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Samelis PV, Koulouvaris P, Savvidou O, Mavrogenis A, Samelis VP, Papagelopoulos PJ. Patellar Dislocation: Workup and Decision-Making. Cureus 2023; 15:e46743. [PMID: 38021800 PMCID: PMC10631568 DOI: 10.7759/cureus.46743] [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] [Accepted: 09/30/2023] [Indexed: 12/01/2023] Open
Abstract
Acute patellar dislocation (PD) is usually a problem of adolescents and young adults. In most cases, it is a sports-related injury. It is the result of an indirect force on the knee joint, which leads to valgus and external rotation of the tibia relative to the femur. PD is unlikely to occur on a knee with normal patellofemoral joint (PFJ) anatomy. Acute PD consists of an acute injury of the ligamentous medial patellar stabilizers in the background of factors predisposing to patellar instability. These factors are classified into three groups. The first group refers to the integrity of the ligamentous medial patellar restraints, particularly, the medial patellofemoral ligament (MPFL). The second group refers to an abnormal PFJ anatomy, which renders the patella inherently unstable inside the trochlea. The third group refers to the overall axial and torsional profile of the lower limb and to systemic factors, such as ligament laxity and neuromuscular coordination of movement. PD at a younger age is associated with an increased number and severity of patellar instability predisposing factors and lower stress to dislocate the patella. Acute primary PD is usually treated conservatively, while surgical treatment is reserved for recurrent PD. The aim of treatment is to restore the stability and function of the PFJ and to reduce the risk of patellar redislocation. Surgical procedures to treat patellar instability are classified into non-anatomic and anatomic procedures. Non-anatomic procedures are extensor mechanism realignment techniques that aim to center the patella into the trochlear groove. Anatomic procedures aim to restore the PFJ anatomy (ruptured ligaments, osteochondral fractures), which has been severed after the first incident of PD. Anatomic procedures, especially MPFL reconstruction, are more effective in preventing recurrent PD, compared with non-anatomic techniques. Theoretically, all factors that affect PFJ stability should be evaluated and, if possible, addressed. This is practically impossible. Considering that the MPFL ruptures in almost all PDs, MPFL reconstruction is the primary procedure, which is currently selected by most surgeons as a first-line treatment for patients with recurrent PD. Restoration of the axial and torsional alignment of the lower limbs is also increasingly implemented by surgeons. Non-anatomic surgical techniques, such as tibial-tuberosity osteotomy, are used as an adjunct to anatomic procedures. In the presence of multiple PFJ instability factors, acute MPFL reconstruction may be the treatment of choice for acute primary PD as well. Skeletal immaturity of the patient precludes osseous procedures to avoid premature physis closure and subsequent limb deformity. Unfortunately, restoration of the patient's previous activity level or participation in more strenuous sports is questionable and not easy to predict. In the case of competitive athletes, PD may prevent participation in elite levels of sports.
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Affiliation(s)
- Panagiotis V Samelis
- Orthopaedics, Children's General Hospital Panagiotis and Aglaia Kyriakou, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Panagiotis Koulouvaris
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Olga Savvidou
- Orthopaedics, Attikon University Hospital, Athens, GRC
| | - Andreas Mavrogenis
- Orthopaedics, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | | | - Panayiotis J Papagelopoulos
- Orthopaedic Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
- Orthopaedics, Attikon University Hospital, Athens, GRC
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Jiang J, Yi Z, Li J, Liu Y, Xia Y, Wu M. Medial Patellofemoral Ligament Reconstruction is Preferred to Repair or Reefing for First-Time Patellar Dislocation: A Systematic Review and Meta-analysis. Indian J Orthop 2023; 57:177-188. [PMID: 36777132 PMCID: PMC9880132 DOI: 10.1007/s43465-022-00770-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022]
Abstract
Purpose The purpose of this systematic review aimed to investigate the clinical outcome of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair and medial reefing for patients with first-time patellar dislocation. Methods Databases of PubMed, EMBASE, Cochrane Library and Web of Science were searched up to May 8, 2022. Only articles treating first-time patellar dislocation with MPFL reconstruction, MPFL repair and medial reefing were included in the analysis. Eligible identification, data extraction, quality assessment and statistical analysis were performed by two independent reviewers. The primary outcome measures were the incidences of postoperatively redislocation and reoperation. The second outcomes were the Kujala functional score and complications (including infection, osteoarthritis, and loss of range of motion). Results Twenty-two studies involving 668 patients met the inclusion criteria. Of which, four studies involving 126 patients were in MPFL reconstruction group, ten studies involving 220 patients in MPFL repair group and 9 studies involving 322 patients in medial reefing group. Our results showed that the MPFL reconstruction (1.8%, 95% CI - 0.5 to 4.0%) had a significantly lower rate of postoperative redislocation and reoperation rate than the MPFL repair (15.4%, 95% CI 5.2-25.7%) and medial reefing (18.0%, 95% CI 9.3-26.7%). Besides, no significant differences were found in the Kujala score and complication rate among the three treatments. Conclusion The available evidence demonstrated that MPFL reconstruction could achieve significantly lower redislocation rate and reoperation rate than MPFL repair and medial reefing after first-time patella dislocation. Furthermore, there was not enough evidence to reveal that MPFL reconstruction provided better functional outcome compared with MPFL repair and medial reefing. MPFL reconstruction is a preferred surgical treatment for patients with first-time patellar dislocation. Level of Evidence Level IV, systematic review of Level I-IV.
