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Background: End-stage post-traumatic osteoarthritis of the ankle joint may require arthrodesis if conservative treatment fails and a decision against total ankle replacement is made. We aimed to compare the sex-specific differences in outcomes and objectify them using validated specific scores., Methods: Between 2010 and 2021, 221 patients underwent ankle arthrodesis at our institution, including 143 men (MAA) and 78 women (FAA). In addition to demographic data, the aetiology of osteoarthritis, the Foot Function Index (FFI-D), the Olerud-Molander Score (OMAS), and the Short Form-12 questionnaire (SF-12) were collected in this monocentric study. The mean follow-up time was 5.8 years. End-stage osteoarthritis was mostly due to ankle fractures as a result of sprains, falls, and road traffic accidents., Results: Post-operatively, the mean FFI-D for pain was 17.3 (MAA: 14.7; FAA 22.2) and 43.9 for function (MAA: 41.1; FAA 49.5); the mean OMAS was 58.2; and the mean SF-12 physical component score was 42.5. Women achieved significantly worse results in all scores; only the mental component summary of the SF-12 did not differ between the sexes (p > 0.05). Approximately 34% of women stated that the result in terms of gait pattern was worse than expected (MAA 16.1%; p < 0.05). Again, significantly more men stated that the result was better than expected (MAA: 48.3%; FAA: 31.5%, p < 0.05)., Conclusions: The fact that the clinical results were significantly worse in women after ankle arthrodesis should be considered when determining the indication. However, the expectations of men and women also need to be individually adjusted., (© 2024. The Author(s).)

High-solid-content polystyrene and polyvinyl acetate dispersions of polymer particles with a 50 nm to 500 nm mean particle diameter and 12-55% ( w / w ) solid content have been produced via emulsion polymerization and characterized regarding their optical and physical properties. Both systems have been analyzed with common particle-size-measuring techniques like dynamic light scattering (DLS) and static light scattering (SLS) and compared to inline particle size distribution (PSD) measurements via photon density wave (PDW) spectroscopy in undiluted samples. It is shown that particle size measurements of undiluted polystyrene dispersions are in good agreement between analysis methods. However, for polyvinyl acetate particles, size determination is challenging due to bound water in the produced polymer. For the first time, water-swelling factors were determined via an iterative approach of PDW spectroscopy error ( Χ 2 ) minimization. It is shown that water-swollen particles can be analyzed in high-solid-content solutions and their physical properties can be assumed to determine the refractive index, density, and volume fraction in dispersion. It was found that assumed water swelling improved the reduced scattering coefficient fit by PDW spectroscopy by up to ten times and particle size determination was refined and enabled. Particle size analysis of the water-swollen particles agreed well with offline-based state-of-the-art techniques.

Bioconversion of waste animal fat (WAF) to polyhydroxyalkanoates (PHAs) is an approach to lower the production costs of these plastic alternatives. However, the solid nature of WAF requires a tailor-made process development. In this study, a double-jacket feeding system was built to thermally liquefy the WAF to employ a continuous feeding strategy. During laboratory-scale cultivations with Ralstonia eutropha Re2058/pCB113, 70% more PHA (45 g PHA L -1 ) and a 75% higher space-time yield (0.63 g PHA L -1  h -1 ) were achieved compared to previously reported fermentations with solid WAF. During the development process, growth and PHA formation were monitored in real-time by in-line photon density wave spectroscopy. The process robustness was further evaluated during scale-down fermentations employing an oscillating aeration, which did not alter the PHA yield although cells encountered periods of oxygen limitation. Flow cytometry with propidium iodide staining showed that more than two-thirds of the cells were viable at the end of the cultivation and viability was even little higher in the scale-down cultivations. Application of this feeding system at 150-L pilot-scale cultivation yielded in 31.5 g PHA L -1 , which is a promising result for the further scale-up to industrial scale., (© 2022 The Authors. Microbial Biotechnology published by Society for Applied Microbiology and John Wiley & Sons Ltd.)

