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ZusammenfassungDie Ergebnisse der Recherche zur Besonderen Versorgung in den Fachgebieten, die verschiedenen Perspektiven, die Pretest-Ergebnisse, die Ergebnisse zu den aktuellen Projekten, der Struktur-, Prozess- und Ergebnisqualität sowie der Wirtschaftlichkeit werden präsentiert und diskutiert.

ZusammenfassungEs erfolgt eine Deskription des Status Quo in der Regelversorgung der Fachgebiete Plastische Chirurgie und Handchirurgie. Anschließend wird die Recherche zu Projekten der Besonderen Versorgung in den Fachgebieten erläutert.

ZusammenfassungDerzeitige Vergütungssysteme erlauben es kaum Sektorengrenzen aufzubrechen. Es existieren kaum Anreize zur Ambulantisierung und Ergebnisqualität. Der Reinerlös chirurgischer Einzelpraxen sinkt seit Jahren. Die Anzahl ambulanter Operationen nimmt dementsprechend ab. Ob die Besondere Versorgung in der Plastischen Chirurgie und Handchirurgie den Herausforderungen begegnen kann, soll in dieser Evaluation überprüft werden.

ZusammenfassungEs erfolgt eine Zusammenfassung der Evaluationsergebnisse mit kritischer Bewertung, Fazit und Ausblick.

ZusammenfassungIn diesem Kapitel wird die Methodik der Fragebogenentwicklung, des Pretests, der Studiendurchführung und der statistischen Auswertung dargelegt.

Microcirculation is a critical factor in burn wound healing. Remote ischemic conditioning (RIC) has been shown to improve microcirculation in healthy skin and demonstrated ischemic protective effects on heart, kidney, and liver cells. Therefore, we examined microcirculatory effects of RIC in partial thickness burn wounds. The hypothesis of this study is that RIC improves cutaneous microcirculation in partial thickness burn wounds. Twenty patients with partial thickness burn wounds within 48 hours after trauma were included in this study. RIC was performed with an upper arm blood pressure cuff on a healthy upper arm using three ischemia cycles (5 min inflation to 200 mm Hg) followed by 10-minute reperfusion phases. The third and final reperfusion phase lasted 20 minutes. Microcirculation of the remote (lower/upper extremities or torso) burn wound was continuously quantified, using a combined Laser Doppler and white light spectrometry. The capillary blood flow in the burn wounds increased by a maximum of 9.6% after RIC (percentage change from baseline; P < .01). Relative hemoglobin was increased by a maximum of 2.8% (vs. baseline; P < .01), while cutaneous tissue oxygen saturation remained constant (P > .05). RIC improves microcirculation in partial thickness burn wounds by improving blood flow and elevating relative hemoglobin.

Introduction Stem cell transplantation is one of the most promising strategies to improve healing in chronic wounds as systemic administration of endothelial progenitor cells (EPC) enhances healing by promoting neovascularization and homing though a high amount of cells is needed. In the following study, we analysed whether local application can reduce the number of EPC needed achieving the same beneficial effect on wound healing. Material and Methods Wound healing after local or systemic treatment with EPC was monitored in vivo by creating standardized wounds on the dorsum of hairless mice measuring wound closure every second day. Systemic group received 2 × 106 EPC i.v. and locally treated group 2 × 105 EPC, locally injected. As control PBS injection was performed the same way. Expression of CD31, VEGF, CD90 and, SDF-1α was analysed immunohistochemically for evaluation of neovascularisation and amelioration of homing. Results Local (7.1 ± 0.45 SD) as well as systemic (6.1 ± 0.23 SD) EPC transplantation led to a significant acceleration of wound closure compared to controls (PBS local: 9.7 ± 0.5 SD, PBS systemic 10.9 ± 0.38 SD). Systemic application enhanced CD31 expression on day 6 after wounding and local EPC on 6 and 9 in comparison to control. VEGF expression was not significantly affected. Systemic and local EPC treatment resulted in a significantly enhanced SDF-1α and CD90 expression on all days investigated. Conclusion Local as well as systemic EPC treatment enhances wound healing. Moreover, beneficial effects are obtained with a tenfold decrease number of EPC when applied locally. Thus, local EPC treatment might be more convenient way to enhance wound healing as number of progenitor cells is limited.

Zusammenfassung Hintergrund Die handchirurgische Versorgung in Deutschland unterliegt einem Strukturwandel, der viele Abteilungen in ein Spannungsfeld zwischen Medizin und Ökonomie bringt. Einerseits kommt es zu einer Umverteilung elektiver handchirurgischer Eingriffe aus dem stationären in den ambulanten Sektor, andererseits konzentrieren sich – so unser Eindruck – stationär zu behandelnde handchirurgische Notfälle mehr und mehr an großen Kliniken. Vor diesem Hintergrund fehlen Daten zur Versorgungsrealität von handchirurgischen Notfällen, die diese Arbeit durch eine 10-Jahresanalyse handtraumatologischer Fälle unter epidemiologischen, strukturellen und ökonomischen Aspekten an einer Klinik der Maximalversorgung erhebt und zur Diskussion stellt. Material und Methoden Anhand einer Datenbankabfrage über ICD-Codes wurden handtraumatologische (Hauptdiagnose), stationär behandelte Fälle zwischen 2009 und 2018 identifiziert und im Hinblick auf epidemiologische und wirtschaftliche Kennzahlen (Alter, Geschlecht, Komorbiditäten, Case-Mix-Index, Erlös, Verweildauern, OP-Zeiten) unter verschiedenen Aspekten über PIVOT-Tabellen analysiert. Ausgeschlossen wurden Patienten unter 16 Jahren, Unterarmfrakturen sowie intensivmedizinische Patienten. Ergebnisse Im untersuchten Zeitraum und Zentrum war der typische handchirurgische Traumapatient männlich und durchschnittlich 44 Jahre alt. Der Patient Clinical Complexity Level war in 80 % aller Fälle 0. Der Anteil an Arbeitsunfällen lag durchschnittlich bei ca. 25 %. Die 3 Top-DRGs waren die I32F (18,5 %), X01B (11,3 %) sowie die I32A (7,2 %). Auffällig war über die Jahre ein massiver Fallzahlanstieg von ca. 300 auf über 1000 Fälle/Jahr. Gleichzeitig wurde die Versorgung handchirurgischer Notfälle in 4 von 5 anderen Kliniken in einem Umkreis von 100 km zurückgefahren. Insbesondere außerhalb der Kernarbeitszeit kam es hierdurch zu einer Mehrbelastung. Die mittlere Verweildauer lag bei ca. 4–5 Tagen, die durchschnittliche Schnitt-Naht-Zeit unter 60 Minuten und der durchschnittliche CMI bei 1,23. Damit erlösten diese Patienten im Jahr 2018 4370 €, wobei die BG-Erlöse durchschnittlich 387 € niedriger lagen. Schlussfolgerung Ausgehend von einer höchstwahrscheinlich mehr oder weniger gleichgebliebenen Zahl handchirurgischer Notfälle führen wir den deutlichen Fallzahlanstieg in der Handtraumatologie in unserer Klinik nicht auf eine Zunahme der Verletzungen zurück, sondern auf eine zunehmende Konzentration dieser Fälle in wenigen handchirurgischen Zentren, da aus wirtschaftlichen Gründen die Versorgung von Notfällen an kleineren Häusern zunehmend reduziert wird und dies, obwohl unter wirtschaftlichen Aspekten Handverletzungen interessant sind; lassen sich doch mit wenig Aufwand verhältnismäßig gute Erlöse erzielen, die bei Überschreiten einer kritischen Patientenzahl die Vorhaltekosten einer Dienst-Versorgung amortisieren. Dort, wo sich die Versorgung handtraumatologischer Fälle konzentriert, kommt es insbesondere außerhalb der Kernarbeitszeit zu einer Mehrbelastung, unter Umständen mit negativen Auswirkungen auf die elektive Handchirurgie.

