Oliver Lotter

A clinical evaluation of Biobrane® and Suprathel® in acute burns and reconstructive surgery

BACKGROUND In the treatment of superficial partial-thickness burns, various skin substitutes and temporary dressings offer potential advantages over traditional treatments. Nonetheless, the search for an ideal temporary skin substitute or biosynthetic wound dressing is still a continuous quest. This research aimed to provide objective data on the long-term outcome of Biobrane(®) and Suprathel(®). METHODS Eight months after the initial burn treatment of Biobrane(®) and Suprathel(®), skin elasticity was measured objectively using a Cutometer(®) and the scarring process was quantified using the Vancouver Scar Scale (VSS). RESULTS The median healing time for patients treated with Biobrane(®) was up to 1.8 days shorter then the Suprathel(®) group. Regarding the Vancouver Scar Scale (VSS), neither the single parameter, nor the total score were significantly different in both groups. In comparison, the Biobrane(®) group demonstrated superior Cutometer(®) parameters in regards to maximal extension, elasticity, retraction and pliability. Despite higher levels of Biobrane(®) group, the differences in the viscoelastic analysis of both substitutes did not vary significantly. CONCLUSION Using both substitutes, we observed satisfying results in superficial partial-thickness burn treatment, without any significant differences. Since the treatment of burned patients is associated with high socioeconomic load, the cost factor should be one of the most important criteria in dermal substitute selection.

Critical analysis of causality between negative ulnar variance and Kienböck disease.

Background: Negative ulnar variance has been associated with Kienböck disease, both supporting a causal link and providing a basis for therapeutic recommendations. The aim of this study was to determine whether there is a causal relationship between Kienböck disease and negative ulnar variance. Methods: The causal relationship between Kienböck disease and negative ulnar variance was assessed using three methodologies: (1) an analysis of the quantitative and qualitative distribution of ulnar variance in a case-control study of 81 patients with Kienböck disease and a control group of 212 healthy wrists; (2) a systematic literature review and meta-analysis of six case-control studies (including the case-control study presented in this article) to test for an association between Kienböck disease and negative ulnar variance; and (3) a determination of causal relationship by using the Bradford Hill criteria. Results: The case-control study indicated that when Kienböck disease is associated with negative ulnar variance (59 of 81), in 75 percent of the cases negative ulnar variance was equal (29 of 59) or less (15 of 59) pronounced on the contralateral healthy side. The odds ratio generated from the meta-analysis demonstrated a significant association between Kienböck disease and negative ulnar variance (OR, 3.58; 95 percent CI, 1.59 to 8.06; p = 0.002, random effects method). Six of nine Bradford Hill criteria do not support a causal relationship. Conclusions: The significant association between Kienböck disease and negative ulnar variance can be well explained by selection bias because magnetic resonance imaging, which may detect and allow exclusion of a potential ulnar impaction syndrome, was performed in only the Kienböck disease group in all six case-control studies. The application of the Bradford Hill criteria does not provide sufficient scientific evidence to support a causal relationship between Kienböck disease and negative ulnar variance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Fibulo-scapho-lunate arthrodesis after resection of the distal radius for giant-cell tumor of the bone

Giant‐cell tumors of the distal radius are rare. They have a high‐risk of local recurrence and a risk of pulmonary metastasis. Curettage alone or combined with adjunctive agents is often associated with local recurrence.

