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

Necrotising fasciitis (NF) and Fournier's gangrene are still a source of high morbidity and mortality and a significant health-care resource consumption. These difficult cases are increasingly being referred to burn centres for specialised wound and critical care issues. Besides the total body surface area (TBSA) affected, location, co-morbidities, age and an immediate surgical treatment are important prognostic factors. The treatment of these patients is challenging and best performed by prompt diagnosis, immediate radical surgical debridement and aggressive critical care management. Referral to a major burn centre may help provide optimal surgical intervention, wound care and critical care management. As soon as the patient is stabilised, reconstruction of the injured areas becomes the main focus. As often seen, complete loss of dermal structures needs a depth adjusted – ‘multilayer’ – reconstruction especially in critical areas. In modern reconstructive surgery, concepts of layer-specific reconstruction, including dermal substitution have to be considered. In this article, we present our recent experiences of five patients with NF who underwent dermal reconstruction with Matriderm® not only for better skin quality but also in some cases as an alternative to flap surgery when joint capsules or tendons were exposed. [Copyright &y& Elsevier]

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

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

Introduction: Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI)., Patients and Methods: A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m 2 ), normal weight/ control group (BMI: 18.5-24.9 kg/m 2 ), overweight group (BMI: 25-29.9 kg/m 2 ), moderately obese group (BMI: 30-34.9 kg/m 2 ), and severely obese group (BMI ≥ 35 kg/m 2 ). Surgical complications were accounted for and the five BMI groups were then compared., Results: Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p > 0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p < 0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p < 0.01)., Conclusion: Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications., Competing Interests: Declaration of Competing Interest All authors have no conflict of interest. There was no funding., (Copyright © 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background:  Since 2015/16 the DGPRÄC collects, evaluates and publishes the research activities of academic sections, departments and clinics for plastic surgery at university hospitals in Germany, in order to raise the awareness of plastic surgical research performance., Materials and Methods:  The directors of plastic surgical academic institutions were contacted via the DGPRÄC and asked to report any requested/approved and rejected research applications to public, non-public and industrial funding organizations. Data was collected in our previously established online database: https://docs.google.com/forms/d/e/1FAIpQLSe6F5xmTyw-k7VKJx&#95;2jkPA4LBXsA0sgBGMrC3rx&#95;4bHj6uzQ/viewform?usp=sf&#95;link. In addition, applications were identified via the DFG's public database GEPRIS., Results:  A total of 41 funding applications to the public funding institutes DFG, BMBF, BMWi, BMG and EU were identified. 75.6 % (31/41) of the applications had already been approved at the time of data collection, of which 77.4 % (24/31) were DFG, 9.7 % (3/31) were BMWi, 6.5 % (2/31) were EU and 3.2 % (1/31) were BMBF or BMG applications. The average funding amounted to 358 301 Euro. In 50.0 % (12/24) of the cases, the approved DFG proposals were assigned to the subject review board 205-27 Orthopedics, Trauma Surgery, Reconstructive Surgery., Conclusion:  The continuous publication of plastic surgical research funding reports submitted by the convention of university plastic surgeons of the DGPRÄC portraits the excellent, collaborative research activity in the field of plastic surgery., Competing Interests: Die Autoren geben an, dass kein Interessenskonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Immediate breast reconstruction (IBR) at the time of mastectomy is gaining popularity, as studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress and lower treatment costs. Using the largest database available in Europe, the presented study compared outcomes and complications of IBR vs. delayed breast reconstruction (DBR)., Methods: 3926 female patients underwent 4577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups according to the time of reconstruction: an IBR and a DBR group. Surgical complications were accounted for and the groups were then compared., Results: Overall, the rate of partial-(1.0 versus 1.2 percent of cases; p = 0.706) and total flap loss (2.3 versus 1.9 percent of cases; p = 0.516) showed no significant difference between the groups. The rate of revision surgery was slightly, but significantly lower in the IBR group (7.7 versus 9.8 percent; p = 0.039). Postoperative mobilization was commenced significantly earlier in the IBR group (mobilization on postoperative day 1: 82.1 versus 68.7 percent; p < 0.001), and concordantly the mean length of hospital stay was significantly shorter (7.3 (SD3.7) versus 8.9 (SD13.0) days; p < 0.001)., Conclusion: IBR is feasible and cannot be considered a risk factor for complications or flap outcome. Our results support the current trend towards an increasing number of IBR. Especially in times of economic pressure in health care, the importance of a decrease of hospitalization cannot be overemphasized.

