[Reconstruction options for infection-related defects : Plastic surgery armamentarium]. / Rekonstruktionsmöglichkeiten infektionsbedingter Defekte : Plastisch-chirurgisches Armamentarium.

BACKGROUND: The occurrence of infections has always been feared in all surgical disciplines. Plastic reconstructive surgery faces the challenge of treating infection-related defects on a patient-specific basis, which requires a multidisciplinary treatment concept. Satisfactory treatment success can only be achieved through radical debridement for infection cleansing, optimization of the perfusion situation paired with targeted anti-infective treatment and, if necessary, with soft tissue reconstruction by plastic surgery. OBJECTIVE: This article presents the current possibilities of plastic and reconstructive surgery with respect to the reconstruction of infection-related defects. MATERIAL AND METHODS: Proven and reliable strategies are presented and supplemented by promising experimental approaches. RESULTS: Due to the often multilayered defect situation caused by infections, from the epidermis to cancellous bone, the entire armamentarium of plastic and reconstructive surgery is used for reconstruction. CONCLUSION: The early involvement of plastic surgery in the treatment of infections and the interdisciplinary and multimodal treatment approach have proven their worth in the treatment of complex infection situations.

Reconstruction of an Extensive Segmental Radial Shaft Bone Defect by Vascularized 3D-Printed Graft Cage.

We report here a 46-year-old male patient with a 14 cm segmental bone defect of the radial shaft after third degree open infected fracture caused by a shrapnel injury. The patient underwent fixed-angle plate osteosynthesis and bone reconstruction of the radial shaft by a vascularized 3D-printed graft cage, including plastic coverage with a latissimus dorsi flap and an additional central vascular pedicle. Bony reconstruction of segmental defects still represents a major challenge in musculo-skeletal surgery. Thereby, 3D-printed scaffolds or graft cages display a new treatment option for bone restoration. As missing vascularization sets the limits for the treatment of large-volume bone defects by 3D-printed scaffolds, in the present case, we firstly describe the reconstruction of an extensive radial shaft bone defect by using a graft cage with additional vascularization.

Nerve Decompression in the Lower Leg Results in an Improvement in Symptoms in Patients With Both Diabetic and Idiopathic Polyneuropathy.

BACKGROUND: Patients suffering from polyneuropathy often complain of pain, tingling, and numbness sensations, as well as an increased risk of falling with the corresponding subsequent complications. If symptoms persist after conservative treatment options have been exhausted, nerve decompression in the lower extremity, as described by Dellon, can bring about an improvement in symptoms in many patients. Dellon originally reported that this surgery led to very successful outcomes in patients with diabetic polyneuropathy. In this study, we compare our postsurgical results in patients with diabetic versus idiopathic polyneuropathy. METHODS: Thirty-three patients with idiopathic or diabetic polyneuropathy who had undergone Dellon nerve decompression in the lower extremity between 2011 and 2013 were included in the retrospective study. Pain (numeric rating scale [NRS] 0-10; 0, no pain; 10, worst imaginable pain), tingling, numbness, Hoffmann-Tinel sign, and Semes-Weinstein monofilament were assessed in 20 patients with diabetic polyneuropathy and in 13 patients with idiopathic polyneuropathy. RESULTS: Three months after surgery, a significant reduction in pain was evident in patients with diabetic polyneuropathy, from a preoperative level of NRS 4.9 (minimum, 0; maximum, 10) to 2 (minimum, 0; maximum, 8; P = 0.005). Ninety percent of patients complained of tingling ( P = 0.000) before surgery and 18% after surgery, whereas 100% complained of numbness before surgery and 41% ( P = 0.000) after surgery. One hundred percent of patients had no measurable surface sensitivity before surgery (measured with the Semes-Weinstein monofilament), whereas 3 months after surgery, only 24% of patients still had no measurable surface sensitivity ( P = 0.000). A positive Hoffmann-Tinel sign was recorded in 85% of patients before surgery and only in 11% 3 months after surgery ( P = 0.000). In the case of patients with idiopathic polyneuropathy, a reduction in pain was evident 3 months after surgery, from a preoperative level of NRS 3.9 (minimum, 0; maximum, 9) to 2.2 (minimum, 0; maximum, 9; P = 0.058). Seventy-seven percent of patients complained of tingling before surgery and 42% after surgery ( P = 0.111), whereas 92% complained of numbness before surgery and 50% after surgery ( P = 0.030). Seventy-seven percent of patients had no measurable surface sensitivity before surgery (measured with the Semes-Weinstein monofilament), whereas 3 months after surgery, only 33% of patients still had no measurable surface sensitivity ( P = 0.047). A positive Hoffmann-Tinel sign was recorded in 62% of patients before surgery and only in 17% 3 months after surgery ( P = 0.041). CONCLUSIONS: Not only patients with diabetic polyneuropathy but also those with idiopathic polyneuropathy benefit from Dellon nerve decompression surgery in the lower extremities.

