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Frequently burns of the hand occur as part of a major thermal injury, but appropriate treatment of the hands has high priority, because even small burns of the hand may result in severely limited function and compromised aesthetic appearance. The functional importance of the hand cannot be overemphasized, because the patient's ability to perform useful work after recovery or the ability to care for themselves is to a great degree determined by residual hand function. This article describes the management of burn injuries involving the hand, stressing the importance of appropriate initial treatment. A comprehensive review of hand reconstruction and rehabilitation, to optimize form and function, is provided., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: With the increasing success of organ transplantation, many traditional contraindications to organ procurement are being reconsidered. Burn disease has constituted a traditional contraindication to solid organ procurement because of concerns that such organs may have been compromised by ischemia secondary to burn shock and contaminated by bacteremia. With the current shortage of solid organs, the transplant community continues to look for ways to increase the number of organ donors, including the use of marginal donors., Methods: Between 1999 and 2009 we have successfully procured 14 organs from four burn patients, who had suffered concurrent anoxic brain injury. There were one male and three female patients with an average age of 43.3 years and a total burned body surface area of 32.5%. Organ transplantation was performed at an average of 4.75days after the injury. Eight kidneys, three livers, two hearts and one pancreas were procured and transplanted into 13 patients., Results: We were able to follow-up on the organ recipients for an average of 80.5 months. The 5-year survival of the donated organs following transplant was 78.6% and the 5-year organ recipient survival was 92.3%., Conclusions: Organ procurement after burns is not contraindicated and transplantation can be performed with good long-term results., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

Improvements in critical care and burn victim resuscitation have led to increased survival of burned patients. Initial resuscitation, early excision of burned tissues, prevention of burn wound sepsis, and wound coverage remain mainstays of care. Many burn wounds require complex reconstruction. This is particularly important in the hand. Coverage of tendons, ligaments, joints, vessels, nerves, and bones of the hand requires healthy vascularized tissue to maintain viability and function. Local flaps or regional flaps may be within the burn zone of injury. Refined microvascular free tissue transfer techniques offer free tissue transfer as a procedure that can be safely performed., (Published by Elsevier Inc.)

Objective: The aim of the present study was to evaluate the efficacy of a newly developed cognitive-behavioral group training, specifically designed for burn patients., Method: In a multicenter-study data pre- and post treatment and at 6-month follow-up were obtained from participants of the group program (Intervention group, IG; n=86) and a control group who received treatment as usual (TAU; n=128). Outcome variables of psychological distress, resources and health-related quality of life of both groups were compared using linear mixed models., Results: Up to 6 months after group treatment, the IG reported a substantial decline of general symptom severity as well as posttraumatic stress, whereas the TAU group showed no significant change over time. Optimism increased in the IG after group treatment, but not in the TAU group. Regarding overall quality of life both groups showed a gradual improvement over the three assessment points., Conclusion: The newly developed burn-specific cognitive-behavioral group intervention had positive effects on psychological well-being and resources of burn participants. As a consequence, the group intervention has been implemented as inherent part of the regular burn treatment in two rehabilitation centers in Germany., (Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.)

The aim of this study was to identify the long-term quality of life after severe burn injury. In a prospective longitudinal design, N = 265 burn patients were examined 6, 12, 24, and 36 months after burn injury. A multilevel approach was used to measure stability and change in self-reported health status. Besides injury-related variables, self-report instruments included measures of quality of life, psychological distress, personality, and specific burn outcome measures. Fitting of unconditional growth models indicated that there was significant intra- and inter-individual variation in self-reported physical and mental health short form-12. Over the course of 3 years, participants reported on average a slight improvement of physical quality of life. Physical health was mainly predicted by mobility and level of burn severity. Variance in mental health status was mainly predicted by gender, mobility, neuroticism, level of depression and posttraumatic stress disorder (PTSD)-related avoidance. Thus mobility (i.e., simple abilities) seems a crucial variable for overall quality of life. An early identification and treatment of patients with high levels of depression and PTSD-related avoidance may contribute to better mental health.

Introduction: Thermal injuries with more than 20% of burned body surface area (BSA) lead to systemic shock with generalised oedema in addition to local tissue destruction. This condition, known as burn injury, is caused by immunmodulative mediators whose individual significance is not known in detail. We present an experimental model where plasma of burned animals (burn plasma) is transmitted to healthy animals, to trigger burn iniury without performing direct burn trauma., Material and Methods: The systemic oedema is measured by extravasation of fluorescent albumin in mesenterial venules of Wistar rats. In addition, leukocyte-endothelial interactions ("leukocyte rolling and sticking") is examined., Results: The systemic capillary leak is induced by both direct thermal trauma as well as by infusion of burn plasma. This is evident even after plasma dilution (1% in Ringer's lactate) of the burn plasma. In addition, topical therapy for burned animals (donors) with cerium nitrate led to a significant reduction of plasma extravasation in receiver animals. In addition, systemic antioxidant therapy with high-dose vitamin C of receiver animals, led to a significant reduction of the capillary leak. Leukocyte-endothelial interactions are not significantly affected in either case., Conclusion: In summary, for the first time a reliable model of burn injury has been established, which eliminates mediator-independent effects. In addition, our studies show that antioxidant therapy with high doses of vitamin C and topical treatment with cerium nitrate both reduce the systemic capillary leak in receiver animals. Their positive influence could therefore soon be integrated in clinical treatment algorithms., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: A prospective, randomized, non-blinded, clinical study was conducted to evaluate the feasibility and practicability as well as pain reduction and ease of handling of Flammazine® versus Octenidine-Gel® s a primary local antiseptic before synthetic skin substitute application in partial-thickness burns., Methods: Thirty patients with a median age of 42 years suffering from second-degree burns were included in the study. Burns were randomly selected, one area was treated with Flammazine®/gauze, another area in the same patient was treated with Octenidine-Gel®/gauze as initial antiseptic treatment. Within 24 h the first gauze change was performed followed by wound inspection, disinfection and synthetic skin substitute application. The study focused on patient pain score, analysis of wound bed and ease of handling of the two local antiseptic agents., Results: There was a significant difference between Flammazine® versus Octenidine-Gel® regarding patient pain score and ease of handling. Octenidine-Gel® was less painful (p < 0.05) and easier to handle (p < 0.05). There was no significant difference for wound bed evaluation between the two antiseptic agents. A tendency for better wound bed preparation was seen with the use of Octenidine-Gel®., Conclusion: Based on the findings of this study Octenidine-Gel® is recommended as a local antiseptic agent, because when compared to Flammazine®, Octenidine-Gel® proved to be better in terms of ease of care, simplicity application, with gentler and faster detachment of the gel from wound surfaces and consequently far less pain during dressing changes., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Acetic acid is a traditional antiseptic agent that has been used for more than 6000 years. The main goal of this study was to demonstrate the suitability of Suprathel (PolyMedics Innovations GmbH, Denkendorf, Germany) in combination with various antiseptic agents to create an "antiseptic-matrix" especially designed for problematic microorganisms such as Proteus vulgaris, Acinetobacter baumannii, or Pseudomonas aeruginosa, which are frequently associated with burns. The study was designed to test the in vitro antimicrobial effect of a "Suprathel-antiseptic matrix" (Suprathel combined with acetic acid 3%, povidone-iodine 11% [Betaisodona], polyhexanide 0.04% [Lavasept], phenoxyethanol 2%/octenidine dihydrochloride 0.1% [Octenisept], mafenide acetate 5%, and chlorhexidine gluconate 1.5%/cetrimid 15% [Hibicet]). As a means to assess the typical bacterial spectrum of a burn unit, the following Gram-negative and Gram-positive bacteria strains were tested: Escherichia coli, P vulgaris, P aeruginosa, A baumannii, Enterococcus faecalis, Staphylococcus epidermidis, Staphylococcus aureus, methicillin-resistant S aureus, and β-hemolytic streptococcus groups A and B. The tests showed a positive bactericidal effect of the Suprathel-antiseptic matrix, particularly with problematic Gram-negative bacteria such as P vulgaris, P aeruginosa, and A baumannii, except for the combination of Suprathel and mafenide acetate. It can be concluded that Suprathel-antiseptic matrix appears to be suitable as a local antiseptic agent, but clinical studies need to be performed to confirm these in vitro observations. The authors' previous studies have shown that acetic acid demonstrates a wide antiseptic spectrum for microorganisms typically found in burn patients. The combination of Suprathel and acetic acid worked well in this study and appears to be promising for future clinical application.

