Andreas Gohritz

Changes in bacterial isolates from burn wounds and their antibiograms: a 20-year study (1986-2005).

BACKGROUND Our aim is to elucidate shifts in the bacterial spectrum colonising burn wounds and corresponding antibiotic susceptibilities during a 20-year study period. METHODS Microbiological results from burn patients collected between 1986 and 2005 were analysed retrospectively. RESULTS Staphylococcus aureus was isolated most frequently (20.8%), followed by Escherichia coli (13.9%), Pseudomonas aeruginosa (11.8%), coagulase-negative staphylococci (CNS) (10.9%), Enterococcus sp. (9.7%), Enterobacter cloacae (5.6%), Klebsiella pneumoniae (5%), Acinetobacter sp. (3.2%), Proteus mirabilis (2%) and Stenotrophomonas maltophilia (1.4%). Susceptibility of S. aureus to broad-spectrum substances such as ciprofloxacin or penicillinase-stable penicillins has waned, others such as cotrimoxazole or netilmicin remained effective. Not a single resistance against vancomycin was recorded. Increases in methicillin-resistant S. aureus (MRSA) were pronounced (3% in 1986-1997 (the first of the three study periods) to 16% in 1998-2001 and 13% in 2002-2005). Results for methicillin-resistant CNS (MRCNS) show an even greater increase. P. aeruginosa has shown increasing susceptibility against netilmicin (1986-1989: 84%, 2002-2005: 95%). Susceptibility of P. aeruginosa to ceftazidime has decreased markedly. S. maltophilia has shown clinically relevant susceptibility mainly against ciprofloxacin. Acinetobacter sp. have shown little susceptibility to most antibiotics. Imipenem or meropenem have been very reliable reserve antibiotics throughout the study period for the fermenting Enterobacteriaceae (E. coli, K. pneumoniae, E. cloacae and P. mirabilis), with susceptibilities of or near 100%. CONCLUSION In-depth knowledge of the bacteria causing infectious complications and of their antibiotic susceptibilities is a prerequisite for treating burn patients. Our study shows shifts in the microbial spectrum and their antibiogram, which mandate frequent reassessments.

Lipomas after blunt soft tissue trauma: are they real? Analysis of 31 cases

Background  Soft tissue trauma and lipomas are common occurrences in surgical practice. Lipomas are defined as benign tumours of adipose tissue with so far unexplained pathogenesis and aetiology. A link between preceding blunt soft tissue trauma at the site of the tumour and the formation of lipomas has been described earlier. These soft tissue tumours have been named ‘post‐traumatic lipomas’.

Percutaneous collagen induction therapy: an alternative treatment for burn scars

OBJECTIVE This study aims to evaluate percutaneous collagen induction (PCI) in post-burn scarring. BACKGROUND Patients with scarring after burn frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. Their scars are generally treated by tissue transfer, W- and Z-plasties, flaps, cortisone injections or ablative procedures that injure or destroy the epidermis and its basement membrane and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis. PATIENTS A total of 16 consecutive patients (average age: 37+/-15.5 years, average body mass index (BMI): 25.7) in Germany with post-burn scarring. INTERVENTION PCI using the Medical Roll-CIT (Vivida, Cape Town, South Africa). This device was designed to multiply-puncture the skin to the level of the dermal scar to institute remodelling. Patients were prepared with topical vitamin A and C cosmetic creams for a minimum of 4 weeks preoperatively to maximise collagen stimulation. OUTCOME MEASURES The outcome was measured rating (visual analogue scale (VAS) and Vancouver Scar Scale (VSS)), histological specimen 12 months after intervention. RESULTS On average, patients rated their improvement as a mean of 80% better (+/-15.5) than before treatment. Histologic examination revealed considerable increase in collagen and elastin deposition 12 months postoperatively. The epidermis demonstrated 45% thickening of stratum spinosum and normal rete ridges as well as the normalisation of the collagen/elastin matrix in the reticular dermis at 1 year postoperatively. CONCLUSIONS This pilot study shows that PCI appears to be a safe method for treating post-burn scarring without destroying the epidermis. The procedure can be repeated safely and is also applicable in regions where laser treatments and deep peels are of limited use. However, it is necessary to initiate an efficacy trial to prove the data of this pilot study.

