[Trauma surgical relevance of bite injuries by animals and humans]. / Unfallchirurgisch Relevantes zu Bissverletzungen von Mensch und Tier.

Bite injuries require differentiated treatment due to the deeply inoculated polymicrobial pathogen spectrum, possible concomitant injuries and pronounced soft tissue damage. Dog bites are the most common bite injuries but are less complicated to heal than human and cat bites. The location of the bite greatly depends on the age and the size of the bite victim as well as the type of bite perpetrator. In every case detection of the pathogen should be carried out to provide the best possible adapted treatment in the event of an exacerbation. The primary antibiotic treatment should be empirical with amoxicillin + clavulanic acid or ampicillin + sulbactam and, if necessary, adjusted according to the antibiogram. Depending on the findings, surgical treatment includes excision of the bite canal and a customized wound debridement. It is important to check the vaccination status of those involved and if indicated, to carry out postexposure prophylaxis for tetanus and rabies.

[Two-stage microsurgical soft tissue reconstruction of a complex sacral wound using an arteriovenous loop]. / Zweizeitige mikrochirurgische Weichteilrekonstruktion einer komplexen sakralen Wunde unter Verwendung eines arteriovenösen Loops.

The surgical reconstruction of sacral soft tissue defects is challenging, and complications are frequent. We report a successful two-stage three-dimensional microsurgical soft tissue reconstruction of a wide and deep sacral defect anastomosing a free combined ALT/TFL/rectus femoris flap to an ipsilateral vena saphena magna arteriovenous loop which was applied primarily. This case shows that complex microsurgical procedures can be promising in this demanding patient population if the indication is correct and the operative/perioperative strategy is clear.

Soft Tissue Reconstruction of Complex Infrainguinal Wounds Following Revisionary Vascular Surgery.

BACKGROUND: Large, full-thickness infrainguinal wounds following revision revascularization procedures of the lower extremity are a challenging complication for reconstructive surgery. Frequently, these patients present with various comorbidities and after several previous reconstructive attempts. Therefore no straightforward soft tissue reconstruction is likely. METHODS: Patients who presented with large, complex inguinal wounds for soft tissue reconstruction were analyzed retrospectively in terms of flap choice, outcome, and complication rates. A focus was set on the reconstructive technique and a subgroup analysis was assessed. RESULTS: Nineteen patients (11 men, 8 women) who received 19 flaps (17 pedicled, 2 free flaps) were included in this retrospective study. Average patient age was 73.3 years (range: 53-88). Ten fasciocutaneous flaps (anterolateral thigh [ALT], 52.6%) and 9 muscle flaps (47.4%) were applied. Among muscle flaps, 3 pedicled gracilis flaps, 4 pedicled rectus abdominis flaps, and 2 free latissimus dorsi flaps were used. No flap losses were observed except 1 case of limited distal flap necrosis (gracilis group). Body mass index ranged from 19 to 37, mean 26.8. Mean surgery time in all patients was 165.9 min (range: 105-373). Revision surgery due to local wound healing problems averaged 1.6 in all patients. In all cases sufficient soft tissue reconstruction was achieved and bypasses were preserved. Lengths of stay averaged 27.2 days (range: 14-59). Mortality was considerably (10.5%) due to systemic complications (one patient died due to a heart attack 4 weeks postoperatively, another patient died due to an extensive pulmonary embolism 2 weeks postoperatively). CONCLUSIONS: Soft tissue reconstruction of complex inguinal wounds after revision vascular surgery is challenging and wound healing problems are expectable. In addition to the rectus abdominis flap the pedicled ALT flap is feasible in a broad variety of medium to large wounds. Free flap reconstruction is recommended for very large defects. A structured interdisciplinary approach is required for the management of complex wounds after vascular surgery to prevent and to deal with complications and perioperative morbidity.

Use of Cold Plasma in Wound Healing: A Case Report.

