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Published in: BMC Musculoskeletal Disorders 1/2017

Open Access 01-12-2017 | Research article

Glutamate signaling through the NMDA receptor reduces the expression of scleraxis in plantaris tendon derived cells

Authors: Christoph Spang, Ludvig J. Backman, Sandrine Le Roux, Jialin Chen, Patrik Danielson

Published in: BMC Musculoskeletal Disorders | Issue 1/2017

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Abstract

Background

A body of evidence demonstrating changes to the glutaminergic system in tendinopathy has recently emerged. This hypothesis was further tested by studying the effects of glutamate on the tenocyte phenotype, and the impact of loading and exposure to glucocorticoids on the glutamate signaling machinery.

Methods

Plantaris tendon tissue and cultured plantaris tendon derived cells were immunohisto-/cytochemically stained for glutamate, N-Methyl-D-Aspartate receptor 1 (NMDAR1) and vesicular glutamate transporter 2 (VGluT2). Primary cells were exposed to glutamate or receptor agonist NMDA. Cell death/viability was measured via LDH/MTS assays, and Western blot for cleaved caspase 3 (c-caspase 3) and cleaved poly (ADP-ribose) polymerase (c-PARP). Scleraxis mRNA (Scx)/protein(SCX) were analyzed by qPCR and Western blot, respectively. A FlexCell system was used to apply cyclic strain. The effect of glucocorticoids was studies by adding dexamethasone (Dex). The mRNA of the glutamate synthesizing enzymes Got1 and Gls, and NMDAR1 protein were measured. Levels of free glutamate were determined by a colorimetric assay.

Results

Immunoreactions for glutamate, VGluT2, and NMDAR1 were found in tenocytes and peritendinous cells in tissue sections and in cultured cells. Cell death was induced by high concentrations of glutamate but not by NMDA. Scleraxis mRNA/protein was down-regulated in response to NMDA/glutamate stimulation. Cyclic strain increased, and Dex decreased, Gls and Got1 mRNA expression. Free glutamate levels were lower after Dex exposure.

