Negative pressure wound therapy in burns: a prospective, randomized-controlled trial.

BACKGROUND: Negative-pressure-wound-therapy (NPWT) has become a widely used tool for the coverage and active treatment of complex wounds, including burns. This study aimed to evaluate the effectiveness of NPWT in acute burns of upper and lower extremities and to compare results to the standard-of-care (SOC) at our institution. METHODS: Patients that were admitted to our institution between May 2019 and November 2021 with burns on extremities between 0.5 % and 10 % of the total body surface area (%TBSA) were included and randomized to either NPWT or SOC (polyhexanide gel, fatty gauze, and cotton wool). Treatment was performed until complete wound healing. Patients that required skin grafts, received additional NPWT after grafting independent on the initial group allocation. RESULTS: Sixty-five patients suffering from burn injury between May 2019 and November 2021 were randomized into treatment with NPWT (n = 33) or SOC (n = 32); of these, 33 patients (NPWT) and 28 patients (SOC) had complete data sets and were included in the analysis. Both groups were similar regarding age (39.8 ± 13.7 vs. 44.8 ± 16.2 years,p = 0.192), total burn size (3.1 ± 2.3 vs. 3.4 ± 2.8 %TBSA,p = 0.721) and treated wound size (1.9 ± 1.2 vs. 1.5 ± 0.8 %TBSA,p = 0.138). We found no differences regarding healing time (11.0 ± 4.9 vs. 8.6 ± 3.8,p = 0.074, and significant differences in a number of dressing changes throughout the study (2.4 ± 1.5 vs 4.2 ± 1.9,p < 0.001). The Kaplan-Meier time-to-event analysis exhibited no statistically significant difference in the time to healing or skin grafting (p = 0.085) in NPWT group compared with SOC group. The median time to healing or skin grafting was 10(8-11) days for NPWT and 9(7-11) days for SOC. The hazard ratio for healing or skin graft was HR= 0.64(0.38-1.08). The results of the time-to-event analysis as well as the Kaplan-Meier curve on the PPS confirmed this result. We found no differences in secondary surgical operations 15.2 vs 21.4 % pain or functional outcomes. CONCLUSIONS: In this study, we found no significant difference between the two groups in terms of time to detect wound healing. We also found no difference regarding further operations for wound closure, pain and/or scarring. However, dressing changes were significantly less frequent for patients that were treated with NPWT, which may be a psychological and logistical advantage.

The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction.

BACKGROUND: This study aimed to evaluate the impact of semi-absorbable mesh on donor-site morbidity and patient-reported outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: We conducted a retrospective cohort study of all patients who had DIEP flap breast reconstruction in our department from July 2007 to March 2019. Patients were invited to a comparative follow-up visit and grouped according to donor-site closure: primary fascial closure (the no-mesh group) and fascial reinforcement with semi-absorbable mesh in a subfascial position (the mesh group). The primary outcome of interest was donor-site morbidity, including bulging, hernia formation and rectus abdominis muscle strength. We also surveyed, surgical site complications and patient-reported outcomes using Patient and Observer Scar Assessment Scale v2.0 and BREAST-Q© version 2.0. RESULTS: A total of 191 patients had received DIEP flap breast reconstruction. Eighty-five patients (44.5%) with 108 DIEP flaps (53 patients in the mesh group and 32 patients in the no-mesh group) were included in the study. The mean BMI of the patients was significantly higher in the mesh group (mesh group, 26.9 vs. no-mesh group, 25.0, with p = 0.03). The incidence of hernia was significantly reduced in the mesh group (mesh group, 2.8% vs. no-mesh group, 13.5%, with p = 0.03). The incidence of bulging and the extent of rectus abdominis muscle strength were similar for both groups. Operative surgical site complications were reduced in the mesh group (mesh group, 7.5% vs. no-mesh group, 18.8%). There was no difference in patients' physical well-being and satisfaction with the donor site between groups. Patient-reported scar outcome was significantly better in the no-mesh group (p < 0.001). CONCLUSION: Our novel method of donor-site closure with semi-absorbable mesh in a subfascial position for reinforcement of the anterior rectus fascia on the DIEP donor site is safe. It has no negative impact on surgical site complications and patient-reported outcomes, while reducing the incidence of hernias on the donor-site in DIEP flap breast reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

ICF-based multidisciplinary rehabilitation program for complex regional pain syndrome of the hand: efficacy, long-term outcomes, and impact of therapy duration.