ABSTRACT: The treatment of chronic wounds remains a serious medical and social problem. There are many innovative therapeutic approaches for the treatment of chronic wounds, one of which is cold plasma therapy. This case report describes an 85-year-old patient who presented with a chronic wound on his lower right leg. Despite repeated surgical wound debridements, his wound did not improve. Therefore, the authors initiated cold plasma therapy for his chronic wound. Through repeated application of cold plasma, the wound was completely healed within 8 weeks. As a noninvasive procedure, the cold plasma treatment was well tolerated and had no adverse effects. This case report provides promising results and could be the basis for further studies to confirm the effectiveness of active wound dressings with cold plasma in the treatment of chronic wounds.

[Suspected factitious disorder: identifying self-inflicted wounds in plastic surgery]. / Verdacht auf artifizielle Störung ­ Automutilation im chirurgischen Alltag erkennen.

BACKGROUND: Patients with factitious disorders artificially generate, aggravate or feign injuries or illnesses, which can result in severe physical impairment and misuse of the healthcare system. The symptomatology is characterized by a protracted course of disease with frequent changes of practitioners and multiple invasive procedures due to anomalous, mostly chronic findings. Elaborate clinical presentations, lack of knowledge of disease characteristics and the fast-paced everyday clinical practice can lead to maintaining the disease through non-recognition or mistreatment. METHODS: Based on selective literature research and clinical case reports from a university clinic for plastic surgery, this article provides a review about common features of factitious disorders as well as treatment strategies. RESULTS: If a factitious disorder is suspected, invasive treatments should be restricted and psychosomatic or psychiatric expertise obtained. Within an empathic physician-patient relation and with psychotherapeutic support, patients can be gradually introduced to the diagnosis and therapy options and treatment terminations could be avoided. CONCLUSION: Knowledge of indicators for factitious disorders, which may become evident in medical history, findings and illness-affirming behaviour, is key to identify affected patients and initiate appropriate treatment. For this purpose, factitious disorders should be included in differential diagnostic considerations even in primarily somatic medical specialties. Since the diagnosis is often based on evidence and complicated by withheld information or medical confidentiality, the establishment of a central reporting register could facilitate the diagnostic process and improve therapy in the future.

Effects of Extracorporeal Shock Waves on Microcirculation and Angiogenesis in the in vivo Wound Model of the Diver Box.

INTRODUCTION: Extracorporeal shock waves (ESWs) have been shown to have a positive effect on skin wound healing; however, little is known on the regeneration of the microcirculation and angiogenesis as well as the different application modes. METHODS: A total of 40 BALB/c mice were provided with dorsal skin fold chambers and were divided into 3 therapy groups (n = 30) and one control group (n = 10). The 3 therapy groups were treated with shock waves at different pulse rates (500-1,000 pulses/min) and application frequencies (day 0 and day 6 or day 0 only). Photographic documentation and intravital microscopy were carried out on day 1, 2, 4, and 6 after wounding. RESULTS: Using the newly developed Diver Box, shock waves could be applied in vivo without mechanical tissue damage. Shock wave therapy to skin wounds demonstrated to induce faster wound closure rates in the beginning than controls in groups with higher pulse rates and frequencies of the shock waves. Furthermore, the regeneration of microcirculation and perfusion in the healing skin was significantly improved after the application of, in particular, higher pulse rates as given by increased numbers of perfused capillaries and functional vessel density. The study of inflammation showed, especially in high-pulse ESW groups, higher leukocyte counts, and rolling leukocytes over time until day 6 as a response to the induction of inflammatory reaction after ESW application. Angiogenesis showed a marked increase in positive areas as given by sprouts, coils, and recruitments in all ESW groups, especially between days 4 and 6. CONCLUSION: The major findings of this trial demonstrate that ESW therapy to skin wounds is effective and safe. This is demonstrated by the initially faster wound closure rate, but later the same wound closure rate in the treatment groups than in controls. Furthermore, during the regeneration of microcirculation and perfusion in the healing skin, a significant improvement was observed after the application of, in particular, higher ESW pulse rates, suggesting an ESW-related increase in nutrient and oxygen supply in the wound tissue.

