New reconstruction for bone integration of non-vascularized autogenous bone graft with better bony union and revascularisation.

INTRODUCTION: Phalangeal defects are often seen after tumor resection, infections, and in complex open hand fractures. In many cases, reconstruction is difficult and amputation is performed to avoid prolonged rehabilitation that is often associated with a poor outcome. In these cases, the maintenance of length and function presents a reconstructive challenge. METHODS: We reviewed 11 patients who underwent extensive phalangeal reconstruction with non-vascularized bone graft from the iliac crest using a key-in-slot-joint technique to provide acceptable function and bony union. RESULTS: In each case, non-vascularized bone graft with a length of 1.4-6.0 cm was used to reconstruct the phalanx. Follow-up ranged from 6 weeks to 5 months, and in all cases, there was bony union after 6 weeks. We evaluated range of motion, function, and as well pain and grip strength of the fingers. CONCLUSIONS: This case series suggests that a key-in-slot technique allows non-vascularized bone graft to be used in complex large phalangeal bone defects. Due to better bone contact, a sufficient perfusion and revascularisation of the non-vascularized bone graft can be achieved for a quicker and stable bony union. This method appears to be an alternative to amputation in selected cases with a satisfactory soft-tissue envelope.

Evidence based postoperative treatment of distal radius fractures following internal locking plate fixation.

Originally, the treatment method of choice for distal radial fractures (DRF) has been a non-operative approach with six to eight weeks of plaster casting. The introduction of volar locking plate systems at the beginning of the 21 st century has pushed trends towards open reduction and internal fixation (ORIF). While the introduction of fixed angle locking plates together with the increasing knowledge on wrist function and related variable outcomes has led to consensus that operative fixation in instable DRF is the treatment method of choice, there is no agreement on a postoperative care of these injuries. The authors will discuss the available evidence for current concepts of postoperative treatment of DRFs following fixed angle fixation under socioeconomical, biomechanical and burden of disease aspects. Further, relevant randomized controlled trials are evaluated with regard to applied postoperative treatment regimes and related risks for complications.

Postoperative monitoring of local and free flaps with contrast-enhanced ultrasound (CEUS)--analysis of 112 patients.

PURPOSE: Tissue defects are a common problem in trauma surgery and oncology. Flap transplantation is often the only therapy to cover such defects. Several monitoring systems are currently available but none has made it to the clinical routine. The aim of this study was to assess perfusion disturbances of local and free flaps using contrast-enhanced ultrasound (CEUS). MATERIALS AND METHODS: 112 patients were examined during the first 72 hours after operation. CEUS was performed by one experienced examiner with a linear transducer (6 - 9 MHz, LOGIQE9/GE) after a bolus injection of 2.4 ml sulfohexa-fluoride microbubbles (SonoVue®, Bracco, Italy). Retrospective vascular perfusion was quantified by evaluating the stored DICOM cine loops using the perfusion software QONTRAST® (Bracco, Italy). Over a total penetration depth of 3 cm, every centimeter was analyzed separately. 27 complications were observed. Complete flap loss was only seen in 4 cases, while 23 flaps had to undergo minor revision and survived. RESULTS: Regarding the complete flap size, quantitative analysis showed significantly higher perfusion values in patients without complications compared to patients with complications: PEAK 16.5 vs. 10.0 (p = 0.001), TTP 32.6 vs. 22.2 (p = 0.001), RBV: 738.8 vs. 246.2 (p < 0.001), RBF 17.5 vs. 10.1 (p < 0.001) and MTT 43.1 vs. 29.5 (p = 0.001). Analysis of the correlation of the different flap types, age, sex and etiology of the tissue defect to the complication rate showed no statistical correlation. CONCLUSION: CEUS was capable of detecting vascular disturbances after flap transplantation. TTP, RBV and MTT seem to be the most accurately parameters and are not susceptible to malfunction during measurement.

Quantitative assessment of bone microvascularization after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS).

