D Le Nen

Publications (69)30.22 Total impact

• Article: [Long-term functional outcomes of digital ischemia under tourniquet: About three cases.]

  F Mallard, Y Saint-Cast, J Richou, D Le Nen
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  ABSTRACT: Digital tourniquet is a quick, simple and reliable method to ensure a bloodless operative field distal to the MP joint. However, a forgotten tourniquet is an exceptional but serious complication related to digital ischemia. Few cases were reported in literature without a long-term outcome. Three digits of three patients, aged 70, 49 and 14 at the time of accident, had a tourniquet left in place for 2 days for the first two and 6 days for the last one. Final assessment was carried out 3, 4 and 16 years respectively after the initial accident. All fingers survived with sequelae such as pain, cold intolerance, dysesthesia, allodynia, joint stiffness and skin and nail trophic disorders. A hypertrophic scar was still visible at the site of the tourniquet. Capillary pulse was normal in all cases. Radiological changes were visible when the tourniquet had been left for more than 2 days. The impact on professional and day life activities was considerable. No surgery for the sequelae was done. Avoiding a missed finger tourniquet requires a suitable tourniquet with a visual reminder and its removal must be considered a crucial part of the surgery.
  Chirurgie de la Main 10/2012; · 0.53 Impact Factor
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  Available from: Ahmed Zemirline

  Article: [Complete wrist denervation: A retrospective study of 27 cases with a mean follow-up period of 77months.]

  E Simon, A Zemirline, J Richou, W Hu, D Le Nen
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  ABSTRACT: OBJECTIVES: Complete wrist denervation is a palliative operation, which yields still controversial outcomes. The aim of our study is to assess the late outcomes of complete wrist denervation. METHODS: In a retrospective continuous review of 27 complete and isolated denervations of the wrist joint performed by the same surgeon in 27 patients (15 men for 12 women) from 1995 to 2007, the pain (VAS), the function (Dash-score), the range of motion, the strength (Jamar) and the radiological changes were assessed at a mean follow-up period of 77 months (12 to 157). RESULTS: At final follow-up, 12 patients (44%) were completely free of pain and 11 (41%) had little pain, four (15%) had moderate and severe pain. The average time to achieve the complete pain relief was 3 months and 3 weeks. Pain relief was stable over time in 89% of cases. There was a significant improvement in range of motion: 11° flexion/extension; 8° pronosupination. In average, the Jamar grip strength was 85% of the healthy side. The Dash-score was in average 30.4 (22 to 60). The extension of the osteoarthritic surface was observed in 14 patients (52%). Six complications were noted: one complex regional pain syndrome, five neuromas four of which resolved spontaneously. Two patients were re-operated. Eighteen patients were very satisfied (67%), six patients were satisfied (22%) and three patients were moderately satisfied (11%). CONCLUSIONS: Complete wrist denervation is an intervention with few complications indicated in chronic wrist pain of any aetiology.
  Chirurgie de la Main 08/2012; · 0.53 Impact Factor
• Article: Gastrocnemius medial flaps

  D. Le Nen, W. Hu, M. Liot, G. Moineau, R. Gerard
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  ABSTRACT: With reference to the data reported in the literature and to the anatomical vascular basis, the authors expose different techniques and maneuvers used for dissection of gastrocnemius flaps. The use of muscular and myocutaneous gastrocnemius flaps and some modifications of the standard surgical technique aiming to gain more versatility are described. So that, the range of these flaps can be planned to cover the greatest part of the lower extremity of the leg.
  Interactive Surgery 04/2012; 2(2):118-127.
• Article: [Thumb salvage after infected toe-to-hand vascularised transfer with induced membrane technique].