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Affiliation(s)
- Jin Jiang
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Zhi Yi
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Junmin Li
- Department of Pharmacy, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yan Liu
- School of Pharmacy, Lanzhou University, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
| | - Meng Wu
- Department of Orthopaedics, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu China
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Smith TO, Gaukroger A, Metcalfe A, Hing CB. Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database Syst Rev 2023; 1:CD008106. [PMID: 36692346 PMCID: PMC9872769 DOI: 10.1002/14651858.cd008106.pub4] [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: 01/25/2023]
Abstract
BACKGROUND Patellar (knee cap) dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. It affects up to 42/100,000 people, and is most prevalent in those aged 20 to 30 years old. It is uncertain whether surgical or non-surgical treatment is the best approach. This is important as recurrent dislocation occurs in up to 40% of people who experience a first time (primary) dislocation. This can reduce quality of life and as a result people have to modify their lifestyle. This review is needed to determine whether surgical or non-surgical treatment should be offered to people after patellar dislocation. OBJECTIVES To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL, Physiotherapy Evidence Database and trial registries in December 2021. We contacted corresponding authors to identify additional studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating primary or recurrent lateral patellar dislocation in adults or children. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were recurrent patellar dislocation, and patient-rated knee and physical function scores. Our secondary outcomes were health-related quality of life, return to former activities, knee pain during activity or at rest, adverse events, patient-reported satisfaction, patient-reported knee instability symptoms and subsequent requirement for knee surgery. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 10 studies (eight randomised controlled trials (RCTs) and two quasi-RCTs) of 519 participants with patellar dislocation. The mean ages in the individual studies ranged from 13.0 to 27.2 years. Four studies included children, mainly adolescents, as well as adults; two only recruited children. Study follow-up ranged from one to 14 years. We are unsure of the evidence for all outcomes in this review because we judged the certainty of the evidence to be very low. We downgraded each outcome by three levels. Reasons included imprecision (when fewer than 100 events were reported or the confidence interval (CI) indicated appreciable benefits as well as harms), risk of bias (when studies were at high risk of performance, detection and attrition bias), and inconsistency (in the event that pooled analysis included high levels of statistical heterogeneity). We are uncertain whether surgery lowers the risk of recurrent dislocation following primary patellar dislocation compared with non-surgical management at two to nine year follow-up. Based on an illustrative risk of recurrent dislocation in 348 people per 1000 in the non-surgical group, we found that 157 fewer people per 1000 (95% CI 209 fewer to 87 fewer) had recurrent dislocation between two and nine years after surgery (8 studies, 438 participants). We are uncertain whether surgery improves patient-rated knee and function scores. Studies measured this outcome using different scales (the Tegner activity scale, Knee Injury and Osteoarthritis Outcome Score, Lysholm, Kujala Patellofemoral Disorders score and Hughston visual analogue scale). The most frequently reported score was the Kujala Patellofemoral Disorders score. This indicated people in the surgical group had a mean score of 5.73 points higher at two to nine year follow-up (95% CI 2.91 lower to 14.37 higher; 7 studies, 401 participants). On this 100-point scale, higher scores indicate better function, and a change score of 10 points is considered to be clinically meaningful; therefore, this CI includes a possible meaningful improvement. We are uncertain whether surgery increases the risk of adverse events. Based on an assumed risk of overall incidence of complications during the first two years in 277 people out of 1000 in the non-surgical group, 335 more people per 1000 (95% CI 75 fewer to 723 more) had an adverse event in the surgery group (2 studies, 144 participants). Three studies (176 participants) assessed participant satisfaction at two to nine year follow-up, reporting little difference between groups. Based on an assumed risk of 763 per 1000 non-surgical participants reporting excellent or good outcomes, seven more participants per 1000 (95% CI 199 fewer to 237 more) reported excellent or good satisfaction. Four studies (256 participants) assessed recurrent patellar subluxation at two to nine year follow-up. Based on an assumed risk of patellar subluxation in 292 out of 1000 in the non-surgical group, 73 fewer people per 1000 (95% CI 146 fewer to 35 more) had patellar subluxation as a result of surgery. Slightly more people had subsequent surgery in the non-surgical group. Pooled two to nine year follow-up data from three trials (195 participants) indicated that, based on an assumed risk of subsequent surgery in 215 people per 1000 in the non-surgical group, 118 fewer people per 1000 (95% CI 200 fewer to 372 more) had subsequent surgery after primary surgery. AUTHORS' CONCLUSIONS We are uncertain whether surgery improves outcome compared to non-surgical management as the certainty of the evidence was very low. No sufficiently powered trial has examined people with recurrent patellar dislocation. Adequately powered, multicentre, randomised trials are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the pathological variations that may be relevant to both choice of these interventions.
