Acute Microcirculatory Effects of Remote Ischemic Conditioning in Superficial Partial Thickness Burn Wounds.

Microcirculation is a critical factor in burn wound healing. Remote ischemic conditioning (RIC) has been shown to improve microcirculation in healthy skin and demonstrated ischemic protective effects on heart, kidney, and liver cells. Therefore, we examined microcirculatory effects of RIC in partial thickness burn wounds. The hypothesis of this study is that RIC improves cutaneous microcirculation in partial thickness burn wounds. Twenty patients with partial thickness burn wounds within 48 hours after trauma were included in this study. RIC was performed with an upper arm blood pressure cuff on a healthy upper arm using three ischemia cycles (5 min inflation to 200 mm Hg) followed by 10-minute reperfusion phases. The third and final reperfusion phase lasted 20 minutes. Microcirculation of the remote (lower/upper extremities or torso) burn wound was continuously quantified, using a combined Laser Doppler and white light spectrometry. The capillary blood flow in the burn wounds increased by a maximum of 9.6% after RIC (percentage change from baseline; P < .01). Relative hemoglobin was increased by a maximum of 2.8% (vs. baseline; P < .01), while cutaneous tissue oxygen saturation remained constant (P > .05). RIC improves microcirculation in partial thickness burn wounds by improving blood flow and elevating relative hemoglobin.

Deep wrist injuries from suicide attempts vs. accidents do not differ regarding sensorimotor outcome, but regarding patient-reported outcome measures.

Despite the clinical importance of deep wrist injuries (DWIs), data comparing the outcome of suicide attempt survivors vs. accident survivors are lacking. Patients admitted to our Clinic for acute treatment of a DWI from 2008 to 2016 were contacted for a follow-up assessment of sensory, motor and functional outcomes. Patients also completed the Disability of the Arm, Shoulder and Hand Questionnaire, the Modified Mayo Wrist Score, the Boston Carpal Tunnel Questionnaire, and the WHOQOL-BREF questionnaires. 51 patients could be followed up, on average 4.3 ± 2.9 years after their injury. Suicide attempt survivors did not differ from accidents survivors concerning two-point discrimination, grip and pinch strength, but showed poorer outcomes in self-reported disability, symptom severity, and quality of life. Patients with DWIs from suicide attempts vs. accidents do not differ in sensorimotor outcomes but patient-reported outcome measures. Level of Evidence: II.

[Use of acellular allogeneic nerve transplants for nerve defects of the hand : Experience from a German hand surgery center]. / Einsatz von azellulären allogenen Nerventransplantaten bei Nervendefekten an der Hand : Erfahrung aus einem deutschen handchirurgischen Zentrum.

Peripheral nerve injuries are often encountered in traumatological care. The aim of this manuscript is to provide initial data, experiences and performance reports from Germany in the implantation of acellular human nerve transplants in peripheral sensory nerve defects of the hand and to put these data in the context of a comprehensive review of the literature. Of the patients 4 (7 digital nerves) were examined 6 months postoperatively and 5 patients (6 digital nerves) were examined 1 year after the operation (3 were also at the 6­month examination). All patients had a clinical improvement after nerve reconstruction (≥ S3 according to the classification of sensory recovery of the Medical Research Council modified by Mackinnon and Dellon). Disadvantages of our clinical study are the small number of patients, the inhomogeneity (primary and secondary nerve reconstruction) and the lack of comparison with other nerve reconstruction methods.

[The Emergency Classification of Hand Injuries: Analyzing Urgency Assessment among German Hand Surgeons]. / Zeitliche Dringlichkeitsstufen bei der operativen Versorgung von handchirurgischen Notfällen: Eine Umfrage unter deutschen Handchirurgen.