Conclusions

In conclusion, NMDA receptor stimulation leads to a reduction of scleraxis expression that may be involved in a change of phenotype in tendon cells. Glutamate synthesis is increased in tendon cells in response to strain and decreased by glucocorticoid stimulation. This implies that locally produced glutamate could be involved in the tissue changes observed in tendinopathy.
Literature
1.
go back to reference Nedergaard M, Takano T, Hansen AJ. Beyond the role of glutamate as a neurotransmitter. Nat Rev Neurosci. 2002;3:748–55.CrossRefPubMed Nedergaard M, Takano T, Hansen AJ. Beyond the role of glutamate as a neurotransmitter. Nat Rev Neurosci. 2002;3:748–55.CrossRefPubMed
2.
go back to reference Kalariti N, Pissimissis N, Koutsilieris M. The glutamatergic system outside the CNS and in cancer biology. Expert Opin Investig Drugs. 2005;14:1487–96.CrossRefPubMed Kalariti N, Pissimissis N, Koutsilieris M. The glutamatergic system outside the CNS and in cancer biology. Expert Opin Investig Drugs. 2005;14:1487–96.CrossRefPubMed
3.
go back to reference Moriyama Y, Yamamoto A. Glutamatergic chemical transmission: look! Here, there, and anywhere. J Biochem. 2004;135:155–63.CrossRefPubMed Moriyama Y, Yamamoto A. Glutamatergic chemical transmission: look! Here, there, and anywhere. J Biochem. 2004;135:155–63.CrossRefPubMed
4.
go back to reference Hinoi E, Yoneda Y. Possible involvement of glutamatergic signaling machineries in pathophysiology of rheumatoid arthritis. J Pharmacol Sci. 2011;116:248–56.CrossRefPubMed Hinoi E, Yoneda Y. Possible involvement of glutamatergic signaling machineries in pathophysiology of rheumatoid arthritis. J Pharmacol Sci. 2011;116:248–56.CrossRefPubMed
5.
go back to reference Cowan RW, Seidlitz EP, Singh G. Glutamate signaling in healthy and diseased bone. Front Endocrinol. 2012;3:89.CrossRef Cowan RW, Seidlitz EP, Singh G. Glutamate signaling in healthy and diseased bone. Front Endocrinol. 2012;3:89.CrossRef
6.
go back to reference Alfredson H, Thorsen K, Lorentzon R. In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surg Sports Traumatol Arthrosc. 1999;7:378–81.CrossRefPubMed Alfredson H, Thorsen K, Lorentzon R. In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surg Sports Traumatol Arthrosc. 1999;7:378–81.CrossRefPubMed
7.
go back to reference Alfredson H, Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique—no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand. 2000;71:475–9.CrossRefPubMed Alfredson H, Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique—no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand. 2000;71:475–9.CrossRefPubMed
8.
go back to reference Alfredson H, Forsgren S, Thorsen K, Lorentzon R. In vivo microdialysis and immunohistochemical analyses of tendon tissue demonstrated high amounts of free glutamate and glutamate NMDAR1 receptors, but no signs of inflammation, in Jumper’s knee. J Orthop Res. 2001;19:881–6.CrossRefPubMed Alfredson H, Forsgren S, Thorsen K, Lorentzon R. In vivo microdialysis and immunohistochemical analyses of tendon tissue demonstrated high amounts of free glutamate and glutamate NMDAR1 receptors, but no signs of inflammation, in Jumper’s knee. J Orthop Res. 2001;19:881–6.CrossRefPubMed
9.
go back to reference Gibson W, Arendt-Nielsen L, Sessle BJ, Graven-Nielsen T. Glutamate and capsaicin-induced pain, hyperalgesia and modulatory interactions in human tendon tissue. Exp Brain Res. 2009;194:173–82.CrossRefPubMed Gibson W, Arendt-Nielsen L, Sessle BJ, Graven-Nielsen T. Glutamate and capsaicin-induced pain, hyperalgesia and modulatory interactions in human tendon tissue. Exp Brain Res. 2009;194:173–82.CrossRefPubMed
10.
