[Medicine aboard cruise ships--law insurance specifics]. / Versicherungsrechtliche Betrachtungen zur Tätigkeit des Arztes an Bord von Kreuzfahrtschiffen.

The booming cruise industry, associated with ships with more passengers and crew on board, results in growing medical needs for the ship doctor. The ship's doctor insurance policy includes different jurisdictions, namely national law, international law, tort law, insurance law and labor law. In addition, international agreements must be taken into account, which complicates the design of an adequate insurance policy. Equally high are the costs and defense costs for the ship's doctor in case of liability. In order to limit the liability for all parties is to ask for appropriately qualified medical staff, hired on board.

Pirogow's Amputation: A Modification of the Operation Method.

Introduction. Pirogow's amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers the ability to stay mobile without the use of a prosthesis, it is rarely performed. This paper proposes a modification regarding the operation method of the Pirogow amputation. The results of the modified operation method on ten patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score). Material and Methods. We modified the original method by rotating the calcaneus. To fix the calcaneus to the tibia, Kirschner wire and a 3/0 spongiosa tension screw as well as a Fixateur externe were used. Results. 70% of those questioned who were amputated following the modified Pirogow method indicated an excellent or very good result in total points whereas in the control group (original Pirogow's amputation) only 40% reported excellent or very good result. In addition, the level of pain experienced one year after the completed operation showed different results in favour of the group being operated with the modified way. Furthermore, patients in both groups showed differences in radiological results, postoperative leg length difference, and postoperative mobility. Conclusion. The modified Pirogow amputation presents a valuable alternative to the original amputation method for patients with the corresponding indications. The benefits are found in the significantly reduced pain, difference in reduced radiological complications, the increase in mobility without a prosthesis, and the reduction of postoperative leg length difference.

[Pirogow's amputation as an alternative to lower leg amputation?]. / Die Amputation nach Pirogow als Alternative zur Unterschenkelamputation?

Pirogow's amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers numerous advantages for the patient, such as the ability to stay mobile without the use of a prosthesis, it is rarely performed (0.1% of all lower limb amputations). The results of the operations on 20 patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score), and these results were then compared to those of 20 patients who underwent lower leg amputation. Using a point system the criteria pain, functional and radiological assessment, difference in leg length, and mobility without prosthesis were recorded and evaluated. 65% of those questioned who were amputated following the Pirogow method indicated an excellent or very good result, in the control group 60% of those having undergone a lower leg amputation responded similarly, indicating an excellent or very good result.In 30% in the Pirogow group in contrast to 20% after lower leg amputation postoperative complications lead to a revision-operation. In patients suffering from diabetes or restricted perfusion of the lower extremity an amputation at the level of the ankle has to be considered critically keeping the necessity of a revision-operation in mind. However, if it can be carried out successfully, the benefits of Pirogow-amputation are found in the significantly reduced difference in leg length and the increase in mobility without prosthesis.

[Wound healing complications in smokers, non-smokers and after abstinence from smoking]. / Wundheilungsstörungen bei Rauchern, Nichtrauchern und nach Rauchstopp.

BACKGROUND: The pulmonary and cardiovascular ramifications of smoking are well documented and this also applies to increased wound healing complications in smokers. The aim of this study was to ascertain whether preoperatively refraining from smoking would affect the incidence of wound healing disorders. MATERIAL AND METHODS: Between 2006 and 2008 a total of 295 patients underwent aesthetic (n = 167) or reconstructive surgery (n = 128). They were divided into three groups: A (n = 98) non-smokers for at least 2 years, B (n = 99) patients who refrained from smoking 6 weeks prior to surgery and C (n = 98) smokers. Smoking abstinence was verified by cotinine tests. Wound healing complications were defined as dehiscent wounds, wound infections, atypical scar formation and adiponecrosis. RESULTS: Smokers developed wound healing complications in 48.2% of cases, non-smokers in 21.0% and patients who had stopped smoking for 6 weeks in 30.8% of cases (p = 0.006). CONCLUSION: Elective surgery should only be performed on non-smokers and smokers who had refrained from smoking for at least 6 weeks to reduce wound healing complications as far as possible.

