Non-surgical treatments for Osteochondritis dissecans
Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C
In this article, we will cover research on Platelet Rich Plasma Therapy and treatment of Osteochondritis dissecans in youth athletes as a means to help non-surgically accelerate healing. The main focus of this article will be on knees and elbows.
If you are reading this article you are likely the parent of a teenage athlete who is trying to stay in his/her sport(s). Your child has been diagnosed with Osteochondritis dissecans. The treatment you are being recommended includes weeks of inactivity and rest. You ask about physical therapy but are told that PT does not really help cartilage re-attach to the bone. You are told only “conservative treatment” that being rest or stopping all activities for a prolonged time or surgery can. When you explore more about the surgical aspects, you find out that while the surgery can help, it does not prevent the recurrence of your child’s Osteochondritis dissecans.
You may be struggling with the advice to have “patience,” and with your desire to help your athlete back to their game. What are your options? One option is to research and find answers. We hope to help you with that here.
Understanding osteochondritis dissecans around the knee
Bone contusions, also known as osteochondritis dissecans or bone bruises, are a common consequence of trauma to the knee. Contusions are frequently associated with other intra-articular lesions, such as ACL injuries or meniscal tears, and their detection on MRI imaging can provide a useful indication of lesions associated with knee instability and pain.
Osteochondritis dissecans is a localized injury or condition affecting an articular surface of a joint, most commonly the knee joint, that progresses to stages in which there is the separation of segments of cartilage with or without subchondral bone, forming loose bodies in the joint. Direct injury, repetitive microtrauma, and mechanical abnormalities of the knee are thought to be important mechanisms responsible for the development of osteochondritis dissecans. Knee ligament laxity is considered to be a factor in the development of osteochondritis dissecans. Increased tibial torsion, which generates knee joint instability, has also been associated with osteochondritis dissecans of the knee.
The knee patient
Often we will see a young patient in our examination room. The parents and the young patient will describe a knee problem that began when the knee became hyperextended during a game or gymnastics competition. The parents will tell us that they went to the “urgent care,” where they were told to use the RICE protocol of Rest, Ice, Compression, and Elevation.
After a few days of RICE, the parents tell us that there was no improvement at all and an appointment and consultation with a specialist lead to an MRI and the discovery of the osteochondral lesion and diagnosis of Osteochondritis dissecans. For many we see, there was good news in that surgery would not be recommended. For others, we see a more concerning recommendation for surgery will be given, especially in the presence of significant symptoms.
My daughter is 15
Knees: My daughter is 15 and she has osteochondritis dissecans in both knees. She also has knee instability from ligaments that need to be tightened. The specialist we are seeing wants to do surgery. She also has been diagnosed with Ehlers-Danlos Syndrome and the surgeon feels that this is causing her pain from the knee popping out of place. My daughter does not want the surgery, I am exploring options for her.
I have a 12-year-old son
Knees: I have a 12-year-old son. It is his left knee that has been the problem. He was diagnosed with osteochondritis dissecans and it was recommended going to complete 6 months of the conservative treatment that included physical therapy, muscle strengthening, and exercise. After 6 months, his pain was gone, which was a blessing, however, he still has issues with function. He can walk okay but he has problems on steps, stairs, hills, and inclines. We have been to a few specialists and they each have a different opinion. Some say operate, some say don’t operate, some say wait and see. We are looking for answers but we only seem to get confused.
My son is a pitcher, or he was a pitcher
Often we will see the young gymnast or the youth league baseball pitcher with significant elbow problems. For the gymnast, the elbow problems present a significant challenge to various routines including the floor exercises. We will often hear parents tell us about their “one-armed” gymnast. For the baseball pitcher, elbow problems mean shut down from playing.
Elbow: My son is a pitcher, or he was a pitcher. About a year ago when he was 14, he was diagnosed with osteochondritis dissecans in his pitching elbow. We were also told at that time about a fracture in his growth plate. He was immediately told to rest and immobilize his arm. This included no throwing for three months. The physical therapy was very successful, enough so that he could return to playing, he just can’t pitch because his elbow is locking up. The doctors think this is from floating pieces of cartilage in his elbow. We have to consider the surgery.
