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Cooper MT. Common Painful Foot and Ankle Conditions: A Review. JAMA 2023; 330:2285-2294. [PMID: 38112812 DOI: 10.1001/jama.2023.23906] [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: 12/21/2023]
Abstract
Importance Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment. Observations Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used. Conclusions and Relevance Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.
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Backhouse MR, Halstead J, Roddy E, Dhukaram V, Chapman A, Arnold S, Bruce J. A multi-professional survey of UK practice in the use of intra-articular corticosteroid injection for symptomatic first metatarsophalangeal joint osteoarthritis. J Foot Ankle Res 2023; 16:71. [PMID: 37845758 PMCID: PMC10580568 DOI: 10.1186/s13047-023-00672-6] [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: 08/10/2023] [Accepted: 10/05/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND The first metatarsophalangeal joint is the most common site of osteoarthritis (OA) in the foot and ankle. Intra-articular corticosteroid injections are widely used for this condition, but little is known about their use in practice. This study explored current practice within the UK National Health Service (NHS) relating to the administration of intra-articular corticosteroids for people with painful first metatarsophalangeal joint (MTPJ) OA. METHODS A cross-sectional survey using Qualtrics online survey platform (Qualtrics, Provo, UT, USA), distributed through professional bodies, special interest groups, and social media. RESULTS One hundred forty-four healthcare professionals responded, including podiatrists (53/144; 39%), orthopaedic surgeons (28/144; 19%), podiatric surgeons (26/144; 17%) and physiotherapists (24/144; 16%). Half of respondents administered up to 25 corticosteroid injections per year (67/136; 49%) but some administered more than fifty (21/136; 15%). Injections were administered across the healthcare system but were most common in hospital settings (64/136; 44%) followed by community (38/136; 26%), with less delivered in primary care (11/136; 8%). Half of respondents routinely used image-guidance, either ultrasound or x-ray/fluoroscopy (65/136; 48%) although over one third used none (52/136; 38%). Imaging guidance was more common amongst medical professionals (21/31; 68%) compared to non-medical health professionals (45/105; 43%). Overall, methylprednisolone acetate was the most common corticosteroid used. Medical professionals mostly injected methylprednisolone acetate (n = 15/27; 56%) or triamcinolone acetonide (n = 11/27; 41%), whereas premixed methylprednisolone acetate with lidocaine hydrochloride was the most common preparation used by non-medical health professionals (41/85; 48%). When injecting non premixed steroid, lidocaine hydrochloride (15/35; 43%) was the most common choice of local anaesthetic for non-medical health professionals but medical professionals showed more variation between lidocaine hydrochloride (8/23; 35%) levobupivacaine hydrochloride (9/23; 39%) and bupivacaine hydrochloride (5/23; 22%). CONCLUSIONS Multiple professional groups regularly administer intra-articular corticosteroids for symptomatic first MTPJ OA across a range of NHS healthcare settings. Overall, methylprednisolone acetate was the most commonly administered steroid and lidocaine hydrochloride the most common local anaesthetic. There was large variation in the use of imaging guidance, type and dose of steroid, local anaesthetic, and clinical pathways used in the intra-articular injection of corticosteroids for people with first MTPJ OA.
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Affiliation(s)
- Michael R Backhouse
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill, CV4 7AL, UK.
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK.
