[Modern concepts of interdisciplinary extremity reconstruction in open fractures]. / Moderne Konzepte der interdisziplinären Extremitätenrekonstruktion bei offenen Frakturen.

The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.

Fibrin Glue Coating Limits Scar Tissue Formation around Peripheral Nerves.

Scar tissue formation presents a significant barrier to peripheral nerve recovery in clinical practice. While different experimental methods have been described, there is no clinically available gold standard for its prevention. This study aims to determine the potential of fibrin glue (FG) to limit scarring around peripheral nerves. Thirty rats were divided into three groups: glutaraldehyde-induced sciatic nerve injury treated with FG (GA + FG), sciatic nerve injury with no treatment (GA), and no sciatic nerve injury (Sham). Neural regeneration was assessed with weekly measurements of the visual static sciatic index as a parameter for sciatic nerve function across a 12-week period. After 12 weeks, qualitative and quantitative histological analysis of scar tissue formation was performed. Furthermore, histomorphometric analysis and wet muscle weight analysis were performed after the postoperative observation period. The GA + FG group showed a faster functional recovery (6 versus 9 weeks) compared to the GA group. The FG-treated group showed significantly lower perineural scar tissue formation and significantly higher fiber density, myelin thickness, axon thickness, and myelinated fiber thickness than the GA group. A significantly higher wet muscle weight ratio of the tibialis anterior muscle was found in the GA + FG group compared to the GA group. Our results suggest that applying FG to injured nerves is a promising scar tissue prevention strategy associated with improved regeneration both at the microscopic and at the functional level. Our results can serve as a platform for innovation in the field of perineural regeneration with immense clinical potential.

[Bionic Surgery Meets Bionic Reconstruction - First In-human use of Robotic Microsurgery in Targeted Muscle Reinnervation]. / Bionische Chirurgie trifft Bionische Rekonstruktion ­ erstes in-human Projekt von robotischer Mikrochirurgie zur Targeted Muscle Reinnervation.

Robotic microsurgery is an emerging field in reconstructive surgery, which provides benefits such as improved precision, optimal ergonomics, and reduced tremors. However, only a few robotic platforms are available for performing microsurgical procedures, and successful nerve coaptation is still a challenge. Targeted muscle reinnervation (TMR) is an innovative reconstructive procedure that rewires multiple nerves to remnant stump muscles, thereby reducing neuroma and phantom limb pain and improving the control of bionic prostheses. The precision of surgical techniques is critical in reducing axonal sprouting around the coaptation site to minimise the potential for neuroma formation. This study reports the first use of a microsurgical robotic platform for multiple nerve transfers in a patient undergoing TMR for bionic extremity reconstruction. The Symani robotic platform, combined with external microscope magnification, was successfully used, and precise handling of nerve tissue and coaptation was easily feasible even in anatomically challenging environments. While the precision and stability offered by robotic assistance may be especially useful for nerve surgery, the high economic costs of robotic microsurgery remain a major challenge for current healthcare systems. In conclusion, this study demonstrated the feasibility of using a robotic microsurgical platform for nerve surgery and transfers, where precise handling of tissue is crucial and limited space is available. Future studies will explore the full potential of robotic microsurgery in the future.

[Robot-assisted Microsurgery in Lower Extremity Reconstruction]. / Roboter-assistierte Mikrochirurgie in der Rekonstruktion der unteren Extremität.

