Araştırma Makalesi
Kemik-patellar tendon-kemik otogrefti veya dörtlü semitendinöz otogreft kullanılarak artroskopik ön çapraz bağ rekonstrüksiyonu uygulanan olguların uzun dönem klinik ve radyolojik sonuçları ile donör saha morbiditilerinin karşılaştırılması
Öz
Amaç: Çok sayıda değişkenin arasından ön çapraz bağ kopuğu sonrası
kemik-patellar tendon-kemik otogrefti veya dörtlü semitendinöz otogreft
kullanılarak artroskopik ön çapraz bağ rekonstrüksiyonu uygulanan iki hasta
grubu ile, hastaların uzun dönem takibinde radyolojik, klinik sonuçlarını,
donör saha morbiditelerini değerlendirmek ve karşılaştırmak amaçlanmıştır.
Gereç ve
Yöntem: Bu çalışmada, Ege Üniversitesi Tıp Fakültesi
Ortopedi ve Travmatoloji polikliniğine Ocak 1994 ve Aralık 2002 tarikleri
arasında artroskopik ön çapraz bağ rekonstrüksiyonu ameliyatı olan 81 hasta
retrospektif olarak değerlendirildi. Hastalar kemik-patellar tendon-kemik (PT)
otogrefti veya dörtlü semitendinöz (ST) otogrefti kullanılanlar olarak iki
gruba ayrıldı. Ameliyat öncesi verilere hastane kayıtlarından ulaşıldı. Son
kontrolde klinik muayeneleri ile Cybex
ve KT-1000 ölçümleri yapıldı. Radyolojik inceleme ile tibial ve femoral tünel
yerleri, patellanın yüksekliği ve osteoartrit durumu değerlendirildi.
Bulgular: Post operatif diz önü ağrısı, patella baja, çıplak diz ve sert zeminde
yürümede ağrı, PT grubunda ST grubuna oranla yüksek bulundu. Diz önünde duyu
kusuru, PT grubunda yüksek bulundu. Radyolojik evre 2, kronik dönemde opere dilenlerde
subakut dönemde opere edilenlere göre ve menüsküs dikişi uygulananlarda eksize
edilenlere göre daha yüksek bulundu.
Sonuç: ST veya PT otogreftleri kullanılarak yapılan artroskopik
rekonstrüksiyonun klinik ve fonksiyonel açıdan karşılaştırılması sonucunda her
iki otogreft materyali ile yeterli fonksiyonel stabilite sağlamaktadır. Donor
saha morbiditesi ile uyumlu olarak diz önü sorunları PT grubunda daha fazla
olmaktadır.
Anahtar Kelimeler
Ön çapraz bağ artroskopi patellar tendon semitendinosus tendon.
Kaynakça
- Myrer JW, Schulthies SS, Fellingham GW. Relative and absolute reliability of the KT-2000 arthrometer for uninjured knees. Testing at 67, 89, 134, and 178 N and manual maximum forces. Am J Sports Med 1996;24(1):104-8.
- Mather RC 3rd, Koenig L, Kocher MS, et al. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am 2013;95(19):1751-9.
- Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg 2000;8(3):141-50.
- Saltzman BM, Cvetanovich GL, Nwachukwu BU, Mall NA, Bush-Joseph CA, Bach BR Jr. Economic analyses in anterior cruciate ligament reconstruction: A qualitative and systematic review. Am J Sports Med 2016;44(5):1329-35.
- Ma Y, Murawski CD, Rahnemai-Azar AA, Maldjian C, Lynch AD, Fu FH. Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: A magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 2015;23(3):661-8.
- Seon JK, Song EK, Park SJ. Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft. Int Orthop 2006;30(2):94-8.
- Breitfuss H, Fröhlich R, Povacz P, Resch H, Wicker A. The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendon--a problem for the patellofemoral joint? Knee Surg Sports Traumatol Arthrosc 1996;3(4):194-8.
- Stringham DR, Pelmas CJ, Burks RT, Newman AP, Marcus RL. Comparison of anterior cruciate ligament reconstructions using patellar tendon autograft or allograft. Arthroscopy 1996;12(4):414-21.
- Bartlett RJ, Clatworthy MG, Nguyen TN. Graft selection in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 2001;83(5):625-34.
- Fox JA, Nedeff DD, Bach BR Jr, Spindler KP. Anterior cruciate ligament reconstruction with patellar autograft tendon. Clin Orthop Relat Res 2002;402(1):53-63.
- Graham SM, Parker RD. Anterior cruciate ligament reconstruction using hamstring tendon grafts. Clin Orthop Relat Res 2002;402(1):64-75.
- Salata MJ, Gibbs AE, Sekiya JK. A systematic review of clinical outcomes in patients undergoing meniscectomy. Am J Sports Med 2010;38(9):1907-16.