Objective: Due to multiple light scattering that occurs inside and between cells, quantitative optical spectroscopy in turbid biological suspensions is still a major challenge. This includes also optical inline determination of biomass in bioprocessing. Photon Density Wave (PDW) spectroscopy, a technique based on multiple light scattering, enables the independent and absolute determination of optical key parameters of concentrated cell suspensions, which allow to determine biomass during cultivation., Results: A unique reactor type, called "mesh ultra-thin layer photobioreactor" was used to create a highly concentrated algal suspension. PDW spectroscopy measurements were carried out continuously in the reactor without any need of sampling or sample preparation, over 3 weeks, and with 10-min time resolution. Conventional dry matter content and coulter counter measurements have been employed as established offline reference analysis. The PBR allowed peak cell dry weight (CDW) of 33.4 g L -1 . It is shown that the reduced scattering coefficient determined by PDW spectroscopy is strongly correlated with the biomass concentration in suspension and is thus suitable for process understanding. The reactor in combination with the fiber-optical measurement approach will lead to a better process management., (© 2022. The Author(s).)

Because of demographic change, geriatric patients are becoming a major challenge for traumatology. Multiple trauma patients and patients with proximal femoral fractures are important groups of patients in geriatric traumatology. This retrospective study compares two patient groups with different severities of injuries, and analyzes their patient characteristics and short-term outcomes, focusing on functionality upon discharge. The investigation aims to present the characterizing features of both patient groups, and to identify the potential risk factors for early functionality after trauma. The patient collective comprises two patient groups: a polytrauma group with 91 patients, and a femoral fracture group with 132 patients. Under the control of potential influencing factors, the present study showed no significant influence of belonging to either of the patient groups (multiple trauma or proximal femoral fracture) on the mobility status at discharge. Age, known dementia, pre-clinical intubation, and the lowest Hb value were identified as significant influencing factors. Despite their old age and vulnerability, the majority of geriatric patients survive accidents. Further prospective investigations concerning the maintenance or restoration of functionality after an accident are therefore desirable.

The high solids semicontinuous emulsion polymerization of polyvinyl acetate using poly (vinyl alcohol-co-vinyl acetate) as protective colloid is investigated by optical spectroscopy. The suitability of Photon Density Wave (PDW) spectroscopy as inline Process Analytical Technology (PAT) for emulsion polymerization processes at high solid contents (>40% ( w / w )) is studied and evaluated. Inline data on absorption and scattering in the dispersion is obtained in real-time. The radical polymerization of vinyl acetate to polyvinyl acetate using ascorbic acid and sodium persulfate as redox initiator system and poly (vinyl alcohol-co-vinyl acetate) as protective colloid is investigated. Starved-feed radical emulsion polymerization yielded particle sizes in the nanometer size regime. PDW spectroscopy is used to monitor the progress of polymerization by studying the absorption and scattering properties during the synthesis of dispersions with increasing monomer amount and correspondingly decreasing feed rate of protective colloid. Results are compared to particle sizes determined with offline dynamic light scattering (DLS) and static light scattering (SLS) during the synthesis.

Background: In the acute care of trauma, some patients with a low estimated risk of death die suddenly and unexpectedly. In this study, we aim to identify predictors for early death within 24 h following hospital admission in low-risk patients., Methods: The TraumaRegister DGU® was used to collect records of patients who were primarily treated in a participating hospital between 2004 and 2013 with a RISC II score below 10%., Results: During the study period, 64,379 patients met the inclusion criteria. The mean RISC II score was 2.0%, and the mean ISS was 16 ± 9. The overall hospital mortality rate was 2.1%, and 0.5% of patients (n = 301) died within the first 24 h. A SPB of ≤ 90 mmHg was associated with an increased risk of death (p < 0.001). An AIS abdomen score of ≥ 3 was associated with increased risk of death within the first 24 h (p < 0.001). A high risk of early death was also seen in patients with an AIS score (thorax) ≥ 3; 51% of those who died died within the first 24 h (p < 0.005). Death in patients over 60 years was more common after 24 h (p < 0.001). Patients with an ASA score of ≥ 3 were more likely to die after the first 24 h (p < 0.001)., Conclusions: Indicators predicting a high risk of early death in patients with a low RISC II score include a SPB ≤ 90 mmHg and severe chest and abdominal trauma. Emergency teams involved in the acute care of trauma patients should be aware of these "red flags" and treat their patients accordingly.