Joseph Beuys: trauma and catharsis.

Joseph Beuys was one of the most significant artists of the 20th century. He was a gunner and radio operator in the German Air Force during World War II, and was severely injured several times. In March 1943 he had a life-changing experience after the dive bomber he was assigned to crashed in the Crimean peninsula. This trauma influenced Beuys' entire artistic career, and is known in art history as the 'Tartar Legend' or 'Tartar Myth'. Profoundly affected by the crash, the severe trauma, the near-death experience and his rescue, which he perceived as a "rebirth", Beuys no longer saw himself, other people or society as a whole in the same way as previously. With his new consciousness, he ignored boundaries and created visions whereby all mankind could experience the healing he had undergone. Beuys did not bring society far enough for the turning point towards "the healing of the world" to be visible, yet today it is important to keep his work alive as a record of his extraordinary strength, which arose from trauma and severe injury, and was carried by a passionate commitment to mankind and to life itself.

[Pharmacological therapy of keloids in an athymic mouse model]. / Pharmakologische keloidtherapie im tiermodell.

PURPOSE: In spite of the high incidence of dermal fibroproliferative disorders, there is no agreement about the treatment of choice. Due to the inability of animals to produce keloid tissue, a standardised model to study the effects of different treatment modalities in vivo is lacking. Therefore, a comparative study on the effect of three pharmacological agents was conducted with human keloid implants in an athymic mouse model. MATERIAL AND METHODS: Cubic keloid tissue blocks from 10 human volunteers were implanted in 54 male, athymic, homozygotic mice. The animals were divided into 4 groups, including an untreated control group. Members of each section received either colchicine, nicardipine or triamcinolone applied transdermally into the keloid tissue or into the peritoneum. The tissue specimens of 5 mice each were explanted according to a predetermined time schedule on days 28, 42 and 56 post-implantation and examined using various histological techniques including standard dye and immune histochemistry. The freeze-dried and moist weights of the keloid tissue were determined and analysed. RESULTS: Statistically significant changes regarding declining weight parameters were seen in the colchicines-treated group. Moreover, the densities of fibroblasts and endothelial cells were significantly reduced through colchicines treatment when compared to the control group and the groups treated with the other agents. The triamcinolone group also showed partially significant changes of weight compared to the control group, whereas no statistically significant effect of nicardipine on any parameter was found. Any influence of the host organism could be excluded as there were no signs of rejection or lymphocytic infiltration. CONCLUSION: Our study represents a successful attempt to create a standardised model for a comparative investigation on keloid tissue in vivo. The effect of colchicine was demonstrated in the light of an inhibitory effect on fibroblastic proliferative activity. The studied model allows a direct comparison of implanted, vascularised keloid tissue and its reactivity to various agents without being biased by numerous unknown variables in humans.

[Fibrin glue and seroma formation following abdominoplasty]. / Fibrinkleber und Serombildung nach Abdominoplastik.

BACKGROUND: Seroma formation is one of the most frequent complications following abdominoplasty. The effect of intraoperative fibrin sealant on the formation of seroma was investigated in patients who had an abdominoplasty. The relevance of slow vs accelerated fibrin polymerization was determined. MATERIAL AND METHODS: Two different thrombin concentrations (4 IE vs 500 IE thrombin/ml) of fibrin sealant were used in two groups of 20 patients each. The control group consisted of 20 patients with abdominoplasties without fibrin glue adhesion. RESULTS: The group with slow-reacting fibrin sealant (4 IE) had a significantly lower rate of seroma formation than both the high concentration fibrin group and controls (P<0.032 and P<0.018, respectively). In addition, the amount of postoperative drainage was significantly lower in the low-dose group (P<0.000). Patients with seroma had a significantly higher weight of resected tissue (P<0.04). The amount of postoperative drainage, age, and body/mass index had no significant effect on the prevalence of complications. CONCLUSION: The use of slow reacting, low-dose fibrin glue demonstrated a protective effect against the formation of seroma following abdominoplasty. The amount of postoperative drainage was significantly lower.

