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Vol 8, No 2 (2020)

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Experimental and theoretical research

Possibilities of using allogeneic mesenchymal stem cells and wound dressings based on aliphatic copolyamide in microautodermoplasty

Gordienko V.A., Zinoviev E.V., Kostyakov D.V., Asadulaev M.S., Shabunin A.S., Yudin V.E., Smirnova N.V., Radeeva A.V., Paneiakh M.B.


Background. The treatment of victims with wound defects is an urgent problem of clinical medicine that doctors of various specialties, mainly surgeons and traumatologists, must face. Regardless of the etiology of the traumatic agent, the wound process is always subjected to fundamental pathophysiological processes. Despite the advances made by medical science in the local treatment of wounds (cell technology, modern wound coverings, and others), surgical procedures remain the main methods, and the search for new techniques to optimize reparative regeneration continues. This ongoing search indicates the absence of a universal algorithm for treating such defects. This lack of a universal treatment algorithm is of particular importance for assisting victims with extensive defects, which often leads to a shortage of donor resources.

Aim. The aim of this study was to increase the efficiency of microautodermoplasty due to the use of allogeneic mesenchymal stem cells and wound dressings based on aliphatic copolyamide.

Materials and methods. This paper presents the results of an experimental study involving 50 rats. All animals were divided into groups considering the choice of the method of the local treatment. The experimental wound was modeled according to its original technique. The evaluation of the effectiveness of the analyzed methods was performed using planimetric and histological research methods, and by calculating the healing index.

Results. The most effective methods for treating experimental wounds using microautodermoplasty (MADP) are wound dressings based on aliphatic copolyamide (CoPA) and adipogenic mesenchymal stem cells (AMSC). By 28 days of treatment after performing MADP + CoPA wound dressings + AMSC, it was possible to reduce the defect area by 16 times compared with the control, and the healing index was the maximum value among all methods — 12.5 units. The high regenerative potential was also confirmed by the results of the histological examination. The worst results were found in the MADP group with AMSK that did not cover the wounds with skin or wound dressing.

Conclusion. The introduction of the analyzed methods into clinical practice will improve the results of treatment of patients with wound defects of various etiologies.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):185-196
pages 185-196 views

Original Study Article

Nonunion of the bone fragments during total hip replacement with T. Paavilainen osteotomy — causes of failure

Avdeev A.I., Voronkevich I.A., Parfeev D.G., Kovalenko A.N., Pliev D.G., Sannikova E.V., Shubnyakov I.I., Tikhilov R.M.


Background. Conservative treatment options for hip dysplasia and hip dislocation in early childhood allow for good results in cases of a timely diagnosis. The preferred treatment option for patients with hip dislocation in adulthood is total hip joint replacement. The shortening osteotomy, proposed by T. Paavilainen, allows the surgeon to restore the difference in the lengths of the lower extremities during arthroplasty of the hip joint. However, according to the results of the Paavilainen technique, as presented by Russian orthopedic surgeons, the problem of nonunion of the greater trochanter fragment with the diaphysis of the femur remains unresolved, as evidenced by a massive group of clinical cases.

Aim. The aim of this study was to identify factors affecting the consolidation of bone fragments after osteotomy of the greater trochanter, according to T. Paavilainen, during total hip arthroplasty and evaluate their significance after fixation with cerclage screws in comparison with a special trochanteric fork-plate.

Materials and methods. The present study includes 208 cases that were treated at the Russian Scientific Research Institute of Traumatology and Orthopedics named after R.R. Vreden from 2003 to 2019 using various fixation techniques of the greater trochanter fragment. Patients were divided into two groups depending on their type of fixation. The quality of consolidation of a greater trochanter fragment with the femur was assessed during a follow-up period of six months or longer. The fragment of the greater trochanter was divided into the part that was not in contact with the diaphysis, or A, and the part that was in contact with the diaphysis, or B. We assessed the effect of the absolute value of the contact between fragments, the B/A ratio, the distance between the points of insertion of the screws into the diaphyseal part of the femur, the quality of the bone by the modified Barnet-Nordin index, and the history of previous surgical interventions on this joint on the consolidation.

