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Background: Defects of the lower leg with exposed tendons or bone require either a local or free flap coverage. The distally pedicled peroneus brevis muscle flap has been proven to be a sufficient local flap alternative., Material and Method: Using this technique the muscle is perfused by the non dominant distal perforators. This allows the muscle to be transposed to more distal lesions. The muscle is then covered with meshed split skin graft. Between 2000 and 2004 12 patients with defects of the lower leg in the distal lower third have been treated by using this muscle flap. The defects were located over the tibial bone, the extensor tendons, the achilles tendon and the lateral malleolar region., Results: All muscles healed primarily, 4 patients had minor wound healing complications of the skin graft, which in all cases healed conservatively. The muscle and skin graft remained stable. Donor site morbidity is restricted to the scar in the lateral lower leg. Pronation of the foot is not impaired., Conclusion: These cases show that the distally based peroneus brevis muscle has a wide range of coverage and even allows a closure down to the calcaneal tuberosity. Additionally, a local flap management with a safe muscle transposition is an economic procedure with short operation time and decreased hospital stay. If the muscle does not cover the wound sufficiently, free flap surgery can still be performed.

Background: Treatment of groin defects remains challenging due to their location and origin. Such defects commonly result from resection of tumours but can also occur after surgical or medical therapy., Material and Methods: From 2003 to 2005, 11 patients were treated with groin defects following radiation therapy and resection of lymph node metastasis, primary carcinoma, and sarcoma. Seven patients received wound closure with rectus femoris muscle flaps, and three had vertical rectus abdominis muscle flaps. One patient was amputated at the hip, and the defect was covered with dorsally pedicled muscle and skin flaps., Results: All flaps healed primarily. There were no secondary infections or lymphorrhea., Conclusion: The flaps described here are well vascularised standard flaps which are easily harvested with no major donor site morbidity. They provide sufficient coverage for the groin, reduce long-term conservative treatment, hospitalisation, and problems such as scar contracture.

Introduction: Replantation is an established procedure in reconstructive surgery. In a bilateral lower leg amputation attempts should be made to rescue at least one extremity, if the patients' vital conditions are stable., Patient and Method: We report on a patient who has suffered a bilateral lower leg amputation. Due to the complex injuries the left leg was heterotopically (cross-over) replanted to the right leg. At the left leg an above knee stump was created. In a second operation a soft tissue defect at the replanted extremity was covered by a free microvascular latissimus dorsi muscle flap. In addition, the tibial nerve was reconstructed. Thirteen months later the patient is able to walk with a prosthesis for his left leg and complete weight bearing of the replanted extremity., Discussion: Indication for replantation depends on accompanying injuries and vital functions of the patient. Compared to a simple amputation a lower leg replantation prolongs hospital stay, delays mobilisation of the patient, and increases the necessary secondary procedures. However, after replantation functional outcome is mostly better than with prosthetic fitting, especially if reconstruction of sensation in the weight-bearing area is successful. Thus, in a bilateral amputation movement and stability, as well as quality of life, are improved by a replanted extremity.

Introduction: Chronic osteomyelitis of the chest wall requires radical debridement and defect coverage with well-perfused tissue. The implantation of synthetic material is still under discussion because of the risk of infection., Methods: A retrospective study was conducted on the complications and functional and aesthetic results of 26 patients with chest wall osteomyelitis after radiation or sternotomy treated by radical debridement and neurovascular pedicled latissimus dorsi muscle., Results: The functional results were excellent with a low complication rate. The muscle showed electric activity synchronous with inspiration and clinically a stabilization of the thoracic defect., Discussion: Maintained muscular activity may play an essential role for stabilizing thoracic defects of up to four ribs or the sternum; implantation of synthetic material is not necessary.

