Wound Healing and Therapy in Soft Tissue Defects of the Hand and Foot from a Surgical Point of View.

Wounds and tissue defects of the hand and foot often lead to severe functional impairment of the affected extremity. Next to general principles of wound healing, special functional and anatomic considerations must be taken into account in the treatment of wounds in these anatomical regions to achieve a satisfactory reconstructive result. In this article, we outline the concept of wound healing and focus on the special aspects to be considered in wounds of the hand and foot. An overview of different treatment and dressing techniques is given with special emphasis on the reconstruction of damaged structures by plastic surgical means.

Coating of an anti-Fas antibody on silicone: first in vivo results.

BACKGROUND: Although the etiology of capsular contracture after breast augmentation has not yet been definitively clarified, the literature contains numerous reports placing the blame on a foreign body reaction. We have developed a procedure for covalently activating a silicone surface with an anti-Fas antibody, which might suppress the foreign body reaction on the silicone surface. OBJECTIVES: The authors evaluate whether surrounding tissue might be influenced by anti-Fas antibody coating on silicone disks in comparison to untreated silicone disks in an in vivo model. METHODS: During this study, 4-mm anti-Fas-coated silicone disks were implanted subcutaneously in the paravertebral region of mice (C57/BL6). Silicone disks passing the activation coating process without anti-Fas antibody incubation were defined as the control group. Twelve weeks after implantation, the disks were removed and the surrounding tissue examined. RESULTS: The tissue surrounding the silicone disks in the experimental group showed significantly increased levels of collagen type 3, elevated levels of matrix metalloproteinase 9, markedly decreased levels of transforming growth factor ß2, and a reduced CD68 expression in the pericapsular tissue. CONCLUSIONS: The first in vivo data reveal that the tissue surrounding a silicone surface can be influenced by the vectored binding of an anti-Fas antibody.

Otfrid Foerster (1873-1941)--self-taught neurosurgeon and innovator of reconstructive peripheral nerve surgery.

Otfrid Foerster (1873-1941) became a self-taught neurosurgeon during and after WW I, playing a critical role in the development of peripheral nerve reconstruction. Although best known for describing dermatomes, he published over 300 articles on the nervous system. Confronted by thousands of nerve injuries during WW I, as well as poor results and disinterest from his surgical colleagues, Foerster began performing neurolysis and tension-free nerve repairs himself under emergency conditions. He pioneered grafting motor nerve defects by expendable cutaneous nerves (e.g., sural) and performed intraplexal neurotizations and various nerve transfers, such as the pectoral, subscapular, long thoracic, and thoracodorsal nerves in brachial plexus injuries. Foerster championed rehabilitation, recognizing the potential of electrostimulation and physiotherapy to influence cortical reorganization (brain plasticity) and improve recovery after nerve injury. Foerster died from tuberculosis in 1941, leaving a rich reconstructive peripheral nerve legacy; his innovative and visionary spirit serves as a role model.

Covalent vectored binding of functional proteins by bifunctional crosslinking at silicone interfaces.

In the daily clinical routine, numerous synthetic medical devices are implanted in the human body, either temporarily or permanently. The synthetic material most often implanted is polydimethylsiloxane (silicone). Numerous studies have demonstrated that silicone is encompassed in a connective tissue capsule by the body, preventing integration into the surrounding tissue. This can result in complications. The aim of our study was to develop a simple procedure to functionalize the silicone surface, thereby positively affecting the material's biocompatibility. By combining a silanization with the use of ester activation, a reactive amino group is generated, which can bind any free carboxyl group. Directional crosslinking of a near-infrared-conjugated fluorophore antibody to the activated silicone surface could be demonstrated on a dose-dependent basis. The redox reaction at a silicone surface coated with an HRP-conjugated antibody caused by the addition of NBT/BCIP could be shown. Covering the silicone discs with an anti-FAS-antibody coating followed by a coincubation with FAS-sensitive T-cells allowed highly significant detection of caspase-3. In summary, our crosslinking procedure enables the stable binding of proteins without the loss of biological function. Through this process, silicones could be endowed with new functions which could improve their biocompatibility.