Results. When the part of the greater trochanter was in contact with the diaphysis of the femur (B) was less than 3.5 cm, the risk ratio of nonunion of the greater trochanter fragment with the diaphysis of the femur increased. Also, a significant factor is the index of the contact of the greater trochanter fragment (B/A less than 1) with the diaphysis of the femur using the T. Paavilainen technique. In addition, the presence of surgical intervention in the hip joint history significantly increases the relative risk (RR) of nonunion of the greater trochanter fragment with the diaphysis of the femur with this method of shortening osteotomy of the femur.

Conclusion. In the absence of timely diagnosis and conservative treatment of children with hip dislocation, reconstructive-plastic techniques on the hip joint do not allow the achievement of proper results and increase the complexity of total hip arthroplasty. According to the results of this study, the absolute value of the contact between fragments (B), the index of the greater trochanter contact with the diaphysis of the femur, and the history of previous surgical intervention on this joint are objective tools for the prognostic assessment of the probability of fragment unions during total hip arthroplasty with the T. Paavilainen technique.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):119-128
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Bone mineral density in children with cerebral palsy and Spina Bifida treated with ibandronate

Kenis V.M., Sapogovskiy A.V., Prokopenko T.N., Bergaliev A.N., Ivanov S.V., Kiseleva T.I.


Background. Bisphosphonates have become a common method for the prevention and treatment of osteoporosis in children with neuromuscular diseases.

Aim. The aim of this study was to assess the mid-term changes of bone mineral density in patients with cerebral palsy and spina bifida treated with ibandronic acid.

Materials and methods. Thirty-four patients were examined and treated: 19 children with cerebral palsy (GMFCS levels III–IV) and 15 children with spina bifida (thoracic and upper lumbar neurosegmental levels), mean age 9.8 ± 2.9 years. Ibandronic acid was administered to all patients (3 consecutive intravenous infusions, 0.1 mg/kg every 3–4 months). The assessment of bone mineral density was performed using dual-energy X-ray absorptiometry.

Results. The Z-score increased from –2.55 to –2.1 (total body less head), and from –2.7 to –1.65 (lumbar spine). Improvement of the Z-score for the lumbar spine was noted after the first infusion, and for the whole body after the first two infusions.

Conclusion. Ibandronic acid infusions improved the bone mineral density in children with cerebral palsy and spina bifida for both the whole body and the lumbar spine. Given the data obtained, weight-bearing exercises can be recommended three months after the first infusion, and dynamic exercises can be performed, preferably after six months.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):129-136
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Surgical management of neuromuscular scoliosis: approaches, pitfalls and outcomes

Negm E.E., Saraph V., Said M.S.


Background. Scoliosis is a common problem among neuromuscular disorders with increased incidence of morbidity and mortality. The management of neuromuscular scoliosis (NMS) is complex and requires a cooperative multi-disciplinary team to provide meticulous perioperative care. Conservative treatment, such as bracing, can delay but not replace surgical correction. However, surgery has the risk of higher perioperative complication rates in this patient population.

Aim. It is a retrospective study to evaluate clinical outcome, approaches, pitfalls in management of NMS patients undergoing surgical correction.

Materials and methods. We retrospectively evaluated patients with NMS who underwent surgery for scoliosis from 2004 to 2018. Sixty-eight patients were included in the study after meticulous preoperative checkup. In most cases an single-pedicle screw construct was used, but in a few others a hybrid construct was used. A follow up was performed to make a clinical and radiological assessment and recorded all measurements and any complications. A telephone questionnaire was used for functional evaluation and patient/parent satisfaction with surgery. Only 52 patients could participate in the questionnaire.

