1
|
Fawley D, Bernard T, Thomason HC, Zagra L, Ten Broeke RHM, Johnson K. Early functional recovery outcomes and return to work after primary total hip arthroplasty: a novel patient reported outcomes questionnaire. J Orthop Surg Res 2024; 19:434. [PMID: 39061099 PMCID: PMC11282613 DOI: 10.1186/s13018-024-04937-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/21/2024] [Indexed: 07/28/2024] Open
Abstract
PURPOSE Clinical and patient reported outcomes are often collected before and after the procedure to benchmark and study outcomes for patients. These outcomes and scores are useful for tracking patient outcomes after surgery, however, the fact that these commonly used measures typically provide information about a patient's level of pain and function at a single point in time is a limitation. METHODS We present early functional recovery and return to work outcomes after primary THA from a novel questionnaire administered in a global, multi-center, prospective clinical study. RESULTS By 6 and 12 weeks post-op, a large proportion of study subjects were able to perform functional recovery outcomes after their THA: walk without an aid (74%; 94%); drive (76%; 97%); basic activities of daily living (94%; 99%); perform light household duties (91%; 96%); perform moderate-to-heavy household duties (54%; 86%); go up and down a flight of stairs (92%; 99%); put on socks/stockings (77%; 93%); bend down to pick up an object from the floor (87%; 97%); stand up from a chair (96%; 99%); perform leisure recreational activities (54%; 84%); perform primary goal identified pre-THA (69%; 86%). 60% were able to return to work by 12 weeks post-op. These questions showed strong association with the Forgotten Joint Score. CONCLUSION Excellent patient reported early functional recovery outcomes and satisfaction were observed at 6- and 12-weeks post-op in this cohort and is the first reported data using a novel PRO. CLINICAL TRIAL REGISTRATION NCT03189303, registered June 14, 2017.
Collapse
Affiliation(s)
- David Fawley
- DePuy Synthes, 700 Orthopaedic Drive, Warsaw, IN, USA.
| | | | | | - Luigi Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - René H M Ten Broeke
- Department of Orthopaedic Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
| | - Kory Johnson
- Orthopaedic Associates of Michigan, 555 Mid Towne St Suite 105, Grand Rapids, MI, USA
| |
Collapse
|
2
|
Zhuang T, Young B, Hooper J, Amanatullah DF, Shapiro L, Kamal RN. Opioid Use After Robotic-Assisted Versus Conventional Total Hip Arthroplasty:A National Database Analysis. Orthopedics 2024:1-6. [PMID: 38976847 DOI: 10.3928/01477447-20240702-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
BACKGROUND In this study, we tested the null hypothesis that robotic-assisted total hip arthroplasty (THA) vs conventional THA was not associated with (1) the amount of postoperative opioid use and (2) the incidence of new, persistent opioid use. MATERIALS AND METHODS We used a large, national administrative database to identify patients 50 years and older undergoing primary robotic or conventional THA. Patients with hip fractures or a history of malignancy, hip infection, or opioid use disorder were excluded. Patients who filled an opioid prescription within 1 year to 30 days preoperatively or who underwent a subsequent procedure within 1 year after THA were excluded. Outcomes included the morphine milligram equivalents (MMEs) filled within the THA perioperative period and the incidence of new, persistent opioid use. Multivariable logistic regression models were used to evaluate associations between robotic-assisted THA and new, persistent opioid use, adjusting for age, sex, insurance plan, region, location of surgery, and comorbidities. RESULTS In the postoperative period, robotic-assisted THA, compared with conventional THA, was associated with a lower mean total MMEs filled per patient (452.2 vs 517.1; P<.001) and a lower mean MMEs per patient per day (71.53 vs 74.64; P<.001). Patients undergoing robotic-assisted THA had decreased odds of developing new, persistent opioid use compared with patients undergoing conventional THA (adjusted odds ratio, 0.82 [95% CI, 0.74-0.90]). CONCLUSION Robotic-assisted THA is associated with lower postoperative opioid use and a decreased odds of developing new, persistent opioid use compared with conventional THA. For the purposes of reducing opioid use, our results support the adoption of robotic-assisted THA. [Orthopedics. 202x;4x(x):xx-xx.].
