[Type 2 dens fracture in the elderly and therapy-linked mortality : Conservative or operative treatment]. / Typ-II-Densfrakturen des alten Menschen und therapiebedingte Mortalität : Konservative oder operative Behandlung.

BACKGROUND: Type II fractures of the odontoid process of the axis are the most common injury of the cervical spine in elderly patients. Only little evidence exists on whether elderly patients should be treated conservatively or surgically. MATERIAL AND METHODS: The mortality and survival probability of 51 patients were determined in a retrospective study. The range of motion, pain and the neck disability index were clinically investigated. RESULTS: Of the 51 patients 37 were treated surgically and 14 conservatively. The conservatively treated group showed a higher mortality (64 % vs. 32 %). Kaplan-Meier analysis revealed a median survival of the conservatively treated group of 29 months, whereby during the first 3 months of treatment this group showed a higher survival probability and afterwards the surgically treated group showed a higher survival probability. The clinical examination of 20 patients revealed limited range of motion of the cervical spine. Additionally, moderate levels of pain and complaints were recorded using the neck disability index. CONCLUSION: Fractures of the odontoid process pose a far-reaching danger for elderly patients. A balanced assessment of the general condition should be carried out at the beginning of treatment of these patients. In the early phase following trauma no differences were found with respect to survival rates but for long-term survival the operatively treated group showed advantages; however, these advantages cannot be causally attributed to the choice of therapy.

[Quality of life and job performance resulting from operatively treated tibial plateau fractures]. / Lebensqualität und Arbeitsfähigkeit nach operativer Behandlung von Tibiakopffrakturen.

BACKGROUND: The aim of this article is to present the functional results and the effect on quality of life of surgically treated tibial plateau fractures in physically active and working patients with multiple and serious injuries. In addition, the relationships between functional and radiological outcome were evaluated and compared with activity in daily and professional life. PATIENTS AND METHODS: In all, 41 injured patients were followed up a mean of 47 months after surgical treatment and examined with radiological, functional, as well as quality of life score. RESULTS: In the radiological scoring, a mean value of 72 points (max 100 points) was achieved. In the activity score, there was an average of 63.5 points (max 100 points). When evaluating the health-related quality of life, an average score of 69.6 points was achieved. There was a significant relationship between radiological and activity scores and the radiological and life quality scores. Furthermore, the relationship between activity and quality of life scores was considered significant. Surgeon's influence on the functional outcome could be confirmed. CONCLUSION: The functional and the radiological results were moderate. Quality of life was permanently affected by the consequences of tibial plateau fracture in 12 patients; 11 patients were not re-employed. However, the quality of life was assessed as good or very good and 28 patients had returned to work. The quality of life was firmly linked to the radiological and functional parameters, which tended to be influenced by the quality of the primary surgical treatment when looking at the overall population.

[Limits to arthroscopic treatment of degenerative triangular fibrocartilage complex lesions depending on the ulnar variance]. / Grenzen der arthroskopischen Behandlung degenerativer Läsionen des ulnokarpalen Komplexes in Abhängigkeit der Ulnavarianz.

PURPOSE: The present prospective study investigated the influence of the static ulnar variance on the success of arthroscopic debridement of degenerative TFCC lesions. PATIENTS AND METHODS: 10 patients with an ulnar positive variance ("Ulna+") and 12 patients with ulnar neutral or ulnar negative variance ("Ulna-/0") were examined preoperatively (U0), as well as at 2 (U2) and 6 (U6) months after arthroscopic debridement of degenerative TFCC lesions and compared with each other. After the U2 investigation due to persistent complaints in 9 of 10 patients with an ulnar positive variance there was a need for further surgery, consisting of ulnar shortening osteotomy (USO). The following parameters were recorded in each case: pain at rest and with load, the summed wrist range of motion - consisting of extension and flexion, radial and ulnar deviation, pronation and supination - compared to the contralateral side, the strength of the affected hand compared to the contralateral side, the Mayo modified wrist score (MMWS), the Krimmer score and the DASH score. Preoperatively there were no significant differences between the 2 cohorts "Ulna+" and "Ulna-/0" except for the characteristic "pain at rest". RESULTS: At 2 months postoperatively (U2), the results in the cohort "Ulna+" remained at a significantly or tendentially poorer level compared to the cohort "Ulna-/0". The subsequent surgical treatment of the subgroup "Ulna+" with USO led to almost complete approximation of the results at 6 months postoperatively (U6). In addition to this, with time (U6) within each subgroup there were tendential or significant improvements of all characteristics compared to the preoperative situation (U0). At U6 four of 22 patients were -unable to work. CONCLUSION: Degenerative lesions of the TFCC can be treated successfully by arthroscopic debridement in cases of ulnar negative and ulnar neutral variance. Patients with ulnar positive variance and persistent complaints after debridement of the TFCC can be treated successfully with a secondary ulnar shortening osteotomy.