[Liposuction curettage versus Botox for axillary hyperhidrosis. A prospective study of the quality of life]. / Liposuktionskürettage versus Botox bei axillärer Hyperhidrosis. Eine prospektive Studie der Lebensqualität.

BACKGROUND: Axillary hyperhidrosis is a dysfunction of the secretion of sweat glands. Conservative treatment modalities are mostly ineffective. Liposuction combined with subcutaneous curettage (TLC) destroys the sweat glands, while Botox injections inhibit the cholinergic transmission. MATERIAL AND METHOD: Of a total of 88 patients, TLC was carried out in 47 and 41 patients received intradermal Botox injections. The effect of both forms of treatment on the quality of life was assessed using a specific hyperhidrosis questionnaire and was correlated with sweat volumes measured by gravimetry. RESULTS: Follow-up after 6 months showed significantly changed sweat volumes of 52+/-41 mg/min of TLC patients versus 78+/-87 mg/min in the Botox group. In the TLC group 91% and in the Botox group 98% were satisfied with the result. CONCLUSION: The stress of a single surgical intervention is to be weighed against the necessary repetitive application of multiple Botox injections. Both methods are superior to other, more radical surgical methods in terms of efficacy and complication rates. Botox and TLC lead to a significant improvement of the quality of life.

[The anatomy of the surgical treatment of migraine]. / Die Anatomie der chirurgischen Migränetherapie.

OBJECTIVE: The transpalpebral resection of the corrugator and depressor supercilii muscles is a new treatment option for migraine headaches. Hyperactive contractility of these muscles can provoke the peripheral compression of the supratrochlear nerve and induce a neurogenic inflammation triggering the symptoms of migraine. In order to gather detailed knowledge of the respective anatomy in the eyebrow region, a macroscopic cadaver study was conducted. MATERIALS AND METHODS: The relevant muscles of the forehead, glabella and eyebrow were dissected in five fresh, non-preserved heads. The supracanthal origins and dermal points of insertion were marked. Following the preparation of the neurovascular structures, the muscles were measured and weighed. The course of the supraorbital and supratrochlear nerves was demonstrated from the forehead to the orbital cavity. RESULTS: There are three, paired groups of muscles in the superomedial region of the orbital rim. They can be divided into the superficial frontalis and procerus muscle, the orbicularis muscle in a middle layer and the corrugator and depressor supercilii in a deeper layer. The corrugator measured approximately 4.5 cm, whose origin is superior and posterior to the depressor origin situated cranial to the medial canthus. The corrugator inserts lateral to the exit of the supraorbital nerve in the dermis above the eyebrow after penetrating the orbicularis and frontalis muscles and a subgaleal fat pad. The length and weight of the muscles is highly variable. The muscle is penetrated by the supratrochlear nerve whereas the supraorbital nerve runs underneath it. The corrugator is innervated medially and laterally by branches of the facial nerve. CONCLUSION: A detailed knowledge of the complex arrangement of the muscles acting upon the glabella and the different communicating subgaleal and preseptal fat pads allow the identification and resection of the corrugator and depressor muscles without damaging the supratrochlear nerve. The course of the specific nerves is variable. The double-innervation of the corrugator suggests its complete resection instead of the selective denervation of the muscle.

[Serious complications of injections--retrospective analysis of incidences, complication-management, prophylaxis and economic aspects]. / Fatale Folgen von Injektionen--Eine Analyse zur Häufigkeit, Komplikationsmanagement, Prophylaxe und ökonomischen Aspekten.

The parenteral drug application is a routinely used method in all medical disciplines. Intramuscular, intraarticular, intravenous injections and infusions can cause local complications such as abscesses, articular infections or paravasates. These local complications can lead to bacteraemia, sepsis and may lead to multiple organ failure associated with high morbidity and mortality. Although these complications are rare, they are sometimes disastrous and result in life threatening clinical conditions. During a retrospective analysis (review period 1998-2002) 24 patients were admitted and hospitalized in our department. Within this report we demonstrate 7 patients with fatal complications after injections. In the majority of cases minor patients' complaints were proceeding before major complications were present. A long and expensive treatment period with multiple surgical interventions ends up in functional disabilities and unsatisfactory aesthetic results. Instead of delayed surgical treatment immediate radical surgical care is crucial to prevent disastrous complications. In case of the inability of sufficient debridement, amputations are sometimes indicated in the sense of "life before limb". Besides the consequences for the patient these disastrous complications have a high socioeconomic impact and result in reduced reimbursement for the hospital stay.