BACKGROUND: Complex regional pain syndrome (CRPS) is a rare but feared complication in hand surgery. Although multimodal therapy concepts are recommended, there is only low evidence on efficacy of such approaches. Furthermore, recommendations regarding therapy duration are lacking. Aim of this study was to validate the efficacy of an International Classification of Functioning, Disability and Health (ICF)-based multidisciplinary rehabilitation concept for treatment of CRPS of the hand and to find correlations between therapy duration and outcome measures. METHODS: Patients with CRPS of the hand after occupational trauma that underwent an ICF-based rehabilitation program between 2010 and 2014 were included in this retrospective study. Besides demographic data, outcomes included pain (VAS), range of motion assessed by fingertip-to-palm-distance (PTPD) and fingernail-to-table-distance (FTTD) as well as strength in grip, 3-point pinch and lateral pinch. All measures were gathered at admission to and discharge from inpatient rehabilitation therapy as well as at follow-up. Statistical analysis included paired t-test, ANOVA and Pearson's correlation analysis. RESULTS: Eighty-nine patients with a mean age of 45 years were included in this study. Duration of rehabilitation therapy was 53 days on average. All outcomes improved significantly during rehabilitation therapy. Pain decreased from 6.4 to 2.2. PTPD of digit 2 to 5 improved from 2.5, 2.8, 2.6, and 2.3 cm to 1.3, 1.4, 1.2, and 1.1 cm, respectively. FTTD of digit 2 to 5 decreased from 1.5, 1.7, 1.5, and 1.6 cm to 0.6, 0.8, 0.7, and 0.7 cm, respectively. Strength ameliorated from 9.5, 3.7, 2.7 kg to 17.9, 5.6, 5.0 kg in grip, lateral pinch, and 3-point pinch, respectively. Improvement in range of motion significantly correlated with therapy duration. 54% of patients participated at follow-up after a mean of 7.5 months. Outcome measures at follow-up remained stable compared to discharge values without significant differences. CONCLUSION: The ICF-based rehabilitation concept is a reliable and durable treatment option for CRPS of the hand. Range of motion improved continuously with therapy duration and thus may serve as an indicator for optimum length of therapy.

[Options for soft tissue reconstruction in pseudarthrosis]. / Möglichkeiten der Weichteilrekonstruktion bei Pseudarthrosen.

BACKGROUND: Pseudarthrosis can develop as a complication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop a coherent and interdisciplinary treatment plan. METHODS: Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via a pedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.

Evidence of stage progression in a novel, validated fluorescence-navigated and microsurgical-assisted secondary lymphedema rodent model.

Secondary lymphedema (SL)is a frequent and devastating complication of modern oncological therapy and filarial infections. A lack of a reliable preclinical model to investigate the underlying mechanism of clinical stage progression has limited the development of new therapeutic strategies. Current first line treatment has shown to be merely symptomatic and relies on lifetime use of compression garments and decongestive physiotherapy. In this study, we present the development of a secondary lymphedema model in 35 rats using pre- and intraoperative fluorescence-guided mapping of the lymphatics and microsurgical induction. In contrast to the few models reported so far, we decided to avoid the use of radiation for lymphedema induction. It turned out, that the model is nearly free of complications and capable of generating a statistically significant limb volume increase by water displacement measurements, sustained for at least 48 days. A translational, accurate lymphatic dysfunction was visualized by a novel VIS-NIR X-ray ICG-Clearance-Capacity imaging technology. For the first-time SL stage progression was validated by characteristic histological alterations, such as subdermal mast cell infiltration, adipose tissue deposition, and fibrosis by increased skin collagen content. Immunofluorescence confocal microscopy analysis suggested that stage progression is related to the presence of a characteristic α SMA+/HSP-47+/vimentin+ fibroblast subpopulation phenotype. These findings demonstrate that the in-vivo model is a reliable and clinically relevant SL model for the development of further secondary lymphedema therapeutic strategies and the analysis of the veiled molecular mechanisms of lymphatic dysfunction.

Open Right Hemicolectomy Is a Safe and Suitable Procedure for Surgical Training: A Comparative Study With 133 Patients.

