Zusammenfassung
Abstract
Hintergrund:
Nach der Exzision eines infizierten Sinus pilonidalis gibt es verschiedene Therapieoptionen des Defekts. Wir verglichen Sekundarheilung und Limberglappenplastik ...hinsichtlich Narbenqualität und Beschwerden, Rezidivhäufigkeit, Arbeitsunfähigkeit und Patientenzufriedenheit 1 Jahr postoperativ.
Methodik:
Von 55 Patienten, welche 2011–2012 im KlinikumStadtSoest an einem Sinus pilonidalis operiert wurden, konnten 16 Patienten mit sekundärer Wundheilung und 17 Patienten mit Limberglappenplastik eingeschlossen werden. Insbesondere interessierten uns die Objektivierbarkeit der Narbenqualität und -elastizität durch die Parameter der Hautdehnbarkeit und -verschieblichkeit. Hierzu kam eine von uns entwickelte Messmethode zur Ermittlung des Sakral-Lumbalen Hautdehnungsquotienten (SL-Quotient) und der Sakralen Hautverschieblichkeit zum Einsatz. 100 gesunde Probanden dienten als Kontrollgruppe. Die Schmerzskalen, Rezidivhäufigkeit, Zufriedenheit der Patienten mit Verlauf und kosmetischem Ergebnis sowie die Dauer der Arbeitsunfähigkeit wurden ebenfalls ermittelt.
Ergebnisse:
Der Sakral-Lumbale Hautdehnungsquotient fiel in der Limberggruppe signifikant besser aus, als in der Sekundärheilungsgruppe. Bezüglich der Verschieblichkeit gab es eine deutliche Tendenz zu günstigeren Werten in der Limberggruppe. Die Dehnbarkeit und Verschieblichkeit in der Limberggruppe entsprach den Referenzwerten aus der gesunden Probandengruppe. Die Dehnbarkeit nach sekundärer Wundheilung war hingegen signifikant (p=0,001) schlechter als in der gesunden Referenzgruppe. Die Dauer der Arbeitsunfähigkeit nach der Lappenplastik war in der Limberggruppe (MW 29 Tage) signifikant (p=0,02) geringer als die Dauer nach der Sinusexzision in der Gruppe mit sekundärer Wundheilung (MW 63 Tage). Bezüglich der Schmerzen, Zufriedenheit mit Verlauf und kosmetischem Ergebnis sowie Anzahl der Rezidive zeigten sich keine Unterschiede zwischen den Patientengruppen.
Schlussfolgerung:
Durch den Wundverschluss mittels Limberglappenplastik nach Exzision eines infizierten Sinus pilonidalis kann nicht nur die Dauer der Arbeitsunfähigkeit reduziert werden, sondern auch eine Narbe entstehen, die besser verschieblich und dehnbar ist, im Vergleich zur Sekundärheilung. Schmerzen und Zufriedenheit waren in beiden Gruppen sehr günstig, ohne Gruppenunterschiede. Folgestudien an einem größeren Patientenkollektiv und mit längerem Follow-up sind geplant. Wir stellen unseren Patienten zunächst weiterhin beide Therapieoptionen als mögliche Alternativen dar.
Summary Functional results regarding shoe modifications, gait analysis and long-term durability of the reconstructed foot have not been reported using insole paedobarography. This article presents ...insole-paedobarographic gait analysis and discusses the various pressure distribution patterns following the reconstruction of the foot. This retrospective study reports on the clinical and functional results in 23 out of 39 patients who received flap coverage of their feet in our department in the period from 2001 to 2010. Mean follow-up time amounted to 46.6 months. Patients were separated into two groups, those with flap coverage to the sole of the foot (group 1) and those with flap coverage to non-weight-bearing areas of the foot (group 2). Gait analysis was accomplished by using insole paedobarography. The results of the gait analysis have shown that in both patient groups, when comparing affected feet with sound feet, the affected feet were exposed to significantly less support time (group 1; affected vs. sound feet: 0.44 ± 0.07 s vs. 0.55 ± 0.11 s, p = 0.047), (group 2; affected vs. sound feet: 0.47 ± 0.07 s vs. 0.54 ± 0.07 s, p = 0.029). In addition, in both patient groups, the analysis of peak-pressure distributions revealed greater pressures on the affected feet compared to the sound feet (group 1; affected vs. sound feet: 47.9 ± 10.13 N cm−2 vs. 36.3 ± 7.5 N cm−2 , p = 0.008), (group 2; affected vs. sound feet: 38.08 ± 13.98 N cm−2 vs. 32.92 ± 14.77 N cm−2 , p = 0.061). The insole paedobarography can contribute to a more precise gait analysis following a soft-tissue reconstruction not only of the sole but also of other foot regions as well. It can help to identify and correct movement sequences and peak-pressure distributions which are damaging to the flaps. The resulting potential minimisation of the ulceration rate can lead to a further optimisation in the rate of completely rehabilitated patients and a reduction in the revision rate.
