The proximally pedicled arteria radialis forearm flap in the treatment of soft tissue defects of the dorsal elbow.

Soft tissue defects of the dorsal side of the elbow require a stable soft tissue reconstruction. Therefore, for the treatment of limited, uninfected defects, local or distant skin flaps should be used. For large and infected defects, the use of the proximally pedicled arteria radialis forearm flap is indicated. We used the flap in 14 patients as an alternative to conventional methods. This neurovascular, septocutaneous flap proved safe and versatile, guaranteeing stable soft tissue reconstruction of the dorsal aspect of the elbow. The flap has an orthograde flow and is nourished by the radial artery. With its long, neurovascular pedicle, it can be transposed in a proximal ulnar or radial direction. Four years after operation, all elbow joints showed a complete range of motion. No further soft tissue instabilities were seen.

The one-stage surgical treatment of multilocated pressure sores using various myocutaneous island flaps.

Report on 32 patients suffering from chronical pressure sores (n = 18 solitary, n = 14 multilocated), Campbell stages IV-VI, overlaying sacral bone, ischial tuberosity and tuber femoris, which were treated by using various combinations of myocutaneous island flaps (uni- or bilaterally glutaeus maximus and/or biceps femoris flaps). Indications, operative procedures, perioperative management and follow-up results are presented. Superficial skin lesions (n = 2) and wound dehiscence (n = 1) appeared as temporary wound complications in the 14 patients with multilocated pressure sores. In all cases stable and durable coverage was achieved without any recurrence. The value of adequate rehabilitation in avoiding relapses is pointed out.

Microsurgery as an integrated part of the rehabilitation of severely burned patients. Case reports.

The first step in the reconstruction of severely burned patients is the preservation of existing functional structures using classical methods. The possibility of using microsurgical techniques for reconstruction in step two completes the concept of rehabilitation.

[Fusion correction of polydactyly]. / Fusionierende Korrektur von Polydaktylien.

Polydactyly is the most common aesthetic hand anomaly. Its surgical correction is indicated for aesthetic, but especially for functional reasons. Independent of the degree and location (pre- or postaxial) of the anomaly the creation of one single unit, which corresponds to the functional as well as to the cosmetical demands is the main purpose of the operative correction. The principle of this operative procedure is the fusion of the two fingers by using all existent structures. Therefore and due to the individuality of each case of polydactyly only after clear exposure identification of soft tissue structures is possible. Resecting procedures of bony and soft tissue structures which are performed before the fusion shall therefore be performed after the exposure and by preservation of all structures, which are necessary for growth, function, sensibility and blood supply. Using these principles clinical experiences which were made with this method are demonstrated while also postoperative results are shown.

Differential diagnosis of acute dactylitis psoriatica.

A bulbous or "sausage-shaped" finger may represent a special type of psoriatic arthritis without any rheumatoid factor activity. Dactylitis psoriatica must be suspected in cases of arthralgias progressing along the phalanges of a finger associated with global soft tissue swelling. Acute dactylitis psoriatica is characterized by an intermittent course combined with psoriatic and partly extremely mild or masked skin and nail changes. X-rays findings are spicular protuberances at diaphyses in a "cloudy collar" image. Symptomatic treatment of dactylitis psoriatica consists of non-steroidal antirheumatic drugs or basic gold salt therapy. In the interval additional surgical treatment using arthro-plasties and arthrodeses is indicated in cases of joint destruction. Amputation of the affected finger is not to be considered as a mandatory causal therapy of dactylitis psoriatica.

[Special technics for improving the results in replantation surgery]. / Spezielle Techniken zur Verbesserung der Ergebnisse in der Replantationschirurgie.

By integrating of special techniques of hand surgery, microsurgery, and plastic surgery into the case of replantations and severe crush amputations, a result can be achieved which improves the function and thus shortens the time of treatment. According to the extent of the injury this can be achieved by immediate reconstruction of bony defects, by bridging long vascular defects and by late-primary soft tissue coverage.

Treatment of total sternal necrosis using the latissimus dorsi muscle flap.

Complications after a median sternotomy incision, which is used currently in most cardiac and mediastinal surgical procedures, although infrequent, are serious. If sternal dehiscence follows median sternotomy, infection extends to vital underlying structures, exposing the anterior part of the heart and ascending aorta. Permanent hemorrhage, septic thrombosis, or septic perforation of prosthetic material demand soft-tissue coverage. In 5 patients with total sternum necrosis the retrosternal space was covered with a latissimus dorsi muscle flap in order to achieve stable protection of the exposed mediastinal organs.

