FOOT & ANKLE

 
A flexion osteotomy for correction of a distal
tibial recurvatum deformity
A RETROSPECTIVE CASE SERIES

P. Scheidegger, Aims
T. Horn Lang, There is little information about how to manage patients with a recurvatum deformity of
C. Schweizer, the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate
L. Zwicky, the functional and radiological outcome of addressing this deformity using a flexion
B. Hintermann osteotomy and to assess the progression of OA after this procedure.

From Clinic of Patients and Methods

Orthopaedics and A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial
Traumatology, recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015.
Kantonsspital Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty
Baselland, Liestal, (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients
Switzerland (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation.
Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score,
tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and
postoperative weight-bearing radiographs.

Results
Postoperatively, the mean score for pain, using a visual analogue scale, decreased
significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle
Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both
p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased
significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no
progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed
further progression.

Conclusion
A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients
(77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a
joint-sacrificing procedure.
Cite this article: Bone Joint J 2019;101-B:682–690.

Symptomatic osteoarthritis (OA) of the ankle can including corrective supra- or inframalleolar
develop from a variety of causes, including frac- osteotomies have shown promising results in
tures and injuries to ligaments.1,2 This may lead patients with OA of the ankle associated with
to malalignment with asymmetrical loading. In coronal plane deformities.6-10 There is, however,
patients with a distal tibial recurvatum deformity, little information about the management of these
the talus is displaced anteriorly and is typically deformities in the sagittal plane. An osteotomy
uncovered,3 causing a reduction in the contact should, theoretically, reduce the peak load in the
area of the tibiotalar joint.4 This may result in ankle joint by normalizing the reaction forces (FJ)
Correspondence should be
sent to B. Hintermann; email: mechanical changes and altered load distribution and thus, prevent or delay the progression of OA.
[email protected] around the ankle, as illustrated in Figure 1. Since Several authors11,12 have included sagittal plane
©2019 The British Editorial the position of the talus is determined by the posi- correction in the management of OA of the ankle.
Society of Bone & Joint Surgery
tion of neighbouring bones and the integrity of the However, the results were not comprehensively
doi:10.1302/0301-620X.101B6.
BJJ-2018-0932.R2 $2.00 surrounding ligaments,5 a distal tibial realignment described.
Bone Joint J
osteotomy should restore the talus to be in line The aim of this study was to evaluate the
2019;101-B:682–690. with the tibial axis. Joint-preserving procedures functional and radiological outcome of a plantar
682 THE BONE & JOINT JOURNAL
 A flexion osteotomy for correction of a distal tibial recurvatum deformity683

FJ Table I. Modified Kellgren and Lawrence Score18

Stage Radiological signs of osteoarthritis

Stage I Early sclerosis and osteophyte formation without joint space
narrowing
Stage II Narrowing of the joint space
FA Stage III Tibiotalar subchondral bone contact
Stage IV Complete destruction of the tibiotalar joint

Table II. Additional procedures performed with the flexion osteotomy

Procedure n (%)
FG Microfracturing of the talus 10 (26)
Cheilectomy of the talar neck 18 (46)
Fibular osteotomy 14 (36)
Calcaneal osteotomy 3 (8)
Ligament reconstruction 7 (18)
Peroneal tendon transfer 3 (8)
Fig. 1 Achilles tendon lengthening 3 (8)