There are various options for wound treatment after the excision of a pilonidal sinus. The aim of our study was to compare secondary healing to Limberg flap wound closure, with a focus on scar ...quality and patient complaints, rate of recurrence, period of absence from work as well as functional and aesthetic results one year after surgery.
33 out of 55 patients who underwent pilonidal sinus excision in our department (KlinikumStadtSoest, Soest, Germany) between 2011 and 2012 were enrolled in the study. 16 of these 33 patients had chosen secondary wound healing and 17 were treated with a Limberg flap for defect coverage. First and foremost, we aimed to objectify scar quality and elasticity by measuring the parameters of skin distensibility and mobility. To this end, we used a self-developed method to ascertain the sacral lumbar skin distension quotient (SL quotient) as well as sacral skin mobility. 100 healthy volunteers served as a control group. Also we collected information about pain, time of absence from work and frequency of recurrence and asked patients about their satisfaction with the functional and aesthetic results.
The results for the sacral lumbar skin distension quotient were significantly better after Limberg flap wound closure compared with secondary wound healing. As regards distensibility, there was a marked trend to more favourable values in the Limberg group. No differences in distensibility and mobility were observed between the Limberg group and the control group, whereas skin distensibility was significantly reduced (p=0.001) in secondary healing compared with the control group. Time off work was significantly longer in secondary healing (mean 63 days) than after Limberg flap (mean 29 days). No differences were identified regarding patient satisfaction, pain scores and frequency of recurrence.
Wound closure via Limberg flap after the excision of an infected pilonidal sinus not only helps to reduce absence from work, but also produces a scar which is more distensible and movable compared with secondary healing. Patient satisfaction and pain scores were very good in both groups, with no differences observed by us. We are planning to collect more data with a bigger sample of patients and a longer follow-up period in future studies. For the time being, we will continue to provide both treatment methods to our patients.
Zusammenfassung
Die zuverlässige Versorgung von Weichteildefekten der unteren Extremität, insbesondere im distalen Anteil, stellt eine besondere chirurgische Herausforderung dar. Im ...interdisziplinären Team sind die Möglichkeit eines Extremitätenerhalts zu evaluieren sowie der Zeitpunkt unter Aspekten der Patientensicherheit und das systematische Vorgehen mit der Definition der geeigneten Lappenplastik festzulegen. Zur Deckung von Defekten im Bereich der unteren Extremität haben sich traditionell lokale Muskellappenplastiken oder freie Lappenplastiken etabliert. Zunehmend finden perforatorbasierte Lappenplastiken bevorzugte Anwendung. Darüber hinaus haben neue chirurgische Techniken und Weiterentwicklungen im Zusammenhang mit dem demografischen Wandel zu einem Paradigmenwechsel geführt.
Some patients with sacral scars, e. g. those developing after pilonidal sinus surgery, report discomfort when sitting or putting strain on the scars. In order to establish objective criteria for the ...assessment of this kind of discomfort and for the evaluation of scar quality after various types of surgical interventions, it is of interest to provide a method which enables physicians to assess skin quality in the sacral region. For this purpose, we developed a mechanical, non-invasive, fast and cost-neutral method for the measurement of skin distensibility and mobility. We examined a healthy sample of 100 study participants to establish benchmark values for scar-free skin in the sacral region and to identify the factors which impact skin quality, e. g. age, weight and sex.