BACKGROUND: Extensive wound defects frequently have to be covered by free flap transplantation. A monitoring device for measuring capillary level perfusion of bone is currently not available. OBJECTIVE: The aim of the study was to detect complications after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS). Additionally quantitative analysis was performed by special perfusion software (QONTRAST®; Bracco, Italy). METHODS: 22 patients were examined after osteocutaneous flap transplantation during the first 72 h after operation. CEUS was performed with a linear transducer (6-9 MHz, LOGIQ E9/GE) after bolus injections of 2.4 ml ultrasound contrast agent (SonoVue®; Bracco, Italy). The osseous perfusion and soft tissue perfusion were analyzed separately and quantitative perfusion analysis was performed. Five patients had to undergo reoperation due to compromised flap microvascularization. RESULTS: In all 5 complications reduced osseous and soft tissue perfusion was seen using CEUS. Additionally using the perfusion parameters TTP (time to PEAK), RBV (regional blood volume), RBF (regional blood flow) und MTT (mean transit time), significantly lower soft tissue and osseous perfusion was detected. CONCLUSION: CEUS seems to be capable of detecting vascular disturbances and of assessing microvascularization of the osseous component after osteocutaneous flap transplantation.

[Timely registration of fatalities in the state of Hessen. Experiences during the influenza A/H1N1 pandemic]. / Zeitnahe Erfassung und Übermittlung von Todesfällen in Hessen. Eine erste Einschätzung zur Influenza-A/H1N1v-Pandemie.

Timely registration of fatalities is important for the assessment of course, extent, risk of age groups, and magnitude or severity of health threats. Nevertheless, timely data of casualties are not available on the state or national level. The current paper describes the implementation and structure of a surveillance system for the timely registration of casualties in the state of Hesse (Germany) and the experience obtained during the pandemic 2009/10. The delay of the case-based registration appears tolerable and after 2 weeks more than 80% of all deaths for a given week are registered. In 2008, the forwarding of the electronically registered data from the registry offices (95% of all cases) to the state statistical office (HSL) had been accelerated from a monthly to a weekly base. The HSL provides--on a weekly basis--this case-based data in accordance with data protection rules to the Hesse State Health Office (HLPUG, "Hessischer Landesprüfungs- und Untersuchungsamt im Gesundheitswesen"). During the pandemic, the data allowed assessment of the excess mortality with a delay of 2 weeks. No significant excess mortality was apparent; however, a slight increase was observed in the age groups 15-34, 35-49, and 50-59. Correlation of time with the severity of the A/H1N1v epidemic was not very strong. Hence, the data did not indicate an excess significantly exceeding the number of death cases registered with the mandatory reporting system of 21 cases for Hesse.

Effect of HBO therapy on adipose-derived stem cells, fibroblasts and co-cultures: In vitro study of oxidative stress, angiogenic potential and production of pro-inflammatory growth factors in co-cultures1.

BACKGROUND: A key moderator of wound healing is oxygen. Wound healing is a dynamic and carefully orchestrated process involving blood cells, cytokines, parenchymal cells (i.e. fibroblasts and mesenchymal stem cells) and extracellular matrix reorganization. Human adipose derived stem cells as well as human fibroblasts produce soluble factors, exhibit diverse effects on inflammation and anti inflammation response and are involved in wound healing processes.Hyperbaric oxygen therapy is an effective adjunct treatment for ischemic disorders such as chronic infection or chronic wounds. In vitro effects of hyperbaric oxygen therapy on human cells were presented in many studies except for those on mono- and co-cultures of human adipose derived stem cells and fibroblasts. OBJECTIVE: The aim of this study was to investigate the effects of hyperbaric oxygen therapy on mono- and co-cultures of human adipose derived stem cells and fibroblasts. METHODS: Mono- and co-cultures from human adipose derived stem cells and fibroblasts were established. These cultures were exposed to hyperbaric oxygen therapy every 24 h for five consecutive days. Measuring experiments were performed on the first, third and fifth day. Therapy effects on the expression of VEGF, IL 6 and reactive oxygen species were investigated. RESULTS: After exposure to hyperbaric oxygen, cell culturess showed a significant increase in the expression of VEGF after 3 and 5 days. All cultures showed significantly reduced formation of reactive oxygen species throughout the experiments. The expression of IL-6 decreased during the experiment in mono-cultures of human adipose derived stem cells and co-cultures. In contrast, mono-cultures of human skin fibroblasts showed an overall significantly increased expression of IL-6. CONCLUSIONS: Hyperbaric oxygen therapy leads to immunmodulatory and proangiogenetic effects in a wound-like enviroment of adipose derived stem cells and fibroblasts.

