Patients with Prior Craniectomy or Craniotomy Have No Increased Risk of Acute Hemorrhage after Mild Traumatic Brain Injury.

The aim of this study was to retrospectively evaluate the risk of acute hemorrhagic complications in patients after either a decompressive craniectomy or a craniotomy sustaining a recurrent mild traumatic brain injury. Furthermore, we analyze whether there is a higher risk for acute hemorrhagic complications considering patients with anticoagulation compared with patients without anticoagulation in both groups. All patients with mild traumatic brain injuries after either decompressive craniectomy or craniotomy, treated between January 2005 and December 2020 at a single level 1 trauma center, were included in this retrospective analysis. Patients were screened for intracranial bleeding after mild traumatic brain injury with computed tomography. Additionally, the type of anticoagulation and its relationship concerning the clinical outcome were assessed. A total of 188 patients who had sustained a mild traumatic brain injury were included in the study. Overall, 22 patients (11.7%) presented intracranial lesions. A bony defect (decompressive craniectomy) was present in 31 patients (16.5%). In 157 patients (83.5%) who underwent decompressive craniectomy, the bony defect was closed during a second operation. There was no significant correlation between both groups on the occurrence of intracranial bleeding (p = 0.216). Furthermore, no difference was present between patients with and without anticoagulation (p = 0.794) concerning acute hemorrhagic complications after recurrent traumatic brain injury. Pre-existing bony defects after decompressive craniectomy showed no higher risk for acute hemorrhagic complications after recurrent mild traumatic brain injury compared with patients who primarily underwent craniotomy. Anticoagulation did not influence the occurrence of intracranial bleeding after mild traumatic brain injury in patients with decompressive craniectomy.

ESTES recommendations on proximal humerus fractures in the elderly.

PURPOSE: The section for the skeletal trauma and sport's injuries of the European Society for Trauma and Emergency Surgery (ESTES) appointed a task force group to reach a consensus among European countries on proximal humeral fractures. MATERIAL/METHODS: The task force group organized several consensus meetings until a paper with final recommendations was confirmed during the ESTES Executive Board meeting in Berlin on 25 October 2018. CONCLUSION: The Recommendations compare conservative and four possible operative treatment options (ORIF, nailing, hemi- and total reverse arthroplasty) and enable the smallest common denominator for the surgical treatment among ESTES members.

Predictive factors influencing the outcome after gunshot injuries to the head-a retrospective cohort study.

BACKGROUND: Civilian gunshot injuries to the head are relatively rare in the irenical European Union, and studies of treatment and outcomes are seldom for this region in the current literature. METHODS: A cohort of 85 patients with civilian head gunshot injuries, who were admitted to our University hospital over a period of 16 years, was reviewed retrospectively. Clinical manifestation, computed tomography scan findings, and surgical treatment were described, with special regard to prognostic factors and outcome. RESULTS: The mean age was 48 years (range, 17.8-98.4 years), and 87% were men. Sixty patients sustained penetrating craniocerebral injuries (P-group) and 25, nonpenetrating gunshot wounds (NP-group). The overall mortality was 87% in the P-group and 4% in the NP-group. The Glasgow Coma Scale (GCS) score at admission was recorded to be 3 to 5 in 58 patients (96%) and 7 patients (28%) in the P-group and NP-group, respectively. Only 8 patients (13%) survived in the P-group compared with 24 patients (96%) in the NP-group. Excluding wound debridement, there were 16 surgical procedures in the P-group and 8 in the NP-group, with a mortality rate of 63% and 13%, respectively. CONCLUSIONS: Glasgow Coma Score at admission and the status of pupils and hemodynamic situation seem to be the most significant predictors of outcome in penetrating craniocerebral gunshot wounds. Computed tomography scans, bi- or multilobar injury, and intraventricular hemorrhage were correlated with poor outcome. Patients with a GCS score >8, normal pupil reaction, and single lobe of brain injury may benefit from early aggressive management.

Biomechanical analysis of fracture healing in guinea-pigs.

To validate the hypothesis that healing of fractures can be accelerated by oral administered L-arginine a guinea-pig model was chosen. A diaphyseal defect fracture was established in the right femur of each of the 32 small animals and stabilized. According to randomization groups the oral administration was realized (2 or 4 weeks medication / solvent). The following biomechanical variables were measured after 4 weeeks in 32 right femora and the corresponding uninjured left femora. The measurement for the healed femur was individually compared with that of the uninjured femur in each animal; bending, force (necessary for refracture) and energy (necessary for refracture). To apply the bending moment in a measurable and reproducible way each end of the femur was secured using a special device. For each femur a strain/momentum graph of the measurements and the essential parameters were drawn (stiffness, end of the linear range, and failure-point). The bending moment was always applied with the same loading rate. The following three variables were used for the biomechanical evaluation; bending stiffness, force until failure and energy necessary for refracture. The bending stiffness reached 73% by the control group and 88% by the 4-week treatment group. The force necessary for refracture was 52% in the control compared with 65% in the 4-week treatment group. The energy necessary for refracture was 36% in the control compared with 73% in the group treated for 4 weeks. The 2 week treatment group showed no statistical significant differences to the control, but the femora from the 4 week treatment group required statistically significant higher energy for refracture than the femora from the control.

Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade.

BACKGROUND AND OBJECTIVES: The use of ultrasonography in regional anesthetic blocks has rapidly evolved over the past few years. It has been speculated that ultrasound guidance might increase success rates and reduce complications. The aim of our study is to compare the success rate and quality of interscalene brachial plexus blocks performed either with direct ultrasound visualization or with the aid of nerve stimulation to guide needle placement. METHODS: A total of 160 patients (American Society of Anesthesiologists physical status classification I-III) scheduled for trauma-related upper arm surgery were included in this randomized study and grouped according to the guidance method used to deliver 20 mL of ropivacaine 0.75% for interscalene brachial plexus blockade. In the ultrasound group (n = 80), the brachial plexus was visualized with a linear 5 to 10 MHz probe and the spread of the local anesthetic was assessed. In the nerve stimulation group (n = 80), the roots of the brachial plexus were located using a nerve stimulator (0.5 mA, 2 Hz, and 0.1 millisecond bandwidth). The postblock neurologic assessment was performed by a blinded investigator. RESULTS: Sensory and motor blockade parameters were recorded at different points of time. Surgical anesthesia was achieved in 99% of patients in the ultrasound vs 91% of patients in the nerve stimulation group (P < .01). Sensory, motor, and extent of blockade was significantly better in the ultrasound group when compared with the nerve stimulation group. CONCLUSIONS: The use of ultrasound to guide needle placement and monitor the spread of local anesthetic improves the success rate of interscalene brachial plexus block.

Unplanned 10-year retention of an external fixator for a proximal tibial fracture.

A 45-year-old homeless male patient did not return for follow-up for routine removal 72 days after an external fixator had been placed for a grade II open fracture of the proximal tibia. Ten years later, he was accidentally referred to our institution for newly incurred fractures of the femoral neck on the same side and also for an opposite-side medial malleolus fracture. The patient was still homeless, with signs of poor personal hygiene, but the original external fixator was in place. Union of his previous proximal tibia fracture had occurred, and there were no signs of any pin-tract infection. Possibilities for this successful outcome include fracture stability, subsequent healing without pin breakage, and 7 weeks of professional wound care before the patient's initial discharge from the hospital, resulting in a scarred skin barrier at the pin-skin interface.

The influence of oral L-arginine on fracture healing: an animal study.

BACKGROUND: The known biological activities of nitric oxide suggest a role in bone healing. We hypothesized that L-arginine, a source of nitric oxide, expedites the healing process of stabilized diaphyseal defects. TYPE OF STUDY: Prospective blinded animal study. METHODS: Using a guinea-pig model, a 7 mm diaphyseal and periosteal defect was produced in the right femur and splinted intramedullary with a 1.4 mm K-wire. The guinea pigs (n = 44) were treated orally in three parallel groups: two treatment groups received high doses of L-arginine (one group for 2 weeks and the other for 4 weeks) and a control group received vehicle only. After four weeks, all animals were killed and both femora explanted. Radiological, histological, histomorphometric and mechanical evaluation was performed blinded. RESULTS: Radiographs showed significantly more healing in the treatment groups (2 weeks, 10/15; 4 weeks, 11/15) than in the control group (3/14). The mechanical energy necessary for femur failure was significantly higher in the 4-week treatment group than in the control group (P < 0.05). Histology and histomorphometry showed significantly increased coverage of nonvascularized bone fragments with newly formed bone in the treatment groups (P < or = 0.05). The contralateral uninjured femora did not show significant differences between groups. CONCLUSIONS: Oral L-arginine expedites healing in stabilized diaphyseal defects in guinea pigs without detrimentally affecting uninjured counterparts.

Measuring the pressure pattern of the joint surface in the uninjured knee.

PURPOSE: Testing an applicable intraoperative system for measuring surface pressure in knee joints, simulating as accurately as possible operating theatre conditions. TYPE OF STUDY: Cadaver study. METHODS: Pressure probes were introduced into the knee joints medially and laterally (K 6900 quad probes) in five cadavers, providing real-time data with computerized data recording (K-scan system, manuf. Tekscan Inc., South Boston, MA). The initial position of the knee was flexed and hanging, as in a leg holder. In simulation of usual operating theatre procedures, the knee was manually extended to 0 degrees and again brought to hanging position. The data are given as relative-pressure values and should serve as the basis for intraoperative use. During arthroscopy, absolute-pressure values would then be influenced by the pressure of the arthroscopy pump. RESULTS: In 90 degrees flexion the average pressure ratio between the medial and lateral joint compartments was initially 1:1.5. When the leg was brought to full extension the pressure in the medial compartment increased, giving a pressure ratio of 1:1 at about 15 degrees and 1.8:1 at full extension. When bringing the leg back again to 90 degrees a similar pressure ratio curve was recorded. CONCLUSIONS: The pressure relationship between the medial and lateral knee compartments could be recorded and was found reproducible in simulated operating-theatre conditions. The measurement of joint surface pressure during implantation of an anterior cruciate ligament graft could provide data for individual intraoperative quality control, thus improving surgical results.