Abstract
Background
Volar locked plating (VLP) and dorsal bridge plating (DBP) are both appropriate surgical strategies for the treatment of complete articular distal radius fractures (DRFs), however, direct comparisons between these fixation methods in this injury pattern is lacking.
Purpose
The purpose of this study was to compare functional, radiographic, and patient-reported outcomes, for complete articular (AO/OTA 23C) DRFs treated with VLP versus dorsal bridge plating DBP.
Methods
This was a retrospective cohort study that included patients aged 18–90 years old who underwent VLP or DBP fixation for AO/OTA 23C DRFs. Polytraumatized patients and those undergoing revision surgery were excluded. Wrist range of motion (ROM) and radiographic outcome measures were collected at 6-month follow-up. PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) were obtained at each follow-up. Surgical complications and patient demographic data were recorded.
Results
After propensity matching, 1069 VLP patients were matched to 214 DBP individuals, rendering all demographic variables examined comparable. DBP patients had higher rates of delayed union(2.0 % vs. 4.2 %; p < 0.05) and tendon rupture (0.5 % vs. 3.3 %; p < 0.05), but similar rates of revision surgery, malunion, and infection at 6-months. Multivariate analysis demonstrated greater wrist flexion, extension, radial and ulnar deviation, supination, protonation, grip strength, PROMIS UE, and PROMIS PF among the VLP group compared to DBP (p < 0.05). VLP patients also demonstrated greater radial height and radial inclination, less articular step-off, and decreased volar tilt (p < 0.05).
Conclusions
VLP was associated with greater ROM, grip strength, PROMIS UE and PF, improved radial height, radial inclination, and less articular step-off and volar tilt at 6-month follow-up compared to DBP. DBP patients also demonstrated higher rates of delayed union and tendon rupture but similar complication rates.
Level of evidence
Therapeutic III.
Keywords: Distal radius fracture, Volar locked plating, Dorsal bridge plating, Comminuted fractures, PROMIS
1. Introduction
Distal radius fractures (DRFs) are most common fractures, with an incidence that continues to increase.1, 2, 3 They are a cause of patient morbidity and pose a large financial burden to the healthcare system.4 DRFs tend to occur in a bimodal distribution – younger patients with high-energy trauma and older patients with low-energy falls, accounting for upwards of 18 % of all fractures in the elderly population.5 The resultant fracture pattern can vary based on the injury mechanism and age of the patient, but the goals of fixation of DRFs remain the same: restore articular congruence, radial height, radial inclination, and volar tilt. Furthermore, an anatomic reduction with adequate construct stability, allows for early motion, preventing stiffness and muscle atrophy.6,7 Historically, more simple fracture patterns had been treated with closed reduction and casting, percutaneous fixation, or external fixation,8 but more recently, volar locked plating (VLP) is becoming more popular and yielding more promising outcomes.9, 10, 11 VLP allows for earlier wrist range of motion (ROM) and is believed to lead to less complications compared to external fixation or K-wire fixation.12
Complete articular fractures (AO/OTA 23C), however, particularly those with associated comminution, can be more challenging to treat with standard periarticular VLP.13 Small fracture fragments can be difficult to stabilize with screws while axial compression forces from the forearm muscles pull on the carpus and contribute to potential collapse of the joint surface.14 Wrist-spanning external fixation has previously been used to neutralize these forces and to treat these challenging fractures, but complications secondary to infection and wrist stiffness associated with this technique15, 16, 17 led, for the most part, to its replacement by dorsal bridge plating (DBP). A dorsal spanning plate is affixed to the radial shaft proximally and to either the second or third metacarpal distally, and, like external fixation, relies on ligamentotaxis for the reduction of fracture. This allows for restoration of radial height and the reduction of fracture fragments, while obviating the need for external hardware and the associated pin site complications.13,18,19 Also termed an “internal fixator”, DBP can provide a buttress against dorsal subsidence and is biomechanically superior compared to traditional external fixation, due to its closer proximity to bone.13,14,20 The DBP fixation technique is especially useful in multifragmentary fractures with either articular or metadiaphyseal comminution that would otherwise be difficult to fix with traditional VLP techniques.14 Additionally, DBP may permit earlier weight-bearing, which is an important consideration in the geriatric and polytrauma populations, both of which may depend on the use of the operative extremity for hygiene and/or walker-use for ambulation.14,18,21
Patient-Reported Outcomes Measurement Information System (PROMIS) is a set of validated PROMs that have been used in many upper extremity pathologies to provide insight on patient's perception of their feelings, views and experience throughout their clinical care. These are routinely collected at our institution, and we utilize in this study to compare various fixation methods in distal radius fractures. Specifically, the purpose of this study was to compare functional, radiographic, and patient-reported outcomes, as well as complication rates, for AO/OTA 23C fractures of the distal radius treated with VLP versus DBP. This study will provide surgeons treating distal radius complete articular fractures with information to counsel their patients on suspected outcomes in regard to range of motion, radiographic, previous patient related outcomes, as well as the preferred way to treat these challenging fractures when either treated with VLP or DBP. The hypothesis of this study was that patients undergoing VLP for complete articular distal radius fractures, compared to DBP, would demonstrate improved patient-reported outcomes and lower complication rates at 6-month follow-up. The secondary hypothesis was that VLP would further result in improved post-operative ROM and superior radiographic outcomes as compared to DBP. Insights from this study may aid treating surgeons in selecting the optimal fixation method for these challenging fractures and in counseling patients about expected outcomes—such as range of motion, radiographic parameters, and functional recovery.
