[Enzymatic débridement as a treatment option for deep dermal burns of the hand]. / Enzymatisches Débridement als Therapieoption bei tiefdermalen Verbrennungen der Hand.

Burns and thermal injuries from other causes often affect exposed body regions such as the hands. Besides aesthetic aspects, deep dermal burns of the skin are often critical from a functional point of view, especially for important subcutaneous structures. This article reports the course of two patients who received enzymatic debridement with bromelain-based salve as a treatment for deep grade burns of the hands.

[Osteoid osteoma in the scaphoid bone as cause of radiocarpal pain in a 15-year-old patient]. / Osteoidosteom im Os scaphoideum als Ursache für radiokarpale Handgelenksbeschwerden bei einem 15-jährigen Patienten.

Osteoid osteomas are benign bone tumors which rarely occur in the hand and impose severe diagnostic problems. The course of the disease is often protracted before the patient receives an adequate surgical treatment. The case of an osteoid osteoma in the scaphoid bone of a 15-year-old patient is presented, who was completely symptom free after a true diagnostic odyssey by resection of the nidus and reconstruction by crest bone graft and spongiosaplasty.

[Secondary plastic and reconstructive measures following deep-dermal burn injuries : Negligent use of bioethanol]. / Sekundär-plastisch-rekonstruktive Maßnahmen nach tiefdermalen Verbrennungsverletzungen : Unsachgemäßer Umgang mit Bioethanol.

One representative case of burns caused by the negligent use of bioethanol, which was treated at our burns centre is used to illustrate the severity and depth of the burn injuries as well as the complexity of the further long-term course of treatment including complex secondary-reconstructive techniques.

[Fatal hyperpyrexia in an adolescent patient with severe burns after a traffic accident]. / Letale Hyperpyrexie bei einem jugendlichen Schwerbrandverletzten nach Verkehrsunfall.

After a motorcycle accident a 16-year-old patient suffered severe burns to 40.5 % of the total body surface area (TBSA) of which 37 % were deep subdermal burns. After tangential and partly epifascial necrosectomy, Integra® was used as a temporary dermis replacement material for the lower extremities, combined with extensive negative pressure wound therapy (NPWT). In the further course of the treatment the patient developed uncontrollable hyperpyrexia with a fatal outcome. Possible influencing factors, such as the dermis replacement material combined with NPWT over large areas as well as the differential diagnoses propofol infusion syndrome, heatstroke and malignant hyperthermia are discussed.

[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.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC) and Research Funding Report 2021/2022]. / Register Forschungsförderung der Deutschen Gesellschaft für Plastische, Rekonstruktive und Ästhetische Chirurgie (DGPRÄC) und Forschungsförderungs-Bericht 2021/2022.

BACKGROUND: Research is an integral part of academic medicine. In plastic surgery, it sets the course for innovations in the specialty. The purpose of this study is to present the research performance of plastic surgeons in Germany for the period 2021/2022 and to compare it with previous periods. MATERIALS AND METHODS: The directors of plastic surgical academic institutions reported all requested/approved and rejected research applications to public, non-public and industrial funding organizations. Data was gathered within an established online database. In addition, the DFG´s public database GEPRIS was screened for plastic surgical research grants. Data was also collected regarding research infrastructure and organization at the participating centers. RESULTS: 105 applications were reported to 54 different funding agencies from 20 plastic surgery centers. 37 funding applications were submitted to the major public funding agencies DFG, BMBF, BMWi, BMG, BMVg, G-BA and EU. Of these, 59,5% (22/37) were DFG, 13,5% (5/37) each BMBF and EU, 5,4% (2/37) BMWi, and 2,7% (1/37) each BMG, BMVg, and G-BA applications. The average funding volume of these proposals was 401,515 euros. Approved DFG proposals were most frequently assigned to the review board 205-27 Orthopedics, Trauma Surgery, Reconstructive Surgery (n=10/16, 62,5%). Over time, the research registry shows an increase in the number of proposals in general and those granted. 70,0% (14/20) of participating sites had their own experimental research laboratory, while only 40,0% (8/20) had their own clinical trial center. CONCLUSION: The 2021/2022 Research Funding Report once again highlights the impressive research accomplishments of the plastic surgery community.

