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Proksimal Humerus ve Cavitas Glenoidealis'in Antropometrik Çalışması: Normal Glenohumeral İlişkiler

Year 2023, , 184 - 191, 30.06.2023
https://doi.org/10.53446/actamednicomedia.1170631

Abstract

Amaç: Omuz eklemi benzersiz düzensiz şekli nedeniyle karmaşık bir anatomik yapıya sahiptir. Omuz eklem bozukluklarının cerrahi tedavisi ve artroskopik işlemler gibi cerrahi müdahaleler için omuz ekleminin anatomisinin detaylı olarak bilinmesi gerekir. Ayrıca omuz ekleminde ırk veya cinsiyete bağlı morfometrik farklılıkların olup olmadığının bilinmesi antropoloji ve bazı klinik alanlarda özellikle adli tıpta faydalı olabilir. Ancak konunun önemine rağmen omuz ekleminin kantitatif anatomisine ilişkin az sayıda çalışma bulunmaktadır. Bu çalışmanın amacı omuz eklemi ölçülerini detaylı olarak sunmaktır.
Gereç ve Yöntem: Toplam 107 kişiye (54 erkek, 53 kadın) ölçüm yapıldı. 6'sı humerus proksimalinde ve 12'si cavitas glenoidealis'te olmak üzere 18 ölçüm yapıldı. Ölçümlerde MR cihazı kullanıldı. Cavitas Glenoidalis'in şekli (gözyaşı damlası, armut biçimli, yuvarlak, oval, ters virgül biçimli) değerlendirildi ve yüzdeleri hesaplandı.
Bulgular: Humerus proksimalindeki tüm değerler erkeklerde daha yüksekti (p<0.05). Yaşa göre karşılaştırmalarda (>40 ve <40), humerus vertikal çapı ve BF uzunluğu dışındaki tüm değerler 40 yaş üzerinde daha yüksek bulundu.
Sonuç: Bu bulgular kemik antropometrisinde articulatio humeri için tekrarlanabilir bir referans noktası sağlayabilir, omuz replasman cerrahisinde değerli bir referans sunabilir ve kemikli glenohumeral instabiliteyi karakterize etmeye yardımcı olabilir.

