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Kebbach M, Geier A, Darowski M, Krueger S, Schilling C, Grupp TM, Bader R. Computer-based analysis of different component positions and insert thicknesses on tibio-femoral and patello-femoral joint dynamics after cruciate-retaining total knee replacement. Knee 2023; 40:152-165. [PMID: 36436384 DOI: 10.1016/j.knee.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/29/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Positioning of the implant components and tibial insert thickness constitute critical aspects of total knee replacement (TKR) that influence the postoperative knee joint dynamics. This study aimed to investigate the impact of implant component positioning (anterior-posterior and medio-lateral shift) and varying tibial insert thickness on the tibio-femoral (TF) and patello-femoral (PF) joint kinematics and contact forces after cruciate-retaining (CR)-TKR. METHOD A validated musculoskeletal multibody simulation (MMBS) model with a fixed-bearing CR-TKR during a squat motion up to 90° knee flexion was deployed to calculate PF and TF joint dynamics for varied implant component positions and tibial insert thicknesses. Evaluation was performed consecutively by comparing the respective knee joint parameters (e.g. contact force, quadriceps muscle force, joint kinematics) to a reference implant position. RESULTS The PF contact forces were mostly affected by the anterior-posterior as well as medio-lateral positioning of the femoral component (by 3 mm anterior up to 31 % and by 6 mm lateral up to 14 %). TF contact forces were considerably altered by tibial insert thickness (24 % in case of + 4 mm increase) and by the anterior-posterior position of the femoral component (by 3 mm posterior up to 16 %). Concerning PF kinematics, a medialised femoral component by 6 mm increased the lateral patellar tilt by more than 5°. CONCLUSIONS Our results indicate that regarding PF kinematics and contact forces the positioning of the femoral component was more critical than the tibial component. The positioning of the femoral component in anterior-posterior direction on and PF contact force was evident. Orthopaedic surgeons should strictly monitor the anterior-posterior as well as the medio-lateral position of the femoral component and the insert thickness.
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Affiliation(s)
- Maeruan Kebbach
- Department of Orthopaedics, Rostock University Medical Center, Germany.
| | - Andreas Geier
- Department of Orthopaedics, Rostock University Medical Center, Germany; Department of Modern Mechanical Engineering, Waseda University, Tokyo, Japan
| | - Martin Darowski
- Department of Orthopaedics, Rostock University Medical Center, Germany
| | - Sven Krueger
- Aesculap AG, Research and Development, Tuttlingen, Germany
| | | | - Thomas M Grupp
- Aesculap AG, Research and Development, Tuttlingen, Germany; Ludwig Maximilians University Munich, Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, Campus Grosshadern, Munich, Germany
| | - Rainer Bader
- Department of Orthopaedics, Rostock University Medical Center, Germany
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Does contemporary bicruciate retaining total knee arthroplasty restore the native knee kinematics? A descriptive literature review. Arch Orthop Trauma Surg 2022; 142:2313-2322. [PMID: 34406507 DOI: 10.1007/s00402-021-04116-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There has been no consensus on the benefit of retaining the anterior cruciate ligament (ACL) in TKAs. This study aims to review recent evidences around the kinematics of bicruciate retaining (BCR) total knee arthroplasty (TKA). MATERIALS AND METHODS A search of the literature was conducted on PubMed and Web of Science. Reports that assessed the BCR TKA kinematics, including both in vitro cadaveric studies and in vivo clinical studies, were reviewed. RESULTS A total number of 169 entries were obtained. By exclusion criteria, five in vitro studies using cadaveric knee specimens and six in vivo studies using patient cohorts were retained. In vitro studies showed a low internal rotation (< 10°) throughout the flexion path in all BCR TKAs. Compared to native knees, the difference in the internal rotation was maximal during early and late flexion; the femur in the BCR TKA was significantly more anteriorly positioned (1.7-3.6 mm from 0° to 110°) and more externally rotated (3.6°-4.2° at 110° and 120°). In vivo studies revealed that the native knee kinematics, in general, were not fully restored after BCR TKA during various knee activates (squatting, level-walking, and downhill-walking). There are asymmetric kinematics during the stance phase of gait cycle and a smaller range of axial rotation (23% patients exhibiting external tibial rotation) throughout the gait cycle in BCR TKAs. CONCLUSIONS Critical insights in the complex BCR TKA biomechanics have been reported from recent laboratory kinematics studies. However, whether contemporary BCR TKAs can fully restore native knee kinematics remains debatable, warranting further investigations.
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Lewis PL, Campbell DG, Lorimer MF, Requicha F, W-Dahl A, Robertsson O. Primary Total Knee Arthroplasty Revised for Instability: A Detailed Registry Analysis. J Arthroplasty 2022; 37:286-297. [PMID: 34763047 DOI: 10.1016/j.arth.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/20/2021] [Accepted: 11/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Instability after total knee arthroplasty is a common but poorly understood complication. METHODS Data from a large national registry was used to study patient and prosthesis characteristics of 2605 total knee arthroplasty revisions for instability. The cumulative percent revision was calculated using Kaplan-Meier estimates, and Cox proportional models used to compare revision rates. The rate of further revision was analyzed with regard to prostheses used in the first revision. RESULTS Instability increased from 6% of all first revision procedures in 2003 to 13% in 2019. The revision risk was lower for minimally stabilized prostheses, males, and patients aged ≥65 years. Polyethylene insert exchange was used for 55% of revision procedures, using a thicker insert in 93% and a change in insert conformity in 24% of cruciate-retaining knees. The increase in either thickness or conformity had no effect on the rate of further revision. After a revision for instability, 24% had a second revision by 14 years. Recurrent instability accounted for 32% of further revisions. A lower second revision rate was seen after revision of both femoral and tibial components, and where constrained components were used. CONCLUSION Revision for instability is increasing. Revising both femoral and tibial components led to a lower rate of second revision compared to a change in insert alone. Recurrent instability was common.
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Affiliation(s)
- Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia
| | | | - Michelle F Lorimer
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia
| | | | - Annette W-Dahl
- Department of Orthopaedics, Faculty of Medicine, Clinical Science Lund, Lund University, Lund, Sweden
| | - Otto Robertsson
- Department of Orthopaedics, Faculty of Medicine, Clinical Science Lund, Lund University, Lund, Sweden
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Sabatini L, Barberis L, Camazzola D, Centola M, Capella M, Bistolfi A, Schiraldi M, Massè A. Bicruciate-retaining total knee arthroplasty: What’s new? World J Orthop 2021; 12:732-742. [PMID: 34754829 PMCID: PMC8554348 DOI: 10.5312/wjo.v12.i10.732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/23/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
Primary total knee arthroplasty (TKA) is a widespread procedure to address end stage osteoarthritis with good results, clinical outcomes, and long-term survivorship. Although it is frequently performed in elderly, an increased demand in young and active people is expected in the next years. However, a considerable dissatisfaction rate has been reported by highly demanding patients due to the intrinsic limitations provided by the TKA. Bicruciate-retaining (BCR) TKA was developed to mimic knee biomechanics, through anterior cruciate ligament preservation. First-generation BCR TKA has not gained popularity due to its being a challenging technique and having poor survival outcomes. Thanks to implant design improvement and surgeon-friendly instrumentation, second-generation BCR TKA has seen renewed interest. This review will focus on surgical indications, kinematical basis, clinical results and latest developments of second-generation BCR TKA.
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Affiliation(s)
- Luigi Sabatini
- Orthopaedics and Traumatology Department, Presidio CTO, Torino 10126, Italy
| | - Luca Barberis
- Orthopaedics and Traumatology Department, Presidio CTO, Torino 10126, Italy
| | - Daniele Camazzola
- Orthopaedics and Traumatology Department, CTO Hospital, Torino 10126, Italy
| | - Michele Centola
- Orthopaedics and Traumatology Department, Presidio CTO, Torino 10126, Italy
| | - Marcello Capella
- Orthopaedics and Traumatology Department, CTO Hospital, Torino 10126, Italy
| | | | - Marco Schiraldi
- Orthopedics and Traumaology Department, Michele e Pietro Ferrero Hospital, Verduno 12060, Italy
| | - Alessandro Massè
- Orthopaedics and Traumatology Department, CTO Hospital, Torino 10126, Italy
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Biomechanical Consequences of Tibial Insert Thickness after Total Knee Arthroplasty: A Musculoskeletal Simulation Study. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11052423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The thickness of the tibial polyethylene (PE) insert is a critical parameter to ensure optimal soft-tissue balancing in the intraoperative decision-making procedure of total knee arthroplasty (TKA). However, there is a paucity of information about the kinetic response to PE insert thickness variations in the tibiofemoral (TF) joint, and subsequently, the secondary effects on the patellofemoral (PF) biomechanics. Therefore, the purpose of this study was to investigate the influence of varying PE insert thickness on the ligament and TF compressive forces, as well as on the PF forces and kinematics, after a cruciate-retaining TKA. A previous patient-specific musculoskeletal model of TKA was adapted to simulate a chair-rising motion in which PE insert thickness was varied with 2 mm increments or decrements compared to the reference case (9 mm), from 5 mm up to 13 mm. Greater PE insert thickness resulted in higher ligament forces and concurrently increased the TF compressive force by 21% (13 mm), but slightly unloaded the PF joint with 7% (13 mm) while shifting the patella distally in the trochlear groove, compared to the reference case. Thinner PE inserts showed an opposite trend. Our findings suggest that the optimal PE insert thickness selection is a trade-off between the kinetic outcomes of the TF and PF joints.
