Limb sparing resection for tumors involving the distal humerus and reconstruction with a modular endoprosthesis.
Total elbow replacements have been used in the treatment of comminuted distal humerus fractures in the elderly as well as for end stage osteoarthritis and rheumatoid arthritis of the elbow joint. (1,3-8) Limb sparing surgery with endoprosthetic replacement is currently an acceptable treatment option for both primary and extensive metastatic tumors that provides the patient with a functional upper extremity and a low complication rate. (1,3,4,6,9,10) It is also an option for resection of primary soft tissue tumors that have secondary bone involvement.
The goals of surgery are safe and reliable resection of tumor and reconstruction that provides a functional painless elbow. The surgical approach should be extensile in nature to permit possible future resections for local recurrence or revisions. Total elbow replacements for fractures and arthritis are routinely performed through a posterior incision, but such an approach may not be safe for oncologic resections as there is frequent tumor extension in proximity to major neurovascular structures. Additionally, the posterior approach is not extensile and cannot provide exposure of the entire humerus or conversion to a total humerus replacement if ever necessary. An anterior approach permits safe mobilization of neurovascular structures away from tumor. This facilitates a safe resection by preventing accidental injury or laceration of important nerves and blood vessels. The tumor can be safely resected and the extremity reconstructed. In this article, we present the palliative and functional outcomes in a retrospective series of patients treated with hinged semiconstrained modular distal humeral replacement (Stryker Inc., Mahwah, NJ) for reconstruction following wide resection of tumors of the distal humerus.
Materials and Methods
We retrospectively reviewed the charts of nine patients treated for tumors of the distal humerus between 2002 and 2013. The diagnoses consisted of three primaries, five metastatic, and one benign aggressive tumor (Fig. 1). There were four male and five female patients ranging in age from 36 to 78 years old (mean: 57 years). Patients were followed for an average of 34 months (range: 3 to 75 months). The patients were initially evaluated with plain radiographs, CT, and MRI to evaluate the tumor extent. CT of the chest and bone scan were obtained for patient with malignancies.
Once the pathology of the tumor was confirmed with biopsy, resection of tumor and reconstruction with a hinged modular distal humeral endoprosthesis was performed. Postoperatively, the patients' functional statuses were rated using the MSTS system. In this system, patients are given scores expressed as a percentage of expected normal performance in six categories: pain, function, emotional acceptance, hand positioning, dexterity, and lifting ability. (1,10,11)
Each surgery consists of three essential stages. The first step is safe resection of the tumor. The neurovascular structures are identified in normal tissues, dissected away from the tumor and protected throughout the procedure. The tumor can then be resected safely. The second step is endoprosthetic reconstruction of the resulting defect. The final step consists of muscle rotation and flexorplasty to cover the endoprosthesis and restore function to the elbow.
Distal Humeral Resection
The patient is positioned supine with a small bump under the ipsilateral scapula. The upper extremity is prepped from the shoulder girdle to the fingertips and placed in an abducted position on a padded Mayo stand. A tourniquet is not used to permit easier identification of vascular structures. An "S" shaped incision starting on the medial border of the biceps muscle is carried laterally across the antecubital fossa and distally along the ulnar border of the brachioradialis muscle. The previous biopsy tract is elliptically excised and left with the resected tumor. Wherever possible, fasciocutaneous flaps are raised. If the tumor involves the fascia, cutaneous flaps are used instead. Medial and lateral antebrachial cutaneous nerves are preserved if possible.
Proximal to the tumor, in the interval between the biceps and triceps muscles, the neurovascular structures are identified within their sheath. While protecting the underlying structures, the fascia is opened from proximally to distally all the way down to the neoplasm or antecubital fossa. The neurovascular structures can be easily visualized, and the brachial artery can be palpated once the sheath is opened.
The brachial artery and veins are meticulously dissected away from the surrounding tissues and from the neoplasm down to and across the antecubital fossa. The biceps aponeurosis is incised to permit visualization of the brachial artery to the point where the ulnar and radial arteries arise. The radial and ulnar arteries are each identified and surrounded with a vessel loop. The inferior ulnar collateral vessels as well as muscular branches to the biceps, brachialis, or triceps muscle may require ligation depending upon the location and position of the tumor in order to mobilize the brachial vessels away from the neoplasm. Once the artery is freed from the neoplasm, attention is turned to mobilizing the major nerves.