With the participant in a standing position, 4 vertically arranged measurement points, which are exactly spaced in cranial to caudal direction by 10 mm-100 mm-10 mm, are marked in the lumbar and sacral region, respectively. The participant is then asked to bend forward and - with arms and legs fully stretched on both sides - to touch both their patellae with the balls of their hands so that the distance between the measurement points can be measured in this position as well. Then, with the participant standing upright again, another measurement is taken to establish the distance by which the lowest point can be manually moved in cranial direction.
The sacral-lumbar skin distension quotient (lumbar skin distension / sacral skin distension×100), which can easily be calculated from the measurements, is independent of age and BMI and has a standard range of about 80-93%. Sacral skin mobility ranges from 11 to 18 mm, but is slightly negatively influenced by a high BMI.
By comparing lumbar and sacral skin distension in the same study participant, we are able to obtain intraindividually valid findings about possible changes in skin and scar quality. Owing to the lack of known published data about sacral skin elasticity, the proposed measurement method, while restricted to a number of special cases, seems to be practicable and independent of the patient's general condition. Compared with devices that have been used for the measurement of elasticity in other skin areas, our procedure is generally available and cost-neutral.
Purpose
Cryotherapy and compression as integral part of the RICE regimen are thought to improve treatment outcome after sport injuries. Using standardized cryotherapy and compression perioperatively ...has been reported with conflicting clinical results. The impact of combined cryotherapy and compression is compared to standard care among patients undergoing wrist arthroscopy.
Methods
Fifty-six patients undergoing wrist arthroscopy were assessed, 54 patients were randomized to either Cryo/Cuff™ (3 × 10 min twice daily) or standard care over 3 weeks. Follow-up clinical visits were at postoperative days 1, 8, and 21. One patient in each group was lost during follow-up. Fifty-two patients were analyzed. Statistics were performed as Intention-to-treat analysis. Outcome parameters were pain, three-dimensional volume of the wrist, range of motion, and DASH score.
Results
The Cryo/Cuff™ group had a 49% reduction in pain level (VAS 3.5 ± 0.4 vs. VAS 1.8 ± 0.2 on the 21st postoperative day) when compared to a reduction of 41% in the control group (VAS 5.1 ± 0.6 preoperatively vs. VAS 3.0 ± 0.5 on the 21st postoperative day). Swelling and range of motion were not as significantly different between the two groups as were DASH scores (DASH-score Cryo/Cuff group preoperatively 37.3 ± 3.5 and postoperatively 36.9 ± 3.5; DASH-score control group preoperatively 42.8 ± 4.3 and postoperatively 41.9 ± 4.9). The CONSORT score reached 17 out of 22.
Conclusion
There was no significant effect of additional home-based combined cryotherapy and compression using the Cryo/Cuff™ wrist bandage, following wrist arthroscopy regarding pain, swelling, range of motion, and subjective impairment assessed using the DASH score over 3 weeks in comparison with the control group.
Carpal tunnel syndrome is common in children with mucopolysaccharidosis type 1H (MPS type 1H). Clinical signs of carpal tunnel syndrome are frequently absent in these children and it is often very ...difficult to perform and interpret neurophysiological investigations. In this article we wish to present our experience and results regarding the diagnosis and postoperative results after decompression of the median nerve.In an interdisciplinary set-up we are currently treating 11 MPS type 1H children following blood stem cell transplantation. 7 patients were operated 12 times (5 bilateral operations) because of a carpal tunnel syndrome (age at the time of operation 83,3 months, (43-143 months), 2 male, 5 female). 6 patients had a follow up after 23,7 months (9-59 months). 6 patients had a histological analysis of the flexor retinaculum. Three patients had a postoperative neurophysiological investigation.Each of the operated patients had at least 1 preoperative clinical sign of a carpal tunnel syndrome. We found at least 1 pathological finding in motor and sensory nerve conduction studies in each patient. 6 of the 7 children operated on were symptom-free at postoperative follow-up. 1 of the 3 patients with a postoperative neurophysiological follow up showed a deterioration of the nerve conduction studies. This patient was free of symptoms postoperatively. Biopsy of the flexor retinaculum confirmed abundant proteoglycan deposition. We had neither postoperative complications nor were revisional operations necessary.The Diagnosis of a carpal tunnel syndrome in children with MPS Typ 1H needs a thorough medical history, the correct interpretation of the clinical symptoms and sophisticated nerve conduction studies. Wether the improvement of the postoperative clinical situation lasts has to be evaluated in a long term investigation especially because in one patient in our group we saw a deterioration of the nerve conduction studies postoperatively.
