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Bansal M, Singh N, Singh A, Siwach G, Saini MK, Raichandani K. The Impact of De-Roofing of Lateral Calcaneal wall in Open Reduction and Internal Fixation of Intra-Articular Fractures: Clinico-Radiological Outcomes of a Novel Technique and Review of Literature. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2024; 14:384-391. [PMID: 39309393 PMCID: PMC11412593 DOI: 10.4103/jwas.jwas_161_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/10/2023] [Indexed: 09/25/2024]
Abstract
Background Most displaced intra-articular calcaneus fractures need to be treated surgically but postoperative soft tissue complications limit to achieve of optimal functional outcomes. Certain mini-invasive techniques lead to better soft tissue healing but anatomical reduction gets compromised. Objectives We aim to evaluate the results of lateral wall de-roofing of the calcaneum to achieve good anatomical reduction as well as to minimise soft tissue complications in the internal fixation of calcaneal fractures. Materials and Methods Thirty-two patients (40 ft) with displaced intra-articular calcaneus fractures (10 were of Sanders type II, 16 were of type III, and 14 were of type IV) were treated between January 2018 and September 2021. All patients were managed surgically with open reduction and internal fixation using lateral extensile approach combined with de-roofing of the lateral wall. All patients were followed up for ≥1 year using functional parameters American Orthopaedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS) and radiological parameters (Bohler angle, Gissane angle, height of the calcaneus, width of the calcaneus and pitch of calcaneus). Results Out of 32 patients, one patient lost to follow-up. At 1 year follow-up, mean AOFAS hindfoot score was 86.2 ± 5 (Sanders type II: 91.2, Sanders type III: 87.6, and Sanders type III: 81.4), mean VAS score was 91.3 ± 2.1, mean Bohler angle (°) was 27.2 ± 4.7, mean Gissane angle (°) was 136.4 ± 5.2, mean calcaneus height was 46.2 ± 2.1 mm and mean calcaneus width was 45.1 ± 3.2 mm. Patients with decreased Bohler angle between postoperative images and follow-up had lower AOFAS hindfoot scores. Complications included persistent swelling (64.10%), stiffness (33.33%), superficial infections (5.12%), and wound dehiscence (10.25%). Conclusion Lateral wall de-roofing is a useful technique which allows the lateral wall to get flattened reducing soft tissue complications and providing bone graft as well. This approach also adequately exposes fracture fragments, subtalar and calcaneocuboid joints for good anatomical reduction. Hence, it can act as a useful adjunct in the internal fixation of intra-articular calcaneus fractures. Level of Evidence III.
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Affiliation(s)
- Mohit Bansal
- Department of Orthopaedics, Dr SN Medical College Jodhpur, Jodhpur, Rajasthan, India
| | - Nirottam Singh
- Department of Orthopaedics, Dr SN Medical College Jodhpur, Jodhpur, Rajasthan, India
| | - Amit Singh
- Department of Orthopaedics, Dr SN Medical College Jodhpur, Jodhpur, Rajasthan, India
| | - Gaurav Siwach
- Department of Orthopaedics, Dr SN Medical College Jodhpur, Jodhpur, Rajasthan, India
| | - Mukesh Kumar Saini
- Department of Orthopaedics, Dr SN Medical College Jodhpur, Jodhpur, Rajasthan, India
| | - Kishore Raichandani
- Department of Orthopaedics, Dr SN Medical College Jodhpur, Jodhpur, Rajasthan, India
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Su Z, Ding M, Zhu N, Cheung JCW, Wong DWC, Sun W, Ni M. Biomechanical role of bone grafting for calcaneal fracture fixation in the presence of bone defect: A finite element analysis. Clin Biomech (Bristol, Avon) 2024; 116:106278. [PMID: 38821036 DOI: 10.1016/j.clinbiomech.2024.106278] [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: 12/26/2023] [Revised: 03/28/2024] [Accepted: 05/20/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND The purpose of this study was to compare the biomechanical stress and stability of calcaneal fixations with and without bone defect, before and after bone grafting, through a computational approach. METHODS A finite element model of foot-ankle complex was reconstructed, impoverished with a Sanders III calcaneal fracture without bone defect and with moderate and severe bone defects. Plate fixations with and without bone grafting were introduced with walking stance simulated. The stress and fragment displacement of the calcaneus were evaluated. FINDINGS Moderate and severe defect increased the calcaneus stress by 16.11% and 32.51%, respectively and subsequently decreased by 10.76% and 20.78% after bone grafting. The total displacement was increased by 3.99% and 24.26%, respectively by moderate and severe defect, while that of posterior joint facet displacement was 86.66% and 104.44%. The former was decreased by 25.73% and 35.96% after grafting, while that of the latter was reduced by 88.09% and 84.78% for moderate and severe defect, respectively. INTERPRETATION Our finite element prediction supported that bone grafting for fixation could enhance the stability and reduce the risk of secondary stress fracture in cases of bone defect in calcaneal fracture.
