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This study aimed to compare the histomorphology of the elbow capsule and its ligaments to gain a better understanding of the clinically relevant biomechanical stabilization. Eleven human elbows were dissected including the joint capsule with its anterior (AJC) and posterior (PJC) parts, the annular ligament (AL), the radial collateral ligament (RCL) and the ulnar collateral ligament with its anterior (AUCL), posterior (PUCL) and transverse (TUCL) parts. Hematoxylin-Eosin and Elastica van Gieson as conventional histology stainings were applied to determine collagenous and elastic fiber arrangements in transmission and polarization light microscopy. The radial collateral ligament and the anterior part of the ulnar collateral ligament showed significantly more densely packed parallel fiber arrangement than the anterior joint capsule, the posterior joint capsule, and the posterior part of the ulnar collateral ligament (p 0.02, respectively). The PUCL had significantly more mixed tight and loose parallel arrangements than the PJC, the annular ligament, the RCL, the AUCL and the transverse part of the ulnar collateral ligamentp 0.02, respectively), while the PJC showed significantly more interlaced mixed tight and loose fiber arrangement than the AL, the RCL and the AUCL (p 0.003, respectively). The AJC had a significantly higher amount of elastic fibers as compared to the AL, the RCL, the AUCL and the TUCL in fascicular regions (p 0.04, respectively), while the AUCL had significantly lesser elastic fibers than the AJC and the PJC (p 0.004, respectively). The densely packed parallel fiber arrangement and few elastic fibers of the AUCL, RCL, and AL indicate a strong biomechanically stabilizing function. The fiber arrangement of the PUCL and the TUCL with few elastic fibers support the medial elbow stabilization. Crimping and elastic fibers provide the viscoelasticity of the joint capsule.

Intra-abdominal compartment syndrome (ACS) is a devastating complication in burn patients with a high mortality. Apart from high-volume resuscitation as known risk factor, also mechanical ventilation seems to influence the development of ACS. The TIRIFIC trial is a retrospective, matched-pair analysis. Thirty-eight burn patients with ACS were matched for burned total body surface area (TBSA), age and mechanical ventilation (MV). In contrast to the already published part I addressing fluid resuscitation as a risk factor, the parameters analyzed in part II were maximum and average PEEP and peak pressure levels as well as serum lactate levels and prokinetic therapy. For subgroup-analysis the ACS-group was split up into an early-onset and late-onset ACS-group according to the median time between burn trauma and ACS. The groups were analyzed with a two-sided Mann-Whitney-U-test with significance set at p < 0.05. In the ACS-group all ventilation pressures (maximum and average PEEP and peak pressure levels) were significantly increased compared to control. The subgroup-analysis showed significantly increased maximum PEEP and peak pressure levels in early- and late-onset ACS-groups versus control. However, the average ventilation pressure levels were only increased in the early-onset ACS-group (average PEEP p = 0.0069; average peak pressure p = 0.05). The TIRIFIC trial showed significantly increased ventilation pressures in the ACS group in general as a surrogate parameter to support early diagnostics. Especially, maximum PEEP levels and peak pressures are significantly increased in both, early- and late-onset ACS. As an addition to the actual WSACS guidelines we suggest IAP measurement in mechanically ventilated burn patients if ventilating pressures are rising continuously without a clear pulmonary or otherwise identifiable reason.

Ultrasound has not yet been established in the diagnostic workup of scapholunate ligament lesions. We aimed to develop a standardised examination procedure to visualise and evaluate the SL ligament.Forty patients (70 hands) were examined prospectively with ultrasonography and the results were compared with arthroscopy and MRI findings. We studied the visibility of the SL ligament and the SL distance on side-to-side comparison and performed a method comparison between MRI/arthroscopy and ultrasound, testing for distinction and accordance. Cut-off values for the SL distance indicating a lesion were determined and all parameters were used for developing a score.An intact ligament appears as a hyperechogenic, fibrillary structure and shows discontinuity or a hypoechogenic space when injured. An intact ligament was visible dorsally in 89.6 % and palmarly in 83.3 %. The SL distance for an intact ligament was 5/2/5.1 mm for the dorsal/middle/palmar aspect (range 3.2-6.7/0.9-4/3.1-7.8 mm) and 6.4/3/6.3 mm (range 5-9.4/2-6.2/4-9.3 mm) for a lesion. The difference between the right and left hand with an intact ligament was a maximum of 2.1/1.1/1.8 mm, an average of 0.4/0.2/0.2 mm; in case of an injury, the maximum difference was 1.2/0.9/1.1 mm. Distance values for radial and ulnar deviation were physiological but partly unpredictable. The cut-off values determined for a lesion are 5.05 mm for the dorsal aspect (sensitivity/specificity 0.95/0.60), 1.95 mm for the middle (1/0.62) and 6.15 mm for the palmar aspect (0.55/0.85). The created sonographic SL ligament score has a high AUC (area under the curve) of 0.93, a sensitivity of 85 % and a specificity of 90 %.The parameters, especially when combined to a score, allow to state whether the SL ligament is intact or not. Ultrasound can, therefore, be recommended as a diagnostic and screening method for an SL ligament lesion und should be used as a routine tool. The criteria must be checked from a perspective with high case numbers.Der Ultraschall ist in der Diagnostik der skapholunären Bandläsion (SL-Band) noch nicht etabliert. Ziel war es, ein standardisiertes Untersuchungsverfahren zur Darstellung und Kriterien zur Beurteilung des SL-Bandes zu entwickeln.Es wurden prospektiv 40 Patienten (70 Hände) sonographisch untersucht und mit Arthroskopie oder Magnetresonanztomographie (MRT) verglichen. Betrachtet wurden die Darstellbarkeit desSL-Bandes, der SL-Abstand im Seitenvergleich sowie ein Methodenvergleich von MRT und Arthroskopie zur Sonographie durchgeführt. Geprüft wurde auf Unterschiede und Übereinstimmung. Es wurden Cut-off-Werte für den SL-Abstand für eine Läsion bestimmt und alle Parameter zur Erstellung eines Scores verwendet.Ein intaktes Band erscheint als hyperechogene, fibrilläre Struktur und zeigt bei Verletzung Banddiskontinuitäten oder einen hypoechogenen Raum. Ein intaktes Band war dorsal in 89,6 % und palmar in 83,3 % darstellbar. Der Abstand für ein intaktes Band betrug dorsal/Mitte/palmar 5/2/5,1 mm (Bereich 3,2–6,7/0,9–4/3,1–7,8 mm), bei Läsion 6,4/3/6,3 mm (5–9,4/2–6,2/4–9,3 mm). Linke und rechte Hand unterschieden sich bei intaktem Band maximal um 2,1/1,1/1,8 mm, im Mittel um 0,4/0,2/0,2 mm und bei Verletzung um 1,2/0,9/1,1 mm. Radial- und Ulnarduktion zeigten physiologische, z. T. jedoch unvorhersehbare Abstandswerte. Als Cut-off-Werte für eine Läsion wurden dorsal (Sensitivität/Spezifität) 5,05 mm (0,95/0,60), Mitte 1,95 mm (1/0,62) und palmar 6,15 mm (0,55/0,85) ermittelt. Der erstellte sonographische SL-Band-Score besitzt eine hohe AUC (Area under the curve) von 0,93, eine Sensitivität von 85 % und eine Spezifität von 90 %.Die Parameter erlauben, v. a. kombiniert als Score, eine Aussage zur Intaktheit des SL-Bandes. Die Sonographie kann somit als Diagnostikum und Screeningmethode für eine SL-Bandläsion empfohlen werden und sollte als Routineinstrument etabliert werden. Perspektivisch muss durch große Fallzahlen eine Überprüfung und Anpassung der Kriterien erfolgen.

