[Smartphone-based photographic wound documentation improves the quality of medical accounting in orthopedic and plastic surgery]. / Qualitätssteigerung der Abrechnungsprüfung durch Smartphone-basierte Fotodokumentation in der Unfall­, Hand- und plastischen Chirurgie.

BACKGROUND: Photographic documentation of wounds, decubitus ulcers, tumors, open fractures and infections is an important part of digital patient files. It is unclear whether the photographic documentation has an effect on medical accounting with health insurance companies. OBJECTIVE: It was hypothesized that Smartphone-based systematic photographic documentation can improve the confirmation of proceeds-relevant diagnoses and procedures as well as the duration. MATERIAL AND METHODS: Staff in the emergency room, operating theater, outpatient clinic and on the wards were equipped with digital devices (Smartphone, tablet) including a photo-app. Medical accounting with the health insurance companies and identification of all case conferences in which the photographic documentation had effected a change in proceeds were analyzed for 2019 in a retrospective manner. RESULTS: Overall, 372 cases were discussed of which 27 cases were affected by the digital photographic documentation. Photographic documentation was used for clarification of the operative procedure (n = 5), primary diagnosis (n = 10), secondary diagnosis (n = 3), and length of hospitalization (n = 9). An average of 2119 € was negotiated and added per case affected by photographic documentation. Hereby, a level 1 trauma center gained an estimated 65,328 € in revenue. DISCUSSION: The use of Smartphone based photographic documentation can improve the overall quality of patient files and thus avoid loss of revenue. The implementation of digital devices with corresponding software is an important component of the digital structural change in hospitals.

[Local flaps as a last attempt to avoid lower extremity amputation: an overview]. / Lokale Lappenplastiken als letzter Versuch vor der Unterschenkelamputation: eine Übersicht.

BACKGROUND: Soft tissue reconstruction in aged patients is challenging. Free tissue transfer can be carried out in healthy patients with a high success rate despite old age. When free tissue transfer is contraindicated in multimorbid patients, local flaps are often chosen, which are associated with a high complication rate. Such salvage interventions must be selected so that an amputation is not disadvantageously influenced by the selection of the donor site or is even impossible. METHODS: The three distally based local flaps the sural artery flap, peroneus brevis muscle flap and perforator-based propeller flaps are discussed with respect to placement of the donor site as well as wound healing disorders. RESULTS: The sural artery flap is disadvantageous as the donor site because the proximal dorsal calf region is affected, which in the case of a below the knee amputation enables soft tissue covering of the stump. CONCLUSION: If a local flap is to be used as a salvage surgery in an attempt to prevent a below the knee amputation in a patient who is not suitable for free tissue transfer, special emphasis must be placed on the donor site of this flap. The proximal dorsal aspects of the distal calf are required for covering a potential stump and should not be violated by harvesting a local flap.

The Fascia-Only Reverse Posterior Interosseous Artery Flap.

PURPOSE: Fascia flaps are a preferred method to reconstruct the soft tissue envelope of the hand when a thin and pliable flap is required to cover exposed tendons. The aim of this study was to report on our experience with the fascia-only reversed posterior interosseous artery flap. Contrary to commonly used fascia flaps, this flap does not require free tissue transfer. METHODS: In this retrospective review, 5 patients were identified, each of whom underwent soft tissue reconstruction with a reversed posterior interosseous artery fascia flap. The operative technique is similar to the harvest of a fasciocutaneous flap except that only the fascia is harvested through a straight incision. RESULTS: No flap loss occurred. In 2 patients a distal wound dehiscence occurred, which healed by secondary intention. No venous congestion or iatrogenic lesion of the motor nerves to the extensor muscles was encountered. CONCLUSIONS: The fascia-only reverse posterior interosseous artery flap represents a locally available, pedicled option. With regard to the quality of the transferred tissue, this flap is comparable to the temporalis fascia flap. Major advantages are that the donor site is confined to the ipsilateral extremity and microsurgery is not required. Contrary to the fasciocutaneous version, no skin graft has to be applied to the donor site, which improves cosmesis. We consider this flap a worthwhile alternative to other fascia flaps. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The role of CT scan in postoperative evaluation of distal radius fractures: Retrospective analysis in regard to complications and revision rates.

