Orthopedics

Feature Article 

Dimensions of the Lateral Malleolar Fossa and Its Potential Violation With Lateral Distal Fibular Plate Fixation

Sapan D. Gandhi, MD; Jeff Cross, MD; Matthew Siljander, MD; Adam Fahs, MD; Kade McQuivey, MD; Paul T. Fortin, MD; Patrick J. Wiater, MD

Abstract

A previously undescribed pitfall of lateral distal fibular locking plates is the risk of violating the lateral malleolar fossa (MF). No previous study has described the dimensions of this fossa. All cases using a lateral distal fibular plate for a fibula fracture from December 2012 to December 2015 (n=365) at a single institution were reviewed. Screws that violated the medial fibular cortical density corresponding to the MF were identified as “at-risk” screws. Available preoperative computed tomography (CT) scans were reviewed (n=69) to measure MF dimensions. Of 365 patients, 115 (31.5%) patients had distal fibular screws at risk of MF violation. There were no significant differences between MF violation and non-violation groups in terms of age, sex, open fracture, syndesmotic fixation, and Weber classification. The MF dimensions were measured on CT scans. Mean height was 12.96 mm (SD, 2.09 mm; range, 9.0–17.3 mm). Mean width was 7.52 mm (SD, 1.37 mm; range, 4.2–10.4 mm). Mean depth was 8.32 mm (SD, 1.59 mm; range, 5.3–11.8 mm). Mean ratio of MF to total fibular width was 0.46 mm (SD, 0.07 mm; range, 0.3–0.65 mm). Mean MF to total fibular depth was 0.42 mm (SD, 0.07 mm; range, 0.28–0.58 mm). There was a difference in dimensions of patients with screws at risk of MF violation compared with those without (MF height: 13.77 vs 12.56, P=.02; MF width: 7.98 vs 7.30, P=.05; MF to fibula width ratio: 0.49 vs 0.44, P=.01; MF to fibula depth ratio: 0.43 vs 0.42, P=.05). The MF violation is a previously unreported but potentially prevalent pitfall of lateral distal fibular plate fixation. Surgeons should be aware of the MF size and exhibit caution when placing screws in the distal locking holes during fibula fixation. [Orthopedics. 2020;43(3):e141–e146.]

Abstract

A previously undescribed pitfall of lateral distal fibular locking plates is the risk of violating the lateral malleolar fossa (MF). No previous study has described the dimensions of this fossa. All cases using a lateral distal fibular plate for a fibula fracture from December 2012 to December 2015 (n=365) at a single institution were reviewed. Screws that violated the medial fibular cortical density corresponding to the MF were identified as “at-risk” screws. Available preoperative computed tomography (CT) scans were reviewed (n=69) to measure MF dimensions. Of 365 patients, 115 (31.5%) patients had distal fibular screws at risk of MF violation. There were no significant differences between MF violation and non-violation groups in terms of age, sex, open fracture, syndesmotic fixation, and Weber classification. The MF dimensions were measured on CT scans. Mean height was 12.96 mm (SD, 2.09 mm; range, 9.0–17.3 mm). Mean width was 7.52 mm (SD, 1.37 mm; range, 4.2–10.4 mm). Mean depth was 8.32 mm (SD, 1.59 mm; range, 5.3–11.8 mm). Mean ratio of MF to total fibular width was 0.46 mm (SD, 0.07 mm; range, 0.3–0.65 mm). Mean MF to total fibular depth was 0.42 mm (SD, 0.07 mm; range, 0.28–0.58 mm). There was a difference in dimensions of patients with screws at risk of MF violation compared with those without (MF height: 13.77 vs 12.56, P=.02; MF width: 7.98 vs 7.30, P=.05; MF to fibula width ratio: 0.49 vs 0.44, P=.01; MF to fibula depth ratio: 0.43 vs 0.42, P=.05). The MF violation is a previously unreported but potentially prevalent pitfall of lateral distal fibular plate fixation. Surgeons should be aware of the MF size and exhibit caution when placing screws in the distal locking holes during fibula fixation. [Orthopedics. 2020;43(3):e141–e146.]

