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Bovine preparations that allow for in vivo measurement of metabolic fluxes across the hindlimb often suffer from limited durability, usually because of failure of the venous catheter. A catheterization procedure that virtually eliminates this occurrence is presented. A silicone rubber catheter is implanted permanently in the femoral vein. It accommodates the repeated insertion and removal at each sampling session of a temporary sampling catheter. A simple and reliable method ensures the positioning of this catheter in the external iliac vein of a conscious, normally standing animal. The application of this approach allowed the study of hindlimb metabolism of cattle for up to 4 mo without a single planned sampling session postponed or missed. This preparation is particularly well suited for studies that require repeated measurements of hindlimb metabolism on the same animals over a period of many months.

The size of the mesh used for surgical repair of groin hernias differs significantly from one technique to another. Such differences are not unimportant, since implantation of a large amount of prosthetic material can induce some drawbacks and may perhaps be avoided in many cases. The weak inguinal area, where inguinal hernias are exteriorized, is smaller than the myopectineal orifice, and a mesh 8-9 cm long and 5-6 cm wide is sufficient to cover this area. The results of methods using a small mesh are good, and large patches provide at best the same results with some real drawbacks. A large mesh spread in the preperitoneal space on the bladder and iliac vessels can induce some difficulties in case of further operation on these organs, and when we operate on a man 30 to 50 years old, we ignore whether he may need that kind of operation many years later. Consequently, in most cases a small patch covering only the weak inguinal area is preferable and a large preperitoneal patch should be used only in selected cases at high risk of recurrence.

Wire guides navigate tortuous anatomy while offering support to the aorta and iliac vessels during the deployment and advancement of endovascular grafts and accessories used in endovascular aortic repair (EVAR).

Endovascular management of traumatic thoracic aortic disruption mostly from motor vehicle accidents (Fig. 39.1) offers a minimal invasive approach to managing critically ill patients while avoiding aortic cross-clamping and extracorporeal circulation.1 Younger patients are particularly challenging because their thoracic aorta is often small, narrow with tighter radius angle of the thoracic arch. Other critical issues include small iliac vessels which may be problematic for delivery of the endograft. The smallest thoracic endograft currently available commercially in the United States is the 26 mm diameter Gore TAG device. Attempts to place this device in aorta 23 mm in diameter can create a situation of significant oversizing which have been associated with numerous instances of device collapse.2

It has been stated that because middle ureteral stones are difficult to detect ultrasonographically, they are not amenable to in situ treatment with EDAP LT-01 lithotripters. In our hands, 15 of 79 patients (mean age 45.1 years) with middle ureteral stones averaging 11.2 mm were successfully treated with an EDAP LT-01 lithotripter with the stones in situ. With an Aloka SSD-650 hand probe, the common iliac vessels were visualized; while the patient was kept prone and using the vessels as a landmark, these stones were detected along dilated ureters and focused on by machine's self-contained probe. In three patients, the stones were not relocated by the EDAP probe because of obesity or nondilated ureters. Of 16 patients whose stones could be focused on by the probe, 15 were treated successfully. Our method of using the common iliac vessels as a landmark for locating and focusing on middle ureteral stones allows us to expand the treatment possibilities of EDAP LT-01 lithotripters.

Resumen Describimos un caso de extensa eliminacion de contraste a traves de uretra tras una uretrocistografia retrograda. El medio de contraste dibuja los cuerpos cavernosos, los vasos iliacos y la cava inferior. Placas posteriores muestran normal eliminacion de contraste por ambas vias urinarias. Abstract We describe a case report in which is shown an extensive extravasation of contrast media from urethra lumen following a retrograde urethrocystography. It is shown filling of cavernous system and, at once, iliac vessels and inferior cava. Later X ray plates demonstrates entire collecting system due to the renal contrast excretion.

