Retention of different all ceramic endocrown materials cemented with two different adhesive techniques.

OBJECTIVE: The purpose of this in vitro study was to evaluate the influence of two adhesive techniques on the retentive force of four all ceramic endocrowns. MATERIALS AND METHODS: Forty maxillary first molars of approximately similar size and shape were collected. The teeth were all decoronated 2 mm above the level of proximal cement-enamel junction (CEJ) and were all endodontically treated. The teeth were then randomly divided equally into four groups (10 each) according to all ceramic material used, as follows: Group I (VE) - Ten prepared molars were restored with hybrid ceramic (Vita Enamic); Group II (LU) - Ten prepared molars were restored with resin Nano-ceramic (Lava Ultimate). Group III (CD) - Ten prepared molars were restored with zirconia-reinforced lithium di-silicate ceramic material (Celtra Duo); Group IV (LZ) - Ten prepared molars were restored with zirconia ceramic (Lava Zirconia). Each group was then subdivided into two equal subgroups (n=5) according to the type of cement (adhesive technique) used for cementation. Subgroup A (RX ARC): the endocrowns were cemented with a total-etch adhesive resin cement (RelyX ARC). Subgroup B (RXU): the endocrowns were cemented with self-adhesive resin luting cement (RelyX UniCem). The restorations were designed with an outer cylindrical handle located on buccal and palatal surfaces to provide a mean for the removal of the endocrowns during the pull-out testing. The cemented endocrowns were thermocycled and then removed along the path of insertion using a universal testing machine at 0.5 mm/min. The retentive force was recorded, and the stress of dislodgement was calculated using the surface area of each preparation. RESULTS: The highest mean dislodgement stresses were 64.3 MPa for Group I (VE), whereas there was no statistically significant difference between Group I, II and III and LZ showed the lowest values with significant difference between the other three groups. Regarding the type of cement, there was a statistically significant difference between RelyX ARC (mean=60.09 MPa) and RelyX Unicem (mean=49.73 MPa). CONCLUSIONS: Retention of Vita Enamic, Lava Ultimate, and Celtra Duo are significantly higher than Lava Zirconia.

Marginal gap distance and cyclic fatigue loading for different all-ceramic endocrowns.

OBJECTIVE: The aim of the study was to evaluate the effect of the fabrication techniques of two types of glass ceramics on the marginal gap distance and the fracture resistance of endocrown restorations after cyclic loading. MATERIALS AND METHODS: Forty extracted mandibular first molars were root canal treated. Decoronation was done for all the endodontically treated teeth 2 mm above the cemento-enamel junction. The teeth were individually fixed vertically into epoxy resin mounting cylinders. All teeth were prepared to receive endocrown restorations. The prepared teeth were randomly divided into four equal groups (n=10) according to the all-ceramic materials and technique used for endocrown construction as follows: Group I (n=10): Pressable lithium disilicate glass ceramics (IPS e-max Press), Group II (n=10): Pressable zirconia-reinforced lithium disilicate glass ceramics (Celtra Press), Group III (n=10): Machinable lithium disilicate glass ceramics (IPS e-max CAD), Group IV (n=10): Machinable zirconia-reinforced lithium disilicate glass ceramics (Celtra Duo). The endocrowns were cemented using dual-cure resin cement. All endocrowns were subjected to fatigue loading. The cycles were repeated 120,000 times to clinically simulate one year chewing condition. Marginal gap distance of all endocrowns was measured directly using a digital microscope with x100 magnification. The load required to failure was recorded in Newton. Data were collected, tabulated, and statistically analyzed. RESULTS: Fracture resistance testing of all-ceramic crowns revealed a statistically significant difference between all different ceramic materials used in this study (p-value <0.001). On the other hand, there was a statistically significant difference between all the four ceramic crowns for the marginal gap distance either before or after fatigue cyclic loading. CONCLUSIONS: After considering the limitation of the current study, the following conclusions were given: endocrowns are considered one of the promising minimally invasive restorations for root canal treated molars. CAD/CAM technology revealed better results than heat press technology regarding the fracture resistance of glass ceramics. Heat Press technology revealed better results than CAD/CAM technology regarding the marginal accuracy of glass ceramics.

