Diagnostic accuracy of fine-needle aspiration and frozen section in nodular thyroid disease.

OBJECTIVE: To assess the diagnostic accuracy of fine-needle aspiration (FNA) and frozen section (FS) in nodular thyroid disease. SETTING: Tertiary care academic medical center. STUDY DESIGN: Retrospective review of 139 consecutive patients undergoing surgery for nodular thyroid disease. FNA and FS sensitivity, specificity, and accuracy were calculated with respect to permanent section histology. RESULTS: Among 63 patients with an FNA interpreted as either benign (n = 38) or malignant (n = 25), FNA was accurate (sensitivity 89%, specificity 97%, accuracy 94%). FS identified only one case of carcinoma missed by FNA. Among 76 patients with a "suspicious" FNA, FS was reasonably accurate (sensitivity 67%, specificity 100%, accuracy 89%), but was deferred in 50% of cases. CONCLUSION: Given high FNA accuracy, more selective use of FS is suggested. SIGNIFICANCE: The study results will assist with intra-institutional patient counseling and intraoperative decision-making with respect to FNA and FS results in patients with nodular thyroid disease.

Posterior scalping flap revisited.

OBJECTIVE: To report our experience in a case series of 5 posterior scalping flaps. DESIGN: Retrospective review of a case series. SETTING: A tertiary academic care otolaryngology-head and neck surgery referral center. PATIENTS: Five patients having undergone posterior scalping flap reconstruction of cutaneous midface defects. METHODS: Reconstruction was performed for 4 cheek defects, 1 of which included the lateral third of the upper and lower lips, and 1 combined midfacial and lateral nasal wall defect. RESULTS: All 5 patients had excellent cosmetic and functional results. The only complication was a single case of partial-thickness distal flap necrosis. CONCLUSION: The posterior scalping flap offers a reliable source of skin with appropriate color and texture and minimal donor-site morbidity.

Videolaryngostroboscopy following vertical partial laryngectomy.

Phonation after partial laryngeal ablative surgery has not often been examined. Videolaryngostroboscopic recordings made after vertical partial laryngectomy (VPL) were retrospectively reviewed and correlated with patient historical and operative factors. Among VPL patients (n = 42), the most common site of vibration during phonation was the contralateral false vocal fold (17/42 patients or 40.5%), followed by the contralateral arytenoid mucosa (10/42 or 23.8%) and the contralateral true vocal fold (8/42 patients or 19.0%). There was no overall difference in vocal quality judgment with respect to site of vibration (ANOVA, p = .373). Vocal quality scores were similar with use of the pyriform mucosal flap versus other reconstructive methods (Student's t-test, p = .568). This study highlights the fact that reconstruction of a new vibratory source after VPL is important for voice production. Because VPL patients infrequently demonstrated true vocal fold vibration, alternative sites (ie, false vocal fold, arytenoid mucosa) must be considered as new phonatory sources after VPL.

Slow tonic muscle fibers in the thyroarytenoid muscles of human vocal folds; a possible specialization for speech.

Most of the sounds of human speech are produced by vibration of the vocal folds, yet the biomechanics and control of these vibrations are poorly understood. In this study the muscle within the vocal fold, the thyroarytenoid muscle (TA), was examined for the presence and distribution of slow tonic muscle fibers (STF), a rare muscle fiber type with unique contraction properties. Nine human TAs were frozen and serially sectioned in the frontal plane. The presence and distribution pattern of STF in each TA were examined by immunofluorescence microscopy using the monoclonal antibodies (mAb) ALD-19 and ALD-58 which react with the slow tonic myosin heavy chain (MyHC) isoform. In addition, TA muscle samples from adjacent frozen sections were also examined for slow tonic MyHC isoform by electrophoretic immunoblotting. STF were detected in all nine TAs and the presence of slow tonic MyHC isoform was confirmed in the immunoblots. The STF were distributed predominantly in the medial aspect of the TA, a distinct muscle compartment called the vocalis which is the vibrating part of the vocal fold. STF do not contract with a twitch like most muscle fibers, instead, their contractions are prolonged, stable, precisely controlled, and fatigue resistant. The human voice is characterized by a stable sound with a wide frequency spectrum that can be precisely modulated and the STF may contribute to this ability. At present, the evidence suggests that STF are not presented in the vocal folds of other mammals (including other primates), therefore STF may be a unique human specialization for speech.

