A single application of cold atmospheric plasma (CAP) improves blood flow parameters in chronic wounds.

OBJECTIVE: To find out whether application of cold atmospheric plasma (CAP) affects microcirculation in chronic wounds. METHODS: We treated 20 patients with chronic wounds on the lower extremity with CAP. Blood flow parameters of wounds were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in tissue depth of 2 and 6-8 mm. Parameters were assessed under standardized conditions before and over the course of 30 min after application of CAP. RESULTS: Deep capillary blood flow increased significantly by up to 24.33% (percentage change) after treatment with CAP and remained significantly elevated until the end of measuring period at 30 min. Superficial oxygen tissue saturation was significantly elevated by 14.05% for the first 5 min after treatment. Postcapillary venous filling pressure was significantly elevated by 10.23% 19 min after CAP and stayed significantly elevated starting from minute 24 until the end of measuring. CONCLUSION: Cold atmospheric plasma increases microcirculation parameters in chronic wounds significantly. As CAP is known for its benefits in wound healing, the effects observed may explain the improved healing of chronic wounds after its use. Whether CAP-application can increase blood flow in chronic wounds for longer periods of time or boosts blood flow when applied more than once should be subject to further research.

Cold atmospheric plasma improves cutaneous microcirculation in standardized acute wounds: Results of a controlled, prospective cohort study.

BACKGROUND: Given the high prevalence of wounds and their challenging treatment, the research of therapies to improve wound healing is of great clinical interest. In addition, the general consequences of developing chronic wounds constitute a large health economic aspect, which underscores the interest in the development of efficient treatment strategies. Direct cold atmospheric plasma (di_CAP) has been shown to have beneficial effects on microcirculation of human tissue (Kisch et al., 2016a). It also affects microbial settlements, which may have supportive effects on wound healing processes (Balzer et al., 2015). To treat these adequately, in our view, the positive effects on wound healing should be objectified by application on standardized wounds. However, wound healing is a complex process, depending on nutrient and oxygen supply by cutaneous blood circulation. In spite of microcirculation has been shown to improve in healthy skin by CAP, a quantification of the effect in a standardized wound model has never been evaluated (Kisch et al., 2016a). Based on this, we hypothesize that CAP also influences the microcirculation in standardized acute wounds in a prospective cohort study. METHODS: Microcirculatory data of 20 healthy subjects (14 males, 6 females; mean age 40.85 ± 15.84 years; BMI 26.83 ± 7.27 kg/m2) were recorded continuously at a standardized acute wound after skin transplantation (donor site) at the thigh. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a dielectric barrier discharge (DBD) plasma device for 90 s to the acute wound area. Immediately after the application, cutaneous microcirculation was assessed for 30 min (min) at the same site. RESULTS: After CAP application, tissue oxygen saturation immediately increased by 5% (92,66 ± 4,76% vs. Baseline 88,21 ± 6,52%, p < 0,01) in the first 60 s and remained significantly elevated for 4 min. Capillary blood flow increased by 19.3% within the first minute of CAP therapy (220.14 ± 65.91 AU vs. Baseline 184.52 ± 56.77 AU, p < 0.001). The statistically highly significant increase in blood flow continued over the entire measurement time. A maximum value was shown in the blood flow in the 15th minute (232.15 ± 58.90 AU, p < 0.001) according to CAP application. With regard to the output measurement, it represents a percentage increase of 25.8%. The measurement of post-capillary venous filling pressure at a tissue depth of 6-8 mm was 59.39 ± AU 12.94 at baseline measurement. After application, there were no significant changes. CONCLUSION: CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the standardized acute wound healing model. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in chronic wounds. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

The repetitive application of cold atmospheric plasma (CAP) improves microcirculation parameters in chronic wounds.