BACKGROUND: Intraarticular fractures of the distal radius present a challenging problem for surgeons. While preoperative CT scans are considered helpful to understand the type of fracture and to choose an adequate approach, the role of postoperative CT scans is not yet clearly defined. The aim of this study was to analyze indications for postoperative CT scans and to evaluate its potential therapeutic consequence in regard to detection of complications and its influence on revision rates in intraarticular fractures. These findings were used to establish an algorithm to help identifying patients that benefit from a postoperative CT scan. PATIENTS AND METHODS: Ninety-two patients with intraarticular fractures were included. AO type C fractures were seen in about 90% of patients, with type C3 being present in 55% of the patients. According to Frykman's classification type 7 and 8 fractures were found in 93%. Data was analyzed in regard to radiographic results, complications and indication for a postoperative CT scan. RESULTS: Six patients underwent revision surgery. When analyzing data in regard to correlation of radiographs and CT Scans a statistically significant correlation was found. CONCLUSIONS: A high correlation between both imaging techniques can be shown. In inconclusive radiographs, CT scans are recommended to rule out intraarticular screw placement or step offs. Due to the number of patients and the retrospective design, further studies are needed.

Toward reconstruction of the subcutaneous fat layer with the use of adipose-derived stromal cell-seeded collagen matrices.

BACKGROUND AIMS: Complex injuries of the upper and lower extremities often result in scarring and subsequent adhesion formation, which may cause severe pain and distinctly reduce range of motion. In revision surgery, replacement of the missing subcutaneous tissue is desirable to prevent new adhesions, to cushion scarred tendons and nerves and to regain tissue elasticity. Therefore, the objective of this study was the in vitro evaluation of cell-seeded collagen matrices to serve as the basis for the reconstruction of the subcutaneous adipose tissue layer. METHODS: Five commercially available acellular dermal collagen matrices were seeded with human adipose-derived stromal cells (hASC). Size and shape stability of cell-matrix constructs were assessed and cell adhesion onto the matrix surface was evaluated histologically. Adipogenic differentiation of hASC on matrices was evaluated by means of histological staining, triglyceride quantification, and quantitative real-time polymerase chain reaction gene expression analysis. RESULTS: The collagen matrix Permacol was the only cell-seeded material that exhibited excellent size and shape stability. For Permacol and Strattice, successful seeding with continuous cell layers on top of the matrices was observed. For both matrices, histological staining, triglyceride quantification and messenger RNA expression of adipogenic transcription factors indicated substantial adipogenic differentiation of hASC after long-term induction as well as after short-term induction of only 4 days. CONCLUSIONS: Of all matrices investigated, only Permacol exhibited adequate handling stability and the development of a thin adipose tissue layer on top of the matrix. Thus, this matrix appears promising to be used in the development of a subcutaneous cushioning layer after complex injuries involving large scar formation.

[Goal-setting in Plastic Surgery using the SMART principle]. / Operative Ausbildungsziele in der Plastischen und Ästhetischen Chirurgie einfach "SMART".

INTRODUCTION: The process of continuous acquisition of surgical expertise is a key element in registrar training. The principle of active, self-directed learning, which is regularly applied in medical school, can also be used to gain surgical expertise in registrar training. METHODS: Surgical training can be compared to acquiring expertise in music or sport, where both intellectual and manual capabilities are required. Specific training principles, including analysis, goal setting, practice and reflection on the process, are commonly encountered in these fields. Smart goal setting is preferred in order to ensure compliance and a successful strategy. This can also be used in plastic surgery training. APPLICATION: Surgical principles as well as partial or complete surgical procedures can be practiced using the smart principle. The fragmentation of a larger task into smaller units allows rapid acquisition of surgical expertise without impeding patient safety. DISCUSSION: Surgical training today happens in a setting caught between economic and medicolegal challenges. The reduction of case load requires simulation practice as well as self-directed learning - which has been shown to improve outcomes. The smart principle allows distinct goal setting which can improve compliance of the student and increase success. As this form of learning is not intuitive to all individuals, supervisors and mentor can support trainees in the acquisition of surgical expertise using this principle.

Subfascial directionality of perforators of the distal lower extremity: an anatomic study regarding selection of perforators for 180-degree propeller flaps.

