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Finger- und Mittelhandknochen (MHK)-Frakturen gehoren zu den haufigsten Frakturen des menschlichen Korpers. Die fruhzeitige Diagnose und Behandlung dieser Frakturen sind essenziell fur ein gutes funktionelles Ergebnis der verletzten Hand. Wir berichten uber die Symptomatik, Diagnostik, Klassifikation und uber die Behandlung dieser Frakturen je nach Lokalisation und Typ. Phalangeal and metacarpal fractures are among the most common fractures of the human body. The early diagnosis and treatment of these fractures are essential for a good functional result of the injured extremity. We report the symptoms, diagnosis, and classification and the treatment of these fractures depending on the type and location of the fracture.

Zusammenfassung Hintergrund Seit 2015/16 werden Forschungsanträge aus Sektionen, Abteilungen und Kliniken für Plastische Chirurgie an den Universitätskliniken Deutschlands durch die Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) gesammelt, ausgewertet und 2-jährlich veröffentlicht. Ziel ist es, dadurch die Forschungsleistung der Plastischen Chirurgen in Deutschland öffentlich sichtbar zu machen, um eine Stärkung der akademischen Forschungsstruktur in Deutschland zu erreichen. Material und Methoden Die Leiter der universitären Einrichtungen wurden über den Verteiler der DGPRÄC kontaktiert und um Mitteilung der beantragten, in Begutachtung befindlichen, abgelehnten und geförderten Projekte jeglicher öffentlicher, nicht-öffentlicher, industrieller oder anderer Förderinstitute in die eigens dafür erstellte online Datenbank gebeten: https://docs.google.com/forms/d/e/1FAIpQLSe6F5xmTyw-k7VKJx_2jkPA4LBXsA0sgBGMrC3rx_4bHj6uzQ/viewform?usp=sf_link. Zusätzlich wurden Anträge über die öffentliche Datenbank der Deutschen Forschungsgemeinschaft (DFG), dem Geförderte Projekte Informationssystem (GEPRIS), identifiziert. Ergebnisse Eine Gesamtzahl von 41 Förderanträgen aus den öffentlichen Förderinstituten DFG, BMBF, BMWi, BMG und EU konnte identifiziert werden. 75,6 % (31/41) der Anträge waren zum Zeitpunkt der Datenerhebung bereits bewilligt, davon waren 77,4 % (24/31) DFG-, 9,7 % (3/31) BMWi-, 6,5 % (2/31) EU- und je 3,2 % (1/31) BMBF- und BMG-Anträge. Das durchschnittliche Fördervolumen entsprach 358 301 Euro. Die bewilligten DFG-Anträge waren in 50,0 % (12/24) der Fälle ausschließlich bzw. unter anderem dem Fachkollegium 205–27 Orthopädie, Unfallchirurgie, rekonstruktive Chirurgie zugeordnet. Schlussfolgerung Mithilfe der vorgelegten Forschungsförderungsberichte des Konvents der leitenden universitär tätigen Plastischen Chirurgen der DGPRÄC erfolgt die Veröffentlichung der exzellenten gemeinschaftlichen akademischen Forschungsleistung in unserem Fachgebiet.

Despite the clinical importance of deep wrist injuries (DWIs), data comparing the outcome of suicide attempt survivors vs. accident survivors are lacking. Patients admitted to our Clinic for acute treatment of a DWI from 2008 to 2016 were contacted for a follow-up assessment of sensory, motor and functional outcomes. Patients also completed the Disability of the Arm, Shoulder and Hand Questionnaire, the Modified Mayo Wrist Score, the Boston Carpal Tunnel Questionnaire, and the WHOQOL-BREF questionnaires. 51 patients could be followed up, on average 4.3 ± 2.9 years after their injury. Suicide attempt survivors did not differ from accidents survivors concerning two-point discrimination, grip and pinch strength, but showed poorer outcomes in self-reported disability, symptom severity, and quality of life. Patients with DWIs from suicide attempts vs. accidents do not differ in sensorimotor outcomes but patient-reported outcome measures. Level of Evidence: II.

Despite the clinical importance of deep wrist injuries (DWIs), data on the timeframe of possible improvements in hand function are scarce. We tested the hypotheses that a) the length of follow-up is positively correlated with the outcome, and b) this correlation is tempered by nerve involvement. All patients admitted to the Clinic of Plastic Surgery with an acute DWI between 2008 and 2016 were contacted for a follow-up examination including two-point discrimination, range of motion, grip, and pinch strength, as well as DASH and MMWS questionnaires and employment status. Possible confounders such as age, handedness, and intentionality of the injury (accidental or suicidal) were assessed and controlled for statistically. Fifty-three patients were reviewed (74% male and 26% female, 86% right-handed, 70% accidental injuries, mean age at injury 42.0 ± 17.1 years), an average of 4.3 ± 2.9 years after their injury. In patients with a nerve injury, length of follow-up had significant effects on two-point discrimination, grip and pinch strength, self-reported symptom severity and impairment. Contrary to conventional knowledge, the clinical outcome of DWIs may improve beyond 3 years when there is nerve involvement. This important prognostic finding has far-reaching implications for both clinicians (e.g., asked to give their medical opinion) and patients (e.g., considering re-training after a DWI).

Objective As suicide attempts by definition entail at least some threat to physical integrity and life, they theoretically qualify as an A1 criterion for posttraumatic stress disorder (PTSD). This study uses the unique opportunity of deep wrist injuries to quantify the effect of intentionality on PTSD rates by comparing suicide attempt survivors with patients who sustained accidental injuries similar in mechanism, localization, and extent. Method Patients who had been admitted with an acute deep wrist injury from 2008 to 2016 filled out the revised Impact of Event Scale and reported other known PTSD risk factors. Mental morbidity and intentionality of the injury were determined by psychiatric consultation during the index hospitalization. Results Fifty-one patients were followed up (72.5% male, 92.2% Caucasian, mean age at injury 42.3 ± 17.5 years, 72.5% accidental injuries), on average 4.2 ± 2.9 years after their injury. The intentionality of the injury alone predicted the severity of intrusions, avoidance, hyperarousal, and probable PTSD (aOR = 14.0). Conclusions Traumatization in the context of a suicide attempt may be a hitherto unknown PTSD risk factor. Patients after suicide attempts, especially medically serious attempts, should be monitored for PTSD symptoms.