- Church S, Keating JF. Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg Br 2005;87(12):1639-42.
- Goradia VK, Grana WA. A comparison of outcomes at 2 to 6 years after acute and chronic anterior cruciate ligament reconstructions using hamstring tendon grafts. Arthroscopy 2001;17(4):383-92.
- Kennedy J, Jackson MP, O'Kelly P, Moran R. Timing of reconstruction of the anterior cruciate ligament in athletes and the incidence of secondary pathology within the knee. J Bone Joint Surg Br 2010;92(3):362-6.
- Woo SL, Wu C, Dede O, Vercillo F, Noorani S. Biomechanics and anterior cruciate ligament reconstruction. J Orthop Surg Res 2006;25(1):1-2.
- George MS, Dunn WR, Spindler KP. Current concepts review: Revision anterior cruciate ligament reconstruction. Am J Sports Med 2006;34(12):2026-37.
- Goradia VK, Grana WA, Pearson SE. Factors associated with decreased muscle strength after anterior cruciate ligament reconstruction with hamstring tendon grafts. Arthroscopy 2006;22(1):80.
- Ejerhed L, Kartus J, Sernert N, Köhler K, Karlsson J. Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up. Am J Sports Med 2003;31(1):19-25.
- Jansson KA, Linko E, Sandelin J, Harilainen A. A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2003;31(1):12-8.
- Webster KE, Feller JA, Hartnett N, Leigh WB, Richmond AK. Comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction: A 15-year follow-up of a randomized controlled trial. Am J Sports Med 2016;44(1):83-90.
- Freedman KB, D'Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: A metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003;31(1):2-11.
- Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 2005;21(7):791-803.
- Beynnon BD, Johnson RJ, Fleming BC. The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res. 2002;(402):9-20.
- Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 1992;15(6):256-64.
- Svensson M, Sernert N, Ejerhed L, Karlsson J, Kartus JT. A prospective comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction in female patients. Knee Surg Sports Traumatol Arthrosc 2006;14(3):278-86.
- Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M. A 7-year follow-up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: Differences and similarities. Am J Sports Med 2005;33(9):1337-45.
- Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: Meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 2005;21(7):791-803.
- Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: A meta-analysis. Arthroscopy 2001;17(3):248-257.
- Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med 2003;31(4):564-73.
- Shaieb MD, Kan DM, Chang SK, Marumoto JM, Richardson AB. A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2002;30(2):214-20.
- Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F. Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial. J Bone Joint Surg Am 2004;86(10):2143-55.
- Matsumoto A, Yoshiya S, Muratsu H, et al. A comparison of bone-patellar tendon-bone and bone-hamstring tendon-bone autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2006;34(2):213-9.
- Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med 2007;35(4):564-74.
- Laxdal G, Sernert N, Ejerhed L, Karlsson J, Kartus JT. A prospective comparison of bone-patellar tendon-bone and hamstring tendon grafts for anterior cruciate ligament reconstruction in male patients. Knee Surg Sports Traumatol Arthrosc 2007;15(2):115-25.
- Tow BP, Chang PC, Mitra AK, Tay BK, Wong MC. Comparing 2-year outcomes of anterior cruciate ligament reconstruction using either patella-tendon or semitendinosus-tendon autografts: a non-randomised prospective study. J Orthop Surg (Hong Kong) 2005;13(2):139-46.
- Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, Renström P. Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84-A(9):1503-13.
- Bizzini M, Gorelick M, Munzinger U, Drobny T. Joint laxity and isokinetic thigh muscle strength characteristics after anterior cruciate ligament reconstruction: bone patellar tendon bone versus quadrupled hamstring autografts. Clin J Sport Med 2006;16(1):4-9.
- Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrosis. Sports Med 1999;27(3):143-56.
- Wang CJ, Huang TW, Jih S. Radiographic assessment of the knee after patellar tendon reconstruction for chronic anterior cruciate ligament deficiency. Chang Gung Med J 2004;27(2):85-90.
- Hantes ME, Zachos VC, Bargiotas KA, Basdekis GK, Karantanas AH, Malizos KN. Patellar tendon length after anterior cruciate ligament reconstruction: A comparative magnetic resonance imaging study between patellar and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 2007;15(6):712-9.
- Tria AJ Jr, Alicea JA, Cody RP. Patella baja in anterior cruciate ligament reconstruction of the knee. Clin Orthop Relat Res 1994;(299):229-34.
- Lin CF, Wu JJ, Chen TS, Huang TF. Comparison of the Insall-Salvati ratio of the patella in patients with and without an ACL tear. Knee Surg Sports Traumatol Arthrosc 2005;13(1):8-11.
