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Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire.Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected.With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %).Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers.· This is the first study on the diagnostic reality of radiology in severely injured patients in Germany. Despite a high level of standardization, significant differences were observed..· Ernstberger A, Reske SU, Brandl A et al. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. Fortschr Röntgenstr 2022; 194: 505 - 514.ZIEL: Systematische Datenerhebung der Integration der Radiologie sowie von Struktur- und Prozessmerkmalen der primären Diagnostik von schwerstverletzten Patienten in Deutschland.Persönliche Kontaktaufnahme mit allen zertifizierten überregionalen (ÜTZ) und regionalen TraumaZentren (RTZ) in Deutschland. Daten zur Infrastruktur, Zusammensetzung des Schockraumteams, Gerätedaten der CT-Scanner und Daten zur Organisation/Durchführung der primären Schwerstverletztendiagnostik wurden mit strukturiertem Fragebogen erfasst.Bei einer Teilnehmerquote von 46,9 % (n = 151) aller deutschen TraumaZentren (N = 322) liegt eine solide Datenbasis vor. Bei den Strukturmerkmalen incl. CT-Ausstattung gab es zwischen ÜTZ und RTZ teilweise hochsignifikante Unterschiede: Bei RTZ lag das CT-Gerät in 63,8 % über 50 m vom Schockraum entfernt (ÜTZ 34,2 %). Bei traumatologischen Schockraumaktivierungen war ein Radiologe in 59,5 % der RTZ anwesend (ÜTZ 88,1 %). Ebenfalls hochsignifikant waren die Ergebnisse beim Vergleich der 24-h-Vorhaltung weiterer radiologischer Untersuchungen und Interventionen wie etwa Magnetresonanztomografie (RTZ 44,9 %, ÜTZ 92,8 %) und Angiografie (RTZ 69,2 %, ÜTZ 97,1 %).Es zeigten sich heterogene Struktur- und Prozessmerkmale der Diagnostik schwerstverletzter Patienten in Deutschland mit hochsignifikanten Unterschieden zwischen ÜTZ und RZT.· Erste Studie zur diagnostischen Realität der Radiologie bei Schwerstverletzten in Deutschland. Trotz aller Standardisierung sind deutliche Unterschiede zu verzeichnen..· Ernstberger A, Reske SU, Brandl A et al. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients – Results of a Survey of Level I and II Trauma Centers in Germany. Fortschr Röntgenstr 2022; 194: 505 – 514.

Purpose Burn care is a highly relevant medical specialty in every part of the world. Different infrastructure, healthcare systems and access to medical supplies lead to different needs, treatment strategies and outcomes. A fundamental tool in a burn care provider’s armamentarium is the use of different dressings. Several studies have investigated the question of the ideal burn dressing, but none could achieve a proper global perspective. With advanced dressings being on the rise, we conducted this study to get a global understanding of the actual use and idea of the ideal burn dressing. Objective The objective of this study was to investigate the understanding of an ‘ideal burn dressing’ on a global scale. Materials and methods A questionnaire about burn care and the ideal burn dressing has been created and translated to five of the most spoken languages world-wide (English, Spanish, French, Chinese, Indonesian). It has been uploaded to an online survey platform and sent out to burn experts worldwide. The voluntary participation was possible for a period of four weeks. Results In total, 196 respondents from 49 countries participated in the study, yielding a response rate of 24.5%. The most important burn dressing characteristics in a cumulative ranking were (1) lack of adhesion (80.54%), (2) pain-free dressing change (79.87%), (3) requirement of fewer dressing changes, while in a linear ranking they were (1) anti-infective (35.14% 1st), pain-reduction (24.14% 2nd), and high absorbency (23.49% 3rd). Silver-based dressings are the most used dressings for superficial (45.21%) and deep (52.78%). 94.81% believe that the choice of burn dressing affects the outcome. Conclusion This investigation has delivered valuable insights into the global perspective of the ideal burn dressing. Yet, the question of the ideal burn dressing is still inconclusive. Wound dressing research is of fundamental interest for patients, healthcare providers and healthcare systems.

