BACKGROUND:In this study, we evaluate the role of RGMa (Repulsive Guidance Molecule a) during peripheral nerve regeneration using the mouse median nerve model.METHODS:By real-time PCR and Western Blot analysis, we examined expression changes of RGMa mRNA and RGMa protein in neural tissue after transection and microsurgical repair of the mouse median nerve distal to the transection site. We evaluated histomorphometrical changes in neural tissue distal to the injury site and functional recovery of the grasping force after median nerve transection and repair in wild-type mice and RGMa+/- heterozygous mice.RESULTS:RT-PCR revealed a 1,8 fold increase of RGMa mRNA two weeks and a 4,4 fold increase of RGMa mRNA 3 weeks after nerve transection and repair in the nerve segment distal to the injury site. In Western blot analysis, we could show a high increase of RGMa in the nerve segment distal to the injury site at day 14. Histomorphometrical analysis showed significant differences between wild-type animals and heterozygous animals. The absolute number of myelinated fibres was significantly higher in operated heterozygous RGMa+/- animals compared to operated wildtye animals. Using the functional grasping test, we could demonstrate that peripheral nerve regeneration is significantly diminished in heterozygous RGMa+/- mice.CONCLUSIONS:Employing the mouse median nerve model in transgenic animals, we demonstrate that RGMa plays an important role during peripheral nerve regeneration.

Background: We analyzed the radiologic outcome of different treatment options for scaphoid nonunion. The results were compared with literature, and a treatment algorithm was proposed. Methods: On the basis of a retrospective case-control study, 286 patients suffering from scaphoid nonunion were treated over a 10-year period. Patients were grouped depending on the location of the nonunion: proximal (n = 126), middle (n = 130), or distal (n = 30) third. In the presence of an avascular proximal fragment or after prior unsuccessful operation, interposition of a vascularized pedicled bone graft from the distal radius was performed (n = 82). Scaphoid healing was detected by conventional radiography and computed tomography. Results: Excellent healing rates of 96.3% were obtained for middle and distal third scaphoid nonunions by conventional iliac crest bone grafting (n = 137). Furthermore, we achieved healing rates of 91.3% for persistent nonunions using a palmar vascularized bone graft from the distal radius after prior unsuccessful operation (n = 23). When using a dorsal vascularized bone graft from the distal radius, scaphoid consolidation was reached in 81.1% for avascular proximal fragments (n = 59). Conclusions: Applying a sophisticated treatment algorithm, the prognosis of scaphoid nonunion is very good.

A histological evaluation of peeling-induced skin changes in subcutaneous undermined preauricular facial skin flaps of nine patients was performed. There were three treatment groups: Trichloroacetic acid (TCA) 25%, TCA 40% and phenol/croton oil; one group served as control. Two independent evaluators determined the epidermal and dermal thickness and the depth of necrosis (micrometre). The percentual tissue damage due to the peeling was calculated, and a one-sample t-test for statistical significance was performed. On the basis of the histomorphological changes, peeling depth was classified as superficial, superficial-partial, deep-partial and full thickness chemical burn. The histological results revealed a progression of wound depth for different peeling agents without full thickness necrosis. TCA peels of up to 40% can be safely applied on subcutaneous undermined facial skin flaps without impairing the vascular patency, producing a predictable chemical burn, whereas deep peels such as phenol/croton oil peels should not be applied on subcutaneous undermined skin so as to not produce skin slough or necrosis by impairing vascular patency.

