Consensus of the German and Austrian Societies for Wound Healing and Wound Management on vacuum closure and the V.A.C. treatment unit.

Within the framework of the Three-Country Congress on V.A.C. Treatment (Vacuum Assisted Closure Treatment) held on May 16/17, 2003 in Salzburg, a Consensus Conference involving members of the Committees of the German and Austrian Societies for Wound Management was convened. In view of the divergence of opinion on the effectiveness of the treatment among the cost carriers, it appeared appropriate for the two Societies for Wound Healing in Germany and Austria to arrive at a consensus on the importance of and the indications for the management of wounds with the vacuum closure method. Since the first clinical applications in the nineteen-forties, both the indication spectrum and the number of applications have increased continually. In addition to diverse vacuum closure systems, there is patented computer-controlled system technology available that is established V.A.C. treatment. Although this is a hospital-based system, it can also be used on an outpatient basis by appropriately trained physicians and nursing staff and in instructed patients. For some indications, vacuum closure and V.A.C. management is considered the treatment of choice, since no equivalent alternative methods are available. A con-benefit analysis shows that vacuum closure and V.A.C. treatment is cost effective.

[V.A.C.-therapy and laser-induced fluorescence of indocyanine-green (IC-view), an assessment of wound perfusion in diabetic foot syndrome]. / V.A.C.(R)-Therapie und Laser-induzierte Fluoreszenz von Indozyaningrün (IC-VIEW) - eine Bestimmung der Wundperfusion beim Diabetischen Fusssyndrom.

Aim of the study was the use of IC-View for monitoring the effect of V.A.C.(R)-therapy on perfusion in diabetic wounds and the surrounding skin. We present data of ten patients with diabetic foot syndrome. Seven men and three women with age from 56 to 86 (mean 68) years were treated with V.A.C.(R)-therapy for 7 to 24 (mean 12) days. The perfusion index was calculated for the wound itself and for the surrounding skin before and at the end of V.A.C.(R)-therapy. The perfusion of the wound showed an increase under V.A.C.(R)-therapy of 31 % (6-62.5 %). The perfusion index calculated for the skin around the defect achieved an increase of 14 % (1.5-38 %). All defects were covered with meshed skin graft.

Long-term results of modified graciloplasty for sphincter replacement after rectal excision.

OBJECTIVE: Restoration of the anal sphincter by means of electrically stimulated (dynamic) graciloplasty is a new therapeutic option for patients with severe faecal incontinence or those having abdomino-perineal resection (APR) of the anorectum. The present study reviews the outcome of total anorectal reconstruction (TAR) after APR for low rectal cancer or recurrent anal cancer. METHODS: From 1992 to 2000, 35 of 64 patients treated with dynamic graciloplasty had a TAR performed either synchronously (n=26) or as a secondary procedure one to five years after rectal excision (n = 9). RESULTS: The most frequent complication was injury or erosion of the neorectum (n = 9) which, was avoided with increasing surgical experience. Defaecation disorders and consequent incontinence were the most common functional problem and had to be treated with periodical enemas. CONCLUSION: Although sphincter replacement by means of TAR after APR led to poorer functional results than those achieved in patients treated with dynamic graciloplasty for faecal incontinence, TAR remains a valid treatment option for patients who do not tolerate a permanent stoma.

[The influence of different therapeutic approaches on the survival of elderly burn patients]. / Behandlungsergebnisse von Brandverletzungen im Alter und ihre Beeinflussung durch intensivtherapeutische Massnahmen.

The present study analyzes the outcome of 51 patients aged more than 65 years, who were admitted between 1993 and 1997 to a specific burns unit with the possibility of intensive care medicine including respirator therapy and hemofiltration. The results were compared to an historical control group treated between 1980 and 1990. The overall survival rate was 54 %. Analyzing the patients' mortality, an increase in the number of nurses, improvement of enteral nutrition and wound monitoring had more influence on the survival rates than respirator therapy, hemofiltration and catecholamines. This is in contrast to our experience with younger individuals. The positive influence of intensive care on survival was restricted only to a small number of cases. The group of patients who died on the intensive care unit showed a relatively long median survival time of 24 days. Septic multiorgan failure was the main cause of death.