For the treatment of carpometacarpal arthritis of the thumb, various therapies are used. Infiltration therapy with autologous substances such as platelet-rich plasma and autologous fat have recently gained increasing attention because of beneficial pain-reducing effects in arthritis and the associated regenerative potential. However, the extent of clinical evidence in this area and how well autologous substances work in terms of pain reduction and improvements in hand function remain unclear.A systematic review and meta-analysis were conducted to evaluate the current evidence and to provide more insight into pain reduction and improvement in hand function after infiltration of autologous substances. The authors identified 11 clinical trials, of which we included eight in the meta-analysis.Autologous substances achieved a good and long-lasting pain reduction, which may also be accompanied by corresponding improvement in hand function. Autologous substances appear to be more effective than corticoid infiltrations. The infiltration of autologous fat seems to be particularly promising in more advanced stages of carpometacarpal arthritis of the thumb. Our meta-analysis showed a mean pain reduction of 2.4 to 3 in visual analogue scale score and a reduction of 18 to 19 points in the Disabilities of the Arm, Shoulder, and Hand questionnaire after infiltration with autologous substances.Both platelet-rich plasma and autologous fat infiltration offer an efficient and long-lasting, minimally invasive therapy option in the treatment of carpometacarpal arthritis of the thumb.

Non-union after fracture depicts a devastating complication in trauma surgery and studies assessing patient-reported outcome measures after stable bone consolidation are rare. Therefore, we aimed to evaluate the long-term impact of aseptic long bone non-union on the patients' physical health state and psychological wellbeing. For this purpose, quality of life after successful surgical treatment of long bone non-union was assessed.Sixty-one patients with aseptic long bone non-union surgically treated in our department between November 2009 and March 2019 with achieved bone consolidation were included. Quality of life was evaluated with the EQ-5D and SF-36 outcome instruments as well as with an ICD-10 based symptom rating (ISR) and compared to normative data.With a minimum follow-up time of one year after the last surgery (mean 4.7 ± 2.7 years) the mean physical health component score of the SF-36 was 38.9 ± 13.7 and the mean mental health component score of the SF-36 was 49.0 ± 5.9, indicating lower quality of life compared to German normative values of 48.4 ± 9.4 (p .001) and 50.9 ± 8.8 (p = 1.61), respectively. The mean EQ-5D index value reached 0.827 ± 0.18 with an EQ-5D VAS rating of 64.4 ± 21.5 compared to scores of 0.922 (p .001) and 72.9 ± 1.1 (p .001) obtained from an age-matched reference population. Mean scores of the ISR did not reveal significant psychological symptom burden in any scale, while an individual analysis showed moderate to severe impairments in 11.5% of the patients in total.Even 4.7 years on average after surgically successful treatment of aseptic long bone non-union, patients still report significant lower quality of life in comparison to normative data. Future clinical studies on non-unions should focus on patient-related outcome measures. Newly emerging treatment strategies and interdisciplinary approaches should be implemented to improve the overall quality of life of non-union patients.

Background. Almost every sector in the health care is affected by the COVID-19 pandemic. Many studies already investigated the effect on different aspects in orthopedic and trauma care. However, the current literature lacks data regarding the consequence on daily surgical business. Thus, the aim of the present study was to analyze the development of knee-related pathologies and surgical procedures in a German university level-one trauma center during the lockdown phase and early lockdown phase to investigate the impact of the COVID-19 lockdown on orthopedic and trauma knee surgery. Material and Methods. The amount of knee joint surgeries performed during the high-peak COVID-19 crisis in the period of January to May 2020 was evaluated retrospectively and compared to the corresponding time periods of the previous years (2017-2019). Results. The COVID-19 lockdown led to a significant decrease in the number of knee injuries in March and April 2020 by 83.3%. Surgical procedures were reduced by 84.8% during the same period. In May 2020, the number of knee joint procedures returned to an almost prepandemic level. The distribution of urgent and elective knee surgery changed to predominantly acute trauma care at the beginning of the COVID-19 lockdown and persisted through to May 2020. Conclusion. The COVID-19 pandemic had a high impact on emergency and elective knee surgery in a level-one trauma center in Germany during the lockdown phase. It also showed that a level-one trauma center in the German healthcare system is able to handle urgent trauma and orthopedic operations during a worldwide medical crisis and to return to a prepandemic level within a short phase.

