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Rodham P, Panteli M, Vun JSH, Harwood P, Giannoudis PV. Lower limb post-traumatic osteomyelitis: a systematic review of clinical outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:1863-1873. [PMID: 35986815 PMCID: PMC10276112 DOI: 10.1007/s00590-022-03364-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The aim of this study was to examine the patient-reported outcomes of patients presenting with post-traumatic osteomyelitis (PTOM) of the lower limb over the past 15 years. This period was chosen to reflect modern treatment principles and increased centralisation of care. METHODS An electronic literature search of the relevant databases (PubMed, Ovid Medline, Embase, and the Cochrane library) was conducted to identify studies published between January 2006 and July 2021 reporting series of greater than 10 patients with PTOM of the tibia or femur at the site of a previous fracture. Studies reporting septic non-union were excluded. RESULTS Sixteen eligible studies were identified and included in the final report. Remission of infection was achieved in 93.2% of cases (range 70-100%), whilst amputation was reported in 1-7% of cases. A variety of patient-reported outcome measures were utilised including the lower extremity functional scale, short musculoskeletal functional assessment, Enneking score, and EQ-5D-3L. Limb-specific functional outcomes returned to levels similar to that of the general population although poorer outcomes were noted in specific cohorts including those with complex anatomic disease and active medical comorbidities. CONCLUSION Infection following fracture fixation remains a difficult problem to treat. Regardless, using modern treatments and techniques patients can have comparable functional outcomes to that of the general population. High-quality studies are required to advance our knowledge into which types of treatments offer a benefit and how to further improve outcomes.
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Affiliation(s)
- Paul Rodham
- NIHR Academic Clinical Fellow, Academic Department of Trauma & Orthopaedics, School of Medicine, Leeds General Infirmary, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, UK.
| | - Michalis Panteli
- Lecturer in Trauma & Orthopaedic Surgery, Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - James S H Vun
- Higher Surgical Trainee in Trauma and Orthopaedics, Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Harwood
- Consultant Trauma and Orthopaedic Surgeon, Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Peter V Giannoudis
- Professor of Trauma and Orthopaedics, Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
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Kaur A, Ang KL, Ali S, Dobbs T, Pope-Jones S, Harry L, Whitaker I, Emam A, Marsden N. Free flaps for lower limb soft tissue reconstruction - A systematic review of complications in 'Silver Trauma' patients. Injury 2023:S0020-1383(23)00294-2. [PMID: 37032183 DOI: 10.1016/j.injury.2023.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/20/2023] [Accepted: 03/28/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND There are 12.5 million people aged 65 years and older living in the UK. The annual incidence of open fracture is 30.7 per 10,000 person-years. In females, 42.9% of all open fractures occur in patients ≥ 65 years. METHODS AND MATERIALS Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study is registered with PROSPERO (CRD42020209149). The aim was to compare the complication profiles of free fasciocutaneous flaps and free muscular flaps in patients aged over 60 years undergoing lower limb soft tissue reconstruction following an open lower limb fracture. The search strategy based on strict inclusion criteria included PubMed, Embase and Google Scholar. RESULTS 15 papers were identified, including 46 patients with 10 free fasciocutaneous flaps and 41 free muscle flaps. There were 3 complications in the fasciocutaneous group (30%) and 9 complications in the muscle group (22%). There was a total of 1 secondary procedure in the fasciocutaneous group and 4 in the muscle group. DISCUSSION There is insufficient data to provide statistical comparison between free fasciocutaneous versus free muscle flaps for lower limb reconstruction performed in those aged over 60 years. This systematic review highlights evidence for the successful use of free tissue transfer in the older population following an open fracture injury and requiring lower limb reconstruction. There is no evidence to suggest the superiority of one tissue type over the other, with the inference that well vascularised tissue is the most significant factor impacting outcome.
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Affiliation(s)
- Anjana Kaur
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK.
