[Prosthetic reconstruction of the upper extremity]. / Prothetische Rekonstruktion der oberen Extremität.

BACKGROUND: Prosthetic replacement after amputation or loss of function of the upper extremity has gained therapeutic value over the last years. The control of upper arm prostheses has been refined by the use of selective nerve transfers, and the indication for prosthetic replacement has been expanded. OBJECTIVES: Overview regarding surgical, therapeutic and prosthetic options in upper extremity amputations or their loss of function. METHODS: Selective literature research including the authors' own experience in everyday clinical practice, as well as a review of medical records. RESULTS: Selective nerve transfers of the amputated nerves of the brachial plexus to the remaining stump muscles can create up to six myosignals for intuitive and simultaneous control of the different prosthetic joints. This way, an efficient and harmonious control of the prosthetic device is possible without the need to change between the different control levels. The prosthetic replacement, with consequent elective amputation, represents a new approach in the functional reconstruction of the upper extremity, especially in patients with a functionless hand after massive soft tissue or nerve damage.

[Prosthetic reconstruction in high amputations of the upper extremity]. / Prothetische Rekonstruktion hoher Amputationen der oberen Extremität.

BACKGROUND: Conventional upper arm prostheses are controlled via two surface electrodes that measure motor activity of two separately innervated muscle groups. The various prosthetic joints are chosen by co-contractions and controlled linearly by these two muscles. A harmonious and natural course of movements is not possible in this way. OBJECTIVES: Overview regarding surgical, therapeutical and prosthetic options in high amputations of the upper extremity. METHODS: Selective literature research including the authors' own experience in everyday clinical practice as well as a review of medical records. RESULTS: Selective nerve transfers of the amputated nerves of the brachial plexus to the remaining stump muscles can create up to six myosignals for intuitive and simultaneous control of the different prosthetic joints. In this way, an efficient and harmonious control of the prosthetic device is possible without the need to change between the different control levels. At the same time, possible neuromas are treated and painless wear of the prosthesis is achieved. Due to the resulting extended use of the prosthetic device, the demands regarding stump quality are increased. Thus, both surgically and by the means of the orthopedic technician a stable stump-socket connection should be achieved to enable optimal prosthetic function.

Oncologic safety of breast conserving surgery after tumour downsizing by neoadjuvant therapy: a retrospective single centre cohort study.

The objective of this study is to analyse local recurrence rates in patients receiving neoadjuvant chemotherapy (nCT) comparing mastecomized (MX) patients with those undergoing breast conserving therapy (BCT). Patients undergoing breast cancer surgery after nCT (3xCMF or 3-6xED) between 1995 and 2007 at our department were retrospectively analysed. The median follow up was 60 months for 308 patients. Patients who were downsized from MX to BCT with partial or complete response (n = 104) had a similar local recurrence free survival (LRFS) compared to patients who did not experience successful downsizing (n = 67) and finally undergoing MX (LRFS MX-BCT 81% vs. MX-MX 91%; P = 0.79). Uni- and multivariate analyses demonstrated that BCT itself was not an independent prognostic factor for a worse LRFS (P = 0.07 and 0.14). After no pathologic change or progressive disease the risk of local recurrence was increased in patients undergoing BCT (MX-BCT; n = 6 LRFS 66%) compared with MX (n = 44; LRFS 90%; P = 0.04). Overall survival in general was better for the BCT group (n = 197) compared with MX group (n = 111) regardless of clinical response (92% vs. 72%; P < 0.0001). Breast conservation, nodal negativity and low or medium grade histology were prognostic factors for an improved OS (P = 0.02, 0.01, 0.004). In conclusion, our study suggests that BCT is oncologically safe after tumour downsizing by nCT in patients primarily scheduled for mastectomy. These patients, however, should not be treated with breast conservation in the absence of any proven response after nCT.

Recent developments in breast-conserving surgery for breast cancer patients.

This invited review deals with the latest knowledge regarding breast conserving therapy in breast conserving patients.

The use of a breast symmetry index for objective evaluation of breast cosmesis.

