[Overlooked compartment syndrome of the hand after burn injury and known polytoxicomania]. / Übersehenes Kompartmentsyndrom an der Hand nach Brandverletzung und bekannter Polytoxikomanie.

A young man suffered the fatal combination of burn injuries and acute kidney failure caused by substantial rhabdomyolysis after lying on the floor in a somnolent condition for 12 h. This symptom constellation should always make physicians aware of a potential compartment syndrome.

[Technique of Suspension Surgery Using Palmaris Longus Tendon for Correction of Severe Blepharoptosis]. / Suspensionsoperation der Ptose des Oberlids durch die Sehne des M. palmaris longus an den M. frontalis.

Background In cases of blepharoptosis, the upper eyelid either cannot or can only be elevated insufficiently. The aetiology may be myogenic, aponeurotic, neurogenic, mechanical, or traumatic. The most common cause of congenital ptosis is myogenic, due to the improper development of the levator muscle. Methods Frontalis suspension operation as a technique of correction often uses silicone slings or fascia lata. On the basis of 3 cases, we present our method using palmaris longus tendon. Results In all 3 cases, intra- and postoperative courses were without adverse events and all cases are still relapse-free. Discussion Our technique using palmaris longus tendon for suspension of the frontalis muscle is a very good alternative to fascia lata or silicone slings. We achieved satisfactory results for eyelid opening and symmetry.

[Nerve injuries after elbow luxation fractures in childhood : Indication and timing for surgical revision]. / Nervenverletzungen nach Ellenbogenluxationsfraktur im Kindesalter : Indikation und Zeitpunkt zur operativen Revision.

BACKGROUND: Supracondylar humerus fractures are very common in pediatric populations. In cases of dislocated fractures, closed reduction and percutaneous K­wire fixation is recommended. Initially, 10-16 % of the patients also present lesion of the ulnar nerve as well as median nerve palsy in 6.4% and radial nerve palsy in 2.6 % of cases, respectively. METHOD: We present the case of a 10-year-old boy with a dislocation of the elbow and fracture of the medial epicondyle. After closed reduction and K­wire fixation from medial, he presents a median nerve palsy. That a lesion of the ulnar nerve is also present is only noticed 3½ years posttraumatically. A surgical decompression and neurolysis of the ulnar and median nerve is performed and the postoperative grip and key strength presented. DISCUSSION: With the help of the presented case we discuss the indication and the point of surgical revision. Clinical assessment and neurosonography are essential for an exact diagnosis.

The Innsbruck hand transplant program: update at 8 years after the first transplant.

We herein provide an update on two bilateral hand and one bilateral forearm transplants with emphasis on immunosuppression (IS), function, morphology, and graft vascular changes at 8 years and 2 years after bilateral hand and 5 years after bilateral forearm transplantation. Between March 2000 and May 2006, three patients underwent bilateral hand or forearm transplantation at our institution. Following induction therapy with antithymocyte globulin (ATG) (n = 2) or alemtuzumab (n = 1), tacrolimus, prednisolone +/- mycophenolate mofetil (MMF) were given for maintenance IS. Later, tacrolimus (n = 1) or MMF (n = 1) was replaced by sirolimus/everolimus for long-term IS. Clinical follow-ups with evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, computed tomography angiography, electrophysiological studies, and somatosensory evoked potentials were performed at regular intervals. Three, six, and three rejection episodes were successfully treated with bolused steroids, anti-CD25 or anti-CD52 antibodies. Subsequently, skin histology remained normal without any evidence of chronic rejection. Hand function continuously improved during the first 3 years and since then remained stable with minor improvements. Investigation of hand arteries revealed no signs of occlusion or stenosis. Motor and intrinsic hand muscle function continues to improve in all patients. Protective sensation was observed in all patients; however, discriminative sensation was only accomplished after hand but not forearm transplantation. No life-threatening adverse events occurred. Despite immunologic challenging postoperative courses, patients are now free of rejection with moderate levels of IS and good functional results. No signs indicating chronic rejection have been encountered.

Altered systemic serologic parameters in patients with silicone mammary implants.