BACKGROUND: Chronic wounds, such as venous leg ulcers, diabetic foot ulcers, and pressure ulcers, impose a significant burden on patients and health care systems worldwide. Cold atmospheric plasma (CAP) accelerates wound healing and decreases bacterial load in chronic wounds in both in vitro and in vivo experiments. For the first time, we examined the effects of a repetitive application of CAP on the microcirculation in chronic wounds. HYPOTHESIS: The repetitive application of cold atmospheric plasma application further improves microcirculation in chronic wounds. METHODS: Twenty patients with chronic wounds were treated repetitively with CAP. The repetitive application consisted of three CAP sessions, each lasting 90 s and separated by a 10-minute microcirculation measuring period. Microcirculation parameters were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in a tissue depth of 2 mm. RESULTS: Tissue oxygen saturation was significantly increased after the first CAP application. The effect amplitude and duration were further increased after the second and third CAP application with a maximum increase by 16,7% (percent change; p = 0,004 vs. baseline) after the third application. There was no significant increase in capillary blood flow until the third CAP application. After the third CAP application, an increase by 22,6% (p = 0,014) was observed. Postcapillary filling pressure was not significantly increased over the measuring period. The repetitive application of CAP further enhances the microcirculation in chronic wounds compared to a single application. CONCLUSION: The repetitive application of CAP boosts and prolongs tissue oxygen saturation and capillary blood flow in chronic wounds compared to a single application. This insight could provide an impetus for new treatment protocols.

Blood Flow in the Scaphoid Is Improved by Focused Extracorporeal Shock Wave Therapy.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) has shown benefits in patients with nonunion or delayed bone healing, pseudarthrosis, and avascular necrosis of bone. Until now, these effects were explained by the release of growth factors, activation of cells, and microfractures occurring after ESWT. Microcirculation is an important factor in bone healing and may be compromised in fractured scaphoids because its blood supply comes from the distal end. Due to this perfusion pattern, the scaphoid bone is prone to nonunion after fracture. The ability of ESWT to enhance microcirculation parameters in soft tissue was of interest to determine if it improves microcirculation in the scaphoid. QUESTIONS/PURPOSES: (1) Does capillary blood flow increase after a single session of ESWT in the scaphoid? (2) Do oxygen saturation in the bone and postcapillary venous filling pressure increase after a single session of ESWT in the scaphoid? METHODS: ESWT (0.3 mJ/mm, 8Hz, 1000 impulses) was applied to the intact scaphoid of 20 volunteers who were without wrist pain and without any important metabolic disorders. Mean age was 43 ± 14 years, 12 men and eight women (40% of total). Volunteers were recruited from January 2017 to May 2017. No anesthetic was given before application of ESWT. An innovative probe designed for measurements in bone by compressing soft tissue and combining laser-Doppler flowmetry and spectrophotometry was used to noninvasively measure parameters of microcirculation in the scaphoid. Blood flow, oxygenation, and venous filling pressure were assessed before and at 1, 2, 3, 5, 10, 15, 20, 25, and 30 minutes after ESWT application. Room temperature, humidity, ambient light and measuring sequences were kept consistent. A paired t-test was performed to compare experimental data with baseline (p < 0.05 taken as significant). RESULTS: At baseline, capillary blood flow of the bone was 108 ± 46 arbitrary units (AUs) (86 to 130). After treatment with ESWT, it was 129 ± 44 AUs (106 to 150; p = 0.011, percentage change of 19 %) at 1 minute, 138 ± 46 AUs (116 to 160; p = 0.002, percentage change of 28%) at 2 minutes, 146 ± 54 AUs (121 to 171; p = 0.002, percentage change of 35%) at 3 minutes and 150 ± 52 AUs (126 to 174; p < 0.001, percentage change of 39%) at 5 minutes. It remained elevated until the end of the measuring period at 30 minutes after treatment at 141 ± 42 AUs (121 to 161; p = 0.002) versus baseline). Oxygen saturation and postcapillary venous filling pressure in bone showed no change, with the numbers available. CONCLUSIONS: A single session of ESWT increased capillary blood flow in the scaphoid during measuring time of 30 minutes. Bone oxygenation and postcapillary venous filling pressure, however, did not change. Because increased oxygenation is needed for improved bone healing, it remains unclear if a sole increase in capillary blood flow can have clinical benefits. As the measuring period was limited to only 30 minutes, bone oxygenation and postcapillary filling pressure may subsequently show change only after the measuring-period ended. CLINICAL RELEVANCE: Further studies need to evaluate if increased capillary blood flow can be sustained for longer periods and if bone oxygenation and postcapillary venous filling pressure remain unchanged even after prolonged or repetitive ESWT applications. Moreover, clinical studies must validate if increased microcirculation has a positive impact on bone healing and to determine if ESWT can be therapeutically useful on scaphoid fractures and nonunions.