The theory as to why your child has Osteochondritis dissecans
Osteochondritis dissecans is a condition of cartilage and subchondral (under the cartilage) bone damage. Young athletes are typically affected in the knee, elbow, ankle, and hip. Repetitive microtrauma from sports is a common cause, especially among older adolescents and teenagers.
Here is learning point information (March 2019) from the National Center for Biotechnology Information and STATPearls publishing at the U.S. National Library of Medicine. (1)
- Osteochondritis dissecans (OCD) or “osteochondral lesion,” is not a fully understood process. It is “idiopathic” which means that doctors are not sure how it starts and develops but they believe there are many factors that lead to this problem. Below we will discuss joint instability as one of these causes.
- Osteochondral lesions range in severity from being asymptomatic (no pain or symptoms) to mild pain or advanced cases having symptoms of joint instability and locking. As the condition develops, cartilage fragments can break away and become “loose bodies,” in the joint causing pain and inflammation. When the patient has a loose fragment, symptoms are generally more severe, with marked joint pain, locking, swelling, and joint instability.
The theory as to why your child has Osteochondritis dissecans
- Doctors think that spontaneous osteonecrosis (joint deterioration caused by reduced blood flow) is thought to occur during the transition from juvenile bone and cartilage development to mature bone and cartilage development in adolescence. The higher prevalence of Osteochondritis dissecans in young athletes suggests a repetitive microtrauma etiology.
Not growing pains
One of the problems that we see in our office is that the young athlete has not had medical treatment because of the thinking that the athlete’s problems, especially in the knee or elbow are all part of “growing pains.” As pointed out in the research we are citing and confirmed by other research studies, these young patients typically show up in the specialists’ office several months to a year after the onset of symptoms.
“The management of osteochondritis dissecans continues to baffle even the savviest of surgeons”
In March 2020, Dr. Eric Edmonds of the University of California at San Diego wrote an editorial in the medical journal Arthroscopy (2). Here he notes:
“The management of osteochondritis dissecans continues to baffle even the savviest of surgeons, with unclear etiology, the unknown relationship of presentation to the outcome, bewildering response to various treatments, and frustratingly difficult-to-predict prognosis. Whether skeletal immaturity may be indicative of surgical success, at least when it comes to lesions requiring screw fixation, remains debatable. Treatment may include activity modification, drilling, fixation, or osteochondral replacement of osteochondritis dissecans lesions in the knee. Regardless, each osteochondritis dissecans lesion must be followed until osseous integration is confirmed by imaging -otherwise, progression of the disease to osteoarthritis is likely.”
Notice the words Dr. Edmonds uses: baffle, unclear, unknown, bewildering, frustratingly difficult.
In the same March 2020 issue of Arthroscopy (3) surgeons from Icahn School of Medicine at Mount Sinai, New York, Wake Forest School of Medicine, Rush University Medical Center, and the University of Wisconsin published these findings on why patients failed surgery. They looked at two groups of patients; 26 skeletally mature patients (average a little less than 18 1-2) and 19 patients with incompletely closed physes (simply an open growth plate – average age just about 15 years old). These patients had screw fixation of osteochondral fragments and 35 of these patients were followed up a minimum of two years after surgery.
The researchers noted:
- “No statistically significant difference in failure rates was found between skeletally mature and immature individuals.”
- The only factor significantly associated with fixation failure was undergoing a prior surgical procedure to address the osteochondritis dissecans lesion.”
- Analysis showed rates of overall survivorship from revision reoperations of 88.6% at 1 year and 68.8% at 5 years.
The researcher’s conclusion: The more surgeries the worse.
“Outcomes after internal fixation of osteochondral fragments are guarded, with a fragment survival rate of 65.7% at a mean of 4.1 years’ follow-up. No difference in fragment survival was noted in skeletally mature versus immature patients. The only independent risk factor identified for fixation failure was the number of previous operations.”
In a July 2019 study in the medical journal Cartilage, (4) research led by doctors at the Rizzoli Orthopaedic Institute, in Bologna, Italy examined the evidence of certain nonsurgical treatment strategies for knee Osteochondritis dissecans. The researchers looked at 27 studies that totaled an examination of 908 knees.
The treatments discussed were:
- (1) restriction of physical activity,
- (2) physiokinesitherapy (movement therapy) and muscle-strengthening exercises,
- (3) physical instrumental therapies, (examples are magnetic stimulation, infrared pulsed laser therapy et al.)
