[Development of arteriosclerosis]. / Entstehung der Arteriosklerose.

Arteriosclerosis is the general term for a group of arterial vascular diseases characterized by arterial wall thickening and loss of elasticity, which are caused by different biological processes. The most commonly used classification defines four distinct histopathological types: arteriolosclerosis, medial sclerosis, fibromuscular intimal hyperplasia and atherosclerosis. The pathobiological remodeling of the arterial wall essentially represents different repair responses of vascular cells to molecular stress factors and microlesions. This article should contribute to the clarification of the nomenclature and the histopathological classification of the disease symptoms, to elucidate the biological processes underlying the different pathologies during arteriosclerosis and to raise awareness for these differences, because these can decisively contribute to the success of selected treatment modalities.

Outcome of carotid artery stenting in the hands of vascular surgeons.

OBJECTIVES: To analyze the procedural and clinical outcomes of carotid artery stenting (CAS) in the hands of endovascular trained vascular surgeons. METHODS: Between April 2008 to May 2013, 1197 patients were treated for extracranial internal carotid artery (ICA) stenosis. The proportion of endovascular treated patients was 5.0% (CAS n = 60 vs. carotid endarterectomy (CEA) n = 1137). All patients in the CAS group (44 males, median age 70 years) were treated by two senior vascular surgeons experienced in endovascular methods. Restenosis was the indication for CAS in 32 out of 60 patients (53.3%). Further indications were contralateral ICA occlusion (n = 14, 23.3%), radiogenic ICA stenosis (n = 5, 8.3%), high-risk candidates for CEA (n = 4, 6.6%), and the presence of contralateral recurrent paresis (n = 2, 3.3%). High-risk patients for CEA were defined as patients with history of severe cardiac disease and patients with impaired general condition. 84.4% (n = 27) of the restenosis were asymptomatic with a mean degree of stenosis of 83.7%, and 12.9% (n = 4) were symptomatic (degree of stenosis of 90%). Mean procedural and fluoroscopy time were 61 and 14 min. Study endpoints were periprocedural stroke-related mortality and morbidity, restenosis rate, and overall survival. Follow-up was performed by duplex ultrasound with a median follow-up period of 12 months (range 1-55). RESULTS: The periprocedural stroke rate of CAS within 30 days was 3.3% (one ischemic stroke, one intracranial hemorrhage); two additional patients suffered TIA (3.3%). None of the patients had a myocardial infarction perioperatively. The mortality rate was 0. CAS procedures were completed in 90.0% (n = 54) of cases. Dropout rate was 8.3% (n = 5) for morphological reasons (e.g., carotid kinking). Intraoperative complication rate was 1.7% (n = 1) including one patient who suffered intraoperative rupture of access vessels. The conversion rate with subsequent CEA procedure was 6.6% (n = 4 of 5). The restenosis rate during follow-up was 3.3% after CAS. The reintervention rate during the median follow-up period of 12 months (1-55 months) was 5.5% (n = 3/54). Two patients received a reintervention with successful balloon angioplasty; in one case, a diagnostic angiography was performed excluding the presence of a relevant restenosis. No additional stent was implanted. The survival rate was 100% at 1 year, 90.4% at 2 years, and 77.7% at 3 years. CONCLUSION: CAS, in the hands of vascular surgeons, is feasible with a moderate perioperative risk in a highly selected patient cohort. A procedure termination rate of approximately 10% shows that the complementary therapy using CAS procedure is not overused by surgeons.

Treatment of stable slipped capital femoral epiphysis: systematic review and exploratory patient level analysis.