BACKGROUND: In recent years, various robotic systems specifically designed for microsurgical tasks have been developed and approved. There is not much evidence for these systems to date. In our study, we examined the use of robot-assisted microsurgery in the reconstruction of the lower extremity. PATIENTS/MATERIAL AND METHODS: Data was prospectively collected between February and November 2023. The Symani robotic system was used in 42 robot-assisted microsurgical procedures on the lower extremity, and the results were evaluated and documented. RESULTS: The average age of the patients was 57±18 years. A total of 39 free flap reconstructions (95%), one lymphatic surgical procedure (3%) and two nerve transfers (5%) were performed. In total, 46 anastomoses and coaptations were carried out. This included six arterial end-to-end anastomoses (11%), seven arterial end-to-side anastomoses (13%), 36 venous end-to-end anastomoses (65%), two lymphovenous anastomoses (4%), and five epineural coaptations in the context of nerve transfers (9%). Arterial end-to-end anastomoses took an average of 26±12 minutes, and arterial end-to-side anastomoses took 42±21 minutes. The venous anastomoses took an average of 33±12 minutes. Epineural coaptations took an average of 24±13 minutes. In no procedure was there a need for a conversion to conventional hand suturing. There were two arterial thromboses (5%), one of which was successfully revised to save the flap. One total flap loss occurred, but there were no partial flap losses. CONCLUSION: Using the Symani robotic system for microsurgical reconstruction of the lower extremity, we were able to demonstrate results that are comparable to conventional microsurgery.

[Nerve Transfers in Peripheral Nerve Lesions]. / Nerventransfers bei peripheren Nervenläsionen.

BACKGROUND: Lesions of peripheral nerves of the upper extremities often lead to persistent, serious limitations in motor function and sensory perception. Affected patients suffer from both private and professional restrictions associated with long-term physical, psychological and socioeconomic consequences. INDICATION: An early indication for a nerve transfer shortens the reinnervation distance and improves the growing of motor and sensory axons into the target organ to facilitate early mobility and sensitivity. When planning the timepoint of the surgical procedure, the distance to be covered by reinnervation as well as the morbidities of donor nerves must be considered individually. RESULTS: Nerve transfers can achieve earlier and safer reinnervation to improve motor and sensory functions after nerve injuries in the upper extremity.

Multicenter consensus statements on the use of low-intensity pulsed ultrasound (LIPUS) in Hand Surgery.

OBJECTIVE: The purpose of this agreement was to establish consensus statements on the use of low-intensity pulsed ultrasound (LIPUS) in hand surgery. METHODS: Based on Delphi consensus methodology, a preliminary list of questions on the use of LIPUS in hand surgery was developed by an interdisciplinary team of hand and plastic surgeons as well as psychologists and experts from communications science. Based on these, questionnaires were invented and a total of three Delphi rounds have been conducted. Delphi panelists consisted of 11 German hand surgeons with a mean experience in hand surgery of 15 years (7-23 years). Questions and statements were revised during this process, resulting in a consensus at the end of round three. RESULTS: After three Delphi rounds, the following recommendations could be derived. LIPUS can be applied for impaired fracture healing of the digits, metacarpals, carpal bones as well as a prophylactic procedure in order to avoid further revision surgery. LIPUS therapy can be useful in addition to revision surgery for delayed union and non-unions. In the case of certain risk factors (replantation, revascularization, osteoporosis, smoking), it can be applied directly postoperatively in order to prevent impaired fracture healing. It should be applied for 90-120 days. CONCLUSION: There is a consensus among German hand surgeons, when and how LIPUS can be applied for improving fracture healing of the hand. Randomized controlled trials with direct comparison of fracture treatment with and without LIPUS are needed to support these statements with objective data.

Short- and long term hyposmia, hypogeusia, dysphagia and dysphonia after facial burn injury - A prospective matched cohort study.