A cannula injury to the deep circumflex iliac vessels led to substantial morbidity and required surgical repair. Surgeons must increase their awareness of the anatomy of these vessels and place laparoscopic ports to minimize the risk of injury. (J Am Assoc Gynecol Laparosc 6(2):221-223, 1999)

Rectangular flaps on the rat or mouse dorsum are frequently used for flap survival elongation research. However, since rectangular flaps are purely random, the survival rate varies among individuals. A reliable animal flap model with low individual variation is desirable for flap survival research, especially in the angiogenic field. We investigated the survival rate of paired flaps in the rat dorsum containing 3 vascular territories in each flap, and determined their usefulness for flap elongation research. Two symmetrical adjoining rectangular flaps (11 x 3 cm each) were drawn on the rat dorsum. Two days after material injection, flaps were elevated with only the deep circumflex iliac vessels as the vascular pedicle. Flaps were immediately sutured back and the flap survival area was measured 7 days after the operation. The control group (n = 9) had saline solution injected in both flaps. The bone marrow group (n = 8) had bone marrow injected in the right flap, and saline solution injected in the left flap. In the control group, the survival rate of the paired flaps was not statistically different (right flap, 89.0+/-5.6%; left flap, 89.3+/-4.5%). In the bone marrow group, the survival rate between the bone marrow injected flap (89.9+/-3.7%), and the saline flap (84.8+/-4.3%) was statistically different. The rat dorsal paired island skin flap model shows low difference in flap survival rate and uses an internal control. This is a suitable model for flap survival elongation research.

We present a patient with intractable postpartum hemorrhage resulting from uterine artery pseudoaneurysm despite bilateral hypogastric artery ligation who was successfully treated by an endovascular approach via the collateral route. Although there is a good argument for postponing surgery until transcatheter embolization has been attempted, this case shows that embolization can still be successful even if the iliac vessels have been ligated.

Cardiac transplantation in small primates represents a unique model for investigating both xenograft and allograft rejection. This report describes our technique for heterotopic transplantation of cardiac grafts into the retroperitoneal iliac vessels of newborn baboons and small primates. Small primates tolerate this position better than either cervical or abdominal placement.

Object.Anterior surgical approaches to the lumbosacral disc spaces are being undertaken with increasing frequency. This increase and the use of minimally invasive techniques themselves have the potential to raise the incidence of major vessel injuries. The purpose of this study was to determine the variability of the vascular anatomy anterior to the lumbosacral spine and to draw conclusions regarding surgical accessibility of the L5—S1 disc space.Methods.Thirty-five cadavers (age range at the time of death 31–87 years) were obtained to evaluate the anatomical features of iliac vessels with respect to the anterior approach to the lumbosacral spine. Direct measurement and morphological classification regarding the relations of these great vessels to the four arbitrary reference points of the lumbosacral disc space were performed. The mean width and height of the L5—S1 disc were 56.4 mm (range 41.6–65.4 mm) and 18.8 mm (range 10–24 mm), repectively. According to the authors' morphological classification, nine specimens (26%) were found to be Type A (standard), 12 (34%) Type B (narrow), two (6%) Type C (ajar), and 12 (34%) Type D (obstacle).Conclusions.The authors have noted quite a variation in the venous vascular anatomy anterior to the lumbosacral disc. During surgical planning for the anterior approach to the lumbosacral spine when using any technique, it is vital to assess carefully radiographic and neuroimaging studies to minimize potentially disastrous vascular complications.

We have read with great interest and applaud Jacobs and colleagues on their production and validation of a Bastion score to classify lower extremity injuries due to improvised explosive devices.1 As the authors indicate, the ideal method of vascular control for class 3 injuries remains unclear. Jacobs and colleagues describe the use of iliac vascular control (either extra- or intraperitoneal) in a total of 51 of 177 limbs injured (46%). After review of the authors findings, we conducted a retrospective analysis of lower extremity injuries cared for during the past 104 days during Op Herrick 15 and 16. Identical triage, resuscitative, and surgical strategies continue to be employed at Bastion hospital. During this time, we have cared for 67 patients with 117 injured limbs as a result of dismounted blast. A total of 41% (n = 48) of limbs injured resulted in traumatic amputation. Consistent with Jacobs report, class 3 injuries were the most common making up 78% of injured lower extremities (see Table 1). Proximal vascular control with temporary occlusion of iliac vessels via laparotomy was utilised in only 6 injured limbs (5% of all injured limbs; no patients underwent extraperitoneal iliac control). When considering Jacobs manuscript, we noted that of 83 class 3 injured limbs without associated abdominal injuries, iliac control was utilised in 19 (23%). We found iliac control in this setting (class 3 injury without associated abdominal injury) necessary in only one patient (see Table 2). Whilst we agree that the classification system appears to be predictive of the initial musculoskeletal treatment, it was much less useful in predicting the need for proximal vascular control. As Table 2 indicates, the 6 limbs that had control of iliac vessels performed tended to be in patients with large injury burden (all had bilateral lower extremity injuries; all had associated injuries according to the ABCD component of the system).