Background:  The loss of a breast, and thus of the female body shape, is often extremely traumatising for women affected. Although free flap grafts have become the gold standard in reconstructive breast surgery, it has not been possible to date to unequivocally document their superiority over conventional alternative techniques. To date, there are no data on the care situation in Germany. Neither the number of reconstructions nor the proportion of the individual techniques is known. A prospective online registry has been set up in order to systematically collect and transparently present the structure and quality of care. The long-term goals are to record the existing quality of care, improve deficits and to certify centres with the appropriate expertise to establish a high level of care nationwide., Methods:  For this purpose, the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) has set up an internet-based database in which treatment data are recorded anonymously. As part of a certification process, auditors checked structure quality, compliance with specifications, and the stringency of the data entered in comparison with the hospital's internal documentation. If the evaluation is positive, the DGPRÄC quality seal is awarded., Results:  Since its introduction in 2012, the database has provided validated information. Initially, only a few departments were prepared to present their results transparently. However, the number has grown steadily in recent years. As a result, the quality recording assumed a pioneering function nationwide and can now be used as a reliable source of information by patients and doctors. The DGPRÄC website features a map of the centres, which are colour-coded according to their respective qualifications. It is thus possible to find a qualified plastic surgeon with comprehensive expertise in acceptable proximity to every oncological breast centre., Conclusion:  The database provides an overview of the quality of the various surgical techniques and thus the possibility of serious self monitoring and scientific analysis. The systematic collection of data has contributed to strengthening the position of plastic surgery in the field of reconstructive breast surgery. However, the financial and personnel resources required to establish the database were clearly underestimated., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Worldwide the incidence of necrotizing fasciitis (NF) is on the rise. This rapidly progressive infection is a true infectious disease emergency due to its high morbidity and mortality. The mainstay of therapy is prompt surgical debridement, intravenous antibiotics, and supportive care with fluid and electrolyte management. Because of its high mortality rate, patients are increasingly referred to burn centres for specialized wound and critical care issues., Methods: A retrospective chart review was performed of 34 consecutive patients over a 5-year period with NF of the upper and/or lower extremities that required surgical debridement and reconstruction., Results: The overall survival rate was 96%, with an average length of hospital stay of 64.0 ± 5.5 days. The time until the first operation was 1.3 days. The average age of the patients was 56.7 ± 10.6 years. The patients averaged 1.6 relevant comorbidities. One patient who had five comorbidities died. The affected total body surface (TBS) averaged 8.2 ± 2.1%., Conclusion: Early recognition and treatment remain the most important factors influencing survival in NF. Yet, early diagnosis of the condition is difficult due to its similarities with other soft-tissue disorders. Repeated surgical debridement and incisional drainage continues to be essential for the survival. However, these infections continue to be a source of high morbidity, mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement and aggressive critical care management. Referral to a major burn centre may help to provide optimal surgical intervention, wound care and critical care management.

