Identification and management of the ilio-inguinal and ilio-hypogastric nerves in open inguinal hernia repair: benefits of self-gripping mesh.

PURPOSE: A large randomized, multicenter European study recently reported a reduction in early pain after open inguinal surgery when self-gripping mesh was used compared with sutured Lichtenstein repair. This secondary exploratory study is focused on the influence of nerve identification and handling on post-operative pain. METHODS: Post-operative VAS pain data and Surgical Pain Scores (SPS) from 507 patients included in this study were analyzed according to whether inguinal nerves were preserved or resected during surgery to investigate whether identification and peri-operative nerve handling impact post-operative pain. RESULTS: Preservation of the ilio-hypogastric nerve during Lichtenstein mesh repair with suture fixation was associated with significantly more post-operative pain compared with resection at each follow-up (p ≤ 0.003). This difference was not significant with self-gripping mesh repair. The decrease from baseline in post-operative VAS and SPS scores were significantly greater after self-gripping mesh repair compared to Lichtenstein repair at 1 year, but only when the ilio-hypogastric nerve was preserved (VAS scores, p = 0.009; SPS scores, p = 0.015). No such difference was observed with the ilio-inguinal nerve. When self-gripping mesh was used, preservation of the ilio-hypogastric nerve was associated with significantly greater decreases in post-operative pain (change in VAS score from baseline) compared with Lichtenstein repair at each follow-up (p ≤ 0.018). CONCLUSIONS: The ilio-hypogastric nerve is in danger of being traumatized during Lichtenstein mesh repair with suture fixation. The use of self-gripping mesh was shown to reduce the level of post-operative pain when the ilio-hypogastric nerve was preserved. Resection of the ilio-hypogastric nerve during Lichtenstein repair eliminates this difference.

Randomized clinical trial comparing self-gripping mesh with suture fixation of lightweight polypropylene mesh in open inguinal hernia repair.

BACKGROUND: Postoperative pain is an important adverse event following inguinal hernia repair. The aim of this trial was to compare postoperative pain within the first 3 months and 1 year after surgery in patients undergoing open mesh inguinal hernia repair using either a self-gripping lightweight polyester mesh or a polypropylene lightweight mesh fixed with sutures. METHODS: Adult men undergoing Lichtenstein repair for primary inguinal hernia were randomized to ProGrip™ self-gripping mesh or standard sutured lightweight polypropylene mesh. RESULTS: In total 557 men were included in the final analysis (self-gripping mesh 270, sutured mesh 287). Early postoperative pain scores were lower with self-gripping mesh than with sutured lightweight mesh: mean visual analogue pain score relative to baseline +1·3 and +8·6 respectively at discharge (P = 0·033), and mean surgical pain scale score relative to baseline +4·2 and +9·7 respectively on day 7 (P = 0·027). There was no significant difference in mid-term (1 month) and long-term (3 months and 1 year) pain scores between the groups. Surgery was significantly quicker with self-gripping mesh (mean difference 7·6 min; P < 0·001). There were no significant differences in reported mesh handling, analgesic consumption, other wound complications, patient satisfaction or hernia recurrence between the groups. CONCLUSION: Self-gripping mesh for open inguinal hernia repair was well tolerated and reduced early postoperative pain (within the first week), without increasing the risk of early recurrence. It did not reduce chronic pain. REGISTRATION NUMBER: NCT00827944 (http://www.clinicaltrials.gov).

Randomized controlled multicenter international clinical trial of self-gripping Parietex™ ProGrip™ polyester mesh versus lightweight polypropylene mesh in open inguinal hernia repair: interim results at 3 months.