BACKGROUND: Several aspects of slipped capital femoral epiphysis (SCFE) treatment remain controversial. Loder's work has been instrumental in changing our understanding and approach to the management of the condition when he introduced the concept of "slip instability" and showed that avascular necrosis (AVN) developed in 47% of unstable slips but none of the stable slips. As the two types of SCFE behave differently in terms of presentation, progress and complications, we approached them as two different conditions to highlight these differences. This paper focuses on treatments of stable SCFE. MATERIALS AND METHODS: An extensive literature search was carried out from multiple databases. One thousand six hundred and twenty-three citations were screened. Three hundred and sixteen full publications were obtained for further scrutiny. Fifty-eight studies (2262 hips) were included in the review. These studies evaluated 6 interventions. AVN was chosen as a surrogate for bad outcome. Secondary outcomes were chondrolysis (CL), femoro-acetabular impingement (FAI), osteoarthritis (OA) and patients' reported outcomes. The latter were pooled when they met our predefined criteria. RESULTS: The type of surgical intervention was an important risk factor. Pinning in situ (PIS) was associated with the lowest AVN rate (1.4%). Moreover, the CL, FAI and OA rates were relatively low in patients who underwent PIS. These were not translated into high patient satisfaction rates among these patients, with only 47% reporting an "excellent" outcome. In contrast, 87% of patients who underwent Ganz surgical dislocation reported an "excellent" outcome. The Ganz surgical dislocation was associated with an AVN rate of 3.3%; double that observed in pinning in situ. CONCLUSION: Pinning in situ is the best treatment for mild and moderate stable slip. Ganz surgical dislocation gives higher patient satisfaction for severe stable slip but the risk of AVN is doubled compared with pinning in situ. Devices that allow continued growth may be better than standard screws. LEVEL OF EVIDENCE: Level III.

Ruptured abdominal aortic aneurysm-epidemiology, predisposing factors, and biology.

PURPOSE: Abdominal aortic aneurysm is a common degenerative vascular disorder associated with sudden death due to aortic rupture. This review describes epidemiology, predisposing factors, and biology of ruptured abdominal aortic aneurysms (rAAAs). METHODS: Based on a selective literature search in Medline (PubMed), original publications, meta-analyses, systematic reviews, and Cochrane reviews were evaluated for rAAA. RESULTS: The hospital admission rate for rAAA is decreasing and is now in the range of approximately 10 per 100,000 population in men. Smoking contributes to about 50 % of population risk for rupture or surgically treated AAA. AAA rupture is a multifaceted biological process involving biochemical, cellular, and proteolytic influences, in addition to biomechanical factors. AAA rupture occurs when the stress (force per unit area) on the aneurysm wall exceeds wall strength. Proteolytic activities of matrix metalloproteinases have been implicated in aneurysm wall weakening and rupture. Aneurysm diameter is the most prominent predisposing factor for aneurysm growth and rupture. Wall stress, aneurysm shape and geometry, intraluminal thrombus, wall thickness, calcification, and metabolic activity influence the rupture risk. CONCLUSION: The best conservative option to avoid AAA rupture consists in smoking cessation and control of hypertension. Many biological factors influence rupture risk.

The effect of bone marrow concentrate and hyperbaric oxygen therapy on bone repair.

Neoangiogenesis represents an essential part of bone regeneration. Therefore the improvement of neovascularization is the subject of various research approaches. In addition autologous mesenchymal stem cells concentrate in combination with bone substitute materials have been shown to support bone regeneration. In a rabbit model we examined the proposed synergistic effect of hyperbaric oxygen therapy (HBOT) and bone marrow concentrate (BMC) with porous calcium phosphate granules (CPG) on neoangiogenesis and osseous consolidation of a critical- size defect. The animal groups treated with HBOT showed a significantly higher microvessel density (MVD) by immunhistochemistry. Furthermore HBOT groups presented a significantly larger amount of new bone formation histomorphometrically as well as radiologically. We conclude that the increase in perfusion as a result of increased angiogenesis may play a key role in the effects of HBOT and consequently promotes bone healing.

AN INCREASE IN RISK FACTORS FOR CARDIOVASCULAR DISEASE IN YOGYAKARTA, INDONESIA: A COMPARISON OF TWO CROSS-SECTIONAL SURVEYS.

