Its signal is increased on all sequences. eCollection 2022 May-Jun. Papadopoulou P. The celery stalk sign. Knee Surg Sports Traumatol Arthrosc. Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. Mucoid degeneration of the anterior cruciate ligament: MRI, clinical, intraoperative, and histological findings. Physiotherapy. J Bone Joint Surg Br. the degree of laxity, and the patient's age and willingness to pursue vigorous postoperative physical therapy are other major determinants. The anterior cruciate ligament (ACL) is an important ligament in the knee. The ligament is mainly responsible for restraining anterior translation of knee. Not really known: Mucoid degeneration of the ACL is seen most commonly in adults (35-55 years of age). Diet therapy and various other treatments (general aspects) Discipline Radiotherapy. CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported. It is lined by the synovial fluid, which provides the nutrition and plays an integral part in healing. At the time the article was last revised Dai Roberts had no recorded disclosures. Some case reports have been published; however, it is difficult to diagnose and is often underdiagnosed or misdiagnosed because of its pathophysiological ambiguity. MRI is better at detecting mucoid degeneration than arthroscopy, as the surface of the ligament is often intact. 2010 Jun;96(4):400-6. doi: 10.1016/j.otsr.2010.02.008. Anterior cruciate ligament mucoid degeneration. The aetiology of MDACL is not fully understood, hence, there are multiple theories on this. Score: 4.7/5 (45 votes) . 2007;90(3):1923. Mucoid degenerated anterior cruciate ligament (ACL) managed by arthroscopic ACL reconstruction: A case series. Ligaments and tendons are accumulated by mucoid change might display a thickened and/or hypertrophied appearance, with an increase in signal intensity. Lintz F, Pujol N, Boisrenoult P, Bargoin K, Beaufils P, Dejour D. Anterior cruciate ligament mucoid degeneration: a review of the literature and management guidelines. [3] and in 1% of patients (3 of 106 knees) in the study of Kim et al. government site. -, Hodler J, Haghighi P, Trudell D, Resnick D. The cruciate ligaments of the knee: Correlation between MR appearance and gross and histologic findings in cadaveric specimens. ADVERTISEMENT: Supporters see fewer/no ads. 2013 Oct;99(6):693-7. doi: 10.1016/j.otsr.2013.04.010. Mucoid degeneration of the anterior cruciate ligament. PubMed J Chin Med Assoc. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Knee Surg Sports Traumatol Arthrosc. 2007;15 (1): 73-86. Bergin D, Morrison WB, Carrino JA et-al. Three reviewers (an experienced librarian and two of the authors) independently searched these databases. This did not appear to affect the postoperative rate of clinically detectable laxity, which was comparable to that in other studies. In the nine included studies, four different scores were used for outcome assessment. Clinical outcome was reported using a variety of scores (the Lysholm and International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the visual analogue scale (VAS) score) in the different studies; these are summarized in Table 4. The cruciate ligament have mechanoreceptors, which are responsible to detect any change in position of the knee, direction, speed and tension. Mucoid degeneration of A C L is more common and literature has also reported many cases, but for PCL only few cases have been reported in English literature. Kumar A, Bickerstaff DR, Grimwood JS, Suvarna SK (1999) Mucoid cystic degeneration of the cruciate ligament. I have multiple issues - spondylolisthesis in L4/L5 and L5/S1, osteopenia and osteoarthritis. In most cases Physiopedia articles are a secondary source and so should not be used as references. Treatment of ACL mucoid degeneration by arthroscopic resection is effective for posterior pain and flexion limitation. Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) is a rare pathological entity with disputed theories of origin. Symptomatic ACL mucoid degeneration in middle-age athletes. W B Saunders Co. (2005) ISBN:0721602703. This series describes the clinicoradiological presentation of patients with mucoid ACL, partial arthroscopic debridement of ACL and outcomes. FOIA Tamer Sweed. Coronal proton density-weighted magnetic resonance imaging shows a thickening of the anterior cruciate ligament. A 48-year-old-male patient presented with knee pain and limitation of motion. 