scholarly journals Bi-unicondylar arthroplasty

2021 ◽  
Vol 10 (11) ◽  
pp. 723-733
Author(s):  
Amy J. Garner ◽  
Oliver W. Dandridge ◽  
Andrew A. Amis ◽  
Justin P. Cobb ◽  
Richard J. van Arkel
Keyword(s):  
Repeated Measures ◽  
Cruciate Ligament ◽  
Full Range ◽  
Oxford Knee Score ◽  
Knee Extensor ◽  
Unicondylar Arthroplasty ◽  
Patient Reported ◽  
Fresh Frozen ◽  
Five Dimension

Aims Bi-unicondylar arthroplasty (Bi-UKA) is a bone and anterior cruciate ligament (ACL)-preserving alternative to total knee arthroplasty (TKA) when the patellofemoral joint is preserved. The aim of this study is to investigate the clinical outcomes and biomechanics of Bi-UKA. Methods Bi-UKA subjects (n = 22) were measured on an instrumented treadmill, using standard gait metrics, at top walking speeds. Age-, sex-, and BMI-matched healthy (n = 24) and primary TKA (n = 22) subjects formed control groups. TKA subjects with preoperative patellofemoral or tricompartmental arthritis or ACL dysfunction were excluded. The Oxford Knee Score (OKS) and EuroQol five-dimension questionnaire (EQ-5D) were compared. Bi-UKA, then TKA, were performed on eight fresh frozen cadaveric knees, to investigate knee extensor efficiency under controlled laboratory conditions, using a repeated measures study design. Results Bi-UKA walked 20% faster than TKA (Bi-UKA mean top walking speed 6.7 km/h (SD 0.9),TKA 5.6 km/h (SD 0.7), p < 0.001), exhibiting nearer-normal vertical ground reaction forces in maximum weight acceptance and mid-stance, with longer step and stride lengths compared to TKA (p < 0.048). Bi-UKA subjects reported higher OKS (p = 0.004) and EQ-5D (p < 0.001). In vitro, Bi-UKA generated the same extensor moment as native knees at low flexion angles, while reduced extensor moment was measured following TKA (p < 0.003). Conversely, at higher flexion angles, the extensor moment of TKA was normal. Over the full range, the extensor mechanism was more efficient following Bi-UKA than TKA (p < 0.028). Conclusion Bi-UKA had more normal gait characteristics and improved patient-reported outcomes, compared to matched TKA subjects. This can, in part, be explained by differences in extensor efficiency. Cite this article: Bone Joint Res 2021;10(11):723–733.

scholarly journals Quadriceps Function and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction in Patients With or Without Knee Osteoarthritis

2018 ◽  
Vol 53 (10) ◽  
pp. 965-975 ◽  
Author(s):  
Grant E. Norte ◽  
Jay Hertel ◽  
Susan A Saliba ◽  
David R. Diduch ◽  
Joseph M. Hart
Keyword(s):  
Knee Osteoarthritis ◽  
Patient Reported Outcomes ◽  
Cruciate Ligament ◽  
Knee Extensor ◽  
Activity Level ◽  
Koos Score ◽  
Patient Reported ◽  
Active Motor ◽  
Anterior Cruciate ◽  
Quadriceps Function