  L Ardouin, D Le Nen
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  ABSTRACT: The induced membrane technique of bone reconstruction described by A.C. Masquelet is a well-known and efficient procedure for the lower limbs but is rarely used in the hand. After debridement, the technique consists first in inducing a foreign body membrane by the implantation of a cement methyl methacrylate polymer spacer and then filling the defect by cancellous bone. We report a case of induced membrane to save an infected vascularized custom made toe-to-hand transfer. The second stage was done 3 months after the first. Bone healing was obtained 4 months later. No specific complication was observed. Induced membrane technique seems to be another possibility for bony defects of the hand besides vascularised or non-vascularised grafts. It is essential to apply the principles of the two stages of the procedure, first respecting the foreign body membrane and second stable fixation of the graft. In sepsis, this allows a second surgical debridement without compromising the graft. Masquelet technique, simple and reproducible, seems an effective salvage procedure for bone defects of the thumb.
  Chirurgie de la Main 12/2011; 31(1):41-4. · 0.53 Impact Factor
• Article: [Neurotization of the deep branch of ulnar nerve with anterior interosseous nerve: anatomic study].

  M Robert, C Blanc, P Gasnier, D Le Nen, W Hu
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  ABSTRACT: The paralysis of the deep branch of ulnar nerve has major consequences on the motricity of the hand that will be felt as more handicapping by the patient than the sensory deficit. The current treatment of ulnar nerve lesions is suture or nerve graft in first intention and is essentially palliative in case of failure. We were interested in the anatomy of the anterior interosseous nerve and the deep branch of ulnar nerve to know if neurotization using direct suture of these two branches was possible in every case. Our anatomical study was done on 15 upper limbs. We dissected the branch of the anterior interosseous nerve innervating the pronator quadratus muscle and performed an intraneural dissection of the deep branch of ulnar nerve. The distance between these two branches was then measured. The mean distance separating the deep branch of ulnar nerve and the anterior interosseous nerve is 2.5mm (-10-10). The direct suture of these two branches is possible in every case of this study. The macroscopic calibre of both branches is similar. Our study shows that the neurotization of the deep branch of ulnar nerve with the anterior interosseous nerve is possible in every case using direct suture, the wrist can be immobilised temporarily in flexion to reduce the tension. Üstun et al. as well as Wang and Zhu showed that their calibre and the number of axons is similar. We think that neurotization of the deep branch of ulnar nerve with the anterior interosseous nerve can be realized in first intention in case of high lesion of ulnar nerve. There is no major functional loss due to the paralysis of the pronator quadratus muscle. Neurotization of the deep branch of ulnar nerve with the anterior interosseous nerve has no major functional loss and gives possible recovery of all the intrinsic muscles innervated by the deep branch of ulnar nerve. This neurotisation can be considered as an alternative to the usual techniques of direct suture or nerve graft, in case of lesion above mid forearm.
  Chirurgie de la Main 10/2011; 30(6):406-9. · 0.53 Impact Factor
• Article: The arthritic wrist. II--the degenerative wrist: indications for different surgical treatments.

  J Laulan, G Bacle, C de Bodman, N Najihi, J Richou, E Simon, Y Saint-Cast, L Obert, A Saraux, P Bellemère, T Dréano, M Le Bourg, D Le Nen
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  ABSTRACT: For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined.
  Orthopaedics & Traumatology Surgery & Research 06/2011; 97(4 Suppl):S37-41. · 0.94 Impact Factor
• Article: The arthritic wrist. I--the degenerative wrist: surgical treatment approaches.

  D Le Nen, J Richou, E Simon, M Le Bourg, Najihi Nabil, C de Bodman, G Bacle, Y Saint-Cast, L Obert, A Saraux, P Bellemère, T Dréano, J Laulan
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  ABSTRACT: The primary goal in treating a degenerative wrist is to provide pain relief, while maintaining strength and mobility if possible. After failure of the recommended conservative treatment, the choice of approaches can be made from a large collection of techniques, some which are well validated. Partial wrist fusion, particularly the Watson procedure, results in a pain-free wrist in 80% of cases, with 50% of the mobility preserved, good grasping strength and stable results for at least 10 years. Proximal row carpectomy provides similar results if the cartilage on the head of the capitate is preserved and the patient is not involved in heavy manual labour. Complete denervation provides pain relief in almost 80% of cases while preserving motion and strength. This is a safe and effective option, with no age limit, that still allows other procedures to be performed in the future. Total wrist fusion also has its place in revision, and even as first-line treatment, because of the reliable outcome in terms of pain and strength, high satisfaction rates, little to no repercussions linked to the loss of mobility and fewer complications. Other techniques are now available. The partial or complete resection of a carpal bone and placement of an implant is back in vogue because of the availability of pyrocarbon. Such implants are an option in the future for localized osteoarthritis or even diffuse affections, and a useful alternative to more invasive procedures. The use of a rib cartilage graft to partially or completely replace a carpal bone or resurface the radius has promising results in terms of pain reduction and fusion. The role of total joint replacement must be defined relative to the classic, reliable techniques that have long-term outcome data. LEVEL OF PROOF: IV.
  Orthopaedics & Traumatology Surgery & Research 06/2011; 97(4 Suppl):S31-6. · 0.94 Impact Factor
• Article: Radius graft pedicled on the anterior interosseous artery for recurrent ulnar nonunion.

