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Treatment of Lisfranc Fracture-Dislocations with

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FOOT & ANKLE INTERNATIONAL
Copyright 2012 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2012.0050
Treatment of Lisfranc Fracture-Dislocations with Primary Partial Arthrodesis
Keith R. Reinhardt, MD; Luke S. Oh, MD; Patrick Schottel, MD; Matthew M. Roberts, MD; David Levine, MD
ABSTRACT
Background: The optimal method of treatment for Lisfranc
fracture-dislocations remains controversial, and the role of
primary partial arthrodesis for combined osseous-ligamentous
Lisfranc injuries is unclear. This study reviewed the outcomes
of Lisfranc injuries treated by primary partial arthrodesis.
Methods: Patients who underwent primary partial arthrodesis
for a primarily ligamentous or combined osseous and ligamen-
tous Lisfranc fracture-dislocation were reviewed retrospectively
and assessed at followup according to radiographic, clinical and
standardized patient-based outcomes. Twenty-five patients (12
ligamentous, 13 combined), median age of 46 (range, 20 to 73)
years, were followed for an average of 42 (range, 24 to 96)
months. Results: The average American Orthopedic Foot and
Ankle Society (AOFAS) score was 81 points (scale 0 to 100), with
patients in general losing points for mild pain, limitations of
recreational activities, and fashionable footwear requirements.
There was no statistical difference between ligamentous and
combined injuries with regard to the physical or mental compo-
nent scores on the SF-36. At latest followup, patients reported an
average return to 85% of their preinjury activity level (range,
50% to 100%). Twenty-one patients (84%) expressed satis-
faction with their outcome and at latest followup, the mean
visual analog pain scale (VAS) score was 1.8 out of 10 (range,
0 to 8). Three patients showed radiographic signs of post-
traumatic arthritis of adjacent joints. Conclusion: Treatment of
both primarily ligamentous and combined osseous and ligamen-
tous lisfranc injuries with primary partial arthrodesis produced
good clinical and patient-based outcomes.
No benefits in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
Corresponding Author:
Keith R. Reinhardt, MD
Hospital for Special Surgery
Orthopaedic Surgery
535 East 70th Street
8th Floor
New York, NY 10021
E-Mail: krr9009@gmail.com
For information on pricings and availability of reprints, email reprints@datatrace.com
or call 410-494-4994, x232.
50
New York, NY
Level of Evidence: III, Retrospective Comparative Study
Key Words: Tarsometatarsal; Lisfranc; Primary Partial Arthro-
desis; Fracture-Dislocation; Midfoot
INTRODUCTION
Lisfranc (tarsometatarsal) fracture-dislocations are un-
common injuries, but have classically been a difficult
problem for the orthopaedic surgeon. Because of the
high potential for chronic disability, prompt diagnosis and
precise anatomic reduction are essential.2,4,6,9,12,15,23 The
various treatments for this injury include closed reduc-
tion and immobilization, closed reduction with percutaneous
pinning,10,21,27 open reduction and internal fixation (ORIF)
either trans-articular2,3,15,18 or extra-articular,1 flexible liga-
mentous fixation,5 primary partial (first three tarsometatarsal
[TMT] joints) arthrodesis,11,16,18 and primary complete (all
five TMT joints) arthrodesis.9,12
Most authors have traditionally considered open reduction
and internal fixation to be the treatment of choice for Lisfranc
fracture-dislocations.3,6,8,15 22,27 More recently, however,
some authors have advocated primary partial arthrodesis as
an alternative to ORIF.11,16 Previously, partial or complete
arthrodesis was not advocated as a primary treatment for
Lisfranc fracture-dislocations, and most considered them to
be salvage operations,14,17,19,24,25 However, trends toward
worse results using ORIF in subsets of patients with primarily
ligamentous Lisfranc injuries led to the proposal of partial
arthrodesis as a primary treatment in these patients,15 which
has been supported by recent Level I evidence.11,16
The applicability of primary partial arthrodesis for com-
bined osseous-ligamentous injuries in addition to the pri-
marily ligamentous Lisfranc injuries remains unclear. The
purpose of this study was to evaluate and compare the clinical
and radiographic outcomes of patients with primarily liga-
mentous and combined osseous-ligamentous Lisfranc injuries
after operative treatment with primary partial arthrodesis.
Secondary aims of the study were to determine if outcomes
following primary partial arthrodesis were affected by the
Foot & Ankle International/Vol. 33, No. 1/January 2012
subtype of Lisfranc injury sustained, and to identify poten-
tially predictive variables of outcomes following partial
arthrodesis regardless of injury subtype.
MATERIALS AND METHODS
Operative records of two foot and ankle fellowship-trained
orthopaedic surgeons (M.M.R. and D.S.L.) were reviewed to
identify patients who underwent primary partial arthrodesis