The cosmetic result after breast surgery is an important marker in clinical studies. Most authors used subjective scales to judge breast cosmesis. However, inter-observer discrepancies are very high and the use of such subjective scales for prospective trials is highly disputed. In this study we present for the first time a new invented breast symmetry index (BSI). This BSI is calculated by subtracting the size and the shape between both breasts (frontal view and side view). The BSI is measured with a software system called breast analysing tool (BAT) from digital photographs. The photographs of 27 patients have been analysed with this software by different physicians to evolve inter-observer reproducibility. The Harris scale for subjective cosmetic analyses has been correlated with the BSI. In our study the inter-observer reproducibility was excellent (Pearson correlation r=0.9; p<0.05) and the BSI was able to significantly differentiate between good and bad cosmesis (BSI values from 0%d to 30%d is good, BSI>30%d is bad cosmesis). Thus the BSI may be used for clinical studies.

[Exoprosthetic Replacement of the Upper Extremity]. / Exoprothetischer Ersatz bei Amputationen der oberen Extremität.

During the last years, the prosthetic replacement in upper limb amputees has undergone different developments. The use of new nerve surgical concepts improved the control strategies tremendously, especially for high-level amputees. Technological innovation in the field of pattern recognition enables the control of multifunctional myoelectric hand prostheses in a natural and intuitive manner. However, the different levels of amputation pose different challenges for the therapeutic team which concern not only the prosthetic attachment; also the expected functional outcome of prosthetic limb replacement differs greatly between the individual levels of amputation. Therefore, especially in partial hand amputations the indication for prosthetic fitting has to be evaluated critically, as these patients may benefit more from biologic reconstructive concepts. The value of the upper extremity, in particular of the hand, is undisputable and, as such represents the driving force for the technological and surgical developments within the exoprosthetic replacement. This article discusses the possibilities and limitations of exoprosthetic limb replacement on the different amputation levels and explores new developments.

Experimental nerve transfer model in the rat forelimb.

BACKGROUND: Nerve transfers are a powerful tool in extremity reconstruction, but the neurophysiological effects have not been adequately investigated. As 81 % of nerve injuries and most nerve transfers occur in the upper extremity with its own neurophysiological properties, the standard rat hindlimb model may not be optimal in this paradigm. Here we present an experimental rat forelimb model to investigate nerve transfers. METHODS: In ten male Sprague-Dawley rats, the ulnar nerve was transferred to the motor branch of long head of the biceps. Sham surgery was performed in five animals (exposure/closure). After 12 weeks of regeneration, muscle force and Bertelli test were performed and evaluated. RESULTS: The nerve transfer successfully reinnervated the long head of the biceps in all animals, as indicated by muscle force and behavioral outcome. No aberrant reinnervation occurred from the original motor source. Muscle force was 2,68 N ± 0.35 for the nerve transfer group and 2,85 N ± 0.39 for the sham group, which was not statically different (p = 0.436). The procedure led to minor functional deficits due to the loss of ulnar nerve function; this, however, could not be quantified with any of the presented measures. CONCLUSION: The above-described rat model demonstrated a constant anatomy, suitable for nerve transfers that are accessible to standard neuromuscular analyses and behavioral testing. This model allows the study of both neurophysiologic properties and cognitive motor function after nerve transfers in the upper extremity.

Prosthetic reconstruction to restore function in transcarpal amputees.

Mutilated hands at the distal level may pose a challenge for reconstruction. Biological treatment options may require multiple surgical interventions and a long rehabilitation course with little hope of good functional outcome. Standard hand prostheses are also not an ideal solution, as they are too long and cumbersome for partial hand injuries. This paper outlines the functional outcomes of prosthetic reconstruction with devices customized for the transcarpal amputation levels. The functional outcome was evaluated with the Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Functional evaluation was performed at least 12 months after final fitting. Psychological assessment was performed with the Short Form-36. The three patients achieved a mean ARAT score of 35.67 ± 0.58. The average SHAP score was 74 ± 7.81. The average DASH score was found to be 16.11 ± 12.03. The reconstructed hand achieved a score of 75.27 ± 8.16% in SHAP and 62.57 ± 1.02% in ARAT in relation to the healthy hand. All patients exhibited average physical and mental component summary scales in the Short Form-36. The majority of transcarpal amputations are seen in manual laborers due to work-related trauma. Returning to work is the main goal in such young and otherwise-healthy patients. As shown with this study, prosthetic fitting results in quick and reliable functional reconstruction. Therefore, this treatment should be considered as an option during the initial decision-making process of reconstructing difficult traumatic injuries of the hand.