S. Altmann

Die chirurgische Behandlung der axillären Hidradenitis suppurativa

Abstract.Introduction: Hidradenitis suppurativa is a chronic inflammatory disease of the cutis with furuncles, fistulas and abscesses, mostly located in the groin and axillary regions. A conservative treatment can not prevent a recurrence. Patients and methods: We report on 16 patients with axillary hidradenitis suppurativa. The inflammatory region was excised, followed by immediate coverage with a transposition flap according to Limberg. Postoperatively, all patients received antibiotic treatment. After 2 weeks, physiotherapy was begun. Results: All wounds healed primarily. Functional and aesthetic results were very satisfactory. Movement of the shoulder showed no restrictions. There was no major complication. The recurrence rate was low. Discussion: Only radical debridement prevents a recurrence. The therapy of choice is radical excision of the affected region and immediate coverage by a transposition flap. Open granulation or split-skin grafting are inferior compared with a primary closure by transposition flap. Using the Limberg flap the donor site can be closed primarily.Zusammenfassung.Einleitung: Die Hidradenitis suppurativa ist eine chronische, einschmelzende und zur Narbenbildung neigende furunculoide Entzündung der Haut. Betroffen sind hauptsächlich die Axillen und Leisten. Die konservative Behandlung kann in der Regel ein Rezidiv nicht verhindern. Daher ist eine chirurgische Therapie indiziert. Patienten und Methode: Wir führten bei 16 Patienten mit einer axillären Hidradenitis suppurativa eine rautenförmige Excision des Infektareals und die anschließende Defektdeckung durch einen Transpositionslappen nach Limberg durch. Postoperativ erhielten die Patienten eine i. v.-Antibiose. Nach 14 Tagen wurde mit intensiver Krankengymnastik begonnen. Ergebnisse: Alle Lappen heilten primär. Bei dieser Therapie war das funktionelle und ästhetische Ergebnis sehr zufriedenstellend. Die Bewegung im betroffenen Schultergelenk war bei allen Patienten problemlos möglich. Es traten keine schwerwiegenden Komplikationen auf. Die Rezidivrate war bei dieser Operationsmethode sehr gering. Diskussion: Nur die radikale Excision des betroffenen Gebiets mit einer anschließenden adäquaten Defektdeckung kann einen dauerhaften Therapieerfolg erzielen. Die offene Wundbehandlung und die Spalthauttransplantation unterliegen im Vergleich zu einer direkten, einzeitigen Defektdeckung. Durch die Verwendung eines Transpositionslappen nach Limberg ist eine sichere Defektdeckung in der Axilla mit primären Verschluss des Hebeareals möglich.

[Soft-tissue defects following olecranon bursitis. Treatment options for closure].

Olecranon bursitis has a high prevalence and is commonly treated conservatively. However, in case of bacterial infection and open injuries with chronic courses, surgery is indicated. Despite high surgical standards, soft-tissue defects cannot always be avoided in primary surgery for infectious olecranon bursitis. For complicated courses with persisting defects, standardized closing procedures are available. For maintaining adequate elbow function and avoiding long disease progression, definite closure of the defect should be achieved. Various treatment options exist: VAC therapy and local, island, distant, and free flaps. Between 1996 and 2007, 12 Patients with complicated olecranon bursitis were treated in our institution. Of them, 11 received surgery. In complicated courses of olecranon bursitis with soft-tissue defects, fistulas, or recurrent wound healing disorders, there are several procedures for plastic covering of the elbow.

Weichteildefekte nach komplizierter Bursitis olecrani

Olecranon bursitis has a high prevalence and is commonly treated conservatively. However, in case of bacterial infection and open injuries with chronic courses, surgery is indicated. Despite high surgical standards, soft-tissue defects cannot always be avoided in primary surgery for infectious olecranon bursitis. For complicated courses with persisting defects, standardized closing procedures are available. For maintaining adequate elbow function and avoiding long disease progression, definite closure of the defect should be achieved. Various treatment options exist: VAC therapy and local, island, distant, and free flaps. Between 1996 and 2007, 12 Patients with complicated olecranon bursitis were treated in our institution. Of them, 11 received surgery. In complicated courses of olecranon bursitis with soft-tissue defects, fistulas, or recurrent wound healing disorders, there are several procedures for plastic covering of the elbow.

