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International Orthopaedics

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Open Access 01-03-2021 | Hip-TEP | Review Article

What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?

Authors: Octavian Andronic, Ori Weiss, Haitham Shoman, Philipp Kriechling, Vikas Khanduja

Published in: International Orthopaedics | Issue 3/2021

Abstract

Purpose

Core decompression (CD) of the femoral head is performed to preserve the hip in avascular necrosis (AVN). The outcome following this procedure differs based on the medical centre and the technique. Also, the time to total hip replacement (THR) and the percentage of patients subsequently undergoing a THR are controversial.

Methods

A systematic review was performed following PRISMA guidelines. The search included CENTRAL, MEDLINE, EMBASE, Scopus, AMED and Web of Science Core Collection databases. Studies reporting the outcome of CD for AVN were assessed. Studies using additional implants, vascularized grafts or any type of augmentation were excluded. Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC) tool.

Trial registration

International prospective register of systematic reviews (PROSPERO) - CRD42018100596.

Results

A total of 49 studies describing 2540 hips were included. The mean weighted follow-up time was 75.1 months and the mean age at surgery was 39 years. Twenty-four of 37 studies reported improvement in all outcome scores, whilst 9/37 studies report only partial improvement post-operatively. Four studies (4/37) described poor clinical outcomes following intervention. Data was pooled from 20 studies, including 1134 hips with a weighted mean follow-up of 56 months. The percentage of hips undergoing THR averaged 38%. The time to THR had a weighted mean of 26 months after CD.

Conclusion

Pooled results from 1134 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 38% of patients underwent a total hip replacement at an average of 26 months following core decompression without augmentation.

Available only for authorised users

Steinberg ME, Larcom PG, Strafford B, Hosick WB, Corces A, Bands RE, Hartman KE (2001) Core decompression with bone grafting for osteonecrosis of the femoral head. A Publication of The Association of Bone and Joint Surgeons® | CORR® 386:71-78

Bergh C, Fenstad AM, Furnes O, Garellick G, Havelin LI, Overgaard S, Pedersen AB, Makela KT, Pulkkinen P, Mohaddes M, Karrholm J (2014) Increased risk of revision in patients with non-traumatic femoral head necrosis. Acta Orthop 85(1):11–17. https://doi.org/10.3109/17453674.2013.874927CrossRefPubMedPubMedCentral

Shah KN, Racine J, Jones LC, Aaron RK (2015) Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med 8(3):201–209. https://doi.org/10.1007/s12178-015-9277-8CrossRefPubMedPubMedCentral

Sultan AA, Mohamed N, Samuel LT, Chughtai M, Sodhi N, Krebs VE, Stearns KL, Molloy RM, Mont MA (2018) Classification systems of hip osteonecrosis: an updated review. Int Orthop. https://doi.org/10.1007/s00264-018-4018-4

Jawad MU, Haleem AA, Scully SP (2012) In brief: Ficat classification: avascular necrosis of the femoral head. Clin Orthop Relat Res 470(9):2636–2639. https://doi.org/10.1007/s11999-012-2416-2CrossRefPubMedPubMedCentral

Smith SW, Meyer RA, Connor PM, Smith SE, Hanley EN Jr (1996) Interobserver reliability and intraobserver reproducibility of the modified Ficat classification system of osteonecrosis of the femoral head. J Bone Joint Surg Am 78(11):1702–1706CrossRef

Yoon BH, Jones LC, Chen CH, Cheng EY, Cui Q, Drescher W, Fukushima W, Gangji V, Goodman SB, Ha YC, Hernigou P, Hungerford M, Iorio R, Jo WL, Khanduja V, Kim H, Kim SY, Kim TY, Lee HY, Lee MS, Lee YK, Lee YJ, Mont MA, Sakai T, Sugano N, Takao M, Yamamoto T, Koo KH (2019) Etiologic classification criteria of ARCO on femoral head osteonecrosis Part 2: alcohol-associated osteonecrosis. J Arthroplast 34(1):169–174.e161. https://doi.org/10.1016/j.arth.2018.09.006CrossRef

