Current diagnostics and treatment of the cubital tunnel syndrome in Austria.

According to the vote of the Austrian Society for Surgery of the Hand (ÖGH) an investigation to collect data on the current state of the treatment of cubital tunnel syndrome was initiated. Over one year a total of 875 patients with cubital tunnel syndrome were operated in Austria, this means an incidence of this nerve entrapment of 0.011%. Most of the operations were done by trauma surgeons (287; 33%). For diagnosis most of the centers rely on clinical symptoms, electroneurophysiology, and elbow X-ray. 40% of the institutions regard conservative therapy as useless and not indicated. If conservative treatment modalities are applied, physiotherapy (97%), non-steroidal anti-inflammatory medication (77%), and glucocorticoid injections (30%) are primarily used. In case of simple nerve entrapment most of the surgeons (72%) prefer simple nerve decompression. If there is additional pathology subcutaneous cubital nerve transposition is recommended (62%). Endoscopic techniques are only use by 3% of the surgeons. In the postoperative care, physiotherapy is favored in 51%, whereas 24% do not judge any postoperative care as beneficial. The three most often encountered complications were incomplete remission, scar contracture and hypertrophy, and postoperative bleeding.

Reconstructive surgery in immunocompromised patients: evaluation and therapy.

BACKGROUND: An increasing number of patients undergoing reconstructive surgery are immunocompromised due to different reasons and different medical treatments. Some of the used immunosuppressive drugs may affect the process of wound healing and thereby, impair the long-term success of surgical treatment. Therefore, this retrospective analysis aimed at the evaluation of the perioperative treatment and surgical outcome of immunocompromised patients undergoing different reconstructive procedures. METHODS: A retrospective review was performed of 8 immunocompromised patients with different primary diseases who needed reconstructive surgery: 2 patients with non-Hodgkin lymphoma, 1 patient with an acute myeloid leukemia, 1 patient with colitis ulcerosa, 1 patient with liver cirrhosis, 1 patient with chronic polyarthritis, and 2 patients with malignant melanoma. RESULTS: In 7 of our 8 presented cases, multiple operations with wound debridements have been necessary to optimize the granulation of the wound bed before reconstructive surgery. 3 out of these 7 patients required further operations due to wound dehiscence or necrosis, with 2 of them as a result of increased immunosuppressive therapy. 5 out of 8 patients needed no further surgical treatment. CONCLUSIONS: Both the perioperative drug therapy and the reconstructive surgery concept need to be determined carefully in each individual case of the immunocompromised patients. Thus, the appropriate point in time of operation to achieve the best possible wound healing as well as the complexity of the procedure will require the consideration of a 'less is more' strategy in selected cases.

Results after simple decompression of the ulnar nerve in cubital tunnel syndrome.

Cubital tunnel syndrome represents the second most common compression neuropathy of the upper limb. For more than four decades there has been a controversy about the best surgical treatment modality for cubital tunnel syndrome. In this study the results of 28 patients with simple ulnar nerve decompression are presented. Data analyses refers to clinical examination, personal interview, DASH-questionnaire, and electrophysiological measurements, which were assessed pre- and postoperatively. 28 patients (15 females, 13 males) were included in this study. The average age at time of surgery was 47.78 years (31.68-73.10 years). The period from onset of symptoms to surgery ranged from 2 to 24 months (mean 6 months). The mean follow-up was 2.11 years (0.91-4.16 years). Postoperatively there was a significant decrease in DASH score from 52.6 points to 13.3 points (p<0.001). Also the electrophysiological findings improved significantly: motor nerve conduction velocity increased from 36.0 m/s to 44.4 m/s (p=0.008) and the motor nerve action potential reached 5,470 mV compared to 3,665 mV preoperatively (p=0.018). A significant increase of grip strength from 59% (in comparison to the healthy hand) to 80% was observed (p=0.002). Pain was indicated by means of a visual analog scale from 0 to 100. Preoperatively the median level of pain was 29 and postoperatively it was 0 (p=0.001). The decrease of the two-point-discrimination of the three ulnar finger nerves was also highly significant (p<0.001) from 11.3 mm to 5.0 mm. Significant postoperative improvement was also observed in the clinical examination concerning muscle atrophy (p=0.002), clawing (p=0.008), paresthesia (p=0.004), the sign of Froment (p=0.004), the sign of Hoffmann-Tinel (p=0.021), and clumsiness (p=0.002). Overall nearly 90% of all patients were satisfied with the result of the operation. In 96.4% of all cases, surgery improved the symptoms and in one patient (3.6%) the success was noted as "poor" because the symptoms remained unchanged. In 35.7% the success was graded as "moderate", in 10.7% as "good" and in 50.0% as "very good".