  C Andro, J Richou, P Schiele, W Hu, D Le Nen
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  ABSTRACT: Recurrent ulnar nonunion challenges the functional prognosis and raises major problems concerning the best therapeutic strategy to follow. The case of a female patient presenting recurrent nonunion of the ulnar diaphysis despite successive treatments is reported. The radius graft pedicled on the anterior interosseous artery from a retrograde approach obtained bone union in 3 months with no functional sequelae. For the first time, we propose a therapeutic alternative calling on a proximally pedicled anterior interosseous flap. This technique can be performed under locoregional anesthesia and does not sacrifice the main artery of the forearm. However, the size of the graft does not entirely compensate for segmentary bone loss. The radius graft pedicled on the anterior interosseus artery is an inventive technique that can solve the problem of difficult ulna nonunions without the disadvantages of vascularized fibula harvesting.
  Orthopaedics & Traumatology Surgery & Research 06/2011; 97(4 Suppl):S12-5. · 0.94 Impact Factor
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  Available from: Ahmed Zemirline

  Article: [Acute ischemia of the hand, an unknown complication of the hydrogen peroxide irrigation. Case report].

  A Zemirline, F Loaëc, L Hélaine, J Richou, D Le Nen
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  ABSTRACT: We report a case of acute transitional ischemia of the hand with acute compartment syndrome of the forearm, following hydrogen peroxide irrigation of a wound. We discuss the physiopathology and management of this complication. Along with numerous related cases of gas embolism, this complication emphasizes the risks of using hydrogen peroxide under pressure, notably in hand surgery.
  Chirurgie de la Main 04/2011; 30(2):117-9. · 0.53 Impact Factor
• Article: [Pedicled bone transfers for digit reconstruction].

  W Hu, D le Nen, N Kerfant
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  ABSTRACT: The techniques of pedicled bone transfer harvested from the forearm and the hand are largely used in digit reconstruction during the last three decades. Comparing with the vascularized bone-free transfer techniques, their realization is generally easier because of the single operative field and the absence of microvascular suture. Based on their clinical experience, the authors try to make the point about the surgical techniques and the indications of the principal pedicled bone transfers harvested from the forearm and the hand for digit reconstruction.
  Chirurgie de la Main 12/2010; 29 Suppl 1:S172-83. · 0.53 Impact Factor
• Article: [Blauth classification of thumb hypoplasia: thought and proposition of modification].

  P Gasnier, N Kerfant, D Le Nen, A Boloorchi, W Hu
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  ABSTRACT: Using the conclusions of the previous article concerning the therapeutic indications for handling hypoplastic thumb, we suggest an amendment to the current Blauth classification. This alteration is based on the management of this congenital anomaly, whereas the Blauth classification describes the morphological characteristics of the malformation. It appears for us more usable in practice by its easiness to be memorized.
  Annales de chirurgie plastique et esthetique 10/2010; 56(4):321-4. · 0.33 Impact Factor
• Article: [Use of dermal substitute Matriderm® in severe injuries of the hand: about one case].

