Measuring quality of care in autologous breast reconstruction: a Delphi consensus.

Measuring and benchmarking quality of care in surgical oncology has been gaining popularity. In autologous breast reconstruction (ABR), a standardized set of indicators to assess quality of care is lacking. In this study, we defined a set of evidence-based quality indicators for autologous breast reconstruction. First, we performed a systematic review to identify factors related to quality of care in ABR. Variables were categorized depending on their function: indicators related to outcome, indicators related to process and case-mix variables. The review was followed by a 3-round Delphi Consensus to determine which indicators and case-mix-variables were considered relevant and feasible for inclusion in an ABR standard set of indicators. 932 unique articles were identified, of which 110 papers were included in the study. Indicators were categorized by function: outcome, process and case-mix variables. In total, 8 process indicators and 41 outcome indicators were extracted. 30 case-mix-variables were included. Following 3 rounds of questioning in the Delphi Consensus, all respondents agreed on type of ABR, oncological outcomes and patient satisfaction for the standard set. Indicators related to complications were consistently ranked highly. Most process indicators were not chosen after 3 rounds of questioning. 11 case-mix-variables were included in the final set. Following the Delphi Consensus, it was possible to identify 33 process and outcome indicators and 11 case-mix-variables for inclusion for a standard set of quality indicators. With the inclusion of both objective and patient-reported outcome measures, this set of indicators provides a multidimensional measurement tool for quality assessment for ABR.

Targeted therapies and checkpoint inhibitors in sarcoma.

Sarcomas are defined as a group of mesenchymal malignancies with over 100 heterogeneous subtypes. As a rare and difficult to diagnose entity, micrometastasis is already present at the time of diagnosis in many cases. Current treatment practice of sarcomas consists mainly of surgery, (neo)adjuvant chemo- and/or radiotherapy. Although the past decade has shown that particular genetic abnormalities can promote the development of sarcomas, such as translocations, gain-of-function mutations, amplifications or tumor suppressor gene losses, these insights have not led to established alternative treatment strategies so far. Novel therapeutic concepts with immunotherapy at its forefront have experienced some remarkable success in different solid tumors while their impact in sarcoma remains limited. In this review, the most common immunotherapy strategies in sarcomas, such as immune checkpoint inhibitors, targeted therapy and cytokine therapy are concisely discussed. The programmed cell death (PD)-1/PD-1L axis and apoptosis-inducing cytokines, such as TNF-related apoptosis-inducing ligand (TRAIL), have not yielded the same success like in other solid tumors. However, in certain sarcoma subtypes, e.g. liposarcoma or undifferentiated pleomorphic sarcoma, encouraging results in some cases when employing immune checkpoint inhibitors in combination with other treatment options were found. Moreover, newer strategies such as the targeted therapy against the ancient cytokine macrophage migration inhibitory factor (MIF) may represent an interesting approach worth investigation in the future.

Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws.

We analyzed the results of 20 unstable metacarpal fractures in 15 patients treated with a cannulated compression screw and no immobilization. All fractures healed within 6 weeks. One patient with multiple fractures and a flexion deficit required arthrolysis of two metacarpophalangeal joints. Another patient had an extension lag. There were no other complications. This fast and easy technique results in good outcomes for unstable metacarpal fractures. The advantages are early active motion without immobilization and stable fixation. Surgical removal of the screw is rarely needed. LEVEL OF EVIDENCE: IV (therapeutic).

Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures.

UNLABELLED: We present the results of 26 patients with 31 consecutive displaced or unstable extra-articular fractures of the base and shaft of the proximal and middle phalanges of the digits of the hand, treated over a period of 12 months with an intramedullary headless compression screw and early mobilization with no splinting. All fractures healed with no major complications. Only one patient, who had a pathological fracture through an enchondroma, required a tenolysis to improve the mobility of the finger. This technique seems to be technically simple, effective and with few drawbacks. LEVEL OF EVIDENCE: IV.

Extending the limits of reconstructive microsurgery in elderly patients.

