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Liu Y, Liu J, Wu X, Jiang E. Risk Factors for Central Nervous System Infections After Craniotomy. J Multidiscip Healthc 2024; 17:3637-3648. [PMID: 39100899 PMCID: PMC11296514 DOI: 10.2147/jmdh.s476125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/14/2024] [Indexed: 08/06/2024] Open
Abstract
The central nervous system (CNS) is less prone to infection owing to protection from the brain-blood barrier. However, craniotomy destroys this protection and increases the risk of infection in the brain of patients who have undergone craniotomy. CNS infection after craniotomy significantly increases the patient's mortality rate and disability. Controlling the occurrence of intracranial infection is very important for post-craniotomy patients. CNS infection after craniotomy is caused by several factors such as preoperative, intraoperative, and post-operative factors. Craniotomy may lead to postsurgical intracranial infection, which is mainly associated with surgery duration, infratentorial (posterior fossa) surgery, cerebrospinal fluid leakage, drainage tube placement, unregulated use of antibiotics, glucocorticoid use, age, diabetes, and other systemic infections. Understanding the risk factors of CNS infection after craniotomy can benefit reducing the incidence of intracranial infectious diseases. This will also provide the necessary guidance and evidence in clinical practice for planning to control intracranial infection in patients with craniotomy.
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Affiliation(s)
- Yufeng Liu
- Department of Cardiovascular Medicine, Luoyang Central Hospital affiliated to Zhengzhou University, Luoyang, Henan, 471000, People’s Republic of China
| | - Jie Liu
- Department of Cardiovascular Medicine, Luoyang Central Hospital affiliated to Zhengzhou University, Luoyang, Henan, 471000, People’s Republic of China
| | - Xiaoyan Wu
- Department of Cardiovascular Medicine, Luoyang Central Hospital affiliated to Zhengzhou University, Luoyang, Henan, 471000, People’s Republic of China
| | - Enshe Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Henan University, Kaifeng, Henan, 475004, People’s Republic of China
- Institute of Nursing and Health, Henan University, Kaifeng, Henan, 475004, People’s Republic of China
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Lewis DC, Athoff AD, Kamalapathy P, Yarboro SR, Miller MD, Werner BC. Risk Factors for Infection and Revision Surgery following Patellar Tendon and Quadriceps Tendon Repairs: An Analysis of 3,442 Patients. J Knee Surg 2022; 35:1495-1502. [PMID: 33853152 DOI: 10.1055/s-0041-1727113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Disruption of the extensor mechanism is debilitating with surgical repair being the accepted treatment. The incidence of infection and reoperation after extensor mechanism repair are not well reported in the literature. Thus, the objective of the current study was to (1) determine the incidence of surgical site infection and reoperation within 1 year of primary extensor mechanism repair and (2) identify independent risk factors for infection and reoperation following patellar and quadriceps tendon repair. A retrospective review of the 100% Medicare Standard Analytic files from 2005 to 2014 was performed to identify patients undergoing isolated patellar tendon repair and quadriceps tendon repair. Diagnosis of infection within 1 year of operative intervention and revision repair were assessed. Extensor mechanism injuries in the setting of total knee arthroplasty and polytrauma were excluded. Multivariate logistic regression analysis was performed to evaluate risk factors for postoperative infection and reoperation within 1 year. Infection occurred in 6.3% of patients undergoing patellar tendon repair and 2.6% of patients undergoing quadriceps tendon repair. Diabetes mellitus (odds ratio [OR] = 1.89, p = 0.005) was found to be an independent risk factor for infection following patellar tendon repair. Reoperation within 1 year occurred in 1.3 and 3.9% following patellar tendon and quadriceps tendon repair, respectively. Age less than 65 years (OR = 2.77, p = 0.024) and obesity (OR = 3.66, p = 0.046) were significant risk factors for reoperation after patellar tendon repair. Hypertension (OR = 2.13, p = 0.034), hypothyroidism (OR = 2.01, p = 0.010), and depression (OR = 2.41, p = 0.005) were significant risk factors for reoperation after quadriceps tendon repair. Diabetes mellitus was identified as a risk factor for infection after patellar tendon repair. Age less than 65 years, peripheral vascular disease, and congestive heart failure were risk factors for infection after quadriceps tendon repair. The current findings can be utilized to counsel patients regarding preoperative risk factors for postoperative complications prior to surgical intervention for extensor mechanism injuries.
