[Developments in the Diagnosis and Therapeutic Strategy of the Apert Hand]. / Entwicklungen in der Diagnostik und Planung der Therapie bei der Apert-Hand.

The necessity for early surgical correction of Apert hands for the overall child development has been highlighted repeatedly in older literature. Nevertheless, uncertainties regarding the time and the scale of the initial surgical treatment still remain. While in former times there were no regular follow-ups after the syndactyly release, we now know that during growth bony changes will develop in the Apert hand requiring regular check-ups and, in some cases, revision surgeries. Affected parents need comprehensive clarification about a clear and time-efficient therapeutic concept. This review article describes our actual concept treating Apert hands.

[The Apert Foot: Anatomical Changes, Classification, Thoughts on surgical Treatment]. / Der Apert-Fuß: Anatomische Veränderungen, Klassifikation und Überlegungen zur Operation.

Diagnosis and therapy of the Apert foot are scarcely described in extant literature. This article describes anatomical changes observed in 30 Apert feet. By analysis of X-rays and computed scans 5 types of bony Apert foot malformations were identified. We developed therapeutic recommendations based on this classification.

[Possible Compartment Syndrome of the Hand in Patients with chronic post-traumatic Pain - 2 Case Reports]. / Fragliches Kompartmentsyndrom an der Hand bei chronischen posttraumatischen Schmerzen ­ 2 Fallberichte.

The authors present two young patients with atypical development of painful post-traumatic hand muscle compartment syndrome. The first patient showed congenital hyperplasia of the thenar and first dorsal interosseous muscle and developed chronic exertional pain that only occurred after trauma and is indicative of compartment syndrome. The second patient developed compression of the second palmar interosseous muscle due to post-traumatic haematoma in the third interdigital space.

[Three-year-old child with osteoid osteoma of the thumb: Diagnostic and therapeutic challenge]. / Dreijähriges Kind mit Osteoid-Osteom am Daumen: diagnostische und therapeutische Herausforderung.

A three-year-old girl experienced a fifteen-month odyssey before the surgical removal of an osteoid-osteoma at the distal phalanx of the thumb to relieve her pain. Osteoid-osteoma is a benign bone tumor rarely found in the hand and not yet described as occurring in a small child in extant literature. In one of the first x-ray examinations, a small foreign body was found in the soft tissues of the right thumb. This finding subsequently led to the assumption that trauma was the cause for the pain.We critically discuss the numerous examinations and therapies that the child underwent as well as the lack of interdisciplinary cooperation among specialists for more than a year. The thumb was immobilized for months because of pain and is slowly being reintegrated into the child's body scheme following the last successful intervention.This publication highlights this tumor's rare occurrence in a small child and the importance of interdisciplinary cooperation facilitated today by digital media. This, along with early diagnosis, could save unnecessary suffering and financial resources.

Three-dimensional CT angiography for surgical planning in congenital hand malformations: a case series presentation.

Between January 2000 and December 2019, three-dimensional computer tomographic (CT) angiography was used in a total of 140 hands (116 patients, mean age 6.8 years) with congenital hand malformation to assess the vascular and bony structures. Analysis showed overall satisfactory three-dimensional CT images for operative planning, including detailed abnormal vascular patterns and bony malformations. Among the 116 patients, six patients with typical findings of a few malformations are reported in detail. Pitfalls in interpretation of the images and the use of three-dimensional CT angiography in surgical planning are discussed. We conclude that three-dimensional CT angiography is useful for preoperative planning of complex congenital hand malformations.Level of evidence: IV.

[Neuroma prevention through a sensitive finger fillet flap and a central hand narrowing operation]. / Neuromprävention durch sensiblen Filetlappen bei zentraler Handverschmälerung.

Two patients with functionless fingers as a result of an injury and various operations presented to obtain a second opinion. We offered a finger and partial middle-hand skeletal resection for the painful and disabled finger. As amputations often cause neuromas, we created a sensitive fillet flat and used it to fill the defect on the palmar aspect of the hand. Both patients are satisfied with the functional and aesthetic results and have not developed a painful neuroma.

[Completeness and reproducibility of surgical reports: A retrospective analysis of documentation quality using the example of Dupuytren's disease]. / Vollständigkeit und Plausibilität von Operationsberichten: Eine retrospektive Analyse der Dokumentationsqualität am Beispiel des Morbus Dupuytren.

