Daniel Druecke

Modulation of scar tissue formation using different dermal regeneration templates in the treatment of experimental full-thickness wounds.

The recovery of skin function is the goal of each burn surgeon. Split‐skin graft treatment of full‐thickness skin defects leads to scar formation, which is often vulnerable and instable. Therefore, the aim of this study was to analyze wound healing and scar tissue formation in acute full‐thickness wounds treated with clinically available biopolymer dermal regeneration templates. Full‐thickness wounds (3 × 3 cm) on both flanks of Gottingen mini pigs (n= 3) were treated with split‐thickness skin graft alone or in combination with a 1‐ethyl‐3‐(3‐dimethylaminopropyl)‐carbodiimide (EDC) cross‐linked‐collagen scaffold, Integra, or a polyethyleneglycol terephthalate‐polybutylene terephthalate (PEGT/PBT) scaffold. The wounds (n= 12 per group) were examined weekly for six weeks to evaluate graft take, contraction (planimetry), and cosmetic appearance. Histologic samples taken after one and six weeks were used to assess scaffold angiogenesis, biocompatibility, and scar tissue quality. In all wounds, one week postwounding graft take was between 93 and 100 percent. The control wound, treated with split‐skin graft, showed little granulation tissue formation, whereas the EDC‐collagen treated wounds showed two to three times more granulation tissue formation. The collagen scaffold was completely degraded within one week. The Integra and PEGT/PBT scaffolds showed angiogenesis only through two‐thirds of the scaffold, which resulted in loss of integrity of the epidermis. Only basal cells survived, proliferated, and regenerated a fully differentiated epidermis within three weeks. Granulation thickness was comparable to collagen scaffold‐treated wounds. After six weeks, control wounds showed a wound contraction of 27.2 ± 6.1 percent, Integra‐treated wounds 34.6 ± 6.4 percent, collagen scaffold‐treated wounds 38.1 ± 5.0 percent, and PEGT/PBT scaffold‐treated wounds 54.5 ± 3.9 percent. The latter wounds had significantly more contraction than wounds of other treatment groups. Microscopically, the control and collagen scaffold‐treated wounds showed an immature scar tissue that was two times thicker in the EDC‐collagen treated wounds. The Integra‐treated wounds showed nondegraded collagen scaffold fibers with partly de novo dermal tissue formation and partly areas with giant cells and other inflammatory cells. The PEGT/PBT scaffold was almost completely degraded. Scaffold particles were phagocytosized and degraded intracellularly by clusters of macrophages. The scar tissue was in the early phase of ECM remodeling. In conclusion, this study showed that the rate of dermal tissue formation and scarring is influenced by the rate of scaffold angiogenesis, degradation, and host response induced by the scaffold materials.

Current indications for glycerol-preserved allografts in the treatment of burn injuries

Current indications for glycerol-preserved allografts in the treatment of burn injuries D. Druecke a,∗, L. Steinstraesser a, H.H. Homann a, H.U. Steinau a, P.M. Vogt b a Department of Plastic Surgery, Burn Center, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany b Department of Plastic Surgery, Burn Center, University Hospital Oststadt-Krankenhaus, University Hannover, Hannover, Germany

Polybrene improves transfection efficacy of recombinant replication‐deficient adenovirus in cutaneous cells and burned skin

The hostile environment found in acute and chronic wounds decreases the physiological half‐life of purified synthetic or recombinant peptides dramatically. Gene therapy, on the other hand, may be a viable option since it relies on the cellular machinery of the host to locally manufacture the proteins of interest. The aim of this study was to evaluate and optimize the local administration of transient cutaneous adenoviral gene delivery in wounds.

Long-term Evaluation of Porous PEGT/PBT Implants for Soft Tissue Augmentation

Porous PEGT/PBT implants with different physico-chemical characteristics were evaluated to identify its potential as biodegradable and biofunctional soft tissue filler. Implants (50 × 10 × 5mm3) were implanted subcutaneously in mini-pigs and tissue response, tissue volume generated and its consistency were assessed quantitatively with a 52 weeks follow-up. The absence of wound edema, skin irritation, and chronic inflammation demonstrated biocompatibility of all implants evaluated. The hydrophobic implants induced the mildest foreign body response, generated highest amount of connective tissue and demonstrated a decrease in copolymer MW of 34—37% compared to 90% decrease of the hydrophilic implants. The rate and extent of copolymer fragmentation seems to be the determining factor of success of soft tissue augmentation using porous PEGT/PBT copolymer implants.