BACKGROUND: The 180-degree propeller flaps allow closure of soft-tissue defects of the distal lower extremity. In addition to twist, the pedicle is often subject to additional kinking which increases proportionally to the angle at which the perforator pierces through the fascia. This study evaluates the directionality of the perforators at the fascial level to guide in the selection process of the best perforator. MATERIAL AND METHODS: Perforators were identified in the lower extremities of 16 fresh cadavers. The angle of fascial perforation was measured. Perforators were grouped according to source vessel and location. Results were analyzed statistically regarding angle of fascial perforation along the source vessel and region. RESULTS: A total of 324 perforators were identified. Distal perforators pierced the fascia at a significantly greater angle than in the proximal and middle segment of the peroneal and anterior tibial vessels (P < 0.005). Perforators originating from the posterior tibial artery pierced the fascia at less acute angles distally. When grouped according to the region of the perforators, no significant difference was found between perforators from all source vessels in the proximal region of the distal lower extremity. Even distally, perforators from the posterior tibial artery traveled almost perpendicular (P < 0.005). CONCLUSION: Perforators traveling in a near perpendicular manner are ideal to serve as a pedicle for 180-degree propeller flaps as solely the twist has to be distributed along the vessel. The posterior tibial artery was the source to perforators with the most constant, near-perpendicular course, predisposing them for use in 180-degree propeller flaps.

[Pedicled anterolateral thigh flap reconstruction in the region of the lower abdomen, groin, perineum, and hip]. / Die gestielte, anterolaterale Oberschenkellappenplastik zur Weichteilrekonstruktion im Bereich von Unterbauch, Leiste, Perineum und Hüfte.

OBJECTIVE: Soft tissue reconstruction of complex defects of the lower abdomen, groin, the perineum and the hip region present a reconstructive challenge. Besides free tissue transfer, pedicled flaps may also be utilized. Harvest of the vertical rectus abdominis flap causes a functional deficit by weakening the abdominal wall. Pedicled, perforator-based flaps minimize functional deficits by preserving muscle. INDICATIONS: Soft tissue defects with exposed vital structures, prosthetic devices or irradiated wound beds. CONTRAINDICATIONS: Previous surgery at the donor site, peripheral vascular disease at the pelvic and thigh region, previous vascular interventions at the donor site. SURGICAL TECHNIQUE: After preoperative localization of the perforators, a retrograde, intramuscular dissection of the pedicle allows sufficient length to be gained in order to transpose the flap into the defect. Tunneling of the flap beneath the rectus femoris muscle and Sartorius muscle is often required for tension-free inset. POSTOPERATIVE MANAGEMENT: Five days of bed-rest postoperatively followed by ambulation. RESULTS: No complete flap loss was encountered in 13 cases. In 2 cases a partial tip necrosis required secondary skin grafting.

Adequacy of palmaris longus and plantaris tendons for tendon grafting.

PURPOSE: The reconstruction of tendon defects is challenging. The palmaris longus and plantaris tendon are generally considered best for tendon grafting. Only a few studies have examined whether these tendons, when present, meet criteria for successful grafting. The purpose of this study was to evaluate these tendons in regard to adequacy as tendon grafts. METHODS: To evaluate adequacy for grafting, the palmaris longus and plantaris tendons were harvested from 92 arms and legs of 46 cadavers. Macroscopic evaluation and measurements concerning presence, length, and diameter of the tendons were obtained. Criteria for adequacy were a minimum length of 15 cm with diameter of 3 mm or, alternatively, 30 cm with a diameter of 1.5 mm. RESULTS: The palmaris longus tendon was present bilaterally in 36 cases and was absent bilaterally in 4 cases. The plantaris tendon was present bilaterally in 38 cases and absent bilaterally in 4 cases. In 29 cadavers, the palmaris longus tendon did not meet the criteria to be used as a tendon graft. Only in 8 cases were the tendons satisfactory for grafting bilaterally. The plantaris tendon met criteria for grafting in 20 cases bilaterally. In 17 cases, the tendons were considered inadequate bilaterally. CONCLUSIONS: Despite their presence, the palmaris longus and plantaris tendons are adequate for grafting less often than previously thought. In less than 50%, the tendons, although present, would serve as useful grafts. CLINICAL RELEVANCE: Our findings underscore the importance of choosing a second donor site before surgery in case the primarily selected tendon is not found to be suitable.

Breast reduction by liposuction in females.

