["True neurologic thoracic outlet syndrome" -- anatomical features and electrophysiological long-term follow-up of lateral thenar atrophy]. / "True Neurologic Thoracic Outlet Syndrome" -- Anatomie und elektrophysiologischer Langzeitverlauf bei lateraler Thenaratrophie.

Atrophies of the intrinsic muscles of the hand are considered to be a typical symptom of the "true neurologic" form of thoracic outlet syndrome (TOS). The classical form of this entity was described as early as 1970, consisting of a cervical rib or a prolonged transverse process of C7, complete with a fibrous band to the first thoracic rib, resulting in atrophy of the intrinsic muscles of the hand. All our TOS patients presenting with such atrophy displayed anatomical findings consistent with this definition. Based on this observation, the TOS classification currently in clinical use, which differentiates between "disputed" and "true neurologic" subgroups of the neurologic form, is reviewed. In all cases of "true neurologic TOS" with atrophy of the intrinsic muscles of the hand, the lateral thenar muscles are affected first. We present the electrophysiological long-term results of such thenar atrophies of seven patients with eight operated extremities after brachial plexus decompression. The amplitude of the neurographically measured potential over the opponens pollicis and the abductor pollicis brevis muscle, respectively, was defined as quantitative parameter for muscles atrophy. Neither distinct reinnervation nor progressive denervation was evident in any of the cases after a follow-up period, on average, of more than five years post surgery. These findings are in conflict with clinical observations reporting a major postoperative improvement of the motor deficits.

Care of burns victims in Europe.

There is no detailed information about the care of burns victims, in Europe, in the case of a fire disaster. Several countries have discussed how to treat burn victims, but only a little is known of their capacity to offer space to other countries in the event of a fire disaster outside the country in question. In Europe, most countries are dependent on England, France and Germany in such cases. Since "Los Alfaques", "Ramstein" and other examples of such disasters, we know how important it is to focus more on burn victims in Europe with respect to national and international cooperation.

Artificial skin, split-thickness autograft and cultured autologous keratinocytes combined to treat a severe burn injury of 93% of TBSA.

Despite refinements in burn shock resuscitation, improvements in surgical techniques, advances in intensive care medicine and the presence of very expert surgeons, the treatement of patients with severe burns exceeding 60% TBSA remains a big challenge. A major problem in the treatment of severe burn injuries is the lack of autologous skin. In selected cases cultured epidermal autograft (CEA) may be used. However, they are available only 2-3 weeks after biopsy, thus requiring a temporary wound closure after necrosectomy. A new option is Integra(TM), an artificial skin consisting of a bilayer membrane system. The three-dimensional porous matrix from bovine tendon collagen and a glycosaminoglycan layer is covered by a silicon sheet. The latter prevents fluid loss from the wounds and serves as a barrier against germ invasion. After adequate vascularisation of the dermal template, the silicon layer is removed and replaced by a thin autograft. We present a 26-year old male who sustained a 93% TBSA burn injury (60% full-thickness burn, 33% partial-thickness burn). He was treated with artificial skin, split-thickness autograft and CEA in combination. The clinical history and the follow-up of approx. 1 year are presented and the results discussed. We consider the survival of this patient being a result of the therapeutic progress of the recent decades.

Reconstruction of skin and soft-tissue defects in crush-injuries of the lower leg in children.

Severe crush injuries with open comminuted fractures of the lower extremity often result in extensive tissue loss. In such a situation early free microsurgical tissue transplantation offers most effective possibilities of treatment. Among others, two of the most eminent advantages of free microsurgical tissue transplantation are: 1. The possibility of tissue replacement which cannot be achieved by traditional procedures such as functional muscle transplantation or the replacement of extremely extensive tissue loss; moreover immediate or early bone coverage by well vascularized soft-tissue is most effective in the prevention of infection. 2. In many cases complete reconstruction can be achieved by a one-stage-procedure: this decreases the morbidity considerably. These advantages are demonstrated by clinical cases, where we used free microsurgical tissue transplantation.

