Clinical efficacy analysis of arthroscopically assisted Orthcord suture fixation in the treatment of tibial intercondylar eminence fractures: a retrospective case-control study

doi:10.21203/rs.3.rs-5256408/v1

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Clinical efficacy analysis of arthroscopically assisted Orthcord suture fixation in the treatment of tibial intercondylar eminence fractures: a retrospective case-control study

https://doi.org/10.21203/rs.3.rs-5256408/v1

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Background: To explore the efficacy of arthroscopically assisted fixation of type II and type III tibial intercondylar eminence fractures with Orthcord sutures.

Method: A retrospective analysis was performed on 80 patients with intercondylar eminence fractures admitted to our hospital from April 2020 to March 2024. According to different surgical methods, the patients were divided into special suture fixation group (n = 30), cannulated screw fixation group (n = 24), and wire fixation group (n = 26). The suture group used arthroscopic orthcord sutures to fix tibial intercondylar eminence fractures, and the cannulated screw group used cannulated compression screws for fixation. Patients in the wire group underwent arthroscopic wire fixation. The basic information of all patients was collected and followed up for 1 year. The Lysholm score of the knee joint was performed at 3 months and 1 year after surgery. The patients' general data, surgical conditions, operation time, blood loss, hospitalization costs, postoperative recovery (Lysholm score of knee joint at 3 months and 1 year after surgery) and other data were analyzed by variance analysis. P < 0.05 was considered statistically significant.

Result: There was no statistical difference in the general data of all patients. One-year follow-up showed that all patients had achieved bone healing without infection, displacement, or bone malformation. The hospitalization time in the wire group was (11 ± 1.02) days, the screw group was (11.58 ± 1.61) days, and the Orhtcord suture group was shortened to (10.03 ± 1.07) days. The differences among the three groups were statistically significant (P < 0.05). At the same time, the cost of Orhtcord suture surgery (1310.7 ± 0.29) $ was significantly lower than that of the other two groups (P＜0.05). The operation time of the suture group (68.13±1.11min) was significantly shorter than that of the wire group (76.76±11.57min) and the screw group (90.62±1.99min) (P＜0.05). In the follow-up, the score of Orhtcord suture 3 months after operation (94.07±2.72 points) was better than that of the wire group (90.23±5.23 points) and the screw group (90.37±5.41 points); the difference was statistically significant (P＜0.05). However, there was no statistically significant difference in the Lysholm score of the three groups of patients 6 months after operation (96.26±1.89, 96.33±2.44, 97.3±1.70) (P＞0.05).

Conclusion: The use of Orhtcord sutures in the arthroscopically assisted treatment of intercondylar ridge fractures can shorten the length of hospital stay and surgery, while greatly reducing hospitalization costs. It can achieve better short-term (3 months) recovery effects while avoiding secondary surgery, and ultimately show no weaker fixation effect than conventional screws and wires when fully weight-bearing is restored.

intercondylar eminence fracture

anterior cruciate ligament lower insertion avulsion fracture

Orhtcord suture

arthroscopic assisted surgery

Tibial intercondylar spine fracture is called anterior cruciate ligament inferior insertion avulsion fracture¹. In recent years, with the increase of various sports injuries and traffic accidents, intercondylar ridge fracture has gradually become a common intra-articular fracture of the knee, and the incidence rate is getting higher and higher². In tram accidents, knee valgus or rotational stress and hyperextension of the knee are likely to cause intercondylar ridge avulsion fractures, which account for 2–5% of all knee injuries. The injury mechanism is mostly caused by motor vehicle accidents, sports injuries, hyperextension, rotation of the knee during falls, or direct violence. During the injury process, the traction of the anterior cruciate ligament will cause avulsion and displacement of the fracture. Intercondylar ridge fracture were first described by Poncet as early as 1875. and the classic X-ray classification system was proposed by Meyers and McKeever³, which was updated and improved by Zaricznyj in 1977 and is still used today.⁴.

