A proposed cleaning classification system for reusable medical devices to complement the Spaulding classification.

A central tenet in infection prevention is application of the Spaulding classification system for the safe use of medical devices. Initially defined in the 1950s, this system defines devices and surfaces as being critical, semi-critical or non-critical depending on how they will be used on a patient. Different levels of antimicrobial treatment, defined as various levels of disinfection or sterilization, are deemed appropriate to reduce patient risk of infection. However, a focus on microbial inactivation is insufficient to address this concern, which has been particularly highlighted in routine healthcare facility practices, emphasizing the underappreciated importance of cleaning and achieving acceptable levels of cleanliness. A deeper understanding of microbiology has evolved since the 1950s, which has led to re-evaluation of the Spaulding classification along with a commensurate emphasis on achieving appropriate cleaning. Albeit underappreciated, cleaning has always been important as the presence of residual materials on surfaces can interfere with the efficacy of the antimicrobial process to inactivate micro-organisms, as well as other risks to patients including device damage, malfunction and biocompatibility concerns. Unfortunately, this continues to be relevant, as attested by reports in the literature on the occurrence of device-related infections and outbreaks due to failures in processing expectations. This reflects, in part, increasing sophistication in device features and reuse, along with commensurate manufacturer's instructions for use. Consequently, this constitutes the first description and recommendation of a new cleaning classification system to complement use of the traditional Spaulding definitions to help address these modern-day technical and patient risk challenges. This quantitative risk-based classification system highlights the challenge of efficient cleaning based on the complexity of device features present, as an isolated variable impacting cleaning. This cleaning classification can be used in combination with the Spaulding classification to improve communication of cleaning risk of a reusable medical device between manufacturers and healthcare facilities, and improve established cleaning practices. This new cleaning classification system will also inform future creation, design thinking and commensurate innovations for the sustainable safe reuse of important medical devices.

Use of real-time immersive digital training and educational technologies to improve patient safety during the processing of reusable medical devices: Quo Vadis?

Hospital acquired infections stemming from contaminated reusable medical devices are of increasing concern. This issue is exaggerated with the introduction of complex medical devices like endoscopes and robotic instrumentation. Although medical device manufacturers validate their cleaning instructions for use, evidence in the literature demonstrates that effective device processing is not being performed consistently within sterile processing departments in clinical settings. The result is increased risks to patient safety. As a solution to this problem, focused one-on-one training increases compliance to the medical device manufacturer's processing instruction. However, often this is not a practical solution for the volume of healthcare staff responsible for device processing activities. This constitutes the first paper to address the blended use of educational and digital technologies to address these challenges and as a result inform safety and sustainability for the medical device sector. Cognitive learning theory is an evidence-based framework for learning. It supports the use of immersive educational experiences using emerging extended reality technologies (e.g., virtual or augmented reality) to increase learning comprehension. The delivery of educational content via these technologies provides an innovative option for repeatable leaning and training outcomes. The motivation is to decrease patient risk of contaminated reusable medical devices. The proposed approach while primary motivated by safety can also enhance sustainability and efficiency enabled by artificial intelligence and robotic instrumentation.

A review of Spaulding's classification system for effective cleaning, disinfection and sterilization of reusable medical devices: Viewed through a modern-day lens that will inform and enable future sustainability.