Lower limb revascularisation preceding surgical wound coverage – An interdisciplinary algorithm for chronic wound closure

BACKGROUND Chronic wounds may occur or persist due to arterial insufficiency. Despite the high prevalence of arterial occlusive disease, a search of the literature has yielded a paucity of data on the benefit of interventions to recanalise lower extremity arteries prior to surgical closure of chronic wounds. OBJECTIVE To investigate the correlation of simple clinical examinations and apparative diagnostics for the detection of arterial occlusive disease of the lower extremity in patients with chronic wounds, and to evaluate the benefit of vascular procedures to optimise wound perfusion before surgical closure. PATIENTS AND METHODS During a 6-year period, 150 patients with chronic lower extremity wounds (no healing for more than 30 days) were included into this prospective study. All patients underwent palpation of foot pulses, Doppler sonography and measurement of occlusive pressures. Positive clinical findings were re-evaluated by angiography. All patients with peripheral extremity vessel occlusions underwent vascular interventions (percutaneous transluminal angioplasty with stenting, open thrombectomy or vascular bypass surgery) prior to surgical wound closure. RESULTS In all 34 patients (21%) with missing foot pulses, suspicious Doppler signals or pathological occlusive pressure measurements, the clinical diagnosis of arterial occlusion was confirmed by angiography. An arterial pathology had previously been diagnosed in merely two of those patients. Nineteen patients underwent percutaneous transluminal angioplasty and 21 stents were implanted; in 10 cases, open thrombectomy or vascular bypasses were performed. In all 34 patients, sufficient peripheral recanalisation and improved wound perfusion were successfully achieved. For definitive wound closure, microsurgical tissue transplantation was performed in 15 patients. Angiography was performed prior to surgery. In 11 patients, regional or local flaps were used. Six patients received split skin grafting only; two wounds healed conservatively following vascular intervention. Vacuum-assisted closure (VAC) therapy was applied in 15 cases. Postoperatively, three cases of impaired wound healing and one infection occurred. CONCLUSIONS Arterial insufficiency can be diagnosed safely by simple clinical examination. All clinically pathological results were successfully confirmed by angiography, allowing for a targeted peripheral vessel reopening to improve wound perfusion before surgery. This straightforward algorithm helped to improve the success of surgical therapy of chronic lower extremity wounds.

Brachialis-to-Extensor Carpi Radialis Longus Selective Nerve Transfer to Restore Wrist Extension in Tetraplegia: Case Report

Active wrist extension allowing tenodesis grip is the key function in high-level tetraplegic patients. It is absent and cannot be restored by traditional tendon transfer in patients who have no transferable muscle below the elbow. We present a 36-year-old man with high-level tetraplegia treated 12 months after injury who regained active wrist extension after transfer of the brachialis muscle branch of the musculocutaneous nerve to the extensor carpi radialis longus muscle branch of the radial nerve. No functional deficit of elbow flexion occurred after reconstruction.

Percutaneous collagen induction. Scarless skin rejuvenation: fact or fiction?

Photoageing is generally treated by ablative procedures that injure the epidermis and basement membrane, and lead to fibrosis of the dermis. Percutaneous collagen induction (PCI) therapy is an alternative treatment for photoaged skin that does not result in clinical signs of dermal fibrosis. In this study, the immediate effects of PCI on the skin were assessed, including the systemic inflammatory response and the production and gene expression of transforming growth factor (TGF) isoforms β1, β2 and β3. Eighty rats were split into four groups: group 1 (n = 24; PCI plus skin care); group 2 (n = 24; skin care only); group 3 (n = 24; PCI only) and group 4 (n = 8; controls). Microarray analysis showed that TGF‐β3, an essential marker for preventing scarring, was upregulated and expressed for 2 weeks postoperatively. PCI might offer a regenerative therapy to improve skin appearance and quality and to improve or even prevent scarring.

A single-stage operation for reconstruction of hand flexion, extension, and intrinsic function in tetraplegia: the alphabet procedure.

