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Dragosloveanu S, Petre MA, Cretu B, Mihailescu AA, Cergan R, Scheau C. Etiology of Total Knee Arthroplasty Revisions: A Two-Decade Institutional Perspective. Cureus 2024; 16:e55263. [PMID: 38425332 PMCID: PMC10904024 DOI: 10.7759/cureus.55263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 03/02/2024] Open
Abstract
Total knee arthroplasty (TKA) implant survival time is determined by various patient and implant-related factors and varies significantly in recent worldwide reports. In our study, we have included 247 TKA revisions in 203 patients performed in our hospital over the last 20 years. Multiple etiologies of revisions were identified and classified into 10 categories. Time to failure was analyzed with regard to etiology, patient demographics, and other relevant data. The overall average time to revision was 44.08 months (95% confidence interval (CI) between 33.34 and 49.82 months). Age at primary implant was negatively correlated with time to revision (hazard ratio (HR) = 1.0521 and 95% CI of HR = 1.0359 to 1.0685) and female patients showed a 1.59 times higher risk of implant failure than males. Periprosthetic joint infection was the cause of 46.56% (n=115) of revisions (out of which 12.55% (n=31) were early infections, diagnosed within the first three months), while aseptic loosening was found in 31.98% (n=79) of cases. Infection correlated with a shorter time to revision compared to aseptic loosening (p<0.05). These findings emphasize the need to intensify efforts to deliver the best patient care, select the best antibiotic regimen, and improve surgical techniques to decrease the incidence of infectious complications.
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Affiliation(s)
- Serban Dragosloveanu
- Department of Orthopaedics and Traumatology, The "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
- Department of Orthopaedics, "Foisor" Clinical Hospital of Orthopaedics, Traumatology, and Osteoarticular Tuberculosis, Bucharest, ROU
| | - Mihnea-Alexandru Petre
- Department of Orthopaedics, "Foisor" Clinical Hospital of Orthopaedics, Traumatology, and Osteoarticular Tuberculosis, Bucharest, ROU
| | - Bogdan Cretu
- Department of Orthopaedics, Bucharest Emergency University Hospital, Bucharest, ROU
| | - Alexandra Ana Mihailescu
- Department of Anesthesiology and Critical Care, "Foisor" Clinical Hospital of Orthopaedics, Traumatology, and Osteoarticular Tuberculosis, Bucharest, ROU
| | - Romica Cergan
- Department of Anatomy, The "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
- Department of Radiology and Medical Imaging, "Foisor" Clinical Hospital of Orthopaedics, Traumatology, and Osteoarticular Tuberculosis, Bucharest, ROU
| | - Cristian Scheau
- Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, Bucharest, ROU
- Department of Radiology and Medical Imaging, "Foisor" Clinical Hospital of Orthopaedics, Traumatology, and Osteoarticular Tuberculosis, Bucharest, ROU
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VASSO MICHELE, CAPASSO LUIGI, CORONA KATIA, POLA ENRICO, TORO GIUSEPPE, SCHIAVONE PANNI ALFREDO. Periprosthetic knee infection: treatment options. Orthop Rev (Pavia) 2022; 14:37537. [DOI: 10.52965/001c.37537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Infection is one of the most catastrophic complication following total knee arthroplasty (TKA) and represents the second most common cause of TKA failure. Treatment of a patient with periprosthetic joint infection (PJI) could require often costly and prolonged hospital stays, weeks or months of antibiotic therapy, and multiple surgical procedures. The best management is still highly debating, whereas many treatment options are available. These include suppressive antibiotics, arthroscopic irrigation and debridement, open debridement with insert exchange, single-stage reimplantation and two-stage reimplantation. The choice of the treatment depends on many variables, including integrity of implant, timing of the infection, host factors (age, health, immunologic status), virulence of the infecting organism and wishes of the patient. The aim of this review is to provide a comprehensive understaning of the different options for knee PJIs.
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Affiliation(s)
- MICHELE VASSO
- University of Campania “Luigi Vanvitelli” - Naples (Italy)
| | - LUIGI CAPASSO
- San Giovanni Calibita “Fatebenefratelli - Isola Tiberina” Hospital - Rome (Italy)
| | | | - ENRICO POLA
- University of Campania “Luigi Vanvitelli” - Naples (Italy)
| | - GIUSEPPE TORO
- University of Campania “Luigi Vanvitelli” - Naples (Italy)
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Lew AR, Burnett RA, Colman MW, Gitelis S, Blank AT. Single-Stage Revision of Infected Total Femoral Replacement. Orthopedics 2022; 45:e280-e283. [PMID: 35700429 DOI: 10.3928/01477447-20220608-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We present 2 cases of infected total femur prosthetic devices treated with a single-stage revision with extensive irrigation and debridement, followed by reimplantation with a prosthesis coated in antibiotic-impregnated cement. Single-stage total femoral replacement with antibiotic-eluting cement around the device was used for 2 cases of limb salvage arthroplasty to reduce complications, maintain patient function, and minimize hospital-associated cost. [Orthopedics. 2022;45(5):e280-e283.].