To find out whether application of cold atmospheric plasma (CAP) affects microcirculation in chronic wounds.We treated 20 patients with chronic wounds on the lower extremity with CAP. Blood flow parameters of wounds were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in tissue depth of 2 and 6-8 mm. Parameters were assessed under standardized conditions before and over the course of 30 min after application of CAP.Deep capillary blood flow increased significantly by up to 24.33% (percentage change) after treatment with CAP and remained significantly elevated until the end of measuring period at 30 min. Superficial oxygen tissue saturation was significantly elevated by 14.05% for the first 5 min after treatment. Postcapillary venous filling pressure was significantly elevated by 10.23% 19 min after CAP and stayed significantly elevated starting from minute 24 until the end of measuring.Cold atmospheric plasma increases microcirculation parameters in chronic wounds significantly. As CAP is known for its benefits in wound healing, the effects observed may explain the improved healing of chronic wounds after its use. Whether CAP-application can increase blood flow in chronic wounds for longer periods of time or boosts blood flow when applied more than once should be subject to further research.

Emergency capacities in the operating theatre are limited and often need to be split among surgical departments. Hand injuries often have to compete with other surgical disciplines for the availability of operating capacity. For this reason, an emergency classification was introduced to define a timespan in which the injury should be taken care of in the OR in order to enable the prioritizing of emergency cases in an interdisciplinary approach when capacities are scarce. However, neither valid data nor specific recommendations concerning the medical urgency of treatment or the forensic background of different hand injuries exist to this date.This work describes how emergency classifications in Germany are applied to hand surgical cases and how certain hand injuries are prioritized among different hand surgeons.An online survey was sent to all members of the German Society for Hand Surgery twice during a time span of several months. The survey featured questions on size and type of clinic or practice and requested an assessment of urgency levels for various hand injuries (immediately - within 2 h - within 6 h - within 12 h - within 24 h or elective care). The analysis of the questionnaire and graphic presentation was carried out using Excel.172 (25 %) out of 700 active members filled in the survey. Among the participants were members of university clinics, hospitals run by the German Statutory Accident Insurance, specialized clinics and primary care clinics. 15 % of participants work in a practice that offers hand-surgical treatment. First and foremost, maximum care hospitals with a hand surgical department participate in the treatment of hand injuries. 64 % of the hospitals use an emergency classification to enable the interdisciplinary prioritizing of surgical emergencies. The categorization of limb-threatening hand injuries appears to be very homogenous among participants whereas non-threatening injuries are assessed rather inconsistently.Emergency treatment of hand injuries primarily depends on available resources and surgical capacities. The assessment of urgency and severity of injuries additionally depends on experience and education. In order to maintain the ability to compete with other surgical disciplines for surgical capacities, a standard classification of hand surgical urgencies needs to be established. As valid data on the treatment of hand injuries are still missing, further studies need to evaluate possible outcomes in order to define the timespan in which surgery should take place.Die handchirurgische Notfallversorgung konkurriert in der Dienstzeit mit anderen chirurgischen Fächern um die zur Verfügung stehende OP-Kapazität. Fachübergreifend existiert in vielen Kliniken eine einheitliche Notfallkategorisierung, die festlegt, innerhalb welcher Zeitfenster eine chirurgische Versorgung von Notfällen erfolgen muss. Allerdings gibt es in der handchirurgischen Literatur keine einheitlichen Daten/Empfehlungen darüber, mit welcher zeitlichen Versorgungsdringlichkeit bestimmte Verletzungsmuster aus medizinischer und forensischer Sicht versorgt werden sollten. ZIEL: Die vorliegende Arbeit unternimmt den Versuch, die Versorgungssituation und den fachlichen Konsens bezüglich der Versorgungsdringlichkeiten in Deutschland mithilfe einer Online-Umfrage zu erfassen.Über den E-Mail-Verteiler der DGH wurde eine Online-Umfrage an alle Mitglieder zweimal im Abstand von mehreren Monaten versandt. Es erfolgte die standardisierte Abfrage von Art und Größe der Klinik bzw. Praxis sowie die Bitte um Einschätzung der zeitlichen Dringlichkeitsstufen für verschiedene handchirurgische Verletzungsmuster (sofort – innerhalb 2 h – innerhalb 6 h – innerhalb 12 h – innerhalb 24 h bzw. elektive Versorgung). Die anschließende Analyse und grafische Aufarbeitung erfolgten mittels Excel.Von rund 700 aktiven Mitgliedern beteiligten sich 172 (25 %) an der Umfrage. Vertreten sind Kollegen sowohl aus Universitätskliniken und BG-Kliniken als auch aus Schwerpunkthäusern und Kliniken der Grund- und Regelversorgung. 15 % sind in der Praxis tätig. An der Notfallversorgung partizipieren erwartungsgemäß hauptsächlich Häuser der Maximalversorgung, überwiegend mit eigener handchirurgischer Dienstbesetzung. 64 % der Häuser haben dabei eine fachübergreifende Notfallkategorisierung. Die Einschätzung der zeitlichen Versorgungsdringlichkeiten bei gefährdenden Verletzungen der Hand wie Amputationen und Kompartmentsyndrom ist insgesamt relativ einheitlich, bei nicht-gefährdenden Verletzungen wie Infekten oder Sehnendurchtrennungen hingegen sehr heterogen.Die Möglichkeit zur Versorgung handchirurgischer Notfälle hängt in erster Linie von den zur Verfügung stehenden Ressourcen und OP-Kapazitäten ab, die Einschätzung der Versorgungsdringlichkeit zusätzlich von Erfahrung und Schule. Um im Wettbewerb mit anderen chirurgischen Disziplinen um limitierte Ressourcen auf eine valide Argumentationsgrundlage zurückgreifen zu können, ist ein allgemeiner Konsens zu Versorgungsdringlichkeiten sinnvoll. Eine dazu valide Studiengrundlage fehlt allerdings bis heute.

