Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?

Background and Objectives: Medical registries evolved from a basic epidemiological data set to further applications allowing deriving decision making. Revision rates after non-traumatic amputation are high and dramatically impact the following rehabilitation of the amputee. Risk scores for revision surgery after non-traumatic lower limb amputation are still missing. The main objective was to create an amputation registry allowing us to determine risk factors for revision surgery after non-traumatic lower-limb amputation and to develop a score for an early detection and decision-making tool for the therapeutic course of patients at risk for non-traumatic lower limb amputation and/or revision surgery. Materials and Methods: Retrospective data analysis was of patients with major amputations lower limbs in a four-year interval at a University Hospital of maximum care. Medical records of 164 patients analysed demographics, comorbidities, and amputation-related factors. Descriptive statistics analysed demographics, prevalence of amputation level and comorbidities of non-traumatic lower limb amputees with and without revision surgery. Correlation analysis identified parameters determining revision surgery. Results: In 4 years, 199 major amputations were performed; 88% were amputated for non-traumatic reasons. A total of 27% of the non-traumatic cohort needed revision surgery. Peripheral vascular disease (PVD) (72%), atherosclerosis (69%), diabetes (42%), arterial hypertension (38%), overweight (BMI > 25), initial gangrene (47%), sepsis (19%), age > 68.2 years and nicotine abuse (17%) were set as relevant within this study and given a non-traumatic amputation score. Correlation analysis revealed delayed wound healing (confidence interval: 64.1% (47.18%; 78.8%)), a hospital length of stay before amputation of longer than 32 days (confidence interval: 32.3 (23.2; 41.3)), and a BKA amputation level (confidence interval: 74.4% (58%; 87%)) as risk factors for revision surgery after non-traumatic amputation. A combined score including all parameters was drafted to identify non-traumatic amputees at risk for revision surgery. Conclusions: Our results describe novel scoring systems for risk assessment for non-traumatic amputations and for revision surgery at non-traumatic amputations. It may be used after further prospective evaluation as an early-warning system for amputated limbs at risk of revision.

Digital Volumetric Measurements Based on 3D Scans of the Lower Limb: A Valid and Reproducible Method for Evaluation in Lymphedema Therapy.

BACKGROUND: Exact quantification of volumetric changes of the extremities is difficult and often error-prone. The aim of this study was to establish a standardized method based on 3-dimensional (3D) scans. Furthermore, this study tests the method in terms of reproducibility and evaluates volume changes after surgical therapy in patients suffering from lymphedema on the lower extremity. METHODS: 3D scans of the lower limb were performed with a mobile 3D scanner; "repeatability" and "interobserver reliability" of digital volumetry were tested. Furthermore, the method was applied on 31 patients suffering from chronic lymphedema. RESULTS: Calculations of repeatability of the volume based on 20 3D scans of the same lower leg showed a mean volume of 2.488 ± 0.011 liters (range: 2.470-2.510). The mean volume of the different examiners did not differ significantly (F(2,18) = 1.579, P = 0.233). The paired t-test showed a significant mean volume decrease of 375 mL (95% confidence interval = 245/505 mL) between pretreatment and post-treatment (t (30) = 5.892, P < 0.001). CONCLUSIONS: 3D volumetry is a noninvasive, easy, and quick method to assess volume changes of the lower leg. Other than the low costs, it is reproducible and precise and therefore ideal for evolution of therapy in lymphedema.

[Closure of a prostatocutaneous urinary fistula while preserving sexual function using a perineal approach with Gracilis flap interposition]. / Funktionsprotektiver Verschluss einer urethrokutanen Fistel der prostatischen Harnröhre über einen perinealen Zugang mit Gracilis-Flap.

We present the case of a 36-year-old man suffering from perianal loss of urine through a cutaneous pore while urinating. Appropriate diagnostic investigation showed a urethrocutaneous fistula of the prostatic urethra of unclear aetiology. Because of the patient's young age and sexual activity, surgical treatment was challenging. The fistula was isolated via a perineal access and ligated close to the prostate without endangering the neurovascular bundles. In order to achieve a secure closure of the fistula, a Gracilis flap was placed as an interposition between the dorsal prostate and the percutaneous fistula outlet. To date, no case has been described of a successful, function-preserving surgical treatment of a prostatocutaneous urinary fistula.