Crossover extremity transfers. Limb salvage in amputations with segmental defects

ZusammenfassungKlinische Situationen, in denen eine heterotope Replantation erforderlich werden kann, sind selten. Liegen beidseitige Amputationen im Bereich der oberen oder unteren Extremitäten vor und ist eine ipsilaterale Replantation nicht möglich, ermöglicht die heterotope Replantation zumindest die Rekonstruktion oder Stumpfverlängerung auf einer Seite. Liegt im Bereich des Stumpfes ein Weichgewebsschaden vor, der die unmittelbare Replantation verhindert, sollten unverletzte distale Extremitätenabschnitte an anderer Körperstelle vorübergehend verwahrt werden. Ist das Amputat soweit zerstört, dass eine Replantation in jedem Fall unmöglich ist, sollte geprüft werden, ob nicht die Verwendung von Gewebeeinheiten aus dem Amputat auf der Stumpfseite zur Verlängerung oder verbesserten Weichgewebsbedeckung verwendet werden können. Vorgestellt wird der Fall eines 34-jährigen Mannes, der durch ein Zug-Überrolltrauma eine subtotale Amputation des linken Unterarms, der rechten Hand und des linken Unterschenkels erlitt. Aufgrund einer segmentalen massiven Zerstörung des überwiegenden Teils der Amputate kam eine orthotope Replantation nicht in Betracht. Es wurde erfolgreich eine heterotope Replantation der linken Hand auf den rechten Unterarm und eine modifizierte Umkehrplastik des linken Fußes zum linken Oberschenkel zur Stumpfdistalisation vorgenommen. AbstractClinical conditions in which crossover extremity transfer should be considered are rare. In the case of bilateral amputation associated with extensive proximal segmental injury, ectopic implantation could be an additional concept for two-stage limb salvage. If replantation is impossible due to segmental damage of the amputated part, at least uninvolved tissue should be harvested for stump lengthening or improving soft-tissue at the ends. The case of a 34-year-old man with segmental amputation of the left forearm and left lower leg and mutilated amputation of the right hand caused by a train accident is presented. Limb salvage was performed by cross-hand replantation and modified rotationplasty of the left foot as a stump lengthening procedure.

The interdisciplinary approach in reconstructive surgery of the extremities

ZusammenfassungAusgedehnte posttraumatische Knochen- und Weichteildefekte, mutilierende Infektionen und Tumorresektionen erfordern den Einsatz multidisziplinärer Konzepte zum Extremitätenerhalt und zur funktionellen Rehabilitation. Die Bündelung von Spezialkenntnissen führt bei diesen Indikationen zur Verminderung von Amputationsraten, Wundheilungsstörungen und Korrektureingriffen. Die Möglichkeiten und Grenzen aktueller Konzepte werden geschildert. Da das neue DRG-System komplexe operative Verfahren und Mehrfachverletzungen bisher unzureichend finanziert, werden Analysen zur Kostensenkung notwendig. Unter der Voraussetzung von klinischen Entscheidungspfaden, die für klare Indikationen, definierte operative Schritte und ein schlüssiges postoperatives Management sorgen, ist eine Reduktion der Defizite durch abteilungsübergreifende Therapiekonzepte zu erwarten. Während in der Vergangenheit die ärztliche Verantwortung für den Patienten und ethische Grundlagen zur freiwilligen interdisziplinären Zusammenarbeit führte, erzwingen zukünftig ökonomische Überlebensstrategien und gerichtlich festgesetzte Standards die Kooperation.AbstractIn cases of extended post-traumatic soft-tissue and bone loss as well as with mutilating infection or radical tumor resection, multidisciplinary options are required to salvage extremities and functional rehabilitation. A surgical team approach allows for reduction of amputation rates, wound healing complications, and secondary procedures in limb oncology and trauma. The goals and limitations of cooperative surgical concepts are described. In the future, continuing medical education will focus not only on indications and techniques but also on complication management, medicolegal problems, and economic deficits due to maladapted legal structures. Provided clear clinical pathways are introduced to guide indications, surgical procedures, and postoperative treatment, marked financial deficits may be avoided. While, in the past, responsibility for the patient and ethical considerations resulted in the development of voluntary interdisciplinary treatment programs, economic strategies and an increasing number of malpractice suits will inevitably produce new imperatives for interdisciplinary cooperation in the future.