The median nerve is dissected in a proximal to distal manner crossing the antecubital fossa. The ulnar nerve is also isolated and dissected from proximal to distal then released from the cubital tunnel and transposed. The radial nerve is identified and mobilized gently. Proximally, the lateral intermuscular septum is opened where it is pierced by the radial nerve to allow mobilization of the nerve away from the posterior aspect of the humerus.
The biceps muscle is released from neoplasm and the underlying brachialis muscle. If the biceps or brachialis displays any neoplastic involvement, a portion may require removal. The biceps muscle is isolated so it can be retracted when necessary.
The pronator teres and common flexor muscles are released from the distal humerus medially leaving a margin of muscle if necessary. The brachioradialis, extensor carpi radialis longus, and common extensor muscles are released laterally from the distal humerus. Part or all of the brachialis muscle may require resection depending upon the extent of the tumor. If the brachialis cannot be preserved due to tumor involvement, it is transected distally near it ulnar insertion and resected together with the distal humerus. Posteriorly, the triceps muscle is elevated off of the distal humerus and may require partial or complete resection of the medial head depending on tumor extent. The lateral and long heads are usually not involved by tumor. The triceps tendon is kept attached to the olecranon, and the olecranon is not osteotomized.
The elbow joint is opened anteriorly, and the capsule released circumferentially; the humeroulnar and radiohumeral joints are then disarticulated. The humerus is osteotomized approximately 2 cm to 3 cm beyond the intramedullary extent of the neoplasm.
Reconstruction of the distal humerus-elbow joint is performed with a modular semiconstrained segmental distal humerus tumor prosthesis (Stryker Inc., Mahwah, NJ) (Fig. 2). The prosthesis consists of a variable sized body component linked to the distal humerus component via a Morse taper. The stem is cemented into the humeral diaphysis, while the ulnar component is cemented into the proximal ulna. The humeral and ulnar components are joined via a semiconstrained hinge. The length of the prosthesis is chosen based on the resected specimen. It may be downsized 2 cm to 3 cm to facilitate soft tissue closure, which can be accommodated for by muscle retensioning. The humeral diaphysis is prepared with flexible reamers to allow for a 1 mm to 2 mm cement mantle around the humeral stem. The olecranon process is opened with a small high speed burr to enter into the medullary canal of the proximal ulna. The proximal tip of the olecranon is burred down slightly to accommodate the ulnar component. The canal of the ulna is then prepared with broaches. Trial components are used prior to final cementation, and the rotation of the humeral component is marked so that the hinge faces directly anteriorly. The modular prosthesis is assembled on the back table. The final humeral and ulnar components are inserted separately, with the humeral component cemented so the hinge will face anteriorly. Once the cement cures, both components are linked together with a hinge.
Soft Tissue and Muscle Reconstruction
The extensor carpi radialis and brachioradialis muscles are rotated and sutured to the remaining biceps muscles to secure soft tissue around the flared distal portion of the humeral endoprosthesis. While the elbow is held in 60[degrees] of flexion and the forearm is fully supinated, the extensor muscles are transferred to the most proximal possible position and sutured to the biceps muscle. The biceps is pulled distally and placed under tension while these muscles are sutured to it. The elbow is kept in 60[degrees] of flexion and fully supinated for the remainder of the procedure.
The origin of the flexor-pronator forearm muscles is also transferred as far proximal as possible and sutured to the medial border of the biceps.
For postoperative analgesia, an epineural catheter is placed proximally into the sheath surrounding the neurovascular structures, where it will bathe the entire brachial plexus with bupivacaine. A drain is also placed at this time.
The remaining muscles are sutured to each other to close over the entire prosthesis and neurovascular structures.
Proximal transfer (tensioning) of the brachioradialis and forearm flexor origins (flexorplasty) is beneficial for restoring elbow flexion power. A layered closure of the skin is performed. A bulky dressing with light compression is applied from the hand to the shoulder while the elbow is maintained in 60[degrees] of flexion in a long arm posterior plaster splint.