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Affiliation(s)
- Zhihao Su
- The Ninth People's Hospital of Wuxi Affiliated to Soochow University, Wuxi 214023, China; School of Medical Instrument, Shanghai University of Medicine and Health Sciences, Shanghai 201318, China; Department of Orthopedics, Shanghai Pudong New Area People's Hospital, Shanghai 201299, China.
| | - Ming Ding
- The Ninth People's Hospital of Wuxi Affiliated to Soochow University, Wuxi 214023, China; School of Nursing, Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China.
| | - Ning Zhu
- School of Medical Instrument, Shanghai University of Medicine and Health Sciences, Shanghai 201318, China; Department of Orthopedics, Shanghai Pudong New Area People's Hospital, Shanghai 201299, China
| | - James Chung-Wai Cheung
- Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China.
| | - Duo Wai-Chi Wong
- Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China.
| | - Wanju Sun
- Department of Orthopedics, Shanghai Pudong New Area People's Hospital, Shanghai 201299, China.
| | - Ming Ni
- Department of Orthopedics, Shanghai Pudong New Area People's Hospital, Shanghai 201299, China; Department of Orthopedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China.
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Bo Y, Gao P, Zang Y, Yang H. Analysis of risk factors associated with incision complications in modified "L" approach for calcaneal fracture. Am J Transl Res 2024; 16:1669-1677. [PMID: 38883363 PMCID: PMC11170585 DOI: 10.62347/bnml7981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/30/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE This study aimed to identify risk factors associated with incision complications following the modified "L" approach for calcaneal fractures. METHODS Data from 100 patients treated with the modified "L" approach for calcaneal fractures between January 2018 and December 2021 were analyzed. These included 52 cases in the poorly healing group and 48 in the well-healing group. Variables such as patient age, sex, body mass index, fracture type (Sanders classification), smoking history, alcohol consumption, diabetes status, timing of surgery, tourniquet use, bone grafting, suture method, and postoperative incision care were evaluated. A nomogram was developed using R software to predict the risk of incision complications, validated through the area under the ROC curve, C-index, and decision curve analysis. RESULTS Both univariate and multivariate regression analyses identified fracture type, smoking history, diabetes, timing of surgery, and duration of tourniquet application as significant predictors of incision complications. These factors were incorporated into a clinical predictive nomogram. The nomogram's calibration curves demonstrated high accuracy, both internally and externally. The unadjusted concordance indes (C-index) was 0.793 [95% confidence interval (CI), 0.825-0.995], and the area under the curve for the nomogram was 0.7875882. Decision curve analysis confirmed the clinical applicability of the model at a threshold probability of 20-60%. CONCLUSION We have developed a reliable clinical nomogram to predict the risk factors for incision complications in the modified "L" approach for calcaneal fractures, enhancing decision-making in clinical settings.