Results. The mean follow up period was 43.28 months, and the mean age at the time of surgery was 14.29 years. The mean preoperative Cobbs angle was 71.7°, while that of final follow-up was 34.6°. The mean Cobbs correction percentage was 53.25%. For correction of fixed pelvic obliquity ≥15°, a sacropelvic extension was done in 60.29% of cases. Complications occurred in 39.71% of operated cases; chest related in 36.11% (of all complications), hardware-related 16.67%, visceral complications (as paralytic ileus) in 13.89%, decubitus ulcer and delayed wound healing in 13.89%, deep wound infection in 8.33%, CNS complications (as status epilepticus) in 8.33%, and death in 2.78% (one case). The results of the questionnaire indicated favorable functional outcomes and patient/family satisfaction with surgery.

Conclusion. Despite the perioperative difficulties seen in patients with NMS, patients who had relatively higher postoperative morbidity and mortality, most patients/parents were satisfied with the results of the spinal deformity surgery. The patients/parents would recommend surgery to other patients with similar disorders.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):137-150
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Neurophysiological signals for estimation of the result of latissimus dorsii muscle transfer to biceps brachii in patients with arthrogryposis

Agranovich O.E., Savina M.V., Ivanov D.A., Boyko A.E., Blagoveshchenskiy Y.D.


Background. One of the leading causes of restriction in daily-living activities in patients with arthrogryposis is severe hypoplasia (or aplasia) of the biceps brachii. Latissimus dorsii muscle transfer to the biceps brachii is one of the most used methods for the reconstruction of active elbow flexion in patients with arthrogryposis.

Aim. The aim of the study is to identify neurophysiological correlates for evaluating the result of the transposition of the latissimus dorsii muscle to the biceps in patients with multiple congenital arthrogryposis.

Materials and methods. From 2011 to 2018, we performed monopolar latissimus dorsii muscle transfer to the biceps for the restoration of active elbow flexion in 30 patients with arthrogryposis (44 upper extremities). The follow-up results were studied in 14 cases. For this purpose, we used clinical examination, surface electromyography (sEMG), and statistical analysis. The patients were examined before and from 1 month to 96 months (7 months; 2–24.5 months) after the surgery. The age of patients was from 1 to 10 years at the time of surgery (4.89 ± 2.42 years).

Results. Our study showed that the age of the child at the time of surgery does not significantly change the index of activation of the latissimus dorsii muscle. A decrease of coactivation of the latissimus dorsii muscle in the long term after surgery correlates with an increase in the strength of the displaced latissimus dorsii muscle, and an improvement in active flexion in the elbow. If the value of the index of coactivation of the latissimus dorsii muscle is less 42%, the muscle strength after surgery reaches 4 points. It was found that the index of coactivation of the latissimus dorsii muscle does not depend on the level of segmental damage to the spinal cord. However, the strength of the muscle depends on the level of spinal cord damage.

Conclusion. The determination of the index coactivation of the latissimus dorsii muscle after surgery can be used to evaluate the results of the latissimus dorsii muscle transfer to the biceps in patients with arthrogryposis. The index of activation of the latissimus dorsii muscle must be less than 42% for effective elbow active flexion.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):151-158
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Gait biometrics in children with cerebral palsy before and after robotic mechanotherapy

Nikityuk I.E., Ikoeva G.A., Kononova E.L., Solokhina I.Y.


Background. The improvement in existing methods and the development of new principles for treating children with cerebral palsy necessitates a quantitative assessment of the parameters of motor activity. However, because of the explicit and complex abnormalities in motor skills in patients with severe forms of cerebral palsy, an evaluation of their locomotor function dynamics using instrumental diagnostic methods remains a serious problem.

Aim. This work aimed to study the walking function in patients with cerebral palsy before and after motor rehabilitation using a biomechanical method with biometric sensors.

