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Biomedical subjects

Christian Krettek

Publications and source records attributed to Christian Krettek.

At least 55 records · Page 3Linked to original sources
PubMed2005

Management of polytraumatized patients with associated blunt chest trauma: a comparison of two European countries.

BACKGROUND: Blunt chest trauma represents one of the most common injuries in polytrauma patients. Blunt chest injury complicating polytrauma is associated with significant prolongation of intensive care stay. Further, it has a great impact on the timing of fixation of skeletal injuries, possibly contributing to adverse outcome. The purpose of this study is to assess whether there are any differences in the management and outcome of polytrauma patients with blunt chest trauma between trauma units in two different countries. Detailed information about advantages and disadvantages of these two systems might allow optimising the management of blunt chest trauma. PATIENTS AND METHODS: This investigation was performed using the polytrauma database of the German Trauma Society and the British Trauma Audit Research Network. After the definition of the inclusion abbreviated injury scale (AIS(chest) > or = 3) and injury severity score (ISS > 16) and exclusion (AIS(head/neck) > or = 2, referral from outside institutions) criteria, patients were recruited solely from these databases. RESULTS: 188 patients from the German database and 181 patients from the British database were enrolled in this study. Demographic data and injury pattern of the two patient populations did not significantly differ. The volume of initial red blood cell transfusion and length of the intensive care stay were significantly higher in Germany (p < 0.05). Mortality in the UK was 9% higher than in Germany (p = 0.057). Time to death in non-survivors was also significantly longer in Germany (p < 0.05). CONCLUSIONS: The reasons for the differences regarding survival times and survival rates seem to be multiple. German patients received more red blood cells, had a longer hospital stay in intensive care and a better survival rate. The use of kinetic therapy in Germany, not standard in the UK, may contribute to a more favourable outcome.

Abbreviated Injury Scale↗
PubMed2005

The current status of road user injuries among the elderly in Germany: a medical and technical accident analysis.

BACKGROUND: The incidence and treatment of injuries involving the elderly road user are of increasing importance for all fields of trauma care to ensure the best possible outcomes. METHODS: Traffic accident reports were analyzed through technical and medical investigation for the involvement of elderly citizens. RESULTS: In 12,309 documented traffic accidents between 1985 and 1998, 1,843 elderly citizens (65 years and older) were involved, 1,260 of which were reported to have been injured. The mean Injury Severity Score among the injured elderly citizens was 7.3. Of the injured elderly road users, 39.5% were car occupants, 27.4% were bicyclists, 29.6% were pedestrians, 1.8% were truck occupants, and 1.7% were motorcyclists. Of the elderly road users in cars, 53% were not injured, in contrast to only 1.1% of the bicyclists and 0.8% of the pedestrians. Serious or severe injuries (Maximum Abbreviated Injury Scale, >/=2] occurred for 36.5% of the injured elderly road users as car occupants (unrestrained, 58%; restrained, 34%), 57.4% as bicyclists, and 65.4% as pedestrians CONCLUSION: A high rate of motor injuries is associated with vehicle accidents and increased levels of severity among the elderly population. This finding is especially evident for elder pedestrians and bicyclists. Also of note, the elderly even appear to be at risk for sustaining an increased level of injury severity when they are restrained or belt protected.

Abbreviated Injury Scale↗
PubMed2005

The multiply injured child.

The treatment of multiple traumas in children requires knowledge of common injury patterns, incidence, mortality, and the consequences and differences between these injuries in children and adult patients. However, epidemiological studies concerning pediatric multiple trauma are rare. To address this, data were collected and analyzed from 682 multiple trauma patients treated at a Level I trauma center. The patients were divided into four age-related groups (< 6 years, 6-12 years, 13-18 years, and 18-40 years) and were evaluated for trauma mechanism, injury distribution, and cause of death. Children aged 6 to 17 years mostly were injured as pedestrians and cyclists whereas infants, preschoolers, and adults more commonly were injured as car passengers. Pediatric patients suffered a significantly higher mortality than adults, with a threefold increased risk of death when injured as passengers in car accidents. Injuries to the head and the legs were most common. A lower incidence of thoracic (28% versus. 62%), abdominal (20% versus 36%), pelvic (22% versus 35%), and upper limb (32% versus 43%) trauma was observed in children (< 18 years) than in adults (18-40 years). Nevertheless, trauma to the thorax, abdomen, and head were associated with a high risk of death in all groups. Spinal cord injuries, especially in the cervical region, also carried a high risk of mortality (36.8 in the group of patients younger than 18 years and 18.9 in the group of patients 18-40 years). Children younger than 6 years had the most severe head injuries. The data show that there are important differences in incidence, mortality, and injury patterns between pediatric and adult patients with multiple traumas.

