Trotz erheblicher Fortschritte in der primären Nervenrekonstruktion erreichen viele Patientinnen und Patienten mit peripheren Nervenläsionen keine ausreichende funktionelle Reinnervation. Insbesondere bei verzögerter Diagnosestellung, komplexen Läsionen oder fortgeschrittener Denervation behalten motorische Ersatzplastiken einen hohen Stellenwert. Ziel dieser Arbeit ist es, die funktionelle Anatomie der Schulter darzustellen, typische Ursachen relevanter Funktionsausfälle zu analysieren und etablierte motorische Ersatzplastiken bei ausgewählten Läsionsmustern zu diskutieren. Der Fokus liegt auf C5/6-Plexusläsionen, Formen der Scapula alata, Läsionen des N. musculocutaneus sowie proximalen Radialisläsionen mit Ausfall der Ellenbogenstreckung im Kontext komplexer Verletzungen, einschließlich Rückenmarkverletzungen (SCI). Es handelt sich um eine narrative Übersichtsarbeit auf Grundlage aktueller Literatur und klinischer Erfahrung. Motorische Ersatzplastiken ermöglichen auch bei irreversiblen Nervenläsionen eine relevante funktionelle Verbesserung. Etablierte Verfahren umfassen unter anderem Trapezius‑, Pectoralis-major- und Latissimus-dorsi-Transfers zur Wiederherstellung der Schulterbeweglichkeit sowie der Ellenbogenflexion. Für die Rekonstruktion der Extension können der posteriore Deltoid- oder der Bizepstransfer erwogen werden. Motorische Ersatzplastiken stellen einen essenziellen Bestandteil der rekonstruktiven Therapie der oberen Extremität dar und ermöglichen bei sorgfältiger Indikationsstellung eine nachhaltige Verbesserung der Alltagsfunktionen.

Introduction: Remote Ischemic Conditioning (RIC) improves cutaneous microcirculation in free flap surgery. As no universal RIC-protocol exists, refinements have manily focused on cycle duration and number. We aimed to assess wether ischemic stimulus intensity, using a tourniquet with additional exsanguination, affects cutaneous microcirculation. Methods: In this randomized controlled trial, 50 healthy volunteers were randomized into two groups (25 each). Both underwent a RIC-protocol of 3 cycles of 10-minute ischemia followed by 10-minute reperfusion. In the control group (Tourniquet, T), ischemia was induced with a surgical tourniquet inflated to 250 mmHg on the right upper arm. In the experimental group (Tourniquet with exsanguination, Te), the arm was additionally exsanguinated using an Esmarch bandage. Cutaneous microcirculation parameters (oxygen saturation [SO2], blood flow [BF| and relative amount of hemoglobin [rHb]) were assessed non-invasively with the Oxygen-To-See (O2C) device. Results: Both groups showed significant changes in all microcirculatory parameters compared to baseline. Although SO2 and BF values tended to be higher during reperfusion in the experimental group (Te), overall differences were not statistically significant (except at the end of the first reperfusion phase in BF [Tmean 1.33+/-0.54 vs. Temean 1.93+/-0.91; p 0.017] and at the beginning of the second reperfusion phase in SO2 [Tmean 1.05+/-0.18 vs. Temean 1.13+/-0.17; p 0.045] respectively). Conclusion: Exsanguination in addition to tourniquet application does not enhance cutaneous microcirculation in RIC protocols. The relatively small sample size remains a limitation and restricts generalizability. Future studies should confirm these findings in larger and more diverse cohorts and explore potential clinical applications.

Peripheral nerve fibrosis is a major determinant of surgical outcome and functional recovery after nerve injury, yet standardized approaches to assess its extent remain scarce. Decades ago, Hanno Millesi introduced a comprehensive classification system that grades the degree of fibrosis according to the anatomical layers affected, ranging from paraneurial to endoneurial involvement. Despite its conceptual clarity and clinical relevance, this system remains largely underutilized in contemporary peripheral nerve research. Recent experimental models addressing perineural scarring and anti-fibrotic strategies rarely apply Millesi's classification, thereby limiting comparability and translation of findings. Here, we argue that greater integration of Millesi's classification could enhance experimental design, improve standardization, and guide the interpretation of preclinical and clinical studies on peripheral nerve regeneration. Renewed attention to this underutilized framework may bridge the gap between histological observations, experimental interventions, and the surgical decision-making process in peripheral nerve surgery.

