[Definition of the quality of hand surgery]. / Definition von Qualität in der Handchirurgie.

The quality of treatment within the total concept of the healthcare system is subject to multifactorial influences. With the intention to improve the quality of hand surgery the German Society for Hand Surgery (DGH) has initiated a number of projects. These include the S3 guidelines codeveloped by the DGH, the hand trauma register of the DGH, the definition of criteria for hand surgical procedures to be performed in an outpatient setting within the framework of a consensus recommendation as well as participation in a large epidemiological study with the special documentation of pathological alterations of the hand to determine the prevalences (study of health in Pomerania, SHIP); however, within these projects the quality of treatment itself is not assessed. In the attempt to document the quality, the currently available quality indicators in hand surgery probably only evaluate the aspects really relevant for the patients to a limited extent. Therefore, the DGH participated at an early stage in the development of assessments within the international study named by the WHO as a lighthouse project. These developed and validated assessments are intended to include all aspects of the results including the individual patient view in order to precisely relate the quality of treatment to an exactly defined pattern of hand injury. The use of these assessments should permanently enable a prediction of outcome quality for each individual patient. All these projects require the largest involvement possible to collect as much data as possible. With this intention the DGH further coordinates and develops these projects within the committees of the extended executive board and attempts to motivate as many surgeons as possible to participate.

[Challenges to endoprosthetic reconstruction after tumor resection around the knee : Management of intra- and postoperative complications]. / Herausforderungen in der Tumorendoprothetik des Kniegelenks : Management von intra- und postoperativen Komplikationen.

BACKGROUND: The good functional outcomes of endoprosthetic knee reconstructions combined with modern oncosurgical concepts have resulted in a decreased rate of primary amputations following tumor resection in the region of the knee, thereby improving the quality of life of affected patients. OBJECTIVE: This study aimed to reappraise complications which are more common than in conventional arthroplasties performed for arthritis or trauma due to the complexity of the surgical procedures, the size of the endoprosthetic reconstructions, and neo-/adjuvant therapies. MATERIAL AND METHODS: Possible intra- and postoperative complications and treatment options are presented. RESULTS: Typical intraoperative complications include malalignment (axis, length, rotation) in implant positioning, unplanned soft tissue defects, impaired implant fixation due to poor bone stock, periprosthetic fractures, vessel/nerve injuries, and lesions/defects of the extensor mechanism. The relevant postoperative complication profile is characterized by local recurrences, periprosthetic infections, thromboembolic events, and mechanical failures (loosening, failure of the constraining mechanism). CONCLUSION: Depending on anatomic conditions and the systemic oncological status of the patient, these complications represent tremendous challenges to reconstructive management. Knowledge of the potential problems enables them to be avoided. This requires profound experience in oncosurgery and tumor endoprosthesis revisions.

Drug safety in paediatric anaesthesia.

Life-threatening drug errors are more common in children than in adults. This is likely to be because of their variations in age and weight, combined with the occasional exposure of most anaesthetists to paediatric patients. Drug administration in anaesthesia is mostly undertaken by a single operator and thus represents a potentially greater risk compared with other areas of medicine. This increased risk is believed to be offset by anaesthetists working with only a limited number of drugs on a very frequent and repetitive basis. However, high rates of errors continue to be reported. Paediatric anaesthesia practice requires individual age- and weight-specific drug dose calculations and is therefore without a 'familiar' or 'usual' dose. The aim of this narrative systematic review of existing recommendations and current evidence of preventive strategies is to identify measures to enhance the safety and quality of drug administration in paediatric anaesthesia. This review collates and grades the evidence of such interventions and recommendations and assesses their feasibility. Most highly effective available measures require low or limited costs and labour. The presented solutions should, therefore, achieve a high level of acceptance and contribute significantly to safety and quality of care in paediatric anaesthesia.

Emergence delirium or pain after anaesthesia--how to distinguish between the two in young children: a retrospective analysis of observational studies.

