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Menta AK, Weber-Levine C, Jiang K, Hersh AM, Davidar AD, Bhimreddy M, Ashayeri K, Sacino A, Chang L, Lubelski D, Theodore N. Robotic assisted surgery for the treatment of spinal metastases: A case series. Clin Neurol Neurosurg 2024; 243:108393. [PMID: 38917745 DOI: 10.1016/j.clineuro.2024.108393] [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: 03/30/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVE Spinal metastases can significantly affect quality of life in patients with cancer and present complex neurosurgical challenges for surgeons. Surgery with instrumentation is often indicated to alleviate pain, preserve neurological function, and ensure mechanical stability. However, distortions in the bony anatomy due to oncological disease can decrease the accuracy of pedicle screw placement. Robotic-assisted surgery may offer an opportunity to increase screw accuracy and improve navigation of spinal lesions compared to conventional techniques. Therefore, we presented our institutional experience evaluating robotic-assisted surgical fixation for spinal metastases. METHODS Patients undergoing robotic-assisted surgery at a large tertiary care center between January 2019 - January 2023 for the treatment of spinal metastases were identified. Patient characteristics, including demographics, tumor pathology, surgical complications, and post-operative outcomes were extracted. The Gertzbein Robbins classification system (GRS) was used to assess pedicle screw placement accuracy in patients with post-operative computed tomography. RESULTS Twenty patients were identified, including 7 females (35 %), with an overall median age of 66 years (range: 39-80 years) and median BMI of 25 kg/m2 (range: 17-34 kg/m2). An average of four spinal levels were instrumented, with metastases located primarily in the thoracic (n=17, 85 %) spine. Common primary tumor types included prostate (n=4), lung (n=2), and plasma cell (n=2) cancers. Most pedicle screws (92 %) were classified as GRS A in patients with postoperative imaging. Post-operative complications were unrelated to the use of the robot, and included pulmonary embolism (n=1), deep vein thrombosis (n=2), and gastric symptoms (n=3). Three patients were readmitted at 30 days, with one reoperation due to tumor recurrence. Four patients were deceased within 6 months of surgery. CONCLUSIONS Despite the inherent high-risk nature of these surgeries, this study underscores the safety and efficacy of robotic-assisted surgery in the management of spinal metastases. Robots can be helpful in ensuring accuracy of pedicle screw placement in patients with metastatic disease.
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Affiliation(s)
- Arjun K Menta
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kelly Jiang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrew M Hersh
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - A Daniel Davidar
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Meghana Bhimreddy
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kimberly Ashayeri
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Louis Chang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA.
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Kow CY, Castle-Kirszbaum M, Kam JK, Goldschlager T. Advances in Surgery for Metastatic Disease of the Spine: An Update for Oncologists. Global Spine J 2024:21925682231155847. [PMID: 39069655 DOI: 10.1177/21925682231155847] [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] [Indexed: 07/30/2024] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE Metastatic spine disease is an increasingly common clinical challenge that requires individualised multidisciplinary care from spine surgeons and oncologists. In this article, the authors describe the recent surgical advances in patients presenting with spinal metastases. METHODS We present an overview of the presentation, assessment, and management of spinal metastases from the perspective of the spine surgeon, highlighting advances in surgical technology and techniques, to facilitate multidisciplinary care for this complex patient group. Neither institutional review board approval nor patient consent was needed for this review. RESULTS Advances in radiotherapy delivery and systemic therapy (including immunotherapy and targeted therapy) have refined operative indications for decompression of neural structures and spinal stabilisation, while advances in surgical technology and technique enable these goals to be achieved with reduced morbidity. Formulating individualised management strategies that optimise outcome, while meeting patient goals and expectations, requires a comprehensive understanding of the factors important to patient management. CONCLUSION Spinal metastases require prompt diagnosis and expert management by a multidisciplinary team. Improvements in systemic, radiation, and surgical therapies have broadened operative indications and increased operative candidacy, and future advances are likely to continue this trend.