BACKGROUND: Population aging strongly affects the demographic development of industrialized countries. While microsurgical procedures were initially believed to be only feasible in patients of younger age because of the duration of the surgical procedure and the higher risk of vascular insufficiency due to age-related comorbidities, it has become evident that these procedures are beneficial even for patients at an advanced age. METHODS: We retrospectively investigated microsurgical procedures in a patient cohort (n = 25 with 27 free flaps) with a minimum age of 78 years with regard to patients' characteristics, flap survival, and postoperative surgical and medical complications. RESULTS: Median age was 81 years (IQR 6). Most defects were located in the head and neck region. The mean operation time was 384 min (standard deviation (SD) 131). Flap failure was observed in three cases (11%). The median length of hospital stay was 17 days (interquartile range (IQR) 8). The mean ASA score was 2.48. Patients' age and ASA group did not correlate. The mortality rate was 4%. Postoperative surgical complications were observed in 11 cases (41%), while 19 patients (70%) showed one or more medical complications. Higher ASA classes tended to show more postoperative complications. However, neither age nor operating time nor ASA status showed significant influence on the occurrence of postoperative medical or surgical complications. CONCLUSION: There is growing demand for structural and functional restoration using free tissue transfer in an aging population. If there are no alternative treatment options available promising similar structural and functional preservation, free tissue transfer is justifiably in very old patients despite a potentially increased flap failure. As such, free tissue transfer is used as a curative treatment concept aiming at a maximum of patients' independence and early ambulation. Occurrence of complications can be diminished by adequate patient selection and thorough perioperative care.

Long-term clinical outcome after epineural coaptation of digital nerves.

UNLABELLED: This study evaluates the long-term clinical outcome and complication rate after digital nerve repair in adults and aims to identify possible prognostic factors of sensory recovery. End-to-end epineural coaptation was performed under magnification. A total of 93 coapted digital nerves were clinically evaluated with a mean follow-up of 3.5 years (range 1-6 years). The mean two-point discrimination was 10.6 mm (versus 4.4 mm for the contralateral side). Cutaneous pressure threshold tested with Semmes-Weinstein monofilaments showed a mean value of 2.7 (versus 2.2 for the contralateral side). Only 2% of our patients developed painful neuromas. None of our patients recovered normal functional sensibility, however, recovery of protective sensation contributed to a high reported level of satisfaction. No correlation was observed between the sensory outcome and age, smoking, mechanism of injury, lesion to or anastomosis of a digital artery, or time of immobilization. The only identified predictor of the result was the surgeon's level of experience. This highlights the importance of adequate training and practice in the surgical repair of smaller peripheral nerves. LEVEL OF EVIDENCE: IV.

Replantation by palmar arteriovenous anastomosis in complex finger amputations.

Digital replantation is a well-established and increasingly common procedure in specialized hand surgery units worldwide. Replantation after complex trauma is often challenging due to severely injured, small-diameter vessels, especially at the distal level. Digit salvage by arteriovenous anastomosis has been inadequately described in the literature for such cases. The objective of this study was to evaluate the outcomes and complications of arteriovenous digital replantation in complex amputations. We reviewed five cases of digital replantation using a single palmar afferent arteriovenous anastomosis and drainage via a dorsal vein. The postoperative protocol followed our standard replantation protocol. All digits survived with no revision procedures. No major complications were observed. One digit developed partial epidermolysis and one thumb developed marginal skin necrosis, both treated conservatively. The color of the replanted digits was not a reliable monitoring parameter but capillary refill was consistently visible. Microangiography performed four months after surgery demonstrated good digit perfusion. Our results support palmar arteriovenous anastomosis as a reliable alternative in digital replantation if distal arteries are unavailable for anastomosis. The results also suggest that this digit salvage procedure can be carried out at a more proximal level than previously reported.

Carpal tunnel syndrome: Analysis of online patient information with the EQIP tool.