Upper aerodigestive tract liposarcoma: report on four cases and literature review.

OBJECTIVE: To report on the clinical behavior, histopathology, treatment, and prognosis of laryngeal, hypopharyngeal, and cervical esophageal liposarcomas. STUDY DESIGN: Retrospective reviews of pathology files and hospital records at a tertiary care hospital and a retrospective search of the English-language literature. METHODS: Cases of upper aerodigestive tract (UADT) liposarcoma with adequate histopathologic documentation and clinical information were included for review. RESULTS: Four cases of UADT liposarcomas were identified. The literature review revealed 26 cases of laryngeal liposarcomas, 7 cases of hypopharyngeal liposarcomas, and 6 cases of esophageal liposarcomas: the mean age at presentation was 55.8 years, the male:female ratio was 5:1, and 60% of the patients presented with dysphagia. Eighty-six percent of tumors had low-grade histologic findings. The recurrence rate after primary resection was 50%. Recurrence correlated with surgical procedure rather than with histologic subtype; 94.7% of recurrences happened after simple excision. Distant metastases occurred in three patients; two of them died of the disease. CONCLUSIONS: The literature supports that UADT liposarcomas are rare and usually of low-grade histologic type. The rate of metastatic disease and tumor-related mortality is low. However, high recurrence rates have been noted, particularly when less radical surgery is employed.

Transverse infrahyoid approach to bilateral glottic tumors.

Glottic exposure and entry for vertical partial laryngectomy procedures has traditionally been through the subglottis. Although this approach is generally satisfactory for the resection of unilateral vocal cord lesions, it may be unsafe in cases in which tumors extend across the midline and/or subglottically. In these instances, we prefer the superior transverse infrahyoid approach to the glottis, which transects the petiole of the epiglottis and reflects the contents of the preepiglottic space posterior and superior. This improved visualization of the larynx has permitted precise tumor excision without sacrifice of uninvolved segments of the vocal cords. This procedure has been performed 35 times over a 15-year period at our institution for the resection of bilateral glottic tumors, with and without subglottic extension. In none of the cases in which it has been employed was there a positive surgical margin.

Human vocalis contains distinct superior and inferior subcompartments: possible candidates for the two masses of vocal fold vibration.

It is not understood how different parts of the thyroarytenoid muscle contribute to vocal fold vibration. This study investigated the medial part of the thyroarytenoid muscle, the vocalis compartment, for anatomic differences that might suggest functionally distinct areas. Twenty human vocal folds were frontally sectioned and stained with hematoxylin and eosin. A single section from the middle of each vocal fold was magnified, and the muscle fascicles of the most superficial 25% of the vocalis compartment were then examined. In all 20 specimens the vocalis compartment could be separated into 2 plainly distinct subcompartments: the inferior vocalis compartment was composed of a single large muscle fascicle that contained densely packed muscle fibers of similar size; the superior vocalis compartment was composed of multiple small fascicles in which the muscle fibers were loosely arranged and varied greatly in size. On average, the inferior vocalis subcompartment composed 60% of the medial surface of the thyroarytenoid muscle. The superior subcompartment composed the remaining 40% of the medial surface, but also continued past the vocal ligament to make up the superior surface of the thyroarytenoid muscle. It is concluded that 2 distinct entities make up the vocalis compartment of the thyroarytenoid muscle. Their anatomy is so markedly different it suggests that they may function independently. One possibility is that they reflect the 2 masses observed in the superior and inferior aspects of the vocal fold during vibration.

Botulinum toxin decreases salivation from canine submandibular glands.