[Pyoderma gangrenosum following AICD implantation: differential diagnosis to necrotizing fasciitis]. / Pyoderma gangraenosum nach AICD-Implantation: Differenzialdiagnose zur nekrotisierenden Fasziitis.

Pyoderma gangrenosum is rarely seen in the surgical disciplines. In the described case the patient was initially diagnosed with necrotizing fasciitis and admitted to the intensive care unit suffering from septic shock. The automated implantable cardioverter defibrillator (AICD), the suspected focus for infection, had already been removed. Following weeks of broad spectrum antibiotics and wound debridement without clinical improvement the alternative diagnosis of pyoderma gangrenosum was reached. Consequently the patient was treated with immunosuppressive therapy and his condition improved rapidly such that he was ultimately discharged to rehabilitation.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2019/2020]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungsbericht 2019/2020.

BACKGROUND: Since 2015/16 the DGPRÄC collects, evaluates and publishes the research activities of academic sections, departments and clinics for plastic surgery at university hospitals in Germany, in order to raise the awareness of plastic surgical research performance. MATERIALS AND METHODS: The directors of plastic surgical academic institutions were contacted via the DGPRÄC and asked to report any requested/approved and rejected research applications to public, non-public and industrial funding organizations. Data was collected in our previously established online database: https://docs.google.com/forms/d/e/1FAIpQLSe6F5xmTyw-k7VKJx_2jkPA4LBXsA0sgBGMrC3rx_4bHj6uzQ/viewform?usp=sf_link. In addition, applications were identified via the DFG's public database GEPRIS. RESULTS: A total of 41 funding applications to the public funding institutes DFG, BMBF, BMWi, BMG and EU were identified. 75.6 % (31/41) of the applications had already been approved at the time of data collection, of which 77.4 % (24/31) were DFG, 9.7 % (3/31) were BMWi, 6.5 % (2/31) were EU and 3.2 % (1/31) were BMBF or BMG applications. The average funding amounted to 358 301 Euro. In 50.0 % (12/24) of the cases, the approved DFG proposals were assigned to the subject review board 205-27 Orthopedics, Trauma Surgery, Reconstructive Surgery. CONCLUSION: The continuous publication of plastic surgical research funding reports submitted by the convention of university plastic surgeons of the DGPRÄC portraits the excellent, collaborative research activity in the field of plastic surgery.

Soluble cell adhesion molecules and parameters of lipoprotein metabolism in patients with severe burns.

BACKGROUND: The role of leukocyte adhesion molecules in patients with burns and their relationship to other parameters of inflammation and lipid metabolism is only recently beginning to be explored. Therefore, we investigated the temporal changes in the levels of soluble cell adhesion molecules and other parameters of inflammation and lipoprotein metabolism in patients with thermal injury. MATERIALS AND METHODS: The serum levels of soluble adhesion molecules, intercellular cell adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), and sE-selectin, C-reactive protein (CRP) and fibrinogen in seven patients with severe burns over a 30- day period were measured to determine the involvement of these factors in the pathophysiology of severe burns. Serum levels of slCAM-1, sVCAM-1 and sE-selectin were determined by ELISA. Furthermore, total cholesterol, high-density lipoprotein cholesterol (HDL chol), low-density lipoprotein cholesterol (LDL chol) and triglycerides (TG) were measured. RESULTS: Blood levels of sICAM-1, sVCAM-1, CRP and fibrinogen increased with maximum values six days after thermal injury. In contrast, serum levels of sE-selectin were elevated two days after thermal injury. The sICAM-1, sVCAM-1 and sE-selectin levels correlated significantly with both the CRP and the fibrinogen levels. Plasma total cholesterol, HDL cholesterol and LDL cholesterol decreased with minimum values four days after thermal injury. Furthermore, an increase of triglyceride levels was observed. CONCLUSION: The observed inflammatory response of soluble cell adhesion molecules could be useful in monitoring endothelial activation immediately following thermal injury. Further studies involving a larger number of patients with burns should help to clarify the extent to which measured parameters, especially the temporal changes ofsCAMs, could be relevant in assessing the morbidity ofpatients with thermal injury.