Context Relationships between quadriceps function and patient-reported outcomes after anterior cruciate ligament reconstruction (ACLR) are variable and may be confounded by including patients at widely different time points after surgery. Understanding these relationships during the clinically relevant phases of recovery may improve our knowledge of specific factors that influence clinical outcomes. Objective To identify the relationships between quadriceps function and patient-reported outcomes in patients &lt;2 years (early) and &gt;2 years (late) after ACLR, including those with posttraumatic knee osteoarthritis. Design Cross-sectional study. Setting Laboratory. Patients or Other Participants A total of 72 patients after ACLR: early (n = 34, time from surgery = 9.0 ± 4.3 months), late (n = 30, time from surgery = 70.5 ± 41.6 months), or osteoarthritis (n = 8, time from surgery = 115.9 ± 110.0 months). Main Outcome Measure(s) The total Knee Injury and Osteoarthritis Outcome Score (KOOS) and Veterans RAND 12-Item Health Survey (VR-12) were used to quantify knee function and global health. Predictors of patient-reported outcomes were involved-limb and symmetry indices of quadriceps function (isokinetic strength [peak torque, total work, average power], maximum voluntary isometric contraction torque, fatigue index, central activation ratio, Hoffmann reflex, active motor threshold) and demographics (age, activity level, pain, kinesiophobia, time since surgery). Multiple linear regression analyses were used to predict KOOS and VR-12 scores in each group. Results In the early patients, knee-extensor work, active motor threshold symmetry, pain, and activity level explained 67.8% of the variance in the KOOS score (P &lt; .001); knee-extensor work, activity level, and pain explained 53.0% of the variance in the VR-12 score (P &lt; .001). In the late patients, age and isokinetic torque symmetry explained 28.9% of the variance in the KOOS score (P = .004). In the osteoarthritis patients, kinesiophobia and isokinetic torque explained 77.8% of the variance in the KOOS score (P = .010); activity level explained 86.4% of the variance in the VR-12 score (P = .001). Conclusions Factors of muscle function and demographics that explain patient-reported outcomes were different in patients early and late after ACLR and in those with knee osteoarthritis.

Does Graft Construct Lengthening at the Fixations Cause an Increase in Anterior Laxity Following Anterior Cruciate Ligament Reconstruction in vivo?

2010 ◽  
Vol 132 (8) ◽  
Author(s):  
Conrad K. Smith ◽  
M. L. Hull ◽  
S. M. Howell
Keyword(s):  
Anterior Cruciate Ligament ◽  
Cruciate Ligament ◽  
Bone Tunnel ◽  
Anterior Cruciate Ligament Graft ◽  
Potential Increase ◽  
Anterior Laxity ◽  
Fresh Frozen ◽  
Anterior Cruciate

A millimeter-for-millimeter relation between an increase in length of an anterior cruciate ligament graft construct and an increase in anterior laxity has been demonstrated in multiple in vitro studies. Based on this relation, a 3 mm increase in length of the graft construct following surgery could manifest as a 3 mm increase in anterior laxity in vivo, which is considered clinically unstable. Hence, the two primary objectives were to determine whether the millimeter-for-millimeter relation exists in vivo for slippage-resistant fixation of a soft-tissue graft and, if it does not exist, then to what extent the increase in stiffness caused by biologic healing of the graft to the bone tunnel offsets the potential increase in anterior laxity resulting from lengthening at the sites of fixation. Sixteen subjects were treated with a fresh-frozen, nonirradiated, nonchemically processed tibialis allograft. Tantalum markers were injected into the graft, fixation devices, and bones. On the day of surgery and at 1, 2, 3, and 4 months, Roentgen stereophotogrammetric analysis was used to compute anterior laxity at 150 N of anterior force and the total slippage from both sites of fixation. A simple linear regression was performed to determine whether the millimeter-for-millimeter relation existed and a springs-in-series model of the graft construct was used to determine the extent to which the increase in stiffness caused by biological healing of the graft to the bone tunnel offset the increase in anterior laxity resulting from lengthening at the sites of fixation. There was no correlation between lengthening at the sites of fixation and the increase in anterior laxity at 1 month (R2=0.0, slope=0.2). Also, the increase in stiffness of the graft construct caused by biologic healing of the graft to the bone tunnel offset 0.7 mm of the 1.5 mm potential increase in anterior laxity resulting from lengthening at the sites of fixation. This relatively large offset of nearly 50% occurred because lengthening at the sites of fixation was small.

Isometry of the Posterior Cruciate Ligament

1998 ◽  
Vol 26 (5) ◽  
pp. 663-668 ◽  
Author(s):  
Gerald J. Ortiz ◽  
Hans Schmotzer ◽  
Johanness Bernbeck ◽  
Scott Graham ◽  
James E. Tibone ◽  
...  
Keyword(s):  
Posterior Cruciate Ligament ◽  
Cruciate Ligament ◽  
Full Range ◽  
Surgical Reconstruction ◽  
Muscle Forces ◽  
Low Load ◽  
Fresh Frozen ◽  
Injured Knee ◽  
Gastrocnemius Muscles ◽  
Isometric Point

