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Necrotizing soft tissue infections are caused by a variety of pathogens and may affect different types of soft tissue. Even today mortality and lethality are very high. The primary symptoms of necrotizing soft tissue infections are local pain out of proportion, swelling, erythema and crepitation in cases of subcutaneous gas. A systemic inflammatory response syndrome (SIRS) is often associated. During the last decades early recognition and initiation of an adequate therapy were able to reduce lethality to an average of 20%. The physical examination remains the diagnostic gold standard and may be supported by typical findings of imaging technologies, e.g. subcutaneous gas on x-rays and laboratory tests. After diagnosis an adequate antibiotic and surgical therapy should be performed immediately.

Purpose: Total hip arthroplasty (THA) is an effective procedure for developmental dysplasia of the hip (DDH); however, it is sometimes difficult to complete for severe cases because of femoral head dislocation, dysplasia of the acetabulum and the femur, disparity in limb length, soft tissue contraction, and muscular atrophy. We aimed at exploring the efficiency of the techniques of release and balance of soft tissues and reconstruction of true socket THA for patients with severe DDH., Methods: From January 2000 to January 2009, 46 adult patients with severe DDH (50 hips) were included in this study. According to the classification system, there were 26 type III and 24 type IV. Among them there were 32 women and 14 men, aged from 38 to 77 years. THA was performed via a lateral approach. All acetabular sockets were reconstructed at the original anatomical location following a meticulous technique of soft tissue release and balance around the hip to restore limb length, to strengthen the abductor and improve its function., Results: All patients had restoration of limb length (range, 2.5-5.5 cm; 30 limbs of more than 4 cm) without injury to the sciatic nerve. One postoperative dislocation occurred due to slight enlargement of the angle of abduction of the acetabulum. The follow-up ranged from 2.2 to 11.5 years (median 6.4 years) in 46 patients, and the Harris score increased from 40.2 preoperatively to 86.5 (P = 0.027). All hips were pain free with good function at the latest follow-up., Conclusion: The meticulous techniques of soft tissue release and balance can be recommended to ensure anatomical reconstruction of the true acetabular socket and to improve abductor function during arthroplasty for DDH.

We performed qualitative and histoquantitative investigations of tissue restoration after implanting polyglycolide (PGA), polydioxanone (PDS), polylevolactide (PLLA), and stainless steel pins in the intramedullary canal of rabbit femurs. The effect of bioabsorbable devices on healing of a cortical bone defect was also assessed. The cortical bone defect was created in the right femur of 80 rabbits. Bioabsorbable and metallic pins in 60 and two metallic pins alone were implanted in 20 intramedullary canals; 80 left femurs served as intact controls. Follow-up times were 3, 6, 12, 24, and 52 weeks. At all time points, collagenous connective tissue, including bone trabeculae, surrounded the implant at the tissue-implant interface, replacing hematopoiesis and fat of the intramedullary canal. The groups did not differ in the area and trabecular bone area fraction of the resulting callus. Residual fragments of PGA and PDS were observed at 24 weeks, and complete degradation occurred within 52 weeks. PGA, PDS, PLLA, and metallic implants induced a bony and fibrous walling-off response in the intramedullary cavity. No inflammation was observed. Complete tissue restoration did not occur within the follow-up, even after complete degradation of PGA and PDS, which had shorter degradation times than PLLA. The cortical bone healing effect was not different between bioabsorbable pins and metallic wires. Thus, these polymers had no specific osteostimulatory or osteoinhibitory properties compared to stainless steel. Within the follow-up period, there were no significant differences in biocompatibility between the implants and no adverse inflammatory foreign-body reactions.

Background: Soft tissue navigation has traditionally been neglected in computer-aided surgery (CAS) because of unpredictable margins of error. In our study, we examined clinical cases in which standard CAS was applied in soft tissue surgery in the head and neck region. Its extended applicability, margins of error, and general performance are described and discussed., Materials and Methods: CAS was applied in surgical procedures for six patients. Five patients had foreign bodies in the head and neck region, and one patient displayed uncertain cervical lymph node enlargement. An optoelectrical navigation system (VectorVision(2), BrainLAB) was used in all cases., Results: Using CAS, 10 out of 11 total foreign bodies were identified. Only one glass splinter attached to the eyeball could not be detected by the navigation system. One glass splinter that was deeply buried within the sphenoid bone was easily found but was left untouched. The parapharyngeal lymph node was identified and extracted in a minimally invasive transpalatinal approach., Conclusions: Soft tissue navigation was successfully applied in all but one case; the success was due to the altered demands in soft tissue navigation as opposed to skull-base surgery. Easy identification of foreign bodies and lymph nodes was possible in the soft tissues of the head and neck, with an acceptable margin of error.

