H. Hussl

Double Hand Transplantation: Functional Outcome after 18 Months:

In March 2000, we performed a double hand transplantation on a patient who had suffered traumatic hand amputations 6 years previously. The transplantations were both successful and, 18 months later, the patient has regained some complex hand functions and remarkably good tactile gnosis.

Clinical experience and indications of the free serratus fascia flap: a report of 21 cases.

&NA; The free “serratus fascia” flap as a free flap was first described by Wintsch and named a free fascia flap of gliding tissue; however, it has not yet been given a distinct name. The particular advantages of this flap consist of an easy access and a low donor‐site morbidity without functional deficit. Additionally, it may be designed very variably and molded even three‐dimensionally as a tendon wraparound flap or folded to fill up cavities. In our clinic, we used this flap in 21 patients for distinct indications and in 7 patients as a vascular graft in fingers or great toe with a minimal adjacent layer of gliding tissue around the vessels for the treatment of cold intolerance after finger replantation or severe finger or toe trauma. In the other cases, this versatile flap served for the coverage of traumatically exposed tendons or bones at the extremities, covered with a skin graft. Eighteen flaps survived completely, whereas 3 flaps developed partial or superficial necrosis. Only once did a major complication by unintentional sacrification of the long thoracic nerve during flap harvesting occur, resulting in a wing scapula. We recommend this flap for defect cover at sites where a thin vascularized gliding layer for defect cover is needed, especially in distal extremities with exposed tendons or nerves, and present the current indications in discussing our experiences. (Plast. Reconstr. Surg. 102: 1939, 1998.)

Subcutaneous or submuscular anterior transposition of the ulnar nerve

Precise clinical and electroneurographic examinations were made of 51 patients before and after anterior transposition of the ulnar nerve. The mean follow-up period was 9.6 years. In 86%, hand function improved, while in 10% it remained unchanged. Subcutaneous transposition was better than submuscular transposition, especially with regard to sensation. This method is simple and involves low morbidity for patients.

Replantations in children and youths: long-term results

SummaryIn 31 (out of 48) patients with 43 (out of 63) replanted or revascularized digits or parts of the extremities a study of long-term results was performed. Their ages were below 16 years at the time of injury. The results concerning function, sensitivity, cold intolerance, growth disturbance, patient acceptance and occupational changes were evaluated. Early complications consisted of venous stasis in 10.6 % (n = 4), skin necrosis of the wound margin in 5.3 % (n = 2) and in finger-tip necrosis in 5.3 % (n = 2). One lower arm and one finger replanted (5.3 %, n = 2) were lost after several revisions due to venous problems. In no case did arterial problems occur. Tendon adhesions were the most common complication in 28.9 % (n = 11), followed by deviation of the axis in a frontal plane of more than 20 ° in 13.3 % (n = 5) and by joint instability in 5.3 % (n = 2). Only twice (5.3 %) did ankylosis or in another case osteomyelitis of the proximal phalanx result. At amputation level II (between the DIP joint and the nail root), 37.5 % (n = 3) developed a reduction of range of active movement (RAM) with a mean of 31.7 °, and once an arthrodesis was necessary, whereas 50 % (n = 4) of the patients have full range of active motion. At amputation level III (between the MP and DIP joint) 52.7 % (n = 10) developed a reduction of RAM at the PIP joint with a mean of 29.5 °, and twice an arthrodesis was necessary, whereas 26.4 % (n = 5) of the patients have full range of active motion. Of the patients 78.9 % (n = 15) developed a reduction of RAM at the DIP joint with a mean of 35.7 °, and twice an arthrodesis was necessary. Only twice was ankylosis present, but 10.5 % (n = 2) of the patients have full range of active motion. Excellent sensory recovery was observed with a mean dynamic two-point discrimination of 4.8 mm. In addition, only 29 % (n = 9) of the patients report a surprisingly low incidence of cold intolerance, which is in contrast to adults with up to 100 % cold intolerance in replanted digits. In 67.7 % a radiologically measured difference of length with a mean of 3.8 mm and clinically measured a difference in the length of the digits with a mean of 4.9 mm was observed without complaints by the patients. Instead, there was moderate discontent with the aesthetically disturbing finger-tip atrophy, which was up to 30 % in 48.4 % of the patients. Of the patients who are now adult, 16.7 % (n = 4) changed their choice of profession due to the trauma or because of the dissatisfactory result. These results and the success rate of 94.7 % suggest the conclusion that one should not hesitate to perform a replantation or revascularization in children with even multiple amputations as the results are excellent.ZusammenfassungBei 31 (von 48) Patienten mit 43 (von 63) replantierten oder revaskularisierten Fingern oder Extremitätenanteilen wurde eine Studie der Langzeitergebnisse durchgeführt, wobei das Alter der Patienten zum Unfallzeitpunkt unter 16 Jahren lag. Es wurden die Ergebnisse in Hinblick auf Funktion, Sensibilität, Kälteintoleranz, Wachstumsstörung, Akzeptanz durch den Patienten sowie auf berufliche Konsequenzen erhoben. Die Untersuchungen ergaben exzellente Rückkehr der Sensibilität sowie gute funktionelle Ergebnisse mit einer nur geringen Rate an Kälteintoleranz. Mit der Erfolgsrate von 94,7 % Einheilung erlauben diese Ergebnisse den Schluß, daß im Kindes- und Jugendalter Replantationen oder Revaskularisationen in jedem Fall und auch bei Mehrfachamputationen indiziert sind und versucht werden sollen.