Development and multicentre validation of a prognostic model to predict resectability of pancreatic head malignancy.

BACKGROUND: At the time of planned pancreatoduodenectomy patients frequently undergo exploratory laparotomy without resection, leading to delayed systemic therapy. This study aimed to develop and validate a prognostic model for the preoperative prediction of resectability of pancreatic head tumours. METHODS: This was a retrospective study of patients undergoing attempted resection for confirmed malignant tumours of the pancreatic head in a university hospital in Hannover, Germany. The prognostic value of patient and tumour characteristics was investigated in a multivariable logistic regression model. External validation was performed using data from two other centres. RESULTS: Some 109 patients were included in the development cohort, with 51 and 175 patients in the two validation cohorts. Eighty patients (73·4 per cent) in the development cohort underwent resection, and 37 (73 per cent) and 141 (80·6 per cent) in the validation cohorts. The main reasons for performing no resection in the development cohort were: local invasion of vasculature or arterial abutment (15 patients, 52 per cent), and liver (12, 41 per cent), peritoneal (8, 28 per cent) and aortocaval lymph node (6, 21 per cent) metastases. The final model contained the following variables: time to surgery (odds ratio (OR) 0·99, 95 per cent c.i. 0·98 to 0·99), carbohydrate antigen 19-9 concentration (OR 0·99, 0·99 to 0·99), jaundice (OR 4·45, 1·21 to 16·36) and back pain (OR 0·02, 0·00 to 0·22), with an area under the receiver operating characteristic (ROC) curve (AUROC) of 0·918 in the development cohort. AUROC values were 0·813 and 0·761 in the validation cohorts. The positive predictive value of the final model for prediction of resectability was 98·0 per cent in the development cohort, and 91·7 and 94·7 per cent in the two external validation cohorts. [Corrections added on 18 July 2018, after first online publication: The figures for OR of the variables time to surgery and CA19-9 in the abstract and in Table 3 and Table 4 were amended from 1·00 to 0·99]. CONCLUSION: For preoperative prediction of the likelihood of resectability of pancreatic head tumours, this validated model is a valuable addition to CT findings.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2017/2018]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungs-Bericht 2017/2018.

INTRODUCTION: This report serves to publicize the research of academic institutions for Plastic Surgery within our society DGPRÄC in 2017/2018 and sequels the funding report of 2015/2016. Applications to public, non-public, or industrial funding organizations were evaluated. At the same time, this paper analyses the number of approved DFG applications in Plastic, Thoracic and Vascular Surgery in the GEPRIS system. Contrary to these specialties, Plastic Surgery is not classified as an independent speciality in the subject structure of the DFG review board which results in a lack of transparency concerning Plastic Surgery research work. MATERIALS AND METHODS: Our previously established online database (https://docs.google.com/forms/d/1OaSnHyKTysawiI1ie7kfUxDf7nJP_RiTUJTsnb7Mq_E/edit) for reporting requested/ approved and rejected research applications to public, non-public and industrial funding organizations was continued and evaluated together with applications found in the DFG's public database GEPRIS. RESULTS: Compared to the previous year's report, the number of approved applications from public research organizations (DFG, BMBF, BMWi, EU) was increased from 23 to 27. We identified 19 approved DFG applications from Plastic Surgery, as compared to 9 and 8 applications by Thoracic and Vascular Surgery, respectively. SUMMARY: Taken together, this data emphasizes that our research is at least equal to that of other newly established surgical specialties within the framework of the DFG. Accordingly, we hope to provide further arguments for an adaptation of the DFG review boards subject structure to include Plastic Surgery as an independent specialty as it is for Vascular Surgery and Thoracic Surgery.

