M. Lehnhardt

Limb Salvage in Malignant Tumors

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patients specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

[Importance of specialized centers in diagnosis and treatment of extremity-soft tissue sarcomas. Review of 603 cases].

ZusammenfassungDie onkologiegerechte Therapie maligner Weichgewebstumoren setzt eine korrekte Diagnosestellung inklusive Angabe des Gradings voraus. Aufgrund der Seltenheit dieser Tumoren, einer Vielzahl verschiedener Subtypen, dem teilweise uneinheitlichen histologischen Erscheinungsbild und nicht repräsentativen Biopsiepräparaten ist diese Klassifikation oft erschwert.Sechshundertdrei konsekutive Patientenakten mit der Diagnose „maligner Weichgewebstumor“ der Extremitäten inklusive Schulter und Glutealbereich wurden im Hinblick auf Diagnoseabweichungen der Primär- und Referenzpathologie sowie deren Abhängigkeit von der Tumorentität, der Befundung aus Primär- oder Rezidivtumor und der beurteilenden pathologischen Einrichtung ausgewertet. Als referenzpathologische Institute dienten das auf Weichgewebstumoren spezialisierte Institut für Pathologie der Ruhr-Universität Bochum am BG-Universitätsklinikum Bergmannsheil in Kooperation mit dem Institut für Pathologie der Universität Jena.Liposarkome und pleomorphe („not otherwise specified“, NOS-)Sarkome stellten mit 24 und 22,6% die größten Gruppen. Von den acht am häufigsten diagnostizierten Sarkomen wurden maligne periphere Nervenscheidentumoren und Leiomyosarkome mit 78,4 und 74,2% der Fälle am häufigsten diskordant diagnostiziert. Die Quote lag für nicht spezialisierte Pathologiepraxen und Einrichtungen an Allgemein- und Universitätskrankenhäusern über 60%. Für eine individuelle, adäquate chirurgische und neo-/adjuvante Therapie ist die referenzpathologische Begutachtung sarkomverdächtiger Tumorproben zu fordern.AbstractCorrect histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorder’s rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.Correct histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorders rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.

Die Bedeutung von Referenzzentren in Diagnose und Therapie von Weichgewebssarkomen der Extremitäten

ZusammenfassungDie onkologiegerechte Therapie maligner Weichgewebstumoren setzt eine korrekte Diagnosestellung inklusive Angabe des Gradings voraus. Aufgrund der Seltenheit dieser Tumoren, einer Vielzahl verschiedener Subtypen, dem teilweise uneinheitlichen histologischen Erscheinungsbild und nicht repräsentativen Biopsiepräparaten ist diese Klassifikation oft erschwert.Sechshundertdrei konsekutive Patientenakten mit der Diagnose „maligner Weichgewebstumor“ der Extremitäten inklusive Schulter und Glutealbereich wurden im Hinblick auf Diagnoseabweichungen der Primär- und Referenzpathologie sowie deren Abhängigkeit von der Tumorentität, der Befundung aus Primär- oder Rezidivtumor und der beurteilenden pathologischen Einrichtung ausgewertet. Als referenzpathologische Institute dienten das auf Weichgewebstumoren spezialisierte Institut für Pathologie der Ruhr-Universität Bochum am BG-Universitätsklinikum Bergmannsheil in Kooperation mit dem Institut für Pathologie der Universität Jena.Liposarkome und pleomorphe („not otherwise specified“, NOS-)Sarkome stellten mit 24 und 22,6% die größten Gruppen. Von den acht am häufigsten diagnostizierten Sarkomen wurden maligne periphere Nervenscheidentumoren und Leiomyosarkome mit 78,4 und 74,2% der Fälle am häufigsten diskordant diagnostiziert. Die Quote lag für nicht spezialisierte Pathologiepraxen und Einrichtungen an Allgemein- und Universitätskrankenhäusern über 60%. Für eine individuelle, adäquate chirurgische und neo-/adjuvante Therapie ist die referenzpathologische Begutachtung sarkomverdächtiger Tumorproben zu fordern.AbstractCorrect histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorder’s rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.Correct histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorders rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.

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.

