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Furuhataetal.
Journal of Orthopaedic Surgery and Research (2022) 17:476
https://doi.org/10.1186/s13018-022-03379-9
RESEARCH ARTICLE
Inferior subluxation ofhumeral head
afterosteosynthesis forgreater tuberosity
fracture
Ryogo Furuhata1*, Atsushi Tanji1, Satoshi Oki2 and Yusaku Kamata3
Abstract
Background: Inferior subluxation of the humeral head is frequently observed immediately after surgery for proximal
humerus fractures; however, the incidence and risk factors of inferior subluxation after osteosynthesis for isolated
greater tuberosity fractures remain unsolved. Additionally, the postoperative course of inferior subluxation has not
been elucidated. The purpose of the present study is to identify the predictors for the occurrence of postoperative
inferior subluxation by multivariate analysis and investigate the postoperative shift of inferior subluxation and its
effect on surgical outcomes.
Methods: We retrospectively identified 68 patients who underwent surgery for isolated greater tuberosity fractures.
The dependent variable was the inferior subluxation at 1 week postoperatively. The explanatory variables were age,
sex, affected side of the shoulder, body mass index, history of smoking, local osteoporosis, time period to surgery, axil‑
lary nerve injury, inferior subluxation before surgery, fracture dislocation, surgical approach, surgical method, opera‑
tive time, amount of blood loss, and postoperative drainage. Baseline variables that were statistically significant in the
univariate analyses were included in the logistic regression analysis. The patients were further categorized into two
groups according to the presence of inferior shoulder subluxation exhibited 1 week postoperatively: patients with
inferior subluxation (+ IS group) and patients without inferior subluxation (− IS group). We compared the incidence of
postoperative complications between the two groups.
Results: Of 68 patients, 17 (25.0%) had inferior shoulder subluxation observed 1 week postoperatively. Multivariate
analysis showed that long operative time was a risk factor for postoperative subluxation (odds ratio = 1.03; P = 0.030).
In all cases, inferior subluxation disappeared within 3 months of surgery. No significant difference in complication rate
was observed between the + IS and − IS groups.
Conclusions: The present study provides novel information regarding postoperative inferior subluxation of fractures
of the greater tuberosity. Inferior subluxation occurred in 25% of patients immediately after surgery. Long operative
time contributes to the onset of postoperative inferior subluxation; however, this was temporary in all cases and had
no significant effect on the surgical outcomes.
Level of Evidence: Level III.
Keywords: Humeral head, Inferior subluxation, Greater tuberosity fracture, Osteosynthesis, Outcome
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Background
Inferior subluxation of the humeral head is frequently
experienced immediately after osteosynthesis for proxi-
mal humerus fractures and occurs in 31–42% of patients
Open Access
*Correspondence: ryogo4kenbisha@gmail.com
1 Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, 284‑1
Yobe‑Cho, Ashikaga‑Shi, Tochigi 326‑0843, Japan
Full list of author information is available at the end of the article
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Page 2 of 7
Furuhataetal. Journal of Orthopaedic Surgery and Research (2022) 17:476
at 1–2weeks after surgery [1, 2]. Most cases are transi-
tory and improve with time; however, persistent inferior
shoulder subluxation observed 1 year postoperatively
is associated with screw articular surface perforation
and low Constant score [3]. erefore, it is important to
identify the risk factors of postoperative subluxation and
investigate its postoperative course.
e causes of inferior subluxation after acute shoulder
trauma include muscle fatigue, such as that of the deltoid
muscle [4], atony of deltoid and rotator cuff muscles [1,
3, 5], loss of negative intraarticular pressure of gleno-
humeral joint [1], peripheral nerve injury [6], and capsu-
lar injury [7]. However, there is limited evidence on the
factors affecting inferior subluxation exhibited immedi-
ately after osteosynthesis for proximal humerus fractures
[2, 3]. In particular, the incidence of inferior subluxation
after an isolated fracture of the greater tuberosity and the
factors affecting its onset remain unknown. Furthermore,
the postoperative changes of inferior subluxation, post-
operative progress, and the effect of postoperative sub-
luxation on surgical outcomes have not been previously
reported.
e aims of the present study were: (1) to identify the
incidence of inferior subluxation immediately after oste-
osynthesis for isolated fracture of the greater tuberosity,
and the factors that affect the incidence by multivariate
analysis, and (2) to investigate the postoperative course
of subluxation and to analyze the influence of postop-
erative subluxation on surgical outcomes. is study was
approved by the Independent Ethics Committee of our
hospitals.