Zusammenfassung Hintergrund In Deutschland wurden vor nunmehr 13 Jahren Fallpauschalen als medizinisch-ökonomisches Klassifikationssystem eingeführt. Im Folgenden soll die Abbildung plastischer Rekonstruktionen bei malignen Hauttumoren im Kopf-Hals-Bereich durch Diagnosis Related Groups (DRG) analysiert werden. Material und Methoden Vier verschiedene Hauptdiagnosen (Malignes Melanom, Basalzellkarzinom, Plattenepithelkarzinom, Carcinoma in situ) an bis zu 6 unterschiedlichen Lokalisationen im Kopf-Hals-Bereich wurden mit folgenden Prozeduren kombiniert und mittels DRG-Grouper untersucht: Exzision mit Primärnaht, Exzision mit temporärer Weichteildeckung, Plastische Deckung durch Eigenhaut, lokale, freie, gestielte regionale Lappen und Fernlappenplastiken sowie Kombinationsdeckungen. Ergebnisse Durch 5750 verschlüsselte Diagnose-Prozeduren-Kombinationen wurden 10 unterschiedliche DRGs bestimmt. Bei großflächigen temporären Weichteildeckungen und Hauttransplantationen dominiert die DRG J22Z (Erlös 2817 €). In 2017 wurden die häufig durchgeführten lokalen Lappenplastiken hiervon abgewertet und führen aktuell in die DRG J11D (Erlös 1903 €). In diesem Zusammenhang sind Fallzusammenführungen durch ein zweizeitiges stationäres Vorgehen (Sitzung 1: Exzision, Sitzung 2: Plastische Deckung) von besonderer Bedeutung. Malignome an der Lippe ergeben eine eher unruhige DRG-Abbildung ohne klar abzuleitende Gruppierungsregeln. Die hochbewertete Basis-DRG J08 (DRGs J08A, J08B und J08C) kann nahezu ausnahmslos durch einzelne zusätzliche OPS-Ziffern erreicht werden. Schlussfolgerung Die derzeitige Fallpauschalensituation für plastische Rekonstruktionen im Rahmen maligner Hauttumoren bietet etliche potentielle Fehlanreize, welche Einfluss auf die Patientenversorgung haben können. Auf der Suche nach einem diversifizierten DRG-Portfolio bietet sich die Basis-DRG J08 neben der gängigen Kodierpraxis mit entsprechenden Fallpauschalen an. Die Autoren sehen darin die Möglichkeit, bei aktueller Abwertung auch ressourcenintensive Spezialfälle aufwandgerecht abzubilden. Vor einer unbegründeten und inflationären Anwendung wird jedoch aufgrund einer fehlenden nachhaltigen Ausrichtung aufgrund von Verwässerung ausdrücklich gewarnt.

Background Diagnosis Related Groups (DRGs) were introduced in Germany as a medico-economic classification system 13 years ago. In this analysis, we looked into the compensation for reconstructive plastic surgery after the excision of malignant head and neck skin tumours by DRGs. Material and methods Four main diagnoses (malignant melanoma, basal cell carcinoma, squamous cell carcinoma, carcinoma in situ) at a maximum of 6 different locations in the head and neck were combined with the following procedures: excision and primary wound closure, excision with temporary soft tissue coverage, split-thickness or full-thickness skin grafting, local, free or regional pedicle flaps, distant flaps as well as combined procedures for coverage. Results We defined 10 different DRGs based on 5750 combinations of diagnoses and procedures. DRG J22Z (revenue: EUR 2817) predominated for large temporary soft tissue coverage and skin grafting techniques. In 2017, local flaps were devaluated and now lead to DRG J11D (revenue: EUR 1903) in most cases. In this context, an aggregation of cases by a two-stage approach (stage 1: excision, stage 2: reconstruction) is particularly important. Malignant tumours of the lips are inconsistently represented by DRGs with a lack of definite rules. The highly rated main group DRG J08 (including DRGs J08A, J08B and J08C) can be achieved almost invariably by addition of specific single procedures. Conclusion The current representation of reconstructive surgery for malignant skin tumours by DRGs is associated with potential disincentive effects, which may have an impact on patient care. In search of a diversified portfolio, the main group DRG J08 should be considered in addition to the common practice of coding. The authors of this study think that this may be a possibility to compensate for the actual devaluation and to achieve resource-related reimbursement in high-cost cases. However, incorrect and inflationary use should be avoided due to the lack of long-term orientation caused by dilution of the DRGs.

The peeling-assisted volume-enhancing (PAVE) lift is a single-stage approach that combines superficial musculoaponeurotic system (SMAS) plication techniques with fat grafting and different peeling agents. To evaluate the safety of this approach, we analyzed the records of 159 patients who underwent surgery between 2008 and 2014.The percentage of complications observed was not higher than values reported in the literature for each treatment entity: surgical facelift: n = 3 haematomas (1.89 %), n = 2; temporary apraxia of the mandibular branch (1.26%); fat transfer: minor asymmetry in n = 5 cases (3.14%); peeling: temporary hyperpigmentation in trichloroacetic acid (n = 5; 3.8%) and phenol peels (n = 4; 3.1%), permanent hypopigmentation (n = 6; 5.6%), formation of skin miliae persisting longer than 2 to 3 months (n = 5; 4.6%) and prolonged erythema (n = 3; 0.28%) in phenol peels.The single-stage use of chemical peels, autologous fat transfer, and surgical rhytidectomy was safe. (C) 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Einleitung: Luftgebunde notfallmasige Zuverlegung eines ansonsten gesunden 23-jahrigen Mannes aufgrund eines Arbeitsunfalles mit schwerer Riss-/Quetschverletzung der linken Hand. Es zeigte sich ein Verlust der Strecksehnen III-V, der Interosseusmuskulatur III-V, des MHK IV/V[for full text, please go to the a.m. URL]

