11.52 mg) (p < 0.001). CPSP was present in 20.24% of patients in the group without blocks and 6.1% of patients with blocks (p = 0.011). Predictor variables of CPSP included pain before surgery (cut-off of 5.5), pain at rest (cut-off of 2.35), pain during active movement (cut-off: 2.5), and opioid consumption (cut-off: 8 mg). Conclusion Peripheral nerve blocks provide adequate analgesia, significantly decrease opioid consumption, improve functional outcomes, and reduce CPSP 2 years after surgery.
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Affiliation(s)
- Svetlana Sreckovic
- Centre of Anaesthesia and Resuscitation, University Clinical Centre of Serbia, Belgrade, Serbia
- Clinic for Orthopaedics Surgery and Traumatology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Nebojsa Ladjevic
- Centre of Anaesthesia and Resuscitation, University Clinical Centre of Serbia, Belgrade, Serbia
- Medical School, University of Belgrade, Belgrade, Serbia
| | - Biljana Milicic
- Department of Medical Statistics and Informatics, Belgrade, Serbia
- School of Dental Medicine, University of Belgrade, Belgrade, Serbia
| | - Goran Tulic
- Clinic for Orthopaedics Surgery and Traumatology, University Clinical Centre of Serbia, Belgrade, Serbia
- Medical School, University of Belgrade, Belgrade, Serbia
| | - Darko Milovanovic
- Clinic for Orthopaedics Surgery and Traumatology, University Clinical Centre of Serbia, Belgrade, Serbia
- Medical School, University of Belgrade, Belgrade, Serbia
| | - Marija Djukanovic
- Centre of Anaesthesia and Resuscitation, University Clinical Centre of Serbia, Belgrade, Serbia
- Medical School, University of Belgrade, Belgrade, Serbia
| | - Marko Kadija
- Clinic for Orthopaedics Surgery and Traumatology, University Clinical Centre of Serbia, Belgrade, Serbia
- Medical School, University of Belgrade, Belgrade, Serbia
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Rosenberger DC, Segelcke D, Pogatzki-Zahn EM. Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors. Curr Opin Support Palliat Care 2023; 17:324-337. [PMID: 37696259 DOI: 10.1097/spc.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
PURPOSE OF REVIEW Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases). RECENT FINDINGS Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated. SUMMARY This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.
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Affiliation(s)
- Daniela C Rosenberger
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
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Dembek DJ, Bicket MC. Advances in the management of persistent pain after total knee arthroplasty. Curr Opin Anaesthesiol 2023; 36:560-564. [PMID: 37338943 DOI: 10.1097/aco.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW Total knee arthroplasty (TKA) is one of the most commonly performed surgical procedures, with additional growth anticipated as the US population ages. Because the prevalence of chronic postsurgical pain ranges from 15 to 25%, identifying persons at risk for persistent pain following surgery allows for preoperative optimization of risk factors as well as early identification and intervention in the postsurgical period. RECENT FINDINGS Clinical understanding of available management techniques is critical to management, which should focus on improving patient mobility and satisfaction while reducing patient disability and healthcare costs. Current evidence supports a multimodal management strategy. This includes pharmacologic and nonpharmacologic interventions, procedural techniques, and identification and optimization of psychosocial and behavioral contributors to chronic pain. Procedural techniques known to confer analgesia include radiofrequency and watercooled neurotomy techniques. More recently, case reports have been published describing analgesic benefit with central or peripheral neuromodulation as a novel, though more invasive analgesic therapy. SUMMARY Identification and early intervention to address persistent pain after TKA is important to optimize patient outcomes. The anticipated growth in TKA underscores the need for future investigations to more fully define potential therapies for chronic pain following TKA.