2. Methods
This study was a propensity score-matched retrospective cohort evaluation conducted at a single, academic level 1 trauma center. Institutional review board (IRB) approval and a waiver of consent was obtained for this study.
Patients meeting specific inclusion and exclusion criteria were identified using current procedural terminology (CPT) codes 25607, 25608, and 25609. Inclusion criteria comprised individuals aged between 18 and 90 years old with AO/OTA 23C fracture classification who underwent operative treatment for closed DRFs between October 1, 2015 and October 1, 2023 at a large level 1 academic trauma institution with a minimum follow-up of 6 months. Follow-up data was collected through April 1, 2024. Classification was determined by radiographic review by orthopaedic surgery resident physicians. Patients not in the specified age range, polytraumatized patients, those with a history of previous wrist surgery, patients who also received adjunctive ORIF in combination with DBP, and those undergoing revision surgery were excluded from the study. Classification into VLP or DBP technique was determined by chart review. After applying inclusion and exclusion criteria, the cohort consisted of a total of 1426 VLP and 239 DBP patients.
In order to help control for potential confounders we utilized propensity score matching was then conducted at a ratio of 5:1 utilizing logistic regression modeling. Covariates included age, BMI, race, sex, and a history of hypothyroidism, diabetes, rheumatoid arthritis, or tobacco use. Race was noted as black, white, or other. Categories for BMI were <20, 20–24.99, 25–29.99, 30–34.99, 35–39.99, and ≥40 kg/m2. Matching utilized a greedy, nearest-neighbor algorithm, with a 5:1 ratio of VLP to DBP, and without replacement. To ensure high-quality matches, a caliper was implemented to limit the distance between propensity scores. The caliper was set at 0.2 times the standard deviation of the logit of the propensity scores for the entire cohort.22,23 The final cohorts consisted of 1069 VLP patients and 214 DBP patients after matching.
All surgical interventions were performed by hand or trauma fellowship-trained orthopedic surgeons. In total, patients from 20 surgeons were included in this study and a variety of implant designs were utilized for VLP and DBP fixation. Both the volar and dorsal approaches were at the discretion of the treating surgeon. For the volar approach all surgeons released pronator quadratus. The repair of the pronator quadratus was determined by each treating surgeon. The articular restoration was confirmed with intraoperative fluoroscopy and wrist arthroscopy was not utilized for any of the cases. Surgeons used their preferred implants for treatment of the complete articular distal radius fractures that includes Trimed, Hand Innovations, Skeletal Dynamics, Synthes, and Smith and Nephew systems. All VLP were conventional, there were no hook plates, fragment specific, or other modifications. DBP fixation to the second or third metacarpal shaft as well as decision to open the extensor retinaculum was at the discretion of the surgeon and all patients were immobilized in a volar slab splint for 2–4 weeks after surgery, followed by the application of a removable wrist brace. Commencement of physical therapy and rehabilitation after VLP were determined by the surgeon and varied from 1 to 6 weeks after surgery. DBP patients underwent plate removal at 2–3 months post-operatively, after which therapy was initiated. All therapy post-operative protocols were similar and did not vary greatly between surgeons and all patients were treated by certified therapist.
