Functionality of middle-aged women after resection-interposition arthroplasty of the trapeziometacarpal joint in comparison to a healthy control group.

INTRODUCTION: Trapeziometacarpal joint osteoarthritis is a very common degenerative joint disease which affects especially women between their fifth and sixth decade of life. To determine the final pinch, grip and functional outcome after trapeziometacarpal arthroplasty and to compare to non-arthritic controls, we hypothesized that patients after the former surgery are expected to have lower grip and pinch strength and a higher DASH score. MATERIALS AND METHODS: 44 women (range 50-65 years of age; median 57 years of age) were examined after resection-interposition arthroplasty because of trapeziometacarpal joint osteoarthritis Eaton-Littler stage 3 and 4 with a minimum follow-up time of 12 months (range 12-99 months; median 47 months) using DASH questionnaire and grip and pinch strength evaluation. The control group consisted of 107 healthy age-matched controls (range 50-64 years of age; median 54 years of age). Differences between both groups were statistically analysed using analysis of covariance. RESULTS: A significant loss of pinch strength and a significant higher DASH score were detected for the patient group in comparison to the controls, whereas grip strength did not differ significantly. CONCLUSIONS: A loss of pinch strength in conjunction with a higher DASH score was detected. The expected loss of pinch strength in conjunction with a reduced physical functionality should be discussed preoperatively with the patient to meet the expectations and to offer the best suitable treatment option.

Subjective outcome, neurophysiological investigations, postoperative complications and recurrence rate of partial medial epicondylectomy in cubital tunnel syndrome.

The aim of the study was to evaluate the clinical outcome with subjective and neurophysiological parameters following partial medial epicondylectomy (pME) and to evaluate complications and recurrence rates. A retrospective analysis was performed in 29 patients (18 males and 11 females) with cubital tunnel syndrome (CuTS) who underwent pME. Mean time follow-up was 41.4 months. For subjective parameters, DASH (Disabilities of Arm, Shoulder and Hand), a self-created questionnaire about postoperative satisfaction and a visual pain scale (VAS) have been used. All patients were classified according to the Mc Gowan Classification (McG) and Wilson & Krout Classification (WKC). The patients were examined by nerve conduction velocity. Total mean of the DASH score was 24.8 points. In a questionnaire with integrated pain score (1-5), 96% of the patients declared a postoperative improvement, whereas 41.4% patients of the latter group were very contented with the results, 37.9% were contented, 17.2% were less contented and 3.4% were discontented. The VAS for evaluation of postoperative pain showed an average of 2.36 (0-5.9) out of 10. Of the patients, 68.0% were classified as grade I according to McG and 68.0% as excellent or good according to WKC. Motor nerve conduction velocity improved from 34.8 m/s preoperatively to 48.2 m/s postoperatively. One patient developed a haematoma and three patients (10.3%) had to be classified as recurrence. High postoperative rates of patient satisfaction and improved neurophysiological results could be achieved by pME.

Scars and perforator-based flaps in the abdominal region: a contraindication?

BACKGROUND: Although multiple strategies for autologous breast reconstruction exist, a vertical midline scar in the abdominal wall as a result of previous laparatomy or abdominoplasty represents a major surgical challenge. To date, little research has been conducted on the regeneration potential of the abdominal wall's superficial vascular, perforator and choke vessel system after surgery using a vertical approache. METHODS: We present the cases of 8 patients, of whom 7 underwent autologous breast reconstruction. One patient received a thigh reconstruction. All patients had a vertical abdominal midline scar as a result of a previous surgical intervention. In 3 of the 7 patients, the breast was reconstructed using an MS-2-vertical rectus abdominis myocutaneous (VRAM) free flap. In 4 of these patients, an MS-2-transverse rectus abdominis myocutaneous (TRAM) free flap was performed. The thigh reconstruction used a transverse deep inferior epigastric perforator (DIEP) free flap. Clinical followup was done 12 months after operation. RESULTS: All 3 patients who received an MS-2-VRAM had good aesthetic results. Vertical midline scars had no negative effect on surgical outcomes, perfusion and tissue viability of the 4 MS-2-TRAM and transverse DIEP free flaps. CONCLUSION: These clinical findings indicate that the regeneration potential of the abdominal wall's superficial vascular system in the presence of vertical surgical scars has been greatly underestimated. Use of MS-2-VRAM free flaps in patients with vertical abdominal scars seems to be a suitable and successful alternative in the reconstruction algorithm.