2011. It contrasts with cystic lesions better known as synovial cysts or intercondylar fossa cysts. The ACL appears on MRI to be enlarged with cystic changes throughout, however it is intact. Palmer W, Bancroft L, Bonar F, Choi JA, Cotten A, Griffith JF, Robinson P, Pfirrmann CW. 2022 Mar;14(1):76-89. doi: 10.4055/cios20163. Typically patients present with knee pain or restricted movement, although often other potential causes for the patient's symptoms are found. Unable to load your collection due to an error, Unable to load your delegates due to an error. Knee Surg Sports Traumatol Arthrosc 19(8):13261333. The authors declare that they have no competing interests. Arthroscopic debridement of the ACL resulted in good pain relief and improved range of movement in all studies, with postoperative improvement in the knee scores. Histologically, there is a mucoid substance in connective tissue containing glycoproteins and mucoproteins [8]. (Table 3). Unauthorized use of these marks is strictly prohibited. Introduction: Mucoid degeneration of the anterior cruciate ligament (ACL) is a little-known entity. Mucoid degeneration itself is described as a yellow or brown substance which can be either seen through the most anterior fibers of the ACL or found by probing between them [ 19, 35] (Fig. 2004 Feb;20(2):141-6. doi: 10.1016/j.arthro.2003.11.030. The .gov means its official. Ahuja A, Parekh C, Salomon A, Lawande M, Daftary A. Skeletal Radiol. The https:// ensures that you are connecting to the Accessibility Anatomopathology samples were collected in 18 cases. Keywords: 2020 Jun 2. el Kadi KI, Marcaillou F, Blanc S, Salloum B, Dimontagliari C, Boutayeb F. Mucoid degeneration of the anterior cruciate ligament: a case report. . Arthroscopy. Arthroscopic debridement of the anterior cruciate ligament (ACL) results in satisfactory pain relief and improvement in knee outcome scores. Arthroscopic diagnostic criteria [7] are (1) continuous ACL fibres, (2) increased ACL volume, (3) yellowish-coloured material expressed on palpation and (4) loss of ACL synovial lining. Orthopedics; anterior cruciate ligament; arthoscopy. This is basically an MRI diagnosis of expansion and increased signal of an intact ACL in a person with knee pain which is worse on knee flexion/bending. On MRI, the ligament is thickened and ill-defined with a "celery stalk" appearance. All patients (100%, n=11) reported an improvement in pain. (A) Bulging of, Fig. The pathogenesis remains controversial. PMC The success of treatment for MDACL and the subsequent risk of instability is not known. The reported restriction of range of movement was flexion deficit in four studies [3, 13, 15, 17], extension deficit in one study [14] and combined flexion and extension deficit in four studies [6, 16, 18, 19] (Table4). (B) Partial resection, MeSH That is usually the journal article where the information was first stated. -. . Kim TH, Lee DH, Lee SH, Kim JM, Kim CW, Bin SI. Instrumental treatment. Anterior cruciate ligament; Arthroscopy; Knee; Mucoid degeneration. Knee Surg & Relat Res 33, 26 (2021). PubMedGoogle Scholar. 1. . Questions just answered: mucoid degeneration of acl physiotherapy. -, Hensen JJ, Coerkamp EG, Bloem JL, De Schepper AM. official website and that any information you provide is encrypted International Journal of Orthopaedics. reported on the co-existence of mucoid degeneration and ganglia of the ACL. Epub 2013 Aug 27. Noninfiltrating synovial cysts of the ACL were excluded. Mucoid change or mucoid degeneration refers to the irreversible tissue degeneration due to the accumulation of mucin within the fibers of tendons, ligaments, and fibrocartilage. For non-comparative studies, this consists of eight questions. The minimum follow-up was 3 years. 