Toxic epidermal necrolysis: use of Biobrane or skin coverage reduces pain, improves mobilisation and decreases infection in elderly patients.

INTRODUCTION: Toxic epidermal necrolysis is a rare disease with high mortality due to generalised infection, sepsis or lung involvement, and requires discontinuation of all potentially triggering medications and intensive care in a specialised burn centre. Apart from wound care with antiseptics, wound coverage may be achieved with a skin substitute; treatments are compared with regard to infection, protein loss, re-epithelialisation and mortality. PATIENTS AND METHODS: Of 14 people with toxic epidermal necrolysis affecting >30% body surface area, eight received daily dressing changes using Lavasept nd six received wound coverage with Biobrane. Demographic data, SCORTEN score, mortality, visual-analog pain scale, mobilisation, time to re-epithelialisation, serum protein, albumin, C-reactive protein and leukocytes, and body temperature were evaluated in all cases. RESULTS: Mean age of patients was 68.0+/-14.8 years, mean body surface area affected was 66.4%, median SCORTEN score was three and overall mortality was 36%. In the Biobrane ompared with the Lavasept control) group, mean pain was significantly reduced (2.9 versus 5.5 on the scale, p<0.05), mobilisation was significantly earlier (walking at 3 days versus 7 days, p=0.003), re-epithelialisation was complete in 12.5 days versus 16 days, and at 9 days there was reduced decrease of serum proteins and significantly lower levels of C-reactive protein and white cells (p<0.05). CONCLUSION: Early wound coverage with synthetic skin substitute such as Biobrane s beneficial compared with conservative antiseptic wound treatment, but mortality rate is not significantly different.

Bilateral cheek-to-nose advancement flap: an alternative to the paramedian forehead flap for reconstruction of the nose.

Skin cancer on the nose is commonly treated with surgical excision resulting in defects that require closure. The surgeon is faced with many reconstructive options. The paramedian forehead flap is one commonly used technique. In this study we describe the bilateral cheek-to-nose advancement flap as an alternative to the paramedian forehead flap in patients with strong nasolabial folds and prominent cheek tissue laxity, who require closure of MOHS surgery defects on the nasal dorsum and sidewall. Twelve patients were treated with the latter flap and evaluated after 2 weeks and 6 months. The patients' subjective and the surgeons' objective evaluation after 6 months were either completely satisfied or satisfied. The bilateral cheek-to-nose advancement flap is a reliable tool in the interventional portfolio of the reconstructive surgeon.

Lipomas after blunt soft tissue trauma: are they real? Analysis of 31 cases.

BACKGROUND: Soft tissue trauma and lipomas are common occurrences in surgical practice. Lipomas are defined as benign tumours of adipose tissue with so far unexplained pathogenesis and aetiology. A link between preceding blunt soft tissue trauma at the site of the tumour and the formation of lipomas has been described earlier. These soft tissue tumours have been named 'post-traumatic lipomas'. OBJECTIVES: In a retrospective review, to analyse all patients with benign adipose tissue tumours treated at our institution between August 2001 and January 2007. METHODS: All cases were reviewed regarding medical history, magnetic resonance imaging findings, intraoperative findings, clinical chemistry and histology. RESULTS: In 170 patients presenting with lipomas, 34 lipomas in 31 patients were identified as post-traumatic. The mean +/- SD age of the patients with post-traumatic lipomas was 52 +/- 14.5 years. The mean time elapsed between soft tissue trauma and lipoma formation was 2.0 years (range 0.5-5). Twenty-five of the 31 patients reported an extensive and slowly resolving haematoma after blunt tissue trauma at the site of lipoma formation. The mean +/- SD body mass index was 29.0 +/- 7.6 kg m(-2). Fourteen of 31 patients presented with an elevated partial thromboplastin time. Eleven of 34 lipomas were found on the upper extremities, five on the lower extremities, 13 on the trunk, and two on the face. All tumours were located subcutaneously, superficial to the musculofascial system. Thirty-three lipomas were removed by surgical excision and one by liposuction following an incisional biopsy. Histological examination revealed capsulated and noncapsulated benign adipose tissue in all 34 tumours. CONCLUSIONS: The existence of a pathogenic link between blunt soft tissue trauma and the formation of post-traumatic lipomas is still controversial. Two potential mechanisms are discussed. Firstly, the formation of so-called post-traumatic 'pseudolipomas' may result from a prolapse of adipose tissue through fascia induced by direct impact. Alternatively, lipoma formation may be explained as a result of preadipocyte differentiation and proliferation mediated by cytokine release following soft tissue damage after blunt trauma and haematoma formation.

