Handchirurgie Mikrochirurgie Plastische Chirurgie最新文献

Background: Surgical procedures of the hand are increasingly performed in an ambulatory setting. Postoperative analgesia is based empirically on the painfulness of individual surgical procedures without these having been examined systematically.

Patients and methods: The painfulness (visual analogue scale) of 722 surgical procedures of the hand and wrist (1 July 2021 to 30 June 2023) was assessed until day 5. Analgesia was conducted empirically in accordance with WHO principles. The primary endpoint was the pain sensation on the first postoperative day in bone and joint procedures compared with soft tissue or endoscopic procedures as well as hardware removals. Secondary endpoints were pain sensation in correlation with gender, age, duration of the procedure and preoperative analgesia.

Results: Bone and joint procedures were associated with significantly (p<0.001) more pain (5.42±2.8) compared with other procedures (3.47±2.6). Female (p=0.001) and younger patients (R>0.2) as well as longer procedure duration (R>0.2) showed a weak association with higher postoperative pain, whereas preoperative consumption of opioids was moderately associated with higher opioid intake (R=0.34). Overall, pain decreased continuously from the evening of the procedure (4.4±2.8) until day 5 (3.7±2.7; 2.8±2.4; 2.1±2.1; 1.6±1.9; 1.3±1.7) CONCLUSION: This data provides a scientific basis for pain medication supply following surgical procedures of the hand and wrist in an ambulatory setting. A broad range of pain perception must be considered, even in seemingly minor surgical procedures.

Background: A preoperative informed consent discussion is an essential element of surgical treatment. Suspected errors in informed consent are frequently the subject of medical liability cases. To ensure a comprehensive documentation of the informed consent discussion, commercial documentation forms are available. Thanks to their comprehensiveness, they are increasingly replacing conventional, typically self-designed forms. In this study, the quality of informed consent discussions was evaluated based on the retrievable knowledge of the informed patients. Informed consent discussions based on self-designed forms were compared with those based on a commercial form.

Materials and methods: A monocentric, prospective, randomised, controlled, clinical longitudinal study was performed with 261 patients. Study participants were randomised into two groups. Informed consent discussions held in group A were documented using a self-designed form, while a commercial form (Thieme Compliance) was used for group B. Data collection was conducted through interviews using a standardised questionnaire, which each participant completed twice: once immediately after the medical informed consent discussion, and again on the morning of the surgery. The average time interval between the informed consent discussion and the surgery was 19 days.

Results: In both groups, the results were approximately the same. Overall, 98% of the respondents felt well or very well informed after the informed consent discussion and were satisfied with the manner of communication and the time frame. Accordingly, 77% of the respondents were not or only slightly nervous about the upcoming surgery. 85% of the participants correctly stated their diagnosis, and 80% correctly identified the planned surgery. However, 24% of the respondents were unable to actively name any of the complications mentioned in the discussion. Preoperatively, this percentage increased to 35%. Following the informed consent discussion, 44% of the respondents were able to list one to two complications, 27% were able to list three to four, and 5% were able to list five or more. Patients in group A tended to perform slightly better.

Conclusion: Similar results can be achieved even if different consent forms are used. Patients are well-informed immediately before hand surgery procedures. High patient satisfaction can be achieved through individualised design and documentation.

Background: Fractures of the distal radius have been traditionally classified based on the suspected mechanism of injury. Among clinicians, the terms "Colles" and "Smith" fractures are commonly used to refer to a distal radius fracture that is either displaced to the dorsal (Colles) or palmar (Smith) side of the radius. When analysing x-rays, it is not uncommon for a Smith fracture to be detected in cases where patients describe a fall on the wrist in an extended position. Thus, the question arises how a flexion-type fracture can occur after an extension injury. So far, only little research has been conducted into this subject.

Material and methods: The aim of this study was to analyse the mechanisms of injury that lead to various types of distal radius fractures. Particular emphasis was placed on "Smith" fractures and on the biomechanical, physiological and anatomical characteristics that contribute to their occurrence. To assess these relationships, data of fractures were collected following a life-like fracture simulation using a "drop-bench" in non-formalin fixated human specimens. These fractures were produced between January 2016 and December 2021. Biographic data of all specimens used were available. Additionally, all biomechanical and physical characteristics of the fracture simulation were fully documented.