BACKGROUND: Early postoperative negative behaviour in preschool children after general anaesthesia is a common problem. The distinction between emergence delirium (ED) and pain is difficult, but management differs between the two. The aim of the current analysis was to identify individual observational variables that can be used to diagnose ED and allow distinction from postoperative pain. METHODS: This retrospective analysis of data from three previous prospective observational studies included children undergoing general anaesthesia for elective adeno-tonsillectomy, sub-umbilical surgery, and MRI scanning. Two trained observers simultaneously applied the Face, Legs, Activity, Cry, Consolability Scale; the Children's Hospital Eastern Ontario Pain Scale; the Children's and Infants' Postoperative Pain Scale or the Paediatric Anaesthesia Emergence Delirium (PAED) scale. Data from each domain of the scales were available at awakening and at five, 10, and 15 min after anaesthesia. Each patient was analysed over time, and subsequently, each evaluation was considered as a single event. The descriptive behaviour items overlapping in the assessed scales were identified as dichotomous variable ('true/false') and then were applied for each evaluation. RESULTS: Children (n=512) were assessed for a total of 2048 evaluations. Most children (69%) displayed at least one episode of ED and/or pain. Almost 15% of children demonstrated both ED and pain. Children with ED showed 'no eye contact' and 'no awareness of surroundings'. Children with pain displayed 'abnormal facial expression', 'crying', and 'inconsolability'. CONCLUSIONS: 'No eye contact' and 'no awareness of surroundings' identifies ED. 'Abnormal facial expression', 'crying', and 'inconsolability' indicate acute pain in children in the early postoperative period.

Defining postoperative stability in children with radial polydactyly.

UNLABELLED: There is little fundamental data on paediatric metacarpophalangeal joint instability in radial polydactyly following surgical reconstruction. We evaluated 27 thumbs in a healthy paediatric population (Group A: eight girls and 19 boys with a mean age of 9.7 years (range 2.7-14.2)) and 12 thumbs following Wassel-IV reconstruction (Group B: eight girls and four boys with a mean age at follow-up of 10.6 years (range 2.7-13.2)). Metacarpophalangeal joint radial deviation, ulnar deviation on stress testing, interphalangeal joint and metacarpophalangeal joint alignment on posterior-anterior radiographs were measured and scored according to parameters defining joint instability. The aim of our study was to provide fundamental data on thumb metacarpophalangeal joint mobility patterns and alignment for further postoperative evaluations in children. The average ulnar deviation and radial deviation on stress testing of the healthy (Group A) metacarpophalangeal joints was 25° (10°-45°) and 30° (10°-55°), respectively. In the operated (Group B) thumbs, the ulnar deviation and radial deviation was greater at 35° (10°-55°) and 30° (10°-70°). Ulnar deviation (UD) of the proximal phalanx at the metacarpophalangeal joint on posterior-anterior radiographs was a mean of 10° (range -10°-30°) in Group B; this was significantly greater than in Group A at a mean of 5° (range -5-20°) (p = 0.029). The mean radial alignment of the interphalangeal joint (distal phalanx relative to the proximal phalanx) was significantly higher in Group B (15°) than Group A (0°) (p = 0.221). In the literature on radial polydactyly, cut off values defining metacarpophalangeal joint instability in children range from 5° to 20°. According to our results, high but physiological metacarpophalangeal joint mobility of the thumb needs to be taken into consideration when evaluating children following reconstruction. Ulnar or radial deviation greater than 30°, in combination with the lack of a definite end point on metacarpophalangeal joint stress testing, may be regarded as unstable. Based on our study on healthy paediatric and reconstructed thumbs, comparison of joint stability with the healthy contralateral hand is recommended in order to define pathological instability. LEVEL OF EVIDENCE: II.

[Free Gracilis Flap for Anatomic Reconstruction after Limb-sparing Sarcoma Resection]. / Freie M. gracilis-Lappenplastik zur anatomischen Rekonstruktion nach gliedmaßen-erhaltender Weichteil-Sarkom Resektion.