Artificial intelligence (AI) is beginning to reshape the landscape of hand surgery, but most clinical evidence still originates from radiology and other surgical specialties. This literature survey provides a comprehensive overview of current and near-term AI applications in the field. Presently, AI enhances diagnostic accuracy by identifying subtle fractures, nerve compressions, and vascular anomalies on imaging that may elude human detection. Presently, AI contributes mainly to diagnosis/imaging (fracture detection; adjuncts for nerve/perfusion studies) and planning (AI-assisted 3D reconstructions), with intraoperative platforms such as augmented reality (AR) microscopes and robotics largely adapted from neurosurgery/spine and only emerging in hand surgery. While many of these visualization platforms themselves are not AI, they increasingly integrate AI-based modules for image processing and real-time data overlay. Early postoperative risk-stratification models (e.g., stiffness, infection, complex regional pain syndrome) and digital rehabilitation are promising but require prospective, multi-center validation. Additionally, AI-driven tools streamline operative documentation and empower patient education through conversational agents. Looking ahead, developments such as implantable micro-sensors for real-time anastomosis monitoring, AI-guided perforator mapping, and miniaturized AR-assisted visualization promise to further transform practice. However, challenges persist - from limited datasets and the need for external validation, to high costs, regulatory hurdles, and ethical concerns surrounding data privacy and algorithm transparency. Achieving the sub-millimeter precision required for safe surgical implementation remains one of the most critical technical challenges. Emphasizing explainable AI and maintaining the surgeon’s central role in decision-making will be crucial to safe implementation. Ultimately, the convergence of AI, advanced imaging, robotics, and microsurgical techniques holds significant promise to elevate precision, outcomes, and patient-centered care in hand surgery.

Abstract Purpose To evaluate oncological outcomes and prognostic factors in patients with radiation-associated angiosarcoma (RAAS) treated at referral centers. Methods We conducted a multi-institutional retrospective cohort study of patients with histopathologically confirmed primary or recurrent RAAS treated at four referral centers in Germany. Endpoints were overall survival (OS) and progression-free survival (PFS), estimated using the Kaplan–Meier method. Prognostic factors were assessed using multivariable Cox regression. Results Among 71 patients (97.2% female; median age 69 years), 90% had a history of breast cancer treated with radiotherapy (RT). RAAS developed after a mean latency of 7 years, with a median RT dose of 59.4 Gy. Over a median follow-up of 13.0 months, OS reached a median of 41.7 months, with 1- and 2-year rates of 82.9% and 61.7%, respectively. Median PFS was 9.5 months, with 1- and 2-year rates of 43.7% and 27.1%. Larger tumor size (HR 1.09, p = 0.032) and metastatic disease at diagnosis (HR 2.98, p = 0.003) were associated with worse OS. Conclusions RAAS are aggressive, frequently relapsing malignancies occurring years after RT. Larger tumor size and metastatic presentation are associated with worse OS. Multi-institutional and translational studies are needed to clarify disease biology, refine risk factors, and guide treatment strategies.

Background: Enchondromas are the most common primary tumors in the small tubular bones of the hand and fractures are often the result of thinned cortical bone. The main question was whether fractured enchondromas influence the long-term clinical and radiological outcome. Methods: Between 2000 and 2019, 57 patients with previously treated fractured (group I) and non-fractured (group II) hand enchondromas (34 female, 23 male, mean age was 39.4 years, ± 13.7) were evaluated for clinical and radiological treatment outcomes. SF-36 and DASH questionnaires as well as patient reported experience measures were used to assess subjective health outcomes. Subsequently, 43 patients underwent clinical and radiological follow-ups. Comparative evaluation of objective treatment outcomes in both groups was conducted in terms of hand functionality, perioperative complications, recurrence rates, and osteogenesis. Results: Almost half the patients suffered enchondromas with fractures (49.1%, n=28). Two patients received additional k-wire-stabilization due to intraoperative instability. Defect resolution could be reached in 97.7% (n=42) of all cases. No recurrence of enchondroma was observed. Groups were equal regarding radiological and clinical outcomes. The patient reported experiences were predominantly positive (86%), both cohorts had good to very good results with a DASH mean score of 4 (±6.3). The SF-36 demonstrated a return to normal quality of life in both groups. Mean follow-up time was 7.78 years (±4.8). Conclusions: Sole curettage of enchondromas yields effective outcomes with good to excellent results regardless of the presence of a fracture. Long-term radiological follow-up is not required until symptomatic recurrence. .

