[Long-term follow-up after surgery for thoracic outlet syndrome (TOS)]. / Langzeitresultate nach operativer Therapie bei Thoracic-outlet-Syndrom (TOS).

This is a long-term follow-up analysis of patients who have been operated on for Thoracic Outlet Syndrome (TOS) at our clinic in order to evaluate the quality of therapy and the criteria of indications for surgery. 39 patients with a total of 45 surgical procedures were examined after a median follow-up of 8.8 years. The results in this study are based exclusively on the subjective outcome assessment by the patients themselves. Assessment of the long-term result in the "vascular TOS" group (13 cases = 29 %) was good in ten cases (77 %), fair in two cases (15 %) and poor in one case (8 %). In agreement with the literature, we were able to achieve the best results in this group. In the "true neurological TOS" group (28 cases = 62 %), assessment of the long-term result was good in 19 cases (68 %), fair in six cases (21 %) and poor in three cases (11 %). A clear tendency to a poor prognosis could be seen in women with a combination of cervical rib and fibrous band and a long delay between onset of symptoms and surgery. Assessment of long-term result in the "disputed TOS" group (four cases = 9 %) showed good results in three cases and a fair result in one case. In the absence of objective pathologies, only few and carefully selected patients were operated upon. The presented long-term results confirm the use of individual therapeutic concepts with special consideration of anatomy and clinical picture.

[Verification of thumb-specific muscles in a triphalangeal thumb with magnetic resonance imaging]. / Nachweis daumenspezifischer Muskulatur beim triphalangealen Daumen mittels MRT.

The presence of three phalanges in the first digit is considered to be a relatively rare congenital hand malformation. Six groups of this deformity can be distinguished: some digits are opposable, others resemble a non-opposable five-fingered hand. In cases of a hypoplastic thenar region with a restrained opposition, a clear verification of thumb-specific musculature has been hardly possible. We report of the possibility of a non-invasive identification of thumb-specific muscles by means of magnetic resonance imaging.

Lyell syndrome revisited: analysis of 18 cases of severe bullous skin disease in a burns unit.

Over the last few years, understanding of the pathophysiology of toxic epidermal necrolysis (TEN), or Lyell's disease, has substantially increased. However, differentiation of severe bullous skin disease remains a challenge for the clinician, and one that is often complicated by late patient referral. We performed a retrospective analysis of all patients with severe bullous skin disease, admitted between 1997 and 2002 to the Burn Centre, which is an integrated part of the Division for Plastic, Hand- and Reconstructive Surgery at the University Hospital of Zurich, Switzerland. We present an overview of our strategies and of the diagnostic and therapeutic difficulties encountered. The final diagnoses of the 18 patients referred to the unit were as follows: eight cases of TEN, one case of staphylococcal scalded-skin syndrome (SSSS), two cases of generalised drug eruption, one case of acute generalised exanthematic pustulosis and one case of febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta (PLEVA). In two cases, the diagnosis remained unclear. In three cases, paraneoplastic origins were suspected but not demonstrated. The overall mortality rate was 33% (six of 18 patients). Remarkably, all patients with histologically confirmed TEN survived. Six of these patients were successfully treated with intravenous immunoglobulins (IVIG). The most common single causative drug inducing TEN (four cases out of eight) was Phenytoin. Establishing an accurate diagnosis-based on a skin biopsy, harvested at an early stage-is more important than ever, because more specific and effective therapeutic modalities are available. As these potentially life-threatening bullous skin disorders are rare, we recommend, that care be provided by an experienced interdisciplinary team, comprising a dermatologist, or dermatopathologist, an intensive care specialist and a plastic surgeon.

[Painful tendon insertion anomaly of the palmaris longus muscle in a professional cellist]. / Schmerzhafte Ansatzanomalie des M. palmaris longus bei einem Konzert-Cellisten.