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Sandiford NA, Wronka K. The multidisciplinary approach to managing prosthetic joint infection: could this lead to improved outcomes? ANNALS OF JOINT 2022; 7:8. [PMID: 38529134 PMCID: PMC10929312 DOI: 10.21037/aoj-2020-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 08/11/2020] [Indexed: 03/27/2024]
Abstract
Periprosthetic joint infection (PJI) is a devastating complication of the total joint arthroplasty (TJA). It presents a great challenge for the treating clinician. Diagnosis as well as management can prove difficult with significant morbidity for the patients and cost for patients, health care providers and society as a whole. Outcomes of equally challenging pathology such as tumors and polytrauma have been shown to be improved when patients are managed by a team as specialists as opposed to single individuals. The purpose of this study is to review the role of the multi-disciplinary team (MDT) approach in the diagnosis and management of PJI. We examine the influence of this approach on clinical outcomes in patients with PJI. We also discuss the organisational and logistical issues associated with establishment of a MDT as well as several other issues not mentioned in the contemporary orthopaedic literature. All published literature examining the role of multidisciplinary care in the management of PJI and the influence of this approach to the management and outcomes of patients with this diagnosis were included. Studies published in languages other than English were excluded. There is a paucity of data on the influence of multidisciplinary care on outcomes of the management of PJI. Evidence suggests that the MDT has important role in ensuring all factors in the management of this complex group are considered and best possible care is delivered. Multicentre randomised clinical trials are required to assess the influence of MDT'S on outcome as well as important questions around the structuring of these teams.
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Affiliation(s)
| | - Konrad Wronka
- Department of Orthopaedic Surgery, West Suffolk Hospital, Bury St Edmonds, UK
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Birlutiu RM, Mihalache M, Mihalache P, Cismasiu RS, Birlutiu V. Mid-term follow-up results after implementing a new strategy for the diagnosis and management of periprosthetic joint infections. BMC Infect Dis 2021; 21:807. [PMID: 34384360 PMCID: PMC8361652 DOI: 10.1186/s12879-021-06407-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/20/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) represent one of the most serious complications associated with joint replacement surgeries, a complication also of modern orthopedic surgery despite the efforts that occurred in this field. Frequently PJIs lead to prolonged morbidity, increased costs and mortality. METHODS We are conducting a single-center observational cohort ongoing study in the Academic Emergency Hospital Sibiu, Romania, study in which sonication of the retrieved and as a rapid method of bacteria detection, molecular identification of bacteria by 16S rRNA beacon-based fluorescent in situ hybridization (bbFISH) are used. RESULTS A total of 61 patients were enrolled in this study. The diagnosis of aseptic loosening was established in 30 cases (49.1%) and the diagnosis of periprosthetic joint infection was established at 31 patients (50.8%). The mean follow-up period in the subgroup of patients diagnosed with periprosthetic joint infections was 36.06 ± 12.59 months (range: 1-54). The 25-months Kaplan-Meier survival rate as the end point, as a consequence of the period of enrollment and a different follow-up period for each type of surgical procedure, was 75% after debridement and implant retention, 91.7% after one-stage exchange, 92.3% after two-stage exchange, and 100% after three-stage exchange. There were no significant differences in survival percentage. CONCLUSIONS Our study has good results similar to previously published data. We cannot recommend one strategy of managing prosthetic joint infections over the other. Definitely, there is a need for prospective randomized controlled trials.
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Affiliation(s)
- Rares Mircea Birlutiu
- Lucian Blaga University of Sibiu, Faculty of Medicine Sibiu, Str. Lucian Blaga, Nr. 2A, 550169, Sibiu, Romania.
