Amyloidoses are a heterogeneous group of diseases characterised by the fibrillar deposition of peptides and proteins in a β-sheet configuration. In Germany, AL and ATTR amyloidosis are among the most common systemic forms. ATTR amyloidosis is characterised by the involvement of ligamentous and tenosynovial tissue prior to cardiac involvement, which, in turn, can be be life-limiting. This highlights the growing clinical relevance of diagnosing ATTR amyloid in resection specimens from hand and plastic surgery procedures. Diseases considered relevant in this context include carpal tunnel syndrome, trigger finger, spontaneous biceps tendon rupture, and spinal canal stenosis. The prevalence of ATTR amyloid increases with age, reaching nearly 50% in the ninth decade of life. Tissue samples obtained during surgery should be fixed in formalin. Amyloid can be detected using Congo red staining and polarisation microscopy. The sensitivity of detection depends on both the amount of tissue obtained and the stage of the disease. It should be noted that all tissue and sample types carry a risk of sampling error. Once amyloid has been detected, it must be classified, as amyloidoses are now treatable and treatment depends on the specific type of amyloidosis.

Wrist arthroscopy is an established procedure for the diagnosis and treatment of wrist pathologies. It is routinely performed in the operating room under wrist distraction. An arthroscope with the smallest possible diameter could enable diagnostic "in-office" arthroscopy in outpatient clinics without a need for distraction on a horizontally positioned hand. Our goal was to develop such an arthroscope in collaboration with Polydiagnost GmbH (P) and to test and compare it with existing arthroscopy systems from Karl Storz SE & Co. KG (KS) and Arthrex GmbH (A).The prototype of a newly developed miniature arthroscope with an overall diameter of 1.3 mm was tested on twelve fresh-frozen wrist specimens by an experienced hand surgeon in a randomised manner. It was compared with the A "Nanoneedle Scope", which has a 2.4 mm arthroscope shaft, and a KS arthroscopy system with a 2.5 mm shaft. Standardised diagnostic tours were performed and recorded. The systems were evaluated and compared based on the following parameters: preparation of working portals, duration of arthroscopy, handling and manoeuvrability, diagnostic assessment of structures, and suitability for diagnostic and therapeutic arthroscopy.The results showed that the newly developed prototype was rated significantly higher than the KS system in terms of handling, ergonomics, operability, and navigability. No significant differences were observed in the duration of portal preparation or diagnostic view. The image quality of the prototype, and thus its suitability for diagnostic and therapeutic arthroscopy, was still found to be inferior compared to the arthroscopy systems from KS and A.The feasibility of distraction-free arthroscopy using a miniaturised arthroscope with satisfactory imaging results was successfully demonstrated. The newly developed prototype showed superior handling compared with established systems but was still inferior in image quality. With improvements in image quality, the prototype could eventually be adopted for clinical use. A reduction in procedure time through portal preparation could not be conclusively demonstrated. The use of smaller arthroscopy systems could potentially shorten the duration of arthroscopy and minimise side-effects.

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?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.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.

Orthoplastic surgery is pivotal in managing occupational accidents under German statutory accident insurance. This review examines current standards in acute care, septic complications, and rehabilitation.Guidelines from the German Social Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV), certification requirements for trauma centres, and retrospective case series from accredited hospitals (2015-2024) were analysed.Modern treatment pathways incorporate plastic-reconstructive techniques in 78% of severely injured patients (SAV). Septic complications after polytrauma occur in 9-12% of cases, with single-stage revision surgeries achieving success in 82% of prosthetic infections. Interdisciplinary rehabilitation reduces average sick leave duration by 23%.Networking between acute care facilities, septic surgery units, and rehabilitation centres improves outcomes. Standardised quality metrics and telemedicine follow-up concepts require further research.