Illustration showing possible biomechanical changes in the ankle joint in

patients with a distal tibial recurvatum deformity when compared with Radiological assessment. Standard pre- and postoperative
normal ankles. The centre of the tibial joint surface is the fulcrum. The
ground reaction force (FG) and the load of the Achilles tendon (FA) add weight-bearing anteroposterior (AP) and lateral radiographs
up to the joint load (FJ). Due to the posterior shift of the fulcrum in these were analyzed. The tibial axis was determined in both planes
patients, the distance between the fulcrum and Achilles tendon de- by connecting the centre of two circles drawn to fit the tibial
creases (smaller leverage), resulting in an increased pull of the Achilles
cortices.13
tendon (FA) and an increased joint load (FJ).
The tibial anterior surface (TAS) and tibiotalar surface (TTS)
angles were measured on the AP radiographs (Fig. 2a).14,15 The
flexion osteotomy in a consecutive series of patients with a sag- grade of OA of the ankle in the coronal plane was classified
ittal plane distal tibial recurvatum deformity. according to Takakura et al14 and Tanaka et al,16 using a slightly
modified scoring system allowing us to classify both valgus and
Patients and Methods varus types of OA.
Between January 2010 and March 2015, 56 ankles in 56 On the lateral radiograph, the sagittal talar position, in rela-
patients were treated with a plantar flexion osteotomy due to tion to the tibia, was measured using the quotient of the lateral
symptomatic overload or OA of the anterior tibiotalar joint, talar station (s)17 and the talar radius (r), taking into account
under the supervision of one of two senior surgeons (includ- the different morphologies of the talus (Fig. 2b). This ratio
ing BH). The study was done according to the Declaration of was named the talar offset ratio (TOR). The tibial lateral sur-
Helsinki and the Guidelines for Good Clinical Practice. All face (TLS) angle was assessed by connecting the most poste-
patients gave informed consent and the study was approved by rior and anterior points of the weight-bearing surface, ignoring
the local Ethics Committee, Ethikkommission Nordwest- und osteophytes.14 The calcaneal pitch was determined using a line
Zentralschweiz. tangential to the inferior surface of the calcaneum and a line
Exclusion criteria included patients with osteochondral tangential to the heel and inferior border of the first metatarsal
lesions of the talus, avascular necrosis of the talar body (greater head or parallel to the ground in those with a shortened radio-
than one-third), a deformity in the coronal plane of > 10°, graph (Fig. 2b). A digital image management system (IMS Cli-
and high tibial deformities after a fracture of the tibial shaft ent, Imagic Bildverarbeitung AG, Glattbrugg, Switzerland) was
(centre of rotation > 10 cm above the tibiotalar joint space). used for the measurements.
A total of 39 ankles in 39 patients, including 12 women and A modification of the Kellgren and Lawrence (K&L) score18
27 men, with a mean age of 47 years (28 to 72) remained for was used to classify the grade of OA of the tibiotalar joint in the
analysis. The mean preoperative body mass index (BMI) was sagittal plane and to compare pre- versus postoperative results
26.0 kg/m2 (19.7 to 34.1). Four patients (10%) were smokers. (Table I).
All had post-traumatic OA: due to fracture in 25 (64%) and lig- Clinical assessment. Clinical assessment included a record of:
amentous injuries in 14 (36%). A total of 35 patients (90%) had 1) pain on a visual analogue scale (VAS);19 2) the American
undergone previous surgery: for fracture in 24 (62%), ligament Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score;20
reconstruction in eight (21%), and anterior tibial osteophytec- 3) the range of movement (ROM) of the ankle using a goni-
tomy in nine (23%); 30 patients had a simultaneous correction ometer;21 and 4) satisfaction measured on a four-point Likert
in the coronal plane. scale (very satisfied, satisfied, moderately satisfied, not satis-
The patients were examined clinically and radiologically at fied). These measurements were taken by a research worker not
the following timepoints: preoperatively, eight and 16 weeks involved in the treatment or analysis of the data (LZ or CS).
postoperatively, and annually thereafter. The mean clinical Surgical technique. The centre of rotation of angulation
­follow-up was 30 months (24 to 76). (CORA) and the apex of the deformity were identified in order
VOL. 101-B, No. 6, JUNE 2019
684 P. Scheidegger, T. Horn Lang, C. Schweizer, L. Zwicky, B. Hintermann 

13 cm 13 cm

8 cm 8 cm

TAS
TLS

TTS TOR = s/r r

Calcaneal pitch

Fig. 2a Fig. 2b

On the anteroposterior (AP) and lateral view, the tibial axis was determined by connecting the midpoints of two circles, approximately 8 cm and
13 cm above the ankle joint, which fit into the outer cortices of the tibia. a) On the AP view, the tibial anterior surface (TAS) angle and tibiotalar
­surface (TTS) angle were measured. b) On the lateral radiograph, the lateral talar station (s) and talar radius (r) were measured and used to calculate
the talar offset ratio (TOR; TOR = s/r). The tibial lateral surface (TLS) angle and calcaneal pitch were also measured.