go back to reference Scott A, Alfredson H, Forsgren S. VGluT2 expression in painful Achilles and patellar tendinosis: evidence of local glutamate release by tenocytes. J Orthop Res. 2008;26:685–92.CrossRefPubMedCentralPubMed Scott A, Alfredson H, Forsgren S. VGluT2 expression in painful Achilles and patellar tendinosis: evidence of local glutamate release by tenocytes. J Orthop Res. 2008;26:685–92.CrossRefPubMedCentralPubMed
11.
go back to reference Schizas N, Lian O, Frihagen F, Engebretsen L, Bahr R, Ackermann PW. Coexistence of up-regulated NMDA receptor 1 and glutamate on nerves, vessels and transformed tenocytes in tendinopathy. Scand J Med Sci Sports. 2010;20:208–15.CrossRefPubMed Schizas N, Lian O, Frihagen F, Engebretsen L, Bahr R, Ackermann PW. Coexistence of up-regulated NMDA receptor 1 and glutamate on nerves, vessels and transformed tenocytes in tendinopathy. Scand J Med Sci Sports. 2010;20:208–15.CrossRefPubMed
12.
go back to reference Schizas N, Weiss R, Lian O, Frihagen F, Bahr R, Ackermann PW. Glutamate receptors in tendinopathic patients. J Orthop Res. 2012;30:1447–52.CrossRefPubMed Schizas N, Weiss R, Lian O, Frihagen F, Bahr R, Ackermann PW. Glutamate receptors in tendinopathic patients. J Orthop Res. 2012;30:1447–52.CrossRefPubMed
13.
go back to reference Molloy TJ, Kemp MW, Wang Y, Murrell GA. Microarray analysis of the tendinopathic rat supraspinatus tendon: glutamate signaling and its potential role in tendon degeneration. J Appl Physiol. 2006;101:1702–9.CrossRefPubMed Molloy TJ, Kemp MW, Wang Y, Murrell GA. Microarray analysis of the tendinopathic rat supraspinatus tendon: glutamate signaling and its potential role in tendon degeneration. J Appl Physiol. 2006;101:1702–9.CrossRefPubMed
14.
go back to reference Glasgow NG, Retchless BS, Johnson JW. Molecular bases of NMDA receptor subtype-dependent properties. J Physiol. 2015;593:83–95.CrossRefPubMed Glasgow NG, Retchless BS, Johnson JW. Molecular bases of NMDA receptor subtype-dependent properties. J Physiol. 2015;593:83–95.CrossRefPubMed
15.
go back to reference Dean BJ, Snelling SJ, Dakin SG, Javaid MK, Carr AJ. In vitro effects of glutamate and N-methyl-D-aspartate receptor (NMDAR) antagonism on human tendon derived cells. J Orthop Res. 2015;33:1515–22.CrossRefPubMed Dean BJ, Snelling SJ, Dakin SG, Javaid MK, Carr AJ. In vitro effects of glutamate and N-methyl-D-aspartate receptor (NMDAR) antagonism on human tendon derived cells. J Orthop Res. 2015;33:1515–22.CrossRefPubMed
16.
go back to reference Lian O, Scott A, Engebretsen L, Bahr R, Duronio V, Khan K. Excessive apoptosis in patellar tendinopathy in athletes. Am J Sports Med. 2007;35:605–11.CrossRefPubMed Lian O, Scott A, Engebretsen L, Bahr R, Duronio V, Khan K. Excessive apoptosis in patellar tendinopathy in athletes. Am J Sports Med. 2007;35:605–11.CrossRefPubMed
17.
go back to reference Millar NL, Wei AQ, Molloy TJ, Bonar F, Murrell GA. Cytokines and apoptosis in supraspinatus tendinopathy. J Bone Joint Surg Br. 2009;91:417–24.CrossRefPubMed Millar NL, Wei AQ, Molloy TJ, Bonar F, Murrell GA. Cytokines and apoptosis in supraspinatus tendinopathy. J Bone Joint Surg Br. 2009;91:417–24.CrossRefPubMed
18.
go back to reference Dean BJ, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum. 2014;43:570–6.CrossRefPubMed Dean BJ, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum. 2014;43:570–6.CrossRefPubMed
19.
go back to reference Dean BJ, Franklin SL, Murphy RJ, Javaid MK, Carr AJ. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy? Br J Sports Med. 2014;48:1620–6.CrossRefPubMed Dean BJ, Franklin SL, Murphy RJ, Javaid MK, Carr AJ. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy? Br J Sports Med. 2014;48:1620–6.CrossRefPubMed
20.
go back to reference Järvinen M, Jozsa L, Kannus P, Järvinen TL, Kvist M, Leadbetter W. Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports. 1997;7:86–95.CrossRefPubMed Järvinen M, Jozsa L, Kannus P, Järvinen TL, Kvist M, Leadbetter W. Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports. 1997;7:86–95.CrossRefPubMed