Adolescent↗
PubMed2005

Intraoperative three-dimensional imaging with a motorized mobile C-arm (SIREMOBIL ISO-C-3D) in foot and ankle trauma care: a preliminary report.

OBJECTIVE: The aim of the study was to assess the feasibility and benefit of the intraoperative use of a mobile C-arm with 3-dimensional imaging (ISO-C-3D). DESIGN: Prospective consecutive clinical study. SETTING: University hospital, level I trauma center. METHODS: The ISO-C-3D was used for intraoperative visualization in foot and ankle trauma care. Conventional C-arms were used to judge the reduction and implant position before the ISO-C-3D was used. Time spent, changes resulting from use of the ISO-C-3D, and surgeons' ratings (visual analogue scale, 0-10 points) were recorded. PATIENTS: Between January 1, 2003 and March 15, 2004, the ISO-C-3D was used in 62 cases (factures: pilon, n = 1; Weber-C ankles, n = 7; isolated dorsal Volkmann, n = 1; talus, n = 3; calcaneus, n = 20; navicular, n = 1; cuboid, n = 1; Lisfranc fracture-dislocation, n = 6; hindfoot arthrodesis with or without correction, n = 12). RESULTS: On average, the operation was interrupted for 440 seconds (range 330-700); 120 seconds, on average, for the ISO-C-3D scan and 210 seconds, on average, for evaluation of the images by the surgeon. In 39% of the cases (24 of 62), the reduction and/or implant position was corrected during the same procedure after the ISO-C-3D scan. The ratings of the 8 surgeons who used the ISO-C-3D were 9.2(5.2-10) for feasibility, 9.5 (6.1-10) for accuracy, and 8.2 (4.5-10) for clinical benefit. CONCLUSION: Intraoperative 3-dimensional visualization with the ISO-C-3D can provide useful information in foot and ankle trauma care that cannot be obtained from plain films or conventional C-arms. During the same procedure, after conventional C-arm scans judged the positioning to be correct and an ISO-C-3D scan was done, the reduction and/or implant position was corrected in 39% of the cases in this study, although not unnecessarily prolonging the operation. The ISO-C-3D appears to be most helpful in procedures with a closed reduction and internal fixation, and/or when axial reformations provide information that is not possible to obtain with a conventional C-arm and/or direct visualization during open reduction and internal fixation.

Ankle Injuries↗
PubMed2005

Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making.

Grading of the clinical status in patients with multiple trauma is important regarding the treatment plan. In recent years, 4 different clinical conditions have been described: stable, borderline, unstable, in extremis. Clinical parameters have been widely used in patients with penetrating injuries, and 3 categories were found to be important: shock, hypothermia, coagulopathy. However, in blunt trauma patients, the role of conventional parameters for decision making regarding the timing of fracture treatment is poorly described. After blunt trauma, additional factors seem to play a role, because the injuries affect multiple body regions. These additional factors are summarized under the term, "soft-tissue injuries," which may include the soft tissues of the extremities, lung, abdomen, and pelvis. The study describes four pathophysiologic cascades that are relevant to the clinical conditions listed above. Threshold values for separation of the patient conditions are documented, leading to a staged surgical strategy.

Decision Making↗
PubMed2005

Genetic predisposition for a compromised immune system after multiple trauma.