Improvement of Superficial and Deep Cutaneous Microcirculation Due to Axillary Plexus Anesthesia Impaired by Smoking.

BACKGROUND: Understanding microvascular physiology is key to any reconstructive procedure. Current concepts in anesthesia increasingly involve regional peripheral nerve blockade during microvascular reconstructive procedures. Whereas favorable effects on perfusion due to these techniques have been reported earlier, little evidence focusing on its effects in most peripheral vascular compartments is available. METHODS: A total of 30 patients who were to receive axillary plexus blockade (APB) were included. Microcirculatory assessment of the dependent extremity was conducted utilizing combined laser-Doppler flowmetry and white light spectroscopy. Two probes (1-2 and 7-8 mm penetration depth) were used to assess changes in microcirculation. RESULTS: APB resulted in significant changes to both superficial and deep cutaneous microcirculation. Changes in blood flow were most prominent in superficial layers with a maximum increase of +617% compared to baseline values. Significantly lower values of +292% were observed in deep measurements. Consecutively, a significant enhancement in tissue oxygen saturation was observed. Further analysis revealed a significant impairment of perfusion characteristics due to reported nicotine consumption (max Bf: +936% vs. +176%). CONCLUSION: Cutaneous microcirculation is strongly affected by APB, with significant differences regarding microvascular anatomy and vascular physiology. Smoking significantly diminishes the elicited improvements in perfusion. Our findings could influence reconstructive strategies as well as dependent perioperative anesthetic management.

Microvascular tissue transfer after the resection of soft tissue sarcomas.

BACKGROUND: Microvascular tissue transfer enables the oncological resection of soft tissue sarcomas of the extremities and the trunk by covering the resulting tissue defects that are often extensive. This study was performed to investigate the long-term survival and functional outcome of patients treated with free flaps after sarcoma resection. METHODS: A total of 78 sarcoma patients received microvascular tissue transfer in our institution between March 2003 and January 2013. In a retrospective analysis, we investigated data such as tumor characteristics as well as survival time and disease-free survival. In a prospective analysis, we assessed the functional outcome and the health-associated quality of life with the TESS and SF-36 questionnaire, respectively. RESULTS: Seventy patients qualified for disease-free survival after tumor resection, 41 patients remained disease free for over 5 years. Forty-five patients reached a survival time of more than 5 years. The functional results experienced by our patients were good with a mean score of 82.6% in the TESS. The physical health-related quality was lower than in the German norm sample and patients suffering from chronical illnesses or cancer, whereas the mental health was only slightly lower than in the norm sample and higher than in the groups with chronic illnesses or cancer (SF-36). CONCLUSION: Microvascular tissue transfer enables tumor resection and limb salvage through the coverage of the resulting defects without impairing patients' prognosis. The long survival times after tumor resection emphasizes the need for good functional results as well as quality of life.

The tight junction protein cingulin regulates the vascular response to burn injury in a mouse model.

Edema formation due to the collapse of physiological barriers and the associated delayed healing process is still a central problem in the treatment of burn injuries. In healthy individuals, tight junctions form a barrier to fluid and small molecules. Cingulin is a cytoplasmic component of tight junctions and is involved in the regulation of the paracellular barrier. Endothelial specific cingulin knock-out mice provide new insight into the influence of tight junction proteins on edema formation and angiogenesis during wound healing. Knock-out mice lacking the head domain of cingulin in endothelial cells (CgnΔEC) were created by breeding Cgnfl/fl mice with Tie1-cre mice. Using a no-touch hot air jet a burn trauma was induced on the ear of the mouse. Over a period of 12 days microcirculatory parameters such as edema formation, angiogenesis and leukocyte-endothelial interactions were visualized using intravital fluorescence microscopy. At baseline, CgnΔEC mice surprisingly showed significantly less tracer extravasation compared to Cgnfl/fl littermates, whereas, after burn injury, edema was consistently higher in CgnΔEC mice. Non-perfused area after wounding was increased, but there was no difference in vessel diameters, contraction or dilation of arteries in CgnΔEC mice. Moreover, cingulin knock-out did not cause a difference in leukocyte adhesion after burn injury. In summary, cingulin limits non-perfused area after burn injury and maintains the paracellular barrier of blood vessels. Since edema formation with serious systemic effects is a central problem of burn wounds, understanding the importance of tight junction proteins might help to find new treatment strategies for burn wounds.

