Experiences with Osteoligamentoplasty According to Weiss for the Treatment of Scapholunate Dissociation.

BACKGROUND: In post-traumatic, dynamic, or static scapholunate (SL) instability, an SL ligament reconstruction is advisable to avoid long-term complications. However, a sufficient primary reconstruction is best achieved in acute injuries. For chronic SL dissociation, there is still no satisfying standard surgical technique. In this context, we evaluated the clinical outcome of Weiss's osteoligamentoplasty as a treatment option. METHODS: Over a three-year period, 16 patients with chronic and symptomatic SL dissociation Grade-II and III, without the signs of osteoarthrosis were, surgically treated using a bone-retinaculum-bone autograft from the distal radius. All patients underwent prior wrist arthroscopy. The clinical outcome was measured using the Mayo-Wrist, Krimmer, and DASH score. In addition, radiological measurements were also performed. RESULTS: The postoperative clinical outcome successfully increased the Mayo-Wrist score: 32 to 64 points, Krimmer score: 30 to 53 points and DASH score: 41 to 30 points. The radiological follow-up demonstrated no evidence of an SL gap or significant loss of reposition in the SL angle in 13 of the 16 cases. Till date, two patients had to be revised to an arthrodesis. CONCLUSIONS: The autogenous osteoligamentary span from the distal radius improves a chronic SL dissociation and, therefore, presents a suitable option to anatomically reconstruct the SL ligament. It leads to a proper realignment of the carpus and could help to prevent arthritic changes of the wrist. Nevertheless, in patients with postoperative high occupational physical strain, the procedure should be performed with reservations. As long as there is no satisfying standard surgical treatment, Weiss's osteoligamentoplasty is a convincing technique.

Patient-rated long-term results after complete denervation of the wrist.

The aim of this study was to examine the long-term results after the denervation of the wrist. Between 1977 and 2001, we treated 375 patients in our clinic. The mean age was 43.5 years; 81% were male and 19% female. The long-term results were assessed by a questionnaire assessing pain on a visual analog scale and patient satisfaction and by the DASH questionnaire. After a mean follow-up of 12.23 years, we found an overall pain reduction of 52.1%. In 67.7% of the patients, we found a relief of pain: of these, 44% are free of pain until today and 56% were temporarily asymptomatic. Patients with a painful osteoarthritic condition without dynamic instability and good range of motion are ideal candidates to benefit from the denervation. The complete denervation of the wrist is an effective treatment option in patients with painful wrist conditions to reduce pain and improve the overall function.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2015/2016]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungs-Bericht 2015/2016.

In addition to the impact factor, research funding also plays a central role in evaluating the academic performance and quality of a researcher, a clinic or a surgical specialty. The scope and quality of research in Plastic Surgery are usually very little known, so that even large funding institutions do not get a full view of research funding in our specialty. Therefore, sometimes traditional structures are not adapted to new needs by the developing younger surgical fields. In peer review sometimes peers are not chosen from the same surgical specialty, but from a different surgical fields being peers in large field of surgery. By this a bias can easily be generated which would not be advantageous for subspecialties such Plastic Surgery. The goal of this paper is to establish an overview in the form of a registry of the German Society of Plastic Reconstructive and Aesthetic Surgeons (DGPRÄC) in order to make the joint academic achievements more visible in the future. At the same time, a research funding report is to be published for the years 2015 and 2016.

[Analysis of Diagnosis Related Groups and their Impact on Health Care in Post Massive Weight Loss Surgery]. / Analyse von Fallpauschalen und deren versorgungsrelevante Effekte in der postbariatrischen Wiederherstellungschirurgie.