Demographics, including age, sex, race, and BMI were extracted from electronic medical records, as were conditions such as diabetes, hypothyroidism, tobacco use, and rheumatoid arthritis. Patient-reported outcome measures (PROMIS PF v1.2/2.0, UE v2.0, and PI v1.1) questionnaires were administered using computer adaptive tests during routine clinic visits, facilitated by iPad tablets. Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF), upper extremity (UE), and pain interference (PI) were tabulated at 6-month follow-up for both VLP and DBP. Complication information, such as rates of malunion, infection, nonunion, tendon rupture, and revision, were ascertained through chart review. Bone density measurements were not included within our study.
Wrist flexion/extension, radial/ulnar deviation, forearm protonation/supination and grip strength compared to the contralateral side were measured by hand therapists and physicians using a Jamar calibrated hydraulic hand dynamometer and goniometer. ROM assessment was performed 6 months post-operatively after VLP surgery, and 6 months after DBP removal. The majority of these patients returned to most of their normal activities and did not continue to follow up beyond 6 months. Evaluation of other unrelated pathologies during these follow up visits was not factored during our study.
With regards to radiographic outcomes, plain x-rays were evaluated by three resident orthopedic physicians at 6 month follow up post-operatively after VLP surgery, and 6 months after DBP removal, who were all blinded to the patients’ identities. Radial inclination and height and articular step-off were determined by posteroanterior radiographs of the wrist, while volar tilt was determined via lateral x-rays. Pre and post operative CT scans were not available for all patients and were not reviewed for this study.
Descriptive statistics consisting of mean and standard deviation values were used to summarize the data, while univariate analysis was utilized to compare demographics, including age, sex, race, and BMI, in addition to medical comorbidities. This analysis also assessed for adequate matching between the VLP and DBP cohorts. Chi-square tests, pooled and un-pooled t-tests, and two-proportion z-tests were all used for assessment of both clinical and radiographic outcomes. Standardized mean differences were utilized to compare matched cohorts while mixed effects regression modeling was employed to account for differences in follow-up duration. Statistical significance was defined by a p-value less than 0.05 for all statistical tests. Analyses were performed using R statistical software (version 4.3.0; R Foundation for Statistical Computing).
3. Results
A total of 1665 patients were included in this study, with 1426 in the VLP and 239 in the DBP cohort (Fig. 1). Overall, there were 47.3 % female patients with an average age of 56.6 years old. The VLP group was significantly younger (55.9yr vs. 60.7yr; p = 0.0001) and had fewer females (45.7 % vs. 56.5 %; p = 0.002) than DBP. BMI, race, tobacco use, and diagnosis of diabetes, rheumatoid arthritis, and hypothyroidism were all similar between the groups (p > 0.05) (Table 1). After 5:1 propensity matching, 1069 VLP patients were matched to 214 DBP individuals, rendering all variables examined comparable with no significant difference (Table 2). All remaining analysis was performed on the matched cohorts. All surgeons were hand or trauma fellowship-trained orthopedic surgeons. The surgeons Tang and Giddens classification ranged from Specialist to Expert with majority of the surgeons being specialist-experienced.24
Fig. 1.
Flow diagram illustrating patient selection with exclusion criteria.
Table 1.
Unmatched volar locked plating versus dorsal bridge plating cohort characteristics.
| Characteristic | Volar Locked Plating (n = 1426) | Dorsal Bridge Plating (n = 239) | p value |
|---|---|---|---|
| Demographics | |||
| Age (SD) | 55.9 (9) | 60.7 (12) | 0.0001 |
| BMI >40 kg/m2 (%) | 64 (6) | 13 (6) | 0.96 |
| Female (%) | 652 (46) | 135 (56) | 0.002 |
| Race (%) | |||
| Black or African American | 75 (7) | 17 (8) | 0.63 |
| White | 930 (87) | 180 (84) | 0.26 |
| Other | 64 (6) | 17 (8) | 0.28 |
| Comorbidities (%) | |||
| Tobacco Use | 310 (29) | 73 (34) | 0.14 |
| Diabetes | 160 (15) | 28 (13) | 0.48 |
| Rheumatoid Arthritis | 64 (6) | 11 (5) | 0.63 |
| Hypothyroidism | 64 (6) | 13 (6) | 0.96 |
SD – Standard deviation.
Table 2.
