Lars-Peter Kamolz

The treatment of hand burns

In more than 80% of all burns, the hand is involved. Even if a burned hand does not play a major role for the survival of a patient, its function and aesthetic appearance are of utmost importance for the re-integration into society and professional life. Adequate treatment demands a number of major decisions: necessity of an escharotomy in the early post-traumatic phase, the timing of surgery and the type of wound coverage, as well as immobilization and rehabilitation. Rapid wound closure is of utmost importance, but infection control and the preservation of active and passive motion are also essential for optimal recovery of the injured hand. The treatment of hand burns requires the interdisciplinary teamwork of surgeons, physio- and occupational therapists, psychologists, motivated health care personnel and consequent treatment strategies.

Adult burn patients with more than 60% TBSA involved-Meek and other techniques to overcome restricted skin harvest availability--the Viennese Concept.

Despite the fact that early excision and grafting has significantly improved outcome over the last decades, the management of severely burned adult patients with ≥60% total body surface area (% TBSA) burned still represents a challenging task for burn care specialists all over the world. In this article, we present our current treatment concept for this entity of severely burned patients and analyze its effect in a comparative cohort study. Surgical strategy comprised the use of split-thickness skin grafts (Meek, mesh) for permanent coverage, fluidized microsphere bead-beds for wound conditioning, temporary coverage (polyurethane sheets, Epigard®; nanocrystalline silver dressings, Acticoat®; synthetic copolymer sheets based on lactic acid, Suprathel®; acellular bovine derived collagen matrices, Matriderm®; allogeneic cultured keratinocyte sheets; and allogeneic split-thickness skin grafts), and negative-pressure wound therapy (vacuum-assisted closure). The autologous split-thickness skin graft expansion using the Meek technique for full-thickness burns and the delayed approach for treating dorsal burn wounds is discussed in detail. To demonstrate differences before and after the introduction of the Meek technique, we have compared patients of 2007 with ≥60% TBSA (n = 10) to those in a matched observation period (n = 7). In the first part of the comparative analysis, all patients of the two samples were analyzed with regard to age, abbreviated burn severity index, Baux, different entities of % TBSA, and survival. In the second step, only the survivors of both years were separated in two groups as follows: patients receiving skin grafts, using the Meek technique (n = 6), were compared with those without Meek grafting (n = 4). When comparing the severely burned patients of 2007 with a cohort of 2006, there were no differences for age (2007: 46.4 ± 13.4 vs. 2006: 39.1 ± 14.8 years), abbreviated burn severity index score (2007: 12.2 ± 1.0 vs. 2006: 12.1 ± 1.2) or % TBSA (2007: 72.1 ± 11.7 vs. 2006: 69.3 ± 8.7% TBSA). In these two rather small groups of severely burned patients with ≥60% TBSA, the overall survival rate of patients was 70.0% (7/10) in 2007 and 42.9% (3/7) in 2006, respectively. Almost all nonsurvivors in both years died within the first 5 days after admission. If assessing the different treatment modalities of the survivors, we found that although the Meek group patients were older (Meek 48.8 ± 13.3 vs. non-Meek 26.8 ± 11.5 years, P = .0381) and had consequently higher Baux scores (Meek 124.0 ± 2.9 vs. non-Meek 93.8 ± 8.5, P = .0095) than the non-Meek patients, this seemed to have no effect on length-of-stay (80.5 ± 9.7 vs. non-Meek 79.8 ± 33.0 days), hospital length-of-stay (85.7 ± 14.8 vs. non-meek 84.3 ± 26.1 days) or number of operations (6.5 ± 1.0 vs. non-Meek 7.0 ± 4.1 operations). The achieved results represent a combination of various treatment changes and, therefore, cannot be attributed to a single modality. The Meek technique is one of the technical options to choose from, to achieve permanent skin replacement; we think that it has its place if integrated in a whole treatment concept for management of severely burned patients.

Principles of burn reconstruction

Due to extraordinary advances concerning the understanding of cellular and molecular processes in wound healing, wound care innovations and new developments concerning burn care have been made; burn care has improved to the extend that persons with burns frequently can survive. The trend in current treatment extends beyond the preservation of life; the ultimate goal is the return of burn victims, as full participants, back into their social and business life [1, 2].

Burns: learning from the past in order to be fit for the future

Many advances have been made in the understanding and treatment of burns. Advances in burn surgery and critical care have decreased mortality and morbidity. Survival from severe burns is no longer the exception, but unfortunately death still occurs. Williams and colleagues have determined in their recent paper the predominant causes of death in order to develop new treatment avenues and future trajectories suitable to increase survival and overall outcome. A lot of burn deaths may be preventable with better airway management and a more precise and adequate volume management, but the leading cause of death in patients suffering from severe burns, which has to be faced, is sepsis. Sepsis due to multidrug-resistant organisms will continue to impede efforts to increase survival, and new strategies that go beyond the surgical and clinical techniques, which are already implemented, have to be developed in order to fight these organisms and their related complications.