Collapse
|
3
|
Buchan GBJ, Hecht CJ, Sculco PK, Chen JB, Kamath AF. Improved short-term outcomes for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system compared to manual technique with fluoroscopic assistance. Arch Orthop Trauma Surg 2024; 144:501-508. [PMID: 37740783 DOI: 10.1007/s00402-023-05061-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: 06/12/2023] [Accepted: 09/01/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND While robotic-assisted total hip arthroplasty (RA-THA) has been associated with improved accuracy of component placement, the perioperative and early postoperative outcomes of fluoroscopy-based RA-THA systems have yet to be elucidated. METHODS This retrospective cohort analysis included a consecutive series of patients who received manual, fluoroscopy-assisted THA (mTHA) and fluoroscopy-based RA-THA at a single institution. We compared rates of complications within 90 days of surgery, length of hospital stay (LOS), and visual analog scale (VAS) pain scores. RESULTS No differences existed between groups with respect to demographic data or perioperative recovery protocols. The RA-THA cohort had a significantly greater proportion of outpatient surgeries compared to the mTHA cohort (37.4% vs. 3.8%; p < 0.001) and significantly lower LOS (26.0 vs. 39.5 h; p < 0.001). The RA-THA cohort had a smaller 90-day postoperative complication rate compared to the mTHA cohort (0.9% vs. 6.7%; p = 0.029). The RA-THA cohort had significantly lower patient-reported VAS pain scores at 2-week follow-up visits (2.5 vs. 3.3; p = 0.048), but no difference was seen after 6-week follow visits (2.5 vs. 2.8; p = 0.468). CONCLUSION Fluoroscopy-based RA-THA demonstrates low rates of postoperative complications, improved postoperative pain profiles, and shortened LOS when compared to manual, fluoroscopy-assisted THA.
Collapse
Affiliation(s)
- Graham B J Buchan
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th, New York, NY, 10021, USA
| | - James B Chen
- Mission Orthopaedic Institute, Providence Mission Hospital, Mission Viejo, CA, 92691, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| |
Collapse
|
4
|
Suarez-Ahedo C, Lopez-Reyes A, Martinez-Armenta C, Martinez-Gomez LE, Martinez-Nava GA, Pineda C, Vanegas-Contla DR, Domb B. Revolutionizing orthopedics: a comprehensive review of robot-assisted surgery, clinical outcomes, and the future of patient care. J Robot Surg 2023; 17:2575-2581. [PMID: 37639163 DOI: 10.1007/s11701-023-01697-6] [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: 05/09/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
Robotic-assisted orthopedic surgery (RAOS) is revolutionizing the field, offering the potential for increased accuracy and precision and improved patient outcomes. This comprehensive review explores the historical perspective, current robotic systems, advantages and limitations, clinical outcomes, patient satisfaction, future developments, and innovation in RAOS. Based on systematic reviews, meta-analyses, and recent studies, this article highlights the most significant findings and compares RAOS to conventional techniques. As robotic-assisted surgery continues to evolve, clinicians and researchers must stay informed and adapt their practices to provide optimal patient care. Evidence from published studies corroborates these claims, highlighting superior component positioning, decreased incidence of complications, and heightened patient satisfaction. However, challenges such as costs, learning curves, and technical issues must be resolved to fully capitalize on these advantages.
Collapse
Affiliation(s)
- Carlos Suarez-Ahedo
- Instituto Nacional de Rehabilitación, Mexico City, Mexico.
- American Hip Institute, Des Plaines, IL, USA.
| | | | | | | | | | - Carlos Pineda
- Instituto Nacional de Rehabilitación, Mexico City, Mexico
| | | | | |
Collapse
|
5
|
Lu H, Sun H, Xiao Q, Xu H, Zhou Q, Li L, Yan T, Wang D, Zhou Z. Perioperative safety and efficacy of robot-assisted total hip arthroplasty in ERAS-managed patients: a pilot study. J Orthop Surg Res 2023; 18:696. [PMID: 37723565 PMCID: PMC10506298 DOI: 10.1186/s13018-023-04180-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/10/2023] [Indexed: 09/20/2023] Open
Abstract
AIMS Robot-assisted total hip arthroplasty (rTHA) boasts superior accuracy in implant placement, but there is a lack of effective assessment in perioperative management in the context of enhanced recovery after surgery (ERAS). This study aimed to compare the effectiveness and safety of rTHA versus conventional total hip arthroplasty (cTHA) in ERAS-managed patients. METHODS In this prospective trial, a total of 60 eligible patients aged between 18 and 80 years were randomly divided into two groups to undergo either rTHA or cTHA. The primary outcomes included blood loss parameters. Secondary outcomes were the duration of the operation, surgical time, WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, Harris score, and postoperative complications. RESULTS The study cohort analyzed 59 eligible participants, 30 of whom underwent rTHA and 29 of whom underwent cTHA. Analysis could not be conducted for one patient due to severe anemia. Notably, the cTHA group had a significantly shorter surgical time than the rTHA group (69.49 ± 18.97 vs. 104.20 ± 19.63 min, P < 0.001). No significant differences were observed between the rTHA and cTHA groups for blood loss parameters, including total blood loss (1280.30 ± 404.01 vs. 1094.86 ± 494.39 ml, P = 0.137) and drainage volume (154.35 ± 121.50 vs. 159.13 ± 135.04 ml, P = 0.900), as well as intraoperative blood loss (126.67 ± 38.80 vs. 118.52 ± 60.68 ml, P = 0.544) and hidden blood loss (982.43 ± 438.83 vs. 784.00 ± 580.96 ml, P = 0.206). Only one patient in the cTHA group required allogeneic blood transfusion. At 3 months postoperatively, both groups showed improvements in WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, and Harris score, with no significant differences found between the two groups. Few complications were reported in both groups without significant differences. CONCLUSIONS Despite the longer surgical time, rTHA did not negatively affect blood loss, pain, or functional recovery or lead to an increased risk of complications in ERAS-managed patients, suggesting that rTHA can be safely and effectively incorporated into an ERAS program for primary THA.
