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We report here a 46-year-old male patient with a 14 cm segmental bone defect of the radial shaft after third degree open infected fracture caused by a shrapnel injury. The patient underwent fixed-angle plate osteosynthesis and bone reconstruction of the radial shaft by a vascularized 3D-printed graft cage, including plastic coverage with a latissimus dorsi flap and an additional central vascular pedicle. Bony reconstruction of segmental defects still represents a major challenge in musculo-skeletal surgery. Thereby, 3D-printed scaffolds or graft cages display a new treatment option for bone restoration. As missing vascularization sets the limits for the treatment of large-volume bone defects by 3D-printed scaffolds, in the present case, we firstly describe the reconstruction of an extensive radial shaft bone defect by using a graft cage with additional vascularization.

The treatment of traumatic major upper limb amputation is complex and of great urgency. Loss of time often represents a majorrestriction for replantation. Thus, logistical and infrastructural developments, such as the expansion of specialised hand trauma centres, are crucial for optimizing delivery of care. Surveillance represents the fundament for a proper, demand-adapted implementation of such therapeutical improvements. However, a comprehensive database for surveillance of these injuries does currently not exist in Germany or Europe.In this study quality reports of German hospitals from 2014 to 2018 were screened retrospectively for traumatic major upper extremity amputations and replantations. A total of 329 amputations and 87 replantations were recorded, accounting for an overall replantation rate (RR) of 26%. Most of the injuries affected the level of the wrist and forearm. Treatment of these injuries experienced an increasing centralisation to medical teaching facilities, which accounted for higher RRs compared with non-teaching facilities. The cumulatively most populous federal states handled most of the amputation injures in this five-year study period.Ratio calculations on the basis of population counts, however, revealed great discrepancies to these results, with Hamburg, Rhineland-Palatinate and Saarland accounting for the highest per capita incidences. In 2018 Germany was provided with 46 specialised hand trauma and replantation centres, which performed 45% of the replantations in that year, revealing a RR of 17%, compared to an overall RR of 14% in that year. Nevertheless, there might be potential for improvement in the geographical distribution of these specialised centres.The provision of highly specialised therapy in highly specialised centres for highly complex injuries is a future challenge in replantation surgery. This data is contributing to logistical improvements for a need-adapted expansion of these specialised hand trauma centres.The study demonstrates an approach of a standardised and comprehensive injury surveillance program based on national quality reports, while underlining the importance of such a national or rather European database for optimisations in medical care.Level of evidence IV.

Background Extremity replantation as well as allotransplantation aim to restore form and function of the amputated limb. Both approaches, however, are clearly limited by the ischemic time. Ex vivo perfusion (EVP), already well-established in the field of solid organ transplantation, represents a promising tool to overcome this restriction. Methods We have currently established the technical requirements to provide EVP to severed limbs in a clinical hospital setting and hereby report of a 48-hour hypothermic EVP (EVP48) of an upper extremity amputated at the level of the proximal humerus, followed by a 2-hour simulated reperfusion (2SR) with donor blood. Results Muscle biopsies revealed histopathologically well preserved, vital muscle tissue after EVP24, and partially grouped muscle fiber necrosis with predominantly vital muscle tissue after EVP48 and 2SR. Analyses of perfusate samples showed a marked decline of biochemical muscle damage markers during EVP48. Cytokine analysis disclosed an isolated increase of the proinflammatory cytokines, interleukine-6, monocyte chemotactic protein-1, and interferon-γ, during EVP and 2SR. Magnetic resonance imaging, performed after EVP48, indicated partial muscle necrosis of the intrinsic hand muscles only, while no signs for infection or inflammation were present. Conclusion Our single case experience shows the general feasibility of an amputated limb ex vivo salvage perfusion setting to allow for delayed replantation up to 24 hours. Nevertheless, an accurate prior planning is crucial to ensure successful implementation of EVP in the acute clinical setting.

Background: Burn patients are predisposed for nosocomial infections during their stay on a burn intensive care unit. Moreover, several outbreaks affecting burn units for example caused by Methicillin-resistant Staphylococcus aureus (MRSA) have been reported. One attempt to address these challenges is the use of universal decolonization. Methods: In 2015 we implemented universal decolonization for all burn patients using the antiseptic agent octenidine for intact skin and the nasopharyngeal mucosa. We conducted a retrospective analysis to evaluate the effect of the decolonization on primary, central line (central venous catheter)-associated bloodstream infections (CLABSI), the frequency of nosocomial clusters (4 or more cases with epidemiologic link and identical molecular pattern) with multidrug-resistant bacteria (MDRB) and the incidence of MRSA. Results: In the decolonization period a reduction of the incidence of CLABSI, nosocomial MRSA acquisition and the frequency of nosocomial MDRB clusters was observed. The incidence rate of CLABSI decreased from 2/1000 central venous catheter days in the pre-decolonization phase to 0.8/1000 central venous catheter days in the decolonization period, although this was not statistically significant. The implementation was accompanied by several feedback talks and training for the staff. The user experience was positive and no adverse effects occurred. Conclusion: Our results show that universal decolonization in burn patients using octenidine is a promising concept to address hospital acquisition of MRSA; occurrence of CLABSI as well as the spread of MDRB causing clusters. It is of high relevance to further assess the value of this measure in terms of reducing CLABSI in burn patients in larger study groups. Therefore further studies including more burn patients guaranteeing adequate sample size are needed. Keywords: Burn unit, Universal decolonization, Octenidine, Bloodstream infection, Multidrug-resistant bacteria, Nosocomial