[In vitro fabrication of tendon substitutes using human mesenchymal stem cells and a collagen type I gel]. / Herstellung von Sehnenkonstrukten aus humanen mesenchymalen Stammzellen und einem Kollagen Typ I Gel.

BACKGROUND AND PURPOSE: Reconstruction of tendon tissue is problematic in many cases. Since direct tendon suture is often impossible, major reconstruction with the use of free tendon transplants or tendon transposition is necessary. Important motor units often have to be sacrificed for reconstructive purposes. In this study we investigated whether long tendon-like substitutes can be fabricated in vitro from human mesenchymal stem cells (MSCs) and a collagen type I gel when cultured under cyclic stretching conditions. MATERIAL AND METHODS: MSCs were obtained from bone marrow aspirates of the iliac crest. Cells were suspended in a collagen type I gel and polymerized in a glass-cylinder with defined size. The fabricated tendon substitutes underwent static stretching for 14 days followed by cyclic stretching for 21 days in a special manufactured bioreactor. Non-stretched substitutes served as a control. RESULTS: Macroscopically the stretched tendon substitutes showed an increased opacity and a smoother surface structure compared to the non-stretched control. The stretched substitutes displayed more spindle-shaped, longitudinal orientated cells, a tendon-like organization of the collagen matrix, and a parallel organization of the collagen fibers when stained with Hematoxylin/Eosin and Elastica. CONCLUSION: Long tendon substitutes could be fabricated from MSCs and a collagen type I gel by cyclic stretching and showed tendon-like parallel collagen fibers and spindle-shaped cells. The use of MSCs in combination with adequate scaffold materials has great therapeutic potential for the development of autologous transplantable tendon substitutes.

[The V.A.C. system (vacuum assisted closure) as bridging between primary osteosynthesis in conjunction with functional reconstructed of soft tissue--open fractures type 2 and type 3]. / Das V.A.C.-System (vacuum assisted closure) als bridging zwischen primärer Osteosynthese und Weichteilrekonstruktion in der Behandlung II degrees -III degrees offener Frakturen polytraumatisierter Patienten.

Open fractures are complex injuries affecting the integrity of bones and adjacent soft tissue. The therapeutic goals in dealing with open fractures should consist of primary osteosynthesis in conjunction with functional reconstruction of soft tissue. In a period over 2 years, 26 patients were treated with extensive trauma in an interdisciplinary approach. These patients suffered from open fractures type 2 and 3. All patients were treated by primary osteosynthesis, and temporary wound closure with V.A.C.-system. Definitive wound closure was achieved by day 31 after injury. In contrast to a review of the pertinent literature we report the successful free tissue transfer in 21 patients during the critical period between 72 hours and several months preceded by the use of V.A.C.-system for the temporary coverage of open wounds.

[Carl von Reyher's studies of wound therapy]. / Carl von Reyhers Studien zur Wundtherapie.

Carl von Reyher (1846-1890), a young Russian army surgeon of the late nineteenth century, established the principle of repeated debridements on a scientific basis. After a visit to Lister's clinic, acquainting himself with antiseptic wound management, von Reyher was the first to present a controlled study of debridement in contaminated gunshot wounds. He was able to show that the combination of primary debridement and antiseptic treatment decreased the mortality rate of gunshot injuries from 66% to 23%. Although published in more than 16 papers and presented at international congresses, Reyher's contribution was completely negated. Finally more than 30 years later in World War I, the Inter-allied Surgical Conference officially endorsed primary excision with delayed wound closure as the rule for treatment of gunshot wounds.

The lymphatic system of the deep inferior epigastric artery perforator flap: an anatomical study.

