Surgical correction of pterygium colli.

BACKGROUND/PURPOSE: Webbing of the neck is a deformity seen in various syndromes, including Turner's, Klippel-Feil, or Escobar-Syndrome. There is little information in literature to provide the surgeon with treatment options for these children. We reviewed our experience with the surgical correction of pterygium colli deformity in eleven patients. METHODS: A retrospective review was conducted on all patients that underwent surgical correction of pterygium colli deformity within the last 8 years. Data recorded included patient demographics, diagnostic evaluation, surgical treatment, complications, and outcome. RESULTS: Eleven patients underwent an operation to correct pterygium colli deformity. Six patients had z-plasties, and three patients underwent bilateral excision of an ellipsoid portion of skin and closure via unilateral advancement flaps. We later modified our technique to combine the unilateral advancement flap with Z-Plasties. The mean age at operation was 10.7 years (range 2-23 years). No postoperative wound infections occurred. Mild recurrence of webbing was found in one case. In four patients we found mild to moderate hypertrophic scarring. Average overall content was 7.8 (scale of 0-10, 10 being total content), and all patients, respectively their parents, would undergo the surgery again. Mean length of follow-up was 28.3 months. CONCLUSION: Our study shows that overall patient satisfaction is very high, but an accurate preoperative planning with the patient and parents and an honest discussion of all questions and concerns raised by the parents are essential.

Mitomycin-C-treated peripheral blood mononuclear cells (PBMCs) prolong allograft survival in composite tissue allotransplantation.

BACKGROUND: Composite tissue allotransplantation (CTA) was introduced as a potential treatment for complex reconstructive procedures and has become a clinical reality. Hand and face transplantation, the most widely recognized forms of CTA, have intensified immunological research in this emerging field of transplantation. Mitomycin C (MMC) is an alkylating agent that suppresses allogeneic T-cell responses. MMC-treated dendritic cells/PBMCs have been shown to induce donor-specific tolerance in solid organ allograft transplantations. METHODS: Fully mismatched rats were used as hind limb donors [Lewis (RT1(1))] and recipients [Brown-Norway (RT1(n))]. Fifty-five allogeneic hind limb transplantations were accomplished in six groups. Group A (n = 10) received donor-derived MMC-treated PBMCs on transplantation day. Group B (n = 10) rats received no immunosuppression, group C (n = 10) received FK506 and prednisolon, group D consisted in isograft transplantation without immunosuppression, group E (n = 10) received non-treated PBMCs, and group F (n = 5) received PBS without any donor-derived cells. Rejection was assessed clinically and histologically. RESULTS: In group A, the survival times of the allografts were prolonged to an average of 8.0 d. Rejection was significantly delayed compared with the averages of the corresponding control groups B, E, and F (5.5, 5.9, and 5.8 d). No rejection was seen in control groups C and D. CONCLUSION: These results demonstrate that MMC-treated donor PBMCs significantly prolong allograft survival when administered systemically on the day of transplantation. However, the immunomodulatory effect is relatively modest with further research being required to clarify dose-effect relations, cell characteristics, and an optimized mechanism and timing for cell application.

Shock wave treatment in composite tissue allotransplantation.

INTRODUCTION: Composite tissue allotransplantation is a newly emerged field of transplantation. Shock wave technology has already been used in the treatment of urologic and orthopedic disorders. Recent studies demonstrated a suppression of the early proinflammatory immune response. METHODS: 50 allogeneic hindlimb transplantations were performed on rats in 5 different groups. Group A (n = 10), (Lewis → Brown-Norway) received 500 impulses of extracorporeal shock wave. Groups B, C, D, and E served as control groups with group B (n = 10) receiving no immunosuppression, group C (n = 10) receiving FK506 and prednisolone, group D (n = 10) receiving no immunosuppression with isograft transplantations (Brown-Norway → Brown-Norway) and group E receiving 500 impulses of extracorporeal shock wave on the contralateral hindlimb. RESULTS: Rejection of the allogeneic hindlimb occurred on average 7.12 days after transplantation in group A (extracorporeal shock wave). Rejection was significantly delayed compared to the control groups B (no immunosuppression) and E (contralateral hindlimb), where rejection of the allogeneic hindlimb occurred on average 5.49 and 5.6 days after transplantation (t test, P < .01). No rejection was seen in groups C and D. CONCLUSIONS: For the first time, shock waves have been applied in a composite tissue allotransplantation model and resulted in a significant immunosuppressive effect. These promising first results have showed that shock wave treatment is clinically relevant in composite tissue allotransplantation and justify subsequent research to improve the experimental and clinical outcome.