Peripheral nerve injuries are often encountered in traumatological care. The aim of this manuscript is to provide initial data, experiences and performance reports from Germany in the implantation of acellular human nerve transplants in peripheral sensory nerve defects of the hand and to put these data in the context of a comprehensive review of the literature. Of the patients 4 (7 digital nerves) were examined 6 months postoperatively and 5 patients (6 digital nerves) were examined 1 year after the operation (3 were also at the 6‑month examination). All patients had a clinical improvement after nerve reconstruction (≥ S3 according to the classification of sensory recovery of the Medical Research Council modified by Mackinnon and Dellon). Disadvantages of our clinical study are the small number of patients, the inhomogeneity (primary and secondary nerve reconstruction) and the lack of comparison with other nerve reconstruction methods.Verletzungen peripherer Nerven werden regelmäßig in der traumatologischen Versorgung angetroffen. Ziel dieser Arbeit ist es, erste Daten, Erfahrungen und Anwendungsberichte aus Deutschland bei der Implantation von azellulären humanen Nerventransplantaten bei peripheren sensiblen Nervendefekten an der Hand anzubieten und diese Daten in den Kontext einer umfassenden Literaturübersicht zu stellen. Bei der 6-Monats-Untersuchung konnten 4 Patienten (7 Nervi digitalis propii) nachuntersucht werden. Ein Jahr postoperativ konnten 5 Patienten (6 Nervi digitalus propii) nachuntersucht werden (3 davon waren auch bei der 6-Monats-Untersuchung). Alle Patienten hatten eine klinische Verbesserung nach der Nervenrekonstruktion (≥ S3 nach der Klassifikation der sensiblen Regeneration nach dem Medical Research Council modifiziert durch Mackinnon und Dellon). Nachteile dieser klinischen Studie sind die kleine Anzahl von Patienten, die Inhomogenität (primäre und sekundäre Nervenrekonstruktion) sowie der fehlende Vergleich zu einer anderen Nervenrekonstruktionsmethode.

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

Zusammenfassung Hintergrund Die handchirurgische Notfallversorgung konkurriert in der Dienstzeit mit anderen chirurgischen Fächern um die zur Verfügung stehende OP-Kapazität. Fachübergreifend existiert in vielen Kliniken eine einheitliche Notfallkategorisierung, die festlegt, innerhalb welcher Zeitfenster eine chirurgische Versorgung von Notfällen erfolgen muss. Allerdings gibt es in der handchirurgischen Literatur keine einheitlichen Daten/Empfehlungen darüber, mit welcher zeitlichen Versorgungsdringlichkeit bestimmte Verletzungsmuster aus medizinischer und forensischer Sicht versorgt werden sollten. Ziel Die vorliegende Arbeit unternimmt den Versuch, die Versorgungssituation und den fachlichen Konsens bezüglich der Versorgungsdringlichkeiten in Deutschland mithilfe einer Online-Umfrage zu erfassen. Material und Methoden Über den E-Mail-Verteiler der DGH wurde eine Online-Umfrage an alle Mitglieder zweimal im Abstand von mehreren Monaten versandt. Es erfolgte die standardisierte Abfrage von Art und Größe der Klinik bzw. Praxis sowie die Bitte um Einschätzung der zeitlichen Dringlichkeitsstufen für verschiedene handchirurgische Verletzungsmuster (sofort – innerhalb 2 h – innerhalb 6 h – innerhalb 12 h – innerhalb 24 h bzw. elektive Versorgung). Die anschließende Analyse und grafische Aufarbeitung erfolgten mittels Excel. Ergebnisse Von rund 700 aktiven Mitgliedern beteiligten sich 172 (25 %) an der Umfrage. Vertreten sind Kollegen sowohl aus Universitätskliniken und BG-Kliniken als auch aus Schwerpunkthäusern und Kliniken der Grund- und Regelversorgung. 15 % sind in der Praxis tätig. An der Notfallversorgung partizipieren erwartungsgemäß hauptsächlich Häuser der Maximalversorgung, überwiegend mit eigener handchirurgischer Dienstbesetzung. 64 % der Häuser haben dabei eine fachübergreifende Notfallkategorisierung. Die Einschätzung der zeitlichen Versorgungsdringlichkeiten bei gefährdenden Verletzungen der Hand wie Amputationen und Kompartmentsyndrom ist insgesamt relativ einheitlich, bei nicht-gefährdenden Verletzungen wie Infekten oder Sehnendurchtrennungen hingegen sehr heterogen. Schlussfolgerung Die Möglichkeit zur Versorgung handchirurgischer Notfälle hängt in erster Linie von den zur Verfügung stehenden Ressourcen und OP-Kapazitäten ab, die Einschätzung der Versorgungsdringlichkeit zusätzlich von Erfahrung und Schule. Um im Wettbewerb mit anderen chirurgischen Disziplinen um limitierte Ressourcen auf eine valide Argumentationsgrundlage zurückgreifen zu können, ist ein allgemeiner Konsens zu Versorgungsdringlichkeiten sinnvoll. Eine dazu valide Studiengrundlage fehlt allerdings bis heute.

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

Two therapeutic options for deep dermal hand burns are autologous split-thickness skin graft (STSG) following tangential excision and the application of the temporary wound dressing Suprathel following removal of burn blisters. We compared elasticity and perfusion of burn scars after both types of therapy at least one year after completion of treatment. A case series of 80 patients of our department with deep dermal hand burns between 2013 and 2018 was examined in the year 2019 at least one year after completion of treatment (24 females and 56 males with a median age of 47.6 years). The clinical assessment of the scar was performed with the Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) and the objective assessment with suction cutometry (MPA 580) and an O2C device on both hands. Our statistical analysis showed no statistically significant differences for the R2 and R5 elasticity values between the two types of therapy. The 95% confidence intervals for the ratios of elasticity, and microcirculatory perfusion parameters and scar scale scores of burn scars to respective healthy areas of skin after STSG and Suprathel-therapy mostly covered 1. Subgroup analysis of R2 viscoelasticity and analyses with adjustments for scar compression therapy, nicotine consumption, age, palmar or dorsal localization of the burn scar and interactions of age with smoking and localization gave similar results. The adjusted analysis of SO2 showed statistically significant lower SO2 values, 9% less, after STSG compared to Suprathel treatment. Split-thickness skin graft following tangential excision and the application of Suprathel following removal of burn blisters may be equivalent options for treatment of deep dermal hand burns. To detect possible small differences, further studies with larger samples are required.

