[Incisional hernias after median laparotomy. A concept for anatomic reconstruction of the abdominal wall]. / Bauchwandhernien nach medianer Laparotomie. Ein Konzept zur "anatomisch-funktionellen" Wiederherstellung.

The abdominal wall is a complex system of fibres and has its function in stabilisation of the lower back and pressure build-up for coughing and evacuation of the bowels. In case of incicional hernias after median laparotomy, which occur in 10-20%, reconstruction is a great challange for the surgeon. As methods of repair doubling of fascias, implantation of mesh grafts and muscle transfers have been described. In the following article we present a concept for anatomic and functional restoration of the abdominal wall in a selected patient population. Besides an exact surgical technique, the patient's compliance for weight reduction, special work-out and wearing a bodice pre- and postoperatively is essential for a good result.

An isometric hand tester: quantifying motor function in the hand.

The aim of this study was to develop and assess an isometric hand tester to measure multiple strength parameters of the muscles of the hand. Nineteen men and 22 women took part in a first study and 17 men were tested in a second one. Five different tests were developed: wrist flexion, wrist extension, metacarpophalangeal joint flexion, thumb adduction and proximal and distal interphalangeal joint flexion. Reliability was tested with an intraclass correlation coefficient for single measures. When the results from men and women were analysed separately, all tests except metacarpophalangeal joint flexion and thumb adduction produced intraclass correlation coefficients greater than 0.7. Combining the genders gave intraclass correlation coefficients greater than 0.9 except for metacarpophalangeal joint flexion and thumb adduction. After adjustments, intraclass correlation coefficients for metacarpophalangeal joint flexion and thumb adduction were between 0.70 and 0.83 in the second study. The new isometric hand tests improve the measurement of intrinsic and extrinsic hand muscle strength.

[Refixation of the M. recti abdomini on the symphysis in traumatic pubis symphysis disruption. Reconstruction to the original anatomic situation]. / Abriss der geraden Bauchmuskeln der Symphyse nach Symphysenruptur. Möglichkeit der Wiederherstellung.

Pelvic fractures may accompany other injuries and can be life-threatening. In addition, the rectus abdominis muscles might also be torn. During fracture reduction, these muscles are fixed to their insertions. The goal should be reconstruction as close as possible to the original anatomic situation. Refixation of the vertical rectus muscles that have retreated cranially results in preventing development of lower abdominal wall hernia.A hernia in combination with a symphysis disruption has been reported very seldom in the available literature. We report here on a case of hernia that developed postoperatively after treatment of traumatic pubic symphysis rupture. Primary open reduction of the symphysis was carried out and the rectus abdominis muscles were refixed to the bones. An attempt was made to repair the incisional hernia that developed by tightening the fascia. Two and a half years after the accident, the patient developed a diastasis and an abdominal wall hernia, which were repaired by refixation of the rectus abdominis muscles to the bones with Mersilene bands. Results nine months after the reconstructive surgical intervention show a firm abdominal wall without recurrence.This case shows that even 2.5 years after an accident, the rectus abdomini muscles can be fixed with Mersilene bands to the bone and anatomic reconstruction of the abdominal wall can be carried out.

A rounded dissector to reduce complications in the minimally invasive repair (Nuss) of pectus excavatum in adolescents and adults.

Occasionally during the minimally invasive repair of pectus excavatum(MIRPE), the conventional flat dissector is not rigid enough to elevate the anterior thoracic wall for bar implantation and its sharp edges may cause vessel or other tissue damage. Asa result of experiencing such complications in four cases, a new highly rigid dissector with a round cross-section was developed and its advantages are presented in a consecutive series of 21 cases.

[Van-der-Woude Syndrome]. / Van-der-Woude-Syndrom.

We report on two families with different expression of a Van-der-Woude-Syndrome (VWS) and with proven mutation of the IRF6- gene. The Van-der-Woude syndrome is a rare disease, typically consisting of congenital pits of the lower lip in combination with cleft lip or cleft palate or both. The Van-der-Woude syndrome is an autosomal dominant syndrome with variable expression. The penetrance is between 0,89 and 0,99. It is important to establish the correct diagnosis by careful investigation of patients with cleft lip or cleft palate and their parents. Genetic counselling is recommended in such cases.

[Combined latissimus dorsi-thoracodorsal artery perforator-transpositional free flap]. / Kombinierter Latissimus-dorsi- und A.-thoracodorsalis-Perforatortranspositionslappen.

BACKGROUND: Reconstruction or complete cover of extended but polygonal defects is limited by the size of transplantable tissue. One of the largest composite tissue components to be transplanted is the myocutaneous latissimus dorsi flap. Under certain circumstances even this large-scale flap is not sufficient for complete defect cover. Based on experiences with the thoracodorsal artery perforator (TAP) flap, the skin island adjacent to the latissimus muscle may be raised, pedicled on the perforator vessels penetrating the underlying muscle. Thus this island may easily be transposed or rotated to enable additional defect cover. METHODS: This method was applied in eight patients for defect cover at the extremities, thorax or for hypopharynx reconstruction. The exact location of perforator vessels may be determined pre- or intraoperatively with a hand Doppler so that skin flap transposition can already be planned before surgery. RESULTS: All of the skin flaps transposed or rotated healed without complications. It may even be assumed that utilizing this method helped to avoid further complications like scar contractures, because tension-free wound closure was feasible. CONCLUSIONS: The combined latissimus dorsi- thoracodorsal artery perforator-transpositional free flap is capable of covering very extensive polygonal as well as defects over joints in order to prevent scar contractions.