INTRODUCTION: Limb-sparing surgery is considered as first choice in most patients with soft tissue sarcomas of the extremities. 5-year survival rates after limb soft tissue sarcoma resection have been promising in many specalised interdisciplinary centres. Quality of life as well as extremity function have thus become an integral aspect of the surgical management of soft tissue sarcomas of the extremities. OBJECTIVE: We herein report on our experience in the anatomic reconstruction of the extremities following limb-sparing soft tissue sarcoma resection using microvascular gracilis muscle flap and skin grafts. PATIENTS AND METHODS: Between 2012 and 2014 an anatomic reconstruction of the hand and foot using gracilis muscle flaps following limb-sparing sarcoma resection (leiomyosarcoma N=2, myxofibrosarcoma N=2, clear cell sarcoma N=1, myxoinflammatory fibroblastic sarcoma N=1, granular cell tumour N=1, pleomorphic sarcoma N=1) was performed in N=8 patients (4 females, 4 males), average age: 44 years (23-76 years), average follow-up time 444 days (98-820). RESULTS: In all patients successful defect coverage with unimpaired wound healing was achieved (adjunctive radiotherapy n=4). The tendon of the harvested gracilis muscle was used for anatomic reconstruction of consequently resected essential anatomic structures (extensor retinaculum n=1, flexor/extensor tendons n=4, extensor expansion n=2, tendon reinsertion n=1, proximal interphalangeal joint collateral ligament n=4, dorsal metatarsal ligament n=1). During follow-up neither local recurrence nor metastasis was observed. CONCLUSION: Reconstruction of multidirectional stability as well as restoring biomechanics and kinetics of the hand and foot should be considered during defect coverage and dead space obliteration management after sarcoma resection of the extremities. For reasons of sound options in anatomic extremity reconstruction with minimal donor site morbidity, the gracilis muscle flap excels in the field of limb-sparing sarcoma resection.

[Optimising care structures for severe hand trauma and replantation and chances of launching a national network]. / Über Versorgungsstrukturen und Möglichkeiten der Optimierung durch Vernetzung bei schweren Handverletzungen und Replantationen.

Severe hand traumata have a significant impact on our health system and on insurance companies, respectively. It is estimated that 33% of all occupational injuries and 9% of all invalidity pensions are due to severe hand trauma. Unfortunately, these high numbers are not only due to the severity of the trauma but to organisational deficiencies. Usually, the patient is treated at the general surgical emergency in the first place and only then forwarded to a microsurgeon. This redirection increases the time that is required for the patient to finally arrive at an expert for hand surgery. On the one hand, this problem can be explained by the population's lack of awareness for distinguished experts for hand and microsurgery, on the other hand, the emergency network, or emergency doctors in particular are not well informed about where to take a patient with a severe hand trauma - clearly a problem of communication between the hospitals and the ambulance. It is possible to tackle this problem, but put participating hand trauma centres have to work hand in hand as a network and thus exploit synergy effects. The French system "FESUM" is a good example for such a network and even comprises centres in Belgium and Switzerland. To improve the treatment of severe hand trauma, a similar alliance was initiated in Germany just recently. The pilot project "Hand Trauma Alliance" (www.handverletzung.com) was started in April 2013 and currently comprises two hospitals within the region of upper Bavaria. The network provides hand trauma replantation service on a 24/7 basis and aims at shortening the way from the accident site to the fully qualified hand surgeon, to improve the therapy of severe hand injuries and to optimise acute patient care in general. In order to further increase the alliance's impact it is intended to extend the project's scope from regional to national coverage - nevertheless, such an endeavour can only be done in collaboration with the German Society for Hand Surgery (DGH). This article comprises 2 parts. First, the state-of-the-art of acute severe hand trauma care is summarised and explained. Subsequently, the above-mentioned pilot project is described in every detail, including positive effects but also barriers that still have to be overcome.

Supporting the collateral ligament complex in radial polydactyly type Wassel IV.

