Wound Closure After Port Implantation-A Randomized Controlled Trial Comparing Tissue Adhesive and Intracutaneous Suturing.

BACKGROUND: Wound healing after pectoral port implantation is a major factor determining the success or failure of the procedure. Infection and wound dehiscence can endanger the functionality of the port system and impede chemotherapy. The cosmetic result is important for patient satisfaction as well. METHODS: From August 2015 to July 2017, adult patients with an indication for port implantation were entered into a prospective, randomized and controlled single-center study. The skin incision was closed either with tissue adhesive or with an intracutaneous suture. The primary endpoints were the total score of the scar evaluated by the patient and the investigator on the POSAS scale (Patient and Observer Scar Assessment Scale: 6 [normal skin] to 60 points), blinded assessment of photographic documentation by ten evaluating physicians, and the patient's reported quality of life. The calculation of case numbers was based only on the patients' overall POSAS assessment, which was tested for non-inferiority. The secondary endpoints were other complications (infection, dehiscence) and the duration of wound closure (trial registration number NCT02551510). RESULTS: 156 patients (60 ± 13 years, 64% women) participated in the study. The patient-assessed total POSAS score of tissue adhesive revealed non-inferiority to suturing (adhesive 11.7 ± 5.8 vs. suture 10.1 ± 4.0, p for non-inferiority <0.001). Both the investigators in their POSAS assessments and the blinded physician evaluators in their assessment of photographically documented wounds rated wound closure by suturing better than closure with tissue adhesive. No significant differences were found between groups with respect to quality of life or the frequency of wound infection or dehiscence. CONCLUSION: Closure of the upper cutaneous layer with tissue adhesive is a suitable and safe method of wound closure after port implantation.

Deviations in positioning variable pitch screws- scaphoid waist fractures.

INTRODUCTION: Operative therapy using a headless cannulated variable pitch compression screw is the gold standard for the treatment of instable scaphoid fractures. HYPOTHESIS: Deviation from the central placement is associated with a loss of stability and stiffness. MATERIAL AND METHODS: An artificial bone model was manufactured and different screw positions (central, 10° and 20° to the long axis) were assessed. A shearing test with axial force on the 45° flexed scaphoid was applied. RESULTS: The inserted variable pitch screw showed the highest stiffness and failure force in a position in the long axis. At 10 degrees, a slight decrease in stiffness (32.7N/mm±9.3N/mm) and failure force (41.6N±13.2N) was observed, while a significant reduction in stiffness (29.3N/mm±4.6N/mm) and failure force (50.3N±19.5N) was measured at 20 degrees. DISCUSSION: Deviations in the angle of insertion of the compression screw cause loss in failure force, thus deviations from the central placement is associated with less stability and stiffness. LEVEL OF PROOF: Controlled laboratory study (basic science study, biomechanical testing).

Acute atraumatic carpal tunnel syndrome due to flexor tendon rupture following palmar plate osteosynthesis in a patient taking rivaroxaban.

INTRODUCTION: Few case reports describe the development of a hematoma under oral anticoagulation as the cause of an atraumatic carpal tunnel syndrome. CASE REPORT: A 76 years old woman presented an acute atraumatic carpal tunnel syndrome of her left hand under oral anticoagulation with rivaroxaban due to atrial fibrillation. 12 years ago, palmar plate osteosynthesis of a distal radius fracture had been performed on the affected wrist. Open decompression of the carpal canal was performed due to persistent severe pain under intense pain therapy and progressive neurological symptoms. The cause of the pain was a hematoma due to a rupture of the flexor pollicis longus and the second flexor digitorum profundus tendon with concomitant synovitis at the plate's distal rim. After decompression, pain relieved and neurological deficits improved rapidly. DISCUSSION: Ruptures of the flexor tendons occur in palmar plate osteosynthesis in up to 1.5% in the long term postoperative course. Very distal plate positions, like in this case, increase that risk. Under anticoagulation, the rupture induced a hematoma increasing local pressure resulting in an acute carpal tunnel syndrome. Acute nerve compression syndromes should be treated surgically without delay. CONCLUSION: Therapy with anticoagulants may increase hematoma after tendon rupture, thus supporting the development of an atraumatic acute carpal tunnel syndrome and complicating the surgical therapy. Hardware removal after fracture healing should be advised in patients with Soong grade 2 plate positions especially those taking anticoagulants.