Author Correction: Rapid and Precise Semi-Automatic Axon Quantification in Human Peripheral Nerves.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Rapid and Precise Semi-Automatic Axon Quantification in Human Peripheral Nerves.

We developed a time-efficient semi-automated axon quantification method using freeware in human cranial nerve sections stained with paraphenylenediamine (PPD). It was used to analyze a total of 1238 facial and masseteric nerve biopsies. The technique was validated by comparing manual and semi-automated quantification of 129 (10.4%) randomly selected biopsies. The software-based method demonstrated a sensitivity of 94% and a specificity of 87%. Semi-automatic axon counting was significantly faster (p < 0.001) than manual counting. It took 1 hour and 47 minutes for all 129 biopsies (averaging 50 sec per biopsy, 0.04 seconds per axon). The counting process is automatic and does not need to be supervised. Manual counting took 21 hours and 6 minutes in total (average 9 minutes and 49 seconds per biopsy, 0.52 seconds per axon). Our method showed a linear correlation to the manual counts (R = 0.944 Spearman rho). Attempts have been made by several research groups to automate axonal load quantification. These methods often require specific hard- and software and are therefore only accessible to a few specialized laboratories. Our semi-automated axon quantification is precise, reliable and time-sparing using publicly available software and should be useful for an effective axon quantification in various human peripheral nerves.

What will the next influenza season bring about: seasonal influenza or the new A(H1N1)v? An analysis of German influenza surveillance data.

For the next influenza season (winter 2009-10) the relative contributions to virus circulation and influenza-associated morbidity of the seasonal influenza viruses A(H3N2), A(H1N1) and B, and the new influenza A(H1N1)v are still unknown. We estimated the chances of seasonal influenza to circulate during the upcoming season using data of the German influenza sentinel scheme from 1992 to 2009. We calculated type and subtype-specific indices for past exposure and the corresponding morbidity indices for each season. For the upcoming season 2009-10 our model suggests that it is unlikely that influenza A(H3N2) will circulate with more than a low intensity, seasonal A(H1N1) with more than a low to moderate intensity, and influenza B with more than a low to median intensity. The probability of a competitive circulation of seasonal influenza A with the new A(H1N1)v is low, increasing the chance for the latter to dominate the next influenza season in Germany.

Transcutaneous pO2 measurement during tourniquet-induced venous occlusion using dynamic phosphorescence imaging.

