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Pineda T, Dejour D. Inconsistent repeatability of the Dejour classification of trochlear dysplasia due to the variability of imaging modalities: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:5707-5720. [PMID: 37919443 DOI: 10.1007/s00167-023-07612-8] [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: 08/08/2023] [Accepted: 09/28/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE The purpose of this systematic review was to critically assess the quality of papers that report on the intra- and inter-observer repeatability of the Dejour classification for trochlear dysplasia, and to identify the possible causes for poor repeatability. METHODS Two authors independently conducted an electronic search (four databases) on 8 February 2023 for studies (English or French) that assessed trochlear dysplasia classifications on imaging of skeletally mature participants. Exclusion criteria were reviews of clinical studies, conference proceedings, or editorials. After title, abstract, and full-text screening, characteristics of eligible studies were tabulated (author, year, journal, study design, cohort characteristics, and intra- and/or inter-observer agreement coefficients). The methodological quality of studies was assessed using the Joanna Briggs Institute (JBI) checklist for analytical cross-sectional studies. Authors analysed three components of the included studies: (1) classifications based on true lateral radiographs and slice imaging; (2) dysplasia graded into Type A vs B vs C vs D and 3) coefficients of intra- and/or inter-observer agreement. RESULTS The electronic search returned 3,178 references, and after removal of duplicates and irrelevant studies, ten were eligible for data extraction. A second search (31 July 2023) yielded one additional study. Eight studies did not include lateral radiographs, two studies did not explicitly state if radiographs were true lateral views, and one used true lateral radiographs in isolation. Classification of trochlear dysplasia into A vs B vs C vs D using different imaging modalities resulted in moderate to near-perfect intra-observer agreement, and slight to near-perfect inter-observer agreement. Studies distinguished between moderate and severe dysplasia using a variety of combinations: A vs B/C/D, A/B vs C/D and A/C vs B/D. CONCLUSION This systematic review revealed that the Dejour classification remains the most widely used to assess trochlear dysplasia and that the majority of studies that assessed the reliability of the Dejour classification, reported moderate to near-perfect inter-observer agreement; however, pooling of results for comparison among the included studies was inappropriate due to substantial variation in imaging protocols and non-standardised criteria to distinguish severe from moderate dysplasia. LEVEL OF EVIDENCE Level IV. TRIAL REGISTRY The PROSPERO registration number is CRD42023386731.
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Affiliation(s)
- Tomas Pineda
- Lyon-Ortho-Clinic, Clinique de La Sauvegarde, 29 Avenue des Sources, 69009, Ramsay Santé, Lyon, France
| | - David Dejour
- Lyon-Ortho-Clinic, Clinique de La Sauvegarde, 29 Avenue des Sources, 69009, Ramsay Santé, Lyon, France
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Xu SM, Dong D, Li W, Bai T, Zhu MZ, Gu GS. Deep learning-assisted diagnosis of femoral trochlear dysplasia based on magnetic resonance imaging measurements. World J Clin Cases 2023; 11:1477-1487. [PMID: 36926411 PMCID: PMC10011995 DOI: 10.12998/wjcc.v11.i7.1477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/27/2023] [Accepted: 02/13/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Femoral trochlear dysplasia (FTD) is an important risk factor for patellar instability. Dejour classification is widely used at present and relies on standard lateral X-rays, which are not common in clinical work. Therefore, magnetic resonance imaging (MRI) has become the first choice for the diagnosis of FTD. However, manually measuring is tedious, time-consuming, and easily produces great variability.
AIM To use artificial intelligence (AI) to assist diagnosing FTD on MRI images and to evaluate its reliability.
METHODS We searched 464 knee MRI cases between January 2019 and December 2020, including FTD (n = 202) and normal trochlea (n = 252). This paper adopts the heatmap regression method to detect the key points network. For the final evaluation, several metrics (accuracy, sensitivity, specificity, etc.) were calculated.
RESULTS The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the AI model ranged from 0.74-0.96. All values were superior to junior doctors and intermediate doctors, similar to senior doctors. However, diagnostic time was much lower than that of junior doctors and intermediate doctors.
CONCLUSION The diagnosis of FTD on knee MRI can be aided by AI and can be achieved with a high level of accuracy.