Materials and methods. We examined 14 patients with cerebral palsy aged 8 to 13 years with III level of restriction of motor activity according to the gross motor function classification system (GMFCS). All patients underwent rehabilitation in the Lokomat robotic simulator for three weeks. The course consisted of 15 sessions of 45 min each. The temporal and dynamic parameters of walking were studied in 14 patients with cerebral palsy before and after a course of locomotor training. The biometry of the step cycle was studied using the STEDIS hardware-software complex, including the Neurosens set of wireless biometric sensors. The temporal characteristics of the step cycle and the force interaction of the lower extremities with the supporting surface during walking were recorded. For comparison, we conducted a biomechanical examination of 18 healthy children of the same age who did not have signs of orthopedic disorders.

Results. Although after a course of mechanotherapy, the indices of the support phases in biometry in children with cerebral palsy did not reach the level of healthy individuals, a physiological tendency to roll foot was observed in the phase of pushing and accelerating the foot. Active braking of the lower limb increased. The studied time parameters showed a relative improvement in the step structure because of the emerging tendency to normalize the ratio of the periods of the double support of the contralateral lower extremities.

Conclusion. Robotic mechanotherapy helps to change the biomechanical pattern of walking of a child with a severe degree of cerebral palsy. An instrumental analysis of walking using wireless biometric sensors allows you to evaluate the results and effectiveness of rehabilitation measures in patients with severe motor impairment objectively.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):159-168
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Analysis of type and frequency dynamics of rehabilitation assistive devices in children with cerebral palsy

Koltsov A.A., Dzhomardly E.I.


Background. Currently, cerebral palsy is the most common neuromuscular disease in the pediatric population. Spastic forms of cerebral palsy are characterized by secondary musculoskeletal complications. They are corrected by the use of assistive devices and, especially, orthoses, along with surgical treatment, botulinum toxin, and others.

Aim. The aim of this study was to assess the type and frequency dynamics of rehabilitation assistive devices in children with spastic forms of cerebral palsy, depending on the level of the gross motor function of the patient.

Materials and methods. A prospective analysis was conducted by questioning 214 parents of children with spastic forms of cerebral palsy who were treated for the period from 2017 to 2019. The patients were divided into five groups according to the gross motor function classification (GMFCS). The statistical processing was performed using the application package Statistica 10 and Microsoft Excel.

Results. Statistically significant differences in variances (p < 0.05) were obtained between the number of rehabilitation assistive devices used in the anamnesis in the year before the questionnaire (period I) and assistive devices used in the last six months before the questionnaire (period II). Repeatedly, patients used orthopedic shoes the most often, and the trunk-hip-knee-ankle-foot orthoses the most rarely. We found five main causes groups of assistive device use failure for children with cerebral palsy.

Conclusion. Statistically significant differences in variances were obtained between the frequency of rehabilitation assistive devices used in the anamnesis and during the last six months before the questionnaire was obtained. It has been confirmed that patients used orthopedic shoes most regularly; of all functional orthoses, hip adductor orthosis was used most often repeatedly, whereas the trunk-hip-knee-foot orthoses were the least common. Factors such as a negative attitude of the child towards the orthosis, uncomfortable in life, the presence of construction errors of the product, the absence of appropriate appointments in the individual rehabilitation and habilitation programs for the patient, have led to the most frequent rejection of the reuse of the technical device for rehabilitation. At the same time, positive or negative dynamics on the condition of the patient affected the regularity of the use of a technical device for rehabilitation in only one in six patients.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):169-178
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Flatfoot or not: subjective perception of the height of the feet arch among orthopedists

Dimitrieva A.J., Kenis V.M., Sapogovskiy A.V.


Background. The visual assessment of flatfoot is the most commonly used method by pediatric orthopedists. It is necessary to confirm good consistency among specialists to justify its use as a standard.

Aim. The aim of this study was to determine the consistency of visual assessment of flatfoot among orthopedists.

Materials and methods. The first stage of this study included 187 primary school-aged children. The main methods used were clinical examination and computer plantography. Then, 130 images of the right foot were randomly selected in standard projections — medial and posterior, which were provided to 32 orthopedists (ten of whom were experts). Specialists needed to note whether the foot presented for analysis was flat. We used the w-Kendall concordance coefficient and τ-Kendall correlation coefficient to determine the inter-rater reliability. After five months, the intra-rater reliability was determined, and the Cohen coefficient was calculated.

