A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up
Allografts and polyetheretherketone (PEEK) cages are the two most commonly used materials in anterior cervical discectomy and fusion (ACDF). However, their effectiveness in two-level ACDF remains controversial. The primary aim of this retrospective study was to compare the clinical and radiological...
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| description | Allografts and polyetheretherketone (PEEK) cages are the two most commonly used materials in anterior cervical discectomy and fusion (ACDF). However, their effectiveness in two-level ACDF remains controversial. The primary aim of this retrospective study was to compare the clinical and radiological outcomes of two-level ACDF with plate fixation using either a structural allograft or a PEEK cage.
From 2010 to 2015, 88 consecutive patients underwent two-level ACDF, of whom 53 received an allograft and 35 patients received a PEEK cage. All PEEK cages were filled with local autografts. All clinical outcomes were prospectively collected before and six months and two years after surgery. Clinical efficacy was evaluated using a visual analogue scale for neck pain and limb pain, the Neck Pain and Disability Score, the Neck Disability Index, the Neurogenic Symptom Score, and the Japanese Orthopedic Association score. Radiological outcomes were assessed preoperatively, immediately after surgery, and at the final follow-up.
A preoperative comparison revealed no difference between the two patient groups in terms of age, sex, body mass index, smoking status, preoperative symptoms, operation level, or follow-up (mean = 42.8 months). No differences in the improvements in clinical outcomes were observed between the two groups. Both groups showed significant improvement in mean disc height, segmental height, and segmental lordosis postoperatively. The fusion rate for the PEEK cage was 100% at both levels, while the fusion rate for the allograft group was 98.1% at the cephalad level and 94.2% at the caudad level (p > 0.05). Subsidence at the cephalad level occurred in 22.9% (8/35) of segments in the PEEK group and 7.7% (4/52) of segments in the allograft group (p = 0.057). At the caudal level, a higher incidence of cage subsidence was noted in the PEEK group than in the allograft group [37.1% (13/35) versus 15.4% (8/52)] (p = 0.02). Overall, subsidence was noted in 30% (21/70) of the PEEK group and in 11% (12/104) of the allograft group (p |
| doi_str_mv | 10.1186/s12891-020-03325-y |
| format | Article |
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From 2010 to 2015, 88 consecutive patients underwent two-level ACDF, of whom 53 received an allograft and 35 patients received a PEEK cage. All PEEK cages were filled with local autografts. All clinical outcomes were prospectively collected before and six months and two years after surgery. Clinical efficacy was evaluated using a visual analogue scale for neck pain and limb pain, the Neck Pain and Disability Score, the Neck Disability Index, the Neurogenic Symptom Score, and the Japanese Orthopedic Association score. Radiological outcomes were assessed preoperatively, immediately after surgery, and at the final follow-up.
A preoperative comparison revealed no difference between the two patient groups in terms of age, sex, body mass index, smoking status, preoperative symptoms, operation level, or follow-up (mean = 42.8 months). No differences in the improvements in clinical outcomes were observed between the two groups. Both groups showed significant improvement in mean disc height, segmental height, and segmental lordosis postoperatively. The fusion rate for the PEEK cage was 100% at both levels, while the fusion rate for the allograft group was 98.1% at the cephalad level and 94.2% at the caudad level (p > 0.05). Subsidence at the cephalad level occurred in 22.9% (8/35) of segments in the PEEK group and 7.7% (4/52) of segments in the allograft group (p = 0.057). At the caudal level, a higher incidence of cage subsidence was noted in the PEEK group than in the allograft group [37.1% (13/35) versus 15.4% (8/52)] (p = 0.02). Overall, subsidence was noted in 30% (21/70) of the PEEK group and in 11% (12/104) of the allograft group (p < 0.05).