The objective of this study was to determine whether botulinum toxin types A and D reduced the production of saliva from the submandibular glands of 18 dogs. The left submandibular glands of 8 dogs were injected with increasing doses of botulinum type A toxin (range 10 to 70 units), and the left glands of 10 dogs were injected with botulinum type D toxin (50 or 100 units). The right gland of each dog was injected with equivalent volumes of saline solution to serve as control. Six days after the injection, the lingual nerve was electrically stimulated for 10 minutes (3 mAmp, 20 Hz). The resulting volume of saliva was collected and weighed. Overall, the glands injected with types A or D toxin produced significantly less saliva than comparable glands injected with saline solution. Six of 8 dogs injected with type A toxin showed a significant decrease in saliva production (range 10.1% to 19.2%, one-sided p value = 0.0375) when compared with the controls. Nine of 10 dogs injected with type D toxin demonstrated a highly significant reduction in saliva production (total average decrease = 60%, two-sided pvalue = 0.001) when compared with the controls. We concluded that intraglandular injections of botulinum toxin types A and D significantly reduced the production of saliva from canine submandibular glands. The potential applications of intraglandular injections of botulinum toxin are discussed.

Complications of microvascular head and neck surgery in the elderly.

OBJECTIVES: To evaluate the complications of head and neck reconstruction using microvascular free tissue transfers (MFTTs) performed in an elderly population and to determine whether these complications are more common than in a younger population. SETTING: Tertiary referral center. PATIENTS AND DESIGN: Retrospective, consecutive chart review of patients older than 70 years who underwent MFTT in the past 5 years (group 1). The complications in this population were compared with those in a second group (group 2) of consecutive patients younger than 70 years who were matched according to the site of the primary tumor. MAIN OUTCOME MEASURES: Surgical and medical complications. RESULTS: The median age for group 1 was 74 years and for group 2, 55 years. The overall complication rate for group 1 was 48%, compared with 57% for group 2. In group 1, surgical morbidity was less common and medical morbidity was more common than in group 2. Mortality rate was 6% for group 1 and 0% for group 2. The types of complications were similar for both groups. There was no difference in complication rates when complications were classified by site of the defect, patient status determined by American Society of Anesthesiologists classification, or use of preoperative radiation. The overall success rate of MFTT was 100% for group 1 and 94% for group 2. CONCLUSIONS: Microvascular free tissue transfers for head and neck reconstruction can be safely performed in the elderly. An age older than 70 years does not increase the rate of surgical complications following head and neck reconstruction with MFTT. Medical complications, however, are more common and are equally divided between bronchopulmonary and cardiovascular effects.

Oromandibular reconstruction using microvascular composite flaps: report of 210 cases.

OBJECTIVE: To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction. DESIGN: Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps. SETTING: Academic medical center. PATIENTS: A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects. INTERVENTION: All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years. MAIN OUTCOME MEASURES: The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites. RESULTS: Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone. CONCLUSIONS: The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.

Reconstruction of the laryngopharynx after hemicricoid/hemithyroid cartilage resection. Preliminary functional results.

OBJECTIVE: To evaluate the use of a sensate radial forearm free flap and free cartilage graft for reconstruction of the laryngopharyngeal defect that results from resection of pyriform sinus carcinoma that extends to the apex of the pyriform sinus and includes the hemithyroid and hemicricoid cartilages. DESIGN: Case series review of 6 patients treated during a 2 1/2-year period with an average follow-up of 23 months. Factors evaluated included oncologic outcome, as well as functional outcome with regard to the onset and quality of the airway, speech, and deglutition. SETTING: Mount Sinai School of Medicine, New York, NY, an academic, tertiary referral center. PATIENTS: Six men ranging in age from 51 to 73 years underwent a partial laryngopharyngectomy that included the hemicricoid and hemithyroid cartilages as well as the ipsilateral thyroid lobe and either unilateral or bilateral lymph node dissections for squamous cell cancer that involved the apex of the pyriform sinus. INTERVENTION: These extensive laryngopharyngeal defects were reconstructed with a sensate radial forearm flap that resurfaced the endolarynx, restored the depth of the pyriform sinus, and reconstructed the remainder of the hypopharynx. In the final 4 patients, a free costal cartilage graft was used to restore the infrastructure of the larynx. OUTCOME MEASURES: The status of the margins, the incidence and site of recurrent cancer, the quality of speech, and the times to decannulation and removal of the gastrostomy tube. RESULTS: Three recurrences developed, with 1 each at the primary site, in the neck, and systemically. All but 1 patient who had completed radiotherapy by the last follow-up had been decannulated, and all but 1 patient regained the ability to maintain nutrition by mouth. Complications were limited to pharyngocutaneous fistulae requiring surgical closure in 3 patients early in the series. CONCLUSIONS: Functional reconstruction of extensive laryngopharyngeal defects can be achieved with a sensate radial forearm flap and a cartilage graft, with favorable functional results and acceptable morbidity, thus expanding the limits of conservation laryngopharyngeal surgery.