A sufficient oxygen supply in skin grafts requires a functioning microcirculation. Venous occlusion impairs the microcirculation and is therefore a major threat of healing. Luminescence life time imaging (LLI) enables the non-invasive and two-dimensional assessment of the transcutaneous oxygen partial pressure (p(tc)O2). In the current trial this new device was applied for monitoring of venous congestion. A tourniquet on the upper arm was inflated up to 40-50 mmHg and released after 10 min in eight healthy volunteers. The p(tc)O2 was measured at the lower arm every minute prior to, during and up to 10 min after cuff occlusion (40 degrees C applied skin temperature) using LLI of platinum(II)-octaethyl-porphyrin immobilized in a polystyrene matrix. For validation the polarographic Clark electrode technique was applied in close proximity and measurement was performed simultaneously. p(tc)O2 measurements prior to (Clark: 50.68+/-5.69 mmHg vs. LLI: 50.89+/-4.96 mmHg) and at the end of the venous congestion (Clark: 16.41+/-4.54 mmHg vs. LLI: 23.82+/-3.23 mmHg) did not differ significantly using the Clark electrode vs. LLI. At the initial congestion respectively reperfusion phase the Clark electrode measured faster decreases respectively increase of p(tc)O2 due to oxygen consumption of this method. This experimental trial demonstrates the applicability of LLI to quantify the p(tc)O2 under changing venous blood flow. The use of planar transparent sensors allows the non-invasive generation of two-dimensional maps of surface pO2 what makes this method particular suitable for monitoring of skin grafts.

Contrast harmonic ultrasound and indocyanine-green fluorescence video angiography for evaluation of dermal and subdermal microcirculation in free parascapular flaps.

PURPOSE: Contrast harmonic ultrasound (CHI) with a linear transducer is a new diagnostic approach that allows dynamic and quantitative flow detection of tissue perfusion in microsurgery. The aim of the study was the evaluation of perfusion of the dermal and subdermal layers of microvascular tissue transplants with CHI in comparison to ICG-fluorescence angiography. MATERIAL AND METHOD: In a prospective clinical study Indocyanine-Green Fluorescence Video Angiography and Contrast Enhanced High Resolution Ultrasound (5-10 MHz; linear transducer; Logiq 9; GE) were used for evaluation of the microcirculation in 10 transplanted free parascapular flaps. Two regions were analysed, the centre of the flap and the region of the anastomosis. The perfusion patterns of both methods were compared. RESULTS: The perfusion indexes measured by ICG-fluorescence angiography correlated very precisely in all patients with the quantitative perfusion curves of contrast-enhanced US with CHI. Two flaps with slow filling and low dye intensity showed low contrast enhancement in CHI with modified perfusion curves with slow increase. In two cases a reduced perfusion and filling were found. There were no statistical differences between the two diagnostic methods (p>0.01). CONCLUSION: CHI improves US detections of dermal and subdermal microcirculation in comparison to ICG fluorescence angiography. CHI is a new diagnostic method for postoperative monitoring of free flaps.

Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction - a randomized controlled trial.

BACKGROUND: Perioperatively, patients' hemodynamics are modulated predominantly by intravenous fluid administration and vasoactive pharmacological support. Vasopressor agents are suspected to be detrimental on free flap survival by the cause of vasoconstriction of the pedicle with consecutive reduced overall flap perfusion and by aggravation of flap dissection. OBJECTIVE: A novel, standardized fluid restrictive perioperative hemodynamic management was assessed for its feasibility in clinical practice in free flap patients undergoing breast reconstruction. METHODS: Patients were randomized to two perioperative regimens with different fluid and vasopressor limits. The primary endpoint regarded flap survival. Secondary endpoints included surgery times, time of patient ambulation and length of hospital stay. RESULTS: There was one total flap failure with liberal fluid administration (LFA). No total or partial flap failure was noted in the fluid restrictive regimen with norepinephrine administration up to 0.04µg/kg/min (FRV). No delay regarding operation time (p = 0.217), patient mobilization (p = 0.550) or hospital discharge (p = 0.662) was registered in the FRV study subpopulation compared to LFA. CONCLUSIONS: The results of this prospective interventional trial could not detect any negative impact of vasopressors, neither for the primary endpoint of flap survival nor for the overall patient outcome. The fear of vasopressor associated flap complications has led to a traditional liberal fluid administration, which failed to demonstrate any benefits when compared to a fluid restrictive vasopressor strategy.

Perfusion maintains functional potential in denervated mimic muscles in early persistent facial paralysis which requires early microsurgical treatment - the histoanatomic basis of the extratemporal facial nerve trunk assessing axonal load in the context of possible nerve transfers.