[Reconstruction of the vascular compromised lower extremity - report of the consensus workshop at the 35. Meeting of the DAM (Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße) 2013 in Deidesheim]. / Rekonstruktion der vaskulär kompromittierten unteren Extremität - Bericht des Consensus-Workshops im Rahmen der 35. Jahrestagung der DAM 2013 in Deidesheim.

INTRODUCTION: As microsurgical reconstruction is now being increasingly performed on patients with critical peripheral perfusion and/or arterial occlusive disease in numerous centres, there is a need for standardisation of interdisciplinary diagnostic approach and treatment regimens in such critically ill patients. In a consensus workshop on reconstruction of the vascular compromised lower extremity during the 35th Annual Meeting of the German working group microsurgery of the peripheral nerves and vessels (DAM) in 2013 in Deidesheim, DAM members together with vascular surgeons and interventional radiologists attempted to establish interdisciplinarily routine pathways for diagnosis and therapy and to consolidate key recommendations for treatment. METHODS: By reviewing the literature and considering the results of the expert meetings, options and limits of therapy were illustrated and recommendations for successful cooperative treatment formulated. RESULTS: By means of interdisciplinary cooperation, limbs can be salvaged and the quality of live as well as survival of patients with severe peripheral vascular disease improved. Different techniques including angioplasty, bypass surgery and microsurgical free flaps can be applied and individualised concepts allow extremity salvage even in patients with severely compromised limbs. Revascularisation provides the possibility of free flap transfer while the risk for the patients is moderate. DISCUSSION: The poor general condition of the patient requires a sufficient interdisciplinary preoperative planning. By means of interdisciplinary cooperation, the limbs can be salvaged. This not only improves the quality of life but also increases the survival time of patients with occlusive vascular disease. Different concepts for this group of patients have been developed. Surgical treatment with a distal bypass or recanalisation and free flap not only allow for the coverage of large defects, but also represent a haemodynamic advantage by increased blood flow in the bypass. This is attributed to the additional vascular bed that is transplanted with the free flap. Limb salvage means relevant improvement, however, the initially less demanding procedure of amputation must always be considered.

[Dupuytren's disease - patient satisfaction and functional results one year after partial fasciectomy and injection of collagenase]. / Morbus Dupuytren - Patientenzufriedenheit und funktionelle Ergebnisse ein Jahr nach partieller Aponeurektomie und Injektion von Kollagenase.

INTRODUCTION: The gold standard in the treatment of Dupuytren's disease is the partial fasciectomy (PF). Injection of a collagenase directly into the Dupuytren cord is an alternative method. In contrast to needle fasciotomy, destruction of the cord is achieved enzymatically and not mechanically. 24 h after injection, the treated finger can be extended passively to disrupt the Dupuytren cord. PATIENTS AND METHODS: Functional outcome and patient satisfaction were prospectively analysed in 2 comparable groups of patients with the same stage of disease. Follow-up was one year. Patients in the first group underwent partial fasciectomy (PF) (n=13), whereas patients in the second group were treated by an injection of collagenase (CG) in the diseased tissue (n=14). Besides clinical examination, outcome was evaluated by validated questionnaires (DASH/MHQ) and a customised questionnaire. RESULTS: Extension after PF (mean residual contracture 7.5°) was better than after collagenase injection (mean residual contracture 13.2°). Side-effects like numbness, impaired blood circulation and pain were less after injection of collagenase than after PF and of shorter duration. Recovery of grip strength was faster in the CG than after PF and collagenase injection was regarded as less discomforting. The results of the questionnaires showed a reduction of hand function 1 month after surgery, whereas better results were observed 1 month after collagenase injection. Recovery in the CG was significantly faster than after PF. DISCUSSION: Collagenase injection, as a less invasive technique, has less and milder side-effects than surgery and demonstrated a better total reduction of Dupuytren's contracture initially, although the residual contractures were higher in the CG after follow-up of 1 year. Patient satisfaction was higher after collagenase injection due to subjectively perceived less negative impact and a comparable functional outcome.