Combining Surgical Innovations in Amputation Surgery-Robotic Harvest of the Rectus Abdominis Muscle, Transplantation and Targeted Muscle Reinnervation Improves Myocontrol Capability and Pain in a Transradial Amputee.

Adding robotic surgery to bionic reconstruction might open a new dimension. The objective was to evaluate if a robotically harvested rectus abdominis (RA) transplant is a feasible procedure to improve soft-tissue coverage at the residual limb (RL) and serve as a recipient for up to three nerves due to its unique architecture and to allow the generation of additional signals for advanced myoelectric prosthesis control. A transradial amputee with insufficient soft-tissue coverage and painful neuromas underwent the interventions and was observed for 18 months. RA muscle was harvested using robotic-assisted surgery and transplanted to the RL, followed by end-to-end neurroraphy to the recipient nerves of the three muscle segments to reanimate radial, median, and ulnar nerve function. The transplanted muscle healed with partial necrosis of the skin mesh graft. Twelve months later, reliable, and spatially well-defined Hoffmann-Tinel signs were detectable at three segments of the RA muscle flap. No donor-site morbidities were present, and EMG activity could be detected in all three muscle segments. The linear discriminant analysis (LDA) classifier could reliably distinguish three classes within 1% error tolerance using only the three electrodes on the muscle transplant and up to five classes outside the muscle transplant. The combination of these surgical procedure advances with emerging (myo-)control technologies can easily be extended to different amputation levels to reduce RL complications and augment control sites with a limited surface area, thus facilitating the usability of advanced myoelectric prostheses.

A Comparative Analysis to Dissect the Histological and Molecular Differences among Lipedema, Lipohypertrophy and Secondary Lymphedema.

Lipedema, lipohypertrophy and secondary lymphedema are three conditions characterized by disproportionate subcutaneous fat accumulation affecting the extremities. Despite the apparent similarities and differences among their phenotypes, a comprehensive histological and molecular comparison does not yet exist, supporting the idea that there is an insufficient understanding of the conditions and particularly of lipohypertrophy. In our study, we performed histological and molecular analysis in anatomically-, BMI- and gender-matched samples of lipedema, lipohypertrophy and secondary lymphedema versus healthy control patients. Hereby, we found a significantly increased epidermal thickness only in patients with lipedema and secondary lymphedema, while significant adipocyte hypertrophy was identified in both lipedema and lipohypertrophy. Interestingly, the assessment of lymphatic vessel morphology showed significantly decreased total area coverage in lipohypertrophy versus the other conditions, while VEGF-D expression was significantly decreased across all conditions. The analysis of junctional genes often associated with permeability indicated a distinct and higher expression only in secondary lymphedema. Finally, the evaluation of the immune cell infiltrate verified the increased CD4+ cell and macrophage infiltration in lymphedema and lipedema respectively, without depicting a distinct immune cell profile in lipohypertrophy. Our study describes the distinct histological and molecular characteristics of lipohypertrophy, clearly distinguishing it from its two most important differential diagnoses.

Control of the extracellular matrix by hypoxic lymphatic endothelial cells: Impact on the progression of lymphedema?

BACKGROUND: Initial lymphatic vessels do not have a continuous basement membrane. Therefore, the ability of lymphatic endothelial cells (LECs) to produce extracellular matrix (ECM) has received little attention. Untreated lymphedema is a chronic disease that progresses to massive fibrosclerosis in advanced stages. Expansion of the intercellular space and fibrosclerosis cause hypoxia, which also affects the LECs. RESULTS: We studied the expression of genes in human LECs in vitro by RNA sequencing, analyzed the effects of hypoxia (1% O2 ) vs. normoxia (21% O2 ), and focused on ECM genes. LECs express fibrillin-1 and many typical components of a basement membrane such as type IV, VIII, and XVIII collagen, laminin ß1, ß2, and α4, perlecan, and fibronectin. Under hypoxia, we found significant upregulation of expression of genes controlling hydroxylation of procollagen (PLOD2, P4HA1), and also cross-linking, bundling, and stabilization of collagen fibrils and fibers. Also striking was the highly significant downregulation of elastin expression, whereas fibulin-5, which controls the assembly of tropoelastin monomers, was upregulated under hypoxia. In the dermis from genital lymphedema, we observed significant PLOD2 expression in initial lymphatics. CONCLUSIONS: Overall, hypoxia results in the picture of a dysregulated ECM production of LECs, which might be partly responsible for the progression of fibrosclerosis in lymphedema.