Improvement of cutaneous microcirculation by cold atmospheric plasma (CAP): Results of a controlled, prospective cohort study.

BACKGROUND: Cold atmospheric plasma (CAP) has proven its benefits in the reduction of various bacteria and fungi in both in vitro and in vivo studies. Moreover, CAP generated by dielectric barrier discharge (DBD) promoted wound healing in vivo. Charged particles, chemically reactive species (such as O3, OH, H2O2, O, NxOy), ultraviolet radiation (UV-A and UV-B), strong oscillating electric fields as well as weak electric currents are produced by DBD operated in air. However, wound healing is a complex process, depending on nutrient and oxygen supply via cutaneous blood circulation. Therefore, this study examined the effects of CAP on cutaneous microcirculation in a prospective cohort setting. HYPOTHESIS: Cold atmospheric plasma application enhances cutaneous microcirculation. METHODS: Microcirculatory data of 20 healthy subjects (11 males, 9 females; mean age 35.2 ± 13.8 years; BMI 24.3 ± 3.1 kg/m(2)) were recorded continuously at a defined skin area at the radial forearm. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90 s to the same defined skin area of 22.5 cm(2). Immediately after the application cutaneous microcirculation was assessed for 30 min at the same site. RESULTS: After CAP application, tissue oxygen saturation immediately increased by 24% (63.8 ± 13.8% from 51.4 ± 13.2% at baseline, p<0.001) and stayed significantly elevated for 8 min. Cutaneous blood flow increased by 73% (41.0 ± 31.2 AU from 23.7 ± 20.8 AU at baseline, p<0.001) and remained upregulated for 11 min. Furthermore, cutaneous blood flow showed two peaks at 14 (29.8 ± 25.0 AU, p=0.049) and 19 min (29.8 ± 22.6 AU, p=0.048) after treatment. Postcapillary venous filling pressure continuously increased, but showed no significant change vs. baseline in the non-specific BMI group. Subgroup analysis revealed that tissue oxygen saturation, postcapillary venous filling pressure and blood flow increased more in case of a lower BMI. CONCLUSION: CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the radial forearm of healthy volunteers. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in diabetic foot ulcers. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

The repetitive use of non-thermal dielectric barrier discharge plasma boosts cutaneous microcirculatory effects.

BACKGROUND: Non-thermal atmospheric plasma has proven its benefits in sterilization, cauterization and even in cancer reduction. Furthermore, physical plasma generated by dielectric barrier discharge (DBD) promotes wound healing in vivo and angiogenesis in vitro. Moreover, cutaneous blood flow and oxygen saturation can be improved in human skin. These effects are mostly explained by reactive oxygen species (ROS), but electric fields, currents and ultraviolet radiation may also have an impact on cells in the treated area. Usually, single session application is used. The aim of this study was to evaluate the effects of the repetitive use of cold atmospheric plasma (rCAP) on cutaneous microcirculation. HYPOTHESIS: The repetitive use of non-thermal atmospheric plasma boosts cutaneous microcirculation effects. METHODS: Microcirculatory data was assessed at a defined skin area of the radial forearm of 20 healthy volunteers (17 males, 3 females; mean age 39.1±14.8years; BMI 26.4±4.6kg/m(2)). Microcirculatory measurements were performed under standardized conditions using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90s and cutaneous microcirculation was assessed for 10min. Afterwards, a second session of CAP application was performed and microcirculation was measured for another 10min. Then, the third application was made and another 20min of microcirculatory parameters were assessed. RESULTS: Tissue oxygen saturation and postcapillary venous filling pressure significantly increased after the first application and returned to baseline values within 10min after treatment. After the second and third applications, both parameters increased significantly vs. baseline until the end of the 40-minute measuring period. Cutaneous blood flow was significantly enhanced for 1min after the first application, with no significant differences found during the remainder of the observation period. The second application improved and prolonged the effect significantly until 7min and the third application until 13min. CONCLUSION: These data indicate that the repetitive use of non-thermal atmospheric plasma boosts and prolongs cutaneous microcirculation and might therefore be a potential tool to promote wound healing.