Purpose: Medical errors are the third leading cause of death in the United States after malignant tumors and cardiovascular disease. Handling of errors becomes more and more eclectic due to the implementation of incident reporting systems and the use of checklists. Since 2015, any German hospital would have a critical incident reporting system (CIRS). The aim of this study is to discover the nationwide utilization and attitude toward CIRS of orthopedic and trauma surgeons., Methods: Between April 10, 2015 and May 22, 2015, a web-based questionnaire, which was designed by an expert team consisting of orthopedic and trauma surgeons, aeronautic human factors specialists, and psychologists (Lufthansa Aviation Training), was sent to all members of the German Society for Orthopedic and Trauma Surgery. The survey consisted of three questions regarding CIRS and its use in German hospitals., Results: A total of 669 orthopedic and trauma surgeons working in German hospitals completed the questionnaire. All participants rated CIRS as useful, although 71.3% of participants did not report a critical incident in the last 12 months. In that time period, only 13.4% of participating residents reported at least one incident, but 44.7% of chief physicians reported one incident within the same period., Conclusion: The present study demonstrates that even though CIRS as a tool is positively appreciated by orthopedic and trauma surgeons working in German hospitals, many do not know about its existence at their own hospital. This can be a reason for the low number of critical incidents reported.

Major traumatic injury (MTI), a life-threatening condition requiring prompt medical intervention, is associated with an extensive inflammatory response often resulting in multiple organ dysfunction. Early stratification of trauma severity and the corresponding inflammation may help optimize resources at the intensive care unit (ICU). The cholinergic system counters inflammation by quickly modulating the immune response. Serum cholinesterase (butyrylcholinesterase, BChE) is an enzyme that hydrolyses acetylcholine. We tested whether a change in the BChE activity correlates with the morbidity and the length of ICU stay. Blood samples from 10 healthy volunteers and 44 patients with MTI were gathered at hospital admission, followed by measurements 12, 24 and 48 hours later. Point-of-care approach was used to determine the BChE activity. Disease severity was assessed by clinical scoring performed within 24 hours following hospital admission. BChE activity, measured at hospital admission, showed a significant and sustained reduction and correlated with disease severity scores obtained 24 hours following admission. BChE activity, obtained at hospital admission, correlated with the length of ICU stay. Bedside measurement of BChE activity, as a complementary addition to established procedures, might prove useful in the primary assessment of the disease severity and might therefore optimize therapy in the ICU.

Background: Trainings in emergency medicine are well structured, but examinations are rarely validated. We are evaluating the impact of pre-hospital emergency trainings on participants and patient care and developed and validated a checklist to assess emergency trainings., Methods: We used videos recorded at the time points directly before (t0), directly after (t1), and one year after (t2) training to develop the PERFECT checklist (Performance Assessment of Emergency Teams and Communication in Trauma Care). The videos were assessed using semi-qualitative/linguistic analysis as well as expert panel appraisal and recommendations using the Delphi method. The checklist was tested for validity and reliability., Results: The inter-rater reliability (ICC = 0.99) and internal consistency (α = 0.99) were high. Concurrent validity was moderate to high (r = 0.65 -r = 0.93 (p<0.001)). We included scales for procedures, non-technical skills, technical skills and global performance. The procedures were done faster in the mean over the timeline (t0: 2:29, 95%CI 1:54-3:03 min., t1: 1:11, 95%C 0:53-1:30 min, t2: 1:14, 95%CI 0:56-1:31 min.). All experts rated the recorded scenarios at t0 with the lowest sum score (mean 31±8), with a significantly better performance of the teams at t1 (mean 69±7). The performance at t2 (mean 66 ± 13) was slightly lower than at t1, but still better than at t0. At t1 and t2, linguistic analysis showed a change in the team leaders communication behaviour, which can be interpreted as a surrogate parameter for reduced stress., Conclusion: The PERFECT checklist has a good validity and high reliability for assessing trauma procedures and teamwork., Competing Interests: DH is a PHTLS instructor. The other authors declare that they have no competing interests.