Importance of primary repair of complex hand injuries with free flaps

Background: The treatment of large and complex hand injuries is particularly challenching concerning the functional and cosmetic outcome. In this kind of injuries the primary defect cover is of paramount importance and so the initial situation for secondary reconstructive options may be evidently improved. Material & methods: Between October 1986 and Mai 1996 43 patients with large complex and combined hand injuries were primarily treated with 49 free flaps. The mean follow-up was 39 (6 to 92) months, the mean hospital stay was 19 (8 to 40) days. Depending on the time of the reconstruction and based on a classification established in our clinic, the patients were distributed among three groups: primarily (within 24 hours), delayed (between 2 and 7 days), and late (after 7 days till 3 weeks posttraumatically) reconstruction. Results: Within the group of primary reconstruction the best results could be achieved, since radical debridement and primary defect cover by healthy tissue (free flap) led to physiological wound healing. That caused reduced hospital stay thus decreased costs, since flap failure, infection and multiple secondary surgical interventions could be diminished. Also earlier rehabilitation and reintegration into social life and profession was achievable. Conclusion: Due to the obtained results a primary treatment of large and complex hand injuries through radical debridement and reconstruction with free flaps seems to be effective and should already be considered in the emergency room.Grundlagen: Die Versorgung von ausgedehnten oder komplexen Handverletzungen stellt besondere Ansprüche im Hinblick auf das funktionelle und ästhetische Ergebnis. Bei dieser Art der Verletzung ist die primäre Weichteildeckung von besonderer Bedeutung, da sich dadurch die Ausgangssituationen für eine Wiederherstellung der Funktion deutlich verbessern lassen. Methodik: Im Zeitraum von Oktober 1986 bis Mai 1996 wurden 43 Patienten mit 49 freien Lappenplastiken bei komplexen und kombinierten Handverletzungen primär behandelt. Der mittlere Nachbeobachtungszeitraum lag bei 39 (6–92) Monaten, der mittlere Krankenhausaufenthalt bei 19 (8–40) Tagen. In Abhängigkeit vom Zeitpunkt der Rekonstruktion mit einem freien Lappen sowie basierend auf der klinikeigenen Klassifikation erfolgte die Einteilung der Patienten in 3 Gruppen: Primärrekonstruktion (innerhalb von 24 h), primär aufgeschobene Rekonstruktion (zwischen 2 und 7 Tagen) und Spätrekonstruktion (nach 7 Tagen bis 3 Wochen posttraumatisch). Ergebnisse: In der Gruppe der Primärrekonstruktion ergaben sich die besten Ergebnisse, da durch ein radikales Débridement und sofortige Defektdeckung mit gesundem Gewebe (freier Lappen) eine physiologische Wundheilung erreichbar ist. Durch diese Art der Versorgung verkürzten sich Krankenhausaufenthalt und damit die Kosten, da Lappenverluste, Infektionen und multiple Mehreingriffe vermieden wurden. Ebenso wurden dadurch frühe Rehabilitation und damit Reintegration ins Arbeitsleben ermöglicht. Schlußfolgerungen: Aufgrund der erzielten Ergebnisse erscheint die frühzeitige Behandlung von komplexen und ausgedehnten Handverletzungen durch radikales Débridement und primäre Rekonstruktion mit freien Lappenplastiken zielführend und sollte bei der Erstbehandlung immer bedacht werden.