PURPOSE:Based on several positive effects of whole-body-vibration (WBV) therapy on recovery after SCI, we looked for correlations between functional (analysis of locomotion), electrophysiological (H-reflex) and morphological (density of functioning capillaries) measurements after SCI and WBV-treatment.METHODS:Severe compression SCI at low-thoracic level (T8) in adult female Wistar rats was followed by WBV twice a day (2 × WBV) over a 12-week post-injury period. Intact rats and rats with SCI but no WBV-therapy ("No-WBV") served as controls. Recovery of locomotion was determined by BBB-locomotor rating, foot stepping angle (FSA), rump-height index (RHI), correct ladder steps (CLS) and H-reflex at 1, 3, 6, 9, and 12 weeks after SCI. Animals were sacrificed by an overdose of Isoflurane (Abbott). One hour later their spinal cords were fixed in 4% PFA for 24 h. Samples from the thoracic cord containing the lesion site and from the lumbar intumescence were cut into 10 μm thick longitudinal frozen sections.RESULTS:All functioning capillaries were unequivocally identified because the endogenous peroxidase of the erythrocytes was clearly visualized with 0.05% diaminobenzidine (DAB). A determination of their absolute (in μm2) and proportional areas (percent of photographed tissue) revealed a significantly denser capillary network in the WBV-treated rats: 1,66 ± 0,41% in the "vibrated" rats versus 0,79 ± 0,19% in the "No-WBV" animals. The portion of the capillary network in intact rats was 1,51 ± 0,69%. Surprisingly, even though the vascularization in the treated animals was significantly increased, this had no beneficial influence on the recovery of functions after SCI.CONCLUSION:The results of this study provide for the first time evidence that intensive WBV-therapy leads to a significantly denser capillary network in the lesioned spinal cord. However, since this higher capillary density is not associated with improved functional recovery (possibly because it exceeded the balance necessary for functional improvements), optional treatments with lower intensity or less time of WBV-therapy should be tested.

Background: Limb elevation is a commonly used approach for reducing edema and increasing venous drainage. Considering the anatomy of the sural flap with retrograde perfusion and hence potentially difficult blood outflow, the best angle for positioning the leg following operation is not yet known.Methods: A total of 14 patients undergoing sural flap lower limb reconstruction were enrolled in the study. We assessed the perfusion dynamics of the flaps using the oxygen-to-see (O2C) device that combines laser light, to determine blood flow, and white light to determine the relative amount of hemoglobin and oxygen saturation. Three different positions were evaluated: 45 degrees angle downward, the horizontal position, and 45 degrees angle upward.Results: The blood flow was significantly higher in the 45 degrees upward position compared to the 45 degrees downward position. The relative amount of hemoglobin was significantly lower in the 45 degrees upward position compared to the 45 degrees downward position. No significant differences with regard to oxygen saturation were observed.Conclusion: The results of this study show a more precise pattern of perfusion due to different positioning. The 45 degrees upward position of the leg generally maintains the best blood flow and venous drainage. However, compared to horizontal positioning, these differences were not statistically significant. As an elevation of 45 degrees can be uncomfortable for patients, we recommend an elevation of the leg which approximates the 45 degrees upward position but is still comfortable. (C) 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background: The prevalence of burns in the general population is high. Despite new research findings, skin burns and its resulting tissue damage are still not entirely understood. In particular, little is known about the depth-dependent alteration of skin biomechanical properties of these wounds.Methods: Thirty-six burn wounds with six different depths were generated on the abdomen of six Gottingen minipigs. The alteration of skin biomechanical properties was evaluated objectively after 15 and 360 min using a Cutometer device. Biopsies for histological evaluation were taken and the depth of burn was correlated with biomechanical properties.Results: Firmness of skin (R0), overall elasticity (R8) and calculated elasticity (Ue) demonstrated a continuous decrease with an increasing depth of burn 15 min after wound generation. Gross elasticity (R2), net elasticity (R5) and amount of elasticity of the whole curve (R7), however, showed an increase of values with increasing depth of injury. A further decrease of elasticity was demonstrated 360 min after wound generation.Conclusion: The alteration of skin biomechanical properties is a function of damaged tissue structures. The presented results demonstrate a depth-dependent decrease of principal elastic parameters with an increasing depth of burn and the results indicate progressive tissue damage over the time. (C) 2014 Elsevier Ltd and ISBI. All rights reserved.

