United States

Background - Multiple autograft choices are available for anterior cruciate ligament reconstruction (ACLR), however the ideal graft choice has not been determined. While there are technical differences, consideration of cost-driving factors that influence ACLR graft choice could help optimize value-based care. This study aims to evaluate the expenses associated with different graft choices for ACLR, considering demographic variables and graft cost. 

Methods – A retrospective chart review was performed from January 2020 to August 2023 for patients undergoing primary ACLR at one health system. All adult patients who have undergone ACL repair surgery within this timeframe were included. Demographic data including sex, age, ethnicity, body mass index (BMI) was collected. Socioeconomic status (SES) was analyzed using median household income (MHI) and area deprivation index (ADI) based on patient addresses (UW-Madison). Graft type and costs were obtained from the electronic medical record. Multiple linear regressions and t-test analyses were performed. 

Results – A total of 389 patients were included with 274 BTB grafts, 64 hamstring grafts, and 51 quad grafts. Mean cost of BTB graft was $3,730.35, hamstring graft was $3,491.43, and quad graft was $4,280.34. Both hamstring and quad grafts were significantly correlated with greater total costs (p=0.018) (p=0.006), while BTB grafts were not (p=0.232). no significant correlations were found between ADI, sex, race, age, insurance type, and smoking and total graft costs. BMI, however, was significantly associated with greater total supply costs (p=0.015). 

Conclusion – Graft selection in ACLR was identified as a modifiable cost driver in this study, with hamstring grafts found to be significantly cheaper and quad grafts significantly more expensive. The average cost is highest when using a quad graft and lowest when using a hamstring graft. BMI also proved to be a contributor to costs in ACLR. 


AMA Research Challenge 2024 

Anterior Cruciate Ligament Reconstruction Graft Choice Cost Driver Analysis: A Value Based Study

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poster

Introduction: As artificial intelligence (AI) continues to gain popularity among patients as an educational resource, it is crucial to understand whether AI can provide reliable information on orthopaedic conditions. While prior studies have investigated the utility of ChatGPT in providing information on common orthopaedic surgeries, they have yet to explore its utility for more rare and complex diseases. This study evaluates the accuracy and comprehensibility of responses produced by ChatGPT to answer common patient questions about osteosarcoma.

Methods: Ten frequently asked questions (FAQs) regarding osteosarcoma were compiled through a literature review and national society patient FAQ pages. ChatGPT (Version 3.5) was subsequently utilized to answer these questions. For each response, a detailed description was written based on relevant literature supporting or refuting the chatbot's claims. Responses were analyzed for accuracy and clarity using a previously validated scoring system for ChatGPT response accuracy and a modified DISCERN score. The responses were independently reviewed by three authors, and scores were averaged as a crowd-sourced scoring strategy. Readability was assessed using five published educational-level indices. FAQ compilation and scoring were completed in collaboration with two fellowship-trained orthopaedic oncology surgeons. 

Results: ChatGPT's responses generally required moderate clarification, with a mean accuracy score of 3 (satisfactory but requiring moderate clarification). One response received a mean rating of 2 (satisfactory requiring minimal clarification), five responses received a rating of 2.5, and four responses received a rating of 3. The 10 responses received an average mean DISCERN score of 36 (classified as poor, 28-38). The interrater reliability between the two orthopaedic oncology surgeons for the DISCERN criteria was 0.601, qualifying as moderate agreement. Readability level ranged from college graduate to 7th grade, exceeding the recommendation for patient educational materials. 

Conclusions: While moderately accurate, most responses regarding osteosarcoma required further clarification and were written at an inaccessible reading level. ChatGPT can therefore be considered a starting point for patient education on osteosarcoma to supplement traditional patient education strategies, but it should not replace professional medical advice. One major limitation of AI that was apparent in the present study is its inability to provide personalized recommendations. The chatbot does not account for varying clinical presentations and degrees of scientific literacy that might affect an individual patient's counseling and treatment options. Future research should apply similar methodologies to other AI platforms to more comprehensively investigate the breadth and accuracy of online resources available to patients.