[Hand infections resulting from underestimation of minimal injuries]. / Die Handinfektion als Folge einer Bagatellisierung von Minimalverletzungen.

Frequently, the timely onset of adequate treatment is delayed when a hand infection is the result of minor trauma. The patients as well as the physicians are tempted to underestimate this complication. To prove that certain forms of trauma correlate with the degree of underestimation, we have prospectively studied the cases of 105 patients who required hospitalisation and surgical interventions between 2001 and 2003. We defined a cut-off point at 48 hours following trauma and differentiated between patients who appeared within this period from those who came later. Lesions at the fingertips, superficial and punctual injuries were more frequent among patients belonging to the group with the longer delay of treatment onset. Also pain was more intense and swelling of axillary lymph nodes was seen in this group more often. Patients who had been treated elsewhere before, were commonly found in this group as well. Patients who came within 48 hours following trauma required less surgical procedures. Also hospitalisation was shorter. Using a discriminant analysis, we calculated a linear equation to calculate a score, which helps to assess the individual degree of underestimation. This scoring system can help to identify patients who would benefit from early surgical treatment of the hand.

[Management of finger-level avulsion injuries]. / Fingeravulsionsverletzungen.

BACKGROUND: In avulsion-type injuries of the fingers recovery of blood circulation is one of the major obstacles. The indication for finger reconstruction is discussed controversely, being influenced by the patient's needs, the degree of damage to the soft tissue and the prospects of success of the healing process. In this study we present our results after reconstruction of avulsion-type injuries of the fingers. Indications for finger reconstruction will be assessed in consideration of the expected outcome. PATIENTS AND METHODS: From 1999 to 2006 we treated 18 patients with finger level avulsion injuries. 15 casualties were caused by rings and three by ropes looped around a digit. The median age at injury was 23 (12 - 66) years. All patients were examined by an independent observer, who did not participate in the operation. Criteria were functional outcome and patient's complaints and satisfaction. Sensibility was evaluated by 2-point discrimination applying the Greulich star. Finger mobility was assessed with the Buck-Gramcko goniometer. RESULTS: According to the classification of Urbaniak as modified by Kay, 2 patients ranked in class II, 3 in class III and 13 suffered from complete avulsion-amputations (class IV). Of the latter, 8 allowed primary reconstruction of the blood circulation. Two fingers required early or late secondary amputation. After finger reconstruction, patients spent a median time of 18 (12 - 32) days in hospital while primary amputation resulted in a shorter stay of 4 (2 - 5) days. Active motion after replantation in the proximal interphalangeal joint was reduced on average to 64 (25 - 100) degrees. The distal interphalangeal joint nearly ankylosed in all patients following replantation except for one case with an active motion of 40 degrees . Good sensibility could be achieved in one case, protective sensibility in three and none in two patients. All patients with preserved fingers would again decide in favour of finger replantation. CONCLUSION: In specialised centres replantation of complete avulsion-type finger amputations can be achieved. The decision for or against replantation should only be made after microsurgical assessment of the severed soft tissue and in consideration of the patient's specific demands. With the right indication for reconstruction, the patient's satisfaction often outweighs even poor functional outcomes.

[Robotic pylorus-preserving pancreaticoduodenectomy : Video article]. / Roboterassistierte pyloruserhaltende Pankreaskopfresektion : Videobeitrag.

Pylorus-preserving pancreaticoduodenectomy is one of the most complex procedures in general surgery. Laparoscopic pancreaticoduodenectomy was initially described in 1994; however, its worldwide distribution is so far limited to only a few specialist centers. Robotic surgery using the DaVinci® system can overcome many limitations of laparoscopic surgery. The system is a promising tool for a more widespread introduction of minimally invasive surgery for pancreatic diseases. Mortality rates of 0-5% and pancreatic fistula rates of 0-35% are described in the literature; therefore, thorough complication management is crucial in the postoperative course. The video presents a robotic pylorus-preserving pancreaticoduodenectomy for periampullary carcinoma in a female patient.