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Affiliation(s)
| | - Mark C Bicket
- Department of Anesthesiology
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
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Meert L, Mertens MG, Meeus M, Vervullens S, Baert I, Beckwée D, Verdonk P, Smeets RJEM. Identification of Metabolic Factors and Inflammatory Markers Predictive of Outcome after Total Knee Arthroplasty in Patients with Knee Osteoarthritis: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105796. [PMID: 37239524 DOI: 10.3390/ijerph20105796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/24/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To identify metabolic factors and inflammatory markers that are predictive of postoperative total knee arthroplasty (TKA) outcome. METHOD A systematic search of the existing literature was performed using the electronic databases PubMed, Web of Science and Embase until the 1st of August 2022. Studies that evaluated the influence of metabolic or inflammatory markers (I) on postsurgical outcome (O) in end-stage knee osteoarthritis patients awaiting primary TKA (P) were included in this review. RESULTS In total, 49 studies were included. Risk of bias of the included studies was low for one study, moderate for 10 studies and high for the remaining 38 studies. Conflicting evidence was found for the influence of body mass index, diabetes, cytokine levels and dyslipidaemia on pain, function, satisfaction and quality of life at more than six months after TKA. CONCLUSIONS Several limitations such as not taking into account known confounding factors, the use of many different outcome measures and a widely varying follow-up period made it challenging to draw firm conclusions and clinical implications. Therefore large-scaled longitudinal studies assessing the predictive value of metabolic and inflammatory factors pre-surgery in addition to the already evidenced risk factors with follow-up of one year after TKA are warranted.
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Affiliation(s)
- Lotte Meert
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, 2610 Wilrijk, Belgium
- Pain in Motion, International Research Group, Vrije Universiteit Brussel, 1050 Brussels, Belgium
| | - Michel Gcam Mertens
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, 2610 Wilrijk, Belgium
- Pain in Motion, International Research Group, Vrije Universiteit Brussel, 1050 Brussels, Belgium
| | - Mira Meeus
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, 2610 Wilrijk, Belgium
- Pain in Motion, International Research Group, Vrije Universiteit Brussel, 1050 Brussels, Belgium
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | - Sophie Vervullens
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, 2610 Wilrijk, Belgium
- Pain in Motion, International Research Group, Vrije Universiteit Brussel, 1050 Brussels, Belgium
| | - Isabel Baert
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, 2610 Wilrijk, Belgium
- Pain in Motion, International Research Group, Vrije Universiteit Brussel, 1050 Brussels, Belgium
| | - David Beckwée
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, 2610 Wilrijk, Belgium
- Rehabilitation Research (RERE) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy (KIMA), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Peter Verdonk
- Antwerp Orthopaedic Center, AZ Monica Hospitals, 2018 Antwerp, Belgium
| | - Rob J E M Smeets
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University and CIR Revalidatie, 5628 WB Eindhoven, The Netherlands
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Taslakian B, Miller LE, Mabud TS, Macaulay W, Samuels J, Attur M, Alaia EF, Kijowski R, Hickey R, Sista AK. Genicular artery embolization for treatment of knee osteoarthritis pain: Systematic review and meta-analysis. OSTEOARTHRITIS AND CARTILAGE OPEN 2023; 5:100342. [PMID: 36865988 PMCID: PMC9971280 DOI: 10.1016/j.ocarto.2023.100342] [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: 01/24/2023] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
Objective Genicular artery embolization (GAE) is a novel, minimally invasive procedure for treatment of knee osteoarthritis (OA). This meta-analysis investigated the safety and effectiveness of this procedure. Design Outcomes of this systematic review with meta-analysis were technical success, knee pain visual analog scale (VAS; 0-100 scale), WOMAC Total Score (0-100 scale), retreatment rate, and adverse events. Continuous outcomes were calculated as the weighted mean difference (WMD) versus baseline. Minimal clinically important difference (MCID) and substantial clinical benefit (SCB) rates were estimated in Monte Carlo simulations. Rates of total knee replacement and repeat GAE were calculated using life-table methods. Results In 10 groups (9 studies; 270 patients; 339 knees), GAE technical success was 99.7%. Over 12 months, the WMD ranged from -34 to -39 at each follow-up for VAS score and -28 to -34 for WOMAC Total score (all p < 0.001). At 12 months, 78% met the MCID for VAS score; 92% met the MCID for WOMAC Total score, and 78% met the SCB for WOMAC Total score. Higher baseline knee pain severity was associated with greater improvements in knee pain. Over 2 years, 5.2% of patients underwent total knee replacement and 8.3% received repeat GAE. Adverse events were minor, with transient skin discoloration as the most common (11.6%). Conclusions Limited evidence suggests that GAE is a safe procedure that confers improvement in knee OA symptoms at established MCID thresholds. Patients with greater knee pain severity may be more responsive to GAE.