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Affiliation(s)
- Chien Yew Kow
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Mendel Castle-Kirszbaum
- Department of Neurosurgery, Monash Health, Melbourne, AU-VIC, Australia
- Department of Surgery, Monash University, Melbourne, AU-VIC, Australia
| | - Jeremy Kt Kam
- Department of Neurosurgery, Monash Health, Melbourne, AU-VIC, Australia
- Department of Surgery, Monash University, Melbourne, AU-VIC, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, AU-VIC, Australia
- Department of Surgery, Monash University, Melbourne, AU-VIC, Australia
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Chanbour H, Chen JW, Bendfeldt GA, Gangavarapu LS, Ahmed M, Chotai S, Luo LY, Berkman RA, Abtahi AM, Stephens BF, Zuckerman SL. Earlier Radiation Is Associated with Improved 1-Year Survival After Metastatic Spine Tumor Surgery. World Neurosurg 2024; 187:e509-e516. [PMID: 38677650 DOI: 10.1016/j.wneu.2024.04.118] [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: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE In patients undergoing metastatic spine surgery, we sought to 1) report time to postoperative radiation therapy (RT), 2) describe the predictive factors of time to postoperative RT, and 3) determine if earlier postoperative RT is associated with improved local recurrence (LR) and overall survival (OS). METHODS A single-center retrospective cohort study was undertaken of all patients undergoing spine surgery for extradural metastatic disease and receiving RT within 3 months postoperatively between January 2010 and January 2021. Time to postoperative RT was dichotomized at <1 month versus 1-3 months. The primary outcomes were LR, OS, and 1-year survival. Secondary outcomes were wound complication, Karnofsky Performance Status, and modified McCormick Scale (MMS) score. Regression analyses controlled for age, body mass index, tumor size, preoperative RT, preoperative/postoperative chemotherapy, and type of RT. RESULTS Of 76 patients undergoing spinal metastasis surgery and receiving postoperative RT within 3 months, 34 (44.7%) received RT within 1 month and 42 (55.2%) within 1-3 months. Patients with larger tumor size (β = -3.58; 95% confidence interval [CI], -6.59 to -0.57; P = 0.021) or new neurologic deficits (β = -16.21; 95% CI, -32.21 to -0.210; P = 0.047) had a shorter time to RT. No significant association was found between time to RT and LR or OS on multivariable logistic/Cox regression. However, patients who received RT between 1 and 3 months had a lower odds of 1-year survival compared with those receiving RT within 1 month (odds ratio, 0.18; 95% CI, 0.04-0.74; P = 0.022). Receiving RT within 1 month versus 1-3 months was not associated with wound complications (7.1% vs. 2.9%; P = 0.556) (odds ratio, 4.40; 95% CI, 0.40-118.0; P = 0.266) or Karnofsky Performance Status/modified McCormick Scale score. CONCLUSIONS Spine surgeons, oncologists, and radiation oncologists should make every effort to start RT within 1 month to improve 1-year survival after metastatic spine tumor surgery.
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Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey W Chen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Mahmoud Ahmed
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leo Y Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Richard A Berkman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Ahluwalia R, Chanbour H, Zeoli T, Abtahi AM, Stephens BF, Zuckerman SL. Does Timing of Radiation Therapy Impact Wound Healing in Patients Undergoing Metastatic Spine Surgery? Diagnostics (Basel) 2024; 14:1059. [PMID: 38786357 PMCID: PMC11120252 DOI: 10.3390/diagnostics14101059] [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: 04/05/2024] [Revised: 05/06/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION The impact of radiation on wound healing after metastatic spine surgery remains an active area of research. In patients undergoing metastatic spine surgery, we sought to (1) assess the relationship between preoperative and/or postoperative radiation on wound complications, and (2) evaluate the relationship between the timing of postoperative radiation and wound complications. METHODS A single-center, retrospective, cohort study of patients undergoing metastatic spine surgery was conducted from 2010 to 2021. The primary exposure variable was the use/timing of radiation. Radiation included both external beam radiotherapy (EBRT) and stereotactic body radiotherapy (SBRT). Patients were trichotomized into the following groups: (1) preoperative radiation only, (2) postoperative radiation only, and (3) no radiation. The primary outcome variable was wound complications, which was defined as dehiscence requiring reoperation, infection requiring antibiotics, or infection requiring surgical debridement. Multivariable logistic/linear regression controlled for age, tumor size, primary organ of origin, and the presence of other organ metastases. RESULTS A total of 207 patients underwent surgery for extradural spinal metastasis. Participants were divided into three groups: preoperative RT only (N = 29), postoperative RT only (N = 91), and no RT (N = 178). Patients who received postoperative RT only and no RT were significantly older than patients who received preoperative RT only (p = 0.009) and were less likely to be white (p < 0.001). No other significant differences were found in basic demographics, tumor characteristics, or intraoperative variables. Wound-related complications occurred in two (6.9%) patients with preoperative RT only, four patients (4.4%) in postoperative RT only, and 11 (6.2%) patients with no RT, with no significant difference among the three groups (p = 0.802). No significant difference was found in wound-related complications, reoperation, and time to wound complications between patients with preoperative RT only and no RT, and between postoperative RT only and no RT (p > 0.05). Among the postoperative-RT-only group, no difference in wound complications was seen between those receiving SBRT (5.6%) and EBRT (4.1%) (p > 0.999). However, patients who received preoperative RT only had a longer time to wound complications in comparison to those who received postoperative RT only (43.5 ± 6.3 vs. 19.7 ± 3.8, p = 0.004). Regarding timing of postoperative RT, the mean (SD) time to RT was 28.7 ± 10.0 days, with a median of 28.7 (21-38) days. No significant difference was found in time to postoperative RT between patients with and without wound complications (32.9 ± 12.3 vs. 29.0 ± 9.7 days, p = 0.391). CONCLUSION In patients undergoing metastatic spine surgery, a history of previous RT or postoperative RT did not significantly affect wound complications. However, those with previous RT prior to surgery had a longer time to wound complications than patients undergoing postoperative RT only. Moreover, timing of RT had no impact on wound complications, indicating that earlier radiation may be safely employed to optimize tumor control without fear of compromising wound healing.