Aggressive digital papillary adenocarcinoma – a rare malignant tumor of the sweat glands: two case reports and a review of the literature

Aggressive digital papillary adenocarcinomas are rare malignant tumors often located on the digits of the hand. Due to lack of pain, slow growth, and an inconspicuous appearance, diagnosis is often missed or delayed. We report two cases and review the present literature to give recommendations for diagnosis and treatment.

Operative decisions for endoscopic treatment of cubital tunnel syndrome.

The authors review the relevant anatomy and provide technical tips for endoscopic decompression of the cubital tunnel. Cubital tunnel syndrome is the second most common nerve compression syndrome in the upper extremity. Until recently, surgeons focused on open decompression combined with submuscular or subcutaneous transposition of the nerve. Decompression was usually limited to the region of the medial epicondyle, and related morbidity was relatively high. Endoscopic decompression is a promising technique because the dissection range can be extended and the scar length can be reduced. The authors review the relevant anatomy for the endoscopic approach and give some recommendations concerning the details of the surgical technique.

Syndromes with focal overgrowth in infancy: Diagnostic approach and surgical treatment.

Abstract Syndromes with focal overgrowth are sporadic diseases and comprise Proteus syndrome and congenital lipomatous overgrowth, vascular malformations, and epidermal naevi (CLOVE) syndrome, and isolated hemihyperplasia. We describe 3 children classified according to standard criteria with dysregulated growth of various tissues that was excised, together with excess toes, and tumours. Correct classification facilitates diagnosis and operations. Interdisciplinary treatment and follow-up are recommended to prevent disfiguration.

Therapieoptionen bei Dekubitalulzera

The aim of this overview is based on remarks on the pathogenesis of and therapy for pressure ulcers and selected but representative cases to demonstrate current options of plastic coverage. As a consequence of the demographic developments, in particular, with regard to the increasing proportion of older patients as well as the advances in modern medicine, the number of multimorbid, geriatric and bedridden patients and of those with prolonged sickbed periods has been steadily growing. Therefore, partly severe manifestations of pressure ulcers at various exposed body regions can be observed in spite of the best preventive intention of care. While in the early stages rather conservative treatment is adequate, surgical intervention might become important and indispensable for a sufficient treatment in advanced stages. To facilitate basic care and to appropriately treat the infectious focus, the methods and procedures of plastic surgery can become relevant. Although there are several options and approaches existing to sanitise and cover defects of pressure ulcers, which are described within the article based on representative cases, preventive measures can still be considered the best approach.

[What do general, abdominal and vascular surgeons need to know on plastic surgery - aspects of plastic surgery in the field of general, abdominal and vascular surgery].

There is overlap between general, abdominal and vascular surgery on one hand and plastic surgery on the other hand, e.g., in hernia surgery, in particular, recurrent hernia, reconstruction of the abdominal wall or defect closure after abdominal or vascular surgery. Bariatric operations involve both special fields too. Plastic surgeons sometimes use skin and muscle compartments of the abdominal wall for reconstruction at other regions of the body. This article aims to i) give an overview about functional, anatomic and clinical aspects as well as the potential of surgical interventions in plastic surgery. General/abdominal/vascular surgeons can benefit from this in their surgical planning and competent execution of their own surgical interventions with limited morbidity/lethality and an optimal, in particular, functional as well as aesthetic outcome, ii) support the interdisciplinary work of general/abdominal/vascular and plastic surgery, and iii) provide a better understanding of plastic surgery and its profile of surgical interventions and options.

