Necrotizing Fasciitis of the Hand: Management with Literature Review.

This report presents a case of necrotizing fasciitis following a seemingly minor injury sustained from handling a spiny plant. Despite initial primary care by a physician, the patient presented with severe septic shock and necrotizing fasciitis of the hand, necessitating emergency surgical intervention. The use of scoring systems aided in the prompt recognition of the condition. Subsequent surgery was required due to infection progression, leading to significant soft tissue defects and functional impairment. The patient underwent multiple reconstructive procedures, including placement of dermis-replacement material and, ultimately, free flap reconstruction, to restore the hand function. This case report highlights the importance of rapid identification of potential cases of necrotizing fasciitis in cases of hand infections, demonstrates that scoring systems can assist in smaller affected body sites such as the hand, and illustrates the difficulties of defect reconstruction following necrotizing fasciitis.

Epidermoid Cysts after Percutaneous Needle Fasciotomy for Dupuytren Contracture: Literature Review.

This case report presents a rare complication after percutaneous needle fasciotomy for Dupuytren contracture: the development of epidermoid cysts. A 60-year-old man who had previously undergone a needle fasciotomy required a subsequent limited fasciectomy due to disease progression. Unexpectedly, epidermoid cysts were discovered during the procedure. The successful removal of the cysts, together with the removal of the contracture cord, resulted in a good functional outcome. The conducted literature review identified four case reports of epidermoid or dermoid cysts after treatment for Dupuytren contracture. The reported cases in the literature and our case emphasize the need for adaptability in the management of Dupuytren contracture and the potential for unexpected complications. Further investigation is essential to understand the relationship between Dupuytren disease and cyst formation.

Necrotizing Fasciitis after Panniculectomy Caused by Finegoldia magna.

Necrotizing fasciitis is a rare yet severe complication after body contouring surgery. We present a case of a 54-year-old woman with a complex medical history who developed necrotizing fasciitis 9 days after panniculectomy and epigastric hernia repair. Microbiological examination revealed Finegoldia magna as the causative agent, a rare pathogen in necrotizing fasciitis. Patients undergoing body contouring may be at increased risk of developing necrotizing fasciitis; therefore, increased attention should be paid to this differential diagnosis in case of postoperative signs of infection. This case report highlights the pivotal importance of early recognition, prompt surgical intervention, and comprehensive medical treatment to improve patient outcomes in necrotizing fasciitis.

Prognostic Factors in Necrotizing Fasciitis: Insights from a Two-Decade, Two-Center Study Involving 209 Cases.

INTRODUCTION: Necrotizing fasciitis (NF) is a critical disease with high morbidity and mortality rates that poses significant challenges in diagnosis and treatment. Prognostic factors for the clinical course of NF remain unclear and are currently under research. This study aims to identify such factors in a large cohort of patients which represents a major comprehensive investigation of prognostic factors for NF. METHODS: Retrospective analysis was conducted on necrotizing fasciitis cases from 2003 to 2023 at two German hospitals. Data included demographics, comorbidities, laboratory findings, infection site, causative microorganisms and outcomes. Statistical analysis involved t-tests, chi-square tests, and ROC analysis. RESULTS: A total of 209 patients were included, with a mortality rate of 18%. Patients were categorized into survivors (n = 171) and non-survivors (n = 38). Non-survivors were significantly older (68.9 ± 13.9 years vs. 55.9 ± 14.3 years; p < 0.01) and exhibited a higher prevalence of peripheral vascular diseases, cancer, and heart, liver, or renal insufficiency. Laboratory findings and scoring results also varied significantly between the two groups. The ROC curve analysis identified age as a predictor of mortality, with an optimal cut-off value of 68.5 years (sensitivity: 60.5%, specificity: 81.9%). Higher age was associated with increased mortality risk. CONCLUSIONS: The patient's age stands out as the primary predictive element for mortality in necrotizing fasciitis. Additionally, we advocate for employing the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF-score), which holds substantial prognostic significance and is straightforward to calculate. Considering our findings, crafting a clinical algorithm or scoring mechanism to forecast mortality in NF would be a promising target for future research.

