[Closure of a prostatocutaneous urinary fistula while preserving sexual function using a perineal approach with Gracilis flap interposition]. / Funktionsprotektiver Verschluss einer urethrokutanen Fistel der prostatischen Harnröhre über einen perinealen Zugang mit Gracilis-Flap.

We present the case of a 36-year-old man suffering from perianal loss of urine through a cutaneous pore while urinating. Appropriate diagnostic investigation showed a urethrocutaneous fistula of the prostatic urethra of unclear aetiology. Because of the patient's young age and sexual activity, surgical treatment was challenging. The fistula was isolated via a perineal access and ligated close to the prostate without endangering the neurovascular bundles. In order to achieve a secure closure of the fistula, a Gracilis flap was placed as an interposition between the dorsal prostate and the percutaneous fistula outlet. To date, no case has been described of a successful, function-preserving surgical treatment of a prostatocutaneous urinary fistula.

Tissue Healing in Hemicraniectomy.

Introduction Decompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse "question mark" ("Dandy flap") incision. The goal of this study was to analyze the details of tissue healing problems in DHC.  Materials and methods A total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the "Dandy flap" incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05. Results The most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins). Conclusion A noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic "Dandy flap" incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.

The Efficacy of Local Flaps in the Treatment of Traumatic Scalp Defects.

BACKGROUND: Scalp defects represent a therapeutic challenge. The aim of this study is to present our experience with local and regional flaps in the treatment of trauma-induced scalp defects. Furthermore, a comparison with other surgical techniques was performed. METHODS: A retrospective evaluation of patient records was performed. Only patients who underwent surgery using local flaps between January 2010 and September 2020 due to traumatic scalp defects were included in the study. RESULTS: In all, 10 cases were identified (3 females, 7 males, average age at surgery of 46.5 years [range: 18-82 years]). Six patients underwent surgery due to tissue defects and four due to scar keloids. Three patients experienced minor postoperative complications, one of which required additional surgery. The mean defect size was 35.75 cm2 (range: 4-79 cm2) among the four patients where the defect size could be determined retrospectively. The mean inpatient follow-up was 12.4 days (range: 2-34 days). CONCLUSIONS: Local flaps can be widely used. In carefully selected cases, they have the fewest disadvantages of all surgical techniques. In our experience, large angiosomes of the main scalp arteries allow the treatment of defects larger than 30 cm2 with local flaps. Our experience also suggests that the dimensions of flap length to flap width can exceed a ratio of 2:1 in the scalp.

Donor defects after lymph vessel transplantation and free vascularized lymph node transfer: A comparison and evaluation of complications.

BACKGROUND: Secondary lymphedema after surgical interventions is a progressive, chronic disease that is still not completely curable. Over the past years, a multitude of surgical therapy options have been described. AIM: To summarize the single-center complications in lymph vessel (LVTx) and free vascularized lymph node transfer (VLNT). METHODS: In total, the patient collective consisted of 87 patients who were undergoing treatment for secondary leg lymphedema during the study period from March 2010 to April 2020. The data collection was performed preoperatively during consultations, as well as three weeks, six months and twelve months after surgical treatment. In the event of complications, more detailed follow-up checks were carried out. In total n = 18 robot-assisted omental lymph node transplantations, n = 33 supraclavicular lymph node transplantations and n = 36 Lymph vessel transplantations were analyzed. An exemplary drawing is shown in Figure 1. A graphical representation of patient selection is shown in Figure 2. Robotic harvest was performed with the Da Vinci Xi Robot Systems (Intuitive Surgical, CA, United States). RESULTS: In total, 11 male and 76 female patients were operated on. The mean age of the patients at study entry was: omental VLNT: 57.45 ± 8.02 years; supraclavicular VLNT: 49.76 ± 4.16 years and LVTx: 49.75 ± 4.95 years. The average observation time postoperative was: omental VLNT: 18 ± 3.48 mo; supraclavicular VLNT: 14.15 ± 4.9 and LVTx: 14.84 ± 4.46 mo. In our omental VLNT, three patients showed a slight abdominal sensation of tension within the first 12 postoperative days. No other donor side morbidities occurred. No intraoperative conversion to open technique was needed. Our supraclavicular VLNT collective showed 10 lift defect morbidities with one necessary surgical intervention. In our LVTx collective, 12 cases of donor side morbidity were registered. In one case, surgical intervention was necessary. CONCLUSION: Concerning donor side morbidity, robot-assisted omental VLNT is clearly superior to supraclavicular lymph node transplantation and LVTx.

Increased levels of VEGF-C and macrophage infiltration in lipedema patients without changes in lymphatic vascular morphology.