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Affiliation(s)
- Daniel C Lewis
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Alyssa D Athoff
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
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Moats C, Cook K, Armantrout K, Crank H, Uttke S, Maher K, Bochart RM, Lawrence G, Axthelm MK, Smedley JV. Antimicrobial prophylaxis does not improve post-surgical outcomes in SIV/SHIV-uninfected or SIV/SHIV-infected macaques (Macaca mulatta and Macaca fascicularis) based on a retrospective analysis. PLoS One 2022; 17:e0266616. [PMID: 35442982 PMCID: PMC9020680 DOI: 10.1371/journal.pone.0266616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 03/23/2022] [Indexed: 12/11/2022] Open
Abstract
Surgical antimicrobial prophylaxis is indicated when performing contaminated surgeries, when specific surgical implants are placed, and for prolonged surgical procedures. Unnecessary prophylactic antibiotics are often utilized for macaque surgeries, despite medical and veterinary guidelines. In this study we compared complication rates in macaques receiving peripheral lymph node (PLN) and laparoscopic biopsies, with and without antimicrobial prophylaxis. A majority of animals were SIV or SHIV infected at the time of surgery, so we also compared post-operative complication rates based on infection status. We found no significant difference in PLN biopsy complication rates for animals that received antimicrobial prophylaxis versus those that did not. Animals who underwent laparoscopic procedures and received prophylactic antibiotics had a higher complication rate than those who did not receive them. Complication rates did not differ significantly for SIV/SHIV infected versus uninfected animals for both laparoscopic biopsy procedures and PLN biopsy procedures. SIV/SHIV infected animals that underwent PLN biopsies had no significant difference in complication rates with and without antimicrobial prophylaxis, and SIV/SHIV infected animals receiving prophylactic antibiotics for laparoscopic biopsies had a higher complication rate than those that did not. This study suggests that perioperative prophylactic antibiotics have no role in the management of SIV/SHIV-infected and uninfected macaques undergoing clean, minimally invasive surgeries. Additionally, we recommend eliminating unnecessary antibiotic use in study animals due to their potential confounding impacts on research models and their potential to promote antimicrobial resistance.
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Affiliation(s)
- Cassandra Moats
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
- Department of Molecular and Comparative Pathobiology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Kimberly Cook
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Kimberly Armantrout
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Hugh Crank
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Samantha Uttke
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Kelly Maher
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Rachele M. Bochart
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - George Lawrence
- Director’s Office, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Michael K. Axthelm
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Jeremy V. Smedley
- Infectious Disease Resource, Oregon National Primate Research Center, Beaverton, Oregon, United States of America
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Shukla A, Srivastava S, Srivastava A, Srivastava T. Surveillance of Microbiological Environment of Operation Theaters. Cureus 2021; 13:e20525. [PMID: 35070559 PMCID: PMC8765562 DOI: 10.7759/cureus.20525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 11/12/2022] Open
Abstract
Introduction Control of infections in the operation theater (OT) is of utmost importance. Microbiological surveillance is an effective tool for identifying and controlling infections. The purpose of this study was to investigate the prevalence rate of microorganisms in OTs, to identify the type of microorganisms, and to detect contamination of various surfaces and air of OT. Methods OTs were properly cleaned with soap and water. All surfaces were disinfected, followed by fumigation with quaternary ammonium compounds. OTs were kept closed overnight. In the morning, they were opened, and samples were collected, taking all aseptic precautions. The settle plate method was used for air sampling, and the swab method was used for surface sampling. Samples were collected from four surfaces of OTs, i.e., floor, wall, table, and light, and samples of the OT air were also collected and immediately transported to the microbiology laboratory of the institution in sterile conditions. Result A total of 1640 swab samples were taken from eight OTs, out of which 487 (29.7%) were found positive for bacterial growth. Most of them were non-pathological microorganisms such as aerobic spore-forming Bacilli and Micrococcus. Among various OTs, septic OT showed the highest bacterial growth (82 positive cultures out of 200). In the surface sampling of various OTs, aerobic spore-forming Bacilli (221/487) was the most common isolate, followed by coagulase-negative Staphylococci (74/487), and Micrococcus (67/487). General surgery, septic, and emergency OTs had maximum air bioload (97, 93, and 91 colony-forming unit (CFU)/M3, respectively). Conclusion In surface sampling of OTs, it was found that septic OT and general surgery OT were most contaminated where the patient load was high. Among all the surfaces, OT walls and tables were most contaminated with pathogenic microorganisms. The average air bioload of all OTs was ranged between 79 and 97 CFU/M3.