| | - Manuela Mihalache
- Lucian Blaga University of Sibiu, Faculty of Medicine Sibiu, Str. Lucian Blaga, Nr. 2A, 550169, Sibiu, Romania
| | - Patricia Mihalache
- Lucian Blaga University of Sibiu, Bd-ul. Victoriei, Nr.10, 550024, Sibiu, Romania
| | - Razvan Silviu Cismasiu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,FOISOR Clinical Hospital of Orthopedics, Traumatology, and Osteoarticular TB Bucharest, Str. Dionisie Lupu nr. 37, Sector 2, 020021, Bucharest, Romania
| | - Victoria Birlutiu
- Lucian Blaga University of Sibiu, Faculty of Medicine Sibiu, Str. Lucian Blaga, Nr. 2A, 550169, Sibiu, Romania.,Academic Emergency Hospital Sibiu - Infectious Diseases Clinic, B-dul Corneliu Coposu, Nr.2-4, 550245, Sibiu, Romania
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6
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Morcos MW, Kooner P, Marsh J, Howard J, Lanting B, Vasarhelyi E. The economic impact of periprosthetic infection in total knee arthroplasty. Can J Surg 2021; 64:E144-E148. [PMID: 33666386 PMCID: PMC8064239 DOI: 10.1503/cjs.012519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background Currently, the gold standard treatment for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is 2-stage revision, but few studies have looked at the economic impact of PJI on the health care system. The objective of this study was to obtain an accurate estimate of the institutional cost associated with the management of PJI in TKA and to assess the economic impact of PJI after TKA compared to uncomplicated primary TKA. Methods We identified consecutive patients in our institutional database who had undergone 2-stage revision TKA for PJI between 2010 and 2014 and matched them on age and body mass index with patients who had undergone uncomplicated primary TKA over the same period. We calculated all costs associated with the 2 procedures and compared mean costs, length of stay, clinical visits and readmission rates between the 2 groups. Results There were 73 patients (mean age 68.8 [range 48–91] yr) in the revision TKA cohort and 73 patients (mean age 65.9 [range 50–86] yr) in the primary TKA cohort. Two-stage revision surgery was associated with a significantly longer hospital stay (mean 22.7 d v. 3.84 d, p < 0.001), more outpatient clinic visits (mean 8 v. 3, p < 0.001), more readmissions (29 v. 0, p < 0.001) and higher overall cost (mean $35 429.97 v. $6809.94, p < 0.001) than primary TKA. Conclusion Treatment for PJI after TKA has an enormous economic impact on the health care system. Our data suggest a fivefold increase in expenditure in the management of this complication compared to uncomplicated primary TKA.
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Affiliation(s)
- Mina W Morcos
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ont. (Morcos); and the Division of Orthopaedic Surgery, Department of Surgery, Western University, London Health Sciences Centre and University Hospital, London, Ont. (Kooner, Marsh, Howard, Lanting, Vasarhelyi)
| | - Paul Kooner
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ont. (Morcos); and the Division of Orthopaedic Surgery, Department of Surgery, Western University, London Health Sciences Centre and University Hospital, London, Ont. (Kooner, Marsh, Howard, Lanting, Vasarhelyi)
| | - Jackie Marsh
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ont. (Morcos); and the Division of Orthopaedic Surgery, Department of Surgery, Western University, London Health Sciences Centre and University Hospital, London, Ont. (Kooner, Marsh, Howard, Lanting, Vasarhelyi)
| | - James Howard
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ont. (Morcos); and the Division of Orthopaedic Surgery, Department of Surgery, Western University, London Health Sciences Centre and University Hospital, London, Ont. (Kooner, Marsh, Howard, Lanting, Vasarhelyi)
| | - Brent Lanting
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ont. (Morcos); and the Division of Orthopaedic Surgery, Department of Surgery, Western University, London Health Sciences Centre and University Hospital, London, Ont. (Kooner, Marsh, Howard, Lanting, Vasarhelyi)
| | - Edward Vasarhelyi
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ont. (Morcos); and the Division of Orthopaedic Surgery, Department of Surgery, Western University, London Health Sciences Centre and University Hospital, London, Ont. (Kooner, Marsh, Howard, Lanting, Vasarhelyi)
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7
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The Role of Poly(Methyl Methacrylate) in Management of Bone Loss and Infection in Revision Total Knee Arthroplasty: A Review. J Funct Biomater 2020; 11:jfb11020025. [PMID: 32290191 PMCID: PMC7353497 DOI: 10.3390/jfb11020025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
Poly(methyl methacrylate) (PMMA) is widely used in joint arthroplasty to secure an implant to the host bone. Complications including fracture, bone loss and infection might cause failure of total knee arthroplasty (TKA), resulting in the need for revision total knee arthroplasty (rTKA). The goals of this paper are: (1) to identify the most common complications, outside of sepsis, arising from the application of PMMA following rTKA, (2) to discuss the current applications and drawbacks of employing PMMA in managing bone loss, (3) to review the role of PMMA in addressing bone infection following complications in rTKA. Papers published between 1970 to 2018 have been considered through searching in Springer, Google Scholar, IEEE Xplore, Engineering village, PubMed and weblinks. This review considers the use of PMMA as both a bone void filler and as a spacer material in two-stage revision. To manage bone loss, PMMA is widely used to fill peripheral bone defects whose depth is less than 5 mm and covers less than 50% of the bone surface. Treatment of bone infections with PMMA is mainly for two-stage rTKA where antibiotic-loaded PMMA is inserted as a spacer. This review also shows that using antibiotic-loaded PMMA might cause complications such as toxicity to surrounding tissue, incomplete antibiotic agent release from the PMMA, roughness and bacterial colonization on the surface of PMMA. Although PMMA is the only commercial bone cement used in rTKA, there are concerns associated with using PMMA following rTKA. More research and clinical studies are needed to address these complications.
