The perfusion index as a noninvasive method for monitoring revascularized and replanted digits.

BACKGROUND: Monitoring replanted digits remains a challenging task in microsurgical units. Previous studies have indicated the perfusion index (PI), a parameter directly proportional to the blood flow, might be a useful tool. OBJECTIVE: The PI is evaluated as a monitoring tool in patients with replanted digits. METHODS: This prospective, non-interventional study includes 31 patients with revascularized or replanted digits. After successful revascularization or replantation, the PI and peripheral oxygen saturation of the affected finger and its contralateral equivalent were measured simultaneously. The values were detected by the device Radical-97® Pulse CO-Oximeter® (Masimo Corporation, 52 Discovery, Irvine, CA 92618, USA). RESULTS: The median PI of affected fingers was 3.5±0.56 for revascularized and 2.2±0.8 for replanted fingers. The difference between the PI values of replanted digits and the healthy contralateral side was highly significant (p < 0.0001). The area under the curve in the receiver operating characteristics was 0.92 for a PI difference > 80.49% and predicted a loss of replant with a specificity of 100% and a sensitivity of 75%. CONCLUSION: The assessment of the PI in patients with reperfusion of a vascular compromised digit is a useful tool to continuously monitor peripheral perfusion. The dynamic behavior of the PI is essential to detect perfusion disturbance.

Monitoring free flaps and replanted digits via perfusion index - A proof of concept study.

BACKGROUND: Early detection and treatment of vascular complications in replanted digits is essential for the survival. The perfusion index (PI) represents a marker of peripheral perfusion as it shows the ratio of pulsatile to non-pulsatile blood flow. OBJECTIVE: To evaluate the feasibility and applicability of the PI as a monitoring tool for free flaps and replanted digits by measuring the inter- and intraindividual changes in PI. METHODS: Five patients were postoperatively monitored according to intern standards by hourly clinical evaluation. Additionally, a pulse oximeter with SET-technology® (Masimo Radial 7, Masimo Corporation, Irvine, USA) was added with a LNCS® Red TFA-1 SpO2 sensor (Masimo Corporation, Irvine, USA) and respectively a LNCS® Neo-3 neonatal finger clip to evaluate the perfusion via PI and SpO2. RESULTS: All patients showed sufficient perfusion in clinical controls. There was no detectable vascular complication during follow-up. Mean perfusion index was 0.93 with a median of 0.44. The patients showed a mean SpO2 of 90.59%with a median of 89.21%. CONCLUSION: Our results show a great intra- and interindividual range of PI and SpO2. SpO2 provided an even greater range than PI. Trends in intraindividual PI changes may be a promising monitoring tool for free flaps and replanted digits.

Elevated phosphatidylinositol 3,4,5-trisphosphate in glia triggers cell-autonomous membrane wrapping and myelination.

In the developing nervous system, constitutive activation of the AKT/mTOR (mammalian target of rapamycin) pathway in myelinating glial cells is associated with hypermyelination of the brain, but is reportedly insufficient to drive myelination by Schwann cells. We have hypothesized that it requires additional mechanisms downstream of NRG1/ErbB signaling to trigger myelination in the peripheral nervous system. Here, we demonstrate that elevated levels of phosphatidylinositol 3,4,5-trisphosphate (PIP3) have developmental effects on both oligodendrocytes and Schwann cells. By generating conditional mouse mutants, we found that Pten-deficient Schwann cells are enhanced in number and can sort and myelinate axons with calibers well below 1 microm. Unexpectedly, mutant glial cells also spirally enwrap C-fiber axons within Remak bundles and even collagen fibrils, which lack any membrane surface. Importantly, PIP3-dependent hypermyelination of central axons, which is observed when targeting Pten in oligodendrocytes, can also be induced after tamoxifen-mediated Cre recombination in adult mice. We conclude that it requires distinct PIP3 effector mechanisms to trigger axonal wrapping. That myelin synthesis is not restricted to early development but can occur later in life is relevant to developmental disorders and myelin disease.

[Interdisciplinarity in German academic Plastic Surgery - irrelevant or forward-looking?] / Interdisziplinarität in der akademischen Plastischen Chirurgie ­ belanglos oder zukunftsorientiert?