[Arterialized venous free flaps for resurfacing hand and finger defects]. / Freie, arterialisierte venöse Lappenplastiken zur Deckung an Hand und Fingern.

BACKGROUND: Soft tissue defects on the hand and on the fingers with exposed functional structures require a thin and sturdy closure. If skin grafts or local flaps are not possible the arterialized venous free flaps represent a good alternative. PATIENTS AND METHODS: This retrospective study included all arterialized venous free flaps used for hand and finger defects since 2005. We evaluated type and technique (for example antegrade vs. retrograde arterial inflow and the number of veins) and size of the flaps. Flap harvesting time was also examined. RESULTS: 11 venous flaps were used for resurfacing hand and finger defects. Most of them were retrogradely arterialized. 10 of 11 flaps healed uneventfully. Due to a thrombosis in an outflowing vein one flap was lost at the sixth postoperative day. Median size of the arterialized flaps was 6×4 cm and the median time for flap harvest was 38 (27-51) min. The donor site was primarily closed in 2 cases and in 9 cases with a skin graft. CONCLUSION: Arterialized venous free flaps represent a reliable and safe option for resurfacing hand and finger defects. Easy and fast harvesting due to the visible venous vascular system is an advantage. The flaps are thin, pliable and can be easily adjusted to the needs of the defect. Using conservative measures it is possible to control side effects like venous pooling, swelling and purplish discoloration. With arterialized venous free flaps early hand therapy is possible, in contrast to heterodigital and local flaps. In comparison to other free flaps it is not necessary to sacrifice an artery at the donor site.

[Reconstructive surgery in patients with a ventricular assist device (VAD)--an interdisciplinary challenge]. / Rekonstruktive Chirurgie bei Patienten mit Herzunterstützungssytemen (Ventricular Assist Device, VAD)--eine interdisziplinäre Herausforderung.

BACKGROUND: Ventricular assist devices (VAD) are implanted with a growing frequency in patients with end-stage heart failure. In spite of technical and therapeutic advances, there is still a high incidence of device infections and healing disturbances with a considerable mortality. Reconstructive plastic surgery is able to provide help in erradicating infections and covering defects. PATIENTS AND METHODS: 11 patients with device infections and soft tissue defects were treated in our institution. All cases were treated with local myocutaneous or muscle flaps. RESULTS: Three patients had postoperative haematomas which had to be revised surgically. One patient had a persistent fistula of mediastinal origin but without clinical symptoms of infection. One patient exhibited an enterocutaneous fistula after defect coverage. CONCLUSION: Patients with VADs have a high possibility of perioperative complications. Therefore a close interdisciplinary approach with plastic and cardiovascular surgeons is absolutely essential.

[Perioperative coagulation management in microsurgery: report of the consensus workshops in the course of the 31st and 32nd Annual Meeting of the German-language Working Group for microsurgery of the peripheral nerves and vessels (DAM) November 2009 in Erlangen and November 2010 in Basel]. / Perioperatives Gerinnungsmanagement in der Mikrochirurgie - Bericht der Konsensus-Workshops im Rahmen der 31. und 32. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) im November 2009 in Erlangen und November 2010 in Basel.