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Affiliation(s)
- Toby O Smith
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Andrew Gaukroger
- Trauma and Orthopaedics, St George's University Hospital NHS trust, London, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Caroline B Hing
- Department of Trauma and Orthopaedic Surgery, St George's Hospital, London, UK
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D'Ambrosi R, Migliorini F, Cerciello S, Guerra G, Corona K, Mangiavini L, Ursino N, Vlaic J, Jelic M. Management of the first episode of traumatic patellar dislocation: an international survey. Knee Surg Sports Traumatol Arthrosc 2022; 31:2257-2265. [PMID: 36477349 DOI: 10.1007/s00167-022-07273-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE This international survey aimed to evaluate the potential controversies regarding the management of first patellar dislocation amongst experienced knee surgeries in the treatment of the first episode of patellar dislocation without osteochondral fragments. METHODS An online survey was conducted from February 2021 to December 2021 to assess the global trend in the diagnosis and management of first-time patellar dislocation without osteochondral fragments. The online survey was accessible on the homepage of the website of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The questionnaire consisted of multiple-choice questions and was divided into three sections. The first section consisted of eight questions regarding demographic information, professional activity, and responder experience. The second section consisted of 13 questions regarding the approach to a first patellar dislocation (clinical examination, imaging, and rehabilitation). The third section contained 2 questions concerning the relevance of patient characteristics to the therapeutic algorithm (age, sports, and pathoanatomical predisposing risk factors). RESULTS A total of 438 orthopaedic surgeons worldwide completed the questionnaire. At the first approach to diagnose a first-time patellar dislocation, 251 (57%) of the surgeons requested plain radiographs, and 158 (36%) requested magnetic resonance imaging (MRI). In conservatively treated patients, 368 (84%) of the respondents recommended the use of a knee brace. Amongst them, 14 (3%) advocated its use for one week, 75 (17%) for two weeks, 123 (28%) for three weeks, 105 (24%) for four weeks, and 97 (22%) for six weeks. In conservatively treated patients, 215 (49%) of the surgeons recommended load to tolerance, 148 (34%) recommended 30% to 60% of the bodyweight, and 75 (17%) advised against weight-bearing. More than half of the surgeons considered a patient aged less than 35 years practising contact sports to be a candidate for the medial patello-femoral ligament (MPFL) procedure. In addition, a tibial tuberosity to trochlear groove distance (TT-TG) distance of 15 to > 20 mm (for > 75% of the surgeons) and a trochlea types C and D (for > 70% of the surgeons) were considered possible indications for direct surgical management. CONCLUSION At the first approach to diagnose a first-time patellar dislocation, plain radiographs and MRI should be performed. In conservatively treated patients, most of the surgeons recommend weight-bearing to tolerance and a knee brace during the first four weeks, with range of motion of full extension to 30° during the first 15 days and up to 60° for an additional 15 days. Surgical management should be performed in patients in the second and third decades of life practising contact sports and in those patients who present types C and D trochlea dysplasia and patella alta. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Riccardo D'Ambrosi
- IRCCS Orthopedic Institute Galeazzi, Milan, Italy. .,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Aachen, Germany
| | - Simone Cerciello
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy.,Casa di Cura Villa Betania, Rome, Italy.,Marrelli Hospital, Crotone, Italy
| | - Germano Guerra
- Department of Medicine, Health Sciences Vincenzo Tiberio, University of Molise, Campobasso, Italy
| | - Katia Corona
- Department of Medicine, Health Sciences Vincenzo Tiberio, University of Molise, Campobasso, Italy
| | - Laura Mangiavini
- IRCCS Orthopedic Institute Galeazzi, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | | | - Mislav Jelic
- Department of Orthopaedic Surgery, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
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MPFL repair after acute first-time patellar dislocation results in lower redislocation rates and less knee pain compared to rehabilitation: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07222-w. [PMID: 36372845 DOI: 10.1007/s00167-022-07222-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/02/2022] [Indexed: 11/14/2022]
Abstract