PURPOSE: To compare clinical outcomes following sutureless Parietex™ ProGrip™ mesh repair to traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures. METHODS: This is a 3-month interim report of a 1-year multicenter international study. Three hundred and two patients were randomized; 153 were treated with Lichtenstein repair (L group) and 149 with Parietex™ ProGrip™ precut mesh (P group) with or without fixation. The primary outcome measure was postoperative pain using the visual analog scale (VAS, 0-150 mm); other outcomes were assessed prior to surgery and up to 3 months postoperatively. RESULTS: Compared to baseline, pain score was lower in the P group at discharge (-10%) and at 7 days (-13%), while pain increased in the L group at discharge (+39%) and at 7 days (+21%). The difference between groups was significant at both time points (P = 0.007 and P = 0.039, respectively). In the P group, patients without fixation suffered less pain compared to those with single-suture fixation (1 month: -20.9 vs. -6.15%, P = 0.02; 3 months: -24.3 vs. -7.7%, P = 0.01). The infection rate was significantly lower in the P group during the 3-month follow-up (2.0 vs. 7.2%, P = 0.032). Surgery duration was significantly shorter in the P group (32.4 vs. 39.1 min; P < 0.001). No recurrence was observed at 3 months in both groups. CONCLUSIONS: Surgery duration, early postoperative, pain and infection rates were significantly reduced with self-gripping polyester mesh compared to Lichtenstein repair with polypropylene mesh. The use of fixation increased postoperative pain in the P group. The absence of early recurrence highlights the gripping efficiency effect.

Analysis of outcome of Lichtenstein groin hernia repair by surgeons-in-training versus a specialized surgeon.

PURPOSE: Groin hernia repair is a common procedure in general surgery, and is taught to and performed by surgeons early in their training. The aim of this observational study was to compare hernia repair performance and results of surgical trainees with those of a specialized surgeon, to identify what factors may influence short and long-term outcome, and areas for improvement in surgical training. METHODS: A non-randomized parallel cohort study was designed; 200 Lichtenstein repairs in adult males were included, of which 96 were performed by surgical trainees. Patient characteristics, surgical experience, and operative data, including duration of procedural parts and surgical complexity, were noted at surgery. Postoperative complications, recurrence, chronic pain and residual symptoms were assessed at long-term follow-up after a median of 34.5 months. RESULTS: Surgical trainees required longer overall operative time, with a disproportionally longer time for mobilizing the sac and cord. They perceived exposure and mobilization as more difficult than the specialist, and also a greater demand on their own experience during surgery. The trainee repairs had a higher rate of postoperative complications (14.7% vs 5.0%) but recurrence rate was the same as for specialist repairs. At long-term follow-up, specialist repairs had higher symptom burden and more chronic pain. CONCLUSIONS: It was more efficient, but not necessarily better, to let a specialized surgeon perform the repairs. It seems likely that targeted training in dissection and mobilization could decrease level of perceived complexity and shorten the operative time required by surgical trainees.

Influence of nerve identification and the resection of nerves 'at risk' on postoperative pain in open inguinal hernia repair.

BACKGROUND: Surgical strategy regarding nerve identification and resection in relation to chronic postoperative pain remains controversial. A central question is whether nerves in the operation field, when identified, should be preserved or resected. In the present study, the hypotheses that the identification and consequent resection of nerves 'at risk' have no influence on postoperative pain has been tested. METHODS: A single-centre study was conducted in 525 patients undergoing Lichtenstein hernioplasty. One surgeon (364 operations, Group A) consequently resected nerves 'at risk' for being injured and nine surgeons (161 operations, Group B) adhered to the general routine of nerve preservation. All cases were ambulatory surgery on anaesthetised patients and the groups were similar with regard to age, body mass index (BMI) and preoperative pain. Self-reported pain at 3 months was recorded on a 10-box visual analogue scale (VAS). The identification and resection of nerves were continuously registered. Statistical calculations were performed with Fisher's exact test and ordinal logistic regression. RESULTS: There was no significant difference in the number of identified nerves in the two groups of patients (iliohypogastricus, P = 0.555; ilioinguinalis, P = 0.831; genital branch, P = 0.214). However, the number of resected nerves was significantly higher in Group A for the iliohypogastric nerve, P < 0.001, but not for ilioinguinalis, P = 0.064, and genital branch, P = 0.362. Non-identification of the ilioinguinal nerve correlated to the highest level of self-reported postoperative pain at 3 months. Patients in Group A, who had nerves 'at risk' resected from the operation field, reported significantly less postoperative pain at 3 months, P = 0.007. CONCLUSION: This register study confirms the importance of nerve identification. Nerve resection strategy with the consequent removal of nerves 'at risk' gives a significantly better outcome in Lichtenstein hernioplasty.

Chronic pain after open inguinal hernia repair: a longitudinal self-assessment study.