21.
go back to reference Zhang J, Wang JH. Production of PGE(2) increases in tendons subjected to repetitive mechanical loading and induces differentiation of tendon stem cells into non-tenocytes. J Orthop Res. 2010;28:198–203.CrossRefPubMed Zhang J, Wang JH. Production of PGE(2) increases in tendons subjected to repetitive mechanical loading and induces differentiation of tendon stem cells into non-tenocytes. J Orthop Res. 2010;28:198–203.CrossRefPubMed
22.
go back to reference Shukunami C, Takimoto A, Oro M, Hiraki Y. Scleraxis positively regulates the expression of tenomodulin, a differentiation marker of tenocytes. Dev Biol. 2006;298:234–47.CrossRefPubMed Shukunami C, Takimoto A, Oro M, Hiraki Y. Scleraxis positively regulates the expression of tenomodulin, a differentiation marker of tenocytes. Dev Biol. 2006;298:234–47.CrossRefPubMed
23.
go back to reference Alberton P, Popov C, Pragert M, Kohler J, Shukunami C, Schieker M, Docheva D. Conversion of human bone marrow-derived mesenchymal stem cells into tendon progenitor cells by ectopic expression of scleraxis. Stem Cells Dev. 2012;21:846–58.CrossRefPubMed Alberton P, Popov C, Pragert M, Kohler J, Shukunami C, Schieker M, Docheva D. Conversion of human bone marrow-derived mesenchymal stem cells into tendon progenitor cells by ectopic expression of scleraxis. Stem Cells Dev. 2012;21:846–58.CrossRefPubMed
24.
go back to reference Chen W, Tang H, Zhou M, Hu C, Zhang J, Tang K. Dexamethasone inhibits the differentiation of rat tendon stem cells into tenocytes by targeting the scleraxis gene. J Steroid Biochem Mol Biol. 2015;152:16–24.CrossRefPubMed Chen W, Tang H, Zhou M, Hu C, Zhang J, Tang K. Dexamethasone inhibits the differentiation of rat tendon stem cells into tenocytes by targeting the scleraxis gene. J Steroid Biochem Mol Biol. 2015;152:16–24.CrossRefPubMed
25.
go back to reference Alberton P, Dex S, Popov C, Shukunami C, Schieker M, Docheva D. Loss of tenomodulin results in reduced self-renewal and augmented senescence of tendon stem/progenitor cells. Stem Cells Dev. 2015;24(5):597–609.CrossRefPubMed Alberton P, Dex S, Popov C, Shukunami C, Schieker M, Docheva D. Loss of tenomodulin results in reduced self-renewal and augmented senescence of tendon stem/progenitor cells. Stem Cells Dev. 2015;24(5):597–609.CrossRefPubMed
26.
go back to reference Dex S, Lin D, Shukunami C, Docheva D. Tenogenic modulating insider factor: Systematic assessment on the functions of tenomodulin gene. Gene. 2016;587:1–17.CrossRefPubMed Dex S, Lin D, Shukunami C, Docheva D. Tenogenic modulating insider factor: Systematic assessment on the functions of tenomodulin gene. Gene. 2016;587:1–17.CrossRefPubMed
27.
go back to reference Masci L, Spang C, van Schie HTM, Alfredson H. Achilles tendinopathy – do plantaris tendon removal and Achilles tendon scraping improve tendon structure? A prospective study using ultrasound tissue characterization. BMJ Open Sport Exerc Med. 2015;1:e000005.CrossRefPubMedCentralPubMed Masci L, Spang C, van Schie HTM, Alfredson H. Achilles tendinopathy – do plantaris tendon removal and Achilles tendon scraping improve tendon structure? A prospective study using ultrasound tissue characterization. BMJ Open Sport Exerc Med. 2015;1:e000005.CrossRefPubMedCentralPubMed
28.
go back to reference Spang C, Alfredson H, Docking SI, Masci L, Andersson G. The plantaris tendon: a narrative review focusing on anatomical features and clinical importance. Bone Joint J. 2016;98-B(10):1312–9. Spang C, Alfredson H, Docking SI, Masci L, Andersson G. The plantaris tendon: a narrative review focusing on anatomical features and clinical importance. Bone Joint J. 2016;98-B(10):1312–9.