Ankle fractures are one of the most common fractures treated by orthopedic surgeons, comprising approximately 9% to 10% of all fractures.1 Unstable ankle fractures often are treated surgically to improve functional outcome, allow early mobilization, and prevent posttraumatic arthritis of the ankle joint.2 The use of lateral distal fibular plates allows orthopedic surgeons to circumvent more extensive posterior dissection required for posterolateral and posterior plating. In addition, compared with traditional one-third tubular plating, lateral distal fibular locking plates allow more stable fixation in osteoporotic bone and offer surgeons the ability to place screws and achieve fixation much more distally on the fibula.

However, a previously undescribed potential pitfall of lateral distal fibular plate fixation, including locking plates, is the violation of the lateral malleolar fossa (MF) by long distal screw placement. The MF, or the digital fossa of the fibula, is an anatomic structure in the posteromedial distal fibula that serves as the attachment of the posterior talofibular ligament.3 In addition, the MF also serves as a recess to allow space for the posterolateral talus and subtalar joint in plantarflexion and eversion. Violation of this fossa with distal screws may not be apparent intraoperatively on fluoroscopy, and because of the intra-articular location, it has the potential to irritate surrounding structures and impinge against the subtalar joint. No previous study has described the size of the MF, quantified the risk of violation of this space with distal fibular screw placement in the setting of distal fibular locking plates, or identified any factors associated with “at-risk” screw placement.

This study was undertaken to (1) identify the frequency of screws placed at risk of violating the MF with lateral distal fibular plate fixation; (2) identify demographic, technical, or fracture factors that may be related to potential violation of the MF; and (3) describe the dimensions and characteristics of the MF of the distal fibula on computed tomography (CT) scans, as understanding the size of the MF is of utmost important to avoid complications associated with violating the MF.

Materials and Methods

After receiving institutional review board approval, a retrospective review of all surgical procedures using a lateral distal fibular plate for the treatment of a distal fibula fracture at a single institution from December 2012 to December 2015 was conducted (N=365). The cases consisted entirely of fractures treated with open reduction and internal fixation using a lateral distal fibular plate for the fibula component of the injury. Inclusion and exclusion criteria are summarized in Table 1.

Inclusion and Exclusion Criteria

Table 1:

Inclusion and Exclusion Criteria

Patient age, sex, body mass index (BMI), fracture type, Weber classification, presence of syndesmotic injury, open or closed injury, estimated blood loss, length of stay (outpatient surgery or hospital stays less than 24 hours were considered 0 days), and operating room time were recorded for each case. In addition, intraoperative fluoroscopic images of the ankle were reviewed to identify any screws violating the lateral cortical density in the distal fibula that corresponded to the lateral MF. Screws that violated cortical density by more than 2 screw threads were identified as “at-risk” screws of violating the MF (Figure 1). The number of screws that were deemed at risk also were recorded for each violation.

Intraoperative internal rotation mortise views were assessed for potential malleolar fossa violation by distal fibula screws. This fluoroscopic view shows the distal-most screw in the fibular construct crossing the medial fibular cortical density that correlates to the malleolar fossa.

Figure 1:

Intraoperative internal rotation mortise views were assessed for potential malleolar fossa violation by distal fibula screws. This fluoroscopic view shows the distal-most screw in the fibular construct crossing the medial fibular cortical density that correlates to the malleolar fossa.

Preoperative CT scans that were available also were reviewed (n=69). For these cases, the MF height, width, and depth were measured, as well as the total fibular width and depth at these levels (Figure 2). The ratios of the MF width and depth to the total fibular width and depth, respectively, were calculated.

Computed tomography scans were reviewed to assess malleolar fossa dimensions. The height of the malleolar fossa (blue line) was measured on the coronal slice that correlated to the midpoint of the malleolar fossa in the axial plane (inset) (A). The depth of the malleolar fossa (blue line) and the fibular depth (red line) were measured on the axial slice that correlated to the midpoint of the malleolar fossa in the coronal plane (inset) (B). The width of the malleolar fossa (blue line) and the fibular width (red line) were measured on the axial slice that correlated to the midpoint of the malleolar fossa in the coronal plane (inset) (C).

Figure 2:

Computed tomography scans were reviewed to assess malleolar fossa dimensions. The height of the malleolar fossa (blue line) was measured on the coronal slice that correlated to the midpoint of the malleolar fossa in the axial plane (inset) (A). The depth of the malleolar fossa (blue line) and the fibular depth (red line) were measured on the axial slice that correlated to the midpoint of the malleolar fossa in the coronal plane (inset) (B). The width of the malleolar fossa (blue line) and the fibular width (red line) were measured on the axial slice that correlated to the midpoint of the malleolar fossa in the coronal plane (inset) (C).

