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[english] Background: After a burn injury certain superficial partial-thickness burn wounds spontaneously progress into deep partial-thickness or full-thickness burn wounds. This poorly understood phenomenon is called burn wound progression. The aim of this study was to investigate whether treatment strategies using warm water (preservation of microcirculation) on the one side and erythropoietin (EPO) (molecule with anti-inflammatory, anti-apoptotic, vasodilatory and neoangiogenic properties) can prevent, delay and/or reduce secondary burn wound progression in a rat model.Methods: We used a burn comb model in 63 rats, creating eight rectangular contact burns (2x1 cm each) intercalated by unburned zones (2x0.5 cm) prone to burn wound progression. In a first experimental set we treated burn wounds with locally applied warm (37°C) or cold (17°C) water for 20 minutes.In a second experimental set, animals were treated systemically with EPO at two different dosages of 500 and 2,500 IU/kg bodyweight (bw) and initiated at 2 different time-points (45 minutes vs. 6 hours after burn injury). Evaluation of microcirculatory perfusion, interspace necrosis and burn depth was performed using respectively laser Doppler flowmetry, planimetry and histology. For statistical analysis the two-way ANOVA-test followed by an adequate post-hoc test (Bonferroni) were used. Results: In untreated control animals a conversion from superficial to full-thickness burns was observed within 24 hours. Warm and cold water treatment significantly delayed burn depth progression, nevertheless after 4 days, burn depth was similar in all three groups. Warm water significantly reduced interspace necrosis compared to untreated controls and cold water with a significantly improved perfusion in the warm water group. Surface extension and particularly burn depth progression were significantly decreased by EPO only if administered at a dosage of bw and initiated 45 minutes after burn injury. EPO administration was associated with an early hyperperfusion resulting from an increase in inducible nitric oxide synthase (iNOS) and a late angiogenic response indicated by increased microvascular density.Conclusion: First aid treatment with warm water prevents extension of the burn on the surface and delays burn depth progression, thereby creating a “therapeutic window” of approximately 4–6 hours after burn injury. This window might be used for systemic use of EPO which prevents burn progression both at the surface and into the depth if first administered 45 minutes after burn induction at a dosage of 500 IU/kg bw.

Implant based breast reconstruction (IBBR) keeps evolving and has been influenced heavily by the use of synthetic and biologic meshes in the last years. In both, subpectoral as well as prepectoral approaches the use of synthetic and biologic meshes has made it possible to place implants precisely according to the breast's footprint and strengthen soft-tissue coverage, particularly in the lower pole of the breast with lower complication rates and better cosmesis. Various mesh options that differ in material, processing, size and cost are currently in clinical use. This review aims to define the role of biologic and synthetic meshes in IBBR regarding the advantages and disadvantages of their use., Competing Interests: Die Autoren geben an, dass keine Interessenskonflikte bestehen, (Thieme. All rights reserved.)

