Severe Soft Tissue Damage Research Articles

A Prospective Study of the Outcome of Patients with Limb Trauma following the Haitian Earthquake in 2010 at One- and Two- Year (The SuTra2 Study).

Background Severe limb trauma is common in earthquake survivors. Overall medium term outcomes and patient-perceived outcomes are poorly documented. Methods and Findings The prospective study SuTra2 assessed the functional and socio-economic status of a cohort of patients undergoing surgery for limb injury resulting in amputation (A) or limb preservation (LP) one year and two years after the 2010 Haiti earthquake. 305 patients [A: n=199 (65%), LP: n=106 (35%)] were evaluated. Their characteristics were: 57% female; mean age 31 years; 74% of principal injuries involved the lower limb; 46% of patients had an additional severe injury; 60% had fractures, of which two-thirds were compound or associated with severe soft tissue damage; 15% of amputations were traumatic. At 2 years, 51% of patients were satisfied with the functional outcome (A: 52%, LP: 49%, ns). Comparison with the 1-year status indicates a worsening of the perceived functional status, significantly more pronounced in amputees, and an increase in pain complaints, mainly in amputees (62% and 80% of pain in overall population at 1- and 2-year respectively). Twenty eight percent (28%) of LP and 66% of A considered themselves as “cured”. 100% of LP and 79% of A would have chosen a conservative approach if an amputation was medically avoidable. Two years after the earthquake, 23·5 % of patients were still living in a tent, 30% were working, and 25·5% needed ongoing surgical management. Conclusions Only half the patients with severe limb injuries, whether managed with amputation or limb preservation, deemed their functional status satisfactory at 2 years. The patients’ perspective, clearly favors limb conservative management whenever possible. Prolonged care and rehabilitation are needed to optimize the outcome for earthquake survivors with limb injuries. Humanitarian respondents to catastrophes have professional and ethical obligations to provide optimal immediate care and ensure scrupulous attention to long-term management. Keywords Haiti earthquake, limb injury, two-year outcome, patients’ perspective, amputation, limb salvage

Multifragmentary Tibial Pilon Fractures: Midterm Results After Osteosynthesis with External Fixation and Multiple Lag Screws

Osteosynthesis of intraarticular tibial pilon fractures is preferably achieved using locking plates via a minimally invasive technique. If combined with severe soft tissue damage there is a high risk of wound-healing deficits after plate osteosynthesis. Thus our aim was to find an alternative method of treatment for those cases with combined soft tissue injuries.We report on five cases with comminuted fractures of the joint surface combined with critical soft tissue condition that were treated with lag screws and external fixation (AO) applied across the ankle joint. All five patients were followed up, undergoing clinical and radiological examination.Using this approach we achieved fracture healing of comminuted fractures without further complications. Clinical follow-up after an average of 55.6 (36–75) months revealed a mean AOFAS score of 81 (62–100).We therefore propose combined treatment using lag screws with external fixation as a practical treatment option for those fractures for which lag screws combined with a locking plate are not feasible or when there is a high risk of wound-healing deficits due to severe soft tissue damage.