Background Chronic wounds, such as venous leg ulcers, diabetic foot ulcers, and pressure ulcers, impose a significant burden on patients and health care systems worldwide. Cold atmospheric plasma (CAP) accelerates wound healing and decreases bacterial load in chronic wounds in both in vitro and in vivo experiments. For the first time, we examined the effects of a repetitive application of CAP on the microcirculation in chronic wounds. Hypothesis The repetitive application of cold atmospheric plasma application further improves microcirculation in chronic wounds. Methods Twenty patients with chronic wounds were treated repetitively with CAP. The repetitive application consisted of three CAP sessions, each lasting 90 s and separated by a 10-minute microcirculation measuring period. Microcirculation parameters were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in a tissue depth of 2 mm. Results Tissue oxygen saturation was significantly increased after the first CAP application. The effect amplitude and duration were further increased after the second and third CAP application with a maximum increase by 16,7% (percent change; p = 0,004 vs. baseline) after the third application. There was no significant increase in capillary blood flow until the third CAP application. After the third CAP application, an increase by 22,6% (p = 0,014) was observed. Postcapillary filling pressure was not significantly increased over the measuring period. The repetitive application of CAP further enhances the microcirculation in chronic wounds compared to a single application. Conclusion The repetitive application of CAP boosts and prolongs tissue oxygen saturation and capillary blood flow in chronic wounds compared to a single application. This insight could provide an impetus for new treatment protocols.

Hand surgery in Germany has been subject to structural changes that strongly affect the balance between medicine and economics. On the one hand there is a shift of elective hand surgery from the inpatient to the outpatient sector. On the other hand - so our observations - emergency hand trauma cases are more concentrated in bigger hospitals. Given this background there is a lack of statistical data on the management of hand trauma care and treatment of patients with hand injuries. This article discusses a 10-year-analysis of hand traumatological cases treated at a maximum care hospital regarding epidemiological, structural and economic aspects.Using a database query using ICD codes, inpatient hand trauma cases were identified between 2009-2018 and analyzed with regard to epidemiological and economic indicators (age, gender, comorbidities, case-mix-index (CMI), revenue, length of stay, length of surgery) using PIVOT tables. Patients under the age of 16 years, forearm fractures and intensive care patients were excluded.In the study period the typical hand surgical trauma patient was male with an average age of 44 years. The Patient-Clinical-Complexity-Level (PCCL) was 0 in 80 % of all cases. The proportion of work-related injuries averaged around 25 %. The three top diagnose related groups (DRG) were the I32F (18.5 %), X01B (11.3 %) and the I32A (7.2 %). A striking point was the massive increase in the overall number of trauma cases over the years from approx. 300 cases in 2009 to over 1000 cases per year in 2018 with a shift of the main workload to on-call and night-shift hours away from core working times. In the study period 4 of 5 others hospitals located in a distance of 100 km reduced and stopped treatment of emergency hand cases. The average length of a hospital stay was approx. 4-5 days, the average cut/suture time less than 60 minutes and the average CMI 1.23. Those cases generate an average proceed of € 4370 in 2018, whereby the cases generated by the work-related injuries averaged € 387 less.On the assumption that the number of emergency hand trauma cases did not really increase in the study period we think that there was a concentration of such cases in a few centres still providing extensive treatment for hand injuries while in smaller hospitals care for emergency hand trauma cases is progressively reduced. However, hand injuries may be worth a second thought for economic reasons because they can create reasonable revenues with rather little effort.If a critical number of patients is exceeded, costs of service provisions can be significantly amortized by the proceed generated by treatment. In those hospitals still taking care for acute hand injuries the workload especially in standby duty increased. What may have a negative input on the numbers of treated elective hand surgery cases.Die handchirurgische Versorgung in Deutschland unterliegt einem Strukturwandel, der viele Abteilungen in ein Spannungsfeld zwischen Medizin und Ökonomie bringt. Einerseits kommt es zu einer Umverteilung elektiver handchirurgischer Eingriffe aus dem stationären in den ambulanten Sektor, andererseits konzentrieren sich – so unser Eindruck – stationär zu behandelnde handchirurgische Notfälle mehr und mehr an großen Kliniken. Vor diesem Hintergrund fehlen Daten zur Versorgungsrealität von handchirurgischen Notfällen, die diese Arbeit durch eine 10-Jahresanalyse handtraumatologischer Fälle unter epidemiologischen, strukturellen und ökonomischen Aspekten an einer Klinik der Maximalversorgung erhebt und zur Diskussion stellt.Anhand einer Datenbankabfrage über ICD-Codes wurden handtraumatologische (Hauptdiagnose), stationär behandelte Fälle zwischen 2009 und 2018 identifiziert und im Hinblick auf epidemiologische und wirtschaftliche Kennzahlen (Alter, Geschlecht, Komorbiditäten, Case-Mix-Index, Erlös, Verweildauern, OP-Zeiten) unter verschiedenen Aspekten über PIVOT-Tabellen analysiert. Ausgeschlossen wurden Patienten unter 16 Jahren, Unterarmfrakturen sowie intensivmedizinische Patienten.Im untersuchten Zeitraum und Zentrum war der typische handchirurgische Traumapatient männlich und durchschnittlich 44 Jahre alt. Der Patient Clinical Complexity Level war in 80 % aller Fälle 0. Der Anteil an Arbeitsunfällen lag durchschnittlich bei ca. 25 %. Die 3 Top-DRGs waren die I32F (18,5 %), X01B (11,3 %) sowie die I32A (7,2 %). Auffällig war über die Jahre ein massiver Fallzahlanstieg von ca. 300 auf über 1000 Fälle/Jahr. Gleichzeitig wurde die Versorgung handchirurgischer Notfälle in 4 von 5 anderen Kliniken in einem Umkreis von 100 km zurückgefahren. Insbesondere außerhalb der Kernarbeitszeit kam es hierdurch zu einer Mehrbelastung. Die mittlere Verweildauer lag bei ca. 4–5 Tagen, die durchschnittliche Schnitt-Naht-Zeit unter 60 Minuten und der durchschnittliche CMI bei 1,23. Damit erlösten diese Patienten im Jahr 2018 4370 €, wobei die BG-Erlöse durchschnittlich 387 € niedriger lagen.Ausgehend von einer höchstwahrscheinlich mehr oder weniger gleichgebliebenen Zahl handchirurgischer Notfälle führen wir den deutlichen Fallzahlanstieg in der Handtraumatologie in unserer Klinik nicht auf eine Zunahme der Verletzungen zurück, sondern auf eine zunehmende Konzentration dieser Fälle in wenigen handchirurgischen Zentren, da aus wirtschaftlichen Gründen die Versorgung von Notfällen an kleineren Häusern zunehmend reduziert wird und dies, obwohl unter wirtschaftlichen Aspekten Handverletzungen interessant sind; lassen sich doch mit wenig Aufwand verhältnismäßig gute Erlöse erzielen, die bei Überschreiten einer kritischen Patientenzahl die Vorhaltekosten einer Dienst-Versorgung amortisieren. Dort, wo sich die Versorgung handtraumatologischer Fälle konzentriert, kommt es insbesondere außerhalb der Kernarbeitszeit zu einer Mehrbelastung, unter Umständen mit negativen Auswirkungen auf die elektive Handchirurgie.