[Compression syndrome of the arteria circumflexa humeri posterior in a volleyball player]. / Kompressionssyndrom der Arteria circumflexa humeri posterior bei einem Volleyballspieler.

The compression syndrome of the posterior circumflex humeral artery is an infrequent vascular compression syndrome and differential diagnosis of the thoracic outlet- and the hypothenar-hammer-syndrome. The diagnosis includes a complete interview and a transfemoral armarteriography. Our report is about an affected volleyball player, the possible pathomechanism that can lead to this syndrome and the current literature.

[Radioscapholunate fusion: long-term results]. / Erfahrungen mit der radiokarpalen Teilarthrodese nach Gordon und King im Langzeitverlauf.

INTRODUCTION: A review of the literature on long-term results (> or = 10 years) following radiocarpal arthrodesis as recommended by Gordon and King shows a paucity of data. Regarding the suitability of this procedure for treating radiocarpal arthrosis, especially in younger patients, we collected and evaluated long-term results of this surgical procedure. MATERIALS AND METHODS: Five patients (four men, one woman), who were treated between 1978 and 1984 at our institution with a partial radiocarpal arthrodesis as described by Gordon and King were reexamined clinically and radiologically by the same examiner in the year 1990 and again in the year 2000. RESULTS: All five patients were very satisfied with the result of the operation. Two patients were completely free of pain, whereas the other three patients reported minor pain in the radiocarpal joint when applying strain. The active range of motion in the operated joint remained constant over the years (mean 60 degrees dorsopalmar, 30 degrees ulnoradial, 162 degrees pro-/supination). Conventional radiological imaging showed proper osseous consolidation in the areas of partial arthrodesis, and slight degenerative intercarpal alterations in the distal radioulnar joint were observed. Complete postprocedural reintegration into the workforce, including manually demanding work, was achieved. CONCLUSIONS: The results of the follow-up examinations of these five patients indicate that satisfying long-term results can be achieved after radiocarpal arthrodesis provided that the procedure is correctly indicated and the operation is conducted in a technically proper manner. This method of radiocarpal arthrodesis is likely also appropriate for young manual labourers suffering from painful radiocarpal arthrosis after distal intraarticular fracture of the radius, scaphoid non-union, scapholunar dissociation and Kienbock's disease.

[Necrotising fasciitis caused by streptococcal toxic shock syndrome]. / Nekrotisierende Fasziitis - durch Streptokokken induziertes Toxisches Schock-Syndrom.

Between 1994 and 1997, sixteen patients suffering from necrotising soft tissue infection were treated at the burn centre of the Division of Reconstructive Surgery, University of Zurich. The case of a 47 year old man is presented: He suffered from a necrotising fasciitis caused by Streptococcal induced Toxic Shock Syndrome (STSS). This example emphasizes the necessity of early diagnosis, priority of surgical intervention, and the antibiotic strategy. Necrotising fasciitis is a serious disease, caused by a variety of bacteria, which shows a high mortality rate, and its frequency was increasing over the last years.

[Breast implant and desmoid tumor: is there an etiological relation?]. / Mammaimplantat und Desmoidtumoren: Besteht ein Zusammenhang?

Desmoid tumor of the breast is a rare lesion. So far only 8 cases in which the tumor origin was linked to a breast implant have been published. Whether there is an etiological relation to the silicone implant or if it is pure coincidence is not evident at this time. We present the case of a 24-year-old female with congenital asymmetric breasts who underwent breast augmentation in our division on the left side and 15 months later had a breast reduction on the other side. Nine years after the first operation we found a suspicious lesion on the side of the breast implant. The histological result of the excisional biopsy showed an aggressive fibromatosis "arising from" the capsule around the silicon implant. We discuss the possible association of breast implant and desmoid tumor of the breast and evaluate the diagnostic and therapeutic options for desmoid tumors of the breast.