BACKGROUND: Emergency capacities in the operating theatre are limited and often need to be split among surgical departments. Hand injuries often have to compete with other surgical disciplines for the availability of operating capacity. For this reason, an emergency classification was introduced to define a timespan in which the injury should be taken care of in the OR in order to enable the prioritizing of emergency cases in an interdisciplinary approach when capacities are scarce. However, neither valid data nor specific recommendations concerning the medical urgency of treatment or the forensic background of different hand injuries exist to this date. PURPOSE: This work describes how emergency classifications in Germany are applied to hand surgical cases and how certain hand injuries are prioritized among different hand surgeons. MATERIAL AND METHODS: An online survey was sent to all members of the German Society for Hand Surgery twice during a time span of several months. The survey featured questions on size and type of clinic or practice and requested an assessment of urgency levels for various hand injuries (immediately - within 2 h - within 6 h - within 12 h - within 24 h or elective care). The analysis of the questionnaire and graphic presentation was carried out using Excel. RESULTS: 172 (25 %) out of 700 active members filled in the survey. Among the participants were members of university clinics, hospitals run by the German Statutory Accident Insurance, specialized clinics and primary care clinics. 15 % of participants work in a practice that offers hand-surgical treatment. First and foremost, maximum care hospitals with a hand surgical department participate in the treatment of hand injuries. 64 % of the hospitals use an emergency classification to enable the interdisciplinary prioritizing of surgical emergencies. The categorization of limb-threatening hand injuries appears to be very homogenous among participants whereas non-threatening injuries are assessed rather inconsistently. CONCLUSION: Emergency treatment of hand injuries primarily depends on available resources and surgical capacities. The assessment of urgency and severity of injuries additionally depends on experience and education. In order to maintain the ability to compete with other surgical disciplines for surgical capacities, a standard classification of hand surgical urgencies needs to be established. As valid data on the treatment of hand injuries are still missing, further studies need to evaluate possible outcomes in order to define the timespan in which surgery should take place.

Traumatizing Oneself-Deep Wrist Injuries Self-Inflicted with Suicidal Intention are Associated with More Severe PTSD Symptomatology than Similar Injuries from Accidents.

OBJECTIVE: As suicide attempts by definition entail at least some threat to physical integrity and life, they theoretically qualify as an A1 criterion for posttraumatic stress disorder (PTSD). This study uses the unique opportunity of deep wrist injuries to quantify the effect of intentionality on PTSD rates by comparing suicide attempt survivors with patients who sustained accidental injuries similar in mechanism, localization, and extent. METHOD: Patients who had been admitted with an acute deep wrist injury from 2008 to 2016 filled out the revised Impact of Event Scale and reported other known PTSD risk factors. Mental morbidity and intentionality of the injury were determined by psychiatric consultation during the index hospitalization. RESULTS: Fifty-one patients were followed up (72.5% male, 92.2% Caucasian, mean age at injury 42.3 ± 17.5 years, 72.5% accidental injuries), on average 4.2 ± 2.9 years after their injury. The intentionality of the injury alone predicted the severity of intrusions, avoidance, hyperarousal, and probable PTSD (aOR = 14.0). CONCLUSIONS: Traumatization in the context of a suicide attempt may be a hitherto unknown PTSD risk factor. Patients after suicide attempts, especially medically serious attempts, should be monitored for PTSD symptoms.

Think big - Plastic surgical treatment of complicated large sacral ulcerations: A case comparison.

OBJECTIVE: Large pressure ulcers are a well know problem occurring frequently on immobilized patients. They can develop rapidly especially over bony prominences on the elderly, ICU patients and on patients after spinal cord injury. Plastic surgical treatment can be challenging if the defects are large and complications occur like affection of anal region or development of a Marjolin's scar ulcer. Large defects of the sacral region are well known in our university hospital. Common local flaps like gluteal rotation or (double) V-Y advancement flap are often used for the treatment of smaller defects. In special cases these therapies are not sufficient. Rarely we use fillet flap of the lower extremity to cover large sacral defects on patients who were unable to walk before. SUBJECTS AND METHOD: In this case report we demonstrate two relatively young paraplegic patients (49 and 57years old) with large sacral defect wounds. One case occurred in 2017, the other in 2019. After spinal cord injury many years ago both of them developed chronic pressure ulcers of the sacral region. In the case of 2017 a Marjolin's scar ulcer developed as a complication. Both patients had previously lost a leg during the surgical treatment. We used the other remaining leg as a fillet flap in combination with interdisciplinary rectum extirpation for sufficient surgical treatment. RESULTS: In both cases adequate coverage of the sacral defect was achieved after interdisciplinary surgical treatment including rectum extirpation. Fillet flaps were safe, even after necessary surgical revisions. In one of the cases a vacuum wound therapy and several debridements were needed. After rehabilitation the patient of the earlier case is able to fully mobilize himself in everyday life and is even able to use public transport. CONCLUSION: Using a fillet flap of the lower extremity to cover large sacral ulcers is often the last possibility of surgical treatment. Though many complications can occur, full rehabilitation and social participation is possible after fillet flap surgery even with loss of both legs. Depending on patient's motivation and availability of orthopedic technology like special electric wheel chairs and other tools full mobility can be achieved.