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Affiliation(s)
- Sheng-Ming Xu
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Dong Dong
- Department of Radiology, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Wei Li
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Tian Bai
- College of Computer Science and Technology, Jilin University, Changchun 130000, Jilin Province, China
| | - Ming-Zhu Zhu
- College of Computer Science and Technology, Jilin University, Changchun 130000, Jilin Province, China
| | - Gui-Shan Gu
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
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Xu C, Ji G, Chen X, Yan L, Liang T, Liu J, Wang F. Sclerostin antibody promotes bone formation through the Wnt/β-catenin signaling pathway in femoral trochlear after patellar instability. Connect Tissue Res 2023; 64:148-160. [PMID: 36379907 DOI: 10.1080/03008207.2022.2135507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The molecular mechanism of patellar instability (PI) remains unknown. The purpose of this study was to explore the function of SOST/sclerostin in PI and examine the effect of sclerostin antibody (Scl-Ab). MATERIALS AND METHODS We randomly divided 60 male 3-week-old C57Bl/6 mice into four groups: sham, PI, Scl-Ab intraperitoneal injection (Scl-Ab IP), Scl-Ab intraarticular injection (Scl-Ab IA). PI was established in the latter three groups. The Scl-Ab IP/IA groups were administered with an intraperitoneal/intraarticular Scl-Ab injection (100 mg/kg, 20 µl), respectively, at 5-day intervals. Distal femurs were collected 30 days after the surgery. The SOST/sclerostin, β-catenin, ALP, OPG and RANKL expression in distal femur were determined. Trochlear morphology and structural parameters of the trabecular and cortical bone compartments were determined by micro-CT. Further sub-regional analysis was performed. HE staining and Masson's trichrome staining were performed to evaluate cartilage changes. RESULTS PI increased the expression of SOST/sclerostin and RANKL, and decreased β-catenin, ALP and OPG levels, while Scl-Ab IP reversed these changes. Scl-Ab IP brought trochlear morphology closer to normality. Additionally, Scl-Ab IP significantly improved most of the bone parameters. Importantly, both PI and Scl-Ab IP acted mainly on trabecular bone. Histological analysis showed that Scl-Ab IP protected cartilage from degeneration. However, Scl-Ab IA did not protect against bone loss or cartilage degradation. CONCLUSIONS SOST/sclerostin plays an important role in PI and systemic Scl-Ab use promotes bone formation through the Wnt/β-catenin signaling pathway in the femoral trochlear after PI.
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Affiliation(s)
- Chenyue Xu
- Department of Orthopaedic Surgery, Hebei Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
| | - Gang Ji
- Department of Orthopaedic Surgery, Hebei Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
| | - Xiaobo Chen
- Department of Orthopaedic Surgery, Hebei Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
| | - Lirong Yan
- College of Basic Medicine, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Tuwan Liang
- College of Medical, Hubei University of Science and Technology, Xianning, Hubei, China
| | - Junle Liu
- College of Basic Medicine, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Fei Wang
- Department of Orthopaedic Surgery, Hebei Medical University Third Affiliated Hospital, Shijiazhuang, Hebei, China
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Assessment of the reliability and validity of imaging measurements for patellofemoral instability: an updated systematic review. Skeletal Radiol 2022; 51:2245-2256. [PMID: 35794393 DOI: 10.1007/s00256-022-04110-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To provide an update on the reliability and validity of all radiological measures used to assess patients presenting with patellofemoral instability. METHODS A search of the CINHAL, EMBASE, MEDLINE, and SCOPUS databases and the Cochrane library was conducted. All studies assessing the validity, reliability, sensitivity, and specificity of radiological measures of the patellofemoral joints of patients with patellofemoral instability from 2010 onwards were considered for inclusion. Discrimination validity, inter- and intra-observer reliability, and the sensitivity and specificity of specific imaging measures were evaluated. RESULTS Seventy-three studies met the selection criteria and were included for analysis. We identified eight radiological measures in four categories with good reliability and validity: the tibial tubercle to trochlear groove distance, specific measures of patellar height (Blackburne-Peel index, Caton-Deschamps index and Insall-Salvati ratios), three measures of trochlear dysplasia (sulcus angle, trochlear depth, and lateral trochlear inclination), and the tibial tubercle to posterior cruciate ligament distance. No included studies examined the reliability and validity of patellofemoral instability ultrasound measures. CONCLUSION Our updated review demonstrated good inter- and intra-observer reliability and discrimination validity for the tibial tubercle-trochlear groove distance, specific patellar height, and trochlear dysplasia measures on MRI. The tibial tubercle to posterior cruciate ligament distance, an indirect measure of rotational asymmetry, was a valid and reliable measure on MRI. Due to a lack of assessments across more than one study, there are a variety of proposed measures with insufficient evidence to determine their validity, reliability, sensitivity, and specificity.