Revitalization of cortical bone allograft by application of vascularized scaffolds seeded with osteogenic induced adipose tissue derived stem cells in a rabbit model.

BACKGROUND: Adipogenous tissue derived stem cells (ASC) are available in abundance in the human body and can differentiate in the presence of lineage-specific induction factors, for example, in myogenic, adipogenic, chondrogenic and osteogenic cells. The aim of this study was to evaluate the impact of osteogenic induced ASC's (O-ASC) on revascularization and cellular repopulation of avital cortical bone employing a vascularized bovine scaffold. METHODS: An inguinal arterio-venous bundle was dissected in the groin of female white New Zealand rabbits (n = 6) and placed centrally inside an O-ASC seeded scaffold via a central drill hole. In the same surgical session this construct was placed into a segment of avital cortical bone allograft from a donor rabbit. Unseeded scaffolds that were implanted and treated in the same fashion served as controls (n = 6). In order to prevent external revascularization, all constructs were wrapped in silicon foil and finally implanted in the rabbits' groin. Three months later, the constructs were explanted and investigated for vascularization of (a) the scaffold (b) the surrounding bone allograft. Histological stainings to determine cell growth, cellular repopulation of the scaffold and the cortical bone matrix, as well as inflammatory parameters were carried out. RESULTS: O-ASC seeded scaffolds showed a significant increase in new vessel formation in the scaffold as well as in the bone allograft compared to unseeded scaffolds. Furthermore, new vital osteocytes as a sign of cellular repopulation inside the bone allograft were found only in the treatment group. Vital chondrocytes were only found in the O-ASC seeded scaffolds as well. CONCLUSION: The presence of O-ASC significantly induce neo-vascularization and osteocytic repopulation of previously avital bone allograft as opposed to unseeded scaffolds in a rabbit model. Hence, this model might be of relevant value for future bone tissue engineering research and for re-vitalizing marginally nourished bone such as in avascular bone necrosis.

Severe frostbite injury in a 19-year-old patient requiring amputation of both distal forearms and lower legs due to delayed rescue: a need for advanced accident collision notification systems?

Frostbite injury is a rare but severe injury especially when rescue triage is prolonged. We here report the case of a 19-year-old male patient with severe frostbite injuries requiring amputation of both distal forearms and both lower legs due to delayed admission to medical care. This case demonstrates that even mild ambient temperatures can cause deleterious injuries if the exposure time is long enough paralleling our knowledge of burn trauma. Immediate admission to medical care is, therefore, paramount and GPS-based automated accident collision notification systems would therefore be of great benefit especially in rural areas.

Suprathel-antiseptic matrix: in vitro model for local antiseptic treatment?

Acetic acid is a traditional antiseptic agent that has been used for more than 6000 years. The main goal of this study was to demonstrate the suitability of Suprathel (PolyMedics Innovations GmbH, Denkendorf, Germany) in combination with various antiseptic agents to create an "antiseptic-matrix" especially designed for problematic microorganisms such as Proteus vulgaris, Acinetobacter baumannii, or Pseudomonas aeruginosa, which are frequently associated with burns. The study was designed to test the in vitro antimicrobial effect of a "Suprathel-antiseptic matrix" (Suprathel combined with acetic acid 3%, povidone-iodine 11% [Betaisodona], polyhexanide 0.04% [Lavasept], phenoxyethanol 2%/octenidine dihydrochloride 0.1% [Octenisept], mafenide acetate 5%, and chlorhexidine gluconate 1.5%/cetrimid 15% [Hibicet]). As a means to assess the typical bacterial spectrum of a burn unit, the following Gram-negative and Gram-positive bacteria strains were tested: Escherichia coli, P vulgaris, P aeruginosa, A baumannii, Enterococcus faecalis, Staphylococcus epidermidis, Staphylococcus aureus, methicillin-resistant S aureus, and ß-hemolytic streptococcus groups A and B. The tests showed a positive bactericidal effect of the Suprathel-antiseptic matrix, particularly with problematic Gram-negative bacteria such as P vulgaris, P aeruginosa, and A baumannii, except for the combination of Suprathel and mafenide acetate. It can be concluded that Suprathel-antiseptic matrix appears to be suitable as a local antiseptic agent, but clinical studies need to be performed to confirm these in vitro observations. The authors' previous studies have shown that acetic acid demonstrates a wide antiseptic spectrum for microorganisms typically found in burn patients. The combination of Suprathel and acetic acid worked well in this study and appears to be promising for future clinical application.

