Larry L. Hench June Wilson OBJECTIVE Millions of people presently enjoy an improved quality of life due to prostheses which repair, augment or replace parts of their skeletal system: bones, joints, teeth, etc. However, all replacement parts have a finite probability of survival. The goal of this book is to compare the survivability data for various skeletal prosthesis systems. All data derive from previously published clinical studies. Where possible statistical comparisons are made and the reasons for failure are discussed. THE NEED FOR SKELETAL PROSTHESES We are an aging population with more than 100 million people in the U. S. and Europe over the age of 50 years. An unfortunate consequence of aging is a progressive deterioration of the quality of skeletal tissues. From the age of 30 years there is a decrease in bone mass for both men and women (Fig. 1. 1). However, for women it is much greater and between 40 and 60 years of age the rate of deterioration of long bones and vertebrae of women is especially severe due to hormonal changes. By the age of 70 most women will have lost from 35 to 60% of their bone mass. The loss of volume of cancellous or trabecular bone leads to a large decrease in mechanical compressive strength (Fig. 1. 2). The clinical consequence is an increasing incidence of vertebral collapse. Cortical bone decreases in tensile strength with age (Fig. 1.

This is a user-friendly guide to the principles of complete denture construction. It is a practical, extensively illustrated book for the general dental practitioner, starting with the examination of the edentulous patient and progressing through the different treatments in a logical way. A range of procedures has been described in sufficient detail so that the dentist can apply the best treatment measure to the specific clinical problem. A final chapter on domiciliary treatment has been included because elderly, housebound patients often present problems such as denture retention (because of the patients' residual ridge atrophy or insufficient muscular control). Reference to original research work has been included so that the reader can explore the research evidence for himself.

Investigation of anorectal disorders has become a very wide field reaching from case history and simple plain radiography to advanced techniques such as defecography, nuclear medicine, endosonography, computed tomography, and magnetic resonance imaging. The place and value of defecography, thedynamic demonstration of bowel evacuation, have not previously been clearly defined. In this highly illustrated volume, radiologists experienced in thisfield describe techniques, radiation risks, and the interpretation of normal and abnormal findings using the aforementioned techniques of investigation. Anorectal surgeons and gastro- enterologists also participatein the discussion of indications and the influence of abnormal findings on patient management. This book will be helpful as a practical guide tothe choice, performance, and interpretation of the appropriate investigationfor a patient with functional anorectal disorders. As such it represents an excellent addition to the library of every physician and specialist withan interest in anorectal disease.

The present volume is concerned with bone surgery in the area of the facial skeleton. We find this branch of maxillofacial surgery espe- cially challenging because in our work within the Surgical Depart- ment of the University of Basle, we are constantly being confronted with the principles of internal fixation - in the care of poly- 1 traumatized patients, in organizing joint AO-ASIF courses or dur- ing trauma conferences. The problems of fracture disease and the unpleasant sequelae of unanatomical healing are by no means alien to maxillofacial surgery. Our main aim is to broaden our experience of the basic principles of stable anatomical fixation and early function in this branch of trauma and corrective surgery. It soon became apparent that pri- mary healing of fractures and osteotomies, as well as undisturbed re- vascularization of bone transplants and long-term tolerance of inert implants and joint prostheses depend on the stability of fixation un- der preload.

This book is dedicated to the memory of Walter Brendel, late Professor of Experimental Surgery and Chairman of the Institute for Surgical Research at the University of Munich, Germany. For 20 years Walter Brendel organized the renowned Round Table Symposium on Applied Immunology, first in Kitzbiihel and later in Axams, Austria. On the occasion of the 20th symposium in January 1989 he gathered together a number of scientists who have been leaders in the field of transplantation immunology and clinical transplantation for the past two decades. All of them had participated at previous meetings, some on a regular basis. Many of the new discoveries in applied immunology and transplantation medicine were first presented and vividly dis cussed at the Round Table Symposia. The annual Kitzbiihel! Axams meetings became well-known and invitations much sought after, not only for this reason but also because of the uniquely intimate atmosphere that promoted the free exchange of research findings and theoretical cut and thrust.