Topically Confined Enhancement of Cutaneous Microcirculation by Cold Plasma.

INTRODUCTION: We aim to explore potentials and modalities of cold atmospheric pressure plasma (CAP) for the subsequent development of therapies targeting an increased perfusion of the lower leg skin tissue. In this study, we addressed the question whether the microcirculation enhancement is restricted to the tissue in direct contact with plasma or if adjacent tissue might also benefit. METHODS: A dielectric barrier discharge (DBD)-generated CAP device exhibiting an electrode area of 27.5 cm2 was used to treat the anterior lower leg of ten healthy subjects for 4.5 min. Subsequently, hyperspectral imaging was performed to measure the tempospatially resolved characteristics of microcirculation parameters in superficial (up to 1 mm) and deeper (up to 5 mm) skin layers. RESULTS: In the tissue area covered by the plasma electrode, DBD-CAP treatment enhances most of the perfusion parameters. The maximum oxygen saturation increase reached 8%, the near-infrared perfusion index (NIR) increased by a maximum of 4%, and the maximum tissue hemoglobin increase equaled 14%. Tissue water index (TWI) was lower in both the control and the plasma groups, thus not affected by the DBD-CAP treatment. Yet, our study reveals that adjacent tissue is hardly affected by the enhancements in the electrode area, and the effects are locally confined. CONCLUSION: Application of DBD-CAP to the lower leg resulted in enhancement of cutaneous microcirculation that extended 1 h beyond the treatment period with localization to the tissue area in direct contact with the cold plasma. This suggests the possibility of tailoring application schemes for topically confined enhancement of skin microcirculation, e.g., in the treatment of chronic wounds.

Tissue Healing in Hemicraniectomy.

Introduction Decompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse "question mark" ("Dandy flap") incision. The goal of this study was to analyze the details of tissue healing problems in DHC.  Materials and methods A total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the "Dandy flap" incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05. Results The most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins). Conclusion A noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic "Dandy flap" incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.

Case Report: Plasticity in Central Sensory Finger Representation and Touch Perception After Microsurgical Reconstruction of Infraclavicular Brachial Plexus Injury.

After brachial plexus injury (BPI), early microsurgery aims at facilitating reconnection of the severed peripheral nerves with their orphan muscles and sensory receptors and thereby reestablishing communication with the brain. In order to investigate this sensory recovery, here we combined functional magnetic resonance imaging (fMRI) and tactile psychophysics in a patient who suffered a sharp, incomplete amputation of the dominant hand at the axilla level. To determine somatosensory detection and discomfort thresholds as well as sensory accuracy for fingers of both the intact and affected hand, we used electrotactile stimulation in the framework of a mislocalization test. Additionally, tactile stimulation was performed in the MRI scanner in order to determine the cortical organization of the possibly affected primary somatosensory cortex. The patient was able to detect electrotactile stimulation in 4 of the 5 fingertips (D1, D2, D4, D5), and in the middle phalanx in D3 indicating some innervation. The detection and discomfort threshold were considerably higher at the affected side than at the intact side, with higher detection and discomfort thresholds for the affected side. The discrimination accuracy was rather low at the affected side, with stimulation of D1/D2/D3/D4/D5 eliciting most commonly a sensation at D4/D1/D3/D2/D5, respectively. The neuroimaging data showed a mediolateral succession from D2 to D5 to D1 to D4 (no activation was observed for D3). These results indicate a successful regrowth of the peripheral nerve fibers from the axilla to four fingertips. The data suggest that some of the fibers have switched location in the process and there is a beginning of cortical reorganization in the primary somatosensory cortex, possibly resulting from a re-education of the brain due to conflicting information (touch vs. vision).

The Efficacy of Local Flaps in the Treatment of Traumatic Scalp Defects.

