Defining postoperative stability in children with radial polydactyly.

UNLABELLED: There is little fundamental data on paediatric metacarpophalangeal joint instability in radial polydactyly following surgical reconstruction. We evaluated 27 thumbs in a healthy paediatric population (Group A: eight girls and 19 boys with a mean age of 9.7 years (range 2.7-14.2)) and 12 thumbs following Wassel-IV reconstruction (Group B: eight girls and four boys with a mean age at follow-up of 10.6 years (range 2.7-13.2)). Metacarpophalangeal joint radial deviation, ulnar deviation on stress testing, interphalangeal joint and metacarpophalangeal joint alignment on posterior-anterior radiographs were measured and scored according to parameters defining joint instability. The aim of our study was to provide fundamental data on thumb metacarpophalangeal joint mobility patterns and alignment for further postoperative evaluations in children. The average ulnar deviation and radial deviation on stress testing of the healthy (Group A) metacarpophalangeal joints was 25° (10°-45°) and 30° (10°-55°), respectively. In the operated (Group B) thumbs, the ulnar deviation and radial deviation was greater at 35° (10°-55°) and 30° (10°-70°). Ulnar deviation (UD) of the proximal phalanx at the metacarpophalangeal joint on posterior-anterior radiographs was a mean of 10° (range -10°-30°) in Group B; this was significantly greater than in Group A at a mean of 5° (range -5-20°) (p = 0.029). The mean radial alignment of the interphalangeal joint (distal phalanx relative to the proximal phalanx) was significantly higher in Group B (15°) than Group A (0°) (p = 0.221). In the literature on radial polydactyly, cut off values defining metacarpophalangeal joint instability in children range from 5° to 20°. According to our results, high but physiological metacarpophalangeal joint mobility of the thumb needs to be taken into consideration when evaluating children following reconstruction. Ulnar or radial deviation greater than 30°, in combination with the lack of a definite end point on metacarpophalangeal joint stress testing, may be regarded as unstable. Based on our study on healthy paediatric and reconstructed thumbs, comparison of joint stability with the healthy contralateral hand is recommended in order to define pathological instability. LEVEL OF EVIDENCE: II.

[Free Gracilis Flap for Anatomic Reconstruction after Limb-sparing Sarcoma Resection]. / Freie M. gracilis-Lappenplastik zur anatomischen Rekonstruktion nach gliedmaßen-erhaltender Weichteil-Sarkom Resektion.

INTRODUCTION: Limb-sparing surgery is considered as first choice in most patients with soft tissue sarcomas of the extremities. 5-year survival rates after limb soft tissue sarcoma resection have been promising in many specalised interdisciplinary centres. Quality of life as well as extremity function have thus become an integral aspect of the surgical management of soft tissue sarcomas of the extremities. OBJECTIVE: We herein report on our experience in the anatomic reconstruction of the extremities following limb-sparing soft tissue sarcoma resection using microvascular gracilis muscle flap and skin grafts. PATIENTS AND METHODS: Between 2012 and 2014 an anatomic reconstruction of the hand and foot using gracilis muscle flaps following limb-sparing sarcoma resection (leiomyosarcoma N=2, myxofibrosarcoma N=2, clear cell sarcoma N=1, myxoinflammatory fibroblastic sarcoma N=1, granular cell tumour N=1, pleomorphic sarcoma N=1) was performed in N=8 patients (4 females, 4 males), average age: 44 years (23-76 years), average follow-up time 444 days (98-820). RESULTS: In all patients successful defect coverage with unimpaired wound healing was achieved (adjunctive radiotherapy n=4). The tendon of the harvested gracilis muscle was used for anatomic reconstruction of consequently resected essential anatomic structures (extensor retinaculum n=1, flexor/extensor tendons n=4, extensor expansion n=2, tendon reinsertion n=1, proximal interphalangeal joint collateral ligament n=4, dorsal metatarsal ligament n=1). During follow-up neither local recurrence nor metastasis was observed. CONCLUSION: Reconstruction of multidirectional stability as well as restoring biomechanics and kinetics of the hand and foot should be considered during defect coverage and dead space obliteration management after sarcoma resection of the extremities. For reasons of sound options in anatomic extremity reconstruction with minimal donor site morbidity, the gracilis muscle flap excels in the field of limb-sparing sarcoma resection.

