Wireless microcurrent stimulation improves blood flow in burn wounds.

RATIONALE: Skin breakdown, as in wounds, leads to an electric potential, defined as current of injury with the intent of wound closure. Burn wounds are defined by different zones of perfusion having a direct influence on further therapy (e.g. conservative management or skin grafting). We studied immediate, quantifiable effects of electric stimulation on skin perfusion in burn wounds. METHOD: Wireless Microcurrent Stimulation (WMCS) was utilised as an adjunct therapeutic modality in 10 patients with partial thickness burn wounds. Microcirculation in the skin was quantified with a Laser Doppler (LDI) before and after WMCS treatment. We included a control group of 10 healthy individuals. RESULTS: A single application of WMCS significantly increased mean flow, velocity and subsequently, haemoglobin and oxygen saturation in partial thickness burn wounds. In healthy skin these parameters increased, but were far less pronounced than in thermally injured skin. CONCLUSION: This study revealed, for the first time that non-contact WMCS improves blood flow in critically perfused partial thickness burn wounds without disturbing the wound or systemically affecting the patient and may represent a promising adjunct tool in burn treatment, with the potential of faster healing by enhanced perfusion of burn wounds and reduction of the zone of stasis. LEVEL OF EVIDENCE: III.

[Revision surgery for carpal and cubital tunnel syndrome]. / Revisionseingriffe beim Karpal- und Kubitaltunnelsyndrom.

BACKGROUND: Carpal tunnel syndrome, a compressive neuropathy of the median nerve at the wrist and cubital tunnel syndrome, a compressive neuropathy of the ulnar nerve at the elbow, are the two most common peripheral nerve compression syndromes. Chronic compressive neuropathy of peripheral nerves causes pain, paraesthesia and paresis. Treatment strategies include conservative options, but only surgical decompression can resolve the mechanical entrapment of the nerve with proven good clinical results. However, revision rates for persistent or recurrent carpal tunnel syndrome is estimated at around 5% and for refractory cubital tunnel syndrome at around 19%. Common causes for failure include incomplete release of the entrapment and postoperative perineural scarring. THERAPY: Precise diagnostic work-up is obligatory before revision surgery. The strategy of revision surgery is first complete decompression of the affected nerve and then providing a healthy, vascularized perineural environment to allow nerve gliding and nerve healing and to avoid recurrent scarring. Various surgical options may be considered in revision surgery, including neurolysis, nerve wrapping and nerve repair. In addition, flaps may provide a well vascularized nerve coverage in the case of recurrent carpal tunnel syndrome. In the case of recurrent cubital tunnel syndrome, anterior transposition of the ulnar nerve is mostly performed for this purpose. RESULTS: In general, revision surgery leads to improvement of symptoms, although the outcome of revision surgery is less favourable than after primary surgery and complete resolution of symptoms is unlikely.

Synergistic motor nerve fiber transfer between different nerves through the use of end-to-side coaptation.

End-to-end nerve repair is a widely used and successful experimental microsurgical technique via which a denervated nerve stump is supplied with reinnervating motor or sensory axons. On the other hand, questions are still raised as concerns the reliability and usefulness of the end-to-side coaptation technique. This study had the aim of the reinnervation of the denervated forearm flexor muscles in baboons through the use of an end-to-side coaptation technique and the synergistic action of the radial nerve. The median and ulnar nerves were transected, and the motor branch of the radial nerve supplying the extensor carpi radialis muscles (MBECR) was used as an axon donor for the denervated superficial forearm flexors. A nerve graft was connected to the axon donor nerve through end-to-side coaptation, while at the other end of the graft an end-to-end connection was established so as to reinnervate the motor branch of the forearm flexors. Electrophysiological investigations and functional tests indicated successful reinnervation of the forearm flexors and recovery of the flexor function. The axon counts in the nerve segments proximal (1038+/-172 S.E.M.) and distal (1050+/-116 S.E.M.) to the end-to-side coaptation site and in the nerve graft revealed that motor axon collaterals were given to the graft without the loss or appreciable misdirection of the axons in the MBECR nerve distal to the coaptation site. The nerve graft was found to contain varying, but satisfactory numbers of axons (269+/-59 S.E.M.) which induced morphological reinnervation of the end-plates in the flexor muscles. Accordingly, we have provided evidence that end-to-side coaptation can be a useful technique when no free donor nerve is available. This technique is able to induce limited, but still useful reinnervation for the flexor muscles, thereby producing a synergistic action of the flexor and extensor muscles which allows the hand to achieve a basic gripping function.