This paper aims to describe changes in risk factors for cardiovascular disease (CVD) over a five year period in urban Indonesia. In 2004 (n = 3,205) and 2009 (n = 2,467) we conducted cross-sectional surveys of residents in Yogjakarta City, Indonesia evaluating risk factors for CVD. Smoking habits, fruit and vegetable intake, physical activity, blood pressure, weight, and height were recorded. The results of these 2 surveys conducted 5 years apart were then compared. The risk for having a CVD event was also calculated. Behavioral CVD risk factors were more common among men. The predicted risk of having a CVD event increased from 8.4% to 11.3% among men between 2004 and 2009. Effective measures need to be taken to change these behaviors among men in Yogyakarta, Indonesia.

[Nellix® endovascular aneurysm sealing (EVAS) - a new technology for endovascular management of infrarenal aortic aneurysms]. / Nellix® Endovascular Aneurysm Sealing (EVAS) - eine neue Technologie zur endovaskulären Ausschaltung infrarenaler Aortenaneurysmen.

BACKGROUND: Recently used endografts for envascular aneurysm repair (EVAR) exclude the pathology by fixation at both the proximal and distal landing zone. Due to endoleaks and migration EVAR is associated with a relevant rate of secondary interventions. The Nellix® system (Endologix Inc., CA, USA) was developed to seal the complete aneurysm using a polymer filling, therefore stabilising endograft-position and reducing the rate of endoleaks and reinterventions. The present contribution introduces the method, describes the technique of implantation and presents the first clinical results. Material und Methods: The Nellix system consists of two balloon-expandable stent grafts made of a cobalt-chromium composition, surrounded with ePTFE and the so-called endobags. During the implantation each endobag is filled with a non-biodegradable polymer, sealing the aneurysm lumina including the proximal and distal landing zone. Hence, lumbar arteries will be sealed to reduce the probability of a type II endoleak. RESULTS: Longterm durability as well as the structural integrity of the Nellix system has been proven over 4 years in sheep experiments. The technical success in a multicentre, prospective registry was 94% without the appearance of severe adverse events (migration, occlusion, secondary endoleak). CONCLUSION: EVAS is a new and different concept of endovascular AAA repair. Recent clinical data of the Nellix system are promising showing a high technical success rate while the need for secondary intervention is low. Further studies in larger cohorts are needed.

[Pelvic vein thrombosis : Current treatment options and importance of recanalization procedures]. / Beckenvenenthrombose : Aktuelle Therapieoptionen und Stellenwert rekanalisierender Verfahren.

Venous thrombosis is a frequent disorder. A distinction is made between an acute phase of the disease and a chronic manifestation, the postthrombotic syndrome. In particular, proximal venous thrombosis/pelvic vein thrombosis can cause a life-threatening pulmonary embolism during the acute phase of the disease. The postthrombotic syndrome is characterized by the remodeling of the affected venous section, which is often caused by inflammation. Locally, the typical clinical finding is caused by scarred stricture of the vein with restricted drainage and peripheral venous hypertension. Acute thrombosis should be primarily treated by therapeutic anticoagulation and compression therapy of the affected extremity. The duration of these measures depends on clinical presentation, cause (provoked, unprovoked) and risk factors for venous thrombosis/recurrent thrombosis. Venous revascularization procedures are important both in the acute phase of the disease and in the treatment of postthrombotic syndrome. The recanalization treatment is mostly carried out as an endovascular or hybrid intervention and venous bypass procedures are reserved for special situations.

Eversion carotid endarterectomy is associated with decreased baroreceptor sensitivity compared to the conventional technique.

