Robert Hierner

Long-Term Results after Lower-Leg Replantation

Background:Although subtotal and total lower-leg amputation have been sucessfully replanted in the past, nowadays there is a common opinion that “these replantations do not justify their efforts, and therefore the patients should undergo primary amputation”.Patients and Methods:In order to clarify this hypothesis, a retrospective clinical study of own cases operated on between 1981—1998 and an extensive literature research we carried out. The following criteria were evaluated: (1) survival rate, (2) individual motor and sensory functions and global lower extremity function judged according to the classification of Chen et al., (3) socioeconomic aspects (operation time, number of operations per patient, time of hospitalization, return to normal life), (4) number and nature of local and/or systemic complications, and (5) subjective judgment by the patient.Results:All replanted lower legs in this series survied. Using the classification of Chen et al. the functional results can be given as follows: stage I 64.2%, stage II 28.5% (thus, a “functional extremity” could be reconstructed in 92.7%), stage III 7.1%, and stage IV 0%. Social reintegration was achieved within 8–10 months after replantation. Four to seven secondary operations were carried out in every patient in order to improve the result. Total duration of therapy was 28–48 months. There were no secondary reamputation.Conclusion:Using an algorithm developed by the authors, there is a significant decrease in replantation frequency on the one hand (30% of all tranferred cases in the own replantation center). However, on the other hand those cases replanted show better functional and aesthetic results and a significantly lower replantation risk. The results of this study as well as those of other large series show that lower-leg replantation is still worthwhile in a well-selected patient group, contrary to what is believed by an increasing number of orthopedic and trauma surgerons.

The allogenic nerve graft

A segmental nerve defect is still best be treated by autologous nerve graft. However, besides its donor side morbidity, extensive nerve defects of peripheral nerves or the brachial plexus often cannot be completely treated due to missing quantity of autologous nerve graft material. Thus two solution are possible: first, incomplete reconstruction — the abandoned nerve trunk is used as additional source of autologous graft material (ulnar nerve in complete brachial plexus palsy), or second, the application of new reconstruction techniques, such as nerve distraction [1], tubes [7] or nerve allografts [3, 9, 14]. Nerve distraction is still in the laboratory phase [1, 11]. Nerve tubes should not be chosen in cases of mixed nerve and=or defect larger than 10mm [2]. Thus the nerve allograft still seems to be the best substitute.

Konzepte der Schulterchirurgie

Infektionen am Schultergelenk sind den Angaben der Literatur zufolge eher selten. Dennoch sind eine Reihe von schwerwiegenden, sogar letalen Komplikationen beschrieben [Ambacher et al., 2002], die in erster Linie durch die zu spate Diagnosestellung, verzogert einsetzende Therapie und die topografische Nahe zum Rumpf bedingt sind.