Microsurgery is a very relevant component of reconstructive surgery. In this context anticoagulation plays an increasing role. At the moment there are no unanimously accepted prospective studies or generally accepted regimes available that could serve as evidence-based guidelines for the prevention of thrombosis in microsurgery. With regard to this problem the aim of a series of workshops during the annual meetings of the German-speaking group for microsurgery in 2009 and 2010 was to establish a first possible consensus. This article reflects the main aspects of the ongoing development of a generally acceptable guideline for anticoagulation in microsurgery as interim report of these consensus workshops. Basically there are 3 main agents in thromboprophylaxis available: antiplatelet drugs, dextran and heparin. In the course of the workshops no general use of aspirin or dextran for anticoagulation in microsurgery was recommended. The use of heparin as anticoagulation agent is advisable for different indications. Low molecular heparins (LMH) have certain advantages in comparison to unfractionated heparins (UFH) and are therefore preferred by most participants. Indications for UFH are still complex microsurgical revisions, renal failure and some specific constellations in patients undergoing reconstruction of the lower extremity, where the continuous administration of heparin is recommended. At the moment of clamp release a single-shot of UFH is still given by many microsurgeons, despite a lack of scientific evidence. Future prospective clinical trials and the establishment of a generally accepted evidence-based guideline regarding anticoagulation treatment in microsurgery are deemed necessary.

[Preventing lower limb amputations in patients suffering from diabetic foot syndrome and peripheral vascular disease - opportunities and limitations]. / Grenzen und Möglichkeiten der Vermeidung von Majoramputationen der unteren Extremität bei Diabetischem Fußsyndrom und arterieller Verschlusskrankheit durch freien Gewebetransfer.

BACKGROUND: The number of patients suffering from a diabetic foot syndrome is increasing. In many cases large plantar or heel defects can only be reconstructed by using a free flap. The free parascapular flap is an alternative to free muscle flaps in the reconstruction of plantar or heel defects. Donor site morbidity is low. Autologous bypass reconstruction or an angioplasty can increase extremity perfusion. PATIENTS AND OPERATIONS: 52 patients with a diabetic foot syndrome have been reconstructed since 2007. 23 of them required a free tissue transfer. On average these patients were 68.7 years of age. A parascapular flap was used in 15 cases, a latissimus dorsi flap with a skin graft in 4 cases, a gracilis muscle flap with a skin graft in 3 cases. In one case a free instep flap of the contralateral foot, which had to be amputated, was used. In 13 cases the flap was anastomosed to the autologous bypass, in one case an AV loop was used. RESULTS: 22 flaps healed primarily. Only 1 patient was not able to walk at discharge. There was one flap loss. 4 patients required an amputation later on due to bypass failure or infection. 2 patients died due to cardiac arrest at the rehabilitation clinic. CONCLUSION: If the correct indication is met, free flaps can prevent diabetes-derived amputations of the lower limb. The parascapular flap can be used for plantar and heel defects. Flap harvesting is quick due to the constant vascular anatomy. The donor site morbidity is low. Reconstruction requires revascularisation in an interdisciplinary setting including vascular surgeons and radiologists. Limb salvage reduces mortality and improves quality of life. Revascularisation and reconstruction should best be done in a single surgical procedure.

[Significance of abdominal wall CT-angiography in planning DIEA perforator flaps, TRAM flaps and SIEA flaps]. / Stellenwert der CT-Angiografie der Bauchwand für die Planung und Operation von DIEP-, TRAM- und SIEA-Lappenplastiken.