The effects of functional load and muscle force application on isometry of the posterior cruciate ligament were determined. Eight fresh-frozen cadaver knees were mounted in a custom-designed rig. A full range of motion and muscle forces were applied through the quadriceps, hamstring, and gastrocnemius tendons during a simulated static squat maneuver. The low-load isometric posterior cruciate ligament point was located 5.63 mm proximal and 0.18 mm anterior to the anatomic center of the posterior cruciate ligament origin on the femur. The high-load state, with no gastrocnemius and hamstring muscle forces applied, shifted the isometric point 6.32 mm proximal and 6.72 mm anterior (P 0.05). Loading the hamstring and gastrocnemius muscles also shifted the isometric point (P 0.05). This study indicated that the most isometric region of the posterior cruciate ligament femoral attachment changed significantly when functional loads and muscle forces were applied to the knee. This finding may have implications for both surgical reconstruction and rehabilitation of the posterior cruciate ligament-injured knee.

scholarly journals The Impact of Meniscal Treatment on Functional Outcomes Six Months After Anterior Cruciate Ligament Reconstruction (107)

2021 ◽  
Vol 9 (10_suppl5) ◽  
pp. 2325967121S0025
Author(s):  
Aaron Casp ◽  
Stephan Bodkin ◽  
F. Winston Gwathmey ◽  
Brian Werner ◽  
Mark Miller ◽  
...  
Keyword(s):  
Patient Reported Outcomes ◽  
Cruciate Ligament ◽  
Meniscal Repair ◽  
Knee Extensor ◽  
Meniscus Repair ◽  
Functional Testing ◽  
Healthy Controls ◽  
Strength Recovery ◽  
Patient Reported ◽  
Anterior Cruciate

Objectives: The incidence of anterior cruciate ligament (ACL) injuries continues to rise, and meniscal injuries are commonly associated with these tears. Treatment of meniscal injuries can impart delayed weightbearing range-of-motion restrictions, which can affect the post-operative rehabilitation protocol. These limitations after a meniscal repair could change how patients are managed and progressed through rehab. The effect of the meniscal treatment and subsequent restrictions on strength recovery after ACL reconstruction (ACLR) is unclear and may affect return-to-play assessments. The purpose of this study was to compare strength, jumping performance and patient reported outcomes between isolated ACLR patients and those undergoing surgical intervention for meniscal pathology at the time of ACLR surgery at a scheduled functional testing assessment an average of 6 months after surgery. Our hypothesis is that those undergoing meniscal repair will have lower strength recovery due to post-operative restrictions. Methods: In this retrospective cohort study, ACLR patients and healthy controls completed patient-reported outcomes (IKDC and KOOS), underwent bilateral isokinetic and isometric strength tests of the knee extensor and flexor groups, as well as functional hop testing as part of a return-to-sport test battery at 5-7 months post-operatively. ACLR patients were stratified as isolated ACLR, ACLR+Meniscectomy (ACLR-MS), ACLR+Meniscal Repair (ACLR-MR) and compared to healthy controls. Patients treated with meniscus repair were restricted to partial weight bearing and to 90 degrees of knee flexion for the first 6 weeks post-surgery. Comparisons were performed between meniscal treatment groups with regard to demographics, patient reported outcomes scales, knee extensor and flexor strength, while stratifying by graft type. Results: 305 participants, including 165 ACLR patients (50 isolated ACLR, 71 ACLR + Meniscal Repair, 44 ACLR + Meniscectomy) and 140 healthy controls were included with an average time post-operatively to functional testing of 5.96±0.47 months. Heathy controls demonstrated higher subjective knee function, unilateral peak extensor torque, and limb symmetry than all meniscal subgroups (p<.001). There were no differences between the IKDC, KOOS subscales, or in unilateral or limb symmetry measures of peak knee extensor or flexor torque between ACLR, ACLR+MS, and ACLR+MR patients (all p-values>.05). Conclusions: Persistent weakness, asymmetry and reduced subjective outcome scores measured at approximately 6 months post index surgery were not influenced by meniscus treatment. Knee flexor and extensor strength, limb symmetry, and patient reported outcomes did not significantly differ across patients undergoing isolated ACLR, ACL + Meniscus Repair, and ACL + meniscectomy. These findings suggest that the weightbearing and range-of-motion restrictions associated with meniscus repair recovery do not result in loss of early strength or patient reported outcomes, and they can be progressed through therapy accordingly.