The Reason Matters: Deep Wrist Injury Patterns Differ with Intentionality (Accident versus Suicide Attempt).

BACKGROUND: Despite the clinical importance of suicidal deep wrist injuries (DWIs), we currently do not know whether their injury patterns differ from accidental injuries. METHODS: This retrospective study included all patients admitted to the Clinic of Plastic Surgery for acute treatment of a DWI from 2008 to 2016, except for isolated injuries to the palmaris longus (PL) and amputations. Intentionality of the injury was determined using documentation of psychiatric evaluations; cases that could not be categorized regarding intentionality were excluded. RESULTS: About 20% of DWIs stemmed from suicide attempts, which involved the nondominant hand in 94.5%. Suicidal DWIs were more likely to involve the median nerve, radial artery, PL, and flexor carpi radialis (FCR), especially on the nondominant hand, but were less likely to involve the ulnar artery and nerve on the dominant hand. The effect of the protective structures PL/flexor carpi ulnaris on the median nerve/ulnar artery could be confirmed for suicidal DWIs, but intactness of the FCR was associated with increased radial artery injuries. Longitudinal cut orientation in suicidal DWIs was associated with more radial artery injuries, but fewer injuries to tendons and nerves. Frequencies of various other injury constellations are tabulated to aid in clinical assessment. CONCLUSIONS: Suicidal and accidental DWIs differed in various aspects of injury pattern. Suicidal injuries were mostly localized to the nondominant radial side, and accidental injuries to the ulnar side. Also, the so-called protective structure FCR had the opposite effect in suicidal injuries. Thus, findings regarding injury patterns in accidental DWIs cannot be generalized to suicidal injuries.

After standard dosage of piperacillin plasma concentrations of drug are subtherapeutic in burn patients.

Infections are a major problem in patients with burn diseases. Mortality is high despite antibiotic therapy as studies are controversial concerning drug underdosing. The aims of this prospective, observational study were to monitor plasma concentrations of piperacillin during standard piperacillin/tazobactam treatment in 20 burn patients and 16 controls from the intensive care unit (ICU) and to optimize doses by in silico analyses. Piperacillin/tazobactam (4/0.5 g, tid) was administered over 0.5 h. Blood samples were taken at 1, 4, and 7.5 h after the end of the infusion. Free piperacillin plasma concentrations were determined. Pharmacokinetic parameters and in silico analysis results were calculated using the freeware TDMx. The primary target was defined as percentage of the day (fT>1xMIC; fT>4xMIC) when piperacillin concentrations exceeded 1xMIC/4xMIC (minimum inhibitory concentration), considering a MIC breakpoint of 16 mg/L for Pseudomonas aeruginosa. In an off-label approach, two burn patients were treated with 8/1 g piperacillin/tazobactam, 3 h qid. fT>1xMIC (55 ± 22% vs. 77 ± 24%) and fT>4xMIC (17 ± 11% vs. 30 ± 11%) were lower in burn than in ICU patients after 4/0.5 g, 0.5 h, tid. In silico analyses indicated that fT>1xMIC (93 ± 12% burn, 97 ± 4% ICU) and fT>4xMIC (62 ± 23% burn, 84 ± 19% ICU) values increase by raising the piperacillin dosage to 8/1 g qid and prolonging the infusion time to 3 h. Off-label treatment results were similar to in silico data for burn patients (84%fT>1xMIC and 47%fT>4xMIC). Standard dosage regimens for piperacillin/tazobactam resulted in subtherapeutic piperacillin concentrations in burn and ICU patients. Dose adjustments via in silico analyses can help to optimize antibiotic therapy and to predict respective concentrations in vivo. Trial registration: NCT03335137, registered 07.11.2017, retrospectively.