Within the past twenty years, the field of robotics has been finding many areas of applications ranging from space to underwater explo rations. One of these areas which is slowly gaining popularity among the users group is the notion of service robotics. This book is an in vestigation and exploration of engineering principles in the design and development of mechanisms and robotic devices that can be used in the field of surgery. Specifically the results of this book can be used for designing tools for class of Minimally Invasive Surgery (MIS). Generally, Minimal Invasive Surgery (MIS), e. g. laparoscopic surgery, is performed by using long surgical tools, that are inserted through small incisions at the ports of entry to the body (e. g. abdominal wall) for reaching the surgical site. The main drawback of current designs of en doscopic tools is that they are not able to extend all the movements and sensory capabilities of the surgeon's hand to the surgical site. By im proving surgical procedures, training, and more practice, it is possible for surgeons to reduce completion time for each task and increase their level of skill. However, even in the best cases the level of performance of a surgeon in Minimally Invasive Surgery is still a fraction of the con ventional surgery. Any dramatically improvement is usually driven by introduction of new tools or systems that in turn bring totally new pro cedures and set of skills.

The Fourth International Copenhagen Symposium on Detec tion of Breast Cancer, which took place in Copenhagen August 1988, made it possible once again for scientists from all over the world to come together to present the latest advances in the fight against breast cancer. This book forms a synthesis of important contributions, with special reference to follow-up screening trials, stereotactic X-ray guided fine-needle aspira tion biopsy procedures, and new and important contributions to our knowledge concerning nonpalpable breast tumors. It is our fervent hope that the reader of this book will be encouraged to join in the struggle against breast cancer, especially screening programs, in order to detect the disease as early as possible, bearing in mind that breast cancer, in spite of recent advances, still is a dreadful strain on women throughout the world. S. Brunner B. Langfeldt Contents E. L. Kitts, Jr., J. Beutel, R. S. Holland, and B. Blank Relative Doses in Mammography: The Future Development of Film/Screen Mammography Systems . . . . '. . . . . . . . . . . . . . . . . . . . . 1 R. McLelland . Earlier Detection of Breast Cancer: An Overview 10 J. Leveque, e. O. Lorino, and J. J. Ferrara Inflammatory Disease of the Breast. . . . . 18 R. McLelland Stellate Lesions of the Breast 24 R. McLelland Screening for Breast Cancer: Opportunities, Status and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . 29 S. A. Feig Follow-up Studies of the Health Insurance Plan Study and the Breast Cancer Detection Demonstration Project Screening Trials in the USA. . . . . . . . . . . . . . . . 39 R."

Sepsis and Innovative Treatment: The Odyssey R. C. Bone The Odyssey by Homer, dates back to the 8th century, B. C. [1]. It is a great epic adventure of Odysseus's dramatic journey from Troy back home to Ithaca. Odysseus survives the ordeals of this journey and returns with new powers and insights. The study of the pathogenesis and treatment of sepsis has also been an odys- sey. I feel we will return from this odyssey with new insights and treatments. However, as with Odysseus, this will occur only after considerable struggle. In the 1980s we had a rather simplistic view of sepsis. It was a highly lethal complication caused by infection and often charac- terized by shock and multi-organ failure. Our knowledge of the inflammatory responses associated with sepsis was embryonic compared to today. The inflammatory response was often treat- ment with mega-dose corticosteroids along with fluid resuscita- tion, vasopressors and antibiotics. Because of the paucity of mul- ti-center controlled trials documenting the risk/benefit ratio of the treatment of sepsis with corticosteroids, two large multi-cen- ter controlled trials were organized to evaluate the role of corti- costeroids in sepsis [2, 3]. Because animal models showed bene- fits of corticosteroids only with pre-treatment or early treatment, a definition of sepsis was used that did not require positive cul- ture documentation or septic shock to be included in the studied population.