Background A surgical report is the surgeon's postoperative documentation of the procedure undertaken. The purpose of this study was to evaluate the completeness and accuracy of data extracted from surgical reports, using the example of Dupuytren's disease. Material and Methods Between 1999 and 2007, surgical data were retrospectively collected from all primary Dupuytren's disease procedures performed at an academic department for plastic and reconstructive surgery and analysed for completeness. A surgical report was assessed as complete if data on indication, affected side and finger(s), tourniquet, type of incision and surgical procedure were stated. Surgical reports of residents and consultants were compared with respect to completeness. For the assessment of accuracy, total fasciectomy procedure reports were compared with intra- and postoperative photo-documentation. Results 424 surgical reports of 366 patients were analysed, 275 created by consultants, 149 by residents. Although 49.5 % of all surgical reports were complete, the indication for surgery was omitted in 53 cases. Information on the affected side and finger(s) was missing in 13 and 6 cases, respectively. In 29 reports, no documentation on tourniquet was found, in 5 the surgical method and in 82 reports the type of incision was lacking. A significant difference between surgical reports of residents and consultants was found for documentation of indication and severity of the Dupuytren's disease, as well as the tourniquet, in favour of residents (p < 0.0001). In 37 surgical reports, total fasciectomy was performed, 26 with intra- or postoperative photodocumentation. By comparison, in 11 of 26 cases (42 %), total fasciectomy could not have been performed. Conclusion Surgical reports are sometimes incomplete and imprecise, independently of whether they were created by residents or consultants. Although they are intended as documentation for doctors and not for forensic reasons, it should be in the surgeon's interest to create complete and exact reports. As surgical reports are part of the patient's chart, surgical associations should develop guidlines with information that should manditorily included in surgical reports.

Characterisation of the inflammatory response in Dupuytren's disease.

BACKGROUND: Dupuytren's disease is characterised by fibrotic nodule and cord formation in the palmar aponeurosis. The pathophysiology of the disease is still unknown, although cell stress and subsequent activation of immune mechanisms seems to be crucial. MATERIALS AND METHODS: Surgically obtained tissue and blood samples of 100 Dupuytren patients were processed by immunohistochemistry, flow cytometry, as well as immunoscope analysis. Macroscopically normal aponeurotic tissue served as control. RESULTS: Locally, microvascular alterations and massive infiltration by mononuclear cells (CD3+, CD4 > CD8, CD45RO > CD45RA, S100 protein, CD56, CD68, scarce CD19 and mast cells) forming perivascular clusters were found in DD tissue. Cytokine profiling of fibromatosis tissue-derived T-cells showed a Th1/TH17-weighted immune response. Immunoscope analysis revealed a restricted T-cell receptor α/ß repertoire pointing to an (auto)antigen-driven process. CONCLUSION: The striking accumulation of immune cells, expression of leukocyte adhesion molecules, as well as pro-inflammatory and pro-fibrotic cytokines near markedly narrowed vessels supports the theory that the abnormal proliferation of fibroblasts and production of extracellular matrix proteins in DD seems to be related to immune-mediated microvascular damage. The restricted T-cell receptor repertoire of intra-lesional T-cells points to an antigen-driven process. T-cells seem to play an important role in the development of Dupuytren's disease.

Effect of extracorporeal shock wave treatment on deep partial-thickness burn injury in rats: a pilot study.

Extracorporeal shock wave therapy (ESWT) enhances tissue vascularization and neoangiogenesis. Recent animal studies showed improved soft tissue regeneration using ESWT. In most cases, deep partial-thickness burns require skin grafting; the outcome is often unsatisfactory in function and aesthetic appearance. The aim of this study was to demonstrate the effect of ESWT on skin regeneration after deep partial-thickness burns. Under general anesthesia, two standardized deep partial-thickness burns were induced on the back of 30 male Wistar rats. Immediately after the burn, ESWT was given to rats of group 1 (N = 15), but not to group 2 (N = 15). On days 5, 10, and 15, five rats of each group were analyzed. Reepithelialization rate was defined, perfusion units were measured, and histological analysis was performed. Digital photography was used for visual documentation. A wound score system was used. ESWT enhanced the percentage of wound closure in group 1 as compared to group 2 (P < 0.05). The reepithelialization rate was improved significantly on day 15 (P < 0.05). The wound score showed a significant increase in the ESWT group. ESWT improves skin regeneration of deep partial-thickness burns in rats. It may be a suitable and cost effective treatment alternative in this type of burn wounds in the future.

Molecular analysis of two novel missense mutations in the GDF5 proregion that reduce protein activity and are associated with brachydactyly type C.

