Bacterial bioburden of wounds: influence of debridement and negative-pressure wound therapy (NPWT).

OBJECTIVE: To clarify the role of microbiological swabs in surgical decision-making, we investigated the effect of negative-pressure wound therapy (NPWT) and serial surgical debridement on bacterial bioburden in hard-to-heal wounds and ultimately correlated them with the success of surgical closure. METHOD: All patients were treated with surgical debridement, jet lavage and NPWT before their wounds were finally closed. The treatment effect was assessed by correlating microbiological swabs obtained immediately after intervention with those obtained after removal of the dressings during the following surgical procedures. The result of the last microbiological swab taken before definitive surgical closure was correlated with the requirement for revision surgery. RESULTS: We included the results of 704 microbiological swabs from 97 patients in 110 wound localisations in this monocentric, retrospective study. NPWT did not improve bacterial bioburden in 77% of cases and the duration of NPWT did not affect the result. Furthermore, no significant effect of NPWT could be found for either anaerobic (p=0.96) or aerobic bacteria (p=0.43). In contrast, surgical debridement decreased bacterial load in approximately 60% of cases. If sterile wound swabs could be obtained at all, it was during the first four surgical debridements in 60% of patients; after that only 10% became sterile. CONCLUSIONS: Sterile microbiological wound swabs before surgical closure were associated with lower rates of revision surgery, while low or medium bacterial loads did not increase revision rates.

Wound fluid under occlusive dressings from diabetic patients show an increased angiogenic response and fibroblast migration.

INTRODUCTION: Metabolic diseases like diabetes mellitus often show prolonged healing and chronic wounds. Occlusive wound dressings are known to support wound closure by creating a moist environment which supports collagen synthesis, epithelialization and angiogenesis. We aimed to assess the effect of occlusion on diabetic wound fluid on the cellular level regarding fibroblast activity and angiogenetic response. MATERIAL AND METHODS: 22 split skin donor sites from 22 patients (11 patients with diabetes mellitus) were treated with occlusive dressings intraoperatively. On day 3, fluid and blood serum samples were harvested while changing the dressings. The influence of wound fluid on fibroblasts was assessed by measuring metabolic activity (Alamar Blue assay, Casey Counter), cell stress/death (LDH assay) and migration (in vitro wound healing assay) of fibroblasts. Angiogenesis of endothelial cells (HUVEC) was analyzed with the tube formation assay. Furthermore, a Magnetic Luminex Assay for multi-cytokines detection was performed focusing on inflammatory and pro-angiogenetic cytokines. RESULTS: The influence of wound fluid under occlusive dressings from diabetic patients showed a significantly increased angiogenic response and fibroblast migration compared to the non-diabetic patient group. Additionally, cell stress was increased in the diabetic group. Cytokine analysis showed an increase in VEGF-A in the diabetic group. CONCLUSION: Occlusive dressings may stimulate regenerative effects in diabetic wounds. Our in-vitro study shows the influence of wound fluid under occlusive dressings from diabetic patients on angiogenesis, migration and proliferation of fibroblasts, which are essential modulators of wound healing and scar modulation.

Lipofilling of Fingertips for Volume Defects after Fingertip Injuries.

INTRODUCTION: Regardless of the good outcomes of conservatively treated fingertip injuries, many patients complain about volume defects and hypoesthesia. Injection of autologous fat into the defect zone may resolve the volume problem and stimulate digital nerve regeneration by adipose derived stem cell transplantation. METHODS: We analyzed 5 volume defects resulting from conservatively treated fingertip injuries in 4 patients (male to female ratio, 2:2), 6 months after the injection of autologous abdominal fat into the defect zone retrospectively. The fat transplantation was performed after complete wound healing was achieved (2.5-13.5 months; mean, 6.5 months). Assessment of 2-point discrimination; finger pulp circumference; the Disability of the Arm, Shoulder, and Hand score; visual analog scale score; and a questionnaire regarding the treatment satisfaction were carried out both preoperatively and at a 6 month follow-up according to the standard of our clinic. RESULTS: In 3 patients, one session of lipofilling was sufficient to correct the contour, whereas 1 patient with 2 fingertip injuries was treated a second time. There was no significant change in finger pulp circumference, in the 2-point discrimination values and the Disability of the Arm, Shoulder, and Hand score results. There was a significant improvement in the visual analog scale scores in 4 of 5 cases, and all patients were very satisfied with the results of the procedure regarding the improvement in hand function in sports, at work and their daily routine. CONCLUSIONS: Lipofilling can be performed with little operative risks, might alleviate the patient's symptoms and reduce pain after conservative treatment of fingertip injuries.