BACKGROUND: Breast reduction by liposuction alone is an appealing technique that has failed to gain widespread acceptance. Despite numerous studies on liposuction, the majority of surgeons remain skeptical. This study aimed to review the indication and limitations of this procedure. METHODS: Two groups of patients that qualify for this procedure can be defined. However, the aesthetic result will be pleasing only for young patients. For elderly patients, liposuction breast reduction will simply achieve a weight reduction of the breast without improving the shape. RESULTS: Universally good liposuction results for breast weight reduction and elevation of the nipple-areolar complex are reported. Improvement in breast shape and correction of ptosis cannot be achieved for elderly patients. Young patients with a preoperatively pleasing breast shape can expect a preservation of the shape with the benefit of minimal scarring. CONCLUSION: Liposuction breast reduction is appealing due to selective removal of fat, ease of the procedure, and minimal scarring. The main disadvantage is that a correction of shape and ptosis is not possible with liposuction, and only young patients can expect an aesthetically pleasing result. Elderly patients may benefit from faster recovery times, a less invasive procedure, and low costs. The application of a new technique to a cancer-prone organ represents a potentially serious medicolegal issue because follow-up imaging may be impaired and a possible spread of cancer cells cannot be ruled out. Despite its technical appeal, breast reduction by liposuction alone mandates a cautious approach.

Reconstruction of pressure sores with perforator-based propeller flaps.

Perforator flaps have been successfully used for reconstruction of pressure sores. Although V-Y advancement flaps approximate debrided wound edges, perforator-based propeller flaps allow rotation of healthy tissue into the defect. Perforator-based propeller flaps were planned in 13 patients. Seven pressure sores were over the sacrum, five over the ischial tuberosity, and one on the tip of the scapula. Three patients were paraplegic, six were bedridden, and five were ambulatory. In three patients, no perforators were found. In 10 patients, propeller flaps were transferred. In two patients, total flap necrosis occurred, which was reconstructed with local advancement flaps. In two cases, a wound dehiscence occurred and had to be revised. One hematoma required evacuation. No further complications were noted. No recurrence at the flap site occurred. Local perforator flaps allow closure of pressure sores without harvesting muscle. The propeller version has the added benefit of transferring tissue from a distant site, avoiding reapproximation of original wound edges. Twisting of the pedicle may cause torsion and venous obstruction. This can be avoided by dissecting a pedicle of at least 3 cm. Propeller flaps are a safe option for soft tissue reconstruction of pressure sores.

Reconstruction of soft tissue defects of the Achilles tendon with rotation flaps, pedicled propeller flaps and free perforator flaps.

INTRODUCTION: Soft tissue defects exposing the Achilles tendon are challenging. Local perforator flaps represent a valuable option gaining increasing popularity. Despite preoperative planning an adequate perforator cannot always be found intraoperatively. The free peroneal artery perforator flap can serve as a back-up option limiting the donor site morbidity to the same extremity without sacrificing major vessels or nerves. METHODS: Nine patients with soft tissue defects exposing the Achilles tendon were treated with local perforator flaps, seven were scheduled for 180° propeller flap coverage after Doppler-ultrasound examination. However, in two patients (22%) no adequate perforators were found intraoperatively. As the perforators for the free peroneal artery perforator flap were routinely mapped out, this flap was harvested for microsurgical reconstruction. RESULTS: One patient with a 180° propeller flap developed a partial flap necrosis, another patient developed superficial epidermolysis, both requiring skingrafting. no complications were seen with free tissue transfer. CONCLUSION: Pedicled perforator flaps as propeller flaps add options to the armamentarium of microsurgeons. Despite thorough preoperative planning the surgeons must be prepared to perform a different method of reconstruction if inadequate vessels are encountered. To limit additional donor site morbidity, local options are preferred. The free peroneal artery perforator flap represents a good option as it matches the original tissue properties closely. The complication rate of propeller flaps in this series is tolerable. Propeller flaps should therefore be considered an alternative but not as a replacement of local fasciocutaneous flaps.

Pedicled perforator flaps for mid-tibial soft tissue reconstruction in medically compromised patients.

