Does patient load affect clinical outcome of burn patients in specialized centers? An analysis of the German Burn Registry.

Hospital volume has been identified as an independent outcome parameter for a number of medical fields and surgical procedures, and there is a tendency to increase required patient numbers for center verification. However, the existing literature does not support a clear correlation between patient load and clinical outcome in adult burn care and recent data from Germany does not exist. We therefore evaluated the effect of patient volume in German burn centers on clinical outcome. Patient data was extracted from the German Burn Registry from 2015 to 2018. For better inter-center comparability, solely burn patients with a TBSA ≥ 10% were included. Mortality, number of surgeries and length of stay (LOS) were evaluated with respect to burn center patient volume. Burn center volume was divided into two and three groups. A total of 2718 patients with a TBSA ≥ 10% were admitted to the participating 17 burn centers. Independent from the division of patient data into either 2 or 3 groups, the TBSA and ABSI score-related severity of burn injuries were comparable between groups. There was no significant difference in mortality due to center size. Nevertheless, patients treated in large volume burn centers showed a significantly increased LOS (+4.5 days, [1.9-7.2] CI, p = 0.001) and required significantly more surgeries (+0.5 surgeries [0.2-0.8] CI, p = 0.002) when compared to the small volume centers. A similar phenomenon regarding mortality and LOS (p 0.001) was observed after dividing the centers into two groups. Interestingly a division into three groups showed significant differences with the best outcome for patients in medium-volume centers. Nevertheless, mortality did not differ significantly. Therefore, our data demonstrates that in contrast to many other medical fields, outcome and mortality are not automatically improved in burn care by simply increasing the patient load, at least in centers treating 20-100 BICU patients/year.

Wireless microcurrent stimulation improves blood flow in burn wounds.

RATIONALE: Skin breakdown, as in wounds, leads to an electric potential, defined as current of injury with the intent of wound closure. Burn wounds are defined by different zones of perfusion having a direct influence on further therapy (e.g. conservative management or skin grafting). We studied immediate, quantifiable effects of electric stimulation on skin perfusion in burn wounds. METHOD: Wireless Microcurrent Stimulation (WMCS) was utilised as an adjunct therapeutic modality in 10 patients with partial thickness burn wounds. Microcirculation in the skin was quantified with a Laser Doppler (LDI) before and after WMCS treatment. We included a control group of 10 healthy individuals. RESULTS: A single application of WMCS significantly increased mean flow, velocity and subsequently, haemoglobin and oxygen saturation in partial thickness burn wounds. In healthy skin these parameters increased, but were far less pronounced than in thermally injured skin. CONCLUSION: This study revealed, for the first time that non-contact WMCS improves blood flow in critically perfused partial thickness burn wounds without disturbing the wound or systemically affecting the patient and may represent a promising adjunct tool in burn treatment, with the potential of faster healing by enhanced perfusion of burn wounds and reduction of the zone of stasis. LEVEL OF EVIDENCE: III.

Theoretical basis for optimal surgical incision planning to reduce hypertrophic scar formation.

BACKGROUND: After approximately 24 weeks of gestation, human cutaneous wounds and incisions heal by scar formation. Continued or unregulated stimulation of tissue fibroblasts is thought to lead to an activated state with ongoing collagen deposition resulting in a visible hypertrophic scar. There is evidence that mechanical forces as sensed by fibroblasts lead to downstream events such as excessive extracellular matrix deposition. Mechanical forces acting on the wound fibroblast are exerted by underlying muscles as well as intrinsic forces found in the dermal component of the surrounding skin. Under static conditions, collagen is oriented parallel to the direction of strain. In an effort to minimize resultant scar formation various and often contradictory lines of non-extension, lines of least tension, have been described for planning optimal surgical incisions. HYPOTHESIS: We hypothesize that it is possible to avoid longitudinal stretch on incisions and thereby minimize resultant pathologic scars if defined anatomical considerations are respected. We hypothesize that placement of skin incisions parallel to lines of minimal longitudinal stretch, non-invasively measured by orientation of collagen orientation would in turn result in minimal scar formation. EVIDENCE: Historical recommendations often derived from human post mortem studies and animal experiments have shed some light on cutaneously observed lines of non-extension. Theoretical considerations of non-extension lines have suggested possible directions of surgical incisions. Post surgical analysis of dermatological interventions have similarly added to our understanding of possible non-extension lines. Measuring anisotropy in the skin can determine collagen orientation in the skin and may therefore allow one to objectively place incisions parallel to non-extension lines. To date no randomized clinical study in humans has addressed whether such an approach would lead to less scarring. A study involving volunteers examining many body areas seems ethically challenged. CONCLUSION: The hypothesis, although not proven, is supported by available evidence. If our hypothesis that measurable cutaneous collagen orientation guided incisions improved scar formation then surgical incision planning would deservedly require more clinical attention. Preoperative measurement or at least pre-closure assessment of anisotropy prior to surgical incision placement or closure would notably reduce the incidence of hypertrophic scars.