Surgical reconstruction is an established method to restore grip and grasp function after traumatic cervical spinal cord injury and tetraplegia. It can offer the patient improved ability to perform activities of daily living. Traditionally, surgical reconstruction of hand function has required separate operations for flexors and extensors. Here, we present a combination of procedures that provides key pinch and finger flexion together with opening of hand as a 1-stage operation. This reconstruction includes 7 individual operations that are performed in the following order: (1) split flexor pollicis longus-extensor pollicis longus distal thumb tenodesis, (2) reconstruction of passive interossei, (3) thumb CMC arthrodesis (4) brachioradialis-flexor pollicis longus tendon transfer, (5) extensor carpi radialis longus-flexor digitorum profundus tendon transfer, (6) EPL tenodesis, and (7) extensor carpi ulnaris tenodesis. We have chosen to entitle this reconstruction the alphabet or ABCDEFG procedure, an abbreviation for Advanced Balanced Combined Digital Extensor Flexor Grip reconstruction. To reduce the risk of adhesions after this extensive surgery and to facilitate relearning the activation of transferred muscles with new functions, early active training is performed. It is concluded that this 1-stage combination of operations can reliably provide grip, grasp, and release function in persons with C6 tetraplegia, patient satisfaction is high, time and effort for patient and caregivers are less, and incidence of complications is comparable with other published treatment modalities.

Ersatzoperationen bei Ausfall motorischer Funktionen an der Hand

Nerve injuries in the upper extremity can result in severe disability. In the last three decades, progress in microsurgical techniques has improved the outcome for nerve injuries and if the prognosis is reasonably good, nerve repair should usually be performed prior to tendon transfer procedures. However, above all proximal lesions of peripheral nerves such as high radial nerve palsy still often yield unsatisfactory results, despite a technically well-executed nerve repair. Prognosis further depends on the time interval since the injury and also on the age of the patient, as the regenerative process is delayed in older patients. The indication for tendon transfers strongly depends on the personal and professional profiles of the individual patient. Tendon transfer procedures alleviate the suffering from functional hand impairment providing a superior alternative to permanent external splints. Tendon transfers are usually secondary procedures for replacing function after evaluation of the functional motor loss. Numerous transfer procedures have been described for every nerve trunk of the upper extremity, their prognosis depending mainly on the extent and pattern of nerve loss, local effects of the trauma (e.g. involvement of soft tissues, joints), and the physiological characteristics of the transferred muscle. Even if the results of the tendon transfers may finally be less satisfactory in cases of complex nerve damage than in isolated motor nerve lesions, they offer a valuable functional benefit, often being the only possibility to restore hand function. Although regrettably underused, tendon transfer improve upper extremity function in more than 70% of patients with cervical spinal cord injury. Reconstruction of key elements such as wrist extension, key grip between the thumb and the index finger, or digital flexion and extension leads to highly improved use of the tetraplegic hand and thus provides new mobility and independence from the help of others. This article presents an overview of the most common procedures to restore hand function in peripheral nerve injuries and tetraplegia in order to provide a systematic approach for decision making.ZusammenfassungNervenverletzungen der oberen Extremität führen oft zu schweren Funktionsbeeinträchtigungen. Ein wichtiges Kriterium für die Indikation zur Ersatzoperation ist das soziale und berufliche Profil des Patienten. Motorische Ersatzoperationen können in jeder Phase nach der Verletzung zu einer Wiederherstellung verlorener Nervenfunktionen und zur Besserung der Handfunktion führen. Sie bieten dem Patienten eine therapeutische Alternative zur dauerhaften Lähmung bzw. zur langfristigen Schienenbehandlung an und verkürzen die Rehabilitationsperiode. An der oberen Extremität sind für alle Stammnerven zahlreiche Ersatzoperationen bekannt, deren Prognose vom Lähmungsmuster, den lokalen Unfallschäden sowie den Eigenschaften des Spendermuskels abhängt. Auch bei komplexen Schädigungen mit geringerer Funktionswiederkehr als nach isolierten motorischen Ausfällen ermöglichen Ersatzoperationen einen wertvollen Funktionsgewinn. Obwohl leider viel zu selten angewandt, bieten motorische Ersatzoperationen auch bei mehr als 70% der Patienten mit Querschnittslähmung im Halsmarkbereich (Tetraplegie) die Möglichkeit zu einer gebesserten Handfunktion. Der Beitrag gibt einen Überblick über die in der Praxis bewährten Techniken der motorischen Ersatzoperationen an der Hand nach peripheren Nervenverletzungen und bei Tetraplegie und soll damit die Indikationsstellung zu diesen Operationen weiter stimulieren.AbstractNerve injuries in the upper extremity can result in severe disability. In the last three decades, progress in microsurgical techniques has improved the outcome for nerve injuries and if the prognosis is reasonably good, nerve repair should usually be performed prior to tendon transfer procedures. However, above all proximal lesions of peripheral nerves such as high radial nerve palsy still often yield unsatisfactory results, despite a technically well-executed nerve repair. Prognosis further depends on the time interval since the injury and also on the age of the patient, as the regenerative process is delayed in older patients. The indication for tendon transfers strongly depends on the personal and professional profiles of the individual patient. Tendon transfer procedures alleviate the suffering from functional hand impairment providing a superior alternative to permanent external splints. Tendon transfers are usually secondary procedures for replacing function after evaluation of the functional motor loss. Numerous transfer procedures have been described for every nerve trunk of the upper extremity, their prognosis depending mainly on the extent and pattern of nerve loss, local effects of the trauma (e.g. involvement of soft tissues, joints), and the physiological characteristics of the transferred muscle. Even if the results of the tendon transfers may finally be less satisfactory in cases of complex nerve damage than in isolated motor nerve lesions, they offer a valuable functional benefit, often being the only possibility to restore hand function. Although regrettably underused, tendon transfer improve upper extremity function in more than 70% of patients with cervical spinal cord injury. Reconstruction of key elements such as wrist extension, key grip between the thumb and the index finger, or digital flexion and extension leads to highly improved use of the tetraplegic hand and thus provides new mobility and independence from the help of others. This article presents an overview of the most common procedures to restore hand function in peripheral nerve injuries and tetraplegia in order to provide a systematic approach for decision making.