Examination of the protective effects of heparin and recombinant tissue plasminogen activator (rtPA) in compromised adipocutaneous free flaps in the rat model using intravital video microscopy.

BACKGROUND: The purpose of this study was to determine whether the focused delivery of heparin or recombinant tissue plasminogen activator (rtPA) by rinsing accords protective effects which increases the survival of free groin flaps following fatal secondary venous stasis. METHODS: Free microvascular groin flaps (n = 40) were transplanted to the necks of adult Sprague-Dawley rats 20 hours before the experiment. The study groups (each n = 10 animals) were: No adjunctive treatment (Group I), Ringer's solution (Group II), heparin solution (100 IU/kg, group III) and rtPA (2 mg/kg, group IV), respectively. The flap vein was then clamped for 35 minutes. Intravital video microscopy was applied and flap viability was assessed 14 days later. RESULTS: Mean flap necrosis was 90% in group I and II, whereas the rate of flap survival was 80% in group III and 60% in group IV, respectively. CONCLUSIONS: Even though clinical and microvascular flap perfusion parameters in both the rtPA-group and heparin group were initially similar, it has been demonstrated here in our investigations that the flaps treated with heparin showed a higher viability rate. Therefore, we can conclude that the focused delivery of heparin and rtPA resulted in a significantly improved flap salvage.

[Optimising care structures for severe hand trauma and replantation and chances of launching a national network]. / Über Versorgungsstrukturen und Möglichkeiten der Optimierung durch Vernetzung bei schweren Handverletzungen und Replantationen.

Severe hand traumata have a significant impact on our health system and on insurance companies, respectively. It is estimated that 33% of all occupational injuries and 9% of all invalidity pensions are due to severe hand trauma. Unfortunately, these high numbers are not only due to the severity of the trauma but to organisational deficiencies. Usually, the patient is treated at the general surgical emergency in the first place and only then forwarded to a microsurgeon. This redirection increases the time that is required for the patient to finally arrive at an expert for hand surgery. On the one hand, this problem can be explained by the population's lack of awareness for distinguished experts for hand and microsurgery, on the other hand, the emergency network, or emergency doctors in particular are not well informed about where to take a patient with a severe hand trauma - clearly a problem of communication between the hospitals and the ambulance. It is possible to tackle this problem, but put participating hand trauma centres have to work hand in hand as a network and thus exploit synergy effects. The French system "FESUM" is a good example for such a network and even comprises centres in Belgium and Switzerland. To improve the treatment of severe hand trauma, a similar alliance was initiated in Germany just recently. The pilot project "Hand Trauma Alliance" (www.handverletzung.com) was started in April 2013 and currently comprises two hospitals within the region of upper Bavaria. The network provides hand trauma replantation service on a 24/7 basis and aims at shortening the way from the accident site to the fully qualified hand surgeon, to improve the therapy of severe hand injuries and to optimise acute patient care in general. In order to further increase the alliance's impact it is intended to extend the project's scope from regional to national coverage - nevertheless, such an endeavour can only be done in collaboration with the German Society for Hand Surgery (DGH). This article comprises 2 parts. First, the state-of-the-art of acute severe hand trauma care is summarised and explained. Subsequently, the above-mentioned pilot project is described in every detail, including positive effects but also barriers that still have to be overcome.

Supporting the collateral ligament complex in radial polydactyly type Wassel IV.