BACKGROUND: Facial burns frequently occur in occupational or household accidents. While dysphagia and dysphonia are known sequelae, little is known about impaired smell and taste after facial burns. METHODS: In a prospective observational controlled study, we evaluated hyposmia via the Sniffin' Stick Test (SnS), hypogeusia via a taste strip test, and dysphonia and dysphagia via validated questionnaires acutely and one-year after burn, respectively. A matched control group consisting of a convenience sample of healthy volunteers underwent the same assessments. RESULTS: Fifty-five facial burn patients (FB) and 55 healthy controls (CTR) were enrolled. Mean burn size was 11 (IQR: 29) % total body surface area (TBSA); CTR and FB were comparable regarding age, sex and smoking status. Acutely, hyposmia was present in 29% of the FB group (CTR: 9%, p = 0.014) and burn patients scored worse on the SnS than CTR (FB: 10; CTR: 11; IQR: 2; p = 0.013). Hyposmia per SnS correlated with subjective self-assessment. Hyposmia and SnS scores improved over time (FB acute: 10.5 IQR: 2; FB one year: 11; IQR: 2; p = 0.042) and returned to normal at one-year post burn in most patients who completed the study (lost to follow-up: 21 patients). Taste strip scores were comparable between FB and CTR, as was the acute prevalence of dysphagia and dysphonia. CONCLUSION: Hyposmia acutely after facial thermal trauma appeared frequently in this study, especially when complicated by inhalation trauma or large TBSA involvement. Of all complete assessments, a fraction of burn patients retained hyposmia after one year while most improved over time to normal. Prevalence of dysphonia, dysphagia and hypogeusia was comparable to healthy controls in this study, perhaps due to overall minor burn severity.

Development of a mathematical formula and online tool to calculate the potential maximum flap width to allow for primary anterolateral thigh donor-site closure in Caucasians.

BACKGROUND: Primary anterolateral thigh (ALT) flap donor-site closure is crucial to achieve patient satisfaction, avoid burdensome secondary surgeries, and avert poor outcomes. Only vague maximum flap width recommendations have been suggested, which fall short of acknowledging individual patient habitus and thigh morphology. Therefore, we aimed at identifying a user-friendly preoperative calculation of maximum flap width for primary closure. METHODS: A total of 429 ALT free flaps performed between 2009 and 2020 were analyzed. A total of 350 donor-sites were closed primarily (82%) and 79 (18%) were split-thickness skin-grafted (STSG). Patient demographics including sex, age, and BMI, operative details, and flap characteristics were compared to assess their impact on the outcome variable. Receiver operating characteristic (ROC) curves were plotted for all significant predictors discriminating between closure and STSG. Areas under the curve (AUCs) were calculated for each parameter combination and optimal cutoffs were determined using Youden's Index. RESULTS: Sex, age, BMI, and flap width alone were poor discriminators. Dividing flap width by BMI and logarithmized BMI yielded AUCs of 0.91 and 0.94, respectively. Including patient sex yielded the best fitting regression model (χ2  = 251.939, p < .0001) increasing the AUC to 0.96 (95% CI: 0.93-0.98, p < .0001). The optimal cutoff value discriminated between primary closure and STSG with 90% sensitivity and 89% specificity. An online calculator of patient-individual maximum ALT width was then programmed. CONCLUSIONS: Sex and BMI are reliable predictors of successful primary ALT donor-site closure in Caucasians. We devised a novel formula for calculating patient-individual maximum ALT widths preoperatively, predicting failure of primary closure with 90% sensitivity in our cohort, available at: https://kitteltaschenbuch.com/altwidth/calculate.htm.

Closing the Gap: Bridging Peripheral Sensory Nerve Defects with a Chitosan-Based Conduit a Randomized Prospective Clinical Trial.