Severe trauma induces sustained changes of the immune response, which are thought to be related to secondary organ dysfunction. Despite a similar injury severity, the extent of the inflammatory response may vary between polytraumatized patients. It is unclear whether inflammatory variability is associated with genetic variations. In this prospective cohort study, patients were included when the following criteria were fulfilled: Injury Severity Score >16, age 18 to 60 years, and a survival >48 h after injury. Four different polymorphisms (TNF-Nco1, IL-1-Taq1, IL-6-174G/C, and IL-8-251A/T) were determined. Patients were separated according to the severity of the systemic inflammatory response syndrome (SIRS; ACCP/SCCM criteria: >2 criteria at 2 consecutive days or at 3 days of the observation period: group +SIRS; <or=2 criteria: group -SIRS). Ninety-seven severely injured patients were included (-SIRS, 56 patients; +SIRS, 41 patients). A significantly higher incidence of the IL-6-174G allele and the IL-6-174G homozygous genotype in +SIRS patients was observed. The IL-6-174G/C polymorphism was associated with the severity of posttraumatic SIRS. This data points toward a genetic predisposition regarding an enhanced inflammatory response after polytrauma that may be associated with adverse outcome.

Adolescent↗
PubMed2005

Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients.

BACKGROUND: Recently, there has been a move away from early total care in patients with severe, multiple injuries to damage control orthopedics (DCO) in an attempt to limit the physiologic insult resulting from operative treatment after trauma. For femoral shaft fracture, this entails initial external fixation and subsequent conversion to an intramedullary nail (IMN). We sought to quantify the inflammatory response to initial surgery and conversion and link this to subsequent organ dysfunction and complications. METHODS: Patients with femoral shaft fracture and a New Injury Severity Score of 20 or more were included. Data were retrospectively collected for 4 days at admission and at exchange procedure (external fixation to intramedullary nail), and the Systemic Inflammatory Response Syndrome (SIRS) score and the Marshall multiorgan dysfunction score were calculated. RESULTS: One hundred seventy-four patients met the inclusion criteria. The DCO group had significantly more severe injuries (New Injury Severity Score of 25.4 vs. 36.2, p < 0.0001) and significantly more head and thoracic injuries (both p < 0.0001). The mean SIRS score was significantly higher in the IMN group, from 12 hours until 72 hours postoperatively (p < 0.05). The mean peak postoperative SIRS score was significantly higher in the IMN group than in the DCO group, at the primary procedure and at conversion, as was the time with an SIRS score greater than 1. At conversion in the DCO group, the preoperative SIRS score correlated with magnitude and duration of elevation in the SIRS and multiorgan dysfunction scores (p < 0.0001). CONCLUSION: It would appear that despite more severe injuries in the DCO group, patients had a smaller, shorter postoperative SIRS and did not suffer significantly more pronounced organ failure than the IMN group. DCO patients undergoing conversion while their SIRS score was raised suffered the most pronounced subsequent inflammatory response and organ failure. According to these data, DCO treatment was associated with a lesser systemic inflammatory response than early total care for femur fractures. The inflammatory status of the patient may be a useful adjunct in clinical decision making regarding the timing of conversion to an intramedullary device.

Abbreviated Injury Scale↗
PubMed2005

A comparison of plates with and without locking screws in a calcaneal fracture model.

BACKGROUND: We compared different plates in an experimental calcaneal fracture model under biocompatible loading. METHODS: Four plates were tested: a plate without locked screws (Synthes), and three different plates with locked screws (Newdeal, Darco, Synthes). Synthetic calcanei (Sawbone) were osteotomized to create a fracture model, and the plates were fixed onto them. Seven specimens for each plate model were subjected to cyclic loading (preload 20 N, 1,000 cycles with 800 N, 0.75 mm/s), and load to failure (0.75 mm/s). Motion, forces, plastic deformation of the plate, and consequent depression of the posterior joint facet were analyzed. RESULTS: During cyclic loading, all plates with locked screws showed statistically significant lower displacement in the primary loading direction than the plates without locked screws. Mean values (mm) of maximal displacements for each plate during cyclic loading were as follows: Synthes, 3.5; Darco, 4.5; Newdeal, 5.0; Synthes without locked screws, 7.5; (p < 0.001). No statistically significant differences between the plates were found in relation to loads to failure and corresponding displacement. CONCLUSION: This is the first biomechanical study to assess the stability of different plates currently in use in our practice for the fixation of calcaneal fractures. Our results showed that plates with locked screws provided greater stability during cyclic loading than the plate without locked screws.

Biomechanical Phenomena↗
PubMed2005

Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response?

