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Chen B, Ye Z, Wu J, Wang G, Yu T. The effect of early weight-bearing and later weight-bearing rehabilitation interventions on outcomes after ankle fracture surgery: A systematic review and meta-analysis of randomised controlled trials. J Foot Ankle Res 2024; 17:e12011. [PMID: 38635458 PMCID: PMC11080868 DOI: 10.1002/jfa2.12011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/29/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVE This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily include ankle function scores, time to return to work/daily life and complication rates. METHODS The China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal, Web of Science, PubMed, Embase and Cochrane Library databases were searched. The focus was on identifying randomised controlled trials centred on early weight-bearing interventions for post-operative ankle fracture rehabilitation. All databases were searched for eligible studies published within the period from database inception to 20 June 2023. The eligible studies were screened according to the inclusion criteria. Study quality was evaluated using the methodology recommended by the Cochrane Handbook for the Systematic Evaluation of Interventions. Two authors independently performed the literature search and data extraction. Eligible studies were subjected to meta-analyses using Review Manager 5.3. Based on the time points at which post-operative ankle function was reported in the studies included in this paper, we decided to perform a meta-analysis of ankle function scores at 6 weeks post-operatively, 12 weeks post-operatively, 24-26 weeks post-operatively and 1 year post-operatively. RESULTS A total of 11 papers, comprising 862 patients, were included. Meta-analysis indicated that patients receiving early weight-bearing interventions, which referred to weight-bearing for 6 weeks post-operatively, experienced enhancements in ankle function scores (Olerud-Molander score, AOFAS score or Baird-Jackson score) at various post-operative milestones: 6 weeks (SMD = 0.69, 95% CI: 0.49-0.88 and p < 0.01), 12 weeks (SMD = 0.57, 95% CI: 0.22-0.92 and p < 0.01) and the 24-26 weeks range (SMD = 0.52, 95% CI: 0.20-0.85 and p < 0.01). The results of subgroup analyses revealed that the effects of early weight-bearing interventions were influenced by ankle range-of-motion exercises. Additionally, early weight bearing allows patients to return to daily life and work earlier, which was evaluated by time when they resumed their preinjury activities (MD = -2.74, 95% CI: -3.46 to -2.02 and p < 0.01), with no distinct elevation in the incidence of complications (RR = 1.49, 95% CI: 0.85-2.61 and p > 0.05). CONCLUSION The results showed that early weight bearing is effective in improving ankle function among post-operative ankle fracture patients and allows patients to return to daily life earlier. Significantly, the safety profile of early weight bearing remains favourable, with no higher risk of complications than late weight bearing.
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Affiliation(s)
- Bocheng Chen
- Physical Education and Sports School of Soochow UniversitySoochow UniversitySuzhouJiangsu ProvinceChina
| | - Ziyan Ye
- Physical Education and Sports School of Soochow UniversitySoochow UniversitySuzhouJiangsu ProvinceChina
| | - Jiaxin Wu
- Physical Education and Sports School of Soochow UniversitySoochow UniversitySuzhouJiangsu ProvinceChina
| | - Guoxiang Wang
- Physical Education and Sports School of Soochow UniversitySoochow UniversitySuzhouJiangsu ProvinceChina
| | - Tiancheng Yu
- Physical Education and Sports School of Soochow UniversitySoochow UniversitySuzhouJiangsu ProvinceChina
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Verstappen C, Driessen MLS, Kalmet PHS, Hermans E, Edwards MJR, Poeze M. Are the non-weight bearing guidelines for the after treatment of calcaneal fractures still decisive? A Dutch survey among orthopaedic and trauma surgeons. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:209-216. [PMID: 37421449 PMCID: PMC10771614 DOI: 10.1007/s00590-023-03637-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE The current rehabilitation for patients with surgically treated displaced intra-articular calcaneal fractures (DIACFs) consists of non-weightbearing for 8-12 weeks. The purpose of the present survey was to investigate the current pre-, peri- and post-operative practices among Dutch foot and ankle surgeons. Moreover, it aims to analyze whether surgeons comply to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) guidelines and which decision criteria were used in the determination of the start of weightbearing. METHODS A survey was distributed among Dutch trauma and orthopaedic surgeons to determine the most common practices in postoperative weightbearing in patients with DIACFs. RESULTS 75 surgeons responded to the survey. 33% of the respondents adhered to the AO guidelines. 4% of the respondents strictly followed non-weightbearing guidelines, while 96% interpret the AO guidelines or their local protocol freely, in any frequency. When respondents tended to deviate from the AO guidelines or local protocol, a good patients' compliance to therapy was expected. 83% of the respondents started weightbearing on the fracture, based on reported patient complaints. 87% of the respondents did not see any relation between early weightbearing and the occurrence of complications, including loosening of osteosynthesis materials. CONCLUSION This study demonstrates that there is limited consensus on the rehabilitation for DIACFs. Moreover, it shows that most surgeons are inclined to interpret the current (AO) guideline or their own local protocol freely. New guidelines, supported with well-founded literature, could help surgeons in a more appropriate daily practice in weightbearing for the rehabilitation of calcaneal fractures.