Interval variables were summarized with mean and standard deviation if the distribution was approximately normal or with median and range otherwise. Categorical variables were summarized with counts and percentages. Surgeries with and without potential MF violations were compared with summary measures; for these comparisons, 2-sample t tests, Wilcoxon rank sum tests, or chi-square tests were used as appropriate. Exact P values were used for the last procedure for small expected frequencies. In addition, 95% confidence intervals also were included for odds ratios for binary variables. SAS System for Windows version 9.3 (SAS Institute Inc, Cary, North Carolina) was used for statistical analysis.

Results

A total of 365 patients (154 males and 211 females) who received lateral distal fibular locking plates for distal fibula fractures were included in the study. Mean age of patients was 51.8 years (SD, 16.8 years; range, 18–95 years). Median BMI was 28.7 kg/m2 (range, 19.2–49.6 kg/m2), median operating room time was 80 minutes (range, 20–310 minutes), median estimated blood loss was 10 mL (range, 0–300 mL), and median length of stay was 1 day (range, 0–40 days). Median number of screws placed in the distal fibula distal to the syndesmosis was 4 (range, 0–8 screws).

Patients had sustained distal fibula fractures as part of bimalleolar ankle fractures (n=205, 56.2%), trimalleolar ankle fractures (n=101, 27.7%), trimalleolar ankle fracture dislocations (n=32, 8.8%), tibial shaft fractures (n=7, 1.9%), and intra-articular distal tibia fractures (n=20, 5.5%). Distal fibula fractures consisted of Weber types A (n=5, 1.4%), B (n=303, 83.0%), and C (n=57, 15.6%). The majority of fractures were closed injuries (n=348, 95.3%). The syndesmosis was disrupted and required fixation in 47.1% of cases (n=172).

A total of 115 patients (31.5%) were identified as having distal fibular screws at risk of MF violation. Of patients with screws at risk for fossa violation, 1 screw was at risk in 60.9% (n=70), 2 screws in 31.3% (n=36), 3 screws in 6.9% (n=8), and 4 screws in 0.9% (n=1). There were no statistically significant differences between groups with and without MF violation in terms of age (P=.31), sex (P=.74), BMI (P=.67), operating room time (P=.34), estimated blood loss (P=.50), length of stay (P=.77), open fracture (P=.38), syndesmotic fixation required (P=.28), and Weber classification (P=.07) (Table 2).

Categorical Variables

Table 2:

Categorical Variables

The MF dimensions on CT scan were measured for those patients with CT scans available (n=69). Mean height was 12.96 mm (SD, 2.09 mm; minimum–maximum, 9.0–17.3 mm). Mean width was 7.52 mm (SD, 1.37 mm; minimum–maximum, 4.2–10.4 mm). Mean depth was 8.32 mm (SD, 1.59 mm; minimum–maximum, 5.3–11.8 mm). Mean ratio of the MF width to total fibular width was 0.46 mm (SD, 0.07 mm; minimum–maximum, 0.3–0.65 mm), and mean ratio of the MF depth to total fibular depth was 0.42 mm (SD, 0.07 mm; minimum–maximum, 0.28–0.58 mm).

For patients with CT scans available, 33.3% (n=23) had screws placed at risk of MF violation. There was a small but statistically significant difference in the dimensions of patients with screws at risk of MF violation compared with patients without screws at risk of MF violation (MF height: 13.77 vs 12.56 mm, P=.02; MF width: 7.98 vs 7.30 mm, P=.05; MF to fibula width ratio: 0.49 vs 0.44 mm, P=.01; and MF to fibula depth ratio: 0.43 vs 0.42 mm P=.05) (Tables 34).