Methods
Study design andpatients
is was a retrospective study including patients who
underwent osteosynthesis for a fracture of the greater
tuberosity at three municipal general hospitals between
2008 and 2021. We included adult patients who under-
went surgery for isolated greater tuberosity fracture
diagnosed by plain radiographs and computed tomog-
raphy (CT). Several previous studies have recom-
mended that a superior displacement of the greater
tuberosity of ≥ 5 mm is an indication for surgery of
the greater tuberosity fracture [8, 9] as it is thought to
cause abnormal shoulder mechanics during shoulder
abduction [10] and subacromial impingement [8, 11].
erefore, the indications for surgery for greater tuber-
osity fractures at the institution where this study was
performed were patients who could undergo general
anesthesia and had a superior displacement of greater
than 5 mm. We determined a superior displacement
when the superior margin of the greater tuberosity
fragment was ≥ 5mm superior to the superior margin
of the articular fragment of the humeral head on the
anteroposterior view of plain radiography or the coro-
nal view of CT, regardless of the fracture pattern. We
excluded patients with other fractures complicating
the affected upper extremity, history of surgery involv-
ing the affected upper extremity, and paralysis of the
affected upper extremity due to cerebral infarction or
other causes, and patients who underwent osteosynthe-
sis using intramedullary nail.
Surgical procedure
Eleven orthopedic surgeons performed surgery. In all
cases, surgery was performed in the beach-chair posi-
tion under general anesthesia. Osteosynthesis was
performed using the delto-pectoral or deltoid split
approaches using plates in 24 patients, cannulated can-
cellous screw (CCS) in 16 patients, transosseous wiring
or suture in 15 patients, suture-bridge technique in 8
patients, and tension band wiring (TBW) in 5 patients,
at the discretion of the surgeon. e implant used for
plate fixation was the PHILOS® plate (Depuy Syn-
thes, Oberdorf, Switzerland), LCP® plate (Depuy Syn-
thes, Oberdorf, Switzerland), or MODE® plate (MDM,
Tokyo, Japan). e implant used for CCS fixation was
the ACE® (Zimmer Biomet, Warsaw, IN, USA) or
Asnis® III cannulated screw system (Stryker, Kalama-
zoo, MI, USA). For transosseous wiring or suture, a
surgical wire or FiberWire® (Arthrex, Naples, FL, USA)
was fastened through the rotator cuff and the bone
hole created distally in the humeral fragment. For the
suture-bridge procedure, suture anchors were inserted
proximally and distally to the fracture site and the bone
fragments were reduced and fixed. Healix Advance™
BR anchor (Mitek, Raynham, MA, USA), JuggerKnot®
anchor (Zimmer Biomet, Warsaw, IN, USA), and Quat-
tro® Link Knotless Anchor (Zimmer Biomet, War-
saw, IN, USA) were used. TBW was performed using
Kirschner wires and surgical wires, AI-Wiring system
(Aimedic MMT, Tokyo, Japan) or RING PIN system
(Nakashima Medical, Okayama, Japan). In this study,
the mean operative time and blood loss for osteosyn-
thesis performed in this study were 100.5 ± 32.5 min
and 65.5 ± 98.1g, respectively. In eight cases, drainage
was performed by inserting an SB VAC™ (Sumitomo
Bakelite, Tokyo, Japan) into the fracture site for 2days
after osteosynthesis. Immobilization of the arm was
achieved by sling fixation postoperatively for 1–3weeks
after which passive range of motion (ROM) exercises
were initiated. Active ROM exercises were initiated
4–6weeks after surgery. Patients did not undergo addi-
tional fixation periods even when inferior subluxation
occurred postoperatively.
