[The distally based dorsal metacarpal artery flap (DMCA)]. / Retrograd gestielte Lappenplastiken der dorsalen Metakarpalarterien (DMCA).

OBJECTIVE: Regional flap for the reconstruction of combined skin and soft-tissue defects of the fingers or the distal parts of the palm. INDICATIONS: Full-thickness soft-tissue defects of the fingers dorsally up to the distal interphalangeal joint, of the fingers palmarly up to the middle phalanx, or of the distal parts of the palm. CONTRAINDICATIONS: Damage of the dorsal metacarpal artery or of the distal anastomosis by trauma or previous operation. Ongoing infections. SURGICAL TECHNIQUE: Preoperative Doppler examination. Planning of a flap using the proximal or distal anastomosis of the metacarpal artery with the palmar system as its pivot point. Raising of an adipofascial flap including as many veins as possible. Alternatively, the metacarpal artery can be raised alone as a fascial flap. Tension-free insertion of the flap into the defect. To avoid venous congestion, we do not recommend subcutaneous tunneling of the flap. The skin bridge should be incised instead. POSTOPERATIVE MANAGEMENT: Loose cotton dressing, periodic monitoring, bed rest for 5 days. After 3 days active and passive physiotherapy can start. Suture removal after 14 days. RESULTS: Reliable and relatively secure flap with a flap loss rate up to 20% in literature. The donor site can be closed primarily up to a flap width of 2 cm. The fourth metacarpal artery is missing in up to 30% of the cases.

"Cat and dog bite injuries of the hand: early versus late treatment".

INTRODUCTION: Animal bites of the hand are common injuries in the emergency department. Serious complications may occur if those injuries are not treated adequately. The purpose of the study was to examine if there is a difference between the treatment of animal bite injuries at an early stage (first treatment within the first 24 h after injury, group I) versus a later stage (first treatment more than 24 h after injury, group II) retrospectively. MATERIALS AND METHODS: Between January 2010 and March 2016, a total of 69 patients with cat and dog bite injuries were treated in our hospital emergency room (ER). 45 patients arrived at the ER within 24 h after the injury (group I). 24 patients were treated more than 24 h after injury for the first time (group II). A retrospective study with evaluation of the clinical data including wound aspect, tissue damage, treatment, and antibiotics was performed. RESULTS: In group I, 27 were outpatients and 18 were in-house patients with an average hospitalization period of 3.3 days ± 1.12 days. 16 patients were treated conservatively. An operation was performed in 29 patients and in 3 patients a second look surgery was necessary. In group II, 5 patients were outpatients and 19 were inpatients with an average hospitalization period of 5.8 days ± 1.9 days. An operation was performed in 22 patients, and 2 were treated conservatively. In five patients, a second look surgery was necessary in group II. CONCLUSION: The study demonstrates that an early treatment of cat and dog bite injuries leads to less second-look operations and a shorter hospitalization. Hence, animal bite injuries of the hands should be treated immediately to avoid further complications. LEVEL OF EVIDENCE: Level 3, therapeutic.

[Plastic surgery in the German second medical licensing examination]. / Die Plastische Chirurgie im 2. Staatsexamen.