References

  • 1-Iannottij, Gabriel JP, Schneck S L, Evans B G, Misra S. The normal glenohumeral relationships. The journal of Bone and Joint Surgery 1992;74A(4):491-500.
  • 2-Neer CS, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone and Joint Surgery 1982;64-A:319-337.
  • 3-Robertson DD, Yuan JIE, Bigliani LU, Flantow EL, Yamaguchi K. Three-dimensional analysis of the proximalpart of the humerus: relavance to artroplasty. The journal of Bone and Joint Surgery 2000;82-A(11)1594-1602.
  • 4-Ballmer FT, Sidles JA, Lippitt SB, Matsen FA. Humeral prostheticarthoplasty: surgically relevant eon siderations. J. Shoulder and elbow Surg.1993;2:2996-304.
  • 5-Bigliani LU, Kelkar R, Flatow EL, Pollock RG, Mow VC. Glenohumeral stability. Biomechanical properties of passive and active stabilizers. Clin. Orthop. 1996; 330:13-30.
  • 6-Boileau P, Walch G. The three-dimenjional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone and Joint Surg 1997;79-B(5):857-865.
  • 7-Friedman RJ. Biomechanics of the shoulder following total shoulder replacement. In Surgery of the Shoulder. Edited by M. Post, B.F. Morrey, and R.J. Hawkins. St. Louis, Mosby-Year Book, 1990.pp:263-266.
  • 8-Harryman DT, Sidles JA, Harris SL, Lippitt SB, Matsen FA. The effect of articular conformity and the size of the humeral head component on laxity and motion after glenohumeral arthroplasty. A study in cadavera J Bone and Joint Surg 1995;77-A:555-563.
  • 9-Iannotti JP, Williams GR, Total shoulder arthroplasty. FACTORS INFLUENCING PROSTHETIC DESIGN. Orthop Clin Nort America 1998; 29:337-391.
  • 10-Jobe CM, Iannotti JP. Limits imposed on glenohumeral motion by joint geometry. J Shoulder and Elbow Surg 1995; 4:281-285.
  • 11-Pearl ML, Volk AG. Coronal plane geometryof the proximal humerus relevant to prosthetic arthroplasty. J Shoulder and Elbow Surg 1996; 5:320-326.
  • 12- Pearl ML, Volk AG. Retroversion of the proximal humerus in relationship prosthetic replacement arthroplasty. J Shoulder and Elbow Surg 1995; 4:286-289.
  • 13- Rietveld AB, Daanen HA, Rozing PM, Obermann WR. The lever arm in glenohumeral abduction after hemiarthroplasty. J Bone and Joint Surg 1988;70-B(4):561-565.
  • 14- Roberts SN, Foley AP, Swallow HM, Wallace WA, Coughlan DP. The geometry of the humeral head and the design prostheses. J Bone and Joint Surg 1991;73-B(4):647-650.
  • 15- Soslowsky LJ, Flatow EL, Bigliani LU, Mow VC. Articular geometry of the glenohumeral joint. Clin Orthop 1992; 285:181-190.
  • 16- Nyffeler RW, Jost B, Pfirrmann CWA, Gerber C. Measurement of glenoid version: Conventional radiographs versus computed tomography scans. J Soulder Elnow Surg 2003;12(5):493-496.
  • 17- Churchill RS, Brems JJ, Kotschi H. Glenoid size, inclination, and version: an anatomic study. J Shoulder Elbow Surg 2001; 10:327-32.
  • 18- Fiedman RJ, Hawthome KB, Genez BM. The use of computerized tomography in the measurement of glenoid version. J Bone Joint Surg Am 1992; 74:1032-7.
  • 19- Gerber C, Terrier F, Zehnder R, Ganz R. The subcoracoid space. An anatomic study. Clin Orthop 1987; 215:132-8.
  • 20- Randelli M, Gambrioli PL. Glenohumeral osteometry by computed tomography in normal and unstable shoulders. Clin Orthop 1986; 208:151-6.
  • 21- Brewer BJ, Wubben RC, Carrera GF. Excessive retroversion of the glenoid cavity. A cause of non-traumatic posterior instability of the shoulder. J Bone Joint Surg Am 1986; 68:724-31.
  • 22- Weishaupt D, Zanetti M, Nyffeler RW, Gerber C, Hadler J. Posterior glenoid rim deficiency in recurrent (atraumatic) posterior shoulder instability. Skeletal Radial 2000; 29:204-10.
  • 23- Mullaji AB, Beddow FH, Lamb CH. CT measurement of glenoid erosion in arthritis. J Bone Joint Surg Br 1994; 76:384-8.
  • 24- Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenod in primary glenohumeral osteoarthritis. J Arthroplasty 1999; 14:756-60.
  • 25- Nyffeler RW, Sheikh R, Jacob HAC, Gerber C. The relevance of orientation of the glenoid component in total shoulder arthroplasty. An experimental investigation. Paper presented at the International Congress on shoulder surgery; Cape Town, South Africa; April 23-26,2001.
  • 26- Moska MJ, Duckworth D, Matsen FA. Contrasting the position of prosthetic joint surfaces in successful and failed shoulder arthroplasties. Paper presented at the International Congress on shoulder surgery; Cape Town, South Africa; April 23-26,2001.