BACKGROUND: The most common local complication in patients with silicone mammary implants (SMIs) is excessive peri-SMI connective tissue capsule formation and its subsequent contracture. However, considerable controversy remains as to whether these implants also cause systemic side effects. The present study was undertaken to identify possible alterations of serological markers in SMI patients that may herald systemic side effects. METHODS: We investigated several systemic serological parameters in 143 individuals, 93 of whom had received SMIs and 50 were controls. The patients were grouped according to the severity of capsular contracture (Baker scores I-IV) and the duration of SMI implants (less than 1 year, between 1 and 5 years, more than 5 years). We also included control groups (female blood donors, nurses with possible professional silicone exposure). Patients with breast cancer and subsequent SMI-reconstruction were excluded from the study since they are generally considered immunocompromised. The following parameters were determined: anti-neutrophil cytoplasmatic autoantibodies (cANCA), anti-nuclear autoantibodies (ANA), anti-cardiolipin antibodies (CL-Ab), rheumatoid factor (RF), complement components (C3, C4), circulating immune complexes (CIC), procollagen III (a marker of active fibrosis), anti-polymer antibodies (APA) and soluble intercellular adhesion molecule-1 (sICAM-1). RESULTS: The following parameters were increased in the sera of SMI patients: CIC, procollagen III, APA, sICAM-1. CONCLUSIONS: We found a set of parameters in serum that correlate with fibrosis development and the duration of the implants in otherwise healthy SMI carriers. Future studies will clarify whether these serological abnormalities will be useful in predicting clinical disease, and also further assess the sensitivity and specificity of these parameters. Our present recommendation as a result of this study is that SMI patients with persistent abnormal serological parameters should be monitored closely by a clinical team that includes rheumatologists.

[About the self-reported quality of life after amputation of the hand in patients with upper extremity tumors]. / Zur Selbsteinschätzung der Lebensqualität von Tumorpatienten nach Amputation der Hand.

PURPOSE/BACKGROUND: Amputation proximal to the wrist may be oncologically dictated in cases of upper extremity soft tissue sarcoma and aggressive fibromatosis. Literature on functional long-term results and patient-oriented assessment is sparse. Our study is concerned with subjective impressions of quality of life and upper extremity health status and their importance in the evaluation and interpretation of results after amputation of the hand. PATIENTS/METHODS: Between 1999 and 2007, 14 patients (6 females/8 males; average age: 25 years) were operated because of a soft tissue sarcoma (n = 11) or aggressive fibromatosis (n = 3). Ten patients underwent limb-sparing surgery. There were two amputations at the level of the forearm. Local recurrence following forequarter amputation due to aggressive fibromatosis required reoperation in another patient. A heterotopic replantation after resection was carried out in one patient. In patients with amputations, the self-reported upper extremity-specific health status and quality of life were measured with the DASH score. Disturbances in body image and symptoms of depression were assessed psychiatrically. RESULTS: In two cases with amputations, minimal impairments in everyday life and a high reported quality of life were observed (DASH scores: 3,5). CONCLUSION: Self-reported upper extremity health status and quality of life following amputation of the hand can be in contrast to the objective pathology. In patient-oriented assessment of results, individual psychosocial factors that may affect results must be taken into consideration. They also must not be neglected when determining whether patients are suitable candidates for prosthetic devices.

[Radical tumour resection in the upper extremity and heterotopic replantation of the hand. Analyses of functional results in two patients]. / Radikale Tumorresektion im Ellenbogenbereich und heterotope Handreplantation. Analyse der funktionellen Ergebnisse bei zwei Patienten.