BACKGROUND: There are 230 defined objectives in the national competency-based catalogue of learning goals in surgery (NKLC) for undergraduate surgical education in Germany. These teaching objectives should be met by the students at the end of their undergraduate education, regardless of their career choice afterward. Assessment drives learning, and thus, alignment of the second state examination and the learning objectives of the NKLC seems reasonable. This study analyses the amount of plastic surgery-based learning objectives in the NKLC. Subsequently, we compared these results with the plastic surgery questions of the German second medical licensing examination compiled by the Central German Institute for Medical and Pharmaceutical Examinations (IMPP). METHODS: Plastic surgery teaching objectives in the NKLC were identified by five plastic surgeons. Exam questions from autumn 2009 to autumn 2014 (number of exams = 11) were retrospectively analyzed, and all exam questions addressing plastic surgery-related objectives were evaluated. The analysis included the total number of questions, mean number of questions for each examination, and the number of questions for each learning objective. RESULTS: Thirty-four learning objectives of the NKLC were identified as "plastic surgery-related" (14.8 % of all NKLC learning objectives). One of these was classified as "only covered by plastic surgery". Ninety-six questions (2.8 % of the total number of 3480 questions) addressed plastic surgery related objectives. Per exam, an average of 8.7 ± 4.0 questions (minimum, 4; maximum, 15) addressed plastic surgery-related learning objectives. During the study period, six learning objectives were not tested at all (2.6 % of all NKLC learning objectives). CONCLUSIONS: Questions focusing on plastic surgery-related learning objectives are not frequent in the second medical licensing examination. Presumably, medical students do not prioritize these objectives and might not have sufficient knowledge of the topics at the beginning of their medical career. A better adjustment of the state examinations and the NKLC seems desirable for plastic surgery-related learning objectives.

Impact of microbial findings on plastic reconstructive surgery outcomes in patients with deep sternal wound infection after cardiac surgery.

Deep sternal wound infection (DSWI) is a life threatening complication after cardiac surgery. In severe cases, flaps are needed to cover the wound. However, it is controversial if an aseptic environment is necessary at the time of wound closure. This is a retrospective study of 73 patients with DSWI treated by debridement and local or free flap from June 2008 until December 2017. The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed. Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83). Positive microbial findings at the time of plastic reconstructive surgery in patients with DSWI are not associated with a higher reoperation or mortality rate or a longer in-hospital stay. Repeated debridement and vacuum-assisted therapy to achieve negative microbial results might not be necessary in the treatment of these patients.Key messagesPositive microbial findings at the time of plastic reconstructive surgery in patients with deep sternal wound infection seems not to be associated with a higher reoperation or mortality rate or a longer in-hospital stay.The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed in 73 patients with deep sternal wound infection.Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83).

Impact of Soong grading on flexor tendon ruptures following palmar plating for distal radial fractures.

The purpose of this study was to evaluate flexor tendon injuries following palmar plating of distal radial fractures relative to the Soong grade. This retrospective cohort study included 113 patients who underwent palmar plate removal after a distal radial fracture between 2010 and 2016. In 13 patients, a greater than 50% injury of the flexor pollicis longus tendon was observed. Of these, nine patients were classified as Soong grade 2, four as Soong grade 1 and none as grade 0. The difference between the Soong groups was statistically significant (p = 0.006). Flexor tenosynovitis was present in eight patients (7%) and more likely in patients with a higher Soong grade (p = 0.026). We conclude that higher Soong grades are associated with significantly more flexor tendon complications. Therefore, elective removal of the palmar plate after union of the fracture should be considered in patients with Soong grades 1 and 2. Level of evidence: IV.

[The importance of hand surgery in the German Medical Licensing Examination]. / Die Handchirurgie im 2. Staatsexamen.

BACKGROUND: The national competency-based catalogue of learning objectives in surgery (NKLC) for undergraduate surgical education in Germany consists of 230 objectives and defines competence levels for each objective. These levels range from "competence level 1: factual knowledge" to "competence level 3: independent action". The German second state examination is not based on these objectives, although it is known that assessment drives learning. This study analyses the proportion of hand surgery-based learning objectives in the NKLC and compares the results with the hand surgery questions of the German second medical licensing examination compiled by the Central German Institute for Medical and Pharmaceutical Examinations (IMPP). METHODS: Hand surgery teaching objectives in the NKLC were identified by five hand surgeons. All exam questions addressing these objectives were identified in the German second medical licensing examinations held from autumn 2009 through autumn 2014 (n = 11). The analysis included the number of hand surgery questions for each examination, the number of learning objectives and the different levels of competence. RESULTS: Forty-seven learning objectives of the NKLC were identified as "hand surgery-related" (20.4 % of all NKLC learning objectives). Nine of them were classified as learning objectives that were "only covered by hand surgery" (3.9 % of all NKLC learning objectives). Two hundred and twenty questions (6.3 % of the total number of 3480 questions) addressed hand surgery-related objectives. Per exam, an average of 20 ± 8.2 questions (minimum: 9; maximum: 37) addressed a hand surgery-related learning objective. An average of 0.5 ± 0.7 questions per exam were related to objectives that only covered hand surgery (minimum: 0; maximum: 2). During the study period, 16 learning objectives were not tested at all (13.7 % of all NKLC learning objectives). These untested objectives included 5 objectives of competence level 1 (10.6 % of all NKLC learning objectives). Six of the 9 objectives that are only covered by hand surgery were not assessed at all. CONCLUSIONS: The number of hand surgery-based learning objectives in the NKLC appears to be high. However, many of these learning objectives are not addressed in the second medical licensing examination. We recommend better adjustments between the state examinations and the NKLC.