Objectives Merkel cell carcinoma (MCC) is a rare, highly aggressive neuroendocrine skin cancer, which typically affects elderly and immunocompromised and/or immunosuppressed patients. The checkpoint inhibitor avelumab, a mAb targeting the anti-programmed cell death ligand 1 (anti-PD-L1), has revolutionized the treatment of metastatic MCC, achieving dramatic improvements in disease control and overall survival. However, checkpoint inhibitors are associated with the development of immune-related adverse events, such as exacerbation of pre-existing RA. Although most immune-related adverse events can be managed successfully with CSs, their frequent and/or long-term use runs the risk of undermining the efficacy of immune checkpoint inhibition. Methods We report two cases of MCC, in which immunosuppressive therapy for the management of RA was administered. Results Immunosuppression for (i) pre-existing and (ii) immune checkpoint inhibitor-exacerbated RA was associated with progression of metastatic MCC. Conclusion Any decision to initiate immunosuppressive treatment for RA in patients receiving immune checkpoint inhibitor therapy should include careful consideration of the risk of potentially fatal cancer progression and be taken after consultation with the patient’s oncologist and rheumatologist. When the immunosuppressive treatment is required, it should be administered for as short a time as possible and under strict clinical and radiological surveillance.

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

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

Given the high prevalence of wounds and their challenging treatment, the research of therapies to improve wound healing is of great clinical interest. In addition, the general consequences of developing chronic wounds constitute a large health economic aspect, which underscores the interest in the development of efficient treatment strategies. Direct cold atmospheric plasma (di_CAP) has been shown to have beneficial effects on microcirculation of human tissue (Kisch et al., 2016a). It also affects microbial settlements, which may have supportive effects on wound healing processes (Balzer et al., 2015). To treat these adequately, in our view, the positive effects on wound healing should be objectified by application on standardized wounds. However, wound healing is a complex process, depending on nutrient and oxygen supply by cutaneous blood circulation. In spite of microcirculation has been shown to improve in healthy skin by CAP, a quantification of the effect in a standardized wound model has never been evaluated (Kisch et al., 2016a). Based on this, we hypothesize that CAP also influences the microcirculation in standardized acute wounds in a prospective cohort study.Microcirculatory data of 20 healthy subjects (14 males, 6 females; mean age 40.85 ± 15.84 years; BMI 26.83 ± 7.27 kg/m2) were recorded continuously at a standardized acute wound after skin transplantation (donor site) at the thigh. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a dielectric barrier discharge (DBD) plasma device for 90 s to the acute wound area. Immediately after the application, cutaneous microcirculation was assessed for 30 min (min) at the same site.After CAP application, tissue oxygen saturation immediately increased by 5% (92,66 ± 4,76% vs. Baseline 88,21 ± 6,52%, p 0,01) in the first 60 s and remained significantly elevated for 4 min. Capillary blood flow increased by 19.3% within the first minute of CAP therapy (220.14 ± 65.91 AU vs. Baseline 184.52 ± 56.77 AU, p 0.001). The statistically highly significant increase in blood flow continued over the entire measurement time. A maximum value was shown in the blood flow in the 15th minute (232.15 ± 58.90 AU, p 0.001) according to CAP application. With regard to the output measurement, it represents a percentage increase of 25.8%. The measurement of post-capillary venous filling pressure at a tissue depth of 6-8 mm was 59.39 ± AU 12.94 at baseline measurement. After application, there were no significant changes.CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the standardized acute wound healing model. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in chronic wounds. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

Large pressure ulcers are a well know problem occurring frequently on immobilized patients. They can develop rapidly especially over bony prominences on the elderly, ICU patients and on patients after spinal cord injury. Plastic surgical treatment can be challenging if the defects are large and complications occur like affection of anal region or development of a Marjolin's scar ulcer. Large defects of the sacral region are well known in our university hospital. Common local flaps like gluteal rotation or (double) V-Y advancement flap are often used for the treatment of smaller defects. In special cases these therapies are not sufficient. Rarely we use fillet flap of the lower extremity to cover large sacral defects on patients who were unable to walk before.In this case report we demonstrate two relatively young paraplegic patients (49 and 57years old) with large sacral defect wounds. One case occurred in 2017, the other in 2019. After spinal cord injury many years ago both of them developed chronic pressure ulcers of the sacral region. In the case of 2017 a Marjolin's scar ulcer developed as a complication. Both patients had previously lost a leg during the surgical treatment. We used the other remaining leg as a fillet flap in combination with interdisciplinary rectum extirpation for sufficient surgical treatment.In both cases adequate coverage of the sacral defect was achieved after interdisciplinary surgical treatment including rectum extirpation. Fillet flaps were safe, even after necessary surgical revisions. In one of the cases a vacuum wound therapy and several debridements were needed. After rehabilitation the patient of the earlier case is able to fully mobilize himself in everyday life and is even able to use public transport.Using a fillet flap of the lower extremity to cover large sacral ulcers is often the last possibility of surgical treatment. Though many complications can occur, full rehabilitation and social participation is possible after fillet flap surgery even with loss of both legs. Depending on patient's motivation and availability of orthopedic technology like special electric wheel chairs and other tools full mobility can be achieved.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) has shown benefits in patients with nonunion or delayed bone healing, pseudarthrosis, and avascular necrosis of bone. Until now, these effects were explained by the release of growth factors, activation of cells, and microfractures occurring after ESWT. Microcirculation is an important factor in bone healing and may be compromised in fractured scaphoids because its blood supply comes from the distal end. Due to this perfusion pattern, the scaphoid bone is prone to nonunion after fracture. The ability of ESWT to enhance microcirculation parameters in soft tissue was of interest to determine if it improves microcirculation in the scaphoid. QUESTIONS/PURPOSES: (1) Does capillary blood flow increase after a single session of ESWT in the scaphoid? (2) Do oxygen saturation in the bone and postcapillary venous filling pressure increase after a single session of ESWT in the scaphoid? METHODS: ESWT (0.3 mJ/mm(2), 8Hz, 1000 impulses) was applied to the intact scaphoid of 20 volunteers who were without wrist pain and without any important metabolic disorders. Mean age was 43 ± 14 years, 12 men and eight women (40% of total). Volunteers were recruited from January 2017 to May 2017. No anesthetic was given before application of ESWT. An innovative probe designed for measurements in bone by compressing soft tissue and combining laser-Doppler flowmetry and spectrophotometry was used to noninvasively measure parameters of microcirculation in the scaphoid. Blood flow, oxygenation, and venous filling pressure were assessed before and at 1, 2, 3, 5, 10, 15, 20, 25, and 30 minutes after ESWT application. Room temperature, humidity, ambient light and measuring sequences were kept consistent. A paired t-test was performed to compare experimental data with baseline (p < 0.05 taken as significant). RESULTS: At baseline, capillary blood flow of the bone was 108 ± 46 arbitrary units (AUs) (86 to 130). After treatment with ESWT, it was 129 ± 44 AUs (106 to 150; p = 0.011, percentage change of 19 %) at 1 minute, 138 ± 46 AUs (116 to 160; p = 0.002, percentage change of 28%) at 2 minutes, 146 ± 54 AUs (121 to 171; p = 0.002, percentage change of 35%) at 3 minutes and 150 ± 52 AUs (126 to 174; p < 0.001, percentage change of 39%) at 5 minutes. It remained elevated until the end of the measuring period at 30 minutes after treatment at 141 ± 42 AUs (121 to 161; p = 0.002) versus baseline). Oxygen saturation and postcapillary venous filling pressure in bone showed no change, with the numbers available. CONCLUSIONS: A single session of ESWT increased capillary blood flow in the scaphoid during measuring time of 30 minutes. Bone oxygenation and postcapillary venous filling pressure, however, did not change. Because increased oxygenation is needed for improved bone healing, it remains unclear if a sole increase in capillary blood flow can have clinical benefits. As the measuring period was limited to only 30 minutes, bone oxygenation and postcapillary filling pressure may subsequently show change only after the measuring-period ended. CLINICAL RELEVANCE: Further studies need to evaluate if increased capillary blood flow can be sustained for longer periods and if bone oxygenation and postcapillary venous filling pressure remain unchanged even after prolonged or repetitive ESWT applications. Moreover, clinical studies must validate if increased microcirculation has a positive impact on bone healing and to determine if ESWT can be therapeutically useful on scaphoid fractures and nonunions.

