[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.

[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.

[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.

[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.

[Value of V.A.C.-therapy in the treatment of sternal infections]. / Der Stellenwert der V.A.C.-Therapie bei Sternumosteomyelitis.

Osteomyelitis of the sternum is a dreaded complication after sternotomy and is related to high mortality. Control of infection by radical debridement is the key to successful treatment. Instability of the thoracic cage can lead to a high complication rate. 16 Patients with an infected and unstable sternum underwent radical debridement with resection of the sternum and adjacent ribs. 6 Patients (group A) received an immediate defect coverage with a pedicled muscle flap. 10 Patients (group B) were treated with a vacuum-assisted closure (V.A.C.)-therapy until stabilization of their general condition and underwent defect coverage in a second operation. Healing of the flaps was uneventful in all cases despite minor problems. 5 patients of group A had severe complications with pulmonary or cardiac failure and thoracic instability which lead to prolonged periods of mechanical ventilation. 2 patients of this group died due to multi organ failure. All patients of group B survived and there were no major complications. All of the patients were free of recurrence from their osteomyelitis during follow-up. V.A.C.-therapy after radical resection of sternum osteomyelitis proved to be an effective measure to bridge time while optimizing the status of the patient and it's wound. With this approach we believe to have lowered the rate of major complications in this multi-morbid patient group by reducing the burden of one large operation and by improving thoracic stability.

[Surgical treatment of groin soft tissue defects]. / Chirurgische Therapieoptionen bei Weichteildefekten der Leiste.

BACKGROUND: Treatment of groin defects remains challenging due to their location and origin. Such defects commonly result from resection of tumours but can also occur after surgical or medical therapy. MATERIAL AND METHODS: From 2003 to 2005, 11 patients were treated with groin defects following radiation therapy and resection of lymph node metastasis, primary carcinoma, and sarcoma. Seven patients received wound closure with rectus femoris muscle flaps, and three had vertical rectus abdominis muscle flaps. One patient was amputated at the hip, and the defect was covered with dorsally pedicled muscle and skin flaps. RESULTS: All flaps healed primarily. There were no secondary infections or lymphorrhea. CONCLUSION: The flaps described here are well vascularised standard flaps which are easily harvested with no major donor site morbidity. They provide sufficient coverage for the groin, reduce long-term conservative treatment, hospitalisation, and problems such as scar contracture.

[Patients' satisfaction and social reintegration after breast reconstruction with the DIEP/TRAM flap]. / Brustrekonstruktion mit dem freien Bauchfettlappen (DIEP/TRAM): Patientenzufriedenheit und soziale Reintegration.

The aim of the study was to evaluate social reintegration and patients' perception after breast reconstruction with the free TRAM/DIEP flap. Between 2004 and 2006, 100 patients with an average age of 48 years with breast cancer, capsular contracture and lymphangioma underwent single or second stage autologous tissue transfer. In 7 patients reconstruction was performed on both sides (altogether 107 flaps). The patients were seen for postoperative evaluation and were asked for their personal acceptance after reconstruction. Postoperatively, no instability of the abdominal wall was seen. 3 patients had a total flap loss, in 2 patients a partial loss was evident, 1 had a hematoma, 2 showed successfully treated thrombosis of the flap vein, and 2 patients suffered from wound healing problems at the flap and 4 patients at the abdomen. Aesthetic results concerning natural feeling and breast symmetry were graded as excellent and patients' satisfaction was high.

[Autologous tissue transplantation (TRAM/DIEP) as an option of therapy in capsular contracture]. / Die autologe Gewebetransplantation (TRAM/DIEP) als Therapieoption bei Kapselfibrose der Brust.

