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Biomedical subjects

Joseph P Iannotti

Publications and source records attributed to Joseph P Iannotti.

At least 19 recordsLinked to original sources
PubMed2006

Evaluation and management of valgus impacted four-part proximal humerus fractures.

UNLABELLED: A valgus impacted, four-part humerus fracture is an uncommon but important injury to recognize in patients with orthopaedic trauma. Recognizing this fracture pattern and understanding the pathoanatomy of it are essential to providing appropriate care. The treatment options for valgus impacted, four-part humerus fractures range from nonoperative care to hemiarthroplasty. The peer-reviewed literature provides insight into the important factors to consider in deciding how to treat patients with valgus impacted, four-part humerus fractures. Recently, less invasive surgical techniques have been reported as a way to preserve the blood supply to the articular fracture fragment, which decreases the risk of developing avascular necrosis. Even though these techniques are becoming more popular, they are not indicated for all patients. Surgeons must use an individualized approach for each patient with this fracture. Satisfactory results have been reported for the nonoperative and operative techniques used to treat valgus impacted, four-part humerus fractures. However, less invasive procedures may help to achieve a more favorable clinical outcome. Limiting the surgical approach and achieving stabilization with minimal fixation helps to preserve the viability of the humeral head and to prevent postoperative morbidity related to osseous and soft tissue healing. Hemiarthroplasty becomes a reasonable treatment option in older patients with substantial displacement of the fracture fragments and poor bone quality that would not support internal fixation. LEVEL OF EVIDENCE: Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.

Arthroplasty↗
PubMed2006

The required research rotation in residency: the University of Pennsylvania experience, 1978-1993.

The University of Pennsylvania orthopaedic surgery residency program under the direction of Dr. Carl T. Brighton was uniquely structured to require a year of research as part of a 5-year program. This requirement was instituted to foster critical thinking, and not necessarily to produce academic orthopaedic surgeons. Nonetheless, measures of academic productivity of the 127 residents who trained under Dr. Brighton's leadership may be instructive. The purpose of this study was to assess metrics of academic productivity. In addition, the six current and former chairmen of orthopaedic surgery programs who performed research while residents at the University of Pennsylvania were surveyed for their impressions regarding required research rotations. Fifty-nine percent of the University of Pennsylvania residents took faculty positions after training; 75% published a peer-reviewed paper after residency; and 17% are current members of the American Orthopaedic Association. Overall, the chairmen surveyed found great value in their own resident research experience, but none have replicated the Brighton model of residency organization. Only two of the six programs have a research year: at both, this research rotation is in addition to the standard 5 years of clinical education and only at one are all residents required to participate.

Authorship↗
PubMed2006

Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. Factors affecting outcome.

BACKGROUND: The purpose of this study was to evaluate the clinical results of latissimus dorsi tendon transfer in patients with an irreparable posterosuperior rotator cuff tear to help determine which patient and anatomic factors affect clinical outcome. METHODS: Fourteen patients with a latissimus dorsi tendon transfer were clinically evaluated with use of the PENN (University of Pennsylvania) shoulder score as well as with quantitative measurement of isometric muscle strength and the range of motion of both shoulders at a minimum of twenty-four months postoperatively. The anatomic results were evaluated with postoperative magnetic resonance imaging and electromyography. RESULTS: Nine patients were satisfied with the outcome, had significant clinical improvement, and reported that they would have the operation again under similar circumstances. The other five patients were dissatisfied with the result and had significantly worse PENN scores, active elevation, and objective measures of strength. Eight of the nine patients with a good clinical result were male, and four of the five with a poor result were female. Patients with a good clinical result had had significantly better preoperative function in active forward flexion and active external rotation compared with the patients with a poor result. The magnetic resonance imaging demonstrated healing of the tendon to the greater tuberosity in twelve patients and equivocal healing in two. There was no significant atrophy of any of the transferred muscles. Electromyography demonstrated clear activity in the transferred latissimus muscle during humeral adduction in all fourteen patients, some electrical activity with active forward elevation in only one patient, and some electrical activity with active external rotation in six of the nine patients with a good clinical result. None of the patients with a poor clinical result demonstrated electrical activity of the transferred muscle with active forward flexion or external rotation. CONCLUSIONS: Synchronous in-phase contraction of the transferred latissimus dorsi is a variable finding following the surgical treatment of irreparable posterosuperior rotator cuff tears, but when it is present it is associated with a better clinical result. Preoperative shoulder function and general strength influence the clinical result. Female patients with poor shoulder function and generalized muscle weakness prior to surgery have a greater likelihood of having a poor clinical result.

