Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_17_библиотеки_им_акад_М_И_Перельмана
.pdf
30
https://t.me/medicina_free
S. M. Yasin
3.2 Total Knee Arthroplasty inEast (and
Sub-Saharan) Africa
in very few private hospitals and at costs unaffordable to
the huge majority.
Even though there is no published data on the scale
Given the prevalence of advanced OA requiring TKA in
different communities in the world, TKA is taken as an
3
underutilized procedure. This being true even in most
civilized countries where access to health care is not a
big issue, it would be reasonable to expect a considerable
mismatch between the demand and availability of TKA
surgeries in less privileged parts of the world such as
East Africa.
In most high-income countries healthcare insurance
is available to those who can afford it and a state-run
safety net program covers the treatment costs for those
who cannot afford.
of the actual demand for knee arthroplasty or prevalence of the main indications in Ethiopia so far, our
experience shows that the number of people with clear
indications for TKA is rising from time to time.
In some government hospitals there is a trend of putting the names and contact addresses of patients who
are candidates for TKA on a waiting list, relying on
links with certain institutions/individual volunteer
arthroplasty surgeons who unpredictably visit them for
free-of-charge surgeries, in order to help those who cannot afford to travel abroad or cover their own costs in
private hospitals. Even though such campaigns have
mostly been conducted for total hip arthroplasties
> In contrast, most sub-Saharan African countries (to
which East Africa belongs) either do not have health
insurers at all or they are yet in the process of developing such a system.
(THAs), few campaigns were also conducted addressing
those who are in need of TKAs.
Since February 2019, a hospital in the southern part
of Ethiopia has started TKA surgeries, probably as the
rst center in Ethiopia’s history to perform TKAs on a
This makes costly procedures such as TKA unaffordable
to the majority, not to mention sociocultural barriers,
which further diminish the number of candidates.
Therefore, in contrast to the developed countries like
Canada, for instance, where willingness to consider total
joint arthroplasty is the strongest predictor of the time
to such a surgery and income is insignicant as a predictive factor (Hawker etal. 2006).
regular basis. So far, there are 300 patients on the hospital’s waiting list and on average 3–4 are added weekly.
As another example, the largest hospital in the country (BLH), located in the capital city, Addis Ababa, has
started to register needy patients with clear indications
for TKA. By the end of December 2019, 77 patients
were put on the waiting list although there was no
announcement of the registration process, no such surgery had been performed in that hospital previously, and
> In countries like Ethiopia and the rest of East Africa,
income is known to be a crucial factor.
there was no known or predicted time when TKA could
be done in the future, except for optimistic promises
awaiting voluntary surgeons and donors.
In general, in the East African region, TKA surgery is in
its infancy for several reasons. Most patients with indications for TKA either do not come to hospitals as from
the outset they believe that their condition is an expected
stage of their aging process to which one should get used
> The most probable explanation for the observed rise
in the demand for TKAs could be the increase of the
aging population and apparent lifestyle changes in
the country.
to, or due of a lack of adequate numbers of properly
trained knee arthroplasty surgeons and implants the
problem is referred to overseas.
Taking a look at the Ethiopian experience, e.g.,
among cases that were referred abroad for advanced
treatments from BLH, the largest hospital in Ethiopia,
in 2008, TKA was found to be the third most common
indication, being preceded only by total hip replacement
and ACL reconstruction (Bezabih and Wamisho 2013).
Over the past several years, knee arthroplasty has
been performed in Ethiopia only by visiting surgeons
from developed countries in the form of campaigns once
in a while. The rest of the patients are referred abroad or
obliged to choose living with their ailments because of
nancial constraints. It is only recently that TKA has
started to be performed on a regular basis, though still
Over the past decade, there are several indicators that
more and more people get used to sedentary life and
“Western” food items such as fast food alongside
increasing urbanization and economic growth. These
conditions have increased the prevalence of obesity, one
of the main risk factors for OA and progressive knee
arthropathy.
While trying to explain the reasons for the observed
recent increment in the prevalence of obesity among the
Ethiopian community, Dagne et al. (2019) identied
new habits like snacking and alcohol drinking as well as
an ongoing improvement of the economic status in the
society to be the main contributory factors. Compared
to previous reports, they also reported that overweight
and obesity are on the rise.