Objective: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and severe skin and mucosal reactions that are associated with high mortality. Despite the severity, an evidence-based treatment protocol for SJS/TEN is still lacking. Method: In this systematic review and meta-analysis, the PubMed database was searched using the following terms: [Stevens–Johnson syndrome] OR [toxic epidermal necrolysis] AND [therapy] OR [treatment] over a 20-year period (1999–2019) in the German and English language. All clinical studies reporting on the treatment of SJS/TEN were included, and epidemiological and diagnostic aspects of treatment were analysed. A meta-analysis was conducted on all comparative clinical studies that met the inclusion criteria. Results: A total of 88 studies met the inclusion criteria, reporting outcomes in 2647 patients. Treatment was either supportive or used systemic corticosteroid, intravenous immunoglobulin, plasmapheresis, cyclosporine, thalidomide or cyclophosphamide therapy. The meta-analysis included 16 (18%) studies, reporting outcomes in 976 (37%) patients. Systemic glucocorticoids showed a survival benefit for SJS/TEN patients in all analyses compared with other forms of treatment. Cyclosporine treatment also showed promising results, despite being used in a small cohort of patients. No beneficial effects on mortality could be demonstrated for intravenous immunoglobulins. Conclusion: Glucocorticoids and cyclosporine may be tentatively recommended as the most promising immunomodulatory therapies for SJS/TEN, but these results should be investigated in future prospective controlled trials.

The analysis of ligamentous mechanoreceptors is difficult due to a high amount of unclassifiable mechanoreceptors, which result from incomplete visualization through limited microscopic techniques.The method was developed using dorsal intercarpal ligaments and dorsal regions of the scapholunate interosseous ligament from human cadaver wrists. Consecutive 70 µm thick cryosections were stained with immunofluorescence markers for protein S100B, neurotrophin receptor p75 (p75), protein gene product 9.5 (PGP 9.5) and 4',6-diamidino-2-phenylindole (DAPI). 3D images of sensory nerve endings were obtained using a confocal laser scanning microscope. Experimental point spread functions (PSF) were used to deconvolve images. Sensory nerve endings were localised in each section plane and classified according to Freeman and Wyke. Finally, confocal data was visualized as 3D-images.The method produced excellent image quality, revealing detailed three-dimensional structures. The created 3D-model of sensory nerve endings could be analyzed in all three dimensions, augmenting visualization of the form and immunoreactive pattern of sensory nerve endings. Deconvolution with experimentally measured PSFs aided in enhancing image quality.Using a triple immunofluorescent staining method allows to visualize the structure of sensory nerve endings more precisely than techniques with serial analysis of different monostaining of neural markers. Imaging in three dimensions enhances morphologic details, which are limited in 2D-microscopy.3D-triple immunofluorescence produces high quality visualization of mechanoreceptors, thereby improving their analysis. As an elaborate technique, it is ideal for defined research questions concerning the microstructure of sensory nerve endings.

We recruited 25 patients after complete wrist denervation and 60 healthy adults to investigate conscious and unconscious proprioception of the wrist. Ipsi- and contralateral joint-position sense, force sense, and wrist reflexes were measured. The latter were triggered by a trapdoor, recording electromyographic signals from the extensor carpi radialis brevis, extensor carpi ulnaris, flexor carpi radialis, and flexor carpi ulnaris muscles. No significant differences were found for joint position sense, force sense, and wrist reflexes between both groups, except for reflex time of the flexor carpi ulnaris after denervation of the left wrist as compared with the left flexor carpi ulnaris in controls or in right operated wrists. At a mean follow-up of 32 months (range 8 to 133), we found no proprioceptive deficit of the conscious proprioceptive qualities of joint position sense, force sense, and the unconscious proprioceptive neuromuscular control of wrist reflex time for most muscles after complete wrist denervation. We conclude from this study that complete wrist denervation does not affect the proprioceptive senses of joint position, force sense, and reflex time of the wrist.

Hair is a defining feature of mammals and has critical functions, including protection, production of sebum, apocrine sweat and pheromones, social and sexual interactions, thermoregulation, and provision of stem cells for skin homeostasis, regeneration, and repair. The hair follicle (HF) is considered a “mini-organ,” consisting of intricate and well-organized structures which originate from HF stem and progenitor cells. Dermal papilla cells are the main components of the mesenchymal compartments in the hair bulb and are instrumental in generating signals to regulate the behavior of neighboring epithelial cells during the hair cycle. Mesenchymal-epithelial interactions within the dermal papilla niche drive HF embryonic development as well as the postnatal hair growth and regeneration cycle. This review summarizes the current understanding of HF development, repair, and regeneration, with special focus on cell signaling pathways governing these processes. In particular, we discuss emerging paradigms of molecular signaling governing the dermal papilla-epithelial cellular interactions during hair growth and maintenance and the recent progress made towards tissue engineering of human hair follicles.

Carbon monoxide (CO) is a toxic, color-, taste- and odorless gas with fatal consequences if undetected. Intoxication caused by CO is frequent possibly leading to a high morbidity and mortality. The disease involves multiple organ systems without a typical clinical presentation. The clinical picture is furthermore unrelated to levels of carboxyhemoglobin - the routine biomarker. Therefore the diagnosis and treatment can be very demanding. This article in detail reviews epidemiology, symptoms, diagnosis and the therapy of this multidisciplinary challenge.