Plasmacytoid dendritic cells: no longer an enigma and now key to transplant tolerance?

Plasmacytoid (p) dendritic cells (DC) are a specialized subset of DC whose primary role was initially defined by the production of type I interferons in response to viral infection. They are now known to also possess a repertoire of functions capable of determining T cell fate and activation. Under homeostatic conditions, non-lymphoid tissue-resident pDC play a critical role in the regulation of mucosal immunity, as well as the development of central and peripheral tolerance. Although these cells display a number of characteristics that differ from conventional DC, particularly altered costimulatory molecule expression and poor allostimulatory capacity when interacting with T cells, this phenotype favors the generation of alloantigen-specific regulatory CD4(+) or CD8(+) T cells critical to the development of graft tolerance. In this minireview, we discuss pDC ontogeny, functional biology and the emerging data that demonstrate the importance of pDC in the induction of tolerance, as well as recent studies that define mechanisms underlying pDC-mediated tolerance to both solid organ and haematopoietic stem cell transplants. We also highlight their use in clinical settings and the potential of pDC both as targets and cellular therapeutic agents to improve the outcome of organ transplantation.

Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis.

BACKGROUND: Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105). METHODS: Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up. RESULTS: In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients. CONCLUSIONS: If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.

Thrombospondin-1: a physiological regulator of nitric oxide signaling.

Thrombospondin-1 is a secreted protein that modulates vascular cell behavior via several cell surface receptors. In vitro, nanomolar concentrations of thrombospondin-1 are required to alter endothelial and vascular smooth muscle cell adhesion, proliferation, motility, and survival. Yet, much lower levels of thrombospondin-1 are clearly functional in vivo. This discrepancy was explained with the discovery that the potency of thrombospondin-1 increases more than 100-fold in the presence of physiological levels of nitric oxide (NO). Thrombospondin-1 binding to CD47 inhibits NO signaling by preventing cGMP synthesis and activation of its target cGMP-dependent protein kinase. This potent antagonism of NO signaling allows thrombospondin-1 to acutely constrict blood vessels, accelerate platelet aggregation, and if sustained, inhibit angiogenic responses. Acute antagonism of NO signaling by thrombospondin-1 is important for hemostasis but becomes detrimental for tissue survival of ischemic injuries. New therapeutic approaches targeting thrombospondin-1 or CD47 can improve recovery from ischemic injuries and overcome a deficit in NO-responsiveness in aging. (Part of a Multi-author Review).

[Successive ruptures of patellar and Achilles tendons. Anabolic steroids in competitive sports]. / Mehrzeitige Rupturen von Patellar- und Achillessehnen. Anabole Steroide im Leistungssport.

Derivatives of testosterone or of 19-nor-testosterone are used as anabolics for the purpose of improving performance although the effect of anabolics is known still to be under discussion. The use of anabolic steroids continues among competitive athletes despite increased controls and increasingly frequent dramatic incidents connected with them. Whereas metabolic dysfunction during anabolic use is well documented, ruptures of the large tendons are rarely reported. Within 18 months, a 29-year-old professional footballer needed surgery for rupture of the patellar tendon and of both Achilles tendons. Carefully directed questioning elicited confirmation that he had taken different anabolic steroids regularly for 3 years with the intention of improving his strength. After each operation anabolic steroids were taken again at a high dosage during early convalescence and training. Minimally invasive surgery and open suturing techniques led to complete union of the Achilles tendons in good time. Training and anabolic use (metenolon 300 mg per week) started early after suturing of the patellar tendon including bone tunnels culminated in histologically confirmed rerupture after 8 weeks. After a ligament reconstruction with a semitendinosus tendon graft with subsequent infection, the tendon and reserve traction apparatus were lost. Repeated warnings of impaired healing if anabolic use was continued had been given without success. In view of the high number of unrecorded cases in competitive and athletic sports, we can assume that the use of anabolic steroids is also of quantitative relevance in the operative treatment of tendon ruptures.