[Reconstruction of posttraumatic bony defects of the lower extremity: callotaxis or free vascularized fibula graft?]. / Rekonstruktion posttraumatischer Knochendefekte an den unteren Extremitäten: Kallusdistraktion oder freie mikrovaskularisierte Knochentransplantation?

PURPOSE/BACKGROUND: Several methods have been established for the treatment of bony defects of the lower extremity. The purpose of this paper is to evaluate the use of a free vascularized fibula graft for these defects in comparison to callotaxis and segmental transport. METHOD AND CLINICAL MATERIAL: Retrospective analysis of data from 32 patients treated between 1981 and 1999 at the University Hospital in Zurich, Switzerland with bony defects of the lower extremity. RESULTS: The reconstruction of the bony defect was successful in 80 % with fibula graft, in 94 % with callotaxis and in 83 % with segmental transport. In the group with the fibula transplantation 2.6 re-interventions due to complications had to be performed, in the callotaxis group there were 3.6 and in the segmental transport group 5.2 surgical re-interventions. The time between primary intervention and full weight bearing was 16 months in the fibula transplantation group, 7.6 months in the callotaxis group and 10.7 months in the segmental transport group. CONCLUSION: The results show that these three options can be used for different indications. Reconstruction can be planned according to the following rules: Segmental bony defects of the entire circumference of up to 5 cm are best treated by initial shortening followed by callus distraction. Bony defects from 5 to 12 cm are best treated by segmental transport while maintaining limb length. Defects > 12 cm are best treated by reconstruction with a vascularized free fibula graft.

Factor V Leiden mutation and thrombotic occlusion of microsurgical anastomosis after free TRAM flap.

The transverse rectus abdominis muscle flap is widely used in free microvascular tissue transfer for breast reconstruction following mastectomy. Flap survival may be compromised by failure at the microsurgical anastomosis due to both venous and arterial thrombosis. It is unclear, whether hereditary thrombophilia represents a risk factor for early thrombotic occlusion following free flap procedures. We present a case of a patient with previously diagnosed activated protein C resistance caused by heterozygous factor V (position 1691 G-->A) Leiden mutation in whom a free transverse rectus abdominis muscle flap was performed. The postoperative course was complicated by repeated thrombosis of both the venous and arterial part of the anastomosis. Immediate thrombectomy and repeated arteriography allowed for partial flap salvage. More data are needed to analyze the impact of hereditary thrombophilia on microvascular anastomosis failure.

[Thermal trauma sustained during epileptic seizures--analysis of 33 cases]. / Analyse von 33 thermischen Verletzungen infolge Epilepsie--Unfallhergang, Folgen und Möglichkeiten der Prävention.

BACKGROUND AND AIMS: Burn injuries are a serious threat to individuals with altered consciousness during epilepsy. The objective of this study detailing 33 individuals who sustained scalds or burn injuries during an epileptic seizure, was to clarify typical injury mechanisms, extent, therapy and sequelae of these injuries and thus identify potential preventive measures to protect this special population from thermal trauma. RESULTS: Overall, 16 women and 17 men with a mean age of 39.6 (range: 21 - 76) years were included in this retrospective review. The burned body area averaged 16 % (maximum: 51 %), 30 of the 33 patients (91 %) required burn wound excision and skin grafting. The mean ABSI score was 5.5 (range: 3 to 11) points. Thermal trauma mostly occurred as hot water scalds (n = 19) during showering or bathing in a tub (n = 15), followed by falls during cooking or into open fire. None of our patients was informed about the risk of experiencing severe thermal injuries during epileptic seizures. The length of intensive care averaged 33 days (maximum: 79 days), all patients survived. The estimated treatment costs were at least 50,000 Euros per patient. DISCUSSION: In conclusion, epileptic seizures can cause severe and deep thermal trauma. Our data shows that most of these injuries happen at home and may be easily prevented by simple safety devices, such as water thermo-regulators or the avoidance of high-risk situations, it seems advisable to inform patients with epilepsy and their families and care-givers of this specific danger.