Postoperative Complications of Flap Procedures in Chest Wall Defect Reconstruction: A Two-Center Experience.

Background and Objectives: Chest wall defect reconstruction is a complex procedure aimed at restoring thoracic structural integrity after trauma, tumor removal, or congenital issues. In this study, postoperative complications were investigated to improve the care of patients with these critical conditions. Materials and Methods: A retrospective study of chest wall reconstructions from 2004 to 2023 was conducted at Klinikum Nürnberg and Evangelisches Waldkrankenhaus Spandau-Berlin. Data included patient demographics, comorbidities, defect etiology, surgery details, and complications using the Clavien-Dindo classification. Results: Among the 30 patients included in the study, a total of 35 complications occurred in 35 thoracic wall defect reconstructions. These complications were classified into 22 major and 13 minor cases. Major complications were more common in patients with cancer-related defects, and considerable variations were observed between free flap and pedicled flap surgeries. Notably, the use of the anterolateral thigh (ALT) flap with vastus lateralis muscle demonstrated promise, exhibiting fewer complications in select cases. The reconstruction of chest wall defects is associated with substantial complications regardless of the etiology of the defect and the particular surgical procedure used. Interestingly, there was a lower complication rate with free flap surgery than with pedicled flaps. Conclusions: The ALT flap with vastus lateralis muscle deserves further research in this field of reconstruction. Multidisciplinary approaches and informed patient discussions are crucial in this complex surgical field, emphasizing the need for ongoing research and technique refinement.

Increase in Streptococcal Necrotizing Fasciitis During and After the Coronavirus Disease 2019 Pandemic.

Background: Necrotizing fasciitis (NF) is a life-threatening and rare condition. However, we report and analyze a remarkably high number of NF cases during the coronavirus disease 2019 (COVID-19) pandemic and especially in the first months after the COVID-19 pandemic. Patients and Methods: We conducted a retrospective analysis of 17 cases of NF treated in our clinic between January and May 2023. Data were collected on demographics, comorbidities, risk factors, laboratory findings, and clinical outcomes. For each individual case two risk indicating scores, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF) were calculated. Results: In the pandemic years 2021 and 2022 there were 21 and 30 patients with NF, respectively, treated in our clinic. Of the 17 included NF cases in this study from January until May 2023, 16 cases required intensive care unit (ICU) admission, six cases required limb amputation, and four cases resulted in death. The microbiologic examination revealed seven cases of polymicrobial infections, eight cases of monomicrobial infections primarily caused by Streptococcus pyogenes, and two cases without microbial growth. The LRINEC score showed a sensitivity of 82%, whereas the LARINF score demonstrated a sensitivity of 100% for identifying cases of NF. Conclusions: This study highlights a notable increase in NF during and after the COVID-19 pandemic, predominantly associated with Streptococcus pyogenes-induced infections. These cases demonstrate a highly aggressive nature, leading to limb amputation or death in more than half of the cases.

Experience with Management of Radial Polydactyly: The Multicenter Analysis of 28 Surgical Procedures with Follow-Up.

Radial polydactyly or thumb duplication is a relatively common congenital malformation of the hand, whereby the surgical techniques can be broadly divided into simple excisions, reconstructions and a Bilhaut-Cloquet procedure. The aim of this study was to identify the appropriate surgical procedures and to present the clinical outcomes that can be achieved. We performed a multicenter analysis of cases of radial polydactyly surgically treated with reconstruction or a Bilhaut-Cloquet procedure between 2015 and 2022. The clinical outcome was assessed using a modification of the Tada score. A total of 28 cases of 27 patients with radial polydactyly were included in the study. The most common Wassel type was type IV (13 cases), and the most common surgical procedure was reconstruction (24 cases). Our study validates an algorithm from the literature as a helpful tool for decision making in selecting a surgical technique for radial polydactyly, although individual surgical experience should also be considered.

Diagnostic and prognostic value of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) based on an 18 years' experience.

