[The soleus muscle flap]. / Die Musculus-soleus-Lappenplastik.

OBJECTIVE: Defect coverage especially in exposed bone of the lower leg by pedicled muscle flaps in association with a split-thickness skin graft. Defect coverage oropharyngeal or at the upper extremity by free soleus flaps. INDICATIONS: Defects of the proximal and middle thirds of the anterior lower leg for the proximally pedicled soleus flap; defects of the middle and distal third of the anterior lower leg for the distally pedicled soleus flap. The free flap is almost ubiquitously useable. CONTRAINDICATIONS: Primary diseases that makes a 2-h operation impossible, relevant affection of supplying vessels (the posterior tibial artery and/or the peroneal artery). Inadequate perfusion of the lower leg due to angiopathy, extensive soft-tissue infection, and wound contamination. SURGICAL TECHNIQUE: Medial, longitudinal incision, slightly posterior to the tibia, according to the desired flap elevation (distally or proximally pedicled). Preparation of relevant vessels, mobilization of the muscle and transposition into local defects or use as a free graft. The pedicled flaps usually need a split-thickness skin graft to cover. POSTOPERATIVE MANAGEMENT: Close monitoring of blood flow, temperature and swelling situation (hourly). Pressure-free wound-dressing of the leg, no circular or constricting dressings. Bedrest for 10 days, then start of flap training with intermittent circular compression, thrombosis prophylaxis, nicotine abstinence, physiotherapy, which depends on the bony situation, compression stocking after 3 weeks. RESULTS: Reliable results achieved at the middle and distal lower leg.

Reconstruction of a four-quadrant full-thickness abdominal wall defect after removal and debridement of an infected mesh hernioplasty.

This case-report shows our experience with a patient, who underwent mesh hernioplasty followed by infection of the mesh and full-thickness loss of the abdominal wall after debridement due to necrosis. The anamnesis included generalised arteriosclerosis, chronic nicotine and alcohol abuse and recurring wound-healing disorders after surgical procedures. The initial infection was treated by radical debridement, targeted antibiotics and V.A.C.(®) Therapy. After this, a staged plastic reconstructive procedure with four pedicled flaps was performed. The functional integrity of the abdominal wall was completely re-established. The patient was able to continue her occupation as a facility manager. Although the use of free flaps is very common in modern plastic and reconstructive surgery, procedures such as pedicled flaps still have their significance for special indications. In this case, a full recovery of the abdominal wall with autologous tissue was successful under difficult vascular conditions by using local flaps.

[Diagnostic value of unspecific requested and implemented MRI for detecting intracarpal lesions, compared to arthroscopic findings at 217 patients]. / Wertigkeit unspezifisch angeforderter und durchgeführter MRT-Diagnostik bei intrakarpalen Verletzungen im Vergleich zum Arthroskopiebefund an 217 Patienten.

AIM: The purpose of this study was to evaluate the diagnostic value of MRI for detecting intracarpal lesions in clinical routine. PATIENTS AND MATERIALS: In a retrospective study, we reviewed the charts of 506 patients who had undergone wrist arthroscopy in our department between May 1998 and November 2002. Out of 506 patients 217 had an MRI. The MRI was performed at 31 different radiology facilities using a number of techniques. The MRI results were compared with the arthroscopic findings, taking the arthroscopic results as a "gold standard" (sensitivity = SEN, specificity = SPE, positive predictive value = PPV, negative predictive value = NPV, accuracy = ACC). RESULTS: The following results were found: For tears of the scapholunate ligament the avalues are SEN 18.5 %, SPE 95 %, PPV 71 %, NPV 66 %, ACC66 %. Not one of 16 tears of the lunotriquetral ligament was found by MRI. CONCLUSION: In our data we found a low sensitivity for unspecific requested and implemented MRI for detecting intracarpal lesions. Therefore the indication for MRI should only be made after experienced hand surgeons have examined the wrist. In our opinion, only direct MR-arthrography is equal to arthroscopy, so that only an experienced radiologist who is familiar with this technique should perform the MRI diagnostics of the hand.