Abstract Purpose Various approaches are used to study microcirculation, however, no modality evaluates microcirculation and histomorphology on cellular levels. We hypothesized that reflectance-mode ...confocal microscopy (RCM) enables simultaneous evaluation in vivo of both microcirculation and histomorphology. Principals The forearm of 20 volunteers was exposed to either local heat stress (HS-group), or to local cold stress (CS-group). RCM was performed prior and after temperature stress to evaluate quantitative blood-cell flow, capillary loop diameter, granular cell size, and basal layer thickness. Results In the HS-group, we observed significant increase in capillary loop diameter and increased blood-cell flow after heat stress. In the CS-group, significant decreases of capillary loop diameter and in blood-cell flow were determined following cold stress. Granular cell size and basal layer thickness differed insignificantly prior and after local temperature stress. Conclusions RCM provides real-time and in vivo high resolution imaging of temperature-dependent changes in the human skin microcirculation and histomorphology on cellular levels.
The purpose of this study was to evaluate the diagnostic value of MRI for detecting intracarpal lesions in clinical routine.
In a retrospective study, we reviewed the charts of 506 patients who had ...undergone wrist arthroscopy in our department between May 1998 and November 2002. Out of 506 patients 217 had an MRI. The MRI was performed at 31 different radiology facilities using a number of techniques. The MRI results were compared with the arthroscopic findings, taking the arthroscopic results as a "gold standard" (sensitivity = SEN, specificity = SPE, positive predictive value = PPV, negative predictive value = NPV, accuracy = ACC).
The following results were found: For tears of the scapholunate ligament the avalues are SEN 18.5 %, SPE 95 %, PPV 71 %, NPV 66 %, ACC66 %. Not one of 16 tears of the lunotriquetral ligament was found by MRI.
In our data we found a low sensitivity for unspecific requested and implemented MRI for detecting intracarpal lesions. Therefore the indication for MRI should only be made after experienced hand surgeons have examined the wrist. In our opinion, only direct MR-arthrography is equal to arthroscopy, so that only an experienced radiologist who is familiar with this technique should perform the MRI diagnostics of the hand.
After excision of a pilonidal sinus, several treatment options are possible, but no gold standard has been established. A literature review revealed no study comparing the costs and time off work ...after either secondary wound closure or treatment with a Limberg transposition flap. The aim of this study was to focus on these aspects by analysing the patients treated at the KlinikumStadtSoest.
Sixty patients with pilonidal sinus after excision were treated either by secondary wound closure or Limberg transposition flap at the KlinikumStadtSoest between 2011 and 2012. The authors analysed retrospectively the patients' demographics, cost, and satisfaction with both techniques and compared them.
For secondary wound closure (group 1) 19 out of 31 patients and for Limberg transposition flap (group 2) 21 out of 29 met the inclusion criteria. Time off work following the final surgery (group 1: 69 day vs. group 2: 30 days, p = 0.046) and the number of dressing changes (group 1: 107 times vs. group 2: 16 times, p = 0.000) were significantly lower in the group of Limberg transposition flap (group 2) as well as the associated costs. The surgery-related costs were lower when treated by secondary wound closure.
Plastic reconstruction with Limberg transposition flap (group 2) provides a chance to reduce the period of incapacity for work due to a shorter treatment period. With that said, patients should nonetheless be offered both techniques as the current literature does not reveal a clear benefit for either procedure.
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