Initial experiences using non-cultured autologous keratinocyte suspension for burn wound closure.

Early complete wound closure and thus reduction of excessive scar formation still represent a major clinical challenge in severely burned patients. A novel concept to cover large burn wounds consists of the application of non-cultured epithelial cell suspension within the first days. Herein, we report our experiences with three patients treated with CellSpray XP. According to the amount of cell suspension required, a skin biopsy was harvested and then processed in an external laboratory. Two days later the suspension containing autologous non-cultured keratinocytes was applied using an aerosol system. All wounds healed rapidly and virtually no signs of hypertrophic scarring were observed 6 months later.

Lyell syndrome revisited: analysis of 18 cases of severe bullous skin disease in a burns unit.

Over the last few years, understanding of the pathophysiology of toxic epidermal necrolysis (TEN), or Lyell's disease, has substantially increased. However, differentiation of severe bullous skin disease remains a challenge for the clinician, and one that is often complicated by late patient referral. We performed a retrospective analysis of all patients with severe bullous skin disease, admitted between 1997 and 2002 to the Burn Centre, which is an integrated part of the Division for Plastic, Hand- and Reconstructive Surgery at the University Hospital of Zurich, Switzerland. We present an overview of our strategies and of the diagnostic and therapeutic difficulties encountered. The final diagnoses of the 18 patients referred to the unit were as follows: eight cases of TEN, one case of staphylococcal scalded-skin syndrome (SSSS), two cases of generalised drug eruption, one case of acute generalised exanthematic pustulosis and one case of febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta (PLEVA). In two cases, the diagnosis remained unclear. In three cases, paraneoplastic origins were suspected but not demonstrated. The overall mortality rate was 33% (six of 18 patients). Remarkably, all patients with histologically confirmed TEN survived. Six of these patients were successfully treated with intravenous immunoglobulins (IVIG). The most common single causative drug inducing TEN (four cases out of eight) was Phenytoin. Establishing an accurate diagnosis-based on a skin biopsy, harvested at an early stage-is more important than ever, because more specific and effective therapeutic modalities are available. As these potentially life-threatening bullous skin disorders are rare, we recommend, that care be provided by an experienced interdisciplinary team, comprising a dermatologist, or dermatopathologist, an intensive care specialist and a plastic surgeon.

[Therapeutic possibilities in hand burns]. / Therapie-Möglichkeiten bei Verbrennungen der Hand.

Four methods of treating the burned hand are possible: conservative treatment of superficial dermal burns, tangential excision and immediate grafting of deep dermal and barely full thickness burns, granulation method with late grafting of deep dermal to deep full thickness burns, flap procedures of full thickness burns. The tangential excision and grafting of deep dermal and barely third degree burns has improved the well being of the patient by good functional and cosmetic results, less hospitalization time (10-14 days) and less pain. The procedure is described. Tangential excision is contraindicated in the very deep burn. In these the growth of granulations or in certain cases the application of skinflaps will produce better results. Important as to the result is the aftercare consisting of compression gloves and physiotherapy. Even with progress the deep burn remains a devastating injury to the delicately operating hand. Nevertheless the appropriate therapy can achieve good results.

Tissue expanders in reconstruction of burn sequelae.

In 20 patients with burn scars and 1 patient with a fresh burn, 33 tissue expanders were implanted. In 16 patients, the expansion fulfilled the goal set with the help of 27 expanders. The results are very satisfactory, but the effort of treatment and the trouble are substantial. Thirteen patients encountered no complications. In terms of expanders, there were 6 major and 11 minor complications. They were infection (three), wound dehiscence (two), insufficient expansion with hematoma (one), leakage (six), superficial skin damage (three), and intercurrent hematoma formation (two). There was no flap necrosis, and thus, apart from superfluous surgery, no real damage. Retrospectively, the major complications could have been avoided by more careful observance of indications. Unfortunately, this seems to be a process that every surgeon must learn by experience and not by theory alone. Here, infection was managed by removal of the expanders. Hematomas should be evacuated early (we drained most expanders), and incidences of leakage can be diminished by using larger valves. Small incisions in healthy tissue for expander insertion may lead to faster onset of expansion, thus, shortening the procedure. Late widening of scars was found only once, perhaps due to a rather long duration of expansion, averaging 13 weeks.