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Althoff AD, Reeves RA, Traven SA, Slone HS, Deal DN, Werner BC. Risk Factors for Infection Following Total Wrist Arthroplasty and Arthrodesis: An Analysis of 6641 Patients. Hand (N Y) 2021; 16:657-663. [PMID: 31808356 PMCID: PMC8461204 DOI: 10.1177/1558944719890036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Infection following wrist arthroplasty (WA) or wrist fusion (WF) is an uncommon but difficult complication often resulting in explantation and prolonged courses of antibiotics. The purposes of this study are to: (1) characterize the demographic trends of individuals undergoing WA and WF; (2) determine the incidence of postoperative infection; and (3) identify risk factors for postoperative infection. Methods: The PearlDiver database was used to query 100% Medicare Standard Analytic files from 2005 to 2014. Patients undergoing WA or radiocarpal WF were identified using Current Procedural Terminology (CPT) codes. Diagnosis for infection within 1 year of operative intervention was assessed by International Classification of Diseases, Ninth Revision codes or CPT codes related to infection. Multivariable logistic regression analyses were performed to evaluate the risk factors for postoperative infection. Results: Of the 6641 patients included, 1137 (17.1%) underwent arthroplasty and 5504 (82.9%) underwent arthrodesis. Within 1 year of the index procedure, 3.5% had a diagnosis of, or procedure for, postoperative infection (WA: n = 40 of 1137; WF: n = 192 of 5504). Risk factors for infection following WA include age >85, tobacco use, depression, diabetes mellitus, and chronic kidney disease. Risk factors following radiocarpal WF include male sex, age >85, body mass index <19 kg/m2, depression, diabetes mellitus, and chronic kidney disease. Posttraumatic origin of wrist arthritis was a risk factor for infection following both WA and WF. Conclusions: Infection following WA and WF is relatively uncommon in a nationally representative Medicare database cohort. Risk factors common to both WA and WF include age >85, depression, diabetes mellitus, chronic kidney disease, and posttraumatic arthritis.
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Affiliation(s)
| | | | | | | | | | - Brian C. Werner
- University of Virginia, Charlottesville, USA,Brian C. Werner, Department of Orthopaedic Surgery, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908-0816, USA.