The Impact of Surgical Margins and Adjuvant Radiotherapy in Patients with Undifferentiated Pleomorphic Sarcomas of the Extremities: A Single-Institutional Analysis of 192 Patients.

Background: Undifferentiated pleomorphic sarcomas are a frequent subtype within the heterogeneous group of soft tissue sarcomas. As the attainment of negative margins can be complicated at the extremities, we determined the prognostic significance of surgical margins in our patient population. Methods: We retrospectively determined the relationship between local recurrence-free survival (LRFS), overall survival (OS), and potential prognostic factors in 192 patients with UPS of the extremities who were suitable for surgical treatment in curative intent. The median follow-up time was 5.1 years. Results: The rates of LRFS and OS after 2 years were 75.7% and 87.2% in patients with R0-resected primary tumors and 49.1% and 81.8% in patients with R1/R2-status (LRFS: p = 0.013; OS: p = 0.001). Adjuvant radiotherapy significantly improved LRFS (5-year: 67.6% vs. 48.4%; p < 0.001) and OS (5-year: 82.8 vs. 61.8; p = 0.016). Both, negative margins and adjuvant radiotherapy were found to be independent prognostic factors in multivariate analysis. Conclusions: The data from this study could underscore the beneficial prognostic impact of negative margins on LRFS and OS. However, the width of negative margins seemed to be not relevant. Notably, adjuvant radiotherapy was not only able to decrease the risk of local failure but also improved OS in a significant manner.

Limb preserving surgery for soft-tissue sarcoma in the hand: a retrospective study of 51 cases.

Our retrospective study analysed the long-term results of a conservative limb-preserving surgical strategy in 51 patients with soft-tissue sarcoma of the hand from a single institution. We assessed survival and prognostic factors, including the surgical margins. No transradial amputations were performed. Microscopically free resection margins were obtained in 45 of the patients. The remaining six patients had microscopically incomplete resection. Forty-four surviving patients had a median follow-up of 6.5 years (range 12-307), and one patient had no follow-up beyond 3 months following surgery. Among those patients, 29 had more than 5 years of follow-up. Five-year local-recurrence-free survival was 65%, metastasis-free survival was 84%, and disease-specific survival was 91%. Tumour size was predictive of all outcome parameters, but positive resection margins adversely affected local recurrence only. Survival was similar to the survival after a more radical surgical approach reported in the literature. Level of evidence: IV.

Long-term Outcome of 181 Patients With Liposarcomas of the Extremity and Truncal Wall.

BACKGROUND/AIM: Liposarcomas (LS) are one of the most common entities within the heterogenous group of soft tissue sarcomas. The aim of this study was to identify prognostic indicators in patients with LS of the extremities and truncal wall. PATIENTS AND METHODS: We analysed the influence of potential prognostic factors on local recurrence-free survival (LRFS) and overall survival (OS) in 181 patients who were suitable for surgical treatment with curative intent. RESULTS: The median follow-up period was 7.1 years. The 5-year LRFS and OS rates were 79.1 and 93.3%. The 5-year OS rate was 94.7% in patients with R0-resected primary tumors and 72.7% in patients with R1/R2-status (p=0.023). In multivariate analysis, only histologic grade was found to be an independent prognostic factor of OS. CONCLUSION: Negative margins were not an independent prognostic factor in our series. Tumor biology reflected by histologic grade dictated the outcome.