for a Lisfranc fracture-dislocation between 1998 and 2006.
During this time period, primary partial arthrodesis was
performed on all patients presenting to our institution with
an operative Lisfranc injury. Patients were included in the
study if they were skeletally mature at the time of injury,
had undergone primary arthrodesis of the first, second,
and/or third tarsometatarsal joints within 6 weeks of the
time of injury, and had a minimum followup of 2 years.
Exclusion criteria were prior ipsilateral foot or ankle surgery
or infection, concurrent ipsilateral lower extremity fractures,
chronic injury of greater than 6 weeks duration, and any
previous attempt at operative management of the same injury.
All participating patients signed informed written consent
and the study protocol was approved by the Institutional
Review Board.
Thirty-four patients met our initial inclusion criteria. Of
those, 25 patients with 25 Lisfranc fracture-dislocations
consented to participate in the study and returned for
followup at a mean of 42 (range, 24 to 96) months. The
study population consisted of 8 males and 17 females, with a
median age at the time of injury of 46 (range, 20 to 73) years.
Patients were separated into two groups based on their pattern
of injury. Ligamentous injuries with associated fractures
of the metatarsal bases, cuneiforms, or the cuboid were
considered combined osseous-ligamentous injuries, whereas
an isolated avulsion of the Lisfranc ligament from the
base of the second metatarsal (fleck sign) was included
with purely ligamentous injuries in a primarily ligamentous
injury subgroup. Overall, there were no open injuries, none
of the injuries were work-related, and the mechanisms of
Table 1: Patient Demographic and Clinical Data by Tarsometatarsal Injury Subtype
Age: median(range)
Female: n (%)
TMT joints injured: median (range)
Patients with comorbidities: n (%)1
1 , Comorbidities considered relevant to arthrodesis included smoking, chronic steroid use, and the use of
bisphosphonates for osteoporosis; 2 , p value for Wilcoxon ranksum test; 3 , p value for Fishers Exact Test.
Copyright 2012 by the American Orthopaedic Foot & Ankle Society
PRIMARY ARTHRODESIS OF LISFRANC INJURIES 51
injury included twisting a plantarflexed forefoot (n = 13),
motor vehicle accidents (n = 5), falls (n = 4), and crush
injury (n = 3). Five patients had involvement of all five
tarsometatarsal joints, four had involvement of four, twelve
had involvement of three, and four had involvement of
two. In the combined osseous-ligamentous group, 10 patients
(77%) had metatarsal fractures, eight patients (62%) had
associated cuneiform fractures, and two patients (15%)
had associated fractures of the cuboid. In the primarily
ligamentous group, two patients (17%) had an associated
fleck sign. The demographic and clinical data according to
injury pattern subtype is further elucidated in Table 1.
There were 12 patients (four males, eight females) in the
primarily ligamentous injury group with a median age of 51.5
(range, 20 to 71) years. In this group, one patient was on a
bisphosphonate for osteoporosis, one patient was a smoker,
and one was on chronic steroids. In the combined osseous-
ligamentous injury group there were 13 patients (four males,
nine females) with a median age of 46 (range, 20 to 73) years.
In this group, one patient was a smoker, one was on chronic
steroids, and two other patients were both smokers and on
chronic steroids. The groups were similar with regard to
the demographic variables of age, gender, comorbidities, and
extent of injury as indicated by the number of tarsometatarsal
joints involved (p > 0.05).
Primary partial arthrodesis consisted of the first TMT joint
alone in three patients, the first and second TMT joints in two
patients, and the first three TMT joints in 20 patients. The
medial intercuneiform joint was also fused in six patients.
Fixation of the lateral TMT joints with temporary Kirschner
wires was required for the fourth TMT joint alone in two
patients, and for both the fourth and fifth TMT joints in three
patients. Proximal tibia or calcaneal bone graft was used in
all patients.
Postoperative management
The postoperative protocol consisted of routine followup
visits at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and
yearly thereafter. Immediately postoperatively the patients
were placed in a posterior splint for 10 days, at which
Combined
Primarily Osseous &
Ligamentous Ligamentous p Value
51.5 (20 71) 46.0 (20 73) 0.91332
8 (66.7) 9 (69.2) 1.00003
3 (2 5) 3 (2 5) 1.00002
3 (25) 4 (31) 0.77693
52 REINHARDT ET AL.
point the splint and sutures were removed, and the patient
was converted to a controlled ankle motion (CAM) boot.
Patients were kept nonweightbearing for the first 6 weeks,
but were encouraged to work on active ankle range of
motion. At 6 weeks, patients began a progressive weightbear-
ing and physical therapy protocol, with full weight-
bearing achieved by 8 weeks postoperatively. Initial
weightbearing was performed in the CAM boot, which was
weaned based on residual pain. Six weeks of gait, balance,