Assessing the Accuracy of ChatGPT to Answer Commonly Asked Patient Questions about Osteosarcoma

Background:

The posterior compartment of the leg typically contains three muscles in the superficial flexor group: the gastrocnemius, plantaris, and soleus. The gastrocnemius muscle forms the major bulk of the posterior compartment of the leg and is instrumental to walking and posture. The gastrocnemius has medial and lateral heads that originate from the medial and lateral condyles of the femur, respectively. The motor nerve supplying the two gastrocnemius heads is the tibial nerve, receiving fibers from the L5, S1, and S2 nerve roots. The posterior leg is cutaneously supplied by the L4-S2 nerve roots. This biarticular muscle distally inserts into the posterior surface of the broad membranous Achilles tendon. However, a third head of the gastrocnemius, is an extremely rare accessory muscle bundle of the gastrocnemius muscle that covers the surface of the popliteal fossa. There has been scarce representation in the literature of bilateral gastrocnemius tertius muscles.


Case Presentation:

In this poster, we present a case report of bilateral anomalous gastrocnemius tertius muscles discovered in a 67-year-old male cadaveric who died of complications related to vascular dementia. Upon routine educational dissection of the cadaver, an extra muscle belly was discovered bilaterally, medial to each gastrocnemius lateral heads, which was determined to be tertius heads of the gastrocnemius muscle. The tertius heads were separated from the gastrocnemius medial and lateral heads by a fascial sheath. Muscle fibers were arranged in a unipennate pattern. The tertius heads attached proximally to the lateral condyle of the femur – at the same attachment point of the lateral head – and distally contributed to the Achilles tendon. The belly length was 24 cm, and width was 2.5 cm. The tertius head muscles were both innervated by a unique branch of the tibial nerve that entered the muscle belly. Vasculature to the tertius heads originated from additional branches of the popliteal artery and veins. The proximal tendon and belly of this muscle were in proximity to the tibial nerve and artery. 


Discussion: 

The gastrocnemius is a powerful plantar flexor and knee flexor. Therefore, this muscle provides significant propulsive force regarding gait mechanics. Anomalies of this muscle bundle is important to recognize as they can have significant implications on future patient outcomes. To our knowledge, bilateral gastrocnemius tertius muscles have only been reported in literature once before. Although believed to be a benign anatomical variant, this can potentially lead to pathologies such as Popliteal Artery Entrapment Syndrome, sural nerve entrapment, and deep vein thrombosis. Compression of these structures by the tertius head may cause numbness, tingling, swelling, and signs of muscle hypoxia in the posterior leg. Therefore, clinicians should be aware of this variant and its clinical relevance. Tertius head-related posterior leg vessel compression should be considered on differential when treating patients with signs and symptoms of popliteal fossa swelling and pain. Finally, it could give rise to future reports with similar presentations that lead to better understanding of the physiology of this anomaly.


Bilateral Gastrocnemius Tertius: A Rare Cadaveric Finding

Background: 
Anterior cruciate ligament reconstruction (ACLR) is frequently recommended to restore the knee's mechanical function after ACL injury. Autograft options include the bone-patellar tendon-bone (BTB) and quadriceps tendon (QT) grafts. A recent study reported that QT grafts result in larger quadriceps strength deficits than BTB grafts at seven months post-ACLR. These deficits may implicate persistent functional deficits, development of osteoarthritis, and/or subsequent ACL injury. However, there is a knowledge gap regarding longitudinal outcomes of quadriceps strength between these grafts. Therefore, this study aimed to provide preliminary evidence on the effect of graft type (BTB vs. QT) on isokinetic quadriceps strength within the first year post-ACLR. It was hypothesized that BTB would demonstrate greater improvements than QT over time.

Methods: 
Twenty-three subjects were consented and tested in this ongoing IRB-approved prospective clinical trial (BTB: n=10, BMI=27.7±5.3 kg/m2, ages 19.6±5.3 years; QT: n=13, BMI=22.9 ± 5.0 kg/m2, ages 18.3±5.0 years). All patients followed a similar rehabilitation program.
Concentric isokinetic leg strength was assessed using a Humac Norm dynamometer (CSMi) during knee extension. The test was first conducted on the unoperated knee, followed by the ACLR knee. After a standardized warm-up, participants performed five maximal effort repetitions at 60°/s. The outcome measures included peak torque (PT), average work per repetition (W), and average power per repetition (P). The percent deficits between limbs were analyzed using a repeated measures analysis of variance (α=0.05) for time (6 vs. 12 months) and graft type (BTB vs. QT).