Burn care and treatment

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Reconstruction/Correction of burn alopecia

Burn alopecia is a significant disfigurement and its sequelae includes not only physical problems, but also psychological problems, such as low self-esteem, unhappiness, and dissatisfaction. Therefore, burn alopecia is a significant challenge for plastic surgeons concerning reconstruction and rehabilitation. The primary goal of reconstruction for burn alopecia is to recreate a natural hair-bearing appearance on the reconstructed scalp.

Rehabilitation and scar management

Survival was once the key parameter of success in managing serious burns, but due to improvements concerning burn care this has changed tremendously. Today, however, the aim of all treatment activities is the return of burn patients back into their private and social life under conditions, which allow independence and social sovereignty. This goal has extended the traditional role of the burn care team beyond wound closure.

Train surfing and other high voltage trauma: Differences in injury-related mechanisms and operative outcomes after fasciotomy, amputation and soft-tissue coverage

BACKGROUND In the context of scarce reports on train surfers among high voltage electric injuries, we conducted a retrospective review between January 1994 and December 2008. METHODS After matching for inclusion criteria we reviewed patient records of 37 true high voltage injuries (12 train surfers [TS] and 25 other high voltage injuries [HV]). RESULTS TS were significantly younger (TS 15.8 years vs. HV 33.3 years, p<0.0001), and had a greater %TBSA (TS 49.7%TBSA vs. HV 21.5%TBSA, p=0.0003) without affecting the median length-of-stay (TS 52 days vs. HV 49 days) or number of operations (TS 4 vs. HV 3). TS had different injury patterns, with a higher percentage of affected extremities (TS 72.9% vs. HV 52.0%, p=0.0468) and associated injuries (TS 58% vs. HV 20%, n.s.) than HV. Both groups demonstrated comparable fasciotomy (TS 71.4% vs. HV 55.8%) and amputation rates (TS 17.1% vs. HV 15.4%). While TS required less flaps (TS 3/12 vs. HV 18/25; p=0.0153), soft-tissue reconstruction revealed an overall low incidence of complication rates (one partial pedicled flap loss and two total free flap losses). CONCLUSIONS Train surfers have proven to be a distinct group of patients among high-voltage injuries notably as a result of a younger age, a shorter electric contact duration and higher velocity-induced trauma. With a possibly declining trend of train surfing-related accidents in an aging society, it will be interesting to see if emerging economies will face comparable phenomena, for which prevention strategies remain key.

Die Pathophysiologie von Verbrennungswunden

Brandverletzungen stellen weltweit ein erhebliches Problem dar. Obwohl die meisten dieser Verletzungen relativ leicht sind, ist z. B. in den USA bei 40.000 bis 60.000 Patienten jahrlich eine Einweisung in ein Krankenhaus oder in ein Verbrennungszentrum fur eine adaquate Behandlung notwendig [1]. Aktuellen Studien zufolge konnte innerhalb der letzten 20 Jahre eine Reduktion der stationaren Aufnahmen und eine 50% ige Senkung der Todesfalle infolge eines thermischen Traumas erreicht werden. Die Grunde dafur sind hauptsachlich wirksame Praventionsstrategien, durch die die Anzahl und der Schweregrad von Brandverletzungen gesenkt werden konnten [2,3]. Fortschritte bei den chirurgischen und intensivmedizinischen Therapiestrategien basieren auf einem besseren Verstandnis der pathophysiologischen Vorgange im Rahmen des thermischen Traumas. Dieses Kapitel soll das heutige Wissen zum Thema „Pathophysiologie der Verbrennungswunde“ darstellen und somit als Verstandnisgrundlage fur die Behandlung von Brandverletzten dienen.

Generation of adipose tissue based on tissue engineering: An overview

Reconstruction of soft tissue is a very common scenario in plastic and reconstructive surgery. In 2008, 4.9 millions of patients had to undergo plastic reconstructive treatment in the USA, 3.8 of those in connection with tumor removal [1]. Apart from that, more than 12.8 millions of cosmetic surgeries were carried out including different forms of soft tissue augmentation with biologic and synthetic filling material and implants [1]. Shortcomings of the conventional plastic-surgical reconstruction of tissue defects i. e. transplanting autologous or allogenic tissue include donor site morbidity in autologous transplants and immunogenicity of allogenic transplants [27, 45, 46, 50]. In addition, the body’s own resources are limited so availability is restricted.