Background: Dermal substitutes are used increasingly in deep partial and full-thickness burn wounds in order to enhance elasticity and pliability. In particular, the dorsum of the hand is an area requiring extraordinary mobility for full range of motion. The aim of this comparative study was to evaluate intra-individual outcomes among patients with full-thickness burns of the dorsum of both hands. One hand was treated with split-thickness skin grafts (STSG) alone, and the other with the dermal substitute Matriderm(®) and split-thickness skin grafts., Material and Methods: In this study 36 burn wounds of the complete dorsum of both hands in 18 patients with severe burns (age 45.1±17.4 years, 43.8±11.8% TBSA) were treated with the simultaneous application of Matriderm(®), a bovine based collagen I, III, V and elastin-hydrolysate based dermal substitute, and split-thickness skin grafting (STSG) in the form of sheets on one hand, and STSG in the form of sheets alone on the other hand. The study was designed as a prospective comparative study. Using both objective and subjective assessments, data were collected at one week and 6 months after surgery. The following parameters were included: After one week all wounds were assessed for autograft survival. Skin quality was measured 6 months postoperatively using the Vancouver Burn Skin Score (VBSS). Range of motion was measured by Finger-Tip-Palmar-Crease-Distance (FPD) and Finger-Nail-Table-Distance (FNTD)., Results: Autograft survival was not altered by simultaneous application of the dermal matrix (p>0.05). The VBSS demonstrated a significant increase in skin quality in the group with dermal substitutes (p=0.02) compared to the control group with non-substituted wounds. Range of motion was significantly improved in the group treated with the dermal substitute (p=0.04)., Conclusion: From our results it can be concluded that simultaneous use of Matriderm(®) and STSG is safe and feasible, leading to significantly better results in respect to skin quality of the dorsum of the hand and range of motion of the fingers. Skin elasticity was significantly improved by the collagen/elastin dermal substitute in combination with sheet-autografts., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Severe burn injuries are traumatic events and can have serious impact on all areas of life frequently causing high emotional distress. In a multicentre study resources and emotional distress of patients with serious burn injuries were assessed during the first hospitalization and at 6 and 12 months follow-up. Patients with severe burn injuries after accidents in a private environment (NBG patients) and patients after occupational accidents covered by the German Social Accident Insurance (BG patients) were compared. All patients reported marked emotional impairment, particularly during the hospitalization. At follow-up a reduction of emotional distress was detected. Nearly half of the patients received a diagnosis of one or more mental disorders according to DSM-IV criteria. When treating patients with burns, special attention should be given to their mental health. They should be offered psychological support to cope with the aftermath of the accident, especially after discharge from hospital when returning to their normal surroundings.

Background: The treatment of burn wounds is still a challenge regarding the management of antiseptic wound conditioning. Especially, in the United States, silver-containing dressings, such as Acticoat and Aquacel are frequently used. Because silver-containing dressings have well-known drawbacks such as an antimicrobial lack against Pseudomonas aeruginosa, we sought to develop an alternative dressing method. In previous studies, we could demonstrate the excellent antiseptic properties of acetic acid against common burn unit germs, and in another study, the feasibility and suitability of a Suprathel-acetic acid matrix as an antiseptic dressing., Materials and Methods: This study was designed to test the in vitro antimicrobial effect of a Suprathel-acetic acid matrix versus Acticoat and Aquacel. To cover the typical bacterial spectrum of a burn unit, the following Gram-negative and Gram-positive bacteria strains were tested: Escherichia coli, extended-spectrum beta-lactamase-positive Klebsiella pneumoniae, P. aeruginosa, Acinetobacter baumannii, Enterococcus faecalis, and methicillin-resistant Staphylococcus aureus., Results: The tests showed an excellent bactericidal effect of the Suprathel-acetic acid matrix particularly with problematic Gram-negative bacteria such as Proteus vulgaris, P. aeruginosa, and Acinetobacter baumannii. The efficiency was superior to that of Acicoat and Aquacel., Conclusions: Our results support the notion, that the Suprathel-acetic acid matrix has an excellent bactericidal effect and therefore seems to be suitable as a local antiseptic agent in the treatment of burn wounds.

Bacterial colonization and infection are still the major causes of delayed healing and graft rejection following burns and they are furthermore the basis for second and third hit sepsis. Topical treatment is necessary to reduce the incidence of burn wound infection. Silver sulphadiazine (SD-Ag) is a frequently used microbicidal agent. However, this treatment causes adverse reactions and side-effects. Additionally, in recent years multiresistant bacteria, which have not been treated sufficiently, are on the rise. On the basis of experimental data and clinical application of a polylacticacid-acetic acid matrix, we performed this study to establish the effectiveness of the antiseptic therapy with the topical application of a polylacticacid-acetic acid matrix to provide an alternative method for burn treatment, using SD-Ag as a reference. Twenty patients with IIb° or III° burns from the Plastic Surgery and Burns Unit were treated within a matched pair comparative setting. One burned area was treated with SD-Ag, the other corresponding area with the polylacticacid-acetic acid matrix. All patients underwent a necrectomy 4-5 days after the trauma. The excised burned skin was sent to our microbiological laboratory to determine the different bacteria per gram in this tissue. Despite the number of 20 patients, statistical significance was not achieved, there were tendencies to a better antiseptic effectiveness of the polylacticacid-acetic acid matrix. These results suggest that the polylacticacid-acetic acid matrix should be studied in greater depth and could be used as a valid alternative for the topical treatment of burns, as it is equivalent or even more effective than SD-Ag., (© 2010 by the Wound Healing Society.)