- (4) limitation of weight-bearing, and
- (5) immobilization.
The analysis showed an overall healing rate of 61.4%, with large variability (10.4% in one study to – 95.8% in another).
- A conservative treatment based on restriction of sport and strenuous activities seems a favorable approach, possibly combined with physiokinesitherapy.
- Negative prognostic factors were also identified:
- larger lesion size,
- more severe lesion stages,
- older age and skeletal maturity,
- the discoid meniscus, and
- clinical presentation with swelling or locking.
The researchers here concluded:
“The literature on conservative treatments for knee Osteochondritis dissecans is scarce. Among different non-surgical treatment options, strenuous activity restriction seems a favorable approach, whereas there is no evidence that physical instrumental therapy, immobilization, or weight-bearing limitation could be beneficial. However, further studies are needed to improve treatment potential and indications for the conservative management of knee Osteochondritis dissecans.”
Pegs, Plugs, and Drills – Is there a surgical role for Osteochondritis dissecans of the knee?
The papers noted above reflect a long line of research. In November 2017 in the publication Orthopaedics and Traumatology, Surgery and Research, (5) doctors in France gave a summary explanation of the standard treatment offered to patients with knee osteochondritis dissecans and the outcomes that may be expected.
- When the radiographic diagnosis of osteochondritis dissecans is made early in a patient, healing can often be obtained simply by restricting sports activities.
- The degree of lesion instability (bone or cartilage tears and cracks) can later be assessed by magnetic resonance imaging to see if healing with restricted sports occurred.
- When the lesion remains unstable (bone and/or articular cartilage tear did not repair and is loose or may tear away) and the pain persists despite a period of rest, surgery is indicated.
- Arthroscopic exploration is always the first step.
- Drilling of the lesion produces excellent outcomes if the lesion is stable. (In this procedure, if the tear flap/bone is fixed, and not a threat to breaking away and floating in the joint, drilling into the bone will bring blood to the cartilage tear and instigate healing. Please see our article Knee articular cartilage surgery and non-surgical repair for a more detailed discussion of various surgical procedures and drilling).
- Unstable lesions require fixation and, in some cases, bone grafting. (The osteocartilaginous block spoken about above has broken away leaving a hole in cartilage or bone or both).
Arthroscopic Drilling for Stable Juvenile Osteochondritis Dissecans
A February 2022 paper in the journal Arthroscopy, Sports Medicine, and Rehabilitation (13) assessed the postoperative timeline for the return to activities of daily living in pediatric patients after arthroscopic drilling of a stable osteochondritis dissecans (OCD) lesion of the knee and to determine the rate of and risk factors for complications after the procedure.
- A total of 139 knees in 131 patients were evaluated, with an average age of 12.7 years, of which 102 (73%) were male knees.
- ” . . . findings suggest that arthroscopic drilling for stable, intact OCD lesions in the pediatric knee is a safe procedure with reliable outcomes and return to activities of daily living and minimal risk of complications. Most patients return to their preoperative daily activity level with a full range of motion of the knee 3 months after surgery. Complications, including reoperations, are related to the progression of the OCD lesion rather than to the surgical procedure. Each 1-cm2 increase in lesion size increases the likelihood of reoperation by 2.93 times. “
The cartilage plug and the bone peg
In the journal, International Orthopaedics, (6) surgeons at the University Hospital of Montpellier suggest cartilage plugs for osteochondritis dissecans of the patella on a short-term basis. The plugs are inserted during an autologous osteochondral mosaicplasty. Cartilage is removed from a non-weight bearing part of the knee and used to replace cartilage defects in the patella. The technique has been found reliable in the short term to restore the patellar joint surface and obtain satisfactory functional results.
Doctors in Japan (7) found that bone peg grafting, the removal of bone from a non-weight bearing bone, and drilling them into an osteochondritis bone defect could get adolescent baseball players back on the field in 12 months.
Understanding osteochondritis dissecans treatments in the elbow
In a May 2019 study in the medical journal Cartilage (8) researchers in Germany offered these observations of the problems of treating osteochondritis dissecans in the elbow:
- What causes osteochondritis dissecans in the elbow or open growth plates “remains as unclear as for the knee.”