Introduction: If tensionless nerve coaptation is not possible, bridging the resulting peripheral nerve defect with an autologous nerve graft is still the current gold standard. The concept of conduits as an alternative with different materials and architectures, such as autologous vein conduits or bioartificial nerve conduits, could not replace the nerve graft until today. Chitosan, as a relatively new biomaterial, has recently demonstrated exceptional biocompatibility and material stability with neural lineage cells. The purpose of this prospective randomized clinical experiment was to determine the efficacy of chitosan-based nerve conduits in regenerating sensory nerves in the hand. Materials and methods: Forty-seven patients with peripheral nerve defects up to 26 mm distal to the carpal tunnel were randomized to receive either a chitosan conduit or an autologous nerve graft with the latter serving as the control group. Fifteen patients from the conduit group and seven patients from the control group were available for a 12-month follow-up examination. The primary outcome parameter was tactile gnosis measured with two-point discrimination. The secondary outcome parameters were Semmens Weinstein Monofilament Testing, self-assessed pain, and patient satisfaction. Results: Significant improvement (in static two-point discrimination) was observed six months after trauma (10.7 ± 1.2 mm; p < 0.05) for chitosan-based nerve conduits, but no further improvement was observed after 12 months of regeneration (10.9 ± 1.3 mm). After six months and twelve months, the autologous nerve graft demonstrated comparable results to the nerve conduit, with a static two-point discrimination of 11.0 ± 2.0 mm and 7.9 ± 1.1 mm. Semmes Weinstein Filament Testing in the nerve conduit group showed a continuous improvement over the regeneration period by reaching from 3.1 ± 0.3 after three months up to 3.7 ± 0.4 after twelve months. Autologous nerve grafts presented similar results: 3.3 ± 0.4 after three months and 3.7 ± 0.5 after twelve months. Patient satisfaction and self-reported pain levels were similar between the chitosan nerve conduit and nerve graft groups. One patient required revision surgery due to complications associated with the chitosan nerve tube. Conclusion: Chitosan-based nerve conduits are safe and suitable for bridging nerve lesions up to 26 mm in the hand. Tactile gnosis improved significantly during the early regeneration period, and functional outcomes were similar to those obtained with an autologous nerve graft. Thus, chitosan appears to be a sufficient substitute for autologous nerve grafts in the treatment of small nerve defects in the hand.

[Differential therapeutic Approaches in Treatment of Carpal Tunnel Syndrome]. / Differentialtherapeutische Herangehensweisen zur Behandlung des Karpaltunnelsyndroms.

Carpal tunnel syndrome (CTS) is one of the most common compression neuropathies. The therapeutic concept should be tailored to each patient individually, with initial non-surgical treatment being the standard of care for early CTS. Primary surgical intervention should be considered in more advanced diseases stages, in case of concomitant pathologies (including space-occupying lesions, complex regional pain syndrome or diabetic neuropathy), if non-surgical strategies have failed or in pregnancy-related CTS. This work aims to discuss common surgical approaches, their clinical application as well as benefits and disadvantages in a pragmatic style. Further, we highlight surgical strategies to address recurrent CTS following failed primary surgery. In view of the recently updated S3 guidelines "Diagnosis and Therapy of Carpal Tunnel Syndrome", this topic is timely and relevant for hand and nerve surgeons.

The Impact of Digital Nerve Injury on the Outcome of Flexor Tendon Tenolysis: A Retrospective Case-Control Study.

BACKGROUND: Tenolysis is an established treatment for flexor tendon adhesions at the hand. Concomitant finger nerve injuries with incomplete reinnervation may negatively influence outcomes. This study investigates the impact of finger nerve injuries on outcomes of flexor tendon tenolysis. METHODS: A retrospective pair-matched study was conducted, including patients undergoing tenolysis for flexor tendon adhesion after primary repair of isolated superficial and deep flexor tendon injury and both finger nerves (test group [TG]). These were compared with patients (control group [CG]) with similar injuries without affection of nerves and pair-matched in age, zone of injury and follow-up. Patients' demographics, finger sensitivity, total active range of motion (TAM) before and after tenolysis and complications were retrieved. RESULTS: For both study groups, 10 patients each were included in this study. There were no significant differences regarding patients' demographics and follow-up. Mean follow-up was 37 (CG) and 41 (TG) months. Total active range of motion was preoperatively 81 ± 47° (CG) and 68 ± 54° (TG) and reached postoperatively 125 ± 57° (CG) and 79 ± 43° (TG). Hence, TAM improvement was significantly higher in patients without nerve damage (58 ± 16 vs 21 ± 11%; P > 0.05). Tendon ruptures occurred significantly more frequent in patients with nerve injury (n = 0.4 ± 0.52) compared with patients of the CG (n = 0; P < 0.05). CONCLUSIONS: This study shows that finger nerve injury with incomplete recovery after combined flexor tendon and nerve injuries of the finger negatively influences the outcomes of flexor tendon tenolysis.