Collapse
Affiliation(s)
- Hanpeng Lu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| | - Haocheng Sun
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| | - Qiang Xiao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| | - Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| | - Qi Zhou
- West China School of Medicine, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| | - Linyuan Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| | - Tingfang Yan
- Yuanhua Intelligent Technology (Shenzhen) Co., Ltd, Shenzhen, People’s Republic of China
| | - Duan Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan People’s Republic of China
| |
Collapse
|
6
|
Kumar V, Patel S, Baburaj V, Rajnish RK, Aggarwal S. Does robotic-assisted surgery improve outcomes of total hip arthroplasty compared to manual technique? A systematic review and meta-analysis. Postgrad Med J 2023; 99:375-383. [PMID: 37294729 DOI: 10.1136/postgradmedj-2021-141135] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Robot-assisted total hip arthroplasty (THA) is an emerging technology that claims to position implants with very high accuracy. However, there is currently limited data in literature on whether this improved accuracy leads to better long-term clinical outcomes. This systematic review compares the outcomes of THA done with the help of robotic assistance (RA) to those done with conventional manual techniques (MTs). METHODS Four electronic databases were searched for eligible articles that directly compared robot-assisted THA to manual THA and had data on the radiological or clinical outcomes of both. Data on various outcome parameters were collected. Meta-analysis was conducted using a random-effects model with 95% CIs. RESULTS A total of 17 articles were found eligible for inclusion, and 3600 cases were analysed. Mean operating time in the RA group was significantly longer than in the MT group. RA resulted in significantly more acetabular cups being placed inside Lewinnek's and Callanan's safe zones (p<0.001) and had significantly reduced limb length discrepancy compared with MT. There were no statistically significant differences in the two groups in terms of incidence of perioperative complications, need for revision surgery and long-term functional outcome. CONCLUSION RA leads to highly accurate implant placement and leads to significantly reduced limb length discrepancies. However, the authors do not recommend robot-assisted techniques for routine THAs due to lack of adequate long-term follow-up data, prolonged surgical times and no significant differences in the rate of complications and implant survivorship compared with conventional MTs.
Collapse
|
7
|
Barsoum W, Gregory D, Needham K, Mont M, Sodhi N, Coppolecchia A, Jacofsky D. Advantages of robotic arm-assisted total hip arthroplasty: a 90-day episode-of-care clinical utility and cost analysis. J Comp Eff Res 2023; 12:e220208. [PMID: 37144744 PMCID: PMC10402783 DOI: 10.57264/cer-2022-0208] [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: 12/11/2022] [Accepted: 03/15/2023] [Indexed: 05/06/2023] Open
Abstract
Aim: Determine the clinical utility and economic differences over a 90-day period between robotic arm-assisted total hip arthroplasty (RATHA) and manual total hip arthroplasty (MTHA). Methods: Leveraging a nationwide commercial payer database, pre-covid THA procedures were identified. Following a 1:5 propensity score match, 1732 RATHA and 8660 MTHA patients were analyzed. Index costs, index lengths of-stay, and 90-day episode-of-care utilization and costs were evaluated. Results: Episode of care costs for RATHA was found to be $1573 lower compared with MTHA (p < 0.0001). Post-index hospital utilization was significantly less likely to occur for RATHA compared with MTHA. Total index costs were also significantly lower for RATHA versus MTHA (p < 0.0001). Conclusion: Index and post-index EOC hospital utilization and costs were lower for RATHA compared with MTHA.