Objective: Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), are skin hypersensitivity reactions defined by epidermal blistering and necrosis. The exact pathophysiology of SJS/TEN is yet to be deciphered, but a number of risk factors have been identified including adverse drug reactions. The diagnosis of SJS/TEN is made on a clinical basis, and treatment consists of supportive care and occasionally immunosuppressants, such as cyclosporin, high-dose intravenous immunoglobulins and/or corticosteroids. Mortality rates can reach 20–25% in adults but are reduced with early intervention. To identify optimal treatment regimens, to better understand the patient cohort affected, and to help identify key risk factors for mortality, we report our experience with the treatment and management of SJS/TEN patients. Methods: A retrospective review of consecutive patients with SJS and/or TEN admitted to a single burns centre in Germany, between 2008 and 2018, was conducted. The primary outcomes of demographics, clinical course, treatment and patient-reported outcomes were recorded and compared with a control group of patients with burns without a diagnosis of SJS/TEN. Results: A total of 23 patients with SJS/TEN met the inclusion criteria: 17 (74%) with TEN; four (17%) with SJS/TEN overlap; and two (9%) with SJS. Of the patients, 14 (61%) were female and nine (39%) were male. Patient age ranged from 32–78 years (mean: 52 years). A matched cohort of 23 patients with burns served as the control group. All patients received standard of care with a multidisciplinary team. Compared with the control group, SJS/TEN patients had higher mortality rates (n=6, 26% versus n=8, 35%, respectively). The average age of death was 69 years in SJS/TEN patients versus 63 years in control group patients. Age and SCORTEN scores were significant predictors of mortality. Conclusions: SJS and TEN are rare but extreme reactions of the skin and mucosa, associated with high disease mortality rates. This 10-year single-centre retrospective review contributes to the bank of information for reviews evaluating the management of SJS/TEN patients.

Background The assessment of thermal burn depth remains challenging. Over the last decades, several optical systems were developed to determine burn depth. So far, only laser doppler imaging (LDI) has been shown to be reliable while others such as infrared thermography or spectrophotometric intracutaneous analysis have been less accurate. The aim of our study is to evaluate hyperspectral imaging (HSI) as a new optical device. Methods Patients suffering thermal trauma treated in a burn unit in Germany between November 2019 and September 2020 were included. Inclusion criteria were age ≥18 years, 2nd or 3rd degree thermal burns, written informed consent and presentation within 24 h after injury. Clinical assessment and hyperspectral imaging were performed 24, 48 and 72 h after the injury. Patients in whom secondary wound closure was complete within 21 days (group A) were compared to patients in whom secondary wound closure took more than 21 days or where skin grafting was indicated (group B). Demographic data and the primary parameters generated by HSI were documented. A Mann Whitney-U test was performed to compare the groups. A p-value below 0.05 was considered to be statistically significant. The data generated using HSI were combined to create the HSI burn index (BI). Using a logistic regression and receiver operating characteristics curve (ROC) sensitivity and specificity of the BI were calculated. The trial was officially registered on DRKS (registration number: DRKS00022843). Results Overall, 59 patients with burn wounds were eligible for inclusion. Ten patients were excluded because of a poor data quality. Group A comprised 36 patients with a mean age of 41.5 years and a mean burnt body surface area of 2.7%. In comparison, 13 patients were allocated to group B because of the need for a skin graft (n = 10) or protracted secondary wound closure lasting more than 21 days. The mean age of these patients was 46.8 years. They had a mean affected body surface area of 4.0%. 24, 48, and 72 h after trauma the BI was 1.0 ± 0.28, 1.2 ± 0.29 and 1.55 ± 0.27 in group A and 0.78 ± 0.14, 1.05 ± 0.23 and 1.23 ± 0.27 in group B. At every time point significant differences were demonstrated between the groups. At 24 h, ROC analysis demonstrated BI threshold of 0.95 (sensitivity 0.61/specificity 1.0), on the second day of 1.17 (sensitivity 0.51/specificity 0.81) and on the third day of 1.27 (sensitivity 0.92/specificity 0.71). Conclusion Changes in microcirculation within the first 72 h after thermal trauma were reflected by an increasing BI in both groups. After 72 h, the BI is able to predict the need for a skin graft with a sensitivity of 92% and a specificity of 71%.

Since pedicle flaps were first described by the Indian physician Sushruta Samhita in the 6th century B. C., they have become an integral part of reconstructive surgery. As more and more research has been conducted into the underlying physical principles, flap monitoring has developed steadily in the last few decades. Hyperspectral Imaging (HSI) is a new quantitative measuring method for assessing the perfusion of the underlying tissue.This study aims to evaluate HSI as a monitoring method for pedicle flaps.In 16 patients who had undergone reconstructive surgery, oxygen saturation, haemoglobin and water concentration of the locoregional flap, necrotic flap areas as well as intact skin were measured on postoperative days 1 to 7. Subsequently, the data were statistically described and graphically illustrated.HSI revealed increased haemoglobin concentration and decreased oxygen and water concentration in necrotic flap areas compared with the monitor island and healthy skin. The distribution of the values collected from the vital skin areas and the monitor island was almost identical.HSI allows for safe, immediate, non-contact measurement of tissue perfusion of transferred tissue areas in patients after pedicle flap surgery. The use of HSI may improve postoperative flap monitoring.Seit der Erstbeschreibung einer lokoregionären Lappenplastik zur Nasenrekonstruktion im 6. Jahrhundert v. Chr. durch den indischen Arzt Sushruta Samhita sind diese ein fester Bestandteil in der Wiederherstellungschirurgie geworden. Neben der konsequenten Weiterentwicklung chirurgischer Operationsmethoden wurden die zu Grunde liegenden physikalischen Messmethoden des Lappenmonitoring in den letzten Dekaden stetig weiterentwickelt. Das Hyperspektralimaging (HSI) stellt eine neue quantitative Messmethode zur Beurteilung der Gewebeperfusion dar. ZIEL: Das Ziel dieser Arbeit ist die Evaluation des HSI als Monitoringverfahren nach lokoregionärer Defektdeckung.Bei insgesamt 16 Patienten wurde nach gefäßgestieltem Gewebetransfer die Sauerstoffsättigung, der Hämoglobingehalt sowie der Wassergehalt von Haut, Monitorinsel und nekrotischen Lappenarealen am 1. bis 7. postoperativen Tag gemessen. Die erhobenen Daten wurden statistisch deskriptiv ausgewertet und grafisch ausgearbeitet.Das HSI zeigte einen erhöhten Hämoglobingehalt, eine Abnahme der Sauerstoffsättigung sowie des Wassergehaltes in den nekrotischen Lappenarealen im Vergleich zur vitalen Monitorinsel und zur gesunden Haut. Monitorinsel und vitale Hautareale wiesen eine nahezu identische Werteverteilung auf.HSI erlaubt die sichere, kontaktfreie und sofortige Bestimmung der Gewebeperfusion von transferierten Gewebearealen bei Patienten nach lokoregionärer Defektdeckung. Daher erscheint die Verwendung von HSI im Rahmen des postoperativen Lappenmonitorings sinnvoll.