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De Rooij L, van Kuijk SMJ, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Negative pressure wound therapy does not decrease postoperative wound complications in patients undergoing mastectomy and flap fixation. Sci Rep 2021; 11:9620. [PMID: 33953312 PMCID: PMC8100146 DOI: 10.1038/s41598-021-89036-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/19/2021] [Indexed: 11/10/2022] Open
Abstract
Patients and breast cancer surgeons are frequently confronted with wound complications after mastectomy. Negative pressure wound therapy (NPWT) is a promising technique for preventing wound complications after skin closure in elective surgery. However, a clinical study evaluating postoperative complications following the use of NPWT, focusing solely on closed incisions in patients undergoing mastectomy, has yet to be performed. Between June 2019 and February 2020, 50 consecutive patients underwent mastectomy with NPWT during the first seven postoperative days. This group was compared to a cohort of patients taking part in a randomized controlled trial between June 2014 and July 2018. Primary outcome was the rate of postoperative wound complications, i.e. surgical site infections, wound necrosis or wound dehiscence during the first three postoperative months. Secondary outcomes were the number of patients requiring unplanned visits to the hospital and developing clinically significant seroma (CSS). In total, 161 patients were analyzed, of whom 111 patients in the control group (CON) and 50 patients in the NPWT group (NPWT). Twenty-eight percent of the patients in the NPWT group developed postoperative wound complications, compared to 18.9% in the control group (OR = 1.67 (95% CI 0.77–3.63), p = 0.199). The number of patients requiring unplanned visits or developing CSS was not statistically significant between the groups. This study suggests that Avelle negative pressure wound therapy in mastectomy wounds does not lead to fewer postoperative wound complications. Additionally, it does not lead to fewer patients requiring unplanned visits or fewer patients developing clinically significant seromas. Trial registration: ClinicalTrials.gov number, NCT03942575. Date of registration: 08/05/2019.
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Affiliation(s)
- L De Rooij
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130 MB, Sittard, The Netherlands.
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - E R M van Haaren
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130 MB, Sittard, The Netherlands
| | - A Janssen
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130 MB, Sittard, The Netherlands
| | - Y L J Vissers
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130 MB, Sittard, The Netherlands
| | - G L Beets
- Department of Surgery, Antoni Van Leeuwenhoek Hospital, Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - J van Bastelaar
- Department of Surgery, Zuyderland Medical Center, Postbus 5500, 6130 MB, Sittard, The Netherlands
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Gorvetzian JW, Epler KE, Schrader S, Romero JM, Schrader R, Greenbaum A, McKee R. Operating room staff and surgeon documentation curriculum improves wound classification accuracy. Heliyon 2018; 4:e00728. [PMID: 30109278 PMCID: PMC6088459 DOI: 10.1016/j.heliyon.2018.e00728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 06/08/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Misclassification of wounds in the operating room (OR) can adversely affect surgical site infection (SSI) reporting and reimbursement. This study aimed to measure the effects of a curriculum on documentation of surgical wound classification (SWC) for operating room staff and surgeons. METHODS Accuracy of SWC was determined by comparing SWC documented by OR staff during the original operation to SWC determined by in-depth chart review. Patients 18 years or older undergoing inpatient surgical procedures were included. Two plan-do-act-study (PDSA) cycles were implemented over the course of 9 months. A total of 747 charts were reviewed. Accuracy of SWC documentation was retrospectively assessed across 248 randomly selected surgeries during a 5-week period prior to interventions and compared to 244 cases and 255 cases of post-intervention data from PDSA1 and PDSA2, respectively. Changes in SWC accuracy were assessed pre- and post-intervention using the kappa coefficient. A p-value for change in agreement was computed by comparing pre- and post-intervention kappa. RESULTS Inaccurate documentation of surgical wound class decreased significantly following curriculum implementation (kappa improved from 0.553 to 0.739 and 0.757; p = 0.001). Classification accuracy improved across all wound classes; however, class III and IV wounds were more frequently misclassified than class I and II wounds, both before and after the intervention. CONCLUSION Implementation of a multidisciplinary documentation curriculum resulted in a significant decrease in SWC documentation error. Improved accuracy of SWC reporting may facilitate a better assessment of SSI risk in a complex patient population.