Breast-conserving therapy (BCT), meaning tumorectomy in combination with systemic therapy and locoregional radiation therapy has become the preferred method to treat early-stage breast cancer. With excellent long-term recurrence-free and overall survival rates, breast surgeons today must deliver du- rable and aesthetically appealing results that guarantee a good quality of life to meet the high patient expectations. Oncoplas- tic breast surgery (OPBS) is an innovative approach to improve the overall results of BCT. Often carried out by a team of a plastic surgeon and an oncologic breast surgeon, OPBS can actively prevent breast deformities without compromising oncological safety. In the following, an overview of the principles and techniques of oncoplastic breast surgery will be given due to its ever-increasing significance and its advantages and dis- advantages will be discussed in the context of reconstructive breast surgery., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Osteoarthritis of the trapeziometacarpal joint is a common and painful affliction that can be diagnosed using conventional X‑ray imaging as well as arthroscopy and if necessary treated; however, the X‑ray classification often does not sufficiently demonstrate the cartilage damage found in arthroscopy., Objective: The aim of the study was to evaluate the diagnostic accuracy of conventional X‑ray imaging compared to arthroscopy for osteoarthritis of the trapeziometacarpal joint., Material and Methods: The preoperative conventional X‑ray images of 23 patients were presented to 10 experienced hand surgeons who were blinded to the arthroscopy results. Their ratings were compared to the results found with arthroscopy., Results: Of the patients 11 were found to have grade 4 cartilage lesions according to the Outerbridge classification, 8 grade 3 lesions, 4 grade 2 lesions and no grade 1 lesions. Overall, 43% (95% confidence interval, CI 37-49%) of the cartilage lesions were diagnosed correctly using conventional X‑rays. For grade 4 lesions 73% (95% CI 65-81%) of the surgeons made the correct diagnosis, in the case of grade 3 lesions 38% (95% CI 27-49%) and in grade 2 lesions 13% (95% CI 3-23%)., Conclusion: This study presents an arthroscopy classification system that is specific for osteoarthritis of the trapeziometacarpal joint and provides an additional method of assessment if the X‑ray grading of osteoarthritis according to Eaton and Littler is too unspecific. Arthroscopy can be used to safely differentiate the treatment-relevant stage and also includes treatment options.

Reconstructive microsurgery using free and pedicled flaps has become a reliable method with a high success rate. Preoperative perforator mapping and intraoperative assessment of perfusion might further reduce flap-associated morbidity.There are various techniques for perforator mapping and perfusion measurement, but no guidelines regarding their use. Therefore, an expert panel at the 40th Annual Meeting of the German-Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels (DAM) discussed and critically reviewed the current literature. The consensus statement represents the expert opinion based on the available literature and provides recommendations regarding the use of preoperative perforator mapping and intraoperative perfusion measurement., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The treatment of complex patients with chronic wounds, such as pressure ulcers, is often not adequately reimbursed in patients with need for daily intensive care due to multimorbidity and chronic co-diagnoses. The present study analyses revenues, principle cost factors as well as possible complications., Methods: We analysed 51 patients with the DRG principle diagnosis of decubitus stage III and IV, treated in our maximum care clinic in 2014 and 2015. Duration of stay, count of surgical procedures as well as frequency and type of complication were analysed. Costs and revenues per patient were calculated and compared to the mean costs stated by the institute of revenue and costs calculations (InEK)., Results: In 25 of 51 cases, the costs exceeded the revenues, which was due to an excessively long stay at the hospital, complications or a large number of operative procedures. On average, the patients could not be treated cost-efficiently at our clinic., Conclusion: The treatment of most multimorbid patients with decubital ulcers is often not adequately reimbursable within the German DRG system. A strict treatment algorithm with a reduced number of operations and intensive patient care are helpful approaches, but may not be sufficient to reduce cost-intensive complications. It seems important to re-evaluate the current DRG codes for these cases., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background Various operative approaches exist for osteoarthritis of the trapeziometacarpal joint. The aim of this two-centre study was to compare the results of Lundsborg's resection arthroplasty with the implantation of the Pyrocardan ® spacer. Patients and methods We treated 20 patients with symptomatic osteoarthritis of the trapeziometacarpal joint in stage III / IV (Eaton-Littler classification). Twelve patients received Lundsborg's resection