Elastic Wrapping of Lower Extremity Free Flaps during Dangling Improves Microcirculation and Reduces Pain as well as Edema.

BACKGROUND: Free tissue transfer has become a common and safe reconstructive procedure. However, total or partial flap losses remain a looming threat, especially for lower extremity free flaps due to the gravitational challenge associated with dependency. Thus, the majority of microsurgical centers apply some kind of structured flap training. However, due to the lack of evidence, these differ greatly, for example, in the application of an elastic wrapping during dangling. Therefore, the aim of this study was to assess the impact of an elastic wrapping on free flap microcirculation, edema, and pain during dangling. METHODS: Standardized dangling was performed from postoperative day (POD) 6 to 9 in 30 patients with microvascular reconstruction of the lower extremity. The first dangling per day was performed without elastic wrapping, followed by another session with 30 mm Hg of elastic wrapping. Tissue oxygen saturation (StO2), regional hemoglobin content (rHb), and blood flow (BF) were continuously measured in the free flap; the circumference of the flap as well as pain was assessed. RESULTS: During wrapped dangling, BF as well as StO2 was significantly increased, while rHb was significantly lower on all PODs. Wrapped dangling was rated significantly more comfortable and the girth of the free flaps was significantly less after wrapped dependency when compared with unwrapped dangling. CONCLUSION: Dangling with an elastic wrapping with 30 mm Hg pressure improved flap microcirculation and reduced pain and edema formation.

[Peroneal palsy as a manifestation of acute diabetic mononeuropathy with complete recovery after surgical decompression - a case report and review of the literature]. / Peronaeusparese bei akuter diabetischer Mononeuropathie mit vollständiger Erholung nach chirurgischer Dekompression ­ Ein Fallbericht und Literaturübersicht.

This article presents the case of a 47-year-old patient with diabetes-related palsy of the peroneal nerve, illustrating the susceptibility of nerves to compression in patients with diabetes. Diagnostic evaluation, treatment and clinical course are presented and discussed in the context of the literature.

A Novel Technique for the Standardized Application of Shock Waves in Experimental Research: The Diver Box.

The Diver Box is designed to prevent impedance differences, energy loss or damage to neighboring structures caused by the use of shock waves with application gels. The Diver Box is an acrylic glass container filled with tempered water and includes a coupling membrane to prevent the impedance jump from air to water and to avoid the continuous propagation of shock waves into the tissue, maintaining wave dynamics. Different modes of extracorporeal shock waves can be applied to a mouse skin wound without energy loss and protected from harmful phase-reversed waves. Macroscopic changes were seen in only 5% to 12% of tested specimens. Hazardous phase reversal, back reflection and mechanical tissue damage can be avoided by use of the Diver Box, ensuring standardized extracorporeal shock wave application.

Effect of surgical margins on prognosis in aggressive fibromatosis: A single-institutional analysis of 90 patients.

The treatment of aggressive fibromatosis poses a therapeutic challenge in an interdisciplinary setting. The extent of surgical resection is still discussed controversially. The present retrospective analysis aimed to determine prognostic factors leading to recurrence. Between 2000 and 2014, 114 patients with aggressive fibromatosis were treated surgically at BG-University Hospital Bergmannsheil (Bochum, Germany). Univariate and multivariate analyses were restricted to 90 participants with information available on surgical margins at the initial procedure. The median follow-up time was 7.7 years. A total of 45 patients (50%) developed recurrence during follow-up. Primary tumors were resected with negative margins (R0) in 50 patients (68%) and with microscopically positive margins (R1) in 28 patients (25%). In addition, tumors in 12 patients (7%) were resected with macroscopically positive margins at the initial surgical procedure. The rates of recurrence-free survival (RFS) after 5 years were 68.8% [95% confidence interval (CI), 53.5-79.9%] in patients with R0-resected primary tumors and 34.1% (95% CI, 19.9-48.9%) in patients with R1/R2-status (P=0.001). Narrow and wide clear margins within the R0-group were not associated with significantly different outcomes. Adjuvant radiation, tumor site and patient age were not associated with a significant alteration of RFS. The current results suggest that the attainment of microscopically negative surgical margins at the initial surgical treatment is associated with a significantly improved prognosis. A conservative surgical approach involving the attainment of narrow negative margins while preserving function should be sought in patients in whom tumor resection is indicated. The decision for resection should be made interdisciplinary in each case based on tumor progression, available treatment alternatives and the decision of the informed patient.

