Orthopedic Hardware Research Articles

Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. Key words: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

Biomechanical and histologic assessment of a novel screw retention technology in an ovine lumbar fusion model

BACKGROUND CONTEXTScrew loosening is a prevalent failure mode in orthopedic hardware, particularly in osteoporotic bone or revision procedures where the screw-bone engagement is limited. PURPOSEThe objective of this study was to evaluate the efficacy of a novel screw retention technology (SRT) in an ovine lumbar fusion model. STUDY DESIGN/SETTINGThis was a biomechanical, radiographic, and histologic study utilizing an ovine lumbar spine model. METHODS: In total, 54 (n=54) sheep lumbar spines (L2–L3) underwent posterior lumbar fusion (PLF) via pedicle screw fixation, connecting rod, and bone graft. Following three experimental variants were investigated: positive control (ideal clinical scenario), negative control (simulation of compromised screw holes), and SRT treatments. Biomechanical and histologic analyses of the functional spinal unit (FSU) were determined as a function of healing time (0, 3, and 12 months postoperative). RESULTSScrew pull-out, screw break-out, and FSU stability of the SRT treatments were generally equivalent to the positive control group and considerably better than the negative control group. Histomorphology of the SRT treatment screw region of interest (ROI) observed an increase in bone percentage and decrease in void space during healing, consistent with ingrowth at the implant interface. The PLF ROI observed similar bone percentage throughout healing between the SRT treatment and positive control. Less bone formation was observed for the negative control. CONCLUSIONSThe results of this study demonstrate that the SRT improved screw retention and afforded effective FSU stabilization to achieve solid fusion in an otherwise compromised fixation scenario in a large animal model.

Optimization of Monoenergetic Extrapolations in Dual-Energy CT for Metal Artifact Reduction in Different Body Regions and Orthopedic Implants

To define an optimal monoenergetic extrapolation (ME) in dual-energy computed tomography (DECT) for metal artifact reduction (MAR) including different body regions and orthopedic implants. DECT scans were acquired with dual-source CT (SOMATOM Force, Siemens, Germany) at tube voltage A 80-100 kV/B Sn150 kV from 39 patients (mean 54.1 ± 20.7 years, 23 male vs. 16 female) with orthopedic implants ranging from wires to joint implants. Scans were assembled in four groups based on scan regions and volume. Single- and weighted-energy images at a ratio of 0.3 and MEs at 100, 130, 160, and 190 keV were produced using vendor-specific postprocessing software (Syngo.Via, Siemens, Germany). Artifact degree was assessed quantitatively by metal-induced Hounsfield unit changes in relation to reference tissues. Visibility of screw-bone interface, hardware integrity, adjacent bone, and soft tissues were visually rated on a four-point Likert scale (0, none; 3, strong artifacts with nondiagnostic quality). Optimal energy was visually determined by side-by-side comparisons. Artifact degree was statistically compared between regions and energies. Metal-induced attenuation changes were most severe in large scan volume groups for all energies. Reference tissue attenuation outside metal artifacts was not affected by ME (p = 0.57). Independent of region, ME at 130-190 keV quantitatively performed significantly better for MAR than the remainder. ME 130 keV showed the highest frequency (54%) in optimal energy ratings based on qualitative image criteria. DECT significantly reduces image artifacts in patients with orthopedic hardware and prospective choice of ME at 130 keV may suit best for optimal MAR, independent of region or implant.

Point vs. traditional method evaluation of hallux valgus: interreader reliability and intermethod performance using X-ray and MRI.