Despite anatomical metacarpophalangeal joint (MCPJ) reconstruction in radial polydactyly (RP) Wassel IV, the prevention of long-term deformity and instability is still an issue. We report on clinical results following our modified surgical procedure with additional support of the hypoplastic radial collateral ligament complex (RCLC) after musculoligamentous MCPJ reconstruction. Fourteen patients (male: 10, female: 4) with radial resection of isolated RP Wassel IV (1987-2006), average age at surgery 1.7 years (0.6-8.6) were included. Distribution to group A and B depended on the procedure for MCPJ reconstruction. In group A (N = 7), RCLC reinsertion + reinforcement using autologous tendon grafts was performed (follow-up: 4.6 years (1.4-6.9)). Group B (RCLC reinsertion without support) consisted of N = 7 patients; follow-up: 9.6 years (8.2-20.2). The healthy contralateral hand (control A/control B) served as a control. Results were evaluated using our modified Tada-score considering: range of motion (ROM), interphalangeal joint (IPJ) and MCPJ stability on stress examination, palmar abduction and grip strength. Better score results (maximum 10) were seen in A: 7.3 (6-9) compared to B: 6.6 (4-10). Subscore 'stability' A: 1.1 (0-2); B: 0.9 (0-2) and 'alignment' A: 0.86 (0-2); B: 0.57 (0-2) showed greatest influence on the score result. Ulnar angulation at MCPJ level compared to healthy thumbs (control A + B) was greater (p < 0.05), with 11.4° (10-20) in group A and 14.3° (-5 to 30) in group B compared to 0° in control A and 5.7° (0-17) in control B. MCPJ ulnar deviation in A + B: 25° (0-35) compared to healthy thumbs control A + B was higher (p < 0.05). Ulnar deviation was higher in B 45° (30-60) compared to 34° (20-50) in A. In B, instability was evident in four, in A, only in one patient. In B, one patient required two re-operations due to MCPJ instability. Equivalent results were recorded regarding pinch grip and palmar abduction. Anatomical MCPJ reconstruction in combination with autologous support of the hypoplastic RCLC to enhance long-term stability is recommended.

[3-dimensional imaging systems: first experience in planning and documentation of plastic surgery procedures]. / 3-dimensionale Bilderfassung: Erste Erfahrungen in der Planung und Dokumentation plastisch-chirurgischer Operationen.

A reproducible 3-dimensional photographic system enables plastic surgeons to perform preoperative planning and helps them to understand the patient's expectations. There are a few systems available that allow a reproducible 3-dimensional scans of the patient with direct simulation of the planned procedure. The Vectra Volumetric 3D Surface Imaging® by Canfield® provides such an option and helps the surgeons to document and compare postoperative changes at different time points. Since January 2011 we are digitally documenting all patients receiving form-modulating procedures in our plastic surgery unit. We present the spectrum of clinical implications and discuss advantages and disadvantages of the system. Furthermore, we have studied the accuracy of the system in comparison to direct measurement in 15 volunteers. The system is especially suited for planning and evaluation of breast augmentation, facial aesthetic and reconstructive surgery as well as volumetric measurements before and after liposuction and lipofilling. Computer-assisted measurements correlate with a median deviation of 2.3% with manually measured distances in the face. We found the user-friendly Vectra® system to be a reliable and reproducible device for planning plastic surgery therapies and for documenting postoperative results.

[Microscope-integrated intraoperative indocyanine green angiography in plastic surgery]. / Intraoperative Indocyaningrün-Fluoreszenzdiagnostik mittels Operationsmikroskop in der plastischen Chirurgie.