Minimal-invasive Osteosynthesen von Pilonfrakturen

The primary aim of minimally invasive osteosynthesis (MIO) is the anatomical reconstruction of the distal tibial articular surface, with preservation of the soft tissue to allow early functional postoperative management. This should lead to a normal bone healing and recovery without arthrosis. Fractures type Rüedi I + II or AO43-B1, -B2, AO43-C1, -C2, rare and relative indications are fractures of type AO43-B3 and -C3 fractures without IIb and III° soft tissue injuries. It may also be used as an additional technique for osteosynthesis with external fixators. Severe comminuted fractures of the pilon with closed or open II and III° soft tissue damage. Severe soft tissue damage (III°). An intensive preoperative analysis of conventional X-rays and CT images is necessary to support the indication for MIO of pilon fractures. The first step is reduction of the fracture with axial traction, in some cases with a distractor or external fixator. The definitive reduction is performed with K-wire joysticks or reduction clamps. The key step is the intraoperative X-ray control of the reduction in various planes, if possible with 3D reconstruction. An alternative is also arthroscopic control of the articular reduction. All manipulations are performed via small incisions. After incision of the skin, all layers of soft tissue are smoothly divided with scissors allowing the soft tissue including vessels and nerves to be moved out of the working channel. All instruments and implants (e.g., K-wires, drill sleeve, screws) are introduced between the opened scissor branches. After lag screw osteosynthesis with 3.5 or 4.5mm conventional screws, the articular block is reduced to the diaphysis and fixed with a minimally invasively inserted plate. Under X-ray control in two planes, the plate is adjusted into position and preliminarily fixed with K-wires. The screws are inserted using the minimally invasive technique. Immediate mobilization starting on day1 with partial weight bearing (sole contact or 12-15kg) for 4-6weeks, postoperative protection with orthesis or split cast for 2-5days depending on degree of swelling, early functional physiotherapy, thrombosis prophylaxis with heparin until complete mobilization. Full weight-bearing depending on fracture type after 6-8weeks. Advantages of minimally invasive osteosynthesis of pilon fractures compared to conventional open reduction and osteosynthesis, include protection of the soft tissue and no further disturbances of circulation-ideal prerequisites for undisturbed bone healing. In 129patients after osteosynthesis of pilon fracture, no reoperations were necessary when using MIO, but reoperation was necessary with other techniques in 17.6% of all patients. In addition, no infections were observed with MIO vs. 13.4% of patients with other techniques. The average Olerud/Molander Score was 95points for the MIO group vs. 58.91 points for all patients treated, while MIO plus an external fixator received a score of 50points. The average Ankle Hindfoot Score was 64.9points, for MIO 87.5points, and for operations consisting of MIO plus an external fixator 58points.

Successful treatment of nonunion in severe finger injury with low-intensity pulsed ultrasound (LIPUS): a case report

IntroductionSevere injuries of the hand or single fingers require immediate treatment but surgical fixation methods are limited depending on soft tissue damage. Thus, it is very common that severe soft tissue damage along with poor osteosynthetic bone fixation results in a delayed healing process or nonunion. Low-intensity pulsed ultrasound (LIPUS) has been proven to stimulate bone formation in in vitro studies and also to significantly accelerate nonunion healing in animal studies and clinical trials but to date there are no data with respect to nonunion in phalanx fracture.Case presentationWe report a case in which we successfully used LIPUS in a 19-year-old Caucasian man with a nonunion of his ring finger after injury and first treatment with K-wire osteosynthesis.ConclusionWe recommend that LIPUS be considered as an option to treat nonunions in fractures of the hand, especially because it is a soft tissue conserving method with a good functional result.

Retrograde Nail for Tibiotalocalcaneal Arthrodesis as a Limb Salvage Procedure for Open Distal Tibia and Talus Fractures with Severe Bone Loss

The treatment of complex fractures of the distal tibia, ankle, and talus with soft tissue damage, bone loss, and nonreconstructable joints for which the optimal timing for reduction and fixation has been missed is challenging. In such cases primary arthrodesis might be a treatment option. We report a series of multi-injured patients with severe soft tissue damage and bone loss, who were treated with a retrograde tibiotalocalcaneal arthrodesis nail as a minimally invasive treatment option for limb salvage. After a median follow-up of 5.4 years, all patients returned to their former profession. The ankle and bone fusion was complete, with moderate functional results and quality of life. Calcaneotibial arthrodesis using a retrograde nail is a good treatment option for nonreconstructable fractures of the ankle joint with severe bone loss and poor soft tissue quality in selected patients with multiple injuries, in particular, those involving both lower extremities, as a salvage procedure.