  • 27- Mc Pherson EJ, Friedman RJ, An YH, Chokesi R, Docley RL, Charleston and Clemson SC. Anthropometric study of normal glenohumeral relationships. J Shoulder Elbow Surg 1997;6(2):105-112.
  • 28- Krueger FJ. A vitallium replica arthroplasty on the shoulder; a case report of aseptic necrosis of the proximal end of the humerus. Surgery 1951; 30:1004-11.
  • 29- Neer CS, Brown THJr, Mc Loughlın HL. Fracture of the neck of the humerus with dislocation of the head fragment. Am J Surg 1953; 85:252-8.
  • 30- Gruen TAW, Sew Hoy A, Hırschowitz D, Makı S, Arnstuz HC. Problems in glenohumeral surface replacements-real or imagined. Engin Med 1979; 8:161-75.
  • 31- Fenlin JM. Total glenohumeral joint replacement. Orthop Clin North Am 1975; 6:565-83.
  • 32- Neer CS. Articular replacement for the humeral head. J Bone Joint Surg Am 1955; 37A:215-28.
  • 33- Neer CS, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982; 64A:319-37.
  • 34- Howell SM, Galinot BJ, Renzı AJ, Masone PS. Normal and abnormal mechanics of the glenohumeral joint in the horizontal plane. J Bone Joint Surg Am 1988; 70A:227-32.
  • 35- Howell SM, Imobersteg AM, Seger DH, Marone PJ. Clarification of the role of the supraspinatus muscle in shoulder function. J Bone Joint Surg Am 1986; 68A:398-404.
  • 36- Inman VT, Saunders JB, De DM, Abbott LC. Observations of the function of the shoulder joint. J Bone Joint Surg Am 1944; 26A:1-30.
  • 37- Pearl MF, Perry J, Torburn L, Gordon LH. An electromyographic analysis of the shoulder during cones and planes of arm motion. Clin Orthop 1992; 284:116-299.
  • 38- Poppen NK, Walker PS. Forces at the glenohumeral joint in abduction. Clin Orthop 1978; 135:165-170.
  • 39- Poppen NK, Walker PS. Normal and abnormal motion of the shoulder. J Bone Joint Surg Am 1976;58A:195-200.
  • 40- Saha AK. Dynamic stability of the glenohumeral joint. Acta Orthop Scand 1971; 42:491-505.
  • 41- Harris WH. The first 32 years of total hip artroplasty, one surgeon’s perspective. Clin Orthop 1992; 274:6-11.
  • 42- Müller ME. Lessons of 30 years of total hip arthroplasty. Clin Orthop 1992; 274:12-21.
  • 43- Friedman RJ, Hawthorne KB, Genez BM. The use of computerized tomography in the measurement of glenoid version. J Bone Joint Surg Am 1992;74A:1032-41.
  • 44- Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. Normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am 1992;74A:491-500.
  • 45- Maki S, Gruen TA. Anthropometric studies of the glenohumeral joint. Trans Orthop Res Soc 1976; 1:162.
  • 46- Soslowsky LS, Flatow EF, Bigliani LU, Mour VC. Articular geometry of the glenohumeral joint. Clin Orthop 1992; 285:181-90.
  • 47- Bargognini TS, Masali M. Antropologiae antropometria. Torino, Unione Tipografico Editor iale Torinese,1987.p.160-3.
  • 48- Marro G. L’esplorazione della necropoli de gebelein. atti Soc Italiana peril Progresso delle Scienze, Pavia,1929.
  • 49- De Wilde LF, Berghs BM, Audenaert E, Sys G, Van Maele GO, Barbaix E. About the variability of the shape of the glenoid cavity. Surg Radiol Anat 2004; 26:54-59.
  • 50- Churchill RS, Brems JJ, Kotschi H. Glenoid size, inclination, and version: an anatomic study. J Shoulder Elbow Surg 2001; 10:327-332.
  • 51- Gallino M, Santamaria E, Doro T. Anthropometry of the scapula: clinical and surgical considerations. J Shoulder Elbow Surg 1998; 7:284-291.
  • 52- Howell SM. The glenoid labral socket. Clin Orthop 1989; 243:122-125.
  • 53- Huber C. The shape and size of the glenoid cavity. Anat Anz 1991; 172:137-142.
  • 54- Mallon WJ, Brown HR, Vogler JB, Martinez S. Radiographic and geometric anatomy of the scapula. Clin Orthop 1992; 277:142-154.
  • 55- Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg (Am) 82A:35-46.
  • 56- Burkhart SS, De Beer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002; 18:488-491.
  • 57- Von Schroeder HP, Kuiper SD, Botte MJ. Osseous anatomy of the scapula. Clin Orthop 2001 Feb; (383):131-9.
  • 58- Prescher A, Klümpen T. Does the area of the glenoid cavity of the scapula show sexual dimorphism? J Anat 1995; 186:223-6.
  • 59- Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders.
  • 60- Mallon WJ, Brown HR, Vogler JB, et al. Radiographic and geometric anatomy of the scapula. Clin Orthop 1992; 277:142-54.
Year 2023, , 184 - 191, 30.06.2023
https://doi.org/10.53446/actamednicomedia.1170631