29.
go back to reference Spang C, Alfredson H, Ferguson M, Roos B, Bagge J, Forsgren S. The plantaris tendon in association with mid-portion Achilles tendinosis: tendinosis-like morphological features and presence of a non-neuronal cholinergic system. Histol Histopathol. 2013;28:623–32.PubMed Spang C, Alfredson H, Ferguson M, Roos B, Bagge J, Forsgren S. The plantaris tendon in association with mid-portion Achilles tendinosis: tendinosis-like morphological features and presence of a non-neuronal cholinergic system. Histol Histopathol. 2013;28:623–32.PubMed
30.
go back to reference Spang C, Harandi VM, Alfredson H, Forsgren S. Marked innervation but also signs of nerve degeneration in between the Achilles and plantaris tendons and presence of innervation within the plantaris tendon in midportion Achilles tendinopathy. J Musculoskelet Neuronal Interact. 2015;15:197–206.PubMedCentralPubMed Spang C, Harandi VM, Alfredson H, Forsgren S. Marked innervation but also signs of nerve degeneration in between the Achilles and plantaris tendons and presence of innervation within the plantaris tendon in midportion Achilles tendinopathy. J Musculoskelet Neuronal Interact. 2015;15:197–206.PubMedCentralPubMed
31.
go back to reference Alfredson H. Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med. 2011;45:1023–5.CrossRefPubMed Alfredson H. Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med. 2011;45:1023–5.CrossRefPubMed
32.
go back to reference Masci L, Spang C, van Schie HTM, Alfredson H. How to diagnose plantaris tendon involvement in midportion Achilles tendinopathy - clinical and imaging findings. BMC Musculoskelet Disord. 2015;17:97.CrossRef Masci L, Spang C, van Schie HTM, Alfredson H. How to diagnose plantaris tendon involvement in midportion Achilles tendinopathy - clinical and imaging findings. BMC Musculoskelet Disord. 2015;17:97.CrossRef
33.
go back to reference Spang C, Scott A, Danielson P, Lorentzon R, Forsgren S. VGluT2 and NMDAR1 expression in cells in the inflammatory infiltrates in experimentally induced myositis: evidence of local glutamate signaling suggests autocrine/paracrine effects in an overuse injury model. Inflammation. 2012;35:39–48.CrossRefPubMed Spang C, Scott A, Danielson P, Lorentzon R, Forsgren S. VGluT2 and NMDAR1 expression in cells in the inflammatory infiltrates in experimentally induced myositis: evidence of local glutamate signaling suggests autocrine/paracrine effects in an overuse injury model. Inflammation. 2012;35:39–48.CrossRefPubMed
34.
go back to reference Panoskaltsis-Mortari A, Bucy RP. In situ hybridization with digoxigenin-labeled RNA probes: facts and artifacts. Biotechniques. 1995;18:300–7.PubMed Panoskaltsis-Mortari A, Bucy RP. In situ hybridization with digoxigenin-labeled RNA probes: facts and artifacts. Biotechniques. 1995;18:300–7.PubMed
35.
go back to reference Furukawa H, Singh SK, Mancusso R, Gouaux E. Subunit arrangement and function in NMDA receptors. Nature. 2005;438:185–92.CrossRefPubMed Furukawa H, Singh SK, Mancusso R, Gouaux E. Subunit arrangement and function in NMDA receptors. Nature. 2005;438:185–92.CrossRefPubMed
36.
go back to reference Chang ZY, Yeh MK, Chiang CH, Chen YH, Lu DW. Erythropoietin protects adult retinal ganglion cells against NMDA-, trophic factor withdrawal-, and TNF-alpha-induced damage. Pos One. 2013;8:e55291.CrossRef Chang ZY, Yeh MK, Chiang CH, Chen YH, Lu DW. Erythropoietin protects adult retinal ganglion cells against NMDA-, trophic factor withdrawal-, and TNF-alpha-induced damage. Pos One. 2013;8:e55291.CrossRef
37.
