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Hurwit DJ, Habet NA, Meade JD, Berk AN, Young BL, Odum S, Wang S, Schallmo MS, Fleischli JE, Trofa DP, Saltzman BM. Biomechanical comparison of Tibial-sided supplemental fixation techniques in Bone-Patellar Tendon-Bone anterior cruciate ligament reconstruction. Knee 2023; 41:66-71. [PMID: 36638705 DOI: 10.1016/j.knee.2022.12.005] [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: 06/11/2022] [Revised: 10/03/2022] [Accepted: 12/14/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this study was to compare the biomechanical properties of a commercially available suture anchor and a screw post for supplemental tibial fixation of a bone-patellar tendon-bone (BTB) graft at time zero. We hypothesized that supplemental fixation using a suture anchor would demonstrate similar biomechanical performance in comparison with a screw post. METHODS Sixteen fresh frozen, healthy human cadaveric knees underwent BTB autograft harvest, placement, and primary tibial-sided interference screw fixation using a standardized technique performed by a single surgeon. Specimens were randomly assigned to one of two tibial-sided supplemental fixation groups (suture anchor or screw post), yielding eight specimens in each group. Each specimen was affixed to a custom loading apparatus, with the tibial tunnel aligned in a vertical position that allowed for parallel "worst-case scenario" loading and eliminated loading variation due to tibial tunnel angle. Grafts were pretensioned to 30 N and biomechanical performance was compared with respect to cyclical loading between 50-250 N for 500 cycles at 0.5 Hz and pull-to-failure loading at 60 mm/min. RESULTS The suture anchor and screw post supplemental constructs demonstrated similar performance with respect to all biomechanical parameters assessed, including yield strength (294.0 N [IQR 267.2-304.2 N] versus 332.1 N [IQR 313.8-350.4 N]; P = 0.079) and ultimate strength (330.1 N [IQR 306.9-418.7 N] versus 374.7 N [IQR 362.0-387.3 N]; P = 0.3798). However, of the eight original specimens in each group, one suture anchor specimen (12.5%) and six metallic screw post specimens (75%) failed during cyclical testing and were unable to undergo displacement and load to failure testing. CONCLUSION This study provides preliminary evidence that supplemental tibial-sided fixation of a BTB ACL graft with a suture anchor has similar loading characteristics or load-to-failure strength when compared to supplemental fixation with a screw post construct. STUDY DESIGN Laboratory Controlled Study. LEVEL OF EVIDENCE Basic Science Study.
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Affiliation(s)
- Daniel J Hurwit
- OrthoCarolina Sports Medicine Center, 1915 Randolph Road, Charlotte, NC 28207, USA
| | - Nahir A Habet
- Atrium Health - Musculoskeletal Institute, 1025 Morehead Medical Drive, Charlotte, NC 28204, USA
| | - Joshua D Meade
- OrthoCarolina Research Institute, 2001 Vail Ave Suite #300, Charlotte, NC 28207, USA; Atrium Health - Musculoskeletal Institute, 1025 Morehead Medical Drive, Charlotte, NC 28204, USA
| | - Alexander N Berk
- OrthoCarolina Research Institute, 2001 Vail Ave Suite #300, Charlotte, NC 28207, USA; Atrium Health - Musculoskeletal Institute, 1025 Morehead Medical Drive, Charlotte, NC 28204, USA
| | - Bradley L Young
- Atrium Health, Department of Orthopaedic Surgery, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28207, USA
| | - Susan Odum
- OrthoCarolina Research Institute, 2001 Vail Ave Suite #300, Charlotte, NC 28207, USA; Atrium Health - Musculoskeletal Institute, 1025 Morehead Medical Drive, Charlotte, NC 28204, USA
| | - Schangcheng Wang
- Atrium Health, Department of Orthopaedic Surgery, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28207, USA; Atrium Health - Musculoskeletal Institute, 1025 Morehead Medical Drive, Charlotte, NC 28204, USA
| | - Michael S Schallmo
- Atrium Health, Department of Orthopaedic Surgery, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28207, USA
| | - James E Fleischli
- OrthoCarolina Research Institute, 2001 Vail Ave Suite #300, Charlotte, NC 28207, USA; OrthoCarolina Sports Medicine Center, 1915 Randolph Road, Charlotte, NC 28207, USA; Atrium Health - Musculoskeletal Institute, 1025 Morehead Medical Drive, Charlotte, NC 28204, USA
| | - David P Trofa
- Columbia University Medical Center, New York, NY 10032, USA
| | - Bryan M Saltzman
- OrthoCarolina Research Institute, 2001 Vail Ave Suite #300, Charlotte, NC 28207, USA; OrthoCarolina Sports Medicine Center, 1915 Randolph Road, Charlotte, NC 28207, USA; Atrium Health - Musculoskeletal Institute, 1025 Morehead Medical Drive, Charlotte, NC 28204, USA.
