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Diagnostic guidelines for chronic ankle pain. From loose bodies to joint venture
Verhagen, R.A.W.
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Verhagen, R. A. W. (2004). Diagnostic guidelines for chronic ankle pain. From loose bodies to joint venture
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Download date: 13 Jul 2017
Chapter r
Effectivenesss of n o n - i n v a s i v e
diagnosticc c o m b i n a t i o n strategies
i nn o s t e o c h o n d r a l lesions of t h e talus
R.A.W.. Verhagen, M. Deutekom, M. Maas, C.N. van Dijk, M.G.W. Dijkgraaf
submitted submitted
Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
Abstract t
Background d
Consideringg the lack of prospective studies on diagnostic strategies for detecting or excluding
osteochondrall lesions of the talus (OLT), there is still no evidence as to which diagnostic
modalityy is the most optimal one. To our knowledge, no prospective study assessing diagnostic
combinationcombination strategies in evaluating OLT has been either performed or published.
Thee aim of this paper is to find the diagnostic combination strategy that best enables us (i) to
preventt unnecessary arthroscopic interventions, (ii) to choose the correct treatment of OLT,
andd (iii) to contain health care expenditures.
Methods s
Patientss with chronic ankle pain (Nank1p = 104) who presented at our outpatient department
weree consecutively included into a diagnostic protocol, consisting of history taking, physical
examination,, and standard radiographs (HPX), and additional diagnostic modalities. Additional
examinationn consisted of an AP mortise view (MX), helical CT scan with multiplanar
reconstructions,, and MRI. The final diagnosis was defined as the diagnosis after arthroscopy,
includingg previous test information (N0LT = 27).
Thirty-fourr diagnostic test combinations were evaluated against the three study objectives.
Testss were used in succession to confirm previous positive test findings (confirmative testing)
or,, contrary, to question the previous negative outcome (supportive testing).
Too assess the diagnostic performance, the combination strategies were ranked according to
thee false positive rate, subsequently according to their accuracy, and finally the costs.
Results s
Thee false positive rate of the various diagnostic combination strategies varied from 0.00 to
0.04,, the accuracy between 0.88 to 0.96, and the costs from €86 to €423. HPX with localization
byy CT and supportive MX has the lowest FP rate with the highest accuracy (0.00 and 0.91,
respectively).. If preference is for the highest degree of accuracy (0.96) HPX and localization
byy CT and supportive MRI is the best option (FP rate 0.02).
Uncertaintyy analyses showed only minor quantitative changes compared to the analysis based
onn point estimates.
Conclusions s
Withh diagnostic combination strategies it is possible to prevent unnecessary arthroscopic
interventions.. None of the combination strategies proves best on all three objectives. Hence,
thee clinician should choose between combination strategies depending on his or her preference
forr either objective.
76 6
Chapterr 7
Introduction n
Thee literature offers a number of different strategies for the evaluation and work-up of
osteochondrall lesions of the talus (OLT). None of these however is based on prospective
studies.1,22 This lack of prospective studies means that there is still no convincing evidence as
too which diagnostic modality is the most optimal. Moreover, current studies evaluate single
diagnosticc procedures only. In daily practice however, a number of procedures are used in
concert. .
Too adequately assess diagnostic strategies one should be explicit about their objectives. For
example,, a high sensitivity test is a prerequisite for detecting OLT, but for its exclusion a low
falsee positive rate is mandatory. Currently the most important non-invasive diagnostic modality
forr identifying osteochondral lesions of the talus is MRI.3 5 However, MRI is only superior if
thee aim of diagnosis is restricted to the detection of OLT. Recently, MRI and helical CT were
shownn to be rather similar in diagnostic performance both in detecting and excluding OLT in
aa prospective study design.6 For this reason, it is important to include the purpose of the
diagnosticc modality in the study criteria.
Inn this study we assessed the diagnostic performance of combination strategies of HPX (history,
routinee physical exam, standard AP and lateral weight bearing radiographs of both ankles),
MXX (AP mortise view - weight bearing - with four centimetres heel rise), helical CT (highresolutionn multidetector helical CT), and MRI.