One hundred years after the first description of autologous fat transplantation, this technique is receiving renewed attention. Initially, critically reviewed by plastic surgery societies, particularly those in the United States, the transfer of autologous fat was recently addressed at the September 2009 annual meeting of the German Society of Plastic Reconstructive and Aesthetic Surgeons in Hannover. In this consensus meeting, the panel reviewed both the current status of autologous fat transfer as well as established data concerning this evolving practice. In Germany, autologous fat transplantation is regulated by the Law on Tissue Transfer and Processing (Gewebegesetz). In an effort to facilitate future comparisons it is mandatory to describe harvesting, processing and reinjection techniques in detail. The consensus panel concluded that fat should be harvested using low vacuum settings and then transplanted in thin layers (Evidence V). Quantification of transplanted fat can best be performed by MRI (Evidence level III). Limited clinical studies are available with only some reaching a level of evidence II. At present, risk associated with autologous fat transplantation is considered to be minor. Tumor induction by autologous fat grafting is not proven. New techniques like stem cell enriched fat grafts may offer new promise for the Plastic and Reconstructive Surgeon., ((c) Georg Thieme Verlag KG Stuttgart-New York.)

Aim: The aim of this study was to determine a) data for the disabilities of arm, shoulder and hand (DASH) score of a non-clinical group as well as to establish b) a comparison of DASH data between different groups of people., Patients and Methods: After collection of 716 DASH questionnaires from healthy, working individuals (non-clinical sample) and 795 questionnaires from patients with injuries and conditions of the upper extremity (clinical sample), the data were assessed according to age, gender, manually or non-manually working into DASH total, DASH activity, DASH impairment, DASH music/sport and DASH work scores. In order to establish a comparability, these data were transformed using T-norms., Results: Median DASH data of the non-clinical sample showed a functional impairment, since they deviated from 0. Men, aged 50-65, who were working manually showed the highest DASH score. Age did not have a significant effect on the DASH score of the clinical sample. The median overall DASH score of the clinical sample was higher than the scores seen with the non-clinical sample., Conclusion: Using T-norms a reference framework has been established for DASH scores, thus making it possible to interpret and compare individual scores between patients., (Georg Thieme Verlag KG Stuttgart, New York.)

This study evaluated the effectiveness of a patient-oriented, hand rehabilitation programme compared to a standard programme regarding functional outcomes, return to work, patient satisfaction and costs. Patients were recruited in two consecutive cohorts. One cohort received the standard treatment programme (n = 75) and the other a programme based on principles of patient orientation (n = 75). Data were collected at the beginning and end of rehabilitation and 6 months after discharge. Clinical variables included range of motion, grip and pinch strength. Self-reported measures included pain, upper extremity functioning, health status, satisfaction and job situation. Analysis of variance for repeated measurements was used to calculate the main effects. The patient-oriented group showed more favourable results with respect to DASH scores (P <.05), pain (P <.001) and patient satisfaction (P <.0001). More patients returned to their former jobs and time off sick was reduced. We concluded that the patient-oriented approach was more effective and cost-saving.

Introduction: Health care insurers in Germany pay 5 billion Euros annually in materials alone for pressure ulcers, diabetic foot ulcers, and ulcus cruris. With such figures it is necessary to consider, economic aspects of treatment., Methods: Due to the lack of evidence-based data on wound treatment costs, we investigated available studies for an effect on treatment costs when standard moist wound therapy was compared with alternative methods. Suited medical parameters are calculated and compared. Daily costs and length of treatment are correlated and compared., Results: Published data show that alternative wound therapies may lead to an earlier wound closure, fewer complications, and reduction in hospital admissions and length of stay. Despite higher daily costs, some alternative wound therapies turn out to be more cost effective, when all economical factors are considered. In this respect a move towards alternative wound therapies could possibly lead to major savings., Discussion: At present there is insufficient evidence to prove the efficacy of various treatment modalities for chronic wounds. This is due to numerous factors such as comorbidities and frequent multimorbidity. Nevertheless critical evaluation of one innovative treatment alone already uncovered an enormous potential for savings in a wider economic context, despite the comparatively higher cost of a single treatment. It is of utmost importance that conservative wound care become firmly embedded in surgical concepts.

