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The application of dermal substitutes in deep partial and full-thickness burn wounds in a two-stage procedure prior to skin grafting has become increasingly popular. Synchronous application of dermal substitutes and skin graft has not yet been established as a standard procedure. In a consecutive study 20 wounds in 10 patients with severe burns (age 49.5+/-16.2 years; TBSA 45.6+/-14.5%) were treated with either simultaneous transplantation of Matriderm((R)), a bovine based collagen I, III, V and elastin hydrolysate based dermal substitute and split-thickness skin grafting (STSG), or STSG alone after appropriate excision of the burn wound. The study was designed as a prospective intra-individual comparative study. After 1 week all wounds were assessed for the percentage of autograft survival. Autograft survival was not altered by simultaneous application of a dermal matrix (p=0.015). Skin elasticity was measured after 3-4 months with the Vancouver Burn Skin Score (VBSS). The VBSS demonstrated a significant increase of elasticity in the group with dermal substitutes (p=0.04) as compared with non-substituted wounds for sheet autograft, but not for meshed autograft (p=0.24). From this pilot study it can be concluded that simultaneous application of a dermal matrix is safe and feasible, yielding significantly better results with respect to skin elasticity. Skin elasticity was considerably improved by the collagen/elastin dermal substitute Matriderm((R)) in combination with sheet autograft. [ABSTRACT FROM AUTHOR]

Nerve injuries in the upper extremity can result in severe disability. In the past three decades, progress in microsurgical techniques and instruments have resulted in improved outcomes for nerve injuries. If the prognosis is reasonably good, nerve repair is usually preferred over tendon or flap transfer procedures. However, lesions of peripheral stem nerves such as high radial nerve palsy may still yield unsatisfactory results, despite technically well-executed nerve repair. Prognosis further depends on the age of the patient; the regenerative process is delayed in older patients. Further criteria for the indication for tendon transfers are the personal and professional profiles of individual patients. Tendon or flap transfers to restore sensation can be performed at any time post trauma when it becomes clear that long-term rehabilitation is required. These procedures abbreviate the interval during which hand function is severely impaired, so that patients have alternatives to persistent nerve palsy with the need of permanent external splints, and long and costly rehabilitation can be shortened. Sophisticated techniques allow minimal donor site morbidity and leave options open in case function of the reconstructed nerve returns. The present article gives an overview of the most common procedures to restore hand function and sensation in the most important digits and provides help for decision making.

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.

Background: Free tissue transplantation is a rarely indicated procedure in burn reconstruction. As the versatility and variability of free flaps have significantly increased during recent years, so too have the indications for these procedures expanded., Material and Methods: We retrospectively report the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience has enabled us to establish reconstructive principles pertinent to the type of injury (burn versus high voltage injuries) and the timing of reconstruction procedures., Results: In high voltage injuries (n = 17) early free flap coverage (< 21 days after trauma) with muscular flaps was the most frequently used type of reconstruction. Reconstruction site was predominately the forearm. In burn injuries (flame, contact, fluid), free flap coverage was performed during a later stage of the treatment course (3 to 6 weeks after trauma), or as a secondary procedure. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and the dorsum of the hand underwent defect coverage in most circumstances. For the reconstruction of complex or large defects (n = 6) combined "chimeric" flaps, preexpansion of free flaps, or the combination of a free and local flap were used. Overall, the flap failure rate was 12 % (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four out of five flap failures occurred within 5 to 21 days after trauma, all five flap failures occurred between five days and six weeks. No flap failure was seen during secondary reconstruction., Conclusion: Our data demonstrate that burn and high voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if our flap failures all occurred during the first six weeks it should not be forgotten that this type of coverage is the only alternative to amputation in selective cases.

We report on a 19-year-old male patient with partial destruction of the index metacarpophalangeal joint due to traumatic middle hand amputation. Six months after replantation the metacarpophalangeal joint defect was reconstructed with an osteochondral metatarsal head graft from the second metatarsophalangeal joint. At a follow-up period of four years the patient achieved full metacarpophalangeal extension, with 40 degrees of flexion and grip strength equal to 90 % of the contralateral index finger. Magnetic resonance imaging showed enhancement of contrast medium as a sign for vitality of the transplant.

Neurofibromas are benign tumors arising from neuroectodermal tissues. They may occur as solitary lesions, or multiple, in which case they are referred to as neurofibromatosis, or von Recklinghausen's disease. We report about a 17-year-old patient with neurofibromatous elephantiasis located in the lateral aspect of the left hemithorax. CT showed massive chest wall infiltration and retroperitoneal tumor growth, but no abnormalities of the cranium. Our surgical treatment consisted of a two-stage, palliative tumor debulking and defect coverage with a splitthickness skin graft. The operative and postoperative course was uneventful.

Between May 1989 and December 2000 in 24 adult patients with pectus excavatum, a subcutaneous implantation of silicone prostheses was performed. Of the 24 patients, 20 were followed. During follow-up the authors encountered seroma complications in 13 patients and postoperative hematoma in 4 patients. The patients stayed in the hospital 5 days on average, and showed excellent aesthetic results in 80% (N = 16), good results in 10% (N = 2), and fair results in 10% (N = 2). Patient satisfaction was also taken into consideration. A follow-up survey questioned whether patients were satisfied with the cosmetic outcome. On a scale of 1 to 5 points, with 1 point being the highest level of satisfaction, 85% of patients used ratings of 1 and 2 to express satisfaction levels. Silicone implant correction of pectus excavatum in adult patients without any impairment of cardiopulmonary function has value. The major advantages are the minimally invasive operation, the short hospital stay, good aesthetic results, and high patient satisfaction