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Schmitt R, Grunz JP, Langer M. Triangular fibrocartilage complex injuries - limitations of the current classification systems and the proposed new 'CUP' classification. J Hand Surg Eur Vol 2023; 48:60-66. [PMID: 36113053 DOI: 10.1177/17531934221121931] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Rainer Schmitt
- Department of Radiology, University Hospital, LMU Munich, Muenchen, Germany.,Department of Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jan-Peter Grunz
- Department of Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Martin Langer
- Department of Hand Surgery, University Hospital Muenster, Muenster, Germany
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2
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Degeneration of the articular disc in the human triangular fibrocartilage complex. Arch Orthop Trauma Surg 2021; 141:699-708. [PMID: 33550482 DOI: 10.1007/s00402-021-03795-2] [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: 12/12/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Traumatic injuries of the triangular fibrocartilage complex (TFCC) are frequent reasons for ulnar wrist pain. The assessment of the extent of articular disc (AD) degeneration is important for the differentiation of acute injuries versus chronic lesions. MATERIALS AND METHODS The AD of the TFCC of eleven human cadaver wrists was dissected. Degeneration was analyzed according to the grading of Krenn et al. Hematoxylin-eosin was used to determine the tissue morphology. Degeneration was evaluated using the staining intensity of alcian blue, the immunohistochemistry of the proteoglycan versican and the immunoreactivity of NITEGE, an aggrecan fragment. RESULTS The staining homogeneity of HE decreased with higher degeneration of the AD and basophilic tissue areas were more frequently seen. Two specimens were characterized as degeneration grade 1, five specimens as grade 2, and four specimens as grade 3, respectively. Staining intensity of alcian blue increased with higher degeneration grade of the specimens. Immunoreactivity for NITEGE was detected around tissue fissures and perforations as well as matrix splits. Immunoreactivity for versican was found concentrated in the tissue around matrix fissures and lesions as well as loose connective tissue at the ulnar border of the AD. Specimens with degeneration grade 2 had the strongest immunoreactivity of NITEGE and versican. Cell clusters were observed in specimens with degeneration grade 2 and 3, which were stained by alcian blue and immunoreactive for NITEGE and versican. Increasing age of the cadaver wrists correlated with a higher degree of degeneration (p < 0.0001, r = 0.68). CONCLUSIONS The fibrocartilage of degenerated ADs contains NITEGE and versican. The amount of the immunoreactivity of these markers allows the differentiation of degenerative changes into three grades. The degeneration of the AD increases with age and emphasizes its important mechanical function.
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Asmus A, Salloum M, Medeiros W, Millrose M, Obladen A, Goelz L, Diehl J, Eisenschenk A, Ekkernkamp A, Kim S. Increase of weight-bearing capacity of patients with lesions of the TFCC using a wrist brace. J Hand Ther 2021; 35:575-580. [PMID: 34011468 DOI: 10.1016/j.jht.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 12/07/2020] [Accepted: 03/21/2021] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Retrospective cross-sectional case series. BACKGROUND Lesions of the triangular fibrocartilage complex (TFCC) can result in pain during axial load and unstable distal radioulnar joint (DRUJ). Conventional wrist orthoses decrease initial pain sufficiently but also prevent any movement during recovery and do not contribute to the stabilization of the DRUJ. PURPOSE In this retrospective analysis, we tested if the weight-bearing capacity of patients with lesions of the triangular fibrocartilage complex was increased by wearing a brace that stabilizes the distal radioulnar joint. METHODS Twenty-three patients had an arthroscopically confirmed TFCC lesion. We compared preoperative dynamic weight-bearing capacity of both hands with and without a commercially available wrist brace (WristWidget). Subgroup analysis was performed for stability of the distal radioulnar joint and etiology of the TFCC lesion. The dynamic ulnar variance was measured in a modified weight bearing test. We used parametric tests for normally distributed values. RESULTS The weight-bearing capacity of the hand with TFCC lesion was significantly lower than of the control hand (16 verus 36 kg; p <0.001). The relative load of the affected hand compared to the unaffected hand increased from 48 % (CI 37-60, SD 27) to 59 % (CI 47-72, SD 29 with a brace. The device had no effect on the control hand. Twelve patients with unstable DRUJ had a lower weight-bearing capacity compared to the eleven with stable joint. The percentage improvement with bracing was higher for those with unstable joints (versus stable) and traumatic lesions (versus degenrative). CONCLUSION The use of a wrist brace significantly increases the weight-bearing capacity and therefore the maximum tolerated axial load of patients with a lesion of the TFCC. Patients with traumatic lesion or unstable DRUJ tend to show lower values than with degenerative lesions or stable joints.