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Affiliation(s)
- Yu Bo
- Department of Trauma and Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750004, Ningxia Hui Autonomous Region, China
| | - Pengcheng Gao
- Department of Trauma and Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750004, Ningxia Hui Autonomous Region, China
| | - Yuan Zang
- Skills Training Center, General Hospital of Ningxia Medical University Yinchuan 750004, Ningxia Hui Autonomous Region, China
| | - Haibo Yang
- Department of Trauma and Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750004, Ningxia Hui Autonomous Region, China
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Ryan G, Poon J, Buckley R. ORIF or ORIF with primary subtalar arthrodesis (PSTA) for a Sanders IV fracture? Injury 2024; 55:111454. [PMID: 38432101 DOI: 10.1016/j.injury.2024.111454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Affiliation(s)
- Gareth Ryan
- University of Calgary, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW Calgary, T2N 5A1, Alberta, Canada
| | | | - Richard Buckley
- University of Calgary, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW Calgary, T2N 5A1, Alberta, Canada.
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Vosoughi AR, Medhati P, Hosseini E, Labidi M, Hoveidaei AH. Clinical outcomes following treatment of deep surgical site infection after fixation of calcaneal fractures: A retrospective case-control study. Foot Ankle Surg 2023; 29:334-340. [PMID: 37032190 DOI: 10.1016/j.fas.2023.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/20/2023] [Accepted: 04/01/2023] [Indexed: 04/11/2023]
Abstract
INTRODUCTION Deep surgical site infection (SSI) may be a complication of open reduction and internal fixation (ORIF) of calcaneal fractures. This study aimed to describe the characteristics of patients with deep SSI following ORIF of calcaneal fractures via extensile lateral approach (ELA). We compared clinical outcomes of these patients, with a minimum follow-up of one year after successful treatment of deep SSI with a matched control group. METHODS In this retrospective case-control study, demographic data, fracture characteristics, bacterial pathogens, medical treatments and surgical approaches were collected, also the outcome was evaluated by the visual analog scale (VAS) for pain, foot function index (FFI) and AOFAS ankle-hindfoot score. The differences in Böhler and Gissane's angles between infected and contralateral feet were measured. By matching a control group of uninfected cases, clinical outcomes were compared between 2 groups using the Mann-Whitney U test. RESULTS Among 331 calcaneus fractures in 308 patients (mean age, 38.0 ± 13.1; male/female ratio, 5.5), 21 had deep SSI (6.3 %). There were 16 (76.2 %) males and 5 (23.8 %) females with a mean age of 35.1 ± 11.7 years. Thirteen (61.9 %) patients had unilateral fractures. The most common Sanders Type was found to be type II. The most frequent type of detected microorganisms was Staphylococcus species. Intravenous antibiotic therapy, mostly clindamycin, imipenem and vancomycin, based on the microbiological results, was prescribed with a mean±SD duration of 28.1 ± 16.5 days. The mean number of surgical debridements was 1.8 ± 1.3. Implants needed to be removed in 16 (76.2 %) cases. Antibiotic-impregnated bone cement was applied in three (14.3 %) cases. The clinical outcomes of 15 cases (follow up, 35.5 ± 13.8; range, 12.6-64.5 months) were 4.1 ± 2.0, 16.7 ± 12.3 and 77.5 ± 20.8 for VAS for pain, FFI % and AOFAS ankle-hindfoot score, respectively. Comparing with the control group (VAS for pain, 2.3 ± 2.7; FFI %, 12.2 ± 16.6, and AOFAS, 84.6 ± 18.0), only VAS pain was statistically lower in this group (p-value: 0.012). The differences in Böhler and Gissane's angles between both feet of infected cases were - 14.3 ± 17.9 and - 7.7 ± 22.5 (worse in the infected side), respectively. CONCLUSION Proper on-time approaches to deep infection following ORIF of calcaneal fractures may lead to acceptable clinical and functional outcomes. Sometimes aggressive approaches with intravenous antibiotic therapy, multiple sessions of surgical debridement, removal of implants and antibiotic impregnated cement are necessary to eradicate deep infection. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amir Reza Vosoughi
- Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Pourya Medhati
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elahe Hosseini