[Nicotine in plastic surgery : a review].

BACKGROUND The surgical complication rate is significantly increased in active smoking patients. However there are no evidence-based recommendations regarding smoking among patients seeking plastic surgical procedures. METHODS MEDLINE analysis was performed of all relevant clinical and experimental papers from 1965 to 2008. RESULTS In face-lift operations smokers present a 13-fold risk of skin necrosis. In mamma reduction procedures the risk among smokers is doubled for number of complications, with T-incision site necrosis (odds ratio 3.1) and infection rate (OR 3.3) significantly elevated among active smokers. Transverse rectus abdominis myocutaneous flaps for breast reconstruction are associated with significantly higher flap necrosis rates for smokers than nonsmokers (19% vs 9%, P=0.005). The smoking history can be indicative, but usually the number of cigarettes is drastically underestimated. Cotinine testing is a method of determining smoking quantitatively up to 4 days before testing. CONCLUSION Four weeks of abstinence from smoking reduces smoking-associated complications. Despite the published evidence, smoking is no longer relevant in the German 2008 Disease-Related Group for plastic surgical procedures.

Subcutaneous wash-out procedure (SWOP) for the treatment of chemotherapeutic extravasations.

INTRODUCTION Extravasations of chemotherapeutic drugs may lead to tissue necrosis and subsequent tissue defects, sometimes resulting in loss of function. In the absence of therapy, approximately one-third of vesicant extravasations will result in ulcerations, some of which necessitate plastic microsurgery to cover the soft tissue defects. The aim of this study was to describe the surgical technique itself and to present clinical results of the procedure in a clinical series of chemotherapeutic extravasation injuries that benefitted from a subcutaneous wash-out procedure (SWOP) by minimisation of serious complications. PATIENTS AND METHODS Over a time period of 3 years, we treated 13 female patients following chemotherapeutic extravasation injury. Nine of the cases involved a high vesicant chemotherapy agent, and four patients involved chemotherapy with low vesicant potential. The therapeutic approach was performed using SWOP exclusively without the application of specific antidotes. RESULTS The mean time interval between the extravasation injury and the SWOP was 345min (140-795min). In none of the cases was there a tissue breakdown, but there was a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues without additional complications over a 3-month follow-up period. CONCLUSION The results of the study suggest that SWOP is a minimally invasive, safe and effective emergency treatment for chemotherapeutic extravasation injury. Based on the absence of comparative studies with regard to the efficacy of conservative therapy, SWOP should be offered as a therapeutic option for chemotherapeutic extravasations, especially in cases of medical malpractice and also as a defence in case of a legal conflict.