Patients suffering from carpal tunnel syndrome (CTS) actively search for medical information on the Internet. The World Wide Web represents the main source of patient information. The aim of this study was to systematically assess the quality of patient information about CTS in the Internet. A qualitative and quantitative assessment of websites was performed with the modified Ensuring Quality Information for Patients (EQIP) tool that contains 36 standardized items. Five hundred websites with information on CTS treatment options were identified through Google, Bing, Yahoo, Ask.com and AOL. Duplicates and irrelevant websites were excluded. One hundred and ten websites were included. Only five websites addressed more than 20 items; quality scores were not significantly different between the various providing groups. A median of 15 EQIP items was found, with the top website addressing 26 out of 36 items. Major complications such as median nerve injury were reported in 27% of the websites and their treatment in only 3%. This analysis revealed several critical shortcomings in the quality of the information provided to patients suffering from CTS. There is a collective need to provide interactive, informative and educational websites for standard procedures in hand surgery. These websites should be compatible with international quality standards for hand surgery procedures.

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap.

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.

Hemi-hamate autograft arthroplasty for acute and chronic PIP joint fracture dislocations.

BACKGROUND: Treatment of fracture dislocations of the PIP joint represents a hand surgical challenge. In hemi-hamate arthroplasty, the palmar joint surface is reconstructed using an osteochondral graft from the hamate and the immediate stability permits early movement. MATERIAL AND METHODS: We performed hemi-hamate reconstructions in 10 patients (mean age 34.9 years), who sustained fractures of the base of the middle phalanx of ≥50% surface and dorsal PIP dislocations. Outcomes were assessed by clinical exam and X-ray. Evaluation criteria were range of motion of PIP and DIP joints, grip strength, joint alignment, complications and donor site morbidity. Mean follow-up was 8.6 months (range 3-14). Fractures mostly involved the 4th and 5th fingers, all patients were male. Indications were subluxation and comminuition in acute cases of <6 weeks (5 patients) and chronic pain and morning stiffness in chronic cases (5 patients). RESULTS: Operative treatment was performed in average after 93 days (range 0-371 days) after injury. Average PIP motion was 71° (range 0-90); DIP motion was 54° (range 10-90) with a mean PIP flexion contracture of 6.5° (range 0-20). Grip strength averaged 95% of the opposite hand. 4 patients had revision surgery (2× arthrolysis PIP joint, 2× screw shortening, 1× neurolysis R. dorsalis N. ulnaris). CONCLUSIONS: Hemi-hamate autograft arthroplasty represents an effective procedure to address severe PIP joint fracture dislocations. It restores the comminuted articular surface in chronic injuries and in the acute injury it is a challenging but valuable alternative to extension block splinting. However, donor site morbidity and revision surgery have to be taken into account.

[The role of surgery in the treatment of cutaneous melanoma]. / Die Rolle der Chirurgie in der Behandlung des kutanen Melanoms.

Historically, melanoma patients were subject to wide local excisions and elective lymph node dissections. Both approaches were the focus of intense scrutiny in the past three decades, and many surgical dogmas were abolished. The role of surgery in providing local control over the primary tumor is largely undisputed. In addition, the surgical management strategies of the regional lymph nodes have undergone considerable change in the past; with lymphatic mapping and sentinel lymph node identification being the most relevant contribution, allowing selection of patients for adjuvant treatment (completion lymph node dissection, Interferon therapy). Surgery has also a place in palliative treatment of isolated systemic metastases for selected cases with good performance status in Stage IV melanoma.

Diagnostic pitfall: pigmented lesion of the nipple--correlation between dermoscopy, reflectance confocal microscopy and histopathology.

We present an unusual case of a nevus of the nipple changing during pregnancy which caused a diagnostic pitfall. Nevi on the nipple and areola are infrequent, and diagnostic criteria for clinical, dermoscopy or reflectance confocal microscopy examination for nevi in this 'special location' are still missing. We comment on the literature on dermoscopic findings in mammary lesions and their management during pregnancy, as well as the challenging histopathology of nevi along the milk line. Finally, we focus on two main limitations of reflectance confocal microscopy: the misinterpretation of dendritic cells and the limitation of the imaging depth.

[Fibrolipohamartoma of the upper extremity: treatment results in six patients over nine years]. / Fibrolipohamartom der oberen Extremität: Verlauf über neun Jahre bei sechs Patienten.