Recent studies indicated a lower osteogenic differentiation potential of adipose tissue-derived stromal cells (ASCs) compared to bone marrow derived mesenchymal stromal cells. The aim of this study was to evaluate the effects of potent combinations of highly osteogenic bone morphogenetic proteins (BMPs) in order to enhance the osteogenic differentiation potential of ASCs. Human ASCs were cultured for 10 days in the presence of osteogenic medium consisting of dexamethasone, ß-glycerophosphate and ascorbat-2-phosphate (OM) supplemented with BMP-2, BMP-6, BMP-9+IGF-2 and BMP-2,-6,-9 (day 1+2: 50 ng/ml, days 3-6: 100 ng/ml, days 7-10: 200 ng/ml). The formation of the osteoblast phenotype was evaluated by quantification of osteoblast-related marker genes using real-time polymerase chain reaction (RT-PCR). Matrix mineralization was assessed by Alizarin Red S staining. Statistical analysis was carried out using the one-way analysis of variance (ANOVA) followed by the Scheffe's post hoc procedure. Osteogenic medium (OM) significantly increased the expression of alkaline phosphatase (ALP) and osteocalcin (p 0.05) and led to a stable matrix mineralization. Under the influence of BMP-9+IGF-2 and BMP-2,-6,-9 the ALP expression further increased compared to ASCs cultured with OM only (p 0.01). However, multiple osteogenic markers showed no change or decreased under the influence of OM and BMP combinations (p 0.05). The current results indicate a restricted osteogenic differentiation potential of ASCs and suggest careful reconsideration of their use in bone tissue engineering applications.

Background Non-thermal atmospheric plasma has proven its benefits in sterilization, cauterization and even in cancer reduction. Furthermore, physical plasma generated by dielectric barrier discharge (DBD) promotes wound healing in vivo and angiogenesis in vitro . Moreover, cutaneous blood flow and oxygen saturation can be improved in human skin. These effects are mostly explained by reactive oxygen species (ROS), but electric fields, currents and ultraviolet radiation may also have an impact on cells in the treated area. Usually, single session application is used. The aim of this study was to evaluate the effects of the repetitive use of cold atmospheric plasma (rCAP) on cutaneous microcirculation. Hypothesis The repetitive use of non-thermal atmospheric plasma boosts cutaneous microcirculation effects. Methods Microcirculatory data was assessed at a defined skin area of the radial forearm of 20 healthy volunteers (17 males, 3 females; mean age 39.1 ± 14.8 years; BMI 26.4 ± 4.6 kg/m 2 ). Microcirculatory measurements were performed under standardized conditions using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90 s and cutaneous microcirculation was assessed for 10 min. Afterwards, a second session of CAP application was performed and microcirculation was measured for another 10 min. Then, the third application was made and another 20 min of microcirculatory parameters were assessed. Results Tissue oxygen saturation and postcapillary venous filling pressure significantly increased after the first application and returned to baseline values within 10 min after treatment. After the second and third applications, both parameters increased significantly vs. baseline until the end of the 40-minute measuring period. Cutaneous blood flow was significantly enhanced for 1 min after the first application, with no significant differences found during the remainder of the observation period. The second application improved and prolonged the effect significantly until 7 min and the third application until 13 min. Conclusion: These data indicate that the repetitive use of non-thermal atmospheric plasma boosts and prolongs cutaneous microcirculation and might therefore be a potential tool to promote wound healing.

Cold atmospheric plasma (CAP) has proven its benefits in the reduction of various bacteria and fungi in both in vitro and in vivo studies. Moreover, CAP generated by dielectric barrier discharge (DBD) promoted wound healing in vivo. Charged particles, chemically reactive species (such as O3, OH, H2O2, O, NxOy), ultraviolet radiation (UV-A and UV-B), strong oscillating electric fields as well as weak electric currents are produced by DBD operated in air. However, wound healing is a complex process, depending on nutrient and oxygen supply via cutaneous blood circulation. Therefore, this study examined the effects of CAP on cutaneous microcirculation in a prospective cohort setting.Cold atmospheric plasma application enhances cutaneous microcirculation.Microcirculatory data of 20 healthy subjects (11 males, 9 females; mean age 35.2 ± 13.8 years; BMI 24.3 ± 3.1 kg/m(2)) were recorded continuously at a defined skin area at the radial forearm. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90 s to the same defined skin area of 22.5 cm(2). Immediately after the application cutaneous microcirculation was assessed for 30 min at the same site.After CAP application, tissue oxygen saturation immediately increased by 24% (63.8 ± 13.8% from 51.4 ± 13.2% at baseline, p0.001) and stayed significantly elevated for 8 min. Cutaneous blood flow increased by 73% (41.0 ± 31.2 AU from 23.7 ± 20.8 AU at baseline, p0.001) and remained upregulated for 11 min. Furthermore, cutaneous blood flow showed two peaks at 14 (29.8 ± 25.0 AU, p=0.049) and 19 min (29.8 ± 22.6 AU, p=0.048) after treatment. Postcapillary venous filling pressure continuously increased, but showed no significant change vs. baseline in the non-specific BMI group. Subgroup analysis revealed that tissue oxygen saturation, postcapillary venous filling pressure and blood flow increased more in case of a lower BMI.CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the radial forearm of healthy volunteers. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in diabetic foot ulcers. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

