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1.
Knee Surg Sports Traumatol Arthrosc ; 25(11): 3596-3604, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27527338

RESUMO

PURPOSE: Hindfoot alignment can affect the weight-bearing kinematics of the knee joint in patients undergoing total knee arthroplasty (TKA). This study evaluated the change in hindfoot alignment after TKA by prospectively analysing the correlation between the knee joint and the hindfoot deformity, the post-operative improvement in the hindfoot deformity, and the long-term post-operative changes in hindfoot alignment. METHODS: This study included 195 knees from 117 patients with osteoarthritis who underwent TKA between 2012 and 2013. The mechanical alignment angle of the knee joint and the hindfoot alignment angle were measured preoperatively and 6 weeks, 1, and 2 years post-operatively. The patients were divided into two groups according to the severity of the preoperative knee joint deformity: <10° varus (group 1, N = 81) and ≥10° varus (group 2, N = 114). The preoperative and post-operative radiologic parameters of the axis of the knee joint and hindfoot were evaluated, and the results were compared. A Spearman correlation analysis was used to assess the differences in both the mechanical alignment and the hindfoot alignment pre- and post-operatively. RESULTS: After TKA, the hindfoot valgus deformity improved from 5.2° (±3.8) valgus to 2.1° (±3.9) valgus. At 6 weeks post-operatively, the hindfoot alignment angle was 1.4° (±3.5) valgus and 2.5° (±4.1) valgus in group 1 and group 2, respectively; the difference between the two groups was not statistically significant. Hindfoot alignment showed greater valgus with increasing varus of the mechanical alignment of the knee joint preoperatively (-0.484, p < 0.001) and post-operatively (-0.147, p = 0.040). The post-operative 1- and 2-year hindfoot alignment angles were 2.2° (±4.2) valgus and 2.2° (±4.1) valgus, respectively. None of the differences between the post-operative hindfoot alignment angles were statistically significant. CONCLUSIONS: The stable improvement in the hindfoot deformity after TKA demonstrates that a valgus deformity of the hindfoot in a patient with a varus knee joint deformity does not require preoperative correction. In patients with a residual hindfoot deformity and pain 6 weeks after TKA, active treatment should be considered because no further improvement can be expected. LEVEL OF EVIDENCE: Prospective cohort study, Level II.


Assuntos
Artroplastia do Joelho , Calcanhar/fisiologia , Articulação do Joelho/fisiologia , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/cirurgia , Idoso , Fenômenos Biomecânicos , Feminino , Calcanhar/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/fisiopatologia , Período Pós-Operatório , Estudos Prospectivos , Suporte de Carga
2.
Knee Surg Sports Traumatol Arthrosc ; 23(6): 1816-23, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25223967

RESUMO

PURPOSE: Medial collateral ligament (MCL) release is one of the essential steps toward the achievement of ligament balancing during the total knee arthroplasty (TKA) in patients with varus deformity. When the varus deformity is severe, complete release of the MCL until balanced is often required. However, it is believed that complete MCL release may lead to catastrophic laxity. The purpose of this prospective study is to compare the medial joint gap opening in postoperative valgus stress radiograph in patients with complete MCL release against patients with partial release. METHODS: Out of 209 primary TKAs performed for degenerative osteoarthritis, complete MCL release was required in 33 cases (group I) by sub-periosteal detachment at proximal tibia using periosteal elevator. For the remaining 176 knees (group II), partial release of MCL was done. At postoperative 6 months and 1 year, both groups were evaluated for comparing the joint gap on valgus stress radiographs using modified Telos device in 0°, 45°, and 90° of flexion. Additional parameters which were analyzed included preoperative varus and valgus stress radiographs in full extension and pre- and postoperative mechanical alignment in each group. The knee range of motion (ROM) and clinical scores were evaluated at 1-year follow-up. RESULTS: The mean values of the joint opening on the postoperative valgus stress test with the knee joint extended, and in the 45° and 90° flexed states at 6 months and at 1 year postoperatively in group I were not statistically significantly different from those of group II. The clinical scores also did not show a statistically significant difference between two groups. There was a statistically significant difference in ROM between two groups, pre- and postoperatively and the difference was 5°, respectively. CONCLUSION: This study suggests that complete MCL release for ligament balancing is a safe procedure and does not lead to postoperative laxity.


