[Flexor tendon injuries of the hand]. / Beugesehnenverletzungen der Hand.

Flexor tendon injuries of the hand are relatively rare but pose significant challenges to both physician and patient. A thorough clinical evaluation enables flexor tendon lacerations to be identified and classified. The flexor tendons of the hand are divided into five anatomic zones (from distal to proximal). Diagnostics, treatment and prognosis may differ depending on which zone is affected. Early, careful and proficient management is needed to ensure good functional outcomes. Various factors influence the outcome, including location, mechanism of injury, presence of concomitant injuries, time of surgery, quality of tendon repair and the rehabilitation protocol. It is important to inform the patient about the importance of thorough rehabilitation and possible complications. Postoperative scarring and adhesions, infections and secondary tendon ruptures due to insufficient primary repairs are especially challenging and potentially necessitate a lengthy and strenuous secondary repair and rehabilitation process.

Recovery of mechanical detection thresholds after direct digital nerve repair versus conduit implantation.

The purpose of this study was to assess sensory and functional nerve recovery after digital nerve injury in patients with an end-to-end suture (S) or with implantation of a collagen conduit (C) to bridge a nerve gap. Fifteen S and 11 C with a follow-up of 6-36 months and 28 healthy control participants were enrolled. Methods of assessments were quantitative sensory testing, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), range of motion and the painDetect questionnaire. After both procedures, sensory profiles showed largely recovered function of C and Aδ fibres but severe loss of Aß-fibre function leading to increased mechanical detection thresholds. There was only minimal allodynia. Severe pain was absent. Patients with conduits reported more functional impairment, especially in work performance, which correlated with the assessed loss of Aß-fibre function. LEVEL OF EVIDENCE: III.

Arthroscopic treatment for ulnar-sided TFCC-tears.

OBJECTIVE: Ruptures of ulnar-sided triangular fibrocartilaginous complex (TFCC) often occur in cases of trauma. Golden standard for diagnosis is the arthroscopy of the wrist. TFCC lesions are classified according to their location if traumatic in origin or if degenerative according to their severity. MATERIALS AND METHODS: Recent literature has focused on the ruptures of ulnar-sided triangular fibrocartilaginous complex. This article describes conservative, operative and arthroscopic surgical techniques to reconstruct the triangular fibrocartilaginous complex and restore distal radioulnar joint stability. RESULTS: The main therapeutic goal should be the stabilization of the DRUJ by reattachment of the torn ligaments in ulnar-sided ruptures to the deep fibers in the fovea. This reinsertion can be performed by transosseous suture, a suture anchor or open. CONCLUSION: Central TFCC tears are typically located close to the sigmoid notch of the radius and are either traumatic or degenerative in origin. While central TFCC lesions are usually treated by arthroscopic debridement using small joint punches or a bipolar high frequency system, the ulnar TFCC avulsions can also be refixed arthroscopically in different techniques.

[Intraosseous Tophaceous Gout of the Hand: Case Report and Literature Review]. / Intraossäre Gichterkrankung der Hand: Falldarstellung und Literaturübersicht.

We report on an intraosseous gout manifestation in the middle phalanx of the left index finger of a 54-year-old patient.

[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.

[Three case reports of frostbite. Management and literature]. / Drei Fallberichte über Erfrierungen. Management und Literatur.

Due to social and demographic changes as well as new leisure activities, the number of frostbite injuries in the general population is on the increase. Because the injuries are primarily located on the hands and feet the consequences for those concerned are devastating. We provide help in grading and introduce concrete therapeutic regimes for frostbite which are illustrated by three case reports from our clinical experience with varying risk profiles.

[Gardner fibroma: case report and discussion of a new soft tissue tumor entity]. / Gardner-Fibrom: Eine neue mesenchymale Tumorentität als Indikatorläsion.

Gardner fibroma represents a rare and recently described soft tissue tumor entity in children and young adults. It consists of haphazardly arranged coarse and hyalinized collagen fibers combined with loosely arranged bland spindle and fibroblastic cells. The case of a 13-year-old male patient with Gardner fibroma and osteoma and multicentric desmoid type fibromatosis in his mother is presented with detection of a (heterozygotic) germline mutation of the APC gene leading to a de novo stop codon (deletion of base pairs 5033-5036). FISH analysis revealed a structural loss of heterozygosity (LOH) in the APC gene on chromosomal locus 5q21 in one out of five analysed desmoids of the mother, no LOH of APC gene in the Gardner fibroma. Gardner fibroma in children and young adults may serve as an indicator lesion for familial adenomatous polyposis (FAP), Gardner syndrome, a familial desmoid type fibromatosis without other manifestations of APC or a new APC gene mutation. For the clinician, this diagnosis should be commented upon accordingly by the surgical pathologist. As the result of a detected APC gene mutation, continuous follow-up for the development of colorectal tumors and desmoid type fibromatosis as well as a familial screening for FAP is recommended.