Repetitive shock wave therapy improves muscular microcirculation.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) is mainly applied in tendon as well as bone problems based on stem-cell activation and healing acceleration. The effect of ESWT on muscle tissue is much less understood to date. However, from a clinical perspective, muscle injuries are of distinct interest especially in elite athletes such as soccer players. MATERIAL AND METHODS: A total of 26 rats were randomized into two groups. Group A received a single application of high-energetic focused ESWT (0.3 mJ/mm(2), 4 Hz, 1000 impulses, 10 J), whereas group B underwent the same procedure every 10 min for three sessions (3 × 0.3 mJ/mm(2), 4 Hz, 3 × 1000 impulses, totaling 30 J). Blood flow at a depth of 8 mm was measured continuously and noninvasively by a combined Laser-Doppler-Imaging and photospectrometric technique (Oxygen-to-see, O2C, LEA Medizintechnik, Germany). RESULTS: One minute after the application of high-energy ESWT blood flow in group A increased by 16.5% (P = 0.007). Thereafter, it decreased from minute 2 after application and remained significantly unchanged to baseline value until the end of the measuring period at 50 min (P = 0.550). Group B showed a similar significant increase in blood flow of 16.4% (P = 0.049) and a decrease afterward, too. After the second focused ESWT blood flow was boosted to 26.6% (P = 0.004), remaining significantly elevated until the third application was initiated. Muscular blood flow was increased to 29.8% after the third focused ESWT (P < 0.001), remaining significantly increased for another 10 min. CONCLUSIONS: Focused ESWT enhances blood flow in the muscle of rats. Moreover, repetitive ESWT extended this beneficial effect.

Prospective clinical study on digital nerve repair with collagen nerve conduits and review of literature.

Little data are available concerning conduit repair of digital nerve lesions. We are presenting a prospective two-center cohort study on digital nerve reconstruction with collagen nerve conduits. The data are put into the context of a comprehensive review of existing literature. Over a period of 3 years, all consecutive digital nerve lesions that could not be repaired by tensionless coaptation with a gap length of less than 26 mm were reconstructed with nerve conduits made from bovine collagen I. Sensibility was assessed 1 week, 3, 6, and 12 months postoperatively by static and moving 2-point-discrimination (2PD) and monofilament testing. Forty-nine digital nerve lesions in 40 patients met the inclusion criteria. The mean nerve gap was 12.3 ± 2.3 mm (span 5-25 mm). Forty nerve reconstructions could be included in the 12-month follow-up. Three cases, assessed 12 months postoperatively, showed excellent sensibility (static 2PD <6 mm). Seventeen achieved good (2PD 6-10 mm), 5 fair (2PD 11-15 mm), 6 poor (2PD >15 mm, but protective sensibility), and 9 achieved no sensibility. Monofilament test results were significantly better if gap length was shorter than 12 mm. Our results confirm tubulization as one possible technique in nerve reconstruction for gap lengths of 5 to 25 mm.

Removal of collagen nerve conduits (NeuraGen) after unsuccessful implantation: focus on histological findings.

Nerve conduits are nonneural, hollow tubular structures designed to bridge the gap of a sectioned nerve, to protect the nerve from scar formation, and to guide the regenerating fibers into the distal nerve stump. In the 8-year experience of our department, four patients aged 14 to 50 years had an unsuccessful implantation of a nerve conduit (NeuraGen, Integra, Plainsboro, NJ). In these four patients, the collagen tubes were replaced by an autogenous nerve graft. The histological specimens showed characteristic histological findings of a scar neuroma without any signs of foreign body reaction in three cases and with minimal foreign body reaction in one case. The collagen nerve tube was completely resorbed in all cases after a time period of 6 to 17 months and could not be detected marco- or microscopically.To our knowledge, this is the first report in the English and German literature describing the histological characteristics of explanted collagen nerve tubes in humans.

Split thickness skin graft versus application of the temporary skin substitute suprathel in the treatment of deep dermal hand burns: a retrospective cohort study of scar elasticity and perfusion.