Enzymatic Debridement for Burn Wound Care: Interrater Reliability and Impact of Experience in Post-intervention Therapy Decision.

Enzymatic debridement (ED) has become a reliable tool for eschar removal. Although ED application is simple, wound bed evaluation and therapy decision post-intervention are prone to subjectivity and failure. Experience in ED might be the key, but this has not been proven yet. The aim of this study was to assess interrater reliability (IR) in post-intervention wound bed evaluation and therapy decision as well as the impact of experience. In addition, the authors introduce video assessment as a valuable tool for post-ED decision-making and education. A video-based survey was conducted among physicians with various experiences in ED. The survey involved multiple-choice and 5-point Likert scale questions about professional status, experience in ED, confidence in post-ED wound bed evaluation, and therapy decision. Subsequently, videos of 15 mixed pattern to full-thickness burns immediately after removal of the enzyme complex were demonstrated. Participants were asked for evaluation of each burn wound, including bleeding pattern and consequent therapy decision. IR ≥ 80% was considered as a consensus. Responses were stratified according to participants' experience in applying ED (<10, 10-19, 20-49, and ≥50 applications). IR was assessed by chi-square test (raw agreement [RA]; ≥80% was considered as a consensus) and by calculation of Krippendorff's alpha. In addition, expert consensus for therapy decision was compared with the actual clinical course of each shown patient. Last, participants were asked for their opinion on video as an assessment tool for post-ED wound bed evaluation, decision-making, and training. Thirty-one physicians from 11 burn centers participated in the survey. The overall consensus (raw agreement [RA] ≥ 80%) in post-ED wound bed evaluation and therapy decision was achieved in 20 and 40%, respectively. Krippendorff's alpha is given by 0.32 (95% confidence interval: 0.15, 0.49) and 0.31 (95% confidence interval: 0.16, 0.47), respectively. Subgroup analysis revealed that physicians with high experience in ED achieved significantly more consensus in post-intervention wound bed evaluation and therapy decision compared with physicians with moderate experience (60 vs 13.3%; P = .02 and 86.7 vs 33.3%; P = .04, respectively). Video analysis was considered a feasible (90.3%) and beneficial (93.5%) tool for post-intervention wound bed evaluation and therapy decision as well as useful for training purposes (100%). Reliability of wound bed evaluation and therapy decision after ED depends on the experience of the rating physician. Video analysis is deemed to be a valuable tool for ED evaluation, decision-making, and user training.

[Selective nerve transfers for thenar branch reconstruction]. / Selektive Nerventransfers zur Reinnervation des motorischen Thenarastes.

OPERATIVE: Reconstruction of thump opposition with selective nerve transfer of the motor branch of the abductor digiti minimi muscle (ADM) to the thenar motor branch. INDICATIONS: Injury of the median nerve or thenar motor branch and resulting loss of thumb opposition. CONTRAINDICATIONS: Combined median and ulnar nerve injuries or brachial plexus lesions of C8-Th1, or a time interval >12 months since denervation of the thenar branch. SURGICAL TECHNIQUE: The ADM motor branch is microsurgically dissected and transferred to the thenar branch. POSTOPERATIVE MANAGEMENT: After successful reinnervation, regular follow-ups and intensive physiotherapy are important for operative outcome. RESULTS: Reconstruction of the opposition of the thumb results in improved range of motion as well as a gain of grip and pinch force.

The Effect of Hyperbaric Oxygen Therapy on Human Adipose-Derived Stem Cells.