Reconstruction of massive defects in the head and neck: the role of simultaneous distant and regional flaps.

BACKGROUND: Massive defects resulting from excision of advanced head and neck tumors may not be amenable to reconstruction using a single technique of tissue transfer. Sixteen patients undergoing reconstruction using simultaneous free flaps and pedicled regional flaps are presented. METHODS: Regional flaps included the pectoralis major, deltopectoral, cervical visor, paramedian forehead, cervicofacial, and nape of neck flaps. Microvascular tissue transfers included the radial forearm, iliac crest, parascapular/latissimus dorsi, rectus abdominis, fibula, and lateral thigh free flaps. RESULTS: Most defects involved both aerodigestive mucosa and external cutaneous skin. Mucosal reconstruction was carried out using the soft-tissue component of the free flaps, whereas vascularized bone was used for mandibular reconstruction. Regional flaps were used to reconstruct skin of the face and neck. CONCLUSIONS: When planned and applied in a stepwise fashion, simultaneous free flaps and regional flaps are complimentary for the reconstruction of complex wounds in the head and neck.

Management of bilateral glottic tumors.

OBJECTIVE: To compare the rates of cure and complication and the time to decannulation and deglutition in patients undergoing resection of bilateral glottic tumors. DESIGN: A 22-year, nonrandomized, prospective, retrospective analysis. SETTING: Two academic tertiary care referral centers. PARTICIPANTS: Seventy-two patients with bilateral glottic carcinoma were treated using bilateral hemilaryngectomy. Depending on the size of the tumor and the extent of thyroid cartilage resection, patients underwent 1 of 3 methods of reconstruction: group 1, placement of an anterior commissure stent (34 patients); group 2, epiglottic laryngoplasty (15 patients); and group 3, staged posterior thyroid alar transposition laryngoplasty (23 patients). INTERVENTION: Resection and reconstruction of 72 larynges with bilateral glottic tumors using the bilateral hemilaryngectomy procedures. MAIN OUTCOME MEASURES: Acceptable rates of cure and complication, intervals to decannulation and deglutition, and quality of speech. RESULTS: High rates of tumor control and cure, low rates of recurrence and complication, acceptable time to decannulation and deglutition, and adequate quality and intelligibility of speech. CONCLUSIONS: Bilateral vocal cord carcinoma can be treated surgically with a high degree of tumor control and cure. The use of all 3 methods maintained laryngeal function with regard to tracheal decannulation, oral alimentation, and speech intelligibility.

Staged repair of cervical tracheoesophageal fistulae.

Acquired, nonmalignant tracheoesophageal (TE) fistulae are most often iatrogenic or trauma induced. When a cervical TE fistula is complicated by tracheal stenosis or malacia, a single-stage repair of the fistula and tracheal defect is usually advocated. Complications of this single-stage repair, which occur in 25% to 50% of patients, are secondary to either excess tension at the tracheal anastomosis or the presence of inflammation at the time of tracheal anastomosis. Complications include recurrent tracheal stenosis, pneumonia, or a recurrent TE fistula. This report describes the senior author's techniques of reconstructing the trachea when tracheal stenosis complicates a TE fistula. These techniques are illustrated in two case reports of patients with postintubation TE fistulae. Current methods of tracheal reconstruction in this setting are reviewed. The incidence of postoperative complications may decrease if tracheal reconstruction is delayed until the fistula is successfully closed.