| | | | - Edward Roddy
- School of Medicine, Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership University NHS Foundation Trust, Stoke-on-Trent, UK
| | - Vivek Dhukaram
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Anna Chapman
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Susanne Arnold
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill, CV4 7AL, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill, CV4 7AL, UK
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
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Parker EB, Hering KA, Chiodo CP, Smith JT, Bluman EM, Martin EA. Intraarticular Injections in the Foot and Ankle: Medication Selection Patterns and Perceived Risk Of Chondrotoxicity. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231216990. [PMID: 38145274 PMCID: PMC10748709 DOI: 10.1177/24730114231216990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023] Open
Abstract
Background Intraarticular corticosteroid injections (ICIs) are widely used to treat foot and ankle conditions. Although laboratory studies indicate certain corticosteroids and local anesthetics used in ICIs are associated with chondrotoxic effects, and selected agents such as ropivacaine and triamcinolone may have less of these features, clinical evidence is lacking. We aimed to identify the patterns of drug selection, perceptions of injectate chondrotoxicity, and rationale for medication choice among surgeons in the American Orthopaedic Foot & Ankle Society (AOFAS). Methods An e-survey including demographics, practice patterns, and rationale was disseminated to 2011 AOFAS members. Frequencies and percentages were calculated for demographic data, anesthetic and steroid choice, rationale for injectate choice, and perception of chondrotoxicity. Bivariate analysis was used to identify practice patterns significantly associated with perceptions of injectate risk and rationale. Results In total, 387 surveys were completed. Lidocaine and triamcinolone were the most common anesthetic and corticosteroid used (51.2% and 39.3%, respectively). Less than half of respondents felt corticosteroids or local anesthetics bear risk of chondrotoxicity. Respondents agreeing that corticosteroids are chondrotoxic were more likely to use triamcinolone (P = .037). Respondents agreeing local anesthetics risk chondrotoxicity were less likely to use lidocaine (P = .023). Respondents choosing a local anesthetic based on literature were more likely to use ropivacaine (P < .001). Conclusion Corticosteroid and local anesthetic use in ICIs varied greatly. Rationale for ICI formulation was also variable, as the clinical implications are largely unknown. Those who recognized potential chondrotoxicity and who chose based on literature were more likely to choose ropivacaine and triamcinolone, as reflected in the basic science literature. Further clinical studies are needed to establish guidelines that shape foot and ankle ICI practices based on scientific evidence and reduce the variation identified by this study. Level of Evidence Level IV, cross-sectional survey study.
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Affiliation(s)
- Emily B. Parker
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kalei A. Hering
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Chiodo
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeremy T. Smith
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric M. Bluman
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth A. Martin
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Tsechelidis OB, Sabido-Sauri R, Aydin SZ. Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review. Clin Ther 2023; 45:852-859. [PMID: 37716837 DOI: 10.1016/j.clinthera.2023.08.002] [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: 04/26/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE Enthesitis is a key manifestation of psoriatic arthritis (PsA) and spondyloarthritis (SpA) and is considered to be the tissue where the disease initiates. Enthesitis leads to pain and substantial limitations in patients with PsA. Treatment is key in achieving remission or minimal disease activity. Whether it is safe to apply injections to entheseal tissue is unknown. This narrative review aimed to summarize the literature on the efficacy and tolerability of entheseal corticosteroid (CS) injections. METHODS The published literature was searched through PubMed as well as identifying relevant articles from their citations, for articles on the anatomic location of the injection, tissue characteristics (eg, whether there is a tendon sheath), blind versus imaging-guided and entheseal versus perientheseal injections, and related studies in animals. Given that articles on SpA are limited, those on mechanical enthesopathies were also included. FINDINGS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA are limited. In most articles on entheseal injection, the entheseal tissue has not actually been targeted. The decision of entheseal injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures such as NSAIDs, physiotherapy, rest, and lifestyle modifications. Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis. Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture. In the authors' perspective, perientheseal injections should be tried before intraentheseal injections. Finally, ultrasound guidance for needle placement is strongly encouraged. IMPLICATIONS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA is limited. With the lack of quality data, recommendations on entheseal corticosteroid injection remain expert opinion.
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Affiliation(s)
| | - Ricardo Sabido-Sauri
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Sibel Zehra Aydin
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada.