Prospective comparative study of functional outcome of treatment of tibial shaft fracture in adult by cast versus intramedullary nailing

All patients with an isolated closed unilateral fracture of the tibial diaphysis admitted in our institution between November 2009 and October 2010 were evaluated for inclusion in the present study. Inclusion criteria were displaced closed fractures. The fractures of type A and B, according to the AO-classification system, were considered suitable for the study.16 The following exclusion criteria were used: 1) Patients who had other major injuries which could influence the final functional result, 2) patients with cardiopulmonary, rheumatological, neurological, or metabolic disease, 3) patients with previous injuries which influenced their general function, 4) patients with fractures within 5 cm distal to the tibial tuberosity or 7 cm proximal to the ankle joint, 5) open fractures, and 6) those with open growth plates. Thirty-four patients (26 men) having a mean age of 38 years fulfilled the criteria and entered the study. The patients gave their informed written consent before inclusion in the study, which was approved by the hospital’s ethics committee. Patients who agreed to participate in the study were randomized using the technique of stratified randomization by minimization.17 This method ensures that the treatment groups are similar as regard to the percentage of patient factors that are considered of major prognostic importance. The aim is to balance the marginal treatment totals for each level of each patient factor. Using a computer minimization program, each patient was allocated according to high-energy, soft-tissue injury (closed), age (under or over 50 years), smoking (yes or no), alcoholism (yes or no), and occupation (sedentary, mobile, heavy, unemployed). Fractures caused by traffic accident or a fall from a height of at least 3 meters were classified as highenergy trauma.18 Patients in each stratum were randomly allocated for treatment by unreamed intramedullary nailing or plaster cast. Seventeen patients were randomized to have an intramedullary nail (group I), and 17 patients were randomized to have a plaster cast (group II). All fractures were unilateral. Nineteen involved the right leg and 4 patients were injured by falling accidents. Traffic accidents caused the injuries in 26 patients, 11 of them were pedestrians, 2 were automobile drivers, and 13 were motorcycle drivers. Two patients were injured in sporting accidents and 2 others were injured at work. The severity of the closed injuries was classified according to (Table 1).19 Eight fractures were caused by low-energy trauma, while 26 fractures were caused by high-energy trauma (Table 1). The type of fracture was classified according to the AO system (Table 2). Seven fractures involved the proximal third of the tibia, 21 the middle third, and 6 the distal third. Twentynine patients had an associated fibula fracture, 8 at the same level as the tibia fracture, and 21 at a different one (Table 2). The median time of delay to operation was 5 days for group I and no days for group II. Gender, smoking habits, age, type of trauma, severity of soft-tissue damage, and degrees of comminution of the fractures were similar in the 2 groups. Closed tibial nailing was performed with the patient lying supine. A calcaneal pin was used if traction was required. We used a longitudinal medial parapatellar incision and approach to the Prospective comparative study of functional outcome of treatment of tibial shaft fracture in adult by cast versus intramedullary nailing

Comparison Study of Therapeutic Results of Closed Tibial Shaft Fracture with Intramedullary Nails Inserted with and without Reaming

Tibia fractures are the most common type of long bone fractures in US. This study aimed at comparing the therapeutic results of closed tibial shaft fracture with intramedullary nails inserted with and without reaming. In this randomized clinical trial study, 60 patients with a fracture of the tibia were examined. The patients were randomly divided into two groups. Thirty patients treated through inserting intramedullary nail with reaming technique (group A). The other 30 patients treated through inserting intramedullary nail without reaming technique (group B). After operation physical examination and control radiography were taken up to 6 month and results were compared. Sixty patients suffering from closed tibial diaphysis fractures were studied. Mean age of the group A and B were 40.24 +/- 12.32 and 38.42 +/- 14.28, respectively. Group A consisted of 24 (80%) males and 6 (20%) females while group B consisted of 24% females and 76% males. Considering fracture based on OTA criteria (p = 0.4) and severity of soft tissue damage based on Tscherne classification (p = 0.6), there was no statistically meaningful difference between groups A and B. The study demonstrated that degree of horizontal displacement, mean time of surgery, post-operation infection, organ shortness at the end of the follow-up period, organ deviation in patients of the group A was significantly more than that of the group B. Time required for callus formation (mean time of union), mean time of full weight bearing time and mean time of return to normal activities in group B was significantly more than that of the group A.