scholarly journals Quadriceps Neuromuscular and Physical Function After Anterior Cruciate Ligament Reconstruction

2020 ◽  
Vol 55 (3) ◽  
pp. 238-245 ◽  
Author(s):  
Jennifer L. Hunnicutt ◽  
Michelle M. McLeod ◽  
Harris S. Slone ◽  
Chris M. Gregory
Keyword(s):  
Physical Performance ◽  
Functional Outcomes ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Knee Extensor ◽  
International Knee Documentation Committee ◽  
Cross Sectional ◽  
Cruciate Ligament Reconstruction ◽  
Patient Reported ◽  
Anterior Cruciate

Context Persistent neuromuscular deficits in the surgical limb after anterior cruciate ligament reconstruction (ACLR) have been repeatedly described in the literature, yet little is known regarding their association with physical performance and patient-reported function. Objective To describe (1) interlimb differences in neuromuscular and functional outcomes and (2) the associations of neuromuscular outcomes with measures of physical and knee-related patient-reported function. Design Cross-sectional study. Setting Laboratory. Patients or Other Participants Thirty individuals after primary, unilateral ACLR (19 males; age = 21.5 years [range, 14–41 years]; 8 months [range = 6–23 months] postsurgery). Main Outcome Measure(s) Knee-extensor isometric and isokinetic peak torque was measured with an isokinetic dynamometer. Cross-sectional area (CSA) was measured bilaterally for each of the quadriceps muscles via magnetic resonance imaging. We measured quadriceps central activation bilaterally via the superimposed-burst technique. Physical performance (single-legged hop tests, step length via spatiotemporal gait analysis) and patient-reported outcomes (International Knee Documentation Committee questionnaire and Knee Injury and Osteoarthritis Outcome Score Sport and Recreation subscale) were also recorded. We conducted Wilcoxon signed rank tests to identify interlimb differences. Spearman ρ correlation analyses revealed associations between limb symmetry and neuromuscular and functional outcomes, as well as with patient-reported function. Results Deficits in the surgical limb as compared with the nonsurgical limb were present for all outcomes (P values &lt; .05). Greater single-legged hop-test symmetry (83%) was significantly correlated with greater symmetry in knee-extensor isometric (63%; rs = 0.567, P = .002) and isokinetic (68%; rs = 0.540, P = .003) strength, as well as greater cross-sectional area of the vastus medialis (78%; rs = 0.519, P = .006) and vastus lateralis (82%; rs = 0.752, P &lt; .001). A higher International Knee Documentation Committee questionnaire score (82.2) was significantly correlated with greater symmetry in knee-extensor isokinetic strength (rs = 0.379, P = .039). Conclusions Although deficits were observed in the surgical limb for all neuromuscular measures, greater symmetry in the size and strength of the quadriceps, rather than activation, was more strongly associated with physical performance after ACLR. Greater symmetry in strength was also more strongly associated with patient-reported function.

scholarly journals Effect of Meniscal Treatment on Functional Outcomes 6 Months After Anterior Cruciate Ligament Reconstruction

2021 ◽  
Vol 9 (10) ◽  
pp. 232596712110312
Author(s):  
Aaron J. Casp ◽  
Stephan G. Bodkin ◽  
F. Winston Gwathmey ◽  
Brian C. Werner ◽  
Mark D. Miller ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Patient Reported Outcomes ◽  
Cruciate Ligament ◽  
Meniscal Repair ◽  
Knee Extensor ◽  
Healthy Controls ◽  
Strength Recovery ◽  
Patient Reported ◽  
Anterior Cruciate