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Affiliation(s)
- Bedros Taslakian
- Division of Vascular and Interventional Radiology, Department of Radiology, NYU Langone Health, New York, NY, United States,Corresponding author. Clinical assistant Professor of Radiology, NYU Grossman School of Medicine; Director of VIR Research Program, Interventional Radiology Section; Director of Clinical Research Integration, Department of Radiology, NYU Langone Health, New York, NY, United States.
| | | | - Tarub S. Mabud
- Division of Vascular and Interventional Radiology, Department of Radiology, NYU Langone Health, New York, NY, United States
| | - William Macaulay
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Jonathan Samuels
- Division of Rheumatology, Department of Medicine, NYU Langone Health, New York, NY, United States
| | - Mukundan Attur
- Division of Rheumatology, Department of Medicine, NYU Langone Health, New York, NY, United States
| | - Erin F. Alaia
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Langone Health, New York, NY, United States
| | - Richard Kijowski
- Division of Musculoskeletal Radiology, Department of Radiology, NYU Langone Health, New York, NY, United States
| | - Ryan Hickey
- Division of Vascular and Interventional Radiology, Department of Radiology, NYU Langone Health, New York, NY, United States
| | - Akhilesh K. Sista
- Division of Vascular and Interventional Radiology, Department of Radiology, Weill Cornell Medicine, New York, NY, United States
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Shu B, Xu F, Zheng X, Zhang Y, Liu Q, Li S, Chen J, Chen Y, Huang H, Duan G. Change in perioperative neutrophil-lymphocyte ratio as a potential predictive biomarker for chronic postsurgical pain and quality of life: an ambispective observational cohort study. Front Immunol 2023; 14:1177285. [PMID: 37122722 PMCID: PMC10130394 DOI: 10.3389/fimmu.2023.1177285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Accurate and accessible predictors of chronic postsurgical pain (CPSP) to identify high-risk postsurgical patients are prerequisite for preventive and interventional strategies. We investigated the incidence and risk factors of CPSP after abdominal surgery, with a focus on plasma immunological markers. Materials and methods This was a retrospective analysis of patients who underwent abdominal surgery under general anesthesia at a tertiary center between January 2021 and January 2022. The preoperative demographics, laboratory test data, and surgical factors of the participants were collected from the electronic medical record system. Postoperative pain intensity and living conditions at 1 year after discharge from the hospital were assessed via a phone survey. Univariate and multivariate analyses were used to explore independent risk factors associated with CPSP. Results A total of 968 patients were included, and 13.53% (n = 131 of 968) of patients reported CPSP 1 year after surgery. Patients with older age, open surgery, higher American Association of Anesthesiologists classification, patient-controlled intravenous analgesia application, longer surgery duration, higher postoperative absolute neutrophil count, and neutrophil-lymphocyte ratio (NLR), lower postoperative absolute lymphocyte count, and higher white blood cell count, were more likely to suffer from CPSP. A changed ratio of NLR (postoperative to preoperative) ≥ 5 significantly correlated with CPSP, moderate to severe pain, maximum numeric rating score since discharge from the hospital, and affected quality of life. Discussion The changed ratio of NLR could be used for the early identification of patients at risk for CPSP and affect the quality of life to alert the clinician to undertake further assessment.