Abstract

References

  • 1-Iannottij, Gabriel JP, Schneck S L, Evans B G, Misra S. The normal glenohumeral relationships. The journal of Bone and Joint Surgery 1992;74A(4):491-500.
  • 2-Neer CS, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone and Joint Surgery 1982;64-A:319-337.
  • 3-Robertson DD, Yuan JIE, Bigliani LU, Flantow EL, Yamaguchi K. Three-dimensional analysis of the proximalpart of the humerus: relavance to artroplasty. The journal of Bone and Joint Surgery 2000;82-A(11)1594-1602.
  • 4-Ballmer FT, Sidles JA, Lippitt SB, Matsen FA. Humeral prostheticarthoplasty: surgically relevant eon siderations. J. Shoulder and elbow Surg.1993;2:2996-304.
  • 5-Bigliani LU, Kelkar R, Flatow EL, Pollock RG, Mow VC. Glenohumeral stability. Biomechanical properties of passive and active stabilizers. Clin. Orthop. 1996; 330:13-30.
  • 6-Boileau P, Walch G. The three-dimenjional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone and Joint Surg 1997;79-B(5):857-865.
  • 7-Friedman RJ. Biomechanics of the shoulder following total shoulder replacement. In Surgery of the Shoulder. Edited by M. Post, B.F. Morrey, and R.J. Hawkins. St. Louis, Mosby-Year Book, 1990.pp:263-266.
  • 8-Harryman DT, Sidles JA, Harris SL, Lippitt SB, Matsen FA. The effect of articular conformity and the size of the humeral head component on laxity and motion after glenohumeral arthroplasty. A study in cadavera J Bone and Joint Surg 1995;77-A:555-563.
  • 9-Iannotti JP, Williams GR, Total shoulder arthroplasty. FACTORS INFLUENCING PROSTHETIC DESIGN. Orthop Clin Nort America 1998; 29:337-391.
  • 10-Jobe CM, Iannotti JP. Limits imposed on glenohumeral motion by joint geometry. J Shoulder and Elbow Surg 1995; 4:281-285.
  • 11-Pearl ML, Volk AG. Coronal plane geometryof the proximal humerus relevant to prosthetic arthroplasty. J Shoulder and Elbow Surg 1996; 5:320-326.
  • 12- Pearl ML, Volk AG. Retroversion of the proximal humerus in relationship prosthetic replacement arthroplasty. J Shoulder and Elbow Surg 1995; 4:286-289.
  • 13- Rietveld AB, Daanen HA, Rozing PM, Obermann WR. The lever arm in glenohumeral abduction after hemiarthroplasty. J Bone and Joint Surg 1988;70-B(4):561-565.
  • 14- Roberts SN, Foley AP, Swallow HM, Wallace WA, Coughlan DP. The geometry of the humeral head and the design prostheses. J Bone and Joint Surg 1991;73-B(4):647-650.
  • 15- Soslowsky LJ, Flatow EL, Bigliani LU, Mow VC. Articular geometry of the glenohumeral joint. Clin Orthop 1992; 285:181-190.
  • 16- Nyffeler RW, Jost B, Pfirrmann CWA, Gerber C. Measurement of glenoid version: Conventional radiographs versus computed tomography scans. J Soulder Elnow Surg 2003;12(5):493-496.
  • 17- Churchill RS, Brems JJ, Kotschi H. Glenoid size, inclination, and version: an anatomic study. J Shoulder Elbow Surg 2001; 10:327-32.
  • 18- Fiedman RJ, Hawthome KB, Genez BM. The use of computerized tomography in the measurement of glenoid version. J Bone Joint Surg Am 1992; 74:1032-7.
  • 19- Gerber C, Terrier F, Zehnder R, Ganz R. The subcoracoid space. An anatomic study. Clin Orthop 1987; 215:132-8.