Impact of scapholunate dissociation on human wrist kinematics.

Neither the complex motions of the scapholunate joint, nor the kinematic changes that occur as a result of injury to it, are fully understood. We used electromagnetic tracking within affected bones to evaluate the physiologic motions in the planes of flexion and extension, and of radial and ulnar deviation of human cadaver wrists, before and after complete transection of the scapholunate ligaments. Despite individual variance between each wrist, we were able to establish a pattern in the changes that occurred after scapholunate ligament injury. During the motions examined, the scaphoid showed an increase in translational deviation in almost all motion axes. In contrast, the movement of the lunate seemed to be impaired, especially in radial-ulnar deviation.

Infection control in german-speaking burn centres: results of an online survey.

To systematically evaluate which infection control measures are in place in burn units, we conducted an online survey among 43 German-speaking burn units. The 29 units that responded and agreed to publication represented more than 125 patient beds. All units were located in advanced care hospitals. A total of 14 units provided single rooms only, and 22 units had a nurse-to-patient ratio of at least 1:2. Infection control practices included pre-emptive barrier precautions (29 units), the use of sterile filters for tap water supply (29 units), and an antibiotic stewardship program (24 units). Microbial screening of the patients on admission (23 units), regular prevalence screening (26 units) and surveillance of nosocomial infections (21 units) were also widely used. The high reply rate to the survey indicates the special relevance of infection control for burn units. Our survey shows that great efforts and several measures are being undertaken to address infection control challenges in burn patient care, but it also underlines the need for increased interdisciplinary infection control and antibiotic stewardship activities.

Afin d'évaluer les mesures préventives des infections déployées, nous avons réalisé une enquête en ligne auprès de 43 Centres de Traitement des Brûlés germanophones. Les 29 CTB ayant répondu (et accepté la publication) représentent 125 lits. Tous les CTB étaient situés dans des hôpitaux de référence. Quatorze CTB n'avaient que des chambres seules, 22 avaient un ratio infirmière/patient de1/2. Les mesures préventives comprenaient les précautions barrière (29), des filtres aux points d'eau (29), un programme d'évaluation de l'antibiothérapie (24). La cartographie bactérienne à l'entrée (23), la surveillance de la prévalence des infections (26) et des infections nosocomiales (21) étaient aussi régulièrement déployées. Le taux de réponse élevé pour ce type d'étude montre l'intérêt porté à la prévention des infections en CTB. Cette étude montre que les CTB portent une attention particulière à la prévention et à la surveillance des infections. Elle démontre aussi l'intérêt d'une approche multidisciplinaire et de la mise en place de programmes d'évaluation de l'antibiothérapie.

Necrotizing fasciitis resulting in fatal lung aspergillosis: Uncommon pathogenesis. A case report.

We present a fatal case of Aspergillus-associated lung failure in a patient with necrotizing fasciitis. The cause of the fasciitis was a retroperitoneal perforation of a colon carcinoma. Being already a rare condition, the fasciitis did not manifest as Fournier's gangrene like similar described cases illustrate, but instead travelled along the fasciae and subcutaneous fat tissue cranially into the thoracic cavity, ultimately leading to a disseminated infection of the lungs. The lethal outcome was thus caused by respiratory failure at a time when the primary focus was already successfully treated, contrary to typical cases of necrotizing fasciitis. This case report depicts the importance of acknowledging opportunistic fungal infections in the practice of emergency surgery. Contributing factors, pathogenesis and possible prevention measures are discussed.

