Handchirurgie Mikrochirurgie Plastische Chirurgie最新文献

There is an emergency indication for the treatment of open fractures. Fracture stabilisation and soft tissue care are equal prerequisites for an uncomplicated course of treatment and a good functional result. However, challenges arise in cases of extensive wound contamination and compromised perfusion, limiting options for stable osteosynthesis in emergency situations. Furthermore, resource constraints may pose a challenge to adhering strictly to the six-hour time window. This prompts deliberations on whether, under certain circumstances, a deviation from the conventional approach is feasible by exploring the possibility of prioritising immediate surgical wound care during emergencies, with definitive fracture care deferred to a later point in time. Between 2019 and 2021, 301 patients with open fractures of the hand skeleton were treated (median age 44 years, 85% male, 15% female). Definitive treatment was carried out as a primary emergency procedure in 215 patients (group A), whereas it was performed at an interval after an average of 3 days in 86 patients (group B), who had received surgical wound care, splint placement, and antibiotic coverage on the day of the injury. In a retrospective study, the following criteria were analysed: comorbidities, injury patterns, injury location, timing of treatment, number of follow-up procedures, infection rate, and duration of hospitalisation. The course was complicated by infection in six patients (1.9%). Five of these patients were in group A (infection rate 2.3%), and only one patient was in group B (infection rate 1.1%). All six infections occurred after crush injuries, all at the fingertip or end joint. These numbers underscore the relevance of soft tissue trauma and primary stump formation. Comorbidities were not statistically significant in our study with a view to the occurrence of infection. In conclusion, it can be stated that, with antibiotic protection, definitive treatment of an open fracture in an interval is possible if it is preceded by initial emergency surgical wound care with subsequent immobilisation.

Background: The masseteric nerve (MN) is often used as a donor nerve for facial reanimation. In addition to already established techniques, MN transfer is rapidly gaining importance, mainly due to the single-stage approach of the procedure and its reconstructive potential. This anatomical study and the associated questionnaire study aimed to evaluate the established methods for identification of the MN and its suitability for direct nerve transfer as well as to assess the importance of MN transfer in the daily clinical routine.

Material and methodology: Bilateral dissection of 25 fresh-frozen head specimens (n=50; 13 female, 12 male) was performed with accompanying measurement of the MN. In a questionnaire study conducted at established centres for facial surgery in German-speaking countries, clinical experience data of MN transfer was collected using the SurveyMonkey software. The data obtained was statistically analysed using Microsoft Excel and presented in numerical tables and boxplots.

Results: Using anatomical landmarks such as the zygomatic arch and the mandibular notch for orientation, the MN was found in 100% of cases. Its average length from the emerging point below the zygomatic arch towards its entry into the masseter muscle was measured to be 22 mm and was the length available for nerve transposition. Tension-free coaptation of the MN with the zygomatic branch was possible in 94% of cases. The questionnaire showed that the MN is considered an important donor nerve for motor nerve transfers and that MN transfer is now largely established as a standard procedure.

Discussion: In accordance with previously published studies, the MN was reliably found at the height of the mandibular notch and, in the vast majority of cases, was suitable for tension-free coaptation with the zygomatic branch. Differences to the existing literature, however, can be seen in the length of the nerve available for nerve transposition and the frequency of its division into several branches before entering the masseter muscle. In German-speaking countries, Cross-Face Nerve Grafting (CFNG) is still the preferred method for facial reanimation surgery. However, MN transfer is also well established by now, both as an alternative and a supplement to other techniques, possibly due to its low donor site morbidity and short time to regeneration.

A desmoid tumour, also known as aggressive fibrous tumour or desmoid fibromatosis, is a rare, benign tumour originating from connective tissue cells. Desmoid tumours account for approximately 0.03+% of all neoplasms and less than 3+% of all soft tissue tumours. The estimated incidence in the general population is 2 to 4 cases per million people per year [1]. Desmoid tumours are characterised by aggressive growth but typically do not metastasize. They often occur in young adults and preferably affect specific body regions such as the abdomen, shoulder, chest, or extremities. The exact cause of the condition is not fully understood, but genetic changes and hormonal factors may play a role. Symptoms of a desmoid tumour depend on its location and size, with pain, swelling, or restricted movement commonly occurring. A diagnosis is typically made through a tissue sample (biopsy) and imaging techniques such as MRI or CT [2]. To our knowledge, this is the first documented case of recurrence of a desmoid tumour in the scar at the donor site of a latissimus dorsi flap previously used for the reconstruction of desmoid resection in the lower leg.