BACKGROUND: Reaming of the femoral canal has been demonstrated to introduce intramedullary contents into the circulation with subsequent pulmonary embolization. The aim of this study was to investigate whether this effect can be minimized by use of a reamer system that provides simultaneous irrigation and aspiration of intramedullary contents. METHODS: A unilateral lung contusion was created and intramedullary femoral nailing was subsequently performed in eighteen female skeletally mature Merino sheep. The animals were divided into three groups, of six animals each, to receive one of three types of treatment: reamed femoral nailing; reaming, irrigation, and aspiration; and unreamed femoral nailing. Blood samples were obtained and a bronchoalveolar lavage was performed at baseline, immediately after creation of the lung contusion, immediately after intramedullary nailing, and at four hours after surgery. Pulmonary permeability, polymorphonuclear leukocyte activity, and systemic hemostatic response were measured. Lung specimens were obtained for histological evaluation. RESULTS: At baseline and immediately after creation of the lung contusion, endothelial permeability was comparable among the three groups. At four hours postoperatively, pulmonary permeability was significantly higher in the group treated with reamed femoral nailing (urea/protein ratio; 256.7) than in the group treated with reaming, irrigation, and aspiration (urea/protein ratio, 91.5) and the group treated with unreamed femoral nailing (urea/protein, 110.64) (p < 0.05). The stimulatory capacity of the polymorphonuclear leukocytes was significantly decreased (p < 0.05) only in the group treated with reamed femoral nailing; the other two groups had no significant decrease postoperatively (p > 0.05). The D-dimer level at four hours postoperatively was significantly higher in the group treated with reamed femoral nailing than it was in the other two groups (p < 0.05). Histological examination showed that the grades of edema and polymorphonuclear leukocyte diapedesis were also highest in the group treated with reamed femoral nailing. CONCLUSIONS: It appears that, in the presence of a unilateral pulmonary injury, the systemic effects of intramedullary reaming of an intact femur can be minimized with use of a modified reamer design that simultaneously irrigates the canal and removes debris. Additional clinical validation of this reaming system is necessary.

Animals↗
PubMed2005

Navigated Iso-C3D-based percutaneous osteoid osteoma resection: a preliminary clinical report.

Minimally invasive osteoid osteoma resection under computer tomography (CT) guidance has yielded good results and has become a viable alternative to open surgical procedures. Limited visualization of the actual drill position under CT guidance can frequently result in inadequate and malpositioned drilling, especially at lesions located in less accessible anatomic regions. With the conventional CT-guided drilling technique, sterility and general operative management poorly correlate with standard operating room conditions, and are at risk of intra- and postoperative complications. The new Iso-C(3D) imaging device provides intraoperative multiplanar reconstructions. Adequate image quality and implementation in navigation systems were described for numerous indications. On the basis of multiplanar reconstructions, minimally invasive navigated techniques under three-dimensional surgical tool control become possible, which is not the case under fluoroscopic or CT-based navigation. We report on our first three cases of navigated Iso-C(3D) osteoid osteoma resection. A minimally invasive resection of the nidus was possible under permanent multiplanar image control. No complications were encountered and all patients reported successful outcomes. Minimally invasive-based navigation offered an effective and reproducible surgical approach. Dependence on CT imaging for proper positioning and complications associated with use away from the operating room environment can be avoided.

Bone Neoplasms↗
PubMed2005

Impact of hypothermia on the immunologic response after trauma and elective surgery.

An Hypothermia is defined as a decrease in core temperature below 35 degrees C. The well-described deleterious effects of accidental hypothermia on outcome in multiple-trauma patients contrast the beneficial effect of controlled hypothermia on organ function during ischemia in elective surgery. Experimental studies have shown that induced hypothermia during hemorrhagic shock might have beneficial effects on outcome. The beneficial effects of induced hypothermia appear to be partly mediated by the prolongation of the "golden hour" with prevention of hypoxic organ dysfunction. However, hypothermia also has been thought to have an impact on the immunologic response after trauma and elective surgery. Induction of hypothermia seems to decrease the release of pro-inflammatory cytokines believed to influence distant organ damage positively, and is mediated by the interaction of polymorphonuclear leucocytes (PMNL) and capillary endothelial cells. Nevertheless, the incidence of posttraumatic infectious complications may be increased after induction of hypothermia due to an overexpression of anti-inflammatory cytokines. Together with this immunosuppressive profile, coagulopathy and bleeding might limit the use of induced hypothermia after multiple trauma and elective surgery. The purpose of this Chapter is to highlight current knowledge regarding the interaction of hypothermia and posttraumatic immune reactivity. A better understanding of these mechanisms would assist the introduction of preventive and therapeutic strategies into clinical practice.