Zusammenfassung Einleitung Im Frühjahr 2020 machte die COVID-19-Pandemie weitreichende Veränderungen und Maßnahmen in bisher nie dagewesenem Ausmaß notwendig. Diese Maßnahmen zielten einerseits darauf ab die Ausbreitung der Virusinfektion einzudämmen, und andererseits die landesweite Krankenversorgung weiterhin zu gewährleisten, insbesondere um im Falle einer größeren Anzahl an mit COVID-19 infizierten Patienten ausreichend Intensivkapazitäten zur Verfügung zu haben. In Bezug auf operative Fächer bedeutete dies das temporäre Aussetzen des Elektivprogramms auf unbestimmte Zeit. Ziel dieser Studie war es die Auswirkung dieser Maßnahmen auf das Behandlungsspektrum eines plastisch-chirurgischen Zentrums zu evaluieren. Methode Die Operationszahlen der klinischen Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie der medizinischen Universität Graz während des sog. Lockdowns von 16.3.2020 bis 26.4.2020 (6 Wochen) sowie 2 Wochen davor wurden retrospektiv erhoben. Die Daten wurden zum korrespondierende Vorjahreszeitraum verglichen. Untersucht wurden u. a. Operationsspektrum, Dringlichkeit, Indikation und Komplikationsraten. Ergebnisse Durch den Wegfall des Elektivprogramms kam es während des Lockdowns im Jahresvergleich zu einem signifikanten Rückgang der OP-Zahlen um 57,5 % (2019: 353, 2020 150 Fälle). Während des Lockdowns wurden im Jahresvergleich signifikant mehr Notfall- und Akuteingriffe durchgeführt (2019: 41, 2020: 58 Fälle, p 0,001). Hinsichtlich Privat- und Arbeitsunfällen gab es keine signifikanten Unterschiede. Es zeigte sich auch kein signifikanter Unterschied bezüglich der Komplikationsrate (2019: 6,8, 2020: 10 %, p = 0,219). Zusammenfassung Ein signifikanter Anteil plastisch-chirurgischer Operationen an einem Universitätsklinikum mit überregionalem Versorgungsauftrag besteht aus Notfalloperationen, akuten und dringenden medizinisch notwendigen Operationen. Während des Lockdowns wurden Operationen ohne signifikanten Anstieg der Komplikationsrate durchgeführt. Trotz sämtlicher Herausforderungen während der Pandemie konnte eine qualitativ konstante Patientenversorgung auf höchstem Niveau gewährleistet werden. Um die während des Lockdowns angehäuften weniger dringenden, jedoch ebenso wichtigen Fälle zeitgerecht und in entsprechend hoher Qualität abzuarbeiten, wird eine Erweiterung der Operationskapazitäten mit Steigerung der Bettenanzahl und der Ambulanzkapazität notwendig sein. Die vorliegenden Ergebnisse zeigen, wie wichtig die Plastische Chirurgie für die medizinische Versorgung insbesondere in Krisenzeiten ist.