BACKGROUND AND AIMS: A right hemicolectomy is a technically demanding procedure and the quality of the operation influences the short- and long-term outcomes. An increasing number of certified centers employ surgeons who are specialized in this procedure. Residency training is obligatory, but trainee surgeons often cannot perform technically demanding procedures because of economical and certification requirements imposed on the center. This study was performed to evaluate the suitability of right hemicolectomy as a training procedure. MATERIAL AND METHODS: Between 2009 and 2013, 133 patients received a right hemicolectomy during cancer treatment. Patient data were analyzed in two cohorts: cohort 1 contained 90 patients who were operated by a resident under supervision, and cohort 2 included 43 patients who were operated by a specialized senior surgeon. Outcome and safety were evaluated by mortality rate, anastomotic leakage, complication rate, and operation time. The resection status and the number of resected lymph nodes were surrogate parameters for oncological quality. Gender, age, American Society of Anesthesiologists classification, body mass index, and general risk factors were compared in both cohorts. RESULTS: There was no significant difference in the rate of anastomotic leakage between the two groups (p = 0.799). Oncological criteria were met in both cohorts and the oncological quality was similar between groups. Furthermore, there were no significant differences in risk factors, operating time, postoperative complications, and mortality between the groups. CONCLUSION: Oncological open right hemicolectomy is a safe and suitable training procedure for residency training under standardized conditions.

[Complex regional pain syndrome following distal fractures of the radius : Epidemiology, pathophysiological models, diagnostics and therapy]. / Komplexes regionales Schmerzsyndrom nach distaler Radiusfraktur : Aktuelle Epidemiologie, pathophysiologische Modelle, Diagnostik und Therapie.

The complex regional pain syndrome (CRPS) still represents an incompletely etiologically understood complication following fractures of the distal radius. The incidence of CRPS following fractures of the distal radius varies between 1 % and 37 %. Pathophysiologically, a complex interaction of inflammatory, somatosensory, motor and autonomic changes is suspected, leading to a persistent maladaptive response and sensitization of the central and peripheral nervous systems with development of the corresponding symptoms. Decisive for the diagnostics are a detailed patient medical history and a clinical hand surgical, neurological and pain-related examination with confirmation of the Budapest criteria. Among the types of apparatus used for diagnostics, 3­phase bone scintigraphy and temperature measurement have a certain importance. A multimodal therapy started as early as possible is the most promising approach for successful treatment. As part of a multimodal rehabilitation the main focus of therapy lies on pain relief and functional aspects.

[Perioperative Management in Microsurgery - Consensus Statement of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / Perioperatives Management in der Mikrochirurgie - Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

Perioperative management of microsurgery is not well standardised. Due to a lack of evidence, different regimes are established in different microsurgical centres. However, trends towards less aggressive perioperative interventions can be identified in recent years, since treatment algorithms without systematic evidence are being progressively abandoned. The available evidence on perioperative issues, such as temperature control, fluid resuscitation, blood transfusions, application of vasodilators or - pressors, as well as anticoagulants, were discussed during the consensus conference on perioperative management at the annual meeting of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels. Common basic standards were identified and a consensus was reached that is described in the following manuscript.

[Nerve Tubes for the Repair of Traumatic Sensory Nerve Lesions of the Hand: Review and Planning Study for a Randomised Controlled Multicentre Trial]. / Nervetubes zur Versorgung von traumatischen sensiblen Nervenläsionen der Hand - Übersicht sowie retrospektive Planungsstudie für eine randomisiert-kontrollierte multizentrische Studie.

