[Is transposition of the ulnar nerve in ulnar nerve sulcus syndrome really indicated?]

Anterior transposition of the ulnar nerve in cubital tunnel syndrome requires ligation of the segmental epineural vessels over 8 to 10 cm in order to free up and mobilize the nerve along its new course. As a result, the blood supply of ulnar nerves already compromised by entrapment is likely to be harmed even more. For the past three years we chose to perform simple decompression of the nerve with or without external/internal neurolysis on 33 patients (34 arms). After a follow-up time of six months to three years (mean 12 months), the outcome was evaluated by complete examination of hand function and by electrophysiologic studies. Four patients were excluded from the analysis due to short follow-up times. Four underwent decompression for mild entrapment symptoms, six for moderate symptoms, and 19 for severe symptoms. The functional outcome was rated as excellent in 26.7% (eight patients) and as good in 33.3% (ten patients). In group 3 (severe entrapment symptoms), seven patients (23.3%) showed moderate results and in four patients (13.3%) the outcome was poor. Considering that most of our patients had severe entrapment with advanced muscle atrophy, the overall outcome of decompression was satisfactory.

[Complications of endoscopic carpal tunnel operations]

This report is about four female patients admitted to our hospital because of pain, dysaesthesia and paraesthesia following endoscopic release of the carpal tunnel, who underwent revisional surgery. Intraoperatively, we found a partial lesion of the median nerve in two cases and an incomplete release of the ligament in the remaining two cases. The complete decompression and epineurotomy of the median nerve and a nerve graft in two patients resulted in clinical improvement.

[Long-term outcome of surgical therapy of acute necrotizing pancreatitis]

This paper discusses the long-term results after surgical treatment of necrotizing pancreatitis. Thirty-one patients were examined 3 years after the operation. The development of diabetes was the main problem in 29% of the patients and depended on the amount of pancreatic tissue resected (never after necrosectomy, in 47% after pancreatic resection; P = 0.005, Fischer's exact test). Of the patients, 77% were in good general condition and 68% were able to work. In 50% of the patients abdominal wall function was impaired but most of them could cope with this insufficiency. Of the patients with alcohol-induced pancreatitis, 75% were abstinent. Considering the severity of the disease, long-term results after surgical treatment of necrotizing pancreatitis are satisfactory.

Modifications of the paraspinous muscle flap: anatomy and clinical application

Soft-tissue defects of the back, particularly involving the paravertebral tissues, are generally covered with myocutaneous, muscle, or fasciocutaneous flaps. The case of a 64-year-old man with a paravertebral malignant fibrous histiocytoma is reported. To ensure adequately radical margins, the ipsilateral trapezius and latissimus dorsi muscles as well as the costal periosteum and the spinous processes were resected between T9 and T12. The resulting defect was covered with a pedicled latissimus dorsi flap and an island flap of the paravertebral muscles. Prompted by this case, we studied the blood supply of the paravertebral muscles in 10 cadavers. The vasculature was visualized after flushing with colored latex and microsurgical dissection. Another 4 specimens were subjected to angiography and tomography. In the majority of cases (8 of 10), three perforators emerging from the intercostal arteries were identified. These were found to communicate in a longitudinal and vertical direction. Before piercing the fascia, they ramified in three layers matching the layers of the paravertebral muscles. Since the intercostal arteries were shown to communicate through anastomoses of adequate caliber, the paravertebral muscles appear to be useful candidates for proximally or distally pedicled transposition or island flaps.

[Compartment syndrome. Frequently missed, with severe sequelae]

Experience and late results in patients with a compartment syndrome which was either missed or diagnosed too late are reported. In the case of 14 patients we were consulted after a delay of 24 h, in another three patients 48 h after the causative event. At that time the diseased extremity was severely swollen, blistered and extremely painful. Ten patients presented with loss of sensitivity; in eight the peripheral pulses were not palpable. CPK was elevated in nine patients (up to 30,000); in six patients CPK was not determined. Causative factors included vascular occlusion (n = 6), paravenous infusions or injections (n = 4), compression in heroin or alcohol abusers (n = 4) and infections secondary to i.m. injections, sepsis or snake bites (n = 4). One patient developed a compartment syndrome after the closure of a muscular hernia. The late results were sobering: eight limbs had to be amputated, another 13 showed muscle necrosis necessitating necrosectomy, and both transitory and persistent median, ulnar, radial and peroneal nerve damage was observed. Our experience shows that dermatofasciotomy should be done on a more generous scale, because it obviously prevents sequelae and because the late complications following inadequately treated compartment syndromes are grave.