Despite anatomical metacarpophalangeal joint (MCPJ) reconstruction in radial polydactyly (RP) Wassel IV, the prevention of long-term deformity and instability is still an issue. We report on clinical results following our modified surgical procedure with additional support of the hypoplastic radial collateral ligament complex (RCLC) after musculoligamentous MCPJ reconstruction. Fourteen patients (male: 10, female: 4) with radial resection of isolated RP Wassel IV (1987-2006), average age at surgery 1.7 years (0.6-8.6) were included. Distribution to group A and B depended on the procedure for MCPJ reconstruction. In group A (N = 7), RCLC reinsertion + reinforcement using autologous tendon grafts was performed (follow-up: 4.6 years (1.4-6.9)). Group B (RCLC reinsertion without support) consisted of N = 7 patients; follow-up: 9.6 years (8.2-20.2). The healthy contralateral hand (control A/control B) served as a control. Results were evaluated using our modified Tada-score considering: range of motion (ROM), interphalangeal joint (IPJ) and MCPJ stability on stress examination, palmar abduction and grip strength. Better score results (maximum 10) were seen in A: 7.3 (6-9) compared to B: 6.6 (4-10). Subscore 'stability' A: 1.1 (0-2); B: 0.9 (0-2) and 'alignment' A: 0.86 (0-2); B: 0.57 (0-2) showed greatest influence on the score result. Ulnar angulation at MCPJ level compared to healthy thumbs (control A + B) was greater (p < 0.05), with 11.4° (10-20) in group A and 14.3° (-5 to 30) in group B compared to 0° in control A and 5.7° (0-17) in control B. MCPJ ulnar deviation in A + B: 25° (0-35) compared to healthy thumbs control A + B was higher (p < 0.05). Ulnar deviation was higher in B 45° (30-60) compared to 34° (20-50) in A. In B, instability was evident in four, in A, only in one patient. In B, one patient required two re-operations due to MCPJ instability. Equivalent results were recorded regarding pinch grip and palmar abduction. Anatomical MCPJ reconstruction in combination with autologous support of the hypoplastic RCLC to enhance long-term stability is recommended.

[Microscope-integrated intraoperative indocyanine green angiography in plastic surgery]. / Intraoperative Indocyaningrün-Fluoreszenzdiagnostik mittels Operationsmikroskop in der plastischen Chirurgie.

The knowledge of tissue perfusion has not only a prognostic value in microvascular surgery but also the intraoperative detection of malperfusion can lead to a quick surgical intervention. Indocyanine green (ICG) angiography allows a topographic analysis of perfusion and is used to assess lymphatic drainage pathways and to analyse the depth of burn injuries. Integrating the technique into an operating microscope enables visualisation of the flow over microanastomoses and allows the assessment of the transit time of blood flow between arterial and venous anastomosis. Using this method we analysed 11 microsurgical free flaps (3 latissimus dorsi, 3 rectus abdominis, 1 gracilis muscle, 2 radial forearm, 1 ALT, and 1 DIEP flap). The topographic analysis was performed after the assessment of the microanastomoses. We observed no flap loss or partial flap necrosis. The transit time between arterial inflow and venous outflow was 32.8 s on average. Here we observed distinct differences between muscle flaps (27.7 s) on the one hand and fasciocutaneous and perforator flaps (47.5 s) on the other hand. We detected one venous thrombosis by ICG angiography in a case where the clinical patency test was not distinct. Revision was performed immediately. Particularly for intraoperative assessment, ICG angiography is a useful, reliable and safe technique. The integration into the operating microscope allows an "angiographic patency test" and the analysis of the transit time allows the evaluation of blood flow within the flap. Especially when planning perforator flaps the method of ICG angiography provides a new level of safety in flap design by quickly demonstrating the borders of perfusion.

Functional resurfacing of the palm: flap selection based on defect analysis.