Acute postoperative infection with Aeromonas hydrophila after using medical leeches for treatment of venous congestion.

INTRODUCTION: Venous convulsion after reconstructive microsurgery procedures is one major complication a surgeon has to deal with. Today, especially in the field of reconstructive microsurgery, medicinal leech therapy enjoys a renaissance. The potential risks such as infections associated with leech therapy are generally underestimated and not sufficiently discussed in literature. METHOD/PATIENTS: We present five male patients with an average age of 47 years. All patients suffered from a trauma incident, which had to be treated as an emergency. Three patients showed, postoperatively, a venous congestion after the reconstructive procedures. Another two patients with flap reconstruction and flap training developed venous problems after 12 and 14 days. In all five cases, the indication was given to use medical leeches (Hirudo medicinalis). In all the patients, a local infection of the injured extremity could be regarded after beginning with the leech treatment. The treatment duration with medical leeches for postoperative venous congestion was an average of 6 days. RESULTS: The reconstructive procedures in all five cases were unfortunately unsuccessful as major local infections were observed. Microbiological analyses showed, in all cases, an infection with Aeromonas hydrophila. CONCLUSION: We recommend making a considered indication for leech therapy, to diagnose wound infections early and to think about prophylactic antibiotics in patients with leech application.

Objective outcome of partial medial epicondylectomy in cubital tunnel syndrome.

AIM: Goal of the study was to evaluate the clinical outcome in cubital tunnel syndrome (CuTS) after partial medial epicondylectomy (pME) with objective parameters. METHOD: A retrospective analysis was performed in 29 (18 male/11 female) patients with CuTS who underwent pME. Mean time follow-up was 41.4 months. Parameters assessed sensibility (two point discrimination (2PD) and Semmes Weinstein Monofilaments (SW)) of the fifth finger and grip and pinch strength. In addition, elbow range of motion, elbow instability, medial elbow pain, Froment sign and Tinel`s sign were evaluated. RESULTS: Postoperative static 2PD of the fifth finger was 12.6 mm. SW values on the operated side (mean 3.58; 2.44-6.65) were comparable to the non-operated side (mean 3.28; 2.44-4.93). Tinel's sign over the ulnar sulcus was positive in 13 cases preoperative and in 16 cases postoperatively. Range of motion of the elbow joint achieved normal values in flexion/extension and pronation/supination with no significant difference in comparison to the non-operated side. Froment sign was positive in 2 cases, negative in 23 cases. Grip strength averaged 48.1 kg in man versus 24.4 kg in women. Pinch strength was 8.6 versus 5.3 kg. Grip strength on the operated side reached up to 91.0% values of the opposite arm. CONCLUSION: Good postoperative objective results were reached by pME. pME is an adequate treatment option in CuTS.

Prognostic Impact of Perineural Invasion in Cutaneous Squamous Cell Carcinoma: Results of a Prospective Study of 1,399 Tumors.

Perineural infiltration (PNI) and desmoplasia are believed to be high-risk factors in the prognosis of squamous cell carcinoma (SCC). In the literature, dependences between PNI, de-differentiation, and desmoplasia remain unclear. The aim of this study was to analyze the respective prognostic impact of these factors in regard to local recurrence and metastasis. Between 2005 and 2015, 1,399 unselected primary SCCs of 1,434 patients were diagnosed. If a patient had multiple tumors, the tumor with the highest risk profile was selected. Histological sections of all tumors with a tumor thickness of ≥6 mm and desmoplastic SCC with a tumor thickness of 2.1-5.9 mm were re-examined for PNI. Median follow-up was 36.5 months. PNI was present exclusively within tumors of the desmoplastic type (14.5%). PNI was present significantly more often in patients developing lymph node metastasis (3% all non-desmoplastic SCC, 17% desmoplastic SCC, and 29% desmoplastic SCC with PNI) and local recurrence (3%, 26%, and 64%) and associated with overall tumor-specific death (4%, 25%, and 54%). Using a multivariate model of disease recurrence, tumor thickness ≥6 mm, tumor horizontal size ≥20 mm, immunosuppression, desmoplasia, and PNI remained significant factors. In conclusion, PNI was found to be an additional marker indicative of an unfavorable prognosis and an independent high-risk factor within the desmoplastic type of SCC.