Attack the tumor counterattack-c-FLIP expression in Jurkat-T-cells protects against apoptosis induced by coculture with SW620 colorectal adenocarcinoma cells.

BACKGROUND: Cancer development relies on a variety of mechanisms that facilitate tumor growth despite the presence of a functioning immune system, employing different mechanisms to escape immune rejection. Tumors may eliminate tumor-infiltrating lymphocytes and suppress anti-tumor immune responses, a process called "tumor counterattack," based on activation-induced cell death via the FAS/FAS-ligand system. To overcome this tumor-cell survival strategy, we examined the hypothesis that the sensitivity of FAS mediated apoptosis of Jurkat-T-cells can be suppressed by FLIP transfection of Jurkat-T-cells. MATERIALS AND METHODS: Jurkat-T-cells were transfected with the FLICE-inhibitory protein FLIP in order to bestow them with a resistance to FAS-receptor-mediated apoptosis. FLIP-transfected and non-transfected Jurkat-T-cells were grown in coincubation with SW620 cells and the rates of apoptosis measured via FACS-analysis of Annexin-V. RESULTS: First, the tumor-counterattack described in the literature was confirmed. About 20% of Jurkat-T-Cells underwent apoptosis in coculture with SW620 cells. After coincubation of SW620 cells with FLIP transfected Jurkat-T-cells the apoptotic rate was significant reduced at levels below 4%. CONCLUSION: Transfection of Jurkat-T-cells with FLIP reduces the sensitivity of Jurkat-T-cells to FAS-mediated apoptosis and may lead to an improved capability to antagonize the inherent tumor survival strategy of SW620 cells.

Angiographic findings in patients with postoperative soft tissue defects following total knee arthroplasty.

PURPOSE: A postoperative defect of the surrounding soft tissue is one main risk factor for implant exposure and infection following total knee arthroplasty (TKR). The main factors that promote infection, tissue ischemia, and hypoxia are strongly associated with arterial insufficiency and the prevalence of impaired peripheral perfusion. We hypothesized that vascular malperfusion is the predisposing reason for soft tissue complications following TKR necessitating plastic reconstructive surgery. METHODS: A retrospective chart review was made among patients (n = 12) with soft tissue defects due to wound infection following a total knee arthroplasty referred to plastic reconstructive surgery. All patients presented with an exposed implant, and angiographic imaging was performed prior to reconstructive procedures. RESULTS: Eight out of twelve patients (67%) had a pathological vascular status. In three of these patients, interventional procedures were performed to ameliorate perfusion. In ten patients (83%), the defect was covered with a plastic reconstructive regional or free tissue transfer. Four patients received a free latissimus dorsi flap and six patients a pedicled a gastrocnemius muscle flap. In one patient, a secondary wound closure was needed after knee arthrodesis and an amputation was performed in another patient due to a multiresistant staphylococcus aureus infection and massive tissue destruction at the time of admission. CONCLUSIONS: We suggest to rule out peripheral occlusive disease among patients undergoing TKR at best prior to orthopedic surgery using pulses and, if in doubt ankle-brachial index and doppler sonography Consequently, if vascular occlusions are then confirmed by angiography, dilatation and stenting or revascularization should be performed, to ameliorate perfusion.

Is there an association between comorbidities and the outcome of microvascular free tissue transfer?

The aim of this study was to evaluate the relevant conditions for safe free flap transfers. The authors retrospectively studied the data from 150 patients who received free flaps at a single institution. Many parameters were analyzed to reveal if there was a correlation with respect to surgical or medical complications. Regarding safety of free tissue transfer, we found a worse prognosis in flaps where a revision of the microanastomosis had to be performed. Platelet count and leukocyte count had an impact on the prognosis. Patients older than 60 years did not have an increased rate of surgical complications. Apart from active osteomyelitis, the presence of comorbid conditions did not significantly impair the outcome of flap transfer, although smoking and diabetes correlated with minor surgical complications like wound breakdown or hematoma, respectively. Besides one case of lethal heart failure of an octogenarian patient, no severe medical complications occurred in this series of patients. Microvascular free tissue transfer is not significantly impaired by age and most comorbidities. Osteomyelitis as well as elevated leukocytes and lowered platelets may increase the complication rate and worsen the surgical prognosis. Smoking and diabetes might prolong the hospital course of the patients.