  • 20- Randelli M, Gambrioli PL. Glenohumeral osteometry by computed tomography in normal and unstable shoulders. Clin Orthop 1986; 208:151-6.
  • 21- Brewer BJ, Wubben RC, Carrera GF. Excessive retroversion of the glenoid cavity. A cause of non-traumatic posterior instability of the shoulder. J Bone Joint Surg Am 1986; 68:724-31.
  • 22- Weishaupt D, Zanetti M, Nyffeler RW, Gerber C, Hadler J. Posterior glenoid rim deficiency in recurrent (atraumatic) posterior shoulder instability. Skeletal Radial 2000; 29:204-10.
  • 23- Mullaji AB, Beddow FH, Lamb CH. CT measurement of glenoid erosion in arthritis. J Bone Joint Surg Br 1994; 76:384-8.
  • 24- Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenod in primary glenohumeral osteoarthritis. J Arthroplasty 1999; 14:756-60.
  • 25- Nyffeler RW, Sheikh R, Jacob HAC, Gerber C. The relevance of orientation of the glenoid component in total shoulder arthroplasty. An experimental investigation. Paper presented at the International Congress on shoulder surgery; Cape Town, South Africa; April 23-26,2001.
  • 26- Moska MJ, Duckworth D, Matsen FA. Contrasting the position of prosthetic joint surfaces in successful and failed shoulder arthroplasties. Paper presented at the International Congress on shoulder surgery; Cape Town, South Africa; April 23-26,2001.
  • 27- Mc Pherson EJ, Friedman RJ, An YH, Chokesi R, Docley RL, Charleston and Clemson SC. Anthropometric study of normal glenohumeral relationships. J Shoulder Elbow Surg 1997;6(2):105-112.
  • 28- Krueger FJ. A vitallium replica arthroplasty on the shoulder; a case report of aseptic necrosis of the proximal end of the humerus. Surgery 1951; 30:1004-11.
  • 29- Neer CS, Brown THJr, Mc Loughlın HL. Fracture of the neck of the humerus with dislocation of the head fragment. Am J Surg 1953; 85:252-8.
  • 30- Gruen TAW, Sew Hoy A, Hırschowitz D, Makı S, Arnstuz HC. Problems in glenohumeral surface replacements-real or imagined. Engin Med 1979; 8:161-75.
  • 31- Fenlin JM. Total glenohumeral joint replacement. Orthop Clin North Am 1975; 6:565-83.
  • 32- Neer CS. Articular replacement for the humeral head. J Bone Joint Surg Am 1955; 37A:215-28.
  • 33- Neer CS, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982; 64A:319-37.
  • 34- Howell SM, Galinot BJ, Renzı AJ, Masone PS. Normal and abnormal mechanics of the glenohumeral joint in the horizontal plane. J Bone Joint Surg Am 1988; 70A:227-32.
  • 35- Howell SM, Imobersteg AM, Seger DH, Marone PJ. Clarification of the role of the supraspinatus muscle in shoulder function. J Bone Joint Surg Am 1986; 68A:398-404.
  • 36- Inman VT, Saunders JB, De DM, Abbott LC. Observations of the function of the shoulder joint. J Bone Joint Surg Am 1944; 26A:1-30.
  • 37- Pearl MF, Perry J, Torburn L, Gordon LH. An electromyographic analysis of the shoulder during cones and planes of arm motion. Clin Orthop 1992; 284:116-299.
  • 38- Poppen NK, Walker PS. Forces at the glenohumeral joint in abduction. Clin Orthop 1978; 135:165-170.
  • 39- Poppen NK, Walker PS. Normal and abnormal motion of the shoulder. J Bone Joint Surg Am 1976;58A:195-200.
