Moist Exposed Burn Ointment (MEBO) in partial thickness burns - a randomized, comparative open mono-center study on the efficacy of dermaheal (MEBO) ointment on thermal 2nd degree burns compared to conventional therapy.

OBJECTIVE: Wound healing in burn wounds presents a challenge in healthcare, and there is still a lack of alternatives in topical burn wound treatments. - The purpose of this study was to evaluate the efficacy of a new therapeutic ointment (MEBO) in the treatment of partial thickness burns. METHODS: 40 patients received either topical treatment with Moist Exposed Burn Ointment (MEBO) or standard Flammazine treatment. All patients suffered from partial-thickness burn injuries (< 20% TBSA). Wounds were evaluated for 60 up to days regarding wound healing, water loss, inflammation, and pain alleviation. RESULTS: For transepidermal water loss, there was a difference of 2.3 gr/m2/h between MEBO, and Flammazine, favoring MEBO. However, this difference was not statistically significant (p=0.78). For all secondary efficacy parameter results were similar. - CONCLUSIONS: This study showed that MEBO ointment for topical treatment of burn injuries presents an attractive alternative for the topical treatment of limited partial thickness thermal burns.

[Severe course of a rare non-tuberculous Mycobacteriosis (M. haemophilum) of the hand - case report and strategic comments]. / Schwerer Verlauf einer seltenen atypischen Mykobakteriose (M. haemophilum) an der Hand - Fallbericht und strategische Anmerkungen.

INTRODUCTION: Mycobacterium haemophilum belongs to the group of atypical mycobacteria and is rarely reported as a cause of upper extremity and hand infections. It is of low virulence. The bacterium seems to be ubiquitous. Sources and mechanism of infection are poorly defined. CASE REPORT: A 48-year-old female patient was admitted with chronic flexor tendon synovitis of the left palm and distal forearm site. Three debridements were carried out and wound swabs were taken. No proof of bacterial colonisation was found. Histologically a granulomatous infection with Langerhans cells was revealed. Effectively calculated monotherapy with ciprofloxacin was begun. Six weeks postoperatively Mycobacterium haemophilum was cultivated in a colaboration with the National Reference Centre for Mycobacteria in Borstel. Medication was changed to triple therapy with clarithromycin, ethambutol and rifabutin. The patient could carry out her daytime job three months postoperatively. One year after first admission functional impairment needed to be treated by scar excision and radical flexor tendon tendolysis. The palmar defect was resurfaced by using a transmetacarpal DMCA 2 flap at the same time. An almost full range of motion was achieved with intensive hand and physiotherapy after a total treatment period of 15 months. DISCUSSION: Patients with upper extremity infections caused by atypical Mycobacteria need qualified hand-surgical care. The decision about need and kind of medicamentous treatment is based on germ differentiation and should be made in cooperation with the National Reference Centre for Mycobacteria in Borstel. To shorten the diagnostic gap between first admission and detection of Mycobacteria in hand infections with a non-typical course of disease we suggest a standardised approach.

Influence of human fibroblasts on development and quality of multilayered composite grafts in athymic nude mice.

In patients after extensive burn injury the lack of split thickness skin graft donor sites, and consecutive delay in wound closure are critical factors of morbidity and mortality. In addition limited functional and aesthetic results after transplantation of split thickness skin grafts present a socioeconomic problem. For improved wound closure the aim of this study was the development of a one stage technique for the establishment of a multi layer composite graft, existing of a collagen-GAG-matrix with silicon layer of a two layer synthetic dermal equivalent (DE) with integrated fibroblasts, and ceratinocytes. - In 64 athymic nude mice the evaluation of the multi layer skin grafts potential to re-establish a human epidermis, and high quality dermal structure was performed. In addition to clinical investigations we measured wound contraction, and analyzed histomorphologic, immunohistologic, "in situ hybridisation", and electro microscopic data. - Our results show, that the seeding of DE with human fibroblasts and ceratinocytes as a composite skin graft reproducible enabled a wound healing with an organised human dermis and epidermis within 10 - 15 days. The histological studies of the grafted composite skin grafts in this model showed morphologically a characteristic dermal-epidermal skin structure with a cornifying epithelium, being of human origin ("in situ hybridisation"). Through the co-cultivation of fibroblasts and ceratinocytes in the DE the generation and structural morphology of collagen fibres, and inflammatory reaction in the neodermis is positively influenced, and as a consequence wound contraction significantly reduced. In regard to the early preparation of composite grafts, and the minimal requirements for donor sites - with dependable stable reconstruction of the integument - this technique may present a step forward in the treatment of patients with extensive burns.