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Affiliation(s)
- A Asmus
- Abteilung für Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Berlin, Germany
| | - M Salloum
- Abteilung für Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Berlin, Germany
| | - W Medeiros
- Wendy Medeiros, Pahoa, HI, United States
| | - M Millrose
- Department of Trauma Surgery and Sports Orthopaedics, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau am Staffelsee, Germany
| | - A Obladen
- Abteilung für Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Berlin, Germany
| | - L Goelz
- Institut für Radiologie und Neuroradiologie, Unfallkrankenhaus Berlin, Berlin, Germany
| | - J Diehl
- Institut für Mathematik und Informatik, Greifswald, Germany
| | - A Eisenschenk
- Abteilung für Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Berlin, Germany; Klinik und Poliklinik für Unfall-, Wiederherstellungschirurgie und Rehabilitative Medizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - A Ekkernkamp
- Klinik und Poliklinik für Unfall-, Wiederherstellungschirurgie und Rehabilitative Medizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - S Kim
- Klinik und Poliklinik für Unfall-, Wiederherstellungschirurgie und Rehabilitative Medizin, Universitätsmedizin Greifswald, Greifswald, Germany; Leibniz Institut für Plasmaforschung und Technologie (INP Greifswald), Greifswald, Germany.
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McNamara CT, Colakoglu S, Iorio ML. A Systematic Review and Analysis of Palmer Type I Triangular Fibrocartilage Complex Injuries: Outcomes of Treatment. J Hand Microsurg 2020; 12:116-122. [PMID: 32788827 DOI: 10.1055/s-0040-1713580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Triangular fibrocartilage complex (TFCC) injuries can present incidentally as an asymptomatic lesion or can cause acute and chronic pain. This study compared different treatment approaches for symptomatic Palmer Type 1 TFCC injuries and rates of improvement using a systematic review of the literature. Two hundred thirty-one articles were identified, 43 met criteria and were included. Two of these articles indicated conservative therapy may be adequate. Patients who underwent debridement for any Type 1 Palmer class returned to work at a rate of 92% ( n = 182), but only 44% ( n = 38) were free of pain. For 1B lesions that underwent repair, 68.3% ( n = 226) were able to return to work and 41% ( n = 52) had persistent pain. 1D lesions were treated with both repair and debridement with similar results. Data for Types 1A and 1C were limited as no authors solely addressed these lesions. For 1A lesions, those treated with traditional treatment of debridement still had high rates of being unable to return to work. The literature remains insufficient, making comparison between studies and techniques difficult. For asymptomatic injuries, there is no need for treatment. For patients with recalcitrant symptoms, surgery improves pain, grip strength, and increases return to work and activity. The level of evidence is IV.
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Affiliation(s)
- Colin T McNamara
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
| | - Salih Colakoglu
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
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Löw S, Spies CK, Unglaub F, Oppermann J, Langer M, Erne H. [Diagnosis and treatment of degenerative disc lesions of the wrist]. DER ORTHOPADE 2019. [PMID: 29523902 DOI: 10.1007/s00132-018-3551-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
BACKGROUND The triangular fibrocartilage complex (TFCC) widens the radiocarpal joint and takes part in load transmission from the carpus to the forearm. It is thereby prone to degenerative changes. The painful situation that can accompany degeneration is called ulnar impaction. DIAGNOSIS Clinical examination helps differentiate between various causes of ulnar-sided wrist pain. Standard X‑rays are needed to determine ulnar variance and stress radiographs can depict narrowing of the ulnocarpal joint space under load. MRI may prove degeneration of the TFCC itself or may indirectly confirm ulnar impaction in the presence of bone marrow edema in the ulnar head or at the proximal ulnar aspect of the lunate. TREATMENT If conservative treatment fails to alleviate symptoms, arthroscopy may be indicated. On the one hand, this completes the diagnostic cascade, and, on the other hand, allows decompression of the ulnocarpal joint space by resection of the TFCC with partial resection of the ulnar head (wafer resection). In the case of ongoing pain, ulnar shortening sufficiently alleviates ulnar-sided wrist pain. Thereby, modern standardized operation techniques are safe enough to ensure bone healing at the osteotomy site. The aim of alleviating ulnar-sided wrist pain is mostly achieved if the correct treatment option is chosen.