The two most widely used measurements for diagnosing and assessing the severity of hallux valgus are the hallux valgus angle (HVA) and the intermetatarsal angle (IMA). Traditionally, these have been measured by using the midaxial lines approximating the axis of each bone. A new simpler point method has been recently suggested for measuring these angles by connecting points along the medial corners of each bone. Interreader reliability of these measurements on X-ray and MRI as well as intermethod and intermodality differences have not been assessed. A series of 56 consecutive patients between 18 and 100years old with no history of foot trauma or orthopedic hardware in their feet were included. All had AP and lateral X-rays and MRI performed on the same foot between April 27, 2015 and March 9, 2016. Two readers measured HVA and IMA using both the traditional midaxial and new point methods. ICC correlations were obtained. The interreader reliability for HVA was similar on point method (0.92) and traditional method (0.94). For the IMA, the ICC was 0.77 on point method versus 0.76 on traditional method. The intermodality agreement (between X-ray and MRI) was higher for HVA (ICC = 0.85, 0.88) as compared to IMA (0.58, 0.74), respectively on both methods. The mean difference between the methods was larger on traditional method = 5.5 for HVA and 2.5° for IMA. HVA is more reliable than IMA on both methods and modalities and a significant difference exists between the magnitudes of values obtained using the two methods. 3.

Evaluation of postoperative MRI in pediatric patients after orthopaedic hardware implantation

Background: MRI is a valuable diagnostic tool in musculoskeletal imaging. However, concerns exist regarding MRI examinations in the presence of metallic implants, including loosening, heating, and migration of the implant, and magnetic field interactions. Few studies have discussed the safety of MRI in the presence of orthopaedic implants, particularly in the immediate postoperative period. This study aimed to evaluate the safety of MRI within 24 hr after orthopaedic hardware implantation and whether MRI may compromise the integrity of fixation. Methods: A retrospective chart review was performed at a single tertiary care pediatric hospital to identify patients who underwent postoperative MRI after hardware implantation (open reduction and femoral osteotomy) for the treatment of developmental dysplasia of the hip during the 6-year study period. Patient records and follow-up imaging were reviewed to assess time between implantation and postoperative MRI, magnetic field strength, implant type, and patient outcomes. Results: Twenty-eight patients (ages 6 mo to 5 yr) were included in this study, accounting for 32 postoperative MRIs. All MRIs were performed within 8 hr postoperatively (average time to MRI 131 min). Implants consisted of four-hole stainless steel plates and four screws in all patients. No complications were observed regarding implant migration, loosening, nonunion, compromised fixation, or thermal effects to soft tissues. Conclusions: To our knowledge, this is the largest cohort studied for the safety of postoperative MRIs, and the only exclusively pediatric study. Based on these findings, we conclude that orthopaedic implants can safely be imaged in the immediate postoperative period.

Value of PCR in sonication fluid for the diagnosis of orthopedic hardware-associated infections: Has the molecular era arrived?

IntroductionBone healing disturbance following fracture fixation represents a continuing challenge. We evaluated a novel fully automated polymerase chain reaction (PCR) assay using sonication fluid from retrieved orthopedic hardware to diagnose infection. Patients and methodsIn this prospective diagnostic cohort study, explanted orthopedic hardware materials from consecutive patients were investigated by sonication and the resulting sonication fluid was analyzed by culture (standard procedure) and multiplex PCR (investigational procedure). Hardware-associated infection was defined as visible purulence, presence of a sinus tract, implant on view, inflammation in peri-implant tissue or positive culture. McNemar’s chi-squared test was used to compare the performance of diagnostic tests. For the clinical performance all pathogens were considered, whereas for analytical performance only microorganisms were considered for which primers are included in the PCR assay. ResultsAmong 51 patients, hardware-associated infection was diagnosed in 38 cases (75%) and non-infectious causes in 13 patients (25%). The sensitivity for diagnosing infection was 66% for peri-implant tissue culture, 84% for sonication fluid culture, 71% (clinical performance) and 77% (analytical performance) for sonication fluid PCR, the specificity of all tests was >90%. The analytical sensitivity of PCR was higher for gram-negative bacilli (100%), coagulase-negative staphylococci (89%) and Staphylococcus aureus (75%) than for Cutibacterium (formerly Propionibacterium) acnes (57%), enterococci (50%) and Candida spp. (25%). ConclusionThe performance of sonication fluid PCR for diagnosis of orthopedic hardware-associated infection was comparable to culture tests. The additional advantage of PCR was short processing time (<5 h) and fully automated procedure. With further improvement of the performance, PCR has the potential to complement conventional cultures.