We describe here two cases treated 17 years apart from each other. The patients were young males with malignant soft tissue tumours of the forearm and elbow joint. Radical tumour resection involved removal of the elbow joint. Neither of the patients consented to upper arm amputation, but agreed to undergo heterotopic replantation of the amputated distal third of the forearm together with the hand to the stump of the upper arm. The tendons of the forearm were attached to the three muscles of the upper arm, and the distal nerves were coapted with the nerve trunks of the upper arm. However, the reconstructive procedures carried out in these two patients were anatomically different. In the first patient, for technical reasons, only the deep flexor tendons were sutured. Furthermore, development of a postoperative haematoma necessitated revision surgery with split-thickness skin graft to cover the defect of the forearm. Long-term immobilisation together with a conservative approach to mobility had resulted in less than optimal results so that it appeared meaningful to re-operate the patient even 17 years after the primary operation to help him gain improved sensibility as well as motor function. These goals were achieved to a surprising extent by scar release, Z-plasty, removal of split-thickness skin graft, neurolysis, arthrodesis of the IP joint of the thumb, and tendon transposition together with intensive early postoperative sensibility and mobility training. In the second patient, longitudinal division of the muscles of the upper arm into different compartments and interweaving of the long tendons of the forearm into these muscles as well as early intensive mobility training and reintegration of the replanted hand in the body scheme resulted in the rapid gain of extremely good functional results so that the patient is now able to employs his heterotopically replanted hand quite effectively in his activities of daily living as a farmer. We believe that the differences in the surgical techniques employed and intensive postoperative training may explain the varying functional outcomes of these two patients. What is surprising is that it was possible to achieve marked functional improvement even after an interval of 17 years.

[A "simple" method for correction of the Apert's hand]. / Eine "einfache" Methode zur Korrektur der Apert-Hand.

In view of the multiple malformations in patients with Apert syndrome, numerous operations need to be carried out on the skull, midface, jaws, hands and in some cases also feet. We describe here a simplified surgical approach to hand surgery that enables several operative steps to be performed during one session and thus reduces the total number of surgical interventions. After visualising with MSCT angiography the bone and soft-tissue malformations and blood vessels, the operation is planned carefully. Transection and removal of the bony and cartilaginous bridges between the symphalangeal fingers is followed by placement of silastic sheets between the separated fingers for a period of 2 - 3 weeks to help form well-vascularised tissue over the spongy bone, which is then covered by full-thickness skin graft to promote healing. Depending on the severity of the Apert hand, numerous surgical procedures can be performed together at one and the same session. This is a simplified method in which the thumb is also straightened either during the same intervention or at a later date. This approach is explained with the help of three of our cases.

Cognitive re-education and early functional mobilisation in hand therapy after bilateral hand transplantation and heterotopic hand replantation--two case reports.

The main challenge for a successful hand therapy after heterotopic hand replantation is the reeducation of patients' sensory and motor perception. The case of a 28-year-old patient is described. After resection of a tumour and amputation of the elbow, tendons of the hand had to be joined to only three muscles of the upper arms. Elbow extension and flexion had to be trained to control the wrist, fingers, and thumb movements. In a similar way, the main focus after ortotopic hand transplantation lies on retraining the wrist, finger, and thumb functions. This is illustrated by a second case of a patient who had lived for 5 years with myoelectric protheses on both lower arms and had forgotten these functions. The final aim in both cases was regaining of daily living and working skills. The therapy was started with fitting supporting thermoplastic splints. Early motioned passive and passive-assistive active mobilisation prevented tendons adherences and initiated hand-functions. An intense sensory remaining programme and cognitive therapeutic exercises ensured the sensory and motoric activation of the referring cortical hand areals. At conclusion of therapy it can be said that both patients have fully taken up their professional duties again and that they are able to manage successfully their activities of daily living on their own.

Cortical motor activation patterns following hand transplantation and replantation.

We studied cortical activation patterns by functional MRI in a patient who received bilateral hand transplantation after amputation 6 years ago. In the early post-operative period, the patient who had had the hand transplantation revealed strong activation of a higher motor area, only weak activation of the primary sensorimotor motor cortex and no activation of the primary somatosensory cortex. At one-year follow-up, a small increase in primary sensorimotor motor cortex activation was observed. Activation of the primary somatosensory cortex was only seen at the 2-year follow-up. Transplantation after long-standing amputation results in cortical reorganisation occurring over a two-year period.

[Reliable Flaps for Congenitally Malformed Hands]. / Bewährte Lappen an der fehlgebildeten Kinderhand.

Congenital hand malformations are rare, but hand function and aesthetics cannot be improved by surgery in every affected child. However, whenever this is possible, it is important to create an individual surgical plan for each child. Growth has to be taken into account in the accurate planning of incisions and local flaps. Just because it is technically possible, not every flap should be used in the malformed child's hand. In the following article, we present a collection of reliable flaps in the surgery of the congenitally malformed hand.