Results: 
In BTB patients, deficits were significantly reduced in PT (mean difference(Δ)=-29.38±6.64 N, p<0.01), W (Δ=-22.75±7.97 J, p=0.01), and P (Δ=-26.25±6.51 W, p<0.01), while no reduction was detected in QT patients in these measures (PT: Δ=-2.78±6.18 N, p=0.66; W: Δ=1.10±7.42 J, p=0.88; P: Δ=0.22±6.06 W, p=0.97).

Conclusion: 
By 12 months, participants with BTB showed greater improvements in quadriceps strength deficits than those with QT, supporting the study hypothesis. These findings are critical as strength deficit reduction correlates with better long-term knee function.
This result may be attributed to a lack of graft-specific rehabilitation regimens, as studies have indicated that QT-specific rehabilitation can reduce strength deficits post-ACLR. Additionally, QT harvesting occurs at the quadriceps tendon, which has a more direct role in the knee extensor mechanism and potentially has a greater impact on strength deficits.
These findings strongly motivate further research with longer follow-ups and larger sample sizes in order to provide more confident conclusions on how to improve rehabilitation programs by graft type.

Bone-Tendon-Bone Yields Greater Quadriceps Strength Improvement Than Quadriceps Tendon after ACL-Reconstruction

Background
Inlay total shoulder arthroplasty (iTSA) serves as a stemless shoulder reconstruction option. While current literature has demonstrated improved patient reported outcomes (PROs) with minimal postoperative revisions and high rates of return to activity, supporting long-term evidence is limited. The purpose of this study was to evaluate the trends in PROs following iTSA over an eleven-year period.

Methods
A historical cohort of our institutional database was used to investigate outcome trends. Inclusion criteria consisted of patients with advanced osteoarthritis treated with iTSA. Patients had preoperative PROs and a minimum of one follow-up assessment between 1-11 years. Outcomes assessments included WOOS%, ASES, activities of daily living (ADLs), VAS pain, patient satisfaction, and range of motion (ROM). Descriptive analyses were conducted using Stata (v.15, College Station, TX). Join-point regression analysis (version 5.0.2, National Cancer Institute) was used to explore trends in functional outcomes, pain relief, and ADLs to determine whether a change in temporal trend was statistically significant. WOOS%, ASES, ADLs, and VAS pain were entered into the model and were assessed at five timepoints: preoperative, 1 year, 2-3 years, 4-7 years, and 8-11 years.

Results
Since 2011, 583 shoulders were treated with iTSA at our institution and 97 met the inclusion criteria, with 10 patients being bilateral. The mean age was 63.7 years ± 10.5 (31 females, 66 males). The average length of follow-up was 60.5 months ± 37.8. Along the postoperative period of up to 2-3 years, there was significant improvement in WOOS% (84.97 AYPPC), ASES (78.22 AYPPC), and VAS pain (-74.50 AYPPC), after which gains were sustained. ADLs improved over time, but there was no significant change in the trend. The median PROs improved at all five timepoints: WOOS% [26(16-40), 85(56-95), 93(77-97), 89(75-97), 92(77-97)], ASES [27(17-40), 83(67-93), 88(68-95), 87(70-97), 90(78-98)], VAS pain [8(6-9), 1(0-3), 1(0-2), 0(0-3), 0(0-0)] and ADLs [4(2-6), 8(6-10), 9(6-10), 8(6-8), 9(6-10)]. Mean ROM improved by 46.49 degrees ± 37.28 on forward elevation and 26.95 degrees ± 18.90 on external rotation.  Mean patient satisfaction on a scale of 1-10 (10=best) for each follow-up timepoint was 8.6 ± 2.4, 9.2 ± 1.6, 8.7 ± 1.8, and 9.6 ± 0.7 respectively (p <0.001). 

Conclusion
iTSA demonstrated significant improvement in pain relief and functional outcomes within 2-3 years, after which gains were sustained over an eleven-year period. ROM improved and patient satisfaction remained high over time. These findings support the use of stemless shoulder reconstruction as a reliable solution for advanced shoulder osteoarthritis.