Objective: To review the effects of burn injury on nutritional requirements and how this can best be supported in a healthcare setting. Method: A literature search for articles discussing nutrition and/or metabolism following burn injury was carried out. PubMed, Embase and Web of Science databases were searched using the key search terms ‘nutrition’ OR ‘metabolism’ AND ‘burn injury’ OR ‘burns’. There was no limitation on the year of publication. Results: A total of nine articles met the inclusion criteria, the contents of which are discussed in this manuscript. Conclusion: Thermal injury elicits the greatest metabolic response, among all traumatic events, in critically ill patients. In order to ensure burn patients can meet the demands of their increased metabolic rate and energy expenditure, adequate nutritional support is essential. Burn injury results in a unique pathophysiology, involving alterations in endocrine, inflammatory, metabolic and immune pathways and nutritional support needed during the inpatient stay varies depending on burn severity and idiosyncratic patient physiologic parameters.

Despite the development of modern intensive care and new antimicrobial agents, the mortality of patients with severe sepsis and septic shock remains high. Systemic inflammation is a consequence of activation of the innate immune system. It is characterized by the intravascular release of proinflammatory cytokines and other vasoactive mediators, with concurrent activation of innate immune cells. The Wnt signaling pathway plays a critical role in the development of multicellular organisms. Abnormal Wnt signaling has been associated with many human diseases, ranging from inflammation and degenerative diseases to cancer. This article reviews the accumulating evidence that the Wnt signaling pathway plays a distinct role in inflammation and sepsis.

Objective: Experimental tests of non-invasive multi- or hyperspectral imaging (HSI) systems reveal the high potential of support for medical diagnostic purposes and scientific biomedical analysis. Until now the use of HSI technologies for medical applications was limited by complex and overly sophisticated systems. We present a new and compact HSI-camera that could be used in normal clinical practice. Method: We assessed the use of the HSI system on the hands of 10 healthy volunteers, looking at control parameters, and those following venous occlusion, arterial occlusion and reperfusion, including tissue oxygenation, tissue haemoglobin index, perfusion in 4–6mm depth=near infrared spectroscopy (NIR), and tissue water index. Pseudo colours used ranged from 0% (blue) to 100% (red). We also assessed differences in the wounds of three patients. Results: The results show good potential in all parameters in the healthy volunteers, which had high conformity with validated reference oximetry measurements. In three wounds, different levels of oxygenation were identified in the wound area, although interpretation of these results is complex. In Cases 2 and 3, following the application of a micro capillary dressing, improvements were seen in perfusion and reduction of the tissue water index (TWI). Conclusion: The camera system proved to be quick, flexible and yielded data with high spatial and spectral resolution. These data will be used to perform a power analysis for a randomised controlled study.

Background: Hyperspectral Imaging (HSI) has a strong potential to be established as a new contact-free measuring method in medicine. Hyperspectral cameras and data processing have to fulfill requirements concerning practicability and validity to be integrated in clinical routine processes. Methods: Calculating physiological parameters which are of significant clinical value from recorded remission spectra is a complex challenge. We present a data processing method for HSI remission spectra based on a five-layer model of perfused tissue that generates perfusion parameters for every layer and presents them as depth profiles. The modeling of the radiation transport and the solution of the inverse problem are based on familiar approximations, but use partially heuristic methods for efficiency and to fulfill practical clinical requirements. Results: The parameter determination process is consistent, as the measured spectrum is practically completely reproducible by the modeling sequence, in other words, the whole spectral information is transformed into model parameters which are easily accessible for physiological interpretation. The method is flexible enough to be applicable on a wide spectrum of skin and wounds. Examples of advanced procedures utilizing extended perfusion representation in clinical application areas (flap control, burn diagnosis) are presented.

The aim of this study was to evaluate the morphology of the six different parts of the interosseous membrane (IOM) in 11 human cadaver forearms, including the distal oblique bundle (DOB), the distal accessory band (DAB), the central band (CB), the proximal accessory band (PAB), the dorsal oblique accessory cord (DOAC), and the proximal oblique cord (POC). Hematoxylin-eosin and Elastica van Gieson stained slices were used to investigate the tissue morphology. The DOB and DOAC were absent in one IOM and the POB in two IOMs, respectively. The CB and DAB were longer than all other structures except for each other. The DOAC was longer than the DOB. The DAB, CB, and PAB, were broader than the DOB, DOAC, and POC. No significant differences were observed regarding structure thickness. All structures were found to consist of densely packed parallel collagen fiber arrangement. The DOB and POC had a higher amount of elastic fibers in the fascicular collagen tissue than the other structures. Elastic fibers were more often equally distributed throughout the structures than condensed epifascicular or at the insertion into bone. The tight parallel collagen composition within the different structures reflects the central stabilizing role of the IOM in the forearm. The higher amount of elastic fibers within the DOB and POC can be attributed to their location close to the distal and proximal radioulnar joints, respectively. Here elastic fibers allow adaption to forearm rotation, whereas the structures of the central part of IOM have less elasticity reflecting the predominant stabilizing function.

The human interosseous membrane (IOM) is a fundamental stabilizer during forearm rotation. To investigate the dynamic aspects of forearm stability, we analyzed sensory nerve endings in the IOM. The distal oblique bundle (DOB), the distal accessory band (DAB), the central band (CB), the proximal accessory band (PAB), the dorsal oblique accessory cord (DOAC) and the proximal oblique cord (POC) were dissected from 11 human cadaver forearms. Sensory nerve endings were analyzed at two levels per specimen as total cell amount/mm(2) after immunofluorescence staining with low‐affinity neurotrophin receptor p75, protein gene product 9.5, S‐100 protein and 4′,6‐diamidino‐2‐phenylindole on an Apotome microscope, according to Freeman and Wyke’s classification. Sensory nerve endings were significantly more commonly found to be equally distributed throughout the structures, rather than being epifascicular, interstitial, or close to the insertion into bone (P ≤ 0.001, respectively). Free nerve endings were the predominant mechanoreceptor in all six structures, with highest density in the DOB, followed by the POC (P ≤ 0.0001, respectively). The DOB had the highest density of Pacini corpuscles. The DOAC and CB had the lowest amounts of sensory innervation. The high density of sensory corpuscles in the DOB, PAB and POC indicate that proprioceptive control of the compressive and directional muscular forces acting on the distal and proximal radioulnar joints is monitored by the DOB, PAB and POC, respectively, due to their closed proximity to both joints, whereas the central parts of the IOM act as structures of passive restraint.