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Parisien RL, Trofa DP, Gualtieri AP, Dodson CC, Li X, Levine WN, Vosseller JT. How Do Sports Medicine and Foot and Ankle Specialists Treat Acute Achilles Tendon Ruptures? Foot Ankle Spec 2021; 14:114-119. [PMID: 31971006 DOI: 10.1177/1938640019901055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The purpose of this study is to evaluate the treatment considerations and surgical techniques utilized by fellowship-trained orthopaedic sports medicine and foot and ankle specialists in the management of Achilles tendon ruptures. Methods. A blinded electronic survey was distributed to 2062 fellowship-trained sports medicine and 1319 fellowship-trained foot and ankle orthopaedic surgeons. The total number of acute Achilles tendon ruptures managed per year, patient-specific factors associated with surgical decision making and surgical techniques were evaluated. Results. Of the 3381 surveys distributed, 524 responses were included for analysis. Only 9% of respondents manage more than 20 acute Achilles tendon ruptures per year with the majority (75%) managing less than 10 per year. Operative management is the treatment of choice for 76% of total respondents with only 8% managing acute ruptures nonoperatively. Activity level and patient age were the single most important factors for 60.8% and 29.3% of surgeons, respectively, with regard to operative versus nonoperative decision making. Socioeconomic status and workers compensation were the least important patient factors. Conclusion. Surgical repair in the young and active patient is the preferred treatment for the majority of fellowship-trained subspecialists who most commonly encounter this pathology.Levels of Evidence: Therapeutic, Level V: Consensus of Expert Analysis.
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Affiliation(s)
- Robert L Parisien
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - David P Trofa
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Anthony P Gualtieri
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Christopher C Dodson
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - William N Levine
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - J Turner Vosseller
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
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Lakey E, Kumparatana P, Moon DK, Morales J, Anderson SE, Baldini T, Pereira H, Hunt KJ. Biomechanical Comparison of All-Soft Suture Anchor Single-Row vs Double-Row Bridging Construct for Insertional Achilles Tendinopathy. Foot Ankle Int 2021; 42:215-223. [PMID: 33030070 DOI: 10.1177/1071100720959023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Two common operative fixation techniques for insertional Achilles tendinopathy are the use of all-soft suture anchors vs synthetic anchors with a suture bridge. Despite increasing emphasis on early postoperative mobilization, the biomechanical profile of these repairs is not currently known. We hypothesized that the biomechanical profiles of single-row all-soft suture anchor repairs would differ when compared to double-row suture bridge repairs. METHODS Achilles tendons were detached from their calcaneal insertions on 6 matched-pair, fresh-frozen cadaver through-knee amputation specimens. Group 1 underwent a single-row repair with all-soft suture anchors. Group 2 was repaired with a double-row bridging suture bridge construct. Achilles-calcaneal displacement was tracked while specimens were cyclically loaded from 10 to 100 N for 2000 cycles and then loaded to failure. Linear mixed models were used to analyze the independent effects of age, body mass index, tendon morphology, repair construct, and footprint size on clinical and ultimate failure loads, Achilles-calcaneal displacement, and mode of failure. RESULTS The suture bridge group was independently associated with an approximately 50-N increase in the load to clinical failure (defined as more than 5 mm tendon displacement). There was no difference in ultimate load to failure or tendon/anchor displacement between the 2 groups. CONCLUSION This cadaveric study found that a double-row synthetic bridge construct had less displacement during cyclic loading but was not able to carry more load before clinical failure when compared to a single-row suture anchor construct for the operative repair of insertional Achilles tendinopathy. CLINICAL RELEVANCE Our data suggest that double-row suture bridge constructs increase the load to clinical failure for operative repairs of insertional Achilles tendinopathy. It must be noted that these loads are well below what occurs during gait and the repair must be protected postoperatively without early mobilization. This study also identified several clinical factors that may help predict repair strength and inform further research.