Background: Meniscal injuries are commonly associated with anterior cruciate ligament (ACL) tears. Treatment of meniscal injuries can impart delayed weightbearing and range of motion restrictions, which can affect the rehabilitation protocol. The effect of meniscal treatment and subsequent restrictions on strength recovery after ACL reconstruction is unclear. Purpose/Hypothesis: The purpose of this study was to compare strength, jumping performance, and patient-reported outcomes between patients who underwent isolated ACL reconstruction (ACLR) and those who underwent surgical intervention for meniscal pathology at the time of ACLR. Our hypothesis was that patients who underwent concurrent meniscal repair (MR) would have lower strength recovery owing to postoperative restrictions. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with ACLR were stratified into isolated ACLR, ACLR and meniscectomy (ACLR-MS), or ACLR-MR groups and were compared with healthy controls. The ACLR-MR group was restricted to partial weightbearing and to 90° of knee flexion for the first 6 weeks postoperatively. All participants completed patient-reported outcomes (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) and underwent bilateral isokinetic and isometric strength tests of the knee extensor and flexor groups as part of a return-to-sports test battery at 5 to 7 months postoperatively. Results: A total of 165 patients with ACLR (50 with isolated ACLR, 44 with ACLR-MS, and 71 with ACLR-MR) and 140 healthy controls were included in the study. Follow-up occurred at a mean of 5.96 ± 0.47 months postoperatively. The control group demonstrated higher subjective knee function, unilateral peak extensor torque, and limb symmetry than did the ACLR-MS and ACLR-MR groups combined ( P < .001 for all). There were no differences in IKDC, KOOS subscales, or unilateral or limb symmetry measures of peak knee extensor or flexor torque among the isolated ACLR, ACLR-MS, and ACLR-MR groups. Conclusion: Persistent weakness, asymmetry, and reduced subjective outcome scores at 6-month follow-up after ACLR were not influenced by meniscal treatment. These findings suggested that the weightbearing and range of motion restrictions associated with meniscal repair recovery do not result in loss of early strength or worse patient-reported outcomes.

An in vitro Comparison of Two Replacement Techniques Utilizing Fascia Lata after Cranial Cruciate Ligament Transection in the Dog

1993 ◽  
Vol 06 (02) ◽  
pp. 85-92 ◽  
Author(s):  
G. L. Coetzee
Keyword(s):  
Femoral Condyle ◽  
Cruciate Ligament ◽  
Maximum Load ◽  
Fascia Lata ◽  
Patellar Ligament ◽  
Cross Sectional ◽  
Cranial Cruciate Ligament ◽  
Replacement Technique ◽  
Over The Top

SummaryThe immediate postoperative biomechanical properties of an “underand-over” cranial cruciate ligament (CCL) replacement technique consisting of fascia lata and the lateral onethird of the patellar ligament, were compared with that of a modified intra- and extracapsular “under-and-over-the-top” (UOTT) method. The right CCL in twelve adult dogs was dissected out and replaced with an autograft. The contralateral, intact CCL served as the control. In group A, the graft was secured to the lateral femoral condyle with a spiked washer and screw. In group B the intracapsular graft was secured to the lateral femoro-fabellar ligament, and the remainder to the patellar tendon. Both CCL replacement techniques exhibited a 2.0 ± 0.5 mm anterior drawer immediately after the operation. After skeletonization of the stifles, the length and cross-sectional area of the intact CCL and CCL substitutes were determined. Each bone-ligament unit was tested in linear tension to failure at a fixed distraction rate of 15 mm/s with the stifle in 120° flexion. Data was processed to obtain the corresponding material parameters (modulus, stress and strain in the linear loading region, and energy absorption to maximum load).The immediate postoperative structural and material properties of the “under-and-over” cranial cruciate ligament replacement technique with autogenous fascia lata, were compared to that of a modified intra- and extracapsular “under-and-over-the-top” (UOTT) method. The combined UOT T technique was slightly stronger (6%), but allowed 2.8 ± 0.9 mm more cranial tibial displacement at maximum linear force.

scholarly journals Patient-Reported Outcomes After Complex Adult Spinal Deformity Surgery: 5-Year Results of the Scoli-Risk-1 Study

2021 ◽  
pp. 219256822098827
Author(s):  
Scott L. Zuckerman ◽  
Meghan Cerpa ◽  
Lawrence G. Lenke ◽  
Christopher I. Shaffrey ◽  
Leah Y. Carreon ◽  
...  
Keyword(s):  
Repeated Measures ◽  
Adult Spinal Deformity ◽  
Corrective Osteotomy ◽  
Leg Pain ◽  
Major Surgery ◽  
Mean Values ◽  
Self Image ◽  
Patient Reported ◽  
Spinal Deformity Surgery