Objective: Self-inflicted burns typically result in extensive injuries requiring intensive care and attention in a specialised burn unit. Burn units should be familiar with the optimal management of self-inflicted burns, including the psychological and psychiatric treatment. This paper describes the experiences of managing these challenging injuries in a German burn centre. Methods: A retrospective review of patients with self-inflicted burns admitted to the burn centre between 2000 and 2017. Demographics, details of injury, presence of psychiatric disorder, clinical course, operative management and patient outcomes were recorded and compared with a control group without self-inflicted burns. Outcome measures included graft take rate, complications and need for further surgery. Results: There were a total of 2055 burn patient admissions, with 17 cases (0.8%) of self-inflicted burns. The mean age was 36±11 years with an mean percentage total body surface area (%TBSA) burned of 43.5±22.5% which was not significantly different from the control group (p=0.184). Schizophrenia and personality disorder were the most common diagnoses in the self-inflicted burns patients (n=11; 65%). Of these, four had sustained previous self-inflicted burns. Length of hospital stay was significantly longer in the self-inflicted burn group than in the control group (49.0±16.7 days, respectively, p=0.002). Conclusion: Attempted suicide by self-inflicted burns represents

Fluid management is one of the anticipated risk factors for intra-abdominal compartment syndrome (ACS). Since fluid requirements depend on the burned total body surface area (TBSA), an independent analysis is necessary to adapt resuscitation protocols and prevent this life-threatening complication. A retrospective multicenter study with matched-pair analysis was conducted in four German burn centers, including 38 burn patients with ACS who underwent decompressive laparotomy. Potential risk factors were analyzed, such as resuscitation volume, total fluid intake, mean fluid administration per day, fluid balance, and blood transfusion. The ACS group and control were compared with a two-tailed Mann-Whitney U test (P < .05). The ACS group was split up into an early and late ACS group for statistical subgroup analysis. Total fluid intake, fluid balance, and the total volume of colloids showed no significant difference in the ACS group (mean TBSA 50%) versus control (mean TBSA 49%). The subgroup analysis showed significant higher total resuscitation volume, fluid administration per kilogram body weight, and fluid balance in the first 24 hours in the late-onset ACS group. This study shows a different risk factor profile for early-onset ACS in the first 4 days after trauma and late-onset ACS. Herein, fluid therapy is a fundamental risk factor for late-onset ACS. In early-onset ACS, fluid administration contributes significantly to the development of intra-abdominal hypertension, but other risk factors seem to turn the balance for the development of early-onset ACS in burn patients.

Expert medical assessments are an integral part of a physician's sphere of activity today. Since subspecialisation is constantly advancing, there is often a limited pool of medical experts available for specific assessment matters. Medical experts have to assess the full proof of facts and the probability of correlations. As regards assessments issued to the statutory accident insurance, the issue of possible pre-existing conditions/damage plays an important role in the discussion surrounding the grounds for liability. Occasional causes or minor injuries are relevant for insurance claims and must be recognised.An insured person with an acral, non-arteriosclerotic circulatory disorder (thrombangiitis obliterans) was involved in an accident at work that resulted in a soft tissue skin defect and the need to amputate the finger. A vascular medical examination found that there was no occasional cause. A hand surgery expert proposed a 25 percent reduction in earning capacity. The accident insurance company followed the decision of the medical experts.Die Begutachtung ist ein Bestandteil der ärztlichen Tätigkeit. Da die Subspezialisierung in der Medizin stetig fortschreitet, sind die Gutachterkollektive für spezielle gutachterliche Fragestellungen häufig klein. Der ärztliche Gutachter hat Tatsachen im Vollbeweis und Zusammenhänge mit hinreichender Wahrscheinlichkeit zu bewerten. In der Begutachtung für die gesetzliche Unfallversicherung spielt in der Erörterung der Haftungsbegründung die Frage nach Vorerkrankungen/Schadensanlage eine wesentliche Rolle. Gelegenheitsursachen bzw. Bagatellverletzungen müssen erkannt werden, weil sich daraus eine Versicherungsrelevanz ergibt.Ein Versicherter mit einer akralen, nicht arteriosklerotischen Durchblutungsstörung (Thrombangiitis obliterans) erlitt einen Arbeitsunfall mit einem Haut-Weichteildefekt, in dessen Folge eine Fingeramputation erforderlich wurde. Das Vorliegen einer Gelegenheitsursache konnte nach gefäßmedizinischer Begutachtung widerlegt werden. Der handchirurgische Gutachter empfahl eine Minderung der Erwerbsfähigkeit von 25 von 100. Der Unfallversicherungsträger folgte der Entscheidung der ärztlichen Gutachter.

There is a pressing need for improved preclinical model systems in which to study human skin wound healing. Here, we report the development and application of a serum-free full thickness human skin wound healing model. Not only can re-epithelialization (epidermal repair) and angiogenesis be studied in this simple and instructive model, but the model can also be used to identify clinically relevant wound-healing promoting agents, and to dissect underlying candidate mechanisms of action in the target tissue. We present preliminary ex vivo data to suggest that Thyroxine (T4), which reportedly promotes skin wound healing in rodents in vivo, may promote key features of human skin wound healing. Namely, T4 stimulates re-epithelialisation and angiogenesis, and modulates both wound healing-associated epidermal keratin expression and energy metabolism in experimentally wound human skin. Functionally, the wound healing-promoting effects of T4 are at least partially mediated via fibroblast growth factor/fibroblast growth factor receptor-mediated signalling, since they could be significantly antagonized by bFGF-neutralizing antibody. Thus, this pragmatic, easy-to-use full-thickness human skin wound healing model provides a useful preclinical research tool in the search for clinically relevant candidate wound healing-promoting agents. These ex vivo data encourage further pre-clinical testing of topical T4 as a cost-efficient, novel agent in the management of chronic human skin wounds.