INTRODUCTION: The aim of the present study was to assess the variation of self-reported pain over a period of 2 years in three groups of patients with no, moderate and severe pain at 3 months after primary open inguinal hernia repair. METHODS: In two cohorts of patients from 2004 (n = 272) and 2005 (n = 292) who had given a self-report of postoperative pain at 3 months, 79 randomly selected patients without pain (box visual analogue scale [VAS] level 10) and all patients with moderate (Box VAS level 7-9) and severe pain (Box VAS level 1-6), 91 and 9, respectively, were included in the case series. The self-assessments were repeated for all patients 1-1.5 and 2-2.5 years after surgery (November 2006). RESULTS: It was observed that moderate pain reappeared among the pain-free patients in 28 and 23% after 1-1.5 and 2-2.5 years, respectively. Of those patients with moderate pain at 3 months, 39 and 49% reported 'no pain' at 1-1.5 and 2-2.5 years, respectively, after surgery. A worsening from moderate pain to severe pain was reported by 22% of patients after 1-1.5 years and by 15% of patients after 2-2.5 years. Hernia recurrence (n = 3) was observed only in patients with increased pain. All nine patients with severe pain at 3 months reported less pain, but only one was pain-free at 2-2.5 years after surgery. CONCLUSION: The study shows that a significant proportion of the patients developed pain later than 3 months after the operation. It further points to a difference in pain evolvement in patients with moderate pain and those with severe postoperative pain at 3 months. Pain can increase in intensity from moderate to severe, both with and without the presence of a clinical recurrence.

Randomized clinical trial of groin hernia repair with titanium-coated lightweight mesh compared with standard polypropylene mesh.

BACKGROUND: Groin hernia repair is one of the commonest operations in general surgery. Existing techniques have very low and acceptable recurrence rates, but chronic pain and discomfort remain a problem for many patients. New mesh materials are being developed to increase biocompatibility, and the aim of this study was to compare a new titanium-coated lightweight mesh with a standard polypropylene mesh. METHODS: A randomized controlled single-centre clinical trial was designed, with the basic principle of one unit, one surgeon, one technique (Lichtenstein under general anaesthesia) and two meshes. Pain before and after surgery, and during convalescence (primary outcomes) was estimated in 317 patients. At 1-year clinical follow-up, recurrence, pain, discomfort and quality of life (secondary outcomes) were evaluated. RESULTS: Patients with the lightweight mesh returned to work after 4 days, compared with 6.5 days for the standard mesh (P = 0.040). The lightweight group returned to normal activity after 7 days, versus 10 days for the standard group (P = 0.005). There was no difference in postoperative pain or recurrence at the 1-year follow-up. CONCLUSION: Patients with the lightweight mesh had a shorter convalescence than those with the standard heavyweight mesh. REGISTRATION NUMBER: ISRCTN36979348 (http://www.controlled-trials.com).

Telomerase is not activated in human hyperplastic and adenomatous parathyroid tissue.

BACKGROUND: Telomerase is a specific enzyme that appears to have a key role in cellular senescence and the progression of neoplastic tissue. High telomerase activity has been found in several cancers, but not in most normal and benign tissue. Little is known about the influence of telomerase on the abnormal growth associated with hyperparathyroidism. OBJECTIVE: To analyse telomerase activity in parathyroid tissue obtained from 29 patients undergoing surgery for primary hyperparathyroidism. DESIGN: Tissue for telomerase activity measurements was collected from six hyperplastic, 20 adenomatous and 22 normal parathyroid glands. METHODS: The highly sensitive PCR-based telomeric repeat amplification protocol, TRAP, combined with ELISA, was used to detect telomerase activity in tissue extracts containing 3.0 microg protein. RESULT: Telomerase was not activated in any of the analysed tissue by 3 microg protein. Reassay of 12 samples containing 6.0 microg protein verified these negative TRAP results. CONCLUSION: Our findings indicate that telomerase is not a part of the mechanism promoting parathyroid proliferation and the underlying conditions remain to be determined.

[Hereditary thyroid cancer can be cured by prophylactic surgery]. / Arftlig tyreoideacancer kan botas med profylaktisk kirurgi.