Antibiotic Prophylaxis for Removal of Lower-Extremity Orthopedic Hardware?

Removal of lower-extremity orthopedic implants is considered a “clean” surgical procedure (i.e., without skin contamination or local infection) for

Imaging of postoperative spinal infections

The spectrum of postoperative spinal infections includes superficial and deep infections, wound infections, spondylodiscitis, intraspinal epidural abscess, infective arachnoiditis, the extraspinal pre- and paravertebral extension of intraspinal abscesses, and necrotic collections. Imaging modalities for detection of these pathologies include plain radiographs, multidetector computed tomography, magnetic resonance imaging (MRI), and radionucleotide scintigraphy. MRI allows adequate visualization of both the bony structures and soft tissues. Contrast enhanced MRI with gadolinium is the imaging modality of choice to delineate postprocedural and postoperative spine infections and complications. MRI has high sensitivity and specificity in the diagnosis of postoperative spondylodiscitis, epidural abscesses, and infective arachnoiditis. Metallic orthopedic hardware may produce artifacts that degrade image quality which is resolved by a metal artifacts reduction sequence to optimize the image quality in bone and soft tissues. F-18 fluorodeoxyglucose positron-emitted tomography is superior to MRI not only in patients with surgical history and high grade infection but also in the patient with low grade spondylodiscitis.

Advanced MR Imaging after Total Hip Arthroplasty: The Clinical Impact.

Recent metal artifact reduction techniques in magnetic resonance imaging (MRI) have sparked a new aera in visualization of the peri-implant region and assessment of failing orthopaedic hardware. Modes of failure after total hip arthroplasty can be classified into four broad categories: osseous abnormalities, implant instability and dislocation, implant-associated synovitis, and soft tissue abnormalities. Although MRI is complementary to plain radiography and computed tomography to diagnose the first two categories, it is paramount to investigate the complications related to the synovium and soft tissues. We review the most common modes of failure of hip implants and the MRI characteristics of various causes of pain and dysfunction after hip arthroplasty including osseous stress reaction and fracture, implant loosening, implant instability, polyethylene wear–induced synovitis, adverse reaction to metal debris, infection, hematoma, recurrent hemarthrosis, heterotopic ossification, muscle, tendon, and nerve abnormalities, and periprosthetic neoplasms.

Increased risk for complications following removal of hardware in patients with liver disease, pilon or pelvic fractures: A regression analysis

PurposeIndications for removing orthopedic hardware on an elective basis varies widely. Although viewed as a relatively benign procedure, there is a lack of data regarding overall complication rates after fracture fixation. The purpose of this study is to determine the overall short-term complication rate for elective removal of orthopedic hardware after fracture fixation and to identify associated risk factors. Materials and methodsAdult patients indicated for elective hardware removal after fracture fixation between July 2012 and July 2016 were screened for inclusion. Inclusion criteria included patients with hardware related pain and/or impaired cosmesis with complete medical and radiographic records and at least 3-month follow-up. Exclusion criteria were those patients indicated for hardware removal for a diagnosis of malunion, non-union, and/or infection. Data collected included patient age, gender, anatomic location of hardware removed, body mass index, ASA score, and comorbidities. Overall complications, as well as complications requiring revision surgery were recorded. Statistical analysis was performed with SPSS 20.0, and included univariate and multivariate regression analysis. Results391 patients (418 procedures) were included for analysis. Overall complication rates were 8.4%, with a 3.6% revision surgery rate. Univariate regression analysis revealed that patients who had liver disease were at significant risk for complication (p=0.001) and revision surgery (p=0.036). Multivariate regression analysis showed that: 1) patients who had liver disease were at significant risk of overall complication (p=0.001) and revision surgery (p=0.039); 2) Removal of hardware following fixation for a pilon had significantly increased risk for complication (p=0.012), but not revision surgery (p=0.43); and 3) Removal of hardware for pelvic fixation had a significantly increased risk for revision surgery (p=0.017). ConclusionsRemoval of hardware following fracture fixation is not a risk-free procedure. Patients with liver disease are at increased risk for complications, including increased risk for needing revision surgery following hardware removal. Patients having hardware removed following fixation for pilon fractures also are at increased risk for complication, although they may not require a return trip to the operating room. Finally, removal of pelvic hardware is associated with a higher return to the operating room.

