The True-Blue technique: Enhanced chondral assessment of the chest wall.

There is a growing understanding and identification of costal cartilage injuries, however, diagnosis of these injuries remains difