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Lewis S, Inglis S, Doyle S. The role of anatomical context in soft-tissue multi-organ segmentation of cadaveric non-contrast-enhanced whole body CT. Med Phys 2023; 50:5061-5074. [PMID: 36847064 PMCID: PMC10440264 DOI: 10.1002/mp.16330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Cadaveric computed tomography (CT) image segmentation is a difficult task to solve, especially when applied to whole-body image volumes. Traditional algorithms require preprocessing using registration, or highly conserved organ morphologies. These requirements cannot be fulfilled by cadaveric specimens, so deep learning must be used to overcome this limitation. Further, the widespread use of 2D algorithms for volumetric data ignores the role of anatomical context. The use of 3D spatial context for volumetric segmentation of CT scans as well as the anatomical context required to optimize the segmentation has not been adequately explored. PURPOSE To determine whether 2D slice-by-slice UNet algorithms or 3D volumetric UNet (VNet) algorithms provide a more effective method for segmenting 3D volumes, and to what extent anatomical context plays in the segmentation of soft-tissue organs in cadaveric, noncontrast-enhanced (NCE) CT. METHODS We tested five CT segmentation algorithms: 2D UNets with and without 3D data augmentation (3D rotations) as well as VNets with three levels of anatomical context (implemented via image downsampling at 1X, 2X, and 3X) for their performance via 3D Dice coefficients, and Hausdorff distance calculations. The classifiers were trained to segment the kidneys and liver and the performance was evaluated using Dice coefficient and Hausdorff distance on the segmentation versus the ground truth annotation. RESULTS Our results demonstrate that VNet algorithms perform significantly better (p < 0.05 $p<0.05$ ) than 2D models. Among the VNet classifiers, those that use some level of image downsampling outperform (as calculated through Dice coefficients) the VNet without downsampling. Additionally, the optimal amount of downsampling depends on the target organ. CONCLUSIONS Anatomical context is an important component of soft-tissue, multi-organ segmentation in cadaveric, NCE CT imaging of the whole body. Different amounts of anatomical contexts are optimal depending on the size, position, and surrounding tissue of the organ.
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Affiliation(s)
- Steven Lewis
- Department of Pathology Anatomical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Stuart Inglis
- Department of Pathology Anatomical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Scott Doyle
- Department of Pathology Anatomical Sciences, University at Buffalo, Buffalo, New York, USA
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Luciani AM, Baylor J, Akoon A, Grandizio LC. Controversies in the Management of Bicolumnar Fractures of the Distal Humerus. J Hand Surg Am 2023; 48:177-186. [PMID: 36379867 DOI: 10.1016/j.jhsa.2022.10.006] [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: 06/26/2022] [Revised: 08/20/2022] [Accepted: 10/10/2022] [Indexed: 11/14/2022]
Abstract
Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.
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Affiliation(s)
- Alfred Michael Luciani
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jessica Baylor
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Anil Akoon
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
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Younis AS, Awad MES, Samy TM, Osman WS, Abdeldayem SM, Zakaria ZM, Fathy A, Metwaly RG. Clinical Efficacy of Preoperative CT-Assisted Planning for Primary Total Knee Arthroplasty: A Pilot Randomized Clinical Trial. J Knee Surg 2022; 35:1385-1392. [PMID: 33618403 DOI: 10.1055/s-0041-1723971] [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
This study aims to determine the mean posterior condylar angle (PCA) in the included population and its relation to coronal alignment; and to know the clinical importance of the use of preoperative computed tomography (CT) scan in total knee arthroplasty (TKA). We randomized 50 patients with primary knee osteoarthritis into 2 groups. We used CT scan axial images to measure the PCA. In the first group we followed the CT scan plan (group 1), but in the second we did not follow the plan and adjusted rotation to the standard three degrees (group 2). The mean age of the included patients was 63 years. The radiological data of the included patients showed 5 patients with valgus deformity and 45 patients with varus deformity with the mean coronal alignment of 7.5 degrees. CT scan showed the mean PCA of 3.7 degrees (1.3 degrees). The axial knee postoperative X-ray showed the mean patellar tilt angle of 2.1 degrees (0.5 degrees) and 1.9 degrees (0.5 degrees) in groups 1 and 2, respectively. The congruence angle was 4 degrees (2.6 degrees) in group 1 and 5.5 degrees (3.2 degrees) in group 2. The median Knee Society functional score in group 1 was 85 (12), while it was 84 (7.5) in group 2. The median postoperative Western Ontario and McMaster Universities Arthritis Index score in group 1 was 84 (18.6) whereas 80.2 (13.6) in group 2. The median postoperative Bartlett score in group 1 was 30 (5), while it was 30 (6) in group 2. The use of preoperative CT scan did not improve the patient functional scores after TKA.
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Affiliation(s)
| | | | - Tarek M Samy
- Department of Orthopaedics, Ain Shams University, Cairo, Egypt
| | | | | | - Zeiad M Zakaria
- Department of Orthopaedics, Ain Shams University, Cairo, Egypt
| | - Ayman Fathy
- Department of Orthopaedics, Ain Shams University, Cairo, Egypt
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Effect Evaluation of Perioperative Fast-Track Surgery Nursing for Tibial Fracture Patients with Computerized Tomography Images under Intelligent Algorithm. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2629868. [PMID: 35845737 PMCID: PMC9249477 DOI: 10.1155/2022/2629868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/23/2022]
Abstract
This study aimed to study the application value of computerized tomography (CT) images under the graph cut algorithm in the effect evaluation of perioperative fast-track surgery (FTS) nursing in tibial fracture. In this study, 80 tibial fracture patients in the perioperative period were selected as the research objects. These objects were randomly divided into two groups according to the examination method. In group A, routine CT examination was performed; in group B, CT examination under the graph cut algorithm was applied. The imaging results showed that there were still 16 cases with collapse of group A and 34 cases with collapse of group B; the difference was statistically significant (P < 0.05). As for 16 cases with collapse in both groups, the average collapse shown in group A was about 2.79 ± 1.31 mm, while that in group B was 5.51 ± 1.88 mm, with a statistically significant difference (P < 0.05). The average broadening in the images of group A was 3.17 ± 1.41 mm and that of group B was 5.72 ± 1.83 mm, suggesting that the difference was statistically significant (P < 0.05). The broadening distance of 3-4 mm was mainly shown in the images of group A and that of 5-8 mm was shown in group B, with a statistical difference (P < 0.05). In terms of the total score, there were 26, 44, 8, and 2 cases that were assessed as excellent, good, common, and bad, respectively, in group A, while 44 cases were assessed as good and 36 cases were assessed as common in group B, which were significantly different (P < 0.05). In summary, the graph cut algorithm not only had a good segmentation effect and segmentation efficiency but also could improve the evaluation of CT images for perioperative FTS nursing effect in patients with tibial fracture.
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Sahovaler A, Daly MJ, Chan HHL, Nayak P, Tzelnick S, Arkhangorodsky M, Qiu J, Weersink R, Irish JC, Ferguson P, Wunder JS. Automatic Registration and Error Color Maps to Improve Accuracy for Navigated Bone Tumor Surgery Using Intraoperative Cone-Beam CT. JB JS Open Access 2022; 7:JBJSOA-D-21-00140. [PMID: 35540727 PMCID: PMC9071254 DOI: 10.2106/jbjs.oa.21.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Computer-assisted surgery (CAS) can improve surgical precision in orthopaedic oncology. Accurate alignment of the patient’s imaging coordinates with the anatomy, known as registration, is one of the most challenging aspects of CAS and can be associated with substantial error. Using intraoperative, on-the-table, cone-beam computed tomography (CBCT), we performed a pilot clinical study to validate a method for automatic intraoperative registration.
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Affiliation(s)
- Axel Sahovaler
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Head & Neck Surgery Unit, University College London Hospitals, London, United Kingdom
| | - Michael J Daly
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Harley H L Chan
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Prakash Nayak
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgical Oncology, Bone and Soft Tissue Disease Management Group, Tata Memorial Centre, Mumbai, India
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sharon Tzelnick
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Michelle Arkhangorodsky
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Jimmy Qiu
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Robert Weersink
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Peter Ferguson
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jay S Wunder
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
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Kumar V, Baburaj V, Patel S, Sharma S, Vaishya R. Does the use of intraoperative CT scan improve outcomes in Orthopaedic surgery? A systematic review and meta-analysis of 871 cases. J Clin Orthop Trauma 2021; 18:216-223. [PMID: 34040978 PMCID: PMC8138210 DOI: 10.1016/j.jcot.2021.04.030] [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] [Received: 03/04/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraoperative imaging is frequently made use of in Orthopaedic surgery. Historically, conventional 2-dimensional fluoroscopy has been extensively used for this purpose. However, 2D imaging falls short when it is required to visualise complex anatomical regions such as pelvis, spine, foot and ankle etc. Intraoperative 3D imaging was introduced to counter these limitations, and is increasingly being employed in various sub-specialities of Orthopaedic Surgery. OBJECTIVES This review aims to outline the clinical and radiological outcomes of surgeries done under the guidance of intraoperative 3D imaging and compare them to those done under conventional 2D fluoroscopy. METHODS Three electronic databases (PubMed, Embase and Scopus) were searched for relevant studies that directly compared intraoperative 3D imaging with conventional fluoroscopy. Case series on intraoperative 3D imaging were also included for qualitative synthesis. The outcomes evaluated included accuracy of implant placement, mean surgical duration and rate of revision surgery due to faulty implants. RESULTS A total of 31 studies from sub-specialities of spine surgery, pelvi-acetabular surgery, foot and ankle surgery and trauma surgery, having data on a total of 658 patients were analysed. The study groups which had access to intraoperative 3D imaging was found to have significantly increased accuracy of implant positioning (Odds Ratio 0.35 [0.20, 0.62], p = 0.0002) without statistically significant difference in mean surgical time (p = 0.57). Analysis of the studies that included clinical follow up showed that the use of intraoperative 3D imaging led to a significant decrease in the need for revision surgeries due to faulty implant placement. CONCLUSION There is sufficient evidence that the application of intraoperative 3D imaging leads to precise implant positioning and improves the radiological outcome. Further research in the form of prospective studies with long term follow up is required to determine whether this superior radiological outcome translates to better clinical results in the long run.