BACKGROUND: Adipose-derived stem cells are considered as candidate cells for regenerative plastic surgery. Measures to influence cellular properties and thereby direct their regenerative potential remain elusive. Hyperbaric oxygen therapy-the exposure to 100% oxygen at an increased atmospheric pressure-has been propagated as a noninvasive treatment for a multitude of indications and presents a potential option to condition cells for tissue-engineering purposes. The present study evaluates the effect of hyperbaric oxygen therapy on human adipose-derived stem cells. METHODS: Human adipose-derived stem cells from healthy donors were treated with hyperbaric oxygen therapy at 2 and 3 atm. Viability before and after each hyperbaric oxygen therapy, proliferation, expression of surface markers and protein contents of transforming growth factor (TGF)-ß, tumor necrosis factor-α, hepatocyte growth factor, and epithelial growth factor in the supernatants of treated adipose-derived stem cells were measured. Lastly, adipogenic, osteogenic, and chondrogenic differentiation with and without use of differentiation-inducing media (i.e., autodifferentiation) was examined. RESULTS: Hyperbaric oxygen therapy with 3 atm increased viability, proliferation, and CD34 expression and reduced the CD31/CD34/CD45 adipose-derived stem cell subset and endothelial progenitor cell population. TGF-ß levels were significantly decreased after two hyperbaric oxygen therapy sessions in the 2-atm group and decreased after three hyperbaric oxygen therapy sessions in the 3-atm group. Hepatocyte growth factor secretion remained unaltered in all groups. Although the osteogenic and chondrogenic differentiation were not influenced, adipogenic differentiation and autodifferentiation were significantly enhanced, with osteogenic autodifferentiation significantly alleviated by hyperbaric oxygen therapy with 3 atm. CONCLUSION: Hyperbaric oxygen therapy with 3 atm increases viability and proliferation of adipose-derived stem cells, alters marker expression and subpopulations, decreases TGF-ß secretion, and skews adipose-derived stem cells toward adipogenic differentiation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Acute and long-term costs of 268 peripheral nerve injuries in the upper extremity.

BACKGROUND: Peripheral nerve injury in the upper extremity is linked to high socioeconomic burden, yet cost-analyses are rare and from small cohorts. The objective of this study was to determine the costs and long-term socioeconomic effects of peripheral nerve injuries in the upper extremity in Germany. METHODS: We analyzed data of 250 patients with 268 work-related upper extremity nerve injuries from acute treatment to long-term follow-up on rehabilitation, sick-leave and disability-pension. RESULTS: Patients were on average 39.9±14.2 years old, male (85%) and mean inpatient treatment was 7±6 days. Location of nerve was 8% (N = 19) proximal to the wrist, 26% (N = 65) at the wrist and metacarpus, and 66% (N = 166) at phalangeal level. Acute in-patient treatment for (single) median nerve injury accounted for 66% with hospital reimbursement of 3.570€, ulnar nerve injury for 24% and 2.650€ and radial nerve injury for 10% and 3.166€, all including finger nerve injuries. The remaining were combined nerve injuries, with significantly higher costs, especially if combined with tendon 5.086€ or vascular injury 4.886€. Based on location, nerve injuries proximal to the wrist averaged 5.360±6.429€, at the wrist and metacarpus 3.534±2.710€ and at the phalangeal level 3.418±3.330€. 16% required rehabilitation with average costs of 5.842€ and stay of 41±21 days. Sick leave was between 11-1109 days with an average of 147 days with socioeconomic costs of 197€/day, equaling on average 17.640€. 30% received a mean yearly disability pension of 3.187€, that would account to 102.167€ per lifetime. CONCLUSION: This large German patient sample indicates that nerve injury has a major impact on function and employment, resulting in significant health care costs. Both proximal and distal nerve injuries led to long-term disability, subsequent sick-leave and in 30% to permanent disability pension. These data are determined to support future studies and health economical work on prevention, treatment and rehabilitation of these often small injuries with great consequences.

Promoting axonal regeneration following nerve surgery: a perspective on ultrasound treatment for nerve injuries.