Compression therapy after complex soft tissue trauma, and flap coverage: optimization of scar development, swelling, function, and aesthetic result.

Problems after severe soft tissue injuries, skin grafting, and flap procedures are uncontrolled hypertrophic scarring, unstable scars, functional deficits, and aesthetic disfigurements. Ongoing swelling and lymphatic stasis are also a common problem, and do contribute to functional problems. After deep skin / soft tissue injuries, an unstructured replacement tissue is formed (scar), and does not have all functions of healthy skin. After an initial increase of vascularisation in the scar region, the formation of unstructured collagen fibers takes place, spontaneously subsiding later with a shrinkage of the tissue. Compression therapy in these patients strongly enhances the reconstitution of form, and function. The consequence is a significant step forward in the rehabilitation of these patients, and earlier social as well as professional reintegration.

[Computer tomographic appearances of intra-abdominal abscesses (author's transl)]. / Röntgensymptomatik intraabdomineller Abszesse im Computertomogramm.

CT diagnosis of intraabdominal abscess was confirmed in 18 patients by laparatomy and in two by autopsy. In CT abscess is characterized by an expansive soft-tissue lesion with different density values, mostly with a central fluid collection and a thickened wall. The peripheral inflammatory reaction leads to obliteration of fat planes surrounding the adjacent organs. Further symptoms are contrast enhancement of the wall and extraluminal gas collection. The combination of all these signs together with a suitable history and clinical findings allow a reliable diagnosis of abscess formation. When only isolated signs are found, differentiation from tumor, pseudocyst or hematoma may be difficult.

[Computer tomographic findings in pelvic and abdominal trauma (author's transl)]. / Computertomographische Symptomatologie des Becken- und Bauchtraumas.

Twenty-two patients with trauma to the pelvis and abdomen were examined by computer tomography. Subcapsular haematomas, haematomas and rupture of organs, intra- and retroperitoneal haematomas and pelvic fractures could be reliably diagnosed in this way. Serial observations on the tissue density of an haematoma allows one to judge its age. Lack of contrast enhancement of an haematoma makes the injection of contrast a useful test. Computer tomography has reduced the indications for angiography in blunt abdominal trauma.

The cervical rib. A predisposing factor for obstetric brachial plexus lesions.

Controversy surrounds the aetiology of obstetric brachial plexus lesions. Most authors consider that it is caused by traction or compression of the brachial plexus during delivery. Some patients, however, present without a history of major traction during delivery, and some delivered by Caesarean section also suffer the injury. In our series of 42 infants, 28 had an Erb's palsy, and the remaining 14 presented with a more extensive lesion, involving the lower roots. In five of these, a complete ossified cervical rib was found. We believe that anatomical variations, such as cervical ribs or fibrous bands, can cause narrowing of the supracostoclavicular space, and render the adjacent nerves more susceptible to external trauma.

The two-stage concept with temporary subcutaneous implantation of a vacuum sealing system: an alternative surgical approach in infected partial abdominal defects after lapratomy or abdominoplasty.

BACKGROUND: Infected abdominal defects after laparatomy or abdominoplasty may present serious complications. The management of a progressive infection in the abdominal region with partial necrosis -without peritoneal irritation - is treated variously. Multiple revisions due to re-infection or seroma are often necessary. The different surgical treatment options almost always necessitate an extended immobilisation and hospitalisation of the patient. PATIENTS AND METHODS: In five patients with infected partial abdominal defects after abdominoplasty (n = 3) or laparatomy (n = 2) successful management of infection was achieved in a two stages with temporary subcutaneous implantation of a polyurethane foam, combined with a vacuum assisted wound closure device, followed by secondary wound closure. In the first step a debridement, subcutaneous implantation of the foam, combined with intermittent subathmospheric pressure through a V.A.C. device was performed. In the second step an explantation of the foam, re-debridement and secondary wound closure was possible over 2 - 4 drains. RESULTS: In all patients - after a temporary immobilisation of 5 days, and systemic antibiotic administration - wound healing was achieved. In one diabetic patient another single revision was necessary, because of the necrosis of a distal wound edge. The mean hospitalisation after application of these procedures was 15 days (12 - 19). CONCLUSIONS: The surgical treatment of infected partial abdominal defects after laparatomy or abdominoplasty - performed in a two-stage procedure with temporary subcutaneous implantation of a V.A.C.-system, and secondary wound closure, offers a high level of safety, and presents an useful alternative tool in the difficult management of these patients.

