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Traumatic peripheral nerve injuries are common and socioeconomically highly relevant. Despite significant microsurgical advances, the results of surgical reconstruction are still far from optimal and the rate of life-long complications, such as impaired motor and sensory function or neuropathic pain, is high. Moreover, the regeneration of peripheral nerves is a complex and fragile process that is not yet completely understood. Hence, there is an urgent need to further elucidate the underlying biological mechanisms. Herein, we propose that the neural lymphatic vasculature and lymphangiogenesis play an essential role in both peripheral nerve injury and regeneration and discuss hypothetical mechanisms implementing the current literature. Finally, specific research approaches to test our hypothesis are introduced.

ZusammenfassungIn der peripheren Nervenchirurgie ist die intraoperative Beurteilung eines pathologischen Nervensegmentes von zentraler Bedeutung. Mittels verschiedener Methoden kann die Vitalität eines Nervs beurteilt und zwischen alleiniger Neurolyse oder Resektion und Nervenrekonstruktion entschieden werden. Neben Nervenmorphologie, intraoperativer Schnellschnittdiagnostik und einfacher Nervenstimulation ist die intraoperative Elektrophysiologie ein wertvolles Instrument des Nervenchirurgen. Ziel dieser apparativen Diagnostik ist das Erfassen objektiver Parameter, welche die Funktion peripherer Nerven dokumentieren. Die intraoperative Elektroneurografie erlaubt die Ableitung eines Nervenaktionspotentials über einem pathologisch veränderten Nervensegment und ist seit vielen Jahren etabliert. Im Gegensatz dazu wird die intraoperative Nadel-Elektromyografie in der peripheren Nervenchirurgie noch kaum benutzt, obwohl sie interessante Vorteile mit sich bringt. Sie kann sowohl bei der Selektion geeigneter Faszikel für motorische Neurotisationen als auch bei der Faszikel-topografischen Ableitung von Kontinuitätsneuromen wertvolle Zusatzinformationen generieren. Die vorliegende Übersichtsarbeit fasst die Möglichkeiten der intraoperativen Elektromyografie anhand von Fallbeispielen aus der Traumatologie und Tumorchirurgie zusammen.

Zusammenfassung. Tendinopathien sind einer der häufigsten Gründe für das Aufsuchen einer Handchirurgin oder eines Handchirurgen. Die Diagnose der Erkrankungen aus diesem Formenkreis kann in aller Regel klinisch gestellt werden. Eine ergänzende Ultraschalluntersuchung hilft das Krankheitsbild zu objektivieren. Die meisten dieser Erkrankungen sprechen auf eine nicht-operative Behandlung an. Falls doch eine operative Behandlung nötig wird, kann diese in der Regel ambulant unter Lokalanästhesie erfolgen. Dieser Artikel gibt eine Übersicht über die häufigsten Tendinopathien an Hand und Handgelenk, ihre Diagnostik und Therapie.

Zusammenfassung. Neuropathischen Schmerzen im Bereich des Handgelenks und der Hand können verschiedenste Ätiologien zugrunde liegen. Mögliche Ursachen umfassen Trauma, iatrogene Schädigung, lokale periphere Kompression, Nerventumoren sowie Systemerkrankungen. Anhaltende Beschwerden führen mitunter zu Chronifizierung und Invalidität und stellen einen starken Einschnitt in die Lebensqualität und die Arbeitsfähigkeit der Betroffenen dar. Eine präzise Diagnostik ist der Schlüssel zu einer adäquaten Therapie mit möglichst zufriedenstellendem funktionellem Ergebnis. Ein interdisziplinärer und multimodaler Approach hat sich bewährt. Diese Übersichtsarbeit gibt einen Einblick in Diagnostik und Therapie von Pathologien, die für neuropathische Schmerzen im Bereich des Handgelenks und der Hand verantwortlich sein können.

Extradigital localizations of glomus tumors (GTs) remain rare and can often lead to missed or delayed diagnosis due to nonspecific symptoms. In this article, we report a case of a GT with a rare lo...

Zusammenfassung. Mit zunehmendem Alter der Bevölkerung steigt die Häufigkeit von Arthrose in der Hand. Dies kann bei Manifestation zu Schmerzen und körperlichen Beeinträchtigungen führen. Die daraus resultierende potenzielle Arbeitsunfähigkeit betrifft die Bevölkerung bei steigendem Rentenalter zunehmend. Dieser Artikel gibt einen Überblick über die häufigsten Formen der Arthrose in der Hand, ihre Diagnosestellung und die aktuellen Behandlungsmöglichkeiten und betont, dass eine multimodale Therapie häufig der effektivste Ansatz ist.