[Lipoma and atypical lipomatous tumor within the same neoplasia: Evidence for a continuous transition]. / Lipom und atypischer lipomatöser Tumor innerhalb einer Neoplasie: Hinweis für einen kontinuierlichen Ubergang.

The case of a lipomatous tumor with a predominant lipoma component and transition to an atypical lipomatous tumor is presented. A deep-seated soft tissue tumor of the right thigh with a maximum size of 14 cm was resected in a 70-year-old female patient. Corresponding to a comparable macroscopic aspect, the lesion revealed the histological features of an ordinary lipoma without atypia in about 80% of the specimen. In the remaining portion (approximately 20%) histopathology showed an atypical lipomatous tumor (ALT, lipoma-like subtype). Immunohistochemistry for MDM 2 and CDK4 revealed no immunoreactivity in the lipoma component, but within the ALT component. Interphase dual-color fluorescence in situ hybridization showed no amplification of the MDM 2 gene and rarely CDK4 gene amplification within the lipoma component, but high level amplification of MDM 2/CDK4 gene in the ALT area, further supporting the morphologically based diagnosis of a lipomatous tumor including areas of a true lipoma and ALT. This case underlines the concept of a continuous stepwise development of lipomatous soft tissue tumors from benign to malignant counterparts as a biological continuum.

[Identification of genes over-expressed in myxoid/round cell liposarcoma. DNA microarray analysis and immunohistochemical correlation]. / Identifikation überexprimierter Gene in myxoid-rundzelligen Liposarkomen. DNA-Mikroarray-Analyse und immunhistochemische Korrelation.

Myxoid/round cell liposarcoma are characterized by typical chromosomal translocations. This genetic alteration might result in specific gene-expression profiles in this tumor entity. To identify over-expressed genes in myxoid/round cell liposarcoma DNA microarray analysis was performed on four tumors and four samples of adult fat tissue. Genes ret, cdk4, cyclin D2 and c-myc showed over-expression by means of microarray analysis and Northern blotting. Immunohistochemistry demonstrated cytoplasmic localization of associated proteins in 36 different tumors. The localization of ret was seen in endothelial cells of plexiform vasculature in addition to its accumulation in tumor cells (25% of cases). The results show an over-expression of cdk4, cyclin D2, c-myc and ret on both the transcriptional and protein level in myxoid/round cell liposarcoma. For cyclin D2 and ret this finding has not been reported in this tumor type. The increase of ret on transcriptional level might be explained by its expression in endothelium in intratumoral plexiform blood vessels. For the molecular pathogenesis of myxoid/round cell liposarcoma our findings imply the involvement of these four genes in the deregulation of the cell cycle, especially as cdk4 and cyclin D2 are target genes of c-myc.

[Functional reconstruction of the superficial posterior compartment of the leg after tumour ablation in an infant]. / Funktionelle Rekonstruktion des M. triceps surae nach onkologiegerechter Tumorresektion beim Kleinkind.

A 33-month-old female child was diagnosed with a papillary intralymphatic angioendothelioma, a rare type of low-grade angiosarcoma, on the dorsal lower leg. The soleus and gastrocnemius muscle including the Achilles tendon and the subcutis and cutis were resected. The defect was functionally reconstructed by a neurovascular musculocutaneous latissimus dorsi free-flap transfer.

[Complex regional pain syndrome type II or psychogenic painful finger contracture?]. / CRPS Typ II oder psychogene schmerzhafte Fingerkontraktur?

The case is described of a 45-year-old man with fixed contracture of the proximal interphalangeal joints (digits III-IV) after a stab wound injury in the forearm with subsequent compartment syndrome and partial ulnar injury. Despite neurographic recovery there was permanent contracture during rehabilitation, which was classified as psychogenic. Differential diagnostic aspects of this assumption will be discussed on the basis of clinical criteria as well as 3-phase skeleton scintigraphy and MRT for differentiation between complex regional pain syndrome (CRPS) type II and other posttraumatic changes. Readers are encouraged to make their own diagnosis on the basis of the clinical findings and to discuss the case online (http://www.blogs.springer.com/derschmerz).

[Importance of specialized centers in diagnosis and treatment of extremity-soft tissue sarcomas. Review of 603 cases]. / Die Bedeutung von Referenzzentren in Diagnose und Therapie von Weichgewebssarkomen der Extremitäten. Auswertung von 603 Fällen.

Correct histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorder's rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.

[Anterolateral thigh flaps for reconstruction of traumatological and oncological defects]. / Der freie ALT-Oberschenkellappen in der traumatologischen und onkologischen Defektdeckung.