The knowledge of tissue perfusion has not only a prognostic value in microvascular surgery but also the intraoperative detection of malperfusion can lead to a quick surgical intervention. Indocyanine green (ICG) angiography allows a topographic analysis of perfusion and is used to assess lymphatic drainage pathways and to analyse the depth of burn injuries. Integrating the technique into an operating microscope enables visualisation of the flow over microanastomoses and allows the assessment of the transit time of blood flow between arterial and venous anastomosis. Using this method we analysed 11 microsurgical free flaps (3 latissimus dorsi, 3 rectus abdominis, 1 gracilis muscle, 2 radial forearm, 1 ALT, and 1 DIEP flap). The topographic analysis was performed after the assessment of the microanastomoses. We observed no flap loss or partial flap necrosis. The transit time between arterial inflow and venous outflow was 32.8 s on average. Here we observed distinct differences between muscle flaps (27.7 s) on the one hand and fasciocutaneous and perforator flaps (47.5 s) on the other hand. We detected one venous thrombosis by ICG angiography in a case where the clinical patency test was not distinct. Revision was performed immediately. Particularly for intraoperative assessment, ICG angiography is a useful, reliable and safe technique. The integration into the operating microscope allows an "angiographic patency test" and the analysis of the transit time allows the evaluation of blood flow within the flap. Especially when planning perforator flaps the method of ICG angiography provides a new level of safety in flap design by quickly demonstrating the borders of perfusion.

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.

Surgical management of recurrent thoracolumbar spinal sarcoma with 4-level total en bloc spondylectomy: description of technique and report of two cases.

INTRODUCTION: The descriptions of total spondylectomy and further development of the technique for the treatment of vertebral sarcomas offered for the first time the opportunity to achieve oncologically sufficient resection margins, thereby improving local tumor control and overall survival. Today, single level en bloc spondylectomies are routinely performed and discussed in the literature while only few data are available for multi-level resections. However, due to the topographic vicinity of the spinal cord and large vessels, the multisegmental resections are technically demanding, represent major surgery and only few case reports are available. Surgical options are even more limited in cases of revision surgery and local recurrences when en bloc spondylectomy was considered to be not feasible due to high risk of vital complications in expanding resection margins. Deranged anatomy, implants in situ and extensive intra-/paraspinal scar tissue formation resulting from previously performed approaches and/or radiation are considered the principal complicating factors that usually hold back spine surgeons to perform revision for resection leaving the patient to palliative treatment. METHODS: We present two patient cases with previously performed piecemeal vertebrectomy in the thoracic spine due to a solitary high-grade spinal sarcoma. After extensive re-staging, both patients underwent a multi (4)-level en bloc spondylectomy in our department (one patient with combined en bloc lung resection). Except a local wound disturbance, there was no severe intra- or postoperative complication. RESULTS: After multilevel en bloc spondylectomy both patients showed a good functional outcome without neurological deficits, except those resulting from oncologically scheduled resection of thoracic nerve roots. After a median follow-up of 13 months, there was no local recurrence or distant metastasis. The reconstruction using a posterior screw rod system that is interconnected to an anterior vertebral body replacement with a carbon composite cage showed no implant failure or loosening. In summary, the approach of a multilevel en bloc surgery for revision and oncologically sufficient resection in cases of spinal sarcoma recurrences seems possible. However, interdisciplinary decision making in a tumor board, realistic evaluation of surgical resectability to attain tumor free margins, advanced experiences in spinal reconstructions and involvement of vascular, visceral and thoracic surgical expertise are essential preconditions for acceptable oncological and functional outcome.

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.

[About the self-reported quality of life after amputation of the hand in patients with upper extremity tumors]. / Zur Selbsteinschätzung der Lebensqualität von Tumorpatienten nach Amputation der Hand.

PURPOSE/BACKGROUND: Amputation proximal to the wrist may be oncologically dictated in cases of upper extremity soft tissue sarcoma and aggressive fibromatosis. Literature on functional long-term results and patient-oriented assessment is sparse. Our study is concerned with subjective impressions of quality of life and upper extremity health status and their importance in the evaluation and interpretation of results after amputation of the hand. PATIENTS/METHODS: Between 1999 and 2007, 14 patients (6 females/8 males; average age: 25 years) were operated because of a soft tissue sarcoma (n = 11) or aggressive fibromatosis (n = 3). Ten patients underwent limb-sparing surgery. There were two amputations at the level of the forearm. Local recurrence following forequarter amputation due to aggressive fibromatosis required reoperation in another patient. A heterotopic replantation after resection was carried out in one patient. In patients with amputations, the self-reported upper extremity-specific health status and quality of life were measured with the DASH score. Disturbances in body image and symptoms of depression were assessed psychiatrically. RESULTS: In two cases with amputations, minimal impairments in everyday life and a high reported quality of life were observed (DASH scores: 3,5). CONCLUSION: Self-reported upper extremity health status and quality of life following amputation of the hand can be in contrast to the objective pathology. In patient-oriented assessment of results, individual psychosocial factors that may affect results must be taken into consideration. They also must not be neglected when determining whether patients are suitable candidates for prosthetic devices.