Oxidative stress after burn injuries leads to systemic capillary leakage and leukocyte activation. This study evaluates whether antioxidative treatment with high-dose vitamin C leads to burn edema reduction and prevention of leukocyte activation after burn plasma transfer. Donor rats underwent a burn (n = 7; 100 degrees C water, 12 seconds, 30% body surface area) or sham burn (37 degrees C water; n = 2) procedure and were killed after 4 hours for plasma harvest. This plasma was administered to study rats (continuous infusion). Rats were randomized to four groups (n = 8 each; burn plasma alone [BP]; burn plasma/vitamin C-bolus 66 mg/kg and maintenance dose 33 mg/kg/hr [VC66]; burn plasma/vitamin C-bolus 33 mg/kg and maintenance dose 17.5 mg/kg/hr [VC33]; and sham burn plasma [SB]). Intravital fluorescence microscopy in the mesentery was performed at 0, 60, and 120 minutes for microhemodynamic parameters, leukocyte adherence, and fluorescein isothiocyanate-albumin extravasation. No differences were observed in microhemodynamics at any time. Burn plasma induced capillary leakage, which was significantly higher compared with sham burn controls (P < .001). VC66 treatment reduced microvascular barrier dysfunction to sham burn levels, whereas VC33 had no significant effect. Leukocyte sticking increased after burn plasma infusion, which was not found for sham burn. Vitamin C treatment did not influence leukocyte activation (P > .05). Burn plasma transfer leads to systemic capillary leakage. High-dose vitamin C treatment (bolus 66 mg/kg and maintenance dose 33 mg/kg/hr) reduces endothelial damage to sham burn levels, whereas half the dose is inefficient. Leukocyte activation is not influenced by antioxidative treatment. Therefore, capillary leakage seems to be independent from leukocyte-endothelial interactions after burn plasma transfer. High-dose vitamin C should be considered for parenteral treatment in every burn patient.

Thermal injuries of more than 20% body surface area (BSA) result in systemic capillary leakage with subsequent edema. This can similarly be induced by burn plasma transfer (BPT) from burned individuals to healthy rats. We evaluated if cerium nitrate (CN) bathing can prevent edema after BPT. Therefore, donor rats (DR) underwent thermal injury (100 degrees C water, 30%BSA, 12 s) for positive controls and were additionally bathed in CN (0.05M, at 10 and 120 min) for study groups. For negative controls DR underwent shamburn (37 degrees C water, 30%BSA, 12 s). DR-plasma (harvested 4 h post trauma) was transferred to healthy individuals. Intravital microscopy was performed in mesenteric venules (0/60/120 min). Edema was assessed by FITC-albumin extravasation. Additionally, leukocyte sticking (cells/mm(2)) and micro hemodynamic parameters were assessed. Significant systemic capillary leakage was observed after BPT at 120 min. Edema formation was significantly lower in negative controls. Topical CN application after 10 and 120 min reduced FITC-efflux to baseline levels. Adherent leukocytes increased slightly in all groups. Leukocyte-sticking tended to be reduced after CN bathing. In conclusion, BPT induces burn edema in healthy individuals. CN bathing after 10 and 120 min reduces mediator levels in burned individuals. Therefore, BPT after CN application does not induce burn shock anymore. Burn edema is partially independent from leukocyte activation because CN significantly influences macromolecular leakage whereas leukocyte activation is not significantly altered.

Pressure garment therapy (PGT) is a generally accepted procedure to prevent hypertrophic scarring after severe burns. Wearing pressure garments is uncomfortable and challenging for the patient and, consequently adherence is low. In order to improve adherence, precise knowledge about the advantages and disadvantages of PGT is necessary. In this study we investigated specific aspects which inhibit or reinforce the application of PGT on the patients' part. Twenty-one patients participated in a semi-structured interview concerning their experiences with PGT. The complaints most frequently mentioned were 'physical and functional limitations' caused by the garments, 'additional effort' created by the need to care for garments and 'perceived deficiencies' of the treatment. At the same time, most of the patients reported coping strategies used to persevere with the therapy. Coping can be categorised into 'behavioural' and 'cognitive coping strategies'. Besides the 'expectation of success', 'emotional' as well as 'practical support' and experiencing 'good outcome' were motivating factors for the patients. Based on the analyses of limitations and resources, recommendations for future interventions enhancing adherence are outlined.

Acetic acid has been commonly used in medicine for more than 6000 years for the disinfection of wounds and especially as an antiseptic agent in the treatment and prophylaxis of the plague. The main goal of this study was to prove the suitability of acetic acid, in low concentration of 3%, as a local antiseptic agent, especially for use in salvage procedures in problematic infections caused by organisms such as Proteus vulgaris, Acinetobacter baumannii or Pseudomonas aeruginosa. This study was designed to compare the in vitro antimicrobial effect of acetic acid with those of common local antiseptics such as povidone-iodine 11% (Betaisodona), polyhexanide 0.04% (Lavasept), mafenide 5% and chlohexidine gluconate 1.5% cetrimide 15% (Hibicet). Former studies suggest the bactericidal effect of acetic acid, but these data are very heterogeneous; therefore, a standardised in vitro study was conducted. To cover the typical bacterial spectrum of a burn unit, the following Gram-negative and Gram-positive bacterial strains were tested: Escherichia coli, P. vulgaris, P. aeruginosa, A. baumannii, Enterococcus faecalis, Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus (MRSA) and beta-haemolytic Streptococcus group A and B. The tests showed excellent bactericidal effect of acetic acid, particularly with problematic Gram-negative bacteria such as P. vulgaris, P. aeruginosa and A. baumannii. The microbiological spectrum of acetic acid is wide, even when tested at a low concentration of 3%. In comparison to our currently used antiseptic solutions, it showed similar - in some bacteria, even better - bactericidal properties. An evaluation of the clinical value of topical application of acetic acid is currently underway. It can be concluded that acetic acid in a concentration of 3% has excellent bactericidal effect and, therefore, seems to be suitable as a local antiseptic agent, but further clinical studies are necessary.

Local burn wound care represents an integral part in the treatment of burn victims. A primary treatment goal is to prevent superficial infections, which can lead to life-threatening bacteraemia and sepsis. Secondary goals include improvement of functional and aesthetic outcome of the regenerating skin or scar tissue. Within the last few years numerous innovations have been evolved and some have already been incorporated into the clinical routine. In line with this, the first mid-term studies can be found in the literature. For instance, a hydrosurgical system can now be used for debridement and novel skin substitutes like Suprathel and Matriderm are commercially available. This review article summarises the most recent innovations in local burn wound care and puts them into a scientific perspective.

