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Mendel T, Steinke M, Schenk P, Migliorini F, Schütte V, Reisberg A, Kobbe P, Heinecke M. Conservative management of proximal hamstring avulsion: A clinical study. J Orthop 2024; 55:74-79. [PMID: 38665987 PMCID: PMC11039336 DOI: 10.1016/j.jor.2024.03.032] [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: 12/31/2023] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction The management of proximal hamstring tear (PHT) is debated and consensus regarding recommended measures and individual treatment regimens is lacking. The present investigation evaluated the efficacy of a conservative management of partial and complete PHT. Methods The present observational study was conducted following the STROBE statement. In June 2018 the medical databases of the BG Klinikum Bergmannstrost Halle, Germany were accessed. All the patients with PHT were retrieved. The outcomes of interest were to evaluate the clinical examination, PROMs, imaging, and isokinetic muscle strength at the baseline and last follow-up. Results 31 patients were enrolled in the present study. Nine patients (29 % (9 of 31) described local pain at the ischial tuberosity in sitting situations and also in manual palpation. A persistent gap in the tendon string beneath the tuberosity in manual palpation was reported in 25.8 % (8 of 31). The mean VAS at the last follow-up was 2.3 ± 2.3. The mean LEFS score was 50.9 ± 18.8.Control MRI at follow-up showed scarring restitution in the proximal tendon in all patients in the partial tear group. In the complete tear group, a persisting defect state of the proximal tendon course was found in 45 % (9 of 20). The injured side achieved 81.5 ± 22.2 % of the force of the uninjured side, measured in the flexion movement at 60°/s. At an angular velocity of 240°/s, 83.2 ± 26.3 % of the force of the uninjured side was achieved. Conclusion According to the main findings of the present study, conservative therapy of PTH tears is associated with good clinical outcomes. High-quality investigations are required to establish the proper therapeutic algorithm and advantages of conservative management compared to a surgical approach. Level of evidence Level III.
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Affiliation(s)
- Thomas Mendel
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
- University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Trauma Surgery, Halle, Germany
| | - Mark Steinke
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
| | - Philipp Schenk
- BG Hospital Bergmannstrost Halle, Research Executive Department, Halle, Germany
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100 Bolzano, Italy
| | - Vincent Schütte
- Gesundheitszentrum Halle-Neustadt, Center Orthopaedic Surgery, Halle, Germany
| | - André Reisberg
- BG Hospital Bergmannstrost Halle, Department of Radiology and Neuroradiology, Halle, Germany
| | - Philipp Kobbe
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
- University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Trauma Surgery, Halle, Germany
| | - Markus Heinecke
- Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department, Eisenberg, Germany
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Li ZI, Buldo-Licciardi M, Moore M, Kanakamedala A, Burke CJ, Samim MM, Youm T. Assessment of fatty infiltration of the hamstring muscles in chronic proximal hamstring ruptures and effect on clinical outcomes after surgical repair: a novel application of the Goutallier classification. Arch Orthop Trauma Surg 2024; 144:2171-2179. [PMID: 38480556 DOI: 10.1007/s00402-024-05255-z] [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: 06/15/2023] [Accepted: 02/18/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Increased time to surgery has been previously associated with poorer clinical outcomes after surgical treatment of proximal hamstring ruptures, though the etiology remains unclear. The purpose of this study was to evaluate whether degree of muscle atrophy, as assessed using the Goutallier classification system, is associated with worse outcomes following surgical treatment of chronic proximal hamstring ruptures. MATERIALS AND METHODS This was a retrospective case series of patients who underwent repair of proximal hamstring ruptures from 2012 to 2020 with minimum 2-year follow-up. Patients were included if they underwent primary repair of a proximal hamstring rupture ≥ 6 weeks after the date of injury and had accessible preoperative magnetic resonance imaging (MRI). Exclusion criteria were allograft reconstruction, endoscopic repair, or prior ipsilateral hip surgery. Patients were administered validated surveys: the modified Harris Hip Score (mHHS) and Perth Hamstring Assessment Tool (PHAT). Fatty atrophy on preoperative MRI was independently graded by two musculoskeletal radiologists using the Goutallier classification. Multivariate regression analysis was performed to evaluate associations of preoperative characteristics with muscle atrophy, as well as mHHS and PHAT scores. RESULTS Complete data sets were obtained for 27 patients. A majority of this cohort was male (63.0%), with a mean age of 51.5 ± 11.8 years and BMI of 26.3 ± 3.8. The mean follow-up time was 62.6 ± 23.1 months, and the mean time from injury-to-surgery was 20.4 ± 15.3 weeks. The Goutallier grading inter-reader weighted kappa coefficient was 0.655. Regression analysis demonstrated that atrophy was not significantly associated with PHAT (p = 0.542) or mHHS (p = 0.574) at latest follow-up. Increased age was significantly predictive of muscle atrophy (β = 0.62, p = 0.005) and was also found to be a significant predictor of poorer mHHS (β = - 0.75; p = 0.037). CONCLUSIONS The degree of atrophy was not found to be an independent predictor of clinical outcomes following repair of chronic proximal hamstring ruptures. Increasing age was significantly predictive of increased atrophy and poorer patient-reported outcomes.
