Ski- and snowboard related open peroneal nerve injury: A 20-year retrospective case series study.

INTRODUCTION: Traumatic peroneal nerve injury (PNI) caused by ski or snowboard edges is a severe but scarcely reported accident. METHODS: In a 20-year retrospective study, all skiers and snowboarders with this injury treated surgically at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Innsbruck, Austria, were included, covering a period from 1999/2000 to 2018/2019. RESULTS: In total, 34 patients were included in this study (30 males (88.2%) and 4 (11.8%) females). Of these 34 injured skiers or snowboarders, 33 (97.1%) were recreational athletes and Non-Austrian citizens, and 21 (61.8%) patients sustained accidental injuries without collision. All of the injuries under investigation, i.e., open lacerations, most often with complete transection, were the patients' main injuries. Surgery was performed with direct coaptation in 24 patients (70.6%), and with a suralis nerve graft in the other 10 patients (29.4%). CONCLUSION: Traumatic laceration of the peroneal nerve at the knee level by sharp ski or snowboard edges is a rare but severe injury. Causes for this injury may be multifactorial. Recommendations to reduce the risk of such an injury may follow general instructions and warnings to skiers and snowboarders regarding equipment, familiarity with the region, as well as appropriate skills and training.

[Establishing and evaluating a multinational Science Academy: A new tool for fostering scientific young talents in microsurgical research - a Consensus Statement of the DAM]. / Etablierung und Evaluation einer multinationalen Wissenschaftsakademie: Ein neues Modell zur Stärkung des wissenschaftlichen Nachwuchses in der mikrochirurgischen Forschung ­ Ein Konsensus Papier der DAM.

BACKGROUND: The formation of professional networks and cooperations - in addition to any qualified good education - seems fundamental for a successful career. In a number of disciplines, various symposia or conferences exist. In the field of microsurgery, however, a specific, guided and designated opportunity for junior scientists to network with one another has been missing so far. METHODS: In 2017, a science academy was initiated for the first time by the German-speaking Association for Nerves and Vessels (DAM) with the goal of bringing together and networking microsurgically researching young physicians and scientists. This was intended to happen on a small scale once a year in order to develop synergies for joint research projects. For this purpose, motivated junior researchers were individually selected by their mentors and sent to the academy by the boards of research institutions that are organized in the DAM. After getting to know each other in a relaxed atmosphere, the participants were given the opportunity to present their respective research project within the framework of thematic blocks and moderated by experienced mentors. Each presentation was followed by a round table discussion and small group work, in which knowledge and methods were exchanged and points of contact for possible later cooperation were identified. RESULTS: In the past 3 years, the DAM Science Academy proved to be an optimal format to initiate and promote networks of young researchers comprising microsurgically interested physicians and scientists. There were many lively and in-depth discussions, which were mainly due to the open working atmosphere and the obligation to confidentiality. Most of the synergies were shown i. a. in the field of angiogenesis, bioreactor, carcinoma-ADSC interactions, stem cells, AV loop model, ischemia/reperfusion, and nerve regeneration. The participants consistently gave a very positive feedback in the final evaluation with the wish to continue this academy. CONCLUSION: The DAM Science Academy can be considered a highly suitable complemental platform to the existing networking opportunities among microsurgical researchers. Experience so far suggests that this will hopefully result in long-term cooperations and a permanent transfer of knowledge among the participants.

[Perioperative Management in Microsurgery - Consensus Statement of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / Perioperatives Management in der Mikrochirurgie - Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

Perioperative management of microsurgery is not well standardised. Due to a lack of evidence, different regimes are established in different microsurgical centres. However, trends towards less aggressive perioperative interventions can be identified in recent years, since treatment algorithms without systematic evidence are being progressively abandoned. The available evidence on perioperative issues, such as temperature control, fluid resuscitation, blood transfusions, application of vasodilators or - pressors, as well as anticoagulants, were discussed during the consensus conference on perioperative management at the annual meeting of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels. Common basic standards were identified and a consensus was reached that is described in the following manuscript.