Zusammenfassung Hintergrund Dieser Bericht baut auf dem Forschungsförderungsbericht aus dem Jahr 2015/2016 auf und dient der Bekanntmachung der akademischen Forschungsleistung an Universitätskliniken der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) für 2017/2018. Berücksichtigt wurden dabei Anträge auf Forschungsförderung bei öffentlichen, nicht-öffentlichen, oder industriellen Förderinstituten. Gleichzeitig soll dieser Beitrag die Anzahl der genehmigten Anträge bei der Deutschen Forschungsgemeinschaft (DFG) aus der Plastischen Chirurgie, Thorax- und Gefäßchirurgie gegenüberstellen. Innerhalb dieser jüngeren selbständigen chirurgischen Fachgebiete wird das seit 1993 eigenständige Fachgebiet Plastische Chirurgie in der Fächerstruktur der DFG Fachkollegien immer noch nicht separat geführt, sondern dem Fachkollegium Orthopädie und Unfallchirurgie zugeordnet. Dies führt dazu, dass die Anträge nicht fachspezifisch begutachtet werden. Material und Methoden Die bereits etablierte online Datenbank (https://docs.google.com/forms/d/1OaSnHyKTysawiI1ie7kfUxDf7nJP_RiTUJTsnb7Mq_E/edit) zur Meldung beantragter/ genehmigter und abgelehnter Forschungsförderungen öffentlicher, nicht-öffentlicher und industrieller Förderinstitutionen wurde fortgeführt und gemeinsam mit den Anträgen aus der öffentlichen Datenbank der DFG, das Geförderte Projekte Informationssystem (GEPRIS), ausgewertet. Ergebnisse Im Vergleich zum letzten Beobachtungszeitraum von 2015/2016 nahm die Anzahl genehmigter Anträge aus öffentlichen Einrichtungen (DFG, BMBF, BMWi, EU) von 23 auf 27 zu. Aus den chirurgischen Fachgebieten Thorax- und Gefäßchirurgie waren jeweils 9 bzw. 8 DFG Anträge im GEPRIS dokumentiert, wohingegen 19 Bewilligungen von Anträgen der Plastischen Chirurgie identifiziert wurden. Schlussfolgerung Durch die vorliegende Auswertung konnten wir zeigen, dass das Aufkommen an Anträgen aus dem Fachgebiet der Plastischen Chirurgie denen der anderen eigenständig geführten Fachgebiete entspricht, wobei sogar eine höhere Anzahl zu verzeichnen ist. Vor diesem Hintergrund ist die gegenwärtige Subsummierung seitens der DFG, auch im Hinblick auf eine öffentlich nachvollziehbare Vergabe der Fördersummen, nicht zu akzeptieren.

Infections are a major problem in patients with burn diseases. Mortality is high despite antibiotic therapy as studies are controversial concerning drug underdosing. The aims of this prospective, observational study were to monitor plasma concentrations of piperacillin during standard piperacillin/tazobactam treatment in 20 burn patients and 16 controls from the intensive care unit (ICU) and to optimize doses by in silico analyses. Piperacillin/tazobactam (4/0.5 g, tid) was administered over 0.5 h. Blood samples were taken at 1, 4, and 7.5 h after the end of the infusion. Free piperacillin plasma concentrations were determined. Pharmacokinetic parameters and in silico analysis results were calculated using the freeware TDMx. The primary target was defined as percentage of the day (fT>1xMIC; fT>4xMIC) when piperacillin concentrations exceeded 1xMIC/4xMIC (minimum inhibitory concentration), considering a MIC breakpoint of 16 mg/L for Pseudomonas aeruginosa. In an off-label approach, two burn patients were treated with 8/1 g piperacillin/tazobactam, 3 h qid. fT>1xMIC (55 ± 22% vs. 77 ± 24%) and fT>4xMIC (17 ± 11% vs. 30 ± 11%) were lower in burn than in ICU patients after 4/0.5 g, 0.5 h, tid. In silico analyses indicated that fT>1xMIC (93 ± 12% burn, 97 ± 4% ICU) and fT>4xMIC (62 ± 23% burn, 84 ± 19% ICU) values increase by raising the piperacillin dosage to 8/1 g qid and prolonging the infusion time to 3 h. Off-label treatment results were similar to in silico data for burn patients (84%fT>1xMIC and 47%fT>4xMIC). Standard dosage regimens for piperacillin/tazobactam resulted in subtherapeutic piperacillin concentrations in burn and ICU patients. Dose adjustments via in silico analyses can help to optimize antibiotic therapy and to predict respective concentrations in vivo. Trial registration: NCT03335137, registered 07.11.2017, retrospectively.

Background We report the Case of Prolidase - deficiency syndrome in a 3-year-old boy suffering from atraumatic compartment syndrome in both hands. Case description We discuss four areas of controversy. First, what could be the reason for an atraumatic compartment syndrome in both hands? Second, should we operate on a 3-year-old boy or use a conservative approach? Third, would we have chosen an operative approach knowing the underlying condition? Fourth, how should we proceed postoperatively? Conclusion We chose to operate him and performed a compartment release operation. He was treated interdisciplinary and discharged after fifteen days.

In addition to the impact factor, research funding also plays a central role in evaluating the academic performance and quality of a researcher, a clinic or a surgical specialty. The scope and quality of research in Plastic Surgery are usually very little known, so that even large funding institutions do not get a full view of research funding in our specialty. Therefore, sometimes traditional structures are not adapted to new needs by the developing younger surgical fields. In peer review sometimes peers are not chosen from the same surgical specialty, but from a different surgical fields being peers in large field of surgery. By this a bias can easily be generated which would not be advantageous for subspecialties such Plastic Surgery. The goal of this paper is to establish an overview in the form of a registry of the German Society of Plastic Reconstructive and Aesthetic Surgeons (DGPRAC) in order to make the joint academic achievements more visible in the future. At the same time, a research funding report is to be published for the years 2015 and 2016.

Background:. Despite the clinical importance of suicidal deep wrist injuries (DWIs), we currently do not know whether their injury patterns differ from accidental injuries. Methods:. This retrospective study included all patients admitted to the Clinic of Plastic Surgery for acute treatment of a DWI from 2008 to 2016, except for isolated injuries to the palmaris longus (PL) and amputations. Intentionality of the injury was determined using documentation of psychiatric evaluations; cases that could not be categorized regarding intentionality were excluded. Results:. About 20% of DWIs stemmed from suicide attempts, which involved the nondominant hand in 94.5%. Suicidal DWIs were more likely to involve the median nerve, radial artery, PL, and flexor carpi radialis (FCR), especially on the nondominant hand, but were less likely to involve the ulnar artery and nerve on the dominant hand. The effect of the protective structures PL/flexor carpi ulnaris on the median nerve/ulnar artery could be confirmed for suicidal DWIs, but intactness of the FCR was associated with increased radial artery injuries. Longitudinal cut orientation in suicidal DWIs was associated with more radial artery injuries, but fewer injuries to tendons and nerves. Frequencies of various other injury constellations are tabulated to aid in clinical assessment. Conclusions:. Suicidal and accidental DWIs differed in various aspects of injury pattern. Suicidal injuries were mostly localized to the nondominant radial side, and accidental injuries to the ulnar side. Also, the so-called protective structure FCR had the opposite effect in suicidal injuries. Thus, findings regarding injury patterns in accidental DWIs cannot be generalized to suicidal injuries.