The anatomical basis of the lymphatic system of the deep inferior epigastric perforator (DIEP) flap was studied in 24 abdominoplasty specimens and in three fresh cadavers. Methylene (n = 4), patent (n = 4) and Turnbull's (n = 8) blue were compared by injecting the dye intradermally. To facilitate staining, two different types of vacuum technique were used: a vacuum chamber (n = 4) and the vacuum-assisted method (n = 4). The lymphatic collectors were dissected, and embedded in paraffin for histological investigation. The most useful dye was Turnbull's blue. The vacuum had no effect on the distribution of the dye. Manual injection showed three parallel superficial collectors situated directly under the skin. Turnbull's blue was also injected into the rectus fascia to demonstrate the collectors of the deep abdominal structures. They run horizontally, and perforate the fascia to run with the inferior epigastric artery. Care should be taken when dissecting the pedicle, or removing the epithelium, to avoid destroying the lymphatic system of the flap.

The effect of wound ointments on tissue microcirculation and leucocyte behaviour.

An intact microcirculation is essential for normal healing to occur. Wound repair may be impaired by various endogenous and exogenous factors, such as reduced microvascular perfusion, infection and debris. In the nonhealing wound, radical surgical debridement is critical. To supplement healing, various ointments are used in clinical practice. Little is known about their effects on tissue perfusion. We have therefore selected two substances widely used, the antiseptic Betadine and the enzyme combination Elase and investigated their impact on the microcirculation and on leucocyte activity, using the cremaster muscle as a model. We found that functional capillary density and arteriolar diameters were significantly reduced by Betadine, whereas leucocyte activity was not affected. In the Elase group, capillary flow and arteriolar diameters were significantly increased, and again leucocyte activity was not changed. The mechanism by which Betadine reduces microvascular flow is believed to be the same as in reperfusion injury. The positive effect of Elase on the microcirculation might be attributed to plasmin, which has been shown to dilate blood vessels.

Augustus V. Waller and plastic surgery.

Augustus V. Waller's name is associated eponymously with the regressive changes in transected nerves. This article intends to present the many other aspects of Waller's scientific ventures. Apart from pioneering intravital microscopy, Waller made significant contributions to the understanding of the process of tissue inflammation. In addition to his observations of the degenerative changes in severed nerve fibers, he developed a concept of trophic dependence that is relevant for the management of the regeneration of peripheral nerves in plastic surgery.

The long-term consequences of lightning injuries.

The risk of being struck by lightning is extremely low. Although dying instantly through lightning-induced cardiac arrest is a well-documented cause of death, the majority of cases reported in the literature describe infrequently occurring and enormously disparate sequelae of this injury. A total number of 12 patients were treated in our burn intensive care unit following a lightning accident within a period of 12 years. We have analysed the incidence of cardiac, muscular and sensory disturbances, keraunographic skin markings and significant laboratory results, as well as episodes of audiovisual dysfunction and amnesia at the time of the initial admission. In order to determine possible long-term complications, ten of these 12 patients were evaluated at an average time of 6.7 years following the injury (range, 1 month-12.3 years). Considering specific findings during their hospital stay (average length, 1.58+/-0.23 days), patients were assessed for residual neurologic, ocular, oto-vestibular or psychological deficits. The outcome showed that none of the patients suffered from any deficits or long-term problems that could be related to the original lightning injury. Based on these findings and a literature review, we believe that the overall outcome of lightning injuries is more favourable than generally reported.

[Etiology, clinical aspects and therapy of penoscrotal lymphedema]. / Atiologie, Klinik und Therapie des penoscrotalen Lymphödems.

Penoscrotal lymphedema has serious functional, cosmetic, psychological and potentially malignant consequences. In contrast to the relatively common occurrence of this disease in areas with endemic filariasis, the incidence in the rest of the world is almost exclusively due to therapeutic sequelae of other illnesses or as congenital entities. As conservative forms of treatment have proved to be inefficient, we discuss different surgical options based on the treatment of 12 patients seen in our clinic. Only the complete excision of the edematous and fibrotic tissues, together with reconstructive methods using local flaps and skin grafts, can guarantee a definitive solution, irrespective of the etiology. A detailed anatomical knowledge of the regional lymphatic drainage pathways allows safe operative treatment. Despite the rarity of this disease, a number of different surgical procedures have been reported in the literature that are compared with the findings in our patients.