8600 Rockville Pike Quadriceps and hamstring weakness are common features of people with symptomatic degenerative meniscal tears Surgery may address the structural injury, but . Accessibility what causes mucoid degeneration of acl. Sasaki R, Nagashima M, Takeshima K, Otani T, Okada Y, Aida S, Ishii K. J Int Med Res. In the Lintz study, total resection of the ACL was performed in 17 out of 29 knees, while in the Ventura study total resection was performed in 17 out of 25 patients. By using this website, you agree to our Posterior pain disappeared in 27 cases (93%), on average 3.7 weeks after the procedure. in 1999 [1]. The https:// ensures that you are connecting to the https://doi.org/10.1302/0301-620X.81B2.0810304, Article Morice et al. 8600 Rockville Pike Epub 2018 Apr 21. Resnick D, Kransdorf MJ. Reduction plasty for hypertrophic anterior cruciate ligament mucoid degeneration: clinical and knee laxity outcomes in 23 cases. This systematic review has some limitations. The site is secure. Bergin D, Morrison WB, Carrino JA, Nallamshetty SN, Bartolozzi AR. Role of debulking mucoid ACL in unicompartmental knee arthroplasty: a prospective multicentric study. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Background: Mucoid degeneration of the anterior cruciate ligament (ACL) is an uncommon non-traumatic cause of knee pain and motion restriction, typically seen in a middle-aged population. ANZ J Surg 73(9):712716. The .gov means its official. Mucoid degeneration of the anterior cruciate ligament (ACL) is a very rare cause of knee pain. Treatment for MDACL usually starts non-surgically with anti-inflammatory drugs and physiotherapy. The need for simultaneous or delayed ACL reconstruction should be discussed with patients in case total resection of the ACL is to be performed, particularly in young active patients. (10%) and highest in the study of Ventura et al. 2011;19(3):408411. Disclaimer. Anterior knee pain is the more common complaint. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. https://doi.org/10.1007/s00167-012-1991-9, McIntyre J, Moelleken S, Tirman P (2001) Mucoid degeneration of the anterior cruciate ligament mistaken for ligamentous tears. A long duration of non-specific knee pain in a patient should be evaluated with MRI. MeSH The .gov means its official. 2009 Jul;17(7):737-40. doi: 10.1007/s00167-008-0690-z. This ligament consists of two fibers, mainly, the anterio-medial and postero-lateral fibers, respectively. In contrast to the tear, mucoid degeneration of the ACL characteristically does not cause knee instability [20, 21, 22]. Sasaki R, Nagashima M, Takeshima K, Otani T, Okada Y, Aida S, Ishii K. J Int Med Res. Second, methodological quality assessment showed that three studies had low methodological quality. The aim of this study was to detail the clinical, radiological, arthroscopic, and pathological findings of mucoid degeneration of the anterior cruciate ligament and report the clinical outcomes following arthroscopic treatment. Management of mucoid degeneration of the anterior cruciate ligament: a systematic review. Individuals with mucoid degeneration of the ACL were excluded. 2018. http://journals.sagepub.com/doi/10.1177/2325967118786930, Pandey V, Suman C, Sharma S, Rao SP, Kiran Acharya K, Sambaji C (2014) Mucoid degeneration of the anterior cruciate ligament: management and outcome. Arthroscopic treatment of mucoid hypertrophy of the anterior cruciate ligament. Level of evidence: statement and Disclaimer. Any discrepancy was resolved by the senior author. maude adverse event report: genzyme biosurgery (ridgefield) synvisc one intra-articular hyaluronic acid Data extracted included mean age and gender of the patients, duration of follow up, associated chondral and meniscal lesions, interventions and outcomes. The prevalence of MDACL on magnetic resonance imaging (MRI) ranges from 1.8 to 5.3% [4, 5]. Method. MeSH Springer Nature. Thirteen patients were treated with complete ACL resection for symptomatic MD of the ACL from 2006-2016. Rajani AM, Shah UA, Mittal ARS, Gupta S, Garg R, Punamiya M. Knee Surg Relat Res. Average postoperative differential laxity on the Telos device was 8.3 mm (5 to 13 mm). (100%). An official website of the United States government. Mucoid degeneration of ACL. The extracted data were heterogeneous in terms of outcome assessment. Post-debridement arthroscopic view showing yellowish, Post-debridement arthroscopic view showing yellowish lesion of the anterior cruciate ligament which was, MeSH Both anterior cruciate ligament ganglion cysts and mucoid degeneration have a high association with intraosseous cysts [3] (figures 1 and 2). 