Free microvascular abdominal tissue transfer (TRAM/DIEP) has become standard in breast reconstruction after mastectomy. A new indication for abdominal tissue transfer is severe capsular contracture after augmentation by implants. Capsular contracture following aesthetic or reconstructive augmentation mammaplasty occurs in only a small percentage of cases, but warrants adequate therapy. Between 1999 and 2003, six patients with an average age of 35 years with symptomatic capsular contracture after augmentation mammaplasty underwent autologous tissue transfer with the free TRAM/DIEP flap. The flap was harvested either with a perforator of the deep epigastric artery (DIEP) or as muscle sparing flap (TRAM) and was anastomosed to vessels of the subscapular system. Operation time was reduced by operating with two teams. Besides minor dog-ear deformities at the donor sites, no complications were noted. Postoperatively, neither, instability of the abdominal wall nor flap loss was seen. In some cases, a secondary mastopexy was necessary. Aesthetic results concerning natural feeling and breast symmetry were graded as excellent. In our experience, the free microvascular transfer of abdominal tissue (TRAM/DIEP flap) offers a treatment option for patients seeking alternatives other than repeated capsulectomies and implant changes for severe capsular contracture.

Healing of Achilles tendon, an experimental study: part 2--Histological, immunohistological and ultrasonographic analysis.

In 105 rabbits the course of healing was examined at one, two, four, eight and 12 weeks (21 rabbits per group) after an experimental Achilles tendon rupture. The following treatment modalities were compared: A) primary functional treatment; B) operative functional treatment (resorbable suture); and C) operative functional treatment with fibrin glue. For the functional (after)-treatment a special orthosis was applied. A 7.5 MHz Ultrasound probe was used for ultrasonographic evaluation. The histological specimens were stained in Masson-Goldner and Azan technique. Collagen Type III was depicted immunhistologically. A semiquantitative fibrocyte count was performed. The histological results showed a smooth healing in the primary functional treatment group (A), reaching parallel orientation of collagen fibers at 12 weeks. In the suture group (B), a secondary gapping of the tendon stumps was detectable after one week as in all other groups. In the fibrin group (C), the fibrin was resorbed after four weeks without essential influence to the course of healing. At 12 weeks the histological evaluation in all groups showed approximately normal tendon pattern. Immunohistochemically, all groups showed cell-associated positive reactions for type-III collagen after one week with a maximum after two weeks. The semiquantitative fibrocyte count in the primary functional group showed a maximal number after one week. In the fibrin glue and suture groups the maximal number could be found after two weeks. Sonographically an increase in tendon thickness was detectable up to the fourth week in all groups. The secondary gapping of the tendon stumps in the suture group could also be detected sonographically. The echogenicity of the tendon during the course of healing showed increasing homogeneity and parallelism in all groups. At 12 weeks the echogenicity was comparable in all groups. The experiment suggests the equivalence of primary functional treatment to a combination of operative and functional therapy in Achilles tendon rupture.

[The influence on nerve regeneration by the beta2-receptor agonist clenbuterol]. / Die Beeinflussung der Regeneration peripherer Nerven durch den beta2-Rezeptor-Agonisten Clenbuterol.

PURPOSE: Clenbuterol has shown a neuroprotective action in the central nervous system by induction of growth factors after cellular damage. Additionally, the atrophy of sceletal muscle is attenuated by the application of Clenbuterol after denervation. This experiment was performed to show the influence of Clenbuterol on regeneration of peripheral nerves. MEHOD AND MATERIAL: In a rat model, the sciatic nerve was transected and microsurgically coaptated. Eight animals in each group received a daily oral dosage of 100 microg/kg bodyweight during four, respectively six weeks. Two control groups received only drinking water under the otherwise same protocol. The assessment was done histologically, morphometrically and clinically. The weight ratio of the soleus and extensor digitorum muscles of the operated to the contralateral side was measured. RESULTS: The groups treated with Clenbuterol showed histologically and morphometrically a significantly increased axon count and a better g-ratio. The muscle weight ratio was significantly higher in the Clenbuterol group after six weeks and more animals in this group were able to spread their toes. CONCLUSION: The oral application of Clenbuterol in a rodent model shows a positive influence on nerve regeneration.

Regeneration of peripheral nerves after clenbuterol treatment in a rat model.

