G. Germann

the Concept of Fillet Flaps: Classification, Indications, and Analysis of Their Clinical Value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the “spare parts” concept. By definition, fillet flaps are axial‐pattern flaps that can function as composite‐tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects. From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps). Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytrens contracture, and two with high‐voltage electrical injuries). Thirty‐six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above‐knee or below‐knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet‐of‐thigh or entire‐limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper‐arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet‐of‐sole flap. In another case, wound infection required revision and above‐knee amputation with removal of the flap. Nine free plantar fillet flaps were performed—five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper‐arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one aboveknee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery. Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients. On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor‐site morbidity and facilitate stump‐length preservation or limb salvage. (Plast. Reconstr. Surg. 108: 885, 2001.)

Standardisierung und Validierung der deutschen Version 2.0 des “Disability of Arm, Shoulder, Hand” (DASH)-Fragebogens zur Outcome-Messung an der oberen Extremität

ZusammenfassungDer Fragebogen “Disability of Arm,Shoulder, Hand” (DASH),Version 2.0 (1997),erfasst die subjektiven Wahrnehmungen der Patienten bezüglich ihrer Gesundheit.Dieses Instrument wurde von der American Academy of Orthopedic Surgeons (AAOS),dem Council of Musculoskeletal Speciality Societies und dem Institute for Work and Health,Toronto,entwickelt. Anhand von 78 Fragen misst dieser Fragebogen die wesentlichen Komponenten des gesundheitlichen Status der oberen Extremitäten. Mit dem Ziel,ein auch im deutschen Sprachraum einsetzbares Instrument zu haben, wurde DASH im Sinne der transkulturellen Adaptation übersetzt und validiert.Der Beitrag berichtet über die Methodik der deutschen Übersetzung und der kulturellen Adaptation des DASH.Dies erfolgte unter Anwendung der AAOS-Richtlinien.Im Ergebnis liegt eine standardisierte deutsche Version vor.Die psychometrische Prüfung des übersetzten Fragebogens erfolgte anhand von 6 Patientengruppen (n=342),die sich unterschiedlichen operativen Eingriffen an der Hand unterzogen.Die Ergebnisse unserer Untersuchung ergaben über allen Gruppen gute Resultate hinsichtlich der Konstrukt-,der Kriterien- und der Inhaltsvalidität.Damit ist die Anwendungsreife der deutschen Version bestätigt worden.Die hier vorgelegte Übersetzung ist als einzige Übersetzung im deutschen Sprachraum von der American Academy of Orthopedic Surgeons (AAOS) zertifiziert und akkreditiert.AbstractThe Disability of Arm, Shoulder, Hand (DASH) Version 2.0 questionnaire captures the subjective experience of patients regarding their own health.This 78-item instrument was developed by the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Speciality Societies and the Institute for Work and Health,Toronto and measures components of health-status relevant to upper-extremity conditions.We translated and validated DASH with the aim of producing a tool which could also be used in German-speaking countries.The paper reports the method of translation and cross-cultural adaptation which was carried out according to the AAOS guidelines.The result was a standardised German version of DASH.Psychometric testing of the translated questionnaire was carried out with 6 samples (n=342) who had undergone hand surgery for a variety of conditions. The study yielded good results across all groups with regard to the construct, criterion and content validity.We confirm that the German version is suitable for use in future studies.

The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patient

A retrospective analysis of prospectively collected data was performed to compare the frequency of upper gastrointestinal bleeding (GIB) in seriously burned patients treated with either cimetidine and antacids or enteral nutrition for ulcer prophylaxis. Five hundred and twenty-six seriously burned patients admitted to the burn intensive care unit of the BG Trauma Centre Ludwigshafen during a 4-year period were included into the study. All patients admitted to the burn unit from 1989 to 1991 received i.v. cimetidine (400 mg q4) for ulcer prophylaxis. If the intragastric pH dropped below 3.5, gastric pH was titrated with antacids up to > or = 4 via nasogastric tube. During the second 2-year period (1992-1993) early enteral nutrition alone was regarded to be ulcer protective and no further interventions for ulcer prophylaxis were routinely performed. Signs of overt upper GIB were monitored and documented through the entire study period. The overall occurrence rate of upper GIB in the cimetidine/antacids (C/A) group (n = 253) was 8.3 per cent with six cases of serious bleeding in five patients (1.98 per cent). In the enteral nutrition (EN) group (n = 273) the overall incidence of GIB was 3.3 per cent with two cases of serious bleeding (0.73 per cent). There were no deaths directly related to ulcer haemorrhage. The difference in the overall frequency of overt GIB between the groups studied was statistically significant (< 0.05). In our experience, early enteral nutrition is effective in the prevention of stress haemorrhage in the upper gastrointestinal tract. Additional medicinal prophylaxis is not required in burn patients.