Present knowledge in regional cancer therapy is presented in this volume. The latest research addresses the questions of optimal drug development, the best galenic form and schedule to control tissue distribution at the tumor site and efficient treatment of specific anatomical regions.

"The experience of each one of us is the treasure of all. " Gerard de Nerval In 1952, J. L. Lortat-Jacob [2] reported the first programmed right hepatectomy, which had been carried out for a hepatic metastasis of colorectal origin. Today, excisional surgery of the liver has become a routine procedure, with a low mortality and morbi dity. The varieties of excision have increased and been modified in accordance with the site and number of lesions to be treated. These advances notably stem from both the work on the segmental anatomy of the liver by Couinaud [1] and that of Ton That Tung [3], which have opened the way to a simplified and segmental method of hepa tic resection that is both safe and reliable. This progress has been greatly facilitated by a better knowledge of the effects of vascular clamping of the liver, and by the intro duction of new techniques including per-operative ultrasound, the ultrasonic dissector and the argon coagulator. Improvements in anresthesia have also contributed to the safety of these procedures. The high incidence of colorectal cancer (the second commonest cause of cancer death in France) and the frequent occurrence of hepatic metastases from this tumour, more than justify the search for an effective therapeutic management pro tocol. The important place of surgical resection, the technical advances outlined above, and the prospect of new treatment modalities using adjuvant therapy, are additional reasons for preparing a report on this subject.

are then selected and must meet the general 'biocompatibility' require ments. Prototypes are built and tested to include biocompatibility evalua tions based on ASTM standard procedures. The device is validated for sterility and freedom from pyrogens before it can be tested on animals or humans. Medical devices are classified as class I, II or III depending on their invasiveness. Class I devices can be marketed by submitting notification to the FDA. Class II and III devices require either that they show equivalence to a device marketed prior to 1976 or that they receive pre-marketing approval. The time from device conception to FDA approval can range from months (class I device) to in excess of ten years (class III device). Therefore, much planning is necessary to pick the best regulatory approach. 2. Wound Dressings and Skin Replacement 2.1 Introduction Wounds to the skin are encountered every day. Minor skin wounds cause some pain, but these wounds will heal by themselves in time. Even though many minor wounds heal effectively without scarring in the absence of treatment, they heal more rapidly if they are kept clean and moist. Devices such as Band-Aids are used to assist in wound healing. For deeper wounds, a variety of wound dressings have been developed including cell cultured artificial skin. These materials are intended to promote healing of skin damaged or removed as a result of skin grafting, ulceration, burns, cancer excision or mechanical trauma."

Implantable jOint prostheses which have been under development for more than 25 years, are today being used with success in the rehabilitation of many cases, including patients with extremely severe joint pathology. However, artificial joint designs still pose problems with respect to their function, anchoring, materials employed and the interaction of the prosthesis with the surrounding biological tissues. Some of these problems are associated with considerable therapeutic complications. Further improvement in the artificial joint requires the application of all the modern experimental and research techniques and the close cooperation of medical doctors, engineers and scientists. The International Symposium on Advances in Artificial Hip and Knee Joint Technology held at Erlangen on October 30 and 31, 1975 under the auspices of the Societas Physica Medica Erlangensis, had as its aim the promotion of just this interdisciplinary cooperation. One of the traditional objectives of the Societas has been the advancement of diagnosis and therapy by the adaptation of medical skill to modern technology and scientific engineering concepts. The major objective of this volume is to present, in expanded form, the lectures given by internationally recognized scientists and clinical researchers in the field of artificial joints in the locomotor system, and to make that information available to a wider public. The experience discussed covers the principles and primary methods of joint replacement.