Multiple endocrine neoplasia type 2 (MEN 2) is a rare syndrome in which the consequences for the patient and family members are considerable. Mutation analysis of the RET proto-oncogene is crucial for decision-making regarding each patient. Today, carriers of MEN 2 mutations should be offered prophylactic thyroidectomy with the potential to eliminate the risk for potentially lethal medullary thyroid carcinoma (MTC). Here, we present the first Swedish experience of such operations performed mainly on the basis of genetic analysis. Twenty patients underwent total thyroidectomy at a mean age of 13.5 (6-43) years. In all cases, either manifest MTC (n = 11) or C-cell hyperplasia was found. So far, no patient has any sign of recurrence or developmental insufficiency at 1-5 years follow-up. As the medical and ethical problems in this group of patients are substantial, and as the operations are performed in otherwise healthy children, they should be treated at centers with adequate multidisciplinary expertise and competence.

Inverse relation between mRNA synthesis and secretion of parathyroid hormone in athymic mice grafted with human parathyroid tissue.

Parathyroid hormone (PTH) mRNA in original and transplanted human adenomatous parathyroid tissue and human serum intact PTH (S-iPTH) was measured in athymic mice at 4, 7, 14, and 28 days after transplantation. Parathyroid tissue was obtained during surgery for hyperparathyroidism and implanted subcutaneously. PTH mRNA detection was done with RT-PCR followed by membrane blot and hybridisation and S-iPTH was analysed using a human specific immunoradiometric method. At 4 days, PTH mRNA was 79.6+/-5.3% (mean+/-SE) of that in original tissue whereas S-iPTH was only 5.4 ng/l. At 28 days, PTH mRNA was significantly reduced to 60.7+/-4.1% whereas S-iPTH was increased to 192 ng/l. The reduced PTH mRNA expression in the transplants at 28 days may be explained by an inhibited DNA transcription. The presence of human S-iPTH in transplanted mice at 4 days may be due to cell disintegration and diffusion. The gradual increase in S-iPTH during the experimental period probably reflects increased transplant cell volume and improved graft revascularisation.

Survival of human parathyroid tissue xenotransplanted in nude mice after 9 to 55 months' cryopreservation.

Survival of human parathyroid tissue xenotransplanted after cryopreservation was studied. Peroperative biopsies from 26 patients were cryopreserved and xenotransplanted into nude mice after 9 to 55 months. At 8 to 12 weeks after transplantation, the morphology of the transplanted tissue was compared to that of the original tissue after thawing and before transplantation. Morphologically viable tissue was observed in 20 out of 26 nude mice (77%). Based on the morphological appearance, the parathyroid transplants were arranged into four "quality" groups. No correlation existed between the quality of the transplants and duration of storage, or between the age and sex of the patients. There was no correlation between initial clinical diagnosis or histopathological patterns (primary, secondary and tertiary hyperplasia [n=16], adenoma [n=9], one case undetermined) and transplant survival. After thawing and transplantation, all parathyroid grafts, except one, were morphologically either of the same or somewhat lower quality.

Value of serum thyroglobulin measurement in patients operating on for well differentiated thyroid carcinoma.

OBJECTIVE: To study the clinical relevance of measurements of serum thyroglobulin in patients undergoing total thyroidectomy for well differentiated thyroid cancer. DESIGN: Prospective study. SETTING: University hospital, Sweden. SUBJECTS: 194 patients operated on for well differentiated thyroid cancer from 1 January 1978 to 31 December 1992. INTERVENTIONS: All patients underwent total thyroidectomy by a standard technique, and were prospectively followed up at regular intervals by clinical examination and measurement of the serum thyroglobulin concentration. RESULTS: Six patients whose thyroglobulin concentrations after operation were low or undetectable had gradual increases leading to detection of recurrences that could be treated successfully. Six patients had gradual increases without detectable recurrences. In 12 patients thyroglobulin concentrations remained high after operation with no signs of thyroid tissue remaining, which we interpreted as persistence of the disease. No recurrence was found without an appreciable rise in the thyroglobulin concentration. Thyroglobulin antibodies were found in 81 (42%). CONCLUSION: Measurement of the serum thyroglobulin concentration is a valuable addition to the follow up of patients operated on for highly differentiated thyroid cancer. In many cases it is the first sign of recurrent disease, thereby facilitating early and successful treatment.

Histopathology grading in small breast cancers < or = 10 mm--results from an area with mammography screening.