Yoon BH, Jones LC, Chen CH, Cheng EY, Cui Q, Drescher W, Fukushima W, Gangji V, Goodman SB, Ha YC, Hernigou P, Hungerford M, Iorio R, Jo WL, Khanduja V, Kim H, Kim SY, Kim TY, Lee HY, Lee MS, Lee YK, Lee YJ, Mont MA, Sakai T, Sugano N, Takao M, Yamamoto T, Koo KH (2019) Etiologic classification criteria of ARCO on femoral head osteonecrosis Part 1: glucocorticoid-associated osteonecrosis. J Arthroplast 34(1):163–168.e161. https://doi.org/10.1016/j.arth.2018.09.005CrossRef

Yoon BH, Mont MA, Koo KH, Chen CH, Cheng EY, Cui Q, Drescher W, Gangji V, Goodman SB, Ha YC, Hernigou P, Hungerford MW, Iorio R, Jo WL, Jones LC, Khanduja V, Kim HKW, Kim SY, Kim TY, Lee HY, Lee MS, Lee YK, Lee YJ, Nakamura J, Parvizi J, Sakai T, Sugano N, Takao M, Yamamoto T, Zhao DW (2020) The 2019 revised version of association research circulation osseous staging system of osteonecrosis of the femoral head. J Arthroplast 35(4):933–940. https://doi.org/10.1016/j.arth.2019.11.029CrossRef

10.

Arbeloa-Gutierrez L, Dean CS, Chahla J, Pascual-Garrido C (2016) Core decompression augmented with autologous bone marrow aspiration concentrate for early avascular necrosis of the femoral head. Arthrosc Tech 5(3):e615–e620. https://doi.org/10.1016/j.eats.2016.02.009CrossRefPubMedPubMedCentral

11.

Ma Y, Wang T, Liao J, Gu H, Lin X, Jiang Q, Bulsara MK, Zheng M, Zheng Q (2014) Efficacy of autologous bone marrow buffy coat grafting combined with core decompression in patients with avascular necrosis of femoral head: a prospective, double-blinded, randomized, controlled study. Stem Cell Res Ther 5(5):115. https://doi.org/10.1186/scrt505CrossRefPubMedPubMedCentral

12.

Markel DC, Miskovsky C, Sculco TP, Pellicci PM, Salvati EA (1996) Core decompression for osteonecrosis of the femoral head. Clin Orthop Relat Res 323:226–233CrossRef

13.

Simank HG, Brocai DR, Brill C, Lukoschek M (2001) Comparison of results of core decompression and intertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Cox regression and survivorship analysis. J Arthroplast 16(6):790–794. https://doi.org/10.1054/arth.2001.23580CrossRef

14.

Yoon BH, Lee YK, Kim KC, Ha YC, Koo KH (2018) No differences in the efficacy among various core decompression modalities and non-operative treatment: a network meta-analysis. Int Orthop. https://doi.org/10.1007/s00264-018-3977-9

15.

Andronic O, Shoman H, Weiss O, Khanduja V (2020) What are the outcomes of core decompression in patients with avascular necrosis? Protocol for a systematic review [version 1; peer review: 2 approved]. F1000Research 9(71). https://doi.org/10.12688/f1000research.22167.1

16.

Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P (2015) Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc 13(3):132–140. https://doi.org/10.1097/xeb.0000000000000055CrossRefPubMed

17.

Ancelin D, Reina N, Cavaignac E, Delclaux S, Chiron P (2016) Total hip arthroplasty survival in femoral head avascular necrosis versus primary hip osteoarthritis: case-control study with a mean 10-year follow-up after anatomical cementless metal-on-metal 28-mm replacement. Orthop Traumatol Surg Res 102(8):1029–1034. https://doi.org/10.1016/j.otsr.2016.08.021CrossRefPubMed

18.

Tripathy S, Goyal T, Sen R (2015) Management of femoral head osteonecrosis: current concepts. Indian J Orthop 49(1):28–45. https://doi.org/10.4103/0019-5413.143911CrossRefPubMedPubMedCentral

19.