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Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Michael Buldo-Licciardi
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | - Michael Moore
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | - Ajay Kanakamedala
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | | | | | - Thomas Youm
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
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Wong SE, Julian KR, Carpio JG, Zhang AL. Proximal Hamstring Repair With All-Suture Anchors and an Accelerated Rehabilitation and Bracing Protocol Demonstrates Good Outcomes at 1-Year Follow-Up. Arthrosc Sports Med Rehabil 2024; 6:100891. [PMID: 38362482 PMCID: PMC10867423 DOI: 10.1016/j.asmr.2024.100891] [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: 09/11/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024] Open
Abstract
Purpose To evaluate patient-reported outcomes and risk for rerupture after surgical treatment of proximal hamstring tendon ruptures using all-suture anchors and a unique postoperative bracing strategy. Methods A retrospective review of a prospectively collected database was conducted of patients undergoing proximal hamstring repair or reconstruction from 2020 to 2022 at a tertiary, academic institution. Patients were included if they reached minimum 1-year follow-up and completed postoperative patient-reported outcomes. The surgical protocol for proximal hamstring repairs included all-suture anchors placed either in an open or endoscopic fashion in the ischial tuberosity. After surgery, all patients underwent an accelerated rehabilitation protocol, including 6 weeks touchdown weight-bearing in a hinged knee brace locked in extension for ambulation, allowing passive knee flexion to 90° while seated. Descriptive statistics were used to analyze the data. Results Twenty-one patients were included (mean age 50.4 ± 9.5 years, body mass index 24.4 ± 3.5, 66.7% female). Lower Extremity Functional Scale score achieved postoperatively was 74.2 ± 7.5 (out of 80). Patients had minimal pain (mean visual analog scale pain score of 0.9 ± 1.2). 61.9% of patients were able to return to the same level of activity after based on Tegner score by 1 year. Postoperative Single Assessment Numeric Evaluation activity of daily living was 94.3 ± 8.3, and Single Assessment Numeric Evaluation Sports was 82.3 ± 19.0. Mean Short Form Survey (SF-12) postoperative scores were 51.6 ± 6.8 for SF-12 Physical Component Score and 53.9 ± 9.7 for Mental Component Score. 95.2% (20 of 21) patients were satisfied with their outcome. There were no reruptures, infections, or reoperations. One patient of 21 (4.8%) incurred a postoperative deep venous thrombosis, which was treated with therapeutic anticoagulation for 3 months. Conclusions All-suture anchors for proximal hamstring repair with a unique accelerated postoperative rehabilitation and bracing protocol result in good outcomes and patient satisfaction with minimal risk of complications. Level of Evidence Level IV, case series, therapeutic.