BACKGROUND: Fibrolipohamartoma (FLH) is a rare, benign congenital malformation of peripheral nerves, mainly the median nerve, less frequently of the ulnar or other nerves. Early symptom is an initially painless, slowly growing and circumscript swelling. Affections at the wrist level or the foot are occasionally accompanied by macrodactyly. Although FLH is a congenital disorder, because of absent or discreet symptoms, the diagnosis is often made in early adulthood only due to a compression neuropathy. Magnetic resonance image findings are pathognomonic, biopsies are not necessary. In the medical literature, FLH has been described for the past forty years only by means of case reports or small case series. Meanwhile, surgical decompression is considered as therapeutic gold standard, in case of an accompanying macrodactyly in combination with corrective procedures for length, breadth and axis. AIM OF THE STUDY: To study long term results after surgical compression of FLH und thus an assessment of this therapeutical concept generally accepted as gold standard in this rare entity. PATIENTS AND METHODS: Between 1994 and 2004 we treated 9 patients (8 women, 1 man) with 11 tumors, average age was 38 years (3-62). 2 of the 9 patients had macrodactyly. In 7 patients, the median nerve was affected, in one patient bilaterally, in 5 patients the ulnar nerve, and in one patient both ipsilateral median and ulnar nerves. Of those 9 patients, we were able to follow up 6 clinically and electroneurographically. In addition, the DASH-score was collected. Average follow-up after initial decompression was 9 years (2-23). We performed surgical decompression in 5 patients, one patient was treated conservatively. RESULTS: Patients with affections of the median nerve showed tendentially better results after surgical decompression compared to those with FLH of the ulnar nerve, irrespective of the affected anatomical level. Surgical decompression led to a relief of the symptoms in all patients; an improvement of motor function, hypaesthesia and cold sensitivity, however, could not be demonstrated. CONCLUSION: FLH must be considered in the differential diagnosis of macrodactyly. We recommend surgical decompression, as it leads to relief of the symptoms. It does, however, not have a beneficial effect on already present motor impairments, sensory deficits and cold sensitivity. We strictly advise against tumor resection.

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.

[Glomangiomatosis on the hand. A case report]. / Glomangiomatose der Hand. Ein Fallbericht.

Glomus tumours are solitary benign lesions most frequently located subungually on fingers and toes. In the rare case of a glomangiomatosis, the typical glomus cells are found on the altered vessel wall of the angiomatosis. Due to the rarity of this disease, no therapeutic golden standard has been mentioned in the literature, and a conservative treatment is usually adopted. The case of a 20-year-old craftsman with congenital, painful glomangiomatosis on his left dominant hand, progressively limiting the functionality of this limb, is reported. Two years after unsuccessful partial tumour resection, a surgical treatment based on radical tumour resection in terms of a finger amputation was performed. The 1-year follow-up showed no signs of pain for the patient.

The influence of sentinel lymph node tumour burden on additional lymph node involvement and disease-free survival in cutaneous melanoma--a retrospective analysis of 392 cases.

Twenty per cent of sentinel lymph node (SLN)-positive melanoma patients have positive non-SLN lymph nodes in completion lymph node dissection (CLND). We investigated SLN tumour load, non-sentinel positivity and disease-free survival (DFS) to assess whether certain patients could be spared CLND. Sentinel lymph node biopsy was performed on 392 patients between 1999 and 2005. Median observation period was 38.8 months. Sentinel lymph node tumour load did not predict non-SLN positivity: 30.8% of patients with SLN macrometastases (> or =2 mm) and 16.4% with micrometastases (< or =2 mm) had non-SLN positivity (P=0.09). Tumour recurrences after positive SLNs were more than twice as frequent for SLN macrometastases (51.3%) than for micrometastases (24.6%) (P=0.005). For patients with SLN micrometastases, the DFS analysis was worse (P=0.003) when comparing those with positive non-SLNs (60% recurrences) to those without (17.6% recurrences). This difference did not translate into significant differences in DFS: patients with SLN micrometastasis, either with (P=0.022) or without additional positive non-SLNs (P<0.0001), fared worse than patients with tumour-free SLNs. The 2-mm cutoff for SLN tumour load accurately predicts differences in DFS. Non-SLN positivity in CLND, however, cannot be predicted. Therefore, contrary to other studies, no recommendations concerning discontinuation of CLND based on SLN tumour load can be deduced.

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.

[Surgical treatment of high-voltage electrical injuries]. / Die chirurgische Behandlung von Hochspannungsverletzungen.