Extensive defect coverage of the palm and anatomical reconstruction of its unique functional capacity remains difficult. In manual laborers, reconstruction of sensation, range of motion, grip strength but also mechanical stability is required. Sensate musculo-/fasciocutaneous flaps bear disadvantages of tissue mobility with shifting/bulkiness under stress. Thin muscle and fascial flaps show adherence but preclude sensory nerve coaptation. The purpose of this review is to present our algorithm for reliable selection of the most appropriate procedure based on defect analysis. Defect analysis focusing on units of tactile gnosis provides information to weigh needs for sensation or soft tissue stability. We distinguish radial unit (r)-thenar, ulnar unit (u)-hypothenar and unit (c)-central plus distal palm. Individual parameters need similar consideration to choose adequate treatment. Unit (r) and unit (u) are regions of secondary touch demanding protective sensation. Restoration of sensation using neurovascular, fasciocutaneous flaps is recommended. In unit (c), tactile gnosis is of less, mechanical resistance of greater value. Reconstruction of soft tissue resistance is suggested first in this unit. In laborers, free fascial- or muscle flaps with plantar instep skin grafts may achieve near to anatomical reconstruction with minimal sensation. Combined defects involving unit (c) require correlation with individual parameters for optimal flap selection. Defect coverage of the palm should not consist of merely providing sensate vascularized tissue. The most appropriate procedure should be derived from careful defect analysis to achieve near to anatomical reconstruction. In laborers, defect related demands need close correlation with sensation and mechanical stability to be expected.

How reconstructive transplantation is different from organ transplantation--and how it is not.

An evolution of understanding and knowledge gained over more than 100 years in the field of solid organ transplantation (SOT) led to the first successful clinical cases of composite tissue allotransplantation. In many ways reconstructive transplantation (RT) is similar to SOT; however, certain characteristics make this novel type of transplantation unique, interesting, and challenging for both clinicians/scientists and patients. Currently, RT is a rapidly advancing multidisciplinary clinical reality. With over 100 clinical cases performed over the past 12 years, and encouraging early to midterm results, the relevance of RT for treatment of congenital and acquired tissue defects unsalvageable by conventional reconstruction is significant and holds great potential for the future. We herein report the extraordinary progress in this field with particular discussion of a comparative analysis of the similarities and differences regarding indications, end point, failure, patient and graft survival, and side effects between SOT and RT.

[Free gracilis muscle flap with plantar intermediate thickness skin graft: case report, review of anatomy and functional reconstruction of the palm]. / M. gracilis Lappenplastik mit plantarem Spalthauttransplantat - Fallbericht und Literaturübersicht zur speziellen Anatomie der Hohlhand und ihrer funktionellen Rekonstruktion.

BACKGROUND: Skin and soft-tissue architecture of the palm are unique. Coverage of extensive soft-tissue defects restoring the functional capacity of the palm remains a challenging task. Anatomic restoration with skin from another area is hardly possible. In manual labourers, reconstruction of mechanical soft-tissue stability is required in addition to sensation, range of motion and grip strength. Sensate fasciocutaneous flaps bear disadvantages of tissue mobility, shifting and bulkiness. Published criteria for defect-related flap selection are sparse. MATERIAL AND METHODS: Defect analysis (anatomy, units of tactile gnosis, individual parameters) provides information to weigh needs for sensation or tissue stability, influencing selection of most appropriate procedures. We distinguished 4 units: hypothenar (H), thenar (T) and central palm (Z). (Z) consists of a central palmar unit (c') and the distal palm (d'). Individual parameters (age, profession, dominant hand, psychosocial aspects) were also considered. Units (T) and (H), regions of secondary touch, demand protective sensation by applying sensate fasciocutaneous flaps. In labourers tactile gnosis in (Z) is of less, tissue stability of greater value. An extensive palmar defect (9×13 cm, affecting unit (Z), partially affecting units (T) and (H), of the dominant hand) with combined vessel, nerve, tendon injuries (male labourer, 21 years) was covered after defect analysis with a free gracilis muscle flap and a glabrous intermediate (0.5 mm) thickness skin graft from the instep region. RESULTS: 29 months postoperatively anatomic conditions of palmar soft tissue (Vancouver scar scale: 1), high mechanical soft-tissue stability including normal hand function were evident. Semmes Weinstein testing showed positive pressure sensation. Professional reintegration after 5 months was possible. CONCLUSION: Defect coverage of the palm must not consist of merely providing sensate vascularised tissue. The most appropriate procedure can be derived from careful defect analysis focusing on the affection of units of tactile gnosis to achieve near to anatomic reconstruction. In labourers, patient- and defect-related demands need close correlation with the value of the selected flaps regarding the sensation and mechanical stability to be expected. In selected cases (mechanical irritation, affection of unit (Z), younger age) by combining microvascular muscle flaps with plantar intermediate thickness skin grafts promising functional results with early professional reintegration can be achieved by reconstructing like with like.