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Affiliation(s)
- Stephanie E. Wong
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Kaitlyn R. Julian
- School of Medicine, University of California San Francisco, San Francisco, California, U.S.A
| | - Jocelyn G. Carpio
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Alan L. Zhang
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
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Lefevre N, Kassab Hassan S, Valentin E, Bohu Y, Gerometta A, Meyer A, Grimaud O, Hardy A. Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion. Am J Sports Med 2024; 52:1014-1021. [PMID: 38353118 PMCID: PMC10943598 DOI: 10.1177/03635465241227434] [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: 04/15/2023] [Accepted: 12/06/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND No validated score is available for the prediction of return to sport (RTS) after proximal hamstring avulsion (PHA) surgery. PURPOSE To validate a new assessment tool for patients after PHA surgery: the Parisian Hamstring Avulsion Score (PHAS). STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 3. METHODS All patients at our clinic who had surgery for PHA between January 2015 and March 2018 were included in this study. A suspected clinical diagnosis of PHA was confirmed by magnetic resonance imaging. PHA was repaired by surgical reinsertion with suture anchors. Minimum postoperative follow-up was 2 years, and the PHAS, University of California, Los Angeles (UCLA), score, and Tegner score were used. The PHAS is a patient-reported outcome measure, evaluating the effect of PHA injury with 9 items. It was validated by calculating its psychometric properties, and then correlation analysis was performed to determine the relationship between the PHAS, UCLA score, and Tegner score. Cutoff values for the prediction of RTS were determined. RESULTS A prospective case series study was performed. A total of 156 patients were included. Median age (first quartile; third quartile) was 54.2 years (44.7 years; 61.3 years), and the mean ± SD time of the final follow-up was 69 ± 11.6 months. Two years after surgery, 66.7% (n = 104) of patients were able to RTS. A strong correlation was noted between all 3 scores at 1 year postoperatively. Overall internal consistency was high, with a Cronbach alpha coefficient of 0.86. The intraclass correlation coefficient was 0.96, showing excellent reliability. The minimal detectable change was 12.9. No patients reached the maximum score at 2 years. Analysis of the receiver operating characteristic curves of the 3 scores at postoperative 9 months in relation to the RTS at 1 and 2 years showed area under the curve values of >0.7, indicating significant discriminant capacity for the RTS. A PHAS cutoff value of 86 at 9 months for the prediction of RTS at postoperative 1 year had a sensitivity of 65.6% (95% CI, 53.7%-77.5%) and a specificity of 81.4% (95% CI, 69.8%-93%). CONCLUSION PHAS is a valid and reliable tool for follow-up after PHA surgery. It also offers a simple way to predict RTS.
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Affiliation(s)
| | | | | | - Yoann Bohu
- Clinique du Sport Paris V, Paris, France
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Ebert JR, Breidahl W, Klinken S, Annear PT. Development and application of a proximal hamstring MRI-based scoring tool in patients undergoing proximal hamstring tendon surgical repair. J Orthop 2023; 45:61-66. [PMID: 37860177 PMCID: PMC10582688 DOI: 10.1016/j.jor.2023.10.008] [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: 07/24/2023] [Revised: 10/02/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023] Open
Abstract
Purpose An MRI-based scoring tool assessing surgical repair after proximal hamstring avulsions may provide benefit in the context of research, while serial post-operative MRI will provide insight of what to expect in the clinical context of early re-injury requiring imaging. This study developed and assessed the reliability of a Proximal Hamstring Objective Magnetic Resonance Imaging Score (PHOMRIS), further assessing MRI-based repair status and its correlation with patient-reported outcome. Methods 15 patients that underwent proximal hamstring surgical repair underwent MRI and clinical review pre-operatively and at 3-, 6- and 12-months. Clinical scores included the Lower Extremity Functional Scale (LEFS), the Perth Hamstring Assessment Tool (PHAT) and Tegner Activity Scale (TAS). The MRI-based tool assessed the conjoint (semitendinosus & biceps femoris) and semimembranosus insertion components based on bone-tendon healing, signal and retraction. Inter- and intra-observer reliability of the tool was assessed. Results Inter-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.827, p < 0.0001) and conjoint (rho = 0.851, p < 0.0001) components. Intra-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.852, p < 0.0001) and conjoint (rho = 0.996, p < 0.0001) components. All clinical scores and the semimembranosus hamstrings component MRI score significantly improved (p < 0.05) over time, though the conjoint component did not (p = 0.219). At 12 months, a higher LEFS was significantly associated with a better semimembranosus MRI score (r = -0.57, p = 0.042), though no other significant correlations (p > 0.05) were observed between clinical and MRI measures. Conclusions Excellent reliability was observed for the MRI-based scoring tool, which may prove useful in both a research and clinical setting.