Results: Of the 122 specimens with a full data set, 17 (13.9%) fractures were determined to be Smith fractures based on their radiological appearance. In 10 of these flexion fractures, the wrist was set in dorsal extension. The mean angle of extension was 86.3 degrees for flexion fractures compared to 90.5 degrees for extension fractures. Six out of 10 Smith-type fractures that were set in dorsal extension were also exposed to pronation, whereas only one was exposed to supination. The mean potential energy for fracture creation was 168.0 joules for Smith fractures in dorsal extension, whereas all other fractures showed a mean of 185.2 joules.

Conclusions: It can be concluded that a Smith fracture is not limited to being the result of a fall on the wrist in a flexed position. The same fracture may also be the result of a fall with the wrist in an extended position if certain physical factors are applicable.

Most lesions of the upper extremity are common and benign, and the need for a routine pathology evaluation of these specimens has often been questioned. This study aimed to evaluate the concordance of the initial clinical and final histological diagnoses of tumours which, based on clinical presentation and intraoperative findings, are most likely benign or malignant, and to answer the question whether or not a routine histopathological examination is justified for all tumours in the upper extremity.

Material and methods: We analysed the results of histopathological examinations of benign tumours resected in 346 patients and malignant tumours resected in 6 patients.

Results: Our analysis showed a 100% concordance between the initial (clinical) diagnoses of the tumours as benign or malignant and their final histopathological diagnoses. Only in 12 cases (3.5%) of initially benign tumours did the clinical presentation and/or intraoperative findings raise doubts.

Conclusions: The results of this study show that a routine histological evaluation of all tumours resected from the upper extremity is not justified and may be confined to selected cases in which clinical presentation and/or intraoperative findings raise doubts.

Background: The treatment of severely burned patients is demanding and necessitates specialised centres capable of providing adequate therapy over several months. The establishment of digital management systems in intensive care units signifies a substantial advancement in modern healthcare. Introducing such a system in a specialised intensive care unit for severe burn patients presents opportunities for optimisation but also potential obstacles. This study aims to provide insights into the perception of change from the perspective of staff and discuss the implementation of digital systems in the field of intensive care medicine.

Methods: After a selective sample was established, the impacts of the digital management system were examined across various categories. The data collected through a questionnaire and brief interviews were evaluated in terms of average values within each category, with interpretations taking into account characteristics such as professional group and work experience.

Results: Overall, the digital management system is considered suitable for use in the intensive care unit for severe burn patients by both medical and nursing staff. The continuous monitoring of vital parameters and the reduction of errors in medication administration are highlighted as positive aspects. However, negative points include the inferior documentation of burn wounds and specialised documentation for burn patients.

Conclusion: In due consideration of various factors such as experience, team size, and patient clientele, which impact the usability of the program, some aspects in need of improvement were identified. In summary, however, it can be said that there was a positive and favourable consensus regarding the introduction of such a system in the intensive care unit. Additionally, it can be concluded that the system is described as significantly more effective for a general surgical intensive care unit than for a specialised intensive care unit, e. g. an intensive care unit for severe burn patients.

Background: Liposuction for stage III lipoedema is a guideline-based but also time-consuming treatment, which can be carried out under specific conditions at the expense of the German statutory health insurance companies (SHI) based on a decision made by the German Federal Joint Committee ("Gemeinsamer Bundesausschuss", G-BA), the highest decision-making body in the German healthcare system, in 09/2019. We postulate that the treatment is not reflected in a cost-covering manner in the university cost system.

Methods: This monocentric, retrospective study examined the economic aspects of 92 cases in 48 lipoedema patients treated during the period from 09/2019 to 08/2023 at the expense of the SHI. These cases were filtered out using DRG coding and the Operation and Procedure Classification system ("Operationen- und Prozedurenschlüssel", OPS), and the costs and revenues per patient were calculated using the data from our internal service accounting.