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Furuhataetal. Journal of Orthopaedic Surgery and Research (2022) 17:476
Radiographic evaluation ofinferior subluxation ofhumeral
head
Various methods of humeral head inferior subluxa-
tion have been previously reported [3, 12, 13]. Car-
bone et al. define inferior subluxation as a distance
of ≥ 1cm between the humeral anatomical neck level
and the glenoid inferior edge level [3]. We adopted this
method for this study because a good intra- and excel-
lent inter-rater reliability was reported [3]. Based on
the previous studies [3, 13], plain radiographs of the
shoulder in the upright position taken before surgery
and at 1week, 1month, 3months, and 6months post-
operatively were evaluated by one examiner. Inferior
subluxation on the plain radiograph taken 1week post-
operatively was defined as inferior subluxation imme-
diately after osteosynthesis, as previously described [2]
(Fig.1).
The patients were further divided into two groups
according to the presence of inferior subluxation at
1week postoperatively: patients with inferior subluxa-
tion (+ IS group) and patients without inferior sublux-
ation (− IS group).
Outcome measures
Multivariate analysis was performed to clarify the factors
affecting postoperative subluxation, and inferior subluxa-
tion on plain radiograph at 1week postoperatively was
used as the dependent variable. e explanatory variables
were age, sex, affected side of the shoulder, body mass
index (BMI), history of smoking, local osteoporosis, time
period from injury to surgery, preoperative axillary nerve
injury, fracture dislocation, preoperative inferior sub-
luxation, surgical approach (delto-pectoral/deltoid split
approach), surgical method (plate, CCS, transosseous
wiring, suture-bridge technique, TBW), operative time,
amount of blood loss, and drainage after surgery. Local
osteoporosis was assessed by measuring the average cor-
tical thickness at two points of the humerus, and an aver-
age proximal humeral cortical thickness of ˂ 6mm was
defined as local osteoporosis as previously reported [14].
Axillary nerve injury was assessed using clinical notes on
numbness of the axillary nerve region.
Postoperative outcomes were postoperative com-
plication rate (delayed bone union, nonunion, infec-
tion, screw perforation into the joint, fixation failure)
and ROM (elevation and external rotation [ER] at side)
at 6months after surgery. A single evaluator, who was
Fig. 1 Radiographic assessment of inferior subluxation of the humeral head. A distance of ≥ 1 cm between the humeral anatomical neck level and
the glenoid inferior edge level was defined as the presence of humeral head inferior subluxation. Postoperative radiograph images after surgery
using a cannulated cancellous screw (A) or tension band wiring (B)
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Furuhataetal. Journal of Orthopaedic Surgery and Research (2022) 17:476
blinded on the results of postoperative inferior subluxa-
tion, investigated the postoperative complications based
on the clinical notes and plain radiographic images.
Delayed union was defined as a lack of bone bridging at
6months postoperatively. We defined fixation failure as a
residual displacement of the greater tuberosity fragment
of ≥ 5mm. Postoperative ROM was assessed by the sur-
geon who performed osteosynthesis or the occupational
therapist. We compared the postoperative outcomes
between the + IS and − IS groups during a follow-up
period ≥ 6months.
Statistical analysis
All statistical analysis was conducted using SPSS soft-
ware (version 27.0*, IBM, Armonk, NY, USA). In uni-
variate analyses, we used the Mann–Whitney U test to
compare the average of continuous values (age, BMI,
time from injury to surgery, operative time, and blood
loss). We used Fischer’s exact test to compare the pro-
portions (sex, side of injury, smoking, local osteoporosis,
preoperative axillary nerve injury, fracture dislocation,
preoperative inferior subluxation, surgical approach, sur-
gical method, and postoperative drainage). Baseline vari-
ables with P < 0.05 in univariate analysis were included in
the logistic regression analysis to clarify the independent
predictive factors of inferior subluxation. e regres-
sion model fit was estimated by the Hosmer–Lemeshow
goodness-of-fit test. On the examination of the effect of
subluxation on surgical outcomes, the Mann–Whitney U
test was used to compare the average of ROM and Fis-
cher’s exact test was used to compare the complication
rate. P < 0.05 was considered statistically significant.