Microsurgery has brought about important changes and progress in the treatment of cere bral aneurysms in recent years. Only 12 years ago McKissock, one of the most experienced surgeons in the treatment of aneurysms pompared the results of operative and nonoperative treatment. He found that mortality and morbidity of cerebral aneurysms was not significantly affected by whether the patients have been operated upon or not. This view is held by many neursurgeons, and was confirmed by results of the Co-operative Study in 1969. In the review on treatment of aneurysms in Progress in Neurological Surgery in 1969, techniques such as encasement with plastic compounds, piloinjection, stereotactic copper or electric thrombosis and metallic thrombosis and profound hypothermia in anaesthesia were listed. In general, these techniques now seem to be of little more than historical interest. Progress in recent yeats has been so enormous that one may perhaps gain the impreSSion that the main problems in the treatment of aneurysms have been solved and that there are no more to be surmounted. This is dangerous and complacent thinking, such as Lord Moynihan indulged in during the thirties. For this reason we thought that the time had come to assemble a group of experts who could discuss the various unsolved and contro versial problems of aneurysm surgery in the friendly and relaxed atmosphere of a "work shop.""

The introduction of computed tomography in the diagnosis of pathological intracranial conditions has had considerable significance in cases of cranio cerebral injury. The decisive diagnostic advantage lies in the possibility of demonstrating both gross pathological change directly as well as secondary changes in normal brain structures. Computed tomography has proved its considerable worth, especially in evaluation of patients with craniocerebral injury and its sequelae. The capabilities of CT were quickly recognized and use of the technique spread rapidly. It is likely that CT will be available within a few years in all hospitals and clinics treating patients with craniocerebral injury. We believe it appropriate to present a detailed report on our experience with CT in 1800 cases of craniocerebral injury treated in the neurosurgical departments in Miinchen-GroBhadern and Berlin-Charlottenburg over a period of five years. Both acute posttraumatic complications and late sequelae are discussed extensively. A large number of illustrations is provided in order to facilitate the reader's introduction to CT diagnosis. The great interest in our conjoint study originally published in the German language, induced us to translate this book and to update the clinical material. We wish to thank the Stiftung Volkswagenwerk, the Senat of Berlin, the Ludwig-Maximilians-Universitat in Munich and the Freie Universitat of Berlin for the generous financial support which made this study possible."

The use of the compressed air-driven turbine for the activation of surgical burs and saws as developed by Dr. Robert M. Hall has been a boon for the plastic, max illofacial, and oral surgeon. The development of air instrument surgery coincided with the opening of new vistas in surgery in the area of craniofacial surgery. Cranio facial osteotomies for orbital (ocular) hypertelorism, for the deformities of cranio stenosis (Cronzon's disease, Apert's syndrome) and subcranial osteotomies at various levels of the facial skeleton have brought about dramatic improvements in the form of the facial substructure in patients with gross deformities. In many of these maxillofacial deformities the facial skeleton and dento-alveolar processes must be advanced, recessed or expanded in the lateral dimension. In such cases maloc clusion of the tceth is usual; this is corrected by intermaxillary fixation of the mo bilized bony structures which also reestablishes adequate relationships between the dento-alveolar processes of the upper and lower jaws. This brings us to the subject of surgical orthodontics, a field that is just beginning to expand; its development should bring about closer collaboration between surgeon and orthodontist, resulting in rapid and efficient improvement of malocclusion. The absence of vibration characteristic of the air-driven turbine, in contrast to the mechanically driven drill, allows the surgeon to carry out delicate and precise surgical procedures with less fatigue to himself."

The editorial group has selected these papers for publication in Progress in Orthopaedic Surgery from contributions to the "Reisensburg Workshop of Clinical Trauma Surgery" dealing with the lesions of knee ligaments and cartilage in 1975. They represent a survey of today's knowledge of pathophy siology, diagnostic means, and therapy of these lesions in the German-speaking countries. There are two "Reisensburg Workshops" annually, covering current topics of traumatology sponsored by the Ulm trauma group. Primary attention is focused not upon review lectures but rather upon the extensive discussions thus resulting in recommendations to the practising trauma surgeon in order to facilitate his clinical work. Ulm, November 1977 C. Burri, A. Ruter Introduction This volume of Progress in Orthopaedic Surgery presents a selection of papers dealing with injuries to the ligament support and articular surfaces of the knee. The menisci are not discussed as separate entities, but rather in their correct perspective as part of the knee jointsupport mechanism. As the editor for this volume, I have tried to select the most representative articles which cover this subject. These are publications from our European colleagues and reflect their opinion and experience. I have tried not to change their content or meaning in any way. This volume has been divided into six basic segments. Each deserves comment."