A Rare Manifestation of Primary Bone Lymphoma: Solitary Diffuse Large B-Cell Lymphoma of the Little Finger.

Solitary primary non-Hodgkin bone lymphoma of the hand is a rare entity with only 3 cases reported in the literature. We report the case of a 77-year-old patient with isolated large B-cell bone lymphoma of the proximal phalanx of the little finger without rheumatoid arthritis or methotrexate treatment. The patient was treated with digital amputation and at 6 months' follow-up showed no relapse or dissemination of the disease.

An Unusual Presentation of an Osteoid Osteoma in the Lunate Bone.

An osteoid osteoma is a rare benign tumor of the carpal bones. It is extremely rarely found in the lunate bone in patients above 30 years of age. We present a case report of a 61-year-old man with an osteoid osteoma of the left wrist, which was masked by degenerative carpal bone disease and a comorbidity of an inflammatory bowel disease. The mainstay of imaging including plain radiographs, computed tomography, magnetic resonance imaging, and bone scintigraphy led to the clinical diagnosis of a lunatomalacia. The tumor was removed by coincidence during removal of the diseased lunate bone. Postoperatively, the patient was immediately free of pain and remained free at his 3 months postoperative follow-up.

A biomechanical analysis of plate fixation using unicortical and bicortical screws in transverse metacarpal fracture models subjected to 4-point bending and dynamical bending test.

In the published literature there are controversial data to the biomechanical stability of monocortical comparing to the bicortical fixation of metacarpal fractures. The aim of this study was to compare the biomechanical stability of monocortical and bicortical locking osteosynthesis in quasi-static and dynamic 4-point bending tests of composite third metacarpal bone (4th Gen third metacarpal, Sawbones, Malmö, Sweden) fixed with 7-hole locking plate (XXS System, Biotech-Ortho, Wright, Memphis, TN). The tests to determine quasi-static yield and bending strength as well as fatigue strength were conducted in 4 groups of 10 samples after creating standardized mid-shaft transverse osteotomies using a diamont belt grinder (0.3 mm saw blade). The force applied was the dorsal apex loading, similar to the forces applied to metacarpals during normal finger flexion and extension.In the quasi-static testing, no plate breakage was observed in each group. All metacarpals broke at their thinnest part. The average bending strength of the bicortical samples (10.54 ±â€Š0.998 Nm) was significantly higher comparing to the monocortical samples (8.57 ±â€Š0.894 Nm) (P < .001).In the dynamic loading test, all constructs (8 monocortical samples and 7 bicortical) that failed broke at the osteotomy site and the average fatigue strength did not differ in both groups.Consequently, a unicortical plating method may provide adequate strength and stability to metacarpal fractures based on the results of the cyclical loading representative of in vivo loading.

Percutaneous Cannulated Compression Screw Osteosynthesis in Phalanx Fractures: The Surgical Technique, the Indications, and the Results.

Objective: Fractures of metacarpals and phalanges are very common fractures, and there are a lot of treatment modalities. The purpose of the study was to describe the technique of percutaneous fixation of phalangeal fractures using a cannulated compression screw fixation system and its results. Methods: We conducted a prospective clinical study on 43 patients with different types of phalangeal fractures undergoing a percutaneous cannulated compression screw osteosynthesis. Parameters such as average operation time and clinical outcome were evaluated postoperatively. Results: Forty-three patients were treated using a percutaneous cannulated compression screw fixation system for phalanx fractures of the proximal (n = 26), middle phalanx (n = 16), or distal phalanx (n = 1). All fractures healed after 6 to 8 weeks except in 1 patient with secondary loss of reduction occurring 2.5 weeks after surgery. No infections were observed. The mean total active motion values were 247.56° ±16.16° and 244.35° ± 11.61° for the intra-articular fracture and 251.25° ± 19.86° for the shaft fractures; the mean Disabilities of the Arm, Shoulder, and Hand (DASH) score 3 months after the surgery was 1.67 ± 2.74. Conclusions: The advantages of this technique are the avoidance of an open procedure requiring extensive soft-tissue dissection with the risks of tendon adhesions and the achievement of interfragmentary compression. Because of the interfragmentary compression, it is superior to simple K-wires. With regard to indications, our primary focus was on unicondylar proximal interphalangeal joint fractures, shaft fractures, and simple oblique 2-fragment fractures.