Thermal injuries greater than 20% body surface area (BSA) result in systemic shock with generalized edema in addition to local tissue destruction. Burn shock is induced by a variety of mediators, mainly immunomodulative cytokines. This experimental study evaluates if burn shock can be induced in healthy rats by transfer of burn plasma (BP) with mediators. Thermal injury was induced by hot water (100 degrees C water, 12 s, 30% BSA) in male syngenic Wistar rats. Donor rats were killed 4 h posttrauma, and BP was harvested. Burn plasma was transferred to healthy animals by continuous intravenous infusion in three types of dilution (100%, 10%, and 1%). Positive controls were directly examined 4 h after thermal injury, and negative control rats had a continuous infusion done with sham burn (SB) plasma (37 degrees C water, 12 s, 30% BSA). Afterwards, intravital fluorescence microscopy was performed in postcapillary mesenteric venules at 0, 60, and 120 min. Edema formation was assessed by relative changes over time in fluorescence intensity of fluorescein isothiocyanate-albumin in the intravascular versus the extravascular space. The interactions of leucocytes and endothelium were evaluated by quantification of leukocyte sticking. Additionally, microhemodynamic (volumetric blood flow, erythrocyte velocity, venular wall shear rate, venular diameters) and macrohemodynamic parameters (blood pressure, heart frequency, temperature) were assessed online (arterial catheter). For statistics, an ANOVA was performed with Bonferroni adjustment procedure. Differences were considered significant when P < 0.05. There are no statistically significant differences in microhemodynamics or macrohemodynamics between study groups. Burn plasma infusion and thermal injury lead to significant increases in fluorescein isothiocyanate-albumin extravasation, whereas SB plasma shows no significant changes. Even BP diluted in 0.9% saline (10% and 1%) results in a similar transvascular flux of plasma proteins as direct thermal injury. Differences between positive controls and BP infusion are not significant, whereas all groups are statistically different from the SB group (P<0.05). Leukocyte sticking is significantly increased in all groups except the SB group, and the number of adherent leukocytes is dose dependent. The present study demonstrates that as early as 4 h after thermal injury, there are sufficient factors (e.g., cytokines) in BP to induce systemic burn shock in healthy rats even in diluted plasma (1%). However, the "key" cytokines are not identified at this point. The burned tissue is no longer required for burn shock induction, and the pathophysiologic process seems to be self-perpetuating as early as 4 h posttrauma. Leukocytes are activated by thermal injury and BP infusion. The role of leukocyte-endothelium interactions for edema formation remains uncertain and requires further investigation.

The application of dermal substitutes in deep partial and full-thickness burn wounds in a two-stage procedure prior to skin grafting has become increasingly popular. Synchronous application of dermal substitutes and skin graft has not yet been established as a standard procedure. In a consecutive study 20 wounds in 10 patients with severe burns (age 49.5+/-16.2 years; TBSA 45.6+/-14.5%) were treated with either simultaneous transplantation of Matriderm, a bovine based collagen I, III, V and elastin hydrolysate based dermal substitute and split-thickness skin grafting (STSG), or STSG alone after appropriate excision of the burn wound. The study was designed as a prospective intra-individual comparative study. After 1 week all wounds were assessed for the percentage of autograft survival. Autograft survival was not altered by simultaneous application of a dermal matrix (p=0.015). Skin elasticity was measured after 3-4 months with the Vancouver Burn Skin Score (VBSS). The VBSS demonstrated a significant increase of elasticity in the group with dermal substitutes (p=0.04) as compared with non-substituted wounds for sheet autograft, but not for meshed autograft (p=0.24). From this pilot study it can be concluded that simultaneous application of a dermal matrix is safe and feasible, yielding significantly better results with respect to skin elasticity. Skin elasticity was considerably improved by the collagen/elastin dermal substitute Matriderm in combination with sheet autograft.

Background: A new hydrosome wound gel is based on a new mechanism of action. It contains hydrosomes that penetrate to the wound bed and supply the wound with phospholipids, which are identical to membrane phospholipids of human cells. In this manner it supports the proliferative processes during wound healing., Patients and Methods: In a randomized, controlled, intraindividual comparative study of 47 patients with grade IIa burns, the hydrosome wound gel was tested against silver sulfadiazine cream. Digital pictures of the burn wounds were taken daily, and the wounds were analyzed in terms of their reepithelization rate., Results: Wounds receiving the hydrosome wound gel healed 1.5-2 days faster than wounds treated with sulfadiazine cream (9.9+/-4.5 days vs. 11.3+/-4.9 days, p=0.015). In 66% of the patients, faster epithelization was observed with the hydrosome wound gel treatment. The hydrosome gel guaranteed secure prophylaxis against infection, and it was well tolerated and easy to apply., Conclusion: In this study, the treatment of grade IIa burn wounds with hydrosome wound gel led to faster wound closure compared with treatment with sulfadiazine cream. Therefore, hydrosome gel represents a good alternative to sulfadiazine cream.

Local treatment of burn injuries with conventional anti-infective preparations does not provide the moist environment that promotes fast wound healing. In a randomized controlled trial the effects of liposome polyvinyl-pyrrolidone-iodine (PVP-I) hydrogel, a novel formulation of PVP-I in a liposome hydrogel with high water-binding capacity, were investigated in 43 patients with partial-thickness burn wounds in an intraindividual comparison with a conventional silver-sulfadiazine cream. Treatment with liposome PVP-I hydrogel resulted in significantly faster complete healing of the burn wounds compared with silver-sulfadiazine cream (9.9 +/- 4.5 days versus 11.3 +/- 4.9; P < 0.015). The cosmetic result (smoothness, elasticity, appearance) was rated as excellent for 37.0% of study wounds with liposome PVP-I hydrogel compared with 13.0% of wounds treated with silver-sulfadiazine cream. Local tolerability was good; handling and change of dressing were rated as easy. Local treatment with liposome PVP-I hydrogel thus provides fast wound healing with a favorable cosmetic result.

Background: As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded., Methods: The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures., Results: In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined "chimeric" flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction., Conclusions: The authors' data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors' flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.

Emotional distress as well as psychosocial resources in 55 patients with burn injuries was assessed during acute and follow-up treatment. Results showed significantly greater values of emotional distress among patients when compared with norms of the general population. As well as higher levels of general psychopathology, particularly prevalent were anxiety, depression, and posttraumatic symptoms. However, patients also reported high levels of resources such as general optimism, self-efficacy, and perceived social support. Within the sample, no significant correlation between severity of emotional distress and severity of burn injury was found. By psychological assessments a subgroup of highly distressed patients was identified. These patients were highly emotionally distressed while having objective injury severity comparable with the other patients in the sample. Reactions to burn accidents vary individually. The results demonstrate the importance of routine screenings of psychological symptoms. An early identification of patients at-risk allows for tailored psychotherapeutic interventions and can thus help to improve quality of life and general well-being of burn patients on a long-term basis.

Background: The use of the balloon dissector ("space maker") for the implantation of soft tissue expanders is illustrated and technical aspects and advantages are compared to the conventional method., Patients and Methods: Over a 10-year period a group of 90 patients with evaluation records (m = 34, f = 56) was analysed retrospectively. The mean age was 23 years (range: 5 to 62 years). Overall, 164 expanders were implanted and in 73 cases (44.5%) a balloon dissector was used., Results: The mean intraoperative expander filling was increased up to 27% of the volume of the tissue expander after using the balloon dissector; in contrast it was 15% after conventional dissection. The mean duration of expansion was decreased by 9.8% after space maker dissection., Conclusion: The use of the space maker is a scar-sparing technique. Time of operation and overall duration of expansion are reduced. Patient comfort is clearly improved. The negligible costs of a space maker are compensated by the cost reduction due to shorter operating time, fewer outpatient contacts and a low complication rate. The indications for the use of balloon dissectors are the expansion of skin (scar correction after burns, trauma, tumour), breast reconstruction and augmentation, and the prefabrication and rapid intraoperative expansion of musculocutaneous flaps.

