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Ochuba AJ, Mallela DP, Feghali J, Lubelski D, Belzberg AJ, Hicks CW, Abularrage CJ, Lum YW. Development and validation of a prediction model for outcomes after transaxillary first rib resection for neurogenic thoracic outlet syndrome following strict Society for Vascular Surgery diagnostic criteria. J Vasc Surg 2023; 77:606-615. [PMID: 36273663 PMCID: PMC9868109 DOI: 10.1016/j.jvs.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS. METHODS We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation. RESULTS A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88). CONCLUSIONS Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery.
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Affiliation(s)
- Arinze J Ochuba
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deepthi P Mallela
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; The Center for Microbiome and Human Health, Cleveland Clinic, Cleveland, OH
| | - James Feghali
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan J Belzberg
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Ying Wei Lum
- Division of Vascular Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Ogawa T, Onishi S, Mamizuka N, Yoshii Y, Ikeda K, Mammoto T, Yamazaki M. Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13020319. [PMID: 36673129 PMCID: PMC9858151 DOI: 10.3390/diagnostics13020319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/04/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.
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Affiliation(s)
- Takeshi Ogawa
- Department of Orthopedic Surgery, National Hospital Organization Mito Medical Center, 280 Sakuranosato, Ibarakimachi 311-3193, Japan
- Department of Orthopedic Surgery and Sports Medicine, Mito Clinical Education and Training Center, University of Tsukuba Hospital, Mito Kyodo General Hospital, 3-2-7 Miya-Machi, Mito 310-0015, Japan
| | - Shinzo Onishi
- Department of Orthopedic Surgery and Sports Medicine, Mito Clinical Education and Training Center, University of Tsukuba Hospital, Mito Kyodo General Hospital, 3-2-7 Miya-Machi, Mito 310-0015, Japan
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8577, Japan
| | - Naotaka Mamizuka
- Baseball and Sports Clinic, 2-228-1 Kosugi, Park City Musashikosugi the Garden Towers West 1st Floor W4, Nakahara-Ward, Kawasaki 211-0063, Japan
| | - Yuichi Yoshii
- Department of Orthopedic Surgery, Tokyo Medical University Ibaraki Medical Center, Ami 300-0395, Japan
- Correspondence: ; Tel.: +81-298871161
| | - Kazuhiro Ikeda
- Department of Orthopedic Surgery, Kikkoman General Hospital, Noda 278-0005, Japan
| | - Takeo Mammoto
- Department of Orthopedic Surgery and Sports Medicine, Mito Clinical Education and Training Center, University of Tsukuba Hospital, Mito Kyodo General Hospital, 3-2-7 Miya-Machi, Mito 310-0015, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8577, Japan
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Lingyun W, Ke S, Jinmin Z, Yu Q, Jun Q. Derkash's Classification and Vas Visual Analog Scale to Access the Long-Term Outcome of Neurothoracic Outlet Syndrome: A Meta-Analysis and Systematic Review. Front Neurol 2022; 13:899120. [PMID: 35873776 PMCID: PMC9296859 DOI: 10.3389/fneur.2022.899120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Many publications report outcomes of surgical treatment for neurothoracic outlet syndrome (NTOS); however, high-quality meta-analyses regarding objective evaluation system accessing the long-term outcome of NTOS are lacking. This meta-analysis summarizes and compares the outcomes of Derkosh's classification and vas visual analog scale of the supraclavicular neuroplastic of brachial plexus (SNBP) and trams auxiliary first rib resection (TFRR). Methods The Cochrane Library, PubMed, EMBASE, Allied and Complementary Medicine (AMED) were searched for papers published between January 1980 and February 2021, using the keywords “thoracic outlet syndrome,” “treatment, surgical.” Articles were eligible for inclusion if the following criteria were met studies describing outcomes of surgery for NTOS, published in English, human studies, and available in full text. The exclusion criteria were case reports (n < 10), reviews, abstracts, and studies lacking a control group or without evaluation for two types of surgery. Results We included 10 studies with 1,255 cases, out of which 622 were in the SNBP group; and 633 were in the TFRR group. After surgery (≥12 months), Derkash's classification was improved in 425 cases with SNBP and 364 cases with TFRR. OR = 1.34 (95% CI: 0.94, 1.92), P = 0.03; vas visual analog scale was improved in 282 cases in the SNBP group and 214 cases in the TFRR group. OR = 1.08 (95% CI: 0.63, 1.85), P = 0.78. Conclusion This meta-analysis shows that both SNBP and TFRR are effective for NTOS, but that SNBP is better than TFRR in improving Derkash's classification in the long term. Although patients treated with SNBP are more satisfactory, there is no significant difference in vas visual analog scale from TFRR. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021254203, PROSPERO CRD42021254203.