Long-term outcome of fingertip reconstruction with the homodigital neurovascular island flap.

INTRODUCTION: Fingertip injuries are frequent and several surgical strategies exist to reconstruct the amputated part and restore function and appearance. Yet, long-term results are rarely published. The purpose of this study was to examine the long-term clinical outcome of neurovascular island flaps for traumatic fingertip amputation of Allen type III/IV injuries. MATERIALS AND METHODS: We retrospectively analysed a cohort of patients with traumatic fingertip amputation that underwent reconstruction with a neurovascular island flap from January 2003 to December 2014. No mandatory splinting was applied after surgery. 28 participants (29 fingers) were available for follow-up at mean 8 years after reconstruction. Activities of daily living were measured with the disabilities of the arm, shoulder and hand questionnaire. Grip strength and finger motion were assessed using a Jamar dynamometer and a goniometer. Two-point discrimination and Semmes-Weinstein monofilaments were used to evaluate sensory recovery. RESULTS: No intraoperative complications occurred and all flaps survived. Mean flap size was 4.7 ± 0.6 cm2. Active motion of the fingers was over 95% of the contralateral side at follow-up. Three patients showed mild extension lag of the proximal interphalangeal joint. The grip strength of the affected hand and of each of the affected fingers was over 70% of the contralateral side. In comparison to the contralateral side we did not detect any significant difference for the Semmes-Weinstein monofilament test, but two-point discrimination (5.1 ± 1.7 mm) was significantly impaired. According to the Lim classification 1 of 14 nails with hook nail deformity showed grade 3 breaking of the nail. The DASH score was 16.0. All patients returned to their original occupation and patient satisfaction with the procedure was high. CONCLUSIONS: The risk for disabling flexion contracture seems to be small even without mandatory splinting. Neurovascular island flaps for fingertip amputation of Allen type III/IV injuries are a reliable tool in fingertip reconstruction in the long term.

[The revenue from finger replantation and revision amputation: Is it cost-covering?] / Fingeramputationen und -replantationen bei unterschiedlichen Kostenträgern: Ist die Vergütung kostendeckend?

BACKGROUND: Finger amputation injuries are frequently treated conditions in occupational accident hospitals. They are either treated by replantation or revision amputation. The costs of these two treatment options differ significantly. This study aims to determine if the revenue generated from the treatment of finger amputation injuries in the German DRG system is cost-covering and if there are differences depending on the type of health insurance. METHODS: Based on our hospital's cost data from the years 2014 and 2015, we performed an analysis of the revenue generated from finger replantation and finger revision amputation and compared it with the cost data of the nationwide calculation hospitals in Germany. In addition, we compared the revenue generated from patients with statutory health insurance with the revenue from patients with workers' compensation insurance. RESULTS: During the study period, a total of 90 patients were treated for finger amputation. For primary finger revision amputation, the actual costs were lower compared to the cost data of the nationwide calculation hospitals (€ 3551 vs. € 3809, p = 0.442). After deduction of all costs, the revenue was 1,008 Euros for patients with statutory health insurance and 688 Euros for patients with workers' compensation insurance (p = 0.578). In contrast, the costs of complex finger reconstruction procedures were considerably underestimated. In cases of primary finger replantation or secondary finger revision amputation, losses of 260 Euros were recorded for patients with statutory health insurance. In patients with workers' compensation insurance, the revenue of complex finger reconstruction procedures after deduction of all costs was cost-covering (€ 900, p = 0.403). CONCLUSIONS: In the German DRG system, the reimbursement for the treatment of finger amputation depends on the type of health insurance. In patients with workers' compensation insurance, cost-covering revenue is generated from both finger revision amputation and finger replantation, whereas in patients with statutory health insurance, only the revenue of primary finger revision amputation appears to be cost-covering. Hence for finger amputation injuries with subsequent complex reconstruction procedures, a revision of the cost calculation is required to avoid inappropriate incentives in patient care.