Brain Injuries↗
PubMed2004

Total hip arthroplasty in young patients using the thrust plate prosthesis: clinical and radiological results.

INTRODUCTION: The standard treatment for patients who require total hip replacement is the implantation of an intramedullary diaphyseal anchored hip prosthesis. A bone-sparing thrust plate hip prosthesis (TPP) can be used as an alternative device for young patients. The TPP relies on proximal femoral metaphyseal fixation. The theoretical advantage of leaving diaphyseal bone intact is easier conversion to a stemmed prosthesis. This retrospective study evaluated the medium- and short-term results after total joint replacement using the third generation TPP. MATERIALS AND METHODS: Between 1997 and 2001, 58 TPPs were used for 52 patients. Clinical and demographic data were obtained from the patients' charts and our electronic database. Their average age at time of surgery was 40.9+/-11.4 years. At follow-up, the Harris hip score, residual pain, required pain medication, and the ability to lie on the operated side were documented. Radiographic evaluation included standardized radiographs of the hip joint and the pelvis. RESULTS: Four patients required revision surgery (6.9%). For 51 of the remaining 54 TPPs, a postoperative functional and radiological status was obtained. The average follow-up was 26+/-11.0 months. 88% of the patients experienced some or complete relief of pain. The median Harris hip score at follow-up was 73+/-20.5 points. A postoperative hip dislocation occurred in 5 patients (8.6%). CONCLUSION: Since many patients experienced some or complete relief of pain, the TPP can be recommended as a feasible implant for the treatment of hip disorders requiring total hip arthroplasty in young patients. Revision surgeries are facilitated by the good bone stock remaining in the proximal femur.

Adult↗
PubMed2004

Combination of femoral fracture treatment and corrective osteotomy in a child with osteogenesis imperfecta.

The main feature of osteogenesis imperfecta is an excessive fragility and deformability of the bones owing to reduced mass and bone quality. This leads to angular deformity and frequent fractures. These fractures usually heal rapidly, and conservative treatment is the norm. In displaced and unstable fractures, elastic intramedullary nailing is a treatment option. We report a case of a 3-year-old child with osteogenesis imperfecta type I who suffered an undisplaced femoral shaft fracture in the presence of a preexisting 32 degrees femoral antecurvation. This deformity greatly increases the risk of a refracture due to the pathological induction of stress risers. Therefore, fracture treatment by unreamed elastic intramedullary nailing was combined with simultaneous correction osteotomy, resulting in anatomic alignment and uncomplicated fracture healing. The single-stage surgical stabilization performed allowed rapid mobilization along with a decreased likelihood of refracture.

Bone Nails↗
PubMed2004

Improved comfort in lower limb lengthening with the intramedullary skeletal kinetic distractor. Principles and preliminary clinical experiences.

INTRODUCTION: Limb lengthening by external fixators is associated with many problems such as pain at the pin tracts, muscle transfixation, pin tract infections, reduced joint motion, and prolonged fixation time. The intramedullary skeletal kinetic distractor (ISKD) is a new internal, mechanically activated implant, which distracts by mild rotations of 3 degrees. MATERIAL AND METHODS: In a prospective clinical study, four patients with an mean age of 29 years (18-36 years) underwent intramedullary lengthening via ISKD. The average lengthening of three femora and one tibia was 31 mm (26-40 mm). RESULTS: All patients performed the rotations for the distraction themselves without any significant problems. One patient took mild analgesics during the first days of distraction, whereas three patients did not require any analgesics. The average patient discharge occurred 10 days (8-11 days) postoperatively with no complications during the hospital stay. The planned length of distraction was achieved in all patients with normal alignment and normal joint orientation. Full weight bearing was performed on average after 10 weeks (7-14 weeks). Consolidation was noted 80 days (51-111 days) postoperatively with an average consolidation index of 2.9 days/mm. No complications were observed during the follow-up period of 14 months. The Enneking score was 26.8 points, and according to the classification of Paley all patients had an excellent result. CONCLUSIONS: From these preliminary results we conclude that the comfort of limb lengthening with the ISKD is increased by the elimination of fixator-associated complications and by the simple distraction mechanism, which is well tolerated by the patients. Further advantages of the ISKD are early full weight bearing and excellent limb function.