Soohoo NF, Vyas S, Manunga J, Sharifi H, Kominski G, Lieberman JR (2006) Cost-effectiveness analysis of core decompression. J Arthroplast 21(5):670–681. https://doi.org/10.1016/j.arth.2005.08.018CrossRef

20.

Marker DR, Seyler TM, Ulrich SD, Srivastava S, Mont MA (2008) Do modern techniques improve core decompression outcomes for hip osteonecrosis? Clin Orthop Relat Res 466(5):1093–1103. https://doi.org/10.1007/s11999-008-0184-9CrossRefPubMedPubMedCentral

21.

Wang Z, Sun QM, Zhang FQ, Zhang QL, Wang LG, Wang WJ (2019) Core decompression combined with autologous bone marrow stem cells versus core decompression alone for patients with osteonecrosis of the femoral head: a meta-analysis. Int J Surg (London, England) 69:23–31. https://doi.org/10.1016/j.ijsu.2019.06.016CrossRef

22.

Zhang C, Fang X, Huang Z, Li W, Zhang W, Lee GC (2020) Addition of bone marrow stem cells therapy achieves better clinical outcomes and lower rates of disease progression compared with core decompression alone for early stage osteonecrosis of the femoral head: a systematic review and meta-analysis. J Am Acad Orthop Surg. https://doi.org/10.5435/jaaos-d-19-00816

23.

Xu S, Zhang L, Jin H, Shan L, Zhou L, Xiao L, Tong P (2017) Autologous stem cells combined core decompression for treatment of avascular necrosis of the femoral head: a systematic meta-analysis. Biomed Res Int 2017:6136205. https://doi.org/10.1155/2017/6136205CrossRefPubMedPubMedCentral

24.

Aaron RK, Lennox D, Bunce GE, Ebert T (1989) The conservative treatment of osteonecrosis of the femoral head. A comparison of core decompression and pulsing electromagnetic fields. Clin Orthop Relat Res (249):209–218

25.

Abrisham SMJ, Hajiesmaeili MR, Soleimani H, Pahlavanhosseini H (2013) Efficacy of core decompression of femoral head to treat avascular necrosis in intravenous drug users. Acta Med Iran 51(4):250–253PubMed

26.

Aigner N, Schneider W, Eberl V, Knahr K (2002) Core decompression in early stages of femoral head osteonecrosis--an MRI-controlled study. Int Orthop 26(1):31–35CrossRef

27.

Arlet J, Ficat C (1990) Ischemic necrosis of the femoral head. Treatment by core decompression. J Bone Joint Surg Am 72(1):151–152CrossRef

28.

Beckmann J, Schmidt T, Schaumburger J, Rath B, Lüring C, Tingart M, Grifka J (2013) Infusion, core decompression, or infusion following core decompression in the treatment of bone edema syndrome and early avascular osteonecrosis of the femoral head. Rheumatol Int 33(6):1561–1565. https://doi.org/10.1007/s00296-012-2597-8CrossRefPubMed

29.

Beltran J, Knight CT, Zuelzer WA, Morgan JP, Shwendeman LJ, Chandnani VP, Mosure JC, Shaffer PB (1990) Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging. Radiology 175(2):533–536. https://doi.org/10.1148/radiology.175.2.2326478CrossRefPubMed

30.

Bi B, Zhang S, Zhao Y (2019) The effect of robot-navigation-assisted core decompression on early stage osteonecrosis of the femoral head. J Orthop Surg Res 14(1):375. https://doi.org/10.1186/s13018-019-1437-xCrossRefPubMedPubMedCentral

31.

Bozic KJ, Zurakowski D, Thornhill TS (1999) Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head. J Bone Joint Surg Am 81(2):200–209CrossRef

32.

Chen Q, Qian L, Zhang L, Wang DS, Pan Q, Wu QM, He M, Jin Y, Chen Y, Huang RH, Zhai Y, Luo JY, Liao D, Xiao Y, Sunwen YM (2016) Core decompression combined with superselective arterial infusion in treating early nontraumatic osteonecrosis of femoral head. Int J Clin Exp Med 9(6):10281–10288

33.