BACKGROUND: Necrotising fasciitis (NF) represents a rare but often life-threatening condition. Early diagnosis and surgical treatment are of vital importance. The LRINEC score was developed to distinguish necrotising fasciitis from other soft tissue infections (STI) at initial evaluation using six laboratory values. In this retrospective study, we attempted to determine the diagnostic and prognostic value of the LRINEC score. METHODS: A total of 125 patients, hospitalised in our clinic between 2003 and 2021 with a histologically confirmed diagnosis of necrotising fasciitis (NF group) and 319 patients with surgically treated soft tissue infections (STI group) were included in this study. Individual LRINEC scores were calculated and analysed retrospectively. RESULTS: The sensitivity of the LRINEC score at the cut-off point of ≥ 6 was 59%, whereas the specificity was 82%. The positive and negative predictive values were 57% and 84%, respectively. The mean LRINEC score was significantly higher in the NF group than in the STI group (6.0 compared to 2.4, respectively). All clinical outcome parameters such as amputation and mortality rates (15% vs 1%) were found to be significantly higher in the NF group (p<0.001). Within the NF group, there was no statistically significant association between the LRINEC score and clinical outcomes except for the necessary number of operations. CONCLUSION: In isolation, we found the LRINEC score not to be a reliable enough diagnostic tool for the differentiation between NF and other soft tissue infections, because of its low sensitivity. Although we cannot recommend it as a prognostic tool either, we do believe it can be a useful adjunct to the clinical suspicion of NF.

Causative Micro-Organisms in Necrotizing Fasciitis and their Influence on Inflammatory Parameters and Clinical Outcome.

Background: Necrotizing fasciitis (NF) is a potentially fatal soft tissue infection. Four types of pathogens can be distinguished in the pathogen spectrum, although there are strong regional differences with regard to the most common pathogens. Patients and Methods: All cases of NF between 2003 and 2021 with an identified causative agent were analyzed retrospectively. The cases were divided into three groups: polymicrobial, gram-positive and gram-negative. Demographic factors, localization of infection, inflammatory parameters, and clinical outcome were compared between the three groups. Results: A total of 95 cases were analyzed, 41% of which were caused by multiple pathogens. A gram-positive pathogen was reported in 40% of cases and a gram-negative pathogen in 19%. There were significant differences between the three groups with respect to age (with patients in the gram-negative group being on average the oldest) and intensive care unit admissions (which was most frequent in the polymicrobial group). Conclusions: The pathogen spectrum of NF has rarely been studied in a large patient population. Gram-positive pathogens account for the majority of monomicrobial infections in our study. Nevertheless, we recommend calculated broad-spectrum antibiotic therapy given the high number of polymicrobial infections and gram-negative infections. Gram-negative infections may be associated with increased mortality, elevated procalcitonin levels, and are relatively frequent in NF of the lower extremities.

The Role of Macrophage Migration Inhibitory Factor (MIF) and D-Dopachrome Tautomerase (D-DT/MIF-2) in Infections: A Clinical Perspective.

Macrophage migration inhibitory factor (MIF) and its homolog, D-dopachrome tautomerase (D-DT), are cytokines that play critical roles in the immune response to various infectious diseases. This review provides an overview of the complex involvement of MIF and D-DT in bacterial, viral, fungal, and parasitic infections. The role of MIF in different types of infections is controversial, as it has either a protective function or a host damage-enhancing function depending on the pathogen. Depending on the specific role of MIF, different therapeutic options for MIF-targeting drugs arise. Human MIF-neutralizing antibodies, anti-parasite MIF antibodies, small molecule MIF inhibitors or MIF-blocking peptides, as well as the administration of exogenous MIF or MIF activity-augmenting small molecules have potential therapeutic applications and need to be further explored in the future. In addition, MIF has been shown to be a potential biomarker and therapeutic target in sepsis. Further research is needed to unravel the complexity of MIF and D-DT in infectious diseases and to develop personalized therapeutic approaches targeting these cytokines. Overall, a comprehensive understanding of the role of MIF and D-DT in infections could lead to new strategies for the diagnosis, treatment, and management of infectious diseases.