Background Extracorporeal shock wave treatment (ESWT) has proven its clinical benefits in different fields of medicine. Tissue regeneration and healing is improved after shock wave treatment. Even in the case of burn wounds angiogenesis and re-epithelialization is accelerated, but ESWT in extensive burn wounds is impracticable. Hypothesis High energy ESWT influences cutaneous microcirculation at body regions remote from application site. Methods Eighteen Sprague Dawley rats were randomly assigned to two groups and received either high energy ESWT (Group A: total 1000 impulses, 10 J) or placebo shock wave treatment (Group B: 0 impulses, 0 J), applied to the dorsal lower leg of the hind limb. Ten minutes later microcirculatory effects were assessed at the contralateral lower leg of the hind limb (remote body region) by combined Laser-Doppler-Imaging and Photospectrometry. Results In Group A cutaneous capillary blood velocity was significantly increased by 152.8% vs. placebo ESWT at the remote body location (p = 0.01). Postcapillary venous filling pressure remained statistically unchanged (p > 0.05), while cutaneous tissue oxygen saturation increased by 12.7% in Group A (p = 0.220). Conclusion High energy ESWT affects cutaneous hemodynamics in body regions remote from application site in a standard rat model. The results of this preliminary study indicate that ESWT might be beneficial even in disseminated and extensive burn wounds by remote shock wave effects and should therefore be subject to further scientific evaluation.

In diesem Artikel beschreiben wir unsere Erfahrungen bei der Versorgung von Veratzungen mit Diphoterine® und Suprathel®, eine Behandlung, die bei diesen Verletzungsmustern in der Vergangenheit eher im Hintergrund stand. Im untersuchten Zeitraum von Oktober 2012 bis Dezember 2013 behandelten wir 5 Patienten (4 m, 1 w, 2 Kinder und 3 Erwachsene) mit Veratzungen durch Diphoterine®-Spulung und Suprathel®-Auflage. Die Kontrollgruppe beinhaltete 5 Patienten mit ahnlichem Verletzungsmuster, die mit Diphoterine® und Okklusionsverbande behandelt wurden. Es traten keinerlei Wundinfektionen auf und eine Interaktion zwischen Suprathel® und der auslosenden Chemikalie war in keinem der Falle zu beobachten. In den 4 Fallen zeigte sich bei den IIa°-IIb°-Arealen eine gute Wundheilung mit diskreter Narbenbildung im Hautniveau in der Verlaufskontrolle nach 3 Monaten, einer der 5 Patienten musste im Verlauf chirurgisch behandelt werden. Der Verbrennungsmedizin steht mit Suprathel® ein temporarer Hautersatz zur Verfugung auch zur Behandlung von Veratzungen.

Summary:. An osteoid osteoma is a rare benign tumor of the carpal bones. It is extremely rarely found in the lunate bone in patients above 30 years of age. We present a case report of a 61-year-old man with an osteoid osteoma of the left wrist, which was masked by degenerative carpal bone disease and a comorbidity of an inflammatory bowel disease. The mainstay of imaging including plain radiographs, computed tomography, magnetic resonance imaging, and bone scintigraphy led to the clinical diagnosis of a lunatomalacia. The tumor was removed by coincidence during removal of the diseased lunate bone. Postoperatively, the patient was immediately free of pain and remained free at his 3 months postoperative follow-up.

Solitary primary non-Hodgkin bone lymphoma of the hand is a rare entity with only 3 cases reported in the literature. We report the case of a 77-year-old patient with isolated large B-cell bone lymphoma of the proximal phalanx of the little finger without rheumatoid arthritis or methotrexate treatment. The patient was treated with digital amputation and at 6 months' follow-up showed no relapse or dissemination of the disease.

Background Silicone implants have been used in breast augmentation for more than 45 years. Complications, in particular, capsular contracture, still occur with a high incidence. Titanium-coated polypropylene mesh (TCPM; TiLoop Bra®, pfm medical, Cologne, Germany) provides new opportunities for implant-based breast reconstruction. We investigated the influence of the surface of silicone implants on the formation of capsular contracture by comparing textured silicone with TCPM-covered smooth silicone implants.

Infektionen an der Hand stellen haufige Krankheitsbilder in handchirurgischen Abteilungen dar. Die richtige Diagnose und anschliesende Behandlung ist schwierig und wird oft unterschatzt. In der Literatur finden sich unterschiedliche, teils kontroverse Therapieempfehlungen. Die vorliegende Arbeit analysiert retrospektiv ein zweizeitiges Therapieregime. 60 Patienten (Durchschnitt: 51 Jahre, 38 mannlich, 22 weiblich) wurden retrospektiv anhand der Diagnose der Handinfektion (ICD L03.-) untersucht. Bei allen Patienten wurde ein zeitnahes radikales chirurgisches Debridement durchgefuhrt mit nachfolgender offener Wundbehandlung und antibiotischer Therapie. Untersucht wurde, inwieweit wahrend der Second-look-Operation, im Anschluss an eine Phase der offenen Wundbehandlung mit antiseptischen Verbanden, der sekundare Wundverschluss erfolgreich moglich war. Ein erfolgreicher sekundarer Wundverschluss konnte nach durchschnittlich 38,7 Stunden wahrend der Second-look OP bei 92% des Patientenkollektives erreicht werden. 8% der Patienten benotigten weitere Eingriffe. Bei diesen Patienten lag meist eine Grunderkrankungen oder eine verspatete Vorstellung mit initialer antibiotischer Vorbehandlung vor. Eine antibiotische Therapie wurde durchschnittlich fur 8,7 Tage durchgefuhrt. Die durchschnittliche sta­tionare Verweildauer lag bei 4,75 Tagen. Bei 85% der 58 nachuntersuchten Patienten konnte die ambulante Weiterbehandlung nach 3 Wochen, bei wiederhergestellter Funktion und Kraftmas der verletzten Hand, beendet werden. Eine Arbeitsunfahigkeit bestand im Durchschnitt fur 16 Tage. Die zweizeitige chirurgische Therapie stellte in unserem Kollektiv eine suffiziente Behandlung bei Handinfektionen dar. Sie ist ein sicheres Vorgehen, welches, kombiniert mit einer begleitenden antibiotischen Therapie, eine rasche Wiederherstellung der Funktionalitat der verletzten Hand ermoglicht.