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Affiliation(s)
- Eric Lakey
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Pam Kumparatana
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel K Moon
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph Morales
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Todd Baldini
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hélder Pereira
- Orthopedic Surgery Department, Centro Hospitalar Póvoa de Varzim-Vila do Conde, Unidade da Póvoa de Varzim, Póvoa de Varzim, Portugal
| | - Kenneth J Hunt
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Cushman DM, Teramoto M, Asay A, Clements ND, McCormick ZL. Corticosteroid and Local Anesthetic Use Trends for Large Joint and Bursa Injections: Results of a Survey of Sports Medicine Physicians. PM R 2020; 13:962-968. [PMID: 32969178 DOI: 10.1002/pmrj.12499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Physician decision-making surrounding choices for large joint and bursa injections is poorly defined, yet influences patient safety and treatment effectiveness. OBJECTIVE To identify practice patterns and rationale related to injectate choices for large joint and bursal injections performed by physician members of the American Medical Society for Sports Medicine (AMSSM). DESIGN An electronic survey was sent to 3400 members of the AMSSM. Demographic variables were collected: primary specialty (residency), training location, practice location, years of clinical experience, current practice type, and rationale for choosing an injectate. PARTICIPANTS A total of 674 physicians responded (minimum response rate of 20%). INTERVENTION Not applicable. MAIN OUTCOME MEASURES Outcomes of interest included corticosteroid type and dose, local anesthetic type, and total injectate volume for each large joint or bursa (hip, knee, and shoulder). RESULTS Most respondents used triamcinolone (50% to 56% of physicians, depending on injection location) or methylprednisolone (25% to 29% of physicians), 21 to 40 mg (53% to 60% of physicians), diluted with lidocaine (79% to 87%) for all large joint or bursa injections. It was noted that 36.2% (244/674) of respondents reported using >40 mg for at least one injection type. Most (90.5%, 610/674) reported using an anesthetic other than ropivacaine for at least one type of joint or bursa injection. Physicians who reported lidocaine use were less likely to report that their injectate choice was based on the literature that they reviewed (odds ratio [OR] 0.41 [0.27-0.62], P < .001). Respondents predominantly used 5 to 7 mL of total injectate for all large joints or bursae (45% to 54% of respondents), except for the pes anserine bursa, where 3-4 mL was more common (51% of physicians). CONCLUSIONS It appears that triamcinolone and methylprednisolone are the most commonly used corticosteroids for sports medicine physicians; most physicians use 21 to 40 mg of corticosteroid for all injections, and lidocaine is the most-often used local anesthetic; very few use ropivacaine. Over one-third of respondents used high-dose (>40 mg triamcinolone or methylprednisolone) for at least one joint or bursa.
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Affiliation(s)
- Daniel M Cushman
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
| | - Masaru Teramoto
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
| | - Alexandra Asay
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
| | - Nathan D Clements
- Department of Physical Medicine & Rehabilitation, University of Texas Health Science Center, San Antonio, TX
| | - Zachary L McCormick
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
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Cushman DM, Christiansen J, Kirk M, Clements ND, Cunningham S, Teramoto M, McCormick ZL. Image guidance used for large joint and bursa injections; a survey study. PHYSICIAN SPORTSMED 2020; 48:208-214. [PMID: 31560251 DOI: 10.1080/00913847.2019.1674122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: To determine the current rates of use of available image guidance modalities for large joint and bursal injections, in addition to their relationships to physician demographics.Methods: An electronic survey was sent to 3,400 members of the American Medical Society for Sports Medicine (AMSSM), examining types of guidance used for each large joint and bursal injection.Results: A total of 674 sports medicine physicians responded to the survey. Intra-articular hip and glenohumeral joint injections were more commonly performed with ultrasound guidance, while palpation-guidance was more common with all other injections. Physicians who specialized in Physical Medicine & Rehabilitation (PM&R) were more likely to use ultrasound for trochanteric bursa (p = 0.007, OR = 4.16 [1.46-11.8]), while internal medicine-, pediatrics-, and family medicine-trained physicians were more likely to use palpation guidance for at least one joint (p < 0.05). Physicians with fewer years of experience were more likely to use ultrasound for glenohumeral joint injections (p ≤ 0.002 for all age groups with less than 20 years of experience, ORs ranging from 6.3 to 9.2).Conclusion: Palpation-guidance is the most common technique used for large joint and bursal injections, other than for glenohumeral and hip joint injections. PM&R-trained physicians and those with less experience tend to use ultrasound more frequently.