and proprioceptive training was then followed by a strength-
ening protocol. Standard AP, lateral, and oblique radio-
graphs were obtained at each visit beginning with the 6-week
followup. If the fourth and/or fifth tarsometatarsal joints had
been fixed with Kirschner wires, the Kirschner wires were
removed in the office at the 6-week visit prior to initiating
weightbearing.
Followup
Patients were contacted via mail and telephone to partici-
pate in the study and requested to return for clinical followup
as part of the study. During the followup visit all patients
underwent a physical exam, had radiographs, and answered
a series of questionnaires related to their pain and function.
The physical exam consisted of an assessment of the appear-
ance and alignment of the foot, an analysis of their gait, and
range of motion of adjacent joints. Standing AP, lateral, and
oblique radiographs were taken of both feet in each patient
for comparison to the contralateral side. Intraoperative, early
followup (6 weeks and 3 months), and final visit radiographs
were assessed for alignment of the tarsometatarsal joints,
fracture union, status of the fusion, integrity of retained hard-
ware, and adjacent joint arthrosis. Two independent observers
used previously described radiographic parameters to assess
tarsometatarsal joint alignment.26 The quality of the reduc-
tion was judged by the medial column line on the AP radio-
graph, which is a line tangential to the medial aspect of
the navicular and the medial cuneiform.7 In a normal foot
this line should intersect the base of the first metatarsal. The
reduction was considered anatomic if this criterion was met,
nearly anatomic if it was within 2 mm of the base of the first
metatarsal, and non-anatomic if it was more than 2 mm.
At latest followup, functional outcomes were assessed
using the American Orthopaedic Foot and Ankle Society
(AOFAS) score13 for the midfoot, which is based on a
0 to 100 point scale, with a score of 100 indicating the
most optimal function. This is a widely-used, although not
validated, functional outcome score. Patients also completed
the SF-36 form, which is a short questionnaire with 36
items used to measure physical and mental health on a scale
from 0 to 100, with higher scores indicating better perceived
functioning.28 Patients rated their pain levels on a visual
analog pain scale (VAS) from 0 (no pain) to 10 (worst pain).
Finally, patients were asked about their satisfaction with their
outcome (very dissatisfied, somewhat dissatisfied, somewhat
satisfied, or very satisfied) and return to previous levels of
Copyright 2012 by the American Orthopaedic Foot & Ankle Society
Foot & Ankle International/Vol. 33, No. 1/January 2012
sports or activities via a clinical questionnaire. Specifically,
they were asked to estimate their current level of activity as
a percentage of their activity level before the injury, and to
describe any activities that they were prevented from doing
because of the current function of their foot.
Statistical analysis
Descriptive statistics were calculated for variables of
interest. Continuous variables were represented by means and
standard deviations or medians and ranges, while frequencies
and percentages were reported for categorical and binary
outcome variables. The Wilcoxon ranksum test was used to
analyze continuous variables and Fishers Exact Test was
used to evaluate binary and categorical variables. Univariate
analysis of variance (ANOVA) was performed to assess the
association of variables of interest to the primary outcome
of AOFAS score. A p value less than 0.05 was considered
to be statistically significant. Post hoc power analysis, using
alpha at 0.05 and beta at 0.8, for a 20% difference in the
AOFAS score (mean, 81 + 17) revealed 17 patients would
be needed per group. Analyses were conducted using SAS
software version 9.1 (SAS Institute, Cary, NC).
RESULTS
Overall 84% of patients (21 out of 25) were either
somewhat satisfied or very satisfied with their outcome
following primary partial arthrodesis (Figure 1). Only one
patient across both groups was very dissatisfied. Within the
primarily ligamentous group seven patients were very satis-
fied, two were somewhat satisfied, and three were some-
what dissatisfied. In the combined injury group, eleven
patients were very satisfied, one was somewhat satis-
fied, and one was very dissatisfied. Patient satisfaction
did not differ between groups (p = 0.1820). The average
VAS pain score overall at latest followup was 1.8 points out
of 10 (range, 0 to 8 points). The average pain scores did
not differ between groups, with an average primarily liga-
mentous group pain score of 1.5 points out of 10 (range,
12
10
8
# of Patients
6
4
2
0
Very dissastisfied Somewhat
Dissastisfied
Somewhat Satisfied Very Satisfied
Patient Satisfaction Level
Primarily ligamentous Combined osseous + ligamentous
Fig. 1: Patient satisfaction level according to injury subtype.
Foot & Ankle International/Vol. 33, No. 1/January 2012 PRIMARY ARTHRODESIS OF LISFRANC INJURIES 53