Zusammenfassung. Schmerzen im Handgelenk sind ein Problem, das Betroffene in ihren alltäglichen Aktivitäten deutlich einschränken kann. Die Ursachen sind mannigfaltig und die Behandlung häufig anspruchsvoll. Bei der Aufarbeitung der korrekten Diagnose ist ein systematischer Ansatz daher hilfreich. Ziel dieses Artikels ist, einen klaren Ansatz für die Evaluation von Handgelenkschmerzen bei Erwachsenen aufzuzeigen.

Tendinopathies - Common Diagnoses in Hand Surgery

Pain In the Thumb and Other Fingers

The Painful Wrist

Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective

The field of hand surgery is constantly evolving to meet challenges of populations with increasing age and higher demands for active living. While our surgical care has improved over the last decades, it seems that future major improvement in outcomes of clinical treatment will come through advances in biologics and the translation of major discoveries in basic science. This article aims to provide an update on where basic science solutions may answer some of the most critical issues in hand surgery, with a focus on augmentation of tissue repair.

RATIONALE Degloving foot injuries are challenging to treat and associated with life-long sequelae for patients. An appropriate debridement of ischemic soft tissues with maximal preservation of glabrous skin is key during the reconstruction of these injuries. Indocyanine green (ICG) fluorescence angiography is an established technique for the intraoperative evaluation of tissue perfusion. PATIENT CONCERNS Two patients sustained complex foot injuries in traffic accidents, including multiple fracture dislocations and extensive degloving of the plantar skin. DIAGNOSIS Clinical inspection revealed significant degloving of the glabrous skin in both patients. INTERVENTIONS After fracture fixation, ICG fluorescence angiography-assisted debridement with immediate latissimus dorsi free flap reconstruction was performed. OUTCOMES In both cases, this technique allowed a precise debridement with maximal preservation of the glabrous skin. The healing of the remaining glabrous skin was uneventful and the 6-month follow-up was characterized by stable soft tissues and satisfying ambulation. LESSONS ICG fluorescence angiography is a safe, user-friendly, and quick procedure with minimal risks, expanding the armamentarium of the reconstructive surgeon. It is highly useful for the debridement of extensive plantar degloving injuries and may also help to minimize the number of procedures and the risk of infection.

Pancreatic islet transplantation still represents a promising therapeutic strategy for curative treatment of type 1 diabetes mellitus. However, a limited number of organ donors and insufficient vascularization with islet engraftment failure restrict the successful transfer of this approach into clinical practice. To overcome these problems, we herein introduce a novel strategy for the generation of prevascularized islet organoids by the fusion of pancreatic islet cells with functional native microvessels. These insulin‐secreting organoids exhibit a significantly higher angiogenic activity compared to freshly isolated islets, cultured islets, and non‐prevascularized islet organoids. This is caused by paracrine signaling between the β‐cells and the microvessels, mediated by insulin binding to its corresponding receptor on endothelial cells. In vivo, the prevascularized islet organoids are rapidly blood‐perfused after transplantation by the interconnection of their autochthonous microvasculature with surrounding blood vessels. As a consequence, a lower number of islet grafts are required to restore normoglycemia in diabetic mice. Thus, prevascularized islet organoids may be used to improve the success rates of clinical islet transplantation., This study introduces a novel strategy to accelerate the revascularization of transplanted islets by the fusion of microvascular fragments (MVF) with pancreatic islet cells. These prevascularized islet organoids may be used to improve the success rate of clinical islet transplantation.

Lipedema is a chronic adipose tissue disorder characterized by the disproportional subcutaneous deposition of fat and is commonly misdiagnosed as lymphedema or obesity. The molecular determinants of the lipedema remain largely unknown and only speculations exist regarding the lymphatic system involvement. The aim of the present study is to characterize the lymphatic vascular involvement in established lipedema. The histological and molecular characterization was conducted on anatomically-matched skin and fat biopsies as well as serum samples from eleven lipedema and ten BMI-matched healthy patients. Increased systemic levels of vascular endothelial growth factor (VEGF)-C (P = 0.02) were identified in the serum of lipedema patients. Surprisingly, despite the increased VEGF-C levels no morphological changes of the lymphatic vessels were observed. Importantly, expression analysis of lymphatic and blood vessel-related genes revealed a marked downregulation of Tie2 (P P = 0.02) consistent with an increased macrophage infiltration (P = 0.009), without changes in the expression of other lymphatic markers. Interestingly, a distinct local cytokine milieu, with decreased VEGF-A (P = 0.04) and VEGF-D (P = 0.02) expression was identified. No apparent lymphatic anomaly underlies lipedema, providing evidence for the different disease nature in comparison to lymphedema. The changes in the lymphatic-related cytokine milieu might be related to a modified vascular permeability developed secondarily to lipedema progression.