The differential diagnosis of juvenile digital fibromatosis.

Juvenile digital fibromatosis is a rare condition in which distinctive benign soft tumours occur in the hands and feet of children and adolescents. If bony involvement is found at presentation a malignant soft tissue tumour must be excluded and extensive investigation is required using plain x-rays, scintigraphy and angiography. Histological examination, however, is the only definitive diagnostic measure. In this paper a case of juvenile digital fibromatosis is presented with a discussion of the differential diagnosis.

[Reconstruction of the neck outline after burns using microsurgical technics]. / Rekonstruktion der Halskontur nach Verbrennungen mit mikrochirurgischer Technik.

Cervical burn contractures require early correction because of aesthetic, mechanical and functional reasons. Respiration may be impaired and intubation prove difficult due to contractures. If correction of the contracture is not possible with conventional techniques, then free flaps may be used for neck reconstruction. In this series seven patients had two radial arm flaps, two had latissimus dorsi myocutaneous flaps, one had a latissimus dorsi muscle flap, one a dorsalis pedis flap, and one had a groin flap. Six out of seven free flaps healed without any complications. In one case, using a free groin flap a superficial necrosis was excised and skin grafted. In all cases unrestricted movement of the neck was achieved after physiotherapy. By contouring the flaps a good cosmetic result was achieved.

[Diagnosis and therapy of psychogenic paralyses in the hand region]. / Diagnose und Therapie psychogener Lähmungen im Handbereich.

Beside the importance of its prehensile function the human hand plays an essential role in the conveyance of expression. Manual gestures support the mimic and confirm the spoken word. Based on the psychofunctional connection between mimic and gesture the hand becomes an outlet for psychogenic disorders. The resultant projection of emotional processes into motor disorders has been a matter of conjecture etiologically. Psychogenic manifestation in isolated motor disorders of the hand is considered to be either a functional nervous disorder or a focal dystonia. In comparison to the conversion phenomena reported up until now, in which flexor muscle units of the hand are involved with increased muscular activity (spasm), the cases presented here are characterized by a functional motor disorder manifested as an isolated paralysis of a selective extensor muscle unit (M. extensor pollicis longus) of the hand. After a multidisciplinary approach including clinical morphology, neurology, EMG and psychiatry the final diagnosis of a psychogenic paralysis of the hand is made using direct electro-stimulation of the neuromuscular unit with a needle electrode under simultaneous elimination of the psychic influence (general anesthesia without muscular relaxation). Through such confirmed motor inactivity the psychic genesis of the clinically existing paralysis is proven. Through immediate introduction of a multimodal therapy including physical and psychiatric treatment psychogenic paralyses of the hand can be restored totally.

[Reconstruction of large defects of the oral mucosa with free, revascularized jejunum transplants]. / Die Rekonstruktion grosser Mundschleimhautdefekte mit dem freien, revaskularisierten Jejunumtransplantat.

The resection of oropharyngeal cancer often creates large mucosal defects which may impair chewing, swallowing or speech function severely. Therefore, proper reconstruction is crucial for the patient. In five cases with cancer of the floor of the mouth, the tongue, the cheek and the soft palate respectively, a successful reconstruction was achieved by means of a free revascularized jejunal graft. Tumour resection and preparation of the jejunal graft are performed synchronously by two surgical teams. After suturing the graft into the oropharyngeal defect its mesenteric vessels are usually anastomosed to the facial artery and the external jugular vein. Results showed that the jejunal graft is a most adequate substitute for oropharyngeal defects and superior to skin flaps. In a sixth patient the graft was lost because of an arterial thrombosis. This failure was not life threatening, but led to a poor functional result. Postoperative radiation therapy was tolerated by the transplanted jejunal mucosa in spite of a marked inflammatory reaction.

[Circulation in myocutaneous flaps in the area of the tibia]. / Problematik der Durchblutung bei Hautmuskellappen im Unterschenkelbereich.

After a free myocutaneous flap transfer to the lower leg the necessary circulation may be prevented by spasm of the donor vessel, despite of a tension-free anastomosis. Application of bupivacaine-hydrochloride through a peridural catheter results in a sympathetic blockade. The ability thus to influence vascular spasms pharmacologically has been evaluated. Three clinical cases are presented discussing the surgical consequences of such pharmacological intervention.

[Covering of chronic sacral ulcers by myocutaneous gluteus maximus island flaps]. / Deckung chronischer Sakralulzera durch den myokutanen Glutaeus maximus-Insellappen.