Adult↗
PubMed2006

Porcine small intestine submucosa augmentation of surgical repair of chronic two-tendon rotator cuff tears. A randomized, controlled trial.

BACKGROUND: Evidence to justify the use of porcine small intestine submucosa to augment repairs of large and massive rotator cuff tears is based on favorable results found in studies of Achilles tendon and infraspinatus tendon repairs in canines. The purpose of this study was to determine the effectiveness of a small intestine submucosal patch to augment the repair of chronic two-tendon rotator cuff tears in humans. METHODS: Thirty shoulders with a chronic two-tendon rotator cuff tear that was completely repairable with open surgery were randomized to be treated with either augmentation with porcine small intestine mucosa or no augmentation. All patients completed a PENN shoulder-score questionnaire preoperatively and at the time of the latest follow-up (at an average of fourteen months). Magnetic resonance imaging showed that nine shoulders had a large tear and twenty-one had a massive tear. All patients underwent a magnetic resonance imaging scan with intra-articular gadolinium one year after the repair to assess the status of the rotator cuff. RESULTS: The rotator cuff healed in four of the fifteen shoulders in the augmentation group compared with nine of the fifteen in the control group (p = 0.11). The median postoperative PENN total score was 83 points in the augmentation group compared with 91 points in the control group (p = 0.07). Healing of the defects in both groups demonstrated a strong correlation with the patients' clinical scores. The median postoperative PENN total score was 96 points in the group with a healed repair and 81 points in the group with a failed repair (p = 0.007). The percentage change between the preoperative and postoperative patient satisfaction scores was 400% in the group with a healed repair, and 50% in the group with a failed repair (p = 0.04). CONCLUSIONS: Augmentation of the surgical repair of large and massive chronic rotator cuff tears with porcine small intestine submucosa did not improve the rate of tendon-healing or the clinical outcome scores. On the basis of these data, we do not recommend using porcine small intestine submucosa to augment repairs of massive chronic rotator cuff tears done with the surgical and postoperative procedures described in this study.

Adult↗
PubMed2006

Commercial extracellular matrix scaffolds for rotator cuff tendon repair. Biomechanical, biochemical, and cellular properties.

BACKGROUND: We are not aware of any in vitro study comparing the biomechanical, biochemical, and cellular properties of commercial extracellular matrix materials marketed for rotator cuff tendon repair. In this study, the properties of GraftJacket, TissueMend, Restore, and CuffPatch were quantified and compared with each other. The elastic moduli were also compared with that of normal canine infraspinatus tendon. METHODS: Samples were tested from different manufacturing lots of four materials: GraftJacket (ten lots), TissueMend (six), Restore (ten), and CuffPatch (six). The Kruskal-Wallis test was used to compare thickness, stiffness, and modulus as well as hydroxyproline, chondroitin/dermatan sulfate glycosaminoglycan, hyaluronan, and DNA contents among these matrices. The moduli of the extracellular matrices were also compared with those of normal canine infraspinatus tendon. RESULTS: All four extracellular matrices required 10% to 30% stretch before they began to carry substantial load. Their maximum moduli were realized in their linear region at 30% to 80% strain. The elastic moduli of all four commercial matrices were an order of magnitude lower than that of canine infraspinatus tendon. TissueMend had significantly higher DNA content than the other three matrices (p<0.0001), although both Restore and GraftJacket also had measurable amounts of DNA. CONCLUSIONS: Our data demonstrate chemical and mechanical differences among the four commercial extracellular matrices that we evaluated. Probably, the source (dermis or small intestine submucosa), species (human, porcine, or bovine), age of the donor (fetal or adult), and processing of these matrices all contribute to the unique biophysical properties of the delivered product. The biochemical composition of commercial extracellular matrices is similar to that of tendon. However, the elastic moduli of these materials are an order of magnitude lower than that of tendon, suggesting a limited mechanical role in augmentation of tendon repair.