4. The site is secure. Radiology. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Lintz F, Pujol N, Dejour D, Boisrenoult P, Beaufils P. Orthop Traumatol Surg Res. Coronal T2 weighted fat suppressed fast spin echo image showed complex anterior cruciate ligament ganglion cyst arising from superior aspect of ligament. Magnetic Resonance Imaging is the most useful tool for differentiating mucoid degeneration of the ACL from an intraligamentous ganglion or other lesions in the knee joint and if this disease is considered preoperatively, it can be diagnosed easily based on characteristic findings. This infiltrating lesion is included in the mucoid pathology of the intercondylar fossa. Manage cookies/Do not sell my data we use in the preference centre. and transmitted securely. 8600 Rockville Pike Google Scholar, Chudasama CH, Chudasama VC, Prabhakar MM (2012) Arthroscopic management of mucoid degeneration of anterior cruciate ligament. Ever since mucoid degeneration of the anterior cruciate ligament (MD-ACL) was named by Kumar et al. Partial resection of the anterior cruciate ligament was done in seven cases and a complete resection in 18 cases. official website and that any information you provide is encrypted However, symptomatic instability was not common. Correlations between degree of knee instability and SIR were assessed for each bundle, each time point, and each sequence. Anterior cruciate ligament (ACL) mucoid degeneration, along with tears and anterior cruciate ligament ganglion cysts, is a relatively common cause of increased signal within the anterior cruciate ligament (ACL ). FOIA The primary intervention was arthroscopic ACL debridement in eight studies; this was combined with notchplasty in cases of impingement with the lateral wall of the notch in five studies [6, 14, 16,17,18] (Table 3). 1. Due to the lack of specific symptoms and signs, its diagnosis is often delayed or even misdiagnosed in clinical practice [ [1] , [2] ]. Mucoid degeneration of the anterior cruciate ligament (ACL) is a rare cause of knee pain. (A) Bulging of the hypertrophied anterior cruciate ligament. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Mucoid degeneration of the anterior cruciate ligament (ACL) is a little-known entity. Management of mucoid degeneration of the anterior cruciate ligament: a systematic review. Its prevalence in magnetic resonance imaging (MRI) is 1.8 to 5.3%, but not all lesions are symptomatic. All rights reserved. The presence of intraligamentous mucoid degeneration in the ACL is demonstrated as a source of knee pain without instability and partial ACL debridement did not preclude adequate knee stability. 2018 Sep;10(3):307-314. doi: 10.4055/cios.2018.10.3.307. 2006;69(9):44952. https://doi.org/10.4103/0019-5413.128765, Article Anterior cruciate ligament mucoid degeneration: a review of the literature and management guidelines. Six studies reported using the pivot shift test; unsurprisingly, Lintz et al. Outcome of Arthroscopic Treatment of Mucoid Degeneration of the Anterior Cruciate Ligament. volume33, Articlenumber:26 (2021) This ranged from 90 to 95% in all studies, except in the report by Kim et al., where only 53.8% of patients (57/106) had complete pain relief after surgery. Mucoid degeneration of the ACL is suspected when an apparently thickened and ill-defined ligament with increased signal intensity on all sequences in MRI is identified in a patient with physically intact ligament and no obvious trauma history. Seventeen females (67%) and eight males (33%) were included in the final analysis. eCollection 2021. All studies focused on the outcome of arthroscopic debridement of MDACL, with no studies on conservative treatment. Possible etiologies include: It is postulated that mucoid degeneration may be a predisposing factor in the formation of ACL ganglion cysts. Pan African Medical Journal. PMC Reeducation. Sweed, T., Mussa, M., El-Bakoury, A. et al. -, Hsu CJ, Wang SC, Fong YC, Huang CY, Chiang IP, Hsu HC. Four studies reported only postoperative scores, which