arthroplasty (centre 1), and in 8 patients a Pyrocardan ® spacer was implanted (centre 2). Both groups were comparable regarding patients´ age, the preoperative pain level, the osteoarthritis stage according to Eaton-Littler, and the duration from the onset of symptoms until surgery. Patient data were retrospectively collected from patient records, and we performed a follow-up examination at least 18 months postoperatively, thereby evaluating the DASH sore, the postoperative time until freedom of symptoms, the pain level according to the visual analogue scale, grip force (Jamar dynamometer), pinch force, and patients' treatment satisfaction (0-10; 10 = highest satisfaction). Results Both groups had a similar length of follow-up with 23.6 ± 5.2 months for the resection group and 26.1 ± 4.0 months for the spacer group. The duration of the operation was 31 ± 5 min for the resection group and 29 ± 7 min for the spacer group (p > 0.05). The DASH score was 21.9 ± 6.2 in the resection group and 18.3 ± 5.0 in the spacer group (p > 0.05). The pain level at the current follow-up was 1.5 ± 0.83 in the spacer group and 1.0 ± 0.74 in the resection group (p > 0.05). The time until freedom of symptoms was significantly shorter in the spacer group with 3.7 ± 1.9 months compared to the resection group with 5.7 ± 3.1 months (p = 0.0001). Grip force and pinch force were not significantly different between both groups. Treatment satisfaction was 9.3 ± 1.6 in the resection group and 7.4 ± 3.0 in the spacer group (p > 0.05). Conclusion Over a follow-up period of 1.5 years, both techniques resulted in a satisfactory usability of the operated hand and a clear reduction of symptoms. The implantation of the Pyrocardan ® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms. However, the implantation of the spacer is associated with additional material costs of a few hundred Euros, which are not incurred in resection arthroplasties. The implantation of the Pyrocardan ® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background Periprosthetic infections are feared complications in aesthetic as well as in reconstructive breast surgery. The purpose of our study was to evaluate our institution's specific culture data and to identify most common organisms and suitable antibiotics for prophylaxis and first line treatment in implant-based breast surgery. Patients and Methods We analyzed all patients with a change or removal of breast implants in the period from 01.01.2012 to 31.12.2015 retrospectively. Based on the medical records, the surgical indications were identified and specifically analyzed for signs of infection and capsular fibrosis. In addition, we assessed all microbiological data of these interventions. Results 468 implant removals or exchanges were performed in 360 patients. Microbiological smears were gathered from 169 patients (249 implants). Bacteria were cultured from 23 implants (21 patients). In 6 additional implants (four patients) a periprosthetic infection was present, without pathogen detection. In most cases, advanced capsular fibrosis was the reason for implant exchange. In 17 smears bacterial detection was carried out despite absence of clinical signs of infection. In 17 cases coagulase-negative staphylococci were detected. In 4 Staphylococcus aureus, and once each E. coli, Morganella morganii and Proprionibacterium acnes (one double infection). All pathogens were sensitive to piperacillin/tazobactam and vancomycin. One resistancy was seen to cefuroxime and amoxicillin/clavulanic acid, and 2 to gentamicin, ciprofloxacin and clindamycin. Conclusion In the majority of cases, pathogen detection was an incidental finding, while capsular contracture caused surgical revision. Pathogens and resistance patterns found in this study differed from the majority of international publications. In our institution, Cefuroxime and amoxicillin/clavulanic acid have been proven to be a reasonable choice for prevention and treatment of periprosthetic infections. Especially in fulminant infections piperacillin/tazobactam would be our choice for initial treatment, until the specific antibiogram is available., Competing Interests: Interessenkonflikt: Die Autoren erklären, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Free flap transplants for soft tissue reconstruction in the lower extremity are associated with a higher rate of complications compared with other areas. Mobilisation and the resulting hydrostatic pressure put strain on the flaps. In general, these effects are countered by slowly increasing hydrostatic pressure with the leg being compressed by elastic bandages. These postoperative regimes are also called dangling procedures or "flap training", but are not scientifically validated and therefore there is no consensus or guideline leading to a standard treatment regime. The goal of our study was to present an overview of currently performed regimes. Material and Methods: We conducted an email survey by sending a questionnaire to departments for plastic and reconstructive surgery in Germany, Austria and Switzerland, which perform free flap transplantations in the lower extremity. The questionnaire ascertained the starting point and the frequency of the dangling procedures, the introduction