Muscle sparing TRAM flaps and DIEA perforator flaps are standard procedures for breast reconstruction. Recently CT-angiography has been established to evaluate perforator vessels pre-operatively. CT-angiography was introduced to our department in July 2009. In a retrospective analysis data of the last 20 patients (altogether 22 flaps) before CT-angiography introduction and the following 20 (also 22 flaps) patients after introduction of CT-angiography were analysed with regard to the ratio of TRAM to DIEP flaps, and the time required to raise the flaps. The same surgeon raised all flaps. As different surgeons performed dissection of the recipient site, anastomoses, and insertion of flaps, and patients received primary (with sentinel or complete lymphadenctomy) or secondary reconstructions, only the time required harvesting the flap was compared. Thus other influences on raising the flap were eliminated. DIEP flaps were harvested with one single perforator. If perfusion or was considered not to be safe via one single perforator a muscle sparing TRAM flap (ms2) was raised. Angiography was performed using a 64-slice multi-detector CT scanner. CT-angiography did not lead to an increased rate of DIEP flaps in relation to ms2-TRAM flaps. Harvesting time of all flap types with CT-angiography on average was 121 min, without CT-angiography 135 min. This was not significantly different. However, separate analysis of DIEP flaps and ms2-TRAM flaps revealed a significant advantage of CT-angiography based harvesting of DIEP flaps of 26 min: with CT-angiography 101 min vs. 127 min without CT-angiography (p<0.028). There were no significant differences for ms2-TRAM flaps. All scans showed course and branching, diameter and size of the inferior epigastric artery. If evident the superficial inferior epigastric artery (SIEA) was marked. Dosage was 292 mGy-606 mGy×cm dependent on body weight. CTDI was 6.8-14.7 mGy. CT-angiography is a reproducible and observer independent procedure that reliably demonstrates the inferior epigastric artery and its perforating branches. Sensitivity is considered to be 99,6%. Additionally the superficial inferior epigastric artery can be evaluated. In our patients the ratio of ms2-TRAM flaps to DIEP flaps was not affected by introducing CT-angiography. However, DIEP flap harvesting was significantly accelerated. Harvesting of ms2-TRAM flaps was not affected. It remains to be seen whether the observed time advantage is really essential for this operation. Preoperative imaging of the perforators allows establishing a detailed, observable and comprehensible operation strategy, which particularly facilitates surgical training and learning of perforator dissection.

[Patients' decision for aesthetic surgery]. / Operationsentscheidung von Patienten in der Ästhetischen Chirurgie.

INTRODUCTION: Aesthetic surgery is a service which entails a high degree of trust. Service evaluation prior to provision is difficult for the patient. This leads to the question of how to manage the service successfully while still focusing on the medical needs. The decision to undergo an operation is not influenced by the operation itself, but by preoperative events which induce the patient to have the operation done. According to "buying decisions" for products or in service management, the decision for an aesthetic operation is extensive; the patient is highly involved and actively searching for information using different directed sources of information. The real "buying decision" consists of 5 phases: problem recognition, gathering of information, alternative education, purchase decision, and post purchase behaviour. PATIENTS AND METHODS: A retrospective survey of 40 female patients who have already undergone an aesthetic operation assessed for problem recognition, which types of information were collected prior to the appointment with the surgeon, and why the patients have had the operation at our hospital. They were also asked how many alternative surgeons they had been seen before. RESULTS: Most of the patients had been thinking about undergoing an operation for several years. They mainly used the web for their research and were informed by other (non-aesthetic) physicians/general practitioners. Requested information was about the aesthetic results and possible problems and complications. Patients came based on web information and because of recommendations from other physicians. 60% of all interviewees did not see another surgeon and decided to have the operation because of positive patient-doctor communication and the surgeon's good reputation. Competence was considered to be the most important quality of the surgeon. However, the attribute was judged on subjective parameters. Environment, office rooms and staff were assessed as important but not very important. Costs of surgery were ranked second. DISCUSSION: Influence on patients' decision is only possible by high quality operation results, which in turn lead to good reputation with (non-aesthetic) physicians and patients. In contrast to print advertisements, the provision of information via the internet is of tremendous importance and must be both information and comprehensible. Not only the aesthetic result should be depicted, but also questions such as "when will I be fit after surgery", and possible problems and complications should be described honestly. Besides the described word-of-mouth recommendations web fora resemble a virtual extension of recommendation. Whether such web based fora will prevail as a significant source of information remains unclear. Board certification in plastic and aesthetic surgery ("Facharzt" qualification) was assessed as very important. Thus, this is relevant information which should be emphasized. Most important for the patients' decision, however, was patient-doctor communication. To develop a basis of trust, communication should be open and reliable. An adequate time span has to be planned for the first appointment with the patient. In addition to aesthetic results, risks and possible complications have to be discussed. An open and comprehensible conversation which does not sugar-coat the operation is assessed as very positive. Finally, based on this consultation the surgeon is suggestive of his surgical competence. This underlines that core competence in aesthetic surgery is a medical one.