Osteoarthritis andOther Indications forTotal Knee Arthroplasty: AnEast African Perspective
https://t.me/medicina_free
31
3
Therefore, lifestyle changes, together with the
improving trust in modern medicine and the raising
awareness (especially in rural areas) regarding the presence of a “medical solution” for the problem mostly
conceived as a natural process of aging which the
patients are destined to live with for the rest of their
lives, are believed to have increased the number of people demanding TKA.
Data on the trend of TKA in the rest of East African
countries are not available, probably due to limited experience and short-lived practice of TKA in the region.
Take-Home Messages
5 OA of the knee is one of the most prevalent types
and has an ongoing increase in incidence in line with
prevalence of aging and obesity.
5 Family history of the condition, aging, obesity,
occupation/type of activity, trauma, other arthritic
conditions, and mechanical factors predispose an
individual to OA.
5 In obese patients, weight loss is an important strat-
egy to check the progression of OA.Exercise programs that do not cause further stress on the knee
and its overlying cartilage along with diet modications should be incorporated into the prevention as
well as management strategies of OA.
5 There is no internationally agreed protocol for when
to pursue TKA in an individual patient with OA or
other degenerative joint diseases. But in general, in
the presence of radiologic evidence for end- stage
degenerative knee joint disease, TKA is recommended when there is a continued pain despite an
attempt of a 6-month course of nonoperative treatment.
5 The scanty studies done in East Africa showed that
by far the vast majority of TKA is done, in the
region, for patients with OA.
5 Lack of healthcare insurance (i.e., affordability of
the surgery) and sociocultural barriers are crucial
factors determining the decision to consider TKA in
East Africa, besides the clinical decisions.
5 The number of patients requiring TKAs is increas-
ing in East Africa, probably because of the increasing incidence of obesity and the society’s improving
awareness on the availability as well as effectiveness
of TKA as a treatment option.
References
Akinpelu AO, Maduagwu SM, Odole AC, Alonge TO (2011)
Prevalence and pattern of knee osteoarthritis in a North Eastern
Nigerian rural community. East African Orthop J 5:48–54
Arden N, Nevitt MC (2006) Osteoarthritis: epidemiology. Best Pract
Res Clin Rheumatol 20(1):3–25
Audrey HX, Abd Razak HR, Andrew TH (2014) The truth behind
subchondral cysts in osteoarthritis of the knee. Open Orthop J
8:7–10
Bannuru RR, Bierma-Zeinstra SMA, Blanco FJ etal (2019) OARSI
guidelines for the non-surgical management of knee, hip, and
polyarticular osteoarthritis. Osteoarthr Cartil 27:1578e1589
Bellamy N, Campbell J, Robinson V etal (2006) Viscosupplementation
for the treatment of osteoarthritis of the knee. Cochrane
Database Syst Rev 19(2):CD005321
Bezabih B, Wamisho BL (2013) Referrals of Ethiopian orthopedic
patients for treatment abroad. COSECSA/ASEA Publication –
East Central Afr J Surg 18(1)
Bliddal H, Leeds AR, Christensen R (2014) Osteoarthritis, obesity
and weight loss: evidence, hypotheses and horizons– a scoping
review. Obes Rev 15:578–586
Coleman B, McChesney S, Twaddle B (2005) Does the priority scor-
ing system for joint replacement really identify those in most
need? N Z Med J 118(1215):U1463
Dagne S, Gelaw YA, Abebe Z, Wassie MM (2019) Factors associated
with overweight and obesity among adults in Northeast
Ethiopia: a cross-sectional study. Diabetes Metab Syndr Obes
12:391–399
Davies PSE, Graham SM, Maqungo S, Harrison WJ (2019) Total
joint replacement in sub-Saharan Africa: a systematic review.