Time Is Fascia: Laboratory and Anamnestic Risk Indicators for Necrotizing Fasciitis.

Background: Necrotizing fasciitis is a potentially fatal soft tissue infection in which the timing of surgical intervention significantly affects clinical outcome. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, the Site other than the lower limb, Immunosuppression, Age <60 years, Renal impairment (creatinine >141), and Inflammatory markers (CRP ≥150, WCC >25) (SIARI) score, and procalcitonin levels are intended to aid in the decision-making process to differentiate between necrotizing fasciitis and soft tissue infections. Methods: A retrospective analysis of cases of necrotizing fasciitis and soft tissue infections treated at Klinikum Nürnberg was performed. The two scores as well as procalcitonin levels were tested for their diagnostic value and a new score, the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF), was created based on the results. Results: Procalcitonin, LRINEC score, and SIARI score showed insufficient discriminatory ability in our study. The newly created LARINF score combined laboratory parameters of the LRINEC score (hemoglobin and C-reactive protein) with procalcitonin and three comorbidities, resulting in a sensitivity of 84% and a specificity of 75% and the highest area under the receiver operating characteristic (ROC) curve of 0.83. Conclusions: The LARINF score is a novel decision-supporting tool. The decision, in which cases surgical exploration should be initiated, remains a clinical one. However, the score seems to provide an improved basis for identifying a rare clinical picture.

Microsurgical Reconstruction of Foot Defects: A Case Series with Long-Term Follow-Up.

(1) Background: Microsurgical reconstruction of foot defects with free flaps is rare as it is a challenging task for a surgeon. For extensive defects, advanced surgical procedures, such as free flap transfer with microsurgical anastomosis, may be the last chance to avoid major amputation. The aim of the study was to examine the opportunities and risks posed by free flap reconstruction of foot defects and to illustrate in which situations reconstruction is useful on the basis of case characteristics. (2) Methods: In this study, we retrospectively analyzed data of cases with free flap reconstruction of the foot from 2007 to 2022. Therefore, demographic data, comorbidities, information about the defect situation, data on the operational procedure, and complications were evaluated. (3) Results: A total of 27 cases with free flap coverage of foot defects could be included. In 24 of these cases (89%), defect coverage was successful. In 18 patients, some form of complication occurred in the postoperative stage. The most frequently used flap was the latissimus dorsi flap, with 13 procedures. (4) Conclusions: Foot reconstruction using free flaps is a proven procedure for the treatment of larger foot defects and can offer a predominantly good functional outcome. The lengthy process and possible complications should be thoroughly discussed in advance so as to provide criteria, suitably adjusted to the individual prerequisites of the patients, for deciding whether limb salvage using advanced surgical procedures should be attempted.

Proliferation of endothelial cells (HUVEC) on specific-modified collagen sponges loaded with different growth factors.

In general, matrices for tissue engineering must maintain structural integrity during the process of tissue formation and promote vascularization of developing tissue. Therefore, collagen sponges, manufactured by an approach that offers the potential of unidirectional pore size, were seeded with human umbilical vein endothelial cells (HUVEC) to demonstrate a positive effect on cell proliferation. In addition, vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) have been used to promote proliferation of HUVEC on optimized collagen sponges. Growth and viability of the cells were evaluated. Potential unidirectional pore structure demonstrated an improvement of both, endothelial cell growth and viability. Supplementation of growth factors showed an additional increase of endothelial cell growth on collagen sponges, which confirmed the high potential of combining this biomaterial with growth factors. The results suggest that a collagen sponge with a potential specific pore size could be a suitable scaffold for endothelial cells and might be a promising implantable biomaterial with enhanced angiogenic capabilities for future clinical applications.

Macrophage Migration Inhibitory Factor-An Innovative Indicator for Free Flap Ischemia after Microsurgical Reconstruction.