Silicon radiation measurements around mammary type implants

SummaryThe Silicon Elastomers, which are widely being used in Plastic and Reconstructive Surgery cause a constrictive fibrosis to a varying degree. The intensity determinations of Silicon radiation show that all capsules around those implants contain intra- and extracellular particles, deriving from the implants. In order to measure the suitability of implant materials manufactured from Silicon Elastomers as well as to test the tissue reactions of different implantation sites, this microchemical technique appears appropriate. A model study of mammary type implants in rabbits revealed that the capsules around Silica free “Barrier” coated implants contained twice as much Silicon as the non coated standard material, that inflatable spheres produced only one third of the Silicon infestation compared to the gel-filled pillows and that the intensity of the phagocytosis of the Silicon Elastomer implant material in the muscle is only one quarter compared to the tissue reactions occuring in the subcutaneous layer.

Musculosceletal Reconstruction in Bilateral Forearm Transplantation

BACKGROUND Improvement of motor function of the upper extremity was investigated in a patient following bilateral forearm transplantation. PATIENTS AND METHODS Following an electric shock injury with amputation of both forearms at the proximal level a bilateral allotransplantation was performed 2003 in a 41-year-old male patient. Missing and insufficient muscles were replaced by donor units. For use of myoprothesis in case of transplant failure remnants of BR, ECRL, ECRB and ECU remained at the recipient. 3.5 mm DCP plating was used without bone grafting to stabilize the forearm bones. PT, FCR, FDS, PL of the donor was fixed to the medial epicondyle of the humerus, ECU and EDC to the periosteum of the ulna. FCU, BR, ECRL; ECRB of the donor were sutured to the corresponding fascia of the recipient muscles. For motor function NIA; NIP and the motor branches of the median nerve for PT, FCR, FDS, PL were coapted. The ulnar nerve was coapted distally to the motor branch for the FCU. Following induction therapy today IS consist of tacrolimus (trough level 8 ng/ml), everolimus (trough level 6 ng/ml) und Prednisone (5 mg/day). RESULTS Both grafts are vital at FU of 6 years and 1 month. During the first 3 years episodes of graft rejection, opportunistic infection and transient metabolic disorder occurred which could be treated successfully by systemic, topical agents and change of IS. Bone healing appeared normal. TRM of the upper extremity improved from 32.7% before surgery to 74.6% of normal, with gain of wrist motion/forearm rotation of 8.7% and finger motion of 33, and 2%. The moderate muscle power (M4/5) of the deep flexors, the extensors and the intrinsic muscles is considered to be due to the long distance of reinnervation, a pre-existing electric damage to the nerv and repeated rejection episodes. CONCLUSION Range of motion of the upper extremity improved primarily by extrinsic muscle function. Muscle strength and grip are moderate. The patient described the following to be most beneficial: the better range of motion, the possibility to perform tasks without visual control, the availability of his range of motion 24 h a day and a new sense of body integrity.

Die Behandlung brandverletzter Hände

ZusammenfassungGrundlagen: Die Behandlung von Verbrennungen der Hände erfordert eine optimale Diagnostik und Therapie und sollte daher spezialisierten Abteilungen vorbehalten bleiben. Methodik: Eine rasche qualifizierte Erstversorgung ist für die weitere Therapie und zur Verhinderung von Komplikationen entscheidend. Die chirurgische Frühexzision vermeidet Infektionen, verhindert das Fortschreiten der Nekrotisierung und ermöglicht den frühzeitigen Beginn der Mobilisierung und Rehabilitation. Die Deckung der Defekte nach dem Debridement erfolgt streckseitig vorwiegend mit Spalthauttransplantaten, beugeseitig mit Vollhauttransplantaten, bei Freiliegen tieferer Strukturen (z. B. Sehnen, Knochen) mit Lappenplastiken. Ergebnisse: Dorsalseitig zeigen Spalthauttransplantate die besten Ergebnisse, volarseitig sind Vollhauttranplantate sowie bei tiefen Verbrennungen Lappenplastiken vorzuziehen. Schlußfolgerungen: Bei guter postoperativer Physikotherapie und konsequenter Nachsorge führt moderne Verbrennungsbehandlung an den Händen zu funktionell wie ästhetisch guten Resultaten. Eine vollständige psychosoziale und berufliche Rehabilitation ist in vielen Fällen möglich.SummaryBackground: Optimal diagnosis and therapy is mandatory for the treatment of burned hands. Methods: Qualified emergency care is essential for planning the further treatment and to minimize complications. Surgical early excision avoids infections, decreases the necrotising of tissues and leads to early rehabilitation. Defects after debridement on the dorsal side of the hand were covered by split-thickness-skingrafts, on the volar side by full-thickness-skingrafts. Exposed tendons or bone were covered by flaps. Results: On the dorsal side the best results were achieved by split thickness skin grafts, on the volar side full thickness skin grafts and in case of exposed deep structures flaps were preferable. Conclusions: Depending on good physiotherapy and follow-up of the patients complete rehabilitation is possible in many cases.