Trop Dr 49(2):120–128
Dieppe P, Basler HD, Chard J etal (1999) Knee replacement surgery
for osteoarthritis: effectiveness, practice variations, indications
and possible determinants of utilization. Rheumatology 38:73–83
Felson DT, Naimark A, Anderson J etal (1987) The prevalence of
knee osteoarthritis in the elderly: the Framingham Osteoarthritis
Study. Arthritis Rheum 30(8):914–918
Hardorn DC, Holmes AC (1997) The New Zealand priority criteria
project. Part 1: overview. Br Med J 314:131–314
Hawker GA, Guan J, Croxford R et al (2006) A prospective
population- based study of the predictors of undergoing total
joint arthroplasty. Arthritis Rheum 54(10):3212–3220
Heidari B (2011) Knee osteoarthritis prevalence, risk factors, patho-
genesis and features: part I.Caspian J Intern Med 2(2):205–212
Heidari B, Abedi H, Firouzjahi A, Heidari P (2010) Diagnostic value
of synovial uid anti-cyclic citrullinated peptide antibody for
rheumatoid arthritis. Rheumatol Int 30:1465–1470
Hepper CT, Halvorson JJ, Duncan ST etal (2009) The efcacy and
duration of intra-articular corticosteroid injection for knee
osteoarthritis: a systematic review of level I studies. J Am Acad
Orthop Surg 17(10):638–646
Hinton R, Moody RL, Alan W, Thomas SF (2002) Osteoarthritis:
diagnosis and therapeutic considerations. Am Fam Physician
65(5):841–848
Katchy AU, Katchy SC, Ekwedigwe HC, Ezeobi I (2018) Total knee
replacement in Nigeria: an assessment of early functional outcome of 68 consecutive knees. Niger J Clin Pract 21:1202–1208
32
https://t.me/medicina_free
S. M. Yasin
Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-
arthrosis. Ann Rheum Dis 16:494e502
Kigera JWM, Kimpiatu P (2015) Incidence of early post operative
infection after primary total knee arthroplasty at an East African
centre. Ann Afr Surg 12:70–72
Kim RH, Springer BD, Douglas DA (2011) Knee reconstruction and
replacement. In: Flynn F (ed) Orthopaedic knowledge update.
3
American Academy of Orthopaedic Surgeons, Rosemont, IL,
pp469–475
Klussmann A, Gebhardt H, Nübling M etal (2010) Individual and
occupational risk factors for knee osteoarthritis: results of a
case-control study in Germany. Arthritis Res Ther 12:R88
Martin JA, Ramakrishnan PA, Lim T etal (2011) Articular cartilage
and intervertebral disk. In: Flynn JM (ed) Orthopaedic knowl-
edge update, 10th edn. American Academy of Orthopaedic
Surgeons, Rosemont, IL, pp23–26
McAlindon TE, Cooper C, Kirwan JR, Dieppe PA (1993)
Determinants of disability in osteoarthritis of the knee. Ann
Rheum Dis 52:258–262
Murphy L, Schwartz TA, Helmick CG et al (2008) Lifetime risk of
symptomatic knee osteoarthritis. Arthritis Rheum 59(9):1207–1213
Niu J, Zhang YQ, Torner J etal (2009) Is obesity a risk factor for
progressive radiographic knee osteoarthritis? Arthritis Rheum
61:329–335
O’Connor MI, Hooten EG (2011) Breakout session: gender dispari-
ties in knee osteoarthritis and TKA. Clin Orthop Relat Res
469:1883–1885
Oosthuizen CR, Takahashi T, Snyckers CH etal (2018) The knee
osteoarthritis grading system for arthroplasty. J Arthroplast
34:450e455
Peat G, Thomas E, Duncan R etal (2007) Estimating the probability
of radiographic osteoarthritis in the older patient with knee
pain. Arthritis Rheum 57(5):794–802
Singh JA, Vessely MB, Harmsen WS etal (2010) A population-based
study of trends in the use of total hip and total knee arthoplasty,
1969–2008. Mayo Clin Proc 85(10):898–904
Tateishi H (2001) Indications for total knee arthroplasty and choice
of prosthesis. JMAJ 44:153–158
Van Manen MD, Nace J, Mont MA (2012) Management of primary
knee osteoarthritis and indications for total knee arthroplasty
for general practitioners. J Am Osteopath Assoc 112:709–715
Wegman A, van der Windt D, van Tulder M etal (2004) Nonsteroidal
antiinammatory drugs or acetaminophen for osteoarthritis of
the hip or knee? A systematic review of the evidence and guidelines. J Rheumatol 31(2):344–354