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Colantonio DF, Kicklighter RK, Le AH, Nowicki MA, Posner MA, Zhou LF, Gee SM. Subcortical Backup Tibial Fixation in Anterior Cruciate Ligament Reconstruction Has Similar Maximal Strength to Current Techniques. Arthrosc Sports Med Rehabil 2022; 5:e93-e101. [PMID: 36866315 PMCID: PMC9971884 DOI: 10.1016/j.asmr.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 10/10/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose To evaluate the biomechanical profile of subcortical backup fixation (subcortical button [SB]) in anterior cruciate ligament (ACL) reconstruction as compared with a bicortical post and washer (BP) and suture anchor (SA) when used with interference screw (IS) primary fixation and to evaluate the utility of backup fixation for tibial fixation with extramedullary cortical button primary fixation. Methods Fifty composite tibias with polyester webbing-simulated graft were used to test constructs across 10 methods. Specimens were separated into the following groups (n = 5): 9-mm IS only, BP (with and without graft and IS), SB (with and without graft and IS), SA (with and without graft and IS), extramedullary suture button (with and without graft and IS), and extramedullary suture button with BP as backup fixation. Specimens were tested under cyclic loading and then loaded to failure. Maximal load at failure, displacement, and stiffness were compared. Results Without a graft, the SB and BP had similar maximal loads (802.46 ± 185.18 N vs 785.67 ± 100.96 N, P = .560), and both were stronger than the SA (368.13 ± 77.26 N, P < .001). With graft and an IS, there was no significant difference in maximal load between the BP (1,461.27 ± 173.75 N), SB (1,362.46 ± 80.47 N), and SA (1,334.52 ± 195.80 N). All backup fixation groups were stronger than the control group with IS fixation only (932.91 ± 99.86 N, P < .001). There was no significant difference in outcome measures between the extramedullary suture button groups with and without the BP (failure loads of 721.39 ± 103.32 N and 718.15 ± 108.61 N, respectively). Conclusions Subcortical backup fixation in ACL reconstruction has similar biomechanical properties to current methods and is a viable backup fixation alternative. Backup fixation methods work synergistically with IS primary fixation to strengthen the construct. There is no advantage to adding backup fixation to extramedullary button (all-inside) primary fixation when all suture strands are secured to the extramedullary button. Clinical Relevance This study provides evidence that subcortical backup fixation is a viable alternative for surgeons during ACL reconstruction.
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Affiliation(s)
- Donald F. Colantonio
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A
| | - Rachel K. Kicklighter
- Department of Civil and Mechanical Engineering, United States Military Academy, West Point, New York, U.S.A
| | - Anthony H. Le
- Department of Civil and Mechanical Engineering, United States Military Academy, West Point, New York, U.S.A.,Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland, U.S.A
| | - Margaret A. Nowicki
- Department of Civil and Mechanical Engineering, United States Military Academy, West Point, New York, U.S.A
| | - Matthew A. Posner
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.,John A. Feagin Sports Medicine Fellowship, West Point, New York, U.S.A.,Department of Orthopaedic Surgery, Keller Army Community Hospital, West Point, New York, U.S.A
| | - Liang F. Zhou
- John A. Feagin Sports Medicine Fellowship, West Point, New York, U.S.A.,Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, U.S.A
| | - Shawn M. Gee
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A.,John A. Feagin Sports Medicine Fellowship, West Point, New York, U.S.A.,Department of Orthopaedic Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, U.S.A.,Address correspondence to Shawn M. Gee, M.D., Department of Orthopaedic Surgery, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA 22060, U.S.A.