ITGAV and ITGA5 diversely regulate proliferation and adipogenic differentiation of human adipose derived stem cells.

The fate of human adipose tissue stem cells (ASCs) is largely determined by biochemical and mechanical cues from the extracellular matrix (ECM), which are sensed and transmitted by integrins. It is well known that specific ECM constituents influence ASC proliferation and differentiation. Nevertheless, knowledge on how individual integrins regulate distinct processes is still limited. We performed gene profiling of 18 alpha integrins in sorted ASCs and adipocytes, identifying downregulations of RGD-motif binding integrins integrin-alpha-V (ITGAV) and integrin-alpha-5 (ITGA5), upregulation of laminin binding and leukocyte-specific integrins and individual regulations of collagen and LDV-receptors in differentiated adipocytes in-vivo. Gene function analyses in in-vitro cultured ASCs unraveled differential functions of ITGA5 and ITGAV. Knockdown of ITGAV, but not ITGA5 reduced proliferation, caused p21(Cip1) induction, repression of survivin and specific regulation of Hippo pathway mediator TAZ. Gene knockdown of both integrins promoted adipogenic differentiation, while transgenic expression impaired adipogenesis. Inhibition of ITGAV using cilengitide resulted in a similar phenotype, mimicking loss of pan-ITGAV expression using RNAi. Herein we show ASC specific integrin expression patterns and demonstrate distinct regulating roles of both integrins in human ASCs and adipocyte physiology suggesting a negative impact of RDG-motif signaling on adipogenic differentiation of ASCs via ITGA5 and ITGAV.

Outcomes for split-thickness skin transplantation in high-risk patients using octenidine.

Skin transplantation is a commonly used surgical technique; however, the complication rate, including postoperative infection and delayed wound healing due to inefficient perfusion, is significantly higher in patients suffering from comorbidities. Hence, a subsequent repeat procedure is often necessary. In this report, two case studies are presented in which an octenidine-based antiseptic is used with a tie-over dressing (TOD) instead of povidone iodine (PVP-iodine), following a split-thickness skin graft. The two patients selected were deemed to be at high risk of impaired wound healing due to comorbidities. The first patient, a confirmed smoker with diabetes, presented with a nodular melanoma that was resected and covered with a split-thickness skin graft. After 5 days of negative pressure wound therapy as a TOD, in combination with PVP-iodine, the graft became necrotic. A second split-thickness skin graft was performed and an antiseptic regimen with octenidine in combination with the same TOD resulted in a completely healed transplant. The second patient, also a confirmed smoker with diabetes and receiving oral corticosteroid treatment, was diagnosed with a skin necrosis on her leg. Following the split-thickness skin graft, octenidine and TOD were applied. The patient's skin graft completely healed without any adverse events. These two case studies indicate that the combination of octenidine and TOD following split-thickness skin transplantation is safe, well-tolerated and appears to have positive benefits in the reconstruction of defects in patients with impaired wound healing.

The combined use of NPWT and instillation using an octenidine based wound rinsing solution: a case study.

Effective wound bed preparation is an essential element in the healing of chronic wounds, including pressure ulcers (PUs). Negative pressure wound therapy (NPWT) reduces oedema, stimulates the formation of granulation tissue and helps remove wound exudate. This helps prepare the wound bed for secondary healing, skin grafting or coverage with flaps. Combining NPWT with an instillation phase using an antiseptic (octenidine based) irrigation solution is a novel approach to PU management. Three patients with Category 4 gluteal PUs were treated with NPWT and instillation fluid, following surgical debridement of necrotic tissue. The aim was to achieve optimal wound bed preparation prior to wound closure by local fasciocutaneous flap. The antiseptic efficacy of octenilin wound irrigation solution in microorganism eradication was quantified by in vitro tests simulating real conditions using leg ulcer vacuum exudates. All wounds completely healed after four weeks, and no adverse incidents occurred due to instillation of octenidine. No recurrence of the PU occurred during a one year follow-up.