BACKGROUND: Nerve tubes are used for bridging of short nerve gaps and for coating of primary end-to-end nerve sutures. This article provides an overview of available implants and their application. Also it presents a retrospective planning study aiming to determine the static 2-point discrimination after primary peripheral nerve repair with and without the use of a nerve tube. The results have been used to determine the sample size of a prospective randomised trial. PATIENTS AND METHODS: 54 peripheral nerve injuries of 41 patients were treated by primary end-to-end nerve sutures with or without the additional use of a nerve tube (n=28 and n=26, respectively). 38 digital nerves and 16 median and ulnar nerves were affected. Nerve tubes were used for the repair of 15 digital nerves and 13 median and ulnar nerves. Clinical follow-up was performed 46 months after surgery (patients without nerve tubes) and 18 months after surgery (patients with nerve tubes), respectively. Static 2-point discrimination (2PD) was measured by double-tip compasses (weight: 18 g) and patients were examined for clinical signs of neuroma. Further examinations included grip strength as a percentage value compared with the uninjured hand and, in case of finger injuries, the range of motion in the proximal and distal interphalangeal joints, Strickland score, DASH score and implant-associated complications. RESULTS: In patients with primary end-to-end sutures for finger injuries, there were no statistically significant differences between treatment with and without nerve tubes regarding 2PD, grip strength, DASH- or Strickland score. However, 2PD values of patients with nerve tubes had an increased spread. Average 2PD in digital nerves was 4.5 mm (3-15; SD: 3.9) without nerve tubes and 5.5 mm (3-15; SD: 5) with nerve tubes. Average 2PD after lesions of the median and ulnar nerves was 10 mm (3-15; SD: 5.9 and 5.4, respectively) in both groups. CONCLUSION: The additional use of a nerve tube showed no superiority in this planning study. The expected average 2PD is 5 mm after digital nerve injuries and 10 mm after lesions of the median or ulnar nerves.

Suprathel(®) for severe burns in the elderly: Case report and review of the literature.

Large burns in aged patients are common and treatment often reveals challenging. Cardiovascular complications significantly contribute to the unfavorable prognosis in this group of high-risk patients. Pain medication and sedation can negatively influence cardiovascular stability. Suprathel(®) is well-known for its almost pain free application and reduction of dressing change intervals, and thus lowers the demand for potentially harmful analgesics and sedatives. We present the case of an 81-year-old patient with 51% of total burned body surface area (ABSI=12), who was completely treated with Suprathel(®). Despite a predicted mortality of more than 80%, the patient survived and was discharged home without significant handicaps 69 days after burn. We hypothesize that Suprathel(®) beneficially contributed to the favorable clinical course of this critical patient as less frequent wound-dressing changes did not induce additional pain or sedative medication and thus improved cardiovascular stability.

[Standardisation of the Initial Treatment of Severely Burned Patients: The Necessary Transfer of Concepts from Trauma Care]. / Standardisierung der Initialbehandlung von Schwerbrandverletzten: Die notwendige Übertragung von Konzepten aus der Schwerverletztenversorgung.

The initial treatment of severely burned patients remains a huge challenge for first responders in emergency services as well as emergency doctors who do not work in a centre for severe burn injuries. The reason for this is the low number of cases in developed countries and a lack of training concepts for the specific aspects of the initial treatment of severe burn injuries. Because of guidelines with limited evidence (S1, S2k) and a lack of structured treatment approaches, uncertainties with respect to initial treatment are still visible. Even within the professional societies and on international comparison, controversial aspects remain. In contrast, optimised and standardised procedures are available for the treatment of severely injured (trauma) patients, based on PHTLS® (Pre Hospital Trauma Life Support) for preclinical and ATLS® (Advanced Trauma Life Support) for in-hospital first aid. This article takes stock of the current structure of care and the relevant evidence for the initial treatment of severe burns. Also it discusses a possible transfer and further development of concepts for primary trauma care by all disciplines involved. Nine essential steps in the primary care of burned patients are identified and evaluated. The need for the introduction of a uniform treatment algorithm is illustrated. The treatment algorithm presented in this article addresses all first responders who are faced with initial treatment in the first 24 hours outside of burn centres. As an essential, new aspect, it offers a transfer and adaptation of concepts from trauma care to standardise the care of severely burned patients.

[Can Topical Negative Pressure Therapy be Performed as a Cost-Effective General Surgery Procedure in the German DRG System?]. / Führt die Vakuumsaugtherapie tatsächlich zu einer Kosteneffektivität in der Allgemeinchirurgie im G-DRG-System?