Locally applied vascular endothelial growth factor A increases the osteogenic healing capacity of human adipose-derived stem cells by promoting osteogenic and endothelial differentiation.

Human adipose‐derived stem cells (hASCs) are known for their capability to promote bone healing when applied to bone defects. For bone tissue regeneration, both sufficient angiogenesis and osteogenesis is desirable. Vascular endothelial growth factor A (VEGFA) has the potential to promote differentiation of common progenitor cells to both lineages. To test this hypothesis, the effects of VEGFA on hASCs during osteogenic differentiation were tested in vitro. In addition, hASCs were seeded in murine critical‐sized calvarial defects locally treated with VEGFA. Our results suggest that VEGFA improves osteogenic differentiation in vitro as indicated by alkaline phosphatase activity, alizarin red staining, and quantitative real‐time polymerase chain reaction analysis. Moreover, local application of VEGFA to hASCs significantly improved healing of critical‐sized calvarial defects in vivo. This repair was accompanied by a striking enhancement of angiogenesis. Both paracrine and, to a lesser degree, cell‐autonomous effects of VEGFA‐treated hASCs were accountable for angiogenesis. These data were confirmed by using CD31−/CD45− mouse ASCsGFP+ cells. In summary, we demonstrated that VEGFA increased osteogenic differentiation of hASCS in vitro and in vivo, which was accompanied by an enhancement of angiogenesis. Additionally, we showed that during bone regeneration, the increase in angiogenesis of hASCs on treatment with VEGFA was attributable to both paracrine and cell‐autonomous effects. Thus, locally applied VEGFA might prove to be a valuable growth factor that can mediate both osteogenesis and angiogenesis of multipotent hASCs in the context of bone regeneration. STEM CELLS 2011;29:286–296

Breast reconstruction with the extended latissimus dorsi flap.

&NA; Autologuous breast reconstruction started with the use of a myocutaneous latissimus dorsi flap. The need for an additional silicone implant to obtain sufficient breast volume intensified the search for new flaps, resulting in the microvascular TRAM flap, which is currently considered the “gold standard” in autologuous breast reconstruction. For patients who are not suited for this procedure or reject this treatment option, a modified extended latissimus dorsi flap was designed and used in 47 patients. Additional volume is obtained by including the scapular flat fascia, based on perforators from the cranial edge of the latissimus dorsi muscle. Flap survival was 100 percent in the series, and sufficient volume could be achieved in 42 patients. Main complications were seromas at the donor site (n = 9). The results demonstrate that in selected patients the extended latissimus dorsi flap provides an excellent alternative to a TRAM flap in reconstruction of small and moderate‐sized breasts. (Plast. Reconstr. Surg. 97: 519, 1996.)

MIDCARPAL ARTHRODESIS WITH COMPLETE SCAPHOID EXCISION AND INTERPOSITION BONE GRAFT IN THE TREATMENT OF ADVANCED CARPAL COLLAPSE (SNAC/SLAC WRIST): OPERATIVE TECHNIQUE AND OUTCOME ASSESSMENT

Thirty-six patients with stage II or III SNAC and SLAC wrists were treated by midcarpal arthrodesis and complete scaphoid excision. When assessed at a mean follow-up of 25 months, pain was significantly reduced both under resting and stress conditions. The active range of motion was 54% of the contralateral wrist and grip strength was 65% of the non-operated hand. The mean DASH score was 28 points, the Mayo wrist score was 63 points, and the Krimmer wrist score was 68. Correlation of the wrist scores with the DASH values demonstrated a significant correlation. Our data demonstrate that midcarpal fusion with complete excision of the scaphoid is a reliable procedure for treating advanced carpal collapse.

Scapholunate Ligament Repair Using the Mitek™ Bone Anchor Technique and Preliminary Results

A retrospective study was done to assess the outcome after repair of completely ruptured scapholunate interosseous ligaments using the Mitek™ Mini G2 bone anchor. From 1994 to 1996. 12 patients underwent scapholunate ligament repair using the bone anchor. A follow-up assessment was done at a mean of 19 months postoperatively and revealed excellent or good results in eight patients, satisfactory in two, and poor in two patients, one of whom had developed lunate necrosis. One patient with an excellent functional result demonstrated recurrent dissociation of the scapholunate gap radiographically. The technique described proved to be simpler than conventional procedures in our hands, and yields similar functional results.

