Abstract
Primary osteoarthritis (OA) of the hip joint
Secondary OA following acetabular dysplasia [hip dysplasia, developmental dysplasia of the hip (DDH), or congenital disease of the hip (CDH)]
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Indications
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Primary osteoarthritis (OA) of the hip joint
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Secondary OA following acetabular dysplasia [hip dysplasia, developmental dysplasia of the hip (DDH), or congenital disease of the hip (CDH)]
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Rheumatoid arthritis (RA)
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Osteonecrosis (ON)
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Legg-Calve-Perthes’ disease (LCP disease)
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Slipped capital femoral epiphysis (SCFE)
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Deteriorated or failed pelvic osteotomy (deteriorated cases)
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Traumatized hip with deformity and malalignment (posttraumatic arthritis)
Preoperative Planning
Clinical Assessment
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Pain
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Limited and painful range of motion
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Abductors sufficiency/deficiency
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Demands for walking supports
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Leg length discrepancy (LLD), true or apparent
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Pelvic obliquity
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Lumbar spine curvatures (stiff or flexible)
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Patient’s expectancies
Radiological Assessment
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Anteroposterior (AP) radiograph of pelvis
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AP and lateral views of the affected hip
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AP and lateral views of the lumbar spine
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Hip to ankle standing radiograph in case of severe LLD, congenital disease of the hip, mechanical axis abnormalities
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Further imaging investigations include:
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CT +/− 3D reconstruction (severe hip deformities, definition of altered anatomy, defects, need for specific implants, design of custom made prostheses)
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MRI (avascular necrosis, evaluation of contralateral hip)
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Bone scans (history of infection, septic loosening, tumors, and metabolic diseases)
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Preoperative Templating
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Useful in all cases of hip arthroplasties.
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Assessment of implant design/type, size, positioning.
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Evaluation of femoral offset, improve biomechanics of reconstructed hip, decrease of wear.
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Templating always performed after clinical evaluation (LLD, gait, abductors sufficiency). Always estimate apparent LLD using the “block” method. Blocks of different heights are placed under the shorter leg until the pelvis is horizontal and the patient feels the legs as comfortably equal.
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Draw a horizontal line through two points at the inferior aspect of the ischial tuberosities or a horizontal line between the inferior aspects of the acetabular teardrops (more reliable points of reference than the ischia).
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A vertical line from the horizontal reference to the estimated center of each femoral head or to the center of the lesser trochanters represents a radiographic estimate of the limb-length discrepancy.
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All measurements should be reduced by a factor of approximately 20% to account for the enlargement of the osseous anatomy on the radiographs. Special magnification markers are used for accurate measurement of magnification.
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Orientation of the acetabular shell: 45° relative to the horizontal plane (AP radiograph) and 20° of anteversion (cross table lateral radiograph). The apex should be positioned just lateral to the teardrop and covered at its superolateral margin.
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Positioning of the acetabular component defines the new centre of rotation of the reconstructed hip.
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At the AP radiograph with the femur internally rotated approximately 20° (so that the true neck-shaft angle is in the same plane as the radiograph), the femoral template is superimposed on the radiograph.
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The optimal femoral component size is then established parallel to the anatomic axis of the proximal part of the femur.
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Align to the anticipated center of rotation by a distance that is equal to the measured LLD.
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Neck length and varus/valgus positioning are marked.
Operative Treatment
Anesthesia
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Regional (spinal/epidural) and/or general anesthesia.
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One hour prior to anticipated skin incision, administer intravenously prophylactic antibiotics as per local hospital protocol (e.g., combination of a second generation cephalosporin and aminoglycoside, or vancomycin in >50% MRSA hospitals).
Table and Equipment
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THA instrumentation set – ensure availability of the complete set of proper implants, according to preoperative templating.
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The instrumentation is set up on the side of the operation.
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Position the table diagonally across the operating room so that the operating area lies in the clean air field.
Patient Positioning
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Place the patient in the true lateral position with the affected limb uppermost. The unaffected limb is secured at 90° of knee flexion for intraoperative assessment of leg length (Fig. 7.1).
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Protect the bony prominences with pads. Place a pillow between the knees.
Draping and Surgical Approach
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Prepare the skin over the buttock, hip, femur, and tibia up to the malleoli with the usual antiseptic solutions (aqueous/alcoholic povidone-iodine, alcoholic chlorexidine).
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Drape the limb using adhesive single-use U-drapes.
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Cover the foot, ankle, and tibia with a socket.
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Isolate the proximal femur using Iobane sterile drapes.
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Drape the affected limb free to leave room for movement during the procedure. Hip flexion of at least 90° is essential for intraoperative assessment of stability.
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Palpate greater trochanter on the outer aspect of the thigh. It is easier to palpate the posterior edge of the trochanter, which is more superficial than the anterior and lateral portions.