  N Kerfant, R Gérard, D Le Nen, W Hu
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  ABSTRACT: Restoring function after hand burns is still a great surgical challenge. Reconstitution of elasticity and pliability are of utmost importance for hand function and aesthetics results. Dermal substitutes have been developed and have been used for many years. The dermal substitute Matriderm® is an acellular three-dimensional matrix composed of native structurally intact collagen fibrils coated with elastin obtained from bovine dermis. The possibility of a one-stage procedure is profitable in treatment of hand burns. The authors report the case of a 43-year-old man admitted for severe burn by flames to 18% of his total body surface area with complete full thickness injury of left hand. After debridement incisions in emergency, early excision and skin graft using Matriderm® were performed. Physical therapy was established at Day 10. At six weeks follow-up, full range of motion was achieved and the patient was able to use his hand in daily activities.
  Chirurgie de la Main 10/2010; 29(6):378-80. · 0.53 Impact Factor
• Article: [Description of an original conservative method for the surgical management of the Blauth IIIb thumb hypoplasia: "relative lengthening - thumb stabilization"].

  W Hu, P Gasnier, D Le Nen, N Kerfant, A Boloorchi
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  ABSTRACT: PROBLEMATIC: Thumb hypoplasia is a rare congenital hand disorder. Despite the recent clarifications concerning many surgical indications, dealing with Blauth IIIb type remains a polemic subject. We hereby suggest "The relative lengthening - thumb stabilization", an original and simple conservative surgery technique for the Blauth IIIb type, in order to satisfy parents and big kids requests of a "five fingered hand". The whole hypoplastic thumb is lowered in a way that lengthens it relatively. An intentional pseudarthrosis is performed between the first metacarpal base and the second metacarpal diaphysis, creating a "new trapeziometacarpal joint". The suggested technique was performed on four IIIb type hypoplasic thumbs of three kids since 1997. The average postoperative follow-up is 9.6years (3.5 to 12.5years). The average Kapandji score is 5.75 (5 to 6). The key pinch prehension strength is by 21.5% in relation to the normal hand and the global prehension strength (according to Jamar Test) is by 67%. The global pinch is possible and natural in all cases. The surgical management of the type IIIb thumb hypoplasia is a real challenge. We regard this technique of relative lengthening with thumb stabilization as an interesting alternative to the other microsurgical conservative surgeries.
  Annales de chirurgie plastique et esthetique 10/2010; 57(4):342-9. · 0.33 Impact Factor
• Article: Anatomic basis of ulnar index metacarpal reverse flow vascularized bone graft for index distal bone loss.

  L Ardouin, D Le Nen, B Geffard, N Hanouz, C Vielpeau, E Salame
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  ABSTRACT: Well-known advantages of vascularized bone grafts led us to determine the anatomical basis of a metacarpal vascularized bone graft to find a solution for distal index bone loss. Seventeen adult human hands from fresh cadavers were dissected and analyzed. For each hand, we studied the second dorsal metacarpal artery, the ulnar dorsal proper digital artery of index, and the ulnar palmar proper digital artery of the index. Location, diameters, origins, and anastomoses were observed, and at the end, the vascularised bone graft was raised. The second dorsal metacarpal artery was present in all hands, always arising from the dorsal carpal arch with a 1-mm mean diameter. The ulnar dorsal proper digital artery of index was isolated on all dissections, with a subcutaneous location on the ulno-dorsal side of the proximal phalanx. The mean diameter of ulnar dorsal proper digital artery at the level of index proximal phalanx was 0.4 mm. We found anastomotic branches between the ulnar dorsal and palmar proper digital artery of index at the level of the proximal phalanx which permitted us to elevate a vascularised bone graft. We succeeded in removing the graft in all specimens. Its pivot point was always more distal than the middle of the proximal phalanx. The arc of rotation allowed the graft to reach the distal phalanx in 80% of the cases. This anatomical study has demonstrated the theoretical possibility of a reversed pedicled bone graft taken from the ulnar neck of the second metacarpal. This graft brings the following benefits: (a) the use of a minor vascular axis, (b) a surgical technique with a dorsal approach allowing the elevation and the use of the graft at the same time. It can be used on the index for failures of DIP joint arthrodesis, huge chondroma, or traumatology.
  Anatomia Clinica 05/2010; 32(8):719-23. · 0.93 Impact Factor
• Article: Proximal row carpectomy: long-term results.