BACKGROUND AND OBJECTIVES: Early persistent facial paralysis is characterized by intact muscles of facial expression through maintained perfusion but lacking nerve supply. In facial reanimation procedures aiming at restoration of facial tone and dynamics, neurotization through a donor nerve is performed. Critical for reanimating target muscles is axonal capacity of both donor and recipient nerves. In cases of complete paralysis, the proximal stump of the extratemporal facial nerve trunk may be selected as a recipient site for coaptation. To further clarify the histological basis of this facial reanimation procedure we conducted a human cadaver study examining macro and micro anatomical features of the facial nerve trunk including its axonal capacity in human cadavers. Axonal loads, morphology and morbidity of different donor nerves are discussed reviewing literature in context of nerve transfers. METHODS: From 6/2015 to 9/2016 in a group of 53 fresh frozen cadavers a total of 106 facial halves were dissected. Biopsies of the extratemporal facial nerve trunk (FN) were obtained at 1 cm distal to the stylomastoid foramen. After histological processing and digitalization of 99 specimens available, 97 were selected eligible for fascicle counts and 87 fulfilled quality criteria for a semi-automated computer-based axon quantification software using ImageJ/Fiji. RESULTS: An average of 3.82 fascicles (range, 1 to 9) were noted (n = 97). 6684±1884 axons (range, 2655- 12457) were counted for the entire group (n = 87). Right facial halves showed 6364±1904 axons (n = 43). Left facial halves demonstrated 6996±1833 axons (n = 44) with no significant difference (p = 0.73). Female cadavers featured 6247±2230 (n = 22), male showed 6769±1809 axons (n = 40). No statistical difference was seen between genders (p = 0.59). A comparison with different studies in literature is made. The nerve diameter in 82 of our specimens could be measured at 1933±424 µm (range, 975 to 3012). CONCLUSIONS: No donor nerve has been described to match axonal load or fascicle number of the extratemporal facial nerve main trunk. However, the masseteric nerve may be coapted for neurotization of facial muscles with a low complication rate and good clinical outcomes. Nerve transfer is indicated from 6 months after onset of facial paralysis if no recovery of facial nerve function is seen.

WITHDRAWN: The use of integrated indocyanine green fluorescence microscope camera for intraoperative lymphography of supermicrosurgery.

Ahead of Print article withdrawn by publisher.

Transepidermal oxygen flux measurement - First clinical application for postoperative wound monitoring.

BACKGROUND: Measurement of skin oxygen is of great interest in diverse fields of medicine. Different pathologies, e.g. infection, ischemia cancer or chronic wounds show a characteristic oxygen distribution and skin oxygen tension. Additionally diverse operative procedures require a reliable postoperative monitoring in order to ensure success of the therapy. OBJECTIVE: Aim of this study was to assess transepidermal oxygen flux for postoperative wound monitoring after operative treatment of fractures close to the hip. METHODS: 22 patients underwent transepidermal oxygen flux measurement at the first postoperative day. Transepidermal oxygen flux measurement was performed using ratiometric luminescence imaging. Examination was conducted in close proximity to the operation wound. The corresponding area at the contralateral side served as reference. RESULTS: Oxygen flux in the operation area was higher (0.084±0.021) than the contralateral side (0.071±0.029). CONCLUSIONS: Transepidermal oxygen flux imaging by ratiometric luminescence imaging seems to be a reliable tool to assess postoperative wound healing. However further investigations in greater populations and under pathologic conditions have to be performed to prove these first results.

Transepidermal oxygen flux during arterial occlusion using ratiometric luminescence imaging.