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Affiliation(s)
| | | | | | | | | | | | | | | | - He Huang
- *Correspondence: He Huang, ; Guangyou Duan,
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Kirksey MA, Lessard SG, Khan M, Birch GA, Oliver D, Singh P, Rotundo V, Sideris A, Gonzalez Della Valle A, Parks ML, Sculco PK, Otero M. Association of circulating gene expression signatures with stiffness following total knee arthroplasty for osteoarthritis: a pilot study. Sci Rep 2022; 12:12651. [PMID: 35879399 PMCID: PMC9314445 DOI: 10.1038/s41598-022-16868-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/18/2022] [Indexed: 11/22/2022] Open
Abstract
A subset of patients undergoing total knee arthroplasty (TKA) for knee osteoarthritis develop debilitating knee stiffness (reduced range of motion) for poorly understood reasons. Dysregulated inflammatory and immune responses to surgery correlate with reduced surgical outcomes, but the dysregulated gene signatures in patients with stiffness after TKA are poorly defined. As a consequence, we are limited in our ability to identify patients at risk of developing poor surgical outcomes and develop preventative approaches. In this pilot study we aimed to identify perioperative blood gene signatures in patients undergoing TKA for knee osteoarthritis and its association with early surgical outcomes, specifically knee range of motion. To do this, we integrated clinical outcomes collected at 6 weeks after surgery with transcriptomics analyses in blood samples collected immediately before surgery and at 24 h after surgery. We found that patients with stiffness at 6 weeks after surgery have a more variable and attenuated circulating gene expression response immediately after surgery. Our results suggest that patients with stiffness following TKA may have distinct gene expression signatures detectable in peripheral blood in the immediate postoperative period.
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Affiliation(s)
- Meghan A Kirksey
- Hospital for Special Surgery, New York, NY, 10021, USA.,Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, 10021, USA.,Weill Cornell Medical College, New York, NY, 10021, USA
| | - Samantha G Lessard
- Hospital for Special Surgery, New York, NY, 10021, USA.,HSS Research Institute, Hospital for Special Surgery, New York, NY, 10021, USA.,Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Marjan Khan
- Hospital for Special Surgery, New York, NY, 10021, USA.,HSS Research Institute, Hospital for Special Surgery, New York, NY, 10021, USA.,Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY, 10021, USA
| | - George A Birch
- Hospital for Special Surgery, New York, NY, 10021, USA.,Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, 10021, USA
| | - David Oliver
- Hospital for Special Surgery, New York, NY, 10021, USA.,HSS Research Institute, Hospital for Special Surgery, New York, NY, 10021, USA.,The David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Purva Singh
- Hospital for Special Surgery, New York, NY, 10021, USA.,HSS Research Institute, Hospital for Special Surgery, New York, NY, 10021, USA.,Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Valeria Rotundo
- Hospital for Special Surgery, New York, NY, 10021, USA.,Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Alexandra Sideris
- Hospital for Special Surgery, New York, NY, 10021, USA.,Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, 10021, USA
| | | | - Alejandro Gonzalez Della Valle
- Hospital for Special Surgery, New York, NY, 10021, USA.,Weill Cornell Medical College, New York, NY, 10021, USA.,The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Michael L Parks
- Hospital for Special Surgery, New York, NY, 10021, USA.,Weill Cornell Medical College, New York, NY, 10021, USA.,The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Peter K Sculco
- Hospital for Special Surgery, New York, NY, 10021, USA.,Weill Cornell Medical College, New York, NY, 10021, USA.,The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Miguel Otero
- Hospital for Special Surgery, New York, NY, 10021, USA. .,Weill Cornell Medical College, New York, NY, 10021, USA. .,HSS Research Institute, Hospital for Special Surgery, New York, NY, 10021, USA. .,Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY, 10021, USA. .,The David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY, 10021, USA.
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