The use of PEEK cages resulted in a higher rate of subsidence in two-level ACDF than the use of allografts. Two-level ACDF using either allografts or PEEK cages resulted in similar clinical outcomes, radiological improvements in alignment and fusion rates.</description><identifier>ISSN: 1471-2474</identifier><identifier>EISSN: 1471-2474</identifier><identifier>DOI: 10.1186/s12891-020-03325-y</identifier><identifier>PMID: 32466749</identifier><language>eng</language><publisher>England: BioMed Central Ltd</publisher><subject>ACDF ; Allograft ; Allografts ; Allografts - standards ; Autografts ; Back surgery ; Body mass index ; Bone Plates ; Cervical ; Cervical Vertebrae - diagnostic imaging ; Cervical Vertebrae - surgery ; Comparative analysis ; Disability Evaluation ; Diskectomy - instrumentation ; Diskectomy - trends ; Female ; Follow-Up Studies ; Humans ; Ketones - administration & dosage ; Ketones - standards ; Lordosis - diagnostic imaging ; Lordosis - etiology ; Male ; Middle Aged ; Musculoskeletal diseases ; Neck ; Neck pain ; Pain ; Patients ; PEEK ; Polyetheretherketone ; Polyethylene Glycols - administration & dosage ; Polyethylene Glycols - standards ; Radiography ; Retrospective Studies ; Spinal Fusion - instrumentation ; Spinal Fusion - trends ; Statistical analysis ; Subsidence ; Surgeons ; Surgery ; Transplantation ; Transplantation, Homologous ; Treatment Outcome</subject><ispartof>BMC musculoskeletal disorders, 2020-05, Vol.21 (1), p.331-331, Article 331</ispartof><rights>COPYRIGHT 2020 BioMed Central Ltd.</rights><rights>2020. This work is licensed under http://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>The Author(s) 2020</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c563t-83132256c2a01aa0aa01413942e8346dcb41929241183fe6f0c0abdf439deef73</citedby><cites>FETCH-LOGICAL-c563t-83132256c2a01aa0aa01413942e8346dcb41929241183fe6f0c0abdf439deef73</cites><orcidid>0000-0002-3862-835X</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7257195/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7257195/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,27901,27902,53766,53768</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32466749$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Moo, Ing How</creatorcontrib><creatorcontrib>Kam, Carmen Jia Wen</creatorcontrib><creatorcontrib>Lai, Maksim Wen Sheng</creatorcontrib><creatorcontrib>Yeo, William</creatorcontrib><creatorcontrib>Soh, Reuben Chee Cheong</creatorcontrib><title>A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up</title><title>BMC musculoskeletal disorders</title><addtitle>BMC Musculoskelet Disord</addtitle><description>Allografts and polyetheretherketone (PEEK) cages are the two most commonly used materials in anterior cervical discectomy and fusion (ACDF). However, their effectiveness in two-level ACDF remains controversial. The primary aim of this retrospective study was to compare the clinical and radiological outcomes of two-level ACDF with plate fixation using either a structural allograft or a PEEK cage.
From 2010 to 2015, 88 consecutive patients underwent two-level ACDF, of whom 53 received an allograft and 35 patients received a PEEK cage. All PEEK cages were filled with local autografts. All clinical outcomes were prospectively collected before and six months and two years after surgery. Clinical efficacy was evaluated using a visual analogue scale for neck pain and limb pain, the Neck Pain and Disability Score, the Neck Disability Index, the Neurogenic Symptom Score, and the Japanese Orthopedic Association score. Radiological outcomes were assessed preoperatively, immediately after surgery, and at the final follow-up.
A preoperative comparison revealed no difference between the two patient groups in terms of age, sex, body mass index, smoking status, preoperative symptoms, operation level, or follow-up (mean = 42.8 months). No differences in the improvements in clinical outcomes were observed between the two groups. Both groups showed significant improvement in mean disc height, segmental height, and segmental lordosis postoperatively. The fusion rate for the PEEK cage was 100% at both levels, while the fusion rate for the allograft group was 98.1% at the cephalad level and 94.2% at the caudad level (p > 0.05). Subsidence at the cephalad level occurred in 22.9% (8/35) of segments in the PEEK group and 7.7% (4/52) of segments in the allograft group (p = 0.057). At the caudal level, a higher incidence of cage subsidence was noted in the PEEK group than in the allograft group [37.1% (13/35) versus 15.4% (8/52)] (p = 0.02). Overall, subsidence was noted in 30% (21/70) of the PEEK group and in 11% (12/104) of the allograft group (p < 0.05).