Thee diagnostic performance of the combination strategies was assessed on three criteria: first,
exclusionn of OLTs preferably with a false positive rate of zero. In our view false positive cases
havee to be eliminated in order to prevent unnecessary arthroscopic procedures for patients
whoo do not have OLT. The second criterion is the accuracy of the diagnostic combination
strategies.. High numbers of correctly identified positive and negative cases of OLT are essential
iff a combination strategy is to be accepted. A high level of accuracy enhances correct clinical
decisionn making.
Thee third criterion is a financial one. Little is known about the financial implications of a
diagnosticc combination strategy for OLT. From a health insurers' point of view, where
combinationn strategies perform comparably, the least costly combination will be considered
thee most preferable, in order to contain health care expenditure as much as possible.
Off these three assessment criteria, we consider a minimal false positive rate to be the most
importantt and minimal health care expenditures the least important.
Inn short, the aim of this paper is to find the diagnostic combination strategy that best enables
uss (i) to prevent unnecessary arthroscopic interventions, (ii) to choose the correct treatment
off OLT, and (iii) to contain health care expenditures.
77 7
Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
Materiall and Methods
Patientt inclusion
Betweenn October 1997 and May 1999 all patients with chronic ankle pain ( N ^ = 104) who
presentedd at our outpatient department were consecutively included in a diagnostic protocol,
approvedd by the Institutional Review Board (IRB) of our hospital.
Studyy protocol single diagnostic tests
Alll patients followed a diagnostic protocol, consisting a routine physical examination and
standardd AP and lateral weight bearing radiographs of both ankles (HPX). After informed
consentt all patients were scheduled for arthroscopy by the senior author (CNvD). In the
interimm additional diagnostics were performed. Additional examination consisted of an AP
mortisee view (weight bearing) of both ankles with four centimetres heel rise (MX),7 CT scan
withh multiplanar reconstructions (MPR) in the sagittal and coronal plane, and MRI.
High-resolutionn multidetector helical CT was performed using a dual helix CT (Twin Flash,
Elscint,, Israel or MX Twin Flash, Picker, USA). Axial data acquisition was performed with
0.55 mm slices 3D data set. Both semi-coronal and sagittal reformatted images of 2 mm were
reconstructed. .
MRII without intravenous or intra-articular contrast was performed on a 1.5-Tesla Vision
systemm (Siemens, Erlangen, Germany), with the ankle joint placed in a circularly polarized
headd coil. Although a flexible extremity coil was available, the CP head coil was chosen since
itt provided the best signal to noise ratio.8 The imaging protocol consisted of sagittal TSTIR,
Tl-weightedd SE, sagittal, coronal, and axial FSE dual echo sequences (3mm), DESS 3D with
reformattedd images in coronal and axial plane (2mm).
Ann experienced musculoskeletal radiologist separately evaluated all CT and MRI scans with
noo knowledge of the patients' history or of the outcome of the standard radiographs. The
radiologistt was blinded to the CT results when evaluating MRI, and vice versa.
Inn contrast to the plain radiographs, the results of CT and MRI were not disclosed to the
surgeonn who performed the arthroscopy. A second orthopaedic surgeon was aware of the
outcomee of the diagnostic tests and informed the patient as to what type of operative procedure
wouldd be done to correct the lesion(s) in the talus.
Thee arthroscopic procedure was performed within twelve weeks after inclusion in the
study.. All arthroscopic procedures were performed by one surgeon (CNvD) in a day surgery
settingg under general or regional anaesthesia with a tourniquet at thigh level. 2.7-mm and
4.0-mmm 30° angle arthroscopes were used. Standard anteromedial and anterolateral portals
weree routinely made. Ankle distraction was achieved using a non-invasive distraction
system. 99 After completion of the diagnostic stage of the arthroscopy with HPX (history,
physicall exam, and standard radiographs), and MX data (heel rise view), the results were
notedd on a standardized form. The results of additional radiographic examinations were
78 8
Chapterr 7
thenn disclosed to the surgeon who then continued the arthroscopic examination to confirm
andd subsequently treat the lesion.
Inn this paper we present the data of patients with OLT. Treatment of OLT included removal
off the affected osteochondral segment, curettage and multiple drilling of the base with a Kwiree (1.6 mm). 1011 All OLTs in this study were treated by arthroscopic means. The more
posteriorlyy located lesions were treated with the ankle in maximum plantar flexion.