A professional cellist suffered four years from pain and fatigue of unknown etiology to his right thumb while playing his cello. These complaints in his performing right hand were potentially threatening his future career, since he was no longer able to play his instrument. Finally, the diagnosis of an anomaly of the insertion of the palmaris longus tendon was made. After resection of the distal portion of this tendon, the patient's symptoms fully resolved. Anatomic anomalies of the upper limb and particularly of the palmaris longus muscle-tendon unit are frequent and may lead to serious complaints in certain professional groups.

Compression neuropathy of the radial palmar thumb nerve.

Compression neuropathy of a single digital nerve is a rare entity. We report the case of a patient with numbness in the distribution of the radial digital nerve of the thumb caused by the use of a walking stick. The nerve was compressed between the handle of the stick, the loop and the radial sesamoid bone of the first metacarpophalangeal joint. The site of the lesion was confirmed by electrophysiologic examination. Orthodromic recording of the sensory response from the radial palmar digital nerve of the thumb documented a complete absence of nerve action potential whereas the ulnar digital thumb nerve showed a normal response. Sensory function was restored when a padded ski glove was used to protect the area of the metacarpophalangeal joint whilst using the stick.

Benefits and pitfalls of vertical scar breast reduction.

A quality assurance study was undertaken three years after beginning the vertical scar breast reduction technique. We examined the rate of early and late complications (major and minor) and compared these to the formerly used inverted-T scar and L scar breast reduction techniques. Inverted-T scar breast reductions have an early complication rate of up to 20% and a late complication rate of 20-30%. Our vertical scar breast reduction is a modified Lassus technique, incorporating a geometrically based and measurable preoperative marking of the breast, a superior pedicle, a central breast resection, an intraoperative positioning of the nipple-areola complex, and occasionally a periareolar skin resection.In the time span examined (September 1998-December 2001) 153 patients could be included in the study. The resection weight per breast ranged from 60 to 1262 g (mean 390+/-210 g, median 380 g). The early complication rate (hematoma, seroma, wound dehiscence, wound infection and necrosis) was 21.6%. Of these cases, 19.6% were minor complications. The late complication or imperfection rate was evaluated very strictly using the standardized, extended scheme of Ferreira (problems of volume, shape, symmetry, areola, scars and position of the breast on the thorax) and was 26%. Major late complications necessitating a reoperation occurred in 11.1% of cases. These complication rates compare well to those of other vertical breast reduction techniques and T scar reductions in our own clinic and in the literature. Given that the vertical scar breast reduction method also results in shorter scars and a significantly better, long-lasting breast projection, this technique is clearly justified to remain the standard method at our clinic.

[Breast implant and desmoid tumor: is there an etiological relation?]. / Mammaimplantat und Desmoidtumoren: Besteht ein Zusammenhang?

Desmoid tumor of the breast is a rare lesion. So far only 8 cases in which the tumor origin was linked to a breast implant have been published. Whether there is an etiological relation to the silicone implant or if it is pure coincidence is not evident at this time. We present the case of a 24-year-old female with congenital asymmetric breasts who underwent breast augmentation in our division on the left side and 15 months later had a breast reduction on the other side. Nine years after the first operation we found a suspicious lesion on the side of the breast implant. The histological result of the excisional biopsy showed an aggressive fibromatosis "arising from" the capsule around the silicon implant. We discuss the possible association of breast implant and desmoid tumor of the breast and evaluate the diagnostic and therapeutic options for desmoid tumors of the breast.

[Reconstruction of posttraumatic bony defects of the lower extremity: callotaxis or free vascularized fibula graft?]. / Rekonstruktion posttraumatischer Knochendefekte an den unteren Extremitäten: Kallusdistraktion oder freie mikrovaskularisierte Knochentransplantation?