Zhang Y, Jordan JM (2010) Epidemiology of osteoarthritis. Clin
Geriatr Med 26:355–369
Zhang W, Moskowitz RW, Nuki G etal (2008) OARSI recommenda-
tions for the management of hip and knee osteoarthritis: part
II. OARSI evidence-based, expert consensus guidelines.
Osteoarthr Cartil 16(2):137–162
Inammatory Arthritis
https://t.me/medicina_free
ZacharyK.Christopher, JaymesonR.Arthur, andMarkJ.Spangehl
Contents
4.1 Introduction – 34
4.2 Case Example – 34
4.3 Preoperative Considerations – 35
4.3.1 General Medical Evaluation – 35
4.3.2
Medications – 35
Orthopedic Evaluation – 40
4.3.3
4.4 Intraoperative Considerations – 41
4.5 Postoperative Considerations – 42
4.5.1 Medications – 42
4.5.2 Complications – 43
4.5.3 Implant Survivorship – 44
33
4
4.6 Conclusion – 44
References – 45
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_4
34
https://t.me/medicina_free
Z. K. Christopher et al.
4.1 Introduction
> For this reason, uncemented TKA in this patient pop-
ulation is strongly discouraged.
Patients with inammatory arthritis planning to
undergo total knee arthroplasty (TKA) present several
unique challenges for orthopedic surgeons. In this chapter, we will briey review how to approach the patient
with inammatory arthritis and outline critical preoperative, intraoperative, and postoperative consider-
4
ations to aid in a successful cemented TKA in this
Further, patients can often exhibit signicant cystic
changes and focal bone loss.
The surgeon should carefully scrutinize preoperative
X-rays to be aware of and prepared to address these
bony defects as bone grafting or augmentation is often
required.
patient population.
Inammatory arthropathies encompass numerous
diseases, all causing systemic inammation, often with
> Bony deformity as well as ligament incompetence
may also be present in these patients.
multiple joint involvement. These diseases include the
following:
5 Rheumatoid arthritis (RA).
5 Psoriatic arthritis.
5 Ankylosing spondylitis.
5 Juvenile idiopathic arthritis (JIA).
5 Systemic lupus erythematosus (SLE).
The surgeon should be prepared with implants that
impart a higher level of constraint if necessary. However, as previously noted, the quality of the subchondral
bone is often decient in these patients and increasing
constraint imparts more mechanical shear on the bone–
cement interface. Hence, each case should be carefully
planned when deciding implant options as additional
> Rheumatoid arthritis is the most common form of
inammatory arthritis in the United States and the
majority of literature on TKA in inammatory
arthritis focuses on this patient population (Schrama
et al. 2010; Bongartz et al. 2008; Cancienne et al.
2016).
xation may be required when managing bony deciency or using an increased level of constraint.
> Systemic effects of inammatory arthritis include
immunosuppression, respiratory and cardiac comor-
bidities, wound healing issues, cervical spine pathol-
ogy, dermatologic manifestations, and malnutrition.
While each disease entity may have several specic
factors that should be considered, it is critical to understand that a common thread among all inammatory
arthropathies is the combination of both local and systemic effects produced by the disease and, therefore,
both local and systemic factors must be considered for
optimizing outcomes.
Furthermore, long-term corticosteroid use and
immunosuppressive medications often render these
patients immunocompromised. Therefore, in addition to
surgical considerations, it is important to ensure medical
optimization prior to the procedure. Consulting with the
patient’s rheumatologist preoperatively, or consulting
one if a patient is presenting with a new diagnosis, is
> Local effects of inammatory arthritis include gener-
alized osteopenia, bony erosions and deformity, and
soft tissue derangement.
recommended. Assessment by a rheumatologist can aid
in optimizing the patient’s medication management,
which has become the mainstay for treatment for the
majority of these conditions.
Studies using magnetic resonance imaging (MRI)
and ultrasonography (US) have been pivotal in our
understanding of the pathogenesis of the inammatory
4.2 Case Example
process at a joint-specic level (Boutry et al. 2007;
Sudoł-Szopińska etal. 2017; Henchie etal. 2019). Common ndings include synovitis, tenosynovitis, bursitis,
and subchondral bone marrow edema and erosions.