Since the first description many variations of the dorsal metacarpal reverse island flap have been published but there is still uncertainty about which vascular component should be included for an optimal result. Therefore, it was the aim of this study to analyze vascular reliability and ischemic complications of dorsal metacarpal artery perforator (DMAP) flaps and dorsal finger perforator (DFP) flaps in our patient collective. We performed 40 of these flaps from the dorsum of hand and fingers for finger injuries. The choice of donor site was made according to the defect's location. Patients were analyzed with respect to flap necrosis, ischemic complications and achievement of overall reconstruction goals. In addition, we divided our patients in two groups, one group where we raised the flap from the dorsum of the proximal phalanx and a second one where the flaps were raised from the intermetacarpal space to identify complication rates based on the pedicles location. Of the 40 flaps, 36 survived completely. 4 partial necroses were observed in flaps transferred to more distal defects and in one flap that was used in a wrap-around technique for both dorsal and palmar proximal phalanx. These perforator flaps are a reliable method to cover finger defects and the dorsal metacarpal artery is not necessary for their survival, since the blood supply comes from perforating branches of the palmar vascular system. There is a clear trend for a higher complication rate in flaps raised from the dorsum of the fingers compared to the intermetacarpal space.

The research committee of the Federation of European Societies for Surgery of the Hand (FESSH) recently reported the results of a survey on research activities of European hand surgeons (Frueh et al., 2019). The survey of more than 500 hand surgeons identified two common factors limiting the success of academic activity in hand surgery: the lack of dedicated research time (71%) and the lack of funding (48%). To stimulate and facilitate research efforts in hand surgery, the research committee of FESSH initiated a number of research grants, which it aims to award annually. For 2020, four applications were awarded grants totalling €70,000.

Background Pulleys are crucial to convert flexor tendon excursion into angular motion at the metacarpophalangeal and interphalangeal joints. Loss of pulley function can lead to significant impairment of hand function and may require surgical reconstruction. This reconstruction can be achieved using different flexor tendons grafts, such as the intrasynovial flexor digitorum superficialis (FDS) or the extrasynovial palmaris longus (PL). However, there is limited knowledge on the micromorphology of human pulleys and the suitability of flexor tendon grafts for their reconstruction remains elusive. Methods In the present cadaver study A2 and A4 pulleys were compared with FDS and PL tendons by means of scanning electron microscopy (SEM), histology and immunohistochemistry. Surface morphology, core structure and vascularization of the specimens were analyzed. Results SEM imaging of the gliding surfaces revealed morphological differences between tendons and pulleys. Moreover, the core structure of FDS samples was characterized by bundles of individual collagen fibrils whereas PL tendons exhibited a less hierarchical microstructure. In contrast, pulleys consisted of lamellar sheets of densely packed collagen fibrils. Finally, immunohistochemical analyses revealed that the flexor tendons and pulleys contain similar numbers of CD31+ microvessels, indicating a comparable tissue vascularization. Conclusion This study provides novel SEM and immunohistochemical insights into the micromorphology of human pulleys and flexor tendon grafts. Intrasynovial flexor tendons may be particularly suitable for pulley reconstruction and preserving the paratenon may be crucial for graft revascularization.

Zusammenfassung. Vier Pathologien bilden zusammen die makrovaskulären Ursachen des Ulcus cruris: Venöse Ulzera (50 %), gemischte venös-arterielle Ulzera (20 %), arterielle Ulzera (5 %) und das Ulcus hypertonicum Martorell (5 %). Die übrigen 20 % verteilen sich auf sehr viele weitere Ursachen. Jedes Ulcus cruris erfordert eine vaskuläre (arterielle und venöse) Abklärung, gegebenenfalls ergänzt durch Biopsie, Mikrobiologie, und eine vertiefte internistische Diagnostik. Venöse Ulzera werden zunächst durch Kompression therapiert. Insuffiziente Stammvenen und deren Seitenäste werden saniert, sofern das tiefe Venensystem durchgängig ist. Okkludierte Beckenvenen werden nach Möglichkeit rekanalisiert und gestentet. Refraktäre venöse Ulzera werden je nach Fläche mit Spalthaut oder Punch Grafts gedeckt. Je nach Ausdehnung der Dermatolipofasziosklerose kann zuvor die Fibrose mit der «Shave-Therapie» oder Fasziektomie abgetragen werden. Mit der Unterdruck-Wundtherapie können tiefere oder kritisch kolonisierte Wunden konditioniert werden. Hautersatzverfahren sind eine Alternative zur Behandlung oberflächlicher venöser Ulzera ohne Epithelisierungstendenz. Für alle weiteren Indikationen muss ihr Stellenwert noch näher untersucht werden. In der chirurgischen Behandlung komplexer chronischer Wunden führt der Aufbau einer Neo-Dermis vor einer Hautverpflanzung zu einer stabileren Narbe. Gemischte venös-arterielle Ulzera (Ulcus cruris mixtum) heilen langsamer und rezidivieren häufiger. Die Kompressionstherapie muss reduziert werden. Bei ausbleibendem Therapieerfolg wird eine arterielle Revaskularisation angestrebt, womit das gemischte in ein venöses Ulcus cruris umgewandelt wird. Arterielle Ulzera (Ulcus cruris arteriosum) benötigen in aller Regel eine arterielle Revaskularisation und danach eine Spalthautverpflanzung. Das Ulcus hypertonicum Martorell ist noch vielerorts unbekannt und wird oft mit dem Pyoderma gangraenosum verwechselt, was die Therapie in eine falsche Richtung lenkt. Wundchirurgie in kleinerer oder grösserer Form, Antibiotika-Therapie bei klinisch relevanter Superinfektion, und Hautverpflanzungen, oft mehrfach wiederholt, führen in aller Regel zur Abheilung dieser äusserst schmerzhaften und bei falscher Behandlung potenziell lebensgefährlichen Wunden.