[Plastic surgical considerations of conservative weight loss in the treatment of morbid obesity]. / Selbstständige Gewichtsreduktion bei morbider Adipositas. Stellenwert aus plastisch-chirurgischer Sicht.

BACKGROUND: According to the literature, conservative weight loss seems to be ineffective for morbidly obese subjects. Nevertheless, the significance of nonsurgical strategies for the treatment of morbid obesity is still unclear. PATIENTS: From 1999 to 2003, 197 reconstructive operations were performed on 120 morbidly obese patients. Initial body mass index (BMI) was higher than 35-40, and weight loss exceeded 40% of the original body weight. RESULTS: Gastric banding was performed in 66% of the patients; 34% reduced their body weight by conservative means. Conservative weight loss could be achieved at each level of BMI. CONCLUSION: Conservative weight loss is a valuable option for the treatment of morbid obesity in a selected group of patients. Condiolates candidates for conservative weight loss should be selected carefully by a multidisciplinary team with psychiatric expertise.

[Effect of cigarette smoking on skin perfusion of the hand]. / Einfluss des Zigarettenrauchens auf die Hautdurchblutung der Hand.

BACKGROUND: Cigarette consumption leads to postoperative wound healing disturbances by impairing skin circulation. MATERIALS AND METHODS: Fourteen nonsmokers and 44 smokers were investigated and classified according to age (<40 and >40 years) and duration of cigarette consumption. Circulation at the tip of the middle finger was measured in both groups under standard conditions with laser Doppler imaging. RESULTS: There was a reduction in skin blood circulation of 24% in smokers (young 39%, older 11%, P=0.001) and 30% in nonsmokers (young 35%, older 18%, P=0.019). With longer duration of cigarette consumption, the effect grew weaker (<10 years 25%, 11-30 years 18%, >30 years 15%). There was no correlation between the number of cigarettes consumed per day and impaired circulation. CONCLUSION: Younger subjects react to cigarette consumption with a stronger reduction in circulation. In elective surgery, especially in young smokers we recommend a 6- to 8-week nicotine abstinence prior to surgical intervention.

[Surgical treatment of persisting and recurrent carpal tunnel syndrome from 1999 to 2003]. / Revisions- und Rezidiveingriffe nach Karpaltunneloperationen von 1999 bis 20031.

The operative treatment of carpal tunnel syndrome is relatively simple and is carried out by doctors from various surgical specialities. In cases of persisting pain or postoperative worsening of the condition, the indication for the procedure could have been wrong or an iatrogenic complication may have to be taken into consideration. We have analysed 42 patients (48 hands) who underwent surgical treatment for carpal tunnel release from 1999 to 2003. We treated eight men and 34 women with an average age of 56 years in this way. Ten patients were initially operated upon by endoscopic release. We found an incompletely transected or even untouched retinaculum flexorum in 16 patients. In eight patients we found an iatrogenic nerve lesion and 24 patients developed serious scarring. Revision surgery should be undertaken only by a surgeon who is a specialist in hand surgery and has extensive experience in this field. In the same context, postoperative hand therapy is essential for a good result, which is performed by occupational therapists in our clinic.

[Chronic compartment syndrome of the flexor muscles in the forearm due to motocross]. / Chronisches Kompartmentsyndrom der Unterarmbeuger beim Motocrossfahren.

A case of a mechanic and motorcyclist is reported who developed unilateral chronic exertional compartment syndrome of the flexor muscles in the forearm. After years of discomfort and medical check-ups, a subcutaneous fasciotomy of the superficial compartments of the flexor muscles in the forearm led to a complete relief of symptoms, which allowed the patient unrestricted activity.

[Xanthoma disseminatum: a rare case involving the upper extremity]. / Xanthoma disseminatum -- ein seltener Befall an der oberen Extremität.

We describe a dramatic case of class II non-Langerhans cell histiocytosis, xanthoma disseminatum, in a 30-year-old male patient with progressive involvement of the skin, vocal cords, eyes, bones and nerves in spite of chemotherapy with Vespesid and immunotherapy with interferon-gamma. At the age of 43 years, the patient required surgical clearance of airways, eyelids and peripheral nerves, but at present exhibits stable disease on a combination of lipid-lowering drugs including thiazolidinedione.