Fig. 3a Fig. 3b Fig. 3c

Fluoroscopic lateral view of an ankle of a 41-year-old man showing: a) a Kirschner wire serving as a guide for the osteotomy; b) the anterior gap
filled with allograft; and c) the plate to secure correction.

to plan the correction on standard weight-bearing radiographs, were performed from medial by drilling several holes and com-
so that the longitudinal axis of the tibia aligned with the centre pleting the cut with an osteotome. Dome-shaped osteotomies to
of rotation of the talus. The approach chosen (anterior open- correct sagittal plane deformities were performed from anterior
ing, dorsal closing wedge, or dome-shaped) was partly deter- in the same way with the insertion of an allograft anteriorly.
mined by existing scars. An anterior opening wedge osteotomy An anterior opening wedge osteotomy was performed in 28
was usually considered when correcting sagittal deformities ankles (72%), a dorsal closing wedge osteotomy in nine (23%),
of < 10°, whereas a dome-shaped osteotomy was usually con­ and a dome-shaped osteotomy in two (5%). Concomitant varus
sidered when correcting deformities of > 10°. In opening oste- deformities were addressed in 20 ankles (51%), with a lateral
otomies, a wedge-shaped allograft (Tutogen Medical GmbH, closing wedge in two, medial opening wedge in 15, and a dome-
Neunkirchen am Brand, Germany) was used to fill the defect. shaped osteotomy in three. A concomitant valgus deformity was
Dome-shaped osteotomies to correct coronal plane deformities addressed in ten ankles (26%). with a medial closing wedge in
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 A flexion osteotomy for correction of a distal tibial recurvatum deformity685

Fig. 4

Kaplan–Meier survival with total ankle arthroplasty or ankle arthrodesis as endpoints. The rate of survival was
67% (95% confidence interval (CI) 48 to 86) after 36.5 months. The dashed line represents the 95% CI.

Table III. Clinical (n = 30) and radiological (n = 39) outcomes

Parameter Preoperative Postoperative p-value

Mean (range)
Visual analogue scale for pain 4.5 (1 to 6) 2.5 (0 to 7) < 0.001*
AOFAS hindfoot score 59 (22 to 85) 75 (25 to 100) < 0.001*
Mean dorsiflexion, ° (range) 7 (5 to 30) 7 (0 to 20) 0.960†
Plantarflexion, ° 25 (10 to 40) 25 (0 to 50) 0.863†
Range of movement, ° 32 (15 to 70) 32 (15 to 65) 0.878†
Mean radiological parameter (range)
Tibial anterior surface angle, ° 87.9 (74.2 to 102.7) 89.0 (77.5 to 99.2) 0.384†
Tibiotalar surface angle, ° 85.9 (70.7 to 102.5) 88.6 (79.2 to 102.0) 0.082†
Tibial lateral surface angle, ° 75.5 (64.0 to 84.5) 82.1 (69.5 to 92.7) < 0.001†
Talar offset ratio 0.42 (0.01 to 1.03) 0.18 (0.19 to 0.73) < 0.001*
Calcaneal pitch, ° 21.9 (11.2 to 32.0) 22.0 (11.5 to 31.6) 0.751†
Takakura score, n (%) < 0.001‡
1 11 (28) 8 (21)
2 3 (8) 8 (21)
3a 3 (8) 5 (13)
3b 7 (18) 4 (10)
4 15 (38) 14 (36)
Sagittal osteoarthritis stage, n (%)§ 0.05‡
I 3 (8) 1 (3)
II 14 (36) 23 (59)
III 22 (56) 13 (33)
IV 0 (0) 2 (5)
*Wilcoxon’s signed-rank test
†Student’s t-test
‡Likelihood quotient
§According to a modified Kellgren and Lawrence18 score
AOFAS, American Orthopaedic Foot and Ankle Society

six, lateral opening wedge in three, and a dome-shaped oste- The additional bony procedures and treatment of concomi-
otomy in one. All osteotomies were fixed with a locking plate tant soft-tissue pathology are shown in Table II. A fibular oste-
(Figs 3a to c). otomy was performed in those in whom an associated fibular