INTRODUCTION: Topical negative pressure therapy (TNPT) has been established for surgical wound therapy with different indications. Nevertheless, there is only sparse evidence regarding its therapeutic superiority or cost-effectiveness in the German DRG system (G-DRG). This study was designed to analyse the cost-effectiveness of TNPT in the G-DRG system with a focus on daily treatment costs and reimbursement in a general surgery care setting. PATIENTS/MATERIALS AND METHODS: In this retrospective study, we included 176 patients, who underwent TNPT between 2007 and 2011 for general surgery indications. Analysis of the cost-effectiveness involved 149 patients who underwent a simulation to calculate the reimbursement with or without TNPT by a virtual control group in which the TNP procedure was withdrawn for DRG calculation. This was followed by a calculation of costs for wound dressings and TNPT rent and material costs. Comparison between the "true" and the virtual group enabled calculation of the effective remaining surplus per case. RESULTS: Total reimbursement by included TNPT cases was 2,323 ,70.04 €. Costs for wound dressings and TNPT rent were 102,669.20 €. In 41 cases there was a cost-effectiveness (27.5%) with 607,422.03 € with TNP treatment, while the control group without TNP generated revenues of 442,015.10 €. Costs for wound dressings and TNPT rent were 47,376.68 €. In the final account we could generate a cost-effectiveness of 6759 € in 5 years per 149 patients by TNPT. In 108 cases there was no cost-effectiveness (72.5%). CONCLUSION: TNPT applied in a representative general surgery setting allows for wound therapy without a major financial burden. Based on the costs for wound dressings and TNPT rent, a primarily medically based decision when to use TNPT can be performed in a balanced product cost accounting. This study does not analyse the superiority of TNPT in wound care, so further prospective studies are required which focus on therapeutic superiority and cost-effectiveness.

Novel use of a flowable collagen-glycosaminoglycan matrix (Integra™ Flowable Wound Matrix) combined with percutaneous cannula scar tissue release in treatment of post-burn malfunction of the hand--A preliminary 6 month follow-up.

INTRODUCTION: Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis. PATIENTS AND METHODS: In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen-glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire. RESULTS: No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2-5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14. DISCUSSION: The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2-5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.

[Reconstruction of Defects after Oncologic Resection and Radiation - Indications for Microsurgical Reconstruction]. / Defektrekonstruktion nach onkologischer Resektion und Bestrahlung - Indikationen zur mikrochirurgischen Rekonstruktion.

The surgical treatment of soft tissue sarcomas in the extremities frequently requires radiation therapy to achieve local tumour control. However, both adjuvant and neoadjuvant radiation are associated with significant morbidity caused by impaired wound healing, ulcers or osteonecrosis with subsequent fractures. This is due to altered local cell mediator levels, fibrosis occurring simultaneously with decreased cell division rates and diminished vascularity. This article describes a number of local conservative treatment options, all of which have limited success rates. In addition, it describes plastic surgical treatment options for radiation-induced local morbidity. Surgical reconstruction includes the full range of plastic reconstructive techniques. However, less complex options such as random pattern flaps or split thickness skin grafts are often associated with complications. Therefore, a large number of cases require free tissue transfer.

[Palliative plastic surgery in multidisciplinary therapeutic concepts]. / Palliative plastische Chirurgie im multimodalen Therapiekonzept.

BACKGROUND: Survival rates even in advanced tumour stage have been improved for some tumour entities due to progress in adjuvant and neoadjuvant therapeutic strategies. Nevertheless, painful, exulcerated or bleeding wounds can impair quality of life for palliative patients. Increasing evidence in palliative treatment has raised options for plastic-reconstructive surgery to be applied for treatment of local wounds which can improve quality of life for the remaining lifetime for the palliative patients in our institutions. METHODS: In this review the role of plastic surgery in the palliative treatment concept is highlighted as well as conservative and operative treatment options are discussed. With regard to the limited evidence, an analysis of the currently available literature was performed and data reviewed. These data were added to a case series of patients of our hospital. RESULTS: The analysis of the literature revealed only few data which all indicate an improvement of quality of life due to reconstructive procedures in the palliative situation. There are some studies dealing with plastic surgical operations in advanced tumour diseases. Plastic surgery procedures become relevant after failure of conservative treatment wound care. The most frequent entities are soft tissue sarcomas, squamous cell carcinomas and breast cancer. Safe and simple flaps should be preferred, but free flaps and tendon transfer are optional procedures, and resection of the thoracic wall can be justified in palliative indications with sufficient soft tissue coverage. The indications for major limb amputation should be restricted to selective cases because quality of life is highly reduced. Radiation is possible even after tissue transfer in some cases, and radiation-induced dermatitis with ulcerations can be treated additionally. DISCUSSION: Opportunities and limitations in plastic and reconstructive surgery should be continuously presented in tumour boards, to clarify these important procedures for palliative patients to all members of the tumour board. There is an increasing impact of plastic surgery for improving the quality of life in palliative patients in a multimodal therapeutical concept.