In 105 rabbits the course of healing was examined at 1, 2, 4, 8 and 12 weeks (21 rabbits per group) after an experimental Achilles tendon rupture. The following treatment modalities were compared: a. operative functional treatment (resorbable suture, Kleinert technique) b. operative functional treatment with fibrin glue c. primary functional treatment. For the functional (after)-treatment a special orthosis was applied. A 7.5 MHz Ultrasound probe was used for the ultrasonographic evaluation. The histological specimens were stained after Masson-Goldner with Azan. Collagen Type III was depicted immunohistologically with polyclonal antibodies. A semiquantitative fibrocytes count was performed. The histological results showed a smooth healing in the prim. functional treatment group reaching parallel orientation of collagen fibers at 12 weeks. In the fibrin glue-group the fibrin was resorbed after 4 weeks without essential influence to the course of healing. In the suture-group a secondary gapping of the tendon stumps was detectable. At 12 weeks the histological evaluation in all groups showed approximately normal tendon pattern. Immunohistochemically all groups showed cell-associated positive reactions for type III-collagen after 1 week with a maximum after 2 weeks. The semiquantitative fibrocyte count in the primary funct. group showed a maximal number after 1 week, in the fibrin glue- and suture-groups the maximal number could be found after 2 weeks. Sonographically an increase in tendon thickness was detectable up to the 4th weeks in all groups. The secondary gapping of the tendon stumps in the suture group could be detected sonographically. The echogenicity of the tendon during the course of healing showed increasing homogeneity and parallelism in all groups. At 12 weeks the echogenicity was comparable in all groups. The experiment could prove the equivalence of the primary functional treatment to operative therapy in Achilles tendon rupture.

The therapy of factitious disorders is a challenge for the treating surgeon. Only a clear understanding of the underlying causes and a good doctor-patient relationship make a successful outcome possible. Discussion about a confrontation of the patient with the diagnosis and the best made of treatment is still in progress. Early diagnosis and the cooperation between surgeons and psychiatrists are the most important parts of dealing with factitious disorders. This article gives an overview of symptoms and therapies. Six case reports demonstrate possibilities of the disorder's appearance.

The biomechanical properties of human Achilles tendon are described with a computer-controlled material-testing machine. With an optimized fixation device for the muscle-tendon-calcaneus system the rupture was intratendineal. The tendons were compared for different rupture speed (1000 mm/min vs 100 mm/min), sex and age ( < 35 years vs > 35 years). The tendons ruptured at 1000 mm/min had better results in terms of maximum rupture force, stiffness and tensile stress, while the results for elongation and energy were less good. None of these differences were statistically significant. Significant differences were found between the sexes: male tendons had higher maximum rupture force and stiffness and a larger cross-sectional area. In the younger tendons significantly higher tensile rupture stress and lower stiffness were found.

In 84 adult rabbits the biomechanical properties of healing Achilles tendon rupture were examined 2, 4, 8 and 12 weeks (21 each group) after the injury. For the first time a mop-end-tear was performed. The following treatment modalities were applied (7 rabbits in each subgroup): (a) operative functional treatment (resorbable suture; Kleinert techniques); (b) operative functional treatment (fibrin glue); (c) primary functional treatment (conservative). The functional after treatment in all groups was performed with a specially developed orthesis, which was taped to the limb. For biomechanical testing a newly developed fixation technique (cryo-clamp) was applied, which guaranteed secure intratendineal rupture. After 2 weeks the fibrin glue-treated tendon ruptures showed the best results with regard to stiffness, tensile stress and max. rupture force. These results and a higher tensile stress of the sutured tendons were significantly different from those in the conservatively treated groups. After 4 weeks the stiffness in the fibrin group and the energy and rupture force in the suture group were significantly higher than in the group treated conservatively. The 8-week results revealed comparable biomechanical properties. The only significant difference was a higher energy in the fibrin glue group than in the conservative treatment group. The experiment revealed no significant biomechanical differences after 3 months. Compared with the results recorded for plaster immobilization in the literature, the functional treatment resulted in a significantly faster course of healing.