Alll these procedures (diagnostic arthroscopy, 'final diagnosis' arthroscopy, and arthroscopic
treatment)) were performed during the same arthroscopic procedure.
Postoperativee care consisted rehabilitative exercises and progressive weight bearing for up
too 6 weeks.
Finall diagnosis - the Gold Standard
Thee final diagnosis was defined as the diagnosis made after diagnostic arthroscopy and included
previouss test information from HPX, MX, helical CT, and MRI (NQLT = 27).
Selectionn of diagnostic combination strategies
Diagnosticc test combinations were selected and defined on data from literature and expert
opinion.12,133 Tests were used in succession to confirm previous positive test findings (confirmative
testing)) or, alternatively, to question the previous negative outcome (supportive testing).
Severall restrictions were put in place. Each combination started with HPX. If MX was used,
itt was always performed directly following HPX. This additional radiograph is inexpensive
andd may prevent unnecessary further testing.
Confirmativee or supportive CT and/or MRI testing was performed in order to detect or exclude
OLT.. A consequence of detecting OLT was the localization of osteochondral lesion. This was
consideredd relevant for preoperative planning as it is of the utmost importance to know where
thee lesion can be expected (anterior, posterior, medial, or lateral). Therefore, after positive
HPXX or MX a confirmative test was performed by means of helical CT or MRI. After a positive
helicall CT no confirmative test (MRI) was performed. In cases of a negative helical CT, a
supportivee MRI may be performed (possible chondral lesion).
AA total of thirty-four feasible diagnostic test combinations were selected and defined (Table 1).
Forr better understanding, diagnostic test combination no. 30 (HPX, confirmative MX,
supportivesupportive MRI and localization by CT/MRI and supportive CT) will be explained in further
detail.. If HPX is positive for OLT (true positive (TP) or false positive (FP)) a confirmative MX
willl be done. If MX is positive, localization will be performed by means of helical CT. If
helicall CT is positive, no further testing is performed. If helical CT is negative, MRI is done to
identifyy a chondral lesion. If MX is negative, a supportive MRI is performed. On the other
handd if HPX is negative for OLT, a supportive CT is performed to exclude OLT.
Thee selected combinations were assessed by means of decision modelling using Data™ from
79 9
Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
TreeAgee software (TreeAge Software, Inc., Williamstown MA, USA). The model is presented
inn detail in the Appendix.
Tablee 1
11
22
33
44
55
66
77
88
99
100
111
122
133
144
155
166
177
188
199
200
211
222
233
244
255
266
277
288
299
300
311
322
333
344
The thirty-four diagnostic test combination for identifying OLT
HPX and localization by CT
HPX and localization by MRI
HPX and localization by CT/MRI
HPX and localization by CT and supportive MRI
HPX and localization by MRI and supportive CT
HPX and localization by MRI and supportive CT/MRI
HPX and localization by CT/MRI and supportive MRI
HPX and localization by CT and supportive MX
HPX and localization by MRI and supportive MX
HPX and localization by CT/MRI and supportive MX
HPX, confirmative MX and localization by CT
HPX, confirmative MX, supportive MRI and localization by CT
HPX, confirmative MX and localization by MRI
HPX, confirmative MX, supportive CT and localization by MRI
HPX, confirmative MX and localization by CT/MRI
HPX, confirmative MX, supportive MRI and localization by CT/MRI
HPX, confirmative MX and localization by CT and supportive CT
HPX, confirmative MX, supportive MRI and localization by CT and supportive CT
HPX, confirmative MX and localization by CT and supportive MRI
HPX, confirmative MX, supportive MRI and localization by CT and supportive MRI
HPX, confirmative MX and localization by CT and supportive CT/MRI
HPX, confirmative MX, supportive MRI and localization by CT and supportive CT/MRI
HPX, confirmative MX and localization by MRI and supportive CT
HPX, confirmative MX, supportive CT and localization by MRI and supportive CT
HPX, confirmative MX and localization by MRI and supportive MRI
HPX^ confirmative MX, supportive CT and localization by MRI and supportive MRI
HPX, confirmative MX and localization by MRI and supportive CT/MRI
HPX, confirmative MX, supportive CT and localization by MRI and supportive CT/MRI
HPX, confirmative MX and localization by CT/MRI and supportive CT
HPX, confirmative MX, supportive MRI and localization by CT/MRI and supportive CT *
HPX, confirmative MX and localization by CT/MRI and supportive MRI
HPX, confirmative MX, supportive MRI and localization by CT/MRI and supportive MRI
HPX, confirmative MX and localization by CT/MRI and supportive CT/MRI
HPX, confirmative MX, supportive MRI and localization by CT/MRI and supportive CT/MR
