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Di Summa PG, de Schoulepnikoff C, Guillier D, Cigna E, Jiga LP, Jandali Z, Vezza D, Giacalone F, Ciclamini D, Battiston B, Elia R, Maruccia M. Orthoplastic limb reconstruction using free fibula flap after trauma: Outcomes from a retrospective European multicenter study. Microsurgery 2024; 44:e31054. [PMID: 37170919 DOI: 10.1002/micr.31054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/08/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Free vascularized fibula flap represents the gold standard vascularized bone graft for the management of segmental long bone defects after traumatic injury. The current study represents the largest retrospective multicenter data collection on the use of free fibula flap (FFF) for extremities' orthoplastic reconstruction after trauma aiming to highlight current surgical practice and to set the basis for updating current surgical indications. METHODS The study is designed as a retrospective analysis of prospectively collected data between 2009 and 2021 from six European University hospitals. Patients who underwent fibula flap reconstruction after acute traumatic injury (AF) or as a late reconstruction (LF) after post-traumatic non-union of upper or lower limb were included. Only extra-articular, diaphyseal fracture were included in the study. Surgical data were collected. Time to bone healing and complications were reported as clinical outcomes. RESULTS Sixty-two patients were included in the study (27 in the AF group and 35 in the LF group). The average patients' age at the time of the traumatic event was 45.3 ± 2.9 years in the AF group and 41.1 ± 2.1 years in the LF group. Mean bone defect size was 7.7 ± 0.6 cm for upper limb and 11.2 ± 1.1 cm (p = .32) for lower limb. Bone healing was uneventful in 69% of treated patients, reaching 92% after complementary procedures. Bone healing time was 7.6 ± 1.2 months in the acute group and 9.6 ± 1.5 months in the late group. An overall complication rate of 30.6% was observed, with a higher percentage of late bone complications in the LF group (34%), mostly non-union cases. CONCLUSIONS FFF reconstruction represents a reliable and definitive solution for long bone defects with bone healing reached in 92% cases with a 8.4 months of average bone healing time.
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Affiliation(s)
- Pietro G Di Summa
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Camille de Schoulepnikoff
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - David Guillier
- Department of Plastic and Maxillo-facial Surgery, University Hospital of Dijion, Dijion, France
| | - Emanuele Cigna
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Lucian P Jiga
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Zaher Jandali
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Daniele Vezza
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Francesco Giacalone
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Davide Ciclamini
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Bruno Battiston
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Rossella Elia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Michele Maruccia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
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Oka K, Kaji Y, Nakamura O, Yamaguchi K, Tobiume S, Nomura Y, Yamamoto T. Addition of a Vascular Bundle Accelerates Bone Union in Femoral Bone Defects. J Reconstr Microsurg 2023; 39:1-8. [PMID: 35272371 DOI: 10.1055/s-0042-1743256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The Masquelet method has become increasingly popular for the treatment of bone defects in recent years. In this method, an induced membrane (IM) with abundant blood circulation, stem cells, and osteogenesis-promoting factors is formed by implanting bone cement during the first surgery. This IM stimulates bone formation in the bone defect after implantation of the bone graft during the second surgery. However, the Masquelet method requires two surgeries and thus a longer treatment period. In the present study, we investigated whether bone defects could be reconstructed in a single surgery by introducing a vascular bundle into the bone defect as an alternative to the IM, in addition to bone grafting. METHODS Thirty-six 12-week-old female Sprague-Dawley rats were used. After creating a 5-mm long bone defect in the femur, a mixture of autologous and artificial bone was grafted into the defect, and a saphenous arteriovenous vascular bundle was introduced. The animals were divided into three groups: the control group (bone defect only), the BG group (bone grafting only), and the BG + V group (bone grafting + vascular bundle introduction). After surgery, radiological and histological evaluations were performed to assess osteogenesis and angiogenesis in bone defects. RESULTS In the BG + V group, significant bone formation was observed in the bone defect on radiological and histological evaluations, and the amount of bone formation was significantly higher than that in the other two groups. Furthermore, cortical bone continuity was observed in many specimens in the BG + V group. On histological evaluation, the number of blood vessels was also significantly higher in the BG + V group than in the other two groups. CONCLUSION Our results suggest that the introduction of a vascular bundle in addition to bone grafting can promote bone formation in bone defects and allow for complete bone defect reconstruction in a single surgery.