BACKGROUND: Scalp defects represent a therapeutic challenge. The aim of this study is to present our experience with local and regional flaps in the treatment of trauma-induced scalp defects. Furthermore, a comparison with other surgical techniques was performed. METHODS: A retrospective evaluation of patient records was performed. Only patients who underwent surgery using local flaps between January 2010 and September 2020 due to traumatic scalp defects were included in the study. RESULTS: In all, 10 cases were identified (3 females, 7 males, average age at surgery of 46.5 years [range: 18-82 years]). Six patients underwent surgery due to tissue defects and four due to scar keloids. Three patients experienced minor postoperative complications, one of which required additional surgery. The mean defect size was 35.75 cm2 (range: 4-79 cm2) among the four patients where the defect size could be determined retrospectively. The mean inpatient follow-up was 12.4 days (range: 2-34 days). CONCLUSIONS: Local flaps can be widely used. In carefully selected cases, they have the fewest disadvantages of all surgical techniques. In our experience, large angiosomes of the main scalp arteries allow the treatment of defects larger than 30 cm2 with local flaps. Our experience also suggests that the dimensions of flap length to flap width can exceed a ratio of 2:1 in the scalp.

A distinct M2 macrophage infiltrate and transcriptomic profile decisively influence adipocyte differentiation in lipedema.

Lipedema is a chronic and progressive adipose tissue disorder, characterized by the painful and disproportionate increase of the subcutaneous fat in the lower and/or upper extremities. While distinct immune cell infiltration is a known hallmark of the disease, its role in the onset and development of lipedema remains unclear. To analyze the macrophage composition and involved signaling pathways, anatomically matched lipedema and control tissue samples were collected intra-operatively from gender- and BMI-matched patients, and the Stromal Vascular Fraction (SVF) was used for Cytometry by Time-of-Flight (CyTOF) and RNA sequencing. The phenotypic characterization of the immune component of lipedema versus control SVF using CyTOF revealed significantly increased numbers of CD163 macrophages. To gain further insight into this macrophage composition and molecular pathways, RNA sequencing of isolated CD11b+ cells was performed. The analysis suggested a significant modification of distinct gene ontology clusters in lipedema, including cytokine-mediated signaling activity, interleukin-1 receptor activity, extracellular matrix organization, and regulation of androgen receptor signaling. As distinct macrophage populations are known to affect adipose tissue differentiation and metabolism, we evaluated the effect of M2 to M1 macrophage polarization in lipedema using the selective PI3Kγ inhibitor IPI-549. Surprisingly, the differentiation of adipose tissue-derived stem cells with conditioned medium from IPI-549 treated SVF resulted in a significant decreased accumulation of lipids in lipedema versus control SVF. In conclusion, our results indicate that CD163+ macrophages are a critical component in lipedema and re-polarization of lipedema macrophages can normalize the differentiation of adipose-derived stem cells in vitro evaluated by the cellular lipid accumulation. These data open a new chapter in understanding lipedema pathophysiology and may indicate potential treatment options.

Effect on healing rates of wounds treated with direct cold atmospheric plasma: a case series.

OBJECTIVE: The response of different critical acute and hard-to-heal wounds to an innovative wound care modality-direct application of cold atmospheric plasma (CAP)-was investigated in this clinical case series. METHOD: Over an observation period of two years, acute wounds with at least one risk factor for chronification, as well as hard-to-heal wounds were treated for 180 seconds three times per week with CAP. CAP treatment was additional to standard wound care. Photographs were taken for wound documentation. The wound sizes before the first CAP treatment, after four weeks, after 12 weeks and at wound closure/end of observation time were determined using image processing software, and analysed longitudinally for the development of wound size. RESULTS: A total of 27 wounds (19 hard-to-heal and eight acute wounds) with a mean wound area of 15cm2 and a mean wound age of 49 months were treated with CAP and analysed. All (100%) of the acute wounds and 68% of the hard-to-heal wounds healed after an average treatment duration of 14.2 weeks. At the end of the observation period, 21% of hard-to-heal wounds were not yet closed but were reduced in size by >80%. In 11% of the hard-to-heal wounds (n=2) therapy failed. CONCLUSION: The results suggested a beneficial effect of additional CAP therapy on wound healing. DECLARATION OF INTEREST: This work was carried out within the research projects 'Plasma for Life' (funding reference no. 13FH6I04IA) with financial support from the German Federal Ministry of Education and Research (BMBF). In the past seven years AFS has provided consulting services to Evonik and has received institutional support by Heraeus, Johnson & Johnson and Evonik. There are no royalties to disclose. The Department for Trauma Surgery, Orthopaedics and Plastic Surgery received charitable donations by CINOGY GmbH. CINOGY GmbH released the di_CAP devices and electrodes for the study. WV and AH were involved in the development of the used di_CAP device (Plasmaderm, CINOGY GmbH). WV is shareholder of the outsourced start-up company CINOGY GmbH.