Results. Our study demonstrated that the inter-rater reliability varied significantly depending on whether the orthopedist specialized in foot pathology. When calculating the concordance coefficient, an increase in the consistency among experts was noted after five months (0.58 and 0.76, respectively), compared with orthopedists who do not specialize in foot pathology. Although some heterogeneity was noted according to experts on the same foot, the overall correlation coefficient corresponded to a good and excellent level of consistency (0.65–0.84). Cohen’s coefficient among specialists corresponded to a good level of confidence (0.72), whereas among orthopedists who do not specialize in foot pathology, there was a low level of confidence (0.31). According to experts, the frequency of flatfoot was 24.6%, whereas according to orthopedists who do not specialize in foot pathology, it was 40.9% when they evaluated images of the same feet.

Conclusion. Experts’ answers regarding which foot should be considered flat demonstrated a good and excellent level of consistency. Therefore, they can be used to determine reference values of anthropometric parameters of the medial foot arch.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):179-184
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Exchange of experience

Plastic surgery of extensive soft tissue defects of the lower leg in children with the use of a parotid flap after its prefabrication with tissue expanders (preliminary report)

Filippova O.V., Govorov A.V., Proshchenko Y.N., Afonichev K.A., Galkina N.S.


Background. Extensive deep soft tissue defects in children are an indication for the microsurgical reconstruction using autotransplantation of a tissue complex. The use of a flap prefabrication before their microsurgical transplantation to various segments and areas is a promising approach in reconstructive surgery.

Aim. The aim of this study was to evaluate the possibilities and immediate results of plastic surgery of extensive soft tissue defects of the lower leg with a tissue complex, after its prefabrication with a tissue expander, and the state of the donor area in different surgical treatment options.

Materials and methods. Six patients aged 13 ± 2.3 years were operated on for deep scar deformities of the lower leg and foot. For plastic surgery, a pericarpial flap was used. In two patients, the flap was prefabricated with tissue expanders at a volume of 720 ml. After filling the expander, the second stage of surgical treatment was performed. First, the expander was removed. Next, the flap on the artery surrounding the scapula was isolated. Last, it was transplanted into a soft tissue defect of the lower leg with the imposition of microvascular anastomoses. A layer-by-layer suture was applied to the donor wound. The Vancouver scale was used to assess the quality of the scar tissue in the donor area.

Results. The removal of the tissue complex after the prefabrication with expanders made it possible to perform plastic surgery of extensive soft tissue defects of the lower leg in one stage of surgical treatment with the application of a cosmetic suture in the donor area. There were no complications in the postoperative period.

At the examination after six months, patients who did not undergo flap prefabrication complained of cosmetic defects and discomfort when moving in the donor area.

The evaluation of the quality of scar tissue by the Vancouver scale showed that the scars in patients after flap prefabrication were similar to optimal (total score in two patients is 2). In two patients without flap prefabrication, the total score was 7, and in two patients, it was 9, which indicated unsatisfactory cosmetic parameters of the postoperative scar.

Conclusion. The prefabrication of a tissue complex using tissue expanders before microsurgical transplantation enables the collection of a large volume of tissue for plastic surgery of extensive defects. It also reduces the risk of trophic complications in the postoperative period and creates optimal conditions for closing the donor site.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):197-206
pages 197-206 views

Сase report

Anterior elbow fracture dislocation with ulnar nerve palsy in a six-year-old child

Ashar N., Liew S., Azmi N., Yeak R., Lingam R., Chen R.


Background. Anterior elbow fracture dislocation is rare, especially in paediatric age group. Of the reported cases to date, three-quarter were posterior dislocation of the elbow. Anterior elbow dislocation is rarely reported, with incidence of only <2%.