Repetitive extracorporeal shock wave applications are superior in inducing angiogenesis after full thickness burn compared to single application

OBJECTIVE Burn wounds remain a challenge due to subsequent wound infection and septicemia, which can be prevented by acceleration of wound healing. The aim of the study was to analyze microcirculation and leukocyte endothelium interaction with particular focus on angiogenesis after full-thickness burn using three different repetitions of low energy shock waves. METHODS Full-thickness burns were inflicted to the ears of hairless mice (n=44; area: 1.6±0.05 mm2 (mean±SEM)). Mice were randomized into four groups: the control group received a burn injury but no shock waves; group A received ESWA (0.03 mJ/mm2) on day one after burn injury; group B received shock waves on day one and day three after burn injury; group C ESWA on day one, three and seven after burn injury. Intravital fluorescent microscopy was used to assess microcirculatory parameters, angiogenesis and leukocyte interaction. Values were obtained before burn (baseline value) immediately after and on days 1, 3, 7 and 12 after burn. RESULTS Shock-wave treated groups showed significantly accelerated angiogenesis compared to the control group. The non-perfused area (NPA) is regarded as a parameter for angiogenesis and showed the following data on day 12 2.7±0.4% (group A, p=0.001), 1.4±0.5% (group B, p<0.001), 1.0±0.3% (group C, p<0.001), 6.1±0.9% (control group). Edema formation is positively correlated with the number of shock wave applications: day 12: group A: 173.2±9.8%, group B: 184.2±6.6%, group C: 201.1±6.9%, p=0.009 vs. control: 162.3±8.7% (all data: mean±SEM). CONCLUSION According to our data shock waves positively impact the wound healing process following burn injury. Angiogenesis showed significantly improved activity after shock wave application. In all three treatment groups angiogenesis was higher compared to the control group. Within the ESWA groups, double applications showed better results than single application and three applications showed better results than single or double applications.

Combined Pollicization and Toe Transfer for Thumb Reconstruction

A 45-year-old orthopaedic surgeon sustained a complete thumb amputation and severe injuries to his index finger in a lawn mower accident. He was treated with a combined second toe transfer and an index finger pollicization.

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.

Photoplanimetric evaluation and impedance measurement of split-thickness skin grafts: a new model for objective wound-healing assessment in clinical trials

Purpose: The objective assessment of wound healing is a challenging task especially in the context of clinical trials. Because the clinical evaluation of wounds and the wound‐healing quality is often influenced by the subjective view of the physician, there is great need for a reliable, quantitative and objective wound model that would help to obtain statistically useful data. Here, we present a wound model and non‐invasive analysis techniques to evaluate human wound healing. The model described was used in a clinical trial on 167 patients treated with a new wound therapeutic agent.

[Sternal osteomyelitis. Etiology, diagnostics and operative therapy concepts].

Deep sternal infections with sternal osteomyelitis are rare conditions with extensive consequences for the patient. The incidence of complications after median sternotomy is as high as 0.4-8 %. Wound and sternal dehiscence and a septic course with mediastinitis leading to septic shock is a feared complication with a high mortality next to the chronic course of the infection with the clinical correlation of presternal fistulas. An early diagnosis and surgical intervention is decisive to enhance the prognosis of the disease, leading to a significant increase in the survival rate of patients.

Surgical correction of pterygium colli

BACKGROUND/PURPOSE Webbing of the neck is a deformity seen in various syndromes, including Turners, Klippel-Feil, or Escobar-Syndrome. There is little information in literature to provide the surgeon with treatment options for these children. We reviewed our experience with the surgical correction of pterygium colli deformity in eleven patients. METHODS A retrospective review was conducted on all patients that underwent surgical correction of pterygium colli deformity within the last 8 years. Data recorded included patient demographics, diagnostic evaluation, surgical treatment, complications, and outcome. RESULTS Eleven patients underwent an operation to correct pterygium colli deformity. Six patients had z-plasties, and three patients underwent bilateral excision of an ellipsoid portion of skin and closure via unilateral advancement flaps. We later modified our technique to combine the unilateral advancement flap with Z-Plasties. The mean age at operation was 10.7 years (range 2-23 years). No postoperative wound infections occurred. Mild recurrence of webbing was found in one case. In four patients we found mild to moderate hypertrophic scarring. Average overall content was 7.8 (scale of 0-10, 10 being total content), and all patients, respectively their parents, would undergo the surgery again. Mean length of follow-up was 28.3 months. CONCLUSION Our study shows that overall patient satisfaction is very high, but an accurate preoperative planning with the patient and parents and an honest discussion of all questions and concerns raised by the parents are essential.