Nerve injury is often associated with limited axonal regeneration and thus leads to delayed or incomplete axonal reinnervation. As a consequence of slow nerve regeneration, target muscle function is often insufficient and leads to a lifelong burden. Recently, the diagnosis of nerve injuries has been improved and likewise surgical reconstruction has undergone significant developments. However, the problem of slow nerve regeneration has not been solved. In a recent meta-analysis, we have shown that the application of low-intensity ultrasound promotes nerve regeneration experimentally and thereby can improve functional outcomes. Here we want to demonstrate the experimental effect of low intensity ultrasound on nerve regeneration, the current state of investigations and its possible future clinical applications.

[Improved diagnostics and therapeutic decision making in traumatic peripheral nerve lesions using MR-neurography]. / Gezielte Therapieplanung bei traumatischen Nervenläsionen mittels MR-Neurographie.

INTRODUCTION: The correct diagnosis of peripheral nerve injuries is essential for choosing the correct treatment in nerve surgery. Especially, nerve defects require early diagnosis to provide quick surgical reconstruction and prevent long-term disabilities. Recent developments in MR-neurography provide surgeons with a diagnostic tool delivering precise information on the structure and possibly function of nerves. Here we describe a series of cases, that benefited from preoperative MR-neurography to identify the correct type of injury. MATERIAL AND METHODS: We demonstrate five traumatic nerve injuries which were evaluated using high-resolution MR-neurography imaging for therapeutic planning, combined with standard clinical, electrophysiological and sonography diagnostics. We show the clinical feasibility, benefit of this new technique for nerve surgery and the correlation of preoperative MR-neurography images to the intraoperative situation (in surgically managed cases). RESULTS: Two cases were successfully treated without surgery based on the intact nerve-integrity found in the MR-neurography, despite pathological electrophysiology and inconclusive sonography. In three cases, the MR-Neurography enabled a precise diagnosis and localization of the nerve lesion. Thereby, a precise surgical reconstruction of the nerve lesion was achieved, confirming the matching of MR-neurography findings and intraoperative situs. DISCUSSION: Although, systematic clinical analyses are not available yet, our data suggest that MR-neurography can help surgeons to correctly define the type of nerve injury and thus identify the appropriate treatment preoperatively. In the presented cases, MR-neurography correctly diagnosed the type of injury and therefore allowed adequate planning and decision making between non-surgical treatment, neurolysis or nerve reconstruction. We believe that MR-neurography is an emerging tool for nerve surgeons to improve the treatment of nerve injuries. CONCLUSION: MR-neurography delivers decisive information on the nerve lesion and helps to identify the necessity to operate and the correct surgical treatment.

[Not Available]. / Kasuistik - 44-jähriger Patient mit Fieber und Hautrötung in der Notaufnahme.

Skin and soft tissue infections may progress rapidly and take a fatal ending unless not treated in time. A 44-year old male patient without any pre-existing conditions got hospitalized with a bursitis ofthe right olecranon and unspecific general symptoms. Within a short period of time he became critically ill due this seemingly harmless infection. We describe our approach leading to the right diagnoses and the treatment of this unexpected progress.

Compound Dorsal Dislocation of Lunate with Trapezoid Fracture.

We report about a dorsal dislocation of the lunate accompanied by a trapezoid fracture in a 41-year old male patient after a motorcycle accident. The lunate dislocation with no dorsal or volar intercalated segment instability (DISI, VISI) was diagnosed by x-ray whereas the trapezoid fracture was only diagnosable by computed tomography. A closed reduction and internal fixation of the lunate by two Kirschner wires was performed, the trapezoid fracture was conservatively treated. Surgery was followed by immobilization, intense physiotherapy and close follow-up. Even though complaints such as swelling and pain subsided during the course of rehabilitation, partial loss of strength and range of motion remained even after 16 months. In conclusion, a conservative treatment of trapezoid fractures seems to be sufficient in most cases. Closed reduction with K-wire fixation led to an overall satisfactory result in our case. For dorsal lunate dislocations in general, open reduction should be performed when close reduction is unsuccessful or DISI/VISI are observed in radiographs after attempted close reduction.