The aim of this study was to analyse retrospectively the pre- and intraoperative factors influencing flap loss after free flap coverage of septic skin defects caused by osteitis of the lower extremity with an anterolateral thigh flap (ALT) or latissimus dorsi (LD) flap.Twenty-seven patients were surgically treated with LD flap coverage and 45 patients with ALT flap coverage between 2004 and 2013. Their anthropometric, pre- and intraoperative parameters were investigated retrospectively.Flap survival was 81.5 % for LD flaps and 82.2 % for ALT flaps. Major complications led to a significantly higher flap loss both in LD (p = 0.01) and ALT flaps (p 0.0001). Furthermore, there was a significant increase in flap loss with pre-existing diabetes mellitus in the LD group (p = 0.001) and with acute osteomyelitis being the underlying cause of the soft tissue defect in the ALT group (p = 0.034). Regardless of the flap's postoperative success, LD flaps were used for significantly larger soft tissue defects to be reconstructed (p = 0.001), with the duration of surgery (p 0.0001) and cold ischaemia time (p = 0.001) being significantly longer compared with ALT flaps.The success of microsurgical flap reconstruction in lower extremities after osteitis was influenced by a low number of cases with preexisting diabetes mellitus, causative acute osteomyelitis, and major complications. Therefore, optimal management of both parameters and precise microsurgical anastomosis are prerequisites for successful plastic reconstruction of soft tissue defects.Ziel der vorliegenden Arbeit war es, Einflussfaktoren für den Verlust von Lappen nach plastischer Rekonstruktion von septischen Hautweichteildefekten bei Osteitis der unteren Extremität mit freiem mikrovaskulären anterolateralen Oberschenkellappen (ALT) oder Latissimus dorsi (LD)-Lappen zu identifizieren.Zwischen 2004 und 2013 wurden aufgrund von septischen Hautweichteildefekten bei Osteitis der unteren Extremität 27 Patienten mit LD-Lappen und 45 Patienten mit ALT-Lappen rekonstruiert und deren anthropometrische, prä- und intraoperative Parameter retrospektiv statistisch ausgewertet.Die Lappen-Überlebensrate betrug für den LD 81,5 % und für den ALT 82,2 %. Major-Komplikationen resultierten sowohl bei LD-Lappen (p = 0,01) als auch bei ALT-Lappen (p 0,0001) signifikant häufiger im Untergang des Lappens. Weiterhin fand sich ein signifikant erhöhter Lappenverlust bei vorbestehendem Diabetes mellitus in der LD-Gruppe (p = 0,001) und bei akuter Osteomyelitis als Ursache für den Hautweichteildefekt in der ALT-Gruppe (p = 0,034). Unabhängig vom postoperativen Erfolg der Lappenplastik wurden LD-Lappen für signifikant größer zu rekonstruierende Hautweichteildefekte genutzt (p = 0,001), deren Operationsdauer (p 0,0001) und kalte Ischämiezeit (p = 0,001) signifikant länger war.Das Gelingen der Lappenplastik bei Osteitis der unteren Extremität wurde trotz geringer Patientenzahl mit vorbestehenden Diabetes mellitus, mit einer ursächlichen akuten Osteomyelitis und Major-Komplikationen beeinflusst, so dass die optimale Behandlung beider Parameter und eine präzise mikrochirurgische Anastomosentechnik Grundvoraussetzungen für die erfolgreiche plastische Hautweichteilrekonstruktion sind.

The combination of an aging population and an increasing prevalence of diseases associated with impaired-wound healing, including obesity, peripheral vascular disease and diabetes, is likely to result in a dramatic increase in the incidence and prevalence of chronic skin wounds. Indeed, systemic reviews are now not only trying to establish both the prevalence and the often under-estimated socio-economic costs of chronic skin wounds, but most importantly are addressing the impact that chronic wounds have on quality of life. Given the clear need for novel approaches to the management of chronic skin ulceration, ideally developed and tested in the human system in a manner that can be rapidly translated into clinical practice, we examined the effects of multipotent primary human nestin

Background Electrical injuries represent life-threatening emergencies. Evidence on differences between high (HVI) and low voltage injuries (LVI) regarding characteristics at presentation, rhabdomyolysis markers, surgical and intensive burn care and outcomes is scarce. Methods Consecutive patients admitted to two burn centers for electrical injuries over an 18-year period (1998–2015) were evaluated. Analysis included comparisons of HVI vs. LVI regarding demographic data, diagnostic and treatment specific variables, particularly serum creatinine kinase (CK) and myoglobin levels over the course of 4 post injury days (PID), and outcomes. Results Of 4075 patients, 162 patients (3.9%) with electrical injury were analyzed. A total of 82 patients (50.6%) were observed with HVI. These patients were younger, had considerably higher morbidity and mortality, and required more extensive burn surgery and more complex burn intensive care than patients with LVI. Admission CK and myoglobin levels correlated significantly with HVI, burn size, ventilator days, surgical interventions, amputation, flap surgery, renal replacement therapy, sepsis, and mortality. The highest serum levels were observed at PID 1 (myoglobin) and PID 2 (CK). In 23 patients (14.2%), cardiac arrhythmias were observed; only 4 of these arrhythmias occurred after hospital admission. The independent predictors of mortality were ventilator days (OR 1.27, 95% CI 1.06–1.51, p = 0.009), number of surgical interventions (OR 0.47, 95% CI 0.27–0.834, p = 0.010) and limb amputations (OR 14.26, 95% CI 1.26–162.1, p = 0.032). Conclusions Patients with electrical injuries, HVI in particular, are at high risk for severe complications. Due to the need for highly specialized surgery and intensive care, treatment should be reserved to burn units. Serum myoglobin and CK levels reflect the severity of injury and may predict a more complex clinical course. Routine cardiac monitoring > 24 h post injury does not seem to be necessary.

Based on a representative case, which was treated in our center for severe burn injuries, the severity of the Waterhouse-Friderichsen syndrome and the complexity of the prolonged course of treatment are illustrated. Special attention is focused on the new treatment paradigm using the CytoSorb® adsorber.

Worldwide, chronic wounds are still a major and increasing problem area in medicine with protracted suffering of patients and enormous costs. Beside conventional wound treatment, for instance kinds of oxygen therapy and cold plasma technology have been tested, providing an improvement in the perfusion of wounds and their healing potential, but these methods are unfortunately not sufficiently validated and accepted for clinical practice to date. Using hyperspectral imaging technology in the visible (VIS) and near infrared (NIR) region with high spectral and spatial resolution, perfusion parameters of tissue and wounds can be determined. We present a new compact hyperspectral camera which can be used in clinical practice. From hyperspectral data the hemoglobin oxygenation (StO2), the relative concentration of hemoglobin [tissue hemoglobin index (THI)] and the so-called NIR-perfusion index can be determined. The first two parameters are calculated from the VIS-part of the spectrum and represent the perfusion of superficial tissue layers, whereas the NIR-perfusion index is calculated from the NIR-part representing the perfusion in deeper layers. First clinical measurements of transplanted flaps and chronic ulcer wounds show, that the perfusion level can be determined quantitatively allowing sensitive evaluation and monitoring for an optimization of the wound treatment planning and for validation of new treatment methods.

Nerve injuries with severe soft tissue damage are rare and demand a complex and individualized treatment approach, in order to limit medical and socioeconomic consequences. Since uniform systematic evidence so far is lacking, inconsistent therapy standards are implemented depending on individual experiences and background of respective microsurgeons.In order to provide best conditions for further healing, basic expert consensus statements were developed in a workshop on the 38th Annual Meeting of the German-speaking Community for Microsurgery of the Peripheral Nerves and Vessels (DAM).Statements were consented in regard of the aspects: timing of nerve and soft tissue repair, techniques of nerve repair, as well as rehabilitation and healing process control.Nervenverletzungen mit schwerem Weichteilschaden sind selten und bedürfen einer komplexen, individualisierten Behandlungsstrategie, um die resultierenden medizinischen und sozioökonomischen Folgen möglichst gering zu halten. Da bisher eine einheitliche systematische Evidenz fehlt, werden abhängig vom individuellen Erfahrungstand der versorgenden Mikrochirurgen uneinheitliche Therapiestandards angewendet. Um beste Voraussetzungen für deren weiteren Heilungsverlauf zu schaffen, wurden in einem Konsensusworkshop der 38. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) Konsensusempfehlungen von einer Expertengruppe erarbeitet. Diese beinhalten die Aspekte Zeitpunkt der Nerven- und Weichteilversorgung, Versorgungsstrategien, sowie Rehabilitation und Heilverfahrenssteuerung.