PURPOSE/BACKGROUND: High-voltage burns represent a challenging surgical entity. Compared to conventional burns, these injuries are characterized by an increased morbidity and worse potential for rehabilitation. The aim of the present study was to analyse the management of high-voltage injuries during the early posttraumatic period with special emphasis on the surgical procedures. PATIENTS/MATERIAL AND METHOD: We retrospectively evaluated the medical records of patients with electrical injuries treated from 1995 - 2007. A total of 61 patients (57 men, 4 females, mean age: 34 +/- 13 years) with high-voltage burns was included for analysis. RESULTS: The majority of high-voltage burns was work-related (75 %). The mean total burn area was 35 % of the total body surface, with a mean of 29 % deep burns. An average of 4.8 +/- 4 operations were performed per patient (range: 1 - 23 operations). Surgical procedures included repeated debridement/necrectomy (100 % of all patients), early escharotomy/fasciotomy (47.5 %), and amputations (18 %). 14 patients (23 %) underwent reconstructive surgery using either local or free flaps. The mortality rate was 15 %. CONCLUSION: The surgical management of high-voltage burns is characterised by repetitive debridements and necrectomies. Despite an aggressive approach to remove necrotic tissue, the mortality in this type of injury is considerably high. Limb salvage may be achieved with the use of free microvascular flaps. However, an amputation of necrotic extremities must be considered in the copresence of septic complications.

Free functional muscle transplantation for facial reanimation: experimental comparison between the one- and two-stage approach.

To investigate functional results of either one- or two-staged free muscle transplantation the scutuloauricularis model in the New Zealand white rabbit was used. Thirty rabbits were allocated to two groups with 15 animals each. In Group 1 (one-stage approach) peroneus brevis (PB) was harvested as a free muscle graft with a 7cm long motor branch. The graft was positioned instead of right scutuloauricularis (SCUT) and its vascular supply microsurgically re-established. The motor branch was transferred to the contralateral side and its proximal end coapted to the cut facial motor branch to left SCUT. Before nerve coaptation biopsies were harvested from the cut motor branch for morphological analysis. In Group 2 (two-stage approach) a 7cm long saphenous nerve graft was taken and coapted to the cut motor branch of SCUT and crossed over to the contralateral side. Nerve specimens from the cut motor branch were taken. Eight months later the free transplantation of PB was performed and its motor branch coapted to the distal end of the cross-over nerve graft. After a total time period of 13 months the final experiments were carried out in each group. Maximal tetanic tensions in reinnervated PB were measured and biopsies of muscle grafts together with nerve biopsies from the distal part of the motor branch were harvested for morphological analysis. Muscle grafts of Group 1 revealed tetanic tension values of 12.5N (SD 3.1) in comparison to 10.6N (SD 3.5) obtained in Group 2. This difference was not statistically significant (p=0.303). In Group 1, the amount of regenerated nerve fibers counted at the distal motor branch site (mean: 2798, SD 1242) was significantly higher (p=0.008) than in Group 2 (mean: 1138, SD 1004). Muscle graft morphology revealed significantly less Type I fibers (p=0.016) and more Type IIb/d fibers (p=0.011) in Group 1 compared to Group 2. However, the overall amount of perimysial connective tissue showed no significant difference in both groups (p=0.478). Free muscle transplantation in a one-stage approach offers similar functional results in comparison to the two-stage approach. Although muscle grafts of the one-stage transplantation underwent a longer period of denervation similar contents of perimysial connective tissue could be observed.

[Cost effectiveness of V.A.C. therapy after post-sternotomy mediastinitis]. / Kosteneffektivität der V.A.C.-Therapie nach Poststernotomie Mediastinitis.

Since November 2001 all patients with postoperative sternum bone infections were treated with V.A.C. therapy. The mean length of stay at intensive care unit was reduced from 9 to 1 day and reduces costs for 33 714.- USD per patient. Additionally patients who had to be closed with pectoralis muscle flap had significant reduced length of stay at ICU (1 vs 4 days, cost effectiveness 14 984.- USD per patient). The V.A.C. therapy after post-sternotomy mediastinitis significantly reduces morbidity and mortalità and is cost effective.