Dermal substitutes are frequently used for the initial coverage of extensive skin defects. The seeding of these implants with adipose tissue-derived microvascular fragments (ad-MVF) has recently been shown to accelerate their vascularization and incorporation. In the present study we analyzed whether these processes are affected by a thromboprophylactic therapy with the low molecular weight heparin (LMWH) enoxaparin (enox). Green fluorescent protein (GFP)+ ad-MVF were isolated from enox- (8 mg/kg s.c.) and vehicle-treated (0.9% NaCl s.c.) (C57BL/6-Tg(CAG-EGFP)1Osb/J mice and seeded onto Integra matrices. Subsequently, these were implanted into full-thickness skin defects within dorsal skinfold chambers of enox- and vehicle-treated C57BL/6 wild-type mice. Repetitive stereomicroscopy and intravital fluorescence microscopy over 2 weeks as well as histological and immunohistochemical analyses on day 14 revealed that enox does not inhibit the reassembly of ad-MVF into new microvascular networks. In addition, treatment with the anticoagulative compound did not promote implant-induced hemorrhage formation. Accordingly, Integra matrices in enox- and vehicle-treated animals exhibited a comparable final microvessel density, fraction of GFP+ blood vessels originating from seeded ad-MVF, collagen fiber content, and epithelialization. These novel findings demonstrate that the seeding of dermal substitutes with ad-MVF may be applied also during thromboprophylactic therapy without affecting implant vascularization and bleeding risk.

Objectives Magnetic resonance lymphography (MRL) in small animals is a promising but challenging tool in preclinical lymphatic research. In this study, we compared the gadolinium (Gd)-based nanoparticle AGuIX with Gd-DOTA for interstitial MRL in healthy rats and in a chronic rat hindlimb lymphedema model. Materials and Methods A comparative study with AGuIX and Gd-DOTA for interstitial MRL was performed in healthy Lewis rats (n = 6). For this purpose, 75 μL of 3 mM AGuIX (containing 30 mM Gd-DOTA side residues) and 75 μL 30 mM Gd-DOTA were injected simultaneously in the right and left hindlimbs. Repetitive high-resolution, 3-dimensional time-of-flight gradient recalled echo MRL sequences were acquired over a period of 90 minutes using a 9.4 T animal scanner. Gadofosveset-enhanced MR angiography and surgical dissection after methylene blue injection served as supportive imaging techniques. In a subsequent proof-of-principle study, AGuIX-based MRL was investigated in a hindlimb model of chronic lymphedema (n = 4). Lymphedema of the right hindlimbs was induced by means of popliteal and inguinal lymphadenectomy and irradiation with 20 Gy. The nonoperated left hindlimbs served as intraindividual controls. Six, 10, and 14 weeks after lymphadenectomy, MRL investigations were performed to objectify lymphatic reorganization. Finally, skin samples of the lymphedematous and the contralateral control hindlimbs were analyzed by means of histology and immunohistochemistry. Results AGuIX-based MRL resulted in high-resolution anatomical depiction of the rodent hindlimb lymphatic system. Signal-to-noise ratio and contrast-to-noise ratio of the popliteal lymph node were increased directly after injection and remained significantly elevated for up to 90 minutes after application. AGuIX provided significantly higher and prolonged signal intensity enhancement as compared with Gd-DOTA. Furthermore, AGuIX-based MRL demonstrated lymphatic regeneration in the histopathologically verified chronic lymphedema model. Collateral lymphatic vessels were detectable 6 weeks after lymphadenectomy. Conclusions This study demonstrates that AGuIX is a suitable contrast agent for preclinical interstitial MRL in rodents. AGuIX yields anatomical imaging of lymphatic vessels with diameters greater than 200 μm. Moreover, it resides in the lymphatic system for a prolonged time. AGuIX may therefore facilitate high-resolution MRL-based analyses of the lymphatic system in rodents.

