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Ehlinger M, Azoti W, Crom LL, Berthe S, Ollivier M, Favreau H, Tamir M, Bahlouli N. Analysis of load distribution on the plate and lateral hinge of a valgus opening high tibial osteotomy during weight-bearing: a finite element analysis. Orthop Traumatol Surg Res 2024:103956. [PMID: 39038516 DOI: 10.1016/j.otsr.2024.103956] [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: 02/29/2024] [Revised: 06/15/2024] [Accepted: 06/27/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION Valgus high tibial osteotomy (HTO) is indicated for managing isolated medial knee osteoarthritis in a young patient with a metaphyseal deformity of the proximal tibia. In a medial opening HTO, maintaining the integrity of the lateral hinge is crucial for ensuring proper healing and correction retention. Using a locked plate to stabilize an HTO is common practice, allowing for earlier weight-bearing. The objective of this study was therefore to measure and track the mechanical load distribution on a locked fixation plate and the lateral hinge of an HTO using a finite element (FE) model simulating single-leg stance loading. HYPOTHESIS The working hypothesis was that during weight-bearing, the plate and the lateral hinge absorb stress asymmetrically, predominantly on the plate. MATERIAL AND METHODS A numerical model of an HTO stabilized with a locked plate was developed based on the actual geometry of a healthy proximal tibia (using Autodesk Fusion 360 and Altair HyperWorks software). In this finite element simulation of loading, a mesh convergence study was conducted to optimize the accuracy of the numerical model results. The primary outcome measure was the maximum stress value in the affected areas (Von Mises stress, in MPa) of the plate and the lateral hinge. RESULTS The maximum stress intensity in the plate was approximately 20.29 MPa. The maximum stress intensity in the bony hinge was about 5.6 MPa. The results of the mesh convergence study for the hinge and the plate enabled defining the most suitable model for future FE studies: a 4 mm mesh for all model elements except for the high-stress area in the plate and the hinge, which were meshed with a 0.7 mm element size. This adaptation provided greater precision in the study. DISCUSSION There is a distribution and allocation of stress both on the plate and the hinge, underlining the significance of the plate and the absolute necessity of preserving the hinge. Predictably, the plate absorbs the majority of the load, more than three times that of the hinge. CONCLUSION The hypothesis is confirmed; however, additional studies would be necessary to validate these numerical results: an experimental component on instrumented cadaveric bones, as well as comparative studies of different fixation plates. LEVEL OF EVIDENCE V, expert opinion; controlled laboratory study.
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Affiliation(s)
- Matthieu Ehlinger
- ICube Laboratory - University of Strasbourg - CNRS, 4 rue de la Manufacture des Tabacs, 67000 Strasbourg, France; Department of Orthopedic Surgery and Traumatology, Hautepierre II Hospital, 1 Avenue Molière, 67098 Strasbourg Cedex, France.
| | - Wiayo Azoti
- INSA Toulouse, 135 Avenue de Rangueil, 31400 Toulouse, France; Clément Ader Institute (ICA), Federal University Toulouse Midi-Pyrénées, UMR CNRS 5312, INSA, ISAE-SUPAERO, IMT Mines Albi, UPS, 3 rue Caroline Aigle, 31400 Toulouse, France
| | - Lil Le Crom
- ICube Laboratory - University of Strasbourg - CNRS, 4 rue de la Manufacture des Tabacs, 67000 Strasbourg, France
| | - Samuel Berthe
- ICube Laboratory - University of Strasbourg - CNRS, 4 rue de la Manufacture des Tabacs, 67000 Strasbourg, France
| | - Matthieu Ollivier
- Department of Orthopedic Surgery, Sainte-Marguerite Hospital, University Hospital of Marseille, 270 Boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Henri Favreau
- Department of Orthopedic Surgery and Traumatology, Hautepierre II Hospital, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Mekki Tamir
- Department of Orthopedic Surgery and Traumatology, Hautepierre II Hospital, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Nadia Bahlouli
- ICube Laboratory - University of Strasbourg - CNRS, 4 rue de la Manufacture des Tabacs, 67000 Strasbourg, France
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Kim SM, Bin SI, Kim JM, Lee BS, Lee HY, Lee SJ. Lateral Distance From the Osteotomy Hinge Point to the Tibial Cortex Is Associated With Lateral Hinge Fracture Type and Fracture Occurrence Time After Medial Open-Wedge High Tibial Osteotomy. Arthroscopy 2024; 40:890-895. [PMID: 37586667 DOI: 10.1016/j.arthro.2023.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE To verify whether the distance from the hinge point to the tibial cortex affects the occurrence time and characteristics of the lateral hinge fracture (LHF) in medial open-wedge high tibial osteotomy. METHODS We retrospectively reviewed 171 knees in 171 patients (121 women, 50 men; mean age, 53.9 years; range, 36-67 years) who had undergone medial open-wedge high tibial osteotomy with locking plate fixation between January 2011 and December 2020. Osteotomy hinge point and LHFs were identified on intraoperative fluoroscopy and immediate postoperative radiographs. LHF type was classified as suggested by Takeuchi et al. Acute fracture was defined as a fracture that occurred during surgery, and delayed fracture was defined as a fracture observed after 1 month postoperatively. The nearest distances from osteotomy hinge point to lateral, distal, and proximal cortex were measured on postoperative radiographs. We compared the distance between the different types and between acute and delayed LHFs. RESULTS There were 55 LHFs (32%) (type I, 40 knees; type II, 14 knees; type III, 1 knee) that occurred acutely in 41 knees and were found as delayed fractures in 14 knees. The patient demographics were not significantly different between non-LHFs and each type of LHFs. Proximal and distal distances were not statistically different among fracture types and between occurrence times. However, lateral distances were significantly shorter in type I LHFs (6.2 ± 1.8 mm) and longer in type II LHFs (9.3 ± 2.3 mm) than in non-LHFs (7.1 ± 2.7 mm) (P = .020 and .004, respectively). The lateral cortical distances were also different between acute LHFs (6.4 ± 1.9 mm) and delayed LHF (9.0 ± 2.7 mm) (P < .001). In the case of fracture type, the frequency of type I decreases with increase in the lateral distance, whereas that of type II increases with increase in the lateral cortical distance. In acute fracture, type I was dominant (85.4%), whereas in delayed fracture, type II was dominant (57.2%). CONCLUSIONS The lateral cortical distance from the hinge point was significantly associated with LHF occurrence. Shorter distance increased the risk for acute type I LHF, whereas longer distance increased the risk for delayed type II LHFs. LEVEL OF EVIDENCE Level III, retrospective comparative prognostic trial.
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Affiliation(s)
- Seung-Min Kim
- Department of Orthopaedic Surgery, Wiltse Memorial Hospital, Anyang, Republic of Korea
| | - Seong-Il Bin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Jong-Min Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bum-Sik Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo-Yeol Lee
- Department of Orthopaedic Surgery, Eulji Medical Center Daejeon Hospital, Eulji University College of Medicine, Daejeon, Republic of Korea
| | - Seon-Jong Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Matache BA, Jean PO, Pelet S, Roger MÈ, Dartus J, Belzile EL. Lateral knee laxity increases the risk of excessive joint line obliquity after medial opening-wedge high tibial osteotomy. Orthop Traumatol Surg Res 2024; 110:103717. [PMID: 37863189 DOI: 10.1016/j.otsr.2023.103717] [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: 02/14/2022] [Revised: 06/04/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Medial opening-wedge high tibial osteotomy (HTO) is a well-recognized treatment for patient with varus knee osteoarthritis. Joint line obliquity has recently been suggested to negatively impact clinical outcomes following HTO, but little is known about what factors lead to increased joint line obliquity. The purpose of the current study was (1) to evaluate whether increased preoperative lateral knee laxity, represented by the joint line convergence angle, results in increased joint line obliquity in a consecutive series of patients treated with HTO and (2) to determine the effect of advanced arthritic changes on joint line obliquity. HYPOTHESIS Increased joint line convergence angle would be associated with increased joint line obliquity. PATIENTS AND METHODS All HTOs performed at our center between 2010-2017 were retrospectively reviewed. Patients were excluded if pre- and postoperative standing alignment radiographs were not available. Varus-producing osteotomies were excluded. Patients were subdivided according to their preoperative joint line convergence angle (≤3° or >3°) and the degree of radiographic arthritic change. The primary outcome measure was the postoperative joint line obliquity. Categorical variables were compared using the paired samples t-test. Survival analysis was performed for failure and overall rate of reoperation. RESULTS During the study period, 90 HTO were performed, and 38 patients (42 knees; M/F: 32/6; mean age: 41.6; mean follow-up: 4.72 years) met the inclusion criteria. The most common surgical indications were varus knee osteoarthritis (n=27, 64.3%) and osteochondritis dissecans (n=7, 8.2%). Patients with a preoperative joint line convergence angle >3° demonstrated significantly greater joint line obliquity postoperatively as compared to those with a joint line convergence angle ≤3° (6.4°±4.6° vs. 2.5°±5.7°, respectively; p=0.02). Patients with advanced arthritic changes had significantly lower preoperative (-3°±3.4° vs. -5.6°±4.1°; p=0.03) and greater postoperative (5.8°±4° vs. 2.2°±6.4°; p=0.04) joint line obliquity as compared to those with minimal arthritic changes. There were 12 complications among the 42 procedures: one conversion to total knee replacement (TKR), one hardware failure (fixation revised), one infection, and 9 hardware removals. Overall survival using conversion to TKR was 96.23% (95% CI 0.92-1.0) at 10 years. DISCUSSION Lateral knee laxity, as defined by a preoperative joint line convergence angle >3°, and advanced arthritic changes are associated with increased postoperative joint line obliquity following medial opening-wedge high tibial osteotomy. Soft-tissue adaptation should be accounted for in order to avoid excessive joint line obliquity following high tibial osteotomy, and the planned correction should be reduced by 25% in patients with a preoperative joint line convergence angle >3° when templating using standing alignment radiographs. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bogdan A Matache
- Hôpital Enfant-Jésus, CHU de Québec-Université Laval, 1401, 18(e) rue, Québec, QC, G1J 1Z4, Canada; Faculty of Medicine, université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, Québec, QC, QC G1V 0A6, Canada.
| | - Pierre-Olivier Jean
- Faculty of Medicine, université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, Québec, QC, QC G1V 0A6, Canada
| | - Stéphane Pelet
- Hôpital Enfant-Jésus, CHU de Québec-Université Laval, 1401, 18(e) rue, Québec, QC, G1J 1Z4, Canada; Faculty of Medicine, université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, Québec, QC, QC G1V 0A6, Canada
| | - Marie-Ève Roger
- Hôpital Enfant-Jésus, CHU de Québec-Université Laval, 1401, 18(e) rue, Québec, QC, G1J 1Z4, Canada; Faculty of Medicine, université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, Québec, QC, QC G1V 0A6, Canada
| | - Julien Dartus
- Hôpital Enfant-Jésus, CHU de Québec-Université Laval, 1401, 18(e) rue, Québec, QC, G1J 1Z4, Canada; Faculty of Medicine, université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, Québec, QC, QC G1V 0A6, Canada; Lille University School of Medicine, 1, avenue Eugène Avinée, 59120 Lille, France
| | - Etienne L Belzile
- Hôpital Enfant-Jésus, CHU de Québec-Université Laval, 1401, 18(e) rue, Québec, QC, G1J 1Z4, Canada; Faculty of Medicine, université Laval, Pavillon Ferdinand-Vandry, 1050, avenue de la Médecine, Québec, QC, QC G1V 0A6, Canada
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Kyung MG, Bae TS, Baek HH, Chang MJ, Kim TW, Kang SB. Optimal hinge level in opening wedge high tibial osteotomy: Biomechanical analysis using finite element method. Clin Biomech (Bristol, Avon) 2023; 107:106027. [PMID: 37315477 DOI: 10.1016/j.clinbiomech.2023.106027] [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: 10/25/2022] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND While the concept of a safe zone, which can minimize the hinge fracture when performing opening wedge high tibial osteotomy, has been introduced, there is a lack of understanding of the biomechanical environment at the lateral tibial cortex. This study aimed to evaluate the effect of the hinge level on the biomechanical environment at the lateral cortex of the tibia with heterogeneous finite element models. METHODS Finite element models of biplanar opening wedge high tibial osteotomy based on computed tomography images of a control subject and three patients with medial compartment knee osteoarthritis were created. In each model, three different hinge levels (proximal, middle, and distal) were set. The process of opening the gap during the operation was simulated, and the maximum von Mises stress values at the lateral tibial cortex were calculated for each hinge level and correction angle. FINDINGS The maximum von Mises stress value at the lateral tibial cortex was the lowest when the hinge was at the middle, while the value was the highest when the hinge was at the distal level. Furthermore, it was demonstrated that a higher correction angle yielded a higher probability of lateral tibial cortex fracture. INTERPRETATION The findings of this study demonstrate that the hinge at the point where the upper end of the articular cartilage of the proximal tibiofibular joint is located provides the least possibility of lateral tibial cortex fracture, as this is an anatomically independent position from the fibula.