OBJECTIVE: Impairment of baroreceptor sensitivity (BRS) has been shown to be associated with blood pressure instability after carotid endarterectomy (CEA). The aim of this study was to determine whether there is a difference in postoperative BRS changes following eversion CEA (E-CEA) and conventional CEA (C-CEA). METHODS: Sixty-four patients undergoing E-CEA (n = 37) and C-CEA (n = 27) were prospectively studied. Non-invasive measurements of mean arterial pressure (MAP), cardiac output (CO) and total peripheral resistance (TPR) were perioperatively obtained over three 10-min periods. Baroreflex gain was calculated as the sequential cross-correlation between heart rate and beat-to-beat systolic blood pressure. RESULTS: Compared with changes observed after C-CEA, E-CEA was associated with an increase in systolic pressure (SP) (P = 0.01), diastolic pressure (DP) (P = 0.008), MAP (P = 0.002) and heart rate (HR) (P = 0.03) on postoperative day 1 (POD-1). BRS decreased after E-CEA from 6.33 to 4.71 ms mmHg(-1) on POD-1 (P = 0.001) and to 5.26 ms mmHg(-1) on POD-3 (P = 0.0004). By contrast, BRS increased after C-CEA from 4.59 to 6.13 ms mmHg(-1) on POD-1 (P = 0.002) and to 6.27 ms mmHg(-1) on POD-3 (P < 0.0001). CONCLUSION: E-CEA and C-CEA have different effects on BRS. This is associated with an altered haemodynamic behaviour after E-CEA and C-CEA, respectively. These findings are likely the result of carotid sinus nerve interruption during E-CEA and preservation with C-CEA.

[Interhospital transfer of severely injured patients in Germany. Evaluation of the DGU trauma register]. / Verlegungsrealität schwerverletzter Patienten in Deutschland. Eine Auswertung im TraumaRegister DGU.

BACKGROUND: The TraumaNetzwerk(D) DGU was founded 3 years ago and since then the majority of trauma centers have been registered and organized into regional trauma network services (TNW). Within these networks assessment criteria for transferring patients to higher level hospitals are defined. The purpose of this study was to evaluate the incidence, causes, implications and quality of care for patients with major trauma who were transferred for definitive treatment before implementation of the TraumaNetzwerk(D) DGU in Germany. PATIENT AND METHODS: The data of 19,035 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) >9 and a blood pressure documented on admission were included into the study. Data were allocated according to patients where therapy was performed completely in the primary hospital of admission (group I; n=16,033; 84.2%) and patients transferred after primary care from one hospital to another centre for definitive care (group II; n=3,002; 15.8%). Comparative parameters were the pattern and severity of injury, physiological state on admission and clinical outcome. RESULTS: Mean ISS and percentage of patients with an ISS ≥25 did not differ significantly between groups. Of the patients who were transferred to a higher level trauma centre (group II) 20.7% needed catecholamines on admission, 10.1% were in shock (blood pressure <90 mmHg) and 2.5% of the patients underwent resuscitation in the emergency department. Patients of group II had a considerably longer hospital stay (31.2±35.5 days) than patients of group I (24.8±27.1 days). Furthermore, treatment costs were significantly higher for group II (I: EUR 23,870; II: EUR 26,054). CONCLUSIONS: A relevant percentage of patients transferred from one hospital to another were hemodynamically and clinically unstable. To what extent the quality of patient transfer and therefore major trauma care is improved by the implementation of regional trauma networks in Germany remains to be seen over the next years.

Assessment of patients' satisfaction in carotid surgery under local anaesthesia by psychometrical testing--a prospective cohort study.

METHODS: Between July 2008 and December 2008 102 consecutive patients undergoing CEA under local anaesthesia (LA) were prospectively evaluated. All patients were psychometrically assessed by the Hospital Anxiety and Depression Scale (HADS), the EuroQol and the Heidelberg peri-anaesthetic questionnaire (HPQ). Furthermore technical issues of cervical plexus block were assessed. RESULTS: Multivariate analysis with an HPQ sum-score of 98 points as a cut-off level for reduced patients' satisfaction demonstrated that HADS-D scores of >9 (OR: 7.228; p = 0.003), insufficient intra-operative pain control (OR: 3.264; p = 0.0322) and complications due to plexus anaesthesia (OR: 3.794; p = 0.0370) were associated with a low patients' satisfaction in carotid surgery under LA. CONCLUSION: The efficacy of the plexus blockade in terms of pain control and side effects affects patients' satisfaction in carotid surgery under LA. When choosing LA for patients undergoing carotid endarterectomy altered states of anxiety and mood reduce satisfaction in carotid surgery under LA and might compromise patients' suitability for LA.