[Critical evaluation of diagnostics and therapeutic strategies in brachial plexus injuries in Austria: a retrospective study on incidence, diagnostics, treatment results and algorithm]. / Kritische Evaluierung der Diagnostik und Behandlung von Verletzungen des Plexus brachialis in Osterreich: Eine retrospektive Studie über Inzidenz, Diagnostik, Behandlungsergebnisse und -algorithmus.

BACKGROUND: Brachial plexus injury is a rare entity, often resulting in lifelong motor and sensory dysfunctions. Sometimes neuropathic pain is predominant. The aim of this retrospective cohort study was to analyse current algorithms of diagnostics and treatment in brachial plexus injuries. The results have been compared to literature. PATIENTS AND METHODS: A retrospective analysis of 214 patients suffering from a brachial plexus injury was conducted. Our results were compared to those in the literature. RESULTS: A sufficient algorithm for the diagnosis of and therapy for brachial plexus injuries was not apparent. Only a few studies have been published concerning this problem. The incidence for Austria is 1.29 cases per 100 000 inhabitants; this represents the middle range compared to international data. The main causes of brachial plexus injury were falls (45 %) and traffic accidents (26.6 %). 20.1 % of patients were multitraumatised, 29.9 % had a closed head injury. In 3.7 % the brachial plexus lesion was associated with spinal cord trauma. In contrast to the literature data (9-13 %), we did not find any stab or gun shot wounds. 5.6 % sustained a vascular injury at the arm or shoulder level; two patients had to undergo an emergency surgical procedure because of this injury. Clinical assessment was generally insufficient. Electrophysiological assessment was performed in 34.6 % of the patients, MRI in 13.6 %. In 38.3 % of the patients no clinical improvement was observed after three months. An operative procedure was performed in 8.4 % of these patients. 61.1 % of these operated patients were not satisfied with the clinical results. Practically no reconstructive procedures had been performed. CONCLUSION: An algorithm for diagnosis and treatment needs to be established. Awareness for the sophisticated treatment of this type of injury has to be stimulated. Precise clinical assessment and knowledge of differentiated treatment options have to be available in order to improve the results.

Nerve regeneration using tubular scaffolds from biodegradable polyurethane.