Histopathological malignancy grading using the Bloom-Richardson classification of ductal cancers was performed for 248 invasive ductal breast cancers < or = 10 mm operated 1978-1985. There were significantly more grade 1 lesions in the prevalence screening round. Grade 3 was correlated with aneuploidy, higher S-phase (SPF), and more receptor negative tumours. There were also significantly more positive lymph nodes in grade 3 lesions, 18% compared to 5% and 12% respectively for grades 1 and 2 (p < 0.05). In life table analysis for survival, when the high risk group of grade 3 lesions was compared to the grade 1 and 2 lesions combined, five-year disease-free survival was 84.6% vs. 99.1% (p < 0.001). With good training and care from the pathologist, malignancy grading seems useful for prognostication of eventual recurrence and death. In tumours 10 mm or smaller only grade 3 lesions need to be included in follow-up systems and should probably have adjuvant treatment. Malignancy grading is especially good in small ductal breast cancers where grading can always be performed while other prognostic determinations are hampered by shortage of material. Lymph node positivity is also low in this group.

Influence of temperature and vacuum mixing on bone cement properties.

To analyze the influence of varying viscosity and mixing temperature (22 degrees C and 6 degrees C) on macro- and microporosity, density, and compressive strength in vacuum mixed bone cement, high, medium, and low viscosity cement were mixed in 2 vacuum mixing systems and compared with bowl mixing at atmospheric pressure. At 22 degrees C, vacuum mixing significantly reduced void volume to less than approximately 3 per mill. The reduction was most pronounced in low viscosity cement. Microporosity also was reduced in all cements by vacuum mixing and to highest degree in low viscosity cement. At 6 degrees C the reduction of micropores was more pronounced in high viscosity cement. In medium and especially low viscosity cement, the prechilling gave an increased number of micropores. Cement density also was significantly reduced in low viscosity cement at 6 degrees C. Vacuum mixing significantly increased compressive strength by approximately 15% in all cement types (30 days). The temperature did not significantly influence compressive strength, but low viscosity cement generally was stronger when mixed at 22 degrees C. It is concluded that vacuum mixing improves cement quality. However, the temperature influences the final result; in particular, low viscosity cement should not be mixed after prechilling to 6 degrees C.

In situ preservation of the parathyroid glands during operations on the Thyroid.

OBJECTIVE: To study the microcirculation of the parathyroids before and after dissection during operations on the thyroid gland to see if there were better ways of preserving them. DESIGN: Prospective open study. SETTING: University hospital, Sweden. SUBJECTS: 16 Patients undergoing operations on the thyroid gland. 20 Parathyroid glands located anteriorly on the thyroid lobe were selected for study. INTERVENTIONS: Recording of microcirculation of the parathyroids with laser Doppler flowmetry. Recording of the macroscopic appearance of the parathyroid glands. MAIN OUTCOME MEASURES: Correlation between reduction in blood flow and the macroscopic appearance of glands while they were ischaemic. RESULTS: Parathyroid microcirculation before dissection gave a mean Doppler signal level of 4.6 (1.4) V. 30 minutes after dissection to preserve the gland the remaining mean (SD) signal was 37 (24)% of the initial level. At the end of the operation the microcirculation tended to recover about 46 (21)% of the original value (p = 0.33). The macroscopic appearance of the gland during the ischaemic period did not correlate well with the reduction in blood flow. CONCLUSION: During dissection to preserve normal parathyroid glands there was a discrepancy between the macroscopic appearance and changes in the microcirculation. The microcirculation recovers and this can be verified by laser Doppler flowmetry.

Growth and function of human parathyroid tissue transplanted to athymic mice.

The morphology, cell proliferation and function of transplanted normal, hyperplastic and adenomatous human parathyroid tissue was studied after transplantation to athymic mice. The iPTH was evaluated in relation to morphology. Human parathyroid tissue collected during surgery for hyperparathyroidism was implanted subcutaneously into athymic mice (nu/nu-BALB/cA) and was analysed 1, 4, 7 and 12 weeks after transplantation. The transplants were examined by light and electron microscopy and by autoradiography after continuous infusion of 3H-thymidine. The relative amount of viable tissue was evaluated using a computer image analysing programme. Graft function was evaluated by measuring human iPTH in mouse serum. A transplant take ratio of 93% was observed. The proliferation rate in adenoma grafts at 12 weeks after transplantation was five and fifteen times that observed in normal and hyperplastic transplants, respectively. In normal and adenoma groups, a continuous increase in iPTH concentrations was observed, but in the hyperplastic group the iPTH remained on the same level. The secretion of iPTH in relation to the amount of transplanted tissue and the fraction of viable tissue was at the same level at 12 weeks in normal and adenomatous grafted animals. In conclusion, human parathyroid tissue was successfully transplanted and maintained its original structure. The growth potential, but not the iPTH secretion, was significantly higher in adenoma grafts compared to grafts from hyperplastic and normal glands.