Management of Grade III Open Dislocated Ankle Fractures

Isolated dislocation of the ankle with grade III open fracture has been scarcely reported. These ankle injuries usually involved mortise fractures, complete dislocation of the tibial astragaloid joint, capsuloligamentous structure disruption, and severe soft-tissue damage. There is no well-recognized regimen that would result in desirable outcomes. Sixteen patients with grade III open dislocated ankle fractures were treated immediately with bioabsorbable implants and an external fixator between January 2003 and June 2007. According to the classification system of Gustilo and Anderson, five patients were grade IIIA, seven were grade IIIB, and four were grade IIIC. Surgical interventions included combined internal fixation with bioabsorbable screws/rods and external fixation. Patients underwent clinical and radiologic examination at an average of 18.1 months after surgery. Outcomes were excellent in seven patients (three IIIA, three IIIB, and one IIIC), good in four (one IIIA, two IIIB, and one IIIC), fair in three (one IIIA, one IIIB, and one IIIC), and poor in two (one IIIB, and one IIIC). In the two patients with poor outcomes, bone defect and cartilage exfoliating in the distal tibia were found during surgery. Painful osteoarthritis in the ankle was discovered 2 years after surgery. Another case had pin tract infections in the external fixator 3 months after surgery. There was no case of late deep infection. It may be a reasonable and desirable option that bioabsorbable implants combined with an external fixator be applied for treatment of severe open dislocated ankle fractures.

Management of Severe Open Ankle–Foot Trauma by a Simple External Fixation Technique: An Alternative During War and in Resource-Poor and Low-Technology Environments

Severe open foot and ankle injuries are still a challenge for the orthopaedic surgeon. Their treatment is even more difficult in third world countries and in war settings where high-energy trauma with severe soft tissue damage is more frequent. Lack of equipment, poor resources and hygiene, and different cultural systems make most of the standard proposed treatments difficult to apply. The authors describe an inexpensive, rapid, minimally invasive, and easy-to-apply external fixation technique for the treatment of severe open ankle-foot fractures. With the main goal of soft tissue management rather than definitive treatment of any bony injuries, this technique was developed over time during many consecutive missions in Sierra Leone and Afghanistan as an alternative to more appropriate treatments with surprisingly satisfactory short- and long-term results.

Local application of VEGF compensates callus deficiency after acute soft tissue trauma—results using a limb‐shortening distraction procedure in rabbit tibia

Acute soft tissue trauma influences callus formation and fracture healing. Several studies showed a relationship between angiogenesis and bone formation during distraction osteogenesis. The purpose of this study was to investigate the influence of controlled release of vascular endothelial growth factor (VEGF) on callus formation in a limb-shortening distraction procedure after acute compartment syndrome. Acute soft tissue trauma with critical increased compartment pressure was generated in 22 rabbits, and the limb was shortened simulating fracture site debridement. In the test group (n=11), a VEGF-coated collagen matrix was locally applied around the fracture, while no collagen was applied in the control group (n=11). Following 10 days in limb shortening, a gradual distraction of 0.5 mm/12 h was performed using an external fixation device and followed up for 40 days. Osseous consolidation occurred in all animals. Average callus diameter (1.54 ± 0.8 vs. 1.27 ± 0.14 mm) and torsional strength (72% vs. 46% of normal) were significantly higher in the test versus the control group. Blood vessel formation increased with a significantly higher number of vessels (6.3 vs. 3.81/mm2 ) and larger cross-sectional area (>40 µm, 90.5% vs. 86%) in the test versus control group. The results showed that locally applied VEGF stimulates fracture healing after acute soft tissue trauma and might be an option for fracture treatment in cases with severe soft tissue damage.