Fixed-angle plates in patella fractures - a pilot cadaver study.

OBJECTIVE: Modified anterior tension wiring with K-wires and cannulated lag screws with anterior tension wiring are currently the fixation of choice for patellar fractures. Failure of fixation, migration of the wires, postoperative pain and resulting revision surgery, however, are not uncommon. After preliminary biomechanical testing of a new fixed-angle plate system especially designed for fixation of patella fractures the aim of this study was to evaluate the surgical and anatomical feasibility of implanting such a plate-device at the human patella. METHODS: In six fresh unfixed female cadavers without history of previous fractures around the knee (average age 88.8 years) a bilateral fixed-angle plate fixation of the patella was carried out after previous placement of a transverse central osteotomy. Operative time, intraoperative problems, degree of retropatellar arthritis (following Outerbridge), quality of reduction and existence of any intraarticular screw placement have been raised. In addition, lateral and anteroposterior radiographs of all specimens were made. RESULTS: Due to the high average age of 88.8 years no patella showed an unimpaired retropatellar articular surface and all were severely osteoporotic, which made a secure fixation of the reduction forceps during surgery difficult. The operation time averaged 49 minutes (range: 36-65). Although in postoperative X-rays the fracture gap between the fragments was still visible, the analysis of the retropatellar surface showed no residual articular step or dehiscence > 0.5 mm. Also in a total of 24 inserted screws not one intraarticular malposition was found. No intraoperative complications were noticed. CONCLUSIONS: Osteosynthesis of a medial third patella fracture with a bilateral fixed-angle plate-device is surgically and anatomically feasible without difficulties. Further studies have to depict whether the bilateral fixed-angle plate-osteosynthesis of the patella displays advantages over the established operative procedures.

[Platelet-rich plasma combined with autologous cancellous bone : An alternative therapy for persistent non-union?]. / Platelet-rich-Plasma in Kombination mit autologer Spongiosa : Eine Alternative bei therapierefraktären Pseudarthrosen?

BACKGROUND: In addition to a stabile osteosynthesis autologous cancellous bone graft remains an essential therapy option in persistent non-union. Despite this therapy regimen persistent non-union can occasionally occur. The aim of this study was to evaluate the treatment of persistent non-union with a combination of platelet-rich plasma (PRP) and autologous cancellous bone. MATERIAL AND METHODS: In this prospective study 17 patients with persistent non-union of long bones were treated by a combination of PRP and autologous iliac crest bone. Inclusion criteria were a minimum of one previously failed cancellous bone transplantation and an atrophic non-union persisting for 6-14 months (mean 9 months). The patients were examined clinically and radiologically at intervals of 3, 6 and 9 months postoperatively. RESULTS: After an average time of 17 months (range 15-23 months) the patients were treated by a combination of PRP and autologous cancellous bone. In all cases the non-union was successfully treated and osseous bridging was found radiologically after an average of 5 months (range 4-7 months) without any complications. CONCLUSION: The combination of PRP and autologous cancellous bone appears to be a safe and effective method for treatment of persistent non-union. The use of PRP does not result in substantial additional costs. Allergies and graft versus host reactions are not expected because of the autologous origin.

[Treatment strategy for carpometacarpal fracture dislocation]. / Behandlungsstrategie bei karpometakarpalen Luxationsfrakturen.

Carpometacarpal (CMC) fracture dislocations of the 2nd through 5th ray are rare injuries whose extent is regularly underestimated in the initial radiographic evaluation of the hand. Obtaining a computed tomography scan is imperative due to the radiographic underrepresentation of the full bone and joint injury. Restoration of bone and joint anatomy of the affected region is of paramount import to prevent joint deterioration and loss of hand durability and dexterity. Early surgical intervention can lead to good functional results. Different operative treatment strategies exist with a common approach being Kirschner wire, screw or plate fixation after closed or open fracture reduction and joint relocation.