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8
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Masters EA, Trombetta RP, de Mesy Bentley KL, Boyce BF, Gill AL, Gill SR, Nishitani K, Ishikawa M, Morita Y, Ito H, Bello-Irizarry SN, Ninomiya M, Brodell JD, Lee CC, Hao SP, Oh I, Xie C, Awad HA, Daiss JL, Owen JR, Kates SL, Schwarz EM, Muthukrishnan G. Evolving concepts in bone infection: redefining "biofilm", "acute vs. chronic osteomyelitis", "the immune proteome" and "local antibiotic therapy". Bone Res 2019; 7:20. [PMID: 31646012 PMCID: PMC6804538 DOI: 10.1038/s41413-019-0061-z] [Citation(s) in RCA: 254] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/17/2019] [Accepted: 06/21/2019] [Indexed: 02/08/2023] Open
Abstract
Osteomyelitis is a devastating disease caused by microbial infection of bone. While the frequency of infection following elective orthopedic surgery is low, rates of reinfection are disturbingly high. Staphylococcus aureus is responsible for the majority of chronic osteomyelitis cases and is often considered to be incurable due to bacterial persistence deep within bone. Unfortunately, there is no consensus on clinical classifications of osteomyelitis and the ensuing treatment algorithm. Given the high patient morbidity, mortality, and economic burden caused by osteomyelitis, it is important to elucidate mechanisms of bone infection to inform novel strategies for prevention and curative treatment. Recent discoveries in this field have identified three distinct reservoirs of bacterial biofilm including: Staphylococcal abscess communities in the local soft tissue and bone marrow, glycocalyx formation on implant hardware and necrotic tissue, and colonization of the osteocyte-lacuno canalicular network (OLCN) of cortical bone. In contrast, S. aureus intracellular persistence in bone cells has not been substantiated in vivo, which challenges this mode of chronic osteomyelitis. There have also been major advances in our understanding of the immune proteome against S. aureus, from clinical studies of serum antibodies and media enriched for newly synthesized antibodies (MENSA), which may provide new opportunities for osteomyelitis diagnosis, prognosis, and vaccine development. Finally, novel therapies such as antimicrobial implant coatings and antibiotic impregnated 3D-printed scaffolds represent promising strategies for preventing and managing this devastating disease. Here, we review these recent advances and highlight translational opportunities towards a cure.
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Affiliation(s)
- Elysia A Masters
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,2Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY USA
| | - Ryan P Trombetta
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,2Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY USA
| | - Karen L de Mesy Bentley
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,3Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY USA.,4Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY USA
| | - Brendan F Boyce
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,3Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY USA
| | - Ann Lindley Gill
- 5Department of Microbiology & Immunology, University of Rochester Medical Center, Rochester, NY USA
| | - Steven R Gill
- 5Department of Microbiology & Immunology, University of Rochester Medical Center, Rochester, NY USA
| | - Kohei Nishitani
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,6Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Masahiro Ishikawa
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,6Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Yugo Morita
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,6Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Hiromu Ito
- 6Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Sheila N Bello-Irizarry
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA
| | - Mark Ninomiya
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA
| | - James D Brodell
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA
| | - Charles C Lee
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA
| | - Stephanie P Hao
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA
| | - Irvin Oh
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,4Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY USA
| | - Chao Xie
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,4Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY USA
| | - Hani A Awad
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,2Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY USA.,4Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY USA
| | - John L Daiss
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,4Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY USA
| | - John R Owen
- 7Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, VA USA
| | - Stephen L Kates
- 7Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, VA USA
| | - Edward M Schwarz
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,2Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY USA.,3Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY USA.,4Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY USA.,5Department of Microbiology & Immunology, University of Rochester Medical Center, Rochester, NY USA
| | - Gowrishankar Muthukrishnan
- 1Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY USA.,4Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY USA
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