BACKGROUND: A physiological oxygen transport through a circulatory and microcirculatory system is essential for execution of cellular functions. Several pathological conditions e.g. infections, ischemia, cancer, diabetes, hypertension or chronic wounds show a change of oxygen distribution and oxygen tension in cellular microenvironment. Additionally complex operative procedures in order to reconstruct tissue defects require a reliable monitoring of microcirculation. OBJECTIVE: Target of this study was to evaluate skin oxygenation during an ischemia-reperfusion experiment using transepidermal oxygen flux imaging. METHODS: Twelve patients at the Department of Plastic and Reconstructive surgery of the University hospital of Regensburg underwent to elective hand operations. During the operation a tourniquet is standardly set on the upper arm to create ischemia in order to facilitate the operative procedure. Measurements were performed at the different time intervals: in rest, under ischemia and after reperfusion. RESULTS: The transepidermal oxygen flux increased during the ischemic condition compared to normal condition and decreased to a lower value during reperfusion (rest: 0.043±0.007, ischemia: 0.063±0.014, reperfusion: 0.030±0.028). CONCULSION: Transepidermal oxygen flux imaging by ratiometric luminescence imaging seems to be a reliable tool to assess skin oxygenation. However dynamic changes seem to be more informative than absolute thresholds. Further investigations are necessary to prove these promising results.

Circulating serum CK level vs. muscle impairment for in situ monitoring burden of disease in Mdx-mice.

BACKGROUND: Duchenne muscular dystrophy (DMD) consists of a lack in the expression of the subsarcolemmal protein dystrophin causing progressive muscle dysfunction. Among the widely applied animal models in DMD research is the C57BL/1010ScSn-Dmdmdx mouse, commonly referred to as the "mdx mouse". The potential benefit of novel interventions in this model is often assessed by variables such as functional improvement, histological changes, and creatine kinase (CK) serum levels as an indicator for the extent of in situ muscle damage. OBJECTIVE: Our objective was to determine to what extent the serum CK-level serves a surrogate for muscle dysfunction. METHODS: In this trial mdx mice were subjected to a four-limb wire-hanging test (WHT) to assess the physical performance as a reference for muscle function. As CK is a component of the muscle fiber cytosol, its serum activity is supposed to positively correlate with progressing muscle damage. Hence serum CK levels were measured to detect the degree of muscle impairment. The functional tests and the serum CK levels were analyzed for their specific correlation. RESULTS: Although physical performance decreased during the course of the experiment, latency to fall times in the WHT did not correlate with the CK level in mdx mice. CONCLUSION: Our data suggests that the serum CK activity might be a critical parameter to monitor the progression of muscle impairment in mdx mice. Further this study emphasizes the complexity of the DMD phenotype in the mdx mouse, and the care with which isolated parameters in this model should be interpreted.

Vascular malformations of upper and lower extremity - from radiological interventional therapy to surgical soft tissue reconstruction - an interdisciplinary treatment.

This article presents our experience in managing peripheral vascular malformations of upper and lower extremities over a 4-year period in a series of 46 patients of the Department of Plastic Surgery treated in the Interdisciplinary Center of Vascular Anomalies (ICVA) at the University of Regensburg. The patients presented vascular malformations of upper and lower extremity and were selected from our prospective vascular anomalies file archive from 2012 to 2016. During this period in the ICVA at University of Regensburg were performed more than 1400 radiological interventional treatments in patients with vascular malformations.The purpose of this retrospective study was to review combined embolotherapy, sclerotherapy (embolo/sclerotherapy), and surgical procedures (surgical excision and soft tissue reconstruction) to manage vascular malformations. Treatments were principally induced to reduce pain, daily physical limitations, social discomfort and recover tegument continuity after ulceration.The 46 patients were first examined with noninvasive radiological procedures. After diagnosis was posed, embolo/sclerotherapy, surgical procedures and clinically as well as radiological follow-ups were coordinated and established by the multidisciplinary team. All vascular malformations were categorized according to the classification approved at the April 2014 General Assembly of International Society for the Study of Vascular Anomalies (ISSVA) in Melbourne, Australia. Arteriovenous malformations (AVMs) were further classified following the Cho-Do and Schobinger classification.Embolo/sclerotherapy shows to be the most appropriate procedure in vascular malformations treatment. Nevertheless was found that in case of complications or lack of improvement as well as to improve functional or aesthetical results, a following partial or complete surgical excision and immediate soft tissue reconstruction seems to be the gold-standard treatment. In addition, the precise clinical and radiological diagnosis as well as an intensive postoperative patient care have a significant positive influence on the clinical outcome and patient satisfaction while decreasing morbidity and recurrence during early and late follow-up.Vascular malformations require a multidisciplinary approach and individual treatment after complex excision and indispensable reconstruction.