[Reconstruction of quadriceps femoris muscle function with muscle transfer]. / Rekonstruktion der M. quadriceps femoris Funktion durch Muskeltransfer.

Femoral nerve palsy, mostly of iatrogen cause, leads to paresis of quadriceps muscle with complete loss of knee extension. Therapeutical options include neurolysis, nerve reconstruction or functional muscle transplantations. Another concept is the transfer of hamstring muscles as described in post polio surgery. We describe our experience of biceps femoris and semitendinosus muscle transfer for reconstruction of knee extension. From 2003 to 2007 seven patients (mean age 43) with complete loss of knee extension after femoral nerve lesion were treated. Nerve palsy was caused by direct lesion, traction, hematoma after collapse, lesion of lumbosacral plexus and an unclear muscle dystrophy. Indication for muscle transfer was due to long standing muscle paresis. All patients received a transfer of biceps femoris and semitendinosus muscle/tendon into the quadriceps tendon. Patients were immobilised in a cast for 6 weeks in extended knee position. Weight bearing started after 8 weeks. Operations went uneventfully. All patients were able to extend the knee postoperatively against gravity and were able to climb stairs without help. 4 Patients had complete knee extension, 2 had a lack of 20 degrees , one of 30 degrees. Daily routine was possible in all cases. No instability of knee joints occurred postoperatively. In a nerve lesion close to the muscle a nerve reconstruction should be aimed. If not performed or with unsuccessful outcome, muscle transfer is a good option to restore function. All recent studies describe good to excellent results with stable knees, allowing the patient to manage daily routine without assistance and to climb stairs up and down. Long term complications such as dislocation of patella or genu recurvatum were not observed in our patients. The latter results as typical complication in polio from weakening knee flexion through biceps femoris transfer, if the gastrocnemius muscle is not forceful enough. However in an isolated femoral nerve lesion this will rarely occur.

[Purple glove syndrome - a case report]. / Purple Glove Syndrom nach peripherer venöser Phenytoin Gabe - Ein Fallbericht.

The purple glove syndrome (PGS) is a soft tissue injury after peripheral intravenous phenytoin administration or oral overdosage. The incidence of PGS is described with 0-6%. Typical symptoms are purple discoloration, oedema, pain, and a decrease of range of motion. In severe cases PGS may lead to abscess, skin loss and compartment syndrome. The established treatment of PGS is immediate interruption of phenytoin injections, splinting, elevation, and close observation. In cases of severe complications (e. g., compartment syndrome), surgical intervention is necessary. The case of a 40-year-old female patient is reported who was transferred to our department 4 days after intravenous phenytoin administration and who underwent successful surgical revision.

[Alternative autologous breast reconstruction using the free microvascular gracilis muscle flap with horizontal skin island]. / Die alternative autologe Brustrekonstruktion mit dem queren Grazilislappen.