Defektdeckung an der ulnaren Handkante, am ulnopalmaren Handgelenk und im Hypothenarbereich durch eine Abductor-digiti-minimi-Muskellappenplastik. Posttraumatische oder postinfektiose Weichteildefekte im Bereich der ulnaren Handkante, des ulnopalmaren Handgelenks und der Hypothenarregion. Osteitis des 5. Mittelhandknochens. Grose Defekte uber 3 × 5 cm, Verletzungen der A. ulnaris oder Verletzungen im Bereich des Gefasstiels. Zunachst Ausmessen des Rotationsradius des M. abductor digiti minimi ausgehend vom Os pisiforme, wobei das distale Lappenende auf Hohe des Grundgelenks lokalisiert ist. Anschliesend ulnare Inzision und Aufsuchen des distalen Muskelansatzes und Absetzen desselben. Praparation des gesamten Muskelbauchs bis zu seinem proximalen Gefasstiel knapp distal des Os pisiforme. Einschwenken und Fixieren des Muskels in den Defekt und abschliesende Defektdeckung durch ein Spalthauttransplantat. Primarer Wundverschluss der Hebestelle. Ruhigstellung mittels palmarer Handgelenkschiene in „Intrinsic-Plus“-Stellung fur 10 Tage und Physiotherapie aus der Schiene heraus. Fettsalbenpflege des Spalthauttransplantats und Kompressionshandschuh nach Mas fur ca. 3 Monate. Bei insgesamt 9 Patienten zuverlassige Defektdeckung bei relativ einfacher Praparation und konstanter Anatomie.

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.

Der Einfluss von Silikonimplantaten auf die Ausbildung einer periprothetischen Kapsel lasst sich gut in tierexperimentellen Studien untersuchen. Neue Oberflachen der Implantate wurden entwickelt, um die Inzidenz der Kapselfibrose zu reduzieren. Zur Begutachtung der Kapselbildung wurde von Wilflingseder et al. 1974 ein histologisches Beurteilungssystem entwickelt. Aufgrund von umfangreichen neuen Erkenntnissen uber die Kapselfibrose ist diese Klassifikation nicht mehr zeitgemas. Aktuelle Erkenntnisse werden nicht berucksichtigt, sodass eine Modifikation erforderlich ist. In einer randomisierten, tierexperimentellen Studie wurden insgesamt 31 Mini-Implantate [17 glatte, 10 mL kochsalzgefullte, Silikonimplantate (Gruppe A) und 14 titanisierte Silikonimplantate (Gruppe B)] in das Dorsum von weiblichen Wistar Ratten implantiert. Nach 12 (Gruppe A/B12) bzw. 36 (Gruppe A/B36) Wochen erfolgte die chirurgische Entfernung mit nachfolgender histomorphologischer und immunhistochemischer Untersuchung der periprothetischen Kapselformation durch 2 unabhangigen Untersucher doppelblind. Die Auswertung der Untersuchungen ergab, dass die innere synovia-like-metaplasia (SLM) sowie die Infiltration durch Entzundungszellen wie Lymphozyten, Histiozyten, Granulozyten und Plasmazellen, entscheidend mitverantwortlich fur die Entwicklung der fibrotischen Kapsel zu sehen sind. Ihr Auftreten korrelierte signifikant miteinander und beeinflusst die Kapselarchitektur masgeblich, wesentlich beeinflusst durch die Oberflache. Aus den gewonnenen Ergebnissen erfolgte eine Anpassung des bestehenden Wilflingseder Klassifikationssystems. Das aktuelle Bewertungsschema enthalt nun folgende Parameter: Kapseldicke, Zelllagen der Kapsel, Dicke der SLM, Kollagenstruktur, Vorkommen von Histiozyten sowie Auftreten von Entzundungszellen. Titanisierte Implantate zeigen nach diesem Klassifikationsschema einen Vorteil in Bezug auf die Ausbildung der Kapselfibrose. Das von Wilflingseder et al. 1974 entwickelte Klassifikationssystem uber die histologische Einteilung der Kapselfibrose ist nicht mehr zeitgemas, da es die aktuellen histologischen und immunhistochemischen Untersuchungsergebnisse nicht berucksichtigt. Der hier vorgestellte, weiterentwickelte Score schliest die neusten Erkenntnisse uber die Entstehung der Kapselfibrose ein und ermoglicht eine objektive histologische Klassifizierung der Veranderungen. Des Weiteren konnten wir zeigen, dass titanisierte Implantate einen vielversprechenden Ansatz in der Reduktion der Kapselfibrose darstellen.

Selbstverletzungen stellen eines der Hauptkriterien der Borderline-Personlichkeitsstorung dar. Dabei bedurfen thermische Verletzungen von Borderline-Patienten der Behandlung des plastischen Chirurgen, der sich aufgrund der komplexen psychiatrischen Storung der Patienten insbesondere bei repetitiven Verletzungen einer sein Fachgebiet uberschreitenden Herausforderung gegenuber sieht. Diese ist nur durch eine multidisziplinare Behandlungsstrategie zu bewaltigen. Anhand von 3 Fallbeispielen soll die Problematik der Behandlung im Spannungsfeld zwischen dem Bestreben nach einer optimalen plastisch-chirurgischen Behandlung der thermischen Verletzung einerseits und der Limitierung dieser Behandlung aufgrund der akuten psychischen Situation der Patienten andererseits dargestellt werden.

Borderline personality disorder (BPD) is a mental illness with a prevalence of 1.5% in Western countries. One of the major characteristics of patients with BPD is self-mutilation of any kind. These patients are especially often seen in our clinic since our institution is collaborating with the department of psychiatry that offers supra-regional specialist inpatient hospital treatment of BPD. Types of self-manipulation are various and include slashing and cutting, burning or freezing, bonebreaking, hitting or incorporation of foreign objects. Due to the difficult-to-treat primary disorder, more wound manipulation or self-injury may occur when tensions continue, even after adequate plastic reconstructive surgical treatment and during hospitalization, which represents a challenge for the plastic reconstructive strategy. We describe special problems associated with plasticreconstructive surgery in the light of BPD and self-mutilation and present our algorithm with a series of recommendations for the treatment of such patients as well as three illustrative case reports.