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Affiliation(s)
- Coen Verstappen
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Pishtiwan H S Kalmet
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Erik Hermans
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael J R Edwards
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
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Chongmuenwai A, Thitirangsi T. Outcomes of Early Weight Bearing in Displaced Intra-articular Calcaneus Fractures Treated with Screws-Only Fixation Technique. Indian J Orthop 2023; 57:461-465. [PMID: 36825263 PMCID: PMC9941380 DOI: 10.1007/s43465-023-00823-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/09/2023] [Indexed: 01/21/2023]
Abstract
Background Displaced intraarticular calcaneus fracture indicates surgical treatment. The current trend is open reduction and internal fixation with a plate or multiple screws through the sinus tarsi approach. Most postoperative protocols are prolonged non-weight bearing that causes a high socioeconomic burden. This study aims to determine the safety of the early weight-bearing protocol of screws-only fixation in calcaneal fracture. Materials and Methods Evaluate displaced intraarticular calcaneus fractures treated with screws-only technique via the sinus tarsi approach in our institution. The first group, from July 2017 to December 2018, allowed patients to start partial weight bearing as tolerated at 4 weeks after surgery. The second group prospectively from January 2019 to March 2020, which assign patients to keep non-weight bearing for 8 weeks. The functional outcomes (Thai Foot and ankle ability measure subjective form, FAAM) were measured 6 months after surgery. The radiographic outcome (Bohler's angle and Gissane angle) was measured on the first day postoperative and 6 months follow-up, and the changes in these angles were recorded. Results There were 28 patients in each group. The outcomes were collected and compared by a T-test. In the early weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 76.4 ± 14.8, 2.4 ± 3.5, and 6.6 ± 7.8, respectively. In the delayed weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 81 ± 14.8, 2 ± 1.8 and 2.6 ± 6.1, respectively. There was no statistically significant difference in FAAM score, Bohler's angle loss, and Gissane's angle change between early and delayed weight-bearing groups. Conclusion Screws fixation in calcaneal fracture may be safe to allow early weight-bearing protocol.
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Affiliation(s)
- Adisorn Chongmuenwai
- Department of Orthopedics, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Tharit Thitirangsi
- Department of Orthopedics, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
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Treatment of displaced intra-articular calcaneal fractures: A single-center experience study with 20 years follow-up. Injury 2022; 53:3535-3542. [PMID: 35803742 DOI: 10.1016/j.injury.2022.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/06/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This study was conducted to identify the patient characteristics, classification, treatment, complications, and functional outcomes of operatively treated displaced intra-articular calcaneal fractures (DIACFs) in a level-I trauma center over a 20-year period. METHODS Patients with a DIACF classified as Sanders ≥2 and operatively treated with percutaneous reduction and screw fixation (PSF) or open reduction and internal fixation (ORIF) between 1998 and 2017 were identified. Pre- and postoperative radiological assessments were performed. Functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). General health and patient satisfaction were assessed using the Short Form-36 Health Survey (SF-36) and the visual analog scale (VAS). RESULTS In total, 120 patients with a DIACF that were operatively treated with PSF or ORIF. Of these patients, 72 with a total of 80 DIACFs completed the questionnaires (60%). The average follow-up was 130 months. Mean scores for PSF and ORIF were 74 and 75 for AOFAS, 78 and 78 for MFS, 68 and 61 for SF-36, and 7.7 and 7.5 for VAS, respectively. An infection was the most common complication associated with ORIF (31%), and hardware removal (58%) was the most common complication in patients treated with PSF. Overall, 36 patients (68%) were able to return to work after a median time 6 months (IQR, 3-7) and 6 months (IQR, 3,25-6,75) for PSF and ORIF treated, respectively CONCLUSION: This long-term follow-up study reviews ORIF using ELA and PSF in the treatment of DIACFs. This study shows that both treatments are capable of restoring the Böhler angle and yield relatively good long-term functional outcomes. Differences in complication rates were apparent, infectious problems are inherent to ORIF using ELA, and hardware removal is associated with PSF.