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Affiliation(s)
- Daniel M Cushman
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Jacob Christiansen
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Melissa Kirk
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Nathan D Clements
- Department of Physical Medicine & Rehabilitation, University of Texas Health Science Center, San Antonio, TX, USA
| | - Shellie Cunningham
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Masaru Teramoto
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Zachary L McCormick
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
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The accuracy of an injection technique for Flexor hallucis longus tendon sheath: A cadaveric study. Foot Ankle Surg 2020; 26:334-337. [PMID: 31122874 DOI: 10.1016/j.fas.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/13/2019] [Accepted: 04/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Corticosteroid injections are used in the conservative treatment of Flexor hallucis longus (FHL) tendinopathy. Studies for imaging guided injection are done, however, the accuracy of blind injection has not yet been studied. PURPOSE The aim of this study was to determine the accuracy of a blind injection technique into the FHL tendon sheath. HYPOTHESIS We hypothesize that a blind injections technique into the FHL tendon sheath based on clinical examination has a high accuracy. STUDY DESIGN Descriptive cadaveric study. METHODS Ten ankles of human cadavers were blindly injected with radiologic contrast mixed with methylene blue into the FHL tendon sheath. After injection, a CT scan of each ankle was performed to evaluate the location of contrast material. CT scans were reviewed by an experienced musculoskeletal radiologist blinded to the procedure. Anatomic dissection was undertaken to assess the location of the injection fluid. RESULTS In nine ankles the radiological contrast was injected in the FHL tendon sheath. In one cadaver there was a technical problem and was therefore excluded. CONCLUSION This study shows that the FHL tendon sheath can be blindly injected based on only clinical examination with high accuracy. LEVEL OF EVIDENCE Descriptive cadaveric study.
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10
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Anderson SE, Lubberts B, Strong AD, Guss D, Johnson AH, DiGiovanni CW. Adverse Events and Their Risk Factors Following Intra-articular Corticosteroid Injections of the Ankle or Subtalar Joint. Foot Ankle Int 2019; 40:622-628. [PMID: 30866653 DOI: 10.1177/1071100719835759] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little data exists regarding the incidence of adverse events and their associated risk factors following intra-articular corticosteroid injection of the ankle and subtalar joint. The aim of this study was to determine the complication rate associated with such injections and to identify any predictive risk factors. METHODS Adult patients who had received an intra-articular ankle or subtalar joint injection between January 2000 and April 2016 at one of 3 regional hospitals (2 level 1 trauma centers and 1 community hospital) were included. Patients with prior intra-articular injection of corticosteroid into the ankle or subtalar joint were excluded. Explanatory variables were sex, age, race, body mass index, diabetes status, tobacco use, presence of fluoroscopic guidance, location of intra-articular injection, and administering physician's years of experience. RESULTS Of the 1708 patients included in the final cohort, 99 patients (5.8%) had a total of 104 adverse events within 90 days postinjection. The most prevalent types of adverse events were postinjection flare in 78 patients (4.6% of total cohort, 75% of adverse events) followed by skin reaction in 10 patients (0.6% of total cohort, 9% of adverse events). No infections were noted. Multivariable logistic regression analysis found that intra-articular injection in the subtalar ( P = .004) was independently associated with development of an adverse event. Fluoroscopic guidance was not found to be protective of an adverse event compared to nonguided injections ( P = .476). CONCLUSION The adverse event rate following intra-articular ankle or subtalar joint corticosteroid injection was 5.8%, with postinjection flare being the most common complication. Infections following injection were not reported. Injection into the subtalar joint was independently associated with the development of an adverse event after intra-articular corticosteroid injection, and this was not mitigated by the use of fluoroscopic guidance. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Sophia E Anderson
- 1 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Bart Lubberts
- 1 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Anne D Strong
- 1 Orthopaedic Foot and Ankle Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Daniel Guss
- 2 Harvard Medical School, Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Boston, MA, USA
| | | | - Christopher W DiGiovanni
- 2 Harvard Medical School, Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Boston, MA, USA
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Ferguson A, Christophersen C, Elattar O, Farber DC. Achilles Tendinopathy and Associated Disorders. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419838294. [PMID: 35097320 PMCID: PMC8696945 DOI: 10.1177/2473011419838294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Degenerative disorders of the Achilles tendon are common, affecting up to 18% of the adult population. A thorough evaluation including a focused history, physical examination, and diagnostic studies helps in choosing the appropriate treatment. Initial treatment is usually nonoperative, consisting of activity modification, bracing, and physical therapy. Patents who fail nonoperative management may be treated operatively with a wide range of procedures from endoscopic surgery to open debridement and tendon transfer. Understanding a patient’s expectations and educating patients about potential treatments and their outcomes enables informed collaborative decision making. This article will review the evaluation and management Achilles tendinopathy and associated disorders.