Brachytherapy in soft tissue tumours: an interdisciplinary challenge!

OBJECTIVE: Interdisciplinary work including surgery and additive radiotherapy is often needed for the therapy of tumours. Beneath this, brachytherapy is an important part of the radiotherapy. It was first used over 100 years ago and is in regular use after the development of afterload technology in the early 1970s. Today it is often used in different tumour therapies, for example in soft tissue sarcoma or breast tumours, in order to decrease the risk of local recurrence. Concerning its benefits, higher doses could be used because of the localized effect with equivalent local control rate and less toxicity of treatment. Moreover, brachytherapy can also shorten the treatment time from 5-7 weeks to some days and is better reconcilable due to its localized effects, thus reducing side effects, as radiation-induced reactions, teleangiectasia and brosis. Precondition for application of brachytherapy is the need of a good soft tissue coverage and wound healing. Therefore, good interdisciplinary cooperation between plastic surgery and radiotherapy is important. After wide surgical resection reconstruction with different kind of flaps are often required, for achieving early wound healing and fast start of radiotherapy. PATIENTS AND METHOD: Between 2011 and 2017 we applied brachytherapy to 13 patients with soft tissue sarcomas and other tumours like merkel-cell-carcinoma, schwannoma, and breast cancer. The treatment consisted of tumour resection, intraoperative insertion of brachytherapy catheters and after that brachytherapy alone or in combination with external beam radiotherapy. In half of the patients a reconstruction with different flaps was required, including pedicled trapezius flap, musculus latissimus dorsi flap and radial forearm flap; in some cases nerve and tendon reconstruction for better function and faster wound healing and so faster start of postoperative brachytherapy was also needed. The mean age of the patients was 55 years (±19) and we could start brachytherapy after 3-21 days after the operation, with a mean start on day 8±5 postoperatively. Three patients received additional percutaneous radiotherapy. The patients who received only brachytherapy got a dose of 2, 5 or 3Gy twice daily, with a mean total dose of 31±3Gy. CONCLUSION: Multidisciplinary work, including surgery as the main procedure and radiotherapy additionally, is needed for a successful treatment of soft tissue tumours. Depending on the type and the stadium of tumour plastic and reconstructive surgery provides soft tissue coverage, faster wound healing and the chance for limb salvage; on the other hand, additive brachytherapy contributes to a good tumour control. Therefore, a close collaboration between the two specialties is of particular importance, in order to improve the effectiveness of the therapy and the postoperative quality of life of the patient.

Stem cells therapy: the future in the management of systemic sclerosis? A case report.

OBJECTIVE: Systemic sclerosis (SSc) is a connective tissue disorder of unknown etiology, with heterogeneous clinical manifestations and chronic and often progressive course. The diffuse cutaneous form of SSc (dcSSc) is characterized by thickening of the skin (scleroderma) and distinctive involvement of multiple internal organs. Patients with limited cutaneous SSc (lcSSc) generally have long-standing Raynaud's phenomenon before other manifestations of SSc appear. Over the last decade the Interest of adipose-derived cell therapy in regenerative medicine has increased continuously. In compare to bone marrow-derived mesenchymal stem cells (MSCs) adipose tissue-derived stem cells (ADSCs) are considered to be ideal for application in regenerative medicine. Zuk et al., introduced a multipotent, undifferentiated, self-renewing progenitor cell population isolated from adipose tissue, called processed lipoaspirate (PLA). However, subcutaneous injections of autologous adipose tissue-derived stromal vascular fraction (ADSVF), which is known to contain mesenchymal stem cells, in hands of Patients with scleroderma for enhancing their impaired hand function is still in an experimental stage, although there are already promising results of the therapy. Commonly available therapeutic options for hands of Patients with systemic sclerosis, vasodilatator drugs and physiotherapy, have many restriction and limited effects. MATERIALS AND METHOD: A 62 years old woman with scleroderma presented with progressive digital necrosis, ulceration, gangrene and impaired wound healing, despite of conventional therapy with vasodilatator drugs. Water-jet-Assisted Liposuction (Body-jet® evo, human med AG, Schwerin, Germany) of subcutaneous abdominal fat was carried out under general anesthesia by an experienced surgeon. Autologous adipose tissue-derived stromal vascular fraction (ADSVF) was harvested by in a single-use Q-graft® collector (human med AG, Schwerin, Germany). Cells were centrifuged in 400G for 5 minutes and cell pellets were aspirated carefully in a 20mL syringe filled with 0.9% NaCl. A total of ca. 2.72 million cells have been isolated. Meanwhile middle phalangeal amputation of digit 2, 3 and 4 of the left hand were performed, without closing the skin of the amputation stumps. The SVF cell suspension was injected subcutaneous into the area of metacarpophalangeal joints in both hands, as well as into the amputation stump of the left middle finger, and under a skin necrosis in the right hand. RESULTS: The therapy was good tolerated by the patient, with absence of adverse reactions. No infection was observed, despite open amputation. Three weeks after the stem cell therapy, no need to further amputation was demonstrated. The patient is still under regular clinical observation, in order to determine the long term effects of the therapy. CONCLUSION: Application of isolated adipose tissue-derived stem cells seems to be a very promising procedure in the treatment of the manifestation of systemic sclerosis. However, more clinical and experimental studies are required, in order to understand the exact mechanisms of action and standardize the therapy.