Clinical case. A 6-year-old girl presented to casualty with left elbow deformity and pain after she tripped and fell in the toilet. Ulnar clawing was present with reduced sensation over ulnar nerve distribution. No wound was found, distal pulses and circulation were good. The X-rays showed anterior dislocation of the left elbow with olecranon fracture. Closed manual reduction was attempted but failed. Open reduction and percutaneous K-wire insertion under general anaesthesia was performed. Medial approach of the elbow was done. Intra-operatively ulnar nerve was found impinged by the distal ulnar fragment but was in continuity. The transverse olecranon fracture was fixed with two K-wires and the radial head was reduced. Ulnar nerve was mobilised until tension-free. Ulnar collateral ligament was repaired. The elbow was immobilised with a splint. Ulnar claw was resolved at 2 weeks. The fracture heals and the K-wires were removed at 6 weeks. At 8 weeks, range of movement of the elbow was full. The elbow was stable in varus and valgus.

Discussion. Anterior elbow dislocation is a high energy trauma and one should be cautious of neurovascular injury. There was no clear recommendation in the literature regarding surgical approach. We chose medial approach of the elbow for ulnar nerve exploration and olecranon fixation.

Conclusion. This rare injury should be treated with high index of suspicious. Surgical approach should be tailored individually according to the instability of the elbow joint and neurovascular status, as in this case was the posteromedial instability associated with ulnar nerve palsy.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):207-212
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Traumatic bilateral posterior hip dislocation in children. A 12 years follow up case report

Soto-Juárez I., Martínez-Pérez R.


Background. Bilateral traumatic hip dislocation in children is a very rare orthopedic emergency. Few case reports are available in literature.

Clinical case. A 4-year-old male child case with a trivial mechanism of injury is presented. Closed reduction in emergency department was achieved after 24 hours of injury, he was placed on Buck’s skin traction for 4 days and during 4 weeks in a spica cast. There was not either clinical sign nor images of early or late complications during follow up until he reached skeletal maturity.

Discussion. Hip dislocation in children is a rare emergency with an incidence of 0.8 cases per million per year, its treatment should not be delayed to minimize late complications such as osteonecrosis, recurrent dislocations, osteoarthritis, neurological lesions, coxa magna and heterotopic ossification. The reported incidence for hip osteonecrosis is 36.4% for late (>6 hours) and 8.2% after early (<6 hours) reduction. After 12 years of follow up no complication was found although the reduction was made 24 hours later.

Conclusions. After immediate reduction a 4 to 6 weeks immobilization period is an effective treatment. Close monitoring to timely identify and treat any further complication is mandatory.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):213-216
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Prospects of hydroxyapatite-based nanomaterials application synthesized by layer-by-layer method for pediatric traumatology and orthopedics

Meleshko A.A., Tolstoy V.P., Afinogenov G.E., Levshakova A.S., Afinogenova A.G., Muldiyarov V.P., Vissarionov S.V., Linnik S.A.


The present brief review focuses on the features of the Layer-by-Layer (LbL) synthesis of coatings containing hydroxyapatite nanoparticles and assesses their use in solving several biomedical problems. This work provides the state-of-art of this field. This method is based on the sequential chemical adsorption of reagents on the substrate surface that makes it possible to apply nanolayers of the specified composition on the surface of a wide range of substrates of complex shape, to control the thickness of the synthesized layers accurately at the nanometer level. It also enables the modification of surface characteristics, including roughness, hydrophilicity, and surface charge, and allows “artificially” constructed multilayers consisting of hybrid organic and inorganic substances to be obtained. The experimental material presented in the review demonstrates the effectiveness of LbL synthesis for creating new 3D scaffolds as bone substitutes, coatings on the surface of metal implants, and drug delivery systems. A promising direction for the development of LbL synthesis is the creation of methods that involve ion-substituted hydroxyapatites as reagents. Success in this area can pave the way for significant advances in biomedicine and open new opportunities for creating a new generation of structures that mimic the structural, compositional, and mechanical properties of the bone mineral phase.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(2):217-230
pages 217-230 views

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