Despite advances in medicine and innovations in many underpinning fields including disease prevention and control, the Spaulding classification system, originally proposed in 1957, remains widely used for defining the disinfection and sterilization of contaminated re-usable medical devices and surgical instruments. Screening PubMed and Scopus databases using a PRISMA guiding framework generated 272 relevant publications that were used in this review. Findings revealed that there is a need to evolve how medical devices are designed, and processed by cleaning, disinfection (and/or sterilization) to mitigate patient risks, including acquiring an infection. This Spaulding Classification remains in use as it is logical, easily applied and understood by users (microbiologists, epidemiologists, manufacturers, industry) and by regulators. However, substantial changes have occurred over the past 65 years that challenge interpretation and application of this system that includes inter alia emergence of new pathogens (viruses, mycobacteria, protozoa, fungi), a greater understanding of innate and adaptive microbial tolerance to disinfection, toxicity risks, increased number of vulnerable patients and associated patient procedures, and greater complexity in design and use of medical devices. Common cited examples include endoscopes that enable non- or minimal invasive procedures but are highly sophisticated with various types of materials (polymers, electronic components etc), long narrow channels, right angle and heat-sensitive components and various accessories (e.g., values) that can be contaminated with high levels of microbial bioburden and patient tissues after use. Contaminated flexible duodenoscopes have been a source of several significant infection outbreaks, where at least 9 reported cases were caused by multidrug resistant organisms [MDROs] with no obvious breach in processing detected. Despite this, there is evidence of the lack of attention to cleaning and maintenance of these devices and associated equipment. Over the last few decades there is increasing genomic evidence of innate and adaptive resistance to chemical disinfectant methods along with adaptive tolerance to environmental stresses. To reduce these risks, it has been proposed to elevate classification of higher-risk flexible endoscopes (such as duodenoscopes) from semi-critical [contact with mucous membrane and intact skin] to critical use [contact with sterile tissue and blood] that entails a transition to using low-temperature sterilization modalities instead of routinely using high-level disinfection; thus, increasing the margin of safety for endoscope processing. This timely review addresses important issues surrounding use of the Spaulding classification system to meet modern-day needs. It specifically addresses the need for automated, robust cleaning and drying methods combined with using real-time monitoring of device processing. There is a need to understand entire end-to-end processing of devices instead of adopting silo approaches that in the future will be informed by artificial intelligence and deep-learning/machine learning. For example, combinational solutions that address the formation of complex biofilms that harbour pathogenic and opportunistic microorganisms on the surfaces of processed devices. Emerging trends are addressed including future sustainability for the medical devices sector that can be enabled via a new Quintuple Helix Hub approach that combines academia, industry, healthcare, regulators, and society to unlock real world solutions.

A standardized method for evaluating test soils used to demonstrate cleaning efficacy.

BACKGROUND: Cleaning and associated validation requirements are essential for the safe use of reusable devices. In the past, test methods and associated endpoints for cleaning validations have varied worldwide. Recent international standards have updated the requirements to include cleaning endpoints and requirements for the use of test soils for demonstrating cleaning efficacy of washer-disinfectors. METHODS: A quantitative comparison of test soils used in cleaning efficacy studies was conducted using a new standardized test method as published in Annexe B ISO 15883-5:2021. Test soils included Artificial Test Soil (ATS 2015), Blood Test Soil (BTS), Coagulated Blood, Defibrinated Blood Soil (DBLSO), Modified Coagulated Blood Soil, Two Component Blood Test Soil and the UK Test Soil (Edinburgh Soil). CONCLUSION: All the test soils demonstrated acceptable performance in accordance with the standard.

Influence of burn severity on endothelial glycocalyx shedding following thermal trauma: A prospective observational study.

OBJECTIVE: Severe burns cause hypermetabolic and inflammatory responses are treated with significant volume resuscitation. This study aimed to evaluate correlations between glycocalyx metabolites and the burn size as well as certain clinical parameters such as administered fluid volumes. STUDY DESIGN: Severely burned patients with a total body surface area (TBSA) burned smaller and larger than 20% were included. Clinical parameters including length of stay, mortality, fluid administration and Sequential Organ Failure Assessment (SOFA) score as well as syndecan and heparansulfate, as laboratory parameters for endothelial damage, were obtained. RESULTS: A total of 39 patients (32 males, 7 females) with a mean age at burn of 45 ± 21 years were included. Syndecan levels decreased and heparansulfate levels increased over time. In both heparansulfate and syndecan, there was no significant difference between burns smaller and larger than 20% TBSA at any time point. Syndecan levels at 24 h after burn correlated significantly with IL-10 levels at admission (R = 0.58 and p < 0.05). There were significant linear correlations of %TBSA and cumulative administration of fluids after 24 h on syndecan levels after 48 h. Correlations between clinical parameters and syndecan or heparansulfate levels over time were not found. CONCLUSIONS: This study shows that even though there are moderate correlations with burn size and administered fluid volume, levels of syndecan and heparansulfate are not predictive for clinical outcomes of burned patients in our cohort. Further studies with higher numbers evaluating the effect of large burns on glycocalyx shedding over a longer period of time are needed. Showing significant glycocalyx shedding in large burn including potentially correlations with clinical outcomes may yield new therapeutic targets.

Low-profile locking-plate vs. the conventional AO system: early comparative results in wrist arthrodesis.