[Prognostic factors in craniocerebral trauma without primary surgically correctable space occupying lesion]. / Prognostische Faktoren beim Schädelhirntrauma ohne primär chirurgisch angehbare Raumforderung.

By means of a retrospective study involving 154 patients with diffuse brain injury, we could show, that simple factors, like coexisting injuries, pupil abnormalities and the Glasgow coma scale, allow us to assess the prognosis of patients outcome a short time after trauma. This prognosis is further modified by cerebral perfusion pressure and secondary pupil abnormalities. The prognostic value of an EEG and a SEP is the same for both methods and was found to be correct in about 2/3 of all cases.

[Lichen ruber ulcerosus plantae]. / Lichen ruber ulcerosus plantae.

A 66-year-old patient suffering from painful ulcerative lichen planus of the feet is presented. Various treatments (topical and oral corticosteroids, irradiation and a 6-month therapy with acitretin) were tried without success. Skin grafting in the affected areas was helpful and resulted with an acceptable and painless state.

Malignant fibrous histiocytoma and atypical fibroxanthoma in renal transplant recipients.

BACKGROUND: Allograft recipients are at increased risk for skin cancer. The incidence of cutaneous squamous cell carcinoma is 50-250 times higher than in the age-matched control population, and basal cell carcinoma is about 10 times more frequent. The incidence of Kaposi's sarcoma is increased 400 to 500 times over that in a control population of the same ethnic origin. However, the incidence of other types of cutaneous sarcoma in organ allograft recipients is largely unknown. CLINICAL OBSERVATION: Within a 2-year-period, we observed 2 patients with cutaneous malignant fibrous histiocytoma and 1 patient with atypical fibroxanthoma among a cohort of 642 renal transplant recipients. For comparison, the incidence for dermatofibrosarcoma protuberans which is the commonest type of cutaneous sarcoma, is 0.45/100,000 persons/year in the non-immunocompromised population. Our observation represents an incidence of 156/100,000/ year (95% confidence interval Cl 28-489/100,000/year) for cutaneous malignant fibrous histiocytoma and of 78/100,000/year (95% CI 4-368/ 100,000/year) for atypical fibroxanthoma. CONCLUSION: To our knowledge, this is the first report on an elevated incidence of cutaneous malignant fibrous histiocytoma and of atypical fibroxanthoma in renal transplant recipients. Future cohort studies on malignancies in organ allograft recipients should aim at defining this risk more exactly.

[Injuries of the lower extremity with vascular lesions of the popliteal area. Management errors]. / Verletzungen der unteren Extremität mit Gefässläsionen im Popliteabereich. Managementfehler.

Lower extreemity injury complicated by limb-threatening vascular injuries of the popliteal artery present an infrequent but difficult management problem. In a retrospective study 37 consecutive patients with severely injured lower extremities after blunt trauma, all complicated by popliteal vascular injury, were evaluated. In 10 patients we found severe management errors: In 7 patients a delay in diagnosis of the vascular injury, in 3 patients with extensive bone and soft-tissue damage an inadequate stabilisation of the fracture. The optimal management of complex injury with associated vascular injuries requires a high index of suspicion and a treatment of all components of such an injury. The initial goals are the accurate diagnosis or exclusion of arterial injury, surgical debridement, adequate bony stabilization with minimal additional bone and soft-tissue trauma, revascularisation by interposition of a vein graft after resection of the damaged segment, immediate fascial decompression and early soft-tissue reconstruction.