INTRODUCTION Toxic epidermal necrolysis (TEN) is associated with a high mortality. The need for mechanical ventilation is associated with an increased mortality in TEN patients. This study investigates the impact of the timing of initiation of the mechanical ventilation on the survival of TEN patients. PATIENTS, MATERIALS AND METHODS A retrospective study of 26 TEN patients was carried out. Primary (on admission (group A) and secondary ventilation (>1 day after admission (group B) were analysed for an association with mortality. RESULTS 8 patients did not require mechanical ventilation. 18 patients needed mechanical ventilation. In group A 8 patients with an epidermolytic body surface area (BSA) of 73 ± 16% and a mean SCORTEN of 3.2 ± 1.1 were analysed. In group B 10 patients with an epidermolytic BSA of 76 ± 19% and a mean SCORTEN of 3.8 ± 0.9 were evaluated. Statistical analysis showed an increased mortality in all mechanically ventilated compared with non-ventilated TEN patients (Odds ratio: 2.0; 95% CI: 1.26-3.17 p = 0.013). CONCLUSIONS Mechanical ventilation in TEN patients is associated with an increased mortality rate, but the timing of initiation of mechanical ventilation does not affect the patient survival rates.

Burn injury is a complex traumatic event with various local and systemic effects, affecting several organ systems beyond the skin. The pathophysiology of the burn patient shows the full spectrum of the complexity of inflammatory response reactions. In the acute phase, inflammation mechanism may have negative effects because of capillary leak, the propagation of inhalation injury and the development of multiple organ failure. Attempts to mediate these processes remain a central subject of burn care research. Conversely, inflammation is a necessary prologue and component in the later-stage processes of wound healing. In this review, we are attempting to present the current science of burn wound pathophysiology and wound healing. We also describe the evolution of innovative strategies for burn management.

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. Patients and methods. This retrospective analysis includes 11 children treated with a free latissimus dorsi muscle flap after severe trauma to the lower leg and foot. Results. 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. Conclusions. 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. © 2010 Wiley-Liss, Inc. Microsurgery 30:537–540, 2010.

Acute intestinal ischemia represents a rare but often fatal disease. In retrospective analysis, up to 86% with this complication had a prior history of cardiovascular disease (Irvinen et al. Ann Chir Gynaecol 83:22-25, 1994). It is also a rare but well-known complication in severe thermally injured patients. Here, we describe our experience with this disease in our critically ill patients suffering from acute thermal injury. In a retrospective analysis of 634 patients who were treated at our burn care center, three patients were identified with intestinal ischemia. Two patients with non-occlusive disease during continuous veno-venous hemofiltration died, while one patient with arterial embolism in a superior mesenteric artery branch survived. Acute intestinal ischemia is a severe and life-threatening complication in thermally injured patients. It can occur even days after the acute trauma and diagnostic criteria are often insecure.

Background: Free tissue transfer in reconstruction of lower extremity wounds is well established. Controversy surrounds type and regimen of intravenous fluid application during microsurgery. Hemodilution is supposed to influence haemostatic process. Patients and Methods: We performed an analysis of 48 patients treated with a free latissimus dorsi muscle flap to the lower leg for posttraumatic soft-tissue coverage. Postoperative latissimus dorsi muscle flap perfusion was controlled by clinical monitoring. Intraoperative infusion management was evlatuated retrospectively. Results: In 4 of 48 included patients, a complete loss of free latissimus dorsi muscle flap was registered. Concomitant increased saline infusion was detected (4,534 ml versus. 6,125 ml; P = 0.048). Similar findings for relation of total infusion volume to body weight were seen (44 ml/kg versus 69 ml/kg; P = 0.01). No significant colloid infusion was detected. Conclusions: We demonstrate the clinical relevance of extensive intraoperative hyperhydration, which can provoke a complete free flap loss. © 2010 Wiley-Liss, Inc. Microsurgery, 2010.

Nerve injuries are common in trauma surgery and appear more frequently if the upper extremity is affected. The aim of this study is to estimate possible predictors of the outcome after nerve injury of the upper extremity and to demonstrate feasible tools to follow up postoperative nerve regeneration for the daily clinical practice. During January 2000 until December 2004, a total of 372 nerve lesions of the upper extremity have been treated in our clinic. Patient's age, site of nerve lesion, concomitant injuries, and the timing of surgical repair could be outlined to be significant predictors for clinical outcome. Digital nerve lesions showed the best regenerative capacity. Most predictors of clinical outcome such as patient's age, concomitant injuries, and site of lesion cannot be influenced. But knowing the predictors helps specify the prognosis of nerve regeneration. For the daily clinical practice, static two-point discrimination, location of Tinel's sign, and grip strength measurement seem to be fast and reproducible tools to follow up nerve regeneration at the upper extremity.

Tubulization as an alternative to autologous nerve grafting successfully bridges relatively short nerve gaps. Digital nerve lesions are ideal for clinical outcome studies, but only a few data have been published so far. We are presenting our clinical experiences based on a review of the outcome and techniques in the current literature. Fifteen digital nerve lesions in 14 patients have been overcome by interpositional grafting of a hollow collagen I conduit. A follow-up of 12 months could be guaranteed in 12 cases. The mean nerve gap was 12.5 +/- 3.7 mm. Four out of 12 patients, assessed 12 months postoperatively, showed excellent sensibility (S4). Five patients achieved good sensibility, one poor, and two no sensibility. Our results confirm tubulization as one possible technique in nerve reconstruction. However, the indication has to be set carefully, and the operation still requires solid microsurgical skills, especially for proper handling and debridement of the severed nerve endings.

Adjuvant therapies may improve the outcome after nerve reconstruction. We analyzed the influence of recombinant human Erythropoietin (rHuEpo), which has proven angiogenic and neuroprotective effects, on the quality of peripheral nerve regeneration. Thirty two female Lewis rats underwent nerve reconstruction by means of tubulization (groups I and II) or autologous sciatic nerve grafting (groups III and IV). Groups I and III received daily subcutaneous rHuEpo injections over 2 weeks (1,000 U/kg bw) with normal saline injections as controls (groups II and IV). Data on histology and muscle weight were collected after 7 weeks. Axon count and diameter were assessed by a new method based on digital segmentation. Atrophy of the tibial muscle was less severe in the rHuEpo-treated group compared to controls resulting in significant higher muscle weight quotients (p = 0.006). The same trend was found in the gastrocnemius muscle, but without being statistically significant. No significant differences in axon count or axon diameter were detected in the presence of rHuEpo treatments. Our findings give evidence for a positive effect of Erythropoietin on functional recovery after nerve grafting. Muscle recovery benefited from rHuEpo administration despite absence of improved neural morphology. Semi-automated axon detection facilitated accurate morphometrical assessment.