Animals↗
PubMed2006

The Penn shoulder score: reliability and validity.

STUDY DESIGN: Psychometric evaluation of a cross-sectional survey. OBJECTIVES: The purpose of this study was to examine the psychometric properties of reliability and validity of the Penn Shoulder Score (PSS). BACKGROUND: Shoulder outcome measures are used to assess patient self-report levels of pain, satisfaction, and function. The PSS is a 100-point shoulder-specific self-report questionnaire consisting of 3 subscales of pain, satisfaction, and function. This scale has been utilized in the literature. However, the measurement properties of reliability and validity, including responsiveness, of the PSS subscales and overall scale need to be established. METHODS AND MEASURES: Patients (n = 40) with shoulder disorders undergoing a course of outpatient physical therapy completed the PSS at initial visit and again within 72 hours to assess test-retest reliability. The Constant Shoulder Score (CSS) and the American Shoulder and Elbow Surgeons Shoulder Score (ASES) were also completed at the initial visit and compared to the PSS to assess convergent construct validity. A separate cohort of patients (n = 109) completed the PSS at initial visit and 4 weeks later. These scores were used to assess internal consistency and responsiveness. RESULTS: Reliability analysis revealed a test-retest ICC2,1 of 0.94 (95% CI, 0.89-0.97). Internal consistency analysis revealed a Cronbach alpha of 0.93. The standard error of measurement (SEM) was +/- 8.5 scale points (based on a 90% CI) and the minimal detectable change (MDC) was +/- 12.1 scale points (based on a 90% CI). The minimal clinically important difference (MCID) for improvement was 11.4 points. Pearson product moment correlation coefficients between the PSS and the CSS and ASES were 0.85 and 0.87, respectively. Responsiveness analysis revealed an effect size of 1.01 and a standardized response mean of 1.27. CONCLUSIONS: This study has demonstrated that the PSS is a reliable and valid measure for reporting outcome of patients with various shoulder disorders.

Adult↗
PubMed2006

Arthrodesis of the shoulder.

Shoulder arthrodesis is an end-stage salvage option for the failing, painful joint that cannot undergo or has failed reconstruction. It is indicated for irreversible and nonreconstructible massive rotator cuff tears and deltoid muscle denervation as well as for detachment of the deltoid from its origin. Rarely, arthrodesis is done to stabilize the glenohumeral joint after many failed attempts at shoulder reconstruction. Arthrodesis for failed prosthetic arthroplasty or tumor resection presents additional challenges because of the associated bone loss on the humeral and/or glenoid side of the joint. Primary arthrodesis requires rigid internal plate fixation and both an extra- and an intra-articular site of fusion. Depending on bone volume and quality needed, the patient may require bracing for 8 to 10 weeks, autogenous or allograft bone grafting, or a vascularized fibular bone graft to reconstruct the bone deficiency, along with prolonged spica cast immobilization. The optimal position for arthrodesis is 20 degrees of forward flexion, 20 degrees of abduction, and 40 degrees of internal rotation, with modifications based on patient body size or other patient-specific factors. Bone fusion is attained in nearly all patients, with marked pain reduction and improved function. Postoperatively, the patient should be able to lift the arm to near shoulder height and to reach the top of the head, the mouth, the ipsilateral back pocket, and the groin. Complications include nonunion, malposition, pain associated with prominent hardware, and periarticular fractures.

Arthrodesis↗
PubMed2006

Extracorporeal shock wave therapy in the treatment of chronic tendinopathies.

Many clinical trials have evaluated the use of extracorporeal shock wave therapy for treating patients with chronic tendinosis of the supraspinatus, lateral epicondylitis, and plantar fasciitis. Although extracorporeal shock wave therapy has been reported to be effective in some trials, in others it was no more effective than placebo. The multiple variables associated with this therapy, such as the amount of energy delivered, the method of focusing the shock waves, frequency and timing of delivery, and whether or not anesthetics are used, makes comparing clinical trials difficult. Calcific tendinosis of the supraspinatus and plantar fasciitis have been successfully managed with extracorporeal shock wave therapy when nonsurgical management has failed. Results have been mixed in the management of lateral epicondylitis, however, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. Extracorporeal shock wave therapy has consistently been more effective with patient feedback, which enables directing the shock waves to the most painful area (clinical focusing), rather than with anatomic or image-guided focusing, which are used to direct the shock wave to an anatomic landmark or structure.