Results
In total, 68 patients met the inclusion and exclusion
criteria. e patient mean age was 61.4 ± 15.7 (range
28–92) years; 42 were women, and 26 were men. e
injury was on the right and on the left side in 37 and 31
patients, respectively. Preoperative axillary nerve injury
and humeral head inferior subluxation were observed in
11 (16.2%) and seven (10.3%) patients, respectively. e
injury consisted of fracture dislocation in 31 patients
(45.6%).
Of the 68 patients, 17 (25.0%) exhibited inferior sub-
luxation at 1 week postoperatively; therefore, the + IS
and − IS groups included 17 and 51 patients, respec-
tively. e results of the univariate analysis revealed
that surgical method (plate) (P = 0.038), longer opera-
tive time (P = 0.002), and higher blood loss (P = 0.048)
were significantly associated with the incidence of infe-
rior subluxation immediately after osteosynthesis. Mul-
tivariate analyses revealed that longer operative time
(odds ratio = 1.03; 95% confidence interval = 1.00–1.05;
P = 0.030) was a risk factor for postoperative subluxation.
e Hosmer–Lemeshow goodness-of-fit test showed no
significant difference from good model fit (P = 0.525)
(Table1).
Figure 2 shows the postoperative course of inferior
subluxation of the + IS and –IS groups. is graph pre-
sents the postoperatively narrowing distance between
the humeral anatomical neck level and glenoid inferior
edge level with time in both groups. Inferior subluxation
persisted at 1month postoperatively in two patients in
the + IS group, although it disappeared in all patients at 3
and 6 postoperative months. No patients in the –IS group
developed a new inferior subluxation within 6 months
after osteosynthesis.
On examination of the effect of subluxation immedi-
ately after osteosynthesis on surgical outcomes, we iden-
tified 60 patients with a follow-up period ≥ 6 months
postoperatively. Two patients in the + IS group and six
patients in the − IS group were excluded because of
insufficient follow-up. e data for ROM were missing
for elevation in 12 patients and for ER in 23 patients.
No significant difference in complication rate was
noted between the + IS and − IS groups (Table2). Two
patients with delayed union achieved union within the
1-year postoperative follow-up period. None of the
patients with fixation failure required reoperation. Addi-
tionally, no significant difference was noted between
the + IS group and − IS group in ROM of elevation (142°
[131–149°] vs. 140° [131–149°], respectively, P = 0.953)
and ER (41° [30–52°] vs. 52° [46–59°], respectively,
P = 0.129) at 6months postoperatively.
Discussion
In the present study, we performed a multivariate analy-
sis to clarify the factors affecting the onset of inferior
subluxation immediately after osteosynthesis for isolated
greater tuberosity fractures and investigated the postop-
erative prognosis of inferior subluxation. Two important
clinical observations should be noted.
First, the results of the multivariate analysis revealed
that operative time significantly affected the incidence of
inferior subluxation at 1week postoperatively for isolated
fracture of the greater tuberosity. is finding is consist-
ent with a previous study investigating postoperative
inferior subluxation of humeral neck fracture or 3-part
proximal humerus fracture [2]. e mechanism of how
operative time affects inferior subluxation immediately
after surgery remains unknown; however, retraction of
the muscles attached to the humerus such as the deltoid
muscle or rotator cuff for a long period during surgery
may cause muscle fatigue or atony, or a long opera-
tive time may affect peripheral nerve traction and com-
pression, leading to postoperative inferior subluxation.