Quantitative sensory testing after macroreplantation: evidence for a specific somatosensory profile.

A comprehensive functional recovery is one of the criteria for successful replantation of an amputated limb. Functionality of a replanted limb is strongly dependent on its regained sensibility. In previous studies concerning the sensibility of replanted limbs, only a few somatosensory submodalities were examined in small samples. The purpose of this study is to provide a full pattern of somatosensory symptoms after replantation. Quantitative sensory testing was performed according to a standardized protocol in a sample of 15 patients who underwent replantation of their upper limb proximal to the radiocarpal joint (macroreplantation). Results indicate that most of these patients showed a specific somatosensory profile characterized by thermal and mechanical hypoesthesia and hyperalgesia in response to pressure pain, whereas no single case of hyperalgesia to heat pain occurred. This distinct profile of impaired somatosensation shares some features of the somatosensory profile of neuropathic pain syndromes. Patients' limbs that were replanted many years before the present quantitative sensory testing showed more sensory deficits than patients with more recent replantations. This knowledge might be helpful in the development of more specific and more successful rehabilitation programs with replanted patients and improves the behavioral function of the replanted limb.

The plasma environment inside geostationary orbit: A Van Allen Probes HOPE survey.

The two full precessions in local time completed by the Van Allen Probes enable global specification of the near-equatorial inner magnetosphere plasma environment. Observations by the Helium-Oxygen-Proton-Electron (HOPE) mass spectrometers provide detailed insight into the global spatial distribution of electrons, H+, He+, and O+. Near-equatorial omnidirectional fluxes and abundance ratios at energies 0.1-30 keV are presented for 2 ≤ L ≤ 6 as a function of L shell, magnetic local time (MLT), and geomagnetic activity. We present a new tool built on the UBK modeling technique for classifying plasma sheet particle access to the inner magnetosphere. This new tool generates access maps for particles of constant energy for more direct comparison with in situ measurements, rather than the traditional constant µ presentation typically associated with UBK. We present for the first time inner magnetosphere abundances of O+ flux relative to H+ flux as a function of Kp, L, MLT, and energy. At L = 6, the O+/H+ ratio increases with increasing Kp, consistent with previous results. However, at L < 5 the O+/H+ ratio generally decreases with increasing Kp. We identify a new "afternoon bulge" plasma population enriched in 10 keV O+ and superenriched in 10 keV He+ that is present during quiet/moderate geomagnetic activity (Kp < 5) at ~1100-2000 MLT and L shell 2-4. Drift path modeling results are consistent with the narrow energy and approximate MLT location of this enhancement, but the underlying physics describing its formation, structure, and depletion during higher geomagnetic activity are currently not understood.

Cortical reorganization after macroreplantation at the upper extremity: a magnetoencephalographic study.

With the development of microsurgical techniques, replantation has become a feasible alternative to stump treatment after the amputation of an extremity. It is known that amputation often induces phantom limb pain and cortical reorganization within the corresponding somatosensory areas. However, whether replantation reduces the risk of comparable persisting pain phenomena as well as reorganization of the primary somatosensory cortex is still widely unknown. Therefore, the present study aimed to investigate the potential development of persistent pain and cortical reorganization of the hand and lip areas within the sensory cortex by means of magnetoencephalographic dipole analyses after replantation of a traumatically amputated upper limb proximal to the radiocarpal joint. Cortical reorganization was investigated in 13 patients with limb replantation using air puff stimulation of the phalanges of both thumbs and both corners of the lower lip. Displacement of the centre of gravity of lip and thumb representations and increased cortical activity were found in the limb and face areas of the primary somatosensory cortex contralateral to the replanted arm when compared to the ipsilateral hemisphere. Thus, cortical reorganization in the primary somatosensory cortex also occurs after replantation of the upper extremity. Patients' reports of pain in the replanted body part were negatively correlated with the amount of cortical reorganization, i.e. the more pain the patients reported, the less reorganization of the subjects' hand representation within the primary somatosensory cortex was observed. Longitudinal studies in patients after macroreplantation are necessary to assess whether the observed reorganization in the primary somatosensory cortex is a result of changes within the representation of the replanted arm and/or neighbouring representations and to assess the relationship between the development of persistent pain and reorganization.

Whistler anisotropy instabilities as the source of banded chorus: Van Allen Probes observations and particle-in-cell simulations.