BACKGROUND: The anterolateral thigh flap (ALT) has become one of the most preferred options for soft tissue defect reconstruction in Asia with an increasing popularity in Europe. The article presents the authors' experience using the ALT flap for various indications in the upper and lower extremities. METHODS: Between January 2005 and March 2007, 60 free ALT flaps were operated for reconstruction of various soft tissue defects. The causes of soft tissue defects included trauma (13), infection (26), and sarcoma resection (21). We operated on 39 male and 19 female patients with an average age of 50.9 years (range: 16-84 years). RESULTS: The flap survival rate was 95.0% percent (57 of 60 flaps); 5% of the flaps died. The donor site was closed primarily in all cases. Donor site complications were minimal. The average operative time was 282 min (69-544 min). Flap-related major complications occurred in 35.0% of patients including reexploration of the anastomoses and partial flap necrosis. Minor complications, e.g., wound infection, hematoma, and swelling were seen in 23 cases. CONCLUSIONS: Our experience indicates that the free ALT flap is a reliable method for soft tissue defect reconstruction. The use of the ALT offers many advantages such as a long and large caliber vascular pedicle, a large skin island as well as minimal donor site morbidity. The surgery can simultaneously performed by two teams with the patient in a supine position.

[Local therapy of grade IIa burns: efficacy and tolerability of a new hydrosome wound gel for the local treatment of grade IIa burns as compared with silver sulfadiazine ointment]. / Lokale Behandlung von Grad-IIa-Verbrennungen : Wirksamkeit und Verträglichkeit eines neuartigen hydrosomalen Wundgels im Vergleich zu Silbersulfadiazin-Creme.

BACKGROUND: A new hydrosome wound gel is based on a new mechanism of action. It contains hydrosomes that penetrate to the wound bed and supply the wound with phospholipids, which are identical to membrane phospholipids of human cells. In this manner it supports the proliferative processes during wound healing. PATIENTS AND METHODS: In a randomized, controlled, intraindividual comparative study of 47 patients with grade IIa burns, the hydrosome wound gel was tested against silver sulfadiazine cream. Digital pictures of the burn wounds were taken daily, and the wounds were analyzed in terms of their reepithelization rate. RESULTS: Wounds receiving the hydrosome wound gel healed 1.5-2 days faster than wounds treated with sulfadiazine cream (9.9+/-4.5 days vs. 11.3+/-4.9 days, p=0.015). In 66% of the patients, faster epithelization was observed with the hydrosome wound gel treatment. The hydrosome gel guaranteed secure prophylaxis against infection, and it was well tolerated and easy to apply. CONCLUSION: In this study, the treatment of grade IIa burn wounds with hydrosome wound gel led to faster wound closure compared with treatment with sulfadiazine cream. Therefore, hydrosome gel represents a good alternative to sulfadiazine cream.

[Crossover extremity transfers. Limb salvage in amputations with segmental defects]. / Heterotope Replantationen. Konzepte zum Extremitätenerhalt bei Mehrfachamputationen.

Clinical conditions in which crossover extremity transfer should be considered are rare. In the case of bilateral amputation associated with extensive proximal segmental injury, ectopic implantation could be an additional concept for two-stage limb salvage. If replantation is impossible due to segmental damage of the amputated part, at least uninvolved tissue should be harvested for stump lengthening or improving soft-tissue at the ends. The case of a 34-year-old man with segmental amputation of the left forearm and left lower leg and mutilated amputation of the right hand caused by a train accident is presented. Limb salvage was performed by cross-hand replantation and modified rotationplasty of the left foot as a stump lengthening procedure.

[Stump retention and extension on the lower extremity]. / Stumpferhalt und Stumpfverlängerung an der unteren Extremität.

Despite new techniques and better health programs in western industrialized nations, the numbers of amputations on the lower extremity remain constant. Approximately 100,000 amputations are performed annually in the U.S. and about 10,000 in Germany, more than 90% for gangrene resulting from ischemia and/or infection. Micro- and macroangiopathic changes in diabetes are the major cause of ischemia in the leg. The preservation of limb length and construction of an end bearing stump are important criteria for the functional outcome after amputation. Especially in trauma and tumor patients with "planned" amputations, all effort should be made to achieve an end bearing stump with sufficient length respectively an amputation level that is suitable for orthosis instead of prosthetic supplementation. After amputation, an interdisciplinary approach is mandatory to achieve sufficient soft tissue coverage or stump distalization. In case of insufficient bearing ability of the stump, various reconstructive possibilities must be considered to assure optimal outcome.

[Unclear soft-tissue tumor]. / Weichteiltumor unklarer Dignität.

Cystic necrotization with liquefaction and calcification of muscle tissue is a rare late sequel of compartmental syndrome. Diagnosis and treatment of this clinical picture is still a problem. In the literature, various therapeutic approaches are described such as incision, needle decompression, and complete compartmental debridement. We report a case in which cystic degradation and liquefaction of three compartments developed 51 years after a complete fracture of the tibia. The patient was treated by radical compartmental resection. No postoperative complication was noted, and almost no functional loss occurred.