Donor defects after lymph vessel transplantation and free vascularized lymph node transfer: A comparison and evaluation of complications.

BACKGROUND: Secondary lymphedema after surgical interventions is a progressive, chronic disease that is still not completely curable. Over the past years, a multitude of surgical therapy options have been described. AIM: To summarize the single-center complications in lymph vessel (LVTx) and free vascularized lymph node transfer (VLNT). METHODS: In total, the patient collective consisted of 87 patients who were undergoing treatment for secondary leg lymphedema during the study period from March 2010 to April 2020. The data collection was performed preoperatively during consultations, as well as three weeks, six months and twelve months after surgical treatment. In the event of complications, more detailed follow-up checks were carried out. In total n = 18 robot-assisted omental lymph node transplantations, n = 33 supraclavicular lymph node transplantations and n = 36 Lymph vessel transplantations were analyzed. An exemplary drawing is shown in Figure 1. A graphical representation of patient selection is shown in Figure 2. Robotic harvest was performed with the Da Vinci Xi Robot Systems (Intuitive Surgical, CA, United States). RESULTS: In total, 11 male and 76 female patients were operated on. The mean age of the patients at study entry was: omental VLNT: 57.45 ± 8.02 years; supraclavicular VLNT: 49.76 ± 4.16 years and LVTx: 49.75 ± 4.95 years. The average observation time postoperative was: omental VLNT: 18 ± 3.48 mo; supraclavicular VLNT: 14.15 ± 4.9 and LVTx: 14.84 ± 4.46 mo. In our omental VLNT, three patients showed a slight abdominal sensation of tension within the first 12 postoperative days. No other donor side morbidities occurred. No intraoperative conversion to open technique was needed. Our supraclavicular VLNT collective showed 10 lift defect morbidities with one necessary surgical intervention. In our LVTx collective, 12 cases of donor side morbidity were registered. In one case, surgical intervention was necessary. CONCLUSION: Concerning donor side morbidity, robot-assisted omental VLNT is clearly superior to supraclavicular lymph node transplantation and LVTx.

A Distinct Cytokine Profile and Stromal Vascular Fraction Metabolic Status without Significant Changes in the Lipid Composition Characterizes Lipedema.

Lipedema is an adipose tissue disorder characterized by the disproportionate increase of subcutaneous fat tissue in the lower and/or upper extremities. The underlying pathomechanism remains unclear and no molecular biomarkers to distinguish the disease exist, leading to a large number of undiagnosed and misdiagnosed patients. To unravel the distinct molecular characteristic of lipedema we performed lipidomic analysis of the adipose tissue and serum of lipedema versus anatomically- and body mass index (BMI)-matched control patients. Both tissue groups showed no significant changes regarding lipid composition. As hyperplastic adipose tissue represents low-grade inflammation, the potential systemic effects on circulating cytokines were evaluated in lipedema and control patients using the Multiplex immunoassay system. Interestingly, increased systemic levels of interleukin 11 (p = 0.03), interleukin 28A (p = 0.04) and interleukin 29 (p = 0.04) were observed. As cytokines can influence metabolic activity, the metabolic phenotype of the stromal vascular fraction was examined, revealing significantly increased mitochondrial respiration in lipedema. In conclusion, despite sharing a comparable lipid profile with healthy adipose tissue, lipedema is characterized by a distinct systemic cytokine profile and metabolic activity of the stromal vascular fraction.

Increased levels of VEGF-C and macrophage infiltration in lipedema patients without changes in lymphatic vascular morphology.