Propensity matched volar locked plating versus dorsal bridge plating cohort characteristics.
| Characteristic | Volar Locked Plating (n = 1069) | Dorsal Bridge Plating (n = 214) | Standardized Difference |
|---|---|---|---|
| Demographics | |||
| Age (SD) | 57.8 (8) | 58.1 (7) | 0.04 |
| BMI >40 kg/m2 (%) | 64 (6) | 13 (6) | 0.01 |
| Female (%) | 652 (61) | 135 (63) | 0.02 |
| Race (%) | |||
| Black or African American | 73 (7) | 17 (8) | 0.02 |
| White | 936 (87) | 180 (84) | 0.03 |
| Other | 60 (6) | 17 (8) | 0.04 |
| Comorbidities (%) | |||
| Tobacco Use | 301 (28) | 68 (31) | 0.04 |
| Diabetes | 151 (14) | 28 (13) | 0.02 |
| Rheumatoid Arthritis | 62 (6) | 10 (5) | 0.02 |
| Hypothyroidism | 61 (6) | 13 (6) | 0.01 |
SD – Standard deviation.
At 6-month follow-up, mean PROMIS UE (35.1 vs. 33.6; p = 0.0001) and PF (46.8 vs. 43.6; p = 0.0001) were significantly improved in the VLP group, whereas PROMIS PI was similar between the cohorts (52.2 vs. 51.9; p > 0.05). In patients that underwent VLP, average ROM at 6-months was significantly improved compared to DBP removal, including wrist flexion (59.4° vs. 55.4°), wrist extension (65.1° vs. 57.1°), forearm protonation (83.2° vs. 81.8°), forearm supination (82.8° vs. 80.1°), radial deviation (17.5° vs. 16.8°), and ulnar deviation (24.6° vs. 23.7°). Similarly, mean grip strength (relative to the uninjured extremity) was higher in the VLP group at 6-months follow-up (68.6 % vs. 56.2 %; p = 0.0001).
All radiographic parameters assessed showed significant differences between the groups at 6-months follow-up. The VLP group demonstrated improved average radial height (11.7 mm vs. 11.4 mm; p = 0.024), radial inclination (21.3° vs. 19.8°; p = 0.0001), and articular step-off (0.73 mm vs. 0.83 mm; p = 0.0001), but also less volar tilt (6.7° vs. 7.1°; p = 0.0001).
Both the VLP and DBP groups demonstrated similar overall revision surgery rates (7.0 % vs. 5.1 %; p = 0.32), even though the VLP group had lower rates of delayed union (2.0 % vs. 4.2 %; p = 0.048) and tendon rupture (0.5 % vs. 3.3 %; p = 0.0001). Malunion and both superficial and deep infection rates were not significantly different between the groups. All propensity matched outcomes can be found in Table 3. None of the volar plates needed to be removed during the study duration.
Table 3.
Propensity matched outcomes at 6-month follow-up.
| Outcome | Volar Locked Plating (n = 1069) | Dorsal Bridge Plating (n = 214) | p value |
|---|---|---|---|
| Range of Motion (degrees; SD) | |||
| Wrist Flexion | 59.4 (5.2) | 55.4 (6.1) | 0.0001 |
| Wrist Extension | 65.1 (5.8) | 57.1 (4.7) | 0.0001 |
| Forearm Pronation | 83.2 (1.5) | 81.8 (1.3) | 0.0001 |
| Forearm Supination | 82.8 (0.9) | 80.1 (1.3) | 0.0001 |
| Wrist Radial Deviation | 17.5 (2.0) | 16.8 (2.5) | 0.0001 |
| Wrist Ulnar Deviation | 24.6 (2.3) | 23.7 (2.6) | 0.0001 |
| Grip Strength (% uninjured) | 68.6 (13.8) | 56.2 (14.6) | 0.0001 |
| Patient Reported Outcomes (SD) | |||
| PROMIS UE | 35.1 (4.0) | 33.6 (3.5) | 0.0001 |
| PROMIS PF | 46.8 (3.1) | 43.6 (3.4) | 0.0001 |
| PROMIS PI | 52.2 (3.8) | 51.9 (4.0) | 0.30 |
| Radiographic Outcomes (SD) | |||
| Radial Height (mm) | 11.7 (1.7) | 11.4 (2.1) | 0.024 |
| Radial Inclination (degrees) | 21.3 (3.4) | 19.8 (3.4) | 0.0001 |
| Volar Tilt (degrees) | 6.7 (1.1) | 7.1 (1.3) | 0.0001 |
| Articular Step-Off (mm) | 0.73 (0.2) | 0.83 (0.2) | 0.0001 |
| Complications (%) | |||
| Need for Revision Surgery | 75 (7) | 11 (5) | 0.32 |
| Malunion | 43 (4) | 11 (5) | 0.46 |
| Nonunion | 21 (2) | 9 (4) | 0.048 |
| Superficial Infection | 32 (3) | 9 (4) | 0.36 |
| Deep Infection | 44 (4) | 3 (2) | 0.06 |
| Tendon Rupture | 5 (1) | 7 (3) | 0.0001 |
SD – Standard deviation.