Treatment of Complex Wounds with NovoSorb® Biodegradable Temporising Matrix (BTM)-A Retrospective Analysis of Clinical Outcomes.

Complex and chronic wounds represent a highly prevalent condition worldwide that requires a multimodal and interdisciplinary treatment approach to achieve good functional and aesthetic outcomes. Due to increasing costs of health care, an aging population and an increase in difficult-to-treat microbial colonization of wounds, complex wounds will become a substantial clinical, social and economic challenge in the upcoming years. In plastic reconstructive surgery, a variety of dermal skin substitutes have been established for clinical use. Since its approval as a dermal skin substitute in Germany, NovoSorb® Biodegradable Temporising Matrix (BTM) has become a valuable therapeutic option for the treatment of full-thickness wound defects. The clinical data published to date are limited to case reports and small-scale case series with the main focus on single wounds. The aim of this single-center study was a retrospective analysis of our own patient collective that has received treatment with BTM for complex wounds. Overall, BTM showed to be a reliable and versatile reconstructive option, especially for patients with multiple co-morbidities and microbiologically colonized wounds. Although the preliminary findings have produced promising results, further investigation and research are warranted regarding long-term outcomes and additional clinical applications.

Radiological changes in shoulder osteoarthritis and pain sensation correlate with patients' age.

PURPOSE: Osteoarthritis (OA) is one of the most common musculoskeletal disorders in the aging population. The correlation of radiographic OA severity, disability and pain is variable and inconsistent for the different joints. This study aims to elucidate the relationship between histological and radiological signs of shoulder OA with pain sensation and functional impairment to potentially adapt the recommendation for surgical treatment for primary total shoulder arthroplasty (TSA). METHODS: Forty-four patients with shoulder OA undergoing TSA using an anatomic stemless implant were included in this study. The radiological OA severity was scored pre-operatively on true ap X-rays according to the Kellgren-Lawrence score (KL-Score). Acromial types according to Bigliani were defined by pre-operative radiological images. The histological OA severity was determined according to the OARSI-Score using bone-cartilage sections from loaded areas of the humeral head. Pain was quantified using the visual analog scale (VAS). The functional status was assessed by the items "mobility" and "strength" out of the Constant-Murley score (CS Score). Demographic data including BMI, age, gender, diabetes mellitus and smoking were recorded. RESULTS: There was no correlation between radiographic and histological severity in shoulder OA. However, a correlation of age and the severity of radiological changes was observed. Further, pain did not correlate with histological or radiological scores, whereas it correlated with age and the presence of diabetes mellitus. The functional shoulder status (mobility, strength) correlated with the severity of radiological changes, but not with the histologic scoring, which correlated with nicotine abuse. CONCLUSION: This study shows that increased age is the main determinant of radiological changes in shoulder OA, as well as pain. Therefore, age and pain sensation should be considered as important parameters for the recommendation for TSA.

SPECT/CT demonstrates the osseointegrative response of a stemless shoulder prosthesis.

BACKGROUND: This study evaluates bone remodeling processes in the proximal humerus induced by the implantation of a stemless shoulder prosthesis with regard to time of response and type and extent of bone turnover. METHODS: Twenty-eight patients with primary osteoarthritis of the shoulder undergoing a stemless shoulder arthroplasty were prospectively evaluated. The local metabolic bone activity in 5 regions of interest (ROIs 1-5) around the implant and in 1 reference region (ROI ref.) in the humeral diaphysis was analyzed after the application of technetium Tc 99m DPD using single-photon emission computed tomography integrated with multidetector computed tomography (SPECT/CT). The study cohort was divided into 4 groups according to the timing of the most recent follow-up appointment to evaluate the primary osseointegrative response after surgery. The bone uptake values were expressed in target (ROIs 1-5) to nontarget (ROI ref.) ratios. RESULTS: No difference within the 4 subgroups with respect to the time of local metabolic bone activity in the ROIs was found at 90 days after surgery. The highest initial metabolic activity and most temporal modifications were found in ROI 1, which was localized in the superior segment of the stem. CONCLUSIONS: SPECT/CT data suggest that the primary osseointegration of a stemless shoulder prosthesis is almost completed 3 months after implantation. Variations in metabolic activity pattern in the ROIs during follow-up may be caused by different loading conditions of the bone.