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Affiliation(s)
- S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Wolfgangstraße 2, 97980, Bad Mergentheim, Deutschland.
| | - C K Spies
- Abteilung Handchirurgie, Vulpius-Klinik, Bad Rappenau, Deutschland
| | - F Unglaub
- Abteilung Handchirurgie, Vulpius-Klinik, Bad Rappenau, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Heidelberg, Deutschland
| | - J Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - M Langer
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - H Erne
- Klinik und Poliklinik für Plastische Chirurgie und Handchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
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Prognostic Factors of Arthroscopic Debridement for Central Triangular Fibrocartilage Complex Tears in Adults Younger Than 45 Years: A Retrospective Case Series Analysis. Arthroscopy 2018; 34:2994-2998. [PMID: 30292592 DOI: 10.1016/j.arthro.2018.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/26/2018] [Accepted: 05/01/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to analyze factors that affect the treatment outcomes of arthroscopic debridement for central triangular fibrocartilage complex (TFCC) lesions in adults <45 years of age. METHODS A total of 71 patients (mean age, 39 years; range, 20-44 years) who had been arthroscopically diagnosed with central TFCC tears were treated with arthroscopic debridement. Demographic, clinical, and arthroscopic findings were examined and analyzed. The response to treatment, including pain numeric rating scale on an ulnar provocation test; Disability of the Arm, Shoulder, and Hand score; and satisfaction with treatment, was assessed at 12-month follow-up. RESULTS The mean pain numeric rating scale (6.6 ± 3.6 to 2.4 ± 2.0, P < .01) and Disability of the Arm, Shoulder, and Hand (59.3 ± 15.0 to 33.7 ± 14.1, P < .01) scores exhibited significant clinical improvement at 12-month follow-up. In terms of satisfaction, 43 patients (70.5%) were satisfied (enthusiastic or satisfied) and 18 (29.5%) were dissatisfied (noncommittal or disappointed). In the satisfied group, there were 24 flap and 19 wearing tears, whereas in the dissatisfied group, there were 4 flap and 14 wearing tears (P = .02). The extent of ulnar plus variance on preoperative radiographs also differed between the 2 groups (0.5 ± 1.2 vs 1.7 ± 1.1, P < .01). There were no significant differences in age, gender, hand dominance, or work level between the groups. After controlling for confounding variables, the wearing type tears (odds ratio, 3.4) and greater ulnar plus variance (odds ratio, 2.0) were associated with a higher likelihood of dissatisfaction after arthroscopic TFCC debridement. CONCLUSIONS Although clinical outcome scores showed significant improvement after arthroscopic debridement for central TFCC tears, wearing type tears and greater ulnar plus variance were associated with dissatisfaction and poorer postoperative outcomes after the procedure. LEVEL OF EVIDENCE Level IV, case series.
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Roh YH, Kim S, Gong HS, Baek GH. Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50 years. Arch Orthop Trauma Surg 2018; 138:1173-1178. [PMID: 29855684 DOI: 10.1007/s00402-018-2969-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few studies have addressed the prevalence of central triangular fibrocartilage complex (TFCC) tears or their risk factors for symptom development. The aim of this study was to determine the prevalence of radiographic central TFCC tears in both symptomatic and asymptomatic individuals, and evaluate clinical characteristics of symptomatic individuals. METHODS In this retrospective case control study, 221 patients younger than 50 years who exhibited positive ulnocarpal provocation test and underwent MRI to identify abnormalities associated with TFCC were age- and sex-matched with 221 controls who had undergone hand or wrist MRI for tumorous lesions or pain in hand other than ulnar-sided wrist. Demographic and radiologic parameters including the degree of ulnar plus variance, the type of central TFCC lesions, the presence of ulna head or carpal bone enhancement, and cartilage degeneration of ulno-carpal or distal radio-ulnar joint were compared. Multivariable regression analysis was carried out to identify independent risk factors for symptom development in patients with central TFCC lesions. RESULTS The prevalence of central TFCC lesions was 68/221 in symptomatic patients, which was not significantly different from that (51/221) in asymptomatic controls. Patients in the symptomatic group had significantly greater ulnar plus variance (1.6 vs. 0.7). They were more likely to have type 1A tears and bony enhancement in ulnar head or carpus on MR images. Multivariable logistic regression analysis revealed that youth, female gender, and presence of bony enhancement were significant risk factors for symptom development in central TFCC lesions. CONCLUSION Based on the findings of this study, prevalence of central TFCC lesions detected on MRI in symptomatic patients seems to be similar to that in asymptomatic individuals. Younger age, female gender, and presence of bony enhancement on MR images seem to be risk factors for symptoms of central TFCC lesions.