The purpose of this study was to observe the interactions between cardiac index (CI), stroke volume index (SVI), central venous pressure (CVP), intra-abdominal pressure (IAP) and total circulating blood volume index (TBVI) during resuscitation of major burns. Sixteen patients with an average TBSA of 46% (26-67%) and an average abbreviated burn severity index of 8.9 (7-11) were included into an intra-individual comparative prospective study over an 18-month period. The COLD Z-021 system (Pulsion Medical Systems, Munich, Germany) was used to obtain CI, SVI and TBVI. Two hundred and thirty-four to 278 intra-individually comparative measurements were performed for the analyses during the first 4 days after the burn injury. Correlations were shown for the interactions between CI and TBVI (r = 0.550; rs = 0.518), SVI and TBVI (r = 0.606; rs = 0.626) and for CVP versus IAP (r = 0.487; rs = 0.474). Poor or no correlations were demonstrated for the comparisons CI versus CVP (r = 0.401; rs = 0.352), CVP-PEEP versus IAP (r = 0.255; rs = 0.272). TBVI versus IAP (r = -0.120; rs = -0.169), TBVI versus CVP (r = 0.025; rs = -0.036), TBVI versus CVP-PEEP (r = -0.046; rs = -0.101), CI versus CVP-PEEP (r = 0.088; rs = 0.092) as well as for IAP versus CI (r = 0.050; rs = 0.034). An additional analysis demonstrated no correlation between TBVI and MAP (r = -0.095; rs = -0.136). Our data provide evidence that the CVP is influenced more by external pressures (IAP) than by the actual intravascular volume status of the patient. Thus, the CVP is not a suitable tool to guide fluid resuscitation during burns with shock. The TBVI may be an ideal value to guide resuscitation because the augmentation of TBVI during fluid resuscitation correlated well with improved cardiac output and stroke volume. Future randomised studies are required to demonstrate whether TBVI guided resuscitation of burns has an impact on outcome.

Background: The system of German diagnosis-related groups (G-DRG) has undergone modifications for burn cases (Y-DRG) since 2003. The DRG catalog includes two of seven Y-DRGs without a case weight., Methods: The BG Trauma Center in Ludwigshafen could demonstrate that the cost of burn care treatment could not be reimbursed through Y-DRGs in 2004., Results: By being accredited as a so-called "individual hospital-based unit" for burn care (Besondere Einrichtung), it was possible to agree to an "all-inclusive" contract. The daily rate is reimbursed with 2792 Euros/day. The reimbursement of the treatment of burn patients is thus cost covering., Conclusion: In summary the budget for 2006 should be calculated by an individualized hospital rate for all Y-DRGs, especially as it was shown that the additional payments (Zusatzentgelte) for selected therapies did not cover the costs of special treatments in burn care in 2005 and 2006. The problem has been recognized and published internationally. The special and cost-intensive treatment of burn patients is difficult to calculate in a system of diagnosis-related groups due to the low number of cases.

Distally based DMCA flaps are an established procedure for soft tissue reconstruction in the hand. Since the introduction of the DMCA flaps, several variants have been developed to match specific defect requirements. The aim of this retrospective study is to give an overview of the experience with the DMCA flaps based on a single center's experience. 41 distally based DMCA flaps have been performed from 2000 to 2004. Twenty-nine times a distally based DMCA flap has been performed, nine times the extended distally based DMCA flap and three times a distally based DMCA fascial flap. In summary, 34 flaps showed no complications, five had a partial necrosis, but were successfully treated with split-thickness skin graft, and two flaps were lost due to infections. The distally based DMCA flaps II to IV have proven to be reliable flaps, but nevertheless require sufficient surgical experience. They are suitable for any kind of defects, including burn reconstruction. Defects of the entire finger can be covered by the various variants of the DMCA flaps.

Background: The purpose of this study was to evaluate the results of conservative and operative treatment for burn injuries in the palmar region of the hand. METHODS AND CLINICAL MATERIAL: One hundred ten patients from the severe burn center in Ludwigshafen, Germany were evaluated a mean of 28 months postoperatively. Sixty-one had been treated with split-thickness skin grafts (43 sheet and 18 mesh grafts). In addition to subjective evaluation (including pain assessment and aesthetic outcome rating by visual analog scale), objective outcome analysis included clinical tests, measurement of active range of motion and grip strength, and sensibility testing with the two-point discrimination and Semmes-Weinstein monofilament tests., Results: Of the patients, 90% were satisfied with the results, showing excellent pain relief with an average score under 13 on the visual analog scale. Aesthetic outcome was rated good with sheet grafts; in appearance, mesh grafts tended to be rated average or insufficient. Functional outcome tests demonstrated a significant correlation between depth of injury and range of motion. Grip strength analysis revealed superior results with sheet grafts. Sensibility in the injured areas was lower than on the contralateral hands. The Semmes-Weinstein test average was 3.4 degrees at the burned area vs 3.0 degrees in healthy hands, underscoring lower sensibility after burns., Conclusion: Surgical treatment of burned palms leads to good subjective and objective results, if specialized burn units are involved. Overall sheet transplantation seems to be the better choice for surgical reconstruction of the palmar burned hand.

Background: Free tissue transplantation is a rarely indicated procedure in burn reconstruction. As the versatility and variability of free flaps have significantly increased during recent years, so too have the indications for these procedures expanded., Material and Methods: We retrospectively report the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience has enabled us to establish reconstructive principles pertinent to the type of injury (burn versus high voltage injuries) and the timing of reconstruction procedures., Results: In high voltage injuries (n = 17) early free flap coverage (< 21 days after trauma) with muscular flaps was the most frequently used type of reconstruction. Reconstruction site was predominately the forearm. In burn injuries (flame, contact, fluid), free flap coverage was performed during a later stage of the treatment course (3 to 6 weeks after trauma), or as a secondary procedure. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and the dorsum of the hand underwent defect coverage in most circumstances. For the reconstruction of complex or large defects (n = 6) combined "chimeric" flaps, preexpansion of free flaps, or the combination of a free and local flap were used. Overall, the flap failure rate was 12 % (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four out of five flap failures occurred within 5 to 21 days after trauma, all five flap failures occurred between five days and six weeks. No flap failure was seen during secondary reconstruction., Conclusion: Our data demonstrate that burn and high voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if our flap failures all occurred during the first six weeks it should not be forgotten that this type of coverage is the only alternative to amputation in selective cases.

Purpose: Coverage of exposed functional structures such as tendons, bones, vessels or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. Free fascial flaps are possible alternatives to cutaneous, fasciocutaneous and muscle flaps. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free serratus fascial flaps in our department., Method and Clinical Material: From 1994 to 2002, ten patients underwent free fascial flap coverage of the hand with eleven serratus fascial flaps. Six patients could be re-examined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was after 34 months., Results: Average active range of motion of the hand, functional improvement and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required., Conclusion: We recommend the use of free serratus fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps since the functional results are excellent; no additional procedures were necessary and the aesthetical results are appealing.

Hands are most frequently involved in severe burns. The treatment of the burned hand is one of the most challenging problems in plastic surgery. The success of therapy is determined by the severity of the initial injury, the first aid provided, and the correct balance between mobilization, splinting and plastic surgery. In this respect, it is vital to have a highly qualified interdisciplinary team approach consisting of plastic surgeons, well-trained physical therapists, psychologists and a highly motivated patient.