Clinical Improvements After Inlay Total Shoulder Arthroplasty are Sustained: A Long-term Follow-up Trending Analysis

Background

In recent years, the use of 3-dimensional (3D) printing in orthopedic surgery has greatly expanded, including the application of 3D-printed implants following bone tumor excision. After complete bone tumor excision, bone defects are typically reconstructed and implanted with a prosthetic. Historically, commercially produced implants have been used, but recent research explores the benefit of individualized 3D-printed prostheses (3DPs). These custom implants more accurately match the complex shapes of orthopedic defects and are especially useful in areas where unusual implants are necessary. The purpose of this review is to compile the available literature surrounding 3D-printed bone tumor prostheses and use patient outcomes to evaluate the efficacy of 3DPs compared to conventional prostheses. This review aims to assess the benefits and limitations of 3DPs and determine if they are a viable alternative to traditional implants.

Methods:
A systematic review was conducted, and the literature search was limited to studies with a comparable non-3DP control. A variety of bone tumor types and locations were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied. Outcome measures of 3DPs and conventional implants were compared in the context of the tumor location and procedure type. The selected outcome measures include operative duration, intraoperative blood loss, hospital stay, cost, complication rate, implant dislocation, and Musculoskeletal Tumor Society Scoring System (MSTS) score.

Results

Operative duration was decreased with 3DP use in 4 studies of pelvic and periacetabular tumors, with a reduction of 125, 70, 63, and 41 minutes respectively. Conversely, thoracolumbar 3DPs showed an average increased operative duration of 54 minutes. Compared to control, reduced intraoperative blood loss was seen in pelvic, periacetabular, and thoracolumbar 3DP procedures. MSTS score, a quality of life measure, was improved in the 3DP group compared to control in all four studies of pelvic and periacetabular tumors. In two cases of pelvic tumors, the 3DP group demonstrated an average decreased risk of implant dislocation by 11.22%. In thoracolumbar tumors, the risk decreased by 7.2%.

Conclusion

Compared to conventional controls, our review demonstrates the benefits of 3DPs in improving patient outcomes and the efficiency of surgical procedures. Intraoperative blood loss, complication rate, and implant dislocation occurrence were all shown to be reduced with the use of 3DPs. 3DP use also revealed an improvement in MSTS score and tumor resection accuracy. Additional studies with comparable controls are necessary to further evaluate the benefits of 3DPs and assess their long-term efficacy.

Clinical Outcomes of the Use of 3-Dimensional Printing Implants in Cases of Bone Tumors: A Meta-Analysis

Abstract Title
Comparison of Clinical Outcomes in Patients with Primary Versus Ipsilateral Revision ACL Reconstruction

Background
Up to 30% of young active patients with a previous anterior cruciate ligament reconstruction (ACLR) suffer a second ACL rupture within the first two years after surgery. To our knowledge, few studies have determined if individuals who undergo a second ACLR report worse knee function and psychological response to injury recovery when compared to individuals who undergo primary ACLR. The aim of this study is to investigate whether there is a difference in functional and psychological outcomes in patients who have undergone an ipsilateral revision ACL reconstruction compared to patients with a primary ACL reconstruction. 

Methods
Data were combined from ongoing retrospective and prospective cohort studies at a single medical center. Patients were included in this study if they were 13-40 years old, underwent primary uncomplicated ACLR or ipsilateral revision ACLR at our institution, and participated in our standardized return to sport testing protocol at least 5 months post-ACLR. Patients were excluded if they experienced perioperative complications that resulted in a delayed standard of care. Surgical characteristics were confirmed via chart review. Primary outcomes of interest included knee function measured by the International Knee Documentation Committee Subjective Knee Evaluation score (IKDC), psychological readiness for return to sport measured by the ACL-RSI score, and isokinetic (60°/s) quadriceps and hamstring strength limb symmetry index (%). Patient-reported and strength outcomes were compared between patients in the primary and revision ACLR groups using ANCOVA while controlling for the effects of age and time since surgery. A-priori alpha level was established as p < 0.05. 