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Furuhataetal. Journal of Orthopaedic Surgery and Research (2022) 17:476
Preoperative inferior subluxation was also shown to be
a significant risk factor for inferior subluxation imme-
diately after surgery [2]; however, preoperative inferior
subluxation was not identified as a significant factor in
the present study. is difference may be ascribed to the
fact that 25% of patients in the reported study had preop-
erative inferior subluxation [2], while this was observed
in a mere 10% of the patients in this study with isolated
greater tuberosity fractures. Another study reported
significant associations between inferior subluxation
at 3months postoperatively and older age, female sex,
Table 1 Univariate and multivariate predictors of inferior subluxation at 1 week after surgery
CI Condence interval, BMI Body mass index, CCS Cannulated cancellous screw, TO Transosseous wire or suture, TBW Tension band wiring
Numbers in square brackets indicate 95% CI
* P < 0.05,
Variables Univariate predictors Multivariate predictors
+ IS group (N = 17) − IS group (N = 51) P-value Odds ratio [95% CI] P-value
Age (years) 60.4 [52.6–68.2] 61.7 [57.4–66.0] 0.686 – –
Sex (female/male) 11/6 31/20 1 – –
Affected side (right/left) 12/5 25/26 0.163 – –
BMI 24.2 [22.4–26.0] 24.0 [22.8–25.1] 0.766 – –
Smoking 6 16 0.772 – –
Local osteoporosis 5 17 1 – –
Time from injury to surgery (days) 8.1 [5.5–11.7] 9.7 [7.3–12.2] 0.599 – –
Preoperative axillary nerve injury 2 9 0.718 – –
Dislocation fracture 9 22 0.578 – –
Preoperative inferior subluxation 3 4 0.355 – –
Surgical approach
(Delto‑pectoral/Deltoid split) 12/5 23/28 0.094 – –
Surgical method
Plate 10 14 0.038* 1.77 [0.47–6.65] 0.397
CCS 3 13 0.743 – –
TO 4 11 1 – –
Suture‑bridge 0 8 0.186 – –
TBW 1 4 1 – –
Operative time (minutes) 121 [109–133] 94 [85–102] 0.002* 1.03 [1.00–1.05] 0.030*
Blood loss (g) 83 [49–116] 60 [31–89] 0.048* 1.00 [1.00–1.01] 0.937
Postoperative drainage 3 5 0.402 – –
Fig. 2 Postoperative course of postoperative inferior subluxation of
the humeral head. The blots show the distance between the humeral
anatomical neck level and glenoid inferior edge level in the + IS (red)
and – IS groups (blue) at 1 week, 1 month, 3 months, and 6 months
after surgery for greater tuberosity fracture. Error bar represents a 95%
confidence interval. M; month, W; week
Table 2 Postoperative complication (+ IS group vs. –IS group)
Complications
N (%) + IS group
(N = 15)
− IS group
(N = 45)
P-value
Delayed union 2 (13.3%) 1 (2.2%) 0.151
Nonunion 0 (0%) 0 (0%) 1
Infection 0 (0%) 0 (0%) 1
Screw perforation 0 (0%) 0 (0%) 1
Fixation failure 1 (6.7%) 5 (11.1%) 1
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Furuhataetal. Journal of Orthopaedic Surgery and Research (2022) 17:476
obesity, and screw joint perforation [3]. Although female
sex and high BMI were observed in a slightly higher
number of patients with postoperative inferior subluxa-
tion in the univariate analysis, these differences were not
significant. is gap may be accounted for by the fact
that the present analysis focused on patients at an ear-
lier stage after surgery (at 1 week postoperatively), so
surgery-related factors may have had a greater influence
on inferior subluxation than patient demographics such
as age, sex, and obesity.
Second, inferior subluxation was observed in 25% of
patients immediately after surgery for a greater tuberos-
ity fracture; however, this improved in all cases within
3 months of surgery and the presence of inferior sub-
luxation just after surgery had no significant influence on
surgical outcome at 6months after surgery. e reported
incidence of inferior subluxation observed immediately
after osteosynthesis for all proximal humerus fractures
is 31–42%, which exceeds the incidence of subluxation
after osteosynthesis for the isolated greater tuberosity
fractures reported in this study. Moreover, while infe-
rior subluxation has been reported to persist more than
6months after surgery in 2.8–4.6% of patients [2, 3], it
improved within 3months postoperatively in all patients
in this study. ese findings suggest that compared to
proximal humerus fractures, isolated fractures of the
greater tuberosity are associated with a lower incidence
and earlier recovery of inferior subluxation observed
immediately after surgery. is difference may also be
explained by the lower invasiveness of surgery for frac-
tures of the greater tuberosity compared to surgery for
proximal humerus fractures. is is consistent with the
shorter operative time and smaller blood loss observed in
this study compared to that in previous reports [2]. Addi-
tionally, while persisting inferior subluxation one year
after surgery for proximal humerus fracture is related
to complication such as screw joint perforation [3], this
complication is rarer following surgery for isolated frac-
ture of the greater tuberosity, thereby potentially contrib-
uting to the improvement in inferior subluxation in all
patients. Despite there being significantly more patients
with longer operative times and greater blood loss in
the + IS group than in the − IS group, no significant
between-group differences were noted in complication
rate or ROM at 6months postoperatively. ese results
were consistent with those of previous studies on proxi-
mal humerus fractures that demonstrated that postoper-
ative inferior subluxation had no significant influence on
the surgical outcome [2, 3].