PURPOSE/BACKGROUND: Several methods have been established for the treatment of bony defects of the lower extremity. The purpose of this paper is to evaluate the use of a free vascularized fibula graft for these defects in comparison to callotaxis and segmental transport. METHOD AND CLINICAL MATERIAL: Retrospective analysis of data from 32 patients treated between 1981 and 1999 at the University Hospital in Zurich, Switzerland with bony defects of the lower extremity. RESULTS: The reconstruction of the bony defect was successful in 80 % with fibula graft, in 94 % with callotaxis and in 83 % with segmental transport. In the group with the fibula transplantation 2.6 re-interventions due to complications had to be performed, in the callotaxis group there were 3.6 and in the segmental transport group 5.2 surgical re-interventions. The time between primary intervention and full weight bearing was 16 months in the fibula transplantation group, 7.6 months in the callotaxis group and 10.7 months in the segmental transport group. CONCLUSION: The results show that these three options can be used for different indications. Reconstruction can be planned according to the following rules: Segmental bony defects of the entire circumference of up to 5 cm are best treated by initial shortening followed by callus distraction. Bony defects from 5 to 12 cm are best treated by segmental transport while maintaining limb length. Defects > 12 cm are best treated by reconstruction with a vascularized free fibula graft.

[Radioscapholunate fusion: long-term results]. / Erfahrungen mit der radiokarpalen Teilarthrodese nach Gordon und King im Langzeitverlauf.

INTRODUCTION: A review of the literature on long-term results (> or = 10 years) following radiocarpal arthrodesis as recommended by Gordon and King shows a paucity of data. Regarding the suitability of this procedure for treating radiocarpal arthrosis, especially in younger patients, we collected and evaluated long-term results of this surgical procedure. MATERIALS AND METHODS: Five patients (four men, one woman), who were treated between 1978 and 1984 at our institution with a partial radiocarpal arthrodesis as described by Gordon and King were reexamined clinically and radiologically by the same examiner in the year 1990 and again in the year 2000. RESULTS: All five patients were very satisfied with the result of the operation. Two patients were completely free of pain, whereas the other three patients reported minor pain in the radiocarpal joint when applying strain. The active range of motion in the operated joint remained constant over the years (mean 60 degrees dorsopalmar, 30 degrees ulnoradial, 162 degrees pro-/supination). Conventional radiological imaging showed proper osseous consolidation in the areas of partial arthrodesis, and slight degenerative intercarpal alterations in the distal radioulnar joint were observed. Complete postprocedural reintegration into the workforce, including manually demanding work, was achieved. CONCLUSIONS: The results of the follow-up examinations of these five patients indicate that satisfying long-term results can be achieved after radiocarpal arthrodesis provided that the procedure is correctly indicated and the operation is conducted in a technically proper manner. This method of radiocarpal arthrodesis is likely also appropriate for young manual labourers suffering from painful radiocarpal arthrosis after distal intraarticular fracture of the radius, scaphoid non-union, scapholunar dissociation and Kienbock's disease.

[Wartenberg's Sign of Ulnar Nerve Lesion. A Contribution to Pathophysiology and to the Differential Diagnosis]. / Das Wartenberg-Zeichen des Nervus ulnaris. Ein Beitrag zur Pathophysiologie und Differenzialdiagnose1.

The abduction stance of the small finger is frequently, but not necessarily due to ulnar nerve paresis. Five cases suffering from bothersome permanent abduction of the small finger and referred under the diagnosis of ulnar nerve paresis are presented. Clinical, electrodiagnostic and imaging evaluation revealed different causes. While partial paresis with the function of the abductor digiti minimi muscle preserved usually results in a disturbing abduction stance, complete paresis of the ulnar nerve causes a less severe abduction posture of the small finger. Operative measures are indicated when the stance of the small finger is disturbing and when sufficient time has passed to make sure that spontaneous recovery cannot be presumed. Clinical, electrodiagnostic and imaging evaluation of three neurogenic cases disclosed a lesion of the ramus profundus distal to the branches innervating hypothenar muscles in one case, ulnar nerve injury with neuromuscular hyperactivity of the abductor digiti minimi muscle following split repair in another case and syringomyelia in the third case. Two patients revealed an abduction posture of the little finger of non-neurogenic origin. One of them showed closed ligament injuries. The other patient revealed necrosis, scarring and contracture of hypothenar muscles and atrophy of the third palmar interosseous muscle following compression in a tight cast.