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Affiliation(s)
- Min Gyu Kyung
- Department of Clinical Medical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Soo Bae
- Department of Biomedical Engineering, Jungwon University, Chungcheongbuk-do, Republic of Korea
| | - Hyeong Ho Baek
- Department of Biomedical Engineering, Jungwon University, Chungcheongbuk-do, Republic of Korea
| | - Moon Jong Chang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea; Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Woo Kim
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Seung-Baik Kang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea; Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Didier A, Favreau H, Ollivier M, Jmal H, Bonnomet F, Bahlouli N, Martz P, Ehlinger M. Experimental investigation of the risk of lateral cortex fracture during valgus tibial osteotomy. Orthop Traumatol Surg Res 2022; 108:103428. [PMID: 36202319 DOI: 10.1016/j.otsr.2022.103428] [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: 12/05/2021] [Revised: 01/23/2022] [Accepted: 03/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Valgus-producing medial opening-wedge proximal tibial osteotomies (V-MOW-PTO) are used to treat isolated medial-compartment knee osteoarthritis in patients with varus malalignment. A fracture of the lateral cortical hinge is a risk factor for poor outcomes. Implantation of a protective K-wire has been suggested to prevent this complication. The primary objective of this bench study was to assess the ability of a protective K-wire to prevent lateral cortical fractures. The secondary objective was to evaluate the influence of the opening speed on fracture risk during the osteotomy. HYPOTHESIS The primary hypothesis was that a protective K-wire decreased the risk of hinge fracture. The secondary hypothesis was that this risk was greater when the opening speed was high. MATERIALS AND METHODS We performed an experimental study of 20 simulated thermoplastic-polymer (ABS) tibias obtained by 3D printing to assess the effects of wedge-opening speed (high vs. low) and presence of a protective K-wire (yes vs. no). The opening rates were determined in a preliminary study of Sawbone® specimens opened using a distractor. The opening rate was measured using an accelerometer via a motion-capture glove. After assessing several high and low opening speeds, we selected 38mm/min and 152mm/min for the study. We divided the 20 ABS specimens into four groups of five each: high speed and K-wire, low speed and K-wire, high speed and no K-wire, and low speed and no K-wire. The force was applied using an Instron™ testing machine until construct failure. The primary outcome measure was the load at failure (N) and the secondary outcome measures were the displacement (mm) and maximum time to failure (s). RESULTS At both speeds, values were significantly higher with vs. without a K-wire for load to failure (low: 253.3N vs. 175.5N, p<0.01; high: 262.2N vs. 154.1N, p<0.01), displacement (low: 11.1mm vs. 8.7mm, p<0.01; high: 11mm vs. 8.9mm; p=0.012), and maximal time to failure (low: 11.4 s vs. 8.9 s; p=0.012; high: 2.2 s vs. 1.8 s; p=0.011). Thus, the osteotomy opening speed seemed to have no influence on the risk of lateral cortex fracture. DISCUSSION Our main hypothesis was confirmed but our secondary hypothesis was refuted: a protective K-wire significantly decreased the risk of hinge fracture, whereas the osteotomy opening speed had no influence. To our knowledge, this is the first published study assessing the potential influence of opening speed on risk of lateral cortex fracture. Our findings were obtained in the laboratory and should be evaluated in clinical practice. LEVEL OF EVIDENCE IV, experimental study.
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Affiliation(s)
- Alexandre Didier
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire ICube, CNRS UMR 7357, 2-4, rue Boussingault, 67000, France
| | - Henri Favreau
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - Matthieu Ollivier
- CNRS, ISM, département de chirurgie orthopédique et traumatologie de chirurgie orthopédique, hôpital Sainte-Marguerite, Institut de la Locomotion, Aix-Marseille université, AP-HM, Marseille, France
| | - Hamdi Jmal
- Laboratoire ICube, CNRS UMR 7357, 2-4, rue Boussingault, 67000, France
| | - François Bonnomet
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - Nadia Bahlouli
- Laboratoire ICube, CNRS UMR 7357, 2-4, rue Boussingault, 67000, France
| | - Pierre Martz
- Service d'orthopédie traumatologie, CHU Dijon, 14, rue Paul-Gaffarel, 21000 Dijon, France; Unité Inserm UMR CAPS U1093. UFR STAPS, Campus universitaire, BP 27877, 21078 Dijon cedex, France
| | - Matthieu Ehlinger
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire ICube, CNRS UMR 7357, 2-4, rue Boussingault, 67000, France.
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Müller S, Frosch KH, Frings J, Berninger M, Krause M. Biplanar high tibial osteotomy for the combined correction of varus and posterior tibial slope malalignment. Orthop Traumatol Surg Res 2022; 109:103339. [PMID: 35643363 DOI: 10.1016/j.otsr.2022.103339] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/16/2022] [Accepted: 03/29/2022] [Indexed: 02/03/2023]
Abstract
Varus malalignment combined with an increased posterior tibial slope (PTS) in the ACL deficient knee is a frequent pathology; yet, treatment for this condition remains challenging. The presented biplanar osteotomy technique allows to simultaneously address both components of malalignment in a single step. A detailed preoperative planning is best achieved by means of a digital planning software and constant intraoperative imaging is performed to verify the correction angle. A bony wedge is resected along with the extension osteotomy according to the preoperative planning and the medial-opening tibial osteotomy site is filled with bone allograft. Two bicortical lag screws are placed in anterior-posterior direction to secure the extension osteotomy, whereas a plate fixation is used for the medial-open osteotomy.
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Affiliation(s)
- Sebastian Müller
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland; Department of Trauma and Orthopaedic Surgery, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany; Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Berninger
- Department of Trauma and Orthopaedic Surgery, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany.
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