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.

[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.

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.

[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.

[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.

[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.

[Primary interdisciplinary reconstruction of perineal defects to reduce wound complications after abdominoperineal resection]. / Interdisziplinäre, primäre Rekonstruktion des Perineums zur Vermeidung von Wundkomplikationen nach abdominoperinealer Rektumexstirpation.

BACKGROUND: Multimodal treatment options for ultra-low neoplasms of the rectum or anal cancer include chemotherapy, radical abdominoperineal resection and/or radiation. Primary wound closure increases the risk of perineal wound complications that require secondary revision. Perineal wound complications may trigger delay of adjacent tumor therapy and thus have an impact on rate of local recurrence and long-term survival for rectal cancer. Simultaneous primary reconstruction of the perineal defect has been shown to reduce the incidence of perineal wound complications as well as hospital stay which enables timely adjacent therapy and may improve prognosis. PATIENTS AND METHODS: This study was designed to retrospectively evaluate wound complications after abdominoperineal resection by comparing a group with and one without primary perineal reconstruction. Between 2005 and 2011, patients were analysed and divided into cohorts 1 and 2. Cohort 1 included n = 33 patients without primary perineal reconstruction. Cohort 2 included n = 4 patients with primary perineal reconstruction. Risk factors were identified for increased wound complications and delay of adjacent therapy. RESULTS: Subgroup analysis revealed that 18 out of 33 patients of cohort 1 had wound complications. In five cases, prolonged wound healing resulted in a delay of adjacent therapies. Four patients suffered from progression of tumour, 2 out of these 4 patients had a history of delayed adjacent therapy. The main risk factor for prolonged wound healing due to postoperative complications was a history of neoadjuvant treatment resulting in a rate of 64.7 %. Cohort 2 undergoing primary reconstruction presented without wound complications or delay in adjuvant therapy. DISCUSSION: A primary perineal reconstruction after APRE can reduce the rate of perineal wound complications. Furthermore, neoadjuvant treatment was shown to carry a major risk for wound complications. Patients after radio-/chemotherapy should undergo a primary reconstruction to prevent procedure-related perioperative morbidity. Subsequently, delays in adjuvant therapy, and prolonged hospital stay can be inhibited. Moreover, quality of life can be increased. The interdisciplinary approach aims at identifying high-risk patients for perineal wound complications who may benefit from primary reconstruction in order to reduce rate of wound complications with potential impact on rate of local recurrence. All these measures contribute to an optimized surgical standard.

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.

Abrogation of TGF-beta by antisense oligonucleotides modulates expression of VEGF and increases angiogenic potential in isolated fibroblasts from radiated skin.

The transforming growth factor-beta (TGF-beta) has been identified as an important component of wound healing. Recent developments in molecular therapy offer good prospects for the modulation of wound healing, specifically those targeting TGF-beta. The aim of this study was to analyze the effect of TGF-beta targeting on the expression of angiogenic vascular endothelial growth factor (VEGF), a key regulator of angiogenesis and in vitro angiogenic activity in fibroblasts isolated from radiation-induced chronic dermal wounds. The expression of angiogenic VEGF in tissue samples from radiation-induced chronic dermal wounds was investigated by immunohistochemistry and microarray technique. The effect of TGF-beta targeting using antisense oligonucleotides on the expression of VEGF in isolated fibroblasts was analyzed by ELISA and multiplex RT-PCR. Human endothelial cells (ECs) were grown in conditioned medium produced from the treated fibroblasts. EC migration was measured using a modified Boyden chamber; EC tube formation was analyzed under a light microscope. Immunohistochemical investigation and microarray analysis demonstrated a decreased expression of VEGF protein and mRNA in tissue samples from radiation-induced chronic dermal wounds compared to normal human skin. Antisense TGF-beta oligonucleotide treatment significantly up-regulated VEGF secretion in vitro. Addition of conditioned medium from TGF-beta antisense-treated fibroblasts resulted in an increase in EC cell migration and tube formation. In conclusion, our results demonstrate that TGF-beta antisense oligonucleotide technology may be a potential therapeutic option for stimulation of angiogenesis in radiation-induced dermal wounds.

TGF-beta antisense oligonucleotides modulate expression of matrix metalloproteinases in isolated fibroblasts from radiated skin.

BACKGROUND: Transforming growth factor-beta (TGF-beta) has been identified as an important component of wound healing. Recent developments in molecular therapy offer exciting prospects for the modulation of wound healing, specifically those targeting TGF-beta. The purpose of this study was to analyze the effect of TGF-beta targeting on the expression of matrix metalloproteinases (MMPs) in fibroblasts isolated from radiation-induced chronic dermal wounds. MATERIALS AND METHODS: The expression of MMPs in tissue samples from radiation-induced chronic dermal wounds was investigated by immunohistochemistry and microarray technique. The effect of TGF-beta targeting using antisense oligonucleotides on the expression of MMPs in isolated fibroblasts was analysed by ELISA and multiplex RT-PCR. RESULTS: Immunohistochemical investigation and microarray analysis demonstrated an increased expression of MMP protein and mRNA in tissue samples from radiation-induced chronic dermal wounds compared to normal human skin. Antisense TGF-beta oligonucleotide treatment significantly down-regulated MMP secretion in vitro. CONCLUSION: TGF-beta antisense oligonucleotide technology may be a potential therapeutic option for the inhibition of proteolytic tissue destruction in radiation-induced chronic wounds.