The use of PEEK cages resulted in a higher rate of subsidence in two-level ACDF than the use of allografts. Two-level ACDF using either allografts or PEEK cages resulted in similar clinical outcomes, radiological improvements in alignment and fusion rates.</description><subject>ACDF</subject><subject>Allograft</subject><subject>Allografts</subject><subject>Allografts - standards</subject><subject>Autografts</subject><subject>Back surgery</subject><subject>Body mass index</subject><subject>Bone Plates</subject><subject>Cervical</subject><subject>Cervical Vertebrae - diagnostic imaging</subject><subject>Cervical Vertebrae - surgery</subject><subject>Comparative analysis</subject><subject>Disability Evaluation</subject><subject>Diskectomy - instrumentation</subject><subject>Diskectomy - trends</subject><subject>Female</subject><subject>Follow-Up Studies</subject><subject>Humans</subject><subject>Ketones - administration & dosage</subject><subject>Ketones - standards</subject><subject>Lordosis - diagnostic imaging</subject><subject>Lordosis - etiology</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Musculoskeletal diseases</subject><subject>Neck</subject><subject>Neck pain</subject><subject>Pain</subject><subject>Patients</subject><subject>PEEK</subject><subject>Polyetheretherketone</subject><subject>Polyethylene Glycols - administration & dosage</subject><subject>Polyethylene Glycols - standards</subject><subject>Radiography</subject><subject>Retrospective Studies</subject><subject>Spinal Fusion - instrumentation</subject><subject>Spinal Fusion - trends</subject><subject>Statistical analysis</subject><subject>Subsidence</subject><subject>Surgeons</subject><subject>Surgery</subject><subject>Transplantation</subject><subject>Transplantation, Homologous</subject><subject>Treatment Outcome</subject><issn>1471-2474</issn><issn>1471-2474</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><sourceid>DOA</sourceid><recordid>eNptkstu1DAUhiMEoqXwAiyQJTZlkeJbbiyQRtUAFZXoAtaWxzlOXZJ4sJ2p8mo8HWdmyqiDUBzbOf7P5_j4z7LXjF4wVpfvI-N1w3LKaU6F4EU-P8lOmaxYzmUlnz6an2QvYryjlFW1aJ5nJ4LLsqxkc5r9XhDjh7UOLvqReItfY3Ld5KdI0r3Pe9hAT_SYIDgfiIGwcUb3pHXRgEl-mHGxJXaKDvOxHzuiSUxhMmkKKNR977ugbSIbCBGpmtz4foZ0C2HX_YTkRyDnN8vl13fE6A4-EIyTAHHqU9z-k8ZAAMhn0IFYj8T7fFq_zJ5Z3Ud49TCeZT8-Lb9ffsmvv32-ulxc56YoRcprwQTnRWm4pkxrio1JJhrJoRaybM1KsoY3XGJNhYXSUkP1qrVSNC2ArcRZdrXntl7fqXVwgw6z8tqpXcCHTumQnOlBtaYuLYgVtcirGol7ryylxkouCmYZsj7uWetpNUBrYExYpCPo8croblXnN6riRcWaAgHnD4Dgf00Qkxq2N9H3egS8M8UlrTnlpaAoffuP9M5PYcRSoYrJEq2A70HVaTyAG63Hfc0WqhYlr0TRoFNQdfEfFT4tDA4tA9Zh_CiB7xNM8DEGsIczMqq27lV79yp0r9q5V82Y9OZxdQ4pf-0q_gCmZu1U</recordid><startdate>20200528</startdate><enddate>20200528</enddate><creator>Moo, Ing How</creator><creator>Kam, Carmen Jia Wen</creator><creator>Lai, Maksim Wen Sheng</creator><creator>Yeo, William</creator><creator>Soh, Reuben Chee Cheong</creator><general>BioMed Central Ltd</general><general>BioMed Central</general><general>BMC</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QP</scope><scope>7RV</scope><scope>7TK</scope><scope>7TS</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>NAPCQ</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>7X8</scope><scope>5PM</scope><scope>DOA</scope><orcidid>https://orcid.org/0000-0002-3862-835X</orcidid></search><sort><creationdate>20200528</creationdate><title>A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up</title><author>Moo, Ing How ; Kam, Carmen Jia Wen ; Lai, Maksim Wen Sheng ; Yeo, William ; Soh, Reuben Chee Cheong</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c563t-83132256c2a01aa0aa01413942e8346dcb41929241183fe6f0c0abdf439deef73</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>ACDF</topic><topic>Allograft</topic><topic>Allografts</topic><topic>Allografts - standards</topic><topic>Autografts</topic><topic>Back surgery</topic><topic>Body mass index</topic><topic>Bone Plates</topic><topic>Cervical</topic><topic>Cervical Vertebrae - diagnostic imaging</topic><topic>Cervical Vertebrae - surgery</topic><topic>Comparative analysis</topic><topic>Disability Evaluation</topic><topic>Diskectomy - instrumentation</topic><topic>Diskectomy - trends</topic><topic>Female</topic><topic>Follow-Up Studies</topic><topic>Humans</topic><topic>Ketones - administration & dosage</topic><topic>Ketones - standards</topic><topic>Lordosis - diagnostic imaging</topic><topic>Lordosis - etiology</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Musculoskeletal diseases</topic><topic>Neck</topic><topic>Neck pain</topic><topic>Pain</topic><topic>Patients</topic><topic>PEEK</topic><topic>Polyetheretherketone</topic><topic>Polyethylene Glycols - administration & dosage</topic><topic>Polyethylene Glycols - standards</topic><topic>Radiography</topic><topic>Retrospective Studies</topic><topic>Spinal Fusion - instrumentation</topic><topic>Spinal Fusion - trends</topic><topic>Statistical analysis</topic><topic>Subsidence</topic><topic>Surgeons</topic><topic>Surgery</topic><topic>Transplantation</topic><topic>Transplantation, Homologous</topic><topic>Treatment Outcome</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Moo, Ing How</creatorcontrib><creatorcontrib>Kam, Carmen Jia Wen</creatorcontrib><creatorcontrib>Lai, Maksim Wen Sheng</creatorcontrib><creatorcontrib>Yeo, William</creatorcontrib><creatorcontrib>Soh, Reuben Chee Cheong</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Calcium & Calcified Tissue Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Neurosciences Abstracts</collection><collection>Physical Education Index</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Nursing & Allied Health Premium</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>BMC musculoskeletal disorders</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Moo, Ing How</au><au>Kam, Carmen Jia Wen</au><au>Lai, Maksim Wen Sheng</au><au>Yeo, William</au><au>Soh, Reuben Chee Cheong</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up</atitle><jtitle>BMC musculoskeletal disorders</jtitle><addtitle>BMC Musculoskelet Disord</addtitle><date>2020-05-28</date><risdate>2020</risdate><volume>21</volume><issue>1</issue><spage>331</spage><epage>331</epage><pages>331-331</pages><artnum>331</artnum><issn>1471-2474</issn><eissn>1471-2474</eissn><abstract>Allografts and polyetheretherketone (PEEK) cages are the two most commonly used materials in anterior cervical discectomy and fusion (ACDF). However, their effectiveness in two-level ACDF remains controversial. The primary aim of this retrospective study was to compare the clinical and radiological outcomes of two-level ACDF with plate fixation using either a structural allograft or a PEEK cage.
From 2010 to 2015, 88 consecutive patients underwent two-level ACDF, of whom 53 received an allograft and 35 patients received a PEEK cage. All PEEK cages were filled with local autografts. All clinical outcomes were prospectively collected before and six months and two years after surgery. Clinical efficacy was evaluated using a visual analogue scale for neck pain and limb pain, the Neck Pain and Disability Score, the Neck Disability Index, the Neurogenic Symptom Score, and the Japanese Orthopedic Association score. Radiological outcomes were assessed preoperatively, immediately after surgery, and at the final follow-up.