Heterotopic ossifications following implant surgery—epidemiology, therapeutical approaches and current concepts

The pathophysiology of heterotopic ossification (HO) is still ill-understood. Several risk factors such as osteoarthritis, male gender and injury patterns like traumatic brain injury and severe soft tissue damage have been described. Furthermore, the pathophysiology of local and systemic factors has been investigated leading to an extended knowledge especially on the molecular level. Knowledge of the involved cell types and mediators led to the now widely used prophylactic and therapeutic strategies to prevent heterotopic ossifications. Out of these findings, the beneficial effects of NSAIDs and radiotherapy on HO prophylaxis have been proven for a number of indications such as total hip arthroplasty and acetabular surgery. However, there is little information about the potential effects on heterotopic ossifications around the elbow. Surgical treatment may be considered in some cases, but there are only limited indications. Generally, only clinically relevant bone formations should be resected. Following surgical resection, beneficial effects on range of motion and pain relief has been described. An accurate perioperative regimen is crucial and includes prophylactic medication. In combination with radiotherapy, low recurrence rates were described but there are still controversies about the optimal timing for surgical resection.

Ultrasonographic Appearance of Bovine Coxofemoral Luxation in Different Directions

Coxofemoral luxation is common in cattle and prognosis is very guarded or poor. Diagnosis is generally based on thorough physical examination by identifying the structure of the hip, but an accurate diagnosis can be challenging, especially in heavy and recumbent cows because large muscle mass covering the pelvis and hip makes palpation of the bony structures difficult. In cattle practice, ultrasound has been widely used as an important ancillary test for a more accurate diagnosis and avoidance of unnecessary treatment. The purpose of this report is to describe ultrasonographic features of twenty two dairy cows (3-7 years) with coxofemoral luxation in three different directions. Five cows with craniodorsal, six with caudodorsal, and eleven with caudoventral luxation were examined ultrasonographically. Only three cows were able to stand and eleven exhibited asymmetry of the hip upon external examination of the hindlimbs. Sonographic findings on the dorsolateral view of the hip in standing and laterally recumbent cows invariably included the ball-shaped femoral head outside the acetabulum in dorsal luxations and heterechoic empty joint cavity of the acetabulum in ventral luxation. On the ventrodorsal view for dorsal recumbency with the frog-leg position, either luxated femoral head or empty acetabular cavity was visible in fifteen examined cows in the three different directions of luxation, but the femoral head of the caudodorsal luxation was translated caudoventrally to the acetabulum owing to severe soft tissue damage around the acetabulum. Transrectal ultrasonography of the caudoventral luxation revealed the ball of the femoral head in or ventral to the obturator foramen with varying amounts of fibrin deposit on it. Ultrasonography can be used to make a definitive diagnosis of coxofemoral luxation in three different directions in recumbent cows, as well as standing cows.

Complete dislocation of the talus: A case report using intraoperative 3D fluoroscopy

In a complete dislocation of the talus, the talus is stripped of all its ligament connections in the triple articulated ankle joint. This case report describes the treatment and the 3-year follow-up of a complete dislocation of the talus with the use of intraoperative 3D imaging. The 19-year-old patient was involved as a driver in a car accident. After the radiological diagnosis of a complete talus dislocation, an emergency operation was performed due to the critical soft tissue condition. The ISO-C3D fluoroscope from the company Siemens (Erlangen, Germany) was utilized for reduction control. Follow-up evaluations were completed three years after the treatment, the patient had no complaints. Since these types of serious injuries are always combined with severe soft tissue damage, the main goals of this treatment have to be debridement and minimized iatrogenic surgical damage. By using intraoperative 3D imaging, immediate reduction control is available, so that revision operations can be avoided. Complete dislocation of the talus is an extremely rare injury, which may cause serious complications. A fast and careful reduction, whether open or closed, should be the goal of treatment. Successful reduction can be determined intraoperatively with the use of 3D imaging.