BACKGROUND: Diagnosis Related Groups (DRG) were introduced in Germany as a medico-economic classification system in 2004. In this analysis, we looked at restorative surgery after massive weight loss, focusing on reimbursement of this fee-per-case system in comparison to costs to deduce possible effects on health care over time. MATERIAL AND METHODS: First we analysed the algorithms for the relevant DRGs including data about length of stay and reimbursement. Furthermore, we integrated cost data from German reference hospitals of the last 5 years as well as single-centre data from a university hospital. RESULTS: Due to a diagnosis-related algorithm, coding will constantly lead to DRG K07Z. In 2016, a new diagnosis code specific to massive weight loss was introduced, which now leads to DRG J10B. As a result, reimbursement is reduced by more than half. In the cost matrix, staff, general ward, operation theatre and anaesthesia were identified as the main cost drivers. As expected, there was a statistically significant correlation between general ward costs and time of stay in hospital as well as operation theatre costs and incision-suture time. Considering the cost data of the reference hospitals, there was an average excess of EUR 781 per case whereas our own cost data revealed a deficit of EUR 1 700 to 2 700 per case. This is mainly due to the fact that approximately one third of our patient cohort underwent highly elaborate circular body lifts. CONCLUSION: It has to be questioned whether a newly introduced main diagnosis code can be applied as such without any underlying cost data having been collected in previous years. Given unchanged treatment measures, the main cost drivers identified by us remain the same, which means that there is no rationale for a drop in revenue. In addition to providing incentives for an efficient use of resources and quality optimisation, this system should offer medical service providers a sustainable and realistic possibility to break even.

[Technique of Autologous Chondrocyte Implantation for Severe Radiocarpal Arthrosis: Status Quo after 24 Months]. / Technik der autologen Chondrozytenimplantation bei ausgeprägter Radiokarpalarthrose: Status quo nach 24 Monaten.

We illustrate the operative technique of autologous chondrocyte implantation (ACI) to restore a 4° cartilage damage of the radius surface in the case of a 22-year-old patient, and report on the clinical and radiological results at 6 and 24 months postoperatively.

[Decompression of Peripheral Nerves in the Treatment of Diabetic Polyneuropathy]. / Dekompression peripherer Nerven als Behandlungskonzept der diabetischen Polyneuropathie.

Polyneuropathy causing ulceration and amputation as a long-term consequence of diabetes mellitus is analysed for its pathophysiology, socioeconomic and medical relevance. Outcomes of decompression of peripheral nerves on the lower extremity regarding sensation, pain, development, and recurrence of ulceration, and amputation is evaluated by a systematic literature review in pubmed, medline and embase. Decompression of peripheral nerves in diabetic peripheral neuropathy seems to be a good treatment option for restoring sensation, decreasing pain, as well as for avoiding the development and recurrence of ulceration and amputation.

Alteration of biomechanical properties of burned skin.

BACKGROUND: The prevalence of burns in the general population is high. Despite new research findings, skin burns and its resulting tissue damage are still not entirely understood. In particular, little is known about the depth-dependent alteration of skin biomechanical properties of these wounds. METHODS: Thirty-six burn wounds with six different depths were generated on the abdomen of six Göttingen minipigs. The alteration of skin biomechanical properties was evaluated objectively after 15 and 360 min using a Cutometer device. Biopsies for histological evaluation were taken and the depth of burn was correlated with biomechanical properties. RESULTS: Firmness of skin (R0), overall elasticity (R8) and calculated elasticity (Ue) demonstrated a continuous decrease with an increasing depth of burn 15 min after wound generation. Gross elasticity (R2), net elasticity (R5) and amount of elasticity of the whole curve (R7), however, showed an increase of values with increasing depth of injury. A further decrease of elasticity was demonstrated 360 min after wound generation. CONCLUSION: The alteration of skin biomechanical properties is a function of damaged tissue structures. The presented results demonstrate a depth-dependent decrease of principal elastic parameters with an increasing depth of burn and the results indicate progressive tissue damage over the time.

[Systematic analysis of the readability of patient information on the websites of clinics for plastic surgery]. / Systematische Analyse der Lesbarkeit von Patienteninformationen auf den Internetseiten von Kliniken für Plastische Chirurgie.

OBJECTIVE: The Internet is becoming increasing-ly important as a source of information for patients in medical issues. However, many patients have problems to adequately understand texts, especially with medical content. A basic requirement to understand a written text is the read-ability of a text. The aim of the present study was to examine texts on the websites of German -plastic-surgical hospitals with patient information regarding their readability. MATERIALS AND METHODS: In this study, the read-ability of texts of 27 major departments of plastic and Hand surgery in Germany was systematically analysed using 5 recognised readability indices. First, texts were searched based on 20 representative key words and themes. Thereafter, texts were assigned to one of 3 major themes in order to enable statistical analysis. In addition to the 5 readability indices, further objective text parameters were also recorded. RESULTS: Overall, 288 texts were found for analyzation. Most articles were found on the topic of "handsurgery" (n=124), less were found for "facial plastic surgery" (n=80) and "flaps, breast and reconstructive surgery" (n=84). Consistently, all readability indices showed a poor readability for the vast majority of analysed texts with the text appearing readable only for readers with a higher educational level. No significant differences in readability were found between the 3 major themes. CONCLUSION: Especially in the communication of medical information, it is important to consider the knowledge and education of the addressee. The texts studied consistently showed a readability that is understandable only for academics. Thus, a large part of the intended target group is probably not reached. In order to adequately deliver online information material, a revision of the analysed internet texts appears to be recommendable.