[Plastic surgical reconstruction methods in interdisciplinary treatment of chronic wounds]. / Plastisch-rekonstruktive Verfahren in der interdisziplinären Therapie chronischer Wunden.

Chronic wounds are an increasingly serious socioeconomic problem. Their most frequent underlying causes are peripheral arterial occlusive disease, chronic venous insufficiency, and diabetic foot syndrome. Such wounds are also found in post-traumatic conditions or as pressure sores in nonambulatory patients. This review presents the reconstructive plastic surgical options and decision-making algorithms embedded for an interdisciplinary approach.

[Pathogenesis of chronic wounds]. / Pathophysiologie der chronischen Wunde.

Chronic, nonhealing wounds and their therapy are not only a medical problem but a severe economic one as well. Such wounds have a great effect on quality of life. Basic research has enhanced our understanding of the stimulation and inhibition of wound healing and provides the basis for introducing new and innovative treatment methods. This paper reviews the most relevant in- and extrinsic factors that disturb physiologic wound healing to result in chronic nonhealing wounds. In addition, molecular intervention modalities targeting various aspects of wound repair are demonstrated.

[Plastic surgical reconstruction of extensive thoracic wall defects after oncologic resection]. / Plastisch-chirurgische Rekonstruktion von Defekten der Thoraxwand nach onkologischen Resektionen. Interdisziplinäre Strategien.

In defect reconstruction following radical oncologic resection of malignant chest wall tumors, adequate soft-tissue reconstruction must be achieved along with function, stability, integrity, and aesthetics of the chest wall. The purpose of this retrospective analysis was to evaluate the oncoplastic concept following radical resection of malignant chest wall infiltration with an interdisciplinary approach. Between 1999 and 2005, 36 consecutive patients (nine males, 27 females, mean age 55 years, range 20-78) were treated with resection for malignant tumors of the chest wall. Indications were locally recurrent breast carcinoma (patient n=22), thymoma (n=1), and desmoid tumor (n=1). Primary lesions of the chest wall were spinalioma (n=1), sarcoma (n=7), and non-small-cell lung cancer (n=2). There were distant metastases of colon and cervical cancer in one patient each. Soft-tissue reconstruction was carried out using primary closure (n=1), external oblique flap (n=1), pectoralis major myocutaneous flap (n=3), latissimus dorsi myocutaneous flap (n=18), vertical or transversal rectus abdominis myocutaneous flap (n=9), free tensor fascia lata- flap (n=6), trapezius flap (n=1), serratus flap (n=1), and one filet flap. In 15 reconstructive procedures microvascular techniques were used. An average of 3.4 ribs were resected. Stability of the chest wall was obtained with synthetic meshes. The latissimus dorsi flap is considered the flap of choice in chest wall reconstruction. However, alternatives such as pectoralis major flap, VRAM/TRAM flap, free TFL flap, and serratus flap must also be considered. Low mortality and morbidity rates allow tumor resection and chest wall reconstruction even in a palliative setting.

[Outcome assessment after reconstruction of complex defects of the forearm and hand with osteocutaneous free flaps]. / Rekonstruktion kombinierter Knochen-/Weichteildefekte an Hand und Unterarm durch freie osteokutane Lappenplastiken.

PURPOSE: Complex defects of the forearm and hand often require microvascular reconstruction with composite osteocutaneous free flaps for limb salvage. Here, a postoperative outcome analysis of 15 patients is presented, who were treated by free composite tissue transplantation between 1992 and 2004 in a single institution. PATIENTS AND METHODS: The assessment focused on the range of motion, the pain and grip strength as well as on the patient's individual physical functioning and self perception, measured with the DASH questionnaire. Additionally complications, return to work and the donor site morbidity were documented. RESULTS: Reasons for the combined defects were trauma, infections or malignant tumors. The patients' average age was 38 years. The average osseous defect was 11.7 cm (range, 6 to 21 cm), all patients suffered from additional soft tissue defects. Microvascular osteoseptocutaneous fibula transplantations (n = 8), osteocutaneous scapular or parascapular flaps (n = 6) and osteocutaneous lateral arm flaps were performed for reconstruction. The mean hospitalisation time was 39.3 days (range, 18 - 73 d). All defects could be reconstructed in a one-step reconstructive procedure after sequential debridements or after radical tumour resection. Two patients developed a pseudarthrosis, one had to undergo an ablation procedure due to persistent infection; however, the flap was well perfused. Every patient had a markedly reduced hand function compared with the unaffected extremity, however the functional results were satisfactory with a mean DASH score of 25.3 (range, 0 to 42). This reflects only a moderate disability in activities of daily living. From the patients' point of view the functional results were more than acceptable when the potential alternatives were taken into consideration. This was also reflected by a high individual satisfaction. CONCLUSION: This retrospective analysis demonstrates that limb salvage with osteocutaneous free flaps is an important tool in the armamentarium for the treatment of composite defects in the forearm and hand. Functional results are good and the patient's high individual satisfaction justifies the use of these difficult reconstructive procedures.

[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.