Soft Tissue Sarcomas of the Extremities: Surgical Margins Can Be Close as Long as the Resected Tumor Has No Ink on It.

BACKGROUND: Soft tissue sarcomas (STS) arising in the extremities pose a therapeutic challenge due to concerns of functional morbidity. Resections with negative margins are the mainstay of therapy, but the prognostic significance of surgical margins remains controversial. The purpose of this study was to determine the prognostic impact of surgical margins and clear margin widths in patients with STS of the extremities. MATERIALS AND METHODS: We assessed the relationship between local recurrence-free (LRFS), disease-specific (DSS), and metastasis-free survival (MFS) and potential prognostic factors retrospectively in a consecutive series of 643 patients treated at our institution between 1996 and 2016. Potential prognostic factors were assessed using univariate and multivariate analyses. RESULTS: The median follow-up time after primary diagnosis was 5.4 years (95% confidence interval [CI]: 4.8-6.0). The five-year estimates of the DSS, LRFS, and MFS rates in the entire cohort were 85.3% (95% CI: 81.6-88.3), 65.3% (95% CI: 60.8-69.5) and 78.0% (95% CI: 74.1-81.4), respectively. Histological grade and the quality of surgical margins were independent prognostic factors of all three survival endpoints (LRFS, DSS, MFS) in multivariate analyses. Within the R0 subgroup, univariate and multivariate analyses of categorized (≤1 mm vs. 1-5 mm vs. >5 mm) and non-categorized margin widths revealed that close and wide negative margins led to similar outcomes. Adjuvant radiation improved local control independently, but not DSS and MFS. CONCLUSION: Microscopically negative margins were associated with better LRFS, DSS, and MFS regardless of whether adjuvant radiation was applied. Here, surgical margins can be close as long as the resected tumor has no ink on it. IMPLICATIONS FOR PRACTICE: In the present retrospective analysis of 643 patients with primary soft issue sarcomas of the extremities, surgical margins could be identified as independent predictors of local recurrence-free, disease-specific, and metastasis-free survival. Given the diminished outcome of patients left with positive margins, surgical efforts should aim to achieve microscopically negative margins whenever feasible. It is noteworthy that only the quality of surgical margins, but not the negative margin width attained, had an influence on the prognosis. Our findings suggest that surgical margins can be close as long as the resected tumor has no ink on it.

[Quo vadis DGPRÄC: associated members' goals for the future]. / Quo vadis DGPRÄC ­ wo wollen die assoziierten Mitglieder hin?

Plastic surgery is extremely diverse and offers various fields of work. To provide optimal support for plastic surgeons in training, it is therefore paramount to know their mid- and long-term goals. To that end, we conducted a web-based survey among the 462 associated members of the German Association of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC). Besides asking questions about the current status, we specifically inquired about the pursued setting and main area of work. 84 completed questionnaires were evaluated. Most respondents saw their future in a private practice setting. Reconstructive surgery and aesthetic surgery were by far the most sought-after fields, while only a few of the associated members pursued a career in hand surgery, and none of them wished to work in burn care. At the same time, they felt that aesthetic surgery was the field where training was most insufficient. Therefore, measures need to be taken to improve the training in aesthetic surgery. Also, it is paramount to increase the attractiveness of both the fields of hand surgery and burn care to assure highly qualified care in the future.