Sinonasal hemangiopericytomas: a clinicopathologic and immunohistochemical study of seven cases.

BACKGROUND: Sinonasal hemangiopericytoma (SNHPC) is a rare lesion usually of low-grade malignant potential. Aggressive and metastatic cases are uncommon, and experience using adjuvant therapy on these cases has been limited. Tumor-induced osteomalacia has a very rare association with SNHPC. Further, the diagnosis of SNHPC remains one of histologic-pattern recognition. Traditionally, immunohistochemistry has aided in excluding other diagnoses; only vimentin has been consistently expressed by the tumor spindle cells of HPC. Recent studies have shown that Factor XIIIa is also expressed by HPC, (as well as tumors of fibrohistiocytic differentiation) and hence may be yet another helpful positive marker in establishing an immunohistochemical profile. METHODS: We identified 7 patients at this institution with SNHPC from 1990 to 1994. Immunohistochemistry was performed on seven formalin-fixed paraffin-embedded tumors utilizing antibodies to factor XIIIa as well as antibodies to vimentin, factor VIII, muscle-specific antigen, cytokeratin, and S-100. RESULTS: All 7 patients were initially seen with nasal obstruction or epistaxis and underwent surgical resection. The period of follow-up was from 3 months to 14 years (mean 54 months) for 7 patients. Three patients had recurrent disease after 3, 5, and 10 years. The first 2 were known to have been originally treated by polypectomy. One patient required adjuvant radiotherapy for metastatic disease and local extension. One patient was initially seen with tumor-induced osteomalacia which dramatically improved following resection of the lesion. The immunohistochemical profile revealed strong expression of vimentin in 7/7 cases, and of factor XIIIa in 4/7 cases; tumor cells did not express the other markers studied. CONCLUSIONS: Adequate surgical resection with negative margins appears to be the appropriate therapy for SNHPC. Our 1 case associated with tumor-induced osteomalacia was reversible after surgical excision of the tumor. The immunohistochemical results suggest that the pattern of vimentin and factor XIIIa positivity, as well as lack of expression of other markers, is consistent with the diagnosis of HPC, which still remains in the domain of histopathology.

Cranial neuropathy secondary to perineural spread of cutaneous malignancies.

Skin cancers of the head and neck are common lesions that rarely metastasize or invade cranial nerves. Perineural spread, when present, typically involves cranial nerves V and VII, because of their extensive subcutaneous distributions. Partial or complete facial palsy, facial hypesthesia, and/or pain may occur months to years after excision of a cutaneous malignancy and is often the first manifestation of regional metastasis. Too often, a history of facial skin cancer is not elicited in the evaluation of patients who present with fifth and/or seventh cranial nerve neuropathies. The initial yield from computerized tomography and magnetic resonance imaging is often limited, leaving most patients with the diagnosis of Bell's palsy. The authors herein present their experience with the diagnosis and management of seven patients who developed a fifth or seventh cranial nerve neuropathy an average of 13.4 months following "complete" excision of a regional skin cancer.

Rhinorrhea is decreased in dogs after nasal application of botulinum toxin.