Revascularisation of human parathyroid tissue transplanted to athymic mice.

The revascularisation process of transplanted human normal, hyperplastic and adenomatous parathyroid tissue was analysed at 2 and 4 days and 1, 2, 4, 7 and 12 weeks after transplantation to athymic mice. The transplants were examined by light and electron microscopy, immunohistochemistry and autoradiography. Vessels were detected by monoclonal antibodies specific for mouse and human endothelial cells. Immunohistochemistry demonstrated ingrowth of vessels from the host into the transplant and at one week numerous capillary sprouts were observed in the peripheral parts of the transplants. During the first week, peak levels of proliferation (labelling index) were observed in endothelial cells and capsular fibroblasts, and the proliferative capacity of endothelial cells was most pronounced in adenoma transplants. Fenestrated capillaries were observed in hyperplastic and adenomatous transplants, but not in transplants of normal tissue. In conclusion, revascularisation of transplanted human parathyroid tissue is enabled by ingrowth of vessels from the host into the transplant. The proliferative capacity of endothelial cells is higher and the process of maturation is faster in hyperplastic and adenomatous tissue compared to normal tissue.

Blood supply and parathyroid hormone secretion in pathological parathyroid glands.

The blood supply of pathologic parathyroid glands and the relation between parathyroid hormone secretion and parathyroid blood perfusion was studied during surgery for hyperparathyroidism. Blood flow in 39 single adenomas and 20 glands classified as primary or secondary hyperplasia were studied intraoperatively with laser Doppler flowmetry. The ipsilateral inferior thyroid artery was occluded during continuous flowmetry recording, which resulted in a 40% reduction of parathyroid blood flow in both groups. In 12 patients with single adenomas, intact parathormone (iPTH) was measured intraoperatively before and during occlusion of the ipsilateral inferior thyroid artery and after extirpation of the adenoma. During occlusion the iPTH levels were mainly unchanged despite blood flow reduction of up to 80%. After removal of the adenoma the iPTH normalized within 15 minutes. In a control group of eight single adenomas, iPTH was measured similarly without vascular occlusion, demonstrating comparable iPTH levels. This study demonstrates similar routes of vascularization for single adenomas and hyperplastic glands, as was earlier seen for normal parathyroid glands. The increased parathyroid hormone secretion from single adenomas appears to remain mainly unchanged during significant blood flow reduction.

Simplified external fixation for primary management of severe musculoskeletal injuries under war and peace time conditions.

This study was undertaken to document whether a basic set of a new unilateral external fixation device could provide sufficient stability in complex musculoskeletal injuries involving upper and lower extremities and in patients with unstable pelvic ring disruptions. The initial clinical evaluation was performed in Sweden (stage 1) followed by field evaluation at the Swedish Field Hospital during the Mogadishu conflict in Somalia (stage 2). In stage 1, there were 90 patients with 116 acute limb injuries and six patients with an unstable pelvic ring disruption. Ninety limb injuries and all six pelvic fractures were primarily stabilized by the external fixation device. The other 26 fractures were managed at the index operation with intramedullary nailing, open reduction, and internal fixation or cast immobilization. Twelve patients had a local pedicle or free vascularized flap for soft tissue coverage. One multiply injured with an open Gustilo IIIB tibial shaft fracture had an early amputation. The basic set provided adequate stabilization for soft tissue recovery in 89 limb injuries (89 of 90), thereby providing optimal conditions for continued management to skeletal consolidation in 88 patients. Hemodynamic stabilization was achieved in all six patients with unstable pelvic fractures. In stage 2, there were 63 patients with war injuries and 33 patients injured in traffic accidents. All were managed under field conditions. The basic set was sufficient for soft tissue recovery in all 96 cases. It is concluded that the rigidity of this device is adequate for stabilization of severe musculoskeletal injuries requiring major surgical procedures. In addition, the simplicity of this device, which allows for only a limited number of possible configurations makes it suitable for inexperienced surgeons working under war or mass-casualty conditions to manage these complex musculoskeletal injuries.