Growth and differentiation factor 5 (GDF5) plays a central role in bone and cartilage development by regulating the proliferation and differentiation of chondrogenic tissue. GDF5 is synthesized as a preproprotein. The biological function of the proregion comprising 354 residues is undefined. We identified two families with a heterozygosity for the novel missense mutations p.T201P or p.L263P located in the proregion of GDF5. The patients presented with dominant brachydactyly type C characterized by the shortening of skeletal elements in the distal extremities. Both mutations gave rise to decreased biological activity in in vitro analyses. The variants reduced the GDF5-induced activation of SMAD signaling by the GDF5 receptors BMPR1A and BMPR1B. Ectopic expression in micromass cultures yielded relatively low protein levels of the variants and showed diminished chondrogenic activity as compared to wild-type GDF5. Interestingly, stimulation of micromass cells with recombinant human proGDF5(T201P) and proGDF5(L263P) revealed their reduced chondrogenic potential compared to the wild-type protein. Limited proteolysis of the mutant recombinant proproteins resulted in a fragment pattern profoundly different from wild-type proGDF5. Modeling of a part of the GDF5 proregion into the known three-dimensional structure of TGFß1 latency-associated peptide revealed that the homologous positions of both mutations are conserved regions that may be important for the folding of the mature protein or the assembly of dimeric protein complexes. We hypothesize that the missense mutations p.T201P and p.L263P interfere with the protein structure and thereby reduce the amount of fully processed, biologically active GDF5, finally causing the clinical loss of function phenotype.

Inferior pole length and long-term aesthetic outcome after superior and inferior pedicled reduction mammaplasty.

BACKGROUND: Long-term aesthetic results after reduction mammaplasty remain an important issue for evaluating the success of different techniques. Superior pedicled techniques are reported to maintain a better breast projection with less bottoming-out of the inferior mammary pole than inferior pedicled techniques. METHODS: The outcomes of 18 patients who had undergone the superior pedicled technique described by Pitanguy and 16 patients operated on using the inferior pedicled technique by Robbins were compared. RESULTS: The mean follow-up period was 49 months in the Pitanguy group and 35 months in the Robbins group. The distance between the inframammary crease and the inferior margin of the nipple-areola complex (NAC) showed a mean elongation of 3.3 cm (80.5 %) after the superior pedicled Pitanguy technique and 3.9 cm (92.9 %) after the inferior pedicled Robbins technique (p = 0.077). Using postoperative photographs, the overall aesthetic result after Pitanguy's technique was judged significantly better than the result after Robbins' technique (p = 0.002). CONCLUSIONS: Distinct postoperative elongation of the inferior mammary pole length must be considered in the preoperative marking for inferior and superior pedicled reduction mammaplasty. Guide values for the elongation can be used for planning unilateral adjustment reduction mammaplasty. To avoid bottoming-out of the inferior mammary pole, the NAC should be located at the level of the inframammary crease and the distance between the inframammary crease and the inferior border of the NAC should not exceed 4-4.5 cm. The definite position of the NAC should be decided after final shaping of the reduced breast toward the end of the operation. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article.

T regulatory cells and TH17 cells in peri-silicone implant capsular fibrosis.

BACKGROUND: The authors investigated the immunological mechanisms underlying extensive peri-silicone implant capsule formation, one of the most frequent postoperative complications in patients receiving silicone mammary implants. METHODS: The authors studied immune response activation by phenotypic and functional characterization of lymphocytes accumulated within this tissue. Intracapsular lymphoid cells and autologous peripheral blood mononuclear cells were isolated and analyzed by flow cytometry. The proportion of T regulatory cells (CD4+ CD25(high) Foxp3+ CD127), the cytokine profiles, and the T cell receptor repertoire of these cells were examined. Intracapsular T regulatory cells were then further analyzed by immunohistochemistry and functional suppression assays. RESULTS: In comparison with peripheral blood, the cellular composition of intracapsular lymphocytes showed a predominance of CD4+ cells. Intracapsular T cells predominantly produced interleukin-17, interleukin-6, interleukin-8, transforming growth factor-ß1, and interferon-γ, suggesting a TH1/TH17-weighted local immune response. Intracapsular T cells displayed a restricted T cell receptor α/ß repertoire. The intact suppressive potential of T regulatory cells was demonstrated in crossover experiments with activated peripheral T cells. They did not, however, suppress intracapsular T cells. Interestingly, ratios of intracapsular T regulatory cells were inversely proportional to the clinical degree of capsular fibrosis. CONCLUSION: The authors' results indicate that silicone implants trigger a specific, antigen-driven local immune response through activated TH1/TH17 cells, suggesting that ensuing fibrosis is promoted by the production of profibrotic cytokines as a consequence of faltering function of local T regulatory cells.

World experience after more than a decade of clinical hand transplantation: update on the Innsbruck program.