At this time no effective long-term therapy exists for the excessive secretion of vasomotor rhinitis. Because rhinorrhea is under parasympathetic control, it was theorized that botulinum toxin--a powerful and long-acting cholinergic blocker that has been successful in the treatment of dystonia--might be useful in blocking the cholinergic control of rhinorrhea. Four male mongrel dogs were studied. Fifty units of type A botulinum toxin was soaked into sterile gauze, which was then packed into the left nasal cavity of each dog for 1 hour. Saline-soaked gauze was similarly introduced into the right nasal cavity to serve as control. Six days later, rhinorrhea was produced by inserting a bipolar needle electrode into the sphenopalatine ganglion and electrically stimulating for 10 minutes (6 mA, 50 Hz). Nasal secretions were collected with a suction catheter placed in the nasal vestibule. Three of four dogs exposed to the toxin showed a 41% average decrease in rhinorrhea (specifically 53%, 41%, and 30%). One dog showed a 10% increase in secretion after exposure to the toxin. We conclude that topically applied botulinum toxin reduced neurally evoked rhinorrhea by an average of 41%. Because some secretion is mediated by noncholinergic neurotransmitters such as vasoactive intestinal peptide, topical application of an anticholinergic substance has limitations. However, because all the nasal parasympathetic nerves appear to originate from cholinergic synapses in the sphenopalatine ganglion, direct injections of toxin into this ganglion may possibly allow complete blockade of all cholinergically mediated rhinorrhea.

Inverted papilloma: a report of 112 cases.

Inverted papilloma is a benign sinonasal tumor which is locally aggressive and has a significant malignant potential. This report updates the experience of the two senior authors, who have treated 112 patients with inverted papilloma at the Mount Sinai Medical Center over a 20-year period. As clinical examination often underestimates tumor extent, preoperative radiographic assessment is of paramount importance in guiding selection of surgical therapy. Complete en bloc excision via lateral rhinotomy and medial maxillectomy was the method of treatment in the majority of patients (84%). In selected patients with limited disease, or in patients who refused en bloc excision, conservative therapy employing intranasal or transantral ethmoidectomy was performed. The recurrence rates for the two groups were 14% and 20%, respectively. Recurrent disease developed throughout the paranasal sinuses, with the maxillary antrum and ethmoid labyrinth constituting the major sites. In two patients presenting with anterior skull base erosion, craniofacial resection was undertaken to eradicate disease. The latter cases underscore the aggressive nature of the tumor if left untreated. The overall rate of squamous carcinoma in this series was 5%. Given the predilection for local recurrence, multicentricity, and the possibility of malignancy, the authors continue to recommend lateral rhinotomy and medial maxillectomy as the standard therapy for the majority of cases. Management principles as well as a review of the literature are discussed.

Rigid fixation of vascularized bone grafts in mandibular reconstruction.

OBJECTIVE: To evaluate the nature of complications and complication rates with the use of three different reconstruction plates for the rigid fixation of vascularized bone grafts in oromandibular reconstruction. DESIGN: We conducted a case series of 95 patients over a 6-year period, with a minimum follow-up of 6 months and a maximum follow-up of 66 months. SETTING: Academic tertiary referral medical center. PATIENTS: Forty-eight patients had vascularized bone grafts fixated to native mandible with AO stainless steel reconstruction plates; 25 patients, with AO titanium plates; and 22 patients, with titanium hollow screw reconstruction plates (THORPs). Types of vascularized flaps, mandibular defects to be reconstructed, and use of radiation therapy were similar among the three groups. INTERVENTION: The surgical approach involved oromandibular reconstruction with a vascularized bone graft rigidly fixated with a reconstruction plate. OUTCOME MEASURES: Clinically and radiographically noted complications and resultant treatment. RESULTS: In the grafts fixated with AO stainless steel reconstruction plates, three plate fractures, seven instances of loose screws, eight plate exposures, and two cases of nonunion occurred. No cases of plate fracture or nonunion occurred in the titanium or THORP groups. One titanium plate and two THORPs were exposed during the study period. One instance of loose screws occurred in the titanium group; none in the THORP group. Seventy-four percent of those complications occurred within 12.4 months (the mean follow-up time of the THORP group). The incidence of complications in the stainless steel group was significantly greater than that in the titanium or THORP groups. No statistically significant increase in the rate of complications was noted when radiation therapy was used as a component of treatment. CONCLUSIONS: To our knowledge, this is the first study to compare three different reconstruction plates for fixation in vascularized bone reconstruction of the mandible. AO THORPs are now used almost exclusively to rigidly fixate vascularized bone grafts because of their advanced design and their potential for osseointegration and because fewer screws are necessary to attain adequate fixation than with conventional AO reconstruction plates.