Antiseptic therapy with a polylacticacid-acetic acid matrix in burns.

Bacterial colonization and infection are still the major causes of delayed healing and graft rejection following burns and they are furthermore the basis for second and third hit sepsis. Topical treatment is necessary to reduce the incidence of burn wound infection. Silver sulphadiazine (SD-Ag) is a frequently used microbicidal agent. However, this treatment causes adverse reactions and side-effects. Additionally, in recent years multiresistant bacteria, which have not been treated sufficiently, are on the rise. On the basis of experimental data and clinical application of a polylacticacid-acetic acid matrix, we performed this study to establish the effectiveness of the antiseptic therapy with the topical application of a polylacticacid-acetic acid matrix to provide an alternative method for burn treatment, using SD-Ag as a reference. Twenty patients with IIb° or III° burns from the Plastic Surgery and Burns Unit were treated within a matched pair comparative setting. One burned area was treated with SD-Ag, the other corresponding area with the polylacticacid-acetic acid matrix. All patients underwent a necrectomy 4-5 days after the trauma. The excised burned skin was sent to our microbiological laboratory to determine the different bacteria per gram in this tissue. Despite the number of 20 patients, statistical significance was not achieved, there were tendencies to a better antiseptic effectiveness of the polylacticacid-acetic acid matrix. These results suggest that the polylacticacid-acetic acid matrix should be studied in greater depth and could be used as a valid alternative for the topical treatment of burns, as it is equivalent or even more effective than SD-Ag.

Suprathel-acetic acid matrix versus acticoat and aquacel as an antiseptic dressing: an in vitro study.

BACKGROUND: The treatment of burn wounds is still a challenge regarding the management of antiseptic wound conditioning. Especially, in the United States, silver-containing dressings, such as Acticoat and Aquacel are frequently used. Because silver-containing dressings have well-known drawbacks such as an antimicrobial lack against Pseudomonas aeruginosa, we sought to develop an alternative dressing method. In previous studies, we could demonstrate the excellent antiseptic properties of acetic acid against common burn unit germs, and in another study, the feasibility and suitability of a Suprathel-acetic acid matrix as an antiseptic dressing. MATERIALS AND METHODS: This study was designed to test the in vitro antimicrobial effect of a Suprathel-acetic acid matrix versus Acticoat and Aquacel. To cover the typical bacterial spectrum of a burn unit, the following Gram-negative and Gram-positive bacteria strains were tested: Escherichia coli, extended-spectrum beta-lactamase-positive Klebsiella pneumoniae, P. aeruginosa, Acinetobacter baumannii, Enterococcus faecalis, and methicillin-resistant Staphylococcus aureus. RESULTS: The tests showed an excellent bactericidal effect of the Suprathel-acetic acid matrix particularly with problematic Gram-negative bacteria such as Proteus vulgaris, P. aeruginosa, and Acinetobacter baumannii. The efficiency was superior to that of Acicoat and Aquacel. CONCLUSIONS: Our results support the notion, that the Suprathel-acetic acid matrix has an excellent bactericidal effect and therefore seems to be suitable as a local antiseptic agent in the treatment of burn wounds.

CASE REPORT Febrile Ulceronecrotic Mucha-Habermann Disease.

OBJECTIVE: Case report and review of the current literature about febrile ulceronecrotic Mucha-Habermann disease (FUMHD). METHODS: Review of our patient's medical records and of the current literature. RESULTS: The FUMHD is a rare and potentially lethal type of pityriasis lichenoides et varioliformis acuta. It is characterized by the sudden onset of ulceronecrotic skin lesions associated with high fever and systemic symptoms. Because of a high case-fatality rate it requires quick and decisive action. Only 40 cases of this severe form of the disease have been reported in the literature to date. We present the case of a 30-year-old male patient with severe FUMHD who was successfully treated in our burn intensive care unit after failed treatment at a dermatological hospital. The patient was treated with topical antiseptics, moisturizers, and artificial skin substitutes, as well as systemic immunosuppressive therapy (glucocorticoids) with which we were able to control the disease activity so that healing of the patient's skin lesions could be achieved. CONCLUSION: Patients with FUMHD should be treated in a specialized center for severely burned patients. Only such centers can provide the structural and logistical capacities necessary for the treatment of such extensive superficial wounds.