Adipose tissue-derived microvascular fragments (ad-MVF) represent effective vascularisation units for the seeding of dermal substitutes. However, particularly in case of extensive skin defects, the required amounts of donor fat tissue for the harvesting of ad-MVF may not always be available. Therefore, we herein determined the lowest ad-MVF density needed to induce a sufficient vascularisation and incorporation of seeded implants. Collagen-glycosaminoglycan matrices (Integra®; diameter: 4 mm) were seeded with 15,000 (HD), 10,000 (MD) and 5,000 (LD) ad-MVF and implanted into full-thickness skin defects within mouse dorsal skinfold chambers, to analyse their in vivo vascularisation and incorporation. Intravital fluorescence microscopy showed a comparable vascularisation of HD and MD ad-MVF-seeded Integra®, which was significantly higher when compared to LD ad-MVF-seeded Integra®. As assessed by photoacoustic imaging, this was associated with an increased oxygenation of the implants. Additional histological and immunohistochemical analyses revealed an enhanced cellular infiltration, collagen content, microvessel density and epithelialisation of HD and MD ad-MVF-seeded Integra®, indicating a better incorporation compared to LD ad-MVF-seeded implants. These findings demonstrate that 80,000 ad-MVF/cm² is the least required density to guarantee an effective vascularisation of the dermal substitute.

Adipose tissue-derived microvascular fragments (ad-MVF) represent promising vascularisation units for bioengineered Integra® matrix wound dressing (MWD). However, due to the sheet-like structure with small pore sizes, the seeding of this matrix with ad-MVF is mainly limited to its surface. Integra® flowable wound matrix (FWM) may be suitable to achieve a more homogeneous distribution and, thus, improved vascularisation, because this gel-like matrix allows for the direct admixture of ad-MVF during sample preparation. To test this hypothesis, we seeded MWD and FWM with an identical number of ad-MVF and assessed their distribution and inter-fragment distance within both matrices. Moreover, ad-MVF-seeded MWD and FWM were implanted into full-thickness skin defects within mouse dorsal skinfold chambers to analyse their vascularisation, epithelialisation and tissue incorporation using intravital fluorescence microscopy, histology and immunohistochemistry. Seeded FWM exhibited a more homogeneous ad-MVF distribution, when compared to MWD. This resulted in a significantly increased inter-fragment distance, preventing the reassembly of ad-MVF into new microvascular networks. Accordingly, the vascularisation of FWM was diminished after implantation, as indicated by a reduced functional microvessel density and blood perfusion. This was associated with a decreased tissue incorporation and epithelialisation of the matrix, when compared to ad-MVF-seeded MWD. Hence, the use of FWM as a carrier system may require a tremendous amount of ad-MVF to shorten their inter-fragment distance and, thus, to maintain their vascularisation capacity for tissue engineering applications.

Intramedullary cannulated compression screws have been introduced for the fixation of unstable metacarpal fractures. In the present study, this technique was compared with dorsal compression plating to evaluate its biomechanical performance in stabilizing metacarpal shaft fractures. In a first set of experiments, the biomechanical characteristics of the screws were analysed in an artificial bone model. In subsequent experiments, midshaft osteotomies were performed in human cadaver metacarpals, followed by plating or intramedullary screw osteosynthesis. The metacarpals were tested to failure in cantilever bending, following a stepwise increasing cyclic loading protocol. We found a significantly lower load at failure and a significantly lower number of cycles to failure in the intramedullary screw group, but both methods offered sufficient stability under these loads. With reference to published loads on the metacarpals during use of the hand, we conclude that intramedullary osteosynthesis yields sufficient strength and stiffness for early active motion. A difference in its fixation stability is noted compared with plate fixation, which may not be clinically relevant.

During residency, most hand surgeons may be encouraged to participate in clinical or basic science research projects. The research committee of the Federation of European Societies for Surgery of the Hand (FESSH) is dedicated to support research activities, especially of young surgeons, including residents. In 2018, we initiated a survey among European hand surgeons to assess hurdles that limit research activity during hand surgery training and to explore if FESSH can take a more active role in promoting research activities.

Sepsis is a leading cause of death worldwide and recent studies have shown white adipose tissue (WAT) to be an important regulator in septic conditions. In the present study, the role of the inflammatory cytokine macrophage migration inhibitory factor (MIF) and its structural homolog D-dopachrome tautomerase (D-DT/MIF-2) were investigated in WAT in a murine endotoxemia model. Both MIF and MIF-2 levels were increased in the peritoneal fluid of LPS-challenged wildtype mice, yet in visceral WAT, the proteins were differentially regulated, with elevated MIF but down-regulated MIF-2 expression in adipocytes. Mif gene deletion polarized adipose tissue macrophages (ATM) towards an anti-inflammatory phenotype while Mif-2 gene knockout drove ATMs towards a pro-inflammatory phenotype and Mif-deficiency was found to increase fibroblast viability. Additionally, we observed the same differential regulation of these two MIF family proteins in human adipose tissue in septic vs healthy patients. Taken together, these data suggest an inverse relationship between adipocyte MIF and MIF-2 expression during systemic inflammation, with the downregulation of MIF-2 in fat tissue potentially increasing pro-inflammatory macrophage polarization to further drive adipose inflammation.