Reverse shoulder arthroplasty as a salvage procedure for failed conventional shoulder replacement due to cuff failure—midterm results

Our goal was to evaluate the objective and subjective midterm outcome after revision of a failed shoulder arthroplasty with a reverse design prosthesis. Twenty consecutive patients with 21 revisions of a primary shoulder arthroplasty using reverse shoulder prosthesis Delta III(®) were followed up postoperatively for a mean of 46months including clinical and radiological examination. Complications were recorded and Constant score, DASH and SF36 were assessed. With the numbers given a significant reduction of pain was achieved from 8.7 to 3.0 (p < 0.001). There was a significant improvement of active flexion from 43° to 97° (p < 0.001) and active abduction from 44° to 90° (p < 0.001). However, at the same time, active external rotation with an adducted humerus decreased significantly from 26° to 12° (p = 0.012). The constant score improved significantly from 16.7 to 55.9 (p < 0.001). Sixteen patients (84%) rated their shoulder better or much better than before. In 43% an intraoperative and in 38% a postoperative complication occurred including two late stage infections which required prosthesis removal. Our results support the use of the reverse prosthesis as revision prosthesis. The reverse design helps to compensate functional deficits due to severe soft-tissue damage except active external rotation. Nevertheless, the revision is a technically demanding procedure reflected in a high rate of intraoperative complications. The rate of secondary infections of 10% remains a special concern.

The Treatment of Intra-articular Calcaneus Fractures with Severe Soft Tissue Damage with a Hinged External Fixator or Internal Stabilization: Long-term Results

We developed a hinged external fixator for the treatment of dislocated intra-articular calcaneus fractures with severe soft tissue damage. The external fixation was performed with a known external fixator system. The screw insertion points were biomechanically tested by defining a virtual rotation axis through the center of the talus to allow early active motion in the ankle joint. Long-term follow-up was performed after an average of 7.3 years. Results were graded with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed according to Sanders classification. Four open fractures and 33 cases with extremely swollen soft tissue, blisters, or compartment syndromes were treated. In 24 cases (64.9%), the hinged fixator was the final method of treatment (group I). A change to open reduction with internal fixation was performed in 13 fractures (35.1%) when soft tissue problems were minimal (group II). There were no late amputations, osteomyelitis, or malunions. According to Sanders classification, group I consisted of 14 type II, 8 type III, and 2 type IV fractures. Pin loosening or pin infection was seen in 4 cases, but there was no redislocation. The Böhler's angle improved in 43%, gaps in the posterior facet were closed in 41%, and any shortening or deviation of the axis was corrected in 82% of the cases. The AOFAS score for the group averaged 66.5. According to Sanders classification, group II consisted of 8 type II and 5 type III fractures. The Böhler's angle improved in 88%, and gaps in the posterior facet were closed in 87%. Any shortening or deviation of the axis was corrected in 95%, and the AOFAS score averaged 61.3. Significant differences in patient outcome scores between open reduction with internal fixation and hinged fixator were not found. P value was > .05. The hinged external fixator frame can be used in all calcaneus fracture types without soft tissue limitation. The hinged fixator allows early movement in the ankle joint, the risk of infection is minimized, and secondary plate fixation remains possible.

Ultrasonic evaluation of pupillary light reflex

Abstract Background Evaluation of pupillary light reflex (PLR) is an important neurological test with a variety of clinical applications. Obstacles such as severe soft tissue damage or hyphema may obstruct the visual access to the pupil, thus rendering direct PLR observation difficult or impossible. Multipurpose ultrasonic systems, however, can overcome this problem. Methods Using ultrasound imaging, a coronal view of the iris and pupil allowed visualization of PLR upon contralateral stimulation with a penlight. The technique was tested in ten healthy volunteers and a trauma case study. Results Satisfactory visualization of the iris was achieved in all subjects, in an average time of 1 min 10 s. Temporal parameters of pupillary constriction, oscillations (hippos) and relaxation could also be measured on M-mode displays. Conclusions Real-time coronal imaging of the iris using multipurpose ultrasound imaging is found to be a practical, fast and recordable method that can be used for evaluating PLR.