[Vascular surgery in the elderly - recommendations for clinical practice]. / Gefäßchirurgie im Alter - Handlungsempfehlungen für die chirurgische Praxis.

Due to the increasingly aging populations of the industrialised countries, the prevalence of vascular disorders is increasing, with an emerging patient subgroup of 80  years and older (octogenarians), often multi-morbid with an increased risk of anaesthesiological and surgical complications. This review article presents evidence-based indications for vascular surgery in the elderly (> 80  years), and the influence of advanced age on surgical results. Guidelines for daily practice were drawn from a thorough analysis of current treatment recommendations for three vascular disorders (carotid artery stenosis, abdominal aortic aneurysm, and peripheral arterial disease) with the aim of assisting the primary care physician in deciding upon the therapeutic management. In summary, evidence indicates that CEA (carotid endarterectomy) is the gold standard therapy for carotid artery stenosis, as opposed to the "best medical treatment" and CAS (carotid artery stenting). With suitable morphology of the aneurysm, endovascular aneurysm repair (EVAR) is the therapy of choice for abdominal aortic aneurysm (AAA). In elderly patients unfit for open repair and with a life expectancy of less than 4  years, EVAR does not offer any survival benefit compared with no intervention. In such patients, conservative therapy should be taken into consideration. Due to the significantly reduced life expectancy after a major amputation, the value of infrainguinal revascularisation is high, with the exception of patients aged > 90  years.

[Definition of the quality of hand surgery]. / Definition von Qualität in der Handchirurgie.

The quality of treatment within the total concept of the healthcare system is subject to multifactorial influences. With the intention to improve the quality of hand surgery the German Society for Hand Surgery (DGH) has initiated a number of projects. These include the S3 guidelines codeveloped by the DGH, the hand trauma register of the DGH, the definition of criteria for hand surgical procedures to be performed in an outpatient setting within the framework of a consensus recommendation as well as participation in a large epidemiological study with the special documentation of pathological alterations of the hand to determine the prevalences (study of health in Pomerania, SHIP); however, within these projects the quality of treatment itself is not assessed. In the attempt to document the quality, the currently available quality indicators in hand surgery probably only evaluate the aspects really relevant for the patients to a limited extent. Therefore, the DGH participated at an early stage in the development of assessments within the international study named by the WHO as a lighthouse project. These developed and validated assessments are intended to include all aspects of the results including the individual patient view in order to precisely relate the quality of treatment to an exactly defined pattern of hand injury. The use of these assessments should permanently enable a prediction of outcome quality for each individual patient. All these projects require the largest involvement possible to collect as much data as possible. With this intention the DGH further coordinates and develops these projects within the committees of the extended executive board and attempts to motivate as many surgeons as possible to participate.

Polylactic Acid (PLA) Biocomposite: Processing, Additive Manufacturing and Advanced Applications.

Over recent years, enthusiasm towards the manufacturing of biopolymers has attracted considerable attention due to the rising concern about depleting resources and worsening pollution. Among the biopolymers available in the world, polylactic acid (PLA) is one of the highest biopolymers produced globally and thus, making it suitable for product commercialisation. Therefore, the effectiveness of natural fibre reinforced PLA composite as an alternative material to substitute the non-renewable petroleum-based materials has been examined by researchers. The type of fibre used in fibre/matrix adhesion is very important because it influences the biocomposites' mechanical properties. Besides that, an outline of the present circumstance of natural fibre-reinforced PLA 3D printing, as well as its functions in 4D printing for applications of stimuli-responsive polymers were also discussed. This research paper aims to present the development and conducted studies on PLA-based natural fibre bio-composites over the last decade. This work reviews recent PLA-derived bio-composite research related to PLA synthesis and biodegradation, its properties, processes, challenges and prospects.