INTRODUCTION: Total wrist arthrodesis represents a reliable salvage procedure for severe painful conditions of the wrist. To date, wrist arthrodesis using a dorsal plate reaching from the distal radius to the third metacarpal is still recommended. A new implant (APTUS© 2.5 TriLock Wrist Fusion Plate, Medartis Suisse) that does not cross the third carpometacarpal joint (CMCJ-3) has been introduced recently. The purpose of this retrospective study was to compare both implants concerning early functional and clinical results. MATERIALS AND METHODS: A total of 20 patients underwent total wrist arthrodesis [10, using the new APTUS© implant (APT); 10 using the Depuy-Synthes© LCP plates (AO)]. The postoperative control interval was 18.2 and 37.2 months in APT and AO, respectively. Clinical assessment included functional parameters such as active range of motion (AROM) for pronation and supination, grip strength, and passive range of motion of the CMCJ-3. Additionally the DASH score and the Krimmer wrist score as well as pain levels at rest and under stress conditions were evaluated. RESULTS: All patients showed osseous healing without complications except one case of non-union in APT. There were no significant differences between both groups concerning grip strength, AROM of the wrist, pain levels, DASH- and Krimmer Score. APT showed a significantly increased passive range of motion of the CMCJ-3 compared to the unaffected contralateral side. CONCLUSIONS: The new implant shows similar functional results compared to the standard procedure. The main advantage of the new implant is the fact that no implant removal is necessary due to the unaffected CMCJ-3. Furthermore the mobility of the CMCJ slightly increased and showed positive impact on hand kinematics.

Severe Fournier's gangrene-a conjoint challenge of gynaecology and plastic surgery.

Necrotizing fasciitis (NF) is a rare soft tissue infection characterized by rapidly progressing necroses and a high mortality. Prompt diagnosis and immediate medical treatment including radical debridement and broad spectrum antibiotics are the key to successful management. We report on a 46-year-old diabetic female who developed extensive, deep necroses in the perineal area and proximal thighs within a few days. After initial gynaecological consultation, she was transferred directly to our department. Due to the suspicion of NF, an immediate radical debridement was performed. Two more debridements were necessary to control the infection. After stabilization, the extensive soft tissue defect was reconstructed using a combination of plastic reconstructive procedures. Due to early diagnosis, direct referral and immediate surgical treatment, the patient survived.

[Midcarpal partial arthrodesis with locking plate osteosynthesis]. / Mediokarpale Teilarthrodese mit winkelstabiler Plattenosteosynthese.

OBJECTIVE: Preservation of residual mobility and pain reduction in the wrist in advanced carpal collapse (scapholunate advanced collapse, SLAC or scaphoid nonunion advanced collapse, SNAC). INDICATIONS: Advanced osteoarthritis of the radiocarpal and intercarpal articulations, SLAC/SNAC stages 2-3. CONTRAINDICATIONS: Arthrotic alterations to the proximal joint surface of the lunate bone or the corresponding joint surface of the radius (lunate fossa). SURGICAL TECHNIQUE: Dorsal longitudinal incision and exposure of the wrist capsule using a radial pedunculated capsular flap. Resection of the scaphoid bone. Chondrolysis of the corresponding joint surface between the capitate bone and the lunate bone as well as between the hamate bone and the triquetral bone. Harvesting and insertion of radial cancellous bone. Repositioning of the lunate bone. Introduction of the plate and filling of the screwholes. Closure of the wrist capsule. Neutral placement of a lower arm plaster cast. Postoperative physiotherapy from out of the supporting cast to an extent of 20-0-20° extension-flexion. For protection the support cast should remain in place for 8 weeks. RESULTS: Complete consolidation of the bone in the X­ray control in all 11 patients 12 weeks postoperatively. No implant-based complications. In one case a postoperative carpal tunnel syndrome had to be surgically treated. The postoperative extent of mobility showed overall satisfactory results with extension-flexion of 53°â€¯± 18° (47% of the healthy side) and radial-ulnar abduction 30 ± 5° (58% of the healthy side). The postoperative values on the visual analog pain scale (VAS) were 0.7 ± 1.2 at rest and 4.3 ± 2.8 under load bearing. The gripping power was 19 ± 14 kg (56% of the non-operated side) and the disabilities of the arm, shoulder, hand (DASH) value was 33 ± 24.

[Morel-Lavallée lesion : Severely injured 13 year old after being run over]. / Morel-Lavallée-Läsion : Schwerstverletzte 13-Jährige nach Überrolltrauma.