Treatment of different types of intercondylar ridge fractures: For type I fractures, conservative treatment with plaster immobilization and regular follow-up is generally recommended because the fracture is relatively stable and the tension of the anterior cruciate ligament is acceptable. Type II and III fractures are prone to secondary meniscus and cartilage damage and accelerated joint wear and degeneration due to fracture displacement, loss of tension of the anterior cruciate ligament, and instability of the knee joint. Surgical treatment is generally required. The surgical methods mainly include traditional open reduction and internal fixation and arthroscopic reduction and internal fixation. Open reduction and internal fixation is a relatively old surgical method. With the continuous development of arthroscopic technology and the concept of small incisions, early and rapid recovery and return to sports, arthroscopic minimally invasive surgery has gradually become the mainstream. Arthroscopic surgical methods include wire fixation, screw fixation⁵ and suture fixation⁶. Among them, Orthcord sutures have better flexibility than wires and screws, and there is no need to remove the implants again after surgery. The non-metallic material does not affect security checks and imaging examinations such as MRI in normal life. This article selected 80 patients with intercondylar eminence fractures admitted to our hospital from October 2020 to March 2024, aiming to explore the effectiveness and economic value of Orthcord suture fixation.

2.1 General data

A total of 80 patients with intercondylar eminence fractures who were hospitalized in our hospital from October 2020 to March 2024 were selected. All patients underwent knee joint X-ray, CT and MRI examinations. Inclusion criteria: ① Patients aged>18 years and epiphysis closed; ② Clear diagnosis of Meyers-Mckeever II and III type fractures of the tibial intercondylar eminence; ③ Lachman test and anterior drawer test were positive; ④ The patient agreed to surgical treatment or actively cooperated and signed an informed consent form. Exclusion criteria: ① Patients with fractures around the knee joint (femur, patella, etc.) and vascular and nerve injuries ② Patients who were lost to follow-up for less than 3 months ③ Patients with posterior cruciate ligament rupture or medial collateral ligament rupture;

All surgeries for this study were performed by the same team, and the study was approved by the ethics committee of this institution.

2.2 Pre-treatment evaluation

Among all patients, 57 were injured in traffic accidents, 10 were injured in slips or falls, 8 were injured in sports such as basketball, football, and badminton, and 5 were injured in falls. The 80 patients were divided into three groups according to the treatment they received: high-strength suture Orthcord group (n = 30): 17 males, 13 females, 11 Meyers-Mckeever type II, 19 type III, wire group (n = 26): 14 males, 12 females, 12 Meyers-Mckeever type II, 15 type III; screw group (n = 24): 13 males, 11 females, 8 Meyers-Mckeever type II, 16 type III. The general data of the three groups of patients are shown in Table 1. The tibial intercondylar eminence is the attachment point of the anterior cruciate ligament to the tibia. There is more blood accumulation in the knee joint after fracture, and the knee joint is swollen 7. Acute injuries usually cannot use scoring scales to assess activity levels. The knee joint is usually in a slightly flexed position, Therefore this study used X-rays (anteroposterior and lateral X-rays of the knee joint, Fig. 1a & 1b) to determine the displacement of the fracture and 3D CT to provide a more accurate fracture type (Fig. 2a 2b 2c), Magnetic resonance imaging is used to assess the tension of the patient's cruciate ligament. At the same time, imaging examinations are used to exclude patients with other injuries (such as the medial collateral ligament, posterior cruciate ligament, etc.)..

Table 1

Comparison of general data of patients in the three groups
Grouping	age	weight	Sex		Side (left/right)	type(II/III)
Grouping	age	weight	M	F	Side (left/right)	type(II/III)
Wire (26)	38.5 ± 9.75	67.6 ± 8.46	14	12	13/13	12/14
Screw (24)	38.3 ± 10.8	65.9 ± 11.8	14	10	10/14	12/12
Suture(30)	38.6 ± 11.2	65.1 ± 10.39	17	13	14/16	12/18
F/X²	0.003	0.404	0.105		0.352	0.559
P	0.997	0.66	0.949		0.839	0.756