Classen T, Warwas S, Jäger M, Landgraeber S (2017) Two-year follow-up after advanced core decompression. J Tissue Eng Regen Med 11(4):1308–1314. https://doi.org/10.1002/term.2056CrossRefPubMed

34.

Cruz-Pardos A, Garcia-Rey E, Ortega-Chamarro JA, Duran-Manrique D, Gomez-Barrena E (2016) Mid-term comparative outcomes of autologous bone-marrow concentration to treat osteonecrosis of the femoral head in standard practice. Hip Int 26(5):432–437. https://doi.org/10.5301/hipint.5000366CrossRefPubMed

35.

Etemadifar M, Kooskzari M, Khalilollah N, Ali MK, Mahsa B (2014) The results of core decompression treatment in patients with avascular necrosis of femoral head in patients at Isfahan City educational hospitals in 2010-2011. Adv Biomed Res 3:93. https://doi.org/10.4103/2277-9175.129363CrossRefPubMedPubMedCentral

36.

Fairbank AC, Bhatia D, Jinnah RH, Hungerford DS (1995) Long-term results of core decompression for ischaemic necrosis of the femoral head. J Bone Joint Surg Br Vol 77(1):42–49CrossRef

37.

Gangji V, Maertelaer V, Hauzeur J-P (2011) Autologous bone marrow cell implantation in the treatment of non-traumatic osteonecrosis of the femoral head: five year follow-up of a prospective controlled study. Bone 49(5):1005–1009. https://doi.org/10.1016/j.bone.2011.07.032CrossRefPubMed

38.

Haberal B, Sahin O, Simsek EK, Mahmuti A, Tuncay IC (2018) Outcomes for core decompression with multiple drilling of the osteonecrosis of the femoral head in patients with solid organ transplantation. Eklem Hastaliklari Cerrahisi 29(3):159–164. https://doi.org/10.5606/ehc.2018.61348CrossRef

39.

Hauzeur JP, De Maertelaer V, Baudoux E, Malaise M, Beguin Y, Gangji V (2018) Inefficacy of autologous bone marrow concentrate in stage three osteonecrosis: a randomized controlled double-blind trial. Int Orthop 42(7):1429–1435. https://doi.org/10.1007/s00264-017-3650-8CrossRefPubMed

40.

Hernigou P, Dubory A, Homma Y, Guissou I, Lachaniette CHF, Chevallier N, Rouard H (2018) Cell therapy versus simultaneous contralateral decompression in symptomatic corticosteroid osteonecrosis: a thirty year follow-up prospective randomized study of one hundred and twenty five adult patients. Int Orthop 42(7):1639–1649. https://doi.org/10.1007/s00264-018-3941-8CrossRefPubMed

41.

Iorio R, Healy WL, Abramowitz AJ, Pfeifer BA (1998) Clinical outcome and survivorship analysis of core decompression for early osteonecrosis of the femoral head. J Arthroplast 13(1):34–41CrossRef

42.

Israelite C, Nelson CL, Ziarani CF, Abboud JA, Landa J, Steinberg ME (2005) Bilateral core decompression for osteonecrosis of the femoral head. Clin Orthop Relat Res 441:285–290CrossRef

43.

Ito H, Matsuno T, Omizu N, Aoki Y, Minami A (2003) Mid-term prognosis of non-traumatic osteonecrosis of the femoral head. J Bone Joint Surg Br Vol 85(6):796–801CrossRef

44.

Kang P, Pei F, Shen B, Zhou Z, Yang J (2012) Are the results of multiple drilling and alendronate for osteonecrosis of the femoral head better than those of multiple drilling? A pilot study. Joint Bone Spine 79(1):67–72. https://doi.org/10.1016/j.jbspin.2011.02.020CrossRefPubMed

45.

Kang JS, Suh YJ, Moon KH, Park JS, Roh TH, Park MH, Ryu DJ (2018) Clinical efficiency of bone marrow mesenchymal stem cell implantation for osteonecrosis of the femoral head: a matched pair control study with simple core decompression. Stem Cell Res Ther 9(1):274. https://doi.org/10.1186/s13287-018-1030-yCrossRefPubMedPubMedCentral

46.