Surgery as a medical discipline has from its beginnings appealed to the imagination of many. It is therefore not surprising to find that its colourful past has induced quite a few authors to take up their pens. The truth of this in the Netherlands is witnessed by a number of dissertations and monographs and especially by the numerous articles related to the history of surgery which have appeared in the medical weekly Nederlands Tijdschrift voor Geneeskunde, particularly during the two decades preceding the Second World War. The memorial volume, published in 1977 by the 'Nederlandse Vereniging voor Heelkunde' (Association of Surgeons of the Netherlands) has thoroughly covered the history of Dutch surgery since the tum of the century, but a chronological survey of the earlier events which led to these modem achievements is still wanting. This book has been written with a view to meeting this need. In it, Dutch surgery has by no means been taken as an isolated phenomenon, but considered in its context with European surgery as a whole. Foreign influences on the on surgery abroad are discussed Netherlands and, conversely, Dutch influences whilst contemporary medical thinking is set against a cultural and political back ground. It is hoped that this approach will allow the book to exceed the narrow boundaries of'campanilismo' and make it of interest to non-Dutch readers as well."

Hemorheologic therapy has gained considerably in importance in recent years. This detailed and comprehensive book enumerates, discusses, and critically evaluates those treatment methods in which therapeutic success rests essentially on achieving an improvement in hemodynamics. After a general account of clinical hemorheology, fundamental aspects of hemorheologic methods and the eval- uation and assessment of hemorheologic parameters are discussed and the pathophysiology is described in detail. The treatment methods and substances that bring about improvement of the hemodynamics are described in chronologic order of first publication, and in each case all known later publications are also discussed in the order in which they appeared. This topical account of hemorheologic therapy - the results reported to date and the spectrum of applications - will be a valuable addition to the library both of the specialist and of all interested doctors in hospital and general practice.

Dieser Band gibt die Referate des 4. Internationalen An{sthesie-Symposiums, 15.-17. Juni 1989 wieder. Amerikanische und europ{ische Spezialisten der unter- schiedlichsten Fachgebiete diskutieren neueste Entwicklungen der Labor- und klinischen Forschung.

Breast Cancer, the second volume in the MD Anderson Solid Tumor Oncology series, this book provides the general surgeon, surgical oncologist, and medical oncologist with the state-of-the art multimodality care for breast cancer. Divided into five sections, the text brings the field's recognized esperts addressing the current status of breast imaging, breast pathology, the role of breast surgery including management of in situ and early stage carcinoma, prophylatic mastectomy, axillary node dissection, sentinel node and lymphatic mapping, and outpatient mastectomy, as well as coverage of special selected topics featuring breast cancer in pregnancy, inflammatory breast cancer and breast sarcoma. An important section on future research reviews on-going studies for the use of in situ laser ablation, cryosurgery, and translational research to bring the busy practitioner up-to-date on state-of-the art advances. This book is a must-have resource on the full specturm of current and prospective treatment options for this challenging disease.

