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Sculco PK, Wright T, Malahias MA, Gu A, Bostrom M, Haddad F, Jerabek S, Bolognesi M, Fehring T, Gonzalez DellaValle A, Jiranek W, Walter W, Paprosky W, Garbuz D, Sculco T, Abdel M, Boettner F, Benazzo F, Buttaro M, Choi D, Engh CA, Garcia-Cimbrelo E, Garcia-Rey E, Gehrke T, Griffin WL, Hansen E, Hozack WJ, Jones S, Lee GC, Lipman J, Manktelow A, McLaren AC, Nelissen R, O’Hara L, Perka C, Sporer S. The Diagnosis and Treatment of Acetabular Bone Loss in Revision Hip Arthroplasty: An International Consensus Symposium. HSS J 2022; 18:8-41. [PMID: 35082557 PMCID: PMC8753540 DOI: 10.1177/15563316211034850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/07/2021] [Accepted: 07/07/2021] [Indexed: 11/21/2022]
Abstract
Despite growing evidence supporting the evaluation, classification, and treatment of acetabular bone loss in revision hip replacement, advancements have not been systematically incorporated into a single document, and therefore, a comprehensive review of the treatment of severe acetabular bone loss is needed. The Stavros Niarchos Foundation Complex Joint Reconstruction Center at Hospital for Special Surgery held an Acetabular Bone Loss Symposium on June 21, 2019, to answer the following questions: What are the trends, emerging technologies, and areas of future research related to the evaluation and management of acetabular bone loss in revision hip replacement? What constitutes the optimal workup and management strategies for acetabular bone loss? The 36 international experts convened were divided into groups, each assigned to discuss 1 of 4 topics: (1) preoperative planning and postoperative assessment; (2) implant selection, management of osteolysis, and management of massive bone loss; (3) the treatment challenges of pelvic discontinuity, periprosthetic joint infection, instability, and poor bone biology; and (4) the principles of reconstruction and classification of acetabular bone loss. Each group came to consensus, when possible, based on an extensive literature review. This document provides an overview of these 4 areas, the consensus each group arrived at, and directions for future research.
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Affiliation(s)
- Peter K. Sculco
- Hospital for Special Surgery, New York, NY, USA,Peter K. Sculco, MD, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021, USA.
| | | | | | - Alexander Gu
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | | | - Fares Haddad
- University College London Hospitals NHS Foundation Trust and Institute of Sport, Exercise & Health, London, UK
| | | | | | | | | | | | - William Walter
- Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Wayne Paprosky
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Donald Garbuz
- Department of Orthopaedics, The University of British Columbia, Vancouver, BC, Canada
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Punnoose DJ, N N, A N S, Kandathil JC, Theruvil B. Total Hip Arthroplasty in Post-traumatic Acetabular Nonunion with Symphysis Pubis Diastasis: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00019. [PMID: 34252069 DOI: 10.2106/jbjs.cc.20.01028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a patient with a long-standing post-traumatic pubic diastasis along with acetabular nonunion who developed painful hip arthritis that needed a total hip arthroplasty. We discuss the unique challenges in the acetabular component positioning. CONCLUSION In patients with symphysis pubis diastasis, the surgeon should be prepared to place the cup in less than normal anteversion. This relative retroversion, which is an unusual position, is due to the external rotation of the whole hemipelvis including the femur. The degree of version of the cup should be guided by intraoperative stability checks and to ensure an impingement free range of motion.
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Affiliation(s)
| | - Nizaj N
- Department of Orthopaedics, VPS Lakeshore Hospital, Kochi, Kerala
| | - Sukesh A N
- Department of Orthopaedics, VPS Lakeshore Hospital, Kochi, Kerala
| | | | - Bipin Theruvil
- Department of Orthopaedics, VPS Lakeshore Hospital, Kochi, Kerala
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Patsiogiannis N, Kanakaris NK, Giannoudis PV. Periprosthetic hip fractures: an update into their management and clinical outcomes. EFORT Open Rev 2021; 6:75-92. [PMID: 33532088 PMCID: PMC7845569 DOI: 10.1302/2058-5241.6.200050] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors. Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries. Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint. Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients. Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.
Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050
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Affiliation(s)
| | - Nikolaos K Kanakaris
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Leeds, UK.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
| | - Peter V Giannoudis
- Department of Trauma and Orthopaedics, Leeds General Infirmary, Leeds, UK.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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Changjun C, Xin Z, Mohammed A, Liyile C, Yue L, Pengde K. Survivorship and clinical outcomes of ‘cup–cage’ reconstruction in revision of hip arthroplasty for chronic pelvic discontinuity: A systematic review. Surgeon 2021; 19:e475-e484. [DOI: 10.1016/j.surge.2020.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/13/2020] [Accepted: 11/26/2020] [Indexed: 12/27/2022]
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Frenzel S, Horas K, Rak D, Boelch SP, Rudert M, Holzapfel BM. Acetabular Revision With Intramedullary and Extramedullary Iliac Fixation for Pelvic Discontinuity. J Arthroplasty 2020; 35:3679-3685.e1. [PMID: 32694031 DOI: 10.1016/j.arth.2020.06.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/02/2020] [Accepted: 06/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Parallel to the increase in revision hip procedures surgeons face more and more complex anatomical challenges with pelvic discontinuity (PD) being one of the worst-case scenarios. Here we report on our clinical results using an asymmetric acetabular component for the treatment of PD. The implant is armed in a monoblock fashion with an extramedullary iliac flange and provides the possibility to augment it with an intramedullary iliac press-fit stem. METHODS In a single-center retrospective cohort study we analyzed prospectively collected data of 49 patients (35 female, 14 male) suffering from unilateral periprosthetic PD treated with an asymmetric acetabular component between 2009 and 2017. The mean follow-up was 71 months (21-114). Complications were documented and radiographic and functional outcomes were assessed. RESULTS Kaplan-Meier analysis revealed a 5-year implant survival of 91% (confidence interval 77%-96%). The 5-year survival with revision for any cause was 87% (CI 74%-94%). The overall revision rate was 16% (n = 8). Two patients required acetabular component revision due to aseptic loosening. Four patients (8%) suffered from periprosthetic infection: one patient was treated with a 2-stage revision, and another one with resection arthroplasty. The other 2 patients were treated with debridement, irrigation, and exchange of the mobile parts. Of 6 patients (12%) suffering from hip dislocation, 2 required implantation of a dual mobility acetabular component. The mean Harris Hip Score improved from 41 preoperatively to 79 at the latest follow-up (P < .001). CONCLUSION Our findings demonstrate that an asymmetric acetabular component with extramedullary and optional intramedullary iliac fixation is a reliable and safe treatment method for periprosthetic PD resulting in good clinical and radiographic mid-term results.
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Affiliation(s)
- Stephan Frenzel
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany; Department of Orthopaedics and Trauma Surgery, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Konstantin Horas
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
| | - Dominik Rak
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
| | | | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany
| | - Boris Michael Holzapfel
- Department of Orthopaedic Surgery, University of Wuerzburg, Wuerzburg, Germany; Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
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Fröschen FS, Randau TM, Hischebeth GTR, Gravius N, Wirtz DC, Gravius S, Walter SG. Outcome of repeated multi-stage arthroplasty with custom-made acetabular implants in patients with severe acetabular bone loss: a case series. Hip Int 2020; 30:64-71. [PMID: 32907426 DOI: 10.1177/1120700020928247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Failed reconstruction in cases of severe acetabular bone loss, with or without pelvic discontinuity, in revision total hip arthroplasty (rTHA) remains a great challenge in orthopaedic surgery. The aim of this study was to describe the outcome of a "second" rTHA with "custom-made acetabular components (CMACs)" after a previously failed reconstruction with CMACs. METHODS 4 patients with severe acetabular bone loss (Paprosky Type IIIB), who required a second rTHA after a previously failed reconstruction with CMAC, due to prosthetic joint infection (PJI), were included in our retrospective study. All prostheses had been constructed on the basis of thin-layer computed-tomography scans of the pelvis. The second rTHA was considered unsuccessful in the event of PJI or aseptic loosening (AL) with need for renewed CMAC explantation. RESULTS The treatment success rate after second rTHA with a CMAC was 50% (2 of 4). In the successful cases, the visual analogue scale (VAS) score and Harris Hip Score (HHS) after the second rTHA (VAS range 2-4; HHS range 45-58 points) did not differ from those after the first rTHA, before onset of symptoms (VAS: range 2-4; HHS: range 47-55 points). In the failed cases, the second CMACs needed to be explanted due to PJI, with renewed detection of previous pathogens. Patients with treatment failure of the second CMAC had required a higher number of revision surgeries after explantation of the first CMAC than patients with a successful outcome. CONCLUSIONS In patients with severe acetabular bone loss and previously failed rTHA with CMACs, repeat rTHA with a CMAC may be a solid treatment option for patients with an "uncomplicated" multi-stage procedure, i.e., without persisting infection after explantation of the original CMAC. While the outcome in terms of clinical function does not appear negatively affected by such a "second attempt," the complication rate and risk of reinfection, nonetheless, is high.