Background: Low bone mineral density (BMD) leads to metaphyseal fractures, which are considered of delayed, qualitatively reduced healing resulting in prolonged care phases and increased socioeconomic costs. Extracorporeal shockwave therapy (ESWT) is already approved to support bone healing of pseudarthrosis and delayed unions. With this study, we examined its influence on bone turnover markers (BTM) during fracture healing in patients with low and normal BMD. Methods: Within a period of 2 years, patients with a metaphyseal fracture of the distal radius or the proximal humerus, requiring surgical osteosynthesis were included into the study. Patients were randomized within their fracture groups whether they received ESWT after surgery or not. ESWT was applied once after surgery with an energy flux density (EFD) of 0.55 mJ/mm² à 3000 shockwaves. In addition, serum levels of vitamin D3, parathyroid hormone (iPTH), bone alkaline phosphatase (BAP), c-telopeptide of type-I-collagen (β-CTX) and serum band 5 tartrate-resistant acid phosphate (TRAP5b) were determined before surgery and post-operatively in week 1, 4, 8, 52. T-score levels as an indicator of the BMD were measured with dual-energy X-ray absorptiometry (DXA). Results: 49 patients (40 females, 9 males; mean age 62 years) with fractures of the metaphyseal distal radius (n=25) or the proximal humerus (n=24) were included in the study. The follow-up time was one year. 24 of them were diagnosed of having low BMD, whereas 25 had a normal BMD. During follow-up time serum levels of bone turnover markers, as well as vitamin D3 and iPTH, showed no significant changes; however, ESWT approaches the decreased serum levels of patients with low BMD to the level of healthy organisms. Conclusions: ESWT as treatment option of fractures in patients with low BMD can lead to an equilibration of levels of bone turnover markers to the levels of patients with normal BMD., Competing Interests: The authors declare that they have no financial or non-financial competing interests.

Objective: To correlate students' performance with their professional background and motivation to take part in Advanced Trauma Life Support (ATLS) courses. We base our analysis on the self-determination theory that differentiates intrinsic (ambition to perform by individual itself) from extrinsic motivation (incentive by external stimuli). Design: We present a non-blinded, monocentric, non-randomized descriptive study of 376 students taking part in an ATLS course at one course site in Germany. Part of a two-day ATLS course are two written tests; we correlate test scores with background information provided by the students in a questionnaire of 13 items (age, sex, adress, board certification, specialty, subspecialty, position, hospital level of care, hospital operator and hospital participation in trauma network, motivation, funding source, condition of funding). Setting: The students were recuited at the BG Trauma Center Ludwigshafen (Germany), a large 528-bed trauma center and one of 13 ATLS course sites in Germany. Participants: 449 ATLS course students taking part in ATLS courses at the above-mentioned course site from February 2009 to May 2010 were sent a questionnaire asking for their background. All 449 course students were eligible to participate. 376 (83.7%) questionnaires were returned, pre- and post-test results of all students aquired and included into our calculations. 312 (83%) were male and 64 (17%) female. The majority (59.3%) of recruited students came from trauma surgery, 21.8% from anesthesiology, 8% from general surgery, 4% from abdominal surgery, 0.5% from vascular or thoracic surgery each and 5.9% from other specialties. Results: Neither age, sex, subspecialty, hospital level of care, hospital operator, or hospital participation in trauma network played a role with respect to motivation or test results. The high degree of intrinsic motivation of consultants (92.3%) had no impact on their test results. Anesthesiologists were higher motivated (75.6% intrinsically motivated) in contrast to all surgical colleagues (63.6%), which showed significant differences in the pre- (89.8% vs. 85.3%, p=0.03) but not the post-test. Of all 13.6% students who were self-payers, 94.1% were intrinsically motivated; the 86.2% whose course fee was accounted for were less likely to be intrinsically motivated (63.9%). Sponsoring however did not have a negative impact on test results. Conditional funding (sponsored only on passing both tests) was detrimental to motivation: 0% of these individuals were intrinsically motivated and they scored significantly lower (82.5%) than all other students in the post-test (86.9%, p=0.002). Overall, intrinsically motivated students overtopped extrinsically motivated students in the post-test (88.0% vs. 83.4%, p<0.001). Conclusions: ATLS course participation is not compulsory for medical doctors in Germany. Intrinsic motivation to take part in these courses is a key prerequisite to increase performance, irrespective of the background of the students. Intrinsically motivated students are ready to invest into their education and vice versa. Conditional funding (course fee only sponsored on passing the course) evokes no intrinsic motivation at all and causes worse results.