Assuntos
Artroplastia do Joelho , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/fisiopatologia , Ligamento Colateral Médio do Joelho/cirurgia , Amplitude de Movimento Articular/fisiologia , Idoso , Feminino , Seguimentos , Humanos , Articulação do Joelho/cirurgia , Masculino , Osteoartrite do Joelho/cirurgia , Estudos Prospectivos , Radiografia
3.
Clin Orthop Relat Res ; 472(1): 316-26, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23982406

RESUMO

BACKGROUND: Failure after total knee arthroplasty (TKA) may be related to emerging technologies, surgical techniques, and changing patient demographics. Over the past decade, TKA use in Korea has increased substantially, and demographic trends have diverged from those of Western countries, but failure mechanisms in Korea have not been well studied. QUESTIONS/PURPOSES: We determined the causes of failure after TKA, the risk factors for failure, and the trends in revision TKAs in Korea over the last 5 years. METHODS: We retrospectively reviewed 634 revision TKAs and 20,234 primary TKAs performed at 19 institutes affiliated with the Kleos Korea Research Group from 2008 to 2012. We recorded the causes of failure after TKA using 11 complications from the standardized complication list of The Knee Society, patient demographics, information on index and revision of TKAs, and indications for index TKA. The influences of patient demographics and indications for index TKA on the risk of TKA failure were evaluated using multivariate regression analysis. The trends in revision procedures and demographic features of the patients undergoing revision TKA over the last 5 years were assessed. RESULTS: The most common cumulative cause of TKA failure was infection (38%) followed by loosening (33%), wear (13%), instability (7%), and stiffness (3%). However, the incidence of infections has declined over the past 5 years, whereas that of loosening has increased and exceeds that of infection in the more recent 3 years. Young age (odds ratio [OR] per 10 years of age increase, 0.41; 95% confidence interval [CI], 0.37-0.49) and male sex (OR, 1.88; 95% CI, 1.42-2.49) were associated with an increased risk of failure. The percentage of revision TKAs in all primary and revision TKAs remained at approximately 3%, but the annual numbers of revision TKAs in the more recent 3 years increased from that of 2008 by more than 23%. CONCLUSIONS: Despite a recent remarkable increase in TKA use and differences in demographic features, the causes and risk factors for failures in Korea were similar to those of Western countries. Infection was the most common cause of failure, but loosening has emerged as the most common cause in more recent years, which would prompt us to scrutinize the cause and solution to reduce it.


Assuntos
Artroplastia do Joelho/efeitos adversos , Prótese do Joelho , Falha de Prótese/etiologia , Infecções Relacionadas à Prótese/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/tendências , Feminino , Humanos , Incidência , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Falha de Prótese/tendências , Infecções Relacionadas à Prótese/etiologia , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Resultado do Tratamento
4.
J Arthroplasty ; 28(10): 1874-7, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23642445

RESUMO

We evaluated the outcomes in 15 patients with infected total knee arthroplasty (TKA) who underwent reimplantation following excision arthroplasty in the presence of five to twenty polymorphonuclear cells per high power field (hpf) on intraoperative frozen section. At a minimum of two years of follow-up, we achieved 100% infection eradication rate with normalization of C-reactive protein levels, no radiolucency on plain radiographs and no clinical evidence of recurred infection. Successful reimplantation for infected TKA is possible despite of the presence of five to twenty polymorphonuclear cells per hpf in intraoperative frozen section with clear appearance of the tissues in the operative field. Clinical and serological confirmations of infection eradication before reimplantation as well as healthy operative findings are equally important factors for a successful reimplantation.


Assuntos
Artroplastia do Joelho/efeitos adversos , Neutrófilos/patologia , Infecções Relacionadas à Prótese/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Proteína C-Reativa/análise , Remoção de Dispositivo , Feminino , Secções Congeladas , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Infecções Relacionadas à Prótese/sangue , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/etiologia , Reimplante
5.
J Clin Immunol ; 30(2): 260-7, 2010 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-20072851

RESUMO

INTRODUCTION: In the present study, we examined the effect of the pro-inflammatory cytokine IL-32gamma, the most biologically active isoform, and its related molecules in fibroblast-like synoviocytes (FLS). MATERIALS AND METHODS: FLS were isolated from synovial tissues of rheumatoid arthritis (RA) patients. The secretion and expression of IL-6 and IL-8 were examined by ELISA and real-time PCR, and the activation of signaling molecules was evaluated by Western blot, electrophoretic mobility shift assay (EMSA), real-time PCR, and siRNA transfection. RESULTS: By IL-32gamma stimulation in RA FLS, the expressions of IL-6 and IL-8 were increased significantly, and the phosphorylated Erk1/2 and AP-1 were expressed prominently in Western blot and EMSA. In the Erk1/2 inhibited cells, IL-32gamma stimulation did not increase the mRNA expression of IL-6 and IL-8. CONCLUSION: Our results suggest that IL-32gamma stimulation can induce the production of IL-6 and IL-8 from RA FLS via Erk1/2 activation.