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Affiliation(s)
- Kunihiko Oka
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Yoshio Kaji
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Osamu Nakamura
- Department of Orthopedic Surgery, Kagawa Prefectural Shirotori Hospital, Higashikagawa City, Kagawa, Japan
| | - Konosuke Yamaguchi
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Sachiko Tobiume
- Department of Orthopedic Surgery, Shikoku Medical Center for Children and Adults, Zentsuji City, Kagawa, Kagawa, Japan
| | - Yumi Nomura
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Tetsuji Yamamoto
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
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Pan RL, Martyniak K, Karimzadeh M, Gelikman DG, DeVries J, Sutter K, Coathup M, Razavi M, Sawh-Martinez R, Kean TJ. Systematic review on the application of 3D-bioprinting technology in orthoregeneration: current achievements and open challenges. J Exp Orthop 2022; 9:95. [PMID: 36121526 PMCID: PMC9485345 DOI: 10.1186/s40634-022-00518-3] [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: 06/16/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Joint degeneration and large or complex bone defects are a significant source of morbidity and diminished quality of life worldwide. There is an unmet need for a functional implant with near-native biomechanical properties. The potential for their generation using 3D bioprinting (3DBP)-based tissue engineering methods was assessed. We systematically reviewed the current state of 3DBP in orthoregeneration. METHODS This review was performed using PubMed and Web of Science. Primary research articles reporting 3DBP of cartilage, bone, vasculature, and their osteochondral and vascular bone composites were considered. Full text English articles were analyzed. RESULTS Over 1300 studies were retrieved, after removing duplicates, 1046 studies remained. After inclusion and exclusion criteria were applied, 114 articles were analyzed fully. Bioink material types and combinations were tallied. Cell types and testing methods were also analyzed. Nearly all papers determined the effect of 3DBP on cell survival. Bioink material physical characterization using gelation and rheology, and construct biomechanics were performed. In vitro testing methods assessed biochemistry, markers of extracellular matrix production and/or cell differentiation into respective lineages. In vivo proof-of-concept studies included full-thickness bone and joint defects as well as subcutaneous implantation in rodents followed by histological and µCT analyses to demonstrate implant growth and integration into surrounding native tissues. CONCLUSIONS Despite its relative infancy, 3DBP is making an impact in joint and bone engineering. Several groups have demonstrated preclinical efficacy of mechanically robust constructs which integrate into articular joint defects in small animals. However, notable obstacles remain. Notably, researchers encountered pitfalls in scaling up constructs and establishing implant function and viability in long term animal models. Further, to translate from the laboratory to the clinic, standardized quality control metrics such as construct stiffness and graft integration metrics should be established with investigator consensus. While there is much work to be done, 3DBP implants have great potential to treat degenerative joint diseases and provide benefit to patients globally.
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Affiliation(s)
- Rachel L Pan
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Kari Martyniak
- Biionix Cluster, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Makan Karimzadeh
- Biionix Cluster, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - David G Gelikman
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Jonathan DeVries
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Kelly Sutter
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Melanie Coathup
- Biionix Cluster, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Mehdi Razavi
- Biionix Cluster, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Rajendra Sawh-Martinez
- College of Medicine, University of Central Florida, Orlando, FL, USA.,Plastic and Reconstructive Surgery, AdventHealth, Orlando, FL, USA
| | - Thomas J Kean
- Biionix Cluster, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA.