[Current Perceptions of Lipofilling on the Basis of the New Guideline on "Autologous Fat Grafting"]. / Aktuelle Erkenntnisse zur Eigenfett Transplantation anhand der neuen Leitlinie "Autologe Fetttransplantation".

Introduction: Autologous fat transfer has recently become an increasingly popular surgical procedure and comprises harvesting, processing and transplantation of adipose tissue, as well as professional follow-up care. This method, as a surgical procedure, can be utilised for trauma-, disease- or age-related soft tissue volume deficits and soft tissue augmentation. As usage is increasing, but the variables of fat harvest, specific indications and fashion of fat transfer are poorly defined, there is a great demand for development of a guideline in the field of reconstructive and aesthetic surgery. Methods: All relevant points were discussed within the scope of a consensus conference including a nominal group process of all societies involved in the procedure and ratified with a strong consensus (>95%). Literature from the standard medical databases over the last 10 years was retrieved, studied and specific guidelines were concluded. Results: Consensus was achieved among all professionals involved on the following points: 1. definition 2. indication/contraindication, 3. preoperative measures 4. donor sites 5. techniques of processing 6. transplantation 7. follow-up care 8. storage 9. efficacy 10. documentation 11. evaluation of patient safety. Conclusion: Definite indications and professional expertise are paramount for autologous fat tissue transfer. Successful transfers are based on the use of correct methods as well as specific instruments and materials. Autologous adipose tissue transplantation is considered to be a safe procedure in reconstructive and aesthetic surgery, due to the low rate of postoperative complications and sequelae.

The cost of post-burn scarring.

Deep burns lead to scarring and contractures for which there is little or no published data on treatment costs. The purpose of this study was to fill this gap by analysing treatment costs for burn sequelae. To do this, German-DRG for in-patient treatment was collected from the Burn Centre Lower Saxony. DRG-related T95.-coding served as a tool for burn-associated sequelae. Data on scar occurrence, plastic-reconstructive surgery and sick leave were collected by a questionnaire. The findings showed that 44.6% patients reported post-burn scarring and 31% needed surgical intervention. The expected risk for readmission was significantly higher (p=0.0002) with scars compared to without. Significantly higher costs for pressure garments were noted for scarred patients (p=0.04). No differences were found for ointments, silicone dressings or pain medication. Treatment costs for patients with scars were 5.6 times higher compared with no scar assessed by G-DRG. No differences were stated subsuming multiple readmissions for post-burn treatment per individual. Significantly higher costs (p=0.03) were noted for patients with burn sequelae other than scars with regard to individual readmissions. It has been revealed that treatment of scars causes higher costs than for other burn sequelae because of multiple surgical interventions. To reduce post-burn scarring and costs, specialized burn centres provide optimal and state-of-the-art treatment. As well as this, more emphasis should be laid on promoting research for the development of novel anti-scarring therapies.

Les brûlures profondes entraînent des cicatrices et des contractures pour lesquels il n'existe pas de données publiées dés coûts de traitement. Le but de cette étude était de combler cette lacune en analysant les coûts de traitement des séquelles de brûlures. Nous avons recueillies les données sur les séquelles de brûlure du Centre de Brûlés de Basse-Saxe en utilisant un questionnaire. Toutes les informations sur les cicatrices, la chirurgie plastique reconstructive et les congés de maladie ont été recueillies. Les résultats ont montré que 44.6% des patients avaient des cicatrices et 31% ont eu besoin d'une intervention chirurgicale. Le risque de réadmission était significativement plus élevé (p = 0,0002) parmi les patients avec des cicatrices. Pour ces patients les coûts étaient considérablement plus élevés pour les vêtements de compression (p = 0,04) mais, en ce qui concerne les pommades, les pansements siliconés ou les médicaments contre la douleur aucune différence n'a été trouvée. Les coûts de traitement pour les patients porteurs de cicatrices étaient 5,6 fois plus élevés par rapport aux patients sans aucune cicatrice. Les coûts plus élevés (p = 0,03) ont été observés chez les patients avec des séquelles de brûlures autre que cicatrices dues aux réadmissions individuelles. Nous avons noté aussi que le traitement des cicatrices entraîne des coûts plus élevés par rapport aux autres séquelles à cause des interventions chirurgicales multiples. Pour réduire les cicatrices post-brûlures, et donc les coûts, les centres spécialisés fournissent un meilleur traitement. De plus, l'accent devrait être mis sur la recherche pour le développement de nouvelles thérapeutiques anti-cicatrices.