- Mechanical factors (throwing activities) seem to play an important role.
- Clinical symptoms are unspecific. Imaging techniques are then important for the diagnosis. In low-grade and stable lesions, treatment involves rest and different degrees of immobilization until healing.
- When surgery is necessary, the procedure depends on the OCD stage and on the state of the cartilage.
High-demand upper extremity activities such as baseball or gymnastics
In February 2020 in the journal, Current Reviews in Musculoskeletal Medicine, (9) researchers wrote of the problem of osteochondritis dissecans in the elbow and the surgical fix and possible failure.
“Patients at high risk for the development of this condition are involved in high-demand upper extremity activity such as baseball or gymnastics. Treatment options include non-operative management, drilling, fixation, loose body removal/microfracture, osteochondral autograft, and osteochondral allograft. Cartilage preservation procedures (i.e., osteochondral autograft) have a significant advantage in terms of clinical and radiographic healing compared with fixation or microfracture. Capitellar OCD lesions (the cartilage covering the outside part of the humerus bone at the elbow), afflict a large number of adolescent athletes today and will likely continue to increase in number from sports-related injuries.
It is critical to recognize and treat these lesions in a timely and appropriate fashion to optimize clinical outcomes. When faced with the failure of healing, surgeons must critically analyze reasons for failure including post-operative compliance, return to high-demand sporting activity, fixation of non-viable fragments, utilization of microfracture, alignment, and concomitant pathology.”
In this video, Ross Hauser gives a brief summary of the possible benefits of Prolotherapy as a surgery alternative
Prolotherapy injections for Osteochondritis dissecans
Ross Hauser, MD, has been treating Osteochondritis dissecans for nearly three decades. He published two case studies in the Journal of Prolotherapy (10) concerning young baseball players seen at Caring Medical.
Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments.
- CASE REPORT #1 – OSTEOCHONDRITIS OF THE KNEE IN A 13-YEAR-OLD
An orthopedic surgeon told J.C. to stop all forms of athletics in order to see if his knees would get better. If they did not improve, he would have to undergo surgery.
J.C. was an active 13-year-old baseball player, who presented to Caring Medical for evaluation of his bilateral knee pain, diagnosed as osteochondritis dissecans. He was a very active young athlete, playing on soccer and baseball teams in addition to participating in rollerblading, swimming, and bicycle riding. He was being followed by an orthopedic surgeon who told J.C. to stop all forms of athletics in order to see if his knees would get better. If they did not improve, he would have to undergo surgery.
At the time of the initial consultation, J.C. had restricted athletics and was using ice and ibuprofen for the pain. The pain was located throughout the knees and increased significantly with activity, especially running. On physical examination, he was found to have several tender points about the knee, as well as some generalized laxity. His X-rays confirmed the diagnosis of osteochondritis dissecans. (See Figures 1 & 2.) J.C. and his parents have explained the process of Prolotherapy but decided to hold off treatment.
- CASE REPORT #2 – THE ELBOW – OSTEOCHONDRITIS OF THE CAPITELLUM IN A 13-YEAR-OLD
L.M., a 13-year-old, came to Caring Medical for possible Prolotherapy treatment on his elbow. L.M. was a pitcher on a junior boys baseball team for his middle school. He had a six-month history of elbow pain, especially severe when pitching. An MRI on 2/24/2010 revealed osteochondritis dissecans of the capitellum. (See Figure 3.) At the time of the initial evaluation, the patient was not able to pitch or throw a baseball at all. The patient had seen several orthopedic surgeons, all suggesting he rest for various periods of time, during which time his elbow would feel better, only to have the pain recur with activity. One orthopedist said he would never pitch again. His goal (as well as his father’s goal for him) was to be able to pitch again.
On physical examination, tenderness was elicited both in the medial and lateral elbow, especially at the locations of the ulnar and radial collateral ligaments. Both radiocapitellar and ulnohumeral joint instability were present, but with a full range of motion. No crepitation was noted. Prolotherapy was injected into and around the bony attachments of the ligament, tendon, and muscle origins of both the medial and lateral elbows, with emphasis on the ligamentous support.
L.M. was next seen once a month later where he reported a 50% reduction in pain and stiffness. He was now able to perform all activities of daily living without pain, including weight lifting, running, and swimming. At this point, however, he had still not thrown a baseball. A second Prolotherapy treatment was given to the same areas as the first.