- Pigozzi F, Di Salvo V, Parisi A, et al. Isokinetic evaluation of anterior cruciate ligament reconstruction: Quadriceps tendon versus patellar tendon. J Sports Med Phys Fitness 2004;44(3):288-93.
Comparison of long-term clinical, radiological and donor site morbidity results of the arthroscopic anterior cruciate ligament reconstruction by using bone-patellar tendon-bone autograft or four-semitendinosus autograft
Öz
Aim: We aimed to evaluate and compare among multiple variables the radiological,
clinical results and donor site morbidity of long-term follow-up of two groups
of patients who underwent arthroscopic anterior cruciate ligament
reconstruction by using bone-patellar tendon-bone autograft or four
semitendinosus autografts after anterior cruciate ligament injury.
Materials and Methods: Eighty-one patients who underwent arthroscopic
anterior cruciate ligament reconstruction surgery between January 1994 and
December 2002 in the Orthopedics and Traumatology Department of Ege University
Faculty of Medicine were retrospectively evaluated. Patients were divided into
two groups using bone-patellar tendon-bone (PT) or quadruple semitendinosus
(ST) autograft. Preoperative data were obtained from hospital records. At the
last visit, clinical examinations and Cybex and KT-1000 measurements were
performed. From the X-rays, tibial and femoral tunnel locations, patellar
height and osteoarthritis status were evaluated.
Results: Post operative knee pain, patella baja, neeling pain on hard ground were
found higher in PT group than ST group. Loss of sensation in front of knee was
found high in PT group. Radiologic grade 2 was found to be higher in patients
operated in chronic period and in patients whose meniscus was excited instead
of repair.
Conclusion: Clinical and functional comparisons of arthroscopic reconstruction with
ST or PT autografts provide adequate functional stability with both autograft
materials. Consistent with donor site morbidity, anterior knee problems are
more prevalent in the PT group.
Anahtar Kelimeler
Anterior cruciate ligament arthroscopy patellar tendon semitendinosus tendon.
Kaynakça
- Myrer JW, Schulthies SS, Fellingham GW. Relative and absolute reliability of the KT-2000 arthrometer for uninjured knees. Testing at 67, 89, 134, and 178 N and manual maximum forces. Am J Sports Med 1996;24(1):104-8.
- Mather RC 3rd, Koenig L, Kocher MS, et al. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am 2013;95(19):1751-9.
- Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg 2000;8(3):141-50.
- Saltzman BM, Cvetanovich GL, Nwachukwu BU, Mall NA, Bush-Joseph CA, Bach BR Jr. Economic analyses in anterior cruciate ligament reconstruction: A qualitative and systematic review. Am J Sports Med 2016;44(5):1329-35.
- Ma Y, Murawski CD, Rahnemai-Azar AA, Maldjian C, Lynch AD, Fu FH. Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: A magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 2015;23(3):661-8.
- Seon JK, Song EK, Park SJ. Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft. Int Orthop 2006;30(2):94-8.
- Breitfuss H, Fröhlich R, Povacz P, Resch H, Wicker A. The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendon--a problem for the patellofemoral joint? Knee Surg Sports Traumatol Arthrosc 1996;3(4):194-8.
- Stringham DR, Pelmas CJ, Burks RT, Newman AP, Marcus RL. Comparison of anterior cruciate ligament reconstructions using patellar tendon autograft or allograft. Arthroscopy 1996;12(4):414-21.
- Bartlett RJ, Clatworthy MG, Nguyen TN. Graft selection in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 2001;83(5):625-34.
- Fox JA, Nedeff DD, Bach BR Jr, Spindler KP. Anterior cruciate ligament reconstruction with patellar autograft tendon. Clin Orthop Relat Res 2002;402(1):53-63.
- Graham SM, Parker RD. Anterior cruciate ligament reconstruction using hamstring tendon grafts. Clin Orthop Relat Res 2002;402(1):64-75.
- Salata MJ, Gibbs AE, Sekiya JK. A systematic review of clinical outcomes in patients undergoing meniscectomy. Am J Sports Med 2010;38(9):1907-16.
- Church S, Keating JF. Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg Br 2005;87(12):1639-42.
- Goradia VK, Grana WA. A comparison of outcomes at 2 to 6 years after acute and chronic anterior cruciate ligament reconstructions using hamstring tendon grafts. Arthroscopy 2001;17(4):383-92.
- Kennedy J, Jackson MP, O'Kelly P, Moran R. Timing of reconstruction of the anterior cruciate ligament in athletes and the incidence of secondary pathology within the knee. J Bone Joint Surg Br 2010;92(3):362-6.
- Woo SL, Wu C, Dede O, Vercillo F, Noorani S. Biomechanics and anterior cruciate ligament reconstruction. J Orthop Surg Res 2006;25(1):1-2.
