Orthopedics

Feature Article 

Bipolar Injury of the Clavicle

Ki Won Lee, MD; Joo-Yul Bae, MD; Dong-Kyo Seo, MD; Jung-Ki Ha, MD; Ho Jong Ra, MD; Joon Hee Kim, MD; Byeong Cheol Ho, MD

Abstract

Eleven patients with bipolar clavicle injuries, including dislocation of both ends of the clavicle, dislocation of the sternoclavicular joint with distal clavicle fracture, dislocation of the acromioclavicular joint with medial clavicle fracture, and segmental fracture of the clavicle, were retrospectively reviewed. The purpose of this study was to report the clinical outcomes and a literature review of bipolar clavicle injury. Nonoperative treatment was performed for 5 patients and surgical treatment for 6 patients. The fracture or dislocation of the lateral end of the clavicle was fixed with a hook plate, and closed reduction of the medial end was performed; if the dislocation was still present, open reduction and anterior sternoclavicular ligament repair was performed. Visual analog scale pain score, Constant score, active range of motion, and radiological images were evaluated. The mean visual analog scale pain score for all patients was 0.7±0.9 (range, 0–2). The mean Constant score for all patients was 89.7±7.6 (range, 72–96). The mean Constant score was 84.2±8.5 (range, 72–96) for conservatively treated patients and 94.3±1.9 (range, 92–96) for surgically treated patients. The mean Constant score was 83.4±7.2 (range, 72–92) for patients in whom optimal reduction of 1 or both ends was not achieved. Residual pain or deformity was seen in 5 patients. The authors suggest operative treatment of bipolar clavicle injuries in younger, active patients when anatomical reduction cannot be achieved and residual deformity, pain, or functional limitations are unacceptable. [Orthopedics. 201x; xx(x):xx–xx.]

Abstract

Eleven patients with bipolar clavicle injuries, including dislocation of both ends of the clavicle, dislocation of the sternoclavicular joint with distal clavicle fracture, dislocation of the acromioclavicular joint with medial clavicle fracture, and segmental fracture of the clavicle, were retrospectively reviewed. The purpose of this study was to report the clinical outcomes and a literature review of bipolar clavicle injury. Nonoperative treatment was performed for 5 patients and surgical treatment for 6 patients. The fracture or dislocation of the lateral end of the clavicle was fixed with a hook plate, and closed reduction of the medial end was performed; if the dislocation was still present, open reduction and anterior sternoclavicular ligament repair was performed. Visual analog scale pain score, Constant score, active range of motion, and radiological images were evaluated. The mean visual analog scale pain score for all patients was 0.7±0.9 (range, 0–2). The mean Constant score for all patients was 89.7±7.6 (range, 72–96). The mean Constant score was 84.2±8.5 (range, 72–96) for conservatively treated patients and 94.3±1.9 (range, 92–96) for surgically treated patients. The mean Constant score was 83.4±7.2 (range, 72–92) for patients in whom optimal reduction of 1 or both ends was not achieved. Residual pain or deformity was seen in 5 patients. The authors suggest operative treatment of bipolar clavicle injuries in younger, active patients when anatomical reduction cannot be achieved and residual deformity, pain, or functional limitations are unacceptable. [Orthopedics. 201x; xx(x):xx–xx.]

Reports of bipolar clavicle injuries are rare. Since Porral1 described the first case of dislocation of both ends of the clavicle in 1831, there have been several similar reports of various injury patterns. The terms bipolar clavicle injury and traumatic floating clavicle have been used to refer to various types of fractures and dislocations of both ends of the clavicle, including dislocation of both ends of the clavicle, dislocation of the sternoclavicular joint with distal clavicle fracture, and fracture of the ends of the clavicle.2–10

These injuries have not been classified, and the optimal treatment is controversial. Nonoperative treatment has been sufficient to achieve good results in asymptomatic, elderly, or low-demand patients. However, concerns over functional results such as deformity, instability, and pain have led some authors to suggest surgical treatment for bipolar clavicle injuries in young and high-demand patients. Table 1 offers a summary of the 29 published studies on various treatment options.11–30

Summary of Previous StudiesSummary of Previous Studies

Table 1:

Summary of Previous Studies

The authors encountered 11 patients with 4 patterns of bipolar injury of the clavicle: (1) dislocation of both ends of the clavicle (3 patients), (2) dislocation of the sternoclavicular (SC) joint with distal one-third clavicle fracture (6 patients), (3) dislocation of the acromioclavicular (AC) joint with medial one-third clavicle fracture (1 patient), and (4) segmental fracture of the clavicle (1 patient). The authors sought to report the clinical outcomes, present a review of the literature, and describe the predominant pattern of bipolar injury of the clavicle.