[Breast reconstruction for patients with breast carcinoma : an analysis based on the data of 4,335 patients from 16 hospitals]. / Brustrekonstruktionen bei Patientinnen mit Mammakarzinom : Eine Analyse anhand der Daten von 4335 Patientinnen aus 16 Kliniken.

BACKGROUND: [corrected] The rate of breast reconstructions after mastectomy because of breast carcinoma has not been thoroughly studied, based on a representatively large data pool. METHODS: We analyzed the data of 4,335 patients with breast carcinoma from 16 hospitals together with the German Breast Center (Westdeutsches Brustcentrum). RESULTS: Of the studied patients, 34% (1,488 of 4,335) had mastectomies. Breast reconstruction was performed in 13% (197) of those with mastectomy. None of the 197 with breast reconstruction was operated on by a plastic surgeon or had a microsurgical reconstructive procedure (free flap). CONCLUSION: The aim of this study is to increase the number of breast reconstructions after mastectomy, including microsurgical procedures, and to improve cooperation between gynecologists and plastic surgeons.

[Dorsal capsulodesis versus triscaphe arthrodesis in patients with scapholunate dissociation. Do the results depend on the diagnosis or the operation?]. / Differenzialindikation der dorsalen Kapsulodese und der STT-Arthrodese bei Patienten mit einer skapholunären Dissoziation. Ist das Ergebnis abhängig von der Diagnose oder dem Operationsverfahren?

BACKGROUND: Dorsal capsulodesis and triscaphe arthrodesis are possible treatment modalities for patients with scapholunate dissociation. In light of overlapping indications for either operation for patients with carpal instability, it is important to compare the postoperative results. METHODS: From 1998 until 2002, we operated on 87 patients suffering from scapholunate dissociation. 52 patients were treated by dorsal capsulodesis after R. Berger and 35 patients were treated by triscaphe arthrodesis as published by Watson. Of these 87 patients, we managed to follow-up 77 patients (47 dorsal capsulodesis und 30 triscaphe arthrodesis) with a physical examination, X-ray of the wrists and Krimmer Score. RESULTS: In terms of grip-strength, range of motion, functional outcome (Krimmer Score), duration of the operation and hospitalisation, the dorsal capsulodesis group performed better (p < 0.05) than the triscaphe arthrodesis group at the time of follow-up. At follow-up, pain reduction was significant in both groups (p < 0.05). Krimmer Score (functional outcome) and the rate of complication was clearly better for the dorsal capsulodesis group as compared to the triscaphe arthrodesis group. CONCLUSION: In case of non-static scapholunate dissociation, dorsal capsulodesis should be the first choice treatment. In case of a young manually working man with static scapholunate dissociation, it should be a case-to-case decision whether performing a triscaphe arthrodesis or a dorsal capsulodesis. With this investigation we wanted to discuss and demonstrate the difficulties with the differential-indication for the two operations. Generally speaking the postoperative results did not depend on the type of scapholunate dissociation (dynamic versus static) but rather on the chosen surgical procedure.

[Late results after nerve transplantation on the upper extremities]. / Spätergebnisse der Nerventransplantation an der oberen Extremität.

PURPOSE: The purpose of this retrospective study was to determine the influence of the type of injury, the time elapsed after the injury, the blood supply to the operation area, the size of the graft, and the applied treatment method on the late results. METHOD AND MATERIAL: In the study period from 1985 through 2000, nerve transplantations had been performed in 281 patients. There were 204 men and 77 women. Reconstructions were applied on the median nerve in 59 patients, ulnar nerve in 48, median and ulnar nerves in 23, radial nerve in ten, and digital nerves in 141 patients. 188 patients presented for late follow-up (66.9%). RESULTS: Evaluation was made according to the Highet scheme. In patients with median nerve transplantation M(3) or better results were seen in 69%, with M(3) being 45.2%. S(3) or better was observed in 64.3%, with S(3) being 47.6%. In patients after ulnar nerve transplantation M(3) or better result was achieved in 56.8%, M(3) being 19%. S(3) or better result was seen in 32.4%, S(3) being 27%. In patients who underwent median and ulnar nerve transplantations M(3) or better result was seen in 36.8%, M(3) being 26.3%. S(3) was in 42.1%, while S(4) did not occur. In patients after radial nerve transplantation M(3) or better effect resulted in 87.5%, M(3) being 12.5%. In patients with digital nerve transplantation S(3) or better result occurred in 57.4 %, S(3) being 47.6%. CONCLUSION: The best result can be achieved with nerve suturing, performed as an optimum from all aspects. However, as far as the surgical technique is concerned, results of using interfascicular grafts are more advantageous than epineural nerve suture based on compromises. In ideal circumstances, transplantation of a nerve graft less than 2 cm is of the same value as a good primary suture. If a nerve graft is longer than 2 cm, and negative local factors are accumulating due to the type of injury, late results will gradually deteriorating. The final outcome definitely depends on the patient's age and the time elapsed from the injury to the operation.