The elbow is immobilized in a long arm splint or hinged elbow brace for a total of 6 weeks to allow for sufficient muscle healing and scarring. Rest and elevation is maintained for the first 3 to 4 days postoperatively. At this point, the epineural catheter and drain are removed, the dressings are changed, and the splint reapplied to maintain the elbow at 60[degrees] of flexion. Motion of the wrist and hand, as well as hand strengthening, are permitted beginning in the early postoperative period. Elbow motion from 30[degrees] to 130[degrees] is allowed in a hinged elbow brace once the splint is removed 6 weeks postoperatively. At 12 weeks after surgery, the brace is adjusted to allow full motion of the elbow. Strengthening of the elbow is initiated at this time with a 2 pound weight limit. The brace is worn for 6 more weeks, usually until approximately week 18. At week 18, resistance strengthening can be increased to a 5 pound weight limit as long as the patient can handle 2 pounds. At 6 months after surgery, the weight limit is 10 pounds. Patients are advised to never lift more than 10 pounds with the extremity.
Survival and Local Recurrence
There were nine patients enrolled in this study. Of the nine cases presented, five were metastatic tumors, three primary tumors, and the remainder had a benign aggressive tumor. Five of the nine cases presented as a pathologic fracture (Fig. 3). Six of the nine patients died of their diseases at a mean of 17 months (range: 3 to 68 months) after main surgery. Three patients were alive and disease-free at a mean follow-up of 69 months (range: 63 to 75 months).
All patients underwent complete resection and prosthetic placement (Fig. 4). One patient developed a local recurrence and died 8 months later. This patient was referred initially by another institution and had previously undergone an arthroscopic procedure of the elbow. The patient presented with a soft tissue mass, which mimicked a benign lesion arising in the elbow. Six months after the limb-sparing surgery, the patient presented with local recurrence, as well as axillary metastases, and then underwent a forequarter amputation, and subsequently died 2 months later.
There were total of seven patients with metastatic lesions. Five patients (56%) presented before their surgeries with metastatic lesions to the bone, and two patients with primary sarcoma tumors developed lung metastasis at 6 and 60 months after surgery. One of the five patients with bone metastasis is alive and disease-free at the 70 month followup. Six of the nine patients (66%) died of their diseases at a mean of 17 months (range: 3 to 68 months), and three patients are alive at a mean of 69 months.
Functional Outcome and Complications
Seven patients demonstrated significant improvement in their elbow pain during the period between the endoprosthetic surgery and their last follow-up. Two patients did not achieve complete pain control but did not require medication for pain management. The mean Musculoskeletal Tumor Society Score (MSTS) for the nine cases was 81% (range: 63% to 97%). The mean for each category was: pain 84%; function 72%; emotional acceptance 89%; hand positioning 82%; manual dexterity with 90%; and lifting ability 70% (Fig 5). All patients achieved at least 110[degrees] arc of motion of the elbow between 8 and 16 weeks after surgery.
No patients presented with aseptic loosening, deep infection, or neurovascular complications. Three patients (33%) experienced one or more complications and underwent a second procedure. One patient experienced a bushings failure at 52 months after surgery and underwent revision of the bushings and hinge through a simple posterior triceps splitting approach. A second patient experienced two bushings failures at 40 months and 68 months after surgery and also underwent revision in both incidences.
A postoperative infection was seen in one patient. The patient had a superficial infection and skin necrosis, which was successfully treated with wound debridement and antibiotics.
One patient developed entrapment of the median nerve in the proximal forearm at 11 months postoperatively. A second surgery was performed for adhesions after which the nerve symptoms resolved completely (Table 1).
Tumors involving the distal humerus are very rare, with little literature available on the subject to date. (1-3) In the past, the treatment options have included amputation, endoprosthetic reconstruction, allo-prosthetic reconstruction, allograft reconstruction, allograft arthrodesis, and resection arthroplasty. (1-4,6,10) The advantage of limb salvage over amputation is the preservation of a functional hand. (4) However, limb salvage should never compromise the long-term oncologic outcome for the sake of a better short-term functional outcome. Of the limb salvage options, endoprosthetic reconstruction may provide superior oncologic outcome. (4,5) Local recurrence rates vary depending on tumor grade and histology and may range from 5% for osteosarcoma to 30% for soft tissue sarcomas and chrondrosarcoma. The highest rates of local recurrence of 20% to 50% are seen in metastases. (10) Local recurrence in our series was present in one patient, demonstrating that this surgery can be safely performed without compromising the oncologic results.