Background In avulsion-type injuries of the fingers recovery of blood circulation is one of the major obstacles. The indication for finger reconstruction is discussed controversely, being influenced by the patient's needs, the degree of damage to the soft tissue and the prospects of success of the healing process. In this study we present our results after reconstruction of avulsion-type injuries of the fingers. Indications for finger reconstruction will be assessed in consideration of the expected outcome. Patients and methods From 1999 to 2006 we treated 18 patients with finger level avulsion injuries. 15 casualties were caused by rings and three by ropes looped around a digit. The median age at injury was 23 (12 - 66) years. All patients were examined by an independent observer, who did not participate in the operation. Criteria were functional outcome and patient's complaints and satisfaction. Sensibility was evaluated by 2-point discrimination applying the Greulich star. Finger mobility was assessed with the Buck-Gramcko goniometer. Results According to the classification of Urbaniak as modified by Kay, 2 patients ranked in class II, 3 in class III and 13 suffered from complete avulsion-amputations (class IV). Of the latter, 8 allowed primary reconstruction of the blood circulation. Two fingers required early or late secondary amputation. After finger reconstruction, patients spent a median time of 18 (12 - 32) days in hospital while primary amputation resulted in a shorter stay of 4 (2 - 5) days. Active motion after replantation in the proximal interphalangeal joint was reduced on average to 64 (25 - 100) degrees. The distal interphalangeal joint nearly ankylosed in all patients following replantation except for one case with an active motion of 40 degrees . Good sensibility could be achieved in one case, protective sensibility in three and none in two patients. All patients with preserved fingers would again decide in favour of finger replantation. Conclusion In specialised centres replantation of complete avulsion-type finger amputations can be achieved. The decision for or against replantation should only be made after microsurgical assessment of the severed soft tissue and in consideration of the patient's specific demands. With the right indication for reconstruction, the patient's satisfaction often outweighs even poor functional outcomes.

Heterotopic ossifications in periarticular tissue can appear after severe head injury, spine trauma or local joint trauma. Following extensive burns, heterotopic ossifications are a rare, severe complication with an unclear pathogenesis. We report one case with this kind of complication in a 50-year old male patient who sustained full and partial thickness burn injuries over 60 % of the body. The thermal injury was accompanied by a severe inhalation injury.

Gastrointestinal complications are a common problem in severe burned patients. Reported complications include paralytic ileus, gastrointestinal tract bleeding, gastric ulcers and acute necrotizing cholecystitis. Although there are no exact data concerning the frequency and outcome of acute intestinal necrotizing ischemia in severe burned patients, it is a well known complication in specialized burn centers. The most common reason for acute intestinal ischemia are arterial embolism, arterial thrombosis, venous thrombosis and non-occlusive disease. The overall survival differs between 81 % and 34 %. The therapy aims at arterial re-perfusion of life-threatening intestinal regions and resection of necrotic tissue. A 45-year-old male patient attempted suicide by inflaming himself with gasoline. He sustained partial and full thickness burn injury of the face and the throat. Additional burn injuries were found at the chest region, both arms and the abdominal wall. The total burn surface area (TBSA) was 42 % including an severe inhalation injury trauma. The ABSI-score (Abbreviated burn severity index) was 10. The combination of a thrombus at the aortic valve with an tachycardic dysrhythmia was the cause for an embolisation with acute intestinal ischemia. The necrotic part of the small intestine was resected, the further course was uncomplicated.

BACKGROUND: Thermal injuries are a major hazard in the early childhood. The aim of our study was to determine psychological behavioural disorders following burn and scald injuries in the childhood and to estimate their dependence on the formation of scar tissue and the social background of the children. PATIENTS: 83 patients aged 0 to 18 years who had been treated for thermal injuries in our clinic between September 2002 and December 2005 were included in the follow-up study. The standardised questionnaires CBCL/4-18 and TACQOL-PF were used to evaluate psychological behavioural disorders and quality of life. The follow-up examinations also served to gain information about the social status of the patient's parents and the current physical complaints. Scars were assessed by the Vancouver Scar Scale (VSS). RESULTS: 50 out of 83 patients took part in our follow-up examinations. 21 children suffered from physical complaints following thermal injury. Dryness of the skin as well as heat and cold intolerance were named most frequently. Internalising (p Language: de

Background Angiogenesis can be enhanced by several growth factors, like vascular endothelial growth factor-165 (VEGF(165)) and basic fibroblast growth factor (bFGF). Delayed release of such growth factors could be provided by incorporation of growth factors in fibrin matrices. In this study, we present a slow release system for VEGF(165) and bFGF in fibrin sealant.Materials and methods In vitro: Pieces of Integra (TM) matrix of 15 mm in diameter were prepared. Integra (TM) matrices were divided into four groups (A=control; B=fibrin sealant; C=fibrin sealant+growth factors; D=growth factors). In vivo: The bioartificial dermal templates were transplanted into a full-skin defect of the back of nu-nu mice. Four different groups included each six matrices at 2 and 4 weeks.Results In vitro: In groups C and D, continuous release of VEGF(165) and bFGF was eminent. The incorporation of growth factors into fibrin sealant evoked a prolonged growth factor release (p Conclusions A model of slow protein release by combining VEGF(165) and bFGF with fibrin sealant was produced. This model resulted in a prolonged bioavailability of growth factors in vivo for functional purposes. Fibrin and collagen can release growth factors in vivo and induce significant and faster neovascularisation in bioartificial dermal templates.

BACKGROUND The aim of this study was to examine the impact of our multidisciplinary therapeutical concept (MTC) on the clinical outcome in posttraumatic defect injuries of the lower extremity. PATIENTS AND METHODS Since 1999, we have performed a free tissue transfer in 37 patients. In group 1 (n = 21), our MTC was started more than two weeks (range: 17 to 83 days) after trauma and in group 2 (n = 16) within two weeks (range: four to twelve days) after trauma. Both groups were comparable with respect to trauma severity. RESULTS 100 % patients of group 1 and 25 % patients of group 2 had clinical and microbiological manifestations of wound infection after admission in our clinic. Significantly more operations were necessary in group 1 compared to group 2 (7.3 +/- 2.6 versus 2.9 +/- 0.8; p < 0.05), until definitive wound closure could be achieved. The postoperative course was uneventful in 35 cases. All injured extremities could be salvaged. Multistaged bone reconstructions by means of spongious or tricortical bone from the iliac crest were successful in all cases. Hospital stay after admission to our clinic was significantly longer in group 1 compared to group 2 (57 +/- 12 days versus 31 +/- 7 days, p < 0.05). CONCLUSIONS In our study, the early start of MTC significantly reduced the risk for wound infection, the number of surgical revisions before definite wound closure and time until bone and wound healing was completed.