2.3 Surgical method:

2.3.1 Orthcord suture group: establish a conventional approach to the knee joint (anterolateral and anteromedial), use the arthroscopic power system to clean the blood accumulation in the suprapatellar bursa, synovium and infrapatellar fat pad that blocks the field of vision, and after the field of vision is clear, clean the blood scab and soft tissue under the intercondylar eminence fracture to expose the fracture fragment and bone bed. Use curved forceps and probe hooks to reduce the fracture fragment, and use 1–2 1.0 Kirschner wires percutaneously to reduce and fix the fracture fragment. Make a small incision below the tibial tuberosity, and use the ACL reconstruction locator to insert two 2.0 Kirschner wires to create a bone tunnel on the anterior medial and anterolateral sides of the bone bed (Figs. 3a and 3b). The external openings of the bone tunnels are all located on the medial side of the tibial tubercle, and the distance between the bone tunnels is more than 1 cm. Through the arthroscopic approach, use right-angle forceps to introduce a double-strand Orthcord high-strength suture, bypass the anterior cruciate ligament in an "8-shaped" fixation, and introduce double-strand steel wires to lead out the Orthcord high-strength suture. After the fracture fragment is properly adjusted to a good position, the suture is tightened and tied at the external opening to fix it. After it is firmly fixed, observe with an arthroscope for any impact and move the knee joint throughout the range of motion.

2.3.2 Steel wire fixation group: fracture reduction and temporary fixation are the same as above. Double-strand steel wires are introduced through the tibial bone tunnel and then pulled out from the arthroscopic approach. The outer wire is used as a guide to pull out the inner double-strand steel wire. After the fracture fragment position is properly adjusted to a satisfactory level and the wire tension is adjusted, it can be tightened. The wire tension should be moderate to prevent the wire from breaking due to excessive pressure and excessive cutting of the fracture fragment.

2.3.3 Hollow screw group: fracture reduction is the same as above. Two small incisions are made on the inner and outer sides of the patella, and the hollow screw guide pin is inserted and fixed through the parapatellar incision. The guide pin positions are more than 4 mm apart, and there is enough space to insert the hollow screw. After confirming that the fracture fragment is in a good position, screw in the hollow pressure screw and use a gasket if necessary.

2.4 Postoperative rehabilitation

All three groups of patients were fixed in the straight position with braces immediately after surgery. After 5 days of cotton leg pressure bandage, the cotton leg was removed and knee flexion functional exercise was performed once. Knee flexion functional exercise was performed again in the second week after surgery. After 3 weeks, knee flexion exercises were performed every other day, and the knee flexion angle was increased by 10° every week. The affected limb was not weight-bearing with crutches within 6 weeks. After 6 weeks, the patient gradually walked with weight under the protection of the brace, and the brace was completely removed after 3 months.

2.5 Postoperative follow-up observation and clinical evaluation

The patients were reexamined at 1, 2, 3, and 6 months after surgery, and X-ray or CT three-dimensional reconstruction was performed to evaluate the fracture healing, MRI examination was performed to evaluate the tension of the anterior cruciate ligament, and the changes in the angle of the patient's knee joint were recorded in time. Six months after surgery, the Lysholm score was used to objectively evaluate the patient's recovery, and the Lachman test was performed to determine the stability of the anterior cruciate ligament.

2.6 Statistical methods

The data collected in the study were analyzed using spss 26.0 software, and the graphs were drawn using GraphPad Prism 8 software. The measurement data such as age, weight, time and score, as well as the patient's hospitalization time, operation time, intraoperative blood loss, postoperative knee function score (Lysholm score of the knee joint 3 months and 1 year after surgery) were expressed as ‾x ± s and analyzed by variance. The measurement data such as gender and recurrence rate were tested by chi-square test. and P<0.05 was considered statistically significant.

There was no statistical difference in the general data of all patients. All patients were followed -up for 1 year after surgery. and bone union was achieved without infection, displacement, or bone malunion. The Lachman test and drawer test were negative after surgery. The hospitalization time of the wire group was (11 ± 1.02) days, the screw group was (11.58 ± 1.61) days, and the Orhtcord suture was shortened to (10.03 ± 1.07) days. The difference between the three groups was statistically significant (P < 0.05). At the same time, the cost of the Orhtcord suture surgery (1310.7 ± 0.29) $ was significantly lower than that of the other two groups (P < 0.05). In terms of operation time, the suture group (68.13 ± 1.11min) was significantly shorter than the wire group (76.76 ± 11.57min) and the screw group (90.62 ± 1.99min) (P < 0.05). In the follow-up, the score of Orhtcord suture at 3 months after surgery (94.07 ± 2.72 points) was better than that of the wire group (90.23 ± 5.23 points) and the screw group (90.37 ± 5.41 points); the difference was statistically significant (P < 0.05). However, there was no statistically significant difference in the Lysholm score among the three groups of patients at 6 months after surgery (96.26 ± 1.89, 96.33 ± 2.44, 97.3 ± 1.70) (P > 0.05). See Table 2