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Affiliation(s)
- Wei Lingyun
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
- Department of Traumatic Hand Surgery, The First Affiliated Hospital of Guilin Medical College, Guilin, China
- *Correspondence: Wei Lingyun
| | - Sha Ke
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
| | - Zhao Jinmin
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
- Zhao Jinmin
| | - Qiao Yu
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
| | - Qin Jun
- Research Centre for Regenerative Medicine, Orthopaedic Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Regenerative Medicine, Guangxi Medical University, Nanning, China
- Collaborative Innovation Centre of Regenerative Medicine and Medical Bio Resource Development and Application Co-constructed by the Province and Ministry, Nanning, China
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Jack MM, Smith BW, Spinner RJ. Neurosurgery for the Neurologist: Peripheral Nerve Injury and Compression (What can be Fixed?). Neurol Clin 2022; 40:283-295. [DOI: 10.1016/j.ncl.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Farina R, Foti PV, Pennisi I, Vasile T, Clemenza M, Rosa GL, Crimi L, Catalano M, Vacirca F, Basile A. Vascular compression syndromes: a pictorial review. Ultrasonography 2022; 41:444-461. [PMID: 35644605 PMCID: PMC9262661 DOI: 10.14366/usg.21233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/23/2022] [Indexed: 12/01/2022] Open
Abstract
Vascular compression syndromes include a group of rare vascular changes due to extrinsic compression of veins or arteries by surrounding structures. These pathologies are often underestimated due to their rarity, clinicians’ poor level of knowledge, and the non-specificity of their symptoms. The best known are Eagle syndrome, thoracic outlet syndrome, nutcracker syndrome, May-Thurner syndrome, Dunbar syndrome, and popliteal entrapment syndrome. This work summarizes the main ultrasonographic characteristics, symptoms, and treatments of choice for these syndromes. Knowledge of these conditions’ characteristic signs is essential for the differential diagnosis. Failure to diagnose these rare diseases can expose patients to serious complications and risks to their health.
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Affiliation(s)
- Renato Farina
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Pietro Valerio Foti
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Isabella Pennisi
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Tiziana Vasile
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Mariangela Clemenza
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Giuliana La Rosa
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Luca Crimi
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Marco Catalano
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Francesco Vacirca
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Antonio Basile
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
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Daley P, Pomares G, Menu P, Gadbled G, Dauty M, Fouasson-Chailloux A. Shoulder Isokinetic Strength Deficit in Patients with Neurogenic Thoracic Outlet Syndrome. Diagnostics (Basel) 2021; 11:diagnostics11091529. [PMID: 34573871 PMCID: PMC8465876 DOI: 10.3390/diagnostics11091529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Neurogenic thoracic outlet syndrome (NTOS) is an impairing painful condition. Patients usually report upper-limb pain, weakness and paresthesia. Shoulder weakness is frequently reported but has never been described with objective strength evaluation. We aimed to compare isokinetic shoulder strength between patients with NTOS and healthy controls. Patients and controls were prospectively evaluated with an isokinetic strength test at 60 and 180°/s, and an endurance test (30 repetitions at 180°/s) of the shoulder rotators. Patients were functionally assessed with QuickDASH questionnaires. One hundred patients and one hundred healthy subjects were included. Seventy-one percent of patients with NTOS were females with a mean age of 39.4 ± 9.6. They were compared to controls, 73% females and the mean age of 38.8 ± 9.8. Patients' mean QuickDASH was 58.3 ± 13.9. Concerning the peak of strength at 60°/s, the symptomatic limbs of patients with NTOS had significantly 21% and 29% less strength than the control limbs for medial and lateral rotators, respectively (p ≤ 0.001). At 180°/s, the symptomatic limbs had significantly 23% and 20% less strength than the controls for medial and lateral rotators, respectively (p ≤ 0.001). The symptomatic limbs had significantly 45% and 30% less endurance than the controls for medial and lateral rotators, respectively (p ≤ 0.001). These deficits were correlated to the QuickDASH. Patients with NTOS presented a significant deficit of strength and endurance of the shoulder rotators correlated to disability. This highlights the interest in upper-limb strength evaluation in the diagnostic process and the follow-up of NTOS.