Accidents in which a person is run over are often associated with multiple serious injuries. Immediate bleeding control is crucial. Pressure and shear stress at the borders of subcutaneous tissue to the muscle fascia can cause hypoperfusion and the emergence of blood-filled cavities that are associated with a high risk of infection and necrosis, a so-called Morel-Lavallée lesion. Insufficient therapy can lead to local complications and furthermore to live-threatening sepsis.

Glypican-2 levels in cerebrospinal fluid predict the status of adult hippocampal neurogenesis.

Adult hippocampal neurogenesis is a remarkable form of brain plasticity through which new neurons are generated throughout life. Despite its important roles in cognition and emotion and its modulation in various preclinical disease models, the functional importance of adult hippocampal neurogenesis in human health has not been revealed because of a lack of tools for monitoring adult neurogenesis in vivo. Therefore, we performed an unbiased proteomics screen to identify novel proteins expressed during neuronal differentiation using a human neural stem cell model, and we identified the proteoglycan Glypican-2 (Gpc2) as a putative secreted marker of immature neurons. Exogenous Gpc2 binds to FGF2 and inhibits FGF2-induced neural progenitor cell proliferation. Gpc2 is enriched in neurogenic regions of the adult brain. Its expression is increased by physiological stimuli that increase hippocampal neurogenesis and decreased in transgenic models in which neurogenesis is selectively ablated. Changes in neurogenesis also result in changes in Gpc2 protein level in cerebrospinal fluid (CSF). Gpc2 is detectable in adult human CSF, and first pilot experiments with a longitudinal cohort indicate a decrease over time. Thus, Gpc2 may serve as a potential marker to monitor adult neurogenesis in both animal and human physiology and disease, warranting future studies.

[Secondary tendon reconstruction on the thumb]. / Sekundäre Sehnenrekonstruktionen am Daumen.

Closed tendon ruptures of the thumb that require secondary reconstruction can affect the extensor pollicis longus (EPL), extensor pollicis brevis (EPB) and flexor pollicis longus (FPL) tendons. Treatment of rupture of the EPB tendon consists of refixation to the bone and temporary transfixation of the joint. In the case of preexisting or posttraumatic arthrosis, definitive arthrodesis of the thumb is the best procedure. Closed ruptures of the EPL and FPL tendons at the wrist joint cannot be treated by direct tendon suture. Rupture of the EPL tendon occurs after distal radius fractures either due to protruding screws or following conservative treatment especially in undisplaced fractures. Transfer of the extensor indicis tendon to the distal EPL stump is a good option and free interposition of the palmaris longus tendon is a possible alternative. The tension should be adjusted to slight overcorrection, which can be checked intraoperatively by performing the tenodesis test. Closed FPL ruptures at the wrist typically occur 3-6 months after osteosynthesis of distal radius fractures with palmar plates and are mostly characterized by crepitation and pain lasting for several weeks. They can be prevented by premature plate removal, synovectomy and carpal tunnel release. For treatment of a ruptured FPL tendon in adult patients the options for tendon reconstruction should be weighed up against the less complicated tenodesis or arthrodesis of the thumb interphalangeal joint.

[Three-dimensional correction of the thoraco-lumbar spine after sarcoma resection : An inter-disciplinary approach with free-tissue transfer]. / Dreidimensionale Korrektur der thorakolumbalen Wirbelsäule nach Resektion eines Sarkoms : Interdisziplinärer Ansatz mit freiem Gewebetransfer.

This article presents the case of a high-grade deformity of the thoraco-lumbar spine. The patient suffered from a sarcoma that was radically resected. Due to adjuvant radiation, the patient suffered from a radiation injury with chronic fistula. In a two-stage approach, the deformity was corrected by a closing-wedge osteotomy of L3 with elongation of the present dorsal spondylodesis (Th10-L4) to Th8 and the iliac bone. Soft-tissue reconstruction was achieved by a free latissimus dorsi flap that was anastomosed to an axillary arterio-venous loop. The presented interdisciplinary approach allowed an almost complete correction of the deformity and stable soft-tissue coverage.

[Perioperative Management in Microsurgery - Consensus Statement of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / Perioperatives Management in der Mikrochirurgie - Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

Perioperative management of microsurgery is not well standardised. Due to a lack of evidence, different regimes are established in different microsurgical centres. However, trends towards less aggressive perioperative interventions can be identified in recent years, since treatment algorithms without systematic evidence are being progressively abandoned. The available evidence on perioperative issues, such as temperature control, fluid resuscitation, blood transfusions, application of vasodilators or - pressors, as well as anticoagulants, were discussed during the consensus conference on perioperative management at the annual meeting of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels. Common basic standards were identified and a consensus was reached that is described in the following manuscript.