Reduction of artifacts caused by orthopedic hardware in the spine in spectral detector CT examinations using virtual monoenergetic image reconstructions and metal-artifact-reduction algorithms.

Aim of this study was to assess the artifact reduction in patients with orthopedic hardware in the spine as provided by (1) metal-artifact-reduction algorithms (O-MAR) and (2) virtual monoenergetic images (MonoE) as provided by spectral detector CT (SDCT) compared to conventional iterative reconstruction (CI). In all, 28 consecutive patients with orthopedic hardware in the spine who underwent SDCT-examinations were included. CI, O-MAR and MonoE (40-200keV) images were reconstructed. Attenuation (HU) and noise (SD) were measured in order to calculate signal-to-noise ratio (SNR) of paravertebral muscle and spinal canal. Subjective image quality was assessed by two radiologists in terms of image quality and extent of artifact reduction. O-MAR and high-keV MonoE showed significant decrease of hypodense artifacts in terms of higher attenuation as compared to CI (CI vs O-MAR, 200keV MonoE: -396.5HU vs. -115.2HU, -48.1HU; both p≤0.001). Further, artifacts as depicted by noise were reduced in O-MAR and high-keV MonoE as compared to CI in (1) paravertebral muscle and (2) spinal canal-CI vs. O-MAR/200keV: (1) 34.7±19.0 HU vs. 26.4±14.4 HU, p≤0.05/27.4±16.1, n.s.; (2) 103.4±61.3 HU vs. 72.6±62.6 HU/60.9±40.1 HU, both p≤0.001. Subjectively both O-MAR and high-keV images yielded an artifact reduction in up to 24/28 patients. Both, O-MAR and high-keV MonoE reconstructions as provided by SDCT lead to objective and subjective artifact reduction, thus the combination of O-MAR and MonoE seems promising for further reduction.

CT and MRI Techniques for Imaging Around Orthopedic Hardware.

· Tissues around orthopaedic hardware can still be well visualised despite metal artifacts.. · Artefact reduction in CT: acquisition parameters, iterative reconstruction, Dual-energy CT and VMI.. · Artefact reduction in MRI: choice of device, sequences, acquisition parameters and MARS. · Do TD, Sutter R, Skornitzke S et al. CT and MRI Techniques for Imaging Around Orthopedic Hardware. Fortschr Röntgenstr 2018; 190: 31 - 41.

Postoperative imaging of orthopaedic hardware in the hand and wrist: is there an added value for tomosynthesis?

To prospectively investigate digital tomosynthesis (DTS) as an alternative to digital radiography (DR) for postoperative imaging of orthopaedic hardware after trauma or arthrodesis in the hand and wrist. Thirty-six consecutive patients (12 female, median age 36 years, range 19-86 years) were included in this institutional review board approved clinical trial. Imaging was performed with DTS in dorso-palmar projection and DR was performed in dorso-palmar, lateral, and oblique views. Images were evaluated by two independent radiologists for qualitative and diagnosis-related imaging parameters using a four-point Likert scale (1=excellent, 4not diagnostic) and nominal scale. Interobserver agreement between the two readers was assessed with Cohen's kappa (k). Differences between DTS and CR were tested with Wilcoxon's signed-rank test. A p-value <0.05 was considered statistically significant. Regarding image quality, interobserver agreement was higher for DTS compared to DR, especially for fracture-related parameters (delineation osteosynthesis material [OSM]: KDTS0.96 versus KDR0.45; delineation fracture margins: KDTS0.78 versus KDR0.35). Delineation of fracture margins and delineation of adjacent joint spaces scored significant better for DTS compared to DR (delineation fracture margins: DTS1.54, DR2.28, p0.001; delineation adjacent joint spaces: DTS1.31, DR2.24, p0.001). Regarding diagnosis-related findings, interobserver agreement was almost equal. DTS showed a significant higher sharpness of fracture margins (DTS1.94, DR2.33, p0.04). Mean dose area product (DAP) for DTS was significant higher compared to DR (mean DR0.219 Gy·cm2, mean DTS0.903 Gy·cm2, p0.001). Fracture healing is more visible and interobserver agreement is higher for DTS compared to DR in the postoperative assessment of orthopaedic hardware in the hand and wrist.