Assuntos
Artrite Reumatoide/imunologia , Fibroblastos/efeitos dos fármacos , Interleucina-6/metabolismo , Interleucina-8/metabolismo , Interleucinas/farmacologia , Artrite Reumatoide/patologia , Células Cultivadas , Ensaio de Imunoadsorção Enzimática , Fibroblastos/imunologia , Fibroblastos/metabolismo , Fibroblastos/patologia , Humanos , Interleucina-33 , Interleucina-6/genética , Interleucina-6/imunologia , Interleucina-8/genética , Interleucina-8/imunologia , Proteína Quinase 3 Ativada por Mitógeno/genética , Proteína Quinase 3 Ativada por Mitógeno/metabolismo , Fosforilação , RNA Interferente Pequeno/genética , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Transdução de Sinais/efeitos dos fármacos , Transdução de Sinais/genética , Transdução de Sinais/imunologia , Membrana Sinovial/imunologia , Membrana Sinovial/patologia , Fator de Transcrição AP-1/genética , Fator de Transcrição AP-1/metabolismo
6.
Knee Surg Sports Traumatol Arthrosc ; 18(10): 1345-51, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20556357

RESUMO

Three hundred and sixty-four low contact stress (LCS) total knee arthroplasties that could be followed up for more than 5 years were clinically and radiographically analyzed. The median postoperative Hospital for Special Surgery score improved from 56 (range 32-77) to 91 (range 64-100) points, but median range of motion did not change from 120° (range 50°-135°) to 120° (range 85°-135°). Complications occurred in 16 cases (4%), and included postoperative polyethylene dislocation and intraoperative tibial condylar fracture, while five knees (1%) required revision surgery due to mechanical reasons. The overall prosthesis survival rate was 91% at 12 years. Although the LCS mobile-bearing knee system has theoretical advantages in terms of wear and loosening, the problem of polyethylene dislocation, intraoperative tibial fracture, and radiolucent lines should be solved for long survival. The clinical relevance of this study is that the LCS system provided good clinical and survival results.


Assuntos
Artroplastia do Joelho/métodos , Prótese do Joelho , Amplitude de Movimento Articular/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Artrite Reumatoide/diagnóstico por imagem , Artrite Reumatoide/cirurgia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Osteoartrite do Joelho/cirurgia , Osteonecrose/diagnóstico por imagem , Osteonecrose/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Desenho de Prótese , Falha de Prótese , Radiografia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Estresse Mecânico , Fatores de Tempo , Resultado do Tratamento
7.
Knee Surg Sports Traumatol Arthrosc ; 18(7): 923-7, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20217395

RESUMO

We hypothesized that changes in patellar thickness following patellar resurfacing affect patellar tilt in total knee arthroplasty (TKA) patients. The study enrolled 272 TKAs and categorized them into four groups according to change in patellar thickness: (A) thinner by 1 mm or more, (B) equal or thinner by less than 1 mm, (C) thicker by 1 mm or less, and (D) thicker by more than 1 mm. Patellar tilt angle was measured postoperatively using Merchant radiography. There were no significant differences in postoperative patellar tilt among groups A, B, and C (n.s). However, the postoperative patellar tilting angle of group D was significantly higher than that of all other groups (P < 0.05). Postoperative patellar tilt increased when the postoperative patella was >1 mm thicker than the preoperative patella.


Assuntos
Artroplastia do Joelho/métodos , Osteotomia/métodos , Patela/anatomia & histologia , Patela/cirurgia , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos , Feminino , Humanos , Prótese do Joelho , Pessoa de Meia-Idade
8.
J Arthroplasty ; 24(5): 825.e5-9, 2009 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-19026518

RESUMO

Duracon (Howmedica, Rutherford, NJ) posterior stabilized total knee system has a snap fit locking mechanism of a tibial polyethylene, including an additional locking screw for further fixation of polyethylene. We report 13 cases of locking screw migration from tibial component after Duracon posterior stabilized primary total knee arthroplasty. Among 13 knees, screw migration in 10 asymptomatic cases was incidentally detected during regular follow-up, and they were just observed in the outpatient clinic. Only 3 knees had moderate pain, swelling, and instability, and revision was done on 2 of 3 knees.