Reconstruction of nasal deformity in Wegener's granulomatosis: contraindication or benefit?

BACKGROUND: Saddle-nose deformity is a well-recognized stigma of patients affected by Wegener granulomatosis (WG). However, plastic surgical repair is seldom performed. In this study, the authors aimed to evaluate their own patients exclusively reconstructed by costal cartilage L-strut of the nose for this specific deformity. METHODS: During a 5-year-period, four women with an average age of 33 years underwent reconstructive rhinoplasty of their saddle-nose deformity caused by WG, which in every case was in remission regarding the nose at the time of surgery. Restoration of the nasal framework was performed by an L-shaped rib cartilage graft. RESULTS: The external form and function of the newly reconstructed nose was preserved during an average follow-up period of 42 months for all the patients. No resorption of the rib cartilage graft was observed. A review of the literature found a total of 22 nasal reconstructions for patients affected by WG. CONCLUSION: According to this patient series and a review of the literature, external nasal reconstruction for patients affected by WG appears to be safe and effective if the disease is in remission before any operation. Despite concern that high-dose immune suppression therapy may increase the risk of failure in primary nasal dorsal repair, this could not be observed in the patients of this series, all of whom were receiving immunosuppressive medication. Therefore, nasal reconstruction to improve the physical appearance and thus the psychological well-being of these chronically ill patients seems to be justified.

[Restoration of active elbow flexion by muscle transfer of the latissimus dorsi]. / Rekonstruktion der aktiven Ellbogenbeugung durch bipolare Transposition des Musculus latissimus dorsi.

OBJECTIVE: Reconstruction of active elbow flexion against gravity (strength grade > or =M(3)) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity. INDICATIONS: Irreparable lesions of the musculocutaneous nerve (C(5)/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C(5)/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor. CONTRAINDICATIONS: Possible recovery of biceps function by reinnervation, spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M(4)). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program. SURGICAL TECHNIQUE: The intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor. POSTOPERATIVE MANAGEMENT: Following postoperative immobilization in an upper-arm Gilchrist bandage at 100 degrees flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8-10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90 degrees for 6 months. RESULTS: According to the authors' experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90 degrees elbow flexion) and strength (at least antigravity strength, > or =M(3)) with acceptable donor morbidity and complication rate.

Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy - worse or worth?

BACKGROUND: Controversy remains regarding timing in the management of complex traumatic lower extremity defects. Many authors recommend a definitive bony and soft tissue reconstruction within a critical period of 72 h, yet in many patients this may be impossible due to concomitant injuries or delayed referral. However, little data are available on the results of delayed flap reconstruction of complex traumatic extremity defects, especially using new technologies of wound coverage such as vacuum-assisted closure (VAC((R))) therapy which may reduce the disadvantages of conventional open wound therapy prior to a subsequent flap reconstruction. METHODS: We retrospectively analysed the soft tissue reconstructions in 43 open extremity fractures during a 4-year period with special regard to complications, overall flap loss and wound infection. RESULTS: A total of 29 male and 13 female patients with 33 open fractures of the lower and 10 of the upper extremity were included. All patients had been referred from a trauma centre at a mean interval of 19 days (range 1-96 days) after the trauma event with temporary VAC((R)) of their wounds after initial fracture fixation and initial debridement of necrotic tissue. Flap reconstruction was thus only possible later than 72 h and definitive wound closure was achieved at a mean time of 28 days (range 3-106 days). Overall, three pedicled flaps were lost and one of 38 microsurgical free flaps (2.6%) underwent necrosis, the cause of which was unrelated to treatment delay. CONCLUSIONS: According to this study, the flap reconstructions performed beyond the frequently quoted critical interval yielded similar results to those of immediate reconstruction within the first 3 days, as reported in the literature. This strategy is in accordance with the principles of 'Damage Control Orthopaedics (DCO)' and may reduce the importance of emergency reconstructions, especially in poly-traumatised patients.

Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels.

BACKGROUND: Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops. METHODS: Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17). RESULTS: Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher's exact test did not indicate a significant difference between a simultaneous or staged flap transfer. CONCLUSIONS: Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.