Anatomy that is not located textbook-perfect in the pelvis gives sonographers difficulty. This article will provide methods to achieve a good transvaginal examination on all patients.

A 45-year-old Japanese woman underwent a laparoscopy-assisted vaginal hysterectomy. Insertion of a trocar injured the left common iliac artery and vein, which were repaired within 2.5 hours. Postoperatively the patient presented an acute compartment syndrome of the left leg. Fasciotomy and rehabilitation rescued her from functional disturbances.

PubMed: 11759802 Conventional transacetabular removal of the migrated acetabular cup can be hazardous due to intraoperative injury to iliac vessels. We present a case of a migrated acetabular cup, in which we used a combined preperitoneal and acetabular approach for its removal. With a bimanual approach, the procedure was safer and easier and allowed mesh repair of the pelvic bone defect. The preperitoneal mesh repair is a well-known method for inguinofemoral hernias. However, it has not been used before in the repair of an acetabular defect after removal of a migrated cup.

We report herein the case of a 63-year-old woman who underwent surgery for recurrent mucinous carcinoma of the cecum. Recurrent metastatic lymph nodes had invaded the right common iliac vessels and right ureter, but she had no distant metastases and no peritoneal dissemination. Extended surgery with en bloc resection of the right iliac vessels and right ureter, and femorofemoral bypass were performed. Postoperatively, several complications developed which were successfully treated by further operations. By 1 year after surgery, she had no recurrent tumors on radiological examination, suggesting that our aggressive surgery with resection of the invaded regional vessels had effectively removed the recurrent tumors. This procedure may therefore significantly prolong the survival time and improve the quality of life of such patients.

Modified Stoppa intrapelvic approach offers many advantages in the treatment of complex pelvic fractures: it allows a wide direct intrapelvic view and an easier fracture reduction of quadrilateral lamina, helps screw introduction and angle and avoid direct contact with iliac vessels and the femoral nerve. Complications are represented by thrombosis after iliac vessels stretching and bladder iatrogenic lesions.

Internal iliac vessels show frequent variations in their branching pattern. We saw variations in the branching pattern of right internal iliac vessels in a male cadaver. The internal iliac artery did not divide into anterior and posterior divisions. There were three common trunks: one for iliolumbar and lateral sacral arteries, another for inferior gluteal and internal pudendal arteries, and the third one for superior vesical and obturator arteries. The superior gluteal and middle rectal arteries arose directly from the main trunk of the internal iliac artery. The internal iliac vein did not have a main trunk. Its anterior and posterior divisions joined with the external iliac vein to form the common iliac vein. Knowledge of these variations might be useful for the urologists and surgeons.

Gadolinium-enhanced ultrafast three-dimensional (3D) spoiled gradient-echo magnetic resonance (MR) imaging is a noninvasive method for evaluating the abdominal aorta and the visceral and iliac vessels. With an enhanced gradient system, 20-48 sections can be obtained during a single 18-32-second patient breath hold. The 3D volume obtained from a single acquisition can be reformatted at a workstation and the vascular anatomy viewed in any projection and with a variety of section thicknesses, making this MR imaging technique particularly useful in the evaluation of aberrant arteries, vascular stenoses, aneurysms, and dissection flaps. Gadolinium-enhanced ultrafast 3D spoiled gradient-echo MR imaging has been used instead of or in addition to conventional contrast material-enhanced MR angiography in patients who have chronic symptoms of mesenteric ischemia, who have abdominal aortic aneurysms, or who are at risk for iodinated contrast material-related renal dysfunction. This technique shows great promise for accurate and noninvasive evaluation of the abdominal aorta and the visceral and iliac vessels.