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Make a 9–12 cm curved incision centered on the posterior aspect of the greater trochanter. In obese patients, a longer incision may be required.
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Begin the incision 4–6 cm above and posterior to the posterior aspect of the greater trochanter (Fig. 7.2).
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Curve the incision across the buttock, cutting over the posterior aspect of the trochanter, and continue distally along the shaft of the femur.
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If the hip is flexed to 90° and a straight longitudinal incision is made over the posterior aspect of the trochanter, it will curve into a “Moore style” incision when the limb is straight.
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Incise fascia lata on the lateral aspect of the femur to uncover vastus lateralis.
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Lengthen the fascial incision superiorly in line with the skin incision and split the fibers of gluteus maximus by blunt dissection.
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Split the muscle gently, so you may be able to pick up, cauterize, and cut the crossing vessels before they are stretched and avulsed by the blunt dissection of the split.
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Retract the fibers of the split gluteus maximus and the deep fascia of the thigh using Charnley’s self-retaining retractor.
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Place a Hoffman’s retractor and elevate the tendon of gluteus medius to uncover the short external rotator muscles.
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Internally rotate the hip to put the short external rotator muscles on a stretch and to pull the operative plane farther from the sciatic nerve (Fig. 7.3).
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Insert stay sutures into piriformis and obturator internus tendons just before their insertion into the greater trochanter.
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Detach the muscles close to their femoral insertion using electrocautery device and reflect them backward, laying them over the sciatic nerve to protect it during the rest of the procedure.
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Incise the posterior joint capsule in an L-shaped fashion to expose the femoral head and neck. The one leg of this capsular incision should run parallel to the proximal border of piriformis.
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Dislocation of the femoral head is achieved by internally rotating, flexing, and adducting the hip.
Implant Positioning
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Place two Hoffman’s retractors at each side of the femoral neck. The medial retractor should be placed at the level of the lesser trochanter, whereas the other one should protect the gluteus medius tendon.
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The resection level of the femoral head-neck is determined by the preoperative templating and marked accordingly using electrocautery or by a methylene blue marker.
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The calcar planer may be used to adjust the neck cut.
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Four Hoffman’s retractors are placed at each side of the acetabulum, at the anterior wall, the posterior wall, the upper rim, and distal to the transverse ligament (Fig. 7.4a).
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The joint capsule, the acetabular labrum, and any osteophytes of the upper rim are removed so to reveal the true size of the acetabulum.
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Progressively ream the acetabulum until bleeding subchondral bone is revealed (Fig. 7.4b).
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The angle of orientation should match that recorded during preoperative templating, which is normally 45° of lateral opening (abduction) and 15–30° of anteversion which can be confirmed by external alignment instrumentation.
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Using the cup impactor, place a trial cup sizer into the reamed acetabulum and assess its position and bone contact.
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The inferior rim of the trial cup should be level with the bottom of the teardrop.
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The acetabular shell is placed in situ with adequate primary stability. Additional screws may be used according to surgeons’ preference. These screws are preferably placed at the posterior superior and posterior inferior quadrants of the acetabulum which are formed by two lines: line A connecting the center of the acetabulum and the anterior superior iliac spine (ASIS) and line B perpendicular to line A.
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A trial insert is placed into the acetabular shell during preparation of the femur.
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Initiate the pilot femoral hole opening with the stepped IM initiator which should be aligned with the femoral canal.
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Use a box osteotome to enter the femoral canal at the junction of the femoral neck and the greater trochanter (Fig. 7.5a).
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Attach the trochanteric reamer to the T-handle or a power reamer and insert it into the canal. Proper alignment of the reamer along the long axis of the femur is important to ensure correct component positioning. Sequential reaming beginning two or three sizes below the preoperatively templated size is recommended. Resistance and chatter from cortical engagement may be used as a signal to stop tapered reaming.
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Broaching of the proximal femur should begin two to three sizes smaller than the preoperatively templated size. Sequentially, advance the broaches down the medullary canal, ensuring proper alignment and anteversion are achieved. To ensure proper alignment, orient the broach laterally toward the greater trochanter. The final broach should fit and fill the proximal femur, with the top of the cutting teeth resting at the point of the desired neck resection. The final broach should look and feel rotationally stable (Fig. 7.5b).
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Trial neck segments and modular heads are tested to assess proper component position, joint stability, range of motion, and leg length (Fig. 7.5c).
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Perform a final trial reduction using the trial acetabular liner and trial femoral head, selecting the optimal liner and modular head for implant stability and leg length.
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Range of motion, presence of femoroacetabular impingement, LLD, and hip stability are assessed.
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With the hip in 90° of flexion and 0° of abduction, internal rotation should be at least 45° with no tendency to dislocate.
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In extension, there should be full external rotation with no tendency to dislocate or impinge.