PURPOSE This study aimed to explore the efficacy of medial patellofemoral ligament (MPFL) repair versus nonoperative rehabilitation treatment on the rate of patellar redislocation and functional outcomes in skeletally mature patients with traumatic, first-time patellar dislocations. MATERIALS AND METHODS MEDLINE, PubMed and EMBASE were searched from database inception to May 2022 for studies examining the management options for acute first-time patellar dislocations. This study was conducted in accordance with PRISMA and R-AMSTAR guidelines. Data on redislocation rates, functional outcomes including the Kujala score for anterior knee pain, and complication rates were extracted. A meta-analysis was used to pool the mean postoperative Kujala score and calculate the proportion of patients sustaining redislocations using a random effects model. Quality assessment of included studies was performed for all included studies using the MINORS and Detsky scores. RESULTS This review included a total of 25 studies and 1,361 patients. The pooled mean redislocation rate in 15 studies comprising 798 patients in the rehabilitation group was 30% (95% CI 25-36%, I2 = 65%). Moreover, the pooled mean redislocation rate in 10 studies comprising 170 patients undergoing MPFL repair was 7% (95% CI 3-12%, I2 = 30%). The pooled mean postoperative Kujala score in 8 studies comprising 396 patients in the rehabilitation group was 82.5 (95% CI 78.3-86.8, I2 = 91%), compared to a score of 88 (95% CI 87-90, I2 = 76%) in 3 studies comprising 94 patients in the repair group. Range of motion deficits was reported in 3.8% of 893 patients in the rehabilitation group and 2.0% of 205 patients in the repair group. CONCLUSION MPFL repair resulted in a lower rate of redislocation, less knee pain, and noninferiority with respect to a range of motion deficits compared to nonoperative treatment for the management of acute first-time patellar dislocations. LEVEL OF EVIDENCE IV.
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Liu Z, Yi Q, He L, Yao C, Zhang L, Lu F, Zhang X, Wu M, Geng B, Xia Y, Jiang J. Comparing Nonoperative Treatment, MPFL Repair, and MPFL Reconstruction for Patients With Patellar Dislocation: A Systematic Review and Network Meta-analysis. Orthop J Sports Med 2021; 9:23259671211026624. [PMID: 34604425 PMCID: PMC8485172 DOI: 10.1177/23259671211026624] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/28/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, and
nonoperative treatment are important treatments for patients with patellar
dislocation. However, it is unclear which treatment leads to better
outcomes. Purpose: To determine the efficacy and safety of the 3 treatments in the treatment of
patellar dislocation and compare the effect of MPFL reconstruction with MPFL
repair, MPFL reconstruction with nonoperative treatment, and MPFL repair
with nonoperative treatment. Study Design: Systematic review; Level of evidence, 3. Methods: The PubMed, Web of Science, Cochrane Library, Embase, CNKI (China National
Knowledge Infrastructure), and Wanfang databases were searched from
inception to December 2020. Included were clinical studies that described
the efficacy and safety of 2 of the 3 treatments, studies directly comparing
the clinical effects of the 2 operative techniques, or studies comparing the
effects of reconstruction or repair with nonoperative treatment. Two
reviewers independently extracted data and assessed the quality of the
included studies with the Cochrane risk-of-bias tools. The outcomes
evaluated were postoperative redislocation rate, revision rate,
complications, and Kujala score. We used traditional direct pairwise
meta-analysis as well as network meta-analysis for comprehensive efficacy of
all 3 treatment measures. Results: Twelve studies were included: 5 compared MPFL reconstruction with MPFL
repair, 2 compared MPFL reconstruction with nonoperative treatment, and 5
compared MPFL repair with nonoperative treatment. The risk of bias was
serious in 4, moderate in 4 and low in 4 articles. MPFL reconstruction led
to significantly reduced redislocation and improved Kujala scores compared
with MPFL repair and nonoperative treatment. MPFL repair led to reduced
redislocation rates compared with nonoperative treatment but did not show an
obvious benefit in primary dislocations. There was no significant difference
among the 3 treatments in terms of revision rate and incidence of
complications, although we found that treatment-related complications were
least likely to occur in nonoperative treatment. Conclusion: The results of this review indicate that MPFL reconstruction decreases
recurrent dislocation compared with MPFL repair or nonoperative treatment,
but it has a higher possibility of complications. MPFL repair resulted in
less postoperative redislocation than nonoperative treatment but did not
show an obvious benefit in primary dislocation.
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Affiliation(s)
- Zhongcheng Liu
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Qiong Yi
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Liangzhi He
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Changjiang Yao
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Lanfang Zhang
- Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Fan Lu
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Xiaohui Zhang
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Meng Wu
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Bin Geng
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Yayi Xia
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
| | - Jin Jiang
- Department of Orthopaedics, Gansu Key Laboratory of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China
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