[Perioperative antibiotic prophylaxis at the Clinic of Reconstructive Surgery of the Zurich University Hospital]. / Zur Umsetzung einer perioperativen Antibiotikaprophylaxe an der Klinik für Wiederherstellungschirurgie des Universitätsspitals Zürich.

With the goal of ensuring maximal safety, surgeons tend to apply antibiotic prophylaxis generously to patients undergoing selective operative procedures. However, the indiscriminate or inappropriate use of prophylactic antibiotics i) leads to the selection of resistant microbial organisms and ii) results in an increase in general medical treatment costs. Given this controversy, the clinic of reconstructive surgery implemented in 1999 a set of guidelines for the proper use of antibiotics. Antibiotic prophylaxis was defined as a pre- or perioperative application of antibiotics as a single to maximum triple-shot dose. It was recommended only for operations involving special risk factors or the implantation of alloplastic material. The recommended medication of choice was the widely-accepted standard first-generation cephalosporin product Cefazolin. We have carried out a quality control trial to analyse prospectively our own experience with the implementation of these guidelines and to compare results with a retrospective group of patients. A total of 792 patients (441 in the retrospective group, 351 in the prospective group) were enrolled in the study. About one third of all patients received an antibiotic prophylaxis. Of these, about 3/4 received the antibiotic prophylaxis without having one of the above-mentioned indications. We observed that 35% of all prophylaxis were given for breast surgery, followed by surgery for scar revisions and lipodystrophy. The most commonly used antibiotic was Cefuroxim rather than Cefazolin. There was no significant reduction in the general application of antibiotic prophylaxis yet apparent in the prospective group. However, there was a clear increase in the use of Cefazolin from 0.2% to 13.2%. We conclude that guidelines can be created to reduce the incidence of uninformed and inappropriate decisions, but their implementation requires time, motivation, and thorough and repeated information campaigns.

[Necrotising fasciitis caused by streptococcal toxic shock syndrome]. / Nekrotisierende Fasziitis - durch Streptokokken induziertes Toxisches Schock-Syndrom.

Between 1994 and 1997, sixteen patients suffering from necrotising soft tissue infection were treated at the burn centre of the Division of Reconstructive Surgery, University of Zurich. The case of a 47 year old man is presented: He suffered from a necrotising fasciitis caused by Streptococcal induced Toxic Shock Syndrome (STSS). This example emphasizes the necessity of early diagnosis, priority of surgical intervention, and the antibiotic strategy. Necrotising fasciitis is a serious disease, caused by a variety of bacteria, which shows a high mortality rate, and its frequency was increasing over the last years.

[Methods, indications and validation of intraoperative nerve conductivity testing]. / Methode, Indikationen und kritische Wertung der intraoperativen Nervenfunktionsdiagnostik*

During nerve surgery, electrodiagnostic methods are applied to assess the availability and viability of nerve fibers and to adjust operative measures accordingly. The validity of this procedure is verified by histology and by the outcome of the operation. This paper explains the techniques of intraoperative nerve action potential (NAP) and somatosensory evoked potential (SEP) recording, how to interpret the electrodiagnostic results, and describes both the special features and the limitations of the methods. We found reliable results of neurography, detecting the presence or absence of spontaneous nerve regeneration across a lesion in continuity months before the reinnervation reached its final target. Based on our results, we suggest that NAP recording of the exposed nerve can widely prevent unnecessary nerve or fascicle resection. Besides this important indication, the nerve function evaluation was successfully used in nerve surgery whenever the quality of the nerve parenchyma was crucial to the operative management. Further indications such as evaluating brachial plexus lesions and the condition of nerve roots, judging the proximal coaptation site in nerve reconstruction, tracing the site of a nerve lesion and identifying the pathophysiology of nerve malfunction are exemplified. Intraoperative nerve conductivity testing should not be considered as a replacement of but rather as a complement to preoperative clinical, electrophysiological and imaging evaluations and a thorough intraoperative morphological examination.