After second-degree burns, thrombosis of the subdermal vascular plexus may occur, necessitating epifascial necrectomy instead of tangential excision to ensure split skin graft healing. Until now, no parameter has been obtained to explain this phenomenon.Thirty-four patients with deep second-degree burn wounds were divided into 2 groups. In group 1, patients' age was60 years, in group 2,60 years. In each patient, 2 microdialysis catheters were introduced into subdermal tissue of deep second-degree thermal wounds immediately after admission. Another 2 catheters were introduced in control tissue. We measured biochemical parameters (lactate, glycerol and glucose) and complement 3a (C3a) until surgery was performed. The surgically removed tissue was examined histologically.In thermal wounds of both groups, glucose levels fell, but lactate and glycerol levels rose compared to healthy tissue. Within the first 24 hours after trauma, C3a levels were significant higher in both groups, compared with controls (P.01). After 24 hours the levels in group 1 had fallen to nonsignificant values, while in group 2 these levels remained high until surgery was performed (P.001). We found significantly more thrombotic blood vessels in deep dermal tissue of group 2 (P.005). Abbreviated burn severity index score was comparable in both groups.C3a is continuously elevated in deep second-degree burned wounds in patients60 years. This finding may be related to the occurrence of significantly more thrombotic blood vessels in deep dermal tissue of elderly patients. Microdialysis therapy is a useful tool to measure metabolic and immunologic parameters in thermally damaged tissue.

PURPOSE A microangiographic technique is described, which allows visualization of small blood vessels with a diameter of approximately 20 microm and quantification of fasciocutaneous blood vessels by means of digital computer analysis in very small laboratory animals. METHOD The left carotid artery of 45 nu/nu mice was cannulated (26 gauge) and a mixture of gelatine, barium sulfate and green ink was injected according to standardized protocol. Fasciocutaneous blood vessels were visualized by digital mammography and analyzed for vessel length and vessel surface area as standardized units (pixel) by computer program. RESULTS With the described microangiography method fasciocutaneous blood vessels can be clearly visualized. Regions of interest (ROIs) can be defined and the containing vascular network quantified. Identical ROIs showed a high reproducibility for measured unit (pixel) < 6.5 +/- 2.4 %. By the use of digital image, processing the quantification of vessels was reliable, reproducible and fast. CONCLUSION Combining microsurgical techniques, pharmacological knowledge and modern computer imaging analysis systems, we were able to visualize and quantify blood vessels with a diameter of approximately 20 microm even in small laboratory animals.

The authors' experience indicates that good functional results are achievable in cases with wide resection of the knee extensor mechanism. They report a low-grade myxoid fibrosarcoma patient in whom a one-stage functional reconstruction was carried out by transfer of a free latissimus dorsi flap without secondary surgical procedures.

Background. Injections of single-dose vascular endothelial growth factor (VEGF)165 have been advocated as a therapeutic tool for angiogenesis in ischemic flaps. We challenged this thesis by employing both VEGF165 and vascular endothelial growth factor receptor-1 (VEGFR-1) (for competitive inhibition of VEGF signal transduction) in different experimental settings of an ischemic rat flap model. Material and methods. 80 isogenic rats were divided in two groups of 40 animals (groups 1A–1D and 2A–2D). The ischemic target was a 7 × 7-cm epigastric island flap, based on the right inferior epigastric pedicle. Group 1 received flap treatment 1 week prior to flap elevation by test substance injection into its flap panniculus carnosus: 1 ml NaCl 0.9% (1A), 1 ml Dulbecco’s modified Eagle’s medium (1B), 1.0 μg VEGF165 (1C), and 10 μg sFLT-1 with 1.0 μg VEGF165 (1D). sFLT-1 is a soluble receptor for VEGF and is able to prevent VEGF signaling through the cell surface receptor. Group 2 had the same flap treatment at the day of flap elevation. Results. In group 1C we found the most vital flap tissue, without reaching significance. Compared with group 1D, however, significantly more flap tissue maintained vital. In groups 2A–2D, no significant results were found with respect to flap survival. Conclusions. Local application of single-dose VEGF165 1 week prior to ischemia dose not have significant clinical angiogenic effects. In this experimental setting, VEGF165-induced angiogenic effects can be significantly inhibited by adding sFLT1 in vivo. A single-dose of VEGF165 under ischemic conditions causes no significantly better flap survival in this model.

This study was designed to evaluate the effect of poor suture technique in microsurgical small-vessel anastomosis on tissue microcirculation. Eighteen male Sprague-Dawley rats were divided into three groups of six animals each: sham control group, regular suture group (control), and inverting suture group. In the regular suture group, a standard single-stitch suture technique was used for microsurgical reanastomosis of the transected common iliac artery. In the inverting suture group, a suture technique was applied inverting the vessel wall, thus simulating poor suture technique. After 24 h, intravital microcirculatory measurements were obtained in the cremaster muscle flap. The inverting suture caused a significant drop in capillary perfusion from 6.40 (sham control) and 5.65 (regular suture) to 1.81 capillaries per visual field (P < 0.005). A poor microsurgical anastomosis may result in a significant reduction of peripheral tissue perfusion, although blood flow through the main feeding vessel is maintained.

In the published literature there are controversial data to the biomechanical stability of monocortical comparing to the bicortical fixation of metacarpal fractures. The aim of this study was to compare the biomechanical stability of monocortical and bicortical locking osteosynthesis in quasi-static and dynamic 4-point bending tests of composite third metacarpal bone (4th Gen third metacarpal, Sawbones, Malmö, Sweden) fixed with 7-hole locking plate (XXS System, Biotech-Ortho, Wright, Memphis, TN). The tests to determine quasi-static yield and bending strength as well as fatigue strength were conducted in 4 groups of 10 samples after creating standardized mid-shaft transverse osteotomies using a diamont belt grinder (0.3 mm saw blade). The force applied was the dorsal apex loading, similar to the forces applied to metacarpals during normal finger flexion and extension. In the quasi-static testing, no plate breakage was observed in each group. All metacarpals broke at their thinnest part. The average bending strength of the bicortical samples (10.54 ± 0.998 Nm) was significantly higher comparing to the monocortical samples (8.57 ± 0.894 Nm) (P

A new telerobotic arm was evaluated in different microsurgical procedures. The system consisted of a robotic arm bearing a microsurgical forceps controlled by a joystick-like master unit operated by the surgeon's hand. The robotic arm functioned as an operating as well as assisting instrument. Advantages of the system were its precise functioning, which was especially important when tissue or instruments had to be held for a longer period of time, as well as its ability to replace an assisting person to some extent. Deficiencies of the system were its 10-min startup, the spatial conflict with in the operative field, and the poor rotation of the robotic tip. In some procedures, the telerobotic arm could replace the standard microsurgical instrument guided by the surgeon's second hand; in other maneuvers it could function as the surgeon's third hand with precision and void of tremor.