  • 40- Saha AK. Dynamic stability of the glenohumeral joint. Acta Orthop Scand 1971; 42:491-505.
  • 41- Harris WH. The first 32 years of total hip artroplasty, one surgeon’s perspective. Clin Orthop 1992; 274:6-11.
  • 42- Müller ME. Lessons of 30 years of total hip arthroplasty. Clin Orthop 1992; 274:12-21.
  • 43- Friedman RJ, Hawthorne KB, Genez BM. The use of computerized tomography in the measurement of glenoid version. J Bone Joint Surg Am 1992;74A:1032-41.
  • 44- Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. Normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am 1992;74A:491-500.
  • 45- Maki S, Gruen TA. Anthropometric studies of the glenohumeral joint. Trans Orthop Res Soc 1976; 1:162.
  • 46- Soslowsky LS, Flatow EF, Bigliani LU, Mour VC. Articular geometry of the glenohumeral joint. Clin Orthop 1992; 285:181-90.
  • 47- Bargognini TS, Masali M. Antropologiae antropometria. Torino, Unione Tipografico Editor iale Torinese,1987.p.160-3.
  • 48- Marro G. L’esplorazione della necropoli de gebelein. atti Soc Italiana peril Progresso delle Scienze, Pavia,1929.
  • 49- De Wilde LF, Berghs BM, Audenaert E, Sys G, Van Maele GO, Barbaix E. About the variability of the shape of the glenoid cavity. Surg Radiol Anat 2004; 26:54-59.
  • 50- Churchill RS, Brems JJ, Kotschi H. Glenoid size, inclination, and version: an anatomic study. J Shoulder Elbow Surg 2001; 10:327-332.
  • 51- Gallino M, Santamaria E, Doro T. Anthropometry of the scapula: clinical and surgical considerations. J Shoulder Elbow Surg 1998; 7:284-291.
  • 52- Howell SM. The glenoid labral socket. Clin Orthop 1989; 243:122-125.
  • 53- Huber C. The shape and size of the glenoid cavity. Anat Anz 1991; 172:137-142.
  • 54- Mallon WJ, Brown HR, Vogler JB, Martinez S. Radiographic and geometric anatomy of the scapula. Clin Orthop 1992; 277:142-154.
  • 55- Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg (Am) 82A:35-46.
  • 56- Burkhart SS, De Beer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002; 18:488-491.
  • 57- Von Schroeder HP, Kuiper SD, Botte MJ. Osseous anatomy of the scapula. Clin Orthop 2001 Feb; (383):131-9.
  • 58- Prescher A, Klümpen T. Does the area of the glenoid cavity of the scapula show sexual dimorphism? J Anat 1995; 186:223-6.
  • 59- Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders.
  • 60- Mallon WJ, Brown HR, Vogler JB, et al. Radiographic and geometric anatomy of the scapula. Clin Orthop 1992; 277:142-54.
There are 60 citations in total.

Details

Primary Language Turkish
Subjects Anatomy
Journal Section Research Articles
Authors

Işık Tuncer 0000-0003-4592-3071

Ahmet Baytok 0000-0002-5826-7694

Mehmet Sedat Durmaz 0000-0002-1340-2477

Publication Date June 30, 2023
Submission Date September 3, 2022
Acceptance Date June 14, 2023
Published in Issue Year 2023

Cite

AMA Tuncer I, Baytok A, Durmaz MS. Proksimal Humerus ve Cavitas Glenoidealis’in Antropometrik Çalışması: Normal Glenohumeral İlişkiler. Acta Med Nicomedia. June 2023;6(2):184-191. doi:10.53446/actamednicomedia.1170631

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