Studies have shown that it is the subchondral bone that
is most signicantly affected (Lereim and Goldie 1975;
Lereim etal. 1974; Yang etal. 1997). This nding is of
particular importance to the arthroplasty surgeon as
this is where prosthetic xation is achieved and where
the bone–cement interface is most robustly xated.
A 33-year-old female presented to the clinic with several
years of bilateral knee pain and a history of rheumatoid
arthritis diagnosed 10years prior. She was being managed by a rheumatologist and had been treated with several medications including prednisone 8 mg daily,
hydroxychloroquine 200mg twice daily, and sulfasalazine 1000mg twice daily. In addition, she used rituximab
twice annually, most recently 3months prior to presentation. She was dependent on a walker or wheelchair
Inammatory Arthritis
https://t.me/medicina_free
35
4
and could only ambulate for very short distances unassisted. She had tried over-the-counter medications
including acetaminophen and NSAIDs without
signicant relief. On examination, she had marked varus
malalignment bilaterally and a lateral thrust. Her varus
was correctable to nearly neutral. She had good range of
motion from 3° to 125° on the left and 0° to 130° on the
right. Neurovascular exam was normal. Plain radiographs demonstrated severe bilateral knee deformities
with signicant tricompartmental arthritis with joint
space narrowing, sclerosis, and varus malalignment
(. Fig.4.1).
The patient ultimately underwent bilateral-staged
TKAs approximately 6weeks apart. Prior to her surgeries, her prednisone was weaned down to 6mg/day. This
medication was continued in the perioperative period
along with sulfasalazine. Preoperative cervical spine
lms revealed 3 mm anterolisthesis of C1 on C2
(.
Fig.4.2). For both knee arthroplasties, varus/valgus-
stabilized cemented implants were utilized with 50mm
stem extensions. On the left side, a medial tibial augment
was used because of severe medial bone deciency. On
the right, a smaller defect was lled with cement.
Prophylactic tobramycin was used in the cement. At
most recent follow-up of 3 years postoperative, the
patient was doing well with no pain and had returned to
activities like 6-mile elliptical exercises. Her knees were
stable to varus and valgus stress without laxity, and both
knees had excellent range of motion from 0° to 135°.
Radiographs demonstrated well-xed, well-positioned
implants without any concerns of loosening (. Fig.4.3).
4.3 Preoperative Considerations
Prior to elective surgery, patients with inammatory
arthritis must undergo a thorough multidisciplinary preoperative evaluation. In addition to the orthopedic evaluation, particular attention should be paid to the
cardiovascular system and the cervical spine. Further,
preoperative and perioperative medication management
in patients with inammatory arthritis has been a subject of much debate and research and, as such, a signicant portion of this chapter will focus on the management
of these various medications.
4.3.1 General Medical Evaluation
> As part of the multidisciplinary workup, a thorough
cardiac evaluation should be performed.
Studies have shown that patients with inammatory
arthritis such as rheumatoid arthritis are at an increased
risk of cardiovascular-related death compared to the
general population (Meune etal. 2009; Ogdie etal. 2015;
Avina-Zubieta etal. 2012). Lindharden etal. evaluated
over four million patients in their cohort study and
found that the risk of myocardial infarction in patients
with RA was similar to that of patients with diabetes
and to that of non-rheumatoid patients who were
10years older (Lindhardsen etal. 2011). Further, Ogdie
etal. showed that psoriatic arthritis may be an independent risk factor for major cardiac events in the perioperative period, particularly in those patients not on
disease-modifying antirheumatic drugs (DMARDs)
(Ogdie etal. 2015). Based on a patient’s cardiac conditions, the primary care/medicine team can determine if
further cardiac testing is warranted outside of the standard electrocardiogram and physical examination. Close
collaboration with these teams to ensure proper perioperative risk evaluation and medical optimization will
help safeguard the best overall outcomes.
> Cervical spine disease is common in patients with
inammatory arthritis, especially in patients with RA
(Kwek et al. 1998; Lopez-Olivo et al. 2012; Krause
and Matteson 2014).
Abnormalities include atlantoaxial subluxation,
atlantoaxial impaction, and subaxial subluxation.