Weichteilsarkome sind seltene, heterogene Tumoren mit hohem Behandlungsaufwand, deren Versorgung spezialisierten Sarkomzentren vorbehalten sein sollte. Die chirurgische R0-Resektion ist dabei einer der wichtigsten positiven Prädiktoren hinsichtlich des krankheitsspezifischen Überlebens. Umfassende gesundheitsökonomische Analysen der stationären Behandlungskosten in der Sarkomchirurgie fehlen bisher weitgehend, sind jedoch essenziell für die Sicherung einer nachhaltigen und kosteneffizienten Versorgung. In dieser retrospektiven monozentrischen Studie wurden die stationären Kosten von 112 Sarkomfällen analysiert, die zwischen 2020 und 2022 in unserem universitären Sarkomzentrum behandelt wurden. Die statistischen Analysen wurden zur Identifikation von Variablen mit Einfluss auf die Fallunterdeckung durchgeführt. Zudem erfolgte die Untersuchung der Erlöse hinsichtlich der Häufigkeit und der Höhe der Unterdeckung anhand der InEK-Kostenmatrix. In 66,1

Background:Allogenic kidney transplantation has been the gold standard treatment for end-stage renal disease. In the research setting, rat models are widely utilized to refine surgical techniques and enhance graft viability. One critical factor affecting transplantation outcomes is the efficiency of the venous anastomosis. This study evaluates the utility of a microvascular coupling device for venous anastomosis in a rat kidney transplantation model. Material and methods:Experimental allogenic kidney transplantations were conducted in male Brown Norway rats (n = 10) as donors and Lewis rats as recipients (n = 17), housed according to institutional guidelines. A microvascular coupling device was used for renal venous anastomosis, and creatinine levels were measured postoperatively to assess kidney function. Procedure times, ischemia duration, and postoperative complications were recorded and analyzed. Results:The venous anastomosis time averaged 6.6 ± 2.2 min. Total ischemia time averaged 42.4 ± 4.9 min. Early postoperative serum creatinine levels were slightly elevated about references thresholds, which normalized by postoperative day 3. Four animals died after successful transplantation due to urethral complications and postrenal failure (23.5 %). Other postoperative mortality was primarily linked to complications unrelated to thrombosis (n = 3, 17.6 %). Conclusion:The use of a microvascular coupling device for venous anastomosis in rat kidney transplantation significantly reduces procedure time and ischemia duration, contributing to more consistent graft outcomes. The simplification of the venous anastomosis process and reduced operative time justify the use of coupling devices. This technique holds promise for advancing preclinical transplant research and improving reproducibility in microsurgical procedures.

Functional lack of knee extension is an important limitation for patients. Whereas in younger patients the limitation of activity usually dominates, in older patients there is also the risk of secondary injuries due to an increased risk of falls due to instability and unsteady gait. Depending on the cause, an improvement in quality of life can be achieved for most patients through various methods of knee extension reconstruction. There are no general restrictions for reconstruction due to comorbidities or age. The present study offers a comprehensive overview of the potential options for reconstruction, as well as a decision-making aid for operative indication, that considers the underlying lesion and patient-specific characteristics. Local reconstructions, functional tendon- and nerve-transfers and free functional muscle transfers are presented. Further information on the postoperative procedure is given, as well as an overview of the expected result. The therapeutic aim should not end with controlling a tumour disease or treating the initial trauma, rather therapy planning should also include functional reconstruction as part of an interdisciplinary therapeutic approach to improve quality of life and participation as well as preventing secondary consequences of disease or trauma.