[Nerve Tubes for the Repair of Traumatic Sensory Nerve Lesions of the Hand: Review and Planning Study for a Randomised Controlled Multicentre Trial]. / Nervetubes zur Versorgung von traumatischen sensiblen Nervenläsionen der Hand - Übersicht sowie retrospektive Planungsstudie für eine randomisiert-kontrollierte multizentrische Studie.

BACKGROUND: Nerve tubes are used for bridging of short nerve gaps and for coating of primary end-to-end nerve sutures. This article provides an overview of available implants and their application. Also it presents a retrospective planning study aiming to determine the static 2-point discrimination after primary peripheral nerve repair with and without the use of a nerve tube. The results have been used to determine the sample size of a prospective randomised trial. PATIENTS AND METHODS: 54 peripheral nerve injuries of 41 patients were treated by primary end-to-end nerve sutures with or without the additional use of a nerve tube (n=28 and n=26, respectively). 38 digital nerves and 16 median and ulnar nerves were affected. Nerve tubes were used for the repair of 15 digital nerves and 13 median and ulnar nerves. Clinical follow-up was performed 46 months after surgery (patients without nerve tubes) and 18 months after surgery (patients with nerve tubes), respectively. Static 2-point discrimination (2PD) was measured by double-tip compasses (weight: 18 g) and patients were examined for clinical signs of neuroma. Further examinations included grip strength as a percentage value compared with the uninjured hand and, in case of finger injuries, the range of motion in the proximal and distal interphalangeal joints, Strickland score, DASH score and implant-associated complications. RESULTS: In patients with primary end-to-end sutures for finger injuries, there were no statistically significant differences between treatment with and without nerve tubes regarding 2PD, grip strength, DASH- or Strickland score. However, 2PD values of patients with nerve tubes had an increased spread. Average 2PD in digital nerves was 4.5 mm (3-15; SD: 3.9) without nerve tubes and 5.5 mm (3-15; SD: 5) with nerve tubes. Average 2PD after lesions of the median and ulnar nerves was 10 mm (3-15; SD: 5.9 and 5.4, respectively) in both groups. CONCLUSION: The additional use of a nerve tube showed no superiority in this planning study. The expected average 2PD is 5 mm after digital nerve injuries and 10 mm after lesions of the median or ulnar nerves.

Suprathel(®) for severe burns in the elderly: Case report and review of the literature.

Large burns in aged patients are common and treatment often reveals challenging. Cardiovascular complications significantly contribute to the unfavorable prognosis in this group of high-risk patients. Pain medication and sedation can negatively influence cardiovascular stability. Suprathel(®) is well-known for its almost pain free application and reduction of dressing change intervals, and thus lowers the demand for potentially harmful analgesics and sedatives. We present the case of an 81-year-old patient with 51% of total burned body surface area (ABSI=12), who was completely treated with Suprathel(®). Despite a predicted mortality of more than 80%, the patient survived and was discharged home without significant handicaps 69 days after burn. We hypothesize that Suprathel(®) beneficially contributed to the favorable clinical course of this critical patient as less frequent wound-dressing changes did not induce additional pain or sedative medication and thus improved cardiovascular stability.

Four-corner fusion: comparison of patient satisfaction and functional outcome of conventional K-wire technique vs. a new locking plate.

BACKGROUND: Four-corner fusion is a standard procedure for advanced carpal collapse. Several operative techniques and numerous implants for osseous fixation have been described. Recently, a specially designed locking plate (Aptus©, Medartis, Basel, Switzerland) was introduced. The purpose of this study was to compare functional results after osseous fixation using K-wires (standard of care, SOC) with four-corner fusion and locking plate fixation. METHODS: 21 patients who underwent four-corner fusion in our institution between 2008 and 2013 were included in a retrospective analysis. In 11 patients, osseous fixation was performed using locking plates whereas ten patients underwent bone fixation with conventional K-wires. Outcome parameters were functional outcome, osseous consolidation, patient satisfaction (DASH- and Krimmer Score), pain and perioperative morbidity and the time until patients returned to daily work. Patients were divided in two groups and paired t-tests were performed for statistical analysis. RESULTS: No implant related complications were observed. Osseous consolidation was achieved in all cases. Differences between groups were not significant regarding active range of motion (AROM), pain and function. Overall patient satisfaction was acceptable in all cases; differences in the DASH questionnaire and the Krimmer questionnaire were not significant. One patient of the plate group required conversion to total wrist arthrodesis without implant-related complications. CONCLUSION: Both techniques for four-corner fusion have similar healing rates. Using the more expensive locking implant avoids a second operation for K-wire removal, but no statistical differences were detected in functional outcome as well as in patient satisfaction when compared to SOC.