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Bartolin PB, Boixadera R, Hudetz D. Experimental testing and finite element method analysis of the anterior cruciate ligament primary repair with internal brace augmentation. Med Eng Phys 2021; 95:76-83. [PMID: 34479695 DOI: 10.1016/j.medengphy.2021.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 11/25/2022]
Abstract
The internal brace (IB) technique is a promising treatment option for repairing the proximal rupture of the anterior cruciate ligament (ACL). This paper presents a biomechanical evaluation of the IB technique. Sixteen cadaveric sheep knees underwent monotonic tensile tests, cyclic loading, and passive flexion-extension testing. Data were compared in a series of eight control specimens with an intact ACL and eight repaired specimens where the ACL was cut and repaired using the IB. In parallel with the mechanical testing, finite element analysis (FEA) was performed to investigate the influence of IB loading on the femur-ACL-tibia complex (FATC). The 3D geometry of the FATC was reconstructed from CT scans of the sheep. The IB 3D model was integrated with the 3D FATC for FEA to obtain the femur-repaired ACL with IB - tibia complex (FRA-IB-TC) group. For the intact specimens, the mean (±SD) failure load in the tensile testing was 937 N (±192 N), while for the FRA-IB-TC specimens, it was 519 N (±52 N). The FRA-IB-TC remained biomechanically stable during the cyclic loading testing. The FEA demonstrated an increase in ACL stress to 24.59 MPa and displacement values of 0.391 mm. The IB construct exhibited shear and notch effects at the button-suture-bone fixation site. Testing on this sheep model allowed us a parametric analysis of the impact of the IB repair technique. However, the results will need to be confirmed in a human model. In conclusion, although the IB technique has biomechanical drawbacks, the mechanical properties of the technique are satisfactory.
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Affiliation(s)
- Petra Bonačić Bartolin
- PhD Student/Teaching Assistant at the Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.
| | - Rachel Boixadera
- Medical Student at University of Cambridge, Cambridge, United Kingdom
| | - Damir Hudetz
- Faculty of Medicine, Assistant Professor at the University of Osijek, Osijek, Croatia
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Dobke LS, Bonadiman JA, Lopes Jr OV, Saggin PR, Israel CL, Spinelli LDF. Estudo biomecânico de diferentes dispositivos de fixação femoral na reconstrução do ligamento patelofemoral medial em joelhos de suínos. Rev Bras Ortop 2020; 55:771-777. [PMID: 33364658 PMCID: PMC7748938 DOI: 10.1055/s-0040-1708520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/12/2019] [Indexed: 10/31/2022] Open
Abstract
Resumo
Objetivo Avaliar diferentes dispositivos de fixação femoral na reconstrução do ligamento patelofemoral medial para comparar sua eficácia quanto à força de fixação até a falha em joelhos suínos.
Métodos Foram ensaiados 30 joelhos de suínos subdivididos em 3 grupos de 10 joelhos. Os enxertos retirados foram dissecados de tendões extensores das patas dos suínos. Cada grupo teve o enxerto fixado ao fêmur com parafuso de interferência, âncora, ou tenodese no tendão adutor. Os 3 métodos foram submetidos à testes biomecânicos utilizando uma máquina universal de ensaio de tração com uma velocidade de 20 mm/min.
Resultados Verificamos que a média mais elevada da resistência linear sob tração lateral (185,45 ± 41,22 N) ocorreu no grupo 1: “fixação por parafuso,” seguido do grupo 2: “fixação por âncora” (152,97 ± 49,43 N), e a média foi menor no grupo 3: “fixação por tenodese” (76,69 ± 18,90 N). Para a margem de erro fixada (5%), comprovou-se a diferença significativa entre os grupos (p < 0,001) e também através dos testes de comparações múltiplas (entre os pares de grupos) verificou-se a ocorrência de diferenças significativas. A variabilidade expressada por meio do coeficiente de variação mostrou-se reduzida, já que a referida medida foi inferior a 33,3%.