We compared dynamic contrast-enhanced three-dimensional time of flight (3DTOF) magnetic resonance angiography (MRA) with two-dimensional time of flight (2DTOF) MRA with cardiac compensated fast gradient recalled echo (C-MON) and conventional angiography (CA) when it was available. C-MON re-orders the normal data acquisition to minimize ghosting artifacts generated by pulsatile flow. The initial phase of the study involved optimization of parameters and comparison C-MON with no C = MON in eight patients and volunteers. The final phase of the study involved 53 patients who were imaged with contrast-enhanced 3DTOF MRA and 2DTOF MRA with C-MON. Thirty of these patients also had CA. In the initial phase, 2DTOF MRA with C-MON was found to be equal (n = 3) or superior (n = 5) to 2DTOF without C-MON. In the final phase, the agreement among all imaging modalities varied from substantial to almost perfect (Cohen's kappa = .6-.83). The lowest agreement was using 2DTOF to evaluate the external iliac segments. The among suggested treatments varied from substantial to almost perfect for all imaging modalities (Cohen's kappa = .73-93). The diagnostic efficacies of 2DTOF with C-MON and contrast-enhanced 3DTOF were high overall, with the lowest value being a specificity of 63% for one reader in the evaluation of an external iliac segment using 2DTOF. In summary, 2DTOF with C-MON helped to eliminate artifacts due to pulsatility in the iliac arterial segments. In our experience, both dynamic contrast-enhanced 3DTOF MRA and 2DTOF MRA with C-MON performed well in the evaluation of the iliac arteries. Both studies have high interobeserver agreement and high diagnostic efficacy. Contrast-enhanced 3DTOF MRA should be reserved for situations in which the iliac vessels are extremely tortuous or occluded or the external iliac segments are poorly seen.

Although vascular complications during revision total hip arthroplasty are rare, the results can be devastating. Reports in the literature describe staged operations, with the first procedure being abdominal to remove cement and/or the acetabular component followed by a second joint reconstruction procedure. A protocol was developed that combines a retroperitoneal approach with revision total hip arthroplasty in one operative procedure in patients at risk for vascular injury. The patient first undergoes a retroperitoneal incision and the iliac artery and vein are dissected free of surrounding tissue. A silicone loop is placed around the iliac artery and vein and brought out through the wound. The wound is temporarily closed using staples. Revision total hip arthroplasty then proceeds in the usual fashion. If hemorrhage is encountered, bleeding can be rapidly controlled by tensioning the abdominal vessel loops and opening the incision for exposure to the vessels. No complications have been encountered in 23 patients when using this approach.

The probability of adverse and undesirable events during and after operations that have not yet occurred in a finite number of patients (n) can be estimated with Hanley's simple formula, which gives the upper limit of the 95% confidence interval of the probability of such an event: upper limit of 95% confidence interval=maximum risk=3/n (for n>30). Doctors and surgeons should keep this simple rule in mind when complication rates of zero are reported in the literature and when they have not (yet) experienced a disastrous complication in a procedure. Just as aeroplanes should not crash, common bile ducts should not be cut and iliac vessels not be punctured during laparoscopic procedures. In reality, however, these things do happen.1 With the boom in endoscopic surgery, surgeons are claiming to have zero mortality or even zero morbidity in their series of operations. A little reminder, not only for surgeons, may be necessary. If a certain adverse event or complication does not occur in a series, it does not mean that it will never …

The epigastric vascular arcade supplies a wide area of the anterior abdominal wall and exhibits a strategic location providing a highly versatile multicomponent flap that can bridge defects from chest to knees (Brown et al., 1975). The vascular tree of this part of the body is a link between the subclavian vessels (via internal mammary and superior epigastric vessels), external iliac vessels (via inferior epigastric vessels) and intercostals (via costomarginal vessels) (Boyd et al., 1984).

We describe a simple, retroperitoneal approach for the removal of acetabular components that have migrated into the pelvis. The dense fibrous tissue layer which surrounds the implant protects the iliac vessels during removal of the cup by this method.

Presented are two cases of stab wounds through the gluteus in which serious damage was incurred by internal organs: in one case there was penetration of the rectum with the appearance of signs of acute abdomen; in the other there was tearing of retroperitoneal muscles and the internal iliac vessels with resultant hypovolemic shock. These observations suggest that there should be greater awareness of the life-threatening nature of stab wounds of the gluteus under similar circumstances.

This study was designed to test the hypothesis that the extent of damage to the internal elastic lamina (IEL) may be a factor in determining the development of atheromatous lesions (lesion area). A bilateral iliac artery arteriosclerotic (AS) model in seven dogs prepared by intimal denudation and fracture of the IEL plus 5% cholesterol diet was investigated. The animals were sacrificed at 10-52 weeks (10, n = 1; 16, n = 3; 20, n = 1; 32, n = 1; 52, n = 1). Histologic analysis of sections (n = 42) of 14 canine iliac AS arteries harvested bilaterally from identical locations along the vessels (2, 7, and 12 cm from the aortic bifurcation) were compared with control segments of caudal and femoral arteries (n = 12) that had intact lamina and no luminal trauma. AS segments at all sites along the length of the traumatized iliac vessels demonstrated significant lesions, while control vessels had no arteriosclerotic changes. AS lesion area was calculated using ocular micrometry and a multiple regression model to test the predictability of the lesion area from the following independent variables: (1) proportion of intact IEL to total IEL (IEL/IELt), (2) sacrifice intervalens (3) frequency of disruptions to the IEL, (4) side and level of the arterial lesion, and (5) respective animals. This analysis revealed that none of the coefficients for the independent variables used in the multiple regression model was significant, suggesting that the extent of AS lesions is not related to the size, frequency, or location of breaks in the IEL, although a break in IEL is required to initiate the lesions. This observation suggests that the migration of cells from the arterial media through the broken laminae or the release of medial biochemical mediators which are normally contained by the elastic lamina is required to develop the AS lesions in this canine model, and that any size break in the lamina initiates the process.