Fluoroscopic guidance of Arndt endobronchial blocker placement for single-lung ventilation in small children.

BACKGROUND: Thoracoscopic surgery may require single-lung ventilation (SLV) in infants and small children. A variety of balloon-tipped endobronchial blockers exist but the placement is technically challenging if the size of the tracheal tube does not allow the simultaneous passage of the fibreoptic scope and the endobronchial blocker. This report describes a technique for endobronchial blocker insertion using fluoroscopic guidance in children undergoing SLV. METHODS: After approval from the local Medical Ethics Committee and parental consent, 18 patients aged 2 years or younger scheduled for thoracic surgery requiring SLV were prospectively included. Following induction of anesthesia, a 5 Fr endobronchial blocker (Cook) Arndt endobronchial blocker) was inserted first into the trachea under direct laryngoscopy. Correct placement in the main bronchus was assessed by fluoroscopy and tracheal intubation next to the endobronchial blocker. Optimal position and balloon inflation was verified using a fibreoptic scope. The duration and number of insertion attempts as well as age, weight and size of the tracheal tube were recorded. RESULTS: Eighteen patients were studied. Median (range) age and weight were 12 (0.2-24) months and 11.2 (4-15) kg, respectively. SLV was successfully achieved in all patients using a 5 Fr endobronchial blocker outside a 3.5-4.5 mm ID tracheal tube within 11.2 (+/-2.2) min. No side effects were observed during the procedure. CONCLUSION: Fluoroscopic-guided insertion of extraluminal endobronchial blocker is an effective and reliable tool to place Arndt endobronchial blockers in small children.

[Effect of cigarette smoking on skin perfusion of the hand]. / Einfluss des Zigarettenrauchens auf die Hautdurchblutung der Hand.

BACKGROUND: Cigarette consumption leads to postoperative wound healing disturbances by impairing skin circulation. MATERIALS AND METHODS: Fourteen nonsmokers and 44 smokers were investigated and classified according to age (<40 and >40 years) and duration of cigarette consumption. Circulation at the tip of the middle finger was measured in both groups under standard conditions with laser Doppler imaging. RESULTS: There was a reduction in skin blood circulation of 24% in smokers (young 39%, older 11%, P=0.001) and 30% in nonsmokers (young 35%, older 18%, P=0.019). With longer duration of cigarette consumption, the effect grew weaker (<10 years 25%, 11-30 years 18%, >30 years 15%). There was no correlation between the number of cigarettes consumed per day and impaired circulation. CONCLUSION: Younger subjects react to cigarette consumption with a stronger reduction in circulation. In elective surgery, especially in young smokers we recommend a 6- to 8-week nicotine abstinence prior to surgical intervention.

[Xanthoma disseminatum: a rare case involving the upper extremity]. / Xanthoma disseminatum -- ein seltener Befall an der oberen Extremität.

We describe a dramatic case of class II non-Langerhans cell histiocytosis, xanthoma disseminatum, in a 30-year-old male patient with progressive involvement of the skin, vocal cords, eyes, bones and nerves in spite of chemotherapy with Vespesid and immunotherapy with interferon-gamma. At the age of 43 years, the patient required surgical clearance of airways, eyelids and peripheral nerves, but at present exhibits stable disease on a combination of lipid-lowering drugs including thiazolidinedione.