** Highlighted diagnostic strategy is clarified in the text.
Decisionn modelling
Thee study protocol generated a full 'patient by diagnostic test' data set, including each patient's
finall diagnosis. From this full data set we derived point estimates for the probabilities and
conditionall probabilities used in the decision model, e.g. the probability of a positive HPX
testt result, or the probability of a true positive MX test result after a false negative HPX result.
Subsequently,, Data™ TreeAge was used to determine the following in each diagnostic
combinationn strategy: the probabilities of (i) a true positive or negative case (accuracy), (ii) a
truee positive case, (iii) a true negative case, (iv) a false positive case, or (v) a false negative
case.. Likewise, the costs related to each diagnostic combination strategy were determined
basedd on national charges for the tests involved and the frequency of the tests, conditionally
80 0
Chapterr 7
uponn the results of previous tests within the combination.14
Assessmentt of diagnostic performance
Too assess the diagnostic performance, the combination strategies were first ranked according
too the false positive rate, i.e. the probability of a false positive case divided by the sum of the
probabilitiess of a false positive and a true negative case (unity minus the specificity of the test
combination).. Among the diagnostic strategies with equally low false positive rates, the
combinationss were subsequently ranked according to their accuracy, i.e. the probability of a
truee positive or negative case. Finally, the cheapest combination strategy was selected from
thee combinations ranking low on the false positive rate and high on accuracy.
Uncertaintyy analyses
Additionall analyses were performed to account for uncertainty surrounding the sensitivity
andd specificity of the tests in our patient sample. To enable uncertainty analyses the point
estimatess for the probabilities in the initial model were replaced by formulas based on (i) the
sensitivityy and specificity of the tests, (ii) the prevalence, and (iii) correction factors to account
forr conditional sensitivity and specificity. Conditional sensitivity and specificity refers to the
likelyy observation that test characteristics differ for subgroups of patients defined by results
fromfrom prior testing. For instance, the sensitivity of GT in a group of patients following a positive
MXX differs from the sensitivity of CT for the group as a whole.
Replacingg the point estimates by formulas helped to maintain the model's internal consistency
whilee performing uncertainty analyses. On rare occasions the use of correction factors for
conditionall sensitivities and specificities in the formulas may have resulted in probabilities
slightlyy below zero or slightly above unity. In such cases these probabilities were automatically
resett to zero and unity respectively. One-way uncertainty analyses were performed for the
sensitivityy and specificity of MX, CT, and MRI, respectively.
Results s
Thee false positive rate of the various diagnostic combination strategies varied from 0.00 to
0.04,, the accuracy between 0.88 to 0.96, and the costs from €86 to €423 (Table 2).
Iff no false positive cases are allowed (FP rate 0.00) four strategies {strategies 1, 8, 11, and 12)
cann be depicted; according to our second criterion, accuracy, the best strategy (0.91) is HPX
withh localization by CT and supportive MX (strategy 8).
Forr an FP rate of 0.01 and 0.02, eight strategies (strategies 2,9, and 13-18)and eleven strategies
(strategies(strategies 3-5, 19, 20, 23, 24,29, and ^ r e s p e c t i v e l y , can be selected.
Inn the group with an FP rate of 0.01 the best strategy is HPX, confirmative MX and localization
byy CT and supportive CT (strategy 17) with an accuracy of 0.94. Strategy /^performs similarly.