The corona crisis of 2020 posed previously unknown challenges to hospitals providing acute care. In addition to the treatment of COVID-19 patients, universities and other acute care hospitals had to provide emergency medical care, including for patients undergoing trauma surgery. The challenge was that no reliable planning figures were available regarding the expected volume for such a crisis situation and therefore no reliable resource planning was possible in this respect. Therefore, the aim of this work was to record the incidence of polytrauma and other injuries during the pandemic crisis in a university trauma surgery clinic and to compare it with the years 2017-2019.In this single-center study, a retrospective analysis of the injury incidence during calendar weeks with existing exit restrictions (12th-19th week) for the year 2020 for trauma surgery patients of a university hospital was performed. At first, the treatment of COVID-19 patients was recorded daily in order to objectify the burden and expenditure of inpatient treatment for these patients. Then, for the evaluation period from 20.03.2020 to 06.05.2020, the numbers of 1. polytrauma, 2. work-related accidents and 3. leisure-related trauma patients were recorded and compared with the numbers from 2017-2019 during the same period.In total, 118 patients were treated with COVID-19 as inpatients during the period under study, of which up to 43 patients had to be treated simultaneously in intensive care on 1 day. Overall, the number of polytrauma, work-related accidents and leisure-time accident patients was lower in 2020 than in the previous years. Nevertheless, with a decline of only -28% (22 ± 4.9 vs. 16), a considerable number of polytrauma patients were recorded, while all work-related accidents (44%, 304 ± 31.3 vs. 170) and also leisure-time accidents (39%, 173 ± 22.7 vs. 106) considerably decreased. In the group of leisure-time accidents, there was initially a remarkable decline in the number of cases per week after the initial restrictions began, but as the duration of the restrictions increased, the number per week has risen to the level of previous years.Even in exceptional situations such as the corona pandemic, there were a significant number of patients in need of acute treatment, especially polytrauma patients. This should be considered in the future in the event of similar exceptional situations in the inpatient care framework when providing trauma surgery care capacities.EINLEITUNG: Die Coronakrise 2020 stellte Kliniken vor schwere Herausforderungen. Neben der Behandlung von COVID(„coronavirus disease“)-19-Patienten war es die Aufgabe der Universitäts- und sonstigen Akutkliniken, eine notfallmedizinische Versorgung sicherzustellen. Aufgrund fehlender Planzahlen gestaltete sich eine genaue Ressourcenplanung schwierig. Daher war das Ziel dieser Arbeit, das Aufkommen von Polytraumata und sonstigen Verletzungen während der Pandemiekrise in einer universitären unfallchirurgischen Klinik zu erfassen und mit den Jahren 2017–2019 zu vergleichen.Es wurde eine retrospektive Analyse unfallchirurgischer Patienten während der Kalenderwochen (KW) mit bestehender Ausgangsbeschränkung (12.–19. KW) im Jahr 2020 durchgeführt. Zunächst erfolgte eine tagesgenaue Erfassung der Behandlung von COVID‑19-Patienten. Zusätzlich wurden für die Auswertungsperiode vom 20.03.2020 bis zum 06.05.2020 die Anzahlen an 1. Polytrauma-, 2. Arbeitsunfall- und 3. Freizeitunfallpatienten erfasst und mit den Zahlen von 2017–2019 verglichen.Maximal 43 COVID‑19-Patienten mussten gleichzeitig intensivmedizinisch betreut werden. Die Summe an unfallchirurgischen Patienten war im Jahr 2020 geringer als in den Vorjahren. Dennoch war mit einem Rückgang von nur −28 % (22 ± 4,9 vs. 16) ein beachtliches Aufkommen an Polytraumata zu verzeichnen, während v. a. die Arbeits- (44 %, 304 ± 31,3 vs. 170) und auch Freizeitunfälle (39 %, 173 ± 22,7 vs. 106) deutlich abnahmen.Auch in Ausnahmesituationen wie der SARS-CoV‑2-Pandemie, war ein erhebliches Aufkommen von akut behandlungsbedürftigen Patienten zu verzeichnen, v. a. in puncto Polytraumapatienten. Dies sollte zukünftig bei ähnlichen Ausnahmesituationen im stationären Versorgungsrahmen bei der Vorhaltung unfallchirurgischer Versorgungskapazitäten bedacht werden.

Background: Fungal burn wound infections are among the most devastating complications in patients who are severely burned. Increasing incidence of burn wound infections caused by fungi led to new challenges in diagnostic and therapeutic approaches. The wide use of broad-spectrum antibiotic agents, an increased prevalence of molds and non-Candida albicans spp., and the variety of available antifungal agents underline the importance of identifying the causative species, to initiate adequate therapy within an adequate timeframe. Methods: Review of the pertinent English and German literature. Results: Fungal burn wound infections go along with a delay of identifying the causative fungus species and can be mistaken for early bacterial burn wound infection. Recently, an increase of uncommon fungal pathogens and fungi resistance against antifungal agents has been reported. Amphotericin B and voriconazole remain the antifungal drugs used most commonly. Conclusions: Adequate therapy remains challenging. Early radical debridement and wound closure play an imperative part, particularly in preventing infections caused by yeasts and molds or any other agent. Prophylactic empiric pharmacologic treatment is reserved for those highly at risk for invasive burn wound infection only. Because of the emergence of drug-resistant fungi, the development of new antifungal drugs is essential for the battle against fungal burn wound infections.