Collapse
Affiliation(s)
- Wael Barsoum
- HOPCo, Phoenix, AZ 85023, USA
- Cleveland Clinic Florida, Weston, FL 33331, USA
| | | | | | - Michael Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Nipun Sodhi
- Long Island Jewish Medical Center, Northwell Health, Long Island, NY 11040, USA
| | | | - David Jacofsky
- HOPCo, Phoenix, AZ 85023, USA
- The CORE Institute, Phoenix, AZ 85015, USA
| |
Collapse
|
8
|
Hewson DW, Scott CEH, Macfarlane AJR. Regional analgesia for total hip arthroplasty and Schwartz's paradox. Br J Anaesth 2023; 130:650-654. [PMID: 37105898 DOI: 10.1016/j.bja.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/29/2023] Open
Abstract
Enhanced recovery after total hip arthroplasty aims to facilitate return to function and early hospital discharge, but the role of novel fascial plane block techniques in such pathways is uncertain. A randomised trial by Kukreja and colleagues describes superior quality of recovery after hip arthroplasty in patients receiving a pericapsular nerve group (PENG) block. We discuss the trial findings in the context of ongoing uncertainty regarding best analgesic practice for this surgical procedure.
Collapse
Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care Medicine, Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK; Department of Anaesthesia, Queen's Medicine Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK; Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - Alan J R Macfarlane
- Department of Anaesthetics, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| |
Collapse
|
9
|
Kunze KN, Bovonratwet P, Polce EM, Paul K, Sculco PK. Comparison of Surgical Time, Short-term Adverse Events, and Implant Placement Accuracy Between Manual, Robotic-assisted, and Computer-navigated Total Hip Arthroplasty: A Network Meta-analysis of Randomized Controlled Trials. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e21.00200. [PMID: 35472191 PMCID: PMC10566925 DOI: 10.5435/jaaosglobal-d-21-00200] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 02/12/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Recent years have observed the increasing utilization of robotic-assisted and computer navigation techniques in total hip arthroplasty (THA), given the proposed benefits of enhanced consistency and precision in implant placement. The purpose of this study was to conduct a systematic review of randomized controlled trials (RCTs) to determine whether differences in surgical times, adverse events, and implant positioning existed between manual, robotic-assisted, and computer navigation THA. METHODS PubMed, OVID/MEDLINE, and Cochrane databases were queried for RCTs comparing robotic-assisted versus manual THA and computer navigation versus manual THA at a minimum 1-year follow-up. Frequentist model network meta-analyses with P-scores were conducted to compare revisions, complications, and surgical times among the three treatment groups. A random-effects meta-analysis between computer navigation and manual THAs was conducted to analyze cup positioning because no robotic-assisted THA studies reported this outcome. RESULTS Five RCTs compared robotic-assisted and manual THAs, while seven compared computer navigation and manual THAs. manual THA was associated with significantly reduced surgical time in comparison with computer navigation (mean difference: 23.3 minutes) and robotic-assisted THAs (mean difference: 8.6 minutes; P < 0.001). No difference was observed in the incidence of all-cause complications (computer navigation: 1.7%, manual: 6.6%, and robotic-assisted: 16.2%) or revisions (computer navigation: 1.0%, manual: 1.7%, and robotic-assisted 4.8%) among the three treatment groups based on the network meta-analysis. In three studies that reported acetabular implant positioning, computer navigation had a significantly higher percentage of acetabular cups placed in the Lewinnek "safe zone" compared with manual THA (79% versus 52%; P = 0.02). CONCLUSIONS manual THA results in markedly shorter surgical times and a similar incidence of complications and revisions compared with robotic-assisted and computer navigation THAs, given the sample sizes available for study. However, computer navigation THA led to increased precision in the placement of acetabular implants.
Collapse
Affiliation(s)
- Kyle N. Kunze
- From the Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY (Dr. Kunze, Dr. Bovonratwet, and Dr. Sculco), University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr. Polce), and the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL (Ms. Paul)
| | - Patawut Bovonratwet
- From the Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY (Dr. Kunze, Dr. Bovonratwet, and Dr. Sculco), University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr. Polce), and the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL (Ms. Paul)
| | - Evan M. Polce
- From the Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY (Dr. Kunze, Dr. Bovonratwet, and Dr. Sculco), University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr. Polce), and the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL (Ms. Paul)
| | - Katlynn Paul
- From the Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY (Dr. Kunze, Dr. Bovonratwet, and Dr. Sculco), University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr. Polce), and the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL (Ms. Paul)
| | - Peter K. Sculco
- From the Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY (Dr. Kunze, Dr. Bovonratwet, and Dr. Sculco), University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr. Polce), and the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL (Ms. Paul)
| |
Collapse
|