Geographical differences in carpometacarpal joint osteoarthritis treatment of the thumb: A survey of 1138 hand surgeons from the USA and Europe.

BACKGROUND: Carpometacarpal osteoarthritis of the thumb (CMC OA) is treated with various therapeutic approaches. However, the literature remains inconclusive regarding the ideal procedure for each disease stage. In this study, we assessed the international application of surgical treatment options including CMC I implants and non-surgical treatment options for CMC OA depending on the disease stage, with a strong focus on the detection of geographical disparities. METHODS: We conducted a large international online survey with members of hand surgical societies of the International Federation of Societies for Surgery of the Hand (IFSSH). The first part of the survey asked about general therapy options of CMC OA depending on the severity of the disease, whereas the second part specifically dealt with the use of prostheses. RESULTS: We could include 10 of 56 IFSSH member societies (6807 surgeons) and received answers from 1138 members (16.7%). Significant differences were detected in an increased use of corticosteroid injections in the USA, and a growing frequency of fat injections in Europe. Regarding use and frequency of the resection arthroplasty, we found similar results in all participating countries. Prosthetic implantation showed a significant difference between the USA and Europe, with far larger numbers stated by European hand surgeons. CONCLUSION: CMC OA is treated differently in the participating countries depending on the stage of the disease. We give an insight into geographical differences in treatment paradigms, with corticosteroid injections being more prevalent in the USA, and prosthesis implantation being more frequently chosen in the selected European countries.

[Economic factors in microsurgery - Report of the consensus workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels - (DAM)]. / Wirtschaftliche Aspekte in der Mikrochirurgie: Bericht zum Konsensus-Workshop der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße ­ (DAM).

In addition to outcome assessments, cost effectiveness of surgical treatments becomes increasingly important. Both, insurance companies and hospital administrations aim for short and efficient procedures to reduce costs.Microsurgical procedures are often surpassing traditional treatment options in terms of function and aesthetics. However, they are more expensive as they require a high level of surgical expertise, more theatre capacity and longer inpatient treatment. Adequate reimbursement is mandatory, if we want to continuously perform these procedures with the best possible quality and outcome. To cover the case-related expenses of each specialty, multidisciplinary procedures require appropriate distribution of reimbursements to each department.The main diagnosis as well as all complications and relevant comorbidities should be documented to obtain the correct DRG. The additional financial benefit of a microsurgical procedure in a multidisciplinary case can be calculated by specifying the procedural increment in pay. Therefore, a fair distribution of revenues to each participating department should be performed. Different models exist, which lead to a benefit in compensation for all departments. Unfortunately, distribution of resources is still insufficiently managed in many hospitals, which hampers high quality multidisciplinary microsurgical procedures. Still, picking the best possible procedure for our patients, independently of financial incentives, is of utmost importance.

Four-corner fusion: Comparing outcomes of conventional K-wire-, locking plate-, and retrograde headless compression screw fixations.