BACKGROUND: While free TRAM or DIEP flaps are still the most common techniques for autologous breast reconstruction, there are also other flaps which are suitable for patients who are not candidates for a TRAM/DIEP flap. In addition to the S-GAP or I-GAP, the transverse myocutaneous gracilis (TMG) flap is an excellent alternative. The tissue utilised is taken from the medial thigh and inferior gluteal area. PATIENTS AND OPERATIONS: We have performed 37 TMG flap operations on 23 patients since 2007. The indications were breast cancer, asymmetry of the breasts and capsular fibrosis. The average age of our patients was 47 years. Incisions are similar to those of a transverse thigh lift. The flap is nourished by perforators from the gracilis and its proximal dominant pedicle. The landmark ventrally is the greater saphenous vein and midpoint of the inferior gluteal fold on the dorsal side. Its size can go up to 30 x 10 cm. Recipient vessels are the internal thoracic vessels. The donor site is closed primarily. All of our patients are immobilised for 2 days and were instructed to avoid sitting for 2 weeks. RESULTS: 12 patients were reconstructed after breast cancer, 8 patients had a capsular fibrosis and 3 patients had an asymmetry. The follow-up period was 8 months. Mean operating time for unilateral reconstruction is 220 minutes, for bilateral reconstruction 325 minutes. The weight of the flaps varied from 220 to 440 grams. It takes approximately 30 minutes to harvest the flap. There was no flap loss. Some of the patients described a tight feeling on the thighs for 3 weeks. They described a hypaesthesia on the dorsal thighs. There was one delayed wound healing caused by haematoma. CONCLUSION: In our department, the TMG has become the most preferred flap for breast reconstruction besides the TRAM/DIEP. Especially slim patients with small breasts or a history of surgery on the abdominal wall are ideal candidates. The tissue from the medial thigh is very similar to the breast tissue. The constant vascular anatomy makes it easy to harvest the flap. The resulting scar is well hidden in the patients' underwear.

[BIAX total wrist arthroplasty: management and results after 42 patients]. / Die BIAX-Handgelenkprothese: Management und Erfahrungen bei 42 Patienten.

The BIAX total wrist arthroplasty was introduced in 1983 by Cooney, Beckenbaugh and Linscheid in the USA. However the production of this prosthesis was discontinued in 2004 without having developed a follow-up model. Between 2001 and 2003 we have implanted the BIAX prosthesis in 42 cases. In contrast to other studies, our patients had more post-traumatic (n = 19) and degenerative athroses (n = 20), only 3 patients had rheumatoid arthritis of the wrist. Follow-up time was 2.6 (+/- 0.8) years. The patients were 53 (+/- 11) years old. Indication for total wrist arthroplasty was comparable to that for arthrodesis. However, as pain reduction is lower in heavy workers these patients were excluded from arthroplasty implantation. Range of movement was preserved by total arthroplasty or slightly improved. Pain was reduced by 4.5 (+/- 2.3) points from 7.6 (+/- 1.0) to 3.0 (+/- 2.1) using a visual analogue scale with 0 points for no pain and 10 points for severe pain. Patient satisfaction with the operation was 7.7 (+/- 2.2, 1 bad, 10 excellent). 4 patients had a postoperative dislocation. After reposition the joints were permanently stable. In one case a flexion contracture of unknown origin was treated by tendon transfer. In 11 patients the prosthesis had to be removed after 2 (+/- 0.9) years. Four of these patients received an arthrodesis, 7 had a change to the Universal2 prosthesis. The reason for explantation was mainly abrasion of the dorsal polyethylene edge of the proximal socket, resulting in foreign body reaction, synovialitis and loosening of the prostheses in 7 patients and permanent dislocation in 2 patients due to the then flattened socket. These complications led us to abandon the implantation of the BIAX prostheses.

[Hereditary thrombophilia in free microvascular flaps--a case report]. / Hereditäre Thrombophilie und ihre Bedeutung für die freie mikrovaskuläre Gewebetransplantation anhand einer Falldarstellung.

Hereditary thrombophilia sums up a large number of haemostatic disorders, which cause thrombosis independently to external influences. The main cases of hereditary thrombophilias are the hereditary antithrombin defect, the activated protein C resistance, the hereditary protein C defect, the hereditary protein S defect, the antiphospholipid antibody syndrome, the hyperhomocysteinaemia, the increased factor VIII activity and the prothrombin-G20210A-polymorphism. We present a patient who was amputated in both breasts due to cancer. A bilateral microvascular TRAM-flap was planned as primary reconstruction on one breast and secondary reconstruction on the other breast. However in the operation the flap vessels revealed irreversible thromboses so that the intended reconstruction could not be completed in this operation. Postoperatively, a combined hereditary thrombophilia was diagnosed: heterocygote activated protein C resistance, antiphospholipid antibody syndrome and hyperhomocysteinaemia.