On L.M.’s third and final Prolotherapy visit, he reported no pain in his elbow and was able to throw a baseball for 15 minutes without pain, along with no other restrictions during his other workouts.
L.M. had a repeat MRI which revealed resolution of the osteochondritis dissecans. (See Figure 4.)
Another case study in the soccer player
In the Journal of Prolotherapy, doctors presented the case (11) of a 20-year-old soccer (footballer) patient with pain in his right knee during walking and playing soccer. The problem became progressively worse over time, with the appearance of an effusion of the knee.
Clinical examination found pain in the antero-internal (front-inner side) aspect of the knee, muscle strength was normal, and there was no limitation of joint movement. Initial CT scan and MRI demonstrated an osteochondral lesion of the internal femoral condyle classified as grade III
Osteochondritis dissecans surgical alternatives – two case studies on Platelet Rich Plasma
Research on Platelet Rich Plasma Therapy, an injection treatment that re-introduces your own concentrated blood platelets into areas of chronic joint and spine deterioration, more commonly referred to as PRP is gaining a lot of attention as a non-surgical option.
In the Journal of Prolotherapy (12) Budak Akman, MD, and his colleagues at Yeditepe University Faculty of Medicine, Orthopaedics and Traumatology Department Istanbul – Turkey reported on this case.
A 16-year-old male patient presented to our hospital with a six-month history of pain in his right knee, increasing in severity over time, after having encountered a traumatic fall in a football (soccer) match 6 months prior. He reported increasing pain especially with walking long distances and physical activities, and although rare, accompanied by a sense of stumbling, friction, and limping.
Showing no positive development in symptoms and physical status for six months, our 16-year-old male patient received two intraarticular platelet-rich plasma injections three months apart, focusing on the lesion of osteochondritis dissecans localized in the right knee.
At the end of the 18th month, the patient did not show any limitation in his physical activities and a radiographic examination confirmed the successful treatment.
Having obtained positive results, we believe that PRP injections are a safe, simple, and minimally invasive treatment option for juvenile OCD which doesn’t respond to conservative therapy before a surgical approach.
FIRST PRP SESSION January 21, 2017
One week prior to the first PRP session, the patient received an intra-articular injection of Prolotherapy and ozone.
PRP was injected into the knee under ultrasound guidance, anteriorly into the articular space, and at the contact of the lesion, visible in ultrasound.
Following the procedure, the patient was advised to walk with crutches for 3 months.
MRI and CT scan at the end of the third month showed decreased lesion size compared with the initial size, appearance of revascularization, and formation of bone bridges between the fragment and the femoral condyle.
SECOND PRP SESSION
The same PRP procedure was repeated, with the same intra-articular Prolotherapy injection and ozone performed one week prior.
Six weeks after the PRP procedure, the patient was allowed to walk with a cane or single crutch. Then after two months, without any aid.
After another three months of follow-up, MRI and CT scans showed complete revascularization of the fragment and attachment of 95%.
The patient has completely returned to soccer for 1 month (matches and full training) without pain and without effusion (ultrasound).
One-step bone marrow-derived cells Transplantation (BMDCT) technique
This is a procedure that we do not do at our center. The research is presented to discuss bone marrow aspirate concentrate treatments. We do not use stem cell therapy on every patient. In fact, we use Bone Marrow Aspirate Concentrate sometimes called stem cell therapy in very few of our patients. The reason? We find that our mainstay treatment, simple dextrose Prolotherapy, administered in the ways documented in the research over 70 years, can in many cases, provide equal and sometimes superior results in some patients.
Bone Marrow treatment involves direct bone marrow aspiration (or also concentrated) to get the stem cells to the site of the injury. The bone marrow is typically extracted from the iliac crest of the pelvis and the concentrated and injected into the body part being treated.