Bacterial biofilms and capsular contracture in patients with breast implants.

BACKGROUND: It has been hypothesized that bacterial biofilms on breast implants may cause chronic inflammation leading to capsular contracture. The association between bacterial biofilms of removed implants and capsular contracture was investigated. METHODS: Breast implants explanted between 2006 and 2010 at five participating centres for plastic and reconstructive surgery were investigated by sonication. Bacterial cultures derived from sonication were correlated with patient, surgical and implant characteristics, and the degree of capsular contracture. RESULTS: The study included 121 breast implants from 84 patients, of which 119 originated from women and two from men undergoing gender reassignment. Some 50 breast prostheses were implanted for reconstruction, 48 for aesthetic reasons and 23 implants were used as temporary expander devices. The median indwelling time was 4·0 (range 0·1-32) years for permanent implants and 3 (range 1-6) months for temporary devices. Excluding nine implants with clinical signs of infection, sonication cultures were positive in 40 (45 per cent) of 89 permanent implants and in 12 (52 per cent) of 23 temporary devices. Analysis of permanent implants showed that a positive bacterial culture after sonication correlated with the degree of capsular contracture: Baker I, two of 11 implants; Baker II, two of ten; Baker III, nine of 23; and Baker IV, 27 of 45 (P < 0·001). The most frequent organisms were Propionibacterium acnes (25 implants) and coagulase-negative staphylococci (21). CONCLUSION: Sonication cultures correlated with the degree of capsular contracture, indicating the potential causative role of bacterial biofilms in the pathogenesis of capsular contracture. REGISTRATION NUMBER: NCT01138891 (http://www.clinicaltrials.gov).

Functional resurfacing of the palm: flap selection based on defect analysis.

Extensive defect coverage of the palm and anatomical reconstruction of its unique functional capacity remains difficult. In manual laborers, reconstruction of sensation, range of motion, grip strength but also mechanical stability is required. Sensate musculo-/fasciocutaneous flaps bear disadvantages of tissue mobility with shifting/bulkiness under stress. Thin muscle and fascial flaps show adherence but preclude sensory nerve coaptation. The purpose of this review is to present our algorithm for reliable selection of the most appropriate procedure based on defect analysis. Defect analysis focusing on units of tactile gnosis provides information to weigh needs for sensation or soft tissue stability. We distinguish radial unit (r)-thenar, ulnar unit (u)-hypothenar and unit (c)-central plus distal palm. Individual parameters need similar consideration to choose adequate treatment. Unit (r) and unit (u) are regions of secondary touch demanding protective sensation. Restoration of sensation using neurovascular, fasciocutaneous flaps is recommended. In unit (c), tactile gnosis is of less, mechanical resistance of greater value. Reconstruction of soft tissue resistance is suggested first in this unit. In laborers, free fascial- or muscle flaps with plantar instep skin grafts may achieve near to anatomical reconstruction with minimal sensation. Combined defects involving unit (c) require correlation with individual parameters for optimal flap selection. Defect coverage of the palm should not consist of merely providing sensate vascularized tissue. The most appropriate procedure should be derived from careful defect analysis to achieve near to anatomical reconstruction. In laborers, defect related demands need close correlation with sensation and mechanical stability to be expected.

[Perioperative coagulation management in microsurgery: report of the consensus workshops in the course of the 31st and 32nd Annual Meeting of the German-language Working Group for microsurgery of the peripheral nerves and vessels (DAM) November 2009 in Erlangen and November 2010 in Basel]. / Perioperatives Gerinnungsmanagement in der Mikrochirurgie - Bericht der Konsensus-Workshops im Rahmen der 31. und 32. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) im November 2009 in Erlangen und November 2010 in Basel.