0 to 4 points) and an average osseous + ligamentous
group pain score of 2.1 points out of 10 (range, 0 to 8
points) (p = 0.7835). In the primarily ligamentous group,
six patients were taking over-the-counter pain medication
intermittently at last followup and six patients were not
taking any pain medication. In the combined group, six
patients were taking over-the-counter pain medication inter-
mittently, one patient was taking prescriptive pain medica-
tion, and another patient was being managed by a chronic
pain service.
At the time of final followup, the overall average AOFAS
midfoot score was 81 (range, 25 to 100) points. Within the
primarily ligamentous group the mean AOFAS score was
83.3 (range, 49 to 100) points, and in the combined injury
group it averaged 78.5 (range, 25 to 100) points (p > 0.05).
Patients lost points most frequently for responses of mild
pain, limitation of recreational activities, and inability to
maintain fashionable footwear. On the SF-36 there was no
difference between groups on either the physical or mental
component summary scores (Table 2).
Patients reporting returning to an average of 85% (range,
50% to 100%) of their pre-injury activity level at latest
followup. By group, primarily ligamentous patients returned
to 86.9% (range, 50% to 100%) and combined injury patients
returned to 83% (range, 50% to 100%) of their pre-injury
activity levels (p = 0.6582) (Table 3). Three patients in
the ligamentous group reported being unable to perform
high-level activities because of the function of their foot,
which included skiing, soccer, and modern dance. Limita-
tion of high-level activities was reported by four patients in
the combined injury group and consisted of skiing, hiking,
running, and dance. The remaining 18 patients (72%) did
not report being limited from doing any activities at latest
followup.
The association of a number of variables and the
final AOFAS outcome score was analyzed to identify
variables that could potentially predict outcome. When all
25 patients were considered together, patient age, number
of tarsometatarsal joints injured, length of followup, and the
presence of a comorbidity were not found to be predictive
of the AOFAS score (p > 0.05 for all variables). According
to the radiographic criteria, the quality of the reduction of
the tarsometatarsal joints was anatomic in 12 patients, nearly
anatomic in ten, and nonanatomic in three. The quality of
tarsometatarsal reduction was also not associated with the
final AOFAS score (p = 0.76).
Of the 25 patients treated with primary partial arthrodesis,
six (24%) underwent additional surgical procedures. Four
patients underwent removal of hardware. Reasons for
removal of hardware included patient preference (n = 2),
a broken screw (n = 1), and painful prominent hardware
(n = 1). Two patients underwent revision arthrodesis for
tarsometatarsal nonunion. One was an avid surfer who devel-
oped a nonunion of the first and third TMT joints (Figure 2,
A and B). His AOFAS score improved from 41 to 82
following revision arthrodesis and bone grafting with prox-
imal tibia autograft, and he returned to surfing at latest
followup (Figure 2C). The other occurred in a smoker with
rheumatoid arthritis on chronic prednisone, who had a persis-
tent nonunion of the second TMT joint despite attempted
revision arthrodesis with proximal tibia autograft. At latest
followup she returned to only 50% of her pre-injury activity
level, was undergoing pain management, and had a final
AOFAS score of 25. In total, there were four nonunions,