Free tissue transplantation in burn reconstruction presents a major challenge to reconstructive surgeons. The results of a retrospective analysis of 68 free flaps in 55 patients are reported. This experience facilitated the establishment of reconstructive principles and a decision-making algorithm for primary and secondary reconstruction of burned extremities. Fourty-two free flaps were used for primary reconstruction. The indications were predominantly extremity salvage.The safety of the microsurgical procedures is correlated with the timing of the reconstruction. The failure rate of the free flaps was 24% in primary reconstruction. Due to an increased post-traumatic thrombogenicity, the period between 5 and 21 days had the highest risk of flap failure (40%).Twenty-six flaps were used for secondary reconstruction, with a success rate of 100%. Due to their elasticity, adipo- and fasciocutaneous flaps provide a useful option for the release of contractures. The large variability demonstrated by the use of 19 different types of free flaps showed that the reconstruction of burned extremities requires a reconstructive concept individualized to each patient as well as sophisticated microsurgical techniques. This clearly demonstrates the importance of a close link between primary burn treatment and reconstructive plastic surgery.

Secondary reconstruction following severe burn trauma has improved markedly over the last few decades using all aspects of modern plastic surgery. In surgical reconstruction of burns, it is essential to design comprehensive, clear-cut, and long-term treatment plans. Good patient compliance and thorough follow-ups are imperative regarding the extent of scar and contracture formation, regularly requiring multiple-step surgery. Each treatment site will have to be evaluated separately, taking into account adequate surgical and conservative measures (the "reconstructive ladder"). Aiming at realistic and satisfactory results, surgery does not suffice alone in treating severely burned patients but also requires a well coordinated and seasoned team of occupational and physical therapists, psychologists, and plastic surgeons.

Current treatment strategies in intensive care medicine permit survival of patients with burns of more than 80% of the total body surface area (TBSA). Major burns result in extensive skin defects. Thus, burn victims often suffer from scar contractures, altered thermoregulation, and unsatisfactory cosmetic results. In addition to the well-established cultivated epithelial autografts, a number of new composite grafts have been developed in the field of tissue engineering. The combination of synthetic and allogenic matrix structures together with an allogenic or autologous epithelium allows the possibility of mimicking skin structure. The aim is to achieve improved wound healing by regeneration of dermal tissue instead of scarring. This article provides an overview of the currently available products which have already been introduced into clinical routine as well as describing advantages and disadvantages of the individual products and their indications.

Burn injuries can be caused by thermal, electrical, chemical, or mechanical trauma or radiation and are relatively rare, as they represent only about 1% of all emergencies. They are caused by accidents at home, during recreational activities, or in the occupational environment. Minor burn traumas are much more common than severe burn injuries with their systemic and potentially life-threatening effects. Altogether, these circumstances may result in a lack of routine for treating such injuries properly by physicians and their colleagues in the emergency room or intensive care unit. A clearly outlined concept for preclinical and clinical treatment can be the keystone of successful further clinical progress. The following article summarizes the current guidelines for first medical aid at the injury scene, burn stabilization and assessment in the emergency room, and the interdisciplinary approach for further clinical care. The treatment of dermatologic emergencies (acute epidermolytic syndromes) or caustic injuries by chemical agents is similar to the treatment of burn victims in many aspects but must be adapted in selected cases.

Successful surgical and intensive care treatment of severely burned patients requires adequate prehospital management and fluid resuscitation adjusted to individual needs of the patient. Burn shock fluid resuscitation is now predominantly performed utilizing crystalloid solutions. Whenever possible, colloid solutions should not be given in the first 24 h after burn injury. The rate of administration of resuscitation fluids should maintain urine outputs between 0.5 ml/kg per h and 1 ml/kg per h and mean arterial pressures of >70 mmHg. Extended hemodynamic monitoring can provide valuable additional information, if burn resuscitation is not proceeding as planned or volume therapy guided by these typical vital signs is not attaining the desired effect. We recommend this in patients with TBSA burns of >30%. Inhalation injuries, pre-existing cardiopulmonary diseases, or TBSA burns of >50% definitely require extended hemodynamic monitoring during burn shock resuscitation. The Swan-Ganz catheter or less invasive transcardiopulmonary indicator dilution methods can be utilized to assess hemodynamic data.

From the years 1991 to 2000, basic data from patients admitted to the intensive care unit of burn centres in Germany, Austria and Switzerland, participating in the German Speaking Association for Burn Treatment, were collected prospectively. Starting in 1991 with 7 hospitals and 618 patients included in the study; in the year 2000, 19 hospitals representing nearly 1500 patients submitted their data. Over a period of 10 years, a total number of 10,259 patients could be included in the study. The majority of patients were adult, the male/female ratio was 70/30. Most of the patients suffered from household accidents, only 25% were occupational accidents. Medium total burn surface area (TBSA) and Abbreviated Burn Severity Index (ABSI) score were quite similar in the participating hospitals, while the medium length of stay in the ICU ranged from 6 to 24 days. The overall mortality was 17.5% and showed no decrease over the period of time.

In a recent clinical trial we evaluated the safety and immunogenicity of a recombinant OprF-OprI vaccine consisting of the mature outer membrane protein I (OprI) and amino acids 190-342 of OprF of Pseudomonas aeruginosa in burn patients and compared the elicited antibodies with antibodies against tetanus as response to a simultaneous immunization given on the day of admission. Safety and immunogenicity of the vaccine had been tested before in healthy human volunteers as published in 1999. In this first clinical trial we immunized eight burn patients suffering from second or third degree burns involving between 35% and 55% of the body surface three times with 100 microg of the OprF-OprI vaccine. The vaccine was found to be very well tolerated. The patients did not show any serious side effects - and in particular no activation of the mediator cascade was observed. None of the subjects showed systemic P. aeruginosa infections during or after the treatment of their burns. The serological tests (ELISA) for detection of antibodies against P. aeruginosa and tetanus toxoid showed seroconversion for seven patients after inoculation. The data indicate that OprF-OprI can be a useful vaccine in the therapeutic management of burn injuries.

The purpose of this study was to compare the approximated values for intrathoracic blood volume (ITBV) and extravascular lung water (EVLW) obtained from a single indicator dilution to the exact data measured by double-indicator dilution. Eighteen patients with an average TBSA of 46.3% (range, 26 to 67%) and an average abbreviated burn severity index of 8.7 (range, 7 to 11) were included into a intraindividual comparative prospective study over a 20-month period. The COLD Z-021 system (Pulsion Medical Systems, Munich, Germany) was used to obtain both the exact measurements, as well as the estimated values for ITBV and EVLW. Two hundred ninety intraindividually comparative measurements were performed during the first 4 days after the burn injury. A good correlation between both techniques was shown for ITBVI (0.77; P <.01) for the overall measurements. However, the overall bias demonstrated a standard deviation higher than the mean value (-87.4 +/- 136 ml/m2), and precision for the estimated values for ITBVI was poor (-491 to 783 ml/m2). Additional analyses demonstrated a poor but significant correlation for low states of ITBV (r =.37; P <.01), but no significant correlations were found between the techniques for normal and high ITBV states. Thus, the approximated ITBV obtained from single thermodilution should not be used to guide volume therapy in major burn resuscitation. Furthermore, the EVLW is neither suitable for diagnostic use nor for therapeutic decisions because it is calculated on the basis of the poorly estimated values for ITBV in single thermodilution. Transcardiopulmonary single thermodilution is not suitable to assess intrathoracic blood volume and extravascular lung water in burn shock. However, the method is suitable to assess cardiac output and its derived parameters in burn resuscitation as shown in previous studies. It still must be proven whether the exactly measured ITBV obtained from transcardiopulmonary double-indicator dilution is superior to the commonly used parameters to guide major burn resuscitation.