Background  Foot drop is a challenging condition that significantly impacts the affected patient's mobility and quality of life. Tendon transfer has emerged as a viable treatment option. We hereby present data of the tendon transfer procedures in patients with foot drop in our department. Besides a detailed description of our surgical technique, we also compare our results with those reported in the literature. Methods  Data from 17 patients (11 males and 6 females) suffering from foot drop due to peripheral nerve or muscle lesions were retrospectively analyzed. All the patients underwent tendon transfer procedures between 2017 and 2022. Assessed outcomes encompassed parameters such as strength of foot dorsiflexion, the necessity for postoperative orthotic devices, and patient satisfaction. Demographic data, the time elapsed from injury/illness to surgery, and the underlying causes of foot drop were collected. Results  Postsurgery, 14 patients regained robust dorsiflexion strength (M4), while 2 exhibited slightly lower strength (M3) and 1 attained equal strength as on the unaffected side (M5). Corrective procedures were undertaken in five patients to address problems with tendon tension. After an average follow-up period of 11.9 months (± 9.13), 82.4% of patients reported a high level of satisfaction, although three patients experienced persistent foot inversion. Most patients (94.1%) no longer required orthotic devices following the operative procedure. Conclusion  A tendon transfer procedure for correction of foot drop has proven to be a safe and effective treatment option, resulting in a high level of patient satisfaction and restoration of quality of life.

Perilunate dislocations (PLD) and perilunate fracture-dislocations (PLFD) are high-energy wrist injuries often linked to significant post-traumatic osteoarthritis. This study aims to determine whether PLD and PLFD yield different radiological outcomes following surgical treatment while identifying prognostic factors for worse outcomes. We retrospectively analyzed 51 patients treated for perilunate injuries between 2000 and 2022. Radiographic evaluation included postoperative carpal alignment, scapholunate distance, ulnar translocation, and postoperative arthrosis according to the Kellgren-Lawrence scale. Logistic regression models were used in the study. The analyzed explanatory variables included: type of injury (PLFD/PLD), Mayfield classification, capsulodesis, repair of intercarpal- and extrinsic ligaments, and number of wrist transfixations. The significance level was set at p ≤ 0.05. The calculations were performed with R (version 4.3.2). Among 51 patients, the mean follow-up was 4.33 years (1-22.13), and the mean age was 37.76 years. PLFD accounted for 55

The management of trunk wall defects can be a challenge in surgical practice, especially when conventional methods such as primary wound closure or skin grafts are insufficient due to the size and depth of the defect, its location, location, or lack of adequate skin and soft tissue coverage. In recent years, perforator-based local flaps have emerged as a modern, muscle-sparing alternative to traditional local myocutaneous or free microsurgical flaps. Particularly in the back region, suitable recipient vessels for free flaps are often unavailable due to vascular anatomy. At the same time, compared to conventional random-pattern flaps, perforator-based flaps offer increased reliability, as they are based on targeted vascular perforators. This allows them to be designed beyond the classic 2:1 length-to-width ratio and enables greater reach with improved perfusion. By utilising perforating vessels, functionally important musculature can largely be preserved, which may lead to reduced postoperative morbidity and faster rehabilitation.This article is aimed at surgically active colleagues without specialised training in plastic-reconstructive surgery who are nonetheless regularly confronted with complex wound situations-for example, following tumour resections, chronic infections, pressure ulcers, or postoperative wound healing disorders. The goal is to provide a practical overview of the principles, indications, and limitations of perforator-based local flaps. In addition to an introduction to the underlying vascular anatomy (angiosome and perforasome theory), preoperative diagnostic procedures, various flap techniques, and typical clinical courses-including potential surgical complications-are presented.A particular focus is placed on the selection of appropriate flap types based on defect location and the presence of local perforators, with the goal of achieving the simplest, safest, and most sustainable soft tissue coverage possible. Clinical case examples illustrate operative approaches in different regions of the trunk wall.