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Tsai TY, Liow MHL, Li G, Arauz P, Peng Y, Klemt C, Kwon YM. Bi-Cruciate Retaining Total Knee Arthroplasty Does Not Restore Native Tibiofemoral Articular Contact Kinematics During Gait. J Orthop Res 2019; 37:1929-1937. [PMID: 31062398 DOI: 10.1002/jor.24333] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 04/12/2019] [Indexed: 02/04/2023]
Abstract
Bi-cruciate retaining (BCR) total knee arthroplasty (TKA) design preserves both anterior and posterior cruciate ligaments with the potential to restore normal posterior femoral rollback and joint kinematics. Abnormal knee kinematics and "paradoxical" anterior femoral translation in conventional TKA designs have been suggested as potential causes of patient dissatisfaction. However, there is a paucity of data on the in vivo kinematics and articular contact behavior of BCR-TKA. This study aimed to investigate in vivo kinematics, articular contact position, and pivot point location of the BCR-TKA during gait. In vivo kinematics of 30 patients with unilateral BCR-TKA during treadmill walking was determined using validated dual fluoroscopic imaging tracking technique. The BCR-TKA exhibited less extension than the normal healthy knee between heel strike and 48% of gait cycle. Although the average external rotation trend observed for BCR TKA was similar to the normal healthy knee, the range of motion was not fully comparable. The lowest point of the medial condyle showed longer anteroposterior translation excursion than the lateral condyle, leading to a lateral-pivoting pattern in 60% of BCR TKA patients during stance phase. BCR-TKA demonstrated no statistical significant differences in anterior-posterior translation as well as varus rotation, when compared to normal healthy knees during the stance phase. However, sagittal plane motion and tibiofemoral articular contact characteristics including pivoting patterns were not fully restored in BCR TKA patients during gait, suggesting that BCR TKA does not restore native tibiofemoral articular contact kinematics. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1929-1937, 2019.
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Affiliation(s)
- Tsung-Yuan Tsai
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts
| | - Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts
| | - Guoan Li
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts
| | - Paul Arauz
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts
| | - Yun Peng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts
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Wada K, Hamada D, Takasago T, Nitta A, Goto T, Tonogai I, Tsuruo Y, Sairyo K. The medial constrained insert restores native knee rotational kinematics after bicruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:1621-1627. [PMID: 30382288 DOI: 10.1007/s00167-018-5249-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/17/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this study was to test the hypothesis that the medial constrained insert would reproduce the native knee kinematics after bicruciate-retaining (BCR) total knee arthroplasty (TKA). METHODS Using an image-free navigation system in six fresh-frozen whole-body cadavers, the rotation angle of the tibia at minimum flexion, at 10° intervals from 0° to 130° flexion, and at maximum flexion during manual passive knee flexion was assessed. The data was collected in native knees, in BCR TKA using a normal flat insert (BCR-XP), and in BCR TKA using a more constrained insert in the medial side (BCR-AS). The differences in the rotation angle of the tibia were statistically evaluated. RESULTS The rotation angles of the tibia in BCR-XP were significantly different from those of the native knees both in the early flexion phase (p = 0.002 at minimum knee flexion, p = 0.002 at 0°, p = 0.041 at 10°, p = 0.009 at 20°, p = 0.026 at 30°) and in the late flexion phase (p = 0.015 at 130°, p = 0.015 at maximum knee flexion), whereas the rotational angles of the tibia in BCR-AS were similar to those of the native knee. CONCLUSION This study shows that the rotational kinematics of the native knee is reproduced after BCR TKA with the medial constrained insert. Surgeons and implant designers should be aware that constraint of the medial side in BCR TKA is a crucial factor for restoration of native kinematics which may lead to better clinical outcome.