In a previous study, the authors found persistence of pedicle blood flow up to 10 years after uncomplicated free latissimus dorsi transfer. In this study, the impact of postoperative complications (hematoma, thrombosis, infection) and successful surgical revision was tested. Since 1982, more than 1200 free tissue transfers have been performed at the authors' institution (Hannover Medical School). Of these, the authors selected two groups of 30 patients each who had received a free latissimus dorsi transfer to the lower leg without microsurgical nerve coaptation for wound coverage. All patients included in this study were carefully selected for clinical homogeneity, with one difference: group I comprised patients who had no postoperative complications after free latissimus dorsi transfer. Group II included only patients with major postoperative complications after the procedure. All flaps in group II survived after successful surgical revision. The arteries, which nourished the lower leg, were visualized and documented by means of a duplex scanner in both groups. Three different time intervals were chosen for measurements of blood flow: 4 to 6 months (groups I.I and II.I), 4 to 6 years (groups I.II and II.II), and 8 to 10 years (groups I.III and II.III). Quantitative measurements of local flap perfusion in milliliters per minute per 100 g tissue were performed by means of the hydrogen clearance technique. In each patient, a total of nine measurements was performed in three phases: phase A, before closing the vascular pedicle by manual compression (n = 3); phase B, with a closed pedicle (n = 3); and phase C, after releasing the vascular pedicle from manual compression (n = 3). Each measurement took approximately 10 minutes. One hundred percent closure of each pedicle in phase B was confirmed by the duplex scanner. Furthermore, all patients were monitored both clinically and by means of the hydrogen clearance technique during phase B for adequate blood supply to the lower leg. Lower leg perfusion showed no statistical differences for phases A, B, and C in all groups of patients. In group I, no statistical differences in local flap perfusion were encountered for phases A and C. In phase B, however, a statistically significant (p < 0.01) complete extinction of local flap perfusion was registered in all patients of group I at the site of the flap's skin paddle. In group II, however, persistent flap perfusion was registered during phase B in up to 50 percent of cases in one subgroup (II.III). No statistically significant alterations of local blood flow were registered in the surrounding tissue of group II during phases A, B, and C. Patients with thrombosis of the venous anastomosis (n = 7) seemed to have the highest incidence of loss of autonomous blood supply through the vascular pedicle (5 out of 11 cases). No inconstant results were found during the repetitive measurements (n = 3) for each patient in each phase. After uncomplicated free tissue transfer, the flap's intact vascular pedicle seems to play an important role in permanent flap survival up to 10 years after the procedure. Postoperative complications after free tissue transfer with successful surgical revision, especially venous thrombosis of the vascular anastomosis, may lead to loss of vascular flap autonomy over time.

Increased Methicillin resistant Saphylcoccus aureus (MRSA)-colonisation/infection is described worldwide. MRSA distribution is important for health economics. We report a case of a MRSA-infection of the hand in a 72 years old immunodeficient patient.

Success rates after free tissue transplantation (FTT) have greatly improved over the last 20 years, partly due to improved technical performance of microvascular anastomoses with better optical and instrumental aids. However, flap failure is still a clinical problem and occurs in 5 to 10%, mainly due to blood vessel thrombosis within the first 24 postoperative hours. The clinical results after FTT can be optimized by in-time diagnosis of irreversibly compromised tissue blood flow and immediate operative reexploration. Therefore, there is a special demand for adequate and reliable postoperative monitoring techniques. This article reviews all monitoring techniques which have been performed in the experimental-clinical setting after FTT thus far.

This study was designed to evaluate the effects of crush injuries to the feeding arteries of a muscle flap on microcirculatory haemodynamics. Eighteen male Sprague-Dawley rats were divided into three experimental groups for intravital microscopy of the cremaster muscle flap. Group 1 served as control. In group 2 the common iliac artery and in group 3 additionally the lower abdominal aorta was crushed with a Kocher clamp (17.4 N) over 5 min. Microcirculatory parameters (red blood cell velocity, vessel diameter, and capillary perfusion) were monitored before and 2 h after crush. In the one-level crush group, red blood cell velocities significantly decreased by 39.17% (P=0.046) in first order arterioles and by 32. 91% (P=0.0106) in second order arterioles. In capillary perfusion, a drop of 48.02% (P=0.0039) was noted. In the two-level crush group, red blood cell velocities significantly dropped over 32.06% (P=0. 0250) in first order arterioles, 35.91% (P=0.0065) in second order arterioles, and 45.69% (P=0.0782) in first order venules. Capillary perfusion was reduced by 20.16% (P=0.374). Arterial crush injuries as possible thrombogenic insults may result in a significant decrease in skeletal muscle perfusion although the blood supply through the crushed supplying vessel is maintained.

Objective Obesity is an important predictor of mortality and morbidity during a hospital stay. There is very little data concerning the impact of the BMI on clinical outcomes in obese burn patients. The purpose of this study is to document the general epidemiological aspects of thermal injuries in an obese population and draw attention to topics relating to the management, rehabilitation and prognosis of burns in this emerging subpopulation of patients. Methods All patients >16 years of age admitted to the burn unit between January 2008 and December 2012 and fulfilling the burn center referral criteria were enrolled in the study. SPSS version 20 (SPSS GmbH Software, Illinois, USA) was employed for data analysis. Results Eleven extreme obese patients (men:women, 6:5) had a mean BMI of 38 kg/m 2 . Their incidence in our study was 5.5%. The mean length of stay was 41.5 days, almost twice that of the non-obese. The presence of co-morbidities such as diabetes, hypertension, cardiac disease, or pulmonary disease, the problematic wound healing and the burn wound infection were significantly higher in the obese patients than in the non-obese. The mortality of obese burned patients was 36.4%. Conclusions These facts indicate admission of these patients to a burn care unit for the best possible treatment although they might not always fulfill criteria for admission to burn intensive care unit. Burn centers must be also prepared in terms of special nursing equipment for obese patients.