BACKGROUND: The soft tissue of the central pretibial area is difficult to reconstruct often requiring free tissue transfer. Especially medically compromised patients are not ideal candidates for free tissue transfer and may benefit from expeditiously harvested local flaps with limited donor site morbidity. As muscle flaps are rare, pedicled flaps based on lateral perforators represent an alternative as the arc of rotation can often be limited to 90°. MATERIAL AND METHODS: A retrospective analysis of patient data was conducted to identify patients over the age of 60 years with comorbidities that underwent pretibial soft tissue reconstruction with a single-pedicle perforator flap. Patient demographics, size and cause of the defect, flap dimension, arc of rotation and complications were recorded. RESULTS: Five patients with an average age of 71.4 years were included. The arc of rotation was 69°, all flaps healed. There were two recurrences of osteomyelitis. CONCLUSION: Lateral perforators originating from the anterior tibial artery or peroneal artery are adequate source vessels for single pedicled perforator flaps even in medically compromised patients. A perforator located proximal to the defect allows limiting the arc of rotation to less than 90°, which increases the safety of the flap. Patients benefit from a simple procedure without a microvascular anastomosis and a donor site confined to one extremity.

[The impact of SARS-CoV-2 restrictions on medical care in Plastic Surgery]. / Die Auswirkungen der SARS-CoV-2-Einschränkungen auf die Patientenversorgung im Fachbereich für Plastische, Rekonstruktive und Ästhetische Chirurgie.

BACKGROUND: To manage the expected COVID-19 patient load major restrictions in in- and outpatient treatment had to be made. Depending on local conditions and order supply differences SARS-CoV-2 restrictions had a massive impact on medical care. To show the impact of plastic surgery on emergency surgery during SARS-CoV-2 pandemic, the amount of surgical emergencies in a single center plastic surgery division were evaluated. METHOD: The number of plastic surgery cases in a university hospital was evaluated during 16.03.2020 to 27.04.2020 and compared with previous years. RESULTS: Due to cancelling of elective surgery the number of cases dropped to 57,3 % of the caseload of previous years. There was no change in ratio of emergency (2020: 56,4 %; 2017-2019: 54,9 %) and urgent (2020: 44,6 %; 2017-2019: 45 %) surgery. No changes in regard to the etiology of trauma cause nor insurance status (occupational insurance/health insurance) were noted. CONCLUSION: Based on the data of this evaluation there is a clear relevance of Plastic Surgery in the setting of general medical care. Even during the pandemic crises a sufficient plastic surgery service is mandatory in a tertiary referral center.

Combination of a total free forearm flap and a sensate local flap for preservation of the shoulder girdle in massive, nonreplantable upper extremity injuries.

BACKGROUND: After massive upper extremity injuries, prosthetic use might be complicated by the formation of pressure ulcerations. Especially the coverage with insensate free flaps may predispose the patient for developing chronic ulcerations when using an upper extremity prosthesis. This complication may be reduced when sensate local flaps are used to cover bony prominences. METHODS: A new operative technique is described. RESULTS: Immediate sensate soft tissue coverage improves prosthetic fitting. Successful manipulation of the prosthesis can be quickly achieved with a decreased risk for pressure ulceration. CONCLUSION: This challenging procedure helps to achieve durable and sensate coverage of bony prominences. The use of local sensate tissue to cover bony prominences reduces the risk for pressure ulceration when wearing a prosthesis. Areas where prosthetic use causes only low pressure and shearing forces are adequately covered with free flaps. Immediate sensibility of local flaps allows prosthetic fitting and use as soon as wound healing has occurred. Return to work is thus expedited.

Ischial pressure sores: reconstruction using the perforator-based reverse flow musculocutaneous 180 degrees propeller flap.

The treatment of pressure sores requires soft tissue reconstruction with thick tissue to provide padding of bony prominences and obliterate dead space. Fasciocutaneous flaps may not provide adequate bulk. Propeller flaps (180 degrees) based on perforators from the gluteal artery may be harvested as a reverse flow musculocutaneous flap including a muscle plug to reconstruct deep cavities. Three patients presenting with deep pressure sores required reconstruction of large cavities. In addition to a regular 180 degrees propeller flap, a muscle plug based on a perforator found in the blade of the propeller was used to add bulk to the flap and obliterate the cavity with well-vascularized tissue. One flap required secondary closure of the donor site due to dehiscence, one hematoma required drainage. All flaps survived completely. No recurrence of osteomyelitis or pressure sores was seen. The 180 degrees propeller flap can be harvested as a reverse flow musculocutaneous flap including a muscle plug in the distal blade. This adds volume which is required to adequately obliterate large cavities in cases of osteomyelitis. This new technique may be useful in other areas as well.

Evaluation of the Intraoperative Blood Flow of Pedicled Perforator Flaps Using Indocyanine Green-fluorescence Angiography.