Background: Injuries caused by explosions or pyrotechnic devices can lead to severe hand injuries with potential long-term consequences for both the affected individual and the healthcare system. The implementation of a nationwide ban on fireworks during the New Year festivities was only temporarily enforced as part of the protective measures during the Covid-19 pandemic. These two exceptional years provide an opportunity for evaluation as a model experiment to demonstrate the impact of a fireworks ban on the frequency of explosion-related hand injuries.

Materials and methods: In a multicentre study, five German hand trauma centres retrospectively collected and analysed all pyrotechnic-related injuries that occurred within seven days around the New Year celebration between 2017 and 2023.

Results: Severe hand injuries from explosions were significantly less frequent at New Year celebrations during the pandemic period compared with data collected in the years before and after Covid-19. After the return to regular sales laws and celebrations in December 2022, a significant increase in injuries was observed, surpassing even the pre-Covid period. Epidemiological data confirmed a high proportion of minors and male victims. The highest number of injuries was observed on New Year's Eve and the first day of January, with adults mainly being injured during the festivities, while children and adolescents were mainly injured during the first days of January.

Conclusions: A national ban proved to be an effective method to prevent severe hand injuries caused by explosive devices and their lifelong consequences. The data obtained in this multicentre study can serve as a basis for informed policy action.

The surgical reconstruction of sacral soft tissue defects is challenging, and complications are frequent. We report a successful two-stage three-dimensional microsurgical soft tissue reconstruction of a wide and deep sacral defect anastomosing a free combined ALT/TFL/rectus femoris flap to an ipsilateral vena saphena magna arteriovenous loop which was applied primarily. This case shows that complex microsurgical procedures can be promising in this demanding patient population if the indication is correct and the operative/perioperative strategy is clear.

Background: In the event of an advanced rectal carcinoma, an evisceration with rectal amputation may become necessary. The resulting defects, due to their extent, depth, or local tissue damage from previous surgeries and radiation, can in many cases only be closed through free microvascular tissue transfer. In this case series, we demonstrate the successful combination of a musculocutaneous musculus vastus lateralis flap (MVL) with a direct connection to the superior gluteal artery.

Materials and methods: Over a 47-month period, we retrospectively examined 11 cases of patients with dorsal pelvic defects after evisceration and rectal amputation that could not be closed using local or regional means. In cases of extensive defects with deep pararectal wound cavities, all these patients underwent defect coverage through a free myocutaneous MVL flap with a direct vascular anastomosis to the superior gluteal vessels.

Results: The mean defect size was 290.0 cm² (SD: 131.2; range: 200-600 cm²). The mean defect depth was 10.5 cm, necessitating MVL flap reconstruction with an average size of 336.3 cm². Three operative revisions were required due to postoperative bleeding. There were no arterial or venous thromboses, and no flap loss occurred. Only one necrosis of a distal flap tip was observed, which could be corrected secondarily by direct suturing. The case-mix evaluation yielded an average value of 24.251 (SD: 21.699; range: 7.036-65.748) points, emphasizing the complexity of the cases.

Conclusions: Our results indicate that a free microvascular MVL flap is a viable therapeutic option for pararectal defects that cannot be closed by local or regional methods. The superior gluteal artery proves to be a safe and sufficient vascular connection. In combination, even extensive defects can be successfully closed.

Background: The deep circumflex iliac artery (DCIA) perforator flap is an established method to reconstruct osteocutaneous defects. However, the cutaneous perforators come with a great anatomic variability. To deal with this problem, we used a sequential chimeric osteocutaneous free flap for reconstruction.

Patients and methods: A 58-year-old man presented with an open tibial fracture after an avalanche accident resulting in an extended osteocutaneous defect in the lower extremity. The injury required osteocutaneous free flap coverage. We reconstructed the defect with a sequential chimeric osteocutaneous DCIA-perforator-SIEA flap.

Results: The preservation of the ascending branch of the deep circumflex iliac vessels offered us the possibility to effectively cover an extended osteocutaneous defect in the lower extremity with a sequential chimeric osteocutaneous DCIA-perforator-SIEA flap. In our patient, the sequential chimeric osteocutaneous DCIA-perforator-SIEA flap healed without complications. A small hernia developed at the inguinal donor site area, but it healed without further complications after surgical treatment. The patient regained an adequate function and returned to daily life and physical exercise.

Conclusion: While preparing the DCIA-perforator free flap, it is important to preserve the ascending branch of the deep circumflex iliac vessels and the vessels needed to harvest either a SIEA or SCIP flap.