| | - Ky-Leigh Ang
- University of Cardiff, Cardiff CF10 3AT, Wales, United Kingdom
| | - Stephen Ali
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK; Reconstructive Surgery & Regenerative Medicine Research Centre (ReconRegen), Swansea University Medical School, Institute of Life Sciences, Swansea, SA2 8PP, UK
| | - Tom Dobbs
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK; Reconstructive Surgery & Regenerative Medicine Research Centre (ReconRegen), Swansea University Medical School, Institute of Life Sciences, Swansea, SA2 8PP, UK
| | - Sophie Pope-Jones
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Lorraine Harry
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Iain Whitaker
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK; Reconstructive Surgery & Regenerative Medicine Research Centre (ReconRegen), Swansea University Medical School, Institute of Life Sciences, Swansea, SA2 8PP, UK
| | - Ahmed Emam
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Nicholas Marsden
- The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
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[Augmentation in surgical sepsis : Chances and limitations in the treatment of osteitis with calcium hydroxyapatite containing antibiotics]. Unfallchirurg 2022; 125:452-459. [PMID: 35546643 DOI: 10.1007/s00113-022-01185-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The surgical treatment of osteitis or fracture-related infections (FRI) is often associated with large bone defects. The treatment of these defects remains a major challenge in trauma surgery. Within the concept of tissue engineering, the development of various hybrid bone graft substitutes, such as calcium hydroxyapatite with added antibiotics, is continuously progressing. OBJECTIVE Chances and limitations in the treatment of osteitis with calcium hydroxyapatite containing antibiotics. MATERIAL AND METHODS Overview of the results of a 2-stage (infection) pseudarthrosis model on rat femurs treated with Cerament® G (Bonesupport, Lund, Schweden). Evaluation of the clinical experiences based on three case examples of osteitis treated with calcium hydroxyapatite containing antibiotics (Cerament® G or Cerament® V). RESULTS After establishment of a 2‑stage pseudarthrosis model on the rat femur, the osteoconductive and osteoinductive potential of calcium hydroxyapatite containing antibiotics could be confirmed. In the clinical application, the use of Cerament® G seems to lead to a more favorable outcome in small cavitary defects. The recurrence rates are higher than previously described, especially for larger segmental defects. CONCLUSION Taking the clinical and experimental results into consideration, a stricter evaluation of the indications for the use of Cerament® G is necessary to achieve the best possible outcome for patients.
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Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects. Diagnostics (Basel) 2022; 12:diagnostics12051207. [PMID: 35626362 PMCID: PMC9139791 DOI: 10.3390/diagnostics12051207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/03/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Chronic osteomyelitis (OM) is a progressive but mostly low-grade infection of the bones. The management of this disease is highly challenging for physicians. Despite systematic treatment approaches, recurrence rates are high. Further, functional and patient-reported outcome data are lacking, especially after osseous defects are filled with bioresorbable antibiotic carriers. Objective: To assess functional and patient-reported outcome measures (PROM) following the administration of Cerament® G or V due to corticomedullary defects in chronic OM. Methods: We conducted a retrospective study from 2015 to 2020, including all patients who received Cerament® for the aforementioned reason. Patients were diagnosed and treated in accordance with globally valid recommendations, and corticomedullary defects were filled with Cerament® G or V, depending on the expected germ spectrum. Patients were systematically followed up, and outcome measures were collected during outpatient clinic visits. Results: Twenty patients with Cierny and Mader type III OM were included in this study and followed up for 20.2 ± 17.2 months (95%CI 12.1–28.3). Ten of these patients needed at least one revision (2.0 ± 1.3 revisions per patient (95%CI 1.1–2.9) during the study period due to OM persistence or local wound complications. There were no statistically significant differences in functional scores or PROMs between groups. Conclusion: The use of Cerament® G and V in chronic OM patients with corticomedullary defects appears to have good functional outcomes and satisfactory PROMs. However, the observed rate of local wound complications and the OM persistence rate may be higher when compared to previously published data.
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Zhu H, Gao Y, Wang C, Chen Z, Yu X, Qi X, Sun Q, Zhang W, Song W. A nomogram for decision-making assistance on surgical treatment of chronic osteomyelitis in long bones: Establishment and validation based on a retrospective multicenter cohort. Int J Surg 2022; 99:106267. [PMID: 35202861 DOI: 10.1016/j.ijsu.2022.106267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/04/2022] [Accepted: 02/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic osteomyelitis remains a major challenge for orthopedic surgeons due to its high recurrence rate. Surgeons currently have few tools to estimate the likelihood of individual recurrence. We here aimed to develop a nomogram to better estimate individual recurrence rate after surgical treatment of chronic osteomyelitis in long bones. METHODS We first retrospectively identified patients as training cohort who had received surgical treatment of chronic osteomyelitis in long bones between January 2010 and January 2016 from four hospitals. Patient demographic, microbiological, clinical, and therapeutic variables were collected and analyzed. Univariate and multivariate analyses were performed successively to identify independently predictive factors for recurrence. To reduce overfitting, the Bayesian information criterion was used to reduce variables in the original model. Nomograms were created with the reduced model after model selection. The nomogram was then internally validated with bootstrap resampling. We then further validated the performance of the established nomogram in validation cohort (data from two distinct institutions). RESULTS Recurrence was found in 136 of 655 (20.8%) and 52 of 201 patients (25.9%) in training and validation cohorts respectively. We included six independent prognostic factors for recurrence in our prediction model: number of previous recurrences, epiphysial involvement, preoperative serum albumin level, axial length of the infectious lesion, lesion-removal method, and application of a muscular flap. After incorporating these six factors, the nomogram achieved good discrimination, with concordance indexes of 0.82 (95% CI, 0.79-0.85) and 0.80 (95% CI, 0.78-0.83) in predicting recurrence in the training and validation cohorts, respectively. Calibration curves were well fitted for both training and validation cohorts. CONCLUSIONS Our nomogram achieved good preoperative prediction of recurrence in chronic osteomyelitis of long bones. Using this nomogram, the recurrence risk can be confidently predicted for each patient and treatment plan. After considering and discussing the functional prognosis with patients, physicians can establish a rational therapeutic plan. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Hongyi Zhu