A preoperative comparison revealed no difference between the two patient groups in terms of age, sex, body mass index, smoking status, preoperative symptoms, operation level, or follow-up (mean = 42.8 months). No differences in the improvements in clinical outcomes were observed between the two groups. Both groups showed significant improvement in mean disc height, segmental height, and segmental lordosis postoperatively. The fusion rate for the PEEK cage was 100% at both levels, while the fusion rate for the allograft group was 98.1% at the cephalad level and 94.2% at the caudad level (p > 0.05). Subsidence at the cephalad level occurred in 22.9% (8/35) of segments in the PEEK group and 7.7% (4/52) of segments in the allograft group (p = 0.057). At the caudal level, a higher incidence of cage subsidence was noted in the PEEK group than in the allograft group [37.1% (13/35) versus 15.4% (8/52)] (p = 0.02). Overall, subsidence was noted in 30% (21/70) of the PEEK group and in 11% (12/104) of the allograft group (p < 0.05).
The use of PEEK cages resulted in a higher rate of subsidence in two-level ACDF than the use of allografts. Two-level ACDF using either allografts or PEEK cages resulted in similar clinical outcomes, radiological improvements in alignment and fusion rates.</abstract><cop>England</cop><pub>BioMed Central Ltd</pub><pmid>32466749</pmid><doi>10.1186/s12891-020-03325-y</doi><tpages>1</tpages><orcidid>https://orcid.org/0000-0002-3862-835X</orcidid><oa>free_for_read</oa></addata></record> |
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| ispartof | BMC musculoskeletal disorders, 2020-05, Vol.21 (1), p.331-331, Article 331 |
| issn | 1471-2474 1471-2474 |
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| source | MEDLINE; Springer Nature - Complete Springer Journals; DOAJ Directory of Open Access Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; PubMed Central; PubMed Central Open Access; Springer Nature OA Free Journals |
| subjects | ACDF Allograft Allografts Allografts - standards Autografts Back surgery Body mass index Bone Plates Cervical Cervical Vertebrae - diagnostic imaging Cervical Vertebrae - surgery Comparative analysis Disability Evaluation Diskectomy - instrumentation Diskectomy - trends Female Follow-Up Studies Humans Ketones - administration & dosage Ketones - standards Lordosis - diagnostic imaging Lordosis - etiology Male Middle Aged Musculoskeletal diseases Neck Neck pain Pain Patients PEEK Polyetheretherketone Polyethylene Glycols - administration & dosage Polyethylene Glycols - standards Radiography Retrospective Studies Spinal Fusion - instrumentation Spinal Fusion - trends Statistical analysis Subsidence Surgeons Surgery Transplantation Transplantation, Homologous Treatment Outcome |
| title | A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-02T00%3A24%3A08IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_doaj_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=A%20comparison%20of%20contiguous%20two-level%20anterior%20cervical%20discectomy%20and%20fusion%20using%20a%20structural%20allograft%20versus%20a%20Polyetheretherketone%20(PEEK)%20cage:%20the%20results%20of%20a%20three-year%20follow-up&rft.jtitle=BMC%20musculoskeletal%20disorders&rft.au=Moo,%20Ing%20How&rft.date=2020-05-28&rft.volume=21&rft.issue=1&rft.spage=331&rft.epage=331&rft.pages=331-331&rft.artnum=331&rft.issn=1471-2474&rft.eissn=1471-2474&rft_id=info:doi/10.1186/s12891-020-03325-y&rft_dat=%3Cgale_doaj_%3EA627359667%3C/gale_doaj_%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2414683968&rft_id=info:pmid/32466749&rft_galeid=A627359667&rft_doaj_id=oai_doaj_org_article_dc86fe3b0f924794831bf00cf42351f1&rfr_iscdi=true |