Two therapeutic options for deep dermal hand burns are autologous split-thickness skin graft (STSG) following tangential excision and the application of the temporary wound dressing Suprathel following removal of burn blisters. We compared elasticity and perfusion of burn scars after both types of therapy at least one year after completion of treatment. A case series of 80 patients of our department with deep dermal hand burns between 2013 and 2018 was examined in the year 2019 at least one year after completion of treatment (24 females and 56 males with a median age of 47.6 years). The clinical assessment of the scar was performed with the Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) and the objective assessment with suction cutometry (MPA 580) and an O2C device on both hands. Our statistical analysis showed no statistically significant differences for the R2 and R5 elasticity values between the two types of therapy. The 95% confidence intervals for the ratios of elasticity, and microcirculatory perfusion parameters and scar scale scores of burn scars to respective healthy areas of skin after STSG and Suprathel-therapy mostly covered 1. Subgroup analysis of R2 viscoelasticity and analyses with adjustments for scar compression therapy, nicotine consumption, age, palmar or dorsal localization of the burn scar and interactions of age with smoking and localization gave similar results. The adjusted analysis of SO2 showed statistically significant lower SO2 values, 9% less, after STSG compared to Suprathel treatment. Split-thickness skin graft following tangential excision and the application of Suprathel following removal of burn blisters may be equivalent options for treatment of deep dermal hand burns. To detect possible small differences, further studies with larger samples are required.

[10 years of hand traumatology - an epidemiological, structural and economic analysis at a maximum care provider]. / 10 Jahre Handtraumatologie ­ eine epidemiologische, strukturelle und ökonomische Standortanalyse an einem Krankenhaus der Maximalversorgung.

BACKGROUND: Hand surgery in Germany has been subject to structural changes that strongly affect the balance between medicine and economics. On the one hand there is a shift of elective hand surgery from the inpatient to the outpatient sector. On the other hand - so our observations - emergency hand trauma cases are more concentrated in bigger hospitals. Given this background there is a lack of statistical data on the management of hand trauma care and treatment of patients with hand injuries. This article discusses a 10-year-analysis of hand traumatological cases treated at a maximum care hospital regarding epidemiological, structural and economic aspects. MATERIAL AND METHODS: Using a database query using ICD codes, inpatient hand trauma cases were identified between 2009-2018 and analyzed with regard to epidemiological and economic indicators (age, gender, comorbidities, case-mix-index (CMI), revenue, length of stay, length of surgery) using PIVOT tables. Patients under the age of 16 years, forearm fractures and intensive care patients were excluded. RESULTS: In the study period the typical hand surgical trauma patient was male with an average age of 44 years. The Patient-Clinical-Complexity-Level (PCCL) was 0 in 80 % of all cases. The proportion of work-related injuries averaged around 25 %. The three top diagnose related groups (DRG) were the I32F (18.5 %), X01B (11.3 %) and the I32A (7.2 %). A striking point was the massive increase in the overall number of trauma cases over the years from approx. 300 cases in 2009 to over 1000 cases per year in 2018 with a shift of the main workload to on-call and night-shift hours away from core working times. In the study period 4 of 5 others hospitals located in a distance of 100 km reduced and stopped treatment of emergency hand cases. The average length of a hospital stay was approx. 4-5 days, the average cut/suture time less than 60 minutes and the average CMI 1.23. Those cases generate an average proceed of € 4370 in 2018, whereby the cases generated by the work-related injuries averaged € 387 less. DISCUSSION: On the assumption that the number of emergency hand trauma cases did not really increase in the study period we think that there was a concentration of such cases in a few centres still providing extensive treatment for hand injuries while in smaller hospitals care for emergency hand trauma cases is progressively reduced. However, hand injuries may be worth a second thought for economic reasons because they can create reasonable revenues with rather little effort.If a critical number of patients is exceeded, costs of service provisions can be significantly amortized by the proceed generated by treatment. In those hospitals still taking care for acute hand injuries the workload especially in standby duty increased. What may have a negative input on the numbers of treated elective hand surgery cases.

Smart Scar Care-Industry 4.0 in Individualized Compression Garments: A Randomized Controlled Crossover Feasibility Study.