Arterielle Gefäßverletzungen im Rahmen offener Frakturen – Management und Versorgung

Vascular injuries are an uncommon finding. In times of peace vascular injuries occur in approximately 1-4 % during traffic accidents. Especially challenging is the treatment of open fractures combined with arterial lesions. These fractures are usually accompanied with severe soft tissue damage and injuries to neurological structures. The overall prognosis of these trauma patients is dependent on fast and sufficient diagnostics and therapy. In particular, for unstable patients time-consuming diagnostics can be dispensed and a primarily operative therapy should be targeted. Vascular reconstruction by direct suture is sometimes only possible with interposition and should be the primary goal. Interposition should be performed with autologous vein material because of the high risk of infection. Here we demonstrate on the basis of our patients the interdisciplinary -management of such trauma patients in our hospital.

Korrektur von sprunggelenksnahen Deformitäten mit dem Taylor Spatial Frame

Post-traumatic supramalleolar deformities and malunions of ankle fusion require mostly a multiplanar correction. In cases of severe soft tissue damage, external fixation and gradual correction is a definite treatment alternative. Between 2003 and 2007 a correction of supramalleolar deformities was performed in 9 patients with the Taylor spatial frame external fixator. The mean age was 30 years (min. 12, max. 68). There were 6 patients with deformities after malunion of supramalleolar fractures and 3 patients with malunion after ankle fusion. The mean angular deformity was 30 degrees and 5 patients had a rotational malposition of 13.6 degrees (min. 5 degrees, max. 25 degrees). 5 patients needed also lengthening (min. 10 mm, max. 40 mm) of the post-traumatic deformed tibia. The mean time of the follow-up examination was 23 months (min. 12, max. 41). Anatomic correction could be achieved in all patients. The average correction time was 36 days (min. 10, max. 82) with an average time period of 163 days (min. 130, max. 218) until the fixator was removed. The healing index of the leg lengthening cases was 77 d/cm. There were 2 pin-tract infections, 1 prolongated callus formation and 1 insufficient callus formation. In cases of post-traumatic supramalleolar deformities with poor soft tissue and bone quality the Taylor spatial frame is a useful tool. Angular, axial, translational and rotatory deformities are corrected simultaneously without complex and time-consuming fixator reconstructions.

Current status and perspectives of brachytherapy for head and neck cancer

Brachytherapy delivers a high radiation dose to a limited volume while sparing surrounding normal tissues. In head and neck cancer, severe soft-tissue damage and bone damage to the mandible has decreased markedly since the introduction of computer dosimetry and the use of spacers during treatment. For the curative treatment of head and neck cancer, the selection of brachytherapy sources from among the several linear and small permanent implant sources available, not only according to the tumor site but also according to the patient's physical and mental condition is important. Following the successful treatment of early head and neck cancer by brachytherapy, two major problems and one minor problem may confront the physician. The major problems are neck node metastasis and a second primary cancer of the respiratory tract or upper digestive tract, and the minor problem is radiation-induced cancer.

Staged Management of High Energy Proximal Tibia Fractures with Severe Soft Tissue Damage

통신저자:김 영 모 대전시 중구 대사동 640번지 충남대학교 의과대학 정형외과학교실 Tel:042-280-7352ᆞFax:042-252-7098 E-mail:osdr69@cnu.ac.kr 접수: 2008. 11. 2 심사 (수정): 2008. 12. 12 게재확정: 2009. 5. 3 Address reprint requests to:Young-Mo Kim, M.D. Department of Orthopaedic Surgery, Chungnam National University School of Medicine, 640, Daesa-dong, Jung-gu, Daejeon 301-721, Korea Tel:82-42-280-7352ᆞFax:82-42-252-7098 E-mail:osdr69@cnu.ac.kr 심한 연부 조직 손상을 동반한 고 에너지 경골 근위부 골절에서의 단계적 치료