INTRODUCTION: In severe nerve lesion, nerve defects and in brachial plexus reconstruction, autologous nerve grafting is the golden standard. Although, nerve grafting technique is the best available approach a major disadvantages exists: there is a limited source of autologous nerve grafts. This study presents data on the use of tubular scaffolds with uniaxial pore orientation from experimental biodegradable polyurethanes coated with fibrin sealant to regenerate a 8 mm resected segment of rat sciatic nerve. METHODS: Tubular scaffolds: prepared by extrusion of the polymer solution in DMF into water coagulation bath. The polymer used for the preparation of tubular scaffolds was a biodegradable polyurethane based on hexamethylene diisocyanate, poly(epsilon-caprolactone) and dianhydro-D-sorbitol. EXPERIMENTAL MODEL: Eighteen Sprague Dawley rats underwent mid-thigh sciatic nerve transection and were randomly assigned to two experimental groups with immediate repair: (1) tubular scaffold, (2) 180 degrees rotated sciatic nerve segment (control). Serial functional measurements (toe spread test, placing tests) were performed weekly from 3rd to 12th week after nerve repair. On week 12, electrophysiological assessment was performed. Sciatic nerve and scaffold/nerve grafts were harvested for histomorphometric analysis. Collagenic connective tissue, Schwann cells and axons were evaluated in the proximal nerve stump, the scaffold/nerve graft and the distal nerve stump. The implants have uniaxially-oriented pore structure with a pore size in the range of 2 micorm (the pore wall) and 75 x 700 microm (elongated pores in the implant lumen). The skin of the tubular implants was nonporous. Animals which underwent repair with tubular scaffolds of biodegradable polyurethanes coated with diluted fibrin sealant had no significant functional differences compared with the nerve graft group. Control group resulted in a trend-wise better electrophysiological recovery but did not show statistically significant differences. There was a higher level of collagenic connective tissue within the scaffold and within the distal nerve stump. Schwann cells migrated into the polyurethane scaffold. There was no statistical difference to the nerve graft group although Schwann cell counts were lower especially within the middle of the polyurethane scaffold. Axon counts showed a trend-wise decrease within the scaffold. CONCLUSION: These results suggest that biodegradable polyurethane tubular scaffolds coated with diluted fibrin sealant support peripheral nerve regeneration in a standard gap model in the rat up to 3 months. Three months after surgery no sign of degradation could be seen.

Synergistic terminal motor end-to-side nerve graft repair: investigation in a non-human primate model.

End-to-side nerve repair has re-emerged in the literature in recent years but clinical applications for this technique are not yet fully defined and clinical reports are rare and controversial. Hypothetically, there might be useful functional results performing peripheral end-to-side nerve graft repair using synergistic terminal branches with defined motor function. An end-to-side nerve graft repair bridging from the terminal motor branch of deep branch of the ulnar nerve to the thenar motor branch of the median nerve was performed in non-human primates. The results in this non-human primate model demonstrate the efficacy of end-to-side nerve graft repair at the level of peripheral terminal motor branches. End-to-side neurorrhaphy may present a viable alternative in conditions of unsuitable end-to-end coaptation and inappropriate nerve grafting procedures.

End-to-side coaptation--controversial research issue or important tool in human patients.

End-to-side coaptation is still a controversial procedure. Many authors reported surprisingly good results; others showed mediocre results only. There are also reports of complete failures. Apparently all authors are right. According to our experience the results depend on the level of end-to-side coaptation and on the nerve fiber composition. End-to-side coaptation between mixed nerves do have very poor expectations. The chances are much better if e.g. a small denervated pure motor nerve is coapted to a functioning small pure motor nerve. The same procedure may produce opposite results according to the circumstances. In our experience end-to-side coaptation is a reliable procedure of great use in selected cases. Main field of application are thin nerves with a well defined function and synergistic terminal motor branches.

Enhanced sensory re-learning after nerve repair using 3D audio-visual signals and kinaesthesia--preliminary results.

Sensory re-learning methods and basics on cortical reorganization after peripheral nerve lesion are well documented. The aim of enhanced sensory re-learning using 3D audio-visual signals and kinaesthetic training is the augmentation of cognitive memory (visual and acoustic sensory memory) and cognitive function for the improvement of cerebral plasticity processes and starts as soon as possible after nerve repair. Preliminary results are shown.

Anatomical structures to provide passive motility of peripheral nerve trunks and fascicles.

It is well known that tendons have to be able to move if the muscle contracts. It is still not generally known that any structure in the body has to be able to move passively against other structures. This is especially important for the movement of limbs. In a monoaxial joint like the humero-ulnar joint only structures in the plane of the joint axis remain fixed. Structures in a certain distance to the flexion or to the extension side have to be able to move against other structures in different levels. The amount of passive motion is dependent on the distance to the plane of the joint axis. Tissues which provide a frictionless passive motion are discussed.

IMF-Therapy (Intention controlled Myo-Feedback)--an innovative method in the treatment of peripheral nerve lesions.