VOL. 101-B, No. 6, JUNE 2019

686 P. Scheidegger, T. Horn Lang, C. Schweizer, L. Zwicky, B. Hintermann 

Table IV. Parameters analyzed according to the need for a joint-sacrificing procedure versus those who did not need such a procedure

Parameter Joint-sacrificing No joint-sacrificing p-value

procedure (n = 9) procedure (n = 30)
Preoperative tibial osteophytectomy, n (%) 0.355*
Yes 3 (33) 6 (20)
No 6 (67) 24 (80)
Preoperative sagittal OA stage, n (%)† 0.394‡
I 0 (0) 3 (10)
II 3 (33) 11 (37)
III 6 (67) 16 (53)
Change in sagittal OA stage, n (%) 0.384*
Better 1 (11) 9 (30)
Unchanged 6 (66) 16 (53)
Worse 2 (22) 5 (17)
Preoperative mean (range)
Tibial anterior surface angle, ° 89.0 (84.4 to 97.4) 87.6 (74.2 to 102.7) 0.550§
Tibiotalar surface angle, ° 75.5 (68.0 to 84.5) 75.4 (64.0 to 83.6) 0.973§
Tibial lateral surface angle, ° 86.0 (73.2 to 95.9) 85.9 (70.7 to 102.5) 0.955§
Talar offset ratio 0.39 (0.24 to 0.57) 0.43 (0.01 to 1.03) 0.706¶
Postoperative mean (range)
Tibial anterior surface angle, ° 89.4 (77.5 to 99.2) 88.9 (77.9 to 98.3) 0.849§
Tibiotalar surface angle, ° 80.7 (69.5 to 92.7) 82.5 (71.2 to 91.2) 0.380§
Tibial lateral surface angle, ° 88.6 (79.2 to 102) 88.6 (79.3 to 97.1) 0.977§
Talar offset ratio 0.22 (0.12 to 0.53) 0.17 (0.19 to 0.73) 0.543¶
*Likelihood quotient
†According to a modified Kellgren and Lawrence18 score
‡Mann–Whitney U test
§Student’s t-test
¶Wilcoxon’s signed-rank test
OA, osteoarthritis

Fig. 5a Fig. 5b Fig. 5c

Anteroposterior and lateral radiographs of a 44-year-old woman with a distal tibial recurvatum deformity after a fracture and nonunion of the fibula
treated elsewhere: a) before; b) one year; and c) two years after a flexion osteotomy.

deformity prevented the talus from moving posteriorly into the addressed due to a remaining inframalleolar deformity, a cor-
ankle mortise or if the congruity of the joint could not be restored rective calcaneal osteotomy was added. If there remained insta-
after the distal tibial osteotomy. Cheilectomy of the talar neck bility of the ankle, ligament reconstruction was performed. In
was performed to remove spurs that may have restricted dorsi- patients with symptomatic dysfunction of the peroneal tendons,
flexion, while anterior tibial rim osteophytes were not removed a revision and/or repair was done. Lengthening of the Achilles
for fear of destabilizing the joint. Removal would have only tendon was considered if there was < 10° dorsiflexion at the end
been considered if the osteophytes caused impingement in max- of the surgery.
imal dorsiflexion. Cartilage treatment or microfracturing were Statistical analysis. In order to assess the test-retest reliability
considered in the presence of wear to the bone and subchondral of the modified K&L sagittal OA score, all radiographs were
sclerosis. If the deformity of the hindfoot could not be fully evaluated twice by the same author (PS), with a time interval of
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 A flexion osteotomy for correction of a distal tibial recurvatum deformity687

Fig. 6a Fig. 6b

Anteroposterior and lateral radiographs of a 41-year-old man (same as in Fig. 3) with a distal tibial recurvatum deformity and nonunion after a
fracture treated elsewhere. a) Before and b) three years after the development of a further nonunion following a flexion osteotomy, treated with a
debridement, and union four months postoperatively.