of weight-bearing on the operated extremity and the incidence of complications occurring during mobilisation. Results: We included 32 departments and compared them by the number of free flap transplantations performed per year. We found a wide variation between the postoperative treatment regimes. In most departments, flap training is started between the 3 rd and 7 th day after surgery and lasts between 5 and 15 min. The intervals with which flap training intensity is increased are inhomogeneous as well. The time until full weight-bearing is exerted on the operated extremity ranges from day 5 to week 3 postoperatively. Complications due to flap training were reported by one third of the participating departments. Conclusion: Elastic compression and patient mobilisation after free flap procedures in the lower extremity are considered to be very important in reducing complications and in protecting the flap from edema and volume overload. This article demonstrates that there is a wide variety in flap training regimes. It aims to help readers evaluate their own regimes and provides guidance for an individualised patient-oriented regime., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Hand infections are common surgical emergencies. There are still controversial opinions regarding the ideal timing of wound closure after radical débridement of the infection. The aim of this retrospective study was to compare the outcome of primary adaptive and secondary wound closures after operative débridement in patients with hand infections., Methods: We retrospectively analysed all infections of the hand treated operatively in our hospital in the years 2011 and 2012 with a follow-up of at least 6 months. We included 16 patients with primary adaptive wound closure (PWC) and 12 patients with secondary wound closure (SWC) in this study. The evaluated parameters were the need for re-operations, the length of hospital stay, the overall satisfaction with the treatment, the characteristics of the scar and the mobility of the hand., Results: No patient had to be re-operated after PWC or SWC, respectively. Patients in the PWC group were kept significantly shorter as inpatients in comparison to patients in the SWC group (3.0 days vs. 5.1 days; p=0.048). Overall patient satisfaction with the treatment and the scar was comparable for both groups, as was the re-establishment of the mobility of the treated hand to preoperative levels., Conclusion: This study shows that wounds after radical débridement for infection of the hand can be closed primarily adaptive without disadvantages for the patient. The length of hospitalisation is significantly shorter if the wound is closed primarily adaptive, a fact that is important for patient comfort and the socio-economic system. Both, primary adaptive and secondary wound closures generally have good outcomes with possible advantages for primary adaptive wound closures concerning the characteristics of the scar., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The regenerative capacity after nerve reconstruction in children is believed to be superior compared to that in adults. However, the available data on this topic are limited. The aim of this work is to improve the age-dependent assessment of the prognosis after surgical treatment of peripheral nerve injuries of the hand., Patients and Methods: 44 of 147 children with complete transections of proper and common digital nerves who were treated from 2000 to 2009 and who were currently 6 years or older, could be included for follow-up (mean time, 7.5 years). In total there were 60 nerve injuries, of which 56 were directly coaptated, 4 needed grafting. Sensitivity of the fingertips was assessed using the 2-point discrimination (2PD) test and the Semmes-Weinstein monofilament test. We also recorded hypersensitivity, sensitivity to cold, and paresthesia. To account for inter-individual differences in normal 2PD, the difference of the 2PD to the uninjured contralateral side was calculated as delta-2PD. The age at the time of the injury, divided into groups of 0-5, 6-10 and 11-15 years was correlated with the clinical outcome (2PD, monofilamenttest). Taking into account the results classified by age presented by Lohmeyer et al. and Mailänder et al., we assessed the correlation between age at injury (0-85 years) and clinical outcome., Results: After 52 of the 56 direct nerve coaptations (93%) normal sensitivity was found with a 2PD<6 mm, 4 times the 2PD was 6 mm. Following nerve grafting a static 2PD of 6-7 mm was measured. Disturbing paresthesia, sensitivity to cold or hypersensitivity were not reported by any patient. The 2PD of the fingers of the opposite uninjured side showed great inter-individual differences. Patient's age and 2PD significantly correlated with significantly poorer results already in the second decade of life., Conclusion: In relation to adults, children have an excellent prognosis after nerve reconstruction. The high inter-individual differences in regular sensitivity, depending on age, co-morbi-dities, etc., suggest putting the results of the injured and uninjured sides into relation. Estimation of the Δs2PD may solve this -problem., (© Georg Thieme Verlag KG Stuttgart · New York.)