Microsurgical reconstruction of the scaphoid and lunate bones with small, free vascularized iliac crest bone grafts

Abstract. The primary surgical goal in repairing a scaphoid nonunion, particularly one associated with avascular fragments, or reconstructing the lunate is to prevent progressive carpal collapse. In patients with persistent nonunion of the scaphoid and progressive aseptic necrosis of the lunate bone, reconstruction can be managed with a small microvascular iliac crest bone transfer. This retrospective study reports on the anatomical fundamentals, the operative procedure (particularly the harvesting of the bone flap and microsurgery), the assessment of the viability of the bone graft and the postoperative results in 80 out of a total of 210 patients on whom the surgery had been performed. From 1985 until 1998, 210 carpal bone reconstructions (134 scaphoid bones and 76 lunate bones) were performed using small, free vascularized iliac crest bone grafts. Of these, 80 patients were preoperatively evaluated and postoperatively followed up clinically and by means of conventional radiography and magnetic resonance imaging (MRI). The total rate of viability and bony union was 91.2%. This means a bone flap loss-rate and, consequently, a progressive arthrosis/necrosis/persistent nonunion of 8.8%. The patients who had vital reconstructed carpal bones did not report pain, but motion and grip strength were decreased as compared with the uninvolved side. This procedure offers stability and vascularity to treat avascular scaphoid nonunion and has proved beneficial in achieving union in avascular scaphoid pseudoarthrosis and lunate necrosis. It can be considered to be the definitive alternative technique. The high rate of union and the absence of progressive carpal arthrosis are the best evidence for the vascularity of the bone graft.

Defektdeckung am Unterschenkel mit gestielten und freien Lappen

ZusammenfassungGrundlagen: Die Defektdeckung am Unterschenkel ist durch den Mangel an lokal verfügbarem Gewebe häufig schwierig und erfordert die Anwendung spezieller Operationstechniken. Methodik: Das Ziel der plastischen Chirurgen in diesen Fällen ist die Wiederherstellung einer stabilen Weichteilbedeckung und die Konsolidierung der knöchernen Strukturen. Lage, Größe und Umfang des Defektes beeinflussen entscheidend die zur Verfügung stehenden Operationsmethoden. Im oberen und mittleren Unterschenkeldrittel erfolgt die Defektdeckung meist mit gestielten Lappen, im unteren Unterschenkeldrittel kommen mikrovaskulär transponierte Lappen zur Anwendung. Ergebnisse: Die Entwicklung dieser neuen gestielten und freien Lappenplastiken hat die Ergebnisse nach Defektdeckungen am Unterschenkel revolutioniert bzw. deutlich verbessert. Schlußfolgerungen: Moderne plastisch chirurgische Methoden ermöglichen die Erhaltung von Extremitäten, die früher amputiert worden wären.SummaryBackground: Reconstruction of lower leg defects can be difficult due to lack of available tissues and flaps in this region. Methods: The goal of the plastic surgeon is the reconstruction of the soft tissues and of functional structures, mainly bone stability. The required methods depend on site and dimension of the defect and on the quality of the involved structures. In the upper and middle third of the lower leg mainly pedicled flaps are used, in the lower third most often microvascular transposed free flaps are the only possibility. Results: The development of these new pedicled and free transfered flaps has been a major breakthrough to achieve good and lasting results in lower leg defect coverage. Conclusions: By using advanced plastic-surgical techniques maintainance of extremities which would have been amputated otherwise is possible.