Surgical management after doxorubicin and epirubicin extravasation.

Doxorubicin and epirubicin are strong antineoplastic agents widely used in chemotherapy. One major complication of their use is skin sloughing after subcutaneous extravasation, the degree of which is often underestimated. Both drugs have a tendency to produce liquefying necrosis in soft tissue and chronic ulcers if extravasation occurs. Three cases of extravasation, their surgical treatment and final results are presented. In cases of doxorubicin and epirubicin extravasation it is very important to perform an early extensive surgical débridement with delayed closure to avoid long hospitalization and disabling results.

[Reimplantation of peripheral parts of the extremities. 808 cases and functional results]. / Reimpianto di parti periferiche d'arto. 808 casi e risultati funzionali.

The Authors present 808 replantations by microsurgery in patients aged between 16 months and 70 years. The functional results were controlled in 369 cases after 10 to 20 months. The less satisfactory function was found in patients over 50 years and following combined injuries of the hand. The replantation of the thumb achieved the best results. The Authors point out that, despite a poor prognosis, some replantations should still be attempted because every case needs to be evaluated individually.

[Exulcerating breast cancer]. / Das exulzerierende Mammakarzinom.

24,000 women a year are submitted in the Federal Republic of Germany to surgery because of breast cancer. This disease causes about 10,000 deaths a year. Early diagnosis by preventative check-up and wide-spread awareness of the disease in the population gives the best chance for reducing mortality. However, in our study we found that only 38% of the patients were presented at a favourable stage. Every tenth patient already had involvement of the thoracic wall or of the skin. Every sixteenth patient had an ulcerated carcinoma of the breast.

[Microsurgical lympho-venous anastomosis in the treatment of secondary lymphoedema of the upper extremity]. / Mikrochirurgische lympho-venöse Anastomose beim sekundären Lymphödem der oberen Extremität.

At the end of the 1960's, lymphonodo-venous anastomosis has been performed by Olszewski and Nielubowicz experimentally as well as in clinical cases. Later on, various authors performed in clinical cases microsurgical anastomoses between lymphcollectors and veins. The rationality of this procedure is based on the knowledge that lymph always find the way back to the venous system, that the pressure of the lymph vessels is higher than in venous system of the extremities and that competent valves guarantee a centripetal flow. Beginning in the middle of the 1980's, we performed microsurgical end-to-end lympho-venous anastomoses in invagination technique for the treatment of secondary arm lymphoedema. The operation can be performed in local anesthesia, the anastomoses are performed on the proximal lower arm and on the medial portion of the upper arm. In each localisation three to four lympho-venous anastomoses are performed. Not only subjectively there is a decrease of the complaints but also variable reduction of the volume of the edematous arms can be achieved. In average the volume-reduction reaches 30 %. Data of a follow-up of 53 patients up to ten years show stable results. This is a long-standing benefit and supports further conservative therapy as manual lymphdrainage. Nevertheless lymphoedema is a chronical and irreversible disease which cannot be definitively cured with operative or with conservative procedures.

[Clinical experiences in the use of lymphovenous anastomoses in secondary lymphedema]. / Klinische Erfahrungen in der Anwendung von lympho-venösen Anastomosen beim sekundären Lymphödem.

Secondary lymphedema of the arm after therapy for breast cancer has a frequency of about 30% in the Federal Republic of Germany. Many authors have performed lympho-venous anastomoses to release lymphostatic edema, most using microsurgical technique. In this paper the authors present microlympho-venous anastomoses done in a telescope-like manner and using fibrin glue. First this technique was applied to dogs, later to patients. Measurement of the limb and of the limb volume at different levels were done pre- and postoperatively. Investigations with radionucleides were undertaken in some cases to measure lymphatic clearance. The operations were performed under local anaesthesia with perioperative antibiotic prophylaxis. The procedure was well tolerated by the patients, achieving a reduction of the swelling of about 30%. Despite the short follow-up of only six months and the limited number of cases we feel that this type of therapy should be offered to patients with secondary lymphedema.

[A rare insertion variant of the extensor pollicis brevis tendon. A case report]. / Eine seltene Insertionsvariante der Extensor pollicis brevis-Sehne. Ein Fallbericht.