Kristensen KD, Pedersen NW, Kiaer T, Starklint H (1991) Core decompression in femoral head osteonecrosis. 18 Stage I hips followed up for 1-5 years. Acta Orthop Scand 62(2):113–114CrossRef

47.

Lakshminarayana S, Dhammi I, Jain A, Bhayana H, Kumar S, Anshuman R (2019) Outcomes of core decompression with or without nonvascularized fibular grafting in avascular necrosis of femoral head: short term followup study. Indian J Orthop 53(3):420–425. https://doi.org/10.4103/ortho.IJOrtho_310_18CrossRefPubMedPubMedCentral

48.

Lausten GS, Mathiesen B (1990) Core decompression for femoral head necrosis. Prospective study of 28 patients. Acta Orthop Scand 61(6):507–511CrossRef

49.

Learmonth ID, Maloon S, Dall G (1990) Core decompression for early atraumatic osteonecrosis of the femoral head. J Bone Joint Surg Br Vol 72(3):387–390CrossRef

50.

Li J, Li ZL, Zhang H, Su XZ, Wang KT, Yang YM (2017) Long-term outcome of multiple small-diameter drilling decompression combined with hip arthroscopy versus drilling alone for early avascular necrosis of the femoral head. Chin Med J 130(12):1435–1440. https://doi.org/10.4103/0366-6999.207470CrossRefPubMedPubMedCentral

51.

Maniwa S, Nishikori T, Furukawa S, Kajitani K, Iwata A, Nishikawa U, Ochi M (2000) Evaluation of core decompression for early osteonecrosis of the femoral head. Arch Orthop Trauma Surg 120(5-6):241–244CrossRef

52.

Mazières B, Marin F, Chiron P, Moulinier L, Amigues JM, Laroche M, Cantagrel A (1997) Influence of the volume of osteonecrosis on the outcome of core decompression of the femoral head. Ann Rheum Dis 56(12):747–750. https://doi.org/10.1136/ard.56.12.747CrossRefPubMedPubMedCentral

53.

Miao H, Ye D, Liang W, Yao Y (2015) Effect of Osteonecrosis intervention rod versus core decompression using multiple small drill holes on early stages of necrosis of the femoral head: a prospective study on a series of 60 patients with a minimum 1-year-follow-up. Open Orthop J 9:179–184. https://doi.org/10.2174/1874325001509010179CrossRefPubMedPubMedCentral

54.

Miyahara HS, Rosa BB, Hirata FY, Gurgel HMC, Ejnisman L, Vicente JRN (2018) What is the role of core decompression in the early stages of osteonecrosis of the femoral head? Evaluation of the surgical result by functional score and radiological follow-up. Rev Bras Ortop 53(5):537–542. https://doi.org/10.1016/j.rboe.2018.07.013CrossRefPubMedPubMedCentral

55.

Mohanty SP, Singh KA, Kundangar R, Shankar V (2017) Management of non-traumatic avascular necrosis of the femoral head—a comparative analysis of the outcome of multiple small diameter drilling and core decompression with fibular grafting. Musculoskelet Surg 101(1):59–66. https://doi.org/10.1007/s12306-016-0431-2CrossRefPubMed

56.

Mont MA, Fairbank AC, Petri M, Hungerford DS (1997) Core decompression for osteonecrosis of the femoral head in systemic lupus erythematosus. Clin Orthop Relat Res 334:91–97

57.

Mont MA, Jones LC, Pacheco I, Hungerford DS (1998) Radiographic predictors of outcome of core decompression for hips with osteonecrosis stage III. Clin Orthop Relat Res 354:159–168CrossRef

58.

Mont MA, Ragland PS, Etienne G (2004) Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res 429:131–138CrossRef

59.