Biofeedback, Psychology↗
PubMed2005

Treatment of glenohumeral subluxation using electrothermal capsulorrhaphy.

PURPOSE: The purpose of this study was to review the results of a relatively homogenous group of patients with glenohumeral subluxation without labral pathology who were treated with an electrothermal capsulorrhaphy procedure. TYPE OF STUDY: Case series without controls. METHODS: From 1997 to 1998, 42 patients underwent electrothermal capsulorrhaphy using a monopolar radiofrequency probe (Oratec Interventions, Menlo Park, CA). Patients with prior capsular repairs, labral pathology that required repair, or capsular avulsion injuries were excluded from the study. Thirty-one patients met the inclusion criteria. Patients had a minimum of 2 years of follow-up (mean, 25 months), and a mean age of 25 years (range, 16 to 38 years). All of the patients had previously failed conservative treatment. There were 25 patients with unidirectional anterior instability, 2 patients with unidirectional inferior instability, 1 patient with unidirectional posterior instability, and 3 patients with multidirectional instability. The patients were assessed using a modified American Shoulder and Elbow Surgeons (ASES) score that examined pain (30 points), function (60 points), and patient satisfaction (10 points). In addition, subjective stability was assessed using a 10-point scale. RESULTS: The average modified ASES score increased to 88 points from 56 preoperatively (P < .01). The average subjective stability scale increased to 8.5 from 4.4 preoperatively (P < .01). Nineteen patients (61%) had an excellent result, 4 (13%) had a good result, 5 (16%) had a fair result, and 3 (10%) had a poor result; 22 of 26 patients who participated in sports were able to return to their preinjury level of play. The subset of patients with isolated anterior instability had results similar to the overall group. There were no instances of axillary neuritis or other neurologic injury. CONCLUSIONS: In carefully selected patients with shoulder instability, including unidirectional anterior instability without associated labral pathology, electrothermal capsulorrhaphy was effective and had few complications. LEVEL OF EVIDENCE: Level IV, case series without controls.

Adolescent↗
PubMed2005

Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcome.

PURPOSE: To compare the outcome of patients who underwent rotator cuff repair using all arthroscopic or mini-open repair techniques. TYPE OF STUDY: Retrospective comparative study. METHODS: We retrospectively reviewed 54 patients who underwent either mini-open or arthroscopic rotator cuff repair. Twenty-six patients underwent mini-open repair and 28 patients had arthroscopic repair. Follow-up averaged 33 months (range, 18 to 48 months) for the mini-open group and 19 months (range, 13 to 26 months) for the arthroscopic group. The patient groups were similar with regard to age, activity level, mechanisms of injury, associated findings at surgery, and tear size measured in square centimeters. The outcome for the 2 groups was evaluated using a modified American Shoulder and Elbow Society (ASES) score. Statistical analysis was performed using Pearson correlations and the Student t test. RESULTS: The tear size averaged 2.7 cm2 for the mini-open group and 2.0 cm2 for the arthroscopic group (P = .754). All patients showed significant improvement in their scores for pain, satisfaction, and function at the time of follow-up. The average preoperative and postoperative scores for the mini-open group were as follows: pain 17 and 27 (30 possible points), satisfaction 3 and 9 (10 possible points), function 32 and 53 (60 possible points), and total 52 and 89 (100 possible points) (P < .05). For patients who underwent arthroscopic repair, average preoperative and postoperative scores were as follows: pain 12 and 26, satisfaction 2 and 9, function 28 and 51, and total, 42 and 86 (P < .05). Improvement in scores within each group was significant, but the difference in total scores between the 2 techniques was not statistically significant. CONCLUSIONS: This study confirms that short-term results for arthroscopic and mini-open rotator cuff repair are similar and supports continued use of arthroscopic repair techniques. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Adult↗
PubMed2005

The effect of humeral component anteversion on shoulder stability with glenoid component retroversion.