  J Richou, C Chuinard, G Moineau, N Hanouz, W Hu, D Le Nen
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  ABSTRACT: To evaluate long-term clinical outcome of proximal carpectomy. Our assumption was that this intervention should result in long-term benefit, making a wrist painless, mobile, and functional, compatible with social and professional life, whatever the initial etiology of the degenerative wrist. We report a continuous single centre retrospective series of 24 patients. Objective (mobility, strength, radiographic evaluation) and subjective (pain, subjective wrist value, functional scores) functions were assessed by an independent observer. Surgery was performed mainly for Kienbock's disease, scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists. The follow-up lasted 116 months in average, during which pain was improved in all cases; 83% of the patients were satisfied with a mean score of 1.2 on a visual analogue scale (VAS) and 76% subjective wrist value (SWV) (disabilities of the arm, shoulder and hand [DASH]: 31). Wrist flexion-extension arc averaged 76 degrees , and the grip strength equivalent to 78% of the contralateral limb. Radiographic modification developed in 52% without any clinical impact. Three patients required arthrodesis and never felt comfortable with their carpectomy. Our study shows a long-term efficacy of proximal row carpectomy. This treatment must be considered in the therapeutic arsenal for a degenerative and painful wrist, and it should no longer be regarded as a salvage procedure. Advantages of this intervention are obvious: technical simplicity, short rehabilitation, immediate functionality of the wrist and few complications.
  Chirurgie de la Main 11/2009; 29(1):10-5. · 0.53 Impact Factor
• Article: [Rotational femoral osteotomies using an endomedullary saw.]

  R Gérard, E Stindel, G Moineau, D Le Nen, C Lefèvre
  Revue de Chirurgie Orthopédique et Traumatologique 10/2009; 95(6):512-518.
• Article: [Does the thumb have two phalanges or three? Development of ideas since Aristotle].

  R Gérard, D Le Nen, J Richou, R Seizeur, T Williams, C Lefèvre
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  ABSTRACT: Many controversies mark the long road of the history of anatomy. The hand is not exempt of them. Even Galen's clear thinking, founded on the strict determinism between the structure of an organ and its function, and based on animal dissection, was criticized. In view of the structural complexity of the hand, we will limit our study to one of the most symptomatic conceptual disagreements: whether the human thumb has two or three phalanges, according to whether we include the first metacarpus, or if the thumb's first phalanx is considered as the initial element. According to the latter theory, there is a missing element in the first digital row, and this missing element is the metacarpus. This theory is ancient and its evolution throughout history is discussed in our study. Finally, we explain the origin and bases of the reasoning that led us to suggest the word 'metaphalanx' to designate the first metacarpus.
  Morphologie 10/2009; 93(301):51-6.
• Article: Prognostic factors for the recovery of hand function following trapeziectomy with ligamentoplasty stabilisation.

  G Moineau, J Richou, M Liot, D Le Nen
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  ABSTRACT: Numerous procedures are in use to treat trapeziometacarpal osteoarthritis. Most of these techniques impair hand function. In a series of trapeziectomies stabilized by ligament reconstruction with tendon suspension, we investigated whether eventual parameters influenced hand function and dexterity. Some parameters influence hand function recovery following trapeziectomy combined to ligamento-tendinous stabilization. This is a continuous, retrospective, single surgeon series; 60 cases of thumb trapeziometacarpal osteoarthritis were treated with trapeziectomy and ligament reconstruction (40 palmaris longus, and 20 half flexor carpi radialis) with no additional metacarpophalangeal (MCP) joint surgery. Besides assessing classical clinical outcome criteria (pain, mobility, force), we analyzed hand function: this was obtained with a questionnaire about different everyday movements. Five types of grip were included in this analysis: spherical, pinch grasp, key pinch, power grip, and precision pinch. Fifty-one trapeziectomies (85%) were evaluated at an average follow-up of 7.5 years (5-11.5). Ninety-four percent of patients had good results for pain. The average Kapandji score for mobility was 9.6 (6-10) with a mean web angle at 36.5 degrees. Hyperextension of the MCP joint occurred in 36 cases and measured an average of 26 degrees (5 degrees-50 degrees). Compared to the contralateral side average strength was 97% with the Jamar dynamometer and 88% for the key pinch. The rate of satisfaction was 96%. Collapse of trapezial height was constant, and at last follow-up, the trapezial index was 50% of its preoperative initial value. The results relative to hand function assessment were good in 58% of patients. The spherical grip was the most difficult to restore. The analysis of the 42% of patients with average or poor hand function showed five prognostic factors for a poor outcome: young age at surgery, persisting postoperative pain, postoperative hyperextension of the MCP joint, reduced postoperative web angle and trapezial space collapse. Level IV. Therapeutic study.
  Orthopaedics & Traumatology Surgery & Research 08/2009; 95(5):352-8. · 0.94 Impact Factor
• Article: [Free dermal fat graft for coverage of the median nerve following failed carpal tunnel release].