e incidence of inferior subluxation 1 week after
osteosynthesis for proximal humerus fractures has
been reported to be 31% [2]; therefore, based on a
power analysis assuming a 30% rate of postoperative
inferior subluxation, approximately 100 patients would
be required to show a 50% difference in the incidence of
postoperative inferior subluxation in this study. Based on
this, the study may have been influenced by factors that
could not be detected (β-error) in the univariate analy-
sis that examined the predictors of postoperative infe-
rior subluxation. However, the number of fractures were
relatively large in this clinical study on 68 patients, while
the majority of reports on surgical outcomes of greater
tuberosity fractures had a sample size of 50 or less [9, 15].
is can be a strength of this study.
However, there are several limitations in this study.
e first limitation is the observational nature of this
study, which may have overlooked residual, unmeasured
confounders that may also play a role in the difference
between the groups. For example, the surgical proce-
dures were performed by 11 orthopedic surgeons in this
study, but we did not analyze the effects of the skills of
surgeons and their assistants. Moreover, the choice of
implant type and surgical technique should be consist-
ent based on the size or comminution of fracture frag-
ment or bone density; however, the fact that the choice
of implants depended on each surgeon’s preference could
be a limitation of this work. Second, this survey did not
include a questionnaire, so we could not measure addi-
tional objective functional outcomes. ird, there are
missing data for the postoperative ROM, which may have
resulted in inadequate assessment of ROM.
Conclusions
e present study provides novel information regarding
postoperative inferior subluxation of greater tuberos-
ity fractures. Inferior subluxation occurred immediately
after surgery in 25% of patients. Long operative time was
associated with postoperative inferior subluxation; how-
ever, this was temporary in all cases and had no signifi-
cant effect on the surgical outcomes.
Abbreviations
CT: Computed tomography; CCS: Cannulated cancellous screw; TBW: Tension
band wiring; ROM: Range of motion; IS: Inferior subluxation; ER: External
rotation.
Acknowledgements
Not applicable
Authors’ contributions
All authors contributed to the study conception and design. The study design
was planned by RF. Material preparation, data collection, and analysis were
performed by RF, SO, and YK. The first draft of the manuscript was written
by RF. AT, SO, and YK contributed to previous versions of the manuscript. All
authors read and approved the final manuscript.
Funding
The authors certify that they or their institutions did not receive any support
(e.g., grants, funding, payment, or other benefits) or a commitment or agree‑
ment to provide such benefits in connection with the research or preparation
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of this manuscript. The authors also received no funding for the design of the
study and the collection, analysis, and interpretation of data and in writing the
manuscript.
Availability of data and materials
Data that support the findings of this study are available from the correspond‑
ing author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by Ashikaga Red Cross Hospital Independent Ethics
Committee (No. 2022–1), Saiseikai Utsunomiya Hospital Independent Ethics
Committee (No. 2020–55), and National Hospital Organization Tokyo Medical
Center Independent Ethics Committee (No. R20‑141). Due to the retrospective
nature of the study, consent was obtained using the opt‑out method for each
patient, on our hospital bulletin board and website. Opt‑out consent relies on
implicit consent, where willingness to participate is tacit or presumed and can
be retracted by active objection.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, 284‑1
Yobe‑Cho, Ashikaga‑Shi, Tochigi 326‑0843, Japan. 2 Department of Orthopae‑
dic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya‑Shi, Tochigi, Japan.
3 Department of Orthopaedic Surgery, National Hospital Organization Tokyo
Medical Center, Meguro‑Ku, Tokyo, Japan.
Received: 30 August 2022 Accepted: 30 October 2022
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