Although indocyanine-green fluorescence angiography (ICG-FA) has been established as a useful tool to assess perfusion in free tissue transfer, only few studies have applied this modality to pedicled perforator flaps. As both volume and reach of pedicled perforator flaps are limited and tip necrosis often equals complete flap failure, ICG-FA may help to detect hypoperfusion in pedicled flaps. METHODS: In 5 patients, soft tissue reconstruction was achieved with pedicled perforator flaps. ICG-FA was utilized intraoperatively to visualize flap perfusion. RESULTS: Three pedicled anterolateral thigh flap flaps and 2 propeller flaps were transferred. ICG-FA detected hypoperfusion in 2 flaps. No flap loss occurred; in 2 cases, prolonged wound healing was encountered. CONCLUSIONS: ICG-FA confirmed clinical findings and reliably detected tissue areas with hypoperfusion. A clear cut-off point between nonvital tissue and such that stabilized in the following clinical course could not be found. ICG-FA is a promising technology which could also be used in pedicled perforator flaps.

The Microvascular Peroneal Artery Perforator Flap as a "Lifeboat" for Pedicled Flaps.

Pedicled perforator flaps have expanded reconstructive options in extremity reconstruction. Despite preoperative mapping, intraoperative findings may require microvascular tissue transfer when no adequate perforators can be found. The free peroneal artery perforator flap may serve as a reliable back-up plan in small defects. METHODS: In 16 patients with small soft tissue defects on the upper and lower extremities, perforator-based propeller flaps were planned. The handheld Doppler device was used to localize potential perforators for a propeller flap in close proximity to the defect. Perforators of the proximal peroneal artery were also marked to allow conversion to microvascular tissue transfer. RESULTS: In 6 cases, no adequate perforators were found intraoperatively. In 4 patients, the peroneal artery perforator flap was harvested and transferred. The pedicle length did not exceed 4 cm. No flap loss occurred. CONCLUSIONS: When no adequate perforator capable of nourishing a propeller flap can be found intraoperatively, the free peroneal artery flap is a good option to reconstruct small soft tissue defects in the distal extremities. The short vascular pedicle is less ideal in cases with a large zone of injury requiring a more distant site of anastomosis or when recipient vessels are located in deeper tissue planes.

Does Distal Radio-ulnar Joint Configuration Affect Postoperative Functional Results after Ulnar Shortening Osteotomy?

BACKGROUND: Reverse oblique distal radio-ulnar joint (DRUJ) configuration is assumed to show inferior postoperative results in ulnar-shortening osteotomy due to osteoarthritis, as the joint force pressure in the DRUJ may be increased. An evaluation and comparison of the postoperative functional results with regard to clinical and radiographic signs of arthritis among different DRUJ configurations was carried out retrospectively. METHODS: Sixty-two patients after ulnar shortening osteotomy were included. The minimum follow-up was 5 years. Preoperative x-rays were assessed for the DRUJ configuration according to the Tolat classification, whereas postoperative radiographs were evaluated with regard to signs of osteoarthritis using the Kallgren-Lawrence-Score. Functional results were evaluated using the disabilities of the arm, shoulder and hand (DASH) and Mayo Wrist Score and measuring range of motion and grip strength. RESULTS: Significantly better functional results were found in patients with parallel configuration of the DRUJ (Tolat type 1 configuration) with regard to DASH score, grip strength, and supination compared with nonparallel configurations. In the Tolat type 1, configurated DRUJ mean DASH score was 9 compared with 18 in the Tolat type 2 and 3 groups. Apart from supination, no differences were observed in range of motion among groups. CONCLUSION: Although long-term postoperative range of motion failed to display statistically significant differences between DRUJ configurations except for supination, better results regarding grip strength and DASH scores were seen in a parallel-aligned DRUJ configuration. Although onset of osteoarthritis does not seem to become apparent within the observation period, nonparallel aligned configuration predisposes to inferior results.

Multiple-level Replantation in Elderly Patients: Risk Versus Benefit.

Multiple-level amputations of the upper extremity represent a surgical challenge generally only attempted in young patients. This case demonstrates a successful replantation in an elderly woman. The postoperative course was complicated by disseminated intravascular coagulopathy most likely due to inadequate resuscitation. Hand trauma is often underestimated in its general severity. Upper extremity amputations need to be handled similar to polytraumatized patients.