Nori M, Marupaka SK, Alluri S, Naseeruddin MD, Irfan KA, Jampala V, Apsingi S, Eachempati KK (2015) MRI evaluation of post core decompression changes in avascular necrosis of HiP. J Clin Diagn Res 9(12):TC04–TC08. https://doi.org/10.7860/JCDR/2015/13995.6967CrossRefPubMedPubMedCentral

60.

Pepke W, Kasten P, Beckmann NA, Janicki P, Egermann M (2016) Core decompression and autologous bone marrow concentrate for treatment of femoral head osteonecrosis: a randomized prospective study. Orthop Rev 8(1):6162. https://doi.org/10.4081/or.2016.6162CrossRef

61.

Powell Iv ET, Lanzer WL, Mankey MG (1997) Core decompression for early osteonecrosis of the hip in high risk patients. Clin Orthop Relat Res 335:181–189CrossRef

62.

Sadile F, Bernasconi A, Carbone F, Lintz F, Mansueto G (2017) Histological fibrosis may predict the failure of core decompression in the treatment of osteonecrosis of the femoral head. Int J Surg (London, England) 44:303–308. https://doi.org/10.1016/j.ijsu.2017.06.079CrossRef

63.

Sallam AA, Imam MA, Salama KS, Mohamed OA (2017) Inverted femoral head graft versus standard core decompression in nontraumatic hip osteonecrosis at minimum 3 years follow-up. Hip Int 27(1):74–81. https://doi.org/10.5301/hipint.5000426CrossRefPubMed

64.

Simank HG, Brocai DR, Strauch K, Lukoschek M (1999) Core decompression in osteonecrosis of the femoral head: risk-factor-dependent outcome evaluation using survivorship analysis. Int Orthop 23(3):154–159CrossRef

65.

Song WS, Yoo JJ, Kim YM, Kim HJ (2007) Results of multiple drilling compared with those of conventional methods of core decompression. Clin Orthop Relat Res 454:139–146. https://doi.org/10.1097/01.blo.0000229342.96103.73CrossRefPubMed

66.

Tabatabaee R, Saberi S, Parvizi J, Mortazavi S, Farzan M (2015) Combining concentrated autologous bone marrow stem cells injection with core decompression improves outcome for patients with early-stage osteonecrosis of the femoral head: a comparative study. J Arthroplasty 30(9 Suppl):11–15. https://doi.org/10.1016/j.arth.2015.06.022CrossRefPubMed

67.

Tooke SM, Nugent PJ, Bassett LW, Nottingham P, Mirra J, Jinnah R (1988) Results of core decompression for femoral head osteonecrosis. Clin Orthop Relat Res 228:99–104

68.

Yan D, Chen L, Li Z, Guo W, Sun W (2015) Autologous mesenchymal stem cell implantation in the management of osteonecrosis of the femoral head. Curr Orthop Pract 26(3):265–268. https://doi.org/10.1097/BCO.0000000000000218CrossRef

69.

Yin H, Yuan Z, Wang D (2016) Multiple drilling combined with simvastatin versus multiple drilling alone for the treatment of avascular osteonecrosis of the femoral head: 3-year follow-up study. BMC Musculoskelet Disord 17(1):344. https://doi.org/10.1186/s12891-016-1199-0CrossRefPubMedPubMedCentral

70.

Yoon TR, Song EK, Rowe SM, Park CH (2001) Failure after core decompression in osteonecrosis of the femoral head. Int Orthop 24(6):316–318CrossRef

Title: What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?
Authors: Octavian Andronic
Ori Weiss
Haitham Shoman
Philipp Kriechling
Vikas Khanduja
Publication date: 01-03-2021
Publisher: Springer Berlin Heidelberg
Keywords: Hip-TEP
Hip Arthroscopy
Hip-TEP
Osteonecrosis
Osteonecrosis of the Femoral Head
Core Decompression
Published in: International Orthopaedics / Issue 3/2021
Print ISSN: 0341-2695
Electronic ISSN: 1432-5195
DOI: https://doi.org/10.1007/s00264-020-04790-9

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?

Abstract

Purpose

Methods

Trial registration

Results

Conclusion

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Purpose

Methods

Trial registration

Results

Conclusion

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