Highlights • Large hospitals with burn units face particular challenges during the COVID-19 pandemic. • The strategy of the University Hospital Graz, including the way back to normality are presented. • Re-booting measures need to be elaborated as carefully as lock-down measures. • Measures include infrastructure, patients and staff and need to be coordinated with local authorities., The first half of the year 2020 has been shaped by quarantines and lock-downs all over the world. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a pandemic, that slowed down not only social interactions and economy, but also medical and health care. Governments and hospitals were forced to create ad hoc emergency plans maintaining the balance between an adequate participation in collective response of shutting-down to avoid a further spreading of the virus, while preserving the ongoing acute care and simultaneously being able to react to an imminent overextension with a collapse of capacities. The University Hospital Graz is one of the largest hospitals in Austria. As transregional trauma and burn centre it provides care for people from all over Austria and faced special challenges. We present the strategy of the University Hospital Graz in dealing with the COVID-19 pandemic and the way back to (new) normality. The strategy includes infrastructural, patient-centred and staff-centred measures. The continuously low numbers of new infections in Austria allowed a loosening of the lock-down measures already. Particular attention has to be paid to attentive screening of patients and triaging of surgeries during the re-boot. The re-boot needs to be slow and steady to reduce the risk of an infectiological relapse. Once this pandemic is defeated, a careful re-evaluation of the different internationally applied strategies should be performed to be prepared for the future.

Introduction: Ankle injuries are common in daily orthopaedic trauma practice, with a high incidence of lateral ligament complex (lat-lig-com) injuries of the ankle joint (AJ). Primarily, these lat-...

Summary Background High temperatures at workplaces lead to health-related risks and premature exhaustion. The coronavirus disease 2019 (COVID-19) pandemic requires many health professionals to perform under unfavorable conditions. Personal protective equipment (PPE) causes thermal stress and negatively affects performance. Patients, materials and methods This pilot project investigated the effects of PPE and additional cooling wear on physiological parameters and concentration of six healthy staff members of the Plastic Surgery Department of the Medical University of Graz, Austria during simulated patient care. In this study two 1‑hour cycles with patient care-related tasks with PPE and PPE + cooling-wear, respectively, were conducted. A third cycle with scrubs exclusively served as baseline/negative control. The assessment occurred immediately pre-cycles and post-cycles. Results Pre-cycle assessments showed no significant differences between the cycles. After PPE cycle, increased physical stress levels and decrements in concentration capacity were observed. Physiological parameters were significantly less affected in the cooling cycle, while concentration capacity slightly increased. Conclusion COVID-19 PPE causes considerable thermal stress, ultimately affecting human performance. As opportunity to withstand thermal stress, and improve patients’ and professionals’ safety, cooling-wear can be considered relevant. Medical personnel performing in exceptional situations may particularly benefit from further development and investigation of cooling strategies.

Introduction: The fast and accurate diagnosis of rib fractures in polytrauma patients is important to reduce the mortality rate and relieve long-term pain and complications. Aim: To evaluate the diagnostic accuracy and potential time savings using automatic rib segmentation and a curved, unfolded view for the detection of rib fractures in trauma patients. Methods: The multidetector computed tomography raw data of 101 consecutive polytrauma patients (72 men; mean age 45 years, age range 17 to 84 years) admitted to a university hospital were retrospectively post-processed to generate a curved, unfolded view of the rib cage. No manual corrections were performed. Patients with reconstruction errors and movement artifacts were excluded from further analysis. All fractures were identified and classified by the study coordinator using the original data set. Two readers (reader 1 and reader 2) evaluated the original axial sections and the unfolded view, separately. The fracture locations, fracture type, and reading times were recorded. Sensitivity and specificity were calculated on a per-rib basis using a ratio estimator. Cohen’s Kappa was calculated as an index of inter-rater agreement. Results: 26 of 101 patients (25.7%) were excluded from further analysis owing to breathing artifacts (6.9%) or incorrect centerline computation in the unfolded view (18.8%). In total, 107 (5.9%) of 1800 ribs were fractured in 25 (33%) of 75 patients. The unfolded view had a sensitivity/specificity of 81%/100% (reader 1) and 71%/100% (reader 2) compared to 94%/100% (reader 1; p = 0.002/p = 0.754) and 63%/99% (reader 2; p < 0.001/p = 0.002). The sensitivity (reader 1; reader 2) was poor for buckled fractures (31%; 38%), moderate for undislocated fractures (78%; 62%), and good for dislocated fractures (94%; 90%). The assessment of the unfolded view was performed significantly faster than that of the original layers (19.5 ± 9.4 s vs. 68.6 ± 32.4 s by reader 1 (p < 0.001); 24.1 ± 9.5 s vs. 40.2 ± 12.7 s by reader 2 (p < 0.001)). Both readers demonstrated a very high interobserver agreement for the unfolded view (κ = 0.839) but only a moderate agreement for the original view (κ = 0.529). Conclusion: Apart from a relatively high number of incorrect centerline reconstructions, the unfolded view of the rib cage allows a faster diagnosis of dislocated rib fractures.