Operative Interdisziplinarität—Extremitäten

ZusammenfassungAusgedehnte posttraumatische Knochen- und Weichteildefekte, mutilierende Infektionen und Tumorresektionen erfordern den Einsatz multidisziplinärer Konzepte zum Extremitätenerhalt und zur funktionellen Rehabilitation. Die Bündelung von Spezialkenntnissen führt bei diesen Indikationen zur Verminderung von Amputationsraten, Wundheilungsstörungen und Korrektureingriffen. Die Möglichkeiten und Grenzen aktueller Konzepte werden geschildert. Da das neue DRG-System komplexe operative Verfahren und Mehrfachverletzungen bisher unzureichend finanziert, werden Analysen zur Kostensenkung notwendig. Unter der Voraussetzung von klinischen Entscheidungspfaden, die für klare Indikationen, definierte operative Schritte und ein schlüssiges postoperatives Management sorgen, ist eine Reduktion der Defizite durch abteilungsübergreifende Therapiekonzepte zu erwarten. Während in der Vergangenheit die ärztliche Verantwortung für den Patienten und ethische Grundlagen zur freiwilligen interdisziplinären Zusammenarbeit führte, erzwingen zukünftig ökonomische Überlebensstrategien und gerichtlich festgesetzte Standards die Kooperation.AbstractIn cases of extended post-traumatic soft-tissue and bone loss as well as with mutilating infection or radical tumor resection, multidisciplinary options are required to salvage extremities and functional rehabilitation. A surgical team approach allows for reduction of amputation rates, wound healing complications, and secondary procedures in limb oncology and trauma. The goals and limitations of cooperative surgical concepts are described. In the future, continuing medical education will focus not only on indications and techniques but also on complication management, medicolegal problems, and economic deficits due to maladapted legal structures. Provided clear clinical pathways are introduced to guide indications, surgical procedures, and postoperative treatment, marked financial deficits may be avoided. While, in the past, responsibility for the patient and ethical considerations resulted in the development of voluntary interdisciplinary treatment programs, economic strategies and an increasing number of malpractice suits will inevitably produce new imperatives for interdisciplinary cooperation in the future.

[Differential diagnosis of "sterile" phlegmonous hand infections].

INTRODUCTION Bacterial infections represent a large proportion of emergencies in hand surgery. In some cases, pyoderma gangrenosum and mycobacterial infection may present with the same symptoms of swelling, pain, and purulent secretion. In these cases, operative treatment would be harmful. Therefore two cases-pyoderma gangrenosum and tuberculosis-are presented here in relation to common bacterial hand infection. METHODS Using two case reports of diseases that only rarely affect the hands, their relevance to differential diagnosis is shown with reference to the literature. RESULTS In both cases, we found clinical symptoms of bacterial hand infection with negative bacterial smear tests. After several debridements, pyoderma gangrenosum of the dorsum of the hand was diagnosed in one patient after pyodermiform lesions at the thigh and the nasal septum were detected and pre-existing colitis ulcerosa was taken into consideration. Corticoid therapy induced complete remission. The second patient with similar clinical symptoms had been operated on at another hospital several times before being transferred to our institution. The presumptive diagnosis of pyoderma gangrenosum was made, and under treatment with prednisone the symptoms quickly improved. After 2 weeks, the wound conditions and the patients condition rapidly worsened. Following amputation at the upper arm level, the patient died of septic multiple organ failure. Autopsy studies revealed tuberculous sepsis originating from the hand. DISCUSSION Patient history should be evaluated carefully because of its value to correct diagnosis. In case of negative smear tests, especially from immunocompromised, elderly patients and in patients with a history of pulmonary tuberculosis, Ziehl-Neelsen staining should be obtained. In case of multilocular affection or pre-existing chronic inflammatory bowel disease, the presumptive diagnosis of pyoderma gangrenosum can be confirmed by biopsies from the lesions margin. In both cases, unnecessary traumatizing operations could thus be avoided and treatment optimized.