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Otto A, Tscholl PM, Pääsuke R, Herbst E, Willinger L, Imhoff AB, Brucker PU. Neither lateral patellar facet nor patellar size are altered in patellofemoral unstable patients: a comparative magnetic resonance imaging analysis. Knee Surg Sports Traumatol Arthrosc 2020; 28:1064-1071. [PMID: 31456062 DOI: 10.1007/s00167-019-05660-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 08/05/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE It remains unclear if morphologic patterns of the patella itself predispose to patellar instability. This study examined established patellar landmarks in relation to the femoral condyle width to clarify differences of patellar morphologies in patellofemoral stable and unstable patients. METHODS Magnetic Resonance Imaging of 50 subjects (20.7 ± 4.4 years; 17 males, 33 females) with patellofemoral instability (study group, SG) and 50 subjects (25.3 ± 5.8 years; 31 males, 19 females) with anterior cruciate ligament rupture (control group, CG) were analyzed. Corresponding patellar value indices (PW-I; LPF-I 1; LPF-I 2) in relation to the femoral condyle width (FCW) were evaluated after the measurement of absolute patellar dimension [patellar width (PW); direct length of the lateral patellar facet (LPF-1); projected length of the lateral patellar facet (LPF-2)]. The patellar shape according to Wiberg, trochlear dysplasia, patellar height, and tibial tubercle-trochlear groove (TT-TG) distance were determined. RESULTS The SG showed a significantly longer absolute (LPF 2) (P = 0.041) and relative (LPF-I 1, LPF-I 2) (P < 0.001) lateral facet of the patella. No significant differences were evaluable for the relative patellar width (PW-I) (ns). A patellar shape type 3 (P = 0.001) as well as a higher position of the patella and TT-TG-distance (P < 0.001) were significantly more often present in the SG. CONCLUSION There are several bony alterations associated with patellofemoral instability, but our data did not show a significantly smaller lateral patellar facet or relative patellar width that could facilitate a patellar dislocation. This helps surgeons, that are considering to surgically address the patella in cases of patellofemoral instability, to better understand its morphologic pattern. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexander Otto
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany.,Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Augsburg, Germany.,Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, CT, USA
| | - Philippe M Tscholl
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospital, Geneva, Switzerland.,Department of Orthopaedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Reedik Pääsuke
- Department of Traumatology and Orthopaedics, Tartu University Hospital, Tartu, Estonia
| | - Elmar Herbst
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Lukas Willinger
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
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Gupta H, Batta NS, Kataria H, Batra V, Upadhyay AD, Jain V, Mishra P, Goel N. A Comparison of the Reliability of the Patellar Tendon-Trochlear Groove (PTTG) Distance and the Tibial Tuberosity-Trochlear Groove (TTTG) Distance Measured on MRI. Malays Orthop J 2020; 14:34-41. [PMID: 32296480 PMCID: PMC7156171 DOI: 10.5704/moj.2003.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Introduction: An increased tibial tuberosity-trochlear groove (TTTG) distance is used for deciding a treatment plan in patello-femoral instability (PFI). The centre of the patellar tendon and the chondral trochlear groove can be directly visualised on MRI, and measured, giving the patellar tendon-trochlear groove (PTTG) distance. A study was designed to compare the inter-rater and the test-retest reliabilities of PTTG and TTTG measurements in MRI of patients without PFI and in a group with PFI. Materials and Methods: This cross-sectional reliability study was done on archival MRI films of 50 patients without patellar instability and 20 patients with patellar instability. TTTG and PTTG distances were independently measured by two orthopaedic surgeons and two radiologists. A hybrid PTTG measurement with bony landmarks on the femoral side and the patellar tendon landmark on the tibial side, was used to estimate the influence of the differences in the femoral and tibial landmarks on the difference in reliabilities. The intra-class correlation coefficient (ICC) was calculated for all four raters, as well as separately for each rater. Results: The PTTG distance had a higher inter-rater reliability (ICC=0.86, 95% CI=0.79-0.92) compared to the TTTG distance (ICC=0.70, 95% CI=0.59-0.80) in patients without PFI. Similar trends were seen in patients with PFI (0.83 vs 0.66). The inter-rater reliability for the hybrid PTTG distance was found to lie in between the TTTG and PTTG. Conclusions: The MRI-based PTTG distance had better inter-rater reliability compared with the MRI-based TTTG distance.