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China Shanghai Eighth People's Hospital, Shanghai, China Shanghai Minhang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China Shanghai Zhujiajiao People's Hospital, Shanghai, China The Fifth Hospital of Wuhan City, Wuhan, Hubei, China Jinghong First People's Hospital, Xishuangbanna, Yunnan, China
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Thai DQ, Jung YK, Hahn HM, Lee IJ. Factors affecting the outcome of lower extremity osteomyelitis treated with microvascular free flaps: an analysis of 65 patients. J Orthop Surg Res 2021; 16:535. [PMID: 34452615 PMCID: PMC8393737 DOI: 10.1186/s13018-021-02686-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/21/2021] [Indexed: 11/19/2022] Open
Abstract
Background Free flaps have been a useful modality in the management of lower extremity osteomyelitis particularly in limb salvage. This study aimed to determine the factors affecting the outcome of free flap reconstruction in the treatment of osteomyelitis. Methods This retrospective study assessed 65 osteomyelitis patients treated with free flap transfer from 2015 to 2020. The treatment outcomes were evaluated in terms of the flap survival rate, recurrence rate of osteomyelitis, and amputation rate. The correlation between outcomes and comorbidities, causes of osteomyelitis, and treatment modalities was analyzed. The following factors were considered: smoking, peripheral artery occlusive disease, renal disease, diabetic foot ulcer, flap types, using antibiotic beads, and negative pressure wound therapy. Result Among the 65 patients, 21 had a severe peripheral arterial occlusive disease. Osteomyelitis developed from diabetic foot ulcers in 28 patients. Total flap failure was noted in six patients, and osteomyelitis recurrence was noted in eight patients, for which two patients underwent amputation surgery during the follow-up period. Only end-stage renal disease had a significant correlation with the recurrence rate (odds ratio = 16.5, p = 0.011). There was no significant relationship between outcomes and the other factors. Conclusion This study showed that free flaps could be safely used for the treatment of osteomyelitis in patients with comorbidities and those who had osteomyelitis developing from diabetic foot ulcers. However, care should be taken in patients diagnosed with end-stage renal disease.
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Affiliation(s)
- Duy Quang Thai
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.,Department of Plastic and Reconstructive Surgery, Hanoi Medical University, 1 Ton That Tung, Kim Lien, Dong Da, Hanoi, Vietnam
| | - Yeon Kyo Jung
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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Pasquesoone L, Barry L, Sturbois-Nachef N, Duquennoy-Martinot V, Chantelot C, Guerre E. The interest of "ortho-plastic" collaboration in management of complex limb injury. ANN CHIR PLAST ESTH 2020; 65:423-446. [PMID: 32654841 DOI: 10.1016/j.anplas.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/21/2020] [Indexed: 01/26/2023]
Abstract
Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.
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Affiliation(s)
- L Pasquesoone
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France.
| | - L Barry
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - N Sturbois-Nachef
- Service d'orthopédie B, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - V Duquennoy-Martinot
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - C Chantelot
- Service de traumatologie, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - E Guerre
- Service d'orthopédie B, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
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Osinga R, Eggimann MM, Lo SJ, Kühl R, Lunger A, Ochsner PE, Sendi P, Clauss M, Schaefer DJ. Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency. J Bone Jt Infect 2020; 5:160-171. [PMID: 32566456 PMCID: PMC7295645 DOI: 10.7150/jbji.47018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction: Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years. Methods and Results: One-hundred sixty patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 47 patients. Of these, six presented with extensor apparatus deficiency. One patient underwent primary arthrodesis and five patients underwent reconstruction of the extensor apparatus. The principle to reconstruct missing tissue 'like with like' was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and two patients who did not qualify for free flap surgery received a pedicled medial sural artery perforator gastrocnemius flap. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo arthrodesis because of recurrent infection and one patient was lost to follow-up. Conclusion: These results show that PJI of the knee and extensor apparatus deficiency is a dreaded combination with a poor long-term outcome. Standardization of surgical techniques for a defined PJI problem and consensus on study variables may facilitate interinstitutional comparisons of outcome data, and hence, improvement of treatment concepts.
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Affiliation(s)
- Rik Osinga
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, United Kingdom
| | | | - Steven John Lo
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, United Kingdom.,Translational Research Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Richard Kühl
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Alexander Lunger
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Peter Emil Ochsner
- Clinic for Orthopedics and Trauma Surgery and Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland, Liestal, Switzerland
| | - Parham Sendi
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.,Institute for Infectious Diseases, University of Bern, Bern, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Clauss
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Clinic for Orthopedics and Trauma Surgery and Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland, Liestal, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Dirk Johannes Schaefer
- Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
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