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Analysis of partial weight bearing after surgical treatment in patients with injuries of the lower extremity. Arch Orthop Trauma Surg 2022; 142:77-81. [PMID: 32880704 PMCID: PMC8732824 DOI: 10.1007/s00402-020-03588-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/16/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION After surgical treatment of injuries of the lower extremity, partial weight bearing is often suggested until soft tissue consolidation. It is doubtful, if this recommendation can be implemented, even in the case that a patient is performing partial weight bearing with a physical therapist. Consequently the question remains, if patients are able to implement partial weight bearing after surgery and which factors favor incompliance. MATERIALS AND METHODS 49 patients, who underwent surgical treatment after injuries of the lower extremity, were equipped with electronic shoe insoles on both sides. Different weight bearing instructions were given depending on the type of injury and surgery (full weight bearing vs. 20 kg weight bearing vs. non-weight bearing). Besides loading, other factors like age, gender, weight and physical activity were evaluated. Statistical analysis was performed using Chi-square and Fisher's exact test with significance set at a p value < 0.05. RESULTS 25 of the 40 patients, who had to perform non- or partial weight bearing, were not able to follow postoperative instructions (compliance rate 37.5%). The average loading of the whole collective was 32.6 kg (4.8-109.2 kg). The specification of loading had no statistically significant influence on real loading (p-value 0.39). Elderly patients were less able to follow instructions than younger patients (36 vs 30.2 kg). Physically active compared to non-active patients overloaded their injured extremity (37.8 vs 28.7 kg). Patients with a high body mass index (BMI) encountered more difficulties to perform partial weight bearing than lightweight patients (36.9 vs 25.1 kg). CONCLUSIONS Most patients were not able to follow loading limitation, even a few days after surgery and even if the patients were trained by a physiotherapist. Excessive weight bearing-related complications should be evaluated.
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Falls from height: Ambulation following spinal cord injury and lower extremity polytrauma. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Calcaneal fracture: results of earlier rehabilitation after open reduction and internal fixation. Arch Orthop Trauma Surg 2021; 141:929-936. [PMID: 32780200 DOI: 10.1007/s00402-020-03575-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION This study aimed to analyze the clinical and radiological outcomes of early weight-bearing and rehabilitation after open reduction and internal fixation (OR/IF) of calcaneal fracture. MATERIALS AND METHODS This retrospective study was conducted on 78 patients with unilateral calcaneal fracture who underwent OR/IF. A mean follow-up period was 45.8 months (range 12-135). Two weeks after surgery, the range of motion (ROM) exercise was started, brace or heel off shoe was applied, and forefoot weight-bearing was allowed. Four weeks after surgery, tolerable weight-bearing ambulation without crutch was allowed. When the patient was not walking, the braces were removed to perform peritalar ROM exercises. Radiologic evaluation was performed by measuring the Böhler angle and incongruency of the subtalar joint surface. Paley grade was used to assess traumatic arthritis. Clinical evaluation was performed by measuring the foot and ankle outcome score (FAOS) and ankle ROM. RESULTS The mean postoperative Böhler angle was 31.7° (P < 0.001) at 2 weeks, 31.2° at 3 months, and 30.1° at the last (P = 0.4). The average Paley grade of the subtalar OA was 1.12. CT imaging revealed that the average step-off of the subtalar joint was 1.26 mm in coronal and 0.84 mm in sagittal. The average ROM results were as follows (contralateral, affected side): there was no significant difference in dorsiflexion [16.9° vs. 16° (P = 0.6)], whereas plantarflexion and inversion were significantly decreased [39.5° vs. 35.3° (P = 0.049) and 50.5° vs. 34.8° (P = 0.04)]. The average FAOS score was 86.1 points, and the highest score was "function" (mean 92.5 points). CONCLUSIONS Earlier rehabilitation after OR/IF is recommended for the treatment of calcaneal fracture.