  F Wallach, J Richou, M Genestet, D Le Nen
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  ABSTRACT: We wished to evaluate the effectiveness of a free dermal fat graft for covering the median nerve in order to improve function after failure of carpal tunnel release. Eight patients with nine failures of carpal tunnel release were reviewed for this retrospective study. They all had significant perineural fibrosis. We performed a free dermal fat graft harvested from the inguinal region on the same side. The mean follow-up was 37 months (range 6 to 112). All patients had a clinical examination, a disability arm and shoulder scoring (DASH) and magnetic resonance imaging (MRI). Five patients were satisfied or very satisfied with the procedure although only two patients returned to work. Mean grip strength was 13 kg (43% of non-operated hand) and the two-point discrimination test was normal or subnormal six times on the eight wrists tested. The mean DASH score was 43 out of 100. MRI scans on eight wrists showed a fat signal in all patients and enhanced signal with gadolinium contrast in six cases. Free dermal fat graft offers a good covering for the median nerve over the carpal tunnel in cases of failure of carpal tunnel release. MRI showed viability of the graft. Clinical results show improvement but symptoms of median nerve irritation persisted. Permanent intraneural changes may explain these limited results.
  Chirurgie de la Main 10/2008; 27(5):208-15. · 0.53 Impact Factor
• Article: [Trapeziectomy and ligamentoplasty with Gore-Tex: preliminary results on 43 patients with trapeziometacarpal joint arthritis].

  G Moineau, J Richou, R Gérard, D Le Nen
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  ABSTRACT: Trapeziectomy with suspension tendinoplasty is one of the most frequent procedures for the treatment of trapeziometacarpal arthritis of the thumb. The authors describe a new technique of total trapeziectomy and suspension tendinoplasty with Gore-Tex nonabsorbable monofilament. They give radiological and clinical results of their first 43 procedures with a minimum follow-up of 18 months. Forty-two patients (43 thumbs), average age of 61 years, underwent this procedure. According to Comtet's classification, they were 16 stage 1, 17 stage 2 and 10 stage 4. At 30 months average follow-up, 93% patients had good results on pain (Alnot's stage 0 or 1). The average opposition was 9.5 out of 10 according to Kapandji and the angle between the two first metacarpals was 36.5 degrees. The average key-pinch force was equal to 4.8 Kg. The average DASH score was 14.2. Collapse of the trapezial space was constant in the radiological study and at the follow-up, the trapezial space ratio was 63% of the preoperative ratio. The most frequent complication was reflex sympathetic dystrophy found in nine patients. The satisfaction rate was 88% and 93% of patients would agree to repeat this procedure. Our technique of suspension tendinoplasty with Gore-Tex monofilament has comparable results with those published with other transplants (Flexor carpiradialis, palmaris longus, abductor pollicis longus...). Our technique has some advantages over others: simplicity of surgical procedure without the need to harvest a tendon, no morbidity at the donor site and less time taken for the procedure. However, it still retains the advantages of suspension tendinoplasty.
  Chirurgie de la Main 09/2008; 27(4):146-53. · 0.53 Impact Factor