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Affiliation(s)
- H Gupta
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - N S Batta
- Department of Radiodiagnosis, Mahajan Imaging, New Delhi, India
| | - H Kataria
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - V Batra
- Department of Radiodiagnosis, Mahajan Imaging, New Delhi, India
| | - A D Upadhyay
- Department of Biostatistics, All India Institute Of Medical Sciences, New Delhi, India
| | - V Jain
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - P Mishra
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - N Goel
- Department of Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Kaiser P, Konschake M, Loth F, Plaikner M, Attal R, Liebensteiner M, Schlumberger M. Derotational femoral osteotomy changes patella tilt, patella engagement and tibial tuberosity trochlear groove distance. Knee Surg Sports Traumatol Arthrosc 2020; 28:926-933. [PMID: 31214737 DOI: 10.1007/s00167-019-05561-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/07/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim was to assess the influence of femoral derotational osteotomy on patella tilt (PT), axial patella engagement (AEI) and tibial tuberosity trochlear groove distance (TTTG). METHODS Derotational femoral osteotomy was performed on ten lower limbs of body donors embalmed with alcohol-glycerine. Femoral torsion, tibial torsion, knee torsion, PT, AEI and TTTG were evaluated on axial CT slices for an absolute femoral torsion of 15°, 20°, 25°, 30°, 35° and 40°. A linear mixed model analysis was used to estimate the effect of femoral torsion on PT, AEI, TTTG and knee torsion adjusted for correlation due to repeated observations. Estimates with 95% confidence intervals were used to represent the mean change in the dependent variables for one unit of change (degree, mm or AEI) in the predictor variable. RESULTS A significant correlation was observed between femoral torsion and AEI (p < 0.001), PT (p < 0.001) and TTTG distance (p = 0.002). In cases of increased internal femoral torsion, a significant decreased AEI (estimate - 0.003, 95% CI - 0.003 to - 0.002), an increased PT (estimate 0.3, 95% CI 0.2-0.4) and an increased TTTG distance (estimate 0.1, 95% CI 0.1-0.2) were observed. No correlation was seen between change in femoral torsion and knee torsion (n.s.). CONCLUSIONS Derotational femoral osteotomy has a significant impact on patella tilt and axial patella engagement. Moreover, TTTG distance is slightly changed by a derotational femoral osteotomy, which has to be taken into account preoperatively when considering surgical procedures. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Peter Kaiser
- Department of Trauma Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Marko Konschake
- Department of Anatomy, Medical University Innsbruck, Innsbruck, Austria
| | - Fanny Loth
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University Innsbruck, Innsbruck, Austria
| | - Michaela Plaikner
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Rene Attal
- Department of Traumatology, LKH Feldkirch, Carinagasse 47, 6807, Feldkirch, Austria.
| | | | - Michael Schlumberger
- Department of Trauma Surgery, Medical University Innsbruck, Innsbruck, Austria.,Center of Arthroscopy and Sports Medicine, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
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Özdemir M, Kavak RP. Chondromalacia Patella among Military Recruits with Anterior Knee Pain: Prevalence and Association with Patellofemoral Malalignment. Indian J Orthop 2019; 53:682-688. [PMID: 31673166 PMCID: PMC6804383 DOI: 10.4103/ortho.ijortho_655_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to investigate the frequency of chondromalacia patella (CMP) and to evaluate its relation with trochlear morphometric and patellofemoral alignment measurements as well as with edema in superolateral region of Hoffa's fat pad (SHFP) in military recruits with anterior knee pain (AKP). MATERIALS AND METHODS Knee magnetic resonance imaging examinations of 288 military recruits with AKP were retrospectively evaluated. Patellar cartilage lesions were graded using modified Noyes system. Quantitative measurements of trochlear morphology (sulcus angle, trochlear sulcus depth, and lateral trochlear inclination [LTI]) and patellofemoral alignment (patellar translation [PT], lateral patellofemoral angle (LPA), Insall-Salvati index, and tibial tuberosity-trochlear groove distance) were made. The SHFP region was assessed for the presence of edema. Mean values of measurements in knees with and without CMP and in knees with early and advanced stage CMP were compared. RESULTS We found CMP in 169 (58.7%) patients. Patients with CMP demonstrated a significantly greater sulcus angle (P = 0.012), smaller LTI (P = 0.004), greater PT (P = 0.01), smaller LPA (P = 0.036), greater Insall-Salvati ratio (P = 0.034), and higher incidence of SHFP edema (P = 0.001) compared to those without CMP. While none of the measurements were associated with the severity of cartilage damage, the incidence of SHFP edema was significantly correlated with the severity of CMP (P = 0.001). CONCLUSION CMP is a common disorder among military recruits with AKP. Patellofemoral malalignment is an important contributory factor in the development of CMP, and the presence of edema in SHFP may be a strong indicator of underlying severe CMP in this population.
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Affiliation(s)
- Meltem Özdemir
- Department of Radiology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey,Address for correspondence: Dr. Meltem Özdemir, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Department of Radiology, Ziraat Mah, Şehit Ömer Halisdemir Cad. No: 20, Altıdağ/Ankara, Turkey. E-mail:
| | - Rasime Pelin Kavak
- Department of Radiology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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