[Early diagnosis and management of femur head necrosis in young adult age]. / A fiatal felnöttkori combfejelhalás korai felismerése és gyógyítása.

There are a lot factors in the genesis of the ischemic femoral head necrosis. In the early stage the intraosseous pressure increases without any clinical or radiological sign. The disease is often bilateral. The early diagnosis (NMR) is essential in the treatment. In the case of a severe femoral head necrosis the radiological investigation of the other side is obligatory, in order to diagnose the early stage of the disease and to prevent the progression of the collapse with core decompression. The object of the adequate treatment of the collapsed femoral head is to release the pain and to avoid the total destruction of the femoral head. The untreated femoral head necrosis results in a painful, arthritic hip, where spontaneous regeneration is limited, and takes 8-10 years. With osteotomy and revascularisation the results are good, and the regeneration takes about 2-3 years. As a result of this treatment, the patients have a moderately limited function, and minimal limping. Rehabilitation is possible into the original profession, or into a somewhat easier job. Remodellation of the femoral head in younger patients following the revascularisation procedure has been observed in our experience in the last few years.

[Microsurgical methods of bone replacement]. / Mikrochirurgische Methoden bei Knochenersatz.

Vascularized bone grafting techniques are ideal for long bone defects in the extremities. The authors report on their experience in this field. From January 1991 to 2nd November 1995, 17 patients were treated by vascularized bone grafts. In ten cases iliac crest, in six cases fibula, and in one case a radial forearm composite flap was used. All patients have shown optimal healing and good bony consolidation, except for one case of circulatory disorder of the fibula graft.

[Is remodeling still possible after collapse in femur head necrosis?]. / Ist die Remodellierung nach Kollaps bei Hüftkopfnekrose doch möglich?

A case of a femoral head necrosis, with collapsed joint surface after fracture of the femoral neck will be presented. Following varisation osteotomy, the necrotic parts of the bone was removed and filled with cancellous bone. A standardized bone block of the iliac crest was implanted into the hole. After the operation the patient was painfree. The X-rays showed the improvement of the bony structure and later a spherical remodeling of the femoral head. This result is in opposition with the earlier opinion of the disability of femoral head remodeling in adults. It is technically very important to pack tight the hole in the femoral head with cancellous bone chips after necrectomy, and to ensure the revascularisation with vascularised bone block.

[Hand injury caused by a funnel-producing machine]. / Tölcsérgyártó-gép okozta kézsérülés.

Authors describe a case of severe hand injury, caused by a funnel producing equipment. In the region between the metacarpals II and III a high pressure, penetrating, mechanical and thermal injury has arisen. The secondary necrosis expanded and this made a covering with soft tissue of full value necessary. Because of the local relations and allergic complications the local and distant possibilities were narrowed. It was possible to find a final solution by the transfer of flaps from the index and III finger and supplementary plastics, using split thickness skin grafts. The result was functionally perfect, esthetically adequate.

[Substitution of soft tissue defects on the lower leg and foot in septic cases]. / Lágyrész defectusok pótlása lábszáron és a lábon szeptikus esetben.

After the spontaneous epithelialisation of the defects of soft parts so called unstable scars remain which, because of ulceration, are sources of infection, endangering both soft parts and bones. Substitution with soft tissues of adequate blood supply enables the complete sanation of the septic foci and by this the rapid healing of the patient with full function. Beside this a better cosmetic result can be achieved. In septic environment, if possible, local muscle flaps and free flaps are used, depending on the extent and localization of the defect. Experiences, gained in these operations are described.