Materials and Methods

This was a retrospective single-center study of patients seen from October 2005 to January 2017 for bipolar injuries of the clavicle. This study received institutional review board approval. During this period, 11 patients were treated by a single surgeon (K.W.L.) for bipolar clavicle injuries. Patients with bipolar dislocation, bipolar fractures, and mixed type injuries (fracture at one end with dislocation at the other end) of the clavicle were included (Table 2).

Data on the 11 Patients With Bipolar Clavicle Injuries

Table 2:

Data on the 11 Patients With Bipolar Clavicle Injuries

Patient Demographics

The average age of the patients was 44.4±8.1 years (range, 34–59 years), and there were 10 men and 1 woman. Nine patients had injury on the left side and 2 had injury on the right. The mean follow-up period was 15.3±6.1 months (range, 8–28 months). There were 4 low-energy injuries (ie, falling during a soccer game [n=2], falling in a drunken state [n=1], or falling from a bicycle [n=1]) and 7 high-energy injuries (ie, falling from a height [n=3] and traffic accidents [n=4]). The 7 high-energy injuries were associated with other organ injuries, such as multiple rib fractures, hemothorax, pneumothorax, head injuries, and injuries of the abdominal organs.

Nonoperative Treatment

Nonoperative treatment was performed for 5 patients. During the nonoperative treatment, a figure-of-8 bandage was applied for 6 weeks followed by stretching and strengthening exercises.

Surgical Treatment

Six patients underwent surgical treatment. The fracture or dislocation of the lateral end around the AC joint was fixed with an AO hook plate (LCP Clavicle Hook Plate; DePuy Synthes, Zuchwil, Switzerland), and closed reduction of the medial end of the clavicle was performed. If dislocation was still present, open reduction and anterior SC ligament repair was performed (patient 6) without additional fixation. Range of motion exercises were started after applying a broad arm sling for 4 weeks. Strengthening exercises were initiated after 6 weeks, and the plate was removed approximately 6 months after the operation.

Functional and Radiologic Assessment

The authors retrospectively reviewed the radiographs and evaluated the functional results at the last follow-up using the visual analog scale pain score, the Constant score,31 and active range of motion assessments. The Constant score results were classified as excellent (100 to 91 points), good (90 to 81 points), satisfactory (80 to 71 points), fair (70 to 61 points), or poor (<60 points). The AC component of the injury was graded with Rockwood's classification.32 The fractures of the distal clavicle were graded with Neer's classification.33 All SC joint dislocations were anterior. The AC joint dislocations were types III and V according to Rockwood's classification. All distal clavicle fractures were type II according to Neer's classification.

Case Presentations

Dislocation of Both Ends of the Clavicle

Patient 1. A 49-year-old man fell from a 4-m stair and sustained a closed bipolar dislocation of the clavicle with anterior dislocation of the SC joint and superior dislocation of AC joint. He was initially admitted to the intensive care unit with the following diagnoses: multiple rib fractures, pneumothorax, and laceration of the kidney and liver. The clavicle remained untreated. Eight weeks after the injury, his general condition had improved and he was referred to the orthopedic department.

On examination, there was an anterior prominence of the clavicle at the SC joint, but no pain was noted. Laterally, the distal end of the clavicle was protruding posteriorly and superiorly, and this region was slightly tender. The clavicle was fixed in this position.

The left shoulder had decreased range of motion, with 40° of forward elevation, 50° of abduction, and 10° of external rotation.

Radiographs and 3-dimensional computed tomography scans revealed anterior dislocation of the medial end and superior dislocation of the lateral end of the left clavicle (Rockwood type V) (Figures 12). Surgical intervention was recommended.

Preoperative posteroanterior (A) and lordotic (B) radiographs showing the dislocated sternoclavicular and acromioclavicular joints in patient 1.