Configuration and localization of the nipple-areola complex in men.

The causes of bilateral absence of the nipple-areola complex in men are seldom congenital, but attributable rather to destruction as a result of trauma, or after mastectomy in female-to-male transsexuals and in male breast cancer, or after the correction of extreme bilateral gynecomastia. Such a bilateral loss becomes a major reconstructive challenge with respect to the configuration and localization of a new nipple-areola complex. Because there is very little information available in the literature, we carried out a cross-sectional study on the configuration and localization of the nipple-areola complex in men.A total of 100 healthy men aged 20 to 36 years were examined under standardized conditions. The first part of the study dealt with the configuration of the nipple-areola complex (dimensions, round or oval shape). The second part concentrated on the localization of the complex on the thoracic wall with respect to anatomic landmarks and in correlation to various parameters such as weight and height of the body, circumference of the thorax, length of sternum, and position in the intercostal space. Of the 100 subjects examined, 91 had oval and seven had a round nipple-areola complex. An asymmetry between the right and the left side was found in two cases. The mean ratio of the horizontal/vertical diameter of an oval nipple-areola complex was 27:20 mm and the mean diameter for a round nipple-areola complex was 23 mm. The center of the nipple-areola complex was in the fourth intercostal space in 75 percent and in the fifth intercostal space in 23 percent of the subjects. To localize the nipple-areola complex on the thoracic wall de novo, at least two reproducible measurements proved to be necessary, composed of a horizontal line (distance from the midsternal line to the nipple = A) and a vertical line (distance from the sternal notch to the intersection of line A, = B). The closest correlation for the horizontal distance A was given by the circumference of the thorax: A = 2.4 cm + [0.09 x circumference of thorax (cm)], (r = 0.68). The best correlation to calculate the vertical distance B was found using the distance A and the length of the sternum: B = 1.2 cm + [0.28 x length of sternum (cm)] + [0.1 x circumference of thorax (cm)], (R = 0.50). In cases of bilateral absence, we recommend creating an oval nipple-areola complex in men. The appropriate localization can be calculated by means of two simple equations derived from the circumference of the thorax and the length of the sternum.

Oral premedication for operations on the face under local anesthesia: a placebo-controlled double-blind trial.

Modern strategies for preventing or controlling pain and anxiety demand a premedication for operations using local anesthesia and for those using sedation or general anesthesia. For optimal patient care, the premedication should be given orally and, with respect to the outpatient basis of the operations, should have a short recovery period. Midazolam, one of the most favored premedications for general anesthesia, has been recommended as a premedication for operations using local anesthesia as well. However, midazolam has only sedative-anxiolytic effects and does not reduce pain sensation, which should be mandatory for operations using local anesthesia. A further requirement is the maintenance of stable hemodynamics for the prevention of postoperative hematomas, especially in the face. For these reasons, another premedication meeting all requirements (anxiolysis, analgesia, and stable hemodynamics) was researched. A randomized, double-blind prospective study was performed from March of 1997 to June of 1998. Five groups totalling 150 patients were included in the study; each group contained 30 patients who had operations performed solely on the face. In the first four groups, the effect of midazolam (0.15 mg/kg(-1)), morphine (0.3 mg/kg(-1)), and clonidine (1.5 microg/kg(-1)) administered orally was compared with a placebo. The fifth group was the control group and received no premedication. To evaluate the effects of the premedications, a corresponding questionnaire was completed independently by the patient and surgeon. With regard to the anxiolytic or analgesic properties of the premedication, 61 percent of the patients preferred pain reduction to anxiety control, and 24 percent of patients preferred reduction of anxiety. The remainder insisted on a reduction of both properties (8 percent) or had no preference (7 percent). Reduction of anxiety was largest in the midazolam and the clonidine groups, but the difference was not significant. The least pain during the application of local anesthesia was experienced by the morphine group (37 percent) and the clonidine group (33 percent), in contrast to the midazolam group (60 percent) (p = 0.04). Morphine and clonidine met the requirements of pain reduction equally well. Nevertheless, considering the rate and intensity of adverse effects with respect to hemodynamic compromises, nausea, and emesis, clonidine is even better suited as an oral premedication for operations on the face using local anesthesia.