Adolescent↗
PubMed2004

Screening for arthrofibrosis after anterior cruciate ligament reconstruction: analysis of association with human leukocyte antigen.

PURPOSE: Arthrofibrosis represents a severe complication of trauma and reconstructive joint surgery because of generalized connective tissue proliferation resulting in painful joint stiffness. It often appears stereotypical in terms of its clinical and pathologic features, comprising excess deposition of extracellular matrix proteins such as collagen type I, III, and VI and proliferation of fibroblasts. However, trauma and surgery around joints does not always lead to fibrosis, suggesting a genetic predisposition. For a number of autoimmune diseases, strong associations have been described. The objective of the study was to investigate whether an association of HLA (human leukocyte antigen) with primary arthrofibrosis exists. TYPE OF STUDY: Retrospective cohort study. METHODS: Seventeen patients with primary arthrofibrosis after autologous anterior cruciate ligament (ACL) reconstruction were identified and clinically reviewed. Blood samples were taken, and DNA was isolated by column extraction method. DNA samples were typed for the loci HLA-A, -B, -C, -DRB1, and -DQB1. Results were compared with the frequencies of allelic groups as determined for the caucasoid population. RESULTS: HLA-Cw*07 was significantly less often found in the patient group than in the general population (P =.022). The opposite effect was seen for Cw*08, which was found in 17.6% of the patient group but only in 3.8% of the reference group (P =.045). A significant difference was also seen for DQB1*06, because 23.5% of the patients but 48.6% of the reference group possessed an allelic variant of this group (P =.048). However, according to the relatively small number of patients, a statistical bias cannot be excluded. CONCLUSIONS: A possible link may exist between arthrofibrosis and HLA-Cw*07- and DQB1*06-negative as well as Cw*08-positive individuals. Further investigation is necesessary to confirm or vitiate the possible association. LEVEL OF EVIDENCE: Level IV.

Adult↗
PubMed2004

L-selectin shows time and gender dependency in association with MODS.

BACKGROUND: Recent investigations have demonstrated gender related immunologic alterations after trauma. These complications arise due to polymorphonuclear granulocytes (PMN) interacting with endothelium via L-selectin. Therefore, the purpose of this study was to investigate gender related differences in the expression of L-selectin in relation to posttraumatic multiple organ dysfunction syndrome (MODS). METHODS: Multiply injured patients were prospectively entered in the study. MODS was determined using the Denver score. The concentration of L-selectin on the surface of PMN was determined using flow cytometry during a 14 days' period. RESULTS: 48 patients were included in the study. The kinetics of L-selectin were different comparing male and female patients. Male patients with MODS initially showed a rapid decrease of surface L-selectin from 80 to 20 ng/ml. A return to admission levels was related to MODS. Male patients without MODS displayed elevated L-selectin levels up to 140 ng/ml. Female patients, however, all showed an initial rapid decrease of L-selectin to 20 ng/ml. Women who developed posttraumatic MODS had significantly increased levels up to 110 ng/ml before development of MODS developed. CONCLUSIONS: We feel that a gender related dimorphism in the initial L-selectin expression following trauma exists and is associated with MODS. These findings indicate new therapeutic means for the treatment of MODS. Therapies should be timely and gender dependently coordinated.

Adolescent↗
PubMed2004

Which navigation when?

If a surgeon is considering purchasing a navigation system, several factors have to be evaluated including, the planned applications, the equipment already installed, and the specific knowledge of the surgeon. For use in traumatology, fluoroscopy and more specifically 3-D fluoro-based computer guidance is preferable. These technologies are based on intraoperative acquired arbitrary images in contrast to CT-based techniques, which refer to preoperative acquired images that represent a so called "cannel reality". However, image quality has to be considered as fluoro-picture quality depending on the anatomical area (eg long bones, spine, pelvis) and body mass index. CT-based navigation provides better image quality and accuracy but is not able to visualize reduction processes. Therefore personal experience in courses or by on-site teaching is recommended prior taking the decision.

Fluoroscopy↗