81 1
Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
Tablee 2
Stratification noff diagnostic test
combinations s
Strategy y
False e
Positive e
rate e
Accuracy y
Costs s
(€) )
88
11
11 1
12 2
0.00 0
0.00 0
0.00 0
0.00 0
0.91 1
0.88 8
0.88 8
0.88 8
126 6
86 6
90 0
96 6
17 7
18 8
99
22
13 3
0.01 1
0.01 1
0.01 1
0.01 1
0.01 1
0.94 4
0.94 4
0.91 1
0.88 8
0.88 8
244 4
251 1
134 4
93 3
95 5
14 4
15 5
16 6
0.01 1
0.01 1
0.01 1
0.88 8
0.88 8
0.88 8
101 1
101 1
107 7
44
19 9
20 0
55
23 3
29 9
24 4
30 0
33
0.02 2
0.02 2
0.02 2
0.02 2
0.02 2
0.02 2
0.02 2
0.02 2
0.02 2
0.96 6
0.96 6
0.96 6
0.94 4
0.94 4
0.94 4
0.94 4
0.94 4
0.88 8
264 4
268 8
274 4
248 8
250 0
255 5
256 6
262 2
104 4
25 5
26 6
31 1
32 2
21 1
22 2
10 0
0.03 3
0.03 3
0.03 3
0.03 3
0.03 3
0.03 3
0.03 3
0.96 6
0.96 6
0.96 6
0.96 6
0.95 5
0.95 5
0.90 0
274 4
279 9
279 9
285 5
405 5
412 2
146 6
77
66
27 7
33 3
28 8
34 4
0.04 4
0.04 4
0.04 4
0.04 4
0.04 4
0.04 4
0.96 6
0.95 5
0.95 5
0.95 5
0.95 5
0.95 5
282 2
408 8
411 1
416 6
417 7
423 3
However,, this means that supportive MRI following a negative MX in strategy 18 is of no
benefit;; in fact, it generates slightly higher costs and more discomfort for the patient.
Whenn the second criterion (accuracy) is stratified the highest score is 0.96 (strategies 4, 7, 19,
20,20, 25, 26, 31, and 32). This score coincides with an FP rate of 0.02. Three strategies (4, 19,
and20)haveand20)have those rates. The costs for all three strategies are nearly equal. Confirmativ
inn strategies 19 and 20 is of no benefit where the false positive rate, the accuracy and the costs
aree concerned. Therefore the best strategy with the highest accuracy is HPX and localization
byy CT and supportive MRI (strategy 4). All other strategies with the same accuracy have a
82 2
Chapterr 7
higherr FP rate than strategy 4. Taking into account the cost strategies, 7, 25, 26, 31, and 32
aree no cheaper than strategy 4, the best strategy with the highest accuracy and an FP rate of
0.022 is strategy 4.
Consideringg the costs, strategy 1 is the cheapest (€86) and strategy 34 the most expensive
(€423).. By achieving a higher accuracy the costs of the diagnostic combination strategy
increase,, while the FP rate remains low.
Too account for uncertainty about the test characteristics in our patient sample, uncertainty
analysess were performed. One-way uncertainty analyses were performed for the sensitivity
off MX between the values 0.667 and 0.741. Forr specificity, the values varied between 0.922
andd 0.948. The same was performed for the other diagnostic modalities: CT
ii
0.852,, CT
o
0.974 and 1.0, MRI
specc
0.923 and 1.0, and MRI
sens
0.778 and
sens
0.947 and 0.974 respectively.
spec
*
*
Thee uncertainty analyses showed only minor quantitative changes compared to the analysis
basedd on point estimates. No shifts with respect to the combination to be preferred. In short,
thee best strategies remained strategy 8, strategy 17, and strategy 4.
Discussion n
Osteochondrall lesions of the talus are an increasingly common problem and new surgical
techniquess are being developed to treat these lesions.1516 However developments are not just
takingg place at the treatment site, the performance of the various diagnostic modalities is also
improvingg (helical CT, MR imaging).
Thiss study introduces a different view of diagnostic strategies: combination strategies to
discriminatee between patients with and without the disease (OLT). In the literature mainly
singlee diagnostic procedures are evaluated. However, in daily practice usually combinations
off strategies are used: standard radiographs, additional mortise views, CT, MRI, etc.
Earlierr studies always focused on detection of an OLT. However, in this study we were not
onlyy interested in the detection of an OLT, but more particularly in its exclusion. The reason
beingg that a false positive case has more consequences than a false negative case. An
arthroscopicc procedure is scheduled if the diagnostic strategy gives a positive outcome. That
iss why false positive cases have to be eliminated. The individuals with a false negative result
willl continue to have symptoms and will come back for further diagnostic evaluation.