[Competency-based medical education: National Catalogue of Learning Objectives in surgery]. / Kompetenzorientierung in der medizinischen Ausbildung: Nationaler Lernzielkatalog Chirurgie.

Competency-based medical education is a prerequisite to prepare students for the medical profession. A mandatory professional qualification framework is a milestone towards this aim. The National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) of the German Medical Faculty Association (MFT) and the German Medical Association will constitute a basis for a core curriculum of undergraduate medical training. The Surgical Working Group on Medical Education (CAL) of the German Association of Surgeons (DGCH) aims at formulating a competency-based catalogue of learning objectives for surgical undergraduate training to bridge the gap between the NKLM and the learning objectives of individual medical faculties. This is intended to enhance the prominence and visibility of the surgical discipline in the context of medical education. On the basis of different faculty catalogues of learning objectives, the catalogue of learning objectives of the German Association of Orthopedics and Orthopedic Surgery and the Swiss Catalogue of Learning Objectives representatives of all German Surgical Associations cooperated towards a structured selection process of learning objectives and the definition of levels and areas of competencies. After completion the catalogue of learning objectives will be available online on the webpage of the DGCH.

[Keloid and hypertrophic scar treatment modalities. An update]. / Therapie von hypertrophen Narben und Keloiden. Ein Update.

Over the past two decades the treatment of hypertrophic scars and keloids has seen substantial changes due to the evolution of current and establishment of new conservative and surgical methods. This review gives an overview of the current research with respect to the multifactorial etiology and pathophysiology of keloids and hypertrophic scars, discusses conservative surgical treatment options and provides an outlook on novel treatment strategies.

[Burns]. / Verbrennungen.

The treatment of burn wounds is subject to a defined management which can be divided into preclinical treatment, emergency room management, and the clinical phase. A decisive factor for the care of a burn patient is correct assessment of the extent of the burn injury. At the location of the accident, vital functions, i.v. catheters, fluid management, the decision for intubation, and sufficient pain control are crucial. The admission of patients to the emergency room should be subject to a standardized protocol, which is quickly and effectively performed by an interdisciplinary team. Emergency room management consists of a mechanical cleaning and subsequent accurate assessment of the extent of the burn injury, monitoring of vital functions, diagnosis and treatment of an inhalation injury as well as associated injuries, and the appropriate care of the burn wounds.

[One-stage defect closure of deperiosted bone and exposed tendons with MATRIDERM® and skin transplantation. Possibilities and limitations]. / Einzeitige Defektdeckung von denudiertem Knochen und freiliegenden Sehnen mittels MATRIDERM® und Spalthaut. Möglichkeiten und Grenzen.

BACKGROUND: Full-thickness skin defects over functional structures (tendons, vessels) or deperiosted bones of the extremities usually require extensive soft tissue reconstruction to cover the defect. A new option for coverage of the defect is the application of MATRIDERM®, a bovine matrix consisting of collagen and elastin, as a neodermis underneath skin transplants. Can this combined one-stage surgical intervention successfully cover deperiosted bone or tendon? PATIENTS AND METHODS: We performed this one-stage procedure in ten patients instead of soft tissue reconstruction. The success of wound coverage with the one-stage method and in combination with skin transplantation for defects generally associated with considerable loss of transplants (deperiosted bones and tendons without paratenons) was determined. RESULTS: In nine of ten patients, complete defect coverage could be achieved. A one-stage wound closure in extensive defects with exposed tendons in four of five locations could be achieved. In deperiosted bone defects the one-stage coverage was only successful in two of six patients. However, complete wound closure could be achieved with a second skin transplantation in a patient with exposed tendon and bone in three of the four locations. CONCLUSION: As a one- or two-stage procedure, MATRIDERM® application with skin transplantation resulted in an effective defect closure without the need for a complex plastic reconstructive procedure. With regard to its functionality it cannot be considered as a substitute for skin flaps. In selected cases MATRIDERM® is an interesting and successful method in plastic reconstructive surgery.