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Siebert MJ, Makarewich CA. Anterolateral Tibial Bowing and Congenital Pseudoarthrosis of the Tibia: Current Concept Review and Future Directions. Curr Rev Musculoskelet Med 2022; 15:438-446. [PMID: 35841513 PMCID: PMC9789274 DOI: 10.1007/s12178-022-09779-y] [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] [Accepted: 06/30/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Congenital pseudarthrosis of the tibia (CPT) is a rare condition closely associated with neurofibromatosis type I. Affected children are born with anterolateral bowing of the tibia which progresses to pathologic fracture, pseudarthrosis, and high risk of refracture even after initial union has been attained. There is currently no consensus on the classification of this disease or consensus on its treatment. The purpose of this review is to (1) review the clinical presentation, etiology, epidemiology, classification, and natural history of congenital pseudarthrosis of the tibia and (2) review the existing trends in treatment of congenital pseudarthrosis of the tibia and its associated complications. RECENT FINDINGS Current treatment protocols focus primarily on combining intramedullary fixation with external or internal fixation to achieve union rates between 74 and 100%. Intramedullary devices should be retained as long as possible to prevent refracture. Cross-union techniques, though technically difficult, have a reported union rate of 100% and no refractures at mid- to long-term follow-up. Vascularized fibular grafting and induced membrane technique can be successful, but at the cost of numerous surgical procedures. Growth modulation is a promising new approach to preventing fracture altogether, though further study with larger patient series is necessary. The primary consideration in treatment of CPT is expected union rate and refracture risk. Combined intramedullary and external or internal fixation, especially with cross-union techniques, show most promise. Perhaps most exciting is further research on preventing fracture through guided growth, which may reduce the morbidity of multiple surgical procedures which have been the mainstay of treatment for CPT thus far.
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Affiliation(s)
- Matthew J. Siebert
- grid.223827.e0000 0001 2193 0096Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 USA
| | - Christopher A. Makarewich
- grid.223827.e0000 0001 2193 0096Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 USA ,grid.415178.e0000 0004 0442 6404Primary Children’s Hospital, Salt Lake City, UT USA ,grid.509583.2Shriners Children’s, Salt Lake City, Utah USA
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Ji C, Li M, Huang M, Xiao X, Long Z, Chen G, Pei Y, Lu Y, Li J. Establishment of a rabbit's model for modified Capanna technique. J Plast Reconstr Aesthet Surg 2022; 75:2119-2126. [DOI: 10.1016/j.bjps.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 01/02/2022] [Accepted: 02/12/2022] [Indexed: 11/24/2022]
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Migliorini F, La Padula G, Torsiello E, Spiezia F, Oliva F, Maffulli N. Strategies for large bone defect reconstruction after trauma, infections or tumour excision: a comprehensive review of the literature. Eur J Med Res 2021; 26:118. [PMID: 34600573 PMCID: PMC8487570 DOI: 10.1186/s40001-021-00593-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/20/2021] [Indexed: 12/16/2022] Open
Abstract
Large bone defects resulting from musculoskeletal tumours, infections, or trauma are often unable to heal spontaneously. The challenge for surgeons is to avoid amputation, and provide the best functional outcomes. Allograft, vascularized fibular or iliac graft, hybrid graft, extracorporeal devitalized autograft, distraction osteogenesis, induced-membrane technique, and segmental prostheses are the most common surgical strategies to manage large bone defects. Given its optimal osteogenesis, osteoinduction, osteoconduction, and histocompatibility properties, along with the lower the risk of immunological rejection, autologous graft represents the most common used strategy for reconstruction of bone defects. However, the choice of the best surgical technique is still debated, and no consensus has been reached. The present study investigated the current reconstructive strategies for large bone defect after trauma, infections, or tumour excision, discussed advantages and disadvantages of each technique, debated available techniques and materials, and evaluated complications and new perspectives.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Gerardo La Padula
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Filippo Spiezia
- Ospedale San Carlo Potenza, Via Potito Petrone, 85100, Potenza, Italy
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England
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Georgiadis AG, Morrison SG, Dahl MT. What's New in Limb Lengthening and Deformity Correction. J Bone Joint Surg Am 2021; 103:1467-1472. [PMID: 34156990 DOI: 10.2106/jbjs.21.00584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Andrew G Georgiadis
- Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Stewart G Morrison
- The Royal Children's Hospital, Parkville, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Mark T Dahl
- Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, St. Paul, Minnesota.,Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Lippross S, Tsaknakis K, Lorenz HM, Hell AK. [Congenital pseudarthrosis of the tibia : A rare often underestimated disorder]. Unfallchirurg 2021; 124:755-767. [PMID: 34398278 DOI: 10.1007/s00113-021-01061-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/29/2022]
Abstract
Congenital pseudarthrosis of the tibia (CPT) is a rare disease that has challenged trauma and orthopedic surgeons for a long time. Clinically CPT mostly presents with progressive varus and antecurvation malformation of the tibia in infancy and childhood. In many cases CPT is associated with neurofibromatosis or fibrous dysplasia. Without knowledge of the clinical picture a discontinuity of the tibia and/or fibula visible on an X‑ray can be misinterpreted as a simple fracture. Histopathological investigations have revealed that a pathological alteration of the periosteum in the region of the pseudarthrosis, a hamartoma, may be essentially responsible for this disorder. Consequently, to treat the CPT a resection of the hamartoma must also be carried out. Multimodal treatment approaches combining pharmacological and surgical treatment, such as the cross-union technique of Paley, seem to have improved the prognosis of CPT.
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Affiliation(s)
- Sebastian Lippross
- Klinik für Orthopädie und Unfallchirurgie, UKSH Campus Kiel, Kiel, Deutschland
| | - Konstantinos Tsaknakis
- Kinderorthopädie, Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Heiko M Lorenz
- Kinderorthopädie, Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Anna K Hell
- Kinderorthopädie, Operatives Kinderzentrum, Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
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Kotsougiani-Fischer D, Fischer S, Warszawski J, Gruetzner PA, Reiter G, Hirche C, Kneser U. Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation. BMC Surg 2021; 21:168. [PMID: 33781250 PMCID: PMC8006355 DOI: 10.1186/s12893-021-01169-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background This study aimed to assess a multidisciplinary team (MDT) meeting approach for the management of patients with complex extremity defects, analyze treatment recommendations, and evaluate factors influencing non-implementation. Methods All patients introduced to an MDT meeting for complex extremity defects from 2015 to 2017 were included in a retrospective cohort study. Patients’ characteristics and defect causes were evaluated. Treatment recommendations (TR) of MDT meetings and subsequent implementation were reviewed (cohort with implementation of TR versus cohort with non-implementation of TR), and factors associated with non-adherence to recommendations were statistically analyzed using logistic regression. Results Fifty-one patients (41 male) with a mean age of 54 years were presented in 27 MDT meetings. Most of the patients (70%) suffered from reconstructive challenging or combined bone- and soft tissue defects, primarily located at the lower extremity (88%). Large skeletal defects, chronic osteomyelitis, and multi-fragmented fractures were present in 65% of cases. Forty-five percent of the patients suffered from peripheral vascular disease, necessitating surgical optimization. Of the 51 MDT decisions, 40 were implemented (78%; (32/40) limb salvage versus 22%; (8/40) limb amputation). Limb salvage was successfully achieved in 91% (29/32) of the cases. Failed limb salvages were due to flap failure (33%; 1/3), recurring periprosthetic joint infections (66%; 2/3) and concomitant reconstructive failure. Patients who underwent limb amputation, as recommended, showed proper stump healing and regained mobility with a prosthesis. Overall the MDT treatment plan was effective in 92.5% (37/40) of the patients, who adhered to the MDT treatment recommendation. In eleven patients (22%; 11/51), the MDT treatment was not implemented. MDT decisions were less likely to be implemented, if amputation was recommended (p = 0.029). Conclusions MDT meetings represent a valid tool to formulate individualized treatment plans, avoiding limb amputation in most patients with severe extremity defects. Recommendation for limb amputation is less likely to be implemented than plans for limb salvage. Trial registration: Retrospectively registered
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Affiliation(s)
- Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany.
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Jan Warszawski
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Paul A Gruetzner
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Gregor Reiter
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
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