Sepsis is a well-recognized healthcare issue worldwide, ultimately resulting in significant mortality, morbidity and resource utilization during and after critical illness. In its most severe form, sepsis causes multi-organ dysfunction that produces a state of critical illness characterized by severe immune dysfunction and catabolism. Sepsis induces the activation of complement factor via 3 pathways and the release of inflammatory cytokines such as tumor necrosis factor alpha (TNF-α) and interleukin-1beta (IL-1β), resulting in a systemic inflammatory response. The inflammatory cytokines and nitric oxide release induced by sepsis decrease systemic vascular resistance, resulting in profound hypotension. The combination of hypotension and microvascular occlusion results in tissue ischemia and ultimately leads to multiple organ failure. Several clinical and experimental studies have reported that treatment using adsorption of cytokines is beneficial during endotoxemia and sepsis. This review article analyzes the efficacy of CytoSorb® adsorber in reducing the inflammatory response during sepsis. The CytoSorb® adsorber is known to have excellent adsorption rates for inflammatory cytokines such as IL-1β, IL-6, IL-8, IL-10, and TNF-α. Studies have demonstrated that treatment with cytokine adsorbing columns has beneficial effects on the survival rate and inflammatory responses in animal septic models. Additionally, several cases have been reported in which treatment with cytokine adsorbing columns is very effective in hemodynamic stabilization and in preventing organ failure in critically ill patients. Although further investigations and clinical trials are needed, treatment with cytokine adsorbing columns may play an important role in the treatment of sepsis in the near future.

Nerve conduits are nonneural, hollow tubular structures designed to bridge the gap of a sectioned nerve, to protect the nerve from scar formation, and to guide the regenerating fibers into the distal nerve stump. In the 8-year experience of our department, four patients aged 14 to 50 years had an unsuccessful implantation of a nerve conduit (NeuraGen, Integra, Plainsboro, NJ). In these four patients, the collagen tubes were replaced by an autogenous nerve graft. The histological specimens showed characteristic histological findings of a scar neuroma without any signs of foreign body reaction in three cases and with minimal foreign body reaction in one case. The collagen nerve tube was completely resorbed in all cases after a time period of 6 to 17 months and could not be detected marco- or microscopically. To our knowledge, this is the first report in the English and German literature describing the histological characteristics of explanted collagen nerve tubes in humans.

Nipple-areola complex (NAC) reconstruction tends to be the final phase of post-mastectomy reconstruction for many cancer patients, as it transforms the amorphous breast mound into a more aesthetically realistic breast. A variety of local-flap based techniques have been reported. In this paper we will describe a cantral-pedicled intracorial skin flap technique. Review of 12 patients showed aesthetic pleasing NAC and durable long-term results of nipple projection.

Background Electrosurgical instruments – one of the useful and most-used instruments within the surgeon's armamentarium – are potentially dangerous by causing unanticipated direct burns; fire occurring as a result of electrosurgical instruments and electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device. Methods The Mega 2000 Patient Return Electrode System produced by Megadyne Medical Products is a noncontact electrode designed to provide adequate electrical return to facilitate function of electrocautery devices. We used this noncontact device in 67 patients (28 women, 39 men) with large burns during their stay in our burn unit and in 11 of these patients (4 women, 7 men) for escharotomies during admission in our burn care. Results The device functioned well in all cases, no additional cutaneous burns on the patients’ body were noticed. Conclusion This paper is a review of our experience with this noncontact electrosurgical grounding in burn surgery highlighting its advantages comparing with the conventional electrosurgical instruments.

Cutaneous wound repair in adult mammals typically does not regenerate original dermal architecture. Skin that has undergone repair following injury is not identical to intact uninjured skin. This disparity may be caused by differences in the mechanisms that regulate postnatal cutaneous wound repair compared to embryonic skin development and thus we seek a deeper understanding of the role that Wnt signaling plays in the mechanisms of skin repair in both fetal and adult wounds. The influence of secreted Wnt signaling proteins in tissue homeostasis has galvanized efforts to identify small molecules that target Wnt-mediated cellular responses. Wnt signaling is activated by wounding and participates in every subsequent stage of the healing process from the control of inflammation and programmed cell death, to the mobilization of stem cell reservoirs within the wound site. Endogenous Wnt signaling augmentation represents an attractive option to aid in the restoration of cutaneous wounds, as the complex mechanisms of the Wnt pathway have been increasingly investigated over the years. In this review, we summarize recent data elucidating the roles that Wnt signaling plays in cutaneous wound healing process.

Human adipose-derived stroma cells (ADSCs) have successfully been employed in explorative therapeutic studies. Current evidence suggests that ADSCs are unevenly distributed in subcutaneous adipose tissue; therefore, the anatomical origin of ADSCs may influence clinical outcomes. This study was designed to investigate proliferation and differentiation capacities of ADSCs from the gluteal and abdominal depot of 8 females. All had normal BMI (22.01 ± 0.39 kg/m(2) ) and waist circumference (81.13 ± 2.33 cm). Examination by physicians and analysis of 31 laboratory parameters did not reveal possibly confounding medical disorders. Gluteal and abdominal adipose tissue was sampled by en bloc resection on day 7 (±1) after the last menses. Histological examination did not reveal significant depot-specific differences. As assessed by BrdU assay, proliferation of cells from both depots was similar after 24 h and analysis of 15 cell surface markers by flow cytometry identified the isolated cells as ADSCs, again without depot-specific differences. ADSCs from both depots differentiated poorly to chondroblasts. Gluteal ADSCs displayed significantly higher adipogenic differentiation potential than abdominal cells. Osteogenic differentiation was most pronounced in gluteal cells, whereas differentiation of abdominal ADSCs was severely impaired. Our data demonstrate a depot-specific difference in ADSC differentiation potential with abdominal cells failing to meet the criteria of multipotent ADSCs. This finding should be taken into account in future explorations of ADSC-derived therapeutic strategies.