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Affiliation(s)
- Jay R. Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Western Australia, 6009, Australia
- HFRC Rehabilitation Clinic, 117 Stirling Highway, Nedlands, Western Australia, 6009, Australia
- Perth Orthopaedic and Sports Medicine Research Institute, West Perth, Western Australia, Australia
| | - William Breidahl
- Perth Radiological Clinic, Subiaco, Perth, Western Australia, 6008, Australia
| | - Sven Klinken
- Perth Radiological Clinic, Subiaco, Perth, Western Australia, 6008, Australia
| | - Peter T. Annear
- Perth Orthopaedic & Sports Medicine Centre, West Perth, Western Australia, 6005, Australia
- Perth Orthopaedic and Sports Medicine Research Institute, West Perth, Western Australia, Australia
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Modified surgical anchor refixation in older patients with acute proximal hamstring rupture: clinical outcome, patient satisfaction and muscle strength. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04752-3. [PMID: 36622424 PMCID: PMC9828366 DOI: 10.1007/s00402-022-04752-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION After conventional surgical refixation of the hamstrings after proximal hamstring rupture, patients frequently experience pain while sitting and deficits in hamstring muscle strength of the operated side. To improve these outcomes, we have modified the surgical anchor placement and have carried out a thorough follow-up examination. MATERIALS AND METHODS Thirteen older patients (8 female, 5 males) with a median age of 64.2 (range, 52.1-80.4) years were surgically treated for acute proximal hamstring rupture using modified anchor placement and participated in a follow-up assessment at a median of 46.2 (11.2-75.0) months after surgery. Patients completed the Perth Hamstring Assessment Tool (PHAT), quality of life questionnaire (EQ-5D-5L) and the Lower Extremity Functional Scale (LEFS), and rated their satisfaction level on a scale from 0 to 100%. Local tenderness on the ischial tuberosity and maximum passive hip flexion were measured on both limbs. Maximum isokinetic knee flexor muscle strength was measured bilaterally using a dynamometer. RESULTS The median (range) PHAT, EQ-5D-5L and LEFS score were 78.8/100 (54.6-99.8), 0.94/1 (0.83-1) and 88.75/100 (61.25-100). The median satisfaction was 100% (90-100%). Only one patient felt discomfort when the ischial tuberosity was palpated. Neither maximum passive hip flexion nor maximum isokinetic flexor muscle strength differed between the operated and non-operated side (P > 0.58). Clinical scores did not correlate with the leg symmetry index of knee flexor muscle strength (Spearman's rho < 0.448, P > 0.125). There were no tendon re-ruptures, or postoperative sciatic radiculopathy, at the time of follow-up. CONCLUSIONS The modified extra-anatomical anchor placement resulted in good clinical and functional outcome of surgical repair of acute proximal hamstring rupture. Especially the absence of postoperative pain while sitting and the comparable muscle strength to the contralateral side is promising. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04867746, registered.