The human being as replacement part donor

In der heutigen Zeit ist die „Ersatzteilchirurgie“ en vogue. Die häufigsten eingesetzten Ersatzteile sind sicherlich die künstlichen Gelenke in der Orthopädie und Chirurgie. Die Verwendung von Kunstnetzen in der Abdominalchirurgie, die Implantation von Silikonprothesen in der Brustrekonstruktion, Kunststoffröhrchen zur Überbrückung von Nervendefekten oder Knochenersatzstoffe – die Liste von etablierten Ersatzteilen in der Chirurgie ist lang. Doch vor lauter Euphorie werden oft die Nachteile und möglichen Komplikationen von Fremdmaterialien vernachlässigt. Zum einen ist die Verwendung von Fremdmaterialien häufig sehr teuer und zum anderen sind Komplikationen wie Entzündungen, Fistelbildungen, Abstoßungsreaktionen oder Materialversagen nicht selten [1–8]. Aktuell zeigt sich am Skandal um die Brustimplantate des Unternehmens Poly Implant Prothèse (PIP), wie gefährlich der Umgang mit nicht ausreichend geprüften Medizinprodukten sein kann. Die Verwendung dieser Brustimplantate führte zum vermehrten Auftreten von chronischen Entzündungen oder Rupturen. Sogar eine kanzerogene Wirkung wurde kurzzeitig diskutiert, konnte jedoch nicht belegt werden. Die Gesundheitsbehörden empfehlen daher den generellen Austausch aller implantierten Prothesen dieses Herstellers. Die gesundheitlichen Schäden der Patientinnen, der finanzielle Schaden und der Imageverlust sind bisher noch nicht absehbar. Etablierte Alternativen bietet der Ersatzteilspender Mensch. Durch die Verwendung von Eigengewebe können langfristig funktionell stabile und ästhetisch ansprechende Ergebnisse erzielt werden. Durch die funktionelle Rekonstruktion der Bauchwand bei Hernien und Bauchwanddefekten mit innerviertem Muskelgewebe kann die Bauchwand physiologisch auf Druckund Spannungsänderungen reagieren. Die Rekonstruktion der Brust nach Ablatio mammae mit Eigengewebe aus Bauch, Bein oder Gesäß bietet langfristig das natürlichste und ästhetisch schönste Ergebnis. Auch in der Extremitätenchirurgie können Schäden an Sehnen, Nerven, Muskeln und Knochen sehr gut durch Eigengewebe rekonstruiert werden. In diesem Beitrag möchten wir anhand von klinischen Beispielen Möglichkeiten zur Verwendung von Eigengewebe alternativ zu Fremdmaterialien aufzeigen. Dabei werden wir auf die Vorteile, aber auch auf die Nachteile des Eigengewebes eingehen.

Die plastische Versorgung von Weichteildefekten nach Endoprothetik an der unteren Extremität

BACKGROUND The implantation of endoprostheses is an established procedure in orthopaedic and trauma surgery. However, the techniques are often associated with a high risk of post-interventional infections and wound healing disorders that can result in loss of the prosthesis or the limb--most likely based on an insufficient debridement and poor soft-tissue coverage. The purpose of this study was to evaluate the efficacy of the coverage methods in our patient population. PATIENTS In the past 10 years 38 patients with exposed knee prostheses and 14 patients following an ankle endoprosthesis were included in this retrospective study over the period from 2001 to 2011. Soft-tissue reconstructions around the knee were mostly performed by unilateral or bilateral gastrocnemius flaps combined with split-skin grafts. One defect was covered with a free flap. 57% of the soft-tissue defects around the ankle are often problematic and were closed by a pedicled peroneus brevis muscle flap and 35% by a free flap (3 with a latissimus dorsi muscle flap, 2 with a free lateral upper arm flap and one with an anterolateral tight flap). RESULTS In our patient population we achieved stable soft-tissue coverage in most of the cases using the above-mentioned flaps. Due to multiple preexisting comorbidities, it was observed that the course was frequently prolonged and wound healing difficulties occurred. These, however, could be controlled by conservative means or small secondary procedures. CONCLUSION A radical debridement and an early appropriate defect coverage of the exposed prosthesis is crucial in the reconstruction process. Through a close interdisciplinary collaboration a stable soft-tissue covering can be achieved. Consequently it is possible to avoid a loss of the endoprosthesis, marked functional deficits or even amputations.