Lipedema is a chronic adipose tissue disorder characterized by the disproportional subcutaneous deposition of fat and is commonly misdiagnosed as lymphedema or obesity. The molecular determinants of the lipedema remain largely unknown and only speculations exist regarding the lymphatic system involvement. The aim of the present study is to characterize the lymphatic vascular involvement in established lipedema. The histological and molecular characterization was conducted on anatomically-matched skin and fat biopsies as well as serum samples from eleven lipedema and ten BMI-matched healthy patients. Increased systemic levels of vascular endothelial growth factor (VEGF)-C (P = 0.02) were identified in the serum of lipedema patients. Surprisingly, despite the increased VEGF-C levels no morphological changes of the lymphatic vessels were observed. Importantly, expression analysis of lymphatic and blood vessel-related genes revealed a marked downregulation of Tie2 (P < 0.0001) and FLT4 (VEGFR-3) (P = 0.02) consistent with an increased macrophage infiltration (P = 0.009), without changes in the expression of other lymphatic markers. Interestingly, a distinct local cytokine milieu, with decreased VEGF-A (P = 0.04) and VEGF-D (P = 0.02) expression was identified. No apparent lymphatic anomaly underlies lipedema, providing evidence for the different disease nature in comparison to lymphedema. The changes in the lymphatic-related cytokine milieu might be related to a modified vascular permeability developed secondarily to lipedema progression.

Latissimus Dorsi Flap in the Treatment of Thoracic Wall Defects After Medial Sternotomy.

Background: This study aimed to describe the subjective and objective results of the latissimus dorsi muscle flap and propose it as a reconstructive option for postoperative thoracic defects. Methods: A systematic search for cases with pedicle-based latissimus dorsi flaps performed after medial sternotomy was conducted, and all cases occurred between 2010 and August 2017. Preoperative, intraoperative, and postoperative factors were retrospectively analyzed and then the correlations between prognostic factors and outcomes of flap surgery were calculated. Furthermore, an evaluation of the subjective quality of life after flap surgery was performed using questionnaires. Results: A total of 25 cases were identified (8 female and 17 male patients) with the mean age of 75.28 years (range, 55-88 years). The average survival rate was 39.63 ± 23.03 months. The proportion of patients with a survival rate of 1 year was 84.00% (21 patients), and the proportion of patients with a 2-year survival rate was 80.00% (20 patients). While 24% of all patients who had latissimus dorsi flap operations experienced no complications, 64% of them developed minor complications (non-life-threatening, Clavien-Dindo grades I-IIIb) and 12% of them developed major complications (life-threatening, Clavien-Dindo grades IV-V). There was a significant correlation between the low survival rate and risk factors such as a positive history of smoking (P = .034), renal insufficiency (P = .022), metabolic syndrome (P = .004), and the presence of postoperative complications (P < .00002). No significant correlation was observed between the survival rate and obesity (P = .396), hyperlipoproteinemia (P = .684), arterial hypertonia (P = .0450), diabetes (P = .891), cardiovascular comorbidities (P = .794), the interval between sternotomy and latissimus flap surgery (P = .075), the duration of flap surgery (P = .207), sternal osteitis (P = .78), and intraoperative application of norepinephrine (P = .818). We identified metabolic syndrome (hazard ratio: 6.27), renal insufficiency (hazard ratio: 3.935), and the presence of postoperative complications (hazard ratio: 2.965) as high-risk prognostic factors. The subjective evaluations revealed positive reports from the patients with an average score of 1.86 ± 1.03 (1.0 = very good; 5.0 = poor). Conclusions: The majority of the patients with defects after median sternotomy were treated successfully with the latissimus dorsi flap. High survival rates, low rates of severe complications, and subjective scoring of improved life quality make this procedure relative safe and reliable. However, some prognostic risk factors limit the outcome, so these factors should be considered during surgical planning.

Adipose Tissue Hypertrophy, An Aberrant Biochemical Profile and Distinct Gene Expression in Lipedema.

BACKGROUND: Lipedema is a common adipose tissue disorder affecting women, characterized by a symmetric subcutaneous adipose tissue deposition, particularly of the lower extremities. Lipedema is usually underdiagnosed, thus remaining an undertreated disease. Importantly, no histopathologic or molecular hallmarks exist to clearly diagnose the disease, which is often misinterpreted as obesity or lymphedema. MATERIALS AND METHODS: The aim of the present study is to characterize in detail morphologic and molecular alterations in the adipose tissue composition of lipedema patients compared with healthy controls. Detailed histopathologic and molecular characterization was performed using lipid and cytokine quantification as well as gene expression arrays. The analysis was conducted on anatomically matched skin and fat tissue biopsies as well as fasting serum probes obtained from 10 lipedema and 11 gender and body mass index-matched control patients. RESULTS: Histologic evaluation of the adipose tissue showed increased intercellular fibrosis and adipocyte hypertrophy. Serum analysis showed an aberrant lipid metabolism without changes in the circulating adipokines. In an adipogenesis gene array, a distinct gene expression profile associated with macrophages was observed. Histologic assessment of the immune cell infiltrate confirmed the increased presence of macrophages, without changes in the T-cell compartment. CONCLUSIONS: Lipedema presents a distinguishable disease with typical tissue architecture and aberrant lipid metabolism, different to obesity or lymphedema. The differentially expressed genes and immune cell infiltration profile in lipedema patients further support these findings.