Experience with 18 cases of chronic sacral ulcers treated with gluteus maximus island flaps and a review of perioperative managements are presented. Sacral pressure sores in immobile patients sometimes require radical surgery. Suitable cover can be obtained by myocutaneous island flaps. In seven patients defects up to six cm in diameter were covered by unilateral gluteus maximus myocutaneous island flaps. Eleven defects up to 17 cm in diameter were closed by bilateral gluteus maximus island flaps. The donor sites were closed primarily by direct approximation. There was no flap necrosis. In two patients wound dehiscence occurred and in another two there was delayed wound infection. In one infected case a fistula became established and this was treated by further excision and advancement of the flaps. In all cases suitable healing with adequate padding was obtained. There has been no recurrence of ulceration after two years.

[Anatomical variations in blood vessels and their effect on the technic in toe transfer]. / Anatomische Variationen der Gefässe und ihr Einfluss auf die Technik beim Zehentransfer.

In the absence of grasp, either traumatic or congenital, free transfer of the second toe to the hand is one of the reconstructive possibilities. An essential prerequisite for the acceptance of the transferred toe is a guaranteed blood supply through the vascular pedicle. The blood supply of the second toe can be either by dorsal or plantar arteries, a fact which is due to anatomic variations. Through preoperative angiographic examination the arterial blood supply of the second toe can be defined. The location and length of the vascular pedicle have to be considered in the design of the anastomosis with the recipient vessels of the hand.

Continuous plexus blockade for improved circulation in microvascular surgery.

Five patients are presented who were fitted with an axillary plexus catheter for postoperative sympathetic blockade: 1 finger replantation, 3 toe-finger transfers, and 1 finger-finger transfer. This catheter caused spasmolysis and an increase in the circulation and in the acral systolic blood pressure. Simultaneously an adequate analgesic effect was achieved through the administration of local anesthetic. The muscle relaxation helped immobilize the extremity. The improved circulation, the analgesic effect, and the suppression of muscular activity through continuous plexus anesthesia help healing in replanted or transferred digits.

[Reconstruction of the esophagus and hypopharynx by free jejunum interposition]. / Die Rekonstruktion des Oesophagus und Hypopharynx durch das freie Jejunum-Interponat.

Beside conventional procedures the hypopharyngeal and esophageal reconstruction using a free jejunum-transfer represents an additional method for primary reconstruction of the hypopharynx and esophagus. Out of 48 free jejunum-transfers 16 were used for bridging an hypopharyngeal or esophageal defect, 32 as a patch for reconstruction of the oral cavity. In 7 patients a hypopharynx carcinoma was resected, in 6 cases the cervical esophagus was infiltrated by carcinoma. 3 patients suffered from an esophageal stenosis caused by corrosion after acid ingestion. 11 free grafts healed without any complications. In 2 cases the jejunum was removed because of necrosis. In 3 cases fistulation from the lower anastomosis was observed. Free, microvascular jejunum-transfer using physiological graft material not only seems to be advantageous for tolerance to radiation but is also a one step surgical procedure.

Free jejunal graft for reconstruction of oral, oropharyngeal, and pharyngoesophageal defects.

A free jejunal graft was used either as a patch or as a conduit in 40 cases of reconstruction of the oral cavity, hypopharynx, and upper esophagus. Compared with previous intraoral reconstructive techniques using skin or myocutaneous flaps, one-stage free jejunal grafts result in low morbidity, rapid postoperative recovery, and no additional head and neck scars. Because of secure vascularization, the retention of temporary mandible implants is made safer. In addition to tongue reconstruction, facial contouring can also be achieved by the use of mesenteric fatty tissue. The well-vascularized physiologic lining created by utilizing the jejunal graft is highly resistant to mechanical stress and postoperative radiation therapy.

[Glycosaminoglycans in Dupuytren contracture]. / Glykosaminoglykane in der Dupuytren'schen Kontraktur.

Connective tissue from specimens of Dupuytren's disease showed higher contents and altered distribution patterns of glycosaminoglycans. Increasing chondroitin sulphate concentrations as well as increasing proportions of 6-sulphated galactosamines were found to be the characteristic changes.

[Joint saving forearm replantation using pedicled latissimus dorsi island flap]. / Gelenkerhaltende Unterarmreplantation mittels gestieltem Latissimus dorsi-Insellappen.

In a case report, replantation of a subtotally amputated forearm at the elbow region is described. The elbow joint was reconstructed. At the end of the operation a huge soft tissue defect remained leaving the vein grafts unprotected. Using a latissimus dorsi myocutaneous island flap, the soft tissue defect was covered and the function of the biceps muscle restored.