(1) Background: Nowadays, the use of microsurgical free flaps is a standard operative procedure in reconstructive surgery. Still, thrombosis of the microanastomosis is one of the most fatal postoperative complications. Clinical evaluation, different technical devices and laboratory markers are used to monitor critical flap perfusion. Macrophage migration inhibitory factor (MIF), a structurally unique cytokine with chemokine-like characteristics, could play a role in predicting vascular problems and the failure of flap perfusion. (2) Methods: In this prospective observational study, 26 subjects that underwent microsurgical reconstruction were observed. Besides clinical data, the number of blood leukocytes, CRP and MIF were monitored. (3) Results: Blood levels of MIF, C-reactive protein (CRP) and leukocytes increased directly after surgery. Subjects that needed surgical revision due to thrombosis of the microanastomosis showed significantly higher blood levels of MIF than subjects without revision. (4) Conclusion: We conclude that MIF is a potential and innovative indicator for thrombosis of the microanastomosis after free flap surgery. Since it is easy to obtain diagnostically, MIF could be an additional tool to monitor flap perfusion besides clinical and technical assessments.

Incidence, Diagnosis and Repair of a Diaphragmatic Hernia Following Hepatic Surgery: A Single Center Analysis of 3107 Consecutive Liver Resections.

Diaphragmatic hernia (DH) after a liver resection (LR) is an uncommon but potentially severe complication. In this retrospective study, we aim to share our experience with DH in our hepatic surgery center. We retrospectively analyzed 3107 patients who underwent a liver resection between January 2012 and September 2019. The diagnosis of DH was based on clinical examination and radiological imaging and confirmed by intraoperative findings during surgical repair. Five out of 3107 (0.16%) patients after LR developed DH. Especially, all five DH patients had a major right-sided LR before (n = 716, 0.7%). The mean time interval between initial LR and occurrence of DH was 30 months (range 15 to 44 months). DH exclusively occurred after a right or extended right hepatectomy. Two patients underwent emergency surgery, three were asymptomatic, and DH was diagnosed in follow-up imaging. Three of these five treated patients (60%) developed DH recurrence: two of three (67%) patients after suture repair alone and the only patient after suture repair in combination with an absorbable mesh. The patient who was treated with a composite mesh implant did not show any signs of DH recurrence after 52 months of follow-up. In patients who develop DH after liver surgery, a mesh augmentation with nonresorbable material is generally recommended. In order to diagnose these patients in an early state, we recommend that special attention be paid and a prompt and targeted diagnostic examination of patients with abdominal complaints after right-sided liver resections take place.

The History of Carbon Monoxide Intoxication.

Intoxication with carbon monoxide in organisms needing oxygen has probably existed on Earth as long as fire and its smoke. What was observed in antiquity and the Middle Ages, and usually ended fatally, was first successfully treated in the last century. Since then, diagnostics and treatments have undergone exciting developments, in particular specific treatments such as hyperbaric oxygen therapy. In this review, different historic aspects of the etiology, diagnosis and treatment of carbon monoxide intoxication are described and discussed.

Integrative Medicine and Plastic Surgery: A Synergy-Not an Antonym.

BACKGROUND: Integrative medicine focuses on the human being as a whole-on the body, mind, and spirit-to achieve optimal health and healing. As a synthesis of conventional and complementary treatment options, integrative medicine combines the pathological with the salutogenetic approach of therapy. The aim is to create a holistic system of medicine for the individual. So far, little is known about its role in plastic surgery. HYPOTHESIS: We hypothesize that integrative medicine based on a conventional therapy with additional anthroposophic therapies is very potent and beneficial for plastic surgery patients. Evaluation and consequence of the hypothesis: Additional anthroposophic pharmacological and non-pharmacological treatments are promising for all areas of plastic surgery. We are convinced that our specific approach will induce further clinical trials to underline its therapeutic potential.

Hydroceles of the Canal of Nuck in Adults-Diagnostic, Treatment and Results of a Rare Condition in Females.

Nuck's hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck's canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck's hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck's hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon's skills. If inguinal channel has been widened by the presence of a Nuck's hydrocele, a mesh plasty, as performed in hernia surgery, should be considered.