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Affiliation(s)
- Pauline Daley
- CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France
| | - Germain Pomares
- Institut Européen de la Main, 2540 Luxembourg, Luxembourg;
- Medical Training Center, Hopital Kirchberg, 2540 Luxembourg, Luxembourg
| | - Pierre Menu
- CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, 44042 Nantes, France
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
| | - Guillaume Gadbled
- CHU Nantes, Clinique Chirurgicale Orthopédique et Traumatologique, 44093 Nantes, France;
| | - Marc Dauty
- CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, 44042 Nantes, France
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
| | - Alban Fouasson-Chailloux
- CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, 44042 Nantes, France
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Correspondence: ; Tel.: +33-240-846-211
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Fouasson-Chailloux A, Daley P, Menu P, Louguet B, Gadbled G, Bouju Y, Abraham P, Dauty M. Hand Strength Deficit in Patients with Neurogenic Thoracic Outlet Syndrome. Diagnostics (Basel) 2021; 11:diagnostics11050874. [PMID: 34068245 PMCID: PMC8153137 DOI: 10.3390/diagnostics11050874] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022] Open
Abstract
Neurogenic thoracic outlet syndrome (NTOS) is a chronic painful and disabling condition. Patients complain about upper-limb paresthesia or weakness. Weakness has been considered one of the diagnostic criteria of NTOS, but objective comparisons to healthy controls are lacking. We compared the grip and the key pinch strengths between NTOS patients and healthy controls. Grip strength was evaluated with a hydraulic hand dynamometer and the key pinch with a pinch gauge. All the patients with NTOS completed a QuickDASH. We included prospectively 85 patients with NTOS, 73% female and 27% male. The mean age was 40.4 ± 9.6. They were compared to 85 healthy subjects, 77.6% female and 22.4% male. Concerning the grip, symptomatic hands of NTOS patients had significantly 30% less strength compared to control hands (p ≤ 0.001), and 19% less strength compared to asymptomatic hands (p = 0.03). Concerning the key pinch, symptomatic hands of patients with NTOS had significantly 19.5% less strength compared to control hands (p ≤ 0.001). Grip and key pinch strengths had a significant correlation with the QuickDASH (r = −0.515 and r = −0.403, respectively; p ≤ 0.001). Patients with NTOS presented an objective hand strength deficit compared to healthy controls. This deficit was significantly correlated to the upper-limb disability. These findings confirm the interest of hand strength evaluation in the diagnostic process of patients with NTOS.
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Affiliation(s)
- Alban Fouasson-Chailloux
- CHU Nantes, Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, F-44042 Nantes, France
- Correspondence: ; Tel.: +33-240-846-211
| | - Pauline Daley
- CHU Nantes, Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France;
| | - Pierre Menu
- CHU Nantes, Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, F-44042 Nantes, France
| | - Bastien Louguet
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
| | - Guillaume Gadbled
- CHU Nantes, Clinique Chirurgicale Orthopédique et Traumatologique, 44093 Nantes, France;
| | - Yves Bouju
- Institut Main Atlantique, 44800 Saint Herblain, France;
| | - Pierre Abraham
- Sports Medicine Department, University Hospital of Angers, 49100 Angers, France;
- Vascular Medicine Department, University Hospital of Angers, 49100 Angers, France
- Mitovasc, UMR CNRS 6015 INSERM 1083, LUNAM University, 49100 Angers, France
| | - Marc Dauty
- CHU Nantes, Service de Médecine Physique et Réadapatation Locomotrice et Respiratoire, 44093 Nantes, France; (P.D.); (P.M.); (M.D.)
- CHU Nantes, Service de Médecine du Sport, 44093 Nantes, France;
- IRMS, Institut Régional de Médecine du Sport, 44093 Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, F-44042 Nantes, France
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