Does Hardware Removal Improve Function Following Ankle Open Reduction and Internal Fixation?

Category: Ankle, Trauma Introduction/Purpose: Orthopaedic hardware removal (HWR) is one of the most common orthopaedic procedures performed, with rates reported between 5% and 16%. Despite the high rates of HWR, there is still no consensus or guideline for removal after osseous healing without infection. Outcome studies for HWR are scarce, particularly in the lower extremity. The purpose of this study is to evaluate the effect of removal of symptomatic ankle hardware using the Short Musculoskeletal Function Assessment (SMFA) dysfunction index as the primary outcome. We hypothesize that HWR after ankle fracture will result in improved functional outcomes. Methods: Utilizing a prospectively collected ankle fracture registry, all patients that underwent HWR between 2013 and 2016 were retrospectively reviewed. Inclusion criteria were skeletal maturity, closed intra-articular ankle fracture, symptomatic ankle hardware and completion of the SMFA questionnaire prior to and 5-months after hardware removal. Exclusion criteria were development of a nonunion, infection or complex regional pain syndrome from initial surgery. The primary outcome was change in SMFA score from baseline. Paired t-test was used to compare baseline and follow-up SMFA scores. A multiple linear regression model evaluated the effects of age, sex, body mass index (BMI), smoking status, number of comorbidities, and Lauge-Hansen fracture classification on outcomes. Results: The study included 43 patients (31 females, 12 males), mean age 49.9 (range, 19 to 83). Mean time from initial surgery to HWR was 37±46 months (range, 2.2 to 209). Follow-up SMFA questionnaires were completed 5.7±0.5 months (range, 5.1 to 7.4) after HWR. The fractures were classified as 23 (53%) supination-external rotation, 6 (14%) pronation-external rotation, 2 (4.7%) pronation-abduction and 1 (2.3%) supination-adduction. Eleven fractures (26%) were classified as pilons. The SMFA dysfunction index improved significantly from baseline to follow-up (3.71±7.4, p=0.002). Significant improvement was seen in the secondary outcomes of SMFA bother index (4.40±8.9, p=0.003) and SMFA daily activities domain (4.12±9.1, p=0.006). Regression analysis revealed a significant improvement in the bother index correlating with female gender (p=0.01) and decreasing number of comorbidities (p=0.03). Conclusion: Our study demonstrates that patients with ankle fractures have a significant improvement in function following the removal of symptomatic ankle hardware. Patients also showed a significant improvement in the bother index and daily activities domain of the SMFA. Further investigation into the specific indications for HWR and the impact of injury and fracture pattern on outcomes is warranted.

Sonography of Non-neoplastic Disorders of the Hand and Wrist Tendons.

Tendon disorders commonly cause hand and wrist disability and curtail the performance of work-related duties or routine tasks. Imaging is often needed for diagnosis, but it requires knowledge of the complex anatomic structures of the tendons of the hand and wrist as well as familiarity with related disorders. This review article aims to provide medical professionals with guidelines for the sonographic assessment of the tendons of hand and wrist and related disorders. Sonographic features of tendon disorders affecting the hand and wrist are described here, specifically: infectious tenosynovitis; tendon rupture or tearing; stenosing forms of tenosynovitis such as De Quervain disease and trigger finger; intersection syndrome; insertional tendinopathy; several forms of tendinous instability such as extensor carpi ulnaris instability, climber finger, and boxer knuckle; and tendinopathy in inflammatory rheumatic diseases. Postsurgical evaluation of the hand and wrist tendons is also discussed, including the healthy and pathologic appearances of operated tendons as well as impingement from orthopedic hardware. In conclusion, sonography is effective in assessing the tendons of the hand and wrist and related disorders and represents a valuable tool for diagnosis.