Lymph node dissection for melanoma using tumescence local anaesthesia: an observational study.

The possibility that tumescence local anaesthesia (TLA) may lead to dissemination of tumour cells in lymph nodes is presently unclear. To evaluate whether infiltration by TLA influences metastatic spread and survival probability, compared to general anaesthesia (GA), based on lymph node dissection in melanoma patients. In total, 281 patients (GA: 162; TLA: 119) with cutaneous melanoma and clinically or histologically-confirmed metastases in regional lymph nodes were included. All patients underwent complete lymph node dissection. Median follow-up was 70 months. The rate of lymph node recurrence at the dissection site was 25.3% in the GA group and 17.6% in the TLA group (p = 0.082). No significant difference was found concerning 10-year melanoma-specific survival (GA: 56.2%, TLA: 67.4%; p = 0.09), disease-free survival (GA: 72.8 %, TLA: 81.1%; p = 0.095), or lymph node-free survival (GA: 72.8%, TLA: 81.1%; p = 0.095). Distant metastases-free survival appeared to be slightly reduced in the TLA group (GA: 49.9%, TLA: 64.0%; p = 0.025). No differences were identified between the GA and TLA groups regarding prognostic outcome for overall survival or disease-free survival.

Surgical treatment of rhinophyma: experience from a German cohort of 70 patients.

Rhinophyma is a deforming soft tissue hyperplasia of the nose and surgical removal represents the treatment of choice. Comprehensive data on surgical therapy and the impact of rhinophyma on patient quality of life are lacking. Patients who received surgery for rhinophyma between 2006 and 2015 were retrospectively evaluated for postoperative complications, clinical outcome, recurrence of rhinophyma, and the impact of rhinophyma on daily life. A total of 143 patients were treated with superficial tumour decortication by scalpel under tumescent anaesthesia. Outcomes were determined by clinical review, clinical files, and a patient questionnaire. Of 143 patients, 70 answered the questionnaire and were included in this study with a mean follow-up time of 54 months. Cosmetic results were evaluated as very good or good in 77% of patients. The majority of patients (87%) were very satisfied or satisfied with the postoperative result. Surgical treatment of rhinophyma improved patients' quality of life in 67% of patients. Recurrence of rhinophyma was detected in 38% of patients. Surgery is an effective therapy for rhinophyma with excellent outcome.

Skin perfusion and pain evaluation with different local anaesthetics in a double blind randomized study following digital nerve block anaesthesia.

OBJECTIVE: Supplementing a local anaesthetic with epinephrine has advantages in hand surgery: faster onset of anaesthesia, extended effect of anaesthetics with prolonged pain reduction, decreased bleeding into the operative field, and abandoned need for tourniquet. We hypothesized that the use of ropivacaine with epinephrine additive in digits allows good skin perfusion rates with prolonged pain reduction. DESIGN: In this prospective, double-blinded, randomized study with 20 volunteers (80 fingers, without operation) the chronological course of changes in digit blood flow, post injection pain status and complication rates after two-injection dorsal technique anaesthetic block with ropivacaine (group 1: ropivacaine 0.75%, group 2: ropivacaine 0.75% and epinephrine 1 : 1.000.000, group 3: local tumescent anaesthesia 0.15% TLA: ropivacaine, lidocaine, saline solution plus epinephrine 1 : 1.000.000) were examined. As a control group, injection of 2% lidocaine in the way with 20 minutes tourniquet (group 4) was used. MAIN OUTCOME: Group 1 showed increased skin perfusion with a maximum of 160.2%, group 2 showed no significant changes with a following significant increase of skin perfusion (+66.6%). In group 3, a significant reduction (-54.1%) was followed by an increase of skin perfusion (+45.7%). In the control group (group 4) the skin perfusion was decreased (-66.2%) and increased significantly after opening the tourniquet (+248.1%). The longest pain reduction was shown for ropivacaine 0.75% and epinephrine with 18.0 hours (group 2); the other groups were between 4.6 to 8.1 hours. CONCLUSION: Using ropivacaine with epinephrine additive in digits could improve the intra-, and postoperative terms.