Introduction: Nestin-expressing cells isolated from different human tissues reveal self-renewal capacity and a multilineage differentiation potential. In particular, adult stem/progenitor cell populations from exocrine glands such as the pancreas, salivary gland and sweat gland are characterized by prominent nestin expression. Interestingly, human mammary gland histological examinations also demonstrated the existence of nestin-positive cells in the ductal compartments. Within the scope of our previous work we wonder whether an isolation of nestin-positive cell populations from human mammary gland biopsies is possible and what characteristics they have in vitro. Cell populations from both sexes were propagated and subjected to a comparison with other gland-derived cell populations. Methods: Human mammary tissue biopsies were mechanically and enzymatically treated, and the isolated acini structures were observed with time-lapse microscopy to track adherently outgrowing cells. The proliferation potential of the cell population was assessed by performing growth curves. On the gene and protein levels we investigated the expression of stem cell markers as well as markers indicating multilineage differentiation. Results: We succeeded in establishing proliferating cell populations from breast tissue biopsies of both sexes. Our results display several similarities to the glandular stem cell populations from other exocrine glands. Beside their proliferation capacity during in vitro culture, the obtained cell populations are characterized by their prominent nestin expression. The cells share surface proteins commonly expressed on adult stem cells. We demonstrated the expression of stem cell-related genes like Oct4, Sox2, KLF4 and Nanog, and confirmed multipotent differentiation capacity by detecting transcripts expressed in endodermal, mesodermal and ectodermal cell types. Conclusion: With this study we present an efficient procedure for isolation and propagation of nestin-positive stem cells obtained from male and female breast tissue, which is frequently available. The established multipotent cell populations could be easily expanded in vitro and thus hold promise for cell-based therapies and personalized medicine.

Human skin harbours multiple different stem cell populations. In contrast to the relatively well-characterized niches of epidermal and hair follicle stem cells, the localization and niches of stem cells in other human skin compartments are as yet insufficiently investigated. Previously, we had shown in a pilot study that human sweat gland stroma contains Nestin-positive stem cells. Isolated sweat gland stroma-derived stem cells (SGSCs) proliferated in vitro and expressed Nestin in 80% of the cells. In this study, we were able to determine the precise localization of Nestin-positive cells in both eccrine and apocrine sweat glands of human axillary skin. We established a reproducible isolation procedure and characterized the spontaneous, long-lasting multipotent differentiation capacity of SGSCs. Thereby, a pronounced ectodermal differentiation was observed. Moreover, the secretion of prominent cytokines demonstrated the immunological potential of SGSCs. The comparison to human adult epidermal stem cells (EpiSCs) and bone marrow stem cells (BMSCs) revealed differences in protein expression and differentiation capacity. Furthermore, we found a coexpression of the stem cell markers Nestin and Iα6 within SGSCs and human sweat gland stroma. In conclusion the initial results of the pilot study were confirmed, indicating that human sweat glands are a new source of unique stem cells with multilineage differentiation potential, high proliferation capacity and remarkable self renewal. With regard to the easy accessibility of skin tissue biopsies, an autologous application of SGSCs in clinical therapies appears promising.

Severely burned patients need extensive initial fluid resuscitation. Formulas to calculate fluid needs during burn shock are well established. However, protocols for normalizing circulating fluid volume after cellular integrity has recovered do not exist. Resultant electrolyte shifts can cause hypernatremia, a possible sign of hypovolemia, which may in turn result in decreased tissue perfusion, subsequently affecting burn wound healing. The purpose of this retrospective chart review was to explore the hypothesis that hypernatremia in burn patients is a possible sign of systemic dehydration and that dehydration may affect burn wound skin graft take. Medical chart data from otherwise healthy burn victims with deep partial-thickness burns (total burn surface area [TBSA]10%) who underwent skin grafting 7 days post injury were reviewed. Thirty (11 female; 19 male) patients with an average TBSA of 30% (± 11%) and an Abbreviated Burn Severity Index (ABSI) score of 7.9 (± 1.8) were included. Of those, 17 had normal average serum levels between day 2 and 6 following injury and 13 developed hypernatremia (serum sodium ≥146 mmol/L) an average of 5.5 days (± 1.5) after injury. Patients in this group underwent an average of 1.3 (± 0.8) re-grafting procedures compared to 0.35 (± 0.5) for patients without hypernatremia (P = 0.001). There was good correlation (r = 0.525) between daily infusion-diuresis ratios (IDR) and serum sodium levels, as well as between serum sodium levels and re-skin grafting occurrences (r = 0.62). The results indicate that research to confirm that hypernatremia is an indicator of dehydration and affects skin graft take is warranted and that protocols to optimize fluid volume following burn shock treatment are needed.

Complete loss of free latissimus dorsi muscle flaps to the leg is frequently reported. The purpose of this study is to analyze the outcome of latissimus dorsi muscle flaps to the lower extremity in children.This retrospective analysis includes 11 children treated with a free latissimus dorsi muscle flap after severe trauma to the lower leg and foot.Fourteen free latissimus dorsi muscle flaps were performed in 11 children with a mean age of 13 ± 4 years. The injuries were caused by traffic accidents, lawnmower accidents, and a crush trauma. Thirteen (92.8%) flaps needed surgical revision. Three complete flap losses and 1 partial flap loss were registered.Free latissimus dorsi muscle flaps seem to be a useful technique for lower extremity salvage after severe injury, but there is a relevant flap failure risk in children.

Introduction: The skin protects against fluid and electrolyte loss. Burn injury does affect skin integrity and protection against fluid loss is lost. Thus, a systemic dehydration can be provoked by underestimation of fluid loss through burn wounds. Purpose: We wanted to quantify transdermal fluid loss in burn wounds. Method: Retrospective study. 40 patients admitted to a specialized burn unit were analyzed and separated in two groups without (Group A) or with (Group B) hypernatremia. Means of daily infusion-diuresis-ratio (IDR) and the relationship to totally burned surface area (TBSA) were analyzed. Results: In Group A 25 patients with a mean age of 47±18 years, a mean TBSA of 23±11%, and a mean abbreviated burned severity index (ABSI) score of 6.9±2.1 were summarized. In Group B 15 patients with a mean age of 47±22 years, a mean TBSA of 30±13%, and a mean ABSI score of 8.1±1.7 were included. Statistical analysis of the period from day 3 to day 6 showed a significant higher daily IDR-amount in Group A (Group A vs. Group B: 786±1029 ml vs. –181±1021 ml; p, GMS German Medical Science; 8:Doc28; ISSN 1612-3174

Frank Siemers *, Martin Struber , Peter Mailander , Alfred Berger , Hans-Gunther Machens a Plastic Surgery, Handsurgery, Burn Unit, University Hospital Schleswig Holstein, Campus Lubeck, Ratzeburger Allee 160, 23538 Lubeck, Germany Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany Department of Plastic, Hand and Reconstructive Surgery – Burn Unit, Hannover Medical School, Hannover, Germany