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Affiliation(s)
- Vishal Kumar
- Department of Orthopaedics, Postgraduate Institute of Medial Education and Research, Chandigarh, India
| | - Vishnu Baburaj
- Department of Orthopaedics, Postgraduate Institute of Medial Education and Research, Chandigarh, India
| | - Sandeep Patel
- Department of Orthopaedics, Postgraduate Institute of Medial Education and Research, Chandigarh, India
| | - Siddhartha Sharma
- Department of Orthopaedics, Postgraduate Institute of Medial Education and Research, Chandigarh, India
| | - Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospitals, New Delhi, India
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Morrey ME, Morrey BF, Sanchez-Sotelo J, Barlow JD, O'Driscoll S. A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty. J Clin Orthop Trauma 2021; 20:101477. [PMID: 34211832 PMCID: PMC8237363 DOI: 10.1016/j.jcot.2021.101477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions. In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.
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Affiliation(s)
- Mark E. Morrey
- Corresponding author. Orthopaedic Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
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The use of ionising radiation in orthopaedic surgery: principles, regulations and managing risk to surgeons and patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:947-955. [PMID: 33825954 DOI: 10.1007/s00590-021-02955-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/21/2021] [Indexed: 12/28/2022]
Abstract
The use of ionising radiation for plain film radiography and computerised tomography is fundamental in both diagnostics and treatment for orthopaedics. However, radiation is not without risk as high exposure can increase the risk of cancer. Little time is spent educating doctors about the relative risks of radiation, both to patients and themselves. In addition, there are common misunderstandings about the best ways to mitigate such risk. We aim to provide an overview of the fundamental principles of the use of ionising radiation and its risks within the context of orthopaedic surgery. While providing a narrative review of the current literature, we discuss the basic physics, standards of good practice and relevant UK and European regulations. We discuss the risks to patients and surgeons and suggest ways that these can be mitigated in the operating theatre. A thorough understanding of the risks, and appropriate procedural rules, with respect to the use of ionising radiation is essential for those in orthopaedic practice.
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Keil H, Luxenhofer M, Vetter SY, Beisemann N, Grützner PA, Franke J. Evaluation of image quality and assessability of a new flat‐panel 3D C‐arm compared to mobile and fixed computed tomography in posterior spinal fixation. Int J Med Robot 2020; 17:e2181. [DOI: 10.1002/rcs.2181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/25/2020] [Accepted: 10/07/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Holger Keil
- Department of Trauma and Orthopaedic Surgery Krankenhausstr Universitätsklinikum Erlangen Erlangen Germany
| | - Miriam Luxenhofer
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Sven Y. Vetter
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Nils Beisemann
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Paul A. Grützner
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
| | - Jochen Franke
- BG Trauma Center Ludwigshafen Department of Trauma and Orthopaedic Surgery Ludwigshafen Germany
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Abstract
BACKGROUND Numerous processes are involved in the orthopedic and trauma surgery operating room (OR). Technical progress, particularly in the area of digitalization, is increasingly changing routine surgical procedures. OBJECTIVE This article highlights the possibilities and also limitations regarding this matter. MATERIAL AND METHODS Based on the current literature this article provides insights into innovations in the areas of digitalization of surgical devices, hybrid OR, machine-2-machine networking, management systems for perioperative efficiency improvement, 3D printing technology and robotics. RESULTS The technical possibilities for the use of digital applications in the surgical environment are rapidly increasing. Close cooperation with industrial partners is important in this context. Technologies from the automotive, gaming and mobile phone industries are being adopted. CONCLUSION Digital technology in the OR can improve treatment quality, patient and staff safety and cost efficiency; however, the networking of devices, implementation of innovations in existing structures and the sometimes high acquisition costs are still limiting factors.
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Affiliation(s)
- B Swartman
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
| | - J Franke
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - C Schnurr
- Klinik für Orthopädie, St. Vinzenz Krankenhaus, Verbund Katholischer Kliniken Düsseldorf, Amalienstr. 9, 40472, Düsseldorf, Deutschland
| | - S Märdian
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - C Willy
- Klinik für Unfallchirurgie und Orthopädie, Bundeswehrkrankenhaus Berlin, Berlin, Deutschland
| | | | | | - D A Back
- Klinik für Unfallchirurgie und Orthopädie, Bundeswehrkrankenhaus Berlin, Berlin, Deutschland
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