Factors affecting outcomes after supermicrosurgical lymphovenous anastomosis in a defined patient population.

BACKGROUND: The optimal surgical treatment for lymphedema is still subject of intensive research. Therefore, it is vital to investigate what significance lymphovenous anastomosis (LVA) has in this context. OBJECTIVE: This study aims to determine the short- and long-term results as well as the most important factors that can improve outcomes after LVA. METHODS: This study includes a complete data set of 26 patients who received LVA for a therapy-resistant lymphedema. Patients were followed up for an average of 23 months. RESULTS: 50% of the patients reported a subjective improvement. Without conservative treatment after the operation the patients showed significant better results (100% vs. 40.9%, p = 0.030). The localization of lymphedema as well as the region of LVA had a significant influence. In patients with lymphedema affecting the entire leg, symptom improvement was significantly lower (35.3% vs. 77.8%, p = 0.039). Patients who received LVA in an upper limb show a significantly higher improvement in symptoms than patients who received LVA in a lower limb (100% vs. 30%, p = 0.021). CONCLUSIONS: We identified factors with a significant influence on the outcome of patients after receiving LVA. Patients with early-stage upper extremity lymphedema seem to benefit most from this procedure.

Effect of direct cold atmospheric plasma (diCAP) on microcirculation of intact skin in a controlled mechanical environment.

OBJECTIVE: The microcirculatory response of intact human skin to exposure with diCAP for different durations with a focus on the effect of implied mechanical pressure during plasma treatment was investigated. METHODS: Local relative hemoglobin, blood flow velocity, tissue oxygen saturation, and blood flow were monitored noninvasively for up to 1 hour in 1-2 mm depth by optical techniques, as well as temperature, pH values, and moisture before and after skin stimulation. The experimental protocol (N = 10) was set up to differentiate between pressure- and plasma-induced effects. RESULTS: Significant increases in microcirculation were only observed after plasma stimulation but not after pressure stimulus alone. For a period of 1 h after stimulation, local relative hemoglobin was increased by 5.1% after 270 seconds diCAP treatment. Tissue oxygen saturation increased by up to 9.4%, whereas blood flow was doubled (+106%). Skin pH decreased by 0.3 after 180 seconds and 270 seconds diCAP treatment, whereas skin temperature and moisture were not affected. CONCLUSIONS: diCAP treatment of intact skin notably enhances microcirculation for a therapeutically relevant period. This effect is specific to the plasma treatment and not an effect of the applied pressure. Prolonged treatment durations lead to more pronounced effects.

Longitudinal high-density EMG classification: Case study in a glenohumeral TMR subject.

Targeted muscle reinnervation (TMR) represents a breakthrough interface for prosthetic control in high-level upper-limb amputees. However, clinically, it is still limited to the direct motion-wise control restricted by the number of reinnervation sites. Pattern recognition may overcome this limitation. Previous studies on EMG classification in TMR patients experienced with myocontrol have shown greater accuracy when using high-density (HD) recordings compared to conventional single-channel derivations. This case study investigates the potential of HD-EMG classification longitudinally over a period of 17 months post-surgery in a glenohumeral amputee. Five experimental sessions, separated by approximately 3 months, were performed. They were timed during a standard rehabilitation protocol that included intensive physio- and occupational therapy, myosignal training, and routine use of the final myoprosthesis. The EMG signals recorded by HD-EMG grids were classified into 12 classes. The first sign of EMG activity was observed in the second experimental session. The classification accuracy over 12 classes was 76% in the third session and ∼95% in the last two sessions. When using training and testing sets that were acquired with a 1-h time interval in between, a much lower accuracy (32%, Session 4) was obtained, which improved upon prosthesis usage (Session 5, 67%). The results document the improvement in EMG classification accuracy throughout the TMR-rehabilitation process.