[Clinical impact of operative multidisciplinarity for severe defect injuries of the lower extremity]. / Klinische Bedeutung der operativen Interdisziplinarität bei schweren Defektverletzungen der unteren Extremität.

BACKGROUND: The aim of this study was to examine the impact of our multidisciplinary therapeutical concept (MTC) on the clinical outcome in posttraumatic defect injuries of the lower extremity. PATIENTS AND METHODS: Since 1999, we have performed a free tissue transfer in 37 patients. In group 1 (n = 21), our MTC was started more than two weeks (range: 17 to 83 days) after trauma and in group 2 (n = 16) within two weeks (range: four to twelve days) after trauma. Both groups were comparable with respect to trauma severity. RESULTS: 100 % patients of group 1 and 25 % patients of group 2 had clinical and microbiological manifestations of wound infection after admission in our clinic. Significantly more operations were necessary in group 1 compared to group 2 (7.3 +/- 2.6 versus 2.9 +/- 0.8; p < 0.05), until definitive wound closure could be achieved. The postoperative course was uneventful in 35 cases. All injured extremities could be salvaged. Multistaged bone reconstructions by means of spongious or tricortical bone from the iliac crest were successful in all cases. Hospital stay after admission to our clinic was significantly longer in group 1 compared to group 2 (57 +/- 12 days versus 31 +/- 7 days, p < 0.05). CONCLUSIONS: In our study, the early start of MTC significantly reduced the risk for wound infection, the number of surgical revisions before definite wound closure and time until bone and wound healing was completed.

[A Rare Case in Hand Surgery: Adder Bite in an Index Finger]. / Handchirurgische Rarität - Kreuzotterbiss am Zeigefinger.

The common European adder is an endangered animal species in Europe. Despite its endangerment, snake bite injuries do occur from time to time, even in Germany. This is a poisoning emergency. Detailed numbers concerning the incidence or lethality of adder bites in Germany do not exist. Only 13% of all cases have a severe course of disease, with children and elderly people prevailing in this patient group. We report the benign course of an adder bite injury of the index finger of a 60-year-old zoologist, which healed completely under symptomatic treatment and surveillance without any operative intervention.

[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.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2015/2016]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungs-Bericht 2015/2016.

In addition to the impact factor, research funding also plays a central role in evaluating the academic performance and quality of a researcher, a clinic or a surgical specialty. The scope and quality of research in Plastic Surgery are usually very little known, so that even large funding institutions do not get a full view of research funding in our specialty. Therefore, sometimes traditional structures are not adapted to new needs by the developing younger surgical fields. In peer review sometimes peers are not chosen from the same surgical specialty, but from a different surgical fields being peers in large field of surgery. By this a bias can easily be generated which would not be advantageous for subspecialties such Plastic Surgery. The goal of this paper is to establish an overview in the form of a registry of the German Society of Plastic Reconstructive and Aesthetic Surgeons (DGPRÄC) in order to make the joint academic achievements more visible in the future. At the same time, a research funding report is to be published for the years 2015 and 2016.

Severe non-pneumonic necrotising infections in children caused by Panton-Valentine leukocidin producing Staphylococcus aureus strains.

Two cases of infection with Panton-Valentine Leukocidin (PVL) producing strains of Staphylococcus aureus are reported. A 15-year-old insulin dependent diabetic developed toxic shock syndrome and an abscess in the deep tissue around his left hip. A 34-day-old infant presented with a right orbital cellulitis with an intra-orbital collection and septicaemia. In both cases PVL-producing strains of Staphylococcus aureus were isolated. Both surgery and prolonged antibiotic combination regimens were required to eradicate the infection. The cases reported here demonstrate the wide range of clinical presentations seen with PVL producing strains, which have so far been mainly associated with furuncles and necrotising pneumonia.