4. Discussion
Complete articular distal radius fractures are challenging injuries to treat since the fractures can often occur fairly distally with significant comminution and in patients with poor bone stock.25 The present study focused on AO/OTA 23C fracture patterns that were treated with either VLP or DBP and revealed that compared to VLP, patients that underwent DBP had higher rates of delayed union and tendon rupture with decreased wrist flexion/extension, radial/ulnar deviation, supination/protonation, grip strength, and less favorable PROMIS UE and PROMIS PF. Additionally, patients that were treated with VLP had greater radial height and inclination as well as less articular step-off, even though VLP resulted in slightly less volar tilt compared to DBP. These findings are applicable to all patients with these injuries—particularly older adults with poor bone stock and degenerative tendons—who may be predisposed to a higher risk of complications.
Furthermore, the two cohorts had similar overall rates of revision surgery, malunion, and infection at 6 months post-operatively even though individuals treated with DBP were found to have higher rates of delayed union than VLP. Nonunion after distal radius surgery is reported to be extremely uncommon as demonstrated by Bacorn and Kurzke, in a study of more than 2000 patients with a nonunion rate of 0.2 %.26 In this study, the rate of delayed union was found to be 4.2 % after DBP and 2 % after VLP and there are several factors that could account for this difference. It is known that the presence of an open fracture, severe comminution, infection, pathologic lesions, and devascularization of bone ends can contribute to poor bony healing.27 Complete articular fractures are typically comminuted, resulting in small bone fragments with poor perfusion and may explain the increased nonunion rate seen in this study's patients.26 This study also found that patients treated with DBP had an increased risk of tendon rupture (3.3 % vs. 0.5 %). In a study of 576 patients treated with VLP, Thorninger et al. found 4.7 % of patients developed tendon complications and, more importantly, AO/OTA type 23C fractures specifically had a statistically significant association with complications after VLP fixation.28 In VLP, repair of the pronator quadratus provides muscular coverage of the plate that can shield the flexor tendons from plate irritation,29 whereas DBP lacks similar protection of the extensor tendons and can lead to irritation and potentially tendon injury.
One additional concern with DBP is that the prolonged immobilization of the carpus usually required to achieve fracture stability and healing may also cause stiffness of the carpus, a phenomenon that is often appreciated after DBP removal.17 VLP on the other hand, stabilizes the distal radius using a fixed-angle plate without spanning the radiocarpal joint allowing for early wrist motion. This was corroborated in this study, as it found that patients treated with VLP demonstrated improvement in all ROM measurements and grip strength when compared to patients with DBP. Regardless, little ROM is needed to carry out activities of daily living (10° of flexion and 15° of extension)30,31 and depending on the activity level of the patient, this may not have important clinical impact on the patients function.
As healthcare systems progress towards value-based healthcare, there has been increased focus on patient-related outcomes.32 Patients treated with VLP in this study had greater PROMIS UE and PROMIS PF, but not PROMIS PI, when compared to the DBP group, which is in agreement with a recent study by Carroll et al. that showed similar improvements in PROMIS UE and PF in VLP versus DBP patients with DRF, regardless of fracture pattern.33 However, these metrics must be interpreted in the context of the minimal clinically important difference (MCID), defined as the smallest change in symptoms that patients perceive as meaningful. MCID can be estimated using either anchor-based or distribution-based approaches. In the anchor-based method, Hollenberg et al. determined the MCID for the PROMIS Physical Function (PF) and Pain Interference (PI) domains to be 5.2 and 6.8 points, respectively.34 In contrast, the distribution-based method defines the MCID as one half of the standard deviation of each PROMIS domain; since each domain is normed to an SD of 10, this yields an MCID of 5 points for all domains.35 In our study the difference in PROMIS UE, PF, and PI scores from VLP to DBP was 1.5, 3.2, and 0.3, respectively. Consequently, although these score differences may achieve statistical significance, they do not reach levels considered clinically meaningful between the VLP and DBP groups.