Die Polyneuropathie als Spätfolge der diabetischen Erkrankung mit ihren Konsequenzen Ulzeration und Amputation wird in ihrer pathophysiologischen Ursache, ihrer sozioökonomischen und sozialmedizinischen Relevanz kurz skizziert und die Ergebnisse der Dekompression peripherer Nerven an der unteren Extremität anhand einer systematischen Literaturrecherche in Pubmed, Embase und Cochrane gelisteten Journalen hinsichtlich Sensibilität, Schmerz, Ulzeration und Amputation analysiert und ausgewertet. Die Dekompression peripherer Nerven erweist sich als sehr gutes Behandlungskonzept zur Wiederherstellung bzw. Verbesserung der Sensibilität, Verminderung der Schmerzsymptomatik und Reduktion von Ulzerationen und Amputationen.

Currently, the diagnosis of burn depth is primarily based on a visual assessment and can be dependent on the surgeons' experience. The goal of this study was to determine the ability of laser Doppler flowmeter combined with a tissue spectrophotometer to discriminate burn depth in a miniature swine burn model. Burn injuries of varying depth, including superficial-partial, deep-partial, and full thickness, were created in seven Göttingen minipigs using an aluminium bar (100 °C), which was applied to the abdominal skin for periods of 1, 3, 6, 12, 30, and 60 seconds with gravity alone. The depth of injury was evaluated histologically using hematoxylin and eosin staining. All burns were assessed 3 hours after injury using a device that combines a laser light and a white light to determine blood flow, hemoglobin oxygenation, and relative amount of hemoglobin. The blood flow (41 vs. 124 arbitrary units [AU]) and relative amount of hemoglobin (32 vs. 52 AU) were significantly lower in full thickness compared with superficial-partial thickness burns. However, no significant differences in hemoglobin oxygenation were observed between these depths of burns (61 vs. 60%). These results show the ability of laser Doppler flowmeter and tissue spectrophotometer in combination to discriminate between various depths of injury in the minipig model, suggesting that this device may offer a valuable tool for burn depth assessment influencing burn management.

Die Polyneuropathie als Spätfolge der diabetischen Erkrankung mit persistierenden Schmerzen und progressivem Sensibilitätsverlust mit der nachfolgenden Konsequenz von Ulzerationen und Amputationen, wird zunehmend bei steigender Anzahl an Diabetikern zu einem ernsten medizinischen und sozioökonomischen Problem unserer Wohlstandsgesellschaft. Bislang führten die etablierten Konzepte zu keiner wesentlichen Verringerung der Diabetes assoziierten Amputationen, obwohl dies vor mehr als einem Jahrzehnt als deklariertes Ziel in der St. Vincent Deklaration der Europäischen Union so formuliert wurde.

Traumatic spinal cord injury (SCI) causes a loss of locomotor function with associated compromise of the musculo-skeletal system. Whole body vibration (WBV) is a potential therapy following SCI, but little is known about its effects on the musculo-skeletal system. Here, we examined locomotor recovery and the musculo-skeletal system after thoracic (T7-9) compression SCI in adult rats. Daily WBV was started at 1, 7, 14 and 28 days after injury (WBV1-WBV28 respectively) and continued over a 12-week post-injury period. Intact rats, rats with SCI but no WBV (sham-treated) and a group that received passive flexion and extension (PFE) of their hind limbs served as controls. Compared to sham-treated rats, neither WBV nor PFE improved motor function. Only WBV14 and PFE improved body support. In line with earlier studies we failed to detect signs of soleus muscle atrophy (weight, cross sectional diameter, total amount of fibers, mean fiber diameter) or bone loss in the femur (length, weight, bone mineral density). One possible explanation is that, despite of injury extent, the preservation of some axons in the white matter, in combination with quadripedal locomotion, may provide sufficient trophic and neuronal support for the musculoskeletal system.

Background: The prevalence of acute cold injury has increased recently. Despite new research findings, these injuries and their resulting tissue damage are still not entirely understood. Especially, little is known about alteration of skin biomechanical properties.Methods: A total of 36 acute cold contact wounds with different depths were generated on the abdomen of six Gottingen minipigs. Alteration of biomechanical properties of skin was evaluated objectively after 15 and 360 min using a Cutometer device. Biopsies for histological evaluation were taken, and the depth of injury was correlated with biomechanical properties.Results: Calculated elasticity (Ue), firmness of skin (R0) and overall elasticity (R8) demonstrated a continuous decrease, whereas other parameters demonstrated an initial increase with increasing depth of injury 15 min after wound generation. All parameters showed an increase compared to healthy skin, 360 min after wound generation. Furthermore, an alteration of values over time was detected.Conclusion: Alteration of biomechanical properties of skin is a function of damaged tissue structures. The presented results demonstrate a decrease of main elastic parameters with increasing depth of injury and indicate progressive tissue damage over time. Skin elasticity measurements are a valuable tool in acute cold contact injury depth assessment and may act as an influencing factor in management decisions. (C) 2014 Elsevier Ltd and ISBI. All rights reserved.