A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration

BackgroundWe systematically reviewed etiological factors of Kienböck’s disease (osteonecrosis of the lunate) discussed in the literature in order to examine the justification for including Kienböck’s disease (KD) in the European Listing of Occupational Diseases.MethodsWe searched the Ovid/Medline and the Cochrane Library for articles discussing the etiology of osteonecrosis of the lunate published since the first description of KD in 1910 and up until July 2012 in English, French or German. Literature was classified by the level of evidence presented, the etiopathological hypothesis discussed, and the authors conclusion about the role of the etiopathological hypothesis. The causal relationship between KD and hand-arm vibration was elucidated by the Bradford Hill criteria.ResultsA total of 220 references was found. Of the included 152 articles, 140 (92%) reached the evidence level IV (case series). The four most frequently discussed factors were negative ulnar variance (n=72; 47%), primary arterial ischemia of the lunate (n=63; 41%), trauma (n=63; 41%) and hand-arm vibration (n=53; 35%). The quality of the cohort studies on hand-arm vibration did not permit a meta-analysis to evaluate the strength of an association to KD. Evidence for the lack of consistency, plausibility and coherence of the 4 most frequently discussed etiopathologies was found. No evidence was found to support any of the nine Bradford Hill criteria for a causal relationship between KD and hand-arm vibration.ConclusionsA systematic review of 220 articles on the etiopathology of KD and the application of the Bradford Hill criteria does not provide sufficient scientific evidence to confirm or refute a causal relationship between KD and hand-arm vibration. This currently suggests that, KD does not comply with the criteria of the International Labour Organization determining occupational diseases. However, research with a higher level of evidence is required to further determine if hand-arm vibration is a risk factor for KD.

Systematic Review and Meta-Analysis on the Work-Related Cause of de Quervain Tenosynovitis: A Critical Appraisal of Its Recognition as an Occupational Disease

Background: The authors systematically reviewed all of the etiopathologic factors discussed in the literature to verify the classification of de Quervain tenosynovitis on the list of occupational diseases. Methods: The authors searched Ovid MEDLINE, EMBASE, and the Cochrane Library for articles discussing the cause of de Quervain tenosynovitis. The literature was classified by the level of evidence presented, the etiopathologic hypothesis discussed, the authors’ conclusion about the role of the etiopathologic hypothesis, and the first author’s professional background. The quality of reporting of the observational studies was evaluated by an extended Strengthening the Reporting of Observational Studies in Epidemiology statement checklist. A meta-analysis of all controlled cohort studies was performed. The Bradford Hill criteria were used to evaluate a causal relationship between de Quervain tenosynovitis and occupational risk factors. Results: A total of 179 references were found, and 80 articles were included. On average, only 35 percent (median, 35 percent; range, 16 to 60 percent) of all items on the extended Strengthening the Reporting of Observational Studies in Epidemiology checklist were addressed per article. The meta-analysis to evaluate the strength of the association between de Quervain tenosynovitis and (1) repetitive, (2) forceful, or (3) ergonomically stressful manual work suggested an odds ratio of 2.89 (95 percent CI, 1.4 to 5.97; p = 0.004). No evidence was found to support the Bradford Hill criteria for a causal relationship between de Quervain tenosynovitis and occupational risk factors. Conclusion: No sufficient scientific evidence was provided to confirm a causal relationship between de Quervain tenosynovitis and occupational risk factors. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

An international opinion research survey of the etiology, diagnosis, therapy and outcome of Kienböck's disease (KD).

OBJECTIVES Every fourth publication on Kienböcks disease (KD) is based for the most part on rather divergent expert opinion. We therefore surveyed expert opinion on KD in three European countries: (1) for the suspected aetiologies; (2) routinely used diagnostic tools; (3) recommended treatment and (4) expected outcome. METHODS A questionnaire consisting of 16 questions was handed out at the national meetings for surgery of the hand in Germany (DE), France (FR) in 2009 and in the United Kingdom (UK) in 2010. RESULTS Among the 126 surgeons who participated in the survey, 82 had a national diploma for surgery of the hand. None of the most commonly discussed etiopathological hypotheses were estimated as being very likely. Hand/arm vibration exposure was considered less likely among respondents in France and the UK than among respondents in Germany. Treatment recommendations are very heterogeneous for stage IIIB according to Lichtman. CONCLUSIONS Expert opinions on diagnostic criteria, the pathogenesis and the choice of treatment are not consistent and may vary from one country to another.