go back to reference Backman LJ, Fong G, Andersson G, Scott A, Danielson P. Substance P is a mechanoresponsive, autocrine regulator of human tenocyte proliferation. Plos One. 2011;6:e27209.CrossRefPubMedCentralPubMed Backman LJ, Fong G, Andersson G, Scott A, Danielson P. Substance P is a mechanoresponsive, autocrine regulator of human tenocyte proliferation. Plos One. 2011;6:e27209.CrossRefPubMedCentralPubMed
38.
go back to reference Danielson P. Reviving the “biochemical” hypothesis for tendinopathy: new findings suggest the involvement of locally produced signal substances. Br J Sports Med. 2009;43:265–8.CrossRefPubMed Danielson P. Reviving the “biochemical” hypothesis for tendinopathy: new findings suggest the involvement of locally produced signal substances. Br J Sports Med. 2009;43:265–8.CrossRefPubMed
39.
40.
go back to reference Spang C, Chen J, Backman L. The tenocyte phenotype of human primary tendon cells in vitro is reduced by glucocorticoids. BMC Musculoskelet Disord. 2016;10:467.CrossRef Spang C, Chen J, Backman L. The tenocyte phenotype of human primary tendon cells in vitro is reduced by glucocorticoids. BMC Musculoskelet Disord. 2016;10:467.CrossRef
42.
go back to reference Olchowik G, Siek E, Tomaszewska M, Tomaszewski M. The evaluation of mechanical properties of animal tendons after corticosteroid therapy. Folia Histochem Cytobiol. 2008;46:373–7.CrossRefPubMed Olchowik G, Siek E, Tomaszewska M, Tomaszewski M. The evaluation of mechanical properties of animal tendons after corticosteroid therapy. Folia Histochem Cytobiol. 2008;46:373–7.CrossRefPubMed
43.
go back to reference Sendzik J, Shakibaei M, Schafer-Korting M, Lode H, Stahlmann R. Synergistic effects of dexamethasone and quinolones on human-derived tendon cells. Int J Antimicrob Agents. 2010;35:366–74.CrossRefPubMed Sendzik J, Shakibaei M, Schafer-Korting M, Lode H, Stahlmann R. Synergistic effects of dexamethasone and quinolones on human-derived tendon cells. Int J Antimicrob Agents. 2010;35:366–74.CrossRefPubMed
44.
go back to reference Takahashi T, Kimoto T, Tanabe N, Hattori TA, Yasumatsu N, Kawato S. Corticosterone acutely prolonged N-methyl-d-aspartate receptor-mediated Ca2+ elevation in cultured rat hippocampal neurons. J Neurochem. 2002;83:1441–51.CrossRefPubMed Takahashi T, Kimoto T, Tanabe N, Hattori TA, Yasumatsu N, Kawato S. Corticosterone acutely prolonged N-methyl-d-aspartate receptor-mediated Ca2+ elevation in cultured rat hippocampal neurons. J Neurochem. 2002;83:1441–51.CrossRefPubMed
45.
go back to reference Jacobs CM, Trinh MD, Rootwelt T, Lømo J, Paulsen RE. Dexamethasone induces cell death which may be blocked by NMDA receptor antagonists but is insensitive to Mg2+ in cerebellar granule neurons. Brain Res. 2006;1070:116–23.CrossRefPubMed Jacobs CM, Trinh MD, Rootwelt T, Lømo J, Paulsen RE. Dexamethasone induces cell death which may be blocked by NMDA receptor antagonists but is insensitive to Mg2+ in cerebellar granule neurons. Brain Res. 2006;1070:116–23.CrossRefPubMed
46.
47.
go back to reference Dean BJ, Snelling SJ, Dakin SG, Murphy RJ, Javaid MK, Carr AJ. Differences in glutamate receptors and inflammatory cells are associated with the resolution of pain in human rotator cuff tendinopathy. Arthritis Res Ther. 2015;17:176.CrossRefPubMedCentralPubMed Dean BJ, Snelling SJ, Dakin SG, Murphy RJ, Javaid MK, Carr AJ. Differences in glutamate receptors and inflammatory cells are associated with the resolution of pain in human rotator cuff tendinopathy. Arthritis Res Ther. 2015;17:176.CrossRefPubMedCentralPubMed
48.
Metadata
Title
Glutamate signaling through the NMDA receptor reduces the expression of scleraxis in plantaris tendon derived cells
Authors
Christoph Spang
Ludvig J. Backman
Sandrine Le Roux
Jialin Chen
Patrik Danielson
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2017
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/s12891-017-1575-4

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