I have particular pleasure in introducing this publication by Gian Pietro Marzoli and Sergio Vesentini. Years ago they enthusiastically accepted my suggestion that they should take specific interest in the clinical and surgical problem of portal hypertension, and assess the proposals of surgical ex- perience with regard to this debated physiopathological picture. These thanks are all the more real because in this way the school's attention remained fixed on a subject that had already attracted it profoundly from the start - with Giovanni Castiglioni and Vittorio Pettinari as heads of the school - and then threatened to die away into general con- formism. In Italy "precariousness" is easily extended to the concept of school continuity. In Warren's proposal (1967) of "distal splenorenal anas- tomosis with disconnection of the spleno-oesophageal from the mesenteric district", I felt there was an intelligent at- tempt to solve all the basic problems, albeit in different ways. An attempt, that is to say, at alleviating the gastro- oesophageal circulation, thus avoiding* haemorrhage, and at ensuring that the liver would maintain the circulatory ef- ficiency with which it was still endowed. The spleen was re- tained, but there was reason to think that, by reducing blood stasis within its ambit, it would be possible to manage or alleviate any hypersplenism: not an absurd hypothesis if the Americans had sometimes noted in their material function- al and even anatomical reversion of the splenopathy after a simple portacaval shunt.

At the beginning of this century, the state of surgical technique only provided for concepts with an extracardial approach to therapy of coronary heart dis eases. Decreasing the heart activity by means of denervating the heart or thyr oidectomy, resulting in a reduction of the heart's oxygen demand, was strived at. Later, the progress of clinical surgery at the closed beating heart allowed for procedures with myocardial access. In this historical stage of indirect revascu larisation, a compensation was supposed to be stimulated operatively by pro viding an adhesion to the surrounding organs or by manipulating the larger heart veins. The simple ligation of the Arteria thoracica interna in the middle third of its course - intended to increase the perfusion of pericardial branches - is based on the fundamental ignorance or misunderstanding of the haemody namic laws. The first intervention to reach temporary popularity was the im plantation of the Arteria thoracica interna into the left ventricular myocardial wall. This so-called "Vineberg procedure" was not very risky and did show some permanent improvements with respect to the patient's complaints or even the prognosis. However, this procedure has been almost completely aban doned, despite the fact that some positive long-term courses have been docu mented. Other indirect revascularisation procedures carried out in the fifties, e. g."

Boston University School of Medicine has established a series of Medical Education Programs in Nutrition held each summer since 1975. These deal with controversies in human clinical nutrition. The subjects have covered various topics, including those dealing with the relation ships between diet and heart disease, diet and cancer, breast. versus bottle-feeding, and dietary fiber and disease. Other noncontroversial topics were also covered at these conferences; they were discussed simply to bring to the attention of the health professional new happenings in nutritional research. These topics dealt with the relationships of nutrition to immune function, to neurotransmitters, to infection, to obesity, and to chemotherapy. This text is a compilation of selected manuscripts of interest to the health professional in the area of human clinical nutrition. Whatever success this text enjoys is in no small way due to the ad ministrative and editorial efforts of our administrative assistant, Mrs Geraldine Rankin - our sincere thanks."

The Nd: YAG laser has finally become the multidisciplinary and muitispeciaity tool of the 1980s. Primarily developed for gastrointestinal applications for controlling bleeding, at present it is also used for endoscopic treatment of gastrointestinal tumors, endobronchial cancer, and bladder and gynecological lesions and finding applications in otorhinolaryngology and neurosurgery. De velopment of laser scalpels and focusing head-pieces has now allowed the Nd: YAG laser to be used for open surgical procedures in general and plastic surgery, head and neck surgery, urology, gynecology, dermatology, and neu rosurgery. The rapid development in ceramic technology has led to contact surgery allowing physicians a choice of excision, vaporization, coagulation, incision, or combinations thereof by easily changing probes rather than having to select new laser wavelengths. This technology is rapidly replacing the carbon dioxide laser which currently has no adequate flexible waveguide for fiberoptic en doscopy, cannot be used in a water medium (e.g., bladder), and has poor coagulation properties when compared to the Nd: YAG laser. Future developments may see the Nd: YAG laser even replacing electro cautery in the operating room due to its greater safety and efficacy. Local hyperthermia (laserthermia) with computer control, photodynamic therapy, and ophthalmic applications make the Nd: YAG laser the most exciting tech nological advancement in medicine and surgery for the 1980s."