[Anal sphincter restoration using dynamic graciloplasty--results of 50 patients]. / Analer Schliessmuskelersatz mittels dynamischer Gracilisplastik--Ergebnisse der Anwendung an 50 Patienten.

During the period from 1992 to 1998, 50 patients underwent anal sphincter restoration by dynamic graciloplasty for primary (n = 26) or secondary (n = 6) total anorectal reconstruction (TAR) following abdominoperineal rectal resection (APR) or acquired (n = 9) or congenital (n = 9) fecal incontinence, respectively. Forty-seven patients were operated on by a single-stage procedure using a modified technique for the muscle wrap ("split sling"). Muscle fiber transformation by controlled stimulation was achieved at the beginning of the learning curve within 8 weeks and in the meantime within 4 weeks. Rectal injury (n = 10) turned out to be the most serious postoperative complication and was observed mainly in patients following TAR (n = 8). As the most prominent functional problem constipation in patients following TAR hampered the postoperative functional result; however, this was overcome by regular enemas. An improvement in the continence status was observed in 80% of the patients treated for fecal incontinence, and following APR 66% of the patients had acceptable results without a permanent colostomy.

Muscle transformation of the sartorius muscle in a canine model: clinical impact for electrodynamic graciloplasty as a "neosphincter".

PURPOSE: Transformation of fast-twitching skeletal muscles to slow-twitching, slowly fatigable muscles has become of clinical interest in the recent past. Transposition and transformation of the gracilis muscle to use it as a substitute for a resected or defected anal sphincter (graciloplasty) have been reported as achieving promising results in the treatment of fecal incontinence caused by sphincter defects or following abdominoperineal anorectal excision for cancer. METHOD: This experimental study used a canine model and the sartorius muscle to evaluate the functional efficiency of two different configurations of the muscle loop to compare the presently applied transformation program (8 weeks) with a shorter (5 weeks) protocol. In six beagle dogs, both sartorius muscles were wrapped around two stomas, either in an alpha fashion or in the so-called split-sling technique. Muscle transformation was achieved by controlled neuromuscular stimulation either during eight (Program A) or five weeks (Program B). After completion of the transformation period, the function of the muscle slings was evaluated by manometry, and histomorphologic evaluation of the sartorius muscles was performed. RESULTS: It was shown that muscle transformation led to a slowly fatigable muscle that made it possible to perform continuos (tetanic) contraction, regardless of the configuration or the duration of the transformation. Median pressures created by these muscles also did not differ significantly. In accordance with these functional findings, the histologic evaluation showed the typical, significant increase of Type I fibers in both muscle slings and following both transformation protocols. Although the decrease of fast-twitching Type II fibers was more pronounced following the conventional (8 weeks) program, this finding did not influence the functional results. CONCLUSIONS: Results of our experiment indicate the possibility for using a shorter transformation protocol for transformation of the gracilis muscle during graciloplasty in the clinical setting. Furthermore, the efficacy and safety of the modified (split-sling) wrap technique was demonstrated.

Complications in the use of diathermy.

Electrical burns in diathermy rarely occur but are not always recognized as such or thoroughly investigated. The literature has proved to be very sparse in terms of reference to complications, although prolonged courses of treatment are required in individual cases. This paper analyses and discusses the problems of burns associated with diathermy that occurred in seven patients.

[Wartenberg syndrome: a rare or rarely diagnosed compression syndrome of the radial nerve?]. / Wartenberg-Syndrom: Ein seltenes oder selten diagnostiziertes Kompressionssyndrom des N. radialis?

Between August 1993 and June 1995, nine female and one male patient with a neuropathy of the superficial branch of the radial nerve (Wartenberg's syndrome) were treated operatively. Hoffmann-Tinel's sign was positive preoperatively as well as Dellon's test. A modified technique involving longitudinal plication of the brachioradialis tendon was used in seven cases. All patients were free of symptoms six weeks after operation.