Lipedema is a chronic adipose tissue disorder characterized by the disproportional subcutaneous deposition of fat and is commonly misdiagnosed as lymphedema or obesity. The molecular determinants of the lipedema remain largely unknown and only speculations exist regarding the lymphatic system involvement. The aim of the present study is to characterize the lymphatic vascular involvement in established lipedema. The histological and molecular characterization was conducted on anatomically-matched skin and fat biopsies as well as serum samples from eleven lipedema and ten BMI-matched healthy patients. Increased systemic levels of vascular endothelial growth factor (VEGF)-C (P = 0.02) were identified in the serum of lipedema patients. Surprisingly, despite the increased VEGF-C levels no morphological changes of the lymphatic vessels were observed. Importantly, expression analysis of lymphatic and blood vessel-related genes revealed a marked downregulation of Tie2 (P < 0.0001) and FLT4 (VEGFR-3) (P = 0.02) consistent with an increased macrophage infiltration (P = 0.009), without changes in the expression of other lymphatic markers. Interestingly, a distinct local cytokine milieu, with decreased VEGF-A (P = 0.04) and VEGF-D (P = 0.02) expression was identified. No apparent lymphatic anomaly underlies lipedema, providing evidence for the different disease nature in comparison to lymphedema. The changes in the lymphatic-related cytokine milieu might be related to a modified vascular permeability developed secondarily to lipedema progression.

Latissimus Dorsi Flap in the Treatment of Thoracic Wall Defects After Medial Sternotomy.

Background: This study aimed to describe the subjective and objective results of the latissimus dorsi muscle flap and propose it as a reconstructive option for postoperative thoracic defects. Methods: A systematic search for cases with pedicle-based latissimus dorsi flaps performed after medial sternotomy was conducted, and all cases occurred between 2010 and August 2017. Preoperative, intraoperative, and postoperative factors were retrospectively analyzed and then the correlations between prognostic factors and outcomes of flap surgery were calculated. Furthermore, an evaluation of the subjective quality of life after flap surgery was performed using questionnaires. Results: A total of 25 cases were identified (8 female and 17 male patients) with the mean age of 75.28 years (range, 55-88 years). The average survival rate was 39.63 ± 23.03 months. The proportion of patients with a survival rate of 1 year was 84.00% (21 patients), and the proportion of patients with a 2-year survival rate was 80.00% (20 patients). While 24% of all patients who had latissimus dorsi flap operations experienced no complications, 64% of them developed minor complications (non-life-threatening, Clavien-Dindo grades I-IIIb) and 12% of them developed major complications (life-threatening, Clavien-Dindo grades IV-V). There was a significant correlation between the low survival rate and risk factors such as a positive history of smoking (P = .034), renal insufficiency (P = .022), metabolic syndrome (P = .004), and the presence of postoperative complications (P < .00002). No significant correlation was observed between the survival rate and obesity (P = .396), hyperlipoproteinemia (P = .684), arterial hypertonia (P = .0450), diabetes (P = .891), cardiovascular comorbidities (P = .794), the interval between sternotomy and latissimus flap surgery (P = .075), the duration of flap surgery (P = .207), sternal osteitis (P = .78), and intraoperative application of norepinephrine (P = .818). We identified metabolic syndrome (hazard ratio: 6.27), renal insufficiency (hazard ratio: 3.935), and the presence of postoperative complications (hazard ratio: 2.965) as high-risk prognostic factors. The subjective evaluations revealed positive reports from the patients with an average score of 1.86 ± 1.03 (1.0 = very good; 5.0 = poor). Conclusions: The majority of the patients with defects after median sternotomy were treated successfully with the latissimus dorsi flap. High survival rates, low rates of severe complications, and subjective scoring of improved life quality make this procedure relative safe and reliable. However, some prognostic risk factors limit the outcome, so these factors should be considered during surgical planning.

Factors affecting outcomes after supermicrosurgical lymphovenous anastomosis in a defined patient population.

BACKGROUND: The optimal surgical treatment for lymphedema is still subject of intensive research. Therefore, it is vital to investigate what significance lymphovenous anastomosis (LVA) has in this context. OBJECTIVE: This study aims to determine the short- and long-term results as well as the most important factors that can improve outcomes after LVA. METHODS: This study includes a complete data set of 26 patients who received LVA for a therapy-resistant lymphedema. Patients were followed up for an average of 23 months. RESULTS: 50% of the patients reported a subjective improvement. Without conservative treatment after the operation the patients showed significant better results (100% vs. 40.9%, p = 0.030). The localization of lymphedema as well as the region of LVA had a significant influence. In patients with lymphedema affecting the entire leg, symptom improvement was significantly lower (35.3% vs. 77.8%, p = 0.039). Patients who received LVA in an upper limb show a significantly higher improvement in symptoms than patients who received LVA in a lower limb (100% vs. 30%, p = 0.021). CONCLUSIONS: We identified factors with a significant influence on the outcome of patients after receiving LVA. Patients with early-stage upper extremity lymphedema seem to benefit most from this procedure.