Study Design: Prospective cohort. Objective: To prospectively evaluate PROs up to 5-years after complex ASD surgery. Methods: The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers. Inclusion criteria was Cobb angle of >80°, corrective osteotomy for congenital or revision deformity, and/or 3-column osteotomy. The following PROs were measured prospectively at intervals up to 5-years postoperative: ODI, SF36-PCS/MCS, SRS-22, NRS back/leg. Among patients with 5-year follow-up, comparisons were made from both baseline and 2-years postoperative to 5-years postoperative. PROs were analyzed using mixed models for repeated measures. Results: Seventy-seven patients (28.3%) had 5-year follow-up data. Comparing baseline to 5-year data among these 77 patients, significant improvement was seen in all PROs: ODI (45.2 vs. 29.3, P < 0.001), SF36-PCS (31.5 vs. 38.8, P < 0.001), SF36-MCS (44.9 vs. 49.1, P = 0.009), SRS-22-total (2.78 vs. 3.61, P < 0.001), NRS-back pain (5.70 vs. 2.95, P < 0.001) and NRS leg pain (3.64 vs. 2.62, P = 0.017). In the 2 to 5-year follow-up period, no significant changes were seen in any PROs. The percentage of patients achieving MCID from baseline to 5-years were: ODI (62.0%) and the SRS-22r domains of function (70.4%), pain (63.0%), mental health (37.5%), self-image (60.3%), and total (60.3%). Surprisingly, mean values ( P > 0.05) and proportion achieving MCID did not differ significantly in patients with major surgery-related complications compared to those without. Conclusions: After complex ASD surgery, significant improvement in PROs were seen at 5-years postoperative in ODI, SF36-PCS/MCS, SRS-22r, and NRS-back/leg pain. No significant changes in PROs occurred during the 2 to 5-year postoperative period. Those with major surgery-related complications had similar PROs and proportion of patients achieving MCID as those without these complications.

scholarly journals Acromioclavicular joint reconstruction implants have differing ability to restore horizontal and vertical plane stability

2021 ◽  
Author(s):  
Mohamed Alkoheji ◽  
Hadi El-Daou ◽  
Jillian Lee ◽  
Adrian Carlos ◽  
Livio Di Mascio ◽  
...  
Keyword(s):  
Repeated Measures ◽  
Acromioclavicular Joint ◽  
Vertical Plane ◽  
Testing System ◽  
Bonferroni Correction ◽  
Joint Reconstruction ◽  
Fresh Frozen ◽  
Robotic Testing ◽  
Robotic Testing System ◽  
Anterior Posterior

Abstract Purpose Persistent acromioclavicular joint (ACJ) instability following high grade injuries causes significant symptoms. The importance of horizontal plane stability is increasingly recognised. There is little evidence of the ability of current implant methods to restore native ACJ stability in the vertical and horizontal planes. The purpose of this work was to measure the ability of three implant reconstructions to restore native ACJ stability. Methods Three groups of nine fresh-frozen shoulders each were mounted into a robotic testing system. The scapula was stationary and the robot displaced the clavicle to measure native anterior, posterior, superior and inferior (A, P, S, I) stability at 50 N force. The ACJ capsule, conoid and trapezoid ligaments were transected and the ACJ was reconstructed using one of three commercially available systems. Two systems (tape loop + screw and tape loop + button) wrapped a tape around the clavicle and coracoid, the third system (sutures + buttons) passed directly through tunnels in the clavicle and coracoid. The stabilities were remeasured. The data for A, P, S, I stability and ranges of A–P and S–I stability were analyzed by ANOVA and repeated-measures Student t tests with Bonferroni correction, to contrast each reconstruction stability versus the native ACJ data for that set of nine specimens, and examined contrasts among the reconstructions. Results All three reconstructions restored the range of A–P stability to that of the native ACJ. However, the coracoid loop devices shifted the clavicle anteriorly. For S–I stability, only the sutures + buttons reconstruction did not differ significantly from native ligament restraint. Conclusions Only the sutures + buttons reconstruction, that passed directly through tunnels in the clavicle and coracoid, restored all stability measures (A, P, S, I) to the native values, while the tape implants wrapped around the bones anteriorised the clavicle. These findings show differing abilities among reconstructions to restore native stability in horizontal and vertical planes. (300 words)

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