Physiotherapy is a well established part of the rehabilitation of peripheral nerve paralysis. The aim of this type of treatment is to re-establish arbitrary functions by improving the patients' active and passive mobility as well as their strength and stamina. IMF-Therapy (Intention controlled Myo-Feedback) is an innovative method in the treatment of peripheral nerve lesions that goes beyond the purely neuro-scientific framework and also takes into account methods and concepts of the psychology of learning. The essential assumption is that things learnt in the past are firmly established in the long term motor memory and can be reactivated by the patient. From results achieved in 32 patients treated with this therapy it can be concluded that IMF-Therapy may be a promising additional rehabilitation tool in peripheral nerve lesion.

In peripheral nerve regeneration environment enriched with activity stimulating factors improves functional recovery.

Enriched environment stimulates brain plasticity processes after brain lesion. Less is known about the influence of enriched environment with activity stimulating factors as determinants of functional outcome after peripheral nerve repair. BDNF (brain-derived neurotrophic factor) plays a role in activity-dependent neuronal plasticity and changes in motor cortex in rats learning complex motor skills. Our study aimed to elucidate if enriched environment influences functional results after peripheral nerve repair. The results in this rat sciatic nerve transection and repair model showed that environment enriched with activity stimulating factors can improve functional results.

[Fascial spaces and recurrent surgery for thoracic outlet syndrome]. / Faszienräume und Rezidiveingriffe beim Thoracic-outlet-Syndrom.

We studied the passive motion of the brachial plexus in relation to movement of the upper extremity by observation during surgery and by measurements in cadavers. The spaces for these movement are defined. The passive motion is provided by gliding tissue. Pathologic changes of the gliding tissue may contribute to the development of the symptoms of the TOS. It is distinguished between reversible and irreversible changes. A recurrent fibrosis may develop in rare cases which may be best treated by microsurgical neurolysis and envelopment of the brachial plexus by a gliding tissue flap.

Glial fibrillary acidic protein in serum after traumatic brain injury and multiple trauma.

BACKGROUND: This study aimed to determine whether glial fibrillary acidic protein (GFAP) is released after traumatic brain injury (TBI), whether GFAP is related to brain injury severity and outcome after TBI, and whether GFAP is released after multiple trauma without TBI. METHODS: This prospective study enrolled 114 patients who had TBI with or without multiple trauma (n = 101) or multiple trauma without TBI (n = 13), as verified by computerized tomography. Daily GFAP measurement began at admission (<12 hours after trauma) and continued for the duration of intensive care (1-22 days). Documentation included categorization of computerized tomography according to Marshall classification, based on daily highest intracranial pressure (ICP), lowest cerebral perfusion pressure (CPP), lowest mean arterial pressure (MAP), and 3-month Glasgow Outcome Score (GOS). RESULTS: The GFAP concentration was lower for diffuse injury 2 than for diffuse injury 4 (p < 0.0005) or nonevacuated mass lesions larger than than 25 mL (p < 0.005), lower for a ICP less than 25 mm Hg than for a ICP of 25 mm Hg or more, lower for a CPP of 60 mm Hg or more than for a CPP of 60 mm Hg or less, lower for a MAP of 60 mm Hg or more than for a MAP less than 60 mm Hg (all p < 0.0005), and lower for a GOS of 1 or 2 than for a GOS of 3, 4 (p < 0.05), or 5 (p < 0.0005). After TBI, GFAP was higher in nonsurvivors (n = 39) than in survivors (n = 62) (p < 0.005). After multiple trauma without TBI, GFAP remained normal. CONCLUSIONS: The findings showed that GFAP is released after TBI, that GFAP is related to brain injury severity and outcome after TBI, and that GFAP is not released after multiple trauma without brain injury.

Circulating S100B is increased after bilateral femur fracture without brain injury in the rat.