Conclusão O uso de parafusos de interferência no túnel ósseo de joelhos porcinos é suficientemente forte para fixação femoral na reconstrução do ligamento patelofemoral medial, assim como a fixação com âncoras montáveis com fio de alta resistência. Entretanto, a tenodese no tendão adutor mostrou-se frágil para essa finalidade.
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Affiliation(s)
- Lothar Schmechel Dobke
- Serviço de Cirurgia do Joelho, Instituto de Ortopedia e Traumatologia (IOT), Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brasil
| | - João Artur Bonadiman
- Serviço de Cirurgia do Joelho, Instituto de Ortopedia e Traumatologia (IOT), Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brasil
| | - Osmar Valadão Lopes Jr
- Serviço de Cirurgia do Joelho, Instituto de Ortopedia e Traumatologia (IOT), Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brasil
| | - Paulo Renato Saggin
- Serviço de Cirurgia do Joelho, Instituto de Ortopedia e Traumatologia (IOT), Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brasil
| | - Charles Leonardo Israel
- Departamento de Engenharia Mecânica, Universidade de Passo Fundo, Passo Fundo, RS, Brasil
- Programa de Pós-Graduação em Projeto e Processos de Fabricação, Universidade de Passo Fundo, Passo Fundo, RS, Brasil
| | - Leandro de Freitas Spinelli
- Serviço de Ortopedia e Traumatologia, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
- Departamento de Engenharia Mecânica, Universidade de Passo Fundo, Passo Fundo, RS, Brasil
- Programa de Pós-Graduação em Projeto e Processos de Fabricação, Universidade de Passo Fundo, Passo Fundo, RS, Brasil
- Departamento de Clínica Cirúrgica, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
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Costa RN, Nadal RR, Saggin PRF, Lopes Junior OV, Spinelli LDF, Israel CL. Biomechanical Evaluation of Different Tibial Fixation Methods in the Reconstruction of the Anterolateral Ligament in Swine Bones. Rev Bras Ortop 2019; 54:183-189. [PMID: 31363265 PMCID: PMC6529319 DOI: 10.1016/j.rbo.2017.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/21/2017] [Indexed: 01/26/2023] Open
Abstract
Objective The present study aims to evaluate different methods of tibial fixation in the reconstruction of the anterolateral ligament (ALL). In addition, the present paper aims to compare the effectiveness of these methods and their mechanisms of failure in swine knees. Methods A total of 40 freshly frozen swine limbs were divided into 4 groups of 10 specimens, according to the tibial fixation technique used. In group A, the tibial fixation of the tendon graft was made through an anchor passing the graft. In group B, the tibial fixation was performed through a metal interference screw in a single bone tunnel. In group C, the tibial fixation included an anchor associated with a tendinous suture (but not with a wire crossing the tendon). In group D, two confluent bony tunnels were drilled and combined with an interference screw in one of them. Results The lowest mean force (70.56 N) was observed in group A, and the highest mean force (244.85 N) was observed in group B; the mean values in the other 2 groups ranged from 171.68 N (group C) to 149.43 N (group D). Considering the margin of error (5%), there was a significant difference between the groups ( p < 0.001). Conclusion Fixation with an interference screw in a single tunnel bone showed the highest tensile strength among the evaluated techniques.