two weeks. The interobserver reliability of the modified K&L cumulative rate of survival of the ankle was 67% (95% CI 48 to
score was also assessed. All pre- and postoperative radiographs 86) after 36 months (Fig. 4).
were measured by two different investigators. A linear weighted Clinical results. The mean follow-up of the 30 remaining
kappa score was used. patients not needing joint-sacrificing surgery was 30 months
For continuous data such as angles, a paired Student’s t-test (24 to 76). The mean VAS pain score decreased from 4.5
was used to compare pre- and postoperative measurements. If (1 to 6) preoperatively to 2.5 (0 to 7) at the latest follow-up
the assumption of normality was not met, Wilcoxon’s signed- (p < 0.001); the mean AOFAS hindfoot score improved from 59
rank test was used. The preoperative sagittal stages of OA in points (22 to 85) to 75 points (25 to 100; p < 0.001). The ROM
patients needing a joint-sacrificing procedure were compared did not change; in particular, dorsiflexion did not significantly
with the stages of those not needing a joint-sacrificing proce- decrease (p = 0.88). While 11 patients were very satisfied and
dure, using a Mann–Whitney-U test. The outcome of the dif- nine patients were satisfied with the outcome, eight (27%) were
ferent stages scored according to the modified K&L score was moderately satisfied, and two (7%) were not satisfied.
compared using a Kruskal–Wallis test. Statistical significance Neither the postoperative VAS for pain nor the postopera-
was set at p < 0.05. tive AOFAS hindfoot score were significantly different when
Survival was assessed using the Kaplan–Meier method with grouping the patients by the preoperative sagittal OA stage
total ankle arthroplasty (TAA) or arthrodesis (AD) as endpoints, according to the modified K&L score and comparing the results
with 95% confidence intervals (CI). SPSS Statistics, version 23 (p = 0.257 and p = 0.940, respectively).
(IBM Corp., Armonk, New York) was used for all analyses. Radiological results. Preoperatively, the sagittal OA stages of
the 39 ankles on the modified K&L score were: three with stage
Results I (8%), 14 with stage II (36%), and 22 with stage III (56%). The
The test-retest reliability yielded a weighted kappa of 0.92 preoperative modified K&L score did not differ significantly
(95% CI 0.85 to 1.0), with 74 agreements out of a total of 78, between patients who needed a subsequent TAA or AD, and
whereas the interobserver reliability yielded a weighted kappa those who did not (p = 0.394).
of 0.66 (95% CI 0.50 to 0.81), with 61 agreements out of a total The radiological measurements prior to and after sagittal
of 78. alignment corrections, as well as the clinical measurements prior
Two patients (5%) developed an infection. Both were suc- to and after sagittal alignment correction in those in whom it did
cessfully treated with antibiotics; one also had hardware not fail, are shown in Table III. Table IV shows the statistics
removal three months postoperatively. Four patients (10%), of the parameters measured when comparing the patients that
two of whom were smokers, had a nonunion requiring revision needed a TAR (n = 9) with the non-failure group (n = 30). Four
fixation. In 12 patients, a debridement was performed, due to of the seven ankles with an increase in modified K&L score
arthrofibrosis in eight, impingement in three, and progressive also had a valgus deformity preoperatively. Figure 5 shows
OA in one. An arteriovenous fistula was resected in one patient. pre- and postoperative radiographs of a 44-year-old woman
The hardware was removed in 31 ankles (79%). with a good outcome. Two years postoperatively, the VAS for
In nine patients (23%), joint-sacrificing surgery was nec- pain decreased by two points, ROM increased by 10°, and the
essary due to progressive symptoms, TAA in seven (18%), AOFAS hindfoot score increased by 18 points. Figure 6 shows
and AD in two (5%) after a mean of 21 months (9 to 36). The pre- and postoperative radiographs of a 41-year-old man with a
VOL. 101-B, No. 6, JUNE 2019
688 P. Scheidegger, T. Horn Lang, C. Schweizer, L. Zwicky, B. Hintermann