Assuntos
Artroplastia do Joelho/efeitos adversos , Parafusos Ósseos/efeitos adversos , Falha de Prótese , Idoso , Artroplastia do Joelho/instrumentação , Materiais Biocompatíveis , Feminino , Migração de Corpo Estranho/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Polietileno
9.
Knee ; 22(3): 180-5, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25728568

RESUMO

BACKGROUND: The lack of standardized diagnostic criteria for periprosthetic joint infection (PJI) poses a challenge to accurate diagnosis of PJI. Recently, the Musculoskeletal Infection Society (MSIS) proposed diagnostic criteria for PJI. However, it is not known how well these proposed criteria accommodate real clinical scenarios. We determined what proportion of patients satisfied the MSIS criteria, and if MSIS criteria were not met, what other rationales were used to diagnose PJI. METHODS: We retrospectively reviewed the records of 303 patients who underwent two-stage exchange arthroplasty for treatment of PJI of the knee at 17 institutions. The rationale for making the diagnosis of PJI was also recorded, if the case did not meet the MSIS criteria. In addition, detailed information about isolated microorganisms were gathered. RESULTS: Among the 303 patients, 198 met the diagnostic criteria proposed by MSIS. Among the 105 patients who did not meet the MSIS criteria, 88% met two or three minor criteria; however joint fluid analysis or histologic analysis was not performed in 85% of these 105 patients. The most common rationale for the diagnosis of PJI was the presence of abnormal physical findings. Microorganisms were identified in only 52% of all patients; the most common organism was coagulase-negative Staphylococcus. CONCLUSIONS: The diagnosis of PJI was based on clinical suspicion in approximately one-third of cases. In this series, joint aspiration or histological analysis was not performed in a large number of patients. Thus, surgeons should perform joint fluid and histologic analysis to assure the accuracy of PJI diagnosis.


Assuntos
Artroplastia do Joelho/efeitos adversos , Prótese do Joelho/efeitos adversos , Infecções Relacionadas à Prótese/diagnóstico , Cirurgiões/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos
10.
Korean J Radiol ; 12(1): 78-88, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21228943

RESUMO

OBJECTIVE: We wanted to compare the two-dimensional (2D) fast spin echo (FSE) techniques and the three-dimensional (3D) fast field echo techniques for the evaluation of the chondromalacia patella using a microscopy coil. MATERIALS AND METHODS: Twenty five patients who underwent total knee arthroplasty were included in this study. Preoperative MRI evaluation of the patella was performed using a microscopy coil (47 mm). The proton density-weighted fast spin echo images (PD), the fat-suppressed PD images (FS-PD), the intermediate weighted-fat suppressed fast spin echo images (iw-FS-FSE), the 3D balanced-fast field echo images (B-FFE), the 3D water selective cartilage scan (WATS-c) and the 3D water selective fluid scan (WATS-f) were obtained on a 1.5T MRI scanner. The patellar cartilage was evaluated in nine areas: the superior, middle and the inferior portions that were subdivided into the medial, central and lateral facets in a total of 215 areas. Employing the Noyes grading system, the MRI grade 0-I, II and III lesions were compared using the gross and microscopic findings. The sensitivity, specificity and accuracy were evaluated for each sequence. The significance of the differences for the individual sequences was calculated using the McNemar test. RESULTS: The gross and microscopic findings demonstrated 167 grade 0-I lesions, 40 grade II lesions and eight grade III lesions. Iw-FS-FSE had the highest accuracy (sensitivity/specificity/accuracy = 88%/98%/96%), followed by FS-PD (78%/98%/93%, respectively), PD (76%/98%/93%, respectively), B-FFE (71%/100%/93%, respectively), WATS-c (67%/100%/92%, respectively) and WATS-f (58%/99%/89%, respectively). There were statistically significant differences for the iw-FS-FSE and WATS-f and for the PD-FS and WATS-f (p < 0.01). CONCLUSION: The iw-FS-FSE images obtained with a microscopy coil show best diagnostic performance among the 2D and 3D GRE images for evaluating the chondromalacia patella.


Assuntos
Condromalacia da Patela/diagnóstico , Imageamento Tridimensional , Imageamento por Ressonância Magnética/métodos , Idoso , Condromalacia da Patela/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética/instrumentação , Masculino , Pessoa de Meia-Idade , Patela/patologia , Sensibilidade e Especificidade
11.
Knee ; 18(3): 177-9, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20510617