Modulation of angiogenesis by dithiolethione-modified NSAIDs and valproic acid.

BACKGROUND AND PURPOSE: Angiogenesis involves multiple signaling pathways that must be considered when developing agents to modulate pathological angiogenesis. Because both cyclooxygenase inhibitors and dithioles have demonstrated anti-angiogenic properties, we investigated the activities of a new class of anti-inflammatory drugs containing dithiolethione moieties (S-NSAIDs) and S-valproate. EXPERIMENTAL APPROACH: Anti-angiogenic activities of S-NSAIDS, S-valproate, and the respective parent compounds were assessed using umbilical vein endothelial cells, muscle and tumor tissue explant angiogenesis assays, and developmental angiogenesis in Fli:EGFP transgenic zebrafish embryos. KEY RESULTS: Dithiolethione derivatives of diclofenac, valproate, and sulindac inhibited endothelial cell proliferation and induced Ser(78) phosphorylation of hsp27, a known molecular target of anti-angiogenic signaling. The parent drugs lacked this activity, but dithiolethiones were active at comparable concentrations. Although dithiolethiones can potentially release hydrogen sulphide, NaSH did not reproduce some activities of the S-NSAIDs, indicating that the dithioles regulate angiogenesis through mechanisms other than release of H(2)S. In contrast to the parent drugs, S-NSAIDs, S-valproate, NaSH, and dithiolethiones were potent inhibitors of angiogenic responses in muscle and HT29 tumor explants assessed by 3-dimensional collagen matrix assays. Dithiolethiones and valproic acid were also potent inhibitors of developmental angiogenesis in zebrafish embryos, but the S-NSAIDs, remarkably, lacked this activity. CONCLUSIONS AND IMPLICATION: S-NSAIDs and S-valproate have potent anti-angiogenic activities mediated by their dithiole moieties. The novel properties of S-NSAIDs and S-valproate to inhibit pathological versus developmental angiogenesis suggest that these agents may have a role in cancer treatment.

[Implantation of matrix-free cartilage transplants in standardized defects in sheep knee joints]. / Die Implantation von matrixfreien dreidimensionalen Knorpeltransplantaten in standardisierte Knorpeldefekte am Schafskniegelenk.

The goal of the current investigation was to make a comparative analysis of regenerative tissue after autologous de novo cartilage transplantation on the femoral condyles of sheep after a chondral defect. One chondral defect measuring 4 mm in diameter was placed in the center of one medial femoral condyle of each of 48 Suffolk sheep. Twelve defects were left to heal spontaneously, 16 defects were covered with periosteal flaps, and 20 defects were filled with autologous de novo cartilage graft. Macroscopic and microscopic assessments were performed at 26 and at 52 weeks. Regeneration was significantly better (p<0.05) in the transplant group than in the control groups at both 26 weeks and 52 weeks. The differences were most evident in the grade of defect filling, cartilage stability, cell distribution, and matrix assessments. Transplantation of immature, autologous de novo cartilage leads to qualitatively better regeneration both macro- and microscopically than does periosteal flap placement alone. The transplanted, immature cartilage tissue undergoes maturation in vivo. The regenerated tissue has hyaline-like features.

[Lecture disasters - and how to prevent them]. / Der grottenschlechte Vortrag - oder wie geht es auch besser.

Presentations at medical conferences can sometimes confuse or compromise understanding of current topics. Although considerable time and financial costs may be taken to be present at such events, all too often one must go through inferior presentations that are poorly structured and do not contribute to one's understanding of the topic at hand. A good presentation is distinguishable by the clear intentions of the speaker to give a good lecture. The presenter has worked extensively with his topic and is familiar with the audience. The presentation has a clear structure and finishes with a take-home message. The speaker takes the listener from his previous level of knowledge to a new understanding. To do so, both voice and body language are used. The supporting slides are simple and direct, and not overloaded with information. The speech conforms exactly with the pre-determined time limit.