Figure 1:

Preoperative posteroanterior (A) and lordotic (B) radiographs showing the dislocated sternoclavicular and acromioclavicular joints in patient 1.

Three-dimensional computed tomography scans showing bipolar dislocation of the clavicle in patient 1: anteroposterior oblique (A) and craniocaudal (B) views.

Figure 2:

Three-dimensional computed tomography scans showing bipolar dislocation of the clavicle in patient 1: anteroposterior oblique (A) and craniocaudal (B) views.

The patient underwent open reduction and internal fixation of the dislocated AC joint using a hook plate (Figure 3). Surgery was not performed for the dislocated SC joint because the patient did not want it. He had no pain and accepted the deformity.

Postoperative posteroanterior (A) and lordotic (B) radiographs showing the anatomically reduced acromioclavicular joint with a hook plate in patient 1.

Figure 3:

Postoperative posteroanterior (A) and lordotic (B) radiographs showing the anatomically reduced acromioclavicular joint with a hook plate in patient 1.

The plate was removed after 6 months. At final follow-up, the patient had forward elevation of 160°, external rotation of 60°, abduction of 130°, and internal rotation of T12 level. Radiographs showed that the AC joint remained well reduced, but the SC joint remained dislocated (Figure 4). The patient did not report pain or loss of strength, but the deformity remained at the SC joint (Figure 4). He had returned to his former work. The Constant score was 92 at final follow-up.

Posteroanterior radiograph at final follow-up (A) and photographs at 28 months (B) showing the normal alignment of the acromioclavicular joint and persistent sternoclavicular joint dislocation in patient 1.

Figure 4:

Posteroanterior radiograph at final follow-up (A) and photographs at 28 months (B) showing the normal alignment of the acromioclavicular joint and persistent sternoclavicular joint dislocation in patient 1.

Dislocation of the SC Joint and Fracture of the Distal One-Third of the Clavicle

Patient 5. A 45-year-old man was struck by a car and sustained a closed dislocation of the SC joint with a displaced distal clavicle fracture (Neer type II) (Figure 5), multiple rib fractures, pneumothorax, and liver laceration. He was initially admitted to the intensive care unit for 3 weeks. Given the patient's medical comorbidities, the authors elected to treat him conservatively with closed reduction of the SC joint and a figure-of-8 bandage for 6 weeks. At 11 months after the injury, he had forward elevation of 160°, external rotation of 60°, abduction of 140°, and internal rotation of T12 level. Radiographs showed that the SC joint remained well reduced and that union of the lateral end of the clavicle was achieved, but the coracoclavicular distance remained widened. The patient had deformity and occasional discomfort at the distal clavicle. The Constant score was 85 at final follow-up.

Initial posteroanterior radiograph showing the dislocated sternoclavicular joint and displaced distal clavicle fracture in patient 5.

Figure 5:

Initial posteroanterior radiograph showing the dislocated sternoclavicular joint and displaced distal clavicle fracture in patient 5.

Dislocation of the AC Joint and Fracture of the Medial One-Third of the Clavicle

Patient 10. A 50-year-old man fell from a 4-m ladder and sustained a closed dislocation of the AC joint (Rockwood type III) with medial clavicle fracture (Figure 6), multiple rib fractures, and hemothorax. The clavicle was treated nonoperatively for 6 weeks. At 10 months after the injury, the patient had forward elevation of 150°, external rotation of 50°, abduction of 130°, and internal rotation of T12 level. Radiographs showed bony union of the medial clavicle fracture, but the AC joint remained widened. The patient had mild pain at the AC joint and mild deformity at the medial one-third of the clavicle. The Constant score was 83 at final follow-up.

Initial posteroanterior radiograph showing the dislocated acromioclavicular joint and displaced medial clavicle fracture in patient 10.

Figure 6:

Initial posteroanterior radiograph showing the dislocated acromioclavicular joint and displaced medial clavicle fracture in patient 10.

Dislocation of the SC Joint and Fracture of the Distal One-Third of the Clavicle

Patient 11. A 34-year-old man fell during a soccer game and sustained a segmental fracture of the clavicle (Figure 7). The clavicle was treated nonoperatively for 6 weeks. At 8 months after the injury, he had full range of motion and normal function of the shoulder. Radiographs showed bony consolidation of the clavicle.