Nanofat grafting is a relatively new technique that has gained popularity in esthetic surgery in recent years. Since its discovery, it has emerged as an effective treatment to improve scar quality and attenuate wrinkles. Nanofat is produced through the mechanical shuffling and filtration of microfat, which is harvested by liposuction. It is easily injectable, rich in adipose-derived stem cells, microvascular fragments, and rich in growth factors that, put together, contribute to its pleasing clinical results. Compared with other stem cell–based therapies, harvesting and processing of nanofat is cost-effective as it requires no additional devices or culturing time. Moreover, the liquid consistency of nanofat allows for easy application in a broad range of clinical cases. Hence, we propose that nanofat should also be considered for use in translational research. Based on current techniques in biomaterial loading with stem cells and microvascular fragments, nanofat has the potential to be a valuable alternative to lengthy tissue regeneration protocols in translational research.

Leg ulcers (ulcus cruris): The frequent macrovascular causes

The primary goal of the surgical treatment of upper brachial plexus injuries is to restore active elbow flexion. Accordingly, Oberlin's transfer has been frequently performed since 1994 and has influenced the development of other nerve transfers. However, the window of opportunity for nerve transfers remains a subject of controversy. The objective of this study was to assess magnetic resonance (MR) neurographic, clinical and electrophysiological long-term results after Oberlin's transfer. For this purpose, we performed a retrospective follow-up study. Six patients with upper brachial plexus or musculocutaneous nerve injuries were assessed; 2 were iatrogenic nerve injuries following shoulder arthroscopy or neurofibroma resection. Direct and indirect signs of neuropathy were objectified with MR neurography. Moreover, clinical and electrodiagnostic follow-up was performed and all patients completed the Disabilities of Arm, Shoulder and Hand score. Mean follow-up was 48 ± 21.9 (range, 20-73) months. Mean age was 40 ± 11.3 years and mean delay to surgery was 9 ± 3.2 months. All patients were satisfied with the functional results and the median Disabilities of Arm, Shoulder and Hand score was 21 (range, 1-57). Biceps strength was improved in 5 patients from Medical Research Council grade M0 to M4-5 and in one patient to M2-3. The donor nerve showed normal motor and sensory action potentials. Follow-up MR neurography demonstrated biceps reinnervation. Taken together, this study reports good long-term results after Oberlin's transfer. MR neurography represents an excellent, noninvasive preoperative planning tool and can be of high value in selected postoperative cases. The combined evaluation of nerves and muscles may help to indicate nerve transfers in delayed cases.

Zusammenfassung. Das Extremitätentrauma mit Weichteilschaden ist eine Herausforderung für die behandelnden Chirurgen. Für das Outcome entscheidend ist ein effizienter interdisziplinärer Behandlungsansatz durch Unfallchirurgen/Orthopäden und Plastische Chirurgen, die so früh wie möglich eine gemeinsame Strategie festlegen. Das Ziel dieses orthoplastischen Vorgehens ist die frühe definitive Frakturstabilisation kombiniert mit Weichteildeckung (fix and flap). Die Weichteilrekonstruktion erfolgt heute nach einem modularen Prinzip und nicht mehr linear gemäss der rekonstruktiven Leiter. Die Vielzahl unterschiedlicher Verletzungsmuster bedingt sehr variable Vorgehensweisen in der Rekonstruktion der Weichteildefekte. Dies erschwert eine standardisierte Behandlung und erfordert massgeschneiderte Lösungen, häufig unter Zuhilfenahme mikrochirurgischer Techniken. Eine funktionelle Wiederherstellung verlangt vielfach eine Kombination von Hauttransplantaten, lokoregionalen und freien Lappenplastiken. Die Vakuumtherapie hat sich als nützliches Werkzeug in der Behandlung komplexer Extremitätenverletzungen erwiesen.

Integra® matrix wound dressing (MWD) is used for the reconstruction of full-thickness skin defects. For the treatment of complex wounds, this dermal substitute is available as a flowable wound matrix (FWM) of identical composition. To clarify whether variations in sample preparation and consistency affect the biocompatibility and tissue incorporation, we herein compared MWD and FWM. The matrices were characterized using scanning electron microscopy and histology. Moreover, they were implanted in mouse dorsal skinfold chambers to analyze their in vivo performance over 2 weeks. Scanning electron microscopy showed a planar surface of MWD whereas FWM presented an irregular, fissured morphology. However, histology of the two matrices revealed an identical fiber thickness, fiber length, and interfiber distance. Repetitive stereo-microscopy and immunohistochemical analyses of MWD and FWM showed a comparable epithelialization of the implants in the dorsal skinfold chamber model. At day 14, both matrices exhibited a low collagen content and microvessel density. Moreover, they were infiltrated by a high number of myeloperoxidase (MPO)-positive neutrophilic granulocytes and a lower number of MAC387-positive macrophages and CD3-positive lymphocytes. These findings demonstrate that differences in preparation and consistency do not affect the tissue response to MWD and FWM, indicating a comparable regenerative capacity in wound healing. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 52-60, 2018.