Ammonia-modified Co(II) sites in zeolites: spin and electron density redistribution through the Co(II)-NO bond.

Electronic factors essential for the bonding of a non-innocent NO ligand to ammonia-modified Co(2+) sites in cobalt-exchanged zeolites are examined for small cluster models using DFT and advanced correlated wave function calculations. The analysis of charge transfer processes between the NO ligand and the cobalt center involves two protocols: valence-bond expansion of the multiconfiguration CASSCF wave function (in terms of fragment-localized active orbitals) and spin-resolved natural orbitals for chemical valence (SR-NOCV). Applicability of SR-NOCV analysis to transition metal complexes involving non-innocent fragments is critically assessed and the approach based on the CASSCF wave function turns out to be much more robust and systematic for all studied models. It is shown that the character and direction of electron density redistribution through the Co-N-O bond, quantified by relative share of the Co(II)-NO(0), Co(III)-NO(-), and Co(I)-NO(+) resonance structures in the total wave function, fully rationalize the activation of the N-O bond upon NH3 co-ligation (evidenced by calculated and measured red-shift of the NO stretching frequency and commonly ascribed to enhanced backdonation). The huge red-shift of νN-O is attributed to an effective electron transfer between the ammonia-modified Co(ii) centers and the NO antibonding π*-orbitals (related to the increased share of the Co(III)-NO(-) form). Unexpectedly, the effect is stronger for the singlet complex with three NH3 ligands than for that with five NH3 ligands bound to the cobalt center. Our results also indicate that high-efficiency electron transfers between the Co(ii) center and the NO ligand may be enabled for the selected spin state and disabled for the other spin state of the adduct. This illustrates how the cobalt center may serve to fine-tune the electronic communication between the NO ligand and its binding site.

Ammonia-modified Co(II) sites in zeolites: IR spectroscopy and spin-resolved charge transfer analysis of NO adsorption complexes.

IR spectroscopic studies and quantum chemical modeling (aided by the analysis of charge transfer processes between co-adsorbed ammonia and the Co(II)-NO adduct) evidence that donor ammonia molecules, ligated to extraframework Co(2+) centers in zeolites, vitally affect the strength of the N-O bond. Calculations indicate that versatility of ammine nitrosyl complexes, differing in the number of NH3 ligands as well as in the geometry and electronic structure of the Co-N-O unit (showing variable activation of NO) may co-exist in zeolite frameworks. However, only combined analysis of experimental and calculation results points to the adducts with three or five NH3 coligands as decisive. The novel finding concerning the interpretation of discussed IR spectra is the assignment of the most down-shifted bands at 1600-1615 cm(-1) to the N-O stretch in the singlet [Co(NH3)3(NO)](2+) adduct, in place of tentative ascription to pentaammine adducts. Theory indicates also that the Co(ii) center (with manifold of close-lying electronic and spin states) acts as a tunable electron donor where the spin state may open or close specific channels transferring electron density from the donor ligands (treated as the part of environment) to the NO molecule.

Nitric oxide as a non-innocent ligand in (bio-)inorganic complexes: spin and electron transfer in Fe(II)-NO bond.

The nature of electron density transfer upon bond formation between NO ligand and Fe(II) center is analyzed on the basis of DFT calculation for two {Fe-NO}(7) complexes with entirely diverse geometric and electronic structures: Fe(II)P(NH3)NO (with bent Fe-N-O unit) and [Fe(II)(H2O)5(NO)](2+) (with linear Fe-N-O structure). Proper identification of an electronic status of the fragments, "prepared" to make a bond, was found necessary to get meaningful resolution of charge and spin transfer processes from a spin-resolved analysis of natural orbitals for chemical valence. The Fe(II)P(NH3)NO adduct (built of NO(0) (S=1/2) and Fe(II)P(NH3) (S=0) fragments) showed a strong π*-backdonation competing with spin transfer via a σ-donation, yielding significant red-shift of the NO stretching frequency. [Fe(II)(H2O)5(NO)](2+) (built of NO(0) (S=1/2) antiferromagnetically coupled to Fe(II)(H2O)5 (S=2) fragment) gave no noticeable charge or spin transfer between fragments; a slight blue-shift of the NO stretching frequency could be related to a residual π-donation due to weak π-bonding.

Soft tissue perineurioma and other unusual tumors in a patient with neurofibromatosis type 1.