Amyloidosis is a rare, typically systemic disease that may cause progressive heart failure when cardiac involvement occurs. The two most common subtypes leading to cardiomyopathy - AL and ATTR amyloidosis - differ substantially in terms of diagnosis, treatment, and prognosis. Retrospective studies have shown that musculoskeletal manifestations such as carpal tunnel syndrome, stenosing tenosynovitis, Dupuytren's contracture, or tendon ruptures often occur years before the diagnosis of cardiac amyloidosis and may serve as early clinical markers. A risk-adapted, targeted histopathological work-up, combined with structured interdisciplinary follow-up care, can significantly contribute to the early detection of previously unrecognized systemic amyloidosis. This review highlights the growing importance of musculoskeletal manifestations in the hand surgery setting as potential early indicators of systemic amyloidosis and proposes a structured clinical pathway for interdisciplinary collaboration with cardiology and haematology.

Language-based artificial intelligence (AI) models offer novel opportunities for optimising clinical workflows. One promising application lies in the automation of postoperative documentation in hand and plastic surgery - specifically, procedural coding and the formulation of postoperative care plans. This study aimed to evaluate the performance of AI models in generating postoperative documentation for hand surgery and plastic surgery procedures.Four standardised operative reports representing common plastic surgical interventions were submitted to ChatGPT o3. The model was prompted to generate procedural codes and to propose appropriate postoperative care recommendations. Coding output was evaluated for accuracy and completeness, while postoperative plans were assessed by three board-certified plastic surgeons using predefined criteria - correctness, completeness, and overall quality - on a 10-point Likert scale (1=very poor, 10=excellent). The time to task completion was recorded in seconds.The AI model achieved a mean coding accuracy of 92.86±14.29% and a completeness score of 90.28±11.45%. Postoperative care recommendations received mean ratings of 7.33±2.10 for completeness, 8.66±0.98 for correctness, and 7.83±1.53 for overall quality. The mean time required for procedural coding was 143.75±46.61 seconds, while postoperative planning required 24.25±11.35.AI models demonstrate promising results in automating postoperative documentation within the field of hand and plastic surgery. Their high coding accuracy, clinically relevant recommendations, and rapid processing make them particularly effective for standardised procedures. Nevertheless, expert review remains essential.

Infection after Achilles tendon (AT) repair can lead to defects in both the tendon and the surrounding soft tissue. In such cases, a two-stage surgical approach is generally adopted, with soft tissue reconstruction performed initially, followed by secondary tendon reconstruction. A reverse sural artery flap (RSAF) after AT repair is not commonly performed due to potential damage to the flap pedicle. This study aims to evaluate the clinical outcomes of simultaneous flexor hallucis longus tendon (FHLT) transfer and RSAF to treat soft tissue and tendon defects resulting from infection after AT repair.We reviewed 20 patients who had undergone one-stage reconstruction of AT and soft tissue defects resulting from infection after AT repair using FHLT transfer and RSAF between October 2012 and October 2022, with a minimum of a 1-year postsurgical follow-up. Surgical outcomes were assessed based on the success of the flap, recurrence of infection, and tendon re-rupture. Clinical evaluation included visual analog scale (VAS) score, ankle range of motion, and patient-reported components of the American Orthopaedic Foot and Ankle Society (AOFAS) score (maximum of 68 points).All flaps were successful. The mean size of the flap was 7.2×4.1 cm. There was no recurrence of infection or tendon re-rupture. The mean VAS and AOFAS scores were 0.5 and 64.6, respectively. The mean ankle joint range of motion was 13.5° for dorsiflexion and 35° for plantar flexion.One-stage reconstruction with FHLT transfer and RSAF is a safe and effective surgical method in patients with tendon and soft tissue defects after AT repair.

Open fractures of the lower extremities are an interdisciplinary challenge that demands not only expertise in trauma and plastic-reconstructive surgery, but also specialised knowledge in vascular surgery, infectious diseases, radiology, and microbiology. However, despite the high morbidity and substantial healthcare costs, there are currently no established interdisciplinary guidelines for managing these injuries in Germany.This review discusses important aspects of orthoplastic treatment strategies and explores the role of telemedical extremity boards in optimising these treatment processes, as demonstrated by the EXPERT innovation fund project at Münster University Hospital. Furthermore, the quality of existing international guidelines is assessed using the British Orthopaedic Association Standard for Trauma (BOAST) (4 guidelines) as an example.With ongoing hospital reforms and the shift toward centralised specialized services, cross-sector digital care models are gaining importance. Establishing interdisciplinary standards, guidelines, and structured communication through telemedicine is key to maintaining the highest quality of care for open fractures and in mitigating the loss of expertise in peripheral regions.