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Affiliation(s)
- Adam Ferguson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Osama Elattar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel C. Farber
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Although the incidence of midportion Achilles tendinopathy is under 1% in the general population, it is quite a common disease in runners that is characterized by the symptom triad of pain, swelling and impaired physical performance. Pain and swelling are located in the area 2 to 7 cm proximal the tendon insertion onto the calcaneus.Diagnosis is made by adequate clinical symptoms and corresponding findings in sonography and/or magnetic resonance imaging scans. Histopathologically, mostly degenerative changes in the tendon structure are found, sometimes accompanied by intra- and paratendinous inflammation.Treatment options are conservative or surgical, but conservative ones should be tried first. The best evidence is available for eccentric exercise protocols, which represent the gold standard in conservative treatment options, followed by extracorporal shockwave (ECSW) therapy and corticoid injections.In about 25% of all cases, because of unsatisfactory nonoperative treatment results, surgery is recommended. Open, minimally invasive as well as tenoscopic methods exist, which show patients' satisfactory rates of about 80%. The return to sport or full physical performance is variable and may take up to 18 months for both treatment regimens.
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de Cesar Netto C, da Fonseca LF, Simeone Nascimento F, O'Daley AE, Tan EW, Dein EJ, Godoy-Santos AL, Schon LC. ☆Diagnostic and therapeutic injections of the foot and ankle-An overview. Foot Ankle Surg 2018; 24:99-106. [PMID: 29409219 DOI: 10.1016/j.fas.2017.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 01/17/2017] [Accepted: 02/02/2017] [Indexed: 02/04/2023]
Abstract
Foot and ankle injections are useful diagnostic and therapeutic tools, particularly when the pain etiology is uncertain. A variety of foot and ankle injuries and pathologies, including degenerative joint disease, plantar fasciitis and different tendinopathies are amenable to injections. Understanding the foot and ankle anatomical landmarks, a thorough physical exam and knowledge of the different injection techniques is key for a successful approach to different pathologies. The objective of this study is to review the use of foot and ankle injections in the orthopaedic literature, present the readers with the senior author's experience and provide a comprehensive clinical guideline to the most common foot and ankle diagnostic and therapeutic injections.
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Affiliation(s)
- Cesar de Cesar Netto
- Medstar Union Memorial Hospital - 3333 Calvert Street, Baltimore, MD, 21218, USA; University of Alabama at Birmingham (UAB) - 1313 13th Street South, Birmingham, Alabama, 35205, USA.
| | | | | | - Andres Eduardo O'Daley
- University of Alabama at Birmingham (UAB) - 1313 13th Street South, Birmingham, Alabama, 35205, USA
| | - Eric W Tan
- University of Southern California (USC), Keck School of Medicine, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA
| | - Eric J Dein
- Johns Hopkins University, School of Medicine, 601 N Caroline Street, Baltimore, MD 21287, USA
| | | | - Lew Charles Schon
- Medstar Union Memorial Hospital - 3333 Calvert Street, Baltimore, MD, 21218, USA
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Abate M, Salini V, Schiavone C, Andia I. Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies. Expert Opin Drug Saf 2016; 16:341-349. [PMID: 28005449 DOI: 10.1080/14740338.2017.1276561] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.