[Bilateral hand salvage of subtotal left hand amputation and complex right wrist destruction]. / Extremitätenerhalt bei subtotaler Handamputation links und komplexer Handgelenkzerstörung rechts.

Complex injuries of the hand and wrist lead to severe loss of function. Complex trauma of the upper extremities may lead to severe disabilities and therefore meticulous reconstruction is of utmost importance to enable good functional outcome and to assure an adequate quality of life. We demonstrate the case of a patient who suffered from complex bilateral injuries at the wrist level including a subtotal amputation of the left hand and third degree open wrist destruction on the contralateral side. Due to the immediate bilateral operation including the unilateral use of an osteocutaneous free fibula flap, both hands could be salvaged in this case. Severe hand and wrist injuries also require intensive postoperative treatment including intensive physiotherapy, occupational therapy, pain therapy and psychological support to achieve a good functional result.

Novel use of a flowable collagen-glycosaminoglycan matrix (Integra™ Flowable Wound Matrix) combined with percutaneous cannula scar tissue release in treatment of post-burn malfunction of the hand--A preliminary 6 month follow-up.

INTRODUCTION: Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis. PATIENTS AND METHODS: In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen-glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire. RESULTS: No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2-5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14. DISCUSSION: The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2-5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.

[Standardisation of the Initial Treatment of Severely Burned Patients: The Necessary Transfer of Concepts from Trauma Care]. / Standardisierung der Initialbehandlung von Schwerbrandverletzten: Die notwendige Übertragung von Konzepten aus der Schwerverletztenversorgung.

The initial treatment of severely burned patients remains a huge challenge for first responders in emergency services as well as emergency doctors who do not work in a centre for severe burn injuries. The reason for this is the low number of cases in developed countries and a lack of training concepts for the specific aspects of the initial treatment of severe burn injuries. Because of guidelines with limited evidence (S1, S2k) and a lack of structured treatment approaches, uncertainties with respect to initial treatment are still visible. Even within the professional societies and on international comparison, controversial aspects remain. In contrast, optimised and standardised procedures are available for the treatment of severely injured (trauma) patients, based on PHTLS® (Pre Hospital Trauma Life Support) for preclinical and ATLS® (Advanced Trauma Life Support) for in-hospital first aid. This article takes stock of the current structure of care and the relevant evidence for the initial treatment of severe burns. Also it discusses a possible transfer and further development of concepts for primary trauma care by all disciplines involved. Nine essential steps in the primary care of burned patients are identified and evaluated. The need for the introduction of a uniform treatment algorithm is illustrated. The treatment algorithm presented in this article addresses all first responders who are faced with initial treatment in the first 24 hours outside of burn centres. As an essential, new aspect, it offers a transfer and adaptation of concepts from trauma care to standardise the care of severely burned patients.

[Reconstruction of Defects after Oncologic Resection and Radiation - Indications for Microsurgical Reconstruction]. / Defektrekonstruktion nach onkologischer Resektion und Bestrahlung - Indikationen zur mikrochirurgischen Rekonstruktion.

The surgical treatment of soft tissue sarcomas in the extremities frequently requires radiation therapy to achieve local tumour control. However, both adjuvant and neoadjuvant radiation are associated with significant morbidity caused by impaired wound healing, ulcers or osteonecrosis with subsequent fractures. This is due to altered local cell mediator levels, fibrosis occurring simultaneously with decreased cell division rates and diminished vascularity. This article describes a number of local conservative treatment options, all of which have limited success rates. In addition, it describes plastic surgical treatment options for radiation-induced local morbidity. Surgical reconstruction includes the full range of plastic reconstructive techniques. However, less complex options such as random pattern flaps or split thickness skin grafts are often associated with complications. Therefore, a large number of cases require free tissue transfer.