The Mexican axolotl is one of the few vertebrates that is able to replace its lost body parts during lifespan. Due to its remarkable regenerative abilities, the axolotl emerged as a model organism especially for limb regeneration. Telomeres and the telomerase enzyme are crucial for regeneration and protection against aging processes and degenerating diseases. Despite its relevance for regeneration, the axolotl telomerase and telomere length have not yet been investigated. Therefore, in the present paper, we reveal the sequence of the axolotl telomerase reverse transcriptase gene (Tert) and protein (TERT). Multiple sequence alignment (MSA) showed the known conserved RT- and TERT-specific motifs and residues found in other TERTs. In addition, we establish methods to determine the Tert expression (RT-PCR) and telomerase activity (Q-TRAP) of adult axolotl and blastema tissues. We found that both differentiated forelimb tissue and regenerating blastema tissue express Tert and show telomerase activity. Furthermore, blastema tissue appears to exhibit a higher Tert expression and telomerase activity. The presence of active telomerase in adult somatic cells is a decisive difference to somatic cells of non-regenerating vertebrates, such as humans. These findings indicate that telomere biology may play a key role in the regenerative abilities of cells.

Introduction. Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for infections in patients both inside and outside of the hospital and causes outbreaks. Here, we demonstrate the characteristics and control of a MRSA outbreak related to a carbon dioxide hydrotherapy bathtub. Methods. We conducted an outbreak investigation and performed a molecular typing of the outbreak strains with pulsed-field gel electrophoresis (PFGE). In addition, we reviewed PubMed and the Outbreak Database for MRSA outbreaks related to hydrotherapy or other bathing activities. Results. Four patients acquired nosocomial MRSA during the 4-week outbreak period. Environmental sampling revealed the presence of MRSA in the bathtub used for hydrotherapy. The environmental and the patients’ isolates showed an indistinguishable restriction pattern in the PFGE. Subsequent discontinuation of bathing stopped the outbreak. The literature search found 9 MRSA outbreak reports related to bathing activities or hydrotherapy. Conclusion. The epidemiologic outbreak investigation together with the molecular findings suggests monoclonal spread of MRSA due to surface contamination of the bathtub. After enhancing the disinfection and cleaning process accompanied by staff training with respect to hand hygiene, no further cases occurred. Standardized and best practice cleaning and disinfection protocols are crucial, especially in critical facilities such as hydrotherapy units. Regular environmental sampling is helpful to monitor these processes and to detect potential contamination.

Introduction: This study aimed to investigate the desires of women in breast reconstruction. Method: A questionnaire to women was given by an online publication and an offline paper printout. The task was to choose between two reconstructive options in an imaginary situation of being diagnosed with breast cancer and having the need to undergo a mutilating operation. In option one, the women were asked if they would want to look as before and receive a breast reconstruction that matches the former breast in size and shape as closely as possible, even if ptotic; or in option two, if they would want to use the opportunity to look aesthetically ideal with a new lifted/rejuvenated appearance of the reconstructed breast, and to accept a changing/lifting breast operation also on the healthy side, which otherwise would not need an operation. Results: The online questionnaire was answered by predominantly a young age group of women with a mean birth year of 1987. From 262 women, 183 (69.8%) chose option one and 79 (30.2%) chose option two. Young women with smaller breasts and a family history of breast cancer were among those who tended even more frequently to opt for option one. The offline questionnaire was answered predominantly by an older age group of women with a mean birth year of 1961. From 110 women, 84 (76%) chose option one and 26 (24%) chose option two. The tendency to prefer option one was even stronger in the older group. Conclusion: The majority of women desire to recreate their own natural and ptotic breast shape in reconstructive surgery without contralateral adjusting surgery. Younger women with smaller breasts and women of all ages with a family history of breast cancer more frequently prefer an operation on only the involved side. Women opted for good rather than excellent breast symmetry.

Abstract Ectopia cordis (EC) is characterized by a complete or partial malposition of the heart outside the thorax. Despite the interdisciplinary treatment, the repair of EC is still very difficult and offers new surgical challenges because of its complexity and various combinations with other anomalies. We report the successful outcome after using a pedicled latissimus dorsi flap in reconstructive surgery in the setting of chronic wound dehiscence in an 8-month-old female infant born with a thoracic EC and omphalocele.