The management of open fractures with extensive soft tissue defects presents a significant challenge to healthcare systems. A key factor for a successful and efficient treatment is the early implementation of an interdisciplinary approach involving both trauma and plastic surgery - commonly referred to as the "orthoplastic approach". This systematic review aims to compare treatment outcomes between patients who were either directly transferred (primary transfer) from the scene of injury to a level 1 trauma centre and those who initially received care at a lower-level hospital and were subsequently transferred (secondary transfer) to a level 1 trauma centre.This systematic review was conducted in accordance with the PRISMA guidelines. A comprehensive literature search was performed in the MEDLINE database. Fourteen studies were included in the final analysis. Patients were categorized into a primary transfer group (PRI) or a secondary transfer group (SEK) for the analysis. Outcomes assessed included transfer time, length of hospital stay, time to initial surgical intervention, timing of definitive bony fixation and soft tissue reconstruction, total number of surgical procedures, reconstruction techniques and their associated complications, as well as rates of non-union and infection.A total of 14 studies comprising 5294 patients were included. Of the reported fractures, 88.6% were classified as Gustilo-Anderson type IIIB or higher. The median length of hospital stay was shorter in the primary transfer group (26.6 days) compared to the secondary transfer group (35.2 days). In the secondary group, delays were observed in time to initial surgical intervention, definitive bony fixation, and final soft tissue reconstruction. The median number of surgical procedures and osteomyelitis was lower in the primary transfer group.Delayed secondary transfer to a level 1 trauma centre may be associated with relevant disadvantages for patients. In addition to timing, early formulation of a reconstructive treatment plan by an interdisciplinary and specialized team is a decisive factor. This may reduce the total number of required interventions and improve functional outcomes. The goal should be the primary implementation of the orthoplastic treatment approach, for which specialized trauma centres offer the best conditions.

The development of secondary lymphoedema is a relevant and frequently observed complication following surgical procedures or trauma. However, one of the main problems is that it is usually not diagnosed or diagnosed very late, resulting in inadequate treatment in many cases. In addition, precise epidemiological data on the incidence of secondary lymphoedema remains scarce. However, delayed or inadequate treatment of secondary lymphoedema usually leads to symptom progression and promotes a chronic course. This underlines the importance of early and accurate diagnosis to guide therapeutic measures and prevent long-term complications. This article provides an overview of the pathophysiology of the lymphatic system, describes the mechanisms underlying the development of post-traumatic lymphoedema, and highlights the role of infections. In addition, it presents the most relevant classification systems, including clinical and imaging-based systems such as Yamamoto's. Current conservative and surgical treatment options are also explained. Interdisciplinary management with modern microsurgical techniques can significantly improve patient prognosis.

As part of a consensus workshop, the following key questions regarding the future of robotic microsurgery were discussed: • What functional and ergonomic requirements should future robotic microsurgery systems meet with respect to their hardware components? • What capabilities are expected of the software in terms of usability and integration into existing hospital systems? • What overarching characteristics must a robotic microsurgical system offer to gain widespread acceptance in clinical practice?Based on a review of the current literature, the above questions were discussed during an expert consensus workshop held by the German Speaking Society for Reconstructive Microsurgery (GSRM) in 2024 in Aachen. The aim was to derive structured, user-centred recommendations for future robotic microsurgical systems. Answers of the Consensus Group: The participants defined the following core requirements for future systems: • Enhanced hardware functionality, ergonomics, and modular design-including wireless, space-saving configurations. • User-friendly software with intuitive operation, smooth scaling, integrated safety functions, and compatibility with clinical IT systems. • Expansion of application areas, sustainability of materials, and integration of emerging technologies such as augmented reality and artificial intelligence.