TAVI risk scoring using established versus new scoring systems: role of the new STS/ACC model.

AIMS: The aim of this study was to validate the recently developed STS/ACC TAVR in-hospital mortality risk score for predicting in-hospital mortality after transcatheter aotic valve implantation (TAVI) and to compare its ability to predict 30-day mortality with that of four other established risk models (EuroSCORE I, EuroSCORE II, STS-PROM, and German AV Score). METHODS AND RESULTS: The study cohort included 946 consecutive patients who underwent TAVI between 2013 and 2015. Each of the five scores was fitted as a continuous linear variable into a logistic regression model estimating 30-day mortality. The STS/ACC TAVR score was additionally analysed for in-hospital mortality. C-statistics and likelihood ratio (LR) test p-values were estimated for each model to describe the model fit. The ability of the STS/ACC score to predict in-hospital mortality was similar to the reported STS/ACC TVT registry data (this study's C-statistic 0.65 vs. STS/ACC TVT registry 0.66). The STS-PROM score (C-statistic=0.68; LR p<0.0001) and the new STS/ACC TAVR score (C-statistic=0.68; LR p<0.0001) were superior to the other scores (EuroSCORE I [C-statistic=0.55; LR p=0.02], EuroSCORE II [C-statistic=0.58; LR p=0.02], German AV Score [C-statistic=0.62; LR p<0.01]) for prediction of 30-day mortality. CONCLUSIONS: These data show the superiority of the STS-PROM and STS/ACC TAVR scores compared with other existing risk calculation models in predicting 30-day mortality after TAVI in a German all-comers population. The STS/ACC TAVR score, however, is easier to calculate (12 vs. 28 variables), and may thus gain wider acceptance and be accompanied by improved inter-observer reliability.

Prognostic value of body mass index and body surface area on clinical outcomes after transcatheter aortic valve implantation.

BACKGROUND: Inverse associations between Body Mass Index (BMI) and Body Surface Area (BSA) with mortality in patients after Transcatheter Aortic Valve Implantation (TAVI) have been reported. This "obesity paradox" is controversial, and it remains unclear which parameter, BMI or BSA, is of greater prognostic value. The aim of this study was to investigate the association of BMI and BSA on short- and mid-term outcomes after TAVI. METHODS AND RESULTS: This prospective, observational study consisted of 917 consecutive patients undergoing TAVI at our center from 2011 to 2014. The association between BMI/BSA and mortality (at 30 days and 1 year) was assessed using restricted cubic spline functions in propensity-adjusted (by Society of Thoracic Surgeons (STS) risk factors) logistic and Cox proportional models, respectively. The median age of the patients was 82.6 years, with a mean STS Predicted Risk of Mortality (STS-PROM) of 6.6 ± 4.3 %. Throughout the study period (mean follow-up time was 297 days), 150 (16.4 %) patients died; 72 (7.9 %) patients died within 30 days of TAVI. After risk adjustment, the association between body constitution and 30-day mortality was not significant for either measure (BMI p = 0.25; BSA p = 0.32). However, BMI (p = 0.01), but not BSA (p = 0.13), was significantly associated with 1-year survival. There was no association between stroke, vascular complications, or length of stay with BMI or BSA. CONCLUSIONS: BMI was associated with survival at 1-year after TAVI. Despite the trend towards implementing BSA in risk score calculation, BMI may be more suitable for the assessment of TAVI patients.