PURPOSE: Several operative approaches and various implants for osseous fixation have been described to achieve four-corner fusion of the wrist. Given the discordance and to aid in further standardizing the technique, this study directly compares the outcomes of K-wire, fusion plate, and headless retrograde compressive screw fixations to achieve four-corner arthrodesis. METHODS: Sixty-four patients underwent four-corner fusion over a period of 5 years and were reviewed retrospectively. Twenty-one patients underwent bone fixation with conventional K-wires, 26 with locking plates, and 17 patients were treated by headless retrograde compressive screw fixations. Patients of the different groups were comparable regarding age, sex, hand dominance, and stage of disease. RESULTS: All study groups showed significant improvements in grip strength, decrease in pain (NRS) at rest and with activity, range-of-motion of the wrist, and wrist function (measured by the DASH-score). When evaluating the three groups amongst each other, overall complication and nonunion rates were low and revealed no significant differences between the groups of patients. However, regarding postoperative NRS at activity, dorsal flexion, and DASH-scores, the "screw" group showed significantly better results than the "wire" group. CONCLUSION: The results show that all examined techniques of four-corner fusion can improve wrist function when compared to preoperative baseline (NRS at rest and activity, postoperative DASH-scores). However, headless retrograde compressive screw fixation had significant better results regarding pain relief (NRS) at activity and postoperative DASH-scores.

Occlusive dressing-induced secretomes influence the migration and proliferation of mesenchymal stem cells and fibroblasts differently.

BACKGROUND: Fingertip injuries treated with occlusive dressings (ODs) lead to nearly scar-free, functionally, and aesthetically pleasing results. We hypothesized that paracrine factors in the wound fluid (secretome) may influence migration and proliferation of mesenchymal stem cells (MSCs) and fibroblasts and modulate the wound-healing process. METHODS: We could collect wound fluid samples from 4 fingertip injuries and 7 split skin donor sites at the 5th day during dressing change. Blood serum samples served as controls. The proliferation rate of MSCs and fibroblasts (HS27) was continuously measured through impedance analysis for 60 h and by Alamarblue analysis after 72 h. Cell migration was evaluated continuously for 15 h and confirmed by the in vitro wound-healing assay. RESULTS: Migration of MSCs under the influence of both wound fluids was significantly faster than controls from 4 to 6 h after incubation and reversed after 9 h. MSC proliferation in wound fluid groups showed a significant increase at 5 and 10 h and was significantly decreased after 45 h. Fibroblasts in wound fluid groups showed overall a significant increase in migration and a significant decrease in proliferation compared to controls. CONCLUSION: OD-induced secretomes influence MSCs and fibroblasts and thereby possibly modulate wound healing and scar tissue formation.

Autologous Fat Injection versus Lundborg Resection Arthroplasty for the Treatment of Trapeziometacarpal Joint Osteoarthritis.

BACKGROUND: Various operative approaches exist for treatment of trapeziometacarpal joint osteoarthritis. The aim of this study was to compare the results of Lundborg resection arthroplasty with solely autologous fat injection. METHODS: Twenty-one patients with symptomatic osteoarthritis of the trapeziometacarpal joint (Eaton-Littler classification stages III/IV) underwent either a Lundborg resection arthroplasty (n = 12) or autologous fat injection into the trapeziometacarpal joint (n = 9). Both groups were comparable regarding demographic and clinical data. Patient records were evaluated retrospectively regarding operative time; Disabilities of the Arm, Shoulder, and Hand questionnaire score; postoperative time until resolution of symptoms; pain level; grip and pinch force; and satisfaction with the treatment. RESULTS: Both groups had similar length of follow-up of at least 12 months. The duration of the operation was significantly shorter in the fat group (13 ± 5 minutes) compared with the resection group (31 ± 5 minutes) (p < 0.05). The Disabilities of the Arm, Shoulder, and Hand questionnaire score (resection group, 21.9 ± 6.2; fat group, 24.0 ± 5.0) and the pain level at follow-up (resection group, 1.0 ± 0.7; fat group, 2.9 ± 0.8) were comparable (p > 0.05). The time until complete resolution of symptoms was significantly shorter in the fat group (1.7 ± 2.1 months) compared with the resection group (5.7 ± 3.1 months) (p < 0.05). Grip and pinch strength and overall satisfaction with the treatment were comparable (p > 0.05). CONCLUSION: Both autologous fat grafting and Lundborg resection arthroplasty resulted in improved function of the operative hand and a clear reduction of symptoms, whereas autologous fat injection seems to have advantages attributable to a shorter time until resolution of symptoms and shorter operative times. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.