[Multislice CT in diagnostic work-up of polytrauma]. / Multislice-Spiral-CT zur Diagnostik beim Polytrauma.

BACKGROUND: In severely injured patients, diagnostic procedures should be as brief as possible. With the use of spiral CT technology, the time required for diagnosis is minimized. QUESTION: Do severely injured patients benefit when primary diagnostic examinations are completed in less than 30 min? How much time is required for primary emergency department (ED) care and how much in the CT scanner? MATERIAL AND METHODS: Between 31 July 2001 and 31 December 2003, severely injured patients with ISS scores over 16 underwent total body spiral CT scans (Siemens Somatom Volume Zoom Multislice CT) after initial ultrasonography. One hundred patients (M:F=25:75) with an average age of 42 years (range: 3-81 years) were evaluated retrospectively. The average ISS score was 32.8+/-12 points (range: 17-75 points). RESULTS: The average time in the ED, prior to CT, was 33+/-14 min. The CT scans lasted 16+/-5 min and the total diagnostic time was 48+/-14 min. Fifty percent of patients were taken immediately to the operating room. The mortality rate in hospital was 13%. The average hospital stay was 30 days, with an average ICU stay of 10 days. CONCLUSION: The shorter the time spent in the ED, the shorter the stays in ICU and in total hospitalization were, regardless of injury severity. With structured management and shortening of diagnostic time with spiral CT, the time in the ED was decreased from 85 to 48 min.

Type I collagen is a molecular target for inhibition of angiogenesis by endogenous thrombospondin-1.

Three-dimensional explant cultures of muscle tissue were used to characterize secreted proteins regulated by endogenous levels of the angiogenesis modulator thrombospondin (TSP)-1. Explants from TSP1 null mice exhibit enhanced neovascularization associated with increased endothelial outgrowth but decreased outgrowth of perivascular smooth muscle cells . The absence of endogenous TSP1 did not diminish activation of latent transforming growth factor-beta and moderately decreased matrix metalloproteinase levels. However, significant changes in other secreted proteins were observed. Endogenous TSP1 decreased mRNA levels for collagens Ialpha1, Ialpha2, and IIIalpha1 and laminin alpha4 and increased collagen IValpha1 mRNA expression. Endogenous TSP1 also decreased the level of type I collagen protein produced by the vascular outgrowths. Collagens Ialpha1, Ialpha2, and IIIalpha1 are known tumor endothelial markers, suggesting that TSP1 coordinately regulates a set of extracellular matrix genes that reverse the angiogenic switch. Suppression of collagen Ialpha1 or Ialpha2 mRNAs using antisense morpholinos inhibited outgrowth in TSP1 null explants and proliferation of TSP1 null endothelial cells, indicating that type I collagen synthesis is limiting for this neovascularization response.

Nitric oxide modulation of low-density mononuclear cell transendothelial migration.

The blood-endothelial cell interface is a region of significant importance in many physiologic and pathologic processes. Blood-borne macromolecules and cells gain access to the subendothelial space and extravascular tissues by traversing the endothelium. Yet the various factors responsible for modulation of this process remain only partially elucidated. Several agents were found to be involved in this process, including nitric oxide (NO) and vascular endothelial growth factor (VEGF). It is known that under stress conditions (e.g., inflammation), NO can modulate the permeability of endothelial-cell monolayers to low-density mononuclear cells (LDMNCs). However, it is not known if NO can modulate such effects in the absence of inflammatory stimulation. In the present study, we utilized a Transwell chamber model to examine endothelial-cell monolayer permeability to LDMNCs in the absence of inflammatory stimuli. We noted that NO donor and L-arginine increased transendothelial-cell migration, whereas nitric oxide synthase (NOS) inhibition decreased migration. These effects were not significantly abrogated by VEGF antibody, suggesting that they were not VEGF-dependent.

Endogenous thrombospondin-1 is not necessary for proliferation but is permissive for vascular smooth muscle cell responses to platelet-derived growth factor.