were comparable to those in other studies. Patients in all studies presented with central or posterior knee pain, mainly with terminal extension in three studies [14, 16, 17]. Lintz F, Pujol N, Boisrenoult P, Bargoin K, Beaufils P, Dejour D. Knee Surg Sports Traumatol Arthrosc. J Chin Med Assoc. Bethesda, MD 20894, Web Policies 2009. https://doi.org/10.1007/s002560100336, Narvekar A, Gajjar S (2004) Mucoid degeneration of the anterior cruciate ligament. ACL (anterior cruciate ligament) mucoid degeneration means the lesion of the ACL. Knee Surg Sports Traumatol Arthrosc. Mucoid degeneration of the anterior cruciate ligament (MD-ACL) was first characterized by Kumar et al. had the largest number of patients (91) with a mean age of 61 years, which was the oldest study population amongst the nine studies [16]. Functional Outcome of Arthroscopic Debridement of Mucoid Degeneration of the Anterior Cruciate Ligament. 2 ). Conclusions: 2021 Sep;50(9):1837-1843. doi: 10.1007/s00256-021-03750-7. 2022 Jun 2;20(1):225-228. doi: 10.33314/jnhrc.v20i01.4182. https://doi.org/10.4103/0019-5413.101037, Srivastava A, Pateliya S, Singh H, Aggarwal S, Srivastava S (2016) Mucoid degeneration of anterior cruciate ligament management and functional outcome of 18 cases. Skeletal Radiology. https://doi.org/10.2214/ajr.182.5.1821283, Article Bookshelf Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Unable to load your collection due to an error, Unable to load your delegates due to an error. Mucoid degeneration of the anterior cruciate ligament: Management and outcome.. sharing sensitive information, make sure youre on a federal The inclusion criteria for this study were (1) studies including symptomatic patients with mucoid degeneration of the ACL, (2) studies of 10 or more patients, (3) a minimum of 6months follow up and (4) patients treated conservatively or surgically (arthroscopic debridement with or without simultaneous ACL reconstruction). Anterior Cruciate Ligament, is an important structure of the knee joint. Here are the search results of the thread mucoid degeneration of acl treatment from Bing. (48.2% (14/29 patients) with symptomatic instability), which may be due to the large number of patients with total resection of the ACL (58.6% (17 out of 29 patients)) (Table 4). Eight studies reported postoperative instability. They reported that a biopsy indicated mucoid degeneration and a relief of symptoms could be obtained through arthroscopic partial resection of the ligament. California Privacy Statement, Kwee RM, Hafezi-Nejad N, Roemer FW, Zikria BA, Hunter DJ, Guermazi A, Demehri S. Association of Mucoid Degeneration of the Anterior Cruciate Ligament at MR Imaging with Medial Tibiofemoral Osteoarthritis Progression at Radiography: Data from the Osteoarthritis Initiative. Hide glossary Glossary. Mucoid degeneration of the anterior cruciate ligament is a rare pathological entity. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Read More Created for people with ongoing healthcare needs but benefits everyone. Conclusions: Mucoid degeneration of the ACL is a clinical condition afflicting active middle-aged people without a single significant traumatic episode with a specific MRI picture. Due to the heterogeneity of data, a meta-analysis was not possible, and a narrative review was deemed most appropriate. official website and that any information you provide is encrypted 1 Its prevalence in magnetic resonance imaging (MRI) is 1.8-5.3%, but not all lesions are symptomatic.2, 3 It is characterized by infiltration of mucoid-like substance (glycosaminoglycans) interspersed within the 8600 Rockville Pike In that case, mucoid degeneration can be extruded from the ligament and will be removed in the saline flow. https://doi.org/10.1016/j.arthro.2008.02.004, Morice A, Coupry A, Lintz F, Robert H (2013) Reduction plasty for hypertrophic anterior cruciate ligament mucoid degeneration: clinical and knee laxity outcomes in 23 cases. Average improvement in flexion was 21.5 degrees (0 to 60 degrees). : A Meta-Analysis. Unauthorized use of these marks is strictly prohibited. Keywords: mucoid degeneration, anterior cruciate ligament, acl reconstruction, arthroscopy, knee PROSPERO. Hsu CJ, Wang SC, Fong YC, Huang CY, Chiang IP, Hsu HC. Arch Orthop Trauma Surg. See this image and copyright information in PMC. 2010 Jun 1;96(4):400-6. The mean MINORS score was 9.5 out of 16 (412). However, MDACL is asymptomatic in most patients. Mucoid degeneration of the anterior cruciate ligament (ACL) is regarded as a degenerative change in the ligament, which is clinically presented with pain on full extension or flexion in the middle-aged population. https://doi.org/10.1186/s43019-021-00110-6, DOI: https://doi.org/10.1186/s43019-021-00110-6. The origin of MDACL may be degenerative or traumatic. The site is secure. 