Background: An efficient medical documentation is mandatory for a trauma-oriented department in the DRG environment. Besides the continuously increasing clinical/administrative demands, the additional documentation for quality assurance, clinical studies, and research requires additional efforts. Standard solutions are only partially effective. Especially in hand surgery there is a high demand for sophisticated clinical documentation, represented by a wide variety of classifications in diagnosis and therapy. The standard documentation tools lack accuracy. The development of a software tool that defines administrative/business processes and simultaneously generates clinical and administrative information was the goal of this project., Methods and Results: With a standard medical terminology, an innovative semantic network, and a completely new graphical user interface, it was possible to develop and introduce a software program specifically adjusted for hand surgery. This program facilitated for the first time a single-stage acquisition of clinically relevant scientific data and the simultaneous generation of DRG, quality assurance, and administrative data relevant for the hospital's revenues., Conclusions: The newly developed software tool is a step forward into a new dimension of medical software, obviating the need for multi/documentation and significantly improving the quality of clinically relevant medical data.

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

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

Purpose: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a standardized outcome measure that captures upper-extremity disability from the perspective of the patient and is used to study clinical outcomes in musculoskeletal disorders. To constitute a frame of reference for clinical values it is important for clinicians to be able to compare clinical DASH scores with those of nonclinical populations. We collected DASH data from a working population in Germany that was outside clinical considerations and used the data to identify disability levels among identified subgroups as a basis for future clinical comparisons., Methods: We evaluated the DASH data using a convenience sample of 716 employed adults. Separate analyses were performed for each of the DASH scores, which were grouped according to age, gender, and type of vocational activity., Results: The rank analysis of variance showed that statistically significant differences were found in Germany, differentiating between gender, age, and self-estimated vocational groups. Tests for interaction analyses of variance showed that increased disability was expressed as significantly higher mean DASH scores among older workers, female workers, and manual workers., Conclusions: This study provides comparative data for our clinical population and allows insight into current disability levels in a nonclinical population.

Fillet flaps offer an additional reconstruction opportunity for complex hand defects after trauma, burns, tumors or infections. This retrospective study elucidates the concept of fillet flaps and presents the results of an overall of 34 plastic surgical reconstructions of the hands in 31 patients. Pedicled axial pattern flaps were used predominantly, except 2 cross finger flaps. In 10 cases the defects were localized in the dorsal and in 9 cases in the palmar aspect of the hand. 14 finger defects and one of the ulnar hand were covered. Very few complications occured. In only 2 cases partial flap loss was observed. An additional wound infection required revision in one case. Another case was left to secondary healing. Prior to any amputation, possible use of spare parts for defect reconstruction should be considered as a matter of principle. Our data suggest that the concept of fillet flaps is suitable for the reconstruction of complex defects of the hands without additional donor site morbidity.

The Disability of Arm, Shoulder, Hand (DASH) Version 2.0 questionnaire captures the subjective experience of patients regarding their own health. This 78-item instrument was developed by the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies and the Institute for Work and Health,Toronto and measures components of health-status relevant to upper-extremity conditions. We translated and validated DASH with the aim of producing a tool which could also be used in German-speaking countries. The paper reports the method of translation and cross-cultural adaptation which was carried out according to the AAOS guidelines. The result was a standardised German version of DASH. Psychometric testing of the translated questionnaire was carried out with 6 samples (n=342) who had undergone hand surgery for a variety of conditions. The study yielded good results across all groups with regard to the construct, criterion and content validity. We confirm that the German version is suitable for use in future studies.

The paper presents the translation of a new measurement tool, the DASH Questionnaire. The DASH (Disability of Arm--Shoulder--Hand) is an outcomes data collection instrument which has been developed by the "American Academy of Orthopaedic Surgeons", the Council of the "Musculoskeletal Specialty Societies", and the "Institute for Work and Health", in order to assess outcomes among patient groups with musculoskeletal disorders. Using a self-report system, patients attribute scores of 1 to 5 on 30 items relating to functional activities and symptoms; a further optional module contains four items relating to disability levels among musicians and athletes. The raw score is then transformed to a 0 to 100 scale, whereby 0 reflects minimum and 100 maximum disability. The subjective nature of this instrument makes it suitable for both postal or in situ clinical surveys. The instrument is in the process of validation for use with a German population.