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Combined anteversion of the socket and femoral head should be approximately 45° (Fig. 7.6). The combined anteversion is defined by co-equatorial placement of the femoral head in respect to the acetabular liner when the leg is in 15° of flexion and 30° of internal rotation.
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Longitudinal pull of the limb with a single triceps force should not lead to telescoping of the hip.
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Abductors are assessed with the drop-kick test (if abductors are too tight, adduction of the hip leads to extension of the knee).
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Following the final trial reduction, remove the trial acetabular liner and insert the appropriate acetabular liner. When inserting a ceramic liner, extreme caution should be taken to avoid fracture or chipping (Fig. 7.7).
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Choose the stem size that matches the final broach, thread it to the inserter, and introduce it to the medullary canal.
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Rotate the stem into its proper orientation and advance the stem into the canal using hand pressure. When resistance is met, usually 10–15 mm above the desired final seating position, advance the stem into position with multiple moderate blows using a mallet.
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Clean and dry the taper and introduce the appropriate femoral head by firmly pushing and twisting the femoral head into place. Using the head impactor, engage the head with several mallet taps.
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Reduce the hip and make a final assessment of leg length, tension of hip abductors, and hip stability (Fig. 7.8).
Closure
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Irrigate the wound thoroughly and achieve hemostasis.
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Reattachment of small external rotator tendons: Using a 3.2-mm drill, make two tunnels at the posterior ridge of the greater trochanter (Fig. 7.9a). With loop wires, pass the stay sutures which have been already inserted to the piriformis and obturator internus tendons through the osseous tunnels and ligate them together over the posterolateral aspect of the trochanter (Fig. 7.9b). Reconstruct the quadratus femoris muscle if possible.
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Close fascia lata (No 2 PDS, Vicryl) over a drain (14/16F) and the subcutaneous fat with absorbable sutures (No 0 PDS, Vicryl).
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Skin closure – stainless steel surgical staples, monofilament non-absorbable sutures, or absorbable sutures placed in the subcuticular layer.
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Secure the position of the leg by using special abduction triangle shaped pillows.
Postoperative Rehabilitation
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One further dose of prophylactic antibiotics is sufficient. Use of antibiotics can be extended until removal of the drains or 48 h postoperatively.
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Start mechanical VTE prophylaxis at admission and continue until the patient no longer has significantly reduced mobility. Start pharmacological VTE prophylaxis after surgery and continue for 28–35 days.
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Routine AP radiograph of the pelvis within 24 h. Cross table lateral hip X-ray for assessment of cup anteversion.
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Routine blood counts at 6 and 12 h postoperatively.
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Use special abduction pillow.
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Remove drains in 48 h otherwise when drainage is less than 30 mL/24 h.
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Hip range of motion and general muscle strength in the operative extremity.
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Sitting exercises.
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Mobilize with partial weight bearing.
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Refine gait pattern and instruct in stair climbing.
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Review home instructions/exercise program with emphasis on hip dislocation/precautions.
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A Zimmer frame, an elevated toilet seat, and follow-up physical therapy are required.
Follow up
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Patients are assessed clinically and radiographically at 1, 3, 6, and 12 months and every 5 years thereafter, unless GPs request (Fig. 7.10).
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Range of motion, impingement, abductor sufficiency, need for assistive devices, level of residual pain, independence, and quality of life parameters are evaluated.
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Orientation of acetabular and femoral components, progressive insert wear, signs of osteolysis, and radiolucent lines around implants are assessed with sequential plain radiographs of the pelvis and the hip.
Further Reading
Anseth SD, Pulido PA, Adelson WS, et al. Fifteen-year to twenty-year results of cementless Harris-Galante porous femoral and Harris-Galante porous I and II acetabular components. J Arthroplasty. 2010;25(5):687–91.
Springer BD, Connelly SE, Odum SM, et al. Cementless femoral components in young patients: review and meta-analysis of total hip arthroplasty and hip resurfacing. J Arthroplasty. 2009;24(6 Suppl):2–8.
Aldinger PR, Jung AW, Breusch S, et al. Survival of the cementless Spotorno stem in the second decade. Clin Orthop Relat Res. 2009;467(9):2297–304.
Yamada H, Yoshihara Y, Henmi O, et al. Cementless total hip replacement: past, present, and future. J Orthop Sci. 2009;14(2):228–41.
Dutton A, Rubash HE. Hot topics and controversies in arthroplasty: cementless femoral fixation in elderly patients. Instr Course Lect. 2008;57:255–9.
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© 2011 Springer-Verlag London Limited
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Babis, G.C., Sakellariou, V.I., Soucacos, P.N., Soucacos, P.N. (2011). Cementless Total Hip Arthroplasty (THA): Posterior Approach. In: Giannoudis, P. (eds) Practical Procedures in Elective Orthopaedic Surgery. Springer, London. https://doi.org/10.1007/978-0-85729-814-0_7
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DOI: https://doi.org/10.1007/978-0-85729-814-0_7
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