Fig. 7a Fig. 7b

Fig. 7c Fig. 7d

Anteroposterior and lateral radiographs of a 41-year-old man with a distal tibial recurvatum deformity after a fracture treated elsewhere. a) Before,
b) one year, and c) two years after a flexion osteotomy still showing a talolisthesis, and d) after conversion to a total ankle arthroplasty due to pro-
gressive osteoarthritis 2.5 years after the flexion osteotomy.

good outcome after developing a nonunion. Three years post- VAS and the AOFAS score increased significantly postopera-
operatively, the VAS for pain decreased by four points, ROM tively. In nine patients (23%), a joint-sacrificing procedure was
decreased by 4°, and the AOFAS hindfoot score increased by required. Unfortunately, analysis of the pre- or postoperative
29 points. Figure 7 shows pre- and postoperative radiographs parameters could not shed light on why the osteotomy failed to
of a 41-year-old man in whom the deformity was not corrected save the joint.
leading to a failure of the flexion osteotomy, requiring a TAA With the flexion osteotomy, the mean TLS angle significantly
two years postoperatively. increased,15,16,24 and the mean TAS and TTS angles changed to
be comparable to previously published values found in a normal
Discussion cohort.13,15,16,25-27 The mean postoperative TOR of 0.183 was
In this study, a series of 39 patients with sagittal malalignment closer to the values for a normal cohort derived from the
of the ankle joint were treated with a flexion osteotomy, giv- literature17,24,28 (between 0.063 and 0.096) compared with the
ing valuable insights into the place of joint-preserving sur- mean preoperative TOR of 0.422. However, although the mean
gery in these patients. There is little in the literature about the TLS, TAS, and TTS angles lie in what is considered a normal
management of sagittal malalignment of the distal tibia. Pre- range after the osteotomy, there remained many patients in
vious authors12,22,23 have mentioned the correction of sagittal whom these angles were abnormal. This suggests that surgeons
malalignment in the treatment of OA of the ankle. Knupp et al11 could address the deformity more aggressively in the future,
described seven patients in whom they performed biplanar cor- and more studies are necessary.
rection to improve the talar coverage. In the present study, a previous tibial osteophytectomy
In 30 patients (77%) in the current study, no joint-sacrificing had been undertaken in nine ankles (23%). A loss of the ante-
procedure has been required so far. Of these, 20 patients (67%) rior tibial rim, as is the case after extended osteophytectomy
reported good or very good satisfaction. Pain decreased on the for anterior impingement, may have destabilized the ankle,
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 A flexion osteotomy for correction of a distal tibial recurvatum deformity689

encouraging anterior displacement of the talus.29 Although 4. Tarr RR, Resnick CT, Wagner KS, Sarmiento A. Changes in tibiotalar joint con-
removal of anterior osteophytes may treat impingement effec- tact areas following experimentally induced tibial angular deformities. Clin Orthop
Relat Res 1985;199:72–80.
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Author information: Funding statement:

No benefits in any form have been received or will be received from a
P. Scheidegger, MD, Attending Surgeon commercial party related directly or indirectly to the subject of this article.
T. Horn Lang, PhD, Research Associate
C. Schweizer, MSc, Research Associate Acknowledgements:
L. Zwicky, MSc, Research Associate The authors thank Markus Knupp, MD, for supervision of the surgeries, Caspar
B. Hintermann, MD, Associated Professor and Chair Steiner, MD, for measuring the data for inter-reliability testing and Roxa Ruiz,
Clinic of Orthopaedic Surgery, Kantonsspital Baselland, Liestal, Switzerland. MD, for her input in the analysis of the results.

Author contributions: Ethical review statement:

P. Scheidegger: Designed the study, Clinical and radiological evaluation, Wrote The study was done according to the Declaration of Helsinki and the Guidelines
the manuscript. for Good Clinical Practice. All patients gave informed consent and the study
T. Horn Lang: Wrote and edited the manuscript. was approved by the local Ethics Committee, Ethikkommission Nordwest- und
C. Schweizer: Collected the data, Wrote the manuscript. Zentralschweiz (2017-01203).
L. Zwicky: Wrote the manuscript, Statistical analysis.
This article was primary edited by J. Scott.
B. Hintermann: Designed the study, Performed the surgeries.

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