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Affiliation(s)
- Frank S Fröschen
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Thomas M Randau
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Gunnar T R Hischebeth
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
| | - Nadine Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Dieter C Wirtz
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Sascha Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany.,Orthopaedic and Trauma Surgery Centre, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Sebastian G Walter
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
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Malahias MA, Ma QL, Gu A, Ward SE, Alexiades MM, Sculco PK. Outcomes of Acetabular Reconstructions for the Management of Chronic Pelvic Discontinuity: A Systematic Review. J Arthroplasty 2020; 35:1145-1153.e2. [PMID: 31784362 DOI: 10.1016/j.arth.2019.10.057] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/11/2019] [Accepted: 10/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A number of articles have been published reporting on the clinical outcomes of various acetabular reconstructions for the management of chronic pelvic discontinuity (PD). However, no systematic review of the literature has been published to date comparing the outcome and complications of different approaches to reconstruction. METHODS The US National Library of Medicine (PubMed/MEDLINE) and EMBASE were queried for publications from January 1980 to January 2019 using keywords pertinent to total hip arthroplasty, PD, acetabular dissociation, clinical or functional outcomes, and revision total hip arthroplasty or postoperative complications. RESULTS Overall, 18 articles were included in this analysis (569 cases with chronic PD). The overall survival rate of the acetabular components used for the treatment of chronic PD was 84.7% (482 of 569 cases) at mid-term follow-up, whereas the most common reasons for revision were aseptic loosening (54 of 569 hips; 9.5%), dislocations (45 of 569 hips; 7.9%), periprosthetic joint infection (30 of 569 hips; 5.3%), and periprosthetic fractures (11 of 569 hips; 1.9%). Both pelvic distraction technique (combined with highly porous shells) and custom triflanges resulted in less than 5% failure rates (96.2% and 95.8%, respectively) at final follow-up. Also, highly effective in the treatment of PD were cup-cages and highly porous shells with and/or without augments with 92% survivorship free of revision for aseptic loosening for both reconstruction methods. Inferior outcomes were reported for conventional cementless shells combined with acetabular plates (72.7%) as well as ilioischial cages and reconstruction rings (66.7% and 60.6% survivorship, respectively). CONCLUSION The current literature contains moderate quality evidence in support of the use of custom triflange implants and pelvic distraction techniques for the treatment of chronic PD, with a less than 5% all-cause revision rate and low complication rates at mean mid-term follow-up. Cup-cages and highly porous shells with or without augments could also be considered for the treatment of PD because both resulted in greater than 90% survival rates. Finally, there is still no consensus regarding the impact of different types of acetabular reconstruction methods on optimizing the healing potential of PD, and further studies are required in this area to better understand the influence of PD healing on construct survivorship and functional outcomes with each reconstruction method.
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Affiliation(s)
- Michael-Alexander Malahias
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY
| | - Qian-Li Ma
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY; Department of Orthopedic Surgery, Fuzhou Second Hospital affiliated to Xiamen University, Fuzhou, Fujian, China
| | - Alex Gu
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY
| | - Sarah E Ward
- Division of Orthopaedic Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael M Alexiades
- Department of Orthopaedics, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY
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8
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Mid-term results after revision total hip arthroplasty with custom-made acetabular implants in patients with Paprosky III acetabular bone loss. Arch Orthop Trauma Surg 2020; 140:263-273. [PMID: 31820093 DOI: 10.1007/s00402-019-03318-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Severe acetabular bone loss, both with or without pelvic discontinuity, remains a challenge in revision total hip arthroplasty (RTHA). The goal of our study was to evaluate the mid-term results for consecutive patients with Paprosky III acetabular bone loss with or without pelvic discontinuity who needed RTHA with custom-made acetabular implants and to compare the results to those of other studies. MATERIALS AND METHODS Sixty-eight (68) patients with severe acetabular bone loss (Paprosky Type IIIa and IIIb), who required RTHA, were included in our study. All prostheses were constructed on the basis of thin-layer computed tomography (CT) scans of the pelvis. The visual analogue scale (VAS), Harrison hip score (HHS), and clinical and radiographic follow-up assessments were used to evaluate the outcome. RESULTS The average follow-up time was 43 months (range 1-120 months). Implant survival at last follow-up was 75% (51 of 68). Kaplan-Meier survival analysis, with explantation as the endpoint, revealed survival rates of 82.7% (3 years) and 77% (5 years). Patients with revision of the acetabular component only had a significant higher survival rate (p 0.012). Overall revision rate was 36.7%. Reinfection rate was 34.4%. Complications included 15 (22%) periprosthetic joint infections (PJI), 7 dislocations (10.2%), and 2 aseptic loosenings (2.9%). Mean VAS at last follow-up was 1.45 compared to 3.2 preoperatively, while mean HHS improved from 21.1 points preoperatively to 61 at last follow-up. The change in both scores was thus significant (p < 0.001). CONCLUSION Defect reconstruction with custom-made modular acetabular implants can be a good, nevertheless expensive, treatment option with clinically and radiologically satisfying results in comparison to recent studies in the literature. Nevertheless, high postoperative complication rates, especially in terms of PJI, remain a challenge.