A new approach of in vivo musculoskeletal tissue engineering using the epigastric artery as central core vessel of a 3-dimensional construct.

The creation of musculoskeletal tissue represents an alternative for the replacement of soft tissue in reconstructive surgery. However, most of the approaches of creating artificial tissue have their limitations in the size as the maximally obtainable dimension of bioartificial tissue (BAT) is limited due to the lack of supporting vessels within the 3-dimensional construct. The seeded myoblasts require high amounts of perfusion, oxygen, and nutrients to survive. To achieve this, we developed a 3-dimensional scaffold which features the epigastric artery as macroscopic core vessel inside the BAT in a rat model (perfused group, n = 4) and a control group (n = 3) without the epigastric vessels and, therefore, without perfusion. The in vivo monitoring of the transplanted myoblasts was assessed by bioluminescence imaging and showed both the viability of the epigastric artery within the 3-dimensional construct and again that cell survival in vivo is highly depending on the blood supply with the beginning of capillarization within the BAT seven days after transplantation in the perfused group. However, further studies focussing on the matrix improvement will be necessary to create a transplantable BAT with the epigastric artery as anastomosable vessel.

Epineurial sheath tube (EST) technique: an experimental peripheral nerve repair model.

OBJECTIVE: Here we present the epineurial sheath tube (EST) technique as a modified microsurgical rat sciatic nerve model. The EST technique provides a cavity or pouch consisting of an outer epineurial sleeve that has been freed from nerve fascicles. This cavity may be appropriate to test the effectiveness and biocompatibility of implanted growth factors, cell suspensions (embedded in solutions or gels), or bioartificial nerve guide constructs. METHODS: A total number of 10 rats underwent the surgical procedure for the EST technique. Cylinders made of fibrin gel served as implants and place-holders. Three animals were euthanized directly after operation, while the others survived for 6 weeks. After immersion fixation (3·9% glutaraldehyde), both conventional histology [semi-thin sections (1 µm), toluidine blue] and scanning electron microscopy were performed. RESULTS: Conventional histology and scanning electron microscopy of samples that had been fixed directly after the surgical procedure displayed the integrity of the closed epineurial tube with the fibrin cylinder in its center. Even after 6 weeks, the outer epineurium was not lacerated, the stitches did not loosen, and the lumen did not collapse, but remained open. DISCUSSION: The practicability of the EST technique could be verified regarding feasibility, reproducibility, mechanical stability, and openness of the lumen. The EST technique can be adapted to other nerve models (e.g. median or facial nerve). It provides a cavity or pouch, which can be used for different neuroscientific approaches including concepts to improve the therapeutic benefit of autologous nerve grafting or therapies to be used as an alternative to autologous nerve grafting.

A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus.

Toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a life-threatening disease with common development of large wounds. Thus, affected patients are usually treated in specialized centers. Herein, we present a case of TEN in a patient infected with human immunodeficiency virus with the additional, unexpected diagnosis of dengue fever. In this context, we discuss cause, diagnosis, pathology, and treatment of TEN and highlight the role of rare and unexpected findings, as in this case an additional tropical virus infection. We underpin the importance of an interdisciplinary approach involving dermatologists, ophthalmologists, intensive care physicians, burn specialists and various other departments and emphasize the challenge of TEN treatment, especially if rare pathological findings occur.