Microsurgery is a very relevant component of reconstructive surgery. In this context anticoagulation plays an increasing role. At the moment there are no unanimously accepted prospective studies or generally accepted regimes available that could serve as evidence-based guidelines for the prevention of thrombosis in microsurgery. With regard to this problem the aim of a series of workshops during the annual meetings of the German-speaking group for microsurgery in 2009 and 2010 was to establish a first possible consensus. This article reflects the main aspects of the ongoing development of a generally acceptable guideline for anticoagulation in microsurgery as interim report of these consensus workshops. Basically there are 3 main agents in thromboprophylaxis available: antiplatelet drugs, dextran and heparin. In the course of the workshops no general use of aspirin or dextran for anticoagulation in microsurgery was recommended. The use of heparin as anticoagulation agent is advisable for different indications. Low molecular heparins (LMH) have certain advantages in comparison to unfractionated heparins (UFH) and are therefore preferred by most participants. Indications for UFH are still complex microsurgical revisions, renal failure and some specific constellations in patients undergoing reconstruction of the lower extremity, where the continuous administration of heparin is recommended. At the moment of clamp release a single-shot of UFH is still given by many microsurgeons, despite a lack of scientific evidence. Future prospective clinical trials and the establishment of a generally accepted evidence-based guideline regarding anticoagulation treatment in microsurgery are deemed necessary.

How reconstructive transplantation is different from organ transplantation--and how it is not.

An evolution of understanding and knowledge gained over more than 100 years in the field of solid organ transplantation (SOT) led to the first successful clinical cases of composite tissue allotransplantation. In many ways reconstructive transplantation (RT) is similar to SOT; however, certain characteristics make this novel type of transplantation unique, interesting, and challenging for both clinicians/scientists and patients. Currently, RT is a rapidly advancing multidisciplinary clinical reality. With over 100 clinical cases performed over the past 12 years, and encouraging early to midterm results, the relevance of RT for treatment of congenital and acquired tissue defects unsalvageable by conventional reconstruction is significant and holds great potential for the future. We herein report the extraordinary progress in this field with particular discussion of a comparative analysis of the similarities and differences regarding indications, end point, failure, patient and graft survival, and side effects between SOT and RT.

[Free gracilis muscle flap with plantar intermediate thickness skin graft: case report, review of anatomy and functional reconstruction of the palm]. / M. gracilis Lappenplastik mit plantarem Spalthauttransplantat - Fallbericht und Literaturübersicht zur speziellen Anatomie der Hohlhand und ihrer funktionellen Rekonstruktion.

BACKGROUND: Skin and soft-tissue architecture of the palm are unique. Coverage of extensive soft-tissue defects restoring the functional capacity of the palm remains a challenging task. Anatomic restoration with skin from another area is hardly possible. In manual labourers, reconstruction of mechanical soft-tissue stability is required in addition to sensation, range of motion and grip strength. Sensate fasciocutaneous flaps bear disadvantages of tissue mobility, shifting and bulkiness. Published criteria for defect-related flap selection are sparse. MATERIAL AND METHODS: Defect analysis (anatomy, units of tactile gnosis, individual parameters) provides information to weigh needs for sensation or tissue stability, influencing selection of most appropriate procedures. We distinguished 4 units: hypothenar (H), thenar (T) and central palm (Z). (Z) consists of a central palmar unit (c') and the distal palm (d'). Individual parameters (age, profession, dominant hand, psychosocial aspects) were also considered. Units (T) and (H), regions of secondary touch, demand protective sensation by applying sensate fasciocutaneous flaps. In labourers tactile gnosis in (Z) is of less, tissue stability of greater value. An extensive palmar defect (9×13 cm, affecting unit (Z), partially affecting units (T) and (H), of the dominant hand) with combined vessel, nerve, tendon injuries (male labourer, 21 years) was covered after defect analysis with a free gracilis muscle flap and a glabrous intermediate (0.5 mm) thickness skin graft from the instep region. RESULTS: 29 months postoperatively anatomic conditions of palmar soft tissue (Vancouver scar scale: 1), high mechanical soft-tissue stability including normal hand function were evident. Semmes Weinstein testing showed positive pressure sensation. Professional reintegration after 5 months was possible. CONCLUSION: Defect coverage of the palm must not consist of merely providing sensate vascularised tissue. The most appropriate procedure can be derived from careful defect analysis focusing on the affection of units of tactile gnosis to achieve near to anatomic reconstruction. In labourers, patient- and defect-related demands need close correlation with the value of the selected flaps regarding the sensation and mechanical stability to be expected. In selected cases (mechanical irritation, affection of unit (Z), younger age) by combining microvascular muscle flaps with plantar intermediate thickness skin grafts promising functional results with early professional reintegration can be achieved by reconstructing like with like.