Subjective and objective outcomes after total wrist arthrodesis in patients with radiocarpal arthrosis or Kienböck's disease.

Sixty patients underwent total wrist arthrodesis for post-traumatic arthrosis, or Kienböcks disease. All of them could be included in the study with complete data. The average follow-up time was 37 months. Forty-nine patients were males, 11 were females; the average age was 48 years. Outcomes were assessed by several methods. Grip strength was measured using the DEXTER-Computer-System and was reduced by 50% compared to the contralateral side. Pain was evaluated pre- and postoperatively with a visual analogue scale from 0 to 100 and was reduced to 55% of the preoperative values. Patients activities of daily living (ADLs) and general postoperative quality of life were estimated with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. For functional evaluation additionally the Mayo and Krimmer wrist scores were used. The overall DASH score was 51.4, the wrist scores reached 46.4 and 50.5, respectively. Both scores correlated significantly with the DASH. It can be concluded from our data that pain relief was sufficient in the most patients, although complete pain relief was rare. Although 80% of the patients complained about reduction of postoperative quality of life with impaired personal hygiene and functional deficits, the majority (80%) would undergo the procedure again. Seventy percent of the patients returned to their original occupation. Compared to other measures commonly used to assess outcomes after wrist arthrodesis, the DASH questionnaire proved to be a very useful tool for the evaluation of subjective outcomes in upper extremity disorders as well.

Emotional Distress and Psychosocial Resources in Patients Recovering From Severe Burn Injury

Emotional distress as well as psychosocial resources in 55 patients with burn injuries was assessed during acute and follow-up treatment. Results showed significantly greater values of emotional distress among patients when compared with norms of the general population. As well as higher levels of general psychopathology, particularly prevalent were anxiety, depression, and posttraumatic symptoms. However, patients also reported high levels of resources such as general optimism, self-efficacy, and perceived social support. Within the sample, no significant correlation between severity of emotional distress and severity of burn injury was found. By psychological assessments a subgroup of highly distressed patients was identified. These patients were highly emotionally distressed while having objective injury severity comparable with the other patients in the sample. Reactions to burn accidents vary individually. The results demonstrate the importance of routine screenings of psychological symptoms. An early identification of patients at-risk allows for tailored psychotherapeutic interventions and can thus help to improve quality of life and general well-being of burn patients on a long-term basis.

The antimicrobial effect of acetic acid—An alternative to common local antiseptics?

Acetic acid has been commonly used in medicine for more than 6000 years for the disinfection of wounds and especially as an antiseptic agent in the treatment and prophylaxis of the plague. The main goal of this study was to prove the suitability of acetic acid, in low concentration of 3%, as a local antiseptic agent, especially for use in salvage procedures in problematic infections caused by organisms such as Proteus vulgaris, Acinetobacter baumannii or Pseudomonas aeruginosa. This study was designed to compare the in vitro antimicrobial effect of acetic acid with those of common local antiseptics such as povidone-iodine 11% (Betaisodona), polyhexanide 0.04% (Lavasept), mafenide 5% and chlohexidine gluconate 1.5% cetrimide 15% (Hibicet). Former studies suggest the bactericidal effect of acetic acid, but these data are very heterogeneous; therefore, a standardised in vitro study was conducted. To cover the typical bacterial spectrum of a burn unit, the following Gram-negative and Gram-positive bacterial strains were tested: Escherichia coli, P. vulgaris, P. aeruginosa, A. baumannii, Enterococcus faecalis, Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus (MRSA) and beta-haemolytic Streptococcus group A and B. The tests showed excellent bactericidal effect of acetic acid, particularly with problematic Gram-negative bacteria such as P. vulgaris, P. aeruginosa and A. baumannii. The microbiological spectrum of acetic acid is wide, even when tested at a low concentration of 3%. In comparison to our currently used antiseptic solutions, it showed similar - in some bacteria, even better - bactericidal properties. An evaluation of the clinical value of topical application of acetic acid is currently underway. It can be concluded that acetic acid in a concentration of 3% has excellent bactericidal effect and, therefore, seems to be suitable as a local antiseptic agent, but further clinical studies are necessary.