A case of unusual birth trauma in the course of a cesarean section is reported. A lesion of the iliac vessels with disruption of the hip joint resulted in extensive necrosis of the lower limb and its eventual amputation.

Percutaneous transluminal angioplasty of the iliac vessels is a generally safe procedure with good results. A rare but potentially fatal complication is iliac artery rupture; we present such a case with its management and review the literature.

Forty embalmed cadavers (24 men and 16 women) were obtained to evaluate the anatomic features of iliac vessels with respect to the anterior approach to the lumbosacral junction. Through a midline longitudinal incision over the linea aspera and retraction of the intraperitoneal contents, exposure of the abdominal aorta, inferior vena cava, and common iliac vessels was done. Direct measurements regarding the relations of these greater vessels to the sacral promontoly were then performed. The results showed the average width of the trigone, measured between the medial edges of the left common iliac vein and the right common iliac artery, was 55.9 mm for male and 55.3 mm for female subjects, respectively. The average height of the trigone, measured from its apex to the sacral promontory, was 36.9 mm for male and 35.2 mm for female subjects separately. The width of the uncovered left common iliac vein averaged 7.2 mm for male and 6.3 mm for female subjects, respectively, with a range of 3-11 mm for both male and female specimens. One should be always aware of the medially placed left common iliac vein and an approach medial to the right common iliac artery to the L5-S1 disk is recommended if anterior surgery is desired.

collaboration in the courses developed for teaching thoracic surgeons the techniques of thoracoscopic and videoassisted thoracic surgery in the laboratory has been an important contribution to education, as well as an opportunity to demonstrate and develop instrumentation with direct feedback from thoracic surgeons. It is likely that novel complications will be encountered from the minimally invasive approach that will be specific to the innovative aspects of the procedure, just as early laparoscopic interventions were associated with unexpected and now readily preventable complications such as trocar laceration of the abdominal aorta and iliac vessels, hypercarbia and aspiration pneumonia from CO, pressurization of the abdomen, or bile duct injury by lasers and cautery. A registry of cases has been developed to document the experience with minimally invasive access for thoracic operations, initiated through the Joint Committee on Thoracoscopy and Video Assisted Thoracic Surgery of

Percutaneous transluminal angioplasty of the iliac vessels is a generally safe procedure with good results. A rare but potentially fatal complication is iliac artery rupture; we present such a case with its management and review the literature.

Summary Two cases in which mandibular reconstruction was accomplished by a free groin osteocutaneous composite graft with microvascular anastomosis of its feeding deep circumflex iliac vessels are presented. The immediate and long-term postoperative results were found to be very satisfactory.

The abdominoinguinal incision provides exposure and renders resectable large tumors located in the lower retroperitoneum, the area of external iliac vessels, and the wall of the pelvis. It is particularly useful for tumors manifesting fixation to these areas. It has been used successfully in 18 patients with malignant tumors and may be expected to increase substantially resectability of tumors in this area and to decrease the need for hemipelvectomy.

In the period from 1976 through 1986, 62 procedures were performed. Of these, 42 were posterior flap hemipelvectomies, 5 anterior flap hemipelvectomies, and 15 internal hemipelvectomies. The median duration of these procedures was 6.5 hours, and the median blood loss was 2,541 ml. Postoperatively, there were no wound problems in 38 procedures (61 percent). The overall rate of flap necrosis was 15 percent, and the overall rate of wound infection, 17 percent. The viability of the posterior flap was not dependent on the level of division of the iliac vessels. By leaving the gluteus maximus muscle attached to the posterior flap, the rate of flap necrosis, initially 55 percent, was eliminated completely in the last 38 patients. Including 11 recently performed procedures, the operative mortality rate was 1 percent (1 of 73 procedures). For patients operated on with curative intent, the estimated 5-year survival rate was 43 percent.