Identifying risk factors for unplanned hospital readmission is beneficial in terms of costs and utilization of resources. This systematic review aimed to identify and compare the rates and common reasons for readmission following reconstructive and esthetic surgery. Adhering to PRISMA guidelines, we searched PubMed, Web of Science, and CENTRAL database. No publication date or language restrictions were applied. Outcomes included 30-day readmission rate, reasons for readmission, and complications after reconstructive or esthetic surgery. Weighted individual study estimates were used to calculate pooled 30-day readmission rates using a random-effects approach. Risk ratios (RRs) or odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe pooled estimates for risk factors. A total of 29 studies were included in the meta-analysis. Overall readmission rates were 10.3% (95%CI 6.3–14.3) after head and neck reconstruction, 4.6% (95%CI 3.7–5.5) after breast reconstruction, 2.4% (95%CI 1.57–3.17) after other breast surgeries, 3.0% (95%CI 0.2–5.8) after esthetic surgery, and 14.1% (95%CI 2.0–26.2) after free tissue transfer of any type. Statistically significant risk factors after head and neck reconstructions included pre-existing diabetes (RR 1.20; 95%CI 1.09–1.33), congestive heart failure (RR 1.67; 95%CI 1.43–1.94), prior radiation (OR1.17; 95%CI 1.06–1.30), and perioperative blood transfusion (OR 1.44; 95%CI:1.22–1.70). There is a large difference for readmission rates depending on the complexity of the procedure. Few studies report unplanned readmission rates in esthetic surgery and general free tissue transfer. Whereas readmissions after head and neck reconstruction are well-evaluated, risk factors for other reconstructive surgeries are poorly reported. Closer follow-up visits and outpatient resources could decrease readmission rates. Level of Evidence: Not ratable.

Soft tissue management and fracture fixation including initial external fixation in Gustilo-Anderson type II and type III open fractures are cornerstones in the treatment but details on timing and type of wound closure, irrigation and debridement, systemic and local antibiotics, antimicrobial-coated implants and the use of Bone Morphogenetic Protein-2 remain controversial. This article looks at current clinical evidence of these items for the management of open fractures. Timing of debridement and wound closure remains critical. Early debridement by an experienced team within 24 h seems adequate while gross contamination, a devascularized limb, a multi-injured patient and compartment syndrome require immediate surgical intervention. Wound closure during the first surgery was shown to result in reduced rates for infections and nonunion. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Regarding types of irrigation fluid, antiseptic and antibacterial solutions did not prove to be superior to saline. High pressure irrigation has not been demonstrated to be beneficial whereas antibiotic administration as soon as possible has been proven to be favorable. Administration of more than 72 h was not superior to shorter systemic antibiotic intervals. For Gustilo-Anderson type I and II, broad spectrum antibiotic therapy is reasonable. Additional aminoglycosides for broader coverage are recommended in Gustilo-Anderson type III fractures. There is newer literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application. Vacuum assisted closure (VAC) could not evidence negative pressure wound therapy to reduce infection risk, improve self-rated disability or quality of life in open fractures, however, enhance treatment costs. Recombinant human bone morphogenetic proteins (rhBMP)-2 showed promising data in Gustilo-Anderson type III open tibial shaft fractures with lower rates of invasive secondary procedures. In conclusion, there is evidence for thorough debridement and irrigation with saline, early soft tissue coverage and the use of systemic and local antibiotics. Except for a short-term soft tissue coverage VAC seems not to be beneficial and rhBMP-2 is an additional tool in Gustilo-Anderson type III open fractures.

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.

BACKGROUND: As the cost of healthcare rises, it is imperative to assess value delivered to patients and impact on the economic viability of institutions. We aimed to characterize plastic surgery operative time management and identified areas for efficiency improvement. METHODS: Procedures from a U.S. academic Plastic Surgery Division from September 2017 to August 2018 were reviewed. Times were categorized into preparation (patient in room to incision), procedure (incision to closure), exit (closure to patient exiting room) and turnover (patient out of room to next patient in room). Median and interquartile ranges (IQR) were calculated. Procedures were classified by relative value units (RVUs) for comparison of procedure complexities and resources. Components were plotted against RVUs; r(2) values were calculated. RESULTS: We analyzed 522 cases; 69 were excluded for missing data, primary surgeon not a plastic surgeon, emergent cases, or burn procedures; a total of 453 cases were analyzed. Median and IQR (minutes) for preparation was (34, 18 minutes; 23% of total), procedure (53, 75 minutes; 36% of total), exit (30, 27 minutes; 20% of total), and turnover (30, 26 minutes; 20% of total). Normalized to RVUs, preparation demonstrated the most variability (r(2)=0.19), followed by exit (r(2)=0.38), and procedure (r(2)=0.57). Average work RVUs per month was 678.1±158.7. Average work RVUs per OR hour was 7.2. CONCLUSIONS: The largest component with greatest variability was preparation for surgery in the OR. Improved efficiency by decreasing variability increases the value of healthcare delivered to patients and OR throughput.