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Affiliation(s)
| | | | - Samuel Schrader
- University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Joshua M. Romero
- University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | | | - Alissa Greenbaum
- University of New Mexico, Department of Surgery, Albuquerque, NM, USA
| | - Rohini McKee
- University of New Mexico, Department of Surgery, Albuquerque, NM, USA
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Controlled release drug delivery systems to improve post-operative pharmacotherapy. Drug Deliv Transl Res 2016; 6:441-51. [DOI: 10.1007/s13346-016-0305-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Ding S, Lin F, Gillespie B. Surgical wound assessment and documentation of nurses: an integrative review. J Wound Care 2016; 25:232-40. [DOI: 10.12968/jowc.2016.25.5.232] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S. Ding
- Gold Coast University Hospital
| | - F. Lin
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University
| | - B.M. Gillespie
- National Health and Medical Research Council NHMRC for Research Excellence in Nursing (NCREN), Menzies Health Institute Queensland, Griffith University
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Abstract
Complications following any form of distal radius fixation remain prevalent. With an armamentarium of fixation options available to practicing surgeons, familiarity with the risks of newer plate technology as it compares with other conventional methods is crucial to optimizing surgical outcome and managing patient expectations. This article presents an updated review on complications following various forms of distal radius fixation.
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Affiliation(s)
- Dennis S Lee
- Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, South Tower, Suite 4200, Nashville, TN 37232, USA.
| | - Douglas R Weikert
- Orthopaedic Surgery and Rehabilitation, Hand and Upper Extremity Center, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East, South Tower, Suite 3200, Nashville, TN 37232, USA
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Abstract
The human wrist joint is unique from functional and anatomic standpoints. Numerous articulations exist within the wrist that allow for many options for partial wrist fusion and arthroplasty. In cases of pancarpal disease, fusion or arthroplasty of the entire wrist joint can be performed. Because of the high functional demand of the wrist, many of these surgical options can fail, leading to devastating complications. This article addresses the types of fusions and arthroplasties available for the wrist and discusses the potential complications associated with each. Methods to prevent these complications are presented and those to treat them once they have occurred are discussed.
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Affiliation(s)
- Michael P Gaspar
- The Philadelphia Hand Center, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107, USA
| | - Patrick M Kane
- The Philadelphia Hand Center, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107, USA
| | - Eon K Shin
- The Philadelphia Hand Center, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107, USA; Department of Orthopedic Surgery, Thomas Jefferson University Hospital, 132 South 10th Street, Philadelphia, PA 19107, USA.
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Abstract
Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome. These complications are frequently encountered and are often challenging to treat. This article systematically outlines the diagnosis and treatment of each of these complications to achieve the best possible outcome for the patient's overall hand function.
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Affiliation(s)
- Varun K Gajendran
- Department of Orthopedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
| | - Vishal K Gajendran
- University of Toledo College of Medicine, 2801 West Bancroft Street, Toledo, OH 43606, USA
| | - Kevin J Malone
- Department of Orthopedic Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
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Tiemann AH, Hofmann GO. Wound irrigation within the surgical treatment of osteomyelitis. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc08. [PMID: 26504692 PMCID: PMC4582480 DOI: 10.3205/iprs000008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The basic treatment of osteomyelitis remains even today the surgical debridement in combination with a wound irrigation by lavage systems. Next to a comprehensive knowledge of the surgical techniques a profound knowledge of the lavage systems, the rinsing solutions used and the philosophies of revision programs are a must. In this article the typical hardware of modern lavage systems is analysed, their advantages and disadvantages are pointed out. In addition we investigate the value of common antiseptic wound irrigation solutions for their use in osteomyelitis therapy. Finally the two basic philosophies of wound revision and irrigation in the course of osteomyelitis therapy are presented and discussed.
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Affiliation(s)
- A H Tiemann
- BG-Kliniken Bergmannstrost, Klinik für Unfall- und Wiederherstellungschirurgie, Abteilung für Septische und Rekonstruktive Chirurgie, Halle, Germany
| | - G O Hofmann
- BG-Kliniken Bergmannstrost, Klinik für Unfall- und Wiederherstellungschirurgie, Halle, Germany ; Friedrich-Schiller-Universität Jena, Kliniken für Unfall-, Hand- und Wiederherstellungschirurgie, Jena, Germany
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