Two-dimensional elastic properties of human skin in terms of an incremental model at the in vivo configuration

The two-dimensional biomechanical behaviour and the collagen content of human skin samples from different anatomical sites was examined. The axes of minimum and maximum shrinkage after excision were determined and correlated with the 'Langer' cleavage lines. Test equipment was developed to restore the original geometry and to measure the loads acting perpendicular to the circumference of the skin specimens. These loads were normalized with respect to the thickness and collagen content and considered as the in vivo tension generated by the surrounding skin area. Using the in vivo geometry of the specimen as reference a set of incremental strains was applied. After stress relaxation was completed the final values of stresses were recorded and related to the incremental strains. The two-dimensional stress-strain relationship was the basis for the evaluation of the incremental elastic moduli. Orthotropic mechanical behaviour was found mainly in regions of reduced in vivo tension. The relationship between the degree of anisotropy at the in vivo configuration and the morphological structure is discussed.

[Intra- and postoperative nerve lesions and their treatment]

Injuries to the central or peripheral nerves caused by medical intervention are called iatrogenic nerve lesions. The caudal relationship between medical intervention and iatrogenic nerve injuries is frequently not very clear. Careful pre- and post-operative examination of the patient, however, will in most instances reveal a nerve lesion in a timely manner. Iatrogenic nerve lesions in the clinical cases available to us were predominantly due to indirect influences, such as pressure, insertion of a retractor or heat; we discovered that only in a few cases a nerve was partially or completely severed or damaged by the material used for osteosynthesis. The pre- and postoperative clinical neurological and electrophysiological examinations of our patients were performed by a neurologist. Nerve-repair was achieved by neurolysis in 19 cases; a primary or secondary suture was performed in three cases. A nerve graft was used in five cases to regain continuity. Those patients (nearly 75%) who underwent restitutive surgery within an six-month period after iatrogenic injury in the primary operation were treated successfully. These results suggest that timely treatment is decisive for good outcome.

Are growth alterations a consequence of surgery for prominent ears?

This study was undertaken to detect growth alterations after surgery for prominent ears. The cartilage excision technique was used in all 77 patients seen for follow-up. Two hundred students served as controls. Auricular measurements were done according to standardized guidelines of anthropometry. There was no significant difference between the retroauricular angle in the surgical group and in controls. The morphologic ear length in the surgical group was significantly smaller than in controls. Maximum ear length was significantly greater in men. Our measurements in the control group were significant below the reference values reported in the literature. Comparing the ear index of both groups with published data, we found a harmony between the width and the length of the ear. We could demonstrate that prominent ears were significantly larger in all other dimensions and that auricular growth does not stop following surgery for prominent ears with the cartilage excision method. We also evaluated subjective criteria such as tolerance to cold, scar formation, and patient satisfaction.

Are growth alterations a consequence of surgery for prominent ears?

This study was undertaken to detect growth alterations after surgery for prominent ears. The cartilage excision technique was used in all 76 patients seen for follow-up. Two hundred students served as controls. Auricular measurements were done according to standardized guidelines of anthropometry. There was no significant difference in the retroauricular angle between the surgical group and controls. The morphologic ear length in the surgical group was significantly smaller than in controls. Maximum ear length was significantly greater in men. Our measurements in the control group were significant below the reference values reported in the literature. Comparing the ear index of both groups with published data, we found a harmony between the width and the length of the ear. We could demonstrate that prominent ears were significantly larger in all other dimensions and that auricular growth does not stop following surgery for prominent ears with the cartilage excision method. We also evaluated subjective criteria such as tolerance to cold, scar formation, and patient satisfaction.

[Functional and electromyographic long-term results following primary microsurgical repair of the recurrent laryngeal nerve]

Six patients with unilateral recurrent nerve paralysis underwent phoniatric follow-up after neurolysis or primary microsurgical repair of the recurrent laryngeal nerve. Four patients were controlled by electromyography of the vocal muscle 14 to 80 months post-operatively. In six patients the paralyzed vocal cords were in median to paramedian position with sustained muscle tonus. Phoniatric parameters were found to be close to the average range in healthy persons. EMG findings indicated degenerative neurogenous paralyses in two patients, signs of reinnervation in another. In one case biphasic action potentials could be recorded.

Experience with 60 inferior rectus abdominis flaps

We report on our experience with the inferior rectus abdominis flap. Since 1984, 60 patients have been operated on with this technique. The inferior rectus abdominis flap was used as a free flap, island flap or pedicle flap (inferiorly based). Pure muscle flaps served to fill bone defects in patients with chronic osteomyelitis or as a biologic cover of infected vascular prostheses following multiple vascular surgery in the groin. The myocutaneous and fasciocutaneous rectus flaps served to cover soft tissue defects of the upper and lower extremities after accidents, degloving and radical tumour surgery. We present data from our collective patients to document the benefits of the inferior rectus abdominis flap and recommend this technique as a safe surgical modality to manage large-surface soft tissue defects.