RESUMO

We checked intraoperative patellar tracking with both 'towel clip technique' and the 'no thumb technique' on 97 patients (167 knees) who underwent primary total knee arthroplasty to decide whether to do or not to do lateral retinacular release. Patellar tracking was assessed under pneumatic tourniquet with the no thumb technique first and re-evaluated with the towel clip technique. The tracking was graded as total contact, good contact, lateral contact and subluxation. The knees graded as total or good contact with the no thumb technique were classified into group A; those graded lateral contact or subluxation by the no thumb technique but total or good contact by the towel clip technique were classified into group B; and those graded lateral contact or subluxation by both techniques were classified into group C; in which lateral releases were performed. One hundred three, 53 and 11 knees were classified into groups A, B and C respectively. Of the 167 knees, 64 (38.3%) showed poor tracking (lateral contact or subluxation) with the no thumb technique alone. Re-evaluation of these knees with the towel clip technique significantly reduced the number with poor tracking to 11 (6.6%) knees requiring lateral retinacular release (p < 0.05). The patients were followed up for 1 year without any patella-related complications occurring. Assessment of the patellar tracking using only the no thumb technique may overestimate the need for lateral retinacular release. The use of the no thumb technique as a screening test, and re-evaluation with the towel clip technique may reduce unnecessary lateral retinacular release.


Assuntos
Artroplastia do Joelho/normas , Prótese do Joelho/normas , Osteoartrite do Joelho/cirurgia , Patela/cirurgia , Idoso , Humanos , Período Intraoperatório , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/fisiopatologia , Estudos Prospectivos , Desenho de Prótese , Amplitude de Movimento Articular
12.
Rheumatol Int ; 23(6): 282-8, 2003 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-12684836

RESUMO

The aim of this study was to evaluate the effect of estrogen on matrix metalloproteinase (MMP)-1, MMP-3, MMP-13, and tissue inhibitor of metalloproteinase (TIMP)-1 in osteoarthritic chondrocytes. Chondrocytes from the knee cartilage of 25 postmenopausal osteoarthritic (OA) patients were cultured under various conditions: 0 pg/mL, 50 pg/mL, 500 pg/mL, and 5,000 pg/mL of 17beta-estradiol, with or without 10-1,000 pg/mL of either interleukin (IL)-1beta or tumor necrosis factor alpha (TNFalpha). MMP-1, MMP-3, MMP-13, and TIMP-1 in the conditioned media were analyzed with immunoblot or enzyme-linked immunosorbent assay (ELISA). Type II collagenolytic activity was measured by fluorogenic type II collagenolytic activity assay. Real-time reverse transcriptase polymerase chain reaction (RT-PCR) using SYBR Green I dye was performed for the quantification of mRNA. Without cytokine stimulation, the secretion of MMP-1 was significantly reduced by 50 pg/mL of 17beta-estradiol (in immunoblot by a median of 12.3%, P=0.007; in ELISA by a median of 18.4%, P=0.001), and 500 pg/mL (in immunoblot by a median of 23.1%, P=0.001; in ELISA by a median of 21.0%, P=0.001). Additionally, under 10 pg/mL TNFalpha, 17beta-estradiol also significantly suppressed the secretion of MMP-1 (in immunoblot by a median of 39.0%, P=0.016; in ELISA by a median of 38.4%, P=0.041). Estrogen did not exert any significant effect on MMP-3, MMP-13, or TIMP-1 expression. With IL-1beta or TNFalpha above 10 pg/mL stimulation, 17beta-estradiol demonstrated no effect on MMP-1, MMP-3, MMP-13, or TIMP-1 secretion. Type II collagenolytic activity in the 50 pg/mL estradiol group decreased by 9.6% (-51.5-5.5%, P>0.05). 17beta-estradiol showed a tendency to decrease in MMP-1 mRNA. Estrogen may improve the imbalance between the amounts of MMPs and TIMP in chondrocytes, and these results suggest that hormone replacement therapy may provide some chondroprotective effect.


Assuntos
Cartilagem Articular/efeitos dos fármacos , Condrócitos/metabolismo , Estradiol/farmacologia , Metaloproteinases da Matriz/metabolismo , Inibidor Tecidual de Metaloproteinase-1/metabolismo , Idoso , Idoso de 80 Anos ou mais , Western Blotting , Cartilagem Articular/metabolismo , Cartilagem Articular/patologia , Células Cultivadas , Meios de Cultivo Condicionados/química , Relação Dose-Resposta a Droga , Combinação de Medicamentos , Feminino , Humanos , Interleucina-1/farmacologia , Metaloproteinases da Matriz/genética , Pessoa de Meia-Idade , Osteoartrite do Joelho/metabolismo , Pós-Menopausa , RNA Mensageiro/metabolismo , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Inibidor Tecidual de Metaloproteinase-1/genética , Fator de Necrose Tumoral alfa/farmacologia
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