Prospective Case-control Study on the Etiopathology of Kienböck Disease

Background: Multiple hypotheses regarding the cause of Kienböck disease have been proposed in seemingly contradictory small case series and cohort studies with inadequate statistical power. A prospective case-control study was conducted to analyze frequently discussed risk and causal factors. Methods: Eighty-one consecutive patients with Kienböck disease and 198 patients with wrist ganglia were referred to the authors’ clinic between 1990 and 2012, and 2003 and 2011, respectively. Patients with wrist ganglia were chosen as a control group because of the similar age distribution compared with the general population and because the common etiopathologic features of wrist ganglia and Kienböck disease can be excluded. Demographic, occupational, and medical information, including age, sex, handedness, ethnicity, education, occupation and employment status, prior treatment, and medical history were collected. Associated conditions and medication were assessed at a follow-up examination. Results: Sixty-five of 81 patients with Kienböck disease and 70 of 198 controls were included in the study. Both groups were comparable with respect to age distribution and handedness. Employment status and job characteristics were similar in both groups. Hand-arm vibration during work or leisure activity over a period of 2 years was present in 23 percent with Kienböck disease and in 24 percent of 70 controls. Cortisone was used in six of 65 cases with Kienböck disease [controls, zero of 70] for an average duration of 46 months. Conclusions: Trauma, hand-arm vibration, heavy manual labor, and comorbidities were not associated with Kienböck disease. Steroid-associated Kienböck disease in six of 65 cases is consistent with the findings reported for osteonecrosis of other parts of the skeleton. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Evaluating the role of Netrin-1 during the early phase of peripheral nerve regeneration using the mouse median nerve model

BACKGROUND Less is known about the role of Netrin-1 in the peripheral nervous system. In this study, we evaluated the role of Netrin-1 using the mouse median nerve model for assessment of peripheral nerve regeneration. METHODS Using real-time PCR and western blot analysis, we examined expression changes of netrin-1 mRNA and Netrin-1 protein after transection and repair of the mouse median nerve in Wild-type animals. We further evaluated histomorphometrical changes as well as the functional recovery of the grasping force after median nerve transection and repair in WT mice and Netrin-1(+/-) heterozygous mice. RESULTS RT-PCR revealed a 1, 9 fold increase of Netrin-1 mRNA two weeks after nerve transection and repair in the nerve segment distal to the injury site. In Western blot analysis, we could show a high increase of Netrin-1 in the nerve segment distal to the injury site at day 14. Histomorphometrical analysis showed significantly higher cross sectional area and a lower fibre density in heterozygous Netrin-1(+/-) mice. Using the functional grasping test, we could show that peripheral nerve regeneration is significantly diminished in heterozygous Netrin-1(+/-) mice. CONCLUSIONS Employing the mouse median nerve model in transgenic animals, we demonstrate that Netrin-1 plays an important role during peripheral nerve regeneration.

Palliative surgery for skeletal metastases from melanoma in the scaphoid – A critical case report appraisal

A 46-year-old woman with a history of metastatic malignant melanoma presented with what appeared to be a scaphoid nonunion. Biopsy and subsequent scaphoid excision confirmed the diagnosis of metastatic melanoma. Her quality of life was improved for her remaining 13 months by scaphoid excision. We assessed our results in relation to the literature.

Development of DRGs in reconstructive breast surgery

Diagnosis-Related Groups (DRG) were introduced in Germany in 2004 as a medico-economic classification system. In this analysis, we looked at reconstructive surgery after breast cancer, focusing on changes of the fee-per-case system in the last 6 years. Immediate, delayed, pedicle and free flaps as well as alloplastic reconstructive methods were analysed using data from German reference hospitals. We analysed the length of stay, reimbursements, costs and profits. The biggest profit margin was found in free perforator flaps. These were up to 3 times higher than in alloplastic reconstruction and pedicle flaps. Due to the fact that the underlying costs for the calculation of reimbursement are always retrospective, we accounted for the rate of price increase. In spite of increasing mean profits, foregone profits of up to €574 per case due to inflation were not taken into consideration. Contrary to actual guidelines, neither the immediate reconstruction of the breast by autologous tissue, nor the bilateral reconstruction is taken into account economically. Although a more differentiated reimbursement of breast reconstruction by DRG has taken place in the last years, the subject still remains a classical example for insufficient mapping of new medical standards in our DRG system. As the choice of surgical therapy is increasingly influenced by free market mechanisms, the risk for economic selection in contradiction to clinical recommendations becomes a real problem. Even 9 years after its introduction, the German DRG system is far from being a learning or quick adapting system.