Tibial ridge fractures are anterior cruciate ligament (ACL) avulsion fractures. Previous studies have found that this type of injury is most common in children (between 8 and 14 years old), but it has also been observed in adults. Tibial ridge fractures account for 2–5% of all pediatric knee injuries and 3% of all adult ACL injuries, with an incidence of approximately 3 per 100,000 children per year. 8 Although tibial ridge fractures are relatively rare in adults in previous studies, with the popularity of electric vehicles and frequent traffic accidents in recent years, the number of adult ridge fractures has been increasing year by year.

In previous studies, Noyes FR⁹ studied the biomechanics of anterior cruciate ligament failure caused by anterior cruciate ligament insertion injury in primates and found that the tibial intercondylar ridge is a bony protuberance between the medial and lateral condylar articular surfaces of the tibia. The anterior and posterior positions of the protuberance are the attachment points of the meniscus and the anterior cruciate ligament. It is anatomically divided into four different areas - the medial and lateral intercondylar spines and the anterior and posterior recesses, and serves as the attachment points of the cruciate ligament and the meniscus. Type I intercondylar ridge fractures can be treated conservatively due to their relatively stable position, but for type II and type III fractures, due to the instability of the fracture, if not promptly treated surgically, the anterior cruciate ligament will fail¹⁰, which will in turn affect the stability of the knee joint, cause meniscus tearing, and eventually cause articular cartilage wear and development of osteoarthritis. Therefore, the goal of treatment is to restore stability and eliminate mechanical obstruction through anatomical reduction and stable internal fixation, which will help to resume exercise early, improve the quality of life, and thus avoid further joint damage.

Traditional surgery for intercondylar ridge fractures is open fracture reduction and internal fixation. In the 1980s, people began to use arthroscopic minimally invasive techniques to treat intercondylar ridge fractures. With the continuous development and maturity of arthroscopic technology, it has become the mainstream method for treating intercondylar ridge fractures¹¹. Current surgical methods for treating intercondylar ridge fractures include Kirschner wires, metal screws, wire anchors, and various biomaterials, such as Orthcord sutures and Ethicon sutures. Each of these various treatment options has its own advantages and disadvantages. There is no unified gold standard for which treatment option is better. Although there are many controversies about the preferred method for treating type II and type III fractures, the main difference is the choice of fixation¹². For example, Kirschner wire fixation, although economical and convenient, studies have shown¹³ that Kirschner wires cannot firmly fix comminuted and small fracture fragments. In the long term, due to the risk of infection, loosening, and dislocation of the tail end of the Kirschner wire, it cannot be used as the preferred method.

Regarding metal screws, Coyle et al.¹⁴ believed that metal screws are suitable for larger fracture fragments, and that the nut poses a risk of cutting the ACL. Poor screw positioning can easily cause intercondylar fossa impact and aggravate cartilage damage. Liao et al.¹⁵ reported that there was no difference between absorbable and non-absorbable sutures in repairing tibial intercondylar eminence fractures. The study by Sekiya et al.¹⁶ showed that titanium plates with loops are also a easy, effective, and strong internal fixation method. In addition, related studies have also shown that suture fixation has greater advantages than screws and wires. Wust et al.¹⁷ reported that Orthcord fiber sutures have better biomechanical properties than traditional arthroscopic repair of absorbable latex polydioxanone¹⁸. Tsukada et al.¹⁹compared the biomechanical effects of different methods such as hollow nails and high-strength sutures in the treatment of tibial intercondylar eminence fractures and proposed that the fixation strength of suture fixation is not weaker than that of hollow nails. In addition, compared with screws, sutures cause less damage to the anterior cruciate ligament and are more reliable. They have achieved very good results in clinical studies.. Eggers et al.²⁰ found that suture fixation provides greater strength than screw fixation in a porcine model.