Initial posteroanterior (A) and lordotic (B) radiographs showing the segmental fracture of the left clavicle with widened coracoclavicular distance in patient 11.

Figure 7:

Initial posteroanterior (A) and lordotic (B) radiographs showing the segmental fracture of the left clavicle with widened coracoclavicular distance in patient 11.

Results

The mean visual analog scale pain score for all patients was 0.7±0.9 (range, 0–2). The mean Constant score for all patients was 89.7±7.6 (range, 72–96); 7 patients had an excellent result, 3 a good result, and 1 a satisfactory result. The mean Constant score of the nonoperatively treated patients (patients 2, 5, 9, 10, and 11) was 84.2±8.5 (range, 72–96). The mean Constant score of the surgically treated patients (patients 1, 3, 4, 6, 7, and 8) was 94.3±1.9 (range, 92–96). The mean Constant score of the patients who did not achieve anatomical reduction on 1 or both ends (patients 1, 2, 5, 9, and 10) was 83.4±7.2 (range, 72–92).

The mean active forward flexion was 156.4°±12.9° (range, 130°–180°). The mean active abduction was 141.8°±25.6° (range, 100°–180°). The mean active external rotation was 56.3°±6.7° (range, 40°–60°).

Bone union and stabilization of the dislocated joints were achieved in all of the patients. Six patients achieved anatomical reduction of both ends of the clavicle, but 5 patients (patients 1, 2, 5, 9, and 10) did not achieve anatomical reduction of 1 or both ends of the clavicle. The authors achieved anatomical reduction in all lesions (dislocations and fractures) in which open reduction and internal fixation was performed. However, in patient 1, anatomical reduction was attempted only in the AC joint and not in the dislocation of the SC joint.

Residual pain or deformity was seen in 5 patients (patients 1, 2, 5, 9, and 10). None of the patients had any postoperative complications such as wound infection, implant failure, instability, or reduction loss.

Discussion

Bipolar injury of the clavicle is rare. Sanders et al15 reported 6 cases, Schemitsch et al7 treated 2 cases, and single case reports have been published by several authors, but bipolar clavicle injuries are less unusual than they were years ago because of the increasing number of traffic and sports accidents. Inexperienced physicians may miss the diagnosis, and patients with multiple trauma may not be referred to orthopedic surgeons because of the treatment of associated injuries. Therefore, the authors believe that the incidence of this injury may be higher than reported.

Bipolar injuries of the clavicle, especially dislocation of the SC joint and posterior dislocation of the AC joint, may be difficult to interpret on plain radiography. Scapinelli20 and Schemitsch et al7 suggested that 3-dimensional computed tomography reconstruction was of great value in visualizing both ends of the clavicle, determining the exact preoperative location of each, and planning surgery.

Regarding the mechanism of injury, 2 hypotheses have been suggested. One theory (simultaneous) suggests that elastic potential energy promotes synchronous dislocation.34 The other theory (consecutive) proposes that an anterior blow on the lateral pole of the clavicle promotes SC joint dislocation, followed by AC dislocation.5,12,13,20

Bipolar clavicle injury is reported mainly to be caused by high-energy injuries and accompanies diverse damages, such as brain trauma, multiple rib fractures, hemothorax, or pneumothorax.11,22,26 It can also occur with low-energy trauma.3,5,13,19

There is no consensus in the literature regarding the best method for treating bipolar clavicle injury. Most bipolar clavicle injuries have been treated nonoperatively with satisfactory results.3–6,8,12,19,24,35 However, despite satisfactory results, deformity or residual pain has been documented.4,7,11,12,15,20 Therefore, interest in surgical interventions for bipolar clavicle injuries has been increasing to prevent the residual deformity and recurrent instability and to reduce pain,7,15,20,26 especially in young and active patients with high demands or in patients with pain or instability.

Sanders et al,15 Scapinelli,20 Schemitsch et al,7 and Jiang et al26 reported superior results from surgical treatment for patients who had persistent pain, deformity, and stiffness after nonoperative treatment initially. In the current study, although all patients were satisfied with the results, those who had unreduced dislocation or fracture on 1 or both ends of the clavicle had low functional score, deformity, and/or residual pain.