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Jokela A, Stenroos A, Kosola J, Valle X, Lempainen L. A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes. Ann Med 2022; 54:978-988. [PMID: 35416097 PMCID: PMC9009934 DOI: 10.1080/07853890.2022.2059560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hamstring injuries are among the most common muscle injuries. They have been reported in many different sports, such as running, soccer, track and field, rugby, and waterskiing. However, they are also present among the general population. Most hamstring injuries are mild strains, but also moderate and severe injuries occur. Hamstring injuries usually occur in rapid movements involving eccentric demands of the posterior thigh. Sprinting has been found to mainly affect the isolated proximal biceps femoris, whereas stretching-type injuries most often involve an isolated proximal injury of the semimembranosus muscle. The main cause of severe 2- or 3-tendon avulsion is a rapid forceful hip flexion with the ipsilateral knee extended. Most hamstring injuries are treated non-surgically with good results. However, there are also clear indications for surgical treatment, such as severe 2- or 3-tendon avulsions. In athletes, more aggressive recommendations concerning surgical treatment can be found. For a professional athlete, a proximal isolated tendon avulsion with clear retraction should be treated operatively regardless of the injured tendon. Surgical treatment has been found to have good results in severe injuries, especially if the avulsion injury is repaired in acute phase. In chronic hamstring injuries and recurring ruptures, the anatomical apposition of the retracted muscles is more difficult to be achieved. This review article analyses the outcomes of surgical treatment of hamstring ruptures. The present study confirms the previous knowledge that surgical treatment of hamstring tendon injuries causes good results with high satisfaction rates, both in complete and partial avulsions. Early surgical repair leads to better functional results with lower complication rates, especially in complete avulsions.KEY MESSAGEsSurgical treatment of hamstring tendon ruptures leads to high satisfaction and return to sport rates.Both complete and partial hamstring tendon ruptures have better results after acute surgical repair, when compared to cases treated surgically later.Athletes with hamstring tendon ruptures should be treated more aggressively with operative methods.
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Affiliation(s)
- Aleksi Jokela
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Antti Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - Jussi Kosola
- Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Xavier Valle
- Medical Department, FC Barcelona, Barcelona, Spain
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Green JS, Moran J, Schneble CA, Zazulak B, Li DT, Jimenez A, Medvecky MJ. Comparative Analysis of Patient-Reported Outcome Measures for Proximal Hamstring Injuries: A Systematic Review. Orthop J Sports Med 2022; 10:23259671221104758. [PMID: 35898205 PMCID: PMC9310242 DOI: 10.1177/23259671221104758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background There is controversy regarding which patient-reported outcome measures (PROMs) should be used for proximal hamstring tendon injuries. Hypothesis It was hypothesized that (1) most (>50%) of the questions on the 13 most common PROMs for proximal hamstring injuries would demonstrate extensive overlap in the health domains and question categories and (2) each of the PROMs would contain a variable distribution of questions within each health domain. Study Design Systematic review. Methods We conducted a literature review through PubMed, Scopus, and CINAHL and identified the 13 most common PROMs for proximal hamstring injuries: Lower Extremity Functional Scale (LEFS), Marx activity rating scale (MARS), 12-item Short Form Survey (SF-12), Tegner activity scale (TAS), Single Assessment Numeric Evaluation (SANE), Perth Hamstring Assessment Tool (PHAT), Proximal Hamstring Injury Questionnaire (PHIQ), modified Harris Hip Score (mHHS), University of California, Los Angeles activity score (UCLA), International Hip Outcome Tool (iHOT-12), Hip Outcome Score (HOS), Sydney Hamstring Origin Rupture Evaluation (SHORE), and Non-Arthritic Hip Score (NAHS). All PROM questions were sorted into 5 health domains (pain, symptoms, activities of daily living, sports, and mindset) and further divided into question categories if they referred to similar tasks or aspects of health. Questions in the same health domain and question category were considered overlapping, and those within a health domain that did not fit into a question category were considered unique. For each PROM, we analyzed the distribution of questions within particular health domains and question categories as well as the amount of overlapping and unique questions. Results Of the 165 questions evaluated, 116 (70.3%) were overlapping, and 49 (29.7%) were unique. The SF-12 contained the most unique questions (9/12 [75.0%]). The MARS, TAS, SANE, and UCLA had 0 unique questions. The PHIQ and iHOT-12 contained questions in all 5 health domains. The PHAT, SHORE, and NAHS contained questions in every health domain except mindset. The LEFS, MARS, SF-12, TAS, mHHS, SANE, UCLA, and HOS contained questions in ≤3 health domains. Conclusion The evaluated PROMs had a high degree of overlapping questions (≥50%) and demonstrated a statistically significant variance in the distribution of questions within each health domain.
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Affiliation(s)
- Joshua S. Green
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | - Jay Moran
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Christopher A. Schneble
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Bohdanna Zazulak
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Don T. Li
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Andrew Jimenez
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Michael J. Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
- Michael J. Medvecky, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, 06520, USA ()
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