Im Rahmen eines Konsensus-Workshops wurden folgende Fragen bezüglich der Darstellung der Anschlussgefäße vor mikrochirurgischen Transplantationen an der unteren Extremität diskutiert: • Braucht der klinisch gefäßgesunde Patient vor der Durchführung einer mikrochirurgischen Rekonstruktion an der unteren Extremität überhaupt eine apparative Diagnostik? • Welche apparative Diagnostik (wenn benötigt) stellt am besten die arteriellen Anschlussoptionen für eine mikrochirurgische Lappenplastik an der unteren Extremität dar? • Wann ist eine apparative Diagnostik der venösen Strombahn vor Durchführung einer mikrochirurgischen Lappenplastik an der unteren Extremität erforderlich: Routinemäßig oder nur in ausgewählten Fällen und welche ist hierfür am besten geeignet? Die Erfahrungen der teilnehmenden Expertinnen und Experten in Zusammenhang mit der aktuellen Literatur zu diesen Fragestellungen wurden im Rahmen eines interdisziplinären Expertenworkshops der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie (DAM) 2024 in Aachen diskutiert. Das Ziel des Workshops bestand darin, Empfehlungen zur Anwendung der bildgebenden Diagnostik unter Berücksichtigung individueller Patientencharakteristika zu erarbeiten und einen konsentierten Algorithmus zum diagnostischen Vorgehen zu entwickeln. Hinsichtlich der oben genannten Fragestellungen wurde von den Teilnehmenden der folgende Konsensus formuliert: • Eine routinemäßige Basisdiagnostik der arteriellen Anschlussgefäße vor freier Lappenplastik an der unteren Extremität mittels klinischer Untersuchung und Duplexsonographie ist zu empfehlen. • Bei Notwendigkeit einer Schnittbildgebung sollte eine CTA oder MRA verwendet werden, für junge Patienten sollte die MRA favorisiert werden. Zusätzlich sollte eine dynamische Bildgebung mittels Duplexsonographie erfolgen. Eine DSA sollte überwiegend in Interventionsbereitschaft durchgeführt werden, die DSA ohne Intervention bleibt speziellen Fragestellungen vorbehalten. • Eine Duplexsonographie zur Darstellung der venösen Anschlussgefäße ist sinnvoll. Bei vorliegenden venösen Pathologien sollte eine weitere Diagnostik mittels vorzugsweise MR-Phlebographie erfolgen.

IntroductionSarcoma is a rare and highly heterogeneous family of mesenchymal tumors. The experience and interdisciplinary approach of specialized high-volume sarcoma centers has a significant impact on disease treatment and outcome for patients. The aim of this retrospective, real-world, multicenter study was to evaluate geographic distribution of sarcoma cases in Southwest Germany and visually depict possible underrepresented areas of sarcoma primary diagnoses. Such descriptive information may indirectly guide future referral patterns and outreach activities of specialized sarcoma centers.MethodsThe absolute number and incidence of sarcoma patients obtained from the Baden-Württemberg Cancer Registry were compared with the data from five individual, high-volume, specialized sarcoma centers. Furthermore, we used a “White-Spot Analysis” as a novel cost-effective approach in epidemiological and public health research for analyzing health care coverage in sarcoma care.ResultsA total of 4,087 sarcoma patients living in the German Federal State of Baden-Württemberg between 2019 and 2022 were included in this study. Of these, 1,650 patients (40%) were treated primarily in specialized sarcoma centers whilst 2,437 patients (60%) received treatment for sarcoma outside of the five main high-volume centers, in underrepresented areas identified through White-Spot Analysis. The sarcoma incidence in Baden-Württemberg was calculated with our data to be 9.18/100,000 inhabitants per year.DiscussionIn future, the access to high-volume centers needs to be facilitated in order to minimize the observed discrepancies between treatment in specialized sarcoma centers and low-volume centers in Southwest Germany. Our analysis highlights such discrepancies and may support future efforts to improve outcomes for sarcoma patients.