When there is a dislocation or fracture of each end of the clavicle, each lesion could be managed according to the specific classification and grade as if it were an isolated injury. Unstable and displaced fractures or dislocations, especially Rock-wood types IV, V, and VI and Neer type II injuries, could be managed surgically.

There is no consensus regarding whether surgery should be performed on both ends of the clavicle or on 1 end alone. Echo et al13 and Sanders et al15 performed surgical intervention of the AC joint only, suggesting that the SC joint injury should be disregarded because good results were obtained without its treatment. Scapinelli,20 Schemitsch et al,7 Jiang et al,26 and Yurdakul et al10 had superior results through surgical treatment of both AC and SC joints in bipolar dislocation of the clavicle. Daolagupu et al,27 Varelas et al,29 and Yalizis et al30 reported good results with surgical treatment of both ends of the clavicle in bipolar fractures of the clavicle. Schemitsch et al7 described 2 patients with bipolar dislocation of the clavicle: 1 was treated with a hook plate at each end and 1 was treated with SC joint hook plating and AC joint closed reduction. They suggested that restoration of the anatomy of the AC and SC joints should be the primary goal of treatment. In the current study, the authors could not achieve anatomical reduction of 1 or both ends of the clavicle in 5 patients (patients 1, 2, 5, 9, and 10); these patients had residual deformity, pain, or low functional score. Therefore, the authors agree with Scapinelli20 and Schemitsch et al7 that surgical correction be recommended for lesions that have not achieved an anatomical reduction.

Surgical treatment of the lateral end of the clavicle is a familiar and standard procedure for orthopedic surgeons. However, surgery of the SC joint has some limitations, such as the proximity of important structures of the mediastinum, low familiarity, potential for loosening or migration of the Kirschner wire after surgery, and possible plate complications after surgery as a result of insufficient soft tissue.2,7,20 It is difficult to determine the best surgical procedure for SC joints. However, the authors agree with other researchers in recent years that it is advisable to use a hook plate for firm fixation.7,36

There are various surgical methods for both ends of the clavicle, such as ligament repair, ligament reconstruction with synthetic material, Kirschner wire fixation, tension band wiring, resection of the distal clavicle, screw fixation, and plating. Recently, surgery using mechanically sound implants, such as a hook plate or a T-plate, has been widely recommended for dislocation or fractures of both ends of the clavicle.1,7,9,26,27,29,30

The authors encountered various types of bipolar injuries of the clavicle. Because of the rarity of these injuries, they were compelled to determine the treatment strategies according to the Neer and Rockwood classifications. The authors initially attempted to classify the subtypes of bipolar clavicle injuries according to injury pattern and devise treatment recommendations. A review of the literature established that the most frequent types of bipolar clavicle injuries are bipolar dislocation followed by the fracture of the lateral one-third of the clavicle with dislocation of the SC joint and bipolar clavicle fractures. Unfortunately, despite their many concerns, there was no correlation between the authors' classification and treatment outcomes owing to the small number of cases. It is not feasible to draw conclusions with a sample this small. The authors' experiences have indicated that surgery tends to produce better results; therefore, they have described it. Although Neer's and Rockwood's classification schemes do not always ensure the determination of treatment options and results, the authors believe that it is currently acceptable to employ them, with surgical treatment being recommended for lesions in which anatomical reduction is not achieved.

Conclusion

Although good results have been reported for nonoperative treatment of bipolar clavicle injury, the authors found a tendency for patients who did not achieve an anatomical reduction to have residual pain, deformity, or low functional score.

The authors suggest that operative treatment of this rare injury is indicated in younger, active patients when anatomical reduction cannot be obtained by nonoperative treatment and residual deformity, pain, or functional limitations are unacceptable. Evaluation of the displacement using 3-dimensional computed tomography, appropriate surgical planning including both ends of the clavicle, and selection of mechanically sound implants, such as a hook plate, are helpful for obtaining better results.

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Summary of Previous Studies

StudyYear PublishedNo. of PatientsAge of Patients, yMedial InjuryLateral InjuryTreatment
Gearen & Petty111982127SC D/LAC D/LSC: neglect AC: closed reduction
Jain51984177SC D/LAC D/LConservative
Cook & Horowitz121987160SC D/LAC D/LConservative
Echo et al131988120SC D/LAC D/LSC: closed reduction AC: pinning
Thomas & Friedman141989128SC D/LFractureSC: closed reduction Clavicle: plating
Sanders et al151990620, 21, 26, 35, 41, 67SC D/LAC D/L2 conservative4 surgical: AC reconstruction
Gaudernak & Poigenfürst161991117SC D/LAC D/LSC: pinning AC: tension band wiring
Arenas et al171993126SC D/LAC D/LSC & AC pinning
Tanlin181996119SC D/LFractureSC: ligament repair Clavicle: pinning & wire
Eni-Olotu & Hobbs31997163SC D/LAC D/LConservative
Caranfil191999171SC D/LAC D/LConservative
Pang et al62003219, 76SC D/L FractureAC D/L FractureConservative
Scapinelli202004118SC D/LAC D/LSC & AC: pinning & wire
Heywood & Clasper212005154FractureFracturePlating both
Argintar et al222011155SC D/LAC D/LTotal claviculectomy
Paša & Kalandra232011132SC D/LAC D/LSC: Orthocord suture AC: Weaver & Dunn
Serra et al82011171SC D/L FractureFractureConservative
Schemitsch et al72011242, 49SC D/LAC D/LSC: hook plate (2 cases) AC: hook plate (1 case)
Yurdakul et al102012121SC D/LAC D/LSC: screw AC: screw
Sethi et al242012170FractureFractureConservative
Schuh et al252012123SC: tension band wiring AC: tension band wiring
Jiang et al262012141SC D/LAC D/LSC: T-plate AC: pinning & wire
Choo et al22012148SC D/LAC D/LSC: ligament reconstruction AC: hook plate
Daolagupu et al272013112FractureFractureMedial: plate Lateral: pinning
Dudda et al282013160SC D/LAC D/LSC: tension band (PDS) AC: hook plate
Gouse et al42013119SC D/LFractureConservative
Sopu et al92015152SC D/L FractureFractureMedial: plate Lateral: conservative
Varelas et al292015168FractureFractureMedial: plate Lateral: plate
Yalizis et al302016138FractureFractureMedial: plate Lateral: hook plate

Data on the 11 Patients With Bipolar Clavicle Injuries

Patient No./Sex/Age, yMechanism of InjuryMedial InjuryLateral InjuryTime to OperationTreatmentFollow-up, moConstant Score
1/M/49Fall Associated injury: rib fractures, pneumothorax, liver lacerationSC D/LAC D/L8 wkSC: neglect AC: hook plate2892
2/M/59Motor cycle Associated injury: rib fracture, pneumothorax, hemothoraxSC D/LAC D/LConservative SC: neglect AC: closed reduction1085
3/M/41Fall Associated injury: rib fracture, pneumothoraxSC D/LAC D/L2 wkSC: closed reduction AC: hook plate1292
4/M/40Traffic accident Associated injury: rib fracture, pneumothorax, hemothoraxSC D/LFracture4 dSC: closed reduction Lateral: hook plate1396
5/M/45Pedestrian traffic accident Associated injury: rib fractures, pneumothorax, liver lacerationSC D/LFractureConservative SC: closed reduction Lateral: closed reduction CC widening1185
6/M/45SlipSC D/LFracture3 dSC: open ligament repair Lateral: hook plate1094
7/F/35Bicycle injurySC D/LFracture4 dSC: closed reduction Lateral: hook plate996
8/M/36SlipSC D/LFracture3 dSC: closed reduction Lateral: hook plate1696
9/M/54Traffic accident Associated injury: peritoneal hemorrhageSC D/LFractureConservative SC: neglect Lateral: closed reduction AC, CC widening2672
10/M/50Fall Associated injury: rib fractures, T12 fracture, hemothoraxFractureAC D/LConservative Medial: closed reduction AC: closed reduction AC widening1083
11/M/34SlipFractureFractureConservative Medial: closed reduction Lateral: closed reduction896
Authors

The authors are from the Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gang-neung, Korea.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Joo-Yul Bae, MD, Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, 38, Bangdong-gil, Sacheon-myeon, Gangneung-si, Gangwon-do, 25440, Korea ( qwonduf@hanmail.net).

Received: November 12, 2017
Accepted: April 23, 2018

10.3928/01477447-20180724-02

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