This retrospective study examines the use and advantages/disadvantages of glycerol preserved human allograft skin in our burn care facility between February 1997 and December 1999. Three hundred and twenty patients were included into the study, 85 of whom were treated with human cadaver skin. The usage of allograft slightly increased the number of operative procedures per percent of the total body surface area burn. There were no adverse effects noted from the use of allograft. The group of patients with allograft use had a significantly larger burn size, ABSI score and length of ICU stay. Demographically the groups were comparable. The considerably easier handling and storage of glycerol preserved allograft skin make it preferable to cryopreserved allograft skin in all indications where it is used as a temporary wound closure. We recommend the usage of cryopreserved skin in cases where the integration of a dermal component as a permanent part of wound closure is desired.

The objective of this study was to validate a new method of transcardiopulmonary thermodilution for assessment of cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI) and additional parameters such as intrathoracic blood volume index and extravascular lung water index (EVLWI) by comparison with conventional pulmonary artery catheter values in a severely burned population. The pulmonary artery measurements were performed continuously with the Vigilance system, and the transcardiopulmonary thermodilution with the PiCCO(R) system. One hundred thirteen measurements with each system on up to six consecutive days were taken in 14 severely burned patients (average TBSA, 49.6%; average ABSI, 10.3), aged 21 to 61 years (mean, 42.2 years) and compared intraindividually. An excellent correlation between the two methods was shown for CI (r = 0.80) and its derived parameters SVI and SVRI in states of low to normal cardiac output. The correlation was poor for cardiac indices greater then 5.5 up to their maximum values (r = 0.46). No correlation between index of oxygenation (PaO2/FiO2) vs EVLW I was observed. There was no difference between survivors and nonsurvivors, and between patients with and without inhalation injury in EVLWI. The method of transcardiopulmonary thermodilution is suitable to assess SVI, CI and SVRI under the special pathophysiologic condition of a major burn for low to normal cardiac output states. It is less reliable when cardiac output is high. The lower cost and less invasive nature are the advantages of the system compared with use of the pulmonary artery catheter. The role of intrathoracic blood volume index and EVLWI in cardiopulmonary monitoring of severely burned patients remains to be further determined.

Introduction: Recombinant growth hormone (rGH) has been used successfully in burned children with a shortened donor-site healing time and length of hospital stay as well as a protein-sparing effect. In adult burn patients, no comparable study exists to date., Material and Methods: The study was performed on 49 adults, aged 18-60, with an Abbreviated Burn Severity Index (ABSI) score of 7-I1 as a randomized, placebo-controlled, double-blind study. The treatment period was 28 days and follow-up period 1 year. rGH was administered subcutaneously at a dose of 0.5 lU/kg per day in 26 patients, 23 patients were in the placebo group. Wound-closure assessment was performed on the day of admission and on each day of dressing change. A wound-closure index (WCI) was calculated., Results: Thirty-seven patients, 19 in the rGH group and 18 in the placebo group, survived and were available for primary efficacy analysis. The mean total body surface area (TBSA) burned was 41.5% (rGH) versus 36.7% (placebo); the average ABSI score was 8.27 (rGH) versus 7.9 (placebo). The wound-closure index was not significantly different in patients treated with rGH (1.92) compared with patients treated with placebo (1.72). WCI for partial thickness-loss burn wounds did not significantly differ from rGH (0.9) to placebo (0.69). The donor site healing time in rGH-treated patients (12 days) was not significantly different compared to placebo patients (10.4 days)., Conclusion: In severely burned adult patients rGH has no positive effect on burn wound or donor-site healing.

Hands are involved in over 70% of all serious burns. This study comprised 80 hands in 41 patients with burns of the dorsum of the hand. Eighty percent of the hands in our study had deep partial-thickness and full-thickness burns that had to be grafted. This study was performed to evaluate the patency of the dorsal metacarpal artery (DMCA) system in burn-injured hands. Sixteen hands healed spontaneously; 62 had to be excised and grafted. Doppler mapping of the dorsum of the hand was completed using an 8-MHz probe. Patent vessels were found in a pattern similar to that of a normal population in spontaneously healed and grafted partial-thickness burns. The incidence of dorsal arteries decreased from 100% for the first DMCA to 80% for the DMCA in the fourth web space. In full-thickness burns the correlation of burned hands to normal volunteers was only 80%. It can be concluded from the data that the DMCA system is not damaged by deep partial-thickness burns that are excised and grafted. The DMCA system is still intact in 80% of patients with full-thickness burns. The potential for elevating a DMCA flap is therefore preserved after burn excision and grafting. Preoperative Doppler examinations are recommended before planning the flaps.

Modern plastic and reconstructive surgery continues to significantly improve the functional and aesthetic post-burn sequelae in children. It has become a major factor in restoring mobility, aesthetic appearance, self-esteem, and quality of life. The entire spectrum of plastic reconstructive procedures should be available to offer the patient an optimal solution to his problems. Therefore, early interdisciplinary co-operation between pediatric and plastic surgeons is mandatory to plan and perform post-burn reconstruction in children and adolescents.

A retrospective analysis of prospectively collected data was performed to compare the frequency of upper gastrointestinal bleeding (GIB) in seriously burned patients treated with either cimetidine and antacids or enteral nutrition for ulcer prophylaxis. Five hundred and twenty-six seriously burned patients admitted to the burn intensive care unit of the BG Trauma Centre Ludwigshafen during a 4-year period were included into the study. All patients admitted to the burn unit from 1989 to 1991 received i.v. cimetidine (400 mg q4) for ulcer prophylaxis. If the intragastric pH dropped below 3.5, gastric pH was titrated with antacids up to > or = 4 via nasogastric tube. During the second 2-year period (1992-1993) early enteral nutrition alone was regarded to be ulcer protective and no further interventions for ulcer prophylaxis were routinely performed. Signs of overt upper GIB were monitored and documented through the entire study period. The overall occurrence rate of upper GIB in the cimetidine/antacids (C/A) group (n = 253) was 8.3 per cent with six cases of serious bleeding in five patients (1.98 per cent). In the enteral nutrition (EN) group (n = 273) the overall incidence of GIB was 3.3 per cent with two cases of serious bleeding (0.73 per cent). There were no deaths directly related to ulcer haemorrhage. The difference in the overall frequency of overt GIB between the groups studied was statistically significant (< 0.05). In our experience, early enteral nutrition is effective in the prevention of stress haemorrhage in the upper gastrointestinal tract. Additional medicinal prophylaxis is not required in burn patients.