Vascularization is a key process in skin tissue engineering, determining the biological function of artificial skin implants. Hence, efficient vascularization strategies are a major prerequisite for the safe application of these implants in clinical practice. Current approaches include (i) modification of structural and physicochemical properties of dermal scaffolds, (ii) biological scaffold activation with growth factor-releasing systems or gene vectors, and (iii) generation of prevascularized skin substitutes by seeding scaffolds with vessel-forming cells. These conventional approaches may be further supplemented by emerging strategies, such as transplantation of adipose tissue-derived microvascular fragments, 3D bioprinting and microfluidics, miRNA modulation, cell sheet engineering, and fabrication of photosynthetic scaffolds. The successful translation of these vascularization strategies from bench to bedside may pave the way for a broad clinical implementation of skin tissue engineering.

Background Recently published data show that many women interested in breast augmentation (BA) actively search the Internet for information. The Internet is currently the main source of information on this topic. Objectives Little is known about the quality of available information on the Internet concerning BA. The goal was to evaluate this in a systematic manner using a validated and reproducible tool. Methods Women (n = 96) unrelated to medicine were asked which keywords they would use to search the Internet if they were interested in BA. Five keywords were used. Qualitative and quantitative assessment was performed with the modified Ensuring Quality Information for Patients (EQIP) tool. A total of 2500 websites containing information on BA were identified using Google, Bing, Yahoo, Ask, and AOL. Results Out of 623 eligible websites, only 153 (25%) addressed more than 20 EQIP items. Scores were higher for encyclopaedias and academic websites compared to hospital and practitioner websites. The median EQIP score was only 15 (IQR = 12-20), and quantitative postoperative morbidity and mortality risk estimates were available in only 38% and 25% of the websites, respectively. Major complications (e.g. capsular contraction, implant safety) were mentioned in only 156 (25%) of the websites. Conclusions This is the first assessment of online patient information on BA using the EQIP tool. This analysis demonstrated several shortcomings in the quality of information provided to BA candidates. There is an immediate need for better informative and educational websites regarding BA procedures that are compatible with international quality standards for plastic surgery.

Background: The treatment of extensive skin defects and bradytrophic wounds remains a challenge in clinical practice. Despite emerging tissue engineering approaches, skin grafts and dermal substitutes are still the routine procedure for the majority of skin defects. Here, we review the role of vascularization and lymphangiogenesis for skin grafting and dermal substitutes from the clinician’s perspective. Summary: Graft revascularization is a dynamic combination of inosculation, angiogenesis, and vasculogenesis. The majority of a graft’s microvasculature regresses and is replaced by ingrowing microvessels from the wound bed, finally resulting in a chimeric microvascular network. After inosculation within 48–72 h, the graft is re-oxygenated. In contrast to skin grafts, the vascularization of dermal substitutes is slow and dependent on the ingrowth of vessel-forming angiogenic cells. Preclinical angiogenic strategies with adipose tissue-derived isolates are appealing for the treatment of difficult wounds and may markedly accelerate skin reconstruction in the future. However, their translation from bench to bedside is still restricted by major regulatory restrictions. Finally, the lymphatic system contributes to edema reduction and the removal of local wound debris. Therapeutic lymphangiogenesis is an emerging field of research in skin reconstruction. Key Messages: For the successful engraftment of skin grafts and dermal substitutes, the rapid formation of a microvascular network is of pivotal importance. Hence, to understand the biological processes behind revascularization of skin substitutes and to implement this knowledge into clinical practice is a prerequisite when treating skin defects. Furthermore, a functional lymphatic drainage crucially contributes to the engraftment of skin substitutes.