Patients who have lost a hand or upper extremity face many challenges in everyday life. For some patients, reconstructive hand transplantation represents a reasonable option for anatomic reconstruction, restoring prehensile function with sensation and allowing them to regain daily living independence. The first clinical case of bilateral hand transplantation at University Hospital Innsbruck was realized on March 17th, 2000. A decade later, a total of 7 hands and forearms were transplanted in 4 patients. This article review the clinical courses of 3 bilateral hand transplant recipients and highlights psychological aspects on reconstructive hand transplantation with special regard to unilateral/bilateral transplantation.

Reduced insulin-like growth factor-I serum levels in formerly obese women subjected to laparoscopic-adjustable gastric banding or diet-induced long-term caloric restriction.

Life-span extension in laboratory rodents induced by long-term caloric restriction correlates with decreased serum insulin-like growth factor-I (IGF-I) levels. Reduced activity of the growth hormone/IGF-I signaling system slows aging and increases longevity in mutant mouse models. In the present study, we show that long-term caloric restriction achieved by two different interventions for 4 years, either laparoscopic-adjustable gastric banding or reducing diet, leads to reduced IGF-I serum levels in formerly obese women relative to normal-weight women eating ad libitum. Moreover, we present evidence that the long-term caloric restriction interventions reduce fasting growth hormone serum levels. The present study indicates that the activity of the growth hormone/IGF-I axis is reduced in long-term calorically restricted formerly obese humans. Furthermore, our findings suggest that the duration and severity of the caloric restriction intervention are important for the outcome on the growth hormone/IGF-I axis in humans.

The internal mammary artery perforator (IMAP) breast-flap harvested from an asymmetric hyperplastic breast for correction of a mild funnel chest deformity.

Pectus excavatum deformity is the most frequent congenital anomaly of the thoracic wall. If the invasive surgical procedures of thoracoplasty are not indicated or the patient refuses them, alternative treatment options should be considered. In such cases, local or distant transposition of autologous tissue could be appropriate. This report presents a selected case of funnel chest deformity and concomitant unilateral breast hyperplasia. Both deformities were corrected simultaneously using a pedicled internal mammary artery perforator (IMAP) flap dissected from the hyperplastic breast. This is a safe, reliable, low-morbidity, one-stage option for adult women that uses an easy-to-harvest flap for simultaneous correction of mild funnel chest deformity and concomitant breast hyperplasia with a single resulting scar.

Adipokine profile and insulin sensitivity in formerly obese women subjected to bariatric surgery or diet-induced long-term caloric restriction.

To better understand the contribution of the fat mass to the effects of long-term caloric restriction in humans, we compared adipokine profile and insulin sensitivity in long-term calorically restricted formerly obese women (CRW) subjected to different interventions, bariatric surgery, or reducing diet, with age- and BMI-matched obese (OW) and normal-weight women (NW) eating ad libitum. Our key findings are that despite a considerably stronger weight loss induced by bariatric surgery, both long-term caloric restriction interventions improved insulin sensitivity to the same degree and led to significantly lower retinol-binding protein-4 and interleukin-6 serum levels than in OW, suggesting that lowering of these two adipokines contributes to the improved insulin sensitivity. Moreover, serum leptin was considerably lower in CRW than in OW as well as in NW, suggesting that CRW develop hypoleptinemia.

Extracorporeal shock wave treatment in ischemic tissues: what is the appropriate number of shock wave impulses?

The dose-dependent effect of extracorporeal shock wave technology (ESWT) was evaluated using a murine skin flap model. Thirty-six Sprague-Dawley rats were divided into six groups (ESWT groups 1 through 5 and a control group). After surgery, shock wave impulses doses were administered: 200 (group 1), 500 (group 2), 1500 (group 3), 2500 (group 4), 5000 (group 5), and 0 (control group 6). Flap viability was evaluated on day 7. Overall, significantly smaller percentages of necrotic zones were observed in groups 2, 3, and 4 compared with groups 1, 5, and the control group ( P < 0.05). ESWT treatment with 200 impulses was found to be ineffective. ESWT treatment of 5000 impulses resulted in a significant increase in the percentage of necrosis compared with other ESWT groups ( P < 0.05). However, ESWT treatments between 500 and 2500 impulses at 0.11 mJ/mm (2) enhanced epigastric skin flap survival significantly.

Familial congenital symmastia: ultrastructurally abnormal breast tissue.

Reports about congenital symmastia and its surgical treatment are few. We report two patients - a mother and daughter - with congenital symmastia in whom breast and fatty tissue was found to be mobile adhering poorly to the chest wall. Although histological examination showed no abnormality of the tissue bridge between the breasts, ultrastructural investigation of breast tissue (including Cooper's ligaments) showed an abnormal arrangement of collagen fibres. Satisfying aesthetic results were achieved by resection of excess soft tissue in the cleavage area through a submammary incision and fixation of the skin with subcutaneous interrupted sutures to the sternal periosteum.