In the current study, all patients had good follow-up results compared with preoperative results in terms of both radiological and clinical examination. This supports the effectiveness of the Orthcord suture technique in repairing adult tibial intercondylar eminence fractures. This suggests that the Orthcord suture method is a very effective method for treating adult tibial intercondylar eminence fractures. This view is also supported by a systematic retrospective analysis by Eggers et al. 21, who compared different internal fixation methods such as wires, screws, non-absorbable sutures, and anchors. Although different methods can achieve good treatment results, the Orthcord suture has less irritation to the joint and does not require secondary removal of the internal fixator, and studies have shown that the Orthocord suture combines flexibility and fixation strength, and the knot safety is better than that of the Aixibang ²². At the same time, in our study, there were 2 cases of internal fixation fracture in the steel wire group, which is an unavoidable situation when using steel wire fixation. The cutting force generated by the steel wire on various parts of the knee joint can directly affect or limit the patient's early postoperative activities, and even cause traumatic arthritis²³. The knee joint is a multi-activity weight-bearing joint, and the fracture will inevitably produce stress on the steel wire during the growth process, causing metal fatigue to a certain extent, and eventually leading to the fracture of the internal fixation. However, there was no such complication for patients using Orthcord sutures. In addition, in terms of treatment costs, both steel wires and screws need to be removed a second time, especially the removal of screws requires the help of arthroscopy, which will eventually lead to costs far higher than the Orthcord suture group. And Orthocord sutures are non-absorbable polyethylene and PDS synthetic sterile sutures with good biocompatibility. They not only have the characteristics of high strength and high wear resistance, but also have less cutting force on soft tissues, thus ensuring the stability of the bone fragment during postoperative knee flexion and extension exercises^24–25.

In addition, in terms of surgical technique, the key requirement for the reduction of intercondylar spine fractures is not to destroy the posterior fibers of the fracture fragment. When fixing, it is only necessary to press down the front end of the tilted part to achieve the requirements of anatomical reduction. During the reduction process, it is often found that the anterior horn of the meniscus or the transverse ligament of the knee is stuck in the gap between the broken ends of the intercondylar spine fracture. At this time, the transverse ligament of the knee or the meniscus should be properly handled. In most cases, the transverse ligament of the knee needs to be planed so that the bone bed can be fully exposed to fully expose the surgical field for easy reduction. Intercondylar spine fractures are rarely combined with anterior cruciate ligament rupture or tibial plateau fracture. Anterior cruciate ligament injuries are mostly partial ruptures. For those with anterior cruciate ligament ruptures, primary or secondary ligament reconstruction should be performed according to the ligament rupture. For those with tibial plateau fractures, the tibial plateau fracture should be reduced at the same time, and then the intercondylar spine fracture should be reduced and fixed internally. Compared with other surgeries, sutures do not need to be shaped, which greatly shortens the operation time and can better restore the tension of the anterior cruciate ligament^26–29. Currently, many surgical methods have been developed for the treatment of tibial intercondylar eminence fractures^30–33, all of which can restore the anatomical structure of the intercondylar ridge fracture and restore the tension of the anterior cruciate ligament. However, there are still many problems to be solved, such as knee extension dysfunction and postoperative anterior cruciate ligament laxity.

This surgery has many advantages, including: arthroscopic surgery has lower morbidity and faster recovery compared to open surgery. Compared with screw and wire fixation, this technique uses suture fixation, eliminating the possibility of secondary surgery to remove traditional internal fixators. This technique fixes the lower end of the anterior cruciate with better stability and minimizes ligament creep. It also eliminates physical damage, implant irritation, and impact caused by poor fixation position caused by internal fixators.

However, this study also has some limitations. First, as a retrospective analysis, the current study only provides limited clinical diagnosis and treatment evidence and lacks mechanical analysis. Second, the sample size is relatively small, and the study will continue and extend the follow-up time. Third, this study did not include type IV comminuted fractures and small avulsed bone fragments, which still need further supplementary research.