2011 Aug;19(8):1326-33. doi: 10.1007/s00167-011-1433-0. Arthroscopic management of mucoid degeneration of anterior cruciate ligament. Arthroscopic resection of ACL mucoid degeneration is effective for treating pain and flexion limitation, but at the expense of anterior laxity. Epub 2021 Nov 24. Postoperative pain relief was reported in seven studies. MUCOID DEGENERATION OF ACL - ARTHROSCOPIC TREATMENT 2,375 views Sep 15, 2019 23 Dislike Dr. Prateek Joshi- Ortho 1.02K subscribers Notice Age-restricted video (based on Community Guidelines). We report a case of a patient with mucoid degeneration of the ACL, presenting with posterior knee pain and no history of a major knee trauma. government site. These appearances must be differentiated from mucoid degeneration of the intact ACL. Arthroscopic debridement of the mucoid degeneration of the ACL was safe and effective in the patient. The appearance can mimic acute or chronic interstitial partial tears of the ACL. There is no consensus on treatment and evidence is scarce. Bookshelf Association between magnetic resonance imaging characteristics and pathological findings in entire posterior cruciate ligament with mucoid degeneration. Besides, the patient may also have trouble in moving. The anterior cruciate ligament (ACL) is one of the more vital and more easily injured ligaments within our knee. After arthroscopic debridement of the lesion, the patient regained full range of motion of the knee and were pain-free at follow-up. 2012;4 (2): 167-70. Roberts CC, Towers JD, Spangehl MJ et-al. bling. Magn Reson Imaging Clin N Am. ACL mucoid degeneration is present on ~10% (range 9-12%) of 3 T MRI examinations and 2% of 1.5 T MRI examinations 6. All patients (100%, n=11) reported a good to very good surgery satisfaction. Hypothesis: The retrospective study by Kim et al. All nine included studies utilized MRI of the knee to establish a radiological diagnosis as an inclusion criterion. Therefore, indications for ACL resection must be carefully selected. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). [6], in 62% of patients (18 of 29) in the study of Lintz et al. -, Kumar A, Bickerstaff DR, Grimwood JS, Suvarna SK. Open Grey database was searched for grey literature using the same keywords. Postoperative symptomatic instability was not common in eight studies, but was observed in 48% of patients in the study of Lintz et al., with two patients having a delayed ACL reconstruction. 2023 BioMed Central Ltd unless otherwise stated. This site needs JavaScript to work properly. [Effectiveness of bone-anterior cruciate ligament-bone allograft in reconstruction of anterior cruciate ligament under arthroscope]. Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. AJR Am J Roentgenol. There was strong association between MDACL and chondral lesions (82%) and between MDACL and meniscal tears (69%). There was more than 20% loss to follow up in the study of Kim et al., while the three prospective studies had no loss to follow up [13, 14, 18]. Knee Surgery, Sports Traumatology, Arthroscopy. Arthroscopic examination analyzed the ACL aspect and its associated lesions (meniscus, cartilage). Anterior cruciate ligament mucoid degeneration: a review of the literature and management guidelines. The mean MINORS score was 9.5 (range 412). It is a chronic degenerative change of a bulky ACL that may lead to notch impingement syndrome in the absence of instability symptoms and significant trauma history [ 1, 2, 3, 4 ]. Loss to follow up was not mentioned in the other five studies [3, 6, 15, 17, 19].
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