[Congenital Fibrosarcoma of the Left Index Finger - An Unusual Case]. / Kongenitales Fibrosarkom am linken Zeigefinger - ein ungewöhnlicher Fall.

Congenital fibrosarcoma is a rare mesenchymal soft tissue tumour, which most commonly develops in the peripheral extremities during infancy. Diagnostic work-up is a challenge for clinicians and pathologists alike, because in many cases the lesion initially resembles a haemangioma on macroscopic inspection. A 4-month-old boy presented with a strongly vascularised tumour of the left index finger, which had been diagnosed as a capillary haemangioma by means of a biopsy performed in another facility. The lesion had been treated with systemic and intralesional cortisone injections. Due to ulceration and the risk of infection, the tumour mass was resected with the index finger being preserved. The histological appearance was inconclusive. PCR revealed a congenital fibrosarcoma. 2 years after surgery, the boy is free from recurrence.

Defining postoperative stability in children with radial polydactyly.

UNLABELLED: There is little fundamental data on paediatric metacarpophalangeal joint instability in radial polydactyly following surgical reconstruction. We evaluated 27 thumbs in a healthy paediatric population (Group A: eight girls and 19 boys with a mean age of 9.7 years (range 2.7-14.2)) and 12 thumbs following Wassel-IV reconstruction (Group B: eight girls and four boys with a mean age at follow-up of 10.6 years (range 2.7-13.2)). Metacarpophalangeal joint radial deviation, ulnar deviation on stress testing, interphalangeal joint and metacarpophalangeal joint alignment on posterior-anterior radiographs were measured and scored according to parameters defining joint instability. The aim of our study was to provide fundamental data on thumb metacarpophalangeal joint mobility patterns and alignment for further postoperative evaluations in children. The average ulnar deviation and radial deviation on stress testing of the healthy (Group A) metacarpophalangeal joints was 25° (10°-45°) and 30° (10°-55°), respectively. In the operated (Group B) thumbs, the ulnar deviation and radial deviation was greater at 35° (10°-55°) and 30° (10°-70°). Ulnar deviation (UD) of the proximal phalanx at the metacarpophalangeal joint on posterior-anterior radiographs was a mean of 10° (range -10°-30°) in Group B; this was significantly greater than in Group A at a mean of 5° (range -5-20°) (p = 0.029). The mean radial alignment of the interphalangeal joint (distal phalanx relative to the proximal phalanx) was significantly higher in Group B (15°) than Group A (0°) (p = 0.221). In the literature on radial polydactyly, cut off values defining metacarpophalangeal joint instability in children range from 5° to 20°. According to our results, high but physiological metacarpophalangeal joint mobility of the thumb needs to be taken into consideration when evaluating children following reconstruction. Ulnar or radial deviation greater than 30°, in combination with the lack of a definite end point on metacarpophalangeal joint stress testing, may be regarded as unstable. Based on our study on healthy paediatric and reconstructed thumbs, comparison of joint stability with the healthy contralateral hand is recommended in order to define pathological instability. LEVEL OF EVIDENCE: II.

Cortical motor activation patterns following hand transplantation and replantation.

We studied cortical activation patterns by functional MRI in a patient who received bilateral hand transplantation after amputation 6 years ago and in a patient who had received unilateral hand replantation within 2 hours after amputation. In the early postoperative period, the patient who had had the hand transplantation revealed strong activation of a higher motor area, only weak activation of the primary sensorimotor motor cortex and no activation of the primary somatosensory cortex. At 1-year follow-up, a small increase in primary sensorimotor motor cortex activation was observed. Activation of the primary somatosensory cortex was only seen at the 2 year follow-up. By contrast, after hand replantation, the activation pattern was similar to that of the uninjured hand within 6 weeks. This included activation of the primary sensorimotor motor cortex, higher motor areas and primary somatosensory cortex. Transplantation after long-standing amputation results in cortical reorganization occurring over a 2-year period. In contrast, hand replantation within a few hours preserves a normal activation pattern.