Introduction: Emergency management of upper cervical spine injuries often requires cervical spine immobilisation and some critical patients also require airway management. The movement of cervical spine created by tracheal intubation and cervical spine immobilisation can potentially exacerbate cervical spinal cord injury. However, the evidence that previous studies have provided remains unclear, due to lack of a direct measurement technique for dural sac's space during dynamic processes. Our study will use myelography method and a wireless human motion tracker to characterise and compare the change of dural sac's space during tracheal intubations and cervical spine immobilisation in the presence of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture., Methods and Analysis: Perform laryngoscopy and intubation, video laryngoscope intubation, laryngeal tube insertion, fiberoptic intubation and cervical collar application on cadaveric models of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. The change of dural sac's space and the motion of unstable cervical segment are recorded by video fluoroscopy with previously performing myelography, which enables us to directly measure dural sac's space. Simultaneously, the whole cervical spine motion is recorded at a wireless human motion tracker. The maximum dural sac compression and the maximum angulation and distraction of the injured segment are measured by reviewing fluoroscopic and myelography images., Ethics and Dissemination: This study protocol has been approved by the Ethics Committee of the State Medical Association Rhineland-Palatinate, Mainz, Germany. The results will be published in relevant emergency journals and presented at relevant conferences., Trial Registration Number: DRKS00010499., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Prehospital trauma care is stressful and requires multi-professional teamwork. A decrease in the number of accident victims ultimately affects the routine and skills and underlines the importance of effective training. Standardized courses, like PHTLS, are established for health care professionals to improve the prehospital care of trauma patients. The aim of the study was to investigate the subjective safety in prehospital trauma care and learning progress by paramedics in a longitudinal analysis., Methods: This was a prospective intervention trial and part of the mixed-method longitudinal EPPTC-trial, evaluating subjective and objective changes among participants and real patient care as a result of PHTLS courses. Participants were evaluated with pre/post questionnaires as well as one year after the course., Results: We included 236 datasets. In the pre/post comparison, an increased performance could be observed in nearly all cases. The result shows that the expectations of the participants of the course were fully met even after one year (p = 0.002). The subjective safety in trauma care is significantly better even one year after the course (p < 0.001). Regression analysis showed that (ABCDE)-structure is decisive (p = 0.036) as well as safety in rare and common skills (both p < 0.001). Most skills are also rated better after one year. Knowledge and specific safety are assessed as worse after one year., Conclusion: The courses meet the expectations of the participants and increase the subjective safety in the prehospital care of trauma patients. ABCDE-structure and safety in skills are crucial. In the short term, both safety in skills and knowledge can be increased, but the courses do not have the power to maintain knowledge and specific subjective safety issues over a year., Trial Registration: German Clinical Trials Register, ID DRKS00004713 , registered 14. February 2014.