We have reexamined the role of endogenous thrombospondin-1 (TSP1) in growth and motility of vascular smooth muscle cells (SMCs). Based on the ability of aortic-derived SMCs isolated from TSP1 null mice and grown in the absence of exogenous TSP1 to grow at comparable rates and to a slightly higher density than equivalent cells from wild-type mice, TSP1 is not necessary for their growth. Low concentrations of exogenous TSP1 stimulate growth of TSP1 null SMCs, but higher doses of TSP1 or its C-terminal domain are inhibitory. However, SMCs from TSP1 null mice are selectively deficient in chemotactic and proliferative responses to platelet-derived growth factor and in outgrowth in three-dimensional cultures. Recombinant portions of the N- and C-terminal domains of TSP1 stimulate SMC chemotaxis through different integrin receptors. Based on these data, the relative deficiency in SMC outgrowth during an ex vivo angiogenic response of muscle tissue from TSP1 null mice is probably due to restriction of platelet-derived growth factor dependent SMC migration and/or proliferation.

[Multistep surgery for spondylosyndesis. Treatment concept of destructive spondylodiscitis in patients with reduced general condition]. / Die mehrzeitige Spondylodese. Behandlungskonzept der destruierenden Spondylodiszitis bei kritisch reduziertem Allgemeinzustand.

OBJECTIVE: Retrospective assessment of multistage surgery in the treatment of progressive spondylodiscitis in patients with critical physical status. PATIENTS: A total of 34 patients (mean age 58.6 years) with 37 progressive spondylodiscitis foci and destruction of one to three vertebral segments (1.9 mean) were recorded within an 8-year period. Time between first complaints and operative treatment was 3 months (mean). Preoperative health status was critically reduced in 11 patients (ASA IV) and poor general condition (ASA III) was seen in 23 patients when vital indication was seen preoperatively. Considerable systemic disease (n=31), further infection focus (n=18), and nosocomial trauma (n=5) were causally related. Spondylodiscitis was seen more frequently in the lumbar (n=20) and thoracolumbar than in the thoracic (n=10) and cervical spine (n=1). Staphylococcus aureus was detectable from operative specimens and hemoculture in 15 cases, MRSA in 6 of these. METHODS: In cases of monosegmentary involvement (n=7) ventral debridement, biopsy, and application of antibiotic chains were followed by autologous interbody bone grafting in a second stage operation. In 29 cases with destruction of two (n=27) and three (n=3) segments, posterior instrumentation including laminectomy in 4 patients was completed by anterior debridement and application of antibiotic chains during a first surgical intervention. After stabilization of physical condition and having reached a macroscopically indisputable implant bed, the ventral fusion with autologous interbody bone grafting or cage in combination with a plate or internal fixation system was performed as the last of several surgical steps. RESULTS: No case of perioperative mortality was observed. Intensive care continued 9.1 days and hospitalization 49.5 days (mean). During a 37.6-month follow-up two late recurrences were observed. CONCLUSION: A multistep surgical procedure under protection of dorsal instrumentation can limit perioperative mortality in patients in critical general condition by avoiding an extended one stage dorsoventral spondylodesis. After eradication of further infection foci and stabilization of physical condition, ventral instrumentation is completed under elective conditions.

Nitric oxide modulation of early angiogenesis.

Angiogenesis is the process of new vessel formation from an existing vasculature network. In all but a few circumstances it is tightly controlled and suppressed. Precise understanding of the factors involved in modulation of angiogenesis has significant potential clinical value. One agent believed to play a role in angiogenesis is nitric oxide. However, there remain substantial uncertainties concerning the specifics of this role. The present study was undertaken to better define the role nitric oxide plays in angiogenesis associated with acute wound healing. Muscle biopsies from the pectoralis major of C57B6 mice were embedded in 500 microl of type I collagen matrix, and incubated in the presence of growth medium for 14 days. Treatment wells received L-Arginine (2 mM), L-NAME (300 microM), or SNAP (10-20 microM). Angiogenic response was quantified as the measure of cell migration through the matrix and as the total cells recovered from the matrix. Whole lung specimens and aortic segments served as sources of endothelial and vascular smooth muscle cells respectively for proliferation studies under similar treatment conditions. Nitric oxide was found to exert either a stimulatory or inhibitory effect on angiogenesis and cell proliferation that was subject to the assay system and specific vascular cell types present. These results suggest that the role of nitric oxide in angiogenesis is context dependent.

[Pitfalls and complications of elastic stable intramedullary nailing (ESIN) of femoral fractures in infancy]. / Pitfalls und Komplikationen der elastisch stabilen intramedullären Nagelung (ESIN) von Femurfrakturen im Kindesalter.