BACKGROUND: We tested the workflow and comparability of compression garments (CG) automatically knitted from 3D-body-scan data (3DBSD) versus manually measured data for scar treatment. Industry 4.0 has found its way into surgery, enhancing the trend toward personalized medicine, which plays an increasingly important role in CG scar therapy. Therefore, we conducted a study to evaluate the workflow from 3DBSD to fast and precisely knitted CG and compared it with standard of care. METHODS: A randomized controlled crossover feasibility study was conducted as part of the individual medical technology research project "Smart Scar Care." Objective and patient-reported outcome measures were documented for 10 patients with hypertrophic burn scars at baseline and after wearing CG automatically knitted from 3DBSD versus CG from manually measured data for one month. RESULTS: The "scan-to-knit" workflow and the study design were feasible in 10 of 10 patients. No adverse effects were found. 3DBSD showed a bias of half a centimeter compared with manually measured data and wider limits of agreement. With respect to fit, comfort, suitability, Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, stiffness and microcirculation, this was a promising pilot study. Stiffness and blood flow were increased in scars compared with normal skin. The highest rank correlations were found between pain and itch, stiffness and Patient and Observer Scar Assessment Scale, Vancouver Scar Scale, and pain. CONCLUSIONS: These results indicate that automatically knitted CG using 3DBSD could become an alternative to the standard of care, especially with regard to economical and faster patient care. The produced scan data opens the door for objective scar science.

Significant [C3a] increase in free flaps after prolonged ischemia.

BACKGROUND: Free tissue transfer (FTT) represents a clinical model to measure ischemia-reperfusion injury (IRI). This study was conducted to detect substances relevant for IRI after FTT. METHODS: Eighteen patients underwent lower leg reconstruction with free myocutaneous latissimus dorsi muscles and were monitored clinically and by microdialysis technique. Patients were retrospectively classified as group A (n = 12) (no prolonged IRI) or group B (n = 6) (prolonged IRI). One catheter was placed into the flap and one into the reference tissue. Samples were collected during ischemia and in 90 min steps after reperfusion. Biochemical substances (glucose, pyruvate, lactate, and glycerol) and immunological substances (interleukin 8 [IL-8], complement 3a [C3a], and regulated on activation normal T cell expressed and secreted [RANTES]) were then analyzed. RESULTS: All free myocutaneous latissimus dorsi flaps healed primarily. Minor complications included revisions of the microvascular anastomoses due to hematoma or thrombus formation and increased total flap ischemia time in group B significantly when compared to group A (P < 0.001). No significant differences of biochemical substance concentrations were detected during reperfusion in target and control tissue of both groups. IL-8 and C3a were at detectable levels, whereas the results for RANTES were inconsistent. Either for group A and group B, we found higher concentrations of C3a in target tissue compared with control tissue. Furthermore, during the first 90 min of reperfusion, we found a highly significant increase of C3a (P < 0.001) in the target tissue of patients with increased ischemia time. CONCLUSIONS: Given our results, C3a is a highly sensitive early indicator of ischemia-reperfusion damage. Our results give further insight into development of IRI after complicated FTT.

Reversible dilative cardiomyopathy after electrical injury: a case report.

BACKGROUND: Dilative cardiomyopathy is an uncommon cardiac complication of electric shock. CASE PRESENTATION: We report a case of a 12-year-old German boy with a high voltage injury who developed a four-chamber dilative cardiomyopathy, which was diagnosed on the 13th week postburn. One year after the accident, echocardiography showed a normal function of his heart with 64% ejection fraction and normal cavities' dimensions. CONCLUSIONS: Despite the fact that dilative cardiomyopathy is not very common in electrical injuries but can be fatal, a prolonged echocardiography follow-up for patients with electrical injury could be recommended. Until now this case is the first child with severe burns after electrocution, who developed a reversible dilative cardiomyopathy.

Novel Treatment of a Malignant Peripheral Nerve Sheath Tumor of the Median Nerve.

Malignant peripheral nerve sheath tumors are rare, associated with a poor prognosis and uncertainty regarding the appropriate management. We report a novel oncologic and reconstructive treatment of a young patient with a malignant peripheral nerve sheath tumor of the median nerve of the left hand. The patient underwent a wide local excision, an opponensplasty, a nerve reconstruction by nerve allografts followed by brachytherapy treatment. Two years later, the patient remains disease free with preserved function of her hand.

The Use of Bone Graft Substitute in Hand Surgery: A Prospective Observational Study.