Clenbuterol is known to act as a neuroprotective substance in the central nervous system, and also reduces muscle atrophy after denervation. The aim of this study was to evaluate its influence on peripheral nerve regeneration. The rat sciatic nerve model was used in four groups (n = 8 per group). After complete nerve transection and microsurgical coaptation, two groups received a daily oral dose of 100 microg/kg clenbuterol and two served as controls. Regeneration was assessed clinically, histologically, and morphometrically after 4 and 6 weeks. The weight ratios of calf muscles were calculated. Histological examination showed significantly increased axon counts in the clenbuterol group and a better degree of myelination. Muscle weight ratios of the clenbuterol group were significantly increased after 6 weeks, and the animals showed improved function of the hindlimb. Thus, therapy with 100 microg/kg clenbuterol daily after coaptation of a sciatic nerve showed a positive influence on clinical, histological, and morphometrical parameters in the rat model. The underlying mechanism remains unclear.

[Therapy of chest wall osteomyelitis]. / Die Therapie der Thoraxwandosteomyelitis.

INTRODUCTION: Chronic osteomyelitis of the chest wall requires radical debridement and defect coverage with well-perfused tissue. The implantation of synthetic material is still under discussion because of the risk of infection. METHODS: A retrospective study was conducted on the complications and functional and aesthetic results of 26 patients with chest wall osteomyelitis after radiation or sternotomy treated by radical debridement and neurovascular pedicled latissimus dorsi muscle. RESULTS: The functional results were excellent with a low complication rate. The muscle showed electric activity synchronous with inspiration and clinically a stabilization of the thoracic defect. DISCUSSION: Maintained muscular activity may play an essential role for stabilizing thoracic defects of up to four ribs or the sternum; implantation of synthetic material is not necessary.

Healing of the Achilles tendon: an experimental study.

Biomechanical properties of healing ruptures in the Achilles tendon of rabbits were examined after two, four, eight and 12 weeks. Treatment modalities were (n7): a) suture, b) fibrin-glue, c) non-surgical treatment. All animals received a functional aftertreatment consisting of a special orthotic support and free ambulation. For biomechanical testing a fixation-technique was applied that guaranteed intratendinous rupture. After two weeks, the tendons treated with fibrin glue showed better results (stiffness, maximum force to rupture, tensile stress to rupture) compared with the non-surgically treated group. The results for sutured tendons were in between those for the other groups. After four weeks, the results for sutured and for glued tendons were nearly equal and slightly better than the tendons in the non-surgical group. Late results revealed comparable biomechanical properties among all treatment groups and control tendons, suggesting our conclusion that non-surgical treatment is equal to repair using sutures or using fibrin glue as measured by stiffness and tensile stress.

[Heterotopic replantation after bilateral lower leg amputation]. / Heterotope Replantation nach bilateraler Unterschenkelamputation.

INTRODUCTION: Replantation is an established procedure in reconstructive surgery. In a bilateral lower leg amputation attempts should be made to rescue at least one extremity, if the patients' vital conditions are stable. PATIENT AND METHOD: We report on a patient who has suffered a bilateral lower leg amputation. Due to the complex injuries the left leg was heterotopically (cross-over) replanted to the right leg. At the left leg an above knee stump was created. In a second operation a soft tissue defect at the replanted extremity was covered by a free microvascular latissimus dorsi muscle flap. In addition, the tibial nerve was reconstructed. Thirteen months later the patient is able to walk with a prosthesis for his left leg and complete weight bearing of the replanted extremity. DISCUSSION: Indication for replantation depends on accompanying injuries and vital functions of the patient. Compared to a simple amputation a lower leg replantation prolongs hospital stay, delays mobilisation of the patient, and increases the necessary secondary procedures. However, after replantation functional outcome is mostly better than with prosthetic fitting, especially if reconstruction of sensation in the weight-bearing area is successful. Thus, in a bilateral amputation movement and stability, as well as quality of life, are improved by a replanted extremity.