In 1987, Ross and coworkers (9) described the first series of 26 patients with tumors and chronic nonunions of the distal humerus treated with a custom made hinged prosthesis. Elbow range of motion showed a mean extension of 35[degrees] (range: 5[degrees] to 65[degrees]) and a mean flexion of 117[degrees] (range: 80[degrees] to 145[degrees]) with a mean resultant arc of motion of 80[degrees] (range: 40 [degrees] to 140[degrees]). There were three local recurrences in this series. Three prostheses were removed due to deep infection, all in patients who had suffered previous open distal humeral fractures. Three patients with aseptic loosening were treated nonoperatively. Another three patients had nerve palsies. The investigators' concluded that a stable arm and good hand function was achieved in all patients. This should be a minimum goal whenever this kind of reconstructive surgery is performed. (9)
In 1999, Sperling and associates (3) were the first to describe the use of the semiconstrained Coonrad-Morrey total elbow arthroplasty (Zimmer Corporation, Warsaw, IN) in the treatment of malignancies of the distal humerus. Thirteen patients underwent a semiconstrained total elbow arthroplasty for seven primary and six metastatic tumors. The prosthesis was used in combination with allograft to make up for variable amounts of bone loss following the resection. Range of motion showed the mean arc of movement at 73[degrees] (range: 20[degrees] to 135[degrees]). Three of 13 patients had a history of metastatic disease and developed local recurrence. One patient underwent excision of heterotopic bone postoperatively. One patient had ulnar paresthesias. The investigators concluded that the function of patients with primary tumors was better than that of patients with metastases to the distal humerus. There was no infection or aseptic loosening. (3)
In 2003, Kulkarni and colleagues (6) described 10 patients treated with custom made endoprosthetic distal humerus replacements (Stanmore Implants, Stanmore, UK) for both primary and metastatic tumors. An anterior approach was used in all operations. The patients had an average flexion contracture of 15[degrees] (range: 0[degrees] to 35[degrees]) and a mean range of motion of 115[degrees] (range: 110[degrees] to 135[degrees]). Four patients required revision for aseptic loosening, and three required an exchange of bushings. There were no local recurrences, nerve palsies, or infections. Four patients eventually died of their disease. (6)
Weber and coworkers in 2003 described the use of a segmental total elbow prosthesis (Stryker Howmedica, Biomet Inc., Zimmer, Warsaw, IN) in 11 of a series of 23 patients. (10) Twelve patients underwent a total humerus reconstruction with endoprosthesis or allograft. The implant used varied from a standard to custom-made endoprosthetic implants with or without allograft. There was local recurrence in six (26%) patients at a mean of 17 months. The mean arc of motion was 110[degrees] with a fixed flexion of 10[degrees] to 15[degrees]. Four patients had postoperative nerve palsies, and two had infections. In five cases, two patients who had an allograft presented with resorption of the graft. Two patients had periprosthetic lysis around the ulnar component. Four cases had neurologic damage; one had a nerve transection, and three cases presented with nerve palsies after the surgery. Two more required additional surgery for aseptic loosening. The functional outcome was evaluated using the MSTS scoring system, and the overall was 83%, which is consistent with our findings. (10)
In 2005, Athwal and associates (4) described 20 patients who underwent total elbow arthroplasty, 19 with a standard semi-constrained Coonrad-Morrey total elbow arthroplasty (Zimmer, Warsaw, IN), and one case with a custom humeral component with an extended flange. Two patients required additional allograft-prosthetic components, and one required allograft struts. (4) The posteromedial approach was used in 11 patients and the triceps sparing approach in 7 patients. Range of motion showed a mean arc of motion of 92[degrees] (range: 35[degrees] to 135[degrees]). In 20 patients, five had local recurrence, and two sustained a periprosthetic fracture, one from a fall, and the other at the site of a metastatic lesion at the tip of the ulnar component. Twenty-five percent of patients suffered nerve injuries. One patient required revision secondary to nonunion at the allograft-host junction of the humeral component. There were no infections in this study. (4)