BACKGROUND: Posterior glenoid bone loss is often seen in association with glenohumeral osteoarthritis. This posterior asymmetric wear can lead to retroversion of the glenoid component and posterior instability after total shoulder arthroplasty. Options for the treatment of this asymmetric wear include eccentric reaming of the so-called high side, bone-grafting, and/or anteverting the humeral component. Although anteverting the humeral component has been advocated by many, it has not been substantiated on the basis of biomechanical data. The purpose of the present study was to determine whether anteverting the humeral component increases the stability of a total shoulder replacement with a retroverted glenoid component. METHODS: A total shoulder arthroplasty was performed in eight human cadaveric shoulders. The glenoid component was placed in 15 degrees of retroversion. Two humeral versions were tested for each specimen: anatomic version and 15 degrees of anteversion relative to anatomic version. The specimens were mounted supine in a custom fixture on a servohydraulic testing system. The humerus was translated posteriorly by one-half of the width of the glenoid. Three positions of humeral rotation were tested for each position of humeral version. Both the energy and the peak load were analyzed as measures of joint stability. RESULTS: There was no significant difference in either energy or peak load between the tests performed with the humeral component in 15 degrees of anteversion and those performed with the component in anatomic version in any of the three rotational positions (p > 0.05). CONCLUSIONS: Although anteverting the humeral component during total shoulder arthroplasty to compensate for glenoid retroversion has been advocated, these data suggest that compensatory anteversion of the humeral component does not increase the stability of a shoulder replacement with a retroverted glenoid component.

Aged↗
PubMed2005

Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears.

BACKGROUND: This prospective multi-institutional study was designed to define the accuracy of ultrasonography, when performed in an orthopaedic surgeon's office, for the diagnosis of rotator cuff tears. METHODS: An anatomic diagnosis and a treatment plan were made on the basis of office-based shoulder ultrasonography, physical examination, and radiographs for ninety-eight patients (ninety-nine shoulders) with a clinical diagnosis of a rotator-cuff-related problem. The results of the ultrasonographic studies were then compared with the results of magnetic resonance imaging and the operative findings. RESULTS: Office-based ultrasonography led to the correct diagnosis for thirty-seven (88%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness tears, twenty-six (70%) of thirty-seven shoulders with a partial-thickness rotator cuff tear only, and sixteen (80%) of twenty shoulders with normal tendons. In no case was the surgical approach (open or arthroscopic) that had been planned on the basis of the ultrasonography altered by the operative findings, but the operative finding of a full-thickness tear resulted in an arthroscopic cuff repair in four shoulders. Magnetic resonance imaging led to the correct diagnosis for forty (95%) of forty-two shoulders with a full-thickness rotator cuff tear or both full and partial-thickness rotator cuff tears, twenty-seven (73%) of thirty-seven shoulders with only a partial-thickness tear, and fifteen (75%) of twenty shoulders with normal tendons. There were no significant differences between magnetic resonance imaging and ultrasonography with regard to the correct identification of a full-thickness tear or its size. The sensitivity of ultrasonography for detecting tear size in the anterior-posterior dimension was 86% (95% confidence interval, 71% to 95%), and that of magnetic resonance imaging was 93% (95% confidence interval, 81% to 99%) (p = 0.26). The sensitivity of ultrasonography for detecting tear size in the medial-lateral dimension was 83% (95% confidence interval, 69% to 93%), and that of magnetic resonance imaging was 88% (95% confidence interval, 74% to 96%) (p = 0.41). CONCLUSIONS: A well-trained office staff and an experienced orthopaedic surgeon can effectively utilize ultrasonography, in conjunction with clinical examination and a review of shoulder radiographs, to accurately diagnose the extent of rotator cuff tears in patients suspected of having such tears. Errors in diagnosis made on the basis of ultrasonography most often consist of an inability to distinguish between partial and full-thickness tears that are approximately 1 cm in size. In this study, such errors did not significantly affect the planned surgical approach.

Arthroscopy↗
PubMed2005

Changes in rotator cuff muscle volume, fat content, and passive mechanics after chronic detachment in a canine model.