Magnetospheric banded chorus is enhanced whistler waves with frequencies ωr <Ω e , where Ω e is the electron cyclotron frequency, and a characteristic spectral gap at ωr ≃Ω e /2. This paper uses spacecraft observations and two-dimensional particle-in-cell simulations in a magnetized, homogeneous, collisionless plasma to test the hypothesis that banded chorus is due to local linear growth of two branches of the whistler anisotropy instability excited by two distinct, anisotropic electron components of significantly different temperatures. The electron densities and temperatures are derived from Helium, Oxygen, Proton, and Electron instrument measurements on the Van Allen Probes A satellite during a banded chorus event on 1 November 2012. The observations are consistent with a three-component electron model consisting of a cold (a few tens of eV) population, a warm (a few hundred eV) anisotropic population, and a hot (a few keV) anisotropic population. The simulations use plasma and field parameters as measured from the satellite during this event except for two numbers: the anisotropies of the warm and the hot electron components are enhanced over the measured values in order to obtain relatively rapid instability growth. The simulations show that the warm component drives the quasi-electrostatic upper band chorus and that the hot component drives the electromagnetic lower band chorus; the gap at âˆ¼Ω e /2 is a natural consequence of the growth of two whistler modes with different properties.

Wheelbarrow tire explosion causing trauma to the forearm and hand: a case report.

INTRODUCTION: Tire explosion injuries are rare, but they may result in a severe injury pattern. Case reports and statistics from injuries caused by exploded truck tires during servicing are established, but trauma from exploded small tires seems to be unknown. CASE PRESENTATION: A 47-year-old german man inflated a wheelbarrow tire. The tire exploded during inflation and caused an open, multiple forearm and hand injury. CONCLUSION: Even small tires can cause severe injury patterns in the case of an explosion. High inflating pressures and low safety distances are the main factors responsible for this occurrence. Broad safety information and suitable filling devices are indispensable for preventing these occurrences.

Above-Knee Replantation Following Traumatic Bilateral Amputation: Sciatic Nerve Transplantation.

A 12-year-old boy who was overrun by a train, sustained traumatic bilateral above-knee amputation and a rupture of the symphysis. The left leg had multiple fractures and soft tissue injuries and amputation was necessary. The right one, although severely crushed, at the amputation site and with a MESS of 9, was replanted accepting some shortening and a soft tissue defect at the amputation site, employing saphenic vein grafts from the amputate (left leg) and an early free latissimus dorsi-flap. Septic complications at the amputation site were managed, and an autologous sciatic nerve graft was performed 8 months after the accident, employing the contralateral above-knee stump as the donor. Protective foot sole sensitivity was noticed after 2 years and 4 months and continued to improve. Further reconstructive procedures included ORIF of a femoral fracture in the contra-lateral stump. On the replanted leg proximal tibia corrective osteotomy and lateral collateral knee ligament reconstruction were performed. A follow-up of 7 years and 9 months demonstrates now a leg capable of full weight bearing and recovery of overall protective sensitivity. The boy made good psycho-social progress after difficulties and feels that the replanted leg is of significantly greater use to him than the hi-tech prosthesis on the other leg.

Indocyanine-green fluorescence video angiography used clinically to evaluate tissue perfusion in microsurgery.

BACKGROUND: Laser-induced fluorescence angiography with indocyanine-green (ICG-FA) is a new diagnostic approach that allows quantitative evaluation of tissue perfusion in microsurgery as well as an analysis of the uptake, distribution, and clearance of dye-marked blood. METHODS: The ICG-FA technique was evaluated for its sensitivity and prognostic value in comparison with clinical parameters (turgor, temperature, reperfusion time, bleeding after puncture) during and after different surgical procedures. Altogether, 91 measurements were made in cases of microvascular repair (n = 43) and free-flap surgery (n = 48). RESULTS: Because of discrepancies between ICG-FA results and clinical findings, the planned postoperative management was changed 43 times (47.2%). In cases of microvascular repair that subsequently resulted in tissue necrosis, ICG fluorescence had a significantly higher prognostic value than any of the clinical parameters (p = 0.03). During free-flap surgery, intraoperative ICG-FA had better sensitivity for flap loss than clinical parameters, but postoperative ICG-FA did not. CONCLUSIONS: Fluorescence angiography with ICG is a sensitive diagnostic tool for detecting compromised tissue perfusion in trauma surgery and microsurgery. Its use may improve perioperative management and thereby lead to better clinical results.