Bone defects are a very common problem in hand surgery, occurring in bone tumor surgery, in complicated fractures, and in wrist surgery. Bone substitutes may be used instead of autologous bone graft to avoid donor site morbidity. In this article, we will review our experience with the use of Cerament bone void filler (Bonesupport, Lund, Sweden) in elective and trauma hand surgery. A prospective clinical study was conducted with 16 patients treated with this bone graft substitute in our department over a period of 3.5 years. Twelve patients (2 female, 10 male; with an average age of 42.42 years) with monostoic enchondroma of the phalanges were treated and 4 patients (1 female, 3 male; with an average age of 55.25 years) with complicated metacarpal fractures with bone defect. Data such as postoperative course with rating of pain, postoperative complications, functional outcome assessment at 1, 2, 3, 6 months, time to complete remodeling were registered. Postoperative redness and swelling after bone graft substitute use was noticed in 7 patients with enchondroma surgery due to the thin soft-tissue envelope of the fingers. Excellent total active motion of the involved digit was noticed in 10 of 12 enchondroma patients and in all 4 fracture patients at 2-month follow-up. In summary, satisfying results are described, making the use of injectable bone graft substitute in the surgical treatment of enchondromas, as well as in trauma hand surgery a good choice.

Immediate Dose-Response Effect of High-Energy Versus Low-Energy Extracorporeal Shock Wave Therapy on Cutaneous Microcirculation.

Elucidation of the precise mechanisms and therapeutic options of extracorporeal shock wave therapy (ESWT) is only at the beginning. Although immediate real-time effects of ESWT on cutaneous hemodynamics have recently been described, the dose response to different ESWT energies in cutaneous microcirculation has never been examined. Thirty-nine Sprague-Dawley rats were randomly assigned to three groups that received either focused high-energy shock waves (group A: total of 1000 impulses, 10 J) to the lower leg of the hind limb, focused low-energy shock waves (group B: total of 300 impulses, 1 J) or placebo shock wave treatment (group C: 0 impulses, 0 J) using a multimodality shock wave delivery system (Duolith SD-1 T-Top, Storz Medical, Tägerwilen, Switzerland). Immediate microcirculatory effects were assessed with the O2C (oxygen to see) system (LEA Medizintechnik, Giessen, Germany) before and for 20 min after application of ESWT. Cutaneous tissue oxygen saturation increased significantly higher after high-energy ESWT than after low-energy and placebo ESWT (A: 29.4% vs. B: 17.3% vs. C: 3.3%; p = 0.003). Capillary blood velocity was significantly higher after high-energy ESWT and lower after low-energy ESWT versus placebo ESWT (group A: 17.8% vs. group B: -22.1% vs. group C: -5.0%, p = 0.045). Post-capillary venous filling pressure was significantly enhanced in the high-energy ESWT group in contrast to the low-energy ESWT and placebo groups (group A: 25% vs. group B: 2% vs. group C: -4%, p = 0.001). Both high-energy and low-energy ESWT affect cutaneous hemodynamics in a standard rat model. High-energy ESWT significantly increases parameters of cutaneous microcirculation immediately after application, resulting in higher tissue oxygen saturation, venous filling pressure and blood velocity, which suggests higher tissue perfusion with enhanced oxygen saturation, in contrast to low-energy as well as placebo ESWT. Low-energy ESWT also increased tissue oxygen saturation, albeit to a lower extent, and decreases both blood velocity and venous filling pressure. Low-energy ESWT reduced tissue perfusion, but improved oxygen saturation immediately after the application.

Fractionated Repetitive Extracorporeal Shock Wave Therapy: A New Standard in Shock Wave Therapy?

BACKGROUND: ESWT has proven clinical benefit in dermatology and plastic surgery. It promotes wound healing and improves tissue regeneration, connective tissue disorders, and inflammatory skin diseases. However, a single treatment session or long intervals between sessions may reduce the therapeutic effect. The present study investigated the effects of fractionated repetitive treatment in skin microcirculation. METHODS: 32 rats were randomly assigned to two groups and received either fractionated repetitive high-energy ESWT every ten minutes or placebo shock wave treatment, applied to the dorsal lower leg. Microcirculatory effects were continuously assessed by combined laser Doppler imaging and photospectrometry. RESULTS: In experimental group, cutaneous tissue oxygen saturation was increased 1 minute after the first application and until the end of the measuring period at 80 minutes after the second treatment (P < 0.05). The third ESWT application boosted the effect to its highest extent. Cutaneous capillary blood flow showed a significant increase after the second application which was sustained for 20 minutes after the third application (P < 0.05). Placebo group showed no statistically significant differences. CONCLUSIONS: Fractionated repetitive extracorporeal shock wave therapy (frESWT) boosts and prolongs the effects on cutaneous hemodynamics. The results indicate that frESWT may provide greater benefits in the treatment of distinct soft tissue disorders compared with single-session ESWT.