A February 2022 paper in the European Journal of Orthopaedic Surgery & Traumatology (14) examined bone marrow aspirate concentrate treatments for osteochondritis dissecans lesions of the knee. The researchers write that “(of the) few treatments that have been proposed: fixation of the fragment, drilling, microfractures, the aim of their study was to analyze bone marrow-derived cells.” This procedure (one-step bone marrow-derived cells Transplantation (BMDCT) technique) is part of an arthroscopic procedure where the knee is cleaned out and then the bone marrow aspirate concentrate is placed or “seeded” on the cartilage. The researchers found that “this technique allows articular surface restoration with viable physiologic osteochondral tissue with a high clinical efficacy and imaging results. The number of cases is still limited, and further studies with larger sample sizes and greater follow-up evaluations are required to confirm our results. Nevertheless, we believe that BMDCT may represent a suitable option to treat OCD lesions in young adults.”
If you have a question about Osteochondritis dissecans, you can get help from our Caring Medical staff.
1 Wood D, Carter KR. Osteochondritis Dissecans. SourceStatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019-.2019 Mar 2.
2 Edmonds EW. Editorial Commentary: Osteochondritis Dissecans of the Knee: The Great Confounder. [Google Scholar]
3 Wang K, Waterman B, Dean R, Redondo M, Cotter E, Manning B, Yanke A, Cole B. The influence of physeal status on rate of reoperation after arthroscopic screw fixation for symptomatic osteochondritis dissecans of the knee. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020 Mar 1;36(3):785-94. [Google Scholar]
4 Andriolo L, Candrian C, Papio T, Cavicchioli A, Perdisa F, Filardo G. Osteochondritis Dissecans of the Knee-Conservative Treatment Strategies: A Systematic Review. Cartilage. 2018 Feb 1:1947603518758435. [Google Scholar]
5 Accadbled F, Vial J, de Gauzy JS. Osteochondritis Dissecans of the Knee. Orthopaedics & Traumatology: Surgery & Research. 2017 Nov 29. [Google Scholar]
6 Chadli L, Cottalorda J, Delpont M, Mazeau P, Thouvenin Y, Louahem D. Autologous osteochondral mosaicplasty in osteochondritis dissecans of the patella in adolescents. Int Orthop. 2017 Jan;41(1):197-202. doi: 10.1007/s00264-016-3198-z. Epub 2016 Apr 27. [Google Scholar]
7 Oshiba H, Itsubo T, Ikegami S, Results of Bone Peg Grafting for Capitellar Osteochondritis Dissecans in Adolescent Baseball Players. Am J Sports Med. 2016 Dec;44(12):3171-3178. Epub 2016 Aug 11. [Google Scholar]
8 Bruns J, Werner M, Habermann CR. Osteochondritis Dissecans of Smaller Joints: The Elbow. Cartilage. 2019 May 21:1947603519847735. [Google Scholar]
9 Chen E, Pandya NK. Failure of Surgery for Osteochondral Injuries of the Elbow in the Pediatric and Adolescent Population. Current Reviews in Musculoskeletal Medicine. 2020 Jan 16:1-8. [Google Scholar]
10 Hauser RA. Journal of Prolotherapy Journal of Prolotherapy. JOP. 2018;10. [Google Scholar]
11 Journal of Prolotherapy. 2017;9:e978-e981.
11 Akman B, Güven M, Bildik C, Şaylı U, Parnianfard A, Rahimli M. MRI Documented Improvement in Patient with Juvenile Osteochondritis Dissecans Treated with Platelet Rich Plasma. Journal of Prolotherapy. 2016;8:e966-70. [Google Scholar]
12 Mekaouche M, Bekairi S, Merabet M, Koriche H. Platelet-Rich Plasma Therapy for Osteochondritis Dissecans. Journal of Prolotherapy. 2017;9:e978-e981.
13 Baghdadi S, Isaacs D, Chan CT, Wells L, Ganley TJ, Lawrence JT. Arthroscopic Drilling for Stable Juvenile Osteochondritis Dissecans of the Knee Is Safe and Patients Reliably Return to Daily Activities by 3 Months. Arthroscopy, Sports Medicine, and Rehabilitation. 2022 Apr 1;4(2):e645-51. [Google Scholar]
14 Baldassarri M, Buda R, Perazzo L, Ghinelli D, Sarino R, Grigolo B, Faldini C. Osteocondritis dissecans lesions of the knee restored by bone marrow aspirate concentrate. Clinical and imaging results in 18 patients. European Journal of Orthopaedic Surgery & Traumatology. 2022 Feb 8:1-1. [Google Scholar]
This page was updated May 2, 2022