BACKGROUND: Plastic and Reconstructive surgery is able to treat patients from head to toe, whereby it can preserve, reform or reconstruct anatomically functional or aesthetic unions. This kind of expertise is appreciated by other medical specialties and is part of high performance medicine in most university clinics. However the standing of academic Plastic Surgery is particularly difficult. In this study we highlight the academic and clinical interdisciplinarity of German academic Plastic Surgery. METHODS: By creating a questionnaire we evaluated educational assignments of academic Plastic Surgery and its interdisciplinary surgical performance at German university hospitals. RESULTS: In 12 of 36 university hospitals there is no kind of Plastic Surgery established. There are 11 university clinics, 5 departments, 4 sections and 4 consultants with Plastic Surgery expertise. 13 university centers took part of investigation. All of them are integrated in the educational curriculum with high discrepancy (2-12 hours per semester). Discrepancy seems not to be affect by clinic independence or team size. 10 of 13 university center wants to augment educational efforts. In 2015 participating 13 university hospitals treated 1476 interdisciplinary patients. In 1165 cases there was no invoicing of services. CONCLUSION: Plastic Surgery is an integral part of high performance medicine, e. g. in traumatological, oncologic or infectious cases. The complex reconstructive procedures are completing successful therapy of other specialties. Missing of invoice these services limits the development of academic Plastic Surgery.In 12 of 36 university hospitals exists no kind of Plastic Surgery. Moreover Plastic Surgery is no integral part in university education order defined by the medical approbation order (ÄApprO). However integration of Plastic Surgery with its interdisciplinary responsibility in the common university curriculum will be a forward looking appreciation of Plastic Surgery.

Arthroscopic Synovectomy Combined with Autologous Fat Grafting in Early Stages of CMC Osteoarthritis of the Thumb.

Background Minimal invasive treatments such as arthroscopic techniques may be adequate to restore the anatomy and functional integrity of the thumb CMC (carpometacarpal) joint. In this paper, we reported the interposition of autologous fat tissue in combination with arthroscopic synovectomy/debridement for early stage of the thumb CMC joint osteoarthritis. Patients and Methods Twelve patients with a mean age of 46 years with early radiological stages of thumb CMC joint osteoarthritis were included. Evaluation of outcome was measured prior and 3, 12, and 24 months after surgery including, Visual Analog Scale (VAS), QuickDASH, grip and pinch strength, range of motion (ROM), and patient satisfaction. Results Pain at rest (or with load) was reduced from preoperative 4,7 (8,7) to 2 (5,9) at 3 to 6 months; 1,4 (4,3) at 12 months; and 0,75 (2,7) at 2 years after the surgery. Initial preoperative QuickDASH value of 52 points reduced to 33 (17-65) at 6 months, 23 (2-70) at 12 months, and 20 (11-29) at 24 months after the surgery. Grip strength and thumb pinch with respect to the contralateral untreated thumb was reduced in the first 12 months but recovered subsequently. ROM was equal to the contralateral thumb. Three patients suffered from tendinitis and required surgical treatment. One patient indicated prolonged pain symptoms. No infections were noted and no donor-site morbidity or side effects were detected. Conclusion Arthroscopic synovectomy combined with autologous fat graft is a reliable surgical option for early thumb CMC joint osteoarthritis and that effect continues for more than 24 months.

Surgical and prosthetic correction of malposed maxillary implants: a case report.

This case report presents a patient who underwent a major correction of malpositioned implants. Two implants were previously placed in a 30-year-old woman to replace the maxillary right central and lateral incisors without any attempt to reconstruct the alveolar and soft tissue defects. This resulted in a significant esthetic problem. The position of the implants was successfully corrected via the mobilization of a bone block in which the implants were maintained. The bone block was then fixed in a predetermined optimal position. After fixing the bone block, gaps were filled with Bio-Oss and covered with a membrane. Nine months after bone healing, a periodontal technique was used to improve soft tissue esthetics. The final result was achieved with the combination of bone surgery, soft tissue management, and progressive adaptation of implant-supported crown restorations.