BACKGROUND: S100B is an acknowledged marker of brain damage. However, trauma without brain damage also causes an increase in S100B. S100B concentrations are highest in multiple trauma patients with long bone fractures. Clinically, extensive long bone fractures are associated with haemorrhagic shock and haemorrhagic shock per se is associated with increased S100B. The aim of our experimental study was to verify the S100B increase in long bone fracture without haemorrhagic shock. METHODS: and results. Bilateral femur fracture was carried out in 10 anaesthetized rats. Blood samples were drawn for immuno-luminometrical S100B measurement 5, 15, 30, 120, and 240 min after fracture. Mean arterial pressure (MAP), heart rate, and body temperature were monitored continuously. S100B increased after bilateral femur fracture and reached a peak 30-120 min after fracture (P<0.001). MAP remained at a level which is not associated with shock in rats. Heart rate and body temperature remained unchanged. Autopsy verified open bilateral femur fracture surrounded only by small zones of clotted blood. CONCLUSIONS: S100B is increased in bilateral femur fracture without haemorrhagic shock in rats. This finding suggests that bone marrow is a potential extracerebral source of S100B.

Acute acalculous cholecystitis after trauma: a prospective study.

OBJECTIVE: The purpose of this study was to identify risk factors for the development of acute acalculous cholecystitis (AAC) and useful criteria to facilitate the decision to perform cholecystectomy. METHODS: This was a prospective study of patients with an Injury Severity Score (ISS) > or = 12 requiring intensive care for > 4 days (n = 255), divided into three groups by ultrasound: AAC (n = 27), hydropic gallbladder (n = 37), and normal gallbladder (n = 191). Multivariate analysis was conducted for trauma scores and laboratory and intensive care unit (ICU) data and complemented by logistic regression analysis. RESULTS: Three factors sufficiently define the risk for AAC: ISS, heart rate, and units of packed red blood cells required at ICU admission. All patients who underwent cholecystectomy (n = 21) had both highly pathologic ultrasound and major clinical symptoms, and all had histologically verified AAC. There was no significant difference in daily laboratory data between patients with and without AAC. CONCLUSION: Patients with a high ISS who are tachycardic and have required several units of packed red blood cells at ICU admission should be monitored early by ultrasound. When ultrasound is highly pathologic together with major clinical symptoms, cholecystectomy should be performed. Daily laboratory data are of no additional value regarding the decision to perform cholecystectomy.

Treatment of chronic neuropathic pain after traumatic central cervical cord lesion with gabapentin.

Central cord syndrome may be associated with severe pain, resistant to conventional pain therapy regimens. Chronic pain may be a persistent problem in rehabilitation of spinal cord injuries. These pain syndromes are long lasting and challenging to treat. Gabapentin has been shown to be useful in treatment of different conditions which may be caused by increased neuronal excitability. This report describes a case where central cord syndrome and its chronic neuropathic pain associated with allodynia was successfully treated with gabapentin.

[Simultaneous reimplantation of both lower legs--5-year follow-up (case report)]. / Simultane beidseitige Unterschenkelreplantation--5-Jahres-Ergebnis.

We are reporting the case of a 29 year old male in whom we performed successful reimplantaton of both lower legs following trauma inflicted by a railroad boxcar. Five years after this accident, the patient's walk is almost normal and both deep sensitivity and two point discrimination on the soles of his feet are sufficient. The patient can walk, run and stand very well on one leg, both on even and on uneven ground.He returned to his job with the railroad 8 months after his accident. Originally the patient was employed as a railroad workman, and is now an office employee. His private life is normal and he enjoys hiking and dancing. In our opinion, sufficient function of the tibial nerve in the reconstructed extremity is important for clinically satisfactory long-term results. Both the Mangled Extremity Severity Score (MESS) and the NISSSA are helpful in making the decision on whether to primarily amputate or reconstruct Gustillo IIIC cases. Good long-term results as well as general cost reduction are achievable following reconstruction of extremities. Amputation of an extremity can be predicted with 100% certainty when MESS is 9 or more. Primary shortening and secondary lengthening of an extremity is a good method of treating Gustillo III C fractures.