Table 2: Physical and Mental Component Summary Scores by

Tarsometatarsal Injury Subtype

Combined
Primarily Osseous +
Ligamentous Ligamentous p Value
Physical Component 48.1 9.5 51.4 11.9 0.41
Score (mean SD)
Mental Component 54.9 8.0 53.6 9.3 0.59
Score (mean SD)

Table 3: Percentage of Pre-Injury Activity Level at Latest Followup as Estimated by

Patients

Primarily Osseous +
Overall Ligamentous Ligamentous p Value
Average activity level 85% 86.9% 83.0% 0.6582

Copyright 2012 by the American Orthopaedic Foot & Ankle Society

54 REINHARDT ET AL. Foot & Ankle International/Vol. 33, No. 1/January 2012

C
A

Fig. 2: A, Weightbearing AP, lateral, and oblique radiographs demonstrating a first and third tarsometatarsal joint nonunion (arrows) in a 38-year-old avid
surfer 15 months following primary partial arthrodesis. B, Sagittal cut CT scan of this patient confirming the persistence of the first TMT joint space. C,
Weightbearing AP, lateral, and oblique radiographs of the same patient with evidence of solid fusion of the first three TMT joints 9 months following revision
arthrodesis with proximal tibia autograft (of note, the patient achieved TMT fusion by 3 months following revision surgery).