Alteration of biomechanical properties of skin in acute cold contact injury.

BACKGROUND: The prevalence of acute cold injury has increased recently. Despite new research findings, these injuries and their resulting tissue damage are still not entirely understood. Especially, little is known about alteration of skin biomechanical properties. METHODS: A total of 36 acute cold contact wounds with different depths were generated on the abdomen of six Göttingen minipigs. Alteration of biomechanical properties of skin was evaluated objectively after 15 and 360 min using a Cutometer device. Biopsies for histological evaluation were taken, and the depth of injury was correlated with biomechanical properties. RESULTS: Calculated elasticity (Ue), firmness of skin (R0) and overall elasticity (R8) demonstrated a continuous decrease, whereas other parameters demonstrated an initial increase with increasing depth of injury 15 min after wound generation. All parameters showed an increase compared to healthy skin, 360 min after wound generation. Furthermore, an alteration of values over time was detected. CONCLUSION: Alteration of biomechanical properties of skin is a function of damaged tissue structures. The presented results demonstrate a decrease of main elastic parameters with increasing depth of injury and indicate progressive tissue damage over time. Skin elasticity measurements are a valuable tool in acute cold contact injury depth assessment and may act as an influencing factor in management decisions.

[Traumatic rupture of a hydrogel-filled breast implant - a case for the Employer's Liability Insurance Association?]. / Traumatische Ruptur eines Hydrogel-Brustimplantates: Ein Fall für die Berufsgenossenschaft?

Today textured breast implants for augmentation and reconstruction are commonly used to reduce the incidence of capsular contractures. Despite modified surfaces, capsular contracture may occur as result of traumatic or iatrogenic ruptures of the implant along with discharge of filling material.We report the interesting case of a female patient with traumatic rupture of one prosthesis in an industrial accident 14 years after implantation of hydrogel-filled breast prostheses. As it was a work related accident, the Employer's Liability Insurance Association is responsible for covering the treatment. The patient history and the histological exam have proven that the accident was work related.

[Development of diagnosis-related groups in different surgical disciplines]. / Entwicklung der Fallpauschalenvergütung in verschiedenen chirurgischen Fachgebieten.

BACKGROUND: Since the introduction of Diagnosis-Re-lat-ed Groups (DRGs) in Germany, the variables of remuneration have continuously changed. Subjectively, reimbursement by DRG has a negative connotation among all specialities. We analysed the development of reimbursement and length of stay in different surgical specialties. MATERIAL AND METHODS: By grouping the top-10-diagnoses and therapies in hand surgery, trauma surgery, general surgery as well as cardiothoracic and vascular surgery between 2004 and 2010, DRGs were obtained, compared and the data deduced. RESULTS: While the lower threshold of length of stay remained almost the same, mean value and upper threshold became shorter in most of the top-10-diagnoses. During the observation period, total reimbursement increased by 30 % in hand surgery, 20 % in general surgery and 17 % in cardiothoracic and vascular surgery, while in trauma surgery it decreased by 1 %. This corresponds to mean annual growth rates of 4.47 %, 3.08 %, 2.68 % and - 0.15 %, respectively. No correlation was found between the 4 disciplines and macro-economic parameters. CONCLUSION: Reductions of mean and upper thresholds of length of stay are present in all surgical disciplines. Total reimbursements developed partially in a contradictory manner. Negative growth involves the danger that hospital investments cannot be realised, especially in the presence of high personnel costs.

[Economic profit of different injuries in a centre for hand surgery - replantation vs. amputation]. / Ökonomischer Profit von Fingerverletzungen in einem handchirurgischen Zentrum - Replantation vs. Amputation.