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Herlyn A, Brakelmann A, Herlyn PK, Gradl G, Mittlmeier T. Calcaneal fracture fixation using a new interlocking nail reduces complications compared to standard locking plates - Preliminary results after 1.6 years. Injury 2019; 50 Suppl 3:63-68. [PMID: 31378540 DOI: 10.1016/j.injury.2019.07.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical treatment of displaced intra-articular calcaneal fractures using a standard extended lateral approach for plate fixation is frequently associated with substantial wound healing complications and infections. This matched pairs analysis compares the new minimally-invasive calcaneal interlocking nailing technique to standard locking plate fixation in terms of reduction capacity, complication rates, and functional outcomes. METHODS Forty feet in 38 patients (mean patient age 52.5 years, range 27-78) were treated with calcaneal locking nail (LN)(n=20) or locking plate (LP)(n=20) and followed clinically and radiologically for 20 months. Follow-up included radiological assessments and functional evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and the Foot Function Index (R-FFI). RESULTS Times for surgery were similar for both techniques (LN 93min, range 34 to 175 vs. LP 101min, range 53 to 305). Length of hospital stay was significantly lower in the LN group (7.6 days, range 3 to 14 vs. LP 11 days, range 6 to 37). Time away from work was shorter by 3.5 days in LN group. LP group had superior range of motion in plantarflexion, eversion, and inversion at follow-up, while LP patients were superior in demonstrating a secure heelstrike (79% vs. LN 58%) and fewer needed permanent walking aids. AOFAS and FFI scores revealed no differences for both groups. Radiographs indicated an adequate reconstruction in both groups, followed by a slight loss of reduction at follow-up (LP 4.7° postoperative vs. follow-up; LN 5.1°). The overall complication rate between groups was significant with 5% complications in the LN group vs. 50% in the LP group (5% deep infection, 35% impaired wound healing, 5% hardware breakage, 5% superficial wound infection; LN: 5% superficial wound infection). CONCLUSIONS The new calcaneal interlocking nail shows promising results in terms of reduction capacity and safety. Use of the minimally invasive locking nail technique minimized the risk of postoperative wound complications and achieved superior functional outcomes compared with standard locking plate fixation via the extended lateral approach.
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Affiliation(s)
- Anica Herlyn
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany.
| | - Anna Brakelmann
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany
| | - Philipp Ke Herlyn
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany
| | - Georg Gradl
- Dept. of Trauma, Orthopedic and Reconstructive Surgery, Klinikum München Harlaching, Sanatoriumsplatz 2, D-81545 München, Germany
| | - Thomas Mittlmeier
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany
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Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ 2019; 364:k5120. [PMID: 30617123 PMCID: PMC6322065 DOI: 10.1136/bmj.k5120] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To compare re-rupture rate, complication rate, and functional outcome after operative versus nonoperative treatment of Achilles tendon ruptures; to compare re-rupture rate after early and late full weight bearing; to evaluate re-rupture rate after functional rehabilitation with early range of motion; and to compare effect estimates from randomised controlled trials and observational studies. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed/Medline, Embase, CENTRAL, and CINAHL databases were last searched on 25 April 2018 for studies comparing operative versus nonoperative treatment of Achilles tendon ruptures. STUDY SELECTION CRITERIA Randomised controlled trials and observational studies reporting on comparison of operative versus nonoperative treatment of acute Achilles tendon ruptures. DATA EXTRACTION Data extraction was performed independently in pairs, by four reviewers, with the use of a predefined data extraction file. Outcomes were pooled using random effects models and presented as risk difference, risk ratio, or mean difference, with 95% confidence interval. RESULTS 29 studies were included-10 randomised controlled trials and 19 observational studies. The 10 trials included 944 (6%) patients, and the 19 observational studies included 14 918 (94%) patients. A significant reduction in re-ruptures was seen after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; P<0.001; I2=22%). Operative treatment resulted in a significantly higher complication rate than nonoperative treatment (4.9% v 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; P<0.001; I2=45%). The main difference in complication rate was attributable to the incidence of infection (2.8%) in the operative group. A similar reduction in re-rupture rate in favour of operative treatment was seen after both early and late full weight bearing. No significant difference in re-rupture rate was seen between operative and nonoperative treatment in studies that used accelerated functional rehabilitation with early range of motion (risk ratio 0.60, 0.26 to 1.37; P=0.23; I2=0%). No difference in effect estimates was seen between randomised controlled trials and observational studies. CONCLUSIONS This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.
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Affiliation(s)
- Yassine Ochen
- Department of Surgery, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
| | - Reinier B Beks
- Department of Surgery, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
- Department of Surgery, Diakonessenhuis Hospital, Utrecht, Netherlands
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis Hospital, Utrecht, Netherlands
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | | | - Marilyn Heng
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
| | | | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - R Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
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