Abstract Background Phantom limb pain (PLP) is a restrictive condition in which patients perceive pain in a limb that is no longer present, greatly reducing their quality of life. Mirror Therapy, wherein patients observe a mirror reflection of their intact limb, has demonstrated efficacy in alleviating PLP. However, its unilateral and seated nature presents limitations. To address these constraints while still reducing PLP, and evaluating the impact of different virtual limb representations (anthropomorphic vs. non-anthropomorphic) on the user’s sense of ownership, agency, and embodiment, PhantomAR was developed. Leveraging wearable first-person augmented reality (AR) technology, PhantomAR extends traditional Mirror Therapy by enabling users to move freely and engage in bimanual tasks. Methods The assistive mixed reality game application PhantomAR was deployed on the Microsoft HoloLens 2 and augmented the user’s residual limb by superimposing a virtual arm or tentacle that was controlled via residual muscles on their stump using an EMG electrode array. This setup allowed patients to engage in a first-person perspective and manipulate virtual objects with both the healthy and augmented limbs, free from the confines of a seated position. The study enrolled 10 able-bodied individuals and 8 individuals with unilateral, transradial amputation. All amputees experienced PLP. The usability of the PhantomAR application was evaluated using the System Usability Scale (SUS) and a user-centric survey. Additionally, the Game Experience was assessed on a 5-point Likert questionnaire (GEQ). Participants rated their phantom sensations using the Numerical Rating Scale and McGill Pain Questionnaire before, during, and after interaction with PhantomAR. The embodiment and agency of the virtual superimposed arm were evaluated with an altered Prosthesis Embodiment Scale. The study protocol included two sessions of 30 min each, during which participants experienced PhantomAR. Results Participants (n = 18) rated PhantomAR highly usable (SUS m = 90.8%, SD = 6.88). Feedback on the Game Experience Questionnaire was overwhelmingly positive, showing high immersion (m = 4.46, SD = 0.08) and positive affect (m = 4.97, SD = 0.05). PLP (n = 8) significantly decreased post-intervention (NRS and McGill Pain Questionnaire, p < .001). Skin temperature in the residual limb increased significantly post-intervention (p < .01) but did not correlate with PLP (r = − 0.08, p = 0.83). Tentacle overlay yielded mixed ownership but high agency ratings. Conclusion PhantomAR leverages mixed reality to significantly reduce Phantom Limb Pain, enhance user engagement, and alter perceptions of ownership and agency of their augmented limb through bi-manual, dynamic, full-body interactions. Trial registration DRKS00033208 (Jan. 5th 2024)

Objectives:At a consensus workshop, the following questions were discussed regarding the preoperative imaging of recipient vessels prior to microsurgical transplantation in the lower extremity: • Is preoperative imaging necessary for patients with clinically intact peripheral vasculature undergoing microsurgical reconstruction of the lower extremity? • Which imaging modality (if required) best visualises the arterial recipient vessels for microsurgical flap reconstruction in the lower extremity? • In which cases is imaging of the venous outflow tract indicated prior to microsurgical flap reconstruction of the lower extremity: should it be performed routinely or only in selected cases, and which modality is best suited for this purpose? Methods:At an interdisciplinary expert workshop held by the German-speaking Society for Reconstructive Microsurgery (GSRM) in Aachen in 2024, the experiences of the participating experts were discussed in the context of the current literature addressing these questions. The workshop aimed to develop recommendations for applying imaging diagnostics that take into account individual patient characteristics, and to establish a consensus-based diagnostic algorithm. Results:Regarding the above-mentioned questions, the participants reached the following consensus: • Routine baseline assessment of the arterial recipient vessels by means of clinical examination and duplex ultrasonography is recommended prior to free flap transfer in the lower extremity. • If additional imaging is required, CT angiography (CTA) or MR angiography (MRA) should be used. In younger patients, MRA should be preferred. Additionally, dynamic imaging using duplex ultrasonography should be performed. Digital subtraction angiography (DSA) should primarily be reserved for cases where intervention is anticipated; diagnostic DSA without intervention should be limited to specific indications. • The evaluation of the venous recipient vessels using duplex ultrasonography is considered useful. If venous pathology is present, further imaging - preferably MR phlebography - should be performed.