INTRODUCTION: The Institute for Reimbursements in Hospital (InEK) annually provides an updated DRG system to ensure the medical service providers with a cost-covering remunera-tion. However, the underlying cost data are often opaque and disclosure of the basis of calculation does not take place. On the basis of cost and revenue data from our clinic between 2010 and 2012, a profit statement for amputations and replantation of one or more fingers was employed and compared with the nationwide data of the calculation clinics. MATERIALS AND METHODS: Inpatient days, the revenue and the costs incurred in our clinic based on the cost matrix of InEK costing manual [4] were determined for amputation (DRG X05B), replantation of one (DRG X07B) and several fingers (DRG X07A). The profit was calculated as the difference between revenues and costs. Further-more, a comparison of our data with the nationwide data of InEK was applied. RESULTS: For each of the 3 DRGs the actual costs in our clinic were higher than the costs generated by InEK. Only amputation appeared profitable, while all limb-preserving interventions were associated with losses for our hospital. There was a clear discrepancy between the data of cost of InEK GmbH to the data of our clinic. CONCLUSION: In order not to create any monetary disincentives at the expense of quality of care of individual patients, a cost-covering patient care for all case groups mentioned above should be ensured. The general distrust in the InEK's data that results from such a discrepancy in the cost data can only be rebutted by increasing transparency and disclosure of the calculation basis.

[Benign subcutaneous emphysema caused by a bellows mechanism of the first interdigital space]. / Benigne subkutane Emphysembildung durch einen Falten-Blasebalg-Mechanismus der ersten Zwischenfingerfalte.

We report 2 cases of subcutaneous emphysema after stab wounds of the first interdigital space. The first diagnosis of a gas gangrene was not confirmed. We hypothese an air incorporation caused by a bellows mechanism. An escape of the air may not be possible due to an one-way valve mechanism. The aim of this report is to describe criteria to distinguish benign emphysema from emphysema caused by infection.

[Clinical functional assessment of various surgical hand arthrodesis techniques]. / Klinisch-funktionelle Nachuntersuchung verschiedener handchirurgischer Versteifungsmethoden.

BACKGROUND: Total and partial arthrodesis of the wrist are currently sophisticated treatment options for many advanced pathological changes of the wrist. This retrospective study analyzed the subjective and objective outcome of different wrist arthrodesis techniques, e.g. total wrist arthrodesis, scaphotrapeziotrapezoid (STT) bone fusion and midcarpal arthrodesis. MATERIALS AND METHODS: Subjective physical and mental quality of life of 98 patients (total wrist arthrodesis n = 43, STT fusion n = 30 and midcarpal arthrodesis n = 25) was measured using the DASH questionnaire. The range of motion and grip strength were analyzed in 48 patients (total wrist arthrodesis n = 21, STT fusion n = 17 and midcarpal arthrodesis n = 10). RESULTS: Patients with partial wrist arthrodesis achieved a significantly better DASH score than patients with total wrist arthrodesis. Grip strength did not show any statistically significant differences between the two groups. Patients with STT fusion showed the best range of motion of the wrist. CONCLUSION: Partial arthrodesis seems to be superior to total wrist arthrodesis. Patients profit from a higher physical and mental quality of life.

Severe posttraumatic radiocarpal cartilage damage: first report of autologous chondrocyte implantation.

STUDY DESIGN: Case report. CLINICAL QUESTION: Traumatic articular cartilage defects predispose to secondary osteoarthritis accompanied by impairment or complete loss of function in the corresponding joint. On this account, the timely and correct diagnosis as well as the selection of an appropriate therapy for reconstruction of articular cartilage defects is important. METHODS: A 22-year-old healthy male patient with history of traumatic intra-articular distal radius fracture is presented with in the course detectable 4° cartilage damage in the fovea scaphoidea and into the fovea lunata. For the first time, autologous chondrocyte implantation by the use of an in situ polymerizable albumin-hyaluronic acid gel was performed to restore the articular cartilage. RESULTS: The assessment 6 months after autologous chondrocyte implantation using the standard DASH questionnaire for upper extremity pointed out an improvement in the patient outcome (DASH score pre-operative: 10.8 and 6 months post-operative: 7.5). The clinical examination also showed an improvement in the range of movement of the wrist without pain. The radiological control investigation (MRI- examination) of the wrist 6 months after implantation also revealed a good integration of the implant. CONCLUSION: The case presented here demonstrates the first use of autologous chondrocyte implantation for cartilage reconstruction using an in situ polymerizable albumin-hyaluronic acid gel after traumatic cartilage lesion with 4° cartilage damage of the wrist in a 22-year-old non-smoking, active and healthy man. Initial results are promising in terms of mobility, pain and patient outcome. However, further clinical studies have to be performed with larger number of cases.