Although no clinical practice guidelines have been established for preoperative imaging in patients with inammatory arthritis, the anesthesiology team should always
be made aware of this condition, as intraoperative positioning and method of intubation may be affected based
on the presence or absence of cervical spine disease. The
anesthesiology team typically requires cervical spine
X-ray including exion–extension views (Lopez-Olivo
et al. 2012). Further, based on anesthesia’s assessment,
the use of regional blocks or exible ber optic bronchoscopy has been increasingly utilized in this patient population in order to mitigate potential adverse events related
to preexisting cervical spine disease (Kwek etal. 1998).
4.3.2 Medications
There are numerous medications used to treat inammatory diseases. It is important to understand each class
and how to manage these medications pre- and postoperatively. In general, many patients with systemic inammatory arthritis are generally immunocompromised. The
American College of Rheumatology and the American
Association of Hip and Knee Surgeons (ACR- AAHKS)
published a series of evidence-based guidelines on perioperative medication management that can be used to
guide decision-making (. Table 4.1; 7 https://www.
rheumatology. org/Portals/0/Files/ACR- AAHKSPerioperative- Management- Guideline. pdf).
36
ab
https://t.me/medicina_free
Z. K. Christopher et al.
4
c
. Fig. 4.1 a–e Preoperative bilateral knee radiographs
ab
Inammatory Arthritis
https://t.me/medicina_free
de
37
4
. Fig. 4.1 (continued)
. Fig. 4.2 a, b Preoperative exion–extension cervical spine radiographs
38
ab
cd
https://t.me/medicina_free
Z. K. Christopher et al.
4
. Fig. 4.3 a–d Postoperative bilateral knee radiographs
Inammatory Arthritis
https://t.me/medicina_free
. Table 4.1 Perioperative medication management in patients with inammatory diseases
DMARDs: Continue these medications through surgery Dosing interval Continue/withhold
Methotrexate Weekly Continue
Sulfasalazine Once or twice daily Continue
Hydroxychloroquine Once or twice daily Continue
Leunomide (Arava) Daily Continue
Doxycycline Daily Continue
Biologic Agents: Stop these medications prior to surgery at the
end of the dosing cycle. Resume medications at minimum 14days
after surgery in the absence of wound healing problems, surgical
site infection, or systemic infection
Adalimumab (Humira) Weekly or every 2weeks Week 2 or 3
Etanercept (Enbrel) Weekly or twice weekly Week 2
Golimumab (Simponi) Every 4weeks (SQ) or
Iniximab (Remicade) Every 4, 6, or 8weeks Week 5, 7, or 9
Abatacept (Orenica) Monthly (IV) or
Certolizumab (Cimzia) Every 2 or 4weeks Week 3 or 5
Rituximab (Rituxan) 2 doses 2weeks apart every
Tocilizumab (Actemra) Every week (SQ) or
Anakinra (Kineret) Daily Day 2
Secukinumab (Cosentyx) Every 4weeks Week 5
Ustekinumab (Stelara) Every 12weeks Week 13
Belimumab (Benlysta) Every 4weeks Week 5
Tofacitinib (Xeljanz): Stop this medication 7days prior to
surgery
Severe Sle-specic Medications: Continue these medications in
the perioperative period
Mycophenolate mofetil Twice daily Continue
Azathioprine Daily or twice daily Continue
Cyclosporine Twice daily Continue
Tacrolimus Twice daily (IV and PO) Continue
Not-severe Sle: Discontinue these medications 1week prior to
surgery
Mycophenolate mofetil Twice daily Continue
Azathioprine Daily or twice daily Continue
Cyclosporine Twice daily Continue
Tacrolimus Twice daily (IV and PO) Continue
Dosing interval Schedule surgery (relative to
last biologic agent dose
administered) during
Week 5
Every 8weeks (IV)
Weekly (SQ)
4–6months
Every 4weeks (IV)
Daily or twice daily 7days after last dose
Dosing interval Continue/withhold
Dosing interval Continue/withhold
Week 9
Week 5
Week 2
Month 7
Week 5
Week 2
39
4
Courtesy of the 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee
Arthroplasty(Goodman etal. 2017)
Соседние файлы в папке Библиотека им академика М.И. Перельмана