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

Thermic injuries are among the most severe injuries in childhood. Burn depth is the most relevant prognostic factor, and still its assessment is both difficult and controversial. This diagnostic uncertainty results in repeated wound assessments over a 10-day period and carries a relevant risk for over- and undertreatment. Precise wound assessment would thus be a significant step toward improved care. Optical coherence tomography (OCT) is a noninvasive laser-based technique with a penetration depth of ∼2 mm. It provides structural images of the skin while dynamic OCT (D-OCT) shows blood vessels. In this study, we investigated burns and scalds in 130 children with OCT and D-OCT to identify patterns of injury related to the depth of the burn wound. OCT and D-OCT images from burned skin differed consistently from normal skin. We observed several not formerly described morphologic patterns associated with burn injuries. Superficial wounds are characterized by a loss of the epidermal layer and a smooth surface. With deeper wounds, surface irregularity, loss of the dermal papillary pattern, disappearance of skin lines, and characteristic changes in the microvascular architecture were observed. This is the first systematic study of D-OCT in the assessment of burn wounds in children. A number of burn-associated patterns of injury were identified. Thus, D-OCT provided an “optical biopsy” of burn wounds that adds significant information about the severity of a burn wound.

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

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

The incidence of insulin-dependent diabetes mellitus (IDDM) is expected to increase significantly. Due to peripheral neuropathy and angiopathy in IDDM patients, feet scalding results in deep burn injuries. Regularly amputations are needed with tremendous consequences. In relatively healthy patients, split-skin graft (SSG) take is better when topical negative pressure (TNP) is applied. We compared the outcome of circular TNP dressing with that of antiseptic dressing on freshly laid SSG after tangential excision in IDDM patients with deep dermal foot scalds. Seventy patients admitted to a burn center with isolated foot burns were identified (2008-2013). Ten of them suffered from IDDM and presented with a deep dermal foot scald. After tangential excision and split-skin grafting, five of them were treated with TNP. The others received an antiseptic dressing regime. Differences were analyzed using either Chi-square or Student's t-test. Group comparison regarding age, gender, body mass index, HbA1c on arrival, glucose in serum, IDDM disease duration, and TBSA revealed no significant differences. But percentage of graft take was at a significantly higher rate in the TNP group (90.2 ± 4.017 vs 39 ± 15.362) and fewer operations had to be performed compared to the control group (2.0 ± 0.447 vs 4.6 ± 0.927). Due to reduced occurrence of necrosis, the number of amputations required was significantly lower in the TNP group. TNP application on freshly laid SSG following tangential excision in IDDM patients after deep dermal foot scalds minimized amputation rates and therefore is of great benefit for such patients.

Interdisciplinary work including surgery and additive radiotherapy is often needed for the therapy of tumours. Beneath this, brachytherapy is an important part of the radiotherapy. It was first used over 100 years ago and is in regular use after the development of afterload technology in the early 1970s. Today it is often used in different tumour therapies, for example in soft tissue sarcoma or breast tumours, in order to decrease the risk of local recurrence. Concerning its benefits, higher doses could be used because of the localized effect with equivalent local control rate and less toxicity of treatment. Moreover, brachytherapy can also shorten the treatment time from 5-7 weeks to some days and is better reconcilable due to its localized effects, thus reducing side effects, as radiation-induced reactions, teleangiectasia and brosis. Precondition for application of brachytherapy is the need of a good soft tissue coverage and wound healing. Therefore, good interdisciplinary cooperation between plastic surgery and radiotherapy is important. After wide surgical resection reconstruction with different kind of flaps are often required, for achieving early wound healing and fast start of radiotherapy.Between 2011 and 2017 we applied brachytherapy to 13 patients with soft tissue sarcomas and other tumours like merkel-cell-carcinoma, schwannoma, and breast cancer. The treatment consisted of tumour resection, intraoperative insertion of brachytherapy catheters and after that brachytherapy alone or in combination with external beam radiotherapy. In half of the patients a reconstruction with different flaps was required, including pedicled trapezius flap, musculus latissimus dorsi flap and radial forearm flap; in some cases nerve and tendon reconstruction for better function and faster wound healing and so faster start of postoperative brachytherapy was also needed. The mean age of the patients was 55 years (±19) and we could start brachytherapy after 3-21 days after the operation, with a mean start on day 8±5 postoperatively. Three patients received additional percutaneous radiotherapy. The patients who received only brachytherapy got a dose of 2, 5 or 3Gy twice daily, with a mean total dose of 31±3Gy.Multidisciplinary work, including surgery as the main procedure and radiotherapy additionally, is needed for a successful treatment of soft tissue tumours. Depending on the type and the stadium of tumour plastic and reconstructive surgery provides soft tissue coverage, faster wound healing and the chance for limb salvage; on the other hand, additive brachytherapy contributes to a good tumour control. Therefore, a close collaboration between the two specialties is of particular importance, in order to improve the effectiveness of the therapy and the postoperative quality of life of the patient.

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

Elucidation of the precise mechanisms and therapeutic options of extracorporeal shock wave therapy (ESWT) is only at the beginning. Although immediate real-time effects of ESWT on cutaneous hemodynamics have recently been described, the dose response to different ESWT energies in cutaneous microcirculation has never been examined. Thirty-nine Sprague-Dawley rats were randomly assigned to three groups that received either focused high-energy shock waves (group A: total of 1000 impulses, 10 J) to the lower leg of the hind limb, focused low-energy shock waves (group B: total of 300 impulses, 1 J) or placebo shock wave treatment (group C: 0 impulses, 0 J) using a multimodality shock wave delivery system (Duolith SD-1 T-Top, Storz Medical, Tagerwilen, Switzerland). Immediate microcirculatory effects were assessed with the O2C (oxygen to see) system (LEA Medizintechnik, Giessen, Germany) before and for 20 min after application of ESWT. Cutaneous tissue oxygen saturation increased significantly higher after high-energy ESWT than after low-energy and placebo ESWT (A: 29.4% vs. B: 17.3% vs. C: 3.3%; p = 0.003). Capillary blood velocity was significantly higher after high-energy ESWT and lower after low-energy ESWT versus placebo ESWT (group A: 17.8% vs. group B: -22.1% vs. group C: -5.0%, p = 0.045). Post-capillary venous filling pressure was significantly enhanced in the high-energy ESWT group in contrast to the low-energy ESWT and placebo groups (group A: 25% vs. group B: 2% vs. group C: -4%, p = 0.001). Both high-energy and low-energy ESWT affect cutaneous hemodynamics in a standard rat model. High-energy ESWT significantly increases parameters of cutaneous microcirculation immediately after application, resulting in higher tissue oxygen saturation, venous filling pressure and blood velocity, which suggests higher tissue perfusion with enhanced oxygen saturation, in contrast to low-energy as well as placebo ESWT. Low-energy ESWT also increased tissue oxygen saturation, albeit to a lower extent, and decreases both blood velocity and venous filling pressure. Low-energy ESWT reduced tissue perfusion, but improved oxygen saturation immediately after the application.