Objective: Care for severely injured patients requires multidisciplinary teamwork. A decrease in the number of accident victims ultimately affects the routine and skills. PHTLS ("Pre-Hospital Trauma Life Support") courses are established two-day courses for medical and non-medical rescue service personnel, aimed at improving the pre-hospital care of trauma patients worldwide. The study aims the examination of the quality of documentation before and after PHTLS courses as a surrogate endpoint of training effectiveness and awareness., Methods: This was a prospective pre-post intervention trial and was part of the mixed-method longitudinal EPPTC (Effect of Paramedic Training on Pre-Hospital Trauma Care) study, evaluating subjective and objective changes among participants and real patient care, as a result of PHTLS courses. The courses provide an overview of the SAMPLE approach for interrogation of anamnestic information, which is believed to be responsible for patient safety as relevant, among others, "Allergies," "Medication," and "Patient History" (AMP). The focus of the course is not the documentation., Results: In total, 320 protocols were analyzed before and after the training. The PHTLS course led to a significant increase (p < 0.001) in the "AMP" information in the documentation. The subgroups analysis of "allergies" (+47.2%), "drugs" (+38.1%), and "medical history" (+27.8%) before and after the PHTLS course showed a significant increase in the information content., Conclusion: In summary, we showed that PHTLS training improves documentation quality, which we used as a surrogate endpoint for learning effectiveness and awareness. In this regard, we demonstrated that participants use certain parts of training in real life, thereby suggesting that the learning methods of PHTLS training are effective. These results, however, do not indicate whether patient care has changed., Competing Interests: BG, CW, DH, MM, MD are PHTLS instructors. Author BG received funding in the form of salary from Megamed Emergency Management GbR, a commercial company. This company offers different trainings for health care personnel. Megamed does not offer PHTLS-courses and has not funded or supported our trial in any way. Mr. Gliwitzky is not paid by Megamed to take part at this trial. The funders have no influence on study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Turbidity measurements are frequently implemented for the monitoring of heterogeneous chemical, physical, or biotechnological processes. However, for quantitative measurements, turbidity probes need calibration, as is requested and regulated by the ISO 7027:1999. Accordingly, a formazine suspension has to be produced. Despite this regulatory demand, no scientific publication on the stability and reproducibility of this polymerization process is available. In addition, no characterization of the optical properties of this calibration material with other optical methods had been achieved so far. Thus, in this contribution, process conditions such as temperature and concentration have been systematically investigated by turbidity probe measurements and Photon Density Wave (PDW) spectroscopy, revealing an influence on the temporal formazine formation onset. In contrast, different reaction temperatures do not lead to different scattering properties for the final formazine suspensions, but give an access to the activation energy for this condensation reaction. Based on PDW spectroscopy data, the synthesis of formazine is reproducible. However, very strong influences of the ambient conditions on the measurements of the turbidity probe have been observed, limiting its applicability. The restrictions of the turbidity probe with respect to scatterer concentration are examined on the basis of formazine and polystyrene suspensions. Compared to PDW spectroscopy data, signal saturation is observed at already low reduced scattering coefficients., Competing Interests: The authors declare that they have no conflict of interest.

The coil-to-globule transition of poly(N-isopropylacrylamide) (PNIPAM) microgel particles suspended in water has been investigated in situ as a function of heating and cooling rate with four optical process analytical technologies (PAT), sensitive to structural changes of the polymer. Photon Density Wave (PDW) spectroscopy, Focused Beam Reflectance Measurements (FBRM), turbidity measurements, and Particle Vision Microscope (PVM) measurements are found to be powerful tools for the monitoring of the temperature-dependent transition of such thermo-responsive polymers. These in-line technologies allow for monitoring of either the reduced scattering coefficient and the absorption coefficient, the chord length distribution, the reflected intensities, or the relative backscatter index via in-process imaging, respectively. Varying heating and cooling rates result in rate-dependent lower critical solution temperatures (LCST), with different impact of cooling and heating. Particularly, the data obtained by PDW spectroscopy can be used to estimate the thermodynamic transition temperature of PNIPAM for infinitesimal heating or cooling rates. In addition, an inverse hysteresis and a reversible building of micrometer-sized agglomerates are observed for the PNIPAM transition process., Competing Interests: The authors declare that they have no conflict of interest.

Introduction: Conventional non-vascularized bone grafts as well as vascularized bone grafts are used to treat scaphoid non-union (SN). Due to limited available studies, the field of application using both grafts for SN still remains controversial. The aim of this study was to evaluate a treatment algorithm for the use of both vascularized versus non-vascularized bone grafts based on clinical outcomes and quality of life (QoL) to improve the level of evidence., Materials and Methods: Based on a retrospective cohort study, including 28 patients with vascularized and 45 patients with conventional bone grafts, functional parameters, radiological outcome, Mayo-wrist-score, and QoL by SF-36 were applied to statistically compare the outcome of these two techniques., Results: Time between last procedure or trauma and study group scaphoid reconstruction was almost double in the vascularized bone grafting group. Comparable union rates were achieved with vascularized as well as non-vascularized bone grafts. Significant differences were observed between both groups for grip strength and radial-ulnar active range of motion. Further functional outcomes, radiological outcomes as well as QoL were found similar for both techniques in patients with surgical union., Discussion and Conclusions: In order to achieve comparable and appropriate treatment results, vascularized bone grafts are recommended for patients with delayed treatment, impaired scaphoid vascularity, and revision surgery. Even in preselected, complex cases, the results are comparable to conventional grafts, which are the basis for further patient education and approve the powerful role of surgical angiogenesis of vascularized bone grafts.