- George MS, Dunn WR, Spindler KP. Current concepts review: Revision anterior cruciate ligament reconstruction. Am J Sports Med 2006;34(12):2026-37.
- Goradia VK, Grana WA, Pearson SE. Factors associated with decreased muscle strength after anterior cruciate ligament reconstruction with hamstring tendon grafts. Arthroscopy 2006;22(1):80.
- Ejerhed L, Kartus J, Sernert N, Köhler K, Karlsson J. Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up. Am J Sports Med 2003;31(1):19-25.
- Jansson KA, Linko E, Sandelin J, Harilainen A. A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2003;31(1):12-8.
- Webster KE, Feller JA, Hartnett N, Leigh WB, Richmond AK. Comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction: A 15-year follow-up of a randomized controlled trial. Am J Sports Med 2016;44(1):83-90.
- Freedman KB, D'Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: A metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003;31(1):2-11.
- Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 2005;21(7):791-803.
- Beynnon BD, Johnson RJ, Fleming BC. The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res. 2002;(402):9-20.
- Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 1992;15(6):256-64.
- Svensson M, Sernert N, Ejerhed L, Karlsson J, Kartus JT. A prospective comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction in female patients. Knee Surg Sports Traumatol Arthrosc 2006;14(3):278-86.
- Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M. A 7-year follow-up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: Differences and similarities. Am J Sports Med 2005;33(9):1337-45.
- Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: Meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 2005;21(7):791-803.
- Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: A meta-analysis. Arthroscopy 2001;17(3):248-257.
- Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med 2003;31(4):564-73.
- Shaieb MD, Kan DM, Chang SK, Marumoto JM, Richardson AB. A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2002;30(2):214-20.
- Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F. Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial. J Bone Joint Surg Am 2004;86(10):2143-55.
- Matsumoto A, Yoshiya S, Muratsu H, et al. A comparison of bone-patellar tendon-bone and bone-hamstring tendon-bone autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2006;34(2):213-9.
- Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med 2007;35(4):564-74.
- Laxdal G, Sernert N, Ejerhed L, Karlsson J, Kartus JT. A prospective comparison of bone-patellar tendon-bone and hamstring tendon grafts for anterior cruciate ligament reconstruction in male patients. Knee Surg Sports Traumatol Arthrosc 2007;15(2):115-25.
- Tow BP, Chang PC, Mitra AK, Tay BK, Wong MC. Comparing 2-year outcomes of anterior cruciate ligament reconstruction using either patella-tendon or semitendinosus-tendon autografts: a non-randomised prospective study. J Orthop Surg (Hong Kong) 2005;13(2):139-46.
- Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, Renström P. Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84-A(9):1503-13.
- Bizzini M, Gorelick M, Munzinger U, Drobny T. Joint laxity and isokinetic thigh muscle strength characteristics after anterior cruciate ligament reconstruction: bone patellar tendon bone versus quadrupled hamstring autografts. Clin J Sport Med 2006;16(1):4-9.
- Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrosis. Sports Med 1999;27(3):143-56.
- Wang CJ, Huang TW, Jih S. Radiographic assessment of the knee after patellar tendon reconstruction for chronic anterior cruciate ligament deficiency. Chang Gung Med J 2004;27(2):85-90.
- Hantes ME, Zachos VC, Bargiotas KA, Basdekis GK, Karantanas AH, Malizos KN. Patellar tendon length after anterior cruciate ligament reconstruction: A comparative magnetic resonance imaging study between patellar and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 2007;15(6):712-9.
- Tria AJ Jr, Alicea JA, Cody RP. Patella baja in anterior cruciate ligament reconstruction of the knee. Clin Orthop Relat Res 1994;(299):229-34.
- Lin CF, Wu JJ, Chen TS, Huang TF. Comparison of the Insall-Salvati ratio of the patella in patients with and without an ACL tear. Knee Surg Sports Traumatol Arthrosc 2005;13(1):8-11.
- Pigozzi F, Di Salvo V, Parisi A, et al. Isokinetic evaluation of anterior cruciate ligament reconstruction: Quadriceps tendon versus patellar tendon. J Sports Med Phys Fitness 2004;44(3):288-93.
Toplam 44 adet kaynakça vardır.
Ayrıntılar
| Birincil Dil | Türkçe |
|---|---|
| Konular | Sağlık Kurumları Yönetimi |
| Bölüm | Araştırma Makaleleri |
| Yazarlar | |
| Yayımlanma Tarihi | 14 Mart 2019 |
| Gönderilme Tarihi | 14 Ağustos 2018 |
| Yayımlandığı Sayı | Yıl 2019Cilt: 58 Sayı: 1 |