[About the self-reported quality of life after amputation of the hand in patients with upper extremity tumors]. / Zur Selbsteinschätzung der Lebensqualität von Tumorpatienten nach Amputation der Hand.

PURPOSE/BACKGROUND: Amputation proximal to the wrist may be oncologically dictated in cases of upper extremity soft tissue sarcoma and aggressive fibromatosis. Literature on functional long-term results and patient-oriented assessment is sparse. Our study is concerned with subjective impressions of quality of life and upper extremity health status and their importance in the evaluation and interpretation of results after amputation of the hand. PATIENTS/METHODS: Between 1999 and 2007, 14 patients (6 females/8 males; average age: 25 years) were operated because of a soft tissue sarcoma (n = 11) or aggressive fibromatosis (n = 3). Ten patients underwent limb-sparing surgery. There were two amputations at the level of the forearm. Local recurrence following forequarter amputation due to aggressive fibromatosis required reoperation in another patient. A heterotopic replantation after resection was carried out in one patient. In patients with amputations, the self-reported upper extremity-specific health status and quality of life were measured with the DASH score. Disturbances in body image and symptoms of depression were assessed psychiatrically. RESULTS: In two cases with amputations, minimal impairments in everyday life and a high reported quality of life were observed (DASH scores: 3,5). CONCLUSION: Self-reported upper extremity health status and quality of life following amputation of the hand can be in contrast to the objective pathology. In patient-oriented assessment of results, individual psychosocial factors that may affect results must be taken into consideration. They also must not be neglected when determining whether patients are suitable candidates for prosthetic devices.

[Optimal result after ear reconstruction following a dog bite injury]. / Optimales Rekonstruktionsergebnis eines Ohres nach Amputationsverletzung durch Hundebiss.

A case of a young woman is reported who lost a big part of the right auricle by a dog bite. An aesthetically satisfying immediate reconstruction after refixation of the deep-ithelialised amputated helical rim could be achieved with the aid of a temporal fascial island flap and full thickness skin grafts.

[Effect of cigarette smoking on skin perfusion of the hand]. / Einfluss des Zigarettenrauchens auf die Hautdurchblutung der Hand.

BACKGROUND: Cigarette consumption leads to postoperative wound healing disturbances by impairing skin circulation. MATERIALS AND METHODS: Fourteen nonsmokers and 44 smokers were investigated and classified according to age (<40 and >40 years) and duration of cigarette consumption. Circulation at the tip of the middle finger was measured in both groups under standard conditions with laser Doppler imaging. RESULTS: There was a reduction in skin blood circulation of 24% in smokers (young 39%, older 11%, P=0.001) and 30% in nonsmokers (young 35%, older 18%, P=0.019). With longer duration of cigarette consumption, the effect grew weaker (<10 years 25%, 11-30 years 18%, >30 years 15%). There was no correlation between the number of cigarettes consumed per day and impaired circulation. CONCLUSION: Younger subjects react to cigarette consumption with a stronger reduction in circulation. In elective surgery, especially in young smokers we recommend a 6- to 8-week nicotine abstinence prior to surgical intervention.