Results
Patients in the primary ACLR group were younger (p=0.002) and the groups also differed based on graft source (p=0.013), and medial meniscus (p=0.041) treatment (meniscectomy, repair, or no treatment) at the time of ACLR. After accounting for time since surgery and age, there were no significant differences between groups for IKDC score (p=0.740), ACL-RSI score (p=0.762), nor knee extension strength LSI (p=0.393); however, the primary ACLR group displayed greater knee flexion strength LSI (p=0.020). 

Conclusion
Patients that underwent revision ACLR had similar outcomes in terms of patient-reported psychological readiness to return to sport, patient-reported knee function, and knee extension strength compared to those who underwent primary ACLR. However, the revision ACLR group demonstrated decreased knee flexion strength. This finding may suggest that patients undergoing recovery from revision ACLR may benefit from increased incorporation of hamstring-specific strength building exercises during rehabilitation to restore knee flexion function and prevent future injury.

Comparison of Outcomes in Revision vs. Primary ACL Reconstruction

Introduction: Reverse total shoulder arthroplasty (RSA) has gained popularity in recent years as an alternative to anatomic total shoulder arthroplasty (TSA) for the treatment of glenohumeral arthritis. The current literature suggests RSA carries a higher all-cause postoperative complication rate than anatomic TSA. The present study aims to more comprehensively compare risk for orthopedic complications and infection in the 90-day period following TSA vs. RSA among patients with osteoarthritis (OA) affecting the shoulder. Materials and Methods: The TriNetX Research NLP network was queried to identify all patients between 65-90 years old who underwent RSA or TSA for OA between the years 2006-2024. Common orthopedic complications (i.e., fracture, dislocation, mechanical failure, stiffness, rotator cuff injury, hematoma) and musculoskeletal infections (i.e., infective arthritis, prosthetic joint infection, osteomyelitis, and other infections involving bone) associated with anatomic TSA were analyzed for risk difference between RSA and TSA. A subsequent multivariate logistic regression was performed to identify patient risk factors for orthopedic complications and infection. Results: Propensity score matching resulted in a cohort of n = 7,755 each for RSA and TSA. RSA carried increased risk compared to TSA for orthopedic complications (OR = 2.251; p<0.0001) and musculoskeletal infections (OR = 2.908; p<0.0001). Significant risk factors (p<0.05) for both orthopedic complications and infection included diabetes, hypertension, depression, liver diseases, and cardiac arrhythmias. Discussion/Conclusion: To our knowledge, this is the largest database study performed to date comparing risk for both infection and orthopedic complications between TSA and RSA performed for OA. RSA carries a greater risk for orthopedic complications and infection than TSA in the 90-day postoperative period when considering elderly patients undergoing surgery for OA. ​​These findings help to provide further clinical context to guide surgical decision making and inform surgeons on current risks and outcomes.

Complications and Risk Factors Following Reverse vs. Anatomic Total Shoulder Arthroplasty for Osteoarthritis

Background
Mental health disorders are associated with increased complication rates and poorer postoperative outcomes for multiple orthopedic procedures. This study aims to analyze the influence of diagnosed mental disorders on postoperative outcomes of individuals undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. 

Methods
Using the TriNetX global health network database, we evaluated postoperative outcomes of patients who underwent arthroscopic ACL reconstruction over a 20-year period. Patients with a documented mental health disorder (e.g., anxiety or depression) within 1 year preceding surgery were compared to patients without mental health disorders. The cohorts were propensity-matched for demographic and medical factors, including hypertension, type 2 diabetes, and obesity. Short- and longterm outcomes were evaluated within 90 days and 3 years postoperative, respectively. Chi-square analysis was performed to compare outcomes between the 2 cohorts. 

Results
A total of 8,351 patients with diagnosed mental health disorders were propensity-score matched at a 1:1 ratio with 82,127 patients without diagnosed mental health disorders. Within 90 days postoperative, patients with diagnosed mental health disorders demonstrated significantly higher odds of postoperative infection (P = 0.0042), lower limb mononeuropathy (P = 0.025), acute postoperative pain (P < 0.0001), knee stiffness (P < 0.0001), and emergency department visits (P < 0.0001). Within 3 years postoperative, these patients had significantly higher odds of opioid abuse (P = 0.0015), knee pain (P < 0.0001), patella fracture (P = 0.0008), and arthrocentesis/aspiration/injection (P = 0.0005), but significantly lower odds of ACL tear (P < 0.0001) and repeat ACL reconstruction (P = 0.0033). 