The radial sensory nerve entrapped between the two slips of a split brachioradialis tendon: a rare aspect of Wartenberg's syndrome.

A retrospective study was designed to verify how often an anatomic variation caused the radial sensory nerve entrapment at the forearm (Wartenberg's syndrome). This variation, in which the superficial branch of the radial nerve emerges from under the fascia between two slips of a split brachioradialis tendon, was mentioned once in a clinical textbook as a basis for nerve entrapment but was found to occur in 5 of 150 dissected arms in 4 of 75 cadavers (3.3% of the investigated arms) in a recent anatomic study. To evaluate the incidence of this variation, 143 operative reports from patients who had Wartenberg's syndrome were reviewed. The variation was observed in seven patients. We conclude that any operation for Wartenberg's syndrome should include a thorough investigation of the site where the radial sensory nerve emerges from under the fascia and, if the nerve emerges through a split brachioradialis tendon, the anomalous tendon slip should be divided.

Mechanical properties of peripheral nerves.

Peripheral nerve trunks are viscoelastic tissues with unique mechanical characteristics. Tensile strength, which includes elastic limit and mechanical failure, concerns surgeons. This study shows that measurements of the load necessary to achieve certain elongations on specimens outside the body do not correspond with in situ measurements. The necessary load is influenced by the presence or absence of branches and by the amount of fibrosis. Because of transverse contraction, elongation beyond a certain limit substantially decreases intrafascicular volume, leading to increased intrafascicular pressure. Stress relaxation is effective only if the nerve repair site is maintained under constant tension. Its beneficial effect disappears after 10 minutes if the repaired nerve is returned to a relaxed state. Therefore, tension at the repair site should be minimized.

[Wartenberg syndrome, caused by a split tendon of the brachioradialis muscle. A report of a rare anatomic variation]. / Wartenberg-Syndrom, verursacht durch eine zweigeteilte Sehne des M. brachioradialis. Ein Bericht über eine seltene anatomische Varietät.

We report a case of radial sensory nerve entrapment caused by a variation of the brachioradialis tendon. The nerve passed through the split tendon and gliding was hindered at this level. After resection of the supernumerary dorsal part of the tendon, relief of pain could be achieved in the 40-year-old patient.

The electrically stimulated (dynamic) graciloplasty for faecal incontinence--first experiences with a modified muscle sling.

Continence following the gracilis stimulated neosphincter reconstruction after total rectal excision is inferior to that obtained in the presence of an intact anal canal. We describe a modification of the alpha loop in which the tendon is brought through the belly of the gracilis muscle. The results in three patients are presented.

[Interdisciplinary management in extremity saving resections of lower extremity tumors]. / Interdisziplinäres Management bei extremitätenerhaltenden Tumorresektionen an der unteren Extremität.

Eighteen patients with tumors of the leg underwent limb saving operations. The large tissue defects were covered by flaps. The use and advantages of these flaps are discussed.

Microsurgical neurolysis: its anatomical and physiological basis and its classification.

Neurolysis is a procedure which has to be performed if the gliding apparatus of a peripheral nerve does not function, and consequently, adhesions and fibrosis develop. The gliding tissue has to provide the ability for the nerve to adapt to the different position of the extremity by longitudinal passive movement. The paraneurium provides movements between the nerve and the surrounding tissue; the interfascicular epineurium provides the possibility of the movement within the nerve. Internal neurolysis is defined as surgery within the nerve if the epifascicular epineurium is completely transected. A classification of different degrees of fibrosis is given with special reference to the procedure which has to be done in each case. Neurolysis is a step-wise procedure with the aim to decompress the fascicles and which is immediately stopped if this aim is achieved. In very severe cases, if the gliding tissue does not regenerate, a gliding tissue flap to envelope the nerve may solve the problem.

Comparison of prognostic indices for burns and assessment of their accuracy.