Background Extracorporeal shock wave therapy (ESWT) is mainly applied in tendon as well as bone problems based on stem-cell activation and healing acceleration. The effect of ESWT on muscle tissue is much less understood to date. However, from a clinical perspective, muscle injuries are of distinct interest especially in elite athletes such as soccer players. Material and methods A total of 26 rats were randomized into two groups. Group A received a single application of high-energetic focused ESWT (0.3 mJ/mm2, 4 Hz, 1000 impulses, 10 J), whereas group B underwent the same procedure every 10 min for three sessions (3 × 0.3 mJ/mm2, 4 Hz, 3 × 1000 impulses, totaling 30 J). Blood flow at a depth of 8 mm was measured continuously and noninvasively by a combined Laser-Doppler-Imaging and photospectrometric technique (Oxygen-to-see, O2C, LEA Medizintechnik, Germany). Results One minute after the application of high-energy ESWT blood flow in group A increased by 16.5% (P = 0.007). Thereafter, it decreased from minute 2 after application and remained significantly unchanged to baseline value until the end of the measuring period at 50 min (P = 0.550). Group B showed a similar significant increase in blood flow of 16.4% (P = 0.049) and a decrease afterward, too. After the second focused ESWT blood flow was boosted to 26.6% (P = 0.004), remaining significantly elevated until the third application was initiated. Muscular blood flow was increased to 29.8% after the third focused ESWT (P Conclusions Focused ESWT enhances blood flow in the muscle of rats. Moreover, repetitive ESWT extended this beneficial effect.

The aim of this study is to determine the epidemiological characteristics of burn patients developing pneumonia, as well as the predisposing factors and the mortality of these patients. Infectious complications present serious problems in severely burned patients. Pneumonia, in particular, is a major cause of morbidity and mortality in burn patients. Patients with inhalation injuries are exposed to a greater risk due to the possible development of infectious complications in the lower respiratory tract. During their stay in our Burn Care Unit, 22.9% of our burn patients developed pneumonia and 10.9 % of these patients died. Risk factors for the development of pneumonia in burn patients were found to be inhalation trauma, high ABSI score, the Baux and modified Baux index, and high ASA score (p0.01). Age and gender showed no significant correlation to the incidence of pneumonia. In this study we were able to determine the incidence of pneumonia in burn patients, their mortality and the strong correlation of the presence of inhalation injury with the development of pneumonia.Le but de cette étude est de déterminer les caractéristiques épidémiologiques des patients brûlés qui développent une atteinte pulmonaire , ainsi que les facteurs prédisposants et le taux de mortalité . La pneumonie est une cause majeure de morbidité et de mortalité chez les patients gravement brûlés. Les patients atteints de lésions par inhalation sont exposés à un risque plus élevé en raison de l’évolution possible de complications infectieuses dans les voies respiratoires inférieures. Au cours de leur séjour dans notre unité de soins aux brûlures, 22,9% de nos patients brûlés ont développé la pneumonie et 10,9% de ces patients sont décédés. Les facteurs de risque pour le développement de la pneumonie chez les patients brûlés retrouvés sont le traumatisme de l’inhalation, le score élevé de ABSI, l’incice de Baux et l’indice Baux modifié, et le score ASA élevé (p0,01). L’âge et le sexe des patients n’ont montré aucune corrélation significative à l’incidence de la pneumonie. Dans cette étude, nous avons pu déterminer l’incidence des complications pulmonaires du fait des lésions par inhalation .chez les patients brûlés, ainsi que sur le taux de mortalité.

Background. ESWT has proven clinical benefit in dermatology and plastic surgery. It promotes wound healing and improves tissue regeneration, connective tissue disorders, and inflammatory skin diseases. However, a single treatment session or long intervals between sessions may reduce the therapeutic effect. The present study investigated the effects of fractionated repetitive treatment in skin microcirculation.Methods. 32 rats were randomly assigned to two groups and received either fractionated repetitive high-energy ESWT every ten minutes or placebo shock wave treatment, applied to the dorsal lower leg. Microcirculatory effects were continuously assessed by combined laser Doppler imaging and photospectrometry.Results. In experimental group, cutaneous tissue oxygen saturation was increased 1 minute after the first application and until the end of the measuring period at 80 minutes after the second treatment(P<0.05). The third ESWT application boosted the effect to its highest extent. Cutaneous capillary blood flow showed a significant increase after the second application which was sustained for 20 minutes after the third application(P<0.05). Placebo group showed no statistically significant differences.Conclusions. Fractionated repetitive extracorporeal shock wave therapy (frESWT) boosts and prolongs the effects on cutaneous hemodynamics. The results indicate that frESWT may provide greater benefits in the treatment of distinct soft tissue disorders compared with single-session ESWT.

Background/Aims: The treatment of peripheral nerve lesions still represents a clinical challenge. Several approaches such as novel biomaterials for nerve guides, addition of growth factors or cellular supplements moved in the focus of research. Especially the application of autologous stem cells is highly promising for future applications. Human sweat gland derived stem cells (hSGSCs) represent an easy accessible source of autologous adult stem cells and did already show a beneficial effect in dermal wound healing. Methods: In this study, the effect of hSGSCs on neurite outgrowth of primary adult or prenatal Dorsal root ganglia (DRG) neurons was analysed in an indirect co-culture model. Additionally, direct co-cultures with hSGSCs as a feeder layer were performed. Results: Adult and prenatal DRG neurons showed increased neurite outgrowth after 24 h co-culture with hSGSCs. The outgrowth increased significantly by the factors 5.6 and 2.6 respectively. Direct co-cultures revealed neurite alignment along the hSGSCs orientation. Conclusion: The paracrine influence of hSGSCs on neurite outgrowth, but also their ability to operate as a feeder layer with guidance properties shows great potential for future applications in peripheral nerve regeneration.

Monopolar electrocautery is a fast and elegant cutting option. However, as it creates surgical smoke containing polycyclic aromatic hydrocarbons (PAHs), it may be hazardous to the health of the surgical team. Although new technologies, such as feedback mode (FM) and Teflon-coated blades (TBs), reduce tissue damage, their impact on surgical smoke creation has not yet been elucidated. Therefore, we analyzed the plume at its source. The aim of this study was to evaluate if electrocautery FM and TBs create less surgical smoke. Porcine tissue containing skin was cut in a standardized manner using sharp-edged Teflon-coated blades (SETBs), normal-shaped TBs, or stainless steel blades (SSBs). Experiments were performed using FM and pure-cut mode. Surgical smoke was sucked through filters or adsorption tubes. Subsequently, filters were scanned and analyzed using a spectrophotometer. A high-performance liquid chromatography (HPLC-UV) was performed to detect benzo[a]pyrene (BaP) and phenanthrene as 2 of the most critical PAHs. Temperature changes at the cutting site were measured by an infrared thermometer. In FM, more surgical smoke was created using SSB compared with TBs (P