[Psychosocial effects of plastic surgery reconstruction of the female breast following amputation for malignant/benign tumor]

A total of 98 woman (malignant/benign tumors of the breast, mastectomy with/without subsequent reconstructive surgery as well as healthy controls) were examined in terms of subjective well-being, psychosomatic reaction patterns, subjective impairment due to mastectomy and satisfaction with the outcome of reconstructive surgery in this empiric retrospective study. In addition, numerous sociographic data were obtained. On the average, the examined women were satisfied with the outcome of reconstructive surgery and tended to be disappointed with regard to the desired psychosocial improvement. Objective tests demonstrate that subjective well-being was less favorable after reconstructive breast surgery than in women without reconstruction. In the group "benign tumor with subsequent reconstruction" the reaction to emotional strain was significantly more characterized by regressive behavior and withdrawal than in the group "benign tumor without reconstruction". In the group "malignant tumor with reconstruction" this difference was less pronounced. On the basis of these results we cannot confirm the assumption that reconstructive surgery of the breast has a supportive function.

[Isolated rupture of the vinculum longum superficiale (V1) following blunt trauma]

The anatomy and topography of the vincula are described. Their role in the blood supply to the flexor tendons is reviewed in the light of current reports. The authors present the case history of a 59-year old patient with blunt trauma to the middle finger of the right hand. This patient suffered from severe pain in the area of the proximal phalanx and the PIP joint of the third finger, as well as from reduced extension with a deficit of 20 degrees in the PIP joint. The differential diagnosis and clinical picture are discussed. The operative findings suggest a rare instance of detachment or rupture of the vinculum of the intact superficial flexor tendon.

[A rare combination of true and false aneurysm of the palm of the hand]

The authors report on a patient having a simultaneous true and false aneurysm along the superficial palmar arch. The clinical diagnosis was substantiated by ultrasound and angiography and the findings confirmed histologically. The classification of aneurysms according to their etiology and pathological anatomy is discussed. The clinical symptoms as well as alternative surgical procedures are illustrated with particular emphasis placed on the restoration of adequate peripheral blood circulation in the digits via microvascular anastomosis.

Sonoanatomy of the muscles of facial expression

Primary anatomic studies served for identification and differentiation of the individual mimetic muscles. As a second step, we investigated the clinical potential of ultrasound imaging to visualize the mimetic musculature in 15 volunteers. This examination technique was used to diagnose pathological alterations, especially associated with facial palsy. The excellent sonographic visualization of the mimetic musculature indicates that this technique may be a valuable adjunct in the diagnosis and differentiation of facial palsy, as well as in planning plastic surgery and reconstructive procedures, and in follow-up care.

[Clinical imaging of the mimetic muscles using high resolution ultrasound]

In comparison to other techniques, high resolution ultrasound has proved to be a good method for clinical imaging of muscles. By free selection of the scan plane and multidimensional viewing it is possible to represent each muscle from origin to insertion and to observe them during function. Pathology produces different types of echogenity. By imaging an EMG needle electrode the exact position within the muscle can be demonstrated. The result of the EMG study can therefore be related to small individual muscles or muscle segments, which are below the size suitable for clinical examination.

Photogrammetry of the muscles of facial expression

The present study has attempted to determine the volume, square measure as well as length, width and thickness of the individual muscles of facial expression by photogrammetry. 15 fresh male head specimens were employed for a careful dissection of muscle layers. The volume was measured using the immersion procedure. The mean values of each parameter together with the standard deviation were summarized. The results suggest that this novelty in the representation of the mimetic muscles will facilitate the planning of corrective interventions in plastic surgery. Moreover, photogrammetry offers additional information on the required size and measurements of donor muscles.

Sonography of the tongue and floor of mouth. Part I: Anatomy

Normal structures of the tongue and floor of the mouth were studied using anatomic sections cut with a stainless steel band saw. The sections were performed on the same planes as used in US and CT scanning. The ultrasound studies were carried out with 20 young and healthy volunteers. CT images were obtained from head-neck preparations that were subsequently used for anatomic sectioning. On comparing these sections to US and CT images, normal structures including intrinsic and extrinsic tongue muscles, vessels and salivary glands were identified. Knowledge of the anatomic landmarks is mandatory for optimal US image reading.

Sonoanatomy of the shoulder

With the aid of ultrasound we tried to visualize the muscles of the shoulder region, the collum scapulae, the axillary artery and vein and the brachial plexus. We were successful with exception of the vessels and the nerves. Knowledge of the anatomical landmarks is essential in ultrasound image reading.

[Real-time sonography in the diagnosis and follow-up of malignant tongue tumors. I. Anatomic basis]

Normal structures of the tongue and floor of the mouth were studied using anatomic sections cut with a stainless steel band saw. The sections were performed on the same planes as used in US and CT scanning. The ultrasound studies were carried out with 20 young and healthy volunteers. CT images were obtained from head/neck preparations that were subsequently used for anatomic sectioning. On comparing these sections to US and CT images, normal structures including intrinsic and extrinsic tongue muscles, vessels and salivary glands were identified. Knowledge of the anatomic landmarks is mandatory for optimal US image reading.