[Resection of infected achilles tendon. Results after soft tissue coverage without tendon reconstruction]. / Resektion der infizierten Achillessehne. Ergebnisse nach plastischer Defektdeckung ohne Achillessehnenersatz.

BACKGROUND: Structural full-thickness defects of the Achilles tendon represent a severely disabling injury which should be treated by reconstruction. This study presents functional outcomes from standardised follow-up of non-reconstructed Achilles tendons with soft tissue coverage alone. PATIENTS AND METHODS: Seven patients were treated with various techniques of soft tissue reconstruction without restoration of the Achilles tendon. After a mean of 11 months postoperatively, the lower extremity was evaluated generally with regard to function, AOFAS score (ankle and hindfoot), and isokinetic torque testing by the Biodex system. RESULTS: All patients showed high mobility, muscle strength, and range of motion at follow-up. The average AOFAS score was 84.7 (maximum 100), and the torque loss in plantar flexion was 44.5% on average compared to the uninvolved side and thus comparable with results after secondary tendon reconstruction. CONCLUSION: After complete loss of the Achilles tendon, compensatory techniques can hinder significant loss of torque and endurance, compared with secondary tendon reconstruction, allowing unsupported mobility and even top athletic performance.

[Several aspects of foam materials and their possible interactions with the wound surface in the vacuum therapy]. / Aktuelle- und Zukunftsaspekte zur Interaktion von Schwamm und Wunde in der Vakuumtherapie.

Tissue engineering research has demonstrated the potential of a variety of different matrix materials to enable cell adhesion, diffusion of nutrients, vascular ingrowth, nutrition and growth promotion. Therefore it appears attractive to apply these features also to topical negative pressure therapy. The article discusses several aspects of foam materials and their possible interactions with the wound surface.

[Outpatient hand surgery--possibilities and limitations]. / Ambulante und kurzzeitstationäre Handchirurgie. Möglichkeiten und Grenzen.

On January 1st 2004, a new contract between the government, health insurance services, and hospitals was inaugurated in Germany. The aim of the contract is to decrease costs for surgical therapies by abolishing or at least minimizing hospitalization of patients. Hand surgery is widely affected by the new contract, since a very large part of surgical therapies for the hand was declared to be compulsory outdoor and another major part to be preferable outdoor. The surgeon may decide whether a patient needs inpatient or outpatient treatment but has to justify his decision. Hospitals and surgical clinics are both allowed to offer outpatient hand surgery and get the same payment under the same regulations. For most hospitals, structural changes will be necessary to offer outpatient surgery without financial loss. In our experience a personal and regular contact between patient and surgeon is most necessary for the best surgical result. Many of the compulsory outpatient operations in hand surgery can be done sufficiently and at high standard. This may not be the case for the second group to be handled not compulsory outdoor. The new contract allows hospitals to offer postoperative care for only 14 days, whereas many specific hand surgical procedures will need the surgeon's control and care for a much longer time. On the other hand, clinics and general practitioners have strict limitations for the prescription of hand therapies. We believe that the quality of hand surgery is highly dependent on sufficient postoperative treatment. If the postoperative care is neglected or restricted, secondary costs such as sick leave will increase.