[Report of the consensus workshop on microsurgical training at the 32nd annual meeting of the german-speaking group for microsurgery of the peripheral nerves and vessels in Basel 2010]. / Bericht zum Workshop und Consensusmeeting zur Mikrochirurgischen Ausbildung an der 32ten Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) 2010 in Basel.

After the foundation of a trinational task force to develop quality criteria for a training and educational system in microsurgery at the annual conference of the German-speaking group for microsurgery of the nerves and vessels (DAM) in Erlangen 2009, at the 2010 conference in Basel, a modular educational system was approved and criteria for a basic course were discussed. Before the next annual conference in 2011 these aspects should be clarified and defined in a spring meet-ing.

Regeneration potential and survival of transplanted undifferentiated adipose tissue-derived stem cells in peripheral nerve conduits.

Adipose tissue-derived stem cells (ADSCs) have shown potential for the treatment of nerve injuries. Most previous efforts have aimed at stimulating regeneration by using neural-differentiation protocols, but the potential of undifferentiated ADSCs to enhance axonal growth as well as their ability to transdifferentiate in situ have been poorly investigated. In this study, using a rat sciatic nerve model we show that ADSCs, transplanted in an artificial nerve conduit, stimulate axonal outgrowth from the proximal nerve stump and evoke greater Schwann cell (SC) proliferation/intrusion in the distal stump. To track the fate of the transplanted cells, we used green fluorescent protein (GFP)-labelling and polymerase chain reaction (PCR) for the detection of the sex determining region Y (SRY) gene in the donor male cells. Both methods indicated a lack of significant quantities of viable cells 14 days after transplantation. These results suggest that any regenerative effect of transplanted ADSCs is more likely to be mediated by an initial boost of released growth factors and/or by an indirect effect on endogenous SCs activity. Future studies need to address long-term cell survival in tissue-engineered nerve conduits to improve the neuroregenerative potential of ADSCs.

Silicone moulding for pressure sore debridement.

The radicality of wound debridement is an important feature of the surgical treatment of pressure sores. Several methods such as injection of methylene blue or hydrogen peroxide have been proposed to facilitate and optimise the surgical debridement technique, but none of them proved to be sufficient. We present an innovative modification of the pseudo-tumour technique consisting in the injection of fluid silicone. Vulcanization of the silicone leads to pressure-sore moulding, permitting a more radical and sterile excision. In a series of 10 paraplegic patients presenting with ischial pressure sores, silicone moulding was used to facilitate debridement. Radical en bloc debridement was achieved in all patients. After a minimal follow-up of 2 years, no complications and recurrences occurred. A three-dimensional (3D) analysis of the silicone prints objectified the pyramidal shape of ischial pressure sores. Our study showed that complete resection without capsular lesion can be easily achieved. Further, it allows the surgeon to analyse the shape and size of the resected defect, which might be helpful to select the appropriate defect coverage technique.

[From pay-for-effort to pay-for-performance--an analysis of the Swiss health care system with focus on the inpatient sector]. / Von der Kostenerstattung zur leistungs- und ergebnisorientierten Vergütung--Eine Analyse des schweizerischen Gesundheitswesens mit Fokus auf dem stationären Bereich.