Electrocautery Devices With Feedback Mode and Teflon-Coated Blades Create Less Surgical Smoke for a Quality Improvement in the Operating Theater.

Monopolar electrocautery is a fast and elegant cutting option. However, as it creates surgical smoke containing polycyclic aromatic hydrocarbons (PAHs), it may be hazardous to the health of the surgical team. Although new technologies, such as feedback mode (FM) and Teflon-coated blades (TBs), reduce tissue damage, their impact on surgical smoke creation has not yet been elucidated. Therefore, we analyzed the plume at its source.The aim of this study was to evaluate if electrocautery FM and TBs create less surgical smoke.Porcine tissue containing skin was cut in a standardized manner using sharp-edged Teflon-coated blades (SETBs), normal-shaped TBs, or stainless steel blades (SSBs). Experiments were performed using FM and pure-cut mode. Surgical smoke was sucked through filters or adsorption tubes. Subsequently, filters were scanned and analyzed using a spectrophotometer. A high-performance liquid chromatography (HPLC-UV) was performed to detect benzo[a]pyrene (BaP) and phenanthrene as 2 of the most critical PAHs. Temperature changes at the cutting site were measured by an infrared thermometer.In FM, more surgical smoke was created using SSB compared with TBs (P < 0.001). Furthermore, differences between FM and pure-cut mode were found for SSB and TB (P < 0.001), but not for SETB (P = 0.911). Photometric analysis revealed differences in the peak heights of the PAH spectrum. In HLPC-UV, the amount of BaP and phenanthrene detected was lower for TB compared with SSB. Tissue temperature variations increased when SSB was used in FM and pure-cut mode. Furthermore, different modes revealed higher temperature variations with the use of SETB (P = 0.004) and TB (P = 0.005) during cutting, but not SSB (P = 0.789).We found that the use of both TBs and FM was associated with reduced amounts of surgical smoke created during cutting. Thus, the surgical team may benefit from the adoption of such new technologies, which could contribute to the primary prevention of smoke-related diseases.

Collection of Wound Exudate From Human Digit Tip Amputations Does Not Impair Regenerative Healing: A Randomized Trial.

The regrowth of amputated digit tips represents a unique regenerative healing in mammals with subcutaneous volume regrowth, restoration of dactylogram, and suppression of scar formation. Although factor analysis in amphibians and even in mice is easy to obtain, safety of harvesting biomaterial from human digit tip amputations for analysis has not yet been described.The aim of this study was to evaluate if recovering wound exudate does hamper clinical outcome or influence microbiologic or inflammation status.A predefined cohort of 18 patients with fresh digit tip amputations was randomly assigned to receive standard therapy (debridement, occlusive dressing) with (n = 9) or without (n = 9) collection of the whole wound exudate in every dressing change. Primary endpoint (lengthening) and secondary endpoints (regeneration of dactylogram, nail bed and bone healing, time to complete wound closure, scar formation, 2-point discrimination, microbiologic analysis, inflammatory factors interleukin (IL)-1α, tumor necrosis factor-α, IL-4, and IL-6) were determined by an independent, blinded observer.Patients' characteristics showed no significant differences between the groups. All patients completed the study to the end of 3 months follow-up. Exudate collection did not influence primary and secondary endpoints. Furthermore, positive microbiologic findings as well as pus- and necrosis-like appearance neither impaired tissue restoration nor influenced inflammatory factor release.Here, the authors developed an easy and safe protocol for harvesting wound exudate from human digit tip amputations. For the first time, it was shown that harvesting does not impair regenerative healing. Using this method, further studies can be conducted to analyze regeneration associated factors in the human digit tip.DRKS.de Identifier: DRKS00006882 (UTN: U1111-1166-5723).