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Wiznia DH, Schwarzkopf R, Iorio R, Long WJ. Factors That Influence Bone-Ingrowth Fixation of Press-Fit Acetabular Cups. JBJS Rev 2019; 7:e2. [DOI: 10.2106/jbjs.rvw.18.00147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Martin JR, Barrett I, Sierra RJ, Lewallen DG, Berry DJ. Construct Rigidity: Keystone for Treating Pelvic Discontinuity. J Bone Joint Surg Am 2017; 99:e43. [PMID: 28463925 DOI: 10.2106/jbjs.16.00601] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pelvic discontinuity is uncommon and presents the surgeon with complex reconstructive challenges. The objective of this study is to report the results of current strategies used in the treatment of pelvic discontinuity. METHODS We retrospectively analyzed prospectively collected data on 113 consecutive revision total hip arthroplasties performed for the treatment of unilateral pelvic discontinuity at a single institution. The study included 18 male and 95 female patients with a mean age of 63 years at the time of revision surgery. Preoperative, immediate postoperative, and latest follow-up radiographs were reviewed to assess healing of the discontinuity as well as acetabular component stability. Treatment modalities included an uncemented cup with a posterior column plate (50 hips; 44%), a cup-cage construct (27 hips; 24%), an antiprotrusio cage with or without a posterior column plate (26 hips; 23%), and an uncemented cup alone (10 hips; 9%). The average duration of follow-up for each of these types of surgical reconstruction was similar (range, 3.9 to 7.2 years). RESULTS Five-year revision-free survivorship of the implant was best with a cup-cage construct (100%) and worst with an uncemented cup with a posterior column plate (80%) and a cup alone (80%). Healing of the discontinuity was achieved in 50% of the hips with an uncemented cup alone, 74% of the hips with an uncemented cup and a posterior column plate, 74% of the hips with a cup-cage construct, and 88% of the hips with an antiprotrusio cage construct (91% of these hips when structural allograft was used). The overall complication rate was 26.5%. The average Harris hip score improved from 54 preoperatively to 69 postoperatively (95% confidence interval: 50 to 57 preoperatively and 65 to 72 postoperatively; p = 0.017). CONCLUSIONS Improved survivorship and healing rates were seen in this series when a reconstruction cage was used as an adjunct to an uncemented cup (cup-cage) or in combination with structural allograft bone that bridged the discontinuity. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- J Ryan Martin
- 1Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Kokubo Y, Oki H, Takeura N, Negoro K, Takeno K, Miyazaki T, Sugita D, Nakajima H. Reconstruction of acetabulum in revision total hip arthroplasty for pelvic discontinuity: report of a difficult case requiring four revision arthroplasty. SPRINGERPLUS 2016; 5:597. [PMID: 27247893 PMCID: PMC4864750 DOI: 10.1186/s40064-016-2247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/27/2016] [Indexed: 11/29/2022]
Abstract
Background Massive bone defects of the acetabulum with pelvic discontinuity are one of the major problems in revision total hip arthroplasty. Several techniques have been described for repair of acetabular defect; however, reconstruction of acetabulum with massive bone defect is still a major problem. We describe a patient who required four revision total hip arthroplasty during a 24-year period. Findings The acetabulum with pelvic discontinuity was successfully reconstructed by stabilization of the posterior column with a plate commonly used for fracture treatment, and stabilization of the anterior column by reinforcement device commonly used for acetabular reconstruction. Fixation of both acetabular columns provided significant improvement of component stability. Conclusions In the case of pelvic discontinuity with massive acetabular bone defect, reconstruction by stabilizing both acetabular columns using reconstruction plate and KT plate is one of the better surgical options.
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Affiliation(s)
- Yasuo Kokubo
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
| | - Hisashi Oki
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
| | - Naoto Takeura
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
| | - Kohei Negoro
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
| | - Kenichi Takeno
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
| | - Tsuyoshi Miyazaki
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
| | - Daisuke Sugita
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Matsuoka Shimoaizuki 23, Eiheiji, Fukui 910-1193 Japan
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