Background: In soft tissue surgery of the head and neck region tissue shifts limit the usefulness of conventional CT/MRI-based navigation procedures. Furthermore, changes caused by invasive measures cannot be visualized., Methods: A novel navigation device for sonography of soft tissues was developed. This consists of a navigated ultrasound scanner, a navigated surgical instrument, and a personal computer with custom-made software. Its use makes an additional visualization by means of CT or MRI dispensable., Results: The system deviation (three-dimensional error) of this newly developed prototype was less than 1 mm. The practical application in a model setup showed good handling properties of the system. Orientation and approach of the surgical instrument to the sonographically visualized target structure were rapid and accurate., Conclusion: This new navigation system does not require additional CT or MRI images. The navigated ultrasound probe shows tissue changes in real time. This navigation system is especially suitable for invasive procedures in soft tissues.

Although acute vascular injury is a common complication in children with severely displaced supracondylar humeral fractures, the management of patients with a pink pulseless hand still remains controversial. Between 1994 and 2006, 66 children with displaced supracondylar fractures of the humerus were treated. Five patients had an absence of the radial pulse with an otherwise well perfused hand. In one patient, radial pulse returned after closed reduction of the fracture. In four patients, open reduction and vascular exploration was required. Three patients had brachial artery occlusion because of thrombus formation. Thrombectomy was performed, which led to the restoration of a palpable radial pulse. In one patient with open fracture, brachial artery contusion and spasm were found, and treated by removal of adventitia. Surgical exploration for the restoration of brachial artery patency should be performed, even in the presence of viable pink hand after an attempt at closed reduction.

Soft-tissue management is a critical factor in total knee arthroplasty, especially in valgus knees. The stepwise release has been based upon surgeon's experience. Computer-assisted surgery has gained increasing scientific interest in recent times and allows the intraoperative measurement of leg axis and gap size in extension and flexion. We therefore aimed to analyse the effect of sequential lateral soft-tissue release and the resulting change in the a.p. limb axis on the one hand and the tibiofemoral gaps on the other hand in extension as well as in flexion in eight cadaveric knees. Measurements were obtained using a CT-free navigation system. In extension the highest increase compared to the previous release step was found for the first (iliotibial band, P = 0.002), second (popliteus muscle, P = 0.0003), third (LCL, 0.007) and the sixth (entire PCL, P = 0.001) release step. In 90 degrees flexion all differences of the lateral release steps were statistically significant (P < 0.004). Massive progression of the lateral gap in flexion was found after the second (popliteus muscle, P = 0.004) and third (LCL, 0.007) release step. Computer-assisted surgery allows measurement of the effect of each release step of the sequential lateral release sequence and helps the surgeon to better assess the result.

The fascial anatomy of the inguinal canal has been investigated. The spermatic cord is fixed by two cords in addition to its embedding in connective tissue after leaving the inguinal canal. The spermatic cord has a special fastening in form of a noose at the deep inguinal ring. The transversalis fascia consists of an internal and an external leaf. A part of the internal leaf forms with three cords this noose and builds so a sphincter-like closure mechanism, which reduces the size of the deep inguinal ring by a local erection of the transversalis fascia. The internal leaf protects from an indirect inguinal hernia as well as from a direct inguinal hernia, because the wall of the so-called Hesselbach's triangle only consists of the internal leaf. A list of the anatomical synonyms is added.

After animal experiments suggested there was an interaction between growth hormone and bone healing, our aim in this paper was to ascertain whether there were any changes or possible interaction between the serum level of growth hormone, somatomedin C and alkaline phosphatase while a fractured bone was healing. To this end, the serum concentrations of growth hormone, somatomedin C, alkaline phosphatase and calcium were ascertained both pre- and post-operatively in two groups of patients--one with bone operations, the other with soft-tissue operations--and the results were compared. Comparing the groups, we found that after bone operations there was no increase in the serum level of growth hormone, nor of somatomedin C. An increase would have implied that these two hormones are directly involved in bone regeneration. There was no change in the serum level of alkaline phosphatase or calcium after either bone or soft-tissue operations.

Lesions produced by splinters of wood in the soft tissues and bones of the limbs are not uncommon and may be difficult to diagnose. A detailed history and a high index of suspicion are the key to making the correct diagnosis. Investigations are usually inconclusive. Complete excision results in prompt resolution.

In 1970-1974, tympamoplastics of type I-III were done in 95 patients with adhesive processes of the middle ear (epithelized tympanon, scarred adhesions of the chain, sclerosis of the tympanon etc.) following chronic inflammation or cholesteatoma. In order to avoid renewal of adhesions, to make possible the growth of mucosa and to obtain pneumatisation of the middle ear, 1 to 3 pieces of silicone foil were inserted to each patient into the middle ear. In 21 patients the silicone foil was removed. Technique of insertion and problems of removal of the foil as well as audiollogical postoperative results are demonstrated and discussed.