Autologous fat transplantation for labia majora reconstruction.

A case of autologous fat transplantation for labia majora augmentation after ablative surgery is presented. The patient reported pain and deformity of the left labium majus after resection for Bowen's disease. The symptoms had not been solved by classic plastic surgical reconstructions including a pudendal thigh fasciocutaneous flap. Use of autologous fat transplantation facilitated an improved aesthetic result while preserving residual sensation to the external genitalia and improving symptoms of mucosal exposure and dryness.

[Viability of autologous fat grafts harvested with the Coleman technique and the tissu trans system (shippert method): a comparative study]. / Vitalitätsvergleich von Fetttransplantaten welche mit der Coleman Technik und dem Tissu Trans System (Shippert Methode) gewonnen wurden.

Various methods for harvesting and refining autologous fat grafts have been described. One of the standard procedures, the Coleman technique, is based on manual aspiration to reduce the negative presssure and the centrifugation of the grafts. The Shippert technique uses automatic liposuction with reduced negative pressure and abstains from centifugation in order not to reduce viability of the graft by exposing it to centrifugal forces. This study intends to compare the viability of fat grafts processed with the above-mentioned methods.Fat grafts were obtained in 9 patients by using both the Tissu Trans system (Shippert technique) and the Coleman technique. To evaluate the impact of centrifugation forces, the grafts harvested with the Coleman technique were treated with standard adjustment of the centrifuge and also with doubled g-force. Viability of fat grafts was analysed with the WST-8 test and with annexin V/PI assay FACS analysis.The viability of fat grafts processed by the Coleman technique was significantly higher compared to the Shippert technique on applying the WST-8 test. Applying the annexin V/PI analysis, the viability of fat grafts was almost equal with both techniques. Whereas the fat grafts processed with the Tissu Trans system are injected without condensation, the grafts refined with the Coleman technique were concentrated 3 times by centrifugation compared to the primary liposuctioned graft volumes.The Coleman technique allows the preparation of a fat graft containing more viable cells than the Shippert technique. This is in part due to the condensation of the graft by centrifugation using the Coleman technique. The factor of condensation of the grafts harvested and refined with the Coleman technique exceeds the factor of increased fat graft viability in comparison to the Shippert technique. The Tissu Trans system is more than twice as fast and easier to use with a preferential use for large volume grafts like in breast augmentation, whereas the Coleman technique produces a more condensed graft, favouring it for fat grafting to the face where less volume is needed.

[Does additive spongiosaplasty improve outcome after surgical therapy for solitary enchondroma in the hand?]. / Einfluss der Spongiosaplastik auf die Behandlungsergebnisse nach chirurgischer Therapie solitärer Enchondrome der Hand.

INTRODUCTION: The necessity of spongiosaplasty in the treatment of solitary enchondroma in the hand has been a subject of controversial discussions for several years. Over a period of 10 years the authors performed single curettage without spongiosaplasty. The aim of this study was to investigate our results and to compare these findings with those of other studies. PATIENTS AND METHOD: Over the last 10 years we have treated 106 patients with solitary enchondroma of the hand by single curettage without bone grafting. All patients underwent postoperative radiological examination. The mean follow-up was 34 months. The results of the X-ray investigation were examined retrospectively concerning the recurrence rates and the Hasselgren score. RESULTS: Two patients (1.9%) have experienced radiological changes according to Hasselgren score IV. One patient (0.8%) demonstrated radiological III° changes according to score of Hasselgren. Including the patient with the radiological changes according to Hasselgren score III, the overall recurrence rate was 2.8%. DISCUSSION: After comparing our results with those of other studies, we conclude that additional bone-grafting does not improve the recurrence rate of solitary enchondromas of the hand.