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Affiliation(s)
- Keizo Wada
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Daisuke Hamada
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan.
| | - Tomoya Takasago
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Akihiro Nitta
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Tomohiro Goto
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Ichiro Tonogai
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Yoshihiro Tsuruo
- Department of Anatomy and Cell Biology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
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Hamada D, Wada K, Takasago T, Goto T, Nitta A, Higashino K, Fukui Y, Sairyo K. Native rotational knee kinematics are lost in bicruciate-retaining total knee arthroplasty when the tibial component is replaced. Knee Surg Sports Traumatol Arthrosc 2018; 26:3249-3256. [PMID: 29368122 DOI: 10.1007/s00167-018-4842-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 01/17/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To compare the kinematics between native knees and knees that have undergone bicruciate-retaining (BCR) total knee arthroplasty (TKA) with cruciate-retaining (CR) TKA converted from BCR TKA in the same whole-body cadaveric specimen using a navigation system and, if differences exist, to investigate the point at which normal kinematics are lost during the procedure. METHODS The rotational kinematics throughout passive flexion of the native knee and of knees after meniscectomy, femoral replacement, BCR TKA, or CR TKA were assessed in nine fresh frozen cadavers using an image-free navigation system. RESULTS The rotational kinematic pattern of a knee after BCR TKA was different from that of a native knee, especially in the early flexion phase, and was similar to that after CR TKA. Screw-home movement was not observed after BCR TKA, but still occurred after meniscectomy or femoral replacement with intact cruciate ligaments and an intact tibial articular surface. CONCLUSION The rotational kinematics of the native knee are not always preserved after BCR TKA. Native rotational kinematics are preserved after meniscectomy and femoral replacement, but are lost after tibial replacement in BCR TKA. Surgeons should pay close attention to maintain the anteroposterior stabilizing function of the ACL in BCR TKA, rather than to restore the native rotational kinematics.
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Affiliation(s)
- Daisuke Hamada
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan.
| | - Keizo Wada
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Tomoya Takasago
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Tomohiro Goto
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Akihiro Nitta
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Kosaku Higashino
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan.,Department of Anatomy and Developmental Neurobiology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Yoshihiro Fukui
- Department of Anatomy and Developmental Neurobiology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto, Tokushima, 770-8503, Japan
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Baumann F. Bicruciate-retaining total knee arthroplasty compared to cruciate-sacrificing TKA: what are the advantages and disadvantages? Expert Rev Med Devices 2018; 15:615-617. [PMID: 30132366 DOI: 10.1080/17434440.2018.1514256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Florian Baumann
- a Department of Trauma Surgery , Regensburg University Medical Center , Regensburg , Germany
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Baumann F, Krutsch W, Worlicek M, Kerschbaum M, Zellner J, Schmitz P, Nerlich M, Tibesku C. Reduced joint-awareness in bicruciate-retaining total knee arthroplasty compared to cruciate-sacrificing total knee arthroplasty. Arch Orthop Trauma Surg 2018; 138:273-279. [PMID: 29124363 DOI: 10.1007/s00402-017-2839-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE There is rising impact of patient-reported outcome (PRO) measurement in joint arthroplasty over the past years. Bicruciate-retaining implants have shown more physiologic knee kinematics and provide superior proprioceptive capacities. The aim of this study was to evaluate if the functional properties of this new implant design lead to improved PRO results after total knee arthroplasty (TKA). METHODS This prospective, controlled trial compares PRO of bicruciate-retaining total knee arthroplasty (BCR-TKA) to unicondylar knee arthroplasty (UKA) and standard posterior-stabilized total knee arthroplasty (PS-TKA). We evaluated 102 patients (34 patients in each group) 18 months postoperatively after knee arthroplasty. Primary outcome measure was the Forgotten Joint Score (FJS). RESULTS The BCR-group showed the same level of joint awareness as the UKA-group (p = 0.999). The second control group of PS-TKA patients had a lower mean score value in the FJS compared to the BCR-group (p = 0.035) and UKA-group (p = 0.031). There was no correlation of age, gender, body mass index (BMI) and the FJS. No relevant floor- or ceiling effects occurred. CONCLUSIONS This study found reduced joint awareness for BCR-TKA compared to a standard total knee arthroplasty. The score values of the BCR-group were equal to the UKA-group. Further prospective, randomized studies to investigate long-term survivorship of bicruciate-retaining implants are needed. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Florian Baumann
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany.
| | - Werner Krutsch
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Michael Worlicek
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Johannes Zellner
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Paul Schmitz
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Michael Nerlich
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
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