Topical intrawound application of vancomycin powder in addition to intravenous administration of antibiotics: A meta-analysis on the deep infection after spinal surgeries.

BACKGROUND: The intrawound application of vancomycin powder in addition to intravenous administration of antibiotics has been reported to be an easy and cost-efficient technique for reducing the deep infection, which is a serious complication of spinal surgeries. The aim of the present meta-analysis was to derive a preliminary estimation on the clinical performance of this technique. HYPOTHESIS: The intrawound application of vancomycin powder in addition to intravenous administration of antibiotics may significantly reduce the risk of deep infection after spinal surgeries. MATERIALS AND METHODS: Studies were identified from PubMed and EMBASE searches. After comprehensive review, data were extracted from eligible studies. A meta-analysis was performed to generate pooled odds ratio (OR) of this technique. RESULTS: Eight studies (4592 patients) were included. The pooled OR (95% CI) was 0.22 (0.07-0.63). I(2) value was 65.2% (P=0.005). The pooled ORs were stable in sensitivity analyses. No analysis of subgroup, meta-regression or publication bias was performed because of inadequate included studies. DISCUSSION: The intrawound application of vancomycin powder in addition to intravenous administration of antibiotics may significantly reduce the risk of deep infection after spinal surgeries. Further studies with large sample size and high quality are needed to provide more evidences. LEVEL OF EVIDENCE: II.

[Microsurgical training in Germany - results of a survey among trainers and trainees]. / Mikrochirurgische Ausbildung in Deutschland - Ergebnisse einer Umfrage unter Weiterbildungsassistenten und Weiterbildern.

Reconstructive microsurgery is an essential part of plastic surgery. To live up to the high technical demands of today's sophisticated techniques, a structured microsurgical training is required. However, such curricula are rare in Germany. We therefore evaluated the concepts and requests of trainers as well as trainees regarding an optimal microsurgical training. We found that the demands of both sides to be fairly similar. How-ever, there were factors potentially hindering the implementation of such curricula, foremost the increasing economic pressure. Based on our findings, representatives of microsurgical trainers and trainees, together with national societies might be able to establish a national curriculum for microsurgical training. The clinical implementation of such a structured train-ing will require significant personal resources. However, this expenditure seems to be justified by the increasing complexity of techniques, the rising demand of patients and the limited time for -surgical training.

Indocyanine green fluorescence-guided sentinel node biopsy: a meta-analysis on detection rate and diagnostic performance.

BACKGROUND: Indocyanine green (ICG) fluorescence-guided sentinel node biopsy (SLNB) has been successfully employed in various kinds of tumors. Clinical results of previous studies on this technique are at different levels of evidence. This Meta-analysis was conducted to provide a more precise estimation on its clinical performance. METHODS: Eligible studies were identified from systematical PubMed and EMBASE searches; data were extracted. A Meta-analysis was performed to generate pooled detection rate, sensitivity, specificity, diagnostic odds ratio (DOR) and summary receiver operator characteristic curves. RESULTS: Fifteen published articles were included. Clinical data of 513 patients were obtained. The pooled detection rate, the pooled sensitivity, the pooled specificity, the pooled DOR and their 95% confidence intervals (95% CI) were 0.96 (0.91-0.99), 0.87 (0.79-0.92), 1.00 (0.99-1.00) and 150.13 (57.42-392.56), respectively. Significant heterogeneities existed among studies. Significant publication bias was found in detection rate. The concentration < 5 mg/ml subgroup and the injected volume ≥2 ml subgroup had higher DORs, sensitivities and detection rates than the concentration ≥ 5 mg/ml subgroup and the injected volume <2 ml subgroup, respectively. CONCLUSION: Based on this Meta-analysis, this technique could be valued promising for detecting the presence of LN metastases. ICG injection with reduced concentration and larger volume may provide improved performance.

Current techniques for lymphatic imaging: State of the art and future perspectives.

Techniques for lymphatic imaging are aiming at accurate, simple and minimal-invasive approaches with less side-effects and repetitive application. Limitations are emerging in conventional techniques, and new techniques have shown their advantages in high resolution and sensitivity as well as transcutaneous imaging. In the present review, these techniques and their applications are reviewed and elucidated, aiming at a better understanding of recent advancements and current trends of lymphatic imaging as well as promising techniques for future research.