[Functional reconstruction of the radial articular surface after giant cell tumor]. / Funktionelle Rekonstruktion der Radiusgelenkfläche nach Riesenzelltumor.

Giant cell tumor is a benign locally aggressive tumor with a high tendency to recurrence, with a small rate of pulmonary metastases. In 90% of cases the tumor occurs in the long bones, especially near the epiphysis. A case of a 37-year-old female with a recurrent giant cell tumor of the distal radius including the radioulnar articular surface, successfully treated with a wide resection and reconstruction of the articular surface between the radius, scaphoid, lunatum, and ulna by an iliac crest graft, is reported.

[Correction of finger clubbing in primary hypertrophic osteoarthropathy (Touraine-Solente-Gole syndrome)]. / Korrektur der Trommelschlegelfinger unter ästhetischen Aspekten bei hereditärer hypertropher Osteoarthropathie (Touraine-Solente-Gole-Syndrom).

Finger clubbing can be a single physical finding. In Touraine-Solente-Gole syndrome, the primary form of hypertrophic osteoarthropathy, it is mostly associated with bone pain, hyperhydrosis, pachydermy and wrinkling of the forehead. In other cases, the presence of clubbing is associated with neoplastic, pulmonary, cardiac or other diseases and is then called Bamberger-Pierre-Marie syndrome, the secondary type of hypertrophic osteoarthropathy. The patient's history and careful physical examination, sometimes accompanied by laboratory and imaging studies, leads to the diagnosis. A patient with hereditary hypertrophic osteoarthropathy and its clinical symptoms is presented. Surgical correction of the clubbing fingers is demonstrated in the paper with bilateral resection and shortening of the nail bed, nail matrix and resection of soft tissue. Clubbing fingers are rare, but they might be part of a syndrome or a symptom of other diseases. Reconstructive surgery for aesthetic reasons can be performed.

[Malignant eccrine poroma]. / Das maligne ekkrine Porom.

INTRODUCTION: Malignant eccrine poroma is a very rare tumour of the sweat glands with high malignancy and presenting with a polymorph clinical and histological picture. CASE REPORT: We describe the case of a 99-year-old patient with a malignant poroma on the buttock. Despite the large size of the tumour, no metastasis was found with standard examination techniques. Radical excision and defect closure with a Limberg flap was performed. RESULT: The healing course was uneventful and without complications. CONCLUSION: The malignant poroma is a tumour of high malignancy which can easily be misdiagnosed because of its different forms of presentation. Radical surgical therapy is the only known effective treatment.

[Distally pedicled peroneus brevis muscle flap for defect coverage on the lower leg]. / Der distal gestielte M.-peroneus-brevis-Lappen zur Defektdeckung am Unterschenkel.

BACKGROUND: Defects of the lower leg with exposed tendons or bone require either a local or free flap coverage. The distally pedicled peroneus brevis muscle flap has been proven to be a sufficient local flap alternative. MATERIAL AND METHOD: Using this technique the muscle is perfused by the non dominant distal perforators. This allows the muscle to be transposed to more distal lesions. The muscle is then covered with meshed split skin graft. Between 2000 and 2004 12 patients with defects of the lower leg in the distal lower third have been treated by using this muscle flap. The defects were located over the tibial bone, the extensor tendons, the achilles tendon and the lateral malleolar region. RESULTS: All muscles healed primarily, 4 patients had minor wound healing complications of the skin graft, which in all cases healed conservatively. The muscle and skin graft remained stable. Donor site morbidity is restricted to the scar in the lateral lower leg. Pronation of the foot is not impaired. CONCLUSION: These cases show that the distally based peroneus brevis muscle has a wide range of coverage and even allows a closure down to the calcaneal tuberosity. Additionally, a local flap management with a safe muscle transposition is an economic procedure with short operation time and decreased hospital stay. If the muscle does not cover the wound sufficiently, free flap surgery can still be performed.