Between 1988 and 2006, Hanna and colleagues reviewed 18 patients who had replacements of the distal humerus with custom-made constrained implants for bone tumors (Stanmore Implants Worldwide Ltd.). (1) They reported 78% of survival for the implant at a mean of 4.4 years. Three patients who required a second procedure had aseptic loosening. Local recurrence and metastases were seen in four patients. These patients had incomplete excisions. Postoperative infections appeared in two cases. One patient had a neuropraxia of the radial nerve. Revision procedure was seen in four patients at the mean of 4.6 years. The functional outcome was assessed with the MSTS (Musculoskeletal Tumor Society) scoring system and TESS (Toronto Extremity Salvage Score). The mean overall scores were 76% and 73%, respectively. (1)
In our series, all patients underwent a complete tumor resection. As described previously, one patient developed local recurrence and died 2 months after the second surgery. Three incidences of bushing failure occurred in two patients, but no prosthesis required removal or replacement. Prostheses were successfully salvaged with the exchange of small plastic bushings. No neurovascular damage was found in our series; we correlate this result with the anterior approach where the complete and meticulous dissection of the neurovascular structure is possible, avoiding the transection or stretching of these structures. One patient had median nerve entrapment after the first year of the endoprosthesis procedure, which was resolved after the second surgery. Only one patient developed local recurrence. Free margins were achieved during surgery; however, the patient had been misdiagnosed in another health care facility and underwent three arthroscopic procedures prior to distal humerus resection. Upon local recurrence 6 months after endoprosthesis implantation, the patient underwent forequarter amputation and died 2 months later. We attribute this low local recurrence rate to the clear identification of the tumor limits and neurovascular structures that are feasible through the anterior approach.
Infection and skin necrosis are another frequent complication with this procedure. We do not describe deep infection or skin necrosis in our series. The lack of these complications in our series correlated with the anterior approach in which an ample medial and lateral flap is obtained and adequate closure is feasible. Only two prosthetic failures were reported due to bushings failure and were successfully resolved with a small posterior incision. No allograft or allo-prosthesis composites were used, avoiding elbow instability, graft healing, and difficult second surgeries.
Five patients died between 3 and 8 months after the surgery for which the main purpose was palliation of pain; in all patients, this objective was accomplished. The mean MSTS score for our series was 81%, and these results are comparable with other publications. The whole series was satisfied with the procedure because patients experienced less or no pain after the surgery, and patients chose to have a functional extremity rather than amputation. Patients had complete shoulder range of motion and manual dexterity, and no elbow instability was found.
Limb sparing resection through an anterior approach and reconstruction with modular distal semiconstrained endoprosthesis for primary and metastatic tumor have been shown to be effective in increasing range of motion, decreasing pain, and have a lower complication rate when compared to a posterior or posteromedial approach as well as reconstruction arthrodesis, amputation, resection arthroplasty, or allograft.
Tumors of the distal humerus can be resected safely through an anterior approach. The neurovascular structures are first identified and protected. Once the tumor is resected, the resultant defect is reconstructed with a modular semiconstrained prosthesis. The prosthesis and neurovascular structures are covered with muscle as the final step of the reconstruction. Soft tissue reconstruction is also possible utilizing muscle transposition or muscle rotation flap. This stepwise approach allows safe tumor resection with a low complication rate and good functional results.
None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.
Joel R. Peterson, M.A., Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey. Camilo E. Villalobos, M.D., Orthopedic Oncology, Hackensack University Medical Center, Hackensack, New Jersey. Rodolfo Zamora, M.D., Orthopedic Oncology, Hackensack University Medical Center, Hackensack, New Jersey. James C. Wittig, M.D., Vice Chairman, Orthopedic Surgery, Hackensack University Medical Center, Hackensack, New Jersey.
Correspondence: James C. Wittig, M.D., Orthopedic Oncology, Hackensack University Medical Center, 20 Prospect Avenue, Suite 501, Hackensack, New Jersey 07601; email@example.com.
(1.) Hanna SA, David LA, Aston WJ, e al. Endoprosthetic replacement of the distal humerus following resection of bone tumors. J Bone Joint Surg Br. 2007 Nov; 89(11):1498-503.
(2.) Pritchard DJ, Dahlin DC. Neoplasm of the elbow. In: Morrey BF: The Elbow and Its Disorders. Philadelphia: W.B. Saunders Co., 1985, pp. 713-735.