Differenzialdiagnose „steriler“ phlegmonöser Entzündungen der Hand

INTRODUCTION Bacterial infections represent a large proportion of emergencies in hand surgery. In some cases, pyoderma gangrenosum and mycobacterial infection may present with the same symptoms of swelling, pain, and purulent secretion. In these cases, operative treatment would be harmful. Therefore two cases-pyoderma gangrenosum and tuberculosis-are presented here in relation to common bacterial hand infection. METHODS Using two case reports of diseases that only rarely affect the hands, their relevance to differential diagnosis is shown with reference to the literature. RESULTS In both cases, we found clinical symptoms of bacterial hand infection with negative bacterial smear tests. After several debridements, pyoderma gangrenosum of the dorsum of the hand was diagnosed in one patient after pyodermiform lesions at the thigh and the nasal septum were detected and pre-existing colitis ulcerosa was taken into consideration. Corticoid therapy induced complete remission. The second patient with similar clinical symptoms had been operated on at another hospital several times before being transferred to our institution. The presumptive diagnosis of pyoderma gangrenosum was made, and under treatment with prednisone the symptoms quickly improved. After 2 weeks, the wound conditions and the patients condition rapidly worsened. Following amputation at the upper arm level, the patient died of septic multiple organ failure. Autopsy studies revealed tuberculous sepsis originating from the hand. DISCUSSION Patient history should be evaluated carefully because of its value to correct diagnosis. In case of negative smear tests, especially from immunocompromised, elderly patients and in patients with a history of pulmonary tuberculosis, Ziehl-Neelsen staining should be obtained. In case of multilocular affection or pre-existing chronic inflammatory bowel disease, the presumptive diagnosis of pyoderma gangrenosum can be confirmed by biopsies from the lesions margin. In both cases, unnecessary traumatizing operations could thus be avoided and treatment optimized.

Carl von Reyhers Studien zur Wundtherapie

ZusammenfassungDer Name Carl Reyher (1846–1890) ist den meisten Chirurgen unbekannt. Dieser russische Militärchirurg entwickelte das Konzept der radikalen Resektion avitalen Gewebes und Entfernung von Fremdkörpern als maßgebliche chirurgische Therapie bei Schussverletzungen. Obwohl der Begriff des Débridements bereits im 16. Jahrhundert von Ambroise Paré in die Medizin eingeführt wurde, gebührt von Reyher das Verdienst der Umsetzung dieser vergessenen Technik und Taktik der Wundtherapie. In zur damaligen Zeit revolutionär modernen, prospektiven Studien konnte er den dramatischen Erfolg der klinischen Anwendung von Listers antiseptischen Überlegungen, verbunden mit wiederholt durchgeführten Débridements, beweisen. Obwohl Reyher mit seinen in zahlreichen Publikationen und Vorträgen propagierten Methoden die Mortalitätsrate nach Schussverletzungen um mehr als 40% senken konnte, erfuhr er dennoch vehemente Ablehnung durch die führenden Chirurgen seiner Zeit. Es dauerte bis zum Ende des 1. Weltkrieges, bevor die Behandlungsprinzipien, die Reyher in der Zeit von 1874–1885 in über 16 Publikationen vorstellte, Anerkennung fanden. Trotz der alltäglichen Anwendung von Reyhers Prinzipien im heutigen chirurgischen Alltag blieb eine Würdigung seiner Pionierleistungen aus.AbstractCarl von Reyher (1846–1890), a young Russian army surgeon of the late nineteenth century, established the principle of repeated debridements on a scientific basis. After a visit to Listers clinic, acquainting himself with antiseptic wound management, von Reyher was the first to present a controlled study of debridement in contaminated gunshot wounds. He was able to show that the combination of primary debridement and antiseptic treatment decreased the mortality rate of gunshot injuries from 66% to 23%. Although published in more than 16 papers and presented at international congresses, Reyhers contribution was completely negated. Finally more than 30 years later in World War I, the Interallied Surgical Conference officially endorsed primary excision with delayed wound closure as the rule for treatment of gunshot wounds.