[Dupuytren's contracture -- surgery of recurrencies]. / Die Dupuytrensche Kontraktur - Rezidiveingriffe.

BACKGROUND: The present study is a retrospective investigation of patients who underwent surgery for recurrence of Dupuytren's contracture. We discuss the indications for this intervention, operative methods, and postoperative therapy. Surgical treatment for recurrence of this condition is incomparably more difficult and risky than the primary operation. METHODS: At the Innsbruck University Clinic for Plastic and Reconstructive Surgery, 50 patients underwent 70 operations for treatment of recurrence of Dupuytren's contracture between March 1999 and September 2004. Thorough pre- and postoperative clinical investigations and assessment of hand status as well as analysis of the indication for the first operation and the surgical method used were carried out. All patients underwent intensive postoperative hand therapy from day 1 for restoration of function and flexibility. RESULTS: After completion of therapy, in 32 patients there was an improved ROM of between 40 and 270 degrees per finger, in five patients an unchanged ROM, and in three patients, reduction in ROM by 5 to 58 degrees; six patients failed to show up for their follow-up despite being asked to do so several times. No data are as yet available on four patients who had undergone primary operation elsewhere and were operated within the past six months for recurrence in our clinic. In nine patients, there was a decrease in sensation immediately after surgery; but improvement was achieved within six months in three of these patients after intensive hand therapy. CONCLUSION: Careful assessment of hand function, establishing the indications for surgery at the right time, choice of the appropriate surgical approach and initiation of intensive hand therapy immediately after surgery are decisive for effective treatment of recurrent Dupuytren's contracture. However, amputations and ray resections cannot be avoided in all cases, especially if nerve injuries incurred during previous operations, resulting in joint stiffness.

[Epithelioid sarcoma of the hand, a seldomly recognized tumor]. / Das Epithelioidsarkom der Hand, selten primär richtig diagnostiziert.

BACKGROUND: The epithelioid sarcoma of the hand is often misdiagnosed. This tumor occurs most frequently in children and young adults, has an uncharacteristic course, and carries a high risk for local recurrence and metastases. The characteristic histopathology is helpful in establishing the correct diagnosis. Differential diagnosis includes synovialoma, fibromatosis and Dupuytren's contracture. Multinodular appearance is not uncommon. PATIENTS AND METHOD: Three young patients (one male and two female) were operated on the hand for treatment of Dupuytren's contracture, synovialoma and fibromas, respectively. The necessity for surgical revision in these patients led to a reevaluation of the primary histological data. The original diagnosis having been found to be incorrect, the correct diagnosis was established namely, epithelioid sarcoma. RESULTS: Surgical revision was performed, which involved partial amputation of the extremity. None of the patients underwent adjuvant radio- or chemotherapy. The patients were followed-up for ten, four and two and a half years, respectively. They are currently free of recurrences. CONCLUSION: Prognosis depends on the size and the location of the tumor. Adequate treatment requires early radical excision; amputation may be required if the primary tumor is located in the fingers or treatment of recurrent growth. The tumor tends to metastasize via the lymphatic system. Patients must be monitored with yearly lung X-rays since recurrence or metastasis may occur many years after the initial diagnosis and treatment.

Anatomical basis for functional treatment of dorsolateral dislocation of the proximal interphalangeal joint.

Dorsolateral dislocation of the proximal interphalangeal (PIP) joint is a common injury to the hand. Closed reduction of the dislocation anatomically realigns the avulsed ligaments; thus patients may be managed non-operatively. Standard treatment involves placement of a dorsal splint to prevent hyperextension and lateral stresses. This allows early active motion of the PIP joint while preventing a flexion contracture. In this fresh cadaver study, the PIP joint in 24 fingers was dorsolaterally dislocated. Four digits had to be excluded from the investigation due to a fracture dislocation with a bony fragment of >40% of the articular surface of the middle phalanx. After closed reduction, seven digits were further studied using the cryosection technique described by Kathrein et al. (1996, Clin. Anat. 9:227-231) to demonstrate the position of the avulsed palmar plate. In another 13 joints, the torn ligaments were examined by gross dissection. In 10 degrees of finger flexion, the avulsed palmar plate lay at its previous attachment to the base of the middle phalanx. The collateral ligament, ruptured at its attachment to the side of the head of the proximal phalanx, returned to its original position and was not interposed in the joint. The split between the collateral ligament and the accessory collateral ligament was also closed. Our data suggest that the ligamentous structures of the PIP joint, namely the palmar plate and collateral ligaments, typically return to their anatomic positions upon simple closed reduction of dorsolateral dislocations in fresh cadavers.