Logistic regression was used to create four individual models of prognostic indices based on our patient population. The simplest index using only three factors, age, extent of full skin thickness burn and inhalation injury, proved to be best. These models were also compared with established indices, like Baux's, Bull's and Roi's. For a specificity below 80 per cent, Baux's rule fits as well as Roi's index does. Changes in treatment modalities and improvement in therapy will influence the accuracy of an index. Indices must be adapted to changing conditions to avoid increasing false prediction of death.

Reduction of the mortality rate in aged burn patients.

The management of elderly burn patients is time consuming for both nursing staff and physicians, and therapy remains often challenging and controversial. In a retrospective study, we analysed the outcome of two periods with different treatment modalities. An increased number of nurses, a change in the local burn wound treatment, better documentation of wound status and general conditions, and last, but not least, of nutritional aid, enabled us to reduce the mortality rate in patients over 65 years of age.

[Results of decompression of the ulnar nerve in Guyon's canal]. / Ergebnisse nach Dekompression des N. ulnaris in der Loge de Guyon.

Between January 1980 and March 1988 twenty-two patients with compression neuropathies of the ulnar nerve in the Guyon's canal were treated. In seven patients the ulnar nerve was simultaneously decompressed at the elbow. Nine patients suffered from disorders of the sensibility and thirteen patients had sensory and motor symptoms. The ulnar nerve compressions were caused by a ganglion, a thrombosed aneurysm of the ulnar artery, or an aberrant branch of the ulnar artery; in ten cases by the fibrotic arch of the origin of the hypothenar muscles and in eight cases by the roof of the Guyon's canal. In one case no abnormality could be found. The follow-up of twenty-one patients showed, that the sensibility was improved or normalized. The motor function was normalized or improved in three patients and remained unchanged in four patients. No correlation could be found between the postoperative results, the intraoperative findings, the patients' age and the period of symptoms.

The gliding apparatus of peripheral nerve and its clinical significance.

Every nerve must have the capacity to adapt to different positions by passive movement relative to the surrounding tissue. This capacity is provided by a gliding apparatus around the nerve trunk. There is another level of gliding provided by the interfascicular epineurium which allows the fascicles to glide against one another. The clinical significance of the gliding apparatus in the context of external and internal neurolysis and nerve repair is discussed. An explanation is offered for the occurrence of the so-called meander-like deformity of fascicles, seen in nerve entrapment syndromes.

[Combined musculocutaneous tensor fasciae latae and rectus femoris flaps for covering an extensive abdominal wall defect]. / Kombinierter muskulokutaner Tensor fasciae latae- und Rectus femoris-Lappen zur Deckung eines ausgedehnten Bauchwanddefektes.

In a 36-year old man a large recurrent sigmoid carcinoma, exophytically infiltrating the abdominal wall, was resected. The full-thickness defect in the middle and lower abdomen was reconstructed with a Vicryl-mesh and a combined tensor fasciae latae-rectus femoris flap.

[Elastic behavior of the median nerve and ulnar nerve in situ and in vitro]. / Dehnungsverhalten des N. medianus und des N. ulnaris in situ und in vitro.

This study was performed to investigate the mechanical properties of the median and the ulnar nerve in ten fresh cadaver extremities in situ and in a second series in vitro in a strain controlled testing equipment. In situ the nerves were fixed in the equipment at the level of the insertion of the pectoral muscle. The extensions of the nerves were tested in the undissected bed of the nerve with loads from 2 to 25 Newtons. The extension rate of three sections was measured: A: Axilla-wrist, B: Axilla-forearm, C: Axilla-elbow. On the contralateral arm the section D: Axilla-wrist was measured after cutting the nerve's branches without destroying the nerve's bed. The values of the section A, B, and C were significantly different. The nerves were less extensible the more distal the load was fixed. The values of the two sections with equal length A, without, and D, after cutting the nerve's branches also were significantly different (p less than 0.001). The in vitro series showed that the nerves were more extensible after removal of the connective tissue of the nerve's bed.