Vascularized transfer of two coherent toe joints in simultaneously reconstructing MCP and PIP of a mutilated finger.

BACKGROUND: The reconstruction of metacarpal- and interphalangeal joints after severe hand injuries has been proven to be challenging. Commonly used procedures like arthrodesis, amputation or ray resection of the finger compromise the functionality of the injured finger. Especially for young patients, the restoration of all functions of the fingers is a priority. Local tissue transfers for finger joint reconstructions is not an option due to inacceptable donor site morbidity; microsurgical tissue transfers in terms of free toe joint transfers have proven to be a valuable method. METHODS: We present the case of a patient who suffered an excessive injury from a circular saw to his dominant hand. The MCP Joints of D2-D4 were fully destroyed, along with the PIP joint of a subtotally amputated D4. Arteries, nerves and tendons could be coapted directly, while primarily reconstructing of the finger joints was impossible. To ensure a possible regain of full functionality, two coherent joints, the MTP and the PIP of one toe, were transferred to the ring finger as a single transplant, reconstructing the MCP and the PIP joints of the injured finger in a one step procedure. Additionally the MCP joint of the D2 was reconstructed by the use of a free PIP-joint transfer, further the MCP joint of the D3 was replaced by an MCP endoprosthesis. RESULTS: After a follow up of 3 years the patient displayed full function of his dominant hand including sensitivity, and has gone back to manual work without limitations. The result was cosmetically acceptable and the donor site defect was easily being tolerated by the patient who is playing soccer in the regional soccer league. CONCLUSION: Free double toe joint transfer has been proven feasible in this patient. While transferring a single toe joint to reconstruct a finger joint is a well-established method, our review of the latest literature showed no case of a free transfer of two coherent joints and three transplanted joints in one hand. The applied microsurgical technique should be considered by microsurgically trained hand surgeons for the treatment of comparable severe hand injuries. In comparison to the most common procedures described for the repair and reconstruction of severely injured finger joints this method showed superior results.

Contrast enhanced ultrasound (CEUS) - an unique monitoring technique to assess microvascularization after buried flap transplantation.

OBJECTIVE: Incidence of patients requiring complex soft tissue or osseous reconstruction has dramatically increased. However most of the monitoring systems have limitations in tissue penetration and are not able to detect microvascular complications after transplantation of so-called buried-flaps, that have no contact to the surface.Aim of the study was to assess contrast enhanced ultrasound (CEUS) as monitoring tool after buried flap transplantations. METHODS: 20 patients were examined after buried flap transplantation using CEUS. Quantitative perfusion analysis (TIC) was performed with an integrated perfusion software using stored cine-loops. Two perfusion-parameters, time to PEAK (TtoPk) and area under the curve (Area), were evaluated using TIC analysis. RESULTS: Minor complications were observed in 3 patients. In these patients a delayed contrast agent wash-in and wash-out was observed. Additionally the perfusion values TtoPk (sec.) and Area (relative Units) were clearly different in the patients with minor complications: TtoPk: 32.0 sec; Area 425.5 rU (without complication), TtoPk: 38.6 sec.; Area: 18.3 rU (wound healing disturbance) and TtoPk: 14.4 sec.; Area: 105.9 rU (hematoma). CONCLUSION: As CEUS can assess microvascularization almost depth-independent, CEUS is an unique method to assess global flap perfusion after buried flap transplantation.