Symptomatic neuromas of the upper and lower extremities present significant challenges for affected individuals in both daily life and professional environments following peripheral nerve injuries. Traditional approaches, such as neuroma excision or conservative therapy methods, have so far predominated. In recent years, however, peripheral nerve surgery has expanded the therapeutic spectrum for neuroma treatment through approaches such as nerve reconstruction with allo-/autografts, end-to-side neurorrhaphy, targeted muscle reinnervation (TMR) surgery, and regenerative peripheral nerve interface (RPNI) procedures (1).

Evaluating an early functional rehabilitation approach for flexor tendon repairs in the context of current concepts ABSTRACT Background: In recent years, an increase in scientific research on the post-treatment of flexor tendon repairs has been observed. To evaluate the effectiveness and safety of the "Early-Active-Motion" concept that has been used in our clinic for over 10 years, a prospective study was developed that detailed both functional outcomes and complication rates over a period of 3 months.90 flexor tendon repairs in Zones 1-3, with and without accompanying injuries, were examined after three, six, nine and 12 weeks. Compliance was not a reason for exclusion. The collected parameters included the DASH, finger mobility according to the Strickland-Score, and other assessments.Out of a total of 90 flexor tendons, follow-up was achieved on 67 over a period of three months. Overall, 43 of the tendons achieved an excellent or good outcome. 20 had a fair outcome, and 4 of the digits had a poor Strickland Score. A total of three ruptures were documented.The "Early-Active-Motion" concept achieves a functionally good outcome with a Strickland-Score of 76 points. It is applicable from Zone 1 to Zone 3, even in complex flexor tendon injuries. Early phase deterioration appears to be an indicator of lower final outcomes.

Focused high-energy extracorporeal shock-wave therapy (ESWT) promotes bone healing through neo-angiogenesis, pooling of stem cells, and activation of osteocytes. This study investigated whether additional intraoperative ESWT improves or accelerates the healing rate of scaphoid reconstruction with non-vascularised bone grafts in cases of pseudarthrosis.This randomised, controlled study included 93 patients who underwent scaphoid reconstruction with a non-vascularised bone graft (radius cancellous bone, iliac crest cancellous bone, or iliac crest corticocancellous graft). The patients were divided into two groups: an intervention group that received intraoperative ESWT in addition to the reconstruction, and a control group that received sole reconstruction. Healing rates as well as the percentage of osseous bridging between the scaphoid and the bone graft were evaluated and compared clinically and radiologically at 12, 18, and 24 weeks postoperatively.After 24 weeks, 80% of the scaphoids (37 of 46) in the intervention group had healed, compared with 66% (31 of 47) in the control group. Healing rates in the proximal third of the scaphoid were 77% in the intervention group and 76% in the control group. In the middle third, healing rates were 82% and 57%, respectively. All pseudarthroses of the distal third healed. After 12 weeks, the percentage of osseous bridging of the scaphoid distal to the graft was significantly higher in the intervention group (87% versus 80%), but not proximal to the graft.A single intraoperative ESWT improves the healing rate of scaphoid reconstruction with a non-vascularised bone graft and accelerates bone healing during the first 12 postoperative weeks.

Limb-threatening extremity defects resulting from high-energy trauma, chronic ischemia, infection, or oncologic resection are frequently associated with a "zone of injury" devoid of suitable recipient vessels, thereby precluding conventional free tissue transfer reconstruction. In this review article, we summarize five decades of technical development and clinical evidence on advanced microsurgical strategies - such as arteriovenous (AV) loops, vascular bypasses, and nutrient flaps - aimed at restoring vascular continuity and enabling durable soft tissue coverage when local anastomosis is precluded. Regardless of the technique employed, meticulous microsurgical execution, thoughtful staging, and interdisciplinary collaboration among plastic, orthopedic, and vascular surgeons are critical to achieving optimal outcomes. Collectively, these strategies provide a versatile, evidence-based armamentarium that enables reconstructive surgeons to preserve limb length, secure durable soft tissue coverage, and restore meaningful function to extremities once considered unsalvageable.