Introduction: Heading is an integral part of football and frequent media reports and previous studies about potential danger of heading and head trauma in football fuelled discussions. Epidemiological data and video analyses regarding the frequency of headings and associated head injuries are still missing in adult elite football. Methods: In a prospective cohort study in the fourth German football league, 100 official matches of the 2015-2016 season were assessed by means of video analysis and a standardized protocol. Head injuries were documented and confirmed by standardised epidemiological injury reports of the teams. Results: Overall, 11,514 headings were analysed in detail. Video analysis yielded a mean of 5.7 headings per player and match (SD: 1.2; min: 0; max: 15). Heading was predominantly performed with the frontal part of the head (76.8%), and nearly two thirds of all headings occurred during defending (65.8%). 71.0% of all headings occured during tacklings, of which 71.9% involved body contact with the opponent player. Video analysis yielded 31 critical incidents (CI) on the head due to heading (incidence: 1.02 per 1000 h match exposure and player). 29 CIs occurred during heading duels (Odds ratio: 5.91), 30 CIs with body contact (odds ratio: 28.8) and 6 CIs with elbow contact (odds ratio: 6.13). Conclusion: Heading duels, especially with body contact and high elbow, are important risk factors for head injuries and key factor for prevention strategies. The impact of 5.7 headings per match on players` brain should be investigated in further research.

European journal of plastic surgery (2022). doi:10.1007/s00238-022-01958-x, Published by Springer, Berlin

See also the editorial by Dodd and MacDermott in this issue.

PURPOSE Surgical simulations are becoming increasingly relevant in musculoskeletal training. They provide the opportunity to develop surgical skills in a controlled environment while reducing the risks for patients. For K-wire internal fixation in musculoskeletal surgery, a force feedback virtual reality (VR) simulator was developed. The aim of this study was to evaluate training results using this technology and compare the results with that of standard teaching on cadavers. METHODS Twenty participants attending an AO Trauma Course during 2020 were randomly allocated in 2 groups. On day 1, group A was trained by senior surgeons using a cadaver and group B was trained by the VR simulator for K-wire insertion in the distal radius. On day 2, all participants performed K-wire insertion on the cadaver model, without assistance, to validate the training effect. RESULTS On a surgical skills test, group B performed better than group A. In group B, the entry point of the first K-wire was closer to the targeted styloid process of the radius, and the protrusion of the K-wires into soft tissue was less than that in group A. CONCLUSIONS Training with the VR simulator for K-wire insertion resulted in better surgical skills than training by a surgeon and cadaver model. CLINICAL RELEVANCE Training with the VR simulator provides the opportunity to improve and refine surgical skills without the risk of harming patients. It offers easier access, unlimited repetitions, and is more cost-effective compared with training sessions with cadavers.

Chronic wounds are a challenging medical entity for patients, medical professionals and healthcare systems. Frequently, patients present themselves to wound specialists after months or even years of unsuccessful treatment. Recent developments have resulted in a multitude of different advanced wound dressings created to treat complex, chronic wounds, one of which is the polylactide dressing Suprathel. This study aimed at investigating the healing potential of Suprathel in chronic wounds and differentiating between old and "young", diabetic and non-diabetic chronic wounds. A prospective, multicentric, non-controlled intervention study was conducted, treating patients with chronic lower leg ulcers (>3 months) with Suprathel and assessing them weekly. Afterwards, a retrospective analysis was performed analysing the wound size initially, after 4 and after 8 weeks of treatment. Furthermore, a differentiation between diabetic and non-diabetic, and chronic wounds older and younger than 12 months, was assessed. A significant reduction in wound size was observed in the study population after 8 weeks of treatment. The effect size in the diabetic wound and the old chronic wound group even reached more than one, with the other groups still showing a large effect of the intervention. This study shows that Suprathel is a valuable tool in the armamentarium of a wound specialist. Not only could we show a positive effect on chronic wounds, we could even demonstrate a significant wound size reduction in chronic wounds of old and young, as well as diabetic wounds, with the treatment of older chronic and diabetic wounds yielding an even larger effect size. Further randomised, controlled studies are necessary to show the full potential of advanced wound dressing materials in large patient cohorts.