Clinical experience has shown that concomitant diseases and risk factors have a significant influence on the patient's outcome. Since none of the currently available score systems consider the impact of concomitant diseases or risk factors on burn trauma mortality, the present study was planned to further evaluate the role of these factors. Four hundred and ninety-eight patients could be included in this retrospective analysis of prospectively collected data. Parameters documented were: sex, age, weight, height, laboratory data, TBSA, inhalation trauma (IHT), full thickness (3 degrees) burn and pre-existing conditions. Single-variable analysis (SVA), logistic regression and CART analysis were performed. The data confirm the role of age and TBSA as the strongest prognostic variables. Chronic alcohol abuse and smoking, IHT and pre-existing cardiac and neurologic conditions were also found to be significant. Borderline groups could be identified in the ABSI score (7-10), where the risk factors cause 'mortality-shifting'. It can be concluded that risk factors and pre-existing conditions have a significant impact on the prognosis of burn mortality and should be incorporated into further refinements of burn admission scores.

Aims of this retrospective study were: (1) to evaluate the feasibility of a protocol for early intragastric feeding: (2) to examine whether the caloric needs can be provided via the intragastric route within 72 h postburn; (3) to determine the influence of a delayed onset of feeding on the success of the feeding protocol; (4) to evaluate whether delayed feeding has any impact on morbidity and mortality. Fifty-five long-term ventilated patients were enrolled in the study. Their mean age was 37.6 years and mean total body surface area burned 44.2 per cent. The mean duration of ventilation amounted to 24.8 days. Intragastric tube feeding was initiated as early as possible after admission. Forty-five patients (81.8 per cent) could be fed successfully and their caloric needs were met within 72 h. In these patients the mean interval between burn injury and the initiation of tube feeding was 11.5 h. The mean interval was 32.4 h in the 10 patients, demonstrating failure of early intragastric feeding. Only four of the 48 patients who had enteral feeding within 18 h postburn failed to meet the caloric needs. The patients fed successfully showed a significantly decreased mortality. Early intragastric feeding after serious burns can be initiated successfully. A time interval of more than 18 h is unfavourable and significantly decreases the success rate.

Heterotopic bone formation is a well-known but rare complication after burns and other traumatic injuries. Pathology, aetiology, progression and management remain controversial. Joint immobilization in concert with an altered metabolism and aggressive physical therapy are suspected to be the cause of heterotopic bone formation. The most frequent sites of manifestation are major joints and large muscle groups. The formation of disseminated large ossifications in soft-tissue and juxta-articular bone bridges of small joints is barely mentioned in the literature. A case of most unusual, massive heterotopic bone formation as a complication after severe burn is presented. In this patient serious complications after the severe burn injury primarily attracted clinical attention, so that diagnostic measures were delayed. Four months later after successful weaning from ventilation, the patient could describe his sites of pain. The therapeutic options were limited because of extensive and unusual localizations. This case emphasizes the necessity of an early and specific radiological diagnosis in long-term ventilated patients to avoid this serious complication.

Objective: 1. To reexamine the predictive value of the variables usually used in admission scores in burned patients (age, total body surface area burned (TBSAB), full thickness burn (FTB), inhalation injury (IHT) and sex). 2. To evaluate whether risk factors (alcohol abuse (AA), nicotine abuse (NA)) or preexisting diseases influence outcome significantly., Design: Retrospective study of prospectively collected data., Patients: 498 burned patients admitted to the burn ICU within a 5 years period. The mean TBSAB was 29% and the mean age 38 years. 42% of the patients suffered burns greater than 30% and the incidence of IHT amounted to 43%., Methods: Univariate analyses were used to determine the independent relation of the variables to mortality. The relative weight of the variables was estimated using the step-wise logistic regression model. An additional analysis of subgroups was performed using classification and regression trees (CART)., Results: The univariate analyses identified the following variables to have significant influence on mortality: age, TBSAB, FTB, IHT, sex, AA, NA, the combination of AA and NA, preexisting neurological diseases and cardiovascular diseases. The step-wise logistic regression analysis identified age and TBSAB to have the most important influence on the outcome. Of minor weight was IHT followed by FTB and sex. The weight of IHT was found to be 1.7 fold higher than the impact of FTB and sex. A significant influence of IHT was found in all patients, but especially in patients with a medium risk of death (20%-45%) regarding age and TBSAB. In this group AA and NA additionally caused a significant impact on mortality. In patients with a higher or lower probability of survival AA and NA did not influence the outcome. The CART analysis identified TBSAB to be the most discriminative variable followed by age. In the group up to 20% TBSAB age was the only additionally significant variable regarding the outcome. In the group with a TBSAB between 20% and 60% age, sex and AA became important variables. In patients up to 72 years with a medium risk of mortality (20%-70%) IHT, AA, combined AA and NA, sex, preexisting neurological diseases and cardiovascular diseases significantly influenced outcome. In older patients IHT was the only additional variable of importance., Conclusions: The study demonstrates that besides the "classical" variables of bum scores as age, TBSAB and IHT other variables such as sex, AA, NA and preexisting diseases have significant influence on the outcome. These variables especially gain important predictive value in patients with a medium risk of mortality.

In 1958 Meek described the so called Meek-Wall dermatome to cut postage stamp skin grafts. This method was eclipsed by the introduction of mesh skin grafts. In 1993 Kreis and colleagues reintroduced a modified Meek technique using a dermatome running on compressed air. This technique has been used in our burn unit since August 1994. The aim of this paper is to compare the modified Meek technique with the mesh graft technique. Within a period of 20 months 41 patients were grafted using the modified Meek technique. The mean TBSAB was 54.4% with 50.0% full thickness burns. All patients were excised early. The expansion ratio was 1:4 and 1:6. In 20 patients the Meek technique was used exclusively for grafting of the trunk and the extremities with the exception of face, neck and hands. In 3 patients with a mean TBSAB of 68.3% a combination of postage stamp autologous skin grafts and cultured epithelial autografts (CEA) was applied. Compared with the mesh graft technique the Meek technique showed the following advantages: 1. The Meek method provides the true expansion ratio. 2. Small graft remnants can be utilized. 3. Grafting of full thickness burns up to 70 to 75% TBSAB becomes possible with one harvest of the donor sites. 4. The reliability of graft take is equal or better. 5. Epithelialization is achieved within 3 to 4 weeks depending on the expansion ratio. 6. The combination of widely expanded postage stamp split thickness grafts and CEA provides an excellent take rate and durable wound closure within a short time and avoids the problems associated with the engraftment of CEA on fascia. The method is simple but more demanding than the mesh technique. Compared with the mesh graft technique the preparation of Meek grafts is more time consuming and requires more staff than the Mesh technique. The cost of materials is higher. In our experience complete coverage of the Meek grafts with an overlay of meshed allografts after removal of the gauze as recommended by Kreis is not necessary using the 1:4 expansion ratio. Greater expansion ratios necessitate an overlay with meshed allografts. Regarding the scar formation no significant differences were observed compared with the mesh graft technique. In conclusion the modified Meek technique is reliable and simple to perform. This technique provides a sufficient expansion ratio enabling to graft patients with burns up to 75% TBSA with only one harvest of donor sides and without the necessity of CEA. In our opinion the Meek technique is reliable and simple to perform. This technique provides a sufficient expansion ratio enabling to graft patients with burns up to 75% TBSA with only one harvest of donor sides and without the necessity of CEA. In our opinion the Meek technique is advantageous in patients with burns greater than 45% TBSAB. In smaller burns mesh grafts should be used because of lower material cost and staff requirements. Especially in extensively burned patients the Meek technique may be cost effective avoiding the need of CEA.