INTRODUCTION: The Swiss health care system is facing the implementation of lump compensation in the form of diagnosis related groups from 2010 on. In addition there is an increasing discussion about the quality of health care in the media. We have analyzed current remuneration in Swiss health care and their steering effects on providers in order to deduct future developments in Swiss health care remuneration. METHODS: Based on the remuneration contracts and tariff regularities at the Basel University Hospital we conducted an internet and literature search. The identified Swiss remuneration systems were classified after remuneration scales and remuneration item using a typology of performance-related remuneration systems. The steering effects of the remuneration systems on the providers were deducted. RESULTS: Remuneration scales can be classified in <>, <> or <>. Remuneration items can be classified in <>, <> or <>. Remuneration systems can lead to increased or decreased services or to patient selection. In the Swiss health care system we find a trend away from traditional <> to <> remuneration systems. In that context diagnosis related groups are identified as an intermediate step in the development of remuneration systems. CONCLUSIONS: Future developments of medical remuneration in terms of a consideration of quality of medical performance and negotiated costs seem likely in Switzerland in the long term. Both, economics and quality should be considered adequately in a health care remuneration system.

A comparative study of two methods of surgical treatment for painful neuroma.

Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (SD 2.7) vs 3.8 (SD 2.4); p < 0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (SD 18) vs 14 (SD 12); p < 0.01). This was associated with an increased level of activity (p < 0.01) and improved function (p < 0.01). Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle.

Sonication of removed breast implants for improved detection of subclinical infection.

BACKGROUND: Capsular fibrosis is a severe complication after breast implantation with an uncertain etiology. Microbial colonization of the prosthesis is hypothesized as a possible reason for the low-grade infection and subsequent capsular fibrosis. Current diagnostic tests consist of intraoperative swabs and tissue biopsies. Sonication of removed implants may improve the diagnosis of implant infection by detachment of biofilms from the implant surface. METHODS: Breast implants removed from patients with Baker grades 3 and 4 capsular contracture were analyzed by sonication, and the resulting sonication fluid was quantitatively cultured. RESULTS: This study investigated 22 breast implants (6 implants with Baker 3 and 16 implants with Baker 4 capsular fibrosis) from 13 patients. The mean age of the patients was 49 years (range, 31-76 years). The mean implant indwelling time was 10.4 years (range, 3 months to 30 years). Of the 22 implants, 12 were used for breast reconstruction and 10 for aesthetic procedures. The implants were located subglandularly (n = 12), submuscularly (n = 6), and subcutaneously (n = 4). Coagulase-negative staphylococci, Propionibacterium acnes, or both were detected in the sonication fluid cultures of nine implants (41%), eight of which grew significant numbers of microorganisms (>100 colonies/ml of sonication fluid). CONCLUSIONS: Sonication detected bacteria in 41% of removed breast implants. The identified bacteria belonged to normal skin flora. Further investigation is needed to determine any causal relation between biofilms and capsular fibrosis.

[Effective acquisition of basic surgical techniques through blended learning]. / Effizienter Erwerb chirurgischer Basistechniken durch "blended learning"

BACKGROUND: Large student numbers and heterogeneous teaching pools hamper standardized teaching and impede objective assessment of surgical skills. This article presents the advantages of new teaching media in a "blended learning" concept for training surgical skills to medical students at the Basel University Medical School in Switzerland. MATERIAL AND METHODS: The surgical skills course (suture course) for medical students was redesigned according to a blended learning concept consisting of an introduction with a multimedia CD-ROM, a practical course, and a skills lab. The learning targets of the course were evaluated through an objective structured clinical examination (OSCE) at the end of each study year. The students' own course evaluations were compared with the OSCE results before and after introduction of the new blended learning. RESULTS: The students' evaluations with regard to teaching material, subjective practical achievement, prospective value for the practical year, and overall course evaluation were significantly higher than in the old course format. The proportion of passed OSCEs was 10% higher after the redesign of the course. CONCLUSION: Blended learning can improve cognition and performance as well as the training efficiency and duration required for mentoring. Thus human resources can be saved indirectly. Surgical procedures may be presented more clearly.