Standardizing nerve crushes with a non-serrated clamp.

Standardized experimental nerve crush attempts should include the number, duration, and intensity (amount of pressure) of crushes. The authors have developed a new crushing device, a clamp with which predetermined forces can be applied to nerves. This allows the exertion of different, standardized forces to crush a nerve within a scale that produces second-degree injuries. The main advantages of the clamp are that it is small, although very robust, is purely mechanical, and is easy to handle. The jaws of the clamp are not serrated, so that pressure on the nerve is uniformly transmitted. To avoid unintended nerve damage, the edges of the jaws are smoothly rounded off. The closure of the clamp is mechanized by a spring. As the spring is exchangeable, any number of different preloads are available. The force can be varied, according to different requirements, and is applicable to variantly thick nerves in any experimental animal, thus enhancing standardization, and making cross-over comparisons of experimental study results possible.

Tattooing agents for nerve marking in experimental surgery.

Experimental nerve surgery involves test procedures, including those for nerve lesions in continuity, that leave no visible traces of impairment after surgery. In such cases, non-resorbable sutures are usually used to mark the lesion sites on the nerves. However, this method has two drawbacks: it is not completely atraumatic, and may be frustrating due to displacement of the suture material. The authors demonstrate the use of carbon tattoo pigment to mark nerve lesions permanently, thus allowing their identification reliably at any later date. Following successful preliminary experiments, the tattooing procedure was used in 12 New Zealand White rabbits that had been operated on for a specific nerve regeneration problem. Altogether, 56 tattoo marks were set. The small pigment spots were well-preserved and clearly visible during a second and third operation 4 and 15 weeks later. Histologic examination identified the carbon granules in the outer epineurium; there were no signs of inflammation. This simple, atraumatic, inert, and permanent method for nerve markings in the experimental animal is recommended.

Modifications in vertical scar breast reduction.

The use of vertical-scar breast reduction techniques is only slowly increasing, even though they have been advocated by Lassus and Lejour and are requested by patients. Possible reasons why surgeons are reluctant to use these techniques are that they are said to be more difficult to learn, they require considerable experience and intuition, and their applicability is confined to small breasts. Several surgeons have developed modifications, combining vertical-scar breast reduction techniques with details of the familiar inverted-T-scar technique. We present a procedure involving two further modifications of the vertical-scar breast reduction technique: first, a standardised, geometrical preoperative drawing from our superior-pedicle T technique, with the aim of establishing a reproducible method of reduction requiring no particular intuitive touch, and, second, the addition of a periareolar skin resection, to give the breast the desired round shape. Between September 1998 and December 1999 we used this technique in a prospective series of 52 patients. The median resection weight was 450 g. The maximal postoperative follow-up was 15 months. There were no acute postoperative complications necessitating reoperation. The late complication rate was within the expected range for such procedures (seven patients, 13.5%) and included vertical-scar widening, areolar distortion, residual wrinkles due to incomplete shrinkage of the undermined skin in the inferior pole and asymmetry of the breast. This procedure enables us to offer patients with moderate to marked hypertrophy a reproducible versatile vertical breast reduction technique. The technique is easy to teach and easy to learn, especially for those who are familiar with the superior pedicle inverted-T-scar technique.