Two brothers are presented with uni- and bilateral congenital palmar subluxation of the metacarpophalangeal joints of the thumbs as well as extensor lag. A hypoplastic extensor pollicis brevis tendon inserting atypically to the tendon of the extensor pollicis longus at the metacarpophalangeal joint level was found. In each case, arthrodesis of the metacarpophalangeal joint of the thumb was performed. This very rare variation of the insertion of the extensor pollicis brevis tendon is presented, surgical therapy and the pertinent literature reviewed.

[Intraoperative histological sections in obstetric brachial plexus lesions--comparison of macroscopic appearance, HE staining and toluidine blue staining]. / Intraoperative Schnellschnittdiagnostik bei der geburtstraumatischen Plexusläsion - Gegenüberstellung von Makroskopie, HE-Schnellschnitten und Semidünnschnitten mit Toluidinblau-Färbung.

In brachial plexus lesions and their revision, evaluation of nerve stumps is very important for the reconstructive strategy. We intraoperatively perform cryostat sections, Haematoxilin-Eosin (HE) stained, and compare the clinical appearance of the nerves to the microscopic results. Toluidine blue staining is later used to validate the structural details. Intraneural fibrosis can be traced safely with both staining methods, in root avulsions a histology is helpful, too. For more proximal, intraforaminal lesions semithin section stained with toluidine-blue are less informative than are HE-stained cryostat sections. In these lesions the clinical control by electrical stimulation and evoked potentials is superior.

Bilateral obstetric brachial plexus paralysis: a case report.

BACKGROUND: Whereas cases of unilateral obstetric brachial plexus paralysis have been sufficiently described and discussed in the literature cases of bilateral obstetric brachial plexus paralysis are extremely rare and so far have not been mentioned and discussed satisfactorily. PATIENTS: We present a case of bilateral obstetric brachial plexus paralysis in an 8-months-old white boy. We performed a neurotisation of the Nervus suprascapularis with the Nervus accessorius and an Oberlin procedure on both sides in two operative steps. RESULTS: In an early follow-up 6 months after the second operation and intensive physiotherapy the little patient was able to crawl with the active help of both arms. CONCLUSIONS: Bilateral obstetric brachial plexus paralysis is a very rare incidence in infants. An interdisciplinary approach including paediatrics, plastic surgeons, neurosurgeons, neurologists, radiologists and physiotherapists is essential for the success of treatment strategies in such cases.

[Neurography: experimental positive visualization of peripheral nerves by x-rays (author's transl)]. / Neurographie: Experimentelle Studie über die Röntgenkontrastmitteldarstellung von peripheren Nerven.

Blunt injuries of peripheral nerves as well as neural lesions following operations could be early differentiated by X-ray visualisation of nerve trunks. Water soluble and oily contrast mediums were injected into the epineural space of the sciatic nerve of rats and rabbits. A good opacification of the whole nerve up to the epidural space of the spinal cord was obtained. Similar results have been achieved by other authors. However, at present there is no standard method for neurography.

[Myocutaneous flaps for reconstruction of large tissue defects of the trunk]. / Myocutane Lappen für Rekonstruktionen von grossen Gewebsdefekten am Rumpf.

Large defects in the thorax and abdominal wall require a stable reconstruction. The use of muscle flaps offers many advantages: 1. Anatomically constant vascular patterns with a good blood circulation of the overlying fascia and skin. 2. Stable reconstruction of the whole wall as well as effective substitution of infected or irradiated tissue. Clinical cases and technical details are presented.

[Birth-related brachial plexus paralysis]. / Geburtsbedingte Plexus brachialis Lähmungen.

According to the literature, in Europe 0.4-1.2 cases of obstetrical plexus brachial paresis occur per 1000 births. A 4-6 times higher energy in axial delivery of the newborn leads to a neurotmesis of the plexus. If the energy used is more than 10 times higher, root avulsion occur. Early operative therapy for obstetrical plexus paresis is mandatory. The best period for an operation is between the 3rd and 6th months of age. CT and MRI imaging as well as electrophysiological investigations are of the utmost importance. Birch, Gilbert and Gu think there is an indication for operation if no active elbow flexion can be performed at the age of 6 months. Primary coaptation is easier in babies than in adults. However, large defects have to be a bridged by autologous nerve grafts. For root avulsions, neurotization with the accessory and phrenic nerves (Gu) is being used more and more. In 362 children with 52 operated cases, after a follow-up from 2 to 10 years, we found 37 functional, useful recoveries. Nine operations were unsatisfactory and two had poor results. In four cases the operation was unnecessary.