Single-stage Matriderm® and skin grafting as an alternative reconstruction in high-voltage injuries.

This article presents a retrospective analysis of a series of nine patients requiring reconstruction of exposed bone, tendons or joint capsules as a result of acute high-voltage injuries in a single burn centre. As an alternative to free tissue transfer, the dermal substitute Matriderm(®) was used in a one-stage procedure in combination with split-thickness skin grafts (STSG) for reconstruction. Nine patients, in the period between 2005 and 2009 with extensive high-voltage injuries to one or more extremities which required coverage of exposed functional structures as bone, tendons or joint capsule, were included. A total of 11 skin graftings and 2 local flaps were performed. Data including regrafting rate, complications, hospital stays, length of rehabilitation and time until return to work were collected. Eleven STSG in combination with Matriderm(®) were performed on nine patients (success rate 89%). One patient died. One patient needed a free-flap coverage as a secondary procedure. The median follow-up was 30 months (range 6-48 months). The clinical results of these nine treated patients concerning skin-quality and coverage of exposed tendons or joint capsule were very good. In high-voltage injuries free-flap failure occurs between 10% and 30% if performed within the first 4-6 weeks after trauma. The use of single-stage Matriderm(®) and skin grafting for immediate coverage described in this article is a reliable alternative to selected cases within this period.

Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects.

OBJECTIVE: In some patients with chest wall defects, free tissue transfer is indicated. Complications arise if multiple operations have left the trunk devoid of recipient vessels. In such patients, an arteriovenous loop between the cephalic vein and the thoracoacromial artery can be used. METHODS: A review of all our patients who underwent chest wall reconstruction with a cephalic vein-thoracoacromial artery loop between 2000 and 2009 was performed (n = 29, 19 women and 10 men). The mean age was 64.9 years. Underlying causes were sternal osteomyelitis (n = 20), tumor (n = 4), and osteoradionecrosis (n = 5). All patients were in American Society of Anesthesiologists classes III and IV. Flap selection, intraoperative and postoperative complications, operative time, time of ventilatory support, mean hospital stay, and midterm survival were recorded. RESULTS: Twenty-five patients received a tensor fascia lata flap, 2 a vertical rectus myocutaneuos flap, and 2 a deep inferior epigastric perforator flap. Mean duration of surgery was 6.8 hours (4.7-10.5 hours). Two transplanted tissue flaps died and/or had to be removed and 4 were revised successfully. Seven patients had wound complications such as infection or prolonged wound healing. Mean time for ventilator support was 93.6 hours (4-463 hours). The median intensive care unit time was 11 days and the overall hospital stay 27.4 days (11-102 days). One-year survival in the whole group was 69.8%. CONCLUSIONS: The concept of arteriovenous loops allows creation of neovessels at the recipient site and has proven to be a superb tool to facilitate free tissue transfer or to provide an exit strategy in situations with unexpected vascular problems at the recipient site.

Necrotizing fasciitis of the extremities: 34 cases at a single centre over the past 5 years.

BACKGROUND: Worldwide the incidence of necrotizing fasciitis (NF) is on the rise. This rapidly progressive infection is a true infectious disease emergency due to its high morbidity and mortality. The mainstay of therapy is prompt surgical debridement, intravenous antibiotics, and supportive care with fluid and electrolyte management. Because of its high mortality rate, patients are increasingly referred to burn centres for specialized wound and critical care issues. METHODS: A retrospective chart review was performed of 34 consecutive patients over a 5-year period with NF of the upper and/or lower extremities that required surgical debridement and reconstruction. RESULTS: The overall survival rate was 96%, with an average length of hospital stay of 64.0 ± 5.5 days. The time until the first operation was 1.3 days. The average age of the patients was 56.7 ± 10.6 years. The patients averaged 1.6 relevant comorbidities. One patient who had five comorbidities died. The affected total body surface (TBS) averaged 8.2 ± 2.1%. CONCLUSION: Early recognition and treatment remain the most important factors influencing survival in NF. Yet, early diagnosis of the condition is difficult due to its similarities with other soft-tissue disorders. Repeated surgical debridement and incisional drainage continues to be essential for the survival. However, these infections continue to be a source of high morbidity, mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement and aggressive critical care management. Referral to a major burn centre may help to provide optimal surgical intervention, wound care and critical care management.