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Affiliation(s)
| | - Rubens Rosso Nadal
- Serviço de Cirurgia do Joelho, Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil
| | | | | | - Leandro de Freitas Spinelli
- Laboratório de Bioengenharia, Biomecânica e Biomateriais, Universidade de Passo Fundo, Passo Fundo, RS, Brasil
| | - Charles Leonardo Israel
- Laboratório de Bioengenharia, Biomecânica e Biomateriais, Universidade de Passo Fundo, Passo Fundo, RS, Brasil
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Agarwala S, Jagani N. Osteotendinous Suturing for Anchorage of Hip Abductor Mechanism in Total Hip Arthroplasty through a Lateral Approach: A Technical Note. J Orthop Case Rep 2018; 8:26-29. [PMID: 30167407 PMCID: PMC6114218 DOI: 10.13107/jocr.2250-0685.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION We describe a novel technique for approximation and reattachment of the capsule, hip abductors, and vastuslateralis muscles during closure of the arthrotomy and surgical wound, after total hip arthroplasty through a modified direct lateral approach. This anatomical restoration of soft tissues could thereby lead to early post-operative rehabilitation and recovery. CASE REPORT This is a method of osteotendinous suturing that could lead to reestablishing the functional continuity of the gluteus minimus, medius muscles, and the anterior capsule through drill holes in the greater trochanter, and thereby preserve the integrity of the hip abductor musculature. This is a simple and easily reproducible technique of soft tissue approximation and reattachment that results in early mobilization and ambulation of the patient with no additional complications and have several advantages over the other methods used for closure. CONCLUSION This osteotendinous technique can be used for arthrotomy closure after both primary and revision total hip arthroplasties through the lateral approach (Hardinge and modified Hardinge) to the hip.
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Affiliation(s)
- Sanjay Agarwala
- Department of Orthopaedics and Trauma, P.D. Hinduja Hospital, Mahim —Mumbai. Maharashtra. India,Address of Correspondence: Dr. Sanjay Agarwala, Department of Orthopaedics and Traumatology, P D Hinduja Hospital and Medical Research Centre, Mahim, Mumbai, Maharashtra. India. E-mail:
| | - Naeem Jagani
- Department of Arthroplasty and Trauma, P.D. Hinduja Hospital, Mahim —Mumbai. Maharashtra. India
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Balazs GC, Brelin AM, Grimm PD, Dickens JF, Keblish DJ, Rue JPH. Hybrid Tibia Fixation of Soft Tissue Grafts in Anterior Cruciate Ligament Reconstruction: A Systematic Review. Am J Sports Med 2016; 44:2724-2732. [PMID: 26801921 DOI: 10.1177/0363546515621541] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Optimal fixation of soft tissue grafts in anterior cruciate ligament (ACL) reconstruction remains a controversial topic, and tibial-sided fixation is frequently cited as the "weak point" of the femur-graft-tibia construct. Some studies have recommended the use of hybrid fixation (combining intratunnel aperture fixation and extracortical suspensory fixation) on the tibial side to increase the strength of the reconstructed ACL and decrease the risk of graft slippage and subsequent failure. However, no consensus has emerged on the necessity or suitability of this technique, relative to single modes of fixation. PURPOSE This study sought answers to the following questions: (1) Does hybrid fixation result in stronger, stiffer initial fixation of soft tissue grafts? (2) Does hybrid fixation reduce side-to-side laxity differences in clinical practice? (3) Does hybrid fixation increase complication rates when compared with a single mode of tibial fixation? STUDY DESIGN Systematic review. METHODS A systematic keyword search of PubMed, EMBASE, the Cochrane Library of Systematic Reviews, and the PROSPERO International Prospective Register of Systematic Reviews was performed. Candidate articles were included if they compared biomechanical or clinical characteristics of tibial-sided hybrid fixation (defined as a combination of aperture and suspensory fixation methods) with single-mode fixation of soft tissue grafts in ACL reconstruction. RESULTS A total of 21 studies (15 biomechanical, 6 clinical) met criteria for inclusion. Most biomechanical studies reported significantly increased strength and stiffness with hybrid fixation versus single modes of fixation. Among clinical studies, 66% reported significantly decreased anterior-posterior laxity when hybrid fixation methods were employed, with the remainder showing no difference. CONCLUSION Hybrid methods of tibial-sided graft fixation in ACL reconstruction result in stronger initial fixation and less side-to-side laxity after healing but do not change patient-reported outcomes at 1- to 3-year follow-up. REGISTRATION PROSPERO International Prospective Register of Systematic Reviews No. 42014015464.
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Affiliation(s)
- George C Balazs
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Alaina M Brelin
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Patrick D Grimm
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jonathan F Dickens
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David J Keblish
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, Maryland, USA
| | - John-Paul H Rue
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, Maryland, USA
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