Using Orhtcord sutures to treat intercondylar ridge fractures under arthroscopy can shorten the hospital stay and operation time, and greatly reduce the cost of hospitalization. It can achieve better short-term (3 months) recovery effect on the basis of avoiding secondary surgery, and the fixation effect is not weaker than that of conventional screws and wires when fully weight-bearing recovery is finally achieved.

Ethics approval and consent to participate

The studies involving human participants were reviewed and approved by the Ethics Committee of Nanyang Hospital of Traditional Chinese Medicine (Nanyang Orthopedic Hospital; KJGG123). The patients/participants provided written informed consent to participate in this study.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by the Henan Provincial Health Commission Project Plan (No. KJGG123) and the 2023 Weifang Science and Technology Development Plan (Medical) Project (No. 2023YX115); 2024 Weifang Health Commission Scientific Research Project Plan (No. WFWSJK-2024-133)

Author contributions

RF-Z and HB-L designed this study. Data were acquired byYQ-W,YX-Q and CY-W. RF-Zand YQ-W analyzed the data. All authors participated in the interpretation of the data. All reviewed and revised the manuscript, and approved the final manuscript as submitted.

Acknowledgements

Not applicable

Correspondence to: HongBo Liu,

Department of Sports Medicine,

Weifang Yidu Central Hospital,

WeiFang 262500, ShanDong, P.R. China

E-mail address: [email protected]

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A female patient was hospitalized for tram injury. Her knee joint was obviously swollen. X-ray examination of the knee joint showed a fracture of the lower insertion point of the anterior cruciate ligament and a raised fracture fragment (the red arrows in the figure show the intercondylar ridge fracture 1a & 1b)

In addition to X-rays, intra-articular fractures usually require CT three-dimensional reconstruction to further clarify the fracture situation. Three-dimensional reconstruction can show displacement of the lower insertion point of the fracture.

As shown in Figure 3a, an arthroscopic approach is established to clear the blood in the joint to expose the fracture fragment and thoroughly clean the bone bed. 3b, an anteromedial and anterolateral bone tunnels are established under the guidance of the locator.

cleaning the blood clots around the fracture, the ligament-connected fracture fragment was seen to be lifted up (4a & 4b), which was consistent with the preoperative MRI examination results. (The red arrow in Figure 4c shows that the anterior cruciate ligament is loose, the fracture fragment is lifted up, and the ligament loses tension)

During the operation, Kirschner wires were used to temporarily fix the fracture fragments (4d) to maintain a stable position, and an anterior cruciate ligament locator was used to create a tibial bone tunnel (4e).

After the bone tunnel was made, Orthcord sutures were introduced and cross-fixed. The tension of the anterior cruciate ligament was restored (4f). The wound was minimally invasive and beautiful. The first dressing change after the operation was minimally invasive and did not require suture removal. It was beautiful and did not require suture removal (4g).

Postoperative knee joint MRI (5a & 5b) was performed. MRI showed that the tension of the anterior cruciate ligament was significantly restored compared with that before the operation (indicated by the red arrow: Figure 5a shows that the anterior cruciate ligament lost tension, and Figure 5b shows that the ligament tension was restored after fixation)

Postoperative review of the knee joint CT three-dimensional reconstruction showed that the fracture was well reduced (5c) was the preoperative CT, and postoperative (5d) showed that the fracture was well reduced.

No competing interests reported.

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Reviewers agreed at journal
11 Nov, 2024
Reviewers invited by journal
11 Nov, 2024
Editor assigned by journal
15 Oct, 2024
Submission checks completed at journal
14 Oct, 2024
First submitted to journal
13 Oct, 2024

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Clinical efficacy analysis of arthroscopically assisted Orthcord suture fixation in the treatment of tibial intercondylar eminence fractures: a retrospective case-control study

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Abstract

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1 Introduction

2 Data and methods

2.1 General data

2.2 Pre-treatment evaluation

2.3 Surgical method:

2.4 Postoperative rehabilitation

2.5 Postoperative follow-up observation and clinical evaluation

2.6 Statistical methods

3 Results

4 Discussion

5 Conclusion

Declarations

References

Figure

Additional Declarations

Status:

Version 1