First described case of prosthetic joint infection with Clostridium disporicum

An orthopedic hardware infection with Clostridium disporicum is described. C. disporicum is a gram positive anaerobic bacillus which can contain two subterminal spores. C. disporicum had not previously been reported in musculoskeletal infections. Gram stains demonstrating gram positive bacilli with two subterminal spores should alert practitioners to the possibility of C. disporicum infection.

Inpatient orthopaedic hardware removal in children: A cross-Sectional study.

Few data describe the specific reasons for inpatient hardware removal in the pediatric population. This study was designed to understand the conditions necessitating inpatient removal following fracture surgery. Cost data was analyzed to understand the financial implications of these procedures. The Kids' Inpatient Database (KID) was evaluated for the year 2012. Patients undergoing open reduction internal fixation following upper and lower extremity fractures as well as those undergoing hardware removal due to hardware complications were identified using ICD-9 CM diagnosis and procedure codes. Univariable and multivariable logistic regression were used to determine predictors of surgical removal due to complications, controlling for patient demographics and comorbidities. The most common indication for removal was infection (1141 patients; 32%), followed by mechanical dysfunction (923; 25.4%), and pain (472; 13%). Logistic regression analysis showed that femur fractures (OR=8.27, 95% CI: 7.63-8.96) and tibia/fibula fractures (OR=1.24, 95% CI: 1.17-1.35) were independent predictors of infection-related hardware removal (P<0.001). Patients who underwent removal due to infection were more likely to have asthma (OR=1.87, 95% CI: 1.62-2.07), smoke tobacco (OR=1.12, 95% CI: 1.05-1.23), and suffer from developmental delays (OR=1.32, 95% CI: 1.19-1.54) (P<0.001). Average hospital charges and costs were $36,349 and $11,792 respectively. While most commonly performed as an outpatient procedure, inpatient hardware removal occurs with relative frequency and is most often performed for infection, mechanical failure, or pain. Risk factors for infection-related removal were identified and provide a basis for further investigation.

Outpatient treatment of osteomyelitis with telavancin

Telavancin is a lipoglycopeptide antibiotic with bactericidal activity against Gram-positive pathogens including Staphylococcus aureus, the most frequent cause of osteomyelitis. Treatment is often challenging due to needs for surgical intervention along with prolonged administration of intravenous antimicrobials, frequently in an outpatient setting. This was a retrospective analysis of the efficacy and safety of telavancin for treatment of osteomyelitis provided as outpatient parenteral antimicrobial therapy (OPAT) in physician office infusion centres. Medical records of 60 patients receiving telavancin for osteomyelitis in 22 physician office infusion centres from 2010 to 2011 and 2013 to 2015 were reviewed. Of these, 60% were treated without hospitalisation, 37% had orthopaedic hardware and 56% had concurrent infections. Staphylococcus aureus was the most common pathogen (78%), primarily methicillin-resistant. The median duration of telavancin treatment in the outpatient setting was 21 days (range 3–105 days). Telavancin was used as first-line therapy in 32% of cases, following prior antibiotic failure in 47% and due to intolerance to previous agents in 22%, predominantly daptomycin or vancomycin. The telavancin dose was 10 mg/kg/day, adjusted for renal function in 25% of patients. The majority of patients self-administered telavancin at home via an elastomeric infusion pump. Overall clinical success was 73%. No significant differences in outcomes were observed with the presence of hardware, concurrent infection, concomitant therapies or type of osteomyelitis. Telavancin-associated adverse events occurred in 57%, with discontinuation in three patients (5%). These data demonstrate the effective and safe OPAT use of telavancin, providing an alternative for successful treatment of patients with osteomyelitis.

Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. Key words: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

Imaging near orthopedic hardware.

3 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:24-39.