Conclusion
Diagnosed mental health disorders were associated with increased shortand long-term postoperative complications following ACL reconstruction, but also demonstrated a potentially protective association with multiple postoperative outcomes, including decreased odds of additional ACL tears and reconstructions.

Diagnosed Mental Health Disorders are Associated With Higher Rates of Postoperative Complications, Additional Procedures, and Lower ACL Tears and Revisions Following Anterior Cruciate Ligament Reconstruction

Background: Patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) often report fluctuations in pain levels associated with weather conditions. Despite common clinical observations, the literature on this relationship remains inconclusive. This study aims to evaluate the correlation between postoperative pain scores and weather parameters, considering demographic and comorbidity factors. 

Methods: A retrospective chart review was conducted on 558 patients from the University of Texas Medical Branch who underwent TKA or THA between January 1, 2020, and December 31, 2023. Inclusion criteria included patients without significant comorbidities affecting surgical outcomes. Postoperative pain scores, recorded using a numerical rating scale (NRS), were correlated with historical weather data (temperature, barometric pressure, humidity) from appointment dates. 

Results: The mean pain score reported was 3.87 (SD 3.0). Weather parameters, including temperature and barometric pressure, did not yield significant correlations or linear regression results with pain scores. Analysis revealed a significant negative correlation between age and pain scores (r = -0.293, p < 0.001), indicating that older patients reported lower pain levels. Body mass index (BMI) was positively correlated with pain scores (p < 0.05), while sex and race/ethnicity showed no significant associations (p > 0.05). Notably, mental health diagnoses significantly influenced pain ratings (p < 0.05). 

Conclusions: This study found no significant relationship between postoperative pain and weather parameters in TKA/THA patients, challenging common assumptions that weather significantly influences pain perception. However, age, BMI, and mental health were identified as significant factors affecting postoperative pain experiences. These findings underscore the need for personalized pain management strategies that account for individual patient characteristics rather than environmental factors.

Do Arthroplasty Patients Have Increased Weather-Related Pain Postoperatively?

Introduction: Patients with pre-existing psychiatric diagnoses have been reported to have suboptimal post operative outcomes in various surgical fields, however, few such studies exist in the orthopaedic surgery literature. The goal of this study was to examine the affect a pre-operative psychiatric diagnosis had on short-term post-operative outcomes in patients undergoing surgical fixation of a pelvic fracture. 

Methods: The American College of Surgeons – Trauma Quality Improvement Program (TQIP) was queried using ICD10 procedure codes to identify patients undergoing operative fixation of a pelvic fracture from 2017-2021. The patient cohort was stratified into two groups, those with a pre-existing psychiatric diagnosis versus those without a pre-existing psychiatric diagnosis. Psychiatric diagnoses included in the TQIP variable were schizophrenia, bipolar disorder, major depressive disorder, social anxiety disorder, posttraumatic stress disorder, and antisocial personality disorder. Our primary outcome measure was pooled infection rate. Secondary outcome measures included infections that comprised the pooled infection variable, as well as other post-operative sequela captured in the TQIP database. Outcome measures between the two cohorts were compared using chi-square and Fisher’s exact test. 

Results: A total of 107,748 patients undergoing pelvic fixation were identified, as well as 11,306 with a mental health/personality disorder at time of admission. Patients with pre-existing psychiatric diagnoses were more likely to also have comorbid conditions than those without a pre-existing psychiatric diagnosis. Furthermore, these patients were more likely to have a positive drug screen on admission compared to those without a pre-existing psychiatric diagnosis. In terms of overall infection, individuals with a pre-existing psychiatric diagnosis were more likely to experience infection overall, as well as dSSI, sSSI, organ space infection and osteomyelitis, compared to those without a psychiatric history (p<0.05).

Conclusions: Patients with pre-existing psychiatric diagnoses represent a unique and significant portion of patients undergoing pelvic fracture surgery. These patients are more likely to suffer from substance misuse and comorbid conditions at time of admission, thus requiring increased attention and optimization both before and following surgery to help mitigate risk of post-operative complications.

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Assessing the Accuracy of ChatGPT to Answer Commonly Asked Patient Questions about Osteosarcoma

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