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Affiliation(s)
- Michele Abate
- a Department of Medicine and Science of Aging , University G. d'Annunzio, Chieti-Pescara , Chieti Scalo , Italy
| | - Vincenzo Salini
- a Department of Medicine and Science of Aging , University G. d'Annunzio, Chieti-Pescara , Chieti Scalo , Italy
| | - Cosima Schiavone
- a Department of Medicine and Science of Aging , University G. d'Annunzio, Chieti-Pescara , Chieti Scalo , Italy
| | - Isabel Andia
- b BioCruces Health Research Institute , Cruces University Hospital , Barakaldo , Spain
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Rompe JD, Furia J, Cacchio A, Schmitz C, Maffulli N. Radial shock wave treatment alone is less efficient than radial shock wave treatment combined with tissue-specific plantar fascia-stretching in patients with chronic plantar heel pain. Int J Surg 2015; 24:135-42. [DOI: 10.1016/j.ijsu.2015.04.082] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/27/2015] [Indexed: 12/21/2022]
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Shah NS, Needleman RL, Bokhari O, Buzas D. 2013 Subtalar Arthroereisis Survey: The Current Practice Patterns of Members of the AOFAS. Foot Ankle Spec 2015; 8:180-5. [PMID: 25813779 DOI: 10.1177/1938640015578514] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in adults and children. Clinical studies of patients who had a SA are sparse and with mixed results and variable indications. The purpose of this study was to determine the current practice among orthopaedic foot and ankle specialists regarding SA. METHODS Web-based questionnaires were e-mailed to members of the American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and practice patterns in regard to performing SA surgery. A total of 572 respondents completed the survey (32% response rate). RESULTS A total of 273 respondents (48%) have performed SA. Of this group, 187 respondents (69%) still perform this procedure (33% of total respondents currently perform SA). Of the respondents, 401 (70%) practice in the United States, 40% have performed SA, and 60% of those still perform this procedure. Of non-US respondents, 66% have performed SA, and 80% of those still perform it. The most common US indications are painful congenital flatfoot, posterior tibial tendon dysfunction, and flatfoot associated with accessory navicular. CONCLUSION Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. A greater percentage of non-US practitioners have performed and continue to perform SA than their counterparts in the United States. There is a common list of surgical indications. Most doctors who still perform this procedure have removed the implants, commonly for pain. SA is still being performed in the United States and throughout the world.
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Affiliation(s)
- Neil S Shah
- Department of Orthopaedic Surgery, Wayne State University, Taylor, Michigan (NSS, RLN, OB, DB)
| | - Richard L Needleman
- Department of Orthopaedic Surgery, Wayne State University, Taylor, Michigan (NSS, RLN, OB, DB)
| | - Omaima Bokhari
- Department of Orthopaedic Surgery, Wayne State University, Taylor, Michigan (NSS, RLN, OB, DB)
| | - David Buzas
- Department of Orthopaedic Surgery, Wayne State University, Taylor, Michigan (NSS, RLN, OB, DB)
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Ruta DJ, Kadakia AR, Irwin TA. What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery? Clin Orthop Relat Res 2014; 472:3204-13. [PMID: 24942966 PMCID: PMC4160501 DOI: 10.1007/s11999-014-3733-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 06/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined. QUESTIONS/PURPOSES We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics. METHODS Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression. RESULTS The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category. CONCLUSIONS Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.
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Affiliation(s)
- David J. Ruta
- />Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, University of Michigan Health Systems, 2098 South Main Street, Ann Arbor, MI 48103 USA
| | - Anish R. Kadakia
- />Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL USA
| | - Todd A. Irwin
- />Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, University of Michigan Health Systems, 2098 South Main Street, Ann Arbor, MI 48103 USA
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Abstract
Heel pain is commonly encountered in orthopaedic practice. Establishing an accurate diagnosis is critical, but it can be challenging due to the complex regional anatomy. Subacute and chronic plantar and medial heel pain are most frequently the result of repetitive microtrauma or compression of neurologic structures, such as plantar fasciitis, heel pad atrophy, Baxter nerve entrapment, calcaneal stress fracture, and tarsal tunnel syndrome. Most causes of inferior heel pain can be successfully managed nonsurgically. Surgical intervention is reserved for patients who do not respond to nonsurgical measures. Although corticosteroid injections have a role in the management of select diagnoses, they should be used with caution.