The thoracodorsal artery perforator (TDAP) flap is a versatile pedicled and free flap with low donor site morbidity and a relatively thin skin paddle. Physical patient characteristics may influence interindividual differences in perforator characteristics and, therefore, help to estimate the safety of the TDAP flap.Dynamic infrared thermography and color duplex ultrasound were applied to assess the TDAP diameter, peak systolic velocity (PSV), end-diastolic velocity, resistance index, and thickness of the latissimus dorsi muscle and the subcutaneous tissue bilaterally in 25 subjects. The effect of handedness on the symmetry of perforator characteristics was investigated.Perforator properties were not significantly altered by sex or body mass index. The mean latissimus dorsi muscle thickness correlated positively with both the perforator diameter (Pearson's r = 0.25, p = 0.0048, n = 124) and the PSV (r = 0.29, p = 0.0012, n = 124). In contrast, a negative correlation was observed between subcutaneous tissue thickness and PSV (r = -0.31, p = 0.0003, n = 124). A comparison of the perforator diameter and the PSV in the dominant and nondominant sides showed no statistically significant difference.The findings of the study indicate that perfusion of the thoracodorsal artery flap is enhanced by the presence of a thicker latissimus dorsi muscle, a thinner subcutaneous tissue, and a reduced quantity of TDAPs.

The management of trunk wall defects can be a challenge in surgical practice, especially when conventional methods such as primary wound closure or skin grafts are insufficient due to the size and depth of the defect, its location, location, or lack of adequate skin and soft tissue coverage. In recent years, perforator-based local flaps have emerged as a modern, muscle-sparing alternative to traditional local myocutaneous or free microsurgical flaps. Particularly in the back region, suitable recipient vessels for free flaps are often unavailable due to vascular anatomy. At the same time, compared to conventional random-pattern flaps, perforator-based flaps offer increased reliability, as they are based on targeted vascular perforators. This allows them to be designed beyond the classic 2:1 length-to-width ratio and enables greater reach with improved perfusion. By utilising perforating vessels, functionally important musculature can largely be preserved, which may lead to reduced postoperative morbidity and faster rehabilitation. This article is aimed at surgically active colleagues without specialised training in plastic-reconstructive surgery who are nonetheless regularly confronted with complex wound situations-for example, following tumour resections, chronic infections, pressure ulcers, or postoperative wound healing disorders. The goal is to provide a practical overview of the principles, indications, and limitations of perforator-based local flaps. In addition to an introduction to the underlying vascular anatomy (angiosome and perforasome theory), preoperative diagnostic procedures, various flap techniques, and typical clinical courses-including potential surgical complications-are presented. A particular focus is placed on the selection of appropriate flap types based on defect location and the presence of local perforators, with the goal of achieving the simplest, safest, and most sustainable soft tissue coverage possible. Clinical case examples illustrate operative approaches in different regions of the trunk wall.

Objective To assess the tolerability of multimodal therapy in soft tissue sarcoma patients, particularly with regard to their quality of life and level of distress. Materials and methods A retrospective cohort study enrolled individuals receiving sarcoma therapy at the sarcoma center of the University of Tuebingen between 2017 and 2022. Participants completed an online survey that included the EORTC's questionnaire (QLQ-C30), coupled with the distress thermometer and demographic inquiries. The primary emphasis was on comparing three distinct modalities: Radiation, Chemotherapy and Surgery. The data were analysed performing one-way ANOVA. Results A total of 237 patients were included in the study. There was a significant difference (p < 0.001) in quality of life according to the EORTC scores (high score = high quality of life) between the different treatments: chemotherapy (mean: 26.8 [standard deviation: 19.5]), radiotherapy (51.0 [21.5]), and surgery (46.9 [28.3]). Similarly, a statistically significant discrepancy (p < 0.001) was found in average distress levels (high score = high level of distress) corresponding to each treatment type: radiation (5.0 [2.7]), surgery (6.0 [2.9]), and chemotherapy (7.4 [2.4]). The rates of patients willing to undergo the same treatment varied across groups, with the highest percentage observed in the surgery group (94.2%), followed by radiation (87.4%), and chemotherapy (73.5%). Conclusion Patients receiving multimodal therapy for soft tissue often find chemotherapy particularly demanding. Impairment of both quality of life and physical well-being is more likely and tends to be more severe compared with radiation or surgery. These observations should be taken into consideration when consenting patients and offering treatment plans.