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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Martin K, Yoder RG. Calcaneus Fracture and Posterior Arthroscopic Primary Subtalar Arthrodesis (C-PASTA). JBJS Essent Surg Tech 2022; 12:e21.00057. [PMID: 36816530 PMCID: PMC9931041 DOI: 10.2106/jbjs.st.21.00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Complex intra-articular calcaneal fractures often resulted in secondary pain and deformity, requiring subsequent subtalar arthrodesis1-3. The literature suggests that primary subtalar arthrodesis in the acute period has good functional results2,3. The literature also demonstrates that posterior arthroscopic subtalar arthrodesis for chronic arthritis has favorable results5. Thus, we propose an approach to treating these difficult intra-articular calcaneal fractures that utilizes a posterior arthroscopic primary subtalar arthrodesis technique-aptly named Calcaneus Fracture and Posterior Arthroscopic Primary Subtalar Arthrodesis (C-PASTA). Description The procedure begins with the patient in the prone position. The subtalar joint is visualized with a 1.9-mm flexible camera through a standard posterior arthroscopic approach. With the help of the C-arm, position in the subtalar joint space is confirmed. The joint space is debrided with use of a 4-0 shaver and then prepared for arthrodesis arthroscopically with use of an osteotome and a burr. Next, we inject allograft demineralized matrix-based bone putty under direct arthroscopic visualization to fill residual gaps or defects. The arthrodesis is performed under fluoroscopic guidance with use of 2 guidewires followed by 2 to 3 titanium compression screws. The first screw is inserted along the posteromedial calcaneus and into the talar dome medially. The second is placed laterally into the head-neck junction of the talus. The third screw is placed distal to proximal from the plantar anterior process to the talar head. Finally, images are obtained in multiple views to ensure proper screw placement, and the screws are tightened sequentially to ensure equal compression across the joint. Alternatives Nonoperative treatment of calcaneal fractures includes cast immobilization with non-weight-bearing, although this treatment is typically reserved for nondisplaced, small extra-articular fractures6. Operative treatment of calcaneal fractures includes open reduction and internal fixation, which is traditionally performed via a sinus tarsi approach or extensile lateral approach. Primary subtalar arthrodesis has been utilized primarily for Sanders type-IV fractures6. Rationale Displaced intra-articular calcaneal fractures are associated with alarmingly high rates of posttraumatic arthritis (30% to 70% within 1 year of injury), and surgical outcomes are inversely proportional to the severity of the fracture pattern, with Sanders III and IV having the worst outcomes1. Treating these most severe fracture patterns with primary open subtalar arthrodesis has shown favorable results in terms of union rates, pain scores, and functional outcomes throughout the literature2,3. However, some authors have reported rates of revision as high as 60%4. Thus, the PASTA procedure has been established, resulting in significantly better time to union, return to work, activities of daily living, and sports activities compared with open techniques5. Thus, given the favorable results of primary open subtalar arthrodesis and the proven results with use of an arthroscopic technique in the non-acute setting, we propose that C-PASTA can serve as an alternative treatment option in the acute setting for patients with Sanders type-III and IV calcaneal fractures. Expected Outcomes We expect the outcomes of this procedure to mirror those found throughout the literature, which shows favorable results for open primary subtalar arthrodesis1-3. With use of an arthroscopic approach, we expect better time to union, return to work, activities of daily living, and sports activities than if the procedure were performed in an open fashion5. In addition, minimizing soft-tissue damage through an arthroscopic approach may decrease the risk of infection and stimulate postoperative healing, perhaps accounting for the more favorable postoperative recovery period compared with an open procedure. Important Tips In the arthroscopic approach to the subtalar joint, identify the flexor hallucis longus, making sure to stay lateral to that tendon to remain in the "safe zone."Utilizing the TRIMANO device (Arthrex) to distract the ankle longitudinally in addition to a solid bump placed on the anterior aspect of the ankle allows for optimal subtalar joint visualization.Fish-scaling with an osteotome followed by bone grafting allows for a good fill between cancellous fragments to stimulate an optimal environment for fusion.Divergent screws should be placed and tightened sequentially to ensure equal compression across the joint. Abbreviations and Acronyms ADL's = activities of daily livingCT = computed tomographySCD = sequential compression deviceAP = anteroposteriorDVT = deep vein thrombosisBID = twice dailyVit = vitamin.