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Abstract
Overuse injuries are a common and important cause of morbidity in elite and recreational athletes. They are increasingly recognized in the sedentary population. This article reviews the major classes of overuse injuries of the lower extremity. The underlying pathologic condition is correlated with the imaging appearances, and the often variable relationship between the imaging appearances and patients' symptoms are reviewed. Attempts at imaged-based grading systems and the ability of imaging to predict patients' prognosis are considered. Image-guided injection therapy for tendinopathy is an important and rapidly changing area; the indications, risks, and potential benefits of these interventions are reviewed.
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Shibuya N, Thorud JC, Humphers JM, Devall JM, Jupiter DC. Is percutaneous radiofrequency coblation for treatment of Achilles tendinosis safe and effective? J Foot Ankle Surg 2012; 51:767-71. [PMID: 22974813 DOI: 10.1053/j.jfas.2012.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Indexed: 02/03/2023]
Abstract
Insertional Achilles tendinosis results in isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. When conservative measures fail, surgical treatment may be necessary. Radiofrequency coblation has been suggested to be an effective procedure for treatment of tendon pathologies. Percutaneous execution of this procedure is very simple as well as minimally invasive, and thus if effective, would be an excellent alternative to an open treatment of insertional Achilles tendinopathy. A review of 47 cases with this percutaneous technique was conducted. In our relatively short-term follow-up (mean = 8.6 months, SD = 9.71, range 1 to 40), the incidence of reoperation was 14.9% (7/47). Rupture of the Achilles tendon was identified in 3 (6.4%) patients. Our cohort had a relatively high body mass index (mean = 37.1, SD = 6.96, range 24.3 to 52.8). We recommend surgeons to be cautious about selecting this procedure in similar, high body mass index patient cohorts for treatment of Achilles tendinosis.
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Affiliation(s)
- Naohiro Shibuya
- Texas A&M Health Science Center, College of Medicine, Temple, TX, USA.
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Shibuya N, Thorud JC, Agarwal MR, Jupiter DC. Is calcaneal inclination higher in patients with insertional Achilles tendinosis? A case-controlled, cross-sectional study. J Foot Ankle Surg 2012; 51:757-61. [PMID: 22819613 DOI: 10.1053/j.jfas.2012.06.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Indexed: 02/03/2023]
Abstract
Insertional Achilles tendinosis is a condition where a patient complains of isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. It has been suggested that this condition is associated with cavus foot deformity. However, to our knowledge, there is no study that has confirmed this observation. We carried out a cross-sectional, case-controlled study to explore the association of increased calcaneal inclination-a surgically important characteristic of cavus foot deformity-with insertional Achilles tendinosis. Patients with Achilles tendinosis and matched controls without the pathology were compared. Although a statistically significant difference was detected in calcaneal inclination angle between these 2 groups (p = .038), we felt that the difference was not clinically significant (calcaneal inclination angle = 20.9 vs. 18.9, respectively). Within the limitations of the study, we conclude that there is no clinically significant difference in calcaneal inclination between those with or without insertional Achilles tendinosis.
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Affiliation(s)
- Naohiro Shibuya
- Texas A&M Health Science Center, College of Medicine, Temple, TX 76502, USA.
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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2012. [DOI: 10.1097/bco.0b013e31824bc119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen CK, Lew HL, Chu NC. Ultrasound-Guided Diagnosis and Treatment of Plantar Fasciitis. Am J Phys Med Rehabil 2012; 91:182-4. [DOI: 10.1097/phm.0b013e3182412187] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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