[Strategies to ensure careers of young academics in plastic surgery - analysis of the current situation and future perspectives]. / Strategien zur Sicherung des wissenschaftlichen Nachwuchses in der Plastischen Chirurgie - Eine Standortbestimmung und Zukunftsaussichten.

Recruitment problems in surgical disciplines have become an increasingly debated topic. On the one hand current career prospects appear to be less attractive than those were seen for the previous generation. On the other hand the demands for a so-called "work-life balance" have changed and the proportion of female students and colleagues in medicine has risen and will continue to increase. Although Plastic Surgery currently seems to be less affected by these problems than other surgical disciplines, securing a qualified supply of young academics in Plastic Surgery is a prerequisite for the further development of this discipline. The traditional model of mentoring is discussed and the role of coaching in a sense of helping the mentorees examine what they are doing in the light of their intentions and goals is reflected. The present article tries to analyze the current status of academic Plastic Surgery from the viewpoint of German university senior surgeons in academic plastic surgery, and aims to highlight the specific prospects for young academics against the backdrop of an often one-sided and superficial perception of this profession.

A European comparison of reimbursement in breast reconstruction.

AIMS: Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. The purpose of this study was to make an international comparison of reimbursement for breast reconstructive surgery. METHODS: We analysed remuneration for unilateral and bilateral female breast reconstruction (pedicled flaps, free flaps, alloplastic procedures) across five different European countries. National grouper software was used to identify Diagnosis Related Groups from which the proceeds were derived. RESULTS: The mean reimbursement was € 5593 for pedicled flaps, € 9149 for free flaps and € 4037 for implant-based reconstructions. The highest payments were in Sweden and the lowest in Italy. When adjusting payments by purchasing power parities, the relation among the countries did not change. The Austrian system makes a clear distinction between one-stage and two-stage delayed reconstructive interventions whereas reimbursement in other countries favoured a two-stage approach. Only one of five national reimbursement systems distinguishes between unilateral and bilateral reconstructions. CONCLUSIONS: Across a spectrum of European countries, reimbursement for breast reconstruction was based on similar procedure-specific systems, although there was a wide variation in tariffs and consideration of other factors such as underlying diagnosis. As delivery of healthcare becomes more rationalised, there is a need for individualised reimbursement which correlates directly with activity. Drawing on the experience of different healthcare systems may lead to development of a more robust and fair system of reimbursement.

[Angiogenesis and vascularisation in adipose tissue engineering]. / Angiogenese und Vaskularisation beim Tissue Engineering von Fettgewebe.

The current standard for the reconstruction of large soft tissue defects with exposed bone, nerves or blood vessels, for example after extensive tumor resections, complex injuries, severe burns or infections, is the local or free microsurgical tissue transfer. Despite the development of new surgical techniques and many synthetic materials, there are still a large number of limitations and complications at the donor and recipient site. Thus, in a subset of patients either complete treatment is not possible or poses problems. Therefore, there is a great need for the development of new methods and materials allowing for a permanent replacement with body own soft tissue. A promising therapeutic approach is the soft tissue replacement with autologous adipose tissue. Innovative research on the reconstruction of soft tissue by adipose tissue, and clinical and experimental studies on the long-term survival and transplantation of autologous adipose tissue showed that the free fat tissue graft without direct vascular connection come along with disappointing results. Often a loss of volume or a complete resorption of the graft because of insufficient tissue quality by lack of cell differentiation was observed. This fact points to the special role of the maintenance and development of the graft's blood supply (angiogenesis and vascularization) crucial for maintaining a constant volume of the tissue. The rapidly growing interdisciplinary field of tissue engineering offers alternative solutions to the existing treatment options with the aim to produce autologous adipose tissue, stable in volume in vitro as well as in vivo, which can be transplanted as a permanent tissue replacement to corresponding parts of the body. Numerous studies have demonstrated the important and most critical factor of vascularisation for quality, volume and long-term survival of transplanted newly generated adipose tissue constructs. Although our understanding of the regulatory mechanisms of adipogenesis is still limited, there are clear indications that the complex sequences of cell interactions in the differentiation and proliferation of adipocytes is directly related to angiogenesis.