Remote effects of extracorporeal shock wave therapy on cutaneous microcirculation.

BACKGROUND: Extracorporeal shock wave treatment (ESWT) has proven its clinical benefits in different fields of medicine. Tissue regeneration and healing is improved after shock wave treatment. Even in the case of burn wounds angiogenesis and re-epithelialization is accelerated, but ESWT in extensive burn wounds is impracticable. HYPOTHESIS: High energy ESWT influences cutaneous microcirculation at body regions remote from application site. METHODS: Eighteen Sprague Dawley rats were randomly assigned to two groups and received either high energy ESWT (Group A: total 1000 impulses, 10 J) or placebo shock wave treatment (Group B: 0 impulses, 0 J), applied to the dorsal lower leg of the hind limb. Ten minutes later microcirculatory effects were assessed at the contralateral lower leg of the hind limb (remote body region) by combined Laser-Doppler-Imaging and Photospectrometry. RESULTS: In Group A cutaneous capillary blood velocity was significantly increased by 152.8% vs. placebo ESWT at the remote body location (p = 0.01). Postcapillary venous filling pressure remained statistically unchanged (p > 0.05), while cutaneous tissue oxygen saturation increased by 12.7% in Group A (p = 0.220). CONCLUSION: High energy ESWT affects cutaneous hemodynamics in body regions remote from application site in a standard rat model. The results of this preliminary study indicate that ESWT might be beneficial even in disseminated and extensive burn wounds by remote shock wave effects and should therefore be subject to further scientific evaluation.

Management of pediatric hand burns.

PURPOSE: Hand burns are common in the pediatric population. Optimal hand function is a crucial component of a high-quality survival after burn injury. This can only be achieved with a coordinated approach to the injuries. The aim of this study was to review the management algorithm and outcomes of pediatric hand burns at our institution. METHODS: In total, 70 children fulfilling our study criteria were treated for a burn hand injury in our Burn Care Center between January 2008 and May 2013. RESULTS: 14 of the 70 pediatric patients underwent surgery because of the depth of the hand burns. The management algorithm depending on the depth of the burn is described. Two patients underwent correction surgery due to burn contractures later. CONCLUSION: For a successful outcome of the burned hand, the interdisciplinary involvement and cooperation of the plastic and pediatric surgeon, hand therapist, burn team, patient and their parents are crucial.

Obese patients in a burn care unit: a major challenge.