Results: After an inpatient stay of 2.64±1.33 days, the total revenue was € 4,726.79±680.98. This included € 1,532.92±856.99 inpatient costs, € 2,686.02±1,174.70 in operating costs, € 940.76±189.18 in anaesthesia costs and € 63.19±125.38 in other costs that had to be paid within the clinic. On average across all treatments, this resulted in a loss of -€ 875.22 /case. In 54 cases (59%), the costs exceeded the revenue. In total, the calculation of all cases resulted in a loss of € -80,520.63. If medical personnel costs are included, this amount rises to over € 100,000.

Conclusion: The results show that the surgical treatment of lipoedema in the German DRG and university cost systems is not cost-covering. This could be relevant in the final economic assessment of the G-BA, which may result in an adjustment of the DRG revenue.

Introduction: Although DIEP (deep inferior epigastric perforator) is the gold standard for breast reconstruction, long-term results with a view to postoperative hairiness and flap skin colouration have rarely been described in the literature.

Methods: Patients who underwent DIEP flap breast reconstruction followed by NAC reconstruction between 2010 and 2019 were invited to our clinic for a survey and a clinical examination. A total of 781 patients were invited. The survey included the BREAST-Q and a study-specific questionnaire. The clinical examination contained specific measurements regarding postoperative hairiness and skin colouration.

Results: A total of 179 patients were examined, with 203 breasts having been reconstructed. Only breasts with a visible flap skin island were taken into further evaluation. A total of 109 DIEP flap and 77 NAC reconstructions were evaluated. In the patient-reported survey, 27.5% (30 of 109) reported additional flap hairiness and 62.4% (68 of 109) reported differences in flap skin colouration compared with the surrounding skin. The clinical examination revealed a significant difference between the skin colouration of the flap compared with the surrounding skin and the skin colouration of the reconstructed NAC compared with the existing original NAC. In both cases, the reconstructions appeared significantly "lighter" (p<0.05). No significant difference was found between patients with and without hair in terms of overall satisfaction evaluated by using the BREAST-Q. Neither did the colour difference have a significant influence on patients' satisfaction.

Conclusion: Additional breast hairiness and different skin colouration is relevant and should be communicated preoperatively.

Background: Apart from surgical procedures for breast and buttock augmentation, copolyamide fillers can be locally injected for an increase in volume. This method is especially popular in Asia.

Patient: A 39-year-old female patient had received a buttock augmentation by injection of a copolyamide filler. She presented with multiple abscesses six years after the augmentation. She had developed multiple fistulas and the filler had migrated down to the thigh muscles.

Results: In the presented case, the patient experienced multiple complications such as abscess formation, filler migration and chronic infection, with a significant time delay. Complete removal of the filler is only possible by removing surrounding tissue as well. Surgical treatment with repeated debridements and administration of an intravenous broad-spectrum antibiotic are the current standard of care. In contrast, the SWOP technique presented here appears to be less invasive and less likely for local recurrence.

Conclusion: A breast or buttock augmentation with copolyamide fillers is associated with a high risk of abscess and fistula formation leading to a permanent disfigurement of the patient.

Background: Achieving a medical professorship marks a significant step in a doctor's academic career, associated with a significant level of responsibility and obligations. The requirements to obtain a medical professorship in Germany vary significantly.

Material and methods: Based on an online search, we studied the statutes and regulations of medical faculties in Germany to determine the requirements for habilitation and an extraordinary professorship within Germany. All 38 German medical faculties were included. The evaluation was carried out for performance requirements in the areas of teaching and research.

Results: The general requirement for a habilitation application is the completion of the medical specialist certification examination. On average, 2.3 years of teaching activity are expected. The minimum number of teaching hours averages 2.6 weekly semester hours. An average of at least 11 publications are required. Of these, an average of 7 must be written as first or last author. For an extraordinary professorship, an average of 4.4 years (min. 2, max. 6) of teaching activity after habilitation is required. The minimum number of teaching hours in semester hours averages 1.9 hours (min. 1, max. 2). The minimum number of publications averages 9 publications (min. 4, max. 24), of which an average of 6.3 must be written as first or last author.

Conclusion: The requirements for habilitation and extraordinary professorship in Germany vary, especially with a view to publications and teaching. Depending on the faculty, lower publication numbers can be compensated by higher "impact factors". Furthermore, there is no national standardisation and comparability in the field of medical academic graduations.