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Affiliation(s)
- Young Hak Roh
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, South Korea.
| | - Sangwoo Kim
- Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Goo Hyun Baek
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Park A, Lutsky K, Matzon J, Leinberry C, Chapman T, Beredjiklian PK. An Evaluation of the Reliability of Wrist Arthroscopy in the Assessment of Tears of the Triangular Fibrocartilage Complex. J Hand Surg Am 2018; 43:545-549. [PMID: 29602654 DOI: 10.1016/j.jhsa.2018.02.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 01/15/2018] [Accepted: 02/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Wrist arthroscopy is generally considered the reference standard in the diagnosis of triangular fibrocartilage complex (TFCC) injuries. There is a paucity of data examining the reliability of wrist arthroscopy as a diagnostic modality for TFCC injuries. The goal of this study was to evaluate the interobserver and intraobserver reliability of the diagnosis of TFCC pathology during wrist arthroscopy. METHODS Twenty-five intraoperative digital videos were captured by the senior author during diagnostic and surgical arthroscopy of the wrist joint for known or suspected articular pathology. The senior author (P.K.B.) confirmed TFCC resilience on visual inspection and ballottement (trampoline effect) to make the diagnosis. Two videos were excluded for poor quality and inadequate visualization. Three hand surgeons subsequently reviewed the remaining 23 videos in a blinded fashion at 2 time points separated by 4 weeks. The reviewers determined if the trampoline test was positive and if a TFCC tear was present. Tears were classified using a morphologic classification. Statistical measures of reliability including percentage agreement and κ coefficients were calculated. RESULTS Agreement between observers for the presence or absence of a tear was 66.7%. The average intraobserver agreement regarding the presence or absence of a tear was 67.4% The kappa value for interobserver agreement was 0.33, whereas the intrarater agreement was 0.88. The 3 reviewers identified an average of 11.3 positive trampoline tests. Agreement between observers for a positive trampoline test was 65.2%. The average percentage of intraobserver agreement regarding a positive trampoline test was 49.3%. In cases where all 3 reviewers agreed on the presence of a TFCC tear, the agreement regarding tear location was 76.6%. CONCLUSIONS Wrist arthroscopy remains instrumental in the treatment of TFCC tears. However, given that inter-rater reliability in the assessment of these tears is probably too low, reconsideration should be given to arthroscopy as the reference standard in the diagnosis of these tears. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.
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Affiliation(s)
- Andrew Park
- Department of Orthopaedic Surgery, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Kevin Lutsky
- Department of Orthopaedic Surgery, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Jonas Matzon
- Department of Orthopaedic Surgery, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Charlie Leinberry
- Department of Orthopaedic Surgery, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Talia Chapman
- Department of Orthopaedic Surgery, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Pedro K Beredjiklian
- Department of Orthopaedic Surgery, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA.
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Löw S, Herold A, Unglaub F, Megerle K, Erne H. Treatment of Ulnar Impaction Syndrome with and without Central TFC Lesion. J Wrist Surg 2018; 7:133-140. [PMID: 29576919 PMCID: PMC5864492 DOI: 10.1055/s-0037-1607073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
Abstract
Background Arthroscopic debridement of the triangular fibrocartilage (TFC) is well accepted in patients with ulnar impaction syndrome with central TFC lesions. Treatment remains controversial, however, when there is no such lesion from radiocarpal view. Purpose This study assessed the clinical outcome of arthroscopic central TFC resection and debridement and secondary ulnar shortening in patients with ulnar impaction with central TFC lesion compared with patients without TFC lesion. Patients and Methods Thirty-two consecutive patients with ulnar impaction syndrome were arthroscopically treated, 16 of whom had a central lesion of the TFC that was debrided. In the 16 patients with no lesion from the radiocarpal view, the TFC was centrally resected and debrided to decompress the ulnocarpal joint. Persisting symptoms necessitated ulnar shortening in four patients in each group. Two patients underwent repeat arthroscopic TFC debridement. All patients were examined at 3, 6, and 12 months, and at final follow-up (mean: 1.7 years) following arthroscopy, respectively ulnar shortening or hardware removal. Results In both groups, pain, Krimmer, and DASH scores significantly improved. Improvements of DASH scores were significantly higher in patients without lesion at 12 months and at final follow-up. For other parameters, no significant difference was found between the two groups. Conclusion In both situations, with and without central TFC lesion, resection and debridement sufficiently reduced the ulnar-sided wrist pain and improved function in three out of four patients, and therefore qualified as the first-line treatment of ulnar impaction syndrome as arthroscopy is performed, anyway. Those patients who complained of persisting or recurrent ulnar-sided wrist pain finally benefitted from ulnar shortening osteotomy as the secondary procedure. Level of Evidence Therapeutic III, case-control study.
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Affiliation(s)
- Steffen Löw
- Section of Hand Surgery, Department of Orthopaedic and Trauma Surgery, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - Alexandra Herold
- Section of Hand Surgery, Department of Orthopaedic and Trauma Surgery, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - Frank Unglaub
- Department of Hand Surgery, Vulpius Clinic, Bad Rappenau, Germany
| | - Kai Megerle
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Holger Erne
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
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