OBJECTIVE: Obesity is an important predictor of mortality and morbidity during a hospital stay. There is very little data concerning the impact of the BMI on clinical outcomes in obese burn patients. The purpose of this study is to document the general epidemiological aspects of thermal injuries in an obese population and draw attention to topics relating to the management, rehabilitation and prognosis of burns in this emerging subpopulation of patients. METHODS: All patients >16 years of age admitted to the burn unit between January 2008 and December 2012 and fulfilling the burn center referral criteria were enrolled in the study. SPSS version 20 (SPSS GmbH Software, Illinois, USA) was employed for data analysis. RESULTS: Eleven extreme obese patients (men:women, 6:5) had a mean BMI of 38kg/m(2). Their incidence in our study was 5.5%. The mean length of stay was 41.5 days, almost twice that of the non-obese. The presence of co-morbidities such as diabetes, hypertension, cardiac disease, or pulmonary disease, the problematic wound healing and the burn wound infection were significantly higher in the obese patients than in the non-obese. The mortality of obese burned patients was 36.4%. CONCLUSIONS: These facts indicate admission of these patients to a burn care unit for the best possible treatment although they might not always fulfill criteria for admission to burn intensive care unit. Burn centers must be also prepared in terms of special nursing equipment for obese patients.

The effect of a bacterial contamination on the formation of capsular contracture with polyurethane breast implants in comparison with textured silicone implants: an animal study.

INTRODUCTION: One of the most common complications following breast augmentation is capsular contracture. The subclinical infection of the implant is often considered to be one of the main risk factors. It is believed that polyurethane (PU) implants, because of their larger foam-like surface, have lower capsular contracture rates due to better tissue integration. It remains unclear if bacterial contamination and biofilm formation result in higher capsular contracture rates under the condition of the increased surface of PU implants compared to textured silicone-gel implants. The effect of this bacterial contamination was examined in an animal-based study. METHODS: A total of 80 mini implants (40 textured silicone-gel implants and 40 PU implants) were implanted in the dorsum of female Wistar rats. In each group, 20 implants were inoculated before implantation with a standard amount of Staphylococcus epidermidis. Capsules and implants were explanted after 60 days, followed by double-blind histological, immunohistochemical, and microbiological examinations. RESULTS: Macroscopic separation of the total capsule in the textured implant group was possible whereas the growth of surrounding tissue into the foam structure of PU implants made separation in that group difficult. After contamination, a thicker capsule could be observed in both groups without significant differences. Histologically, capsules around PU implants showed significantly lower expression of parallel myofibrils. We were able to describe a significant higher infiltration with inflammatory cells in capsules around PU implants both with and without contamination. Microbiological investigations revealed positive growth of S. epidermidis around one PU implant without related signs of capsular contracture. DISCUSSION: This study demonstrates that aside from the surface of silicone implants, bacterial contamination has major impact on the architecture of capsule formation. In our study, we were able to demonstrate that bacterial contamination leads to a thicker capsule and an increased tissue reaction with a higher amount of inflammatory cells. However, a resulting bacterial infection was only demonstrated in one case and had an insignificant influence on capsule architecture. The observed inflammatory reaction around PU implants was observed as a nonbacterial, granulomatose foreign body reaction. EBM RATING: Level I: Evidence obtained from at least one properly designed randomized controlled trial.

Prophylactic antibiotic therapy after inhalation injury.

OBJECTIVE: Inhalation injury is suspected in patients with facial and neck burn-injuries and in patients who suffered burns in an enclosed space. Inhalation injury is associated with a disappointingly high morbidity and mortality in spite of advances in diagnostics and therapy.Prophylactic antibiotic therapy in patients with diagnosed inhalation injury is still a controversial subject.The epidemiologic characteristics of the burn patients with diagnosed inhalation injury in our clinic receiving prophylactic antibiotic therapy and mortality of these patients will be referred in this study. METHODS: Patients >16 years of age admitted to the burn unit between January 2008 and December 2012 and fulfilling the burn center referral criteria according the German Burn Association were enrolled in the study. RESULTS: 58 patients (male:female 47:11) were diagnosed with an inhalation injury by their admission. The average length of hospital stay was 27.5 days, whereas of the patients with no inhalation injury was 16 days (p=0.04). 56.9% of the patients underwent tracheostomy. An escalation of the antibiotic therapy was done in 39.7% of the patients with inhalation injury and in 20.3% of the patients without one. The mortality of inhalation injury patients was 12.1%. CONCLUSIONS: The development of pneumonia is not influenced in a statistical significant way by the use of prophylactic antibiotics. We do recommend the administration of prophylactic antibiotic therapy to patients with diagnosed inhalation trauma, as the mortality of these patients was lower in comparison to other studies.