(3.) Sperling JW, Pritchard DJ, Morrey BF. Total elbow arthroplasty after resection of tumors at the elbow. Clin Orthop Relat Res. 1999 Oct; (367):256-61.
(4.) Athwal GS, Chin PY, Adams RA, Morrey BF. Coonrad-Morrey total elbow arthroplasty for tumor of the distal humerus and elbow. J Bone Joint Surg Br. 2005 Oct; 87(10):1369-74.
(5.) Dean SG, Hollinger EH, Urbaniak JR. Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results. Clin Orthop Relat Res. 1997 Aug; (341):12-22.
(6.) Kulkarni A, Fiorenza F, Grimer RJ, et al. The results of endoprosthetic replacement for tumours of the distal humerus. J Bone Joint Surg Br. 2003 Mar; 85(2):240-3.
(7.) Mighell MA, Dunham RC, Rummel EA, Frankle MA. Primary semi-constrained arthroplasty for chronic fracture-dislocations of the elbow. J Bone Joint Surg Br. 2005 Feb; 87(2):191-5.
(8.) Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am. 1992 Apr; 74(4):979-90.
(9.) Ross AC, Sneath RS, Scales JT. Endoprosthetic Replacement of the humerus and elbow joint. J Bone Joint Surg Br. 1987 Aug; 69(4):652-5.
(10.) Weber KL, Lin PP, Yasko AW. Complex segmental elbow reconstruction after tumor resection. Clin Orthop Relat Res. 2003 Oct; (415):31-44.
(11.) Enneking WF, Dunham W, Gebhardt MC, et al. A system for the functional evaluation of reconstructive procedure after surgical treatment of tumor of the musculoskeletal system. Clin Orthop Relat Res. 1993 Jan; (286):241-6.
Caption: Figure 1 Postoperative AP (A) and lateral (B) x-ray of the elbow, few years after primary resection of Giant Cell Tumor of the bone and augmentation with cement, demonstrating recurrence of the tumor. CT scan of the elbow showing in coronal (C) and sagittal (D) reconstruction a lytic lesion and cortical destruction.
Caption: Figure 2 Distal humerus prosthesis.
Caption: Figure 3 AP (A) and lateral (B) x-ray of distal humerus showing metaphyseal pathologic fracture in a patient with history of metastatic renal cell carcinoma.
Caption: Figure 4 Postoperative AP (A) and lateral (B) radiograph of a distal humerus showing the prosthesis and elbow joint.
Caption: Figure 5 Postoperative picture (A and B) of a patient 3 years after surgery.
Table 1 Demographic Distribution Patient Diagnosis Age Gender Status Presentation 1 Metastatic 56 F Alive Mass renal cell at 70 carcinoma months 2 Lymphoma 76 M Death Pathologic at 3 fracture months 3 Synovial 52 M Death Mass Sarcoma at 68 months 4 Multiple 51 M Death Pathologic Myeloma at 6 fracture months 5 Metastatic 54 F Death Pathologic breast Cancer at 8 fracture months 6 Clear cell 36 F Death Tumor sarcoma at 8 months 7 Plasmacytoma 63 M Alive Pathologic at 63 fracture months 8 GCT 47 F Alive Tumor at 75 recurrence months after previous surgery 9 Multiple 78 F Death Pathologic Myeloma at 7 fracture months Patient Diagnosis Complications MSTS * 1 Metastatic Bushing 93% renal cell failure at 52 carcinoma months after surgery 2 Lymphoma None 67% 3 Synovial None 97% Sarcoma 4 Multiple None 80% Myeloma 5 Metastatic None 67% breast Cancer 6 Clear cell Local skin 67% sarcoma necrosis and infection at 4 weeks and local recurrence 6 months after limb sparing surgery 7 Plasmacytoma None 83% 8 GCT Nerve 93% compression/ entrapment at 11 months and bushing failure at 40 and 68 months after first surgery 9 Multiple None 76% Myeloma * MSTS: Musculoskeletal Tumor Score System.
Please note: Illustration(s) are not available due to copyright restrictions.
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|Author:||Peterson, Joel R.; Villalobos, Camilo E.; Zamora, Rodolfo; Wittig, James C.|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Date:||Jul 1, 2015|
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