BACKGROUND: Long-standing tears of the rotator cuff can lead to substantial and perhaps irreversible changes in the affected rotator cuff muscles. We developed a chronic rotator cuff tear in a canine model to investigate and quantify the time-related changes in passive mechanics, volume, and fat of the infraspinatus muscle. We hypothesized that infraspinatus muscle stiffness would increase, volume would decrease, and fat content would increase at twelve weeks following tendon detachment. METHODS: The right infraspinatus tendon of eight adult mongrel dogs were surgically detached from the proximal part of the humerus. The uninvolved left shoulder served as a control. Muscle volume changes were quantified with use of magnetic resonance imaging. At twelve weeks, the passive mechanical properties of the chronically detached and control muscles were determined intraoperatively with use of a custom-designed device. Intramuscular fat was evaluated histologically at the time that the animals were killed. RESULTS: After twelve weeks of detachment, the stiffness was significantly increased in the detached infraspinatus muscles relative to that in the controls (p < 0.0001). Magnetic resonance image analysis demonstrated that the detached muscle volumes decreased by an average of 32% in the first six weeks and remained constant thereafter. Intramuscular fat increased significantly in the detached muscles and to a greater extent in the lateral regions (p < 0.05). CONCLUSIONS: The chronically detached muscle is not merely a smaller version of the original muscle but, rather, a different muscle. The detached muscle becomes stiffer, and the passive loads required to repair it can become excessive. A significant reduction in muscle volume occurs within days to weeks following tendon detachment (p < 0.0001). The nonuniformity of changes in muscle fat suggests that fat content should be used cautiously as an indicator of muscle quality.

Adipose Tissue↗
PubMed2005

Management of persistent shoulder pain: a treatment algorithm.

Treatment of patients with complex multifactorial diseases can be clarified by the development of clear, evidence-based treatment guidelines or algorithms. This article presents a detailed algorithm for the management of patients who present with persistent shoulder pain secondary to rotator cuff disorder, adhesive capsulitis, or glenohumeral osteoarthritis. The algorithm includes both nonpharmacologic and pharmacologic interventions and provides a stepwise approach for managing patients' care. While "treatment pathways" are set forth for these specific disorders, the algorithm also provides a common nonoperative protocol for general shoulder conditions that should help simplify patient management and guide clinicians to alternative therapies.

Algorithms↗
PubMed2004

Outcome of open reduction and internal fixation of surgical neck nonunions of the humerus.

OBJECTIVE: The purpose of this study was to evaluate the results of open reduction and internal fixation of nonunions of the surgical neck of the humerus. DESIGN: Retrospective review of patients who underwent operative treatment of a surgical neck of the humerus nonunion. SETTING: Shoulder and elbow service at two university centers. PATIENTS: Thirteen patients with a two-part nonunion of the surgical neck of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 12 months' follow-up were included. Patients with avascular necrosis, posttraumatic arthritis, severe humeral head bone loss, or a nonunion of one of the two tuberosities were excluded. INTERVENTION: Open reduction and internal fixation with either a blade plate or a T-plate and autogenous bone graft. MAIN OUTCOME MEASURES: Medical records, operative reports, physical examination, and preoperative and postoperative radiographs were reviewed. Outcome was assessed using Neer's criteria for the evaluation of total shoulder arthroplasty, visual analogue pain scale, range of motion, and ability to perform activities of daily living.RESULTS The results were excellent in 11 patients, satisfactory in 1 patient, and poor in 1 patient. The 11 nonunions in patients with excellent results healed within 6 months. The patient with the poor result initially had a persistent nonunion and required revision, open reduction and internal fixation, and bone grafting. This patient healed and went on to have an excellent result at final follow-up. All fractures were healed at the time of this study. Pain scores decreased from an average of 4.2 preoperatively to 1.2 postoperatively on a 5-point pain scale. Forward elevation in the scapular plane improved from 24 degrees preoperatively to 144 degrees postoperatively. All patients but one were able to attain overhead elevation. All patients were able to perform activities of daily living, such as dressing, bathing, combing hair, and performing perineal care, at final follow-up. Overall satisfaction increased from an average of 1.0 to 9.4 on a 10-point visual analogue scale. CONCLUSIONS: Open reduction and internal fixation with autogenous bone graft results in excellent outcomes even in patients >65 years old and patients with significant medical problems. This treatment method offers predictable fracture healing and has a low complication rate.

Activities of Daily Living↗