Split-thickness skin grafts (STSG) are still the gold standard for the treatment of most skin defects. Hence, there is an ongoing need to improve this procedure. For this purpose, we herein analyzed dermal matrices seeded with adipose tissue-derived microvascular fragments (ad-MVF) in a bradythrophic wound model. In additional experiments, the matrices were covered with autologous STSG 10 days after implantation. Green fluorescence protein (GFP)+ ad-MVF were isolated from C57BL/6-Tg(CAG-EGFP)1Osb/J mice and seeded onto collagen-glycosaminoglycan matrices. Non-seeded and prevascularized matrices were implanted into full-thickness skin defects on the skull of CD1 nu/nu mice for 21 days. Vascularization, lymphangiogenesis and incorporation of the matrices were analyzed using photo-acoustic imaging, trans-illumination stereomicroscopy, histology, and immunohistochemistry. The survival rate of STSG was assessed by planimetry. After 21 days, the density of microvascular and lymphatic networks was significantly higher in prevascularized matrices when compared to controls. This was associated with an improved implant integration. Moreover, prevascularization with ad-MVF allowed successful autologous skin grafting already at day 10, while coverage of non-seeded controls at day 10 resulted in STSG necrosis. In conclusion, ad-MVF represent powerful vascularization units. Seeded on dermal substitutes, they accelerate and enhance the healing of full-thickness skin defects and allow early coverage with STSG.

Background Chronic secondary lymphedema is a well-known complication in oncologic surgery. Autologous lymph node transplantation, lymphovenous anastomosis, and other lymphatic surgeries have been developed in the last decades with rising clinical application. Animal models to explore the pathophysiology of lymphedema and microsurgical interventions have reached great popularity, although the induction of stable lymphedema in animals is still challenging. The aim of this review was to systematically assess lymphedema animal models and their potential use to study surgical interventions. Materials and methods A systematic review according to the PRISMA guidelines was performed without time or language restriction. Studies describing new or partially new models were included in chronological order. Models for primary and secondary lymphedema were assessed, and their potential for surgical procedures was evaluated. Results The systematic search yielded 8590 discrete articles. Of 180 articles included on basis of title, 84 were excluded after abstract review. Ninety-six were included in the final analysis with 24 key articles. Conclusions No animal model is perfect, and many models show spontaneous lymphedema resolution. The rodent limb appears to be the most eligible animal model for experimental reconstruction of the lymphatic function as it is well accessible for vascularized tissue transfer. There is a need for standardized parameters in experimental lymphedema quantification. Also, more permanent models to study the effect of free vascularized lymph node transfer are needed.

Patients suffering from carpal tunnel syndrome (CTS) actively search for medical information on the Internet. The World Wide Web represents the main source of patient information. The aim of this study was to systematically assess the quality of patient information about CTS in the Internet. A qualitative and quantitative assessment of websites was performed with the modified Ensuring Quality Information for Patients (EQIP) tool that contains 36 standardized items. Five hundred websites with information on CTS treatment options were identified through Google, Bing, Yahoo, Ask.com and AOL. Duplicates and irrelevant websites were excluded. One hundred and ten websites were included. Only five websites addressed more than 20 items; quality scores were not significantly different between the various providing groups. A median of 15 EQIP items was found, with the top website addressing 26 out of 36 items. Major complications such as median nerve injury were reported in 27% of the websites and their treatment in only 3%. This analysis revealed several critical shortcomings in the quality of the information provided to patients suffering from CTS. There is a collective need to provide interactive, informative and educational websites for standard procedures in hand surgery. These websites should be compatible with international quality standards for hand surgery procedures.

A functional microvascular network is of pivotal importance for the survival and integration of engineered tissue constructs. For this purpose, several angiogenic and prevascularization strategies have been established. However, most cell-based approaches include time-consuming in vitro steps for the formation of a microvascular network. Hence, they are not suitable for intraoperative one-step procedures. Adipose tissue-derived microvascular fragments (ad-MVF) represent promising vascularization units. They can be easily isolated from fat tissue and exhibit a functional microvessel morphology. Moreover, they rapidly reassemble into new microvascular networks after in vivo implantation. In addition, ad-MVF have been shown to induce lymphangiogenesis. Finally, they are a rich source of mesenchymal stem cells, which may further contribute to their high vascularization potential. In previous studies we have demonstrated the remarkable vascularization capacity of ad-MVF in engineered bone and skin substitutes. In the present study, we report on a standardized protocol for the enzymatic isolation of ad-MVF from murine fat tissue.

Die Dupuytren'sche Erkrankung ist trotz intensiver Grundlagenforschung sowie vielfältiger chirurgischer Therapiekonzepte zum heutigen Zeitpunkt nicht heilbar. Die seit bald 20 Jahren bekannte enzymatische Strangdegradation mittels clostridialer Kollagenase hat sich zu einer wichtigen zusätzlichen Therapieoption entwickelt. War vor wenigen Jahren noch die limitierte Fasziektomie die Therapie der Wahl für die meisten Patienten, kann heute oft primär eine enzymatische Therapie erfolgen mit gegebenenfalls sekundärer Chirurgie bei Rezidiven. Die Injektion von Xiapex® ist – korrekt ausgeführt – eine effektive und sichere Behandlung mit einer Erfolgsrate von 85 % (MCP-Gelenk) resp. 65 % (PIP-Gelenk) nach 3 Jahren. Im folgenden Artikel wird die Therapie des Morbus Dupuytren mit Xiapex®-Injektionen zusammengefasst.

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