At 6-month follow-up, patients treated with VLP showed overall superior radiographic parameters, as demonstrated by greater radial height (11.7 mm vs 11.4 mm), radial inclination (21.3° vs. 19.8°), and less articular step-off (0.73 mm vs. 0.83 mm). The one radiographic exception was volar tilt, with VLP having slightly less volar tilt compared to DBP (6.7° vs. 7.1°). These findings are in line with most studies that have examined the use of DBP in comminuted intra-articular distal radius fractures,19,36 even though, many of these examined more simple, lower-energy fracture patterns. In a study of approximately 2500 DRFs treated with either DBP or VLP, Carroll et al. found that VLP had similar improvements in radial height, radial inclination, and step-off, with a non-significant difference in volar tilt.33 Overall, the differences found in radiographic parameters in the present study are minimal (within 1–2° or 0.1 mm), and may not be clinically relevant.
This study has several limitations. First, although patients with 23C fracture patterns were assessed, this study did not examine subgroups within this classification (i.e. 23C1 vs. 23C2 vs. 23C3). Fractures with 23C3 classification, for example, have more complex articular comminution and may be more preferentially treated with DBP as VLP may not achieve adequate fixation. Future studies analyzing VLP versus DBP within each subgroup may provide additional insight. Secondly, this was a retrospective study, which limits the ability to draw causal conclusions and it is prone to selection bias as the decision to undergo VLP or DBP was based on surgeon preference and not randomized. Additionally, the ROM and strength measurements were taken 6 months after initial VLP surgery but 6 months after DBP plate removal, which may have implications on differences between the cohorts related to time allowed for healing after surgery. Thirdly, radiographic measurements were compared using plain x-rays which might not be as sensitive of a modality as advanced imaging such as CT scans in delineating subtle differences. Nonetheless, radiographic measurements best mirror what surgeons encounter in routine practice. However, because each patient's images were evaluated by one of three orthopedic surgery residents, inter-observer variability may have introduced measurement error. In addition, the PROMIS outcomes were a comparison between groups, and this study did not have pre-injury data to understand how they compared to the post-injury pre-surgery scores. This data would have allowed a better understanding of the magnitude of improvement and potential differences between cohorts. Additionally, this study was based on 6-month follow-up and long-term outcomes cannot be inferred. Lastly, the PROMIS was utilized within our study instead of DASH and PRWE which makes it more challenging to compare with other studies.
5. Conclusion
In this retrospective study patients with complete articular (AO/OTA type 23C) DRFs, VLP was associated with greater ROM, grip strength, PROMIS UE and PF, and improved radiographic outcomes compared to DBP over 6 months of follow-up. DBP patients demonstrated higher rates of delayed union and tendon rupture, however, both fixation options appear to be overall effective in treating these challenging fracture patterns.
Statement of informed consent
A waiver of consent was granted by our IRB due to the retrospective nature of the study.
CRediT
Thomas Carroll: Conceptualization, Methodology, Formal analysis, Data Curation, Writing – Original Draft, Writing – Review and Editing. Akhil Dondapati: Conceptualization, Methodology, Formal analysis, Data Curation, Writing – Original Draft, Writing – Review and Editing. Richard Lander: Data Curation, Writing – Original Draft, Writing – Review and Editing. Andrew Rodenhouse: Data Curation, Writing – Original Draft, Writing – Review and Editing. Urvi Patel: Data Curation, Writing – Original Draft, Writing – Review and Editing. Warren Hammert: Writing – Review and Editing, Supervision, Visualization, Methodology, Conceptualization. Ronald Gonzalez: Writing – Review and Editing, Supervision, Visualization, Methodology, Conceptualization. Constantinos Ketonis: Writing – Review and Editing, Supervision, Visualization, Methodology, Conceptualization.
Statement of funding
No funding was received for this study.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Contributor Information
Thomas J. Carroll, Email: ThomasJ_Carroll@URMC.Rochester.edu.
Akhil Dondapati, Email: Akhil_Dondapati@URMC.Rochester.edu.
Richard Lander, Email: Richard_Lander@URMC.Rochester.edu.
Andrew Rodenhouse, Email: Andrew_Rodenhouse@URMC.Rochester.edu.
Urvi Patel, Email: Urvi_Patel@URMC.Rochester.edu.
Warren C. Hammert, Email: Warren.hammert@duke.edu.
Ronald Gonzalez, Email: Ronald_Gonzalez@URMC.Rochester.edu.
Constantinos Ketonis, Email: Constantinos_Ketonis@URMC.Rochester.edu.
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