A patient with extensive loss of bone and soft tissue from the right heel is presented. The defect was reconstructed using an osteocutaneous flap based on the deep circumflex iliac vessels. Indications for this procedure include extensive loss of bone and soft tissue precluding the use of local flaps. A 30-month period has elapsed since her reconstruction. A single ulcer developed 13 months postoperatively that healed after flap revision. We feel that tailoring the flap to minimize redundancy at the initial operation, subsequent tissue excision if necessary, and reinnervation augment durability of the flap.

Eight patients who received en bloc excision of the ureter and internal iliac vessels for locally advanced upper rectal and rectosigmoid cancer were reported. Indications, techniques, functional results of the ileal ureter, and prognosis of these patients are discussed. Although three patients died of recurrent tumor--one of transperitoneal spread and two of liver metastasis--none of them developed local recurrent growth. As a replacement for the resected ureter, ileal substitution was applied in all eight patients--unilateral in six patients and bilateral in two. Serum creatinine and electrolyte patterns were within the normal range in all patients. A voiding cystogram showed no reflux to the anastomosed ureter, and a mild reflux to the ileal segment. The patients had excellent prognoses with regard to local control and also satisfactory functional results with the ileal ureter. The authors recommend that this procedure be applied to patients with locally advanced cancer such as those in this series.

進行直腸癌190例を対象にリンパ節転移, 特に側方転移の実態と側方郭清の意義を検討した.治癒切除のリンパ節転移率は48%であった.Dukes Cでは, 251番が81%と高率であり, 側方転移も30%に認められ, 側方郭清の重要性が示された.側方リンパ節のうちでは, 262番の転移頻度が24%(20/84) と最も高かった.Dukes C通常側方郭清例の局所再発率は29%, 特に側方転移例では42%と高率であった.この反省の上に立ち, 内腸骨血管合併切除を伴う拡大側方郭清を29例に施行した.うち治癒切除20例 (側方転移は6例) には局所再発を認めず, 本郭清法は進行直腸癌に対し根治性の高い術式と考えられた.

Mandibular reconstructions using free osteocutaneous iliac crest composite flaps based on the deep circumflex iliac vessels have been completed successfully in seven patients. The advantages of the method include reliability of the blood supply to the bone, long and good size of the vascular pedicle and the possibility of taking bone pieces as required for a hemiandible or medial segment reconstruction. The method should be reserved for the very difficult cases of mandibular replacement where more conventional approaches are contraindicated.

One of the 2 patients introduced here had osteoradionecrosis, which has been difficult to reconstruct. The other had a massive adamantinoma that required replacement of the mandible from the midportion of the right ramus to the left angle with the iliac bone using the conventional method. The grafted iliac bone was severely absorbed, however. The mandible in both cases was successfully reconstructed with an osteocutaneous compound flap, using the deep circumflex iliac vessels as the stem. This method is considered a very good procedure for reconstruction of the mandible, which has been difficult by conventional procedures. Because the diameter of the stem is large, vascular anastomosis can be readily performed with an extremely high degree of safety. Pulsation of the stem can be palpated on follow-up even one year after surgery, and there are no signs of bone reabsorption.

A new method of treating large bony defects of the proximal femur is described. The defect is filled with a large vascular-pedicled bone graft from the iliac crest. The graft, being nourished by the deep circumflex iliac vessels, remains viable and therefore induces rapid healing of the bone. This method of bony replacement encourages adequate excision of potentially malignant bone lesions and provides sufficient mechanical support to allow early walking. Six clinical cases are presented to illustrate its application.

Exsanguination due to hemorrhage caused death in 18 percent of patients with penetrating iliac vessel trauma. Improved survival demands earlier recognition and expedient operative control. One hundred fourteen patients were treated at a single institution during an 11 year period. Gunshot wounds were the predominant cause of injury and combined arteriovenous injury was present in 40 percent of the patients. Twenty-one of the 28 deaths were directly related to vascular injury. All deaths occurred in patients who were initially hypotensive. Seventy-six percent of patients presented with entry wounds below the umbilicus, positive abdominal examination, and hypotension. Earlier recognition is based on this triad. Failure to respond to volume repletion portends a grave prognosis, but it is often reversed by rapid operative intervention. All hypotensive patients with entry wounds below the umbilicus and positive abdominal examination should be taken immediately to the operating room for resuscitation and operation.