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Affiliation(s)
- Kevin Martin
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - R. Garrett Yoder
- The Ohio State University College of Medicine, Columbus, Ohio,Email for corresponding author:
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Malik C, Najefi AA, Patel A, Vris A, Malagelada F, Parker L, Heidari N, Jeyaseelan L. Percutaneous subtalar joint screw fixation of comminuted calcaneal fractures: a salvage procedure. Eur J Trauma Emerg Surg 2022; 48:4043-4051. [PMID: 35247058 DOI: 10.1007/s00068-022-01923-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Malunited comminuted calcaneal fractures result in poor function due subtalar joint arthritis and altered biomechanics. We aimed to assess whether percutaneous subtalar joint screws after fracture reduction provide good outcomes for these difficult injuries. METHODS We retrospectively analysed 15 comminuted calcaneal fractures (in 14 patients) treated with percutaneous subtalar screw fixation. All patients had a minimum of 12 months' follow-up. Six patients had open injuries. On the preoperative and the latest postoperative radiograph, Bohlers angle, Gissane angle, calcaneal inclination, width and length, absolute foot height, and posterior facet height were measured. Preoperative computed tomography scans were used to classify the fractures by Sanders classification. Clinical outcome scores were recorded postoperatively. RESULTS Mean age was 34.2 ± 14.2 years. Minimum follow-up was 12 months (mean 17.2 ± 4.4 months). Nine patients had a Sanders 4, 3 had a Sanders 3AB, 2 had a Sanders 3BC, and 1 had a Sanders 3AC fracture. Eighty percent of patients had their angle of Gissane, absolute foot height, calcaneal length and inclination restored by this technique. Bohlers angle was restored back into the normal range in 54% of patients. Mean postoperative AOFAS score was 74 ± 11. AOFAS scores positively correlated with postoperative Bohlers angle (Pearson's correlation coefficient 0.85; p = 0.004). One patient (7%) had a wound breakdown postoperatively and three patients (20%) had heel pain from the screws, which improved after removal. CONCLUSION Percutaneous subtalar screws offer a reliable option to restore calcaneal anatomy in comminuted calcaneal fractures, with low complication rates. Over 80% of patients had their angle of Gissane, calcaneal length and inclination restored, and over 50% of patients had all radiological parameters restored by this technique. It offers the benefits of percutaneous reduction and fixation and this procedure may be considered an effective first stage prior to definitive subtalar fusion. Further work is needed to review the longer-term outcomes and the conversion rate to arthrodesis. LEVEL OF EVIDENCE IV (case series), Therapeutic.
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Affiliation(s)
- Catherine Malik
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK.
| | - Ali Asgar Najefi
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Amit Patel
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Alexandros Vris
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Francesc Malagelada
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Lee Parker
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Nima Heidari
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Lucky Jeyaseelan
- Royal London Hospital, Barts Bone & Joint Health, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
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Abstract
Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. If operative treatment is chosen, anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. Specific approaches are used for rare calcaneal fracture variants.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Michael P Swords
- Michigan Orthopedic Center, Sparrow Hospital, 2815 S. Pennsylvania Avenue, Suite 204 Lansing, MI 48910, USA
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