Endografting in the aortic arch - does the proximal landing zone influence outcome?

OBJECTIVES: To analyse early and midterm results of thoracic aortic endografting (TEVAR) in the aortic arch. METHODS: Between January 1997 and February 2009 178 patients received TEVAR in the aortic arch at our institution. This population was subdivided into four groups according to the proximal landing zone (LZ) classification in the aortic arch by Ishimaru et al. and a retrospective analysis regarding perioperative mortality, morbidity and endoleak formation was performed. RESULTS: The overall 30-day mortality rate was 14% with no statistical significant difference between LZ's 0-3 (p=0.274). Renal insufficiency (hazard ratio (HR) 2.5; p=0.0119), age >75 years (HR 3.1; p=0.0019) and emergency procedures (HR 8.9; p < 0.0001) were independent predictors of death. There was no significant difference regarding type I (p=0.07) or type III (p=0.49) endoleaks between the proximal LZs, but a significant difference regarding the development of type II endoleaks (p=0.01). CONCLUSIONS: The present study showed no influence of the proximal LZ on perioperative mortality and morbidity rate. Furthermore it did not influence relevant (type I/III) endoleak formation.

The progress of early phase bone healing using porous granules produced from calcium phosphate cement.

OBJECTIVE: Bone grafting is a vital component in many surgical procedures to facilitate the repair of bone defects or fusions. Autologous bone has been the gold standard to date in spite of associated donor-site morbidity and the limited amount of available donor bone. The aim of this study was to investigate the progress of bone regeneration and material degradation of calcium phosphate granules (CPG) produced from a calcium phosphate self-setting cement powder compared to the use of autologous bone grafting in the treatment of "critical size defects" on load-bearing long bones of minipigs. METHODS: A critical size defect in the tibial metaphysis of 16 mini-pigs was filled either with autologous cancellous graft or with micro- and macroporous carbonated, apatic calcium phosphate granules (CPG) produced from a calcium phosphate self-setting cement powder. After 6 weeks, the specimens were assessed by X-ray and histological evaluation. The amount of new bone formation was analysed histomorphometrically. RESULTS: The semi-quantitative analysis of the radiological results showed a complete osseous bridging of the defect in three cases for the autograft group. In the same group five animals showed a beginning, but still incomplete bridging of the defect, whereas in the CPG group just two animals developed this. All other animals of the CPG group showed only a still discontinuous new bone formation. Altogether, radiologically a better osseous bridging was observed in the autograft group compared to the CPG group. Histomorphometrical analysis after six weeks of healing revealed that the area of new bone was significantly greater in the autograft group concerning the central area of the defect zone (p<0.001) as well as the cortical defect zone (p<0.002). All defects showed new bone formation, but only in the autograft group defects regenerated entirely. CONCLUSIONS: Within the limits of the present study it could be demonstrated that autologous cancellous grafts lead to a significantly better bone regeneration compared to the application of calcium phosphate granules (CPG) produced from a calcium phosphate self-setting cement powder after 6 weeks. In the early phase of bone-healing, the sole application of CPG appears to be inferior to the autologous cancellous grafts in an in vivo critical size defect on load-bearing long bones of mini-pigs.

Treatment of an asymptomatic penetrating aortic ulcer in a young patient.

We want to report and discuss the indication for open surgery for an asymptomatic penetrating aortic ulcer (PAU) in the era of thoracic endovascular aortic repair (TEVAR). A 31-year-old female presented with the diagnosis of an aneurysm in the distal aortic arch. With respect to the patients young age, the controversial status of connective tissue disorders and in the absence of concomitant disease, open repair was indicated. There was no proof of a mycotic plaque or connective tissue disease in the microbiological-, pathological analysis and at electron-microscopy. The patient was discharged on the thirteenth postoperative day. In spite of good preliminary results of TEVAR in PAU, in selective cases there is still an indication for open surgery.