OBJECTIVE:The treatment of proximal located scaphoid nonunion is a well-known and common problem. For these patients, we used a vascular pedicled bone graft of the distal radius.METHODS:In the last 7 years, 75 patients were treated with the vascular pedicled bone graft. Retrospectively, patients' data, healing rates, and factors influencing scaphoid healing were analyzed.RESULTS:The overall healing rate in cases with proximal located nonunions (n = 54) was approximately 70%. Out of these 54 patients, 47 patients showed avascular proximal fragments. Multivariate analysis showed no significant impact for the factors age, smoking, duration of disease, or previous operation.CONCLUSIONS:In our negative selected patient group, we were able to achieve good results with the usage of a pedicled vascularized bone graft of the distal radius. Our results indicate a favorable outcome for the use of a pedicled vascularized distal radius bone graft in both scaphoid nonunion fractures of the proximal third, with or without an avascular proximal pole.

Background: Until now, the exact pathophysiology of frostbite injuries is poorly understood. The aim of the study is to evaluate the perfusion changes of frostbite injuries to get a better understanding of the exact mechanism underlying the resulting tissue damage. Particular attention has been given to the differentiation of changes between the various injury depths.Methods: Cold contact injury ranging from superficial, superficial-partial, deep-partial to full thickness were generated using seven goettingen minipigs. The perfusion dynamics were assessed before and 3 h after the injuries were inflicted using the O2C-device, which combines a laser light, to determine blood flow, and white light to determine hemoglobin oxygenation and relative amount of hemoglobin. A total of 42 cold contact injuries were inflicted and 84 measurements were carried out.Results: In superficial and superficial partial injuries there was an increase in the blood flow (mean, 20 2.4%, 15 +/- 5.1%, respectively) and in the relative amount of hemoglobin (mean, 29 +/- 9.1%, 28 +/- 7.2%, respectively), whereas the hemoglobin oxygenation did not alter (mean, -0.15 +/- 2.4%, -0.8 +/- 3.1%, respectively). In deep partial injuries there was a decrease in the blood flow (mean range, -4 +/- 2.1 to -17 +/- 4.7%) and an increase in the relative amount of hemoglobin (mean range, 79 +/- 17.2 to 93 +/- 17.7%), whereas the hemoglobin oxygenation did not alter (mean range, -0.7 +/- 3.1 to -2.9 +/- 3.3%). In full thickness injuries there was a drop in the blood flow (mean range, -24 +/- 7.6 to -27 +/- 11.8%) and in the hemoglobin oxygenation (mean range, -16 +/- 3.5 to -19 +/- 2.5%) and an increase in the relative amount of hemoglobin (mean range, +126 +/- 19.8 to 145 +/- 10.9%).Conclusion: The results of this study form a more precise pattern of cold contact injury perfusion changes, which can be a valuable tool to assess the degree of cold contact injury and furthermore the efficacy of novel diagnostic aids, therapeutics and treatment modalities. (C) 2013 Elsevier Ltd and ISBI. All rights reserved.

Objective: Standard methods to evaluate the functional regeneration after injury of the rat median nerve are insufficient to identify any further differences of axonal nerve regeneration after restitution of motor recovery is completed. An important complementary method for assessing such differences is a histomorphometric analysis of the distal to lesion nerve fibers. Recently, an electrophysiological method has been proposed as a sensitive method to examine the quality of axonal nerve regeneration. Methods: A linear regression analysis has been performed to correlate histomorphometric and neurographic data originating from 31 rats subjected to neurotmesis and immediate reconstruction of their right median nerve. Results: A significant linear correlation between the velocity of neuromuscular conduction and the total number of nerve fibers (P = .037) as well as between the amplitude of compound muscle action potential and the total number of nerve fibers (P = .026) has been identified. Interestingly, a significant correlation between the velocity of neuromuscular conduction and the square root of the cross-sectional area of the nerve could be found (P = .008). This corresponds to a linear correlation between the velocity of neuromuscular conduction and the radius of the nerve. Conclusion: These results contribute in a better interpretation of morphological predictors of nerve regeneration and verify the previously described electrophysiological assessment in the median nerve rat model as a valid method.