Scaphoid nonunion develops in approximately 15% of patients following scaphoid fractures. To prevent carpal collapse, targeted diagnosis and early initiation of treatment are crucial.This paper describes the algorithm for scaphoid nonunion treatment established at the Department of Plastic and Hand Surgery at the Medical Center - University of Freiburg. We carried out a monocentric, retrospective analysis of scaphoid reconstructions for scaphoid nonunion performed at our clinic between January 2012 and December 2022. We selected among four treatment options based on the vascularity of the proximal pole and the size of the substance defect, and / or the presence of a humpback deformity. In cases of a vital proximal scaphoid pole, reconstruction was performed using avascular autologous bone grafts: radius cancellous bone if there was no substance defect, or iliac crest bone if there was a relevant substance defect or a humpback deformity. In cases of an avital proximal pole without a relevant substance defect or humpback deformity, reconstruction was performed using a pedicled bone graft from the radius. In the presence of a substance defect or humpback deformity, a medial femoral condyle free flap was used. We analysed the union rate and epidemiological data of the patient cohort.A total of 123 scaphoid reconstructions were included. The median follow-up was 422 days. According to the established algorithm, 13 reconstructions were performed with cancellous bone grafts from the radius, 82 with iliac crest bone grafts, 13 with pedicled bone grafting from the radius, and 15 with medial femoral condyle free flaps. Union rates were 84.6% for reconstructions using cancellous bone grafts from the radius, 79.3% for iliac crest bone grafts, 69.2% for pedicled bone grafts from the radius, and 86.7% for medial femoral condyle free flaps. We identified nicotine abuse as an independent risk factor for scaphoid nonunion in patients undergoing reconstruction with iliac crest bone grafts.In line with current literature, we confirmed the importance of nicotine abstinence in scaphoid reconstructions. Since the treatment algorithm in our analysis was predetermined due to the retrospective design, no conclusions can be drawn regarding the superiority of any method. Prospective, randomised trials are needed to demonstrate the superiority of a treatment method.

There are different options for further treatment following flexor tendon injuries of the hand. These can be divided into passive and active dynamic treatment regimens. The selection of the optimal further treatment depends primarily on the biomechanically acting forces during postoperative finger exercises. Quantitative biomechanical studies are therefore required. The present experiment examined which forces act on the superficial and deep finger flexor tendons in different wrist positions. A measuring device was developed with the help of which both the total forces of the fingers and the isolated forces of the superficial (FDS) and deep (FDP) finger flexor tendons could be quantified in vivo. The measurements were evaluated on the index, middle, ring and little fingers (D2 - D5) of both hands of 50 test subjects, including 31 women (62%) and 19 men (38%). The influencing factors handedness, gender, fingers and wrist position were checked for interdependence using mixed ANOVA (p<0.05) and further differentiated using t-tests and one-factor ANOVAs (p<0.05). There was a statistically significant reduction in finger strength by flexing the wrist. On average, the highest forces were recorded at D3 and the lowest at D5. There was no significant difference between D2 and D4. On average, higher forces were achieved at D2, D3 and D4 by the FDS than by the FDP. At D5 there was a reversed force relationship with a higher force development of the FDP. The sum of the isolated forces of the FDS and FDP at D2 to D4 was around 80%, at D5 it was only 60%. The remaining force development can be explained by the influence of the metacarpal muscles and, in the case of D5, also by the flexor digiti minimi muscle. The results enable a differentiated assessment of the biomechanical forces acting during active finger flexion.

This case report describes the clinical course of necrotising fasciitis as a serious complication following outpatient liposuction. The patient required extensive surgical procedures, including radical debridement, negative pressure wound therapy (NPWT) and multiple flaps to cover the extensive tissue defects, alongside prolonged intensive medical care. This case underscores the risks associated with aesthetic procedures and emphasises the importance of having such procedures performed exclusively by qualified and experienced specialists. This case also impressively demonstrates the importance of early diagnosis and interdisciplinary management.