Hook proteins: association with Alzheimer pathology and regulatory role of hook3 in amyloid beta generation.

Defects in intracellular transport are implicated in the pathogenesis of Alzheimer's disease (AD). Hook proteins are a family of cytoplasmic linker proteins that participate in endosomal transport. In this study we show that Hook1 and Hook3 are expressed in neurons while Hook2 is predominantly expressed in astrocytes. Furthermore, Hook proteins are associated with pathological hallmarks in AD; Hook1 and Hook3 are localized to tau aggregates and Hook2 to glial components within amyloid plaques. Additionally, the expression of Hook3 is reduced in AD. Modelling of Hook3 deficiency in cultured cells leads to slowing of endosomal transport and increases ß-amyloid production. We propose that Hook3 plays a role in pathogenic events exacerbating AD.

Evidence-based flexor tendon repair.

The goal of flexor tendon repair is to achieve normal range of motion of the finger or thumb. The surgical approach depends on the level of injury. Multistrand core suture repairs are recommended for primary flexor tendon repair. It is evident that at least 4 strands are required to an initiate and active range of motion protocol. The epitendinous suture can also increase the strength of the repair. Careful attention to the post-operative therapy regiment is critical to a successful repair.

Axotrophin/MARCH7 acts as an E3 ubiquitin ligase and ubiquitinates tau protein in vitro impairing microtubule binding.

Tau is the major microtubule-associated protein in neurons involved in microtubule stabilization in the axonal compartment. Changes in tau gene expression, alternative splicing and posttranslational modification regulate tau function and in tauopathies can result in tau mislocalization and dysfunction, causing tau aggregation and cell death. To uncover proteins involved in the development of tauopathies, a yeast two-hybrid system was used to screen for tau-interacting proteins. We show that axotrophin/MARCH7, a RING-variant domain containing protein with similarity to E3 ubiquitin ligases interacts with tau. We defined the tau binding domain to amino acids 552-682 of axotrophin comprising the RING-variant domain. Co-immunoprecipitation and co-localization confirmed the specificity of the interaction. Intracellular localization of axotrophin is determined by an N-terminal nuclear targeting signal and a C-terminal nuclear export signal. In AD brain nuclear localization is lost and axotrophin is rather associated with neurofibrillary tangles. We find here that tau becomes mono-ubiquitinated by recombinant tau-interacting RING-variant domain, which diminishes its microtubule-binding. In vitro ubiquitination of four-repeat tau results in incorporation of up to four ubiquitin molecules compared to two molecules in three-repeat tau. In summary, we present a novel tau modification occurring preferentially on 4-repeat tau protein which modifies microtubule-binding and may impact on the pathogenesis of tauopathies.

Ulnar head replacement and related biomechanics.

A stable distal radioulnar joint (DRUJ) is mandatory for the function and load transmission in the wrist and forearm. Resectional salvage procedures such as the Darrach procedure, Bowers arthroplasty, and Sauvé-Kapandji procedure include the potential risk of radioulnar instability and impingement, which can lead to pain and weakness. Soft tissue stabilizing techniques have only limited success rates in solving these problems. In an attempt to stabilize the distal forearm mechanically following ulnar head resection, various endoprostheses have been developed to replace the ulnar head. The prostheses can be used for secondary treatment of failed ulnar head resection, but they can also achieve good results in the primary treatment of osteoarthritis of the DRUJ. Our experience consists of twenty-five patients (follow-up 30 months) with DRUJ osteoarthritis who were treated with an ulnar head prosthesis, with improvement in pain, range of motion, and grip strength. An ulnar head prosthesis should be considered as a treatment option for a painful DRUJ.