Ourr study design has a few limitations. If all the necessary test apparatus is available to the
providerr then diagnostic test combinations can easily be implemented in clinical practice. At
present,, an orthopaedic team can perform MX, CT and MRI freely in daily practice, if clinically
indicated.. The provider will receive revenues for each test performed and more revenues
comee in the more tests are performed. Most probably, combination strategies cost more than
singlee diagnostic strategies. Putting the best diagnostic test combinations in this paper into
thee form of practice guidelines may thus increase the number of tests performed in the patient
83 3
Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
populationn and increase the budget needed to diagnose and perhaps treat these patients. To
containn the expenditure as much as possible we advocated the least costly combination strategy
forr different levels of preferred effectiveness (e.g. false positive rate, accuracy). To address
thee issue of whether a shift: from single diagnostic tests to diagnostic test combinations is
efficientt from a societal perspective, additional data are needed. These include data on patients'
healthh status after diagnostic testing and subsequent treatment, as well as data concerning
productivityy losses related to the diagnosis and treatment of OLT.17
Thee correction factors for conditional sensitivities and specificities in our decision model
weree calculated from the original full patient-by-diagnostic test data set. These correction factors
weree used as constants during the uncertainty analyses. Hence, if the sensitivity of a test changed,
itt affected the performance of that test at every position in the model, irrespective of the numbers
andd results of other tests prior to that position. We suspect that the reported results from the
uncertaintyy analyses are quite robust and are comparable to other solutions that account for
conditionall sensitivity and specificity, i.e. for inter-test dependencies. Further study is needed
too validate this assumption. In short, the choice of the best diagnostic combination strategy was
nott influenced by the quantitative changes of the uncertainty analyses.
Off the 34 diagnostic strategies presented the most effective overall combination strategies for
detectionn or exclusion of OLTs are strategy 8(history taking, routine physical exam, standard
APP and lateral weight bearing radiographs of both ankles, if positive for OLT followed by CT
forr localization; and if negative a supportive MX is performed. If the MX is positive for OLT,
itt will be followed by CT for localization), strategy 77(history taking, routine physical exam,
standardd AP and lateral weight bearing radiographs of both ankles, if positive for OLT followed
byy MX, and if positive localization by CT; and if negative CT to exclude OLT), and strategy 4
(historyy taking, routine physical exam, standard AP and lateral weight bearing radiographs
off both ankles and if positive localization by helical CT; and if negative MRI to exclude OLT).
Thee preference for either strategy depends on the purpose that combination strategy is used
for.. If exclusion of OLT is the most preferred strategy, then strategy 8 (with an FP rate of
0.00)) is the best choice. If preference is for the highest degree of accuracy (0.96), strategy 4\s
thee best option. Strategy 17\s in between with an FP rate of 0.01 and an accuracy of 0.91. For
achievingg a higher accuracy the costs of strategy 77 almost doubled the costs of strategy 8
(€2444 and €126 respectively).
Thee choice between the best strategies may also be influenced by the availability of MR
imaging.. If no MRI facilities are available then strategies 8 and 17 are the best options for
detectingg and excluding osteochondral lesions of the talus. However, strategy 8 costs half
thatt of strategy 17.
Inn short, with diagnostic combination strategies it is possible to prevent unnecessary
arthroscopicc interventions. None of the combination strategies proves best on all three
84 4
Chapterr 7
objectives.. Hence, the clinician should choose between combination strategies depending on
hiss or her preference for either objective.
Appendixx A
Strategyy 30
HPX, confirmative MX, supportive MRI and localization by CT/MRI and supportive CT
tHPX*lMX+CT» »
300 HDf llWfilWllWMX.miJM^IH Mff
wnibc*I»»toiibyCT.<MM
~°\mr>:-icT--
85 5
Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
Appendixx B
Eachh strategy is numbered (1-34). Some HPX+ or HPX- branches are also numbered (1-12);
thee subbranches of these numbered branches constitute a clone. Clones are used in other
combinationn strategies with the same sequence of testing.
86 6
C h a p t e rr 7
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87 7
Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
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Effectivenesss of non-invasive diagnostic combination strategies in osteochondral lesions of the talus
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90 0