three of which were either smokers, on chronic steroids, or
both. Patients who developed a nonunion were more likely to
have a pre-existing comorbidity (smoking, steroid use) than
those who did not (p = 0.05). Of the two nonunions that
did not undergo revision surgery, one developed a fibrous
union that became asymptomatic with a final AOFAS score
of 90, and the other deferred surgery because of mild symp-
toms and returned to 85% of his pre-injury activity level.
Post-traumatic arthrosis of adjacent joints was seen radio-
graphically in three patients (12%).
DISCUSSION
Lisfranc fracture-dislocations continue to be a difficult
injury to treat by the orthopaedic surgeon with poten-
tial for significant morbidity for the patient. Tradition-
ally, these patients were treated with ORIF, while partial
arthrodesis was reserved as a salvage procedure for post-
traumatic arthrosis. However, the literature over time has
revealed that not all Lisfranc injuries are created equal.
Outcomes of particular interest for this injury addressed
in the literature have included incidence of post-traumatic
arthritis, functional outcome scores, return to activity, pain
scores, patient satisfaction, and the need for further surgical
procedures.
In 2000, Kuo et al. reported on the outcomes of 48 patients
following ORIF for either primarily ligamentous or combined
osseous-ligamentous Lisfranc injuries. At a mean followup
of 52 months they found evidence of post-traumatic arthritis
in only 18% percent of the combined osseous-ligamentous
patients compared to 40% in the patients with a primarily
ligamentous injury.15 This led the authors to suggest primary
arthrodesis as an alternative primary treatment for primarily
ligamentous injuries, theorizing that the injury pattern itself
Copyright 2012 by the American Orthopaedic Foot & Ankle Society
rather than the fixation technique was responsible for the
outcome. While post-traumatic arthritis of the TMT joints
following primary arthrodesis is not an issue, there remains
uncertainty regarding the incidence of adjacent joint arthritis.
In our study, three patients (12%) across both groups at
an average 42 months showed radiographic evidence of
adjacent joint post-traumatic arthritis using primary partial
arthrodesis for both combined and primarily ligamentous
injury subtypes. Further, the incidence of adjacent joint
arthritis did not differ based on injury pattern, whereby two
of those patients were in the combined osseous-ligamentous
group (15.4%) and one was in the primarily ligamentous
group (8.3%) (p > 0.05).
With a lack of consensus in the literature regarding optimal
treatment methods for Lisfranc injuries, recent literature has
emphasized the need to compare ORIF to primary partial
arthrodesis.11,16 Ly and Coetzee prospectively randomized
patients to either primary partial arthrodesis or ORIF for
the treatment of primarily ligamentous Lisfranc injuries,
excluding patients with combined osseous-ligamentous inju-
ries. In their study, the average AOFAS outcome score
was significantly better in the 21 patients who underwent
primary partial arthrodesis (86.9) than in the 20 patients who
underwent ORIF (57.1) (p < 0.0001).16 We found similar
results in our patients following primary partial arthrodesis
with an average overall AOFAS score of 81 points. In our
study, patients with combined osseous-ligamentous injuries
scored similarly on the AOFAS to those with primarily
ligamentous injuries (78.5 versus 83.3, respectively).
Ly and Coetzee also found that patients in the primary
arthrodesis group estimated their activity level to be a higher
percentage of their pre-injury activity level than those in the
ORIF group [92% versus 65%, respectively (p < 0.005)].16
Again, our results are reflective of their primary arthrodesis
Foot & Ankle International/Vol. 33, No. 1/January 2012
group in that our patients overall returned to 85% of the
pre-injury activity level. Furthermore, the type of Lisfranc
injury pattern in our study did not impact functional recovery,
with combined injury patients returning to 83% and primarily
ligamentous patients returning to 86.9% of their pre-injury
activity levels (p = 0.6582).
Regarding pain scores, Ly and Coetzees patients rated
their pain on the VAS, reporting less pain in the primary
arthrodesis group compared to ORIF at latest followup
[1.2 versus 4.1, respectively (p = 0.0002)].16 Similarly, the
overall average VAS pain score following primary partial
arthrodesis in our study was 1.8 out of 10, and we found
no differences in pain scores between primarily ligamentous
and combined injury groups.
Following Ly and Coetzee, Henning et al. recently
published a randomized trial comparing primary arthrodesis
to ORIF, which included patients with either combined
osseous-ligamentous or primarily ligamentous Lisfranc inju-
ries. At a mean followup of 53 months, telephone surveys
revealed patient satisfaction rates of 90% in the ORIF group
and 92% in the primary partial arthrodesis group.11 Our
finding of an overall patient satisfaction rate of 84% is similar
following primary partial arthrodesis. Henning et al. also
reported on additional surgical procedures. In their study
79% of the ORIF patients and 17% of the primary partial
arthrodesis patients underwent hardware removal.11 This was
a significant difference, but routine hardware removal had
been built into their ORIF protocol. The incidence of further
surgical procedures seen in our study (24%) is similar, and
this is further supported by that shown in Ly and Coetzees
study whereby 80% of the ORIF and 19% of the primary
partial arthrodesis patients underwent additional surgical
procedures.16
Our study has several limitations. Although patients
returned for clinical followup, identification of patients for
inclusion in the study was done retrospectively and is there-
fore subject to selection bias. Of note is the fact that
during the time period of the study all patients presenting
to the senior authors with Lisfranc injuries were treated with
primary partial arthrodesis regardless of injury severity or
pattern. The sample size of the study is relatively small,
and while this is somewhat dictated by the incidence of this
injury in the general population, it nonetheless introduces the
potential for type II errors (not finding a significant differ-
ence when one truly exists). Post hoc power analysis showed
that 17 patients per group would be needed to detect a clin-
ically relevant difference in our primary outcome, AOFAS
score. We did not find an association between the quality of
the reduction and outcomes, yet authors before us have.15
Furthermore, although radiographic followup assessments
were performed by independent examiners, clinical assess-
ments were done by the operating surgeon, which allowed
for potential bias. In addition, this study did not assess
the athletic or specific sports participation of the partic-
ipants, making it difficult to draw conclusions regarding
Copyright 2012 by the American Orthopaedic Foot & Ankle Society
PRIMARY ARTHRODESIS OF LISFRANC INJURIES 55
return to athletic performance. Finally, although a minimum
clinical followup of 2 years was used, the mean followup of
42 months can be argued to be too soon to properly evaluate
for post-traumatic arthritis of adjacent joints.
CONCLUSION
Primary partial arthrodesis for both combined osseous-
ligamentous and primarily ligamentous Lisfranc fracture-
dislocations allowed patients in general to return to pre-injury
levels of activity, and was associated with low pain scores,
high patient satisfaction rates, and low re-operation rates.
ACKNOWLEDGMENT
The authors wish to thank Huong T. Do for assistance
in designing and performing the statistical analyses for this
study.
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