Over time, we have come to recognize a very complex network of physiological changes enabling wound healing. An immunological process enables the body to distinguish damaged cells and begin a cleaning mechanism by separating damaged proteins and cells with matrix metallopro-teinases, a complement reaction, and free radicals. A wide variety of cell functions help to rebuild new tissue, dependent on energy provision and oxygen supply. Like in an optimized "biorector," disturbance can lead to prolonged healing. One of the earliest investigated local factors is the pH of wounds, studied in close relation to the local perfusion, oxygen tension, and lactate concentration. Granulation tissue with the wrong pH can hinder fibroblast and keratinocyte division and pro-liferation, as well as skin graft takes. Methods for influencing the pH have been tested, such as occlusion and acidification by the topical application of acidic media. In most trials, this has not changed the wound's pH to an acidic one, but it has reduced the strong alkalinity of deeper or chronic wound. Energy provision is essential for all repair processes. New insights into the metabolism of cells have changed the definition of lactate from a waste product to an indispensable energy provider in normoxic and hypoxic conditions. Neovascularization depends on oxygen provision and lactate, signaling hypoxic conditions even under normoxic conditions. An appropriate pH is necessary for successful skin grafting; hypoxia can change the pH of wounds. This review describes the close interconnections between the local lactate levels, metabolism, healing mechanisms, and pH. Furthermore, it analyzes and evaluates the different possible ways to support metabolism, such as lactate enhancement and pH adjustment. The aim of wound treatment must be the optimization of all these components. Therefore, the role of lactate and its influence on wound healing in acute and chronic wounds will be assessed.

ZusammenfassungDie menschliche Haut ist eine effiziente Barriere, die den Organismus vor Noxen schützt. Wunden zerstören diese Barriere. Die Wundheilung ist eine in Phasen ablaufende physiologische Regeneration des zerstörten Gewebes, die im Idealfall zum Verschluss einer Wunde, insbesondere durch Neubildung von Bindegewebe und Kapillaren, führt. Der Wnt-Signalweg ist eine im gesamten Tierreich stark konservierte Signaltransduktionskaskade, durch die grundlegende zelluläre Interaktionen in multizellulären Organismen gesteuert werden. Entsprechend werden durch den Wnt-Signalweg viele Prozesse, z. B. die Balance zwischen Proliferation und Differenzierung oder die Apoptose, koordiniert. Die Wnt-Signalisierung wird durch eine Wunde aktiviert und nimmt an jeder nachfolgenden Phase des Heilungsprozesses teil, beginnend mit der Entzündungskontrolle und des programmierten Zelltods bis zur Mobilisation von Stammzellen innerhalb der Wunde. Die endogene Wnt-Signalverstärkung stellt einen attraktiven therapeutischen Ansatz dar, um die Wiederherstellung von Hautwunden zu unterstützen, da die komplexen Mechanismen des Wnt-Signalwegs im Laufe der Jahre zunehmend verstanden wurden. In dieser Übersichtsarbeit werden die aktuellen Daten zusammengefasst, um die Rolle der Wnt-Signalgebung beim Wundheilungsprozess der Haut zu verdeutlichen.

Obesity and the related medical, social, and economic impacts are relevant multifactorial and chronic conditions that also have a meaningful impact on outcomes following a severe injury, including burns. In addition to burn-specific difficulties, such as adequate hypermetabolic response, fluid resuscitation, and early wound coverage, obese patients also present with common comorbidities, such as arterial hypertension, diabetes mellitus, or nonalcoholic fatty liver disease. In addition, the pathophysiologic response to severe burns can be enhanced. Besides the increased morbidity and mortality compared to burn patients with normal weight, obese patients present a challenge in fluid resuscitation, perioperative management, and difficulties in wound healing. The present work is an in-depth review of the current understanding of the influence of obesity on the management and outcome of severe burns.