Perineurioma is a rare benign peripheral nerve sheath tumor featuring perineurial differentiation. Perineurioma occurs sporadically with only one reported case in the setting of neurofibromatosis type 1 (NF-1). We present a 6.7-cm soft tissue perineurioma of the lower leg in a 51-year-old man with proven NF-1. The tumor displayed whorled and fascicular pattern with infiltrative margins and expressed EMA, GLUT-1, claudin-1, and CD34. Electron microscopy confirmed diagnosis. Furthermore, lipomatosis, cutaneous angiomatous nodules, vasculopathy, and iliac spine lesion consistent with non-ossifying fibroma were observed. Tumor DNA revealed no NF2 mutations or chromosomal aberrations but a germline NF1-deletion (c.449_502delTGTT) was detected in his blood sample. His brother displayed neurofibromas, duodenal ganglioneuroma and colonic juvenile polyp, and his mother a neurofibroma, cutaneous squamous cell carcinoma, and jejunal gastrointestinal stromal tumor (GIST); both were affected by NF-1. In conclusion, perineurioma may rarely be NF-1 related and should be included in the spectrum of neoplasms occurring in this disorder.

Periacetabular bone density after total hip arthroplasty a postmortem analysis.

To clinically verify the bony response to a press-fit acetabular component, this study assessed 5 postmortem-retrieved pelves with unilateral total hip arthroplasties. Changes in periacetabular bone density between implanted and contralateral bone were assessed with dual energy x-ray absorptiometry and computed tomography. At a mean of 9.1 years postarthroplasty, bone density decreased an average of 1.5% to 7.1% proximal and 12.8% medial to the cup. This supports shorter-term in vivo investigations demonstrating periacetabular stress shielding proximal to press-fit cups as well as computer models predicting bone loss medially, but in much greater magnitudes. Unlike femoral remodeling, the average magnitudes of pelvic bone loss are not extensive; therefore, we question whether periacetabular remodeling should be a primary concern for orthopedic surgeons.

Incidence and volume of pelvic osteolysis at early follow-up with highly cross-linked and noncross-linked polyethylene.

Highly cross-linked polyethylene has shown decreased wear rates as compared to conventional polyethylene. However, the impact of this decrease on the occurrence of osteolysis remains uncertain. Forty hips implanted with noncross-linked Enduron and 36 implanted with 5-Mrad cross-linked Marathon polyethylene had a computed tomography at a minimum of 5 years after arthroplasty. Polyethylene wear, osteolysis incidence, location, and volume were compared. The incidence of osteolysis was statistically greater for patients with noncross-linked Enduron (11/40, 28%) compared to patients with the moderately cross-linked Marathon (3/36, 8%; P = .04). The average lesion volume for hips with Enduron liners (7.5 +/- 6.7 cm(3)) was significantly greater than the average lesion volume for hips implanted with Marathon liners (1.2 +/- 0.1 cm(3), P = .01). Marathon cross-linked polyethylene has shown to have a decreased incidence and volume of pelvic osteolysis. Longer follow-up is necessary to determine if Marathon cross-linked polyethylene will continue to demonstrate the encouraging improved wear and osteolysis characteristics.

A randomized prospective evaluation of outcomes after total hip arthroplasty using cross-linked marathon and non-cross-linked Enduron polyethylene liners.

Cross-linked liners were introduced with the promise that they would substantially reduce polyethylene wear. In 1999, our institution initiated a prospective study to compare the outcome of total hip arthroplasty patients who were randomized to non-cross-linked Enduron liners with that of total hip arthroplasty patients who were randomized to Marathon polyethylene liners that had been cross-linked with 5 Mrad (50 kGy) of gamma-irradiation and heat-treated to eliminate free radicals. At a mean follow-up of 5.7 years, the clinical outcomes among the Marathon and Enduron liners were similar. However, the mean wear rate was 0.01 +/- 0.07 mm/y for the Marathon group, which represents a 95% reduction compared with the mean wear rate of 0.19 +/- 0.12 mm/y for the Enduron group. In addition, the incidence of osteolysis was lower in the Marathon group.

The value of anteroposterior pelvic radiographs for evaluating pelvic osteolysis.

We investigated the role of conventional radiographs and computed tomography scans for the routine followup of total hip arthroplasty patients. Among 92 total hip arthroplasties with a mean followup of 8.5 years, 94 acetabular lesions were detected among 63 hips using computed tomography and 42 of these hips had osteolysis diagnosed on radiograph. Using computed tomography as a gold standard, the sensitivity of anteroposterior pelvic radiographs for the detection of acetabular osteolysis was 67% and the specificity was 72%. Although smaller lesions were more frequently missed, osteolysis was diagnosed on radiograph in 20 of 22 total hip arthroplasties with lesion volumes of at least 10 mL. Because larger osteolytic lesions were generally detected on radiograph, two-dimensional and three-dimensional lesion sizes correlated. However, the limits of agreement for the volume estimates based on the radiograph area were -14.6 to 18.7 mL. Although radiographs can be useful to screen for clinically important pelvic osteolysis, computed tomography images are necessary to accurately measure lesion volumes.