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Affiliation(s)
- Ranbir Ahluwalia
- Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN 37212, USA (T.Z.)
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN 37212, USA (T.Z.)
| | - Tyler Zeoli
- Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN 37212, USA (T.Z.)
| | - Amir M. Abtahi
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Byron F. Stephens
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Scott L. Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN 37212, USA (T.Z.)
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Gong JH, Sastry R, Koh DJ, Soliman L, Sobti N, Oyelese AA, Gokaslan ZL, Fridley J, Woo AS. Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis. World Neurosurg 2023; 180:e392-e407. [PMID: 37769839 DOI: 10.1016/j.wneu.2023.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database. METHODS We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure. RESULTS A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P = 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P = 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05). CONCLUSIONS Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.
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Affiliation(s)
- Jung Ho Gong
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Rahul Sastry
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel J Koh
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luke Soliman
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nikhil Sobti
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jared Fridley
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Albert S Woo
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Lee HD, Jang HD, Park JS, Chung NS, Chung HW, Jun JY, Han K, Hong JY. Incidence and Risk Factors for Wound Revision after Surgical Treatment of Spinal Metastasis: A National Population-Based Study in South Korea. Healthcare (Basel) 2023; 11:2962. [PMID: 37998455 PMCID: PMC10671392 DOI: 10.3390/healthcare11222962] [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: 10/05/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Wound complications are commonly seen after surgeries for metastatic spine tumors. While numerous studies have pinpointed various risk factors, there is ongoing debate. Therefore, this study aimed to verify various factors that are still under debate utilizing the comprehensive Korean National Health Insurance Service database. We identified and retrospectively reviewed a cohort of 3001 patients who underwent one of five surgical treatments (corpectomy, decompression and instrumentation, instrumentation only, decompression only, and vertebroplasty) for newly diagnosed spinal metastasis between 2009 and 2017. A Cox regression analysis was performed to determine the risk factors. A total of 197 cases (6.6%) of wound revision were found. Only the surgical method and Charlson comorbidity index were significantly different between the group that underwent wound revision and the group that did not. Regarding surgical methods, the adjusted hazard ratios for decompression only, corpectomy, instrumentation and decompression, and instrumentation only were 1.3, 2.2, 2.2, and 2.4, with these ratios being compared to the vertebroplasty group (p for trend = 0.02). In this regard, based on a sizable South Korean cohort, both surgical methods and medical comorbidity were found to be associated with the wound revision rate among spinal surgery patients for spinal metastasis.
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Affiliation(s)
- Han-Dong Lee
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (H.-D.L.); (N.-S.C.); (H.-W.C.); (J.-Y.J.)
| | - Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Republic of Korea;
| | - Jin-Sung Park
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea;
| | - Nam-Su Chung
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (H.-D.L.); (N.-S.C.); (H.-W.C.); (J.-Y.J.)
| | - Hee-Woong Chung
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (H.-D.L.); (N.-S.C.); (H.-W.C.); (J.-Y.J.)
| | - Jin-Young Jun
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (H.-D.L.); (N.-S.C.); (H.-W.C.); (J.-Y.J.)
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Republic of Korea;
| | - Jae-Young Hong
- Department of Orthopedics, Korea University Hospital, Ansan 15355, Republic of Korea
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Jaipanya P, Chanplakorn P. Spinal metastasis: narrative reviews of the current evidence and treatment modalities. J Int Med Res 2022; 50:3000605221091665. [PMID: 35437050 PMCID: PMC9021485 DOI: 10.1177/03000605221091665] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The treatment for spinal metastasis has evolved significantly during the past decade. An advancement in systemic therapy has led to a prolonged overall survival in cancer patients, thus increasing the incidence of spinal metastasis. In addition, with the improved treatment armamentarium, the prediction of patient survival using traditional prognostic models may have limitations and these require the incorporation of some novel parameters to improve their prognostic accuracy. The development of minimally-invasive spinal procedures and minimal access surgical techniques have facilitated a quicker patient recovery and return to systemic treatment. These modern interventions help to alleviate pain and improve quality of life, even in candidates with a relatively short life expectancy. Radiotherapy may be considered in non-surgical candidates or as adjuvant therapy for improving local tumour control. Stereotactic radiosurgery has facilitated this even in radioresistant tumours and may even replace surgery in radiosensitive malignancies. This narrative review summarizes the current evidence leading to the paradigm shifts in the modern treatment of spinal metastasis.
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Affiliation(s)
- Pilan Jaipanya
- Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand.,Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pongsthorn Chanplakorn
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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