BACKGROUND: The aim of this prospective study was to evaluate the intra- and postoperative problems as well as the complications of elastic stable intramedullary nailing (ESIN) of femur fractures in children. PATIENTS AND METHODS: 47 consecutive children, mean age 6 years, were reviewed clinically and radiologically until hardware removal and after this annually. Mean time of follow up was 37 months. RESULTS: Intraoperatively one cortex perforation and one displacement of a third fragment occurred. Two correction operations were necessary: In one case due to an implant displacement and in another case due to an unacceptable loss of reduction. There were no infections, non union, implant breakage, refracture or disturbance of growth. CONCLUSIONS: ESIN is a safe procedure in femoral shaft fractures of children. Most of the problems and complications can be avoided by a careful consideration of the indication and a correct operation technique.

[Multidirectional atlantoaxial instability of an os odontoideum in an adult]. / Multidirektionale atlantoaxiale Instabilität bei adultem Os odontoideum.

Increasing neck pain in a 29 year old woman after a frontal car collision gave reason for a conventional x-ray that presented a traumatically displaced os odontoideum positioned at the top of the dens axis. No neurological defect was seen. Dynamic flexion/extension film showed a movement to an atlantoaxial dislocation with a shift of the os odontoideum. The sclerotic structure of the corresponding bony surfaces was confirmed by computed tomography, whereas magnetic resonance imaging demonstrated a posttraumatic signal change in front of the base of dens axis and os odontoideum. Fusion was achieved by computed navigation with C1/C2 transfacetal screws as described by Magerl and interspinal fusion with a bicortical autologous iliac crest graft and a posterior tension band as described by Brooks. An exact positioning of screws past the asymmetric course of both arteria vertebrales was possible by navigation. The patient was free of pain 5 months after the fusion.

[Experience with elastic stable intramedullary nailing (ESIN) of shaft fractures in children]. / Erfahrungen mit der elastisch stabilen intramedullären Nagelung (ESIN) diaphysärer Frakturen im Kindesalter.

The aim of this prospective clinical controlled trial was to investigate the early and midterm results of shaft fractures in children treated with elastic stable intramedullary nailing (ESIN). From January 1997 to December 2001, elastic stable intramedullary nailing was carried out on 112 children with 118 diaphyseal fractures. The mean age was 7.7 years. There were 51 fractures of the lower arm, 46 femoral fractures, 14 of the lower leg, and 7 of the humerus. A total of 92 children have been followed up for more than 12 months. The mean time of follow-up was 38 months.The mean time of fluoroscopy was 2.2 min. Open reduction was necessary in 3.4 %. In children with injuries of the lower extremity, full weight bearing was achieved after a mean period of 9.3 days. In 1.8% of the children, reoperation was necessary within the first 10 days after the operation. In 3.6 % there was painful skin irritation due to the protruding end of a nail. No infection or delayed union was observed. Implant removal was done after a mean time of 5.6 months. There was no rotational or angular deformity of more than 5 degrees in children with isolated fractures of the lower extremity. Mean lengthening of the injured leg was 2.4 mm. In three children who had fractures of the upper extremity, a deficit in range of motion of the adjacent joints was detected. The current results show that intramedullary fixation of displaced diaphyseal fractures in children with a flexible titanium nail is a safe, minimally invasive surgical technique producing excellent functional and cosmetic results.

Further experience with innervated autologous flaps in postoncologic breast reconstruction.

Restoration of sensation remains an area of minimal concern in autologous breast reconstruction. In contrast, it is routine for the reconstructive surgeon to include sensory restoration as part of the reconstruction of the upper and lower limb and the head and neck. We have utilized sensate autologous soft tissue units for breast reconstruction and present the results of a four-year period. Among a cohort of 15 women who underwent sensate breast reconstruction improvement in all sensory modalities tested, both rapidity of sensory return and strength of sensation were noted when compared to reported sensory outcomes among women undergoing non-sensate breast reconstruction. Final sensory levels approached but did not equal the non-reconstructed contralateral breast. Operative times and wound healing complications were not statistically increased in sensate reconstructions as compared to a group on non-sensate reconstructions. The results of the study suggest that sensate reconstruction is a reasonable addition to autologous breast reconstruction.