Malleolar Fossa Dimensions on Available Preoperative Computed Tomography Scans

Table 3:

Malleolar Fossa Dimensions on Available Preoperative Computed Tomography Scans

Malleolar Fossa to Fibular Ratios on Available Preoperative Computed Tomography Scans

Table 4:

Malleolar Fossa to Fibular Ratios on Available Preoperative Computed Tomography Scans

Discussion

The use of lateral distal fibula plates has allowed several advantages for fixation of the distal fibula in ankle fractures. Compared with posterior or posterolateral fixation of the fibula, lateral distal fibular plates circumvent the need for more posterior dissection and offer a larger surface to place the plate. In addition, lateral fixation avoids peroneal tendon irritation common with posterior fixation techniques.4 Compared with traditional one-third tubular plating, lateral distal fibular plates allow more distal fixation and also allow the placement of locking screws in the setting of osteoporotic bone or comminuted fractures. However, the authors have found that with lateral dissection of the distal fibula, the lateral MF is rarely visualized, as this is a posterome-dial structure. Screws that violate the MF would not be apparent intraoperatively. Given the overlap of the anterior fibula on anteroposterior and mortise views of the ankle, hardware that violates the MF also may not be apparent on fluoroscopy.

To this end, the authors have found that a previously unrecognized pitfall of laterally placed plates is violation of the fibular digital fossa or the lateral MF. In the current study, 31.5% of patients had screws placed in the distal fibula that were at risk of violating the MF. In addition, no statistically significant patient or injury factors were associated with placement of screws at risk of violating this space. Finally, patients with screws at risk of violating the MF had larger fossa dimensions than patients who did not.

This study had several limitations. Potential biases inherent to a retrospective review existed. The authors attempted to control for these biases as best as possible by reviewing consecutive cases during a specific period of time. It would have been useful to have screw lengths that led to violation of the fossa, but given the retrospective nature of the study and the limitations in documentation, this information could not be obtained. In addition, although assessment of at-risk screws for violation of the MF was done on the intra-operative internal rotation mortise view, which provides the best radiographic view of the lateral ankle mortise, and those cases without this specific view were excluded from the study, the authors recognize that small differences in rotation of the view may lead to differences in the appearance of violation of the fossa by hardware.5

Furthermore, the method of identifying screws that may violate the MF may not accurately predict the true incidence of MF violation and therefore may overestimate the true incidence. Some screws that appear to violate the fossa may be in the anterior fibula and miss the fossa altogether. However, to this point, it would not be possible to measure the true incidence of violation without postoperative cross-sectional imaging. This may add another layer of bias given that those patients having cross-sectional imaging postoperatively typically are symptomatic for some reason. However, the authors' purpose in quantifying violation was not to obtain a precise incidence of this complication, but rather to direct attention to a potentially prevalent pitfall in the use of lateral distal fibular fixation.

Patients generally have good long-term functional outcomes after surgical fixation of unstable ankle fractures, despite more than 60% of these patients developing some level of osteoarthritis after 10 years or longer.6,7 However, continued pain after ankle fracture surgery is common in the short term. At 1 year postoperatively, up to 18.9% of these patients may report persistent pain for an unknown reason.8 To the authors' knowledge, no other studies have documented the clinical significance of violating the MF. Given that this recess allows space for the posterior subtalar joint, violation of this space by screws placed from lateral to medial may cause impingement in plantarflexion and eversion, and potentially may be a source of persistent postoperative pain even after bony union and prior to the development of osteoarthritis. The authors' group aims to examine the effect of violation of the MF in a future cadaveric study.

The current study found that 31.5% of patients who undergo distal fibular plate fixation have screws placed that may violate the MF. As noted earlier, this may not be an exact quantification of screws that violate the lateral MF, and without postoperative cross-sectional imaging, it may not be possible to obtain such an incidence. However, the high percentage of patients with screws that appear to cross the cortical density corresponding to the MF signifies that many surgeons may not be aware of this space and the potential to place prominent hardware. Almost 20% of patients undergo reoperation within 2 years of surgical fixation of ankle fractures, with the number one reason being hardware removal.9 Although the clinical relationship between malleolar violation and hardware removal was outside the scope of the current study, prominent hardware may be one of many causes of subsequent reoperation.

The authors hypothesized that fracture pattern (ie, more distal fracture patterns may require more distal screw placement and may be a risk factor for violation) and the number of screws placed distal to the syndesmosis (ie, the more screws that are placed distally, the higher the risk for MF violation) would be factors involved in at-risk screw placement. Although Weber A fractures in this cohort seemed to be associated with a higher risk of violating the MF, this finding did not reach statistical significance. No other injury, patient, or surgical factors related to placement of at-risk screws of fossa violation were found in the current study, suggesting this may be a purely technical pitfall. Unsurprisingly, patients with larger MF dimensions were at greater risk of having screws that violated this space, as it may be more difficult to avoid violation in these patients.

No previous studies have described the dimensions of the MF, also called the digital fossa of the distal fibula.3 On average, the MF is approximately 13 mm high from the tip of the distal fibula, 7.5 mm wide, and 8.3 mm deep, taking up the medial 46% of the fibular width and the posterior 42% of the fibular depth. When placing distal fibular screws from lateral to medial, surgeons should be aware that placing screws in the posterior half of the fibula may be at increased risk of violating the MF. The authors suggest these screws should be kept unicortical to avoid placing screws that may be symptomatic to the patient. Placement of the lateral distal fibular plate slightly anterior on the fibula may help keep the center screw holes anterior to the MF and may assist in avoiding violation. In addition, filling the posterior holes at the level of the MF with screws no longer than 10 mm will dramatically reduce the risk of violating the MF, as the difference between the MF width and the total fibular width almost never exceeded 10 mm in this study. Another technique that may help avoid violation of the MF would be to fill posterior screws distally first to prevent anterior screws from interfering with C-arm interpretation. When evaluating screws in the lateral malleolus, any view that demonstrates extra-fossa placement of a lateral malleolar screw can be assumed to be safe, similar to placement of screws in the medial malleolus.10

Conclusion

This retrospective study identified MF violation as a potential pitfall of distal lateral fibular plate fixation and also quantified the dimensions of the MF. In this series, as many as 31.5% of patients had screws that were at risk of violating the lateral MF. Future studies should focus on examining the clinical effects of screw violation of the lateral MF. Awareness of the dimensions of the lateral MF may keep surgeons from placing screws in this space, thereby potentially reducing patients' postoperative pain as well as the need for hardware removal.

References

  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–697. doi:10.1016/j.injury.2006.04.130 [CrossRef] PMID:16814787
  2. Michelson JD. Fractures about the ankle. J Bone Joint Surg Am. 1995;77(1):142–152. doi:10.2106/00004623-199501000-00020 [CrossRef] PMID:7822349
  3. Clanton TO, Campbell KJ, Wilson KJ, et al. Qualitative and quantitative anatomic investigation of the lateral ankle ligaments for surgical reconstruction procedures. J Bone Joint Surg Am. 2014;96(12):e98, 1–8. doi:10.2106/JBJS.M.00798 [CrossRef] PMID:24951749
  4. Weber M, Krause F. Peroneal tendon lesions caused by antiglide plates used for fixation of lateral malleolar fractures: the effect of plate and screw position. Foot Ankle Int. 2005;26(4):281–285. doi:10.1177/107110070502600403 [CrossRef] PMID:15829211
  5. Gourineni PV, Knuth AE, Nuber GF. Radiographic evaluation of the position of implants in the medial malleolus in relation to the ankle joint space: anteroposterior compared with mortise radiographs. J Bone Joint Surg Am. 1999;81(3):364–369. doi:10.2106/00004623-199903000-00008 [CrossRef] PMID:10199274
  6. Donken CC, Verhofstad MH, Edwards MJ, van Laarhoven CJ. Twenty-one-year follow-up of supination-external rotation type II-IV (OTA type B) ankle fractures: a retrospective cohort study. J Orthop Trauma. 2012;26(8):e108–e114. doi:10.1097/BOT.0b013e31822c4ea5 [CrossRef] PMID:22198654
  7. Regan DK, Gould S, Manoli A III, Egol KA. Outcomes over a decade after surgery for unstable ankle fracture: functional recovery seen 1 year postoperatively does not decay with time. J Orthop Trauma. 2016;30(7):e236–e241. doi:10.1097/BOT.0000000000000571 [CrossRef] PMID:26978134
  8. Friesgaard KD, Gromov K, Knudsen LF, Brix M, Troelsen A, Nikolajsen L. Persistent pain is common 1 year after ankle and wrist fracture surgery: a register-based questionnaire study. Br J Anaesth. 2016;116(5):655–661. doi:10.1093/bja/aew069 [CrossRef] PMID:27106969
  9. Pincus D, Veljkovic A, Zochowski T, Ma-homed N, Ogilivie-Harris D, Wasserstein D. Rate of and risk factors for intermediate-term reoperation after ankle fracture fixation: a population based cohort study. J Orthop Trauma. 2017;31(10):e315–e320. doi:10.1097/BOT.0000000000000920 [CrossRef] PMID:28614147
  10. Wera JC, Seligson D, Riehl JT. Medial malleolus screws: out in one view and out. Eur J Orthop Surg Traumatol. 2015;25(7):1189–1193. doi:10.1007/s00590-015-1673-7 [CrossRef] PMID:26198780

Inclusion and Exclusion Criteria

Inclusion CriteriaExclusion Criteria
Age 18 years and older Fracture of the distal fibula Use of a lateral distal fibular plate Available intraoperative fluoroscopic images with an internal rotation mortise viewAge younger than 18 years Use of hardware other than a lateral distal fibular plate Use of a lateral distal fibular plate for reasons other than fracture (eg, osteotomy) Tumor Infection Inadequate radiographs available for review

Categorical Variables

VariableNo.POR95% CI for OR

Malleolar Fossa Not at RiskMalleolar Fossa at Risk
Sex.741.080.69–1.69
  Female (n=211)146 (69.2%)65 (30.8%)
  Male (n=154)104 (67.5%)50 (32.5%)
Open.381.560.58–4.20
  Yes (n=348)240 (69.0%)108 (31.0%)
  No (n=17)10 (59.0%)7 (41.0%)
Syndesmosis.281.280.82–1.99
  Yes (n=193)137 (71.0%)56 (29.0%)
  No (n=172)113 (65.7%)59 (34.3%)
Diagnosis.16NANA
  Bimalleolar ankle fractures (n=205)142 (69.3%)63 (30.7%)
  Trimalleolar ankle fractures (n=101)73 (72.3%)28 (27.7%)
  Trimalleolar ankle fracture dislocations (n=32)16 (50.0%)16 (50.0%)
  Pilon (n=7)4 (57.1%)3 (42.9%)
  Tibial shaft (n=20)15 (75%)5 (25%)
Weber classification.07NANA
  Type A (n=5)1 (20%)4 (80%)
  Type B (n=303)210 (69.3%)93 (30.7%)
  Type C (n=57)39 (68.4%)18 (31.6%)

Malleolar Fossa Dimensions on Available Preoperative Computed Tomography Scans

CharacteristicMean (SD), mmDifference in Means95% Confidence IntervalP

Malleolar Fossa Not at Risk (n=46)Malleolar Fossa at Risk (n=23)
Malleolar fossa height12.56 (2.13)13.77 (1.80)−1.21−2.24 to −0.18.02
Malleolar fossa width7.30 (1.36)7.98 (1.29)−0.68−1.36 to −0.00.05
Fibula width16.45 (1.77)16.27 (1.31)0.18−0.65 to 1.01.67
Malleolar fossa depth8.19 (1.58)8.58 (1.62)−0.40−1.21 to 0.42.33
Fibula depth19.66 (2.86)19.89 (3.10)−0.23−1.73 to 1.27.76

Malleolar Fossa to Fibular Ratios on Available Preoperative Computed Tomography Scans

CharacteristicMean (SD), mmDifference in Means95% Confidence IntervalP

Malleolar Fossa Not at Risk (n=46)Malleolar Fossa at Risk (n=23)
Width: malleolar fossa to fibula0.44 (0.06)0.49 (0.07)−0.049−0.083 to −0.014.01
Depth: malleolar fossa to fibula0.42 (0.07)0.43 (0.07)−0.016−0.049 to 0.018.05
Authors

The authors are from the Department of Orthopaedics (SDG, MS, AF, PTF, PJW), Beaumont Health System, Royal Oak, Michigan; the Department of Orthopaedic Surgery (JC), University of Toledo Medical Center, Toledo, Ohio; and the Department of Orthopaedic Surgery (KM), Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona.

Drs Gandhi, Cross, Siljander, Fahs, McQuivey, and Fortin have no relevant financial relationships to disclose. Dr Wiater has received research support from Arthrex.

Correspondence should be addressed to: Sapan D. Gandhi, MD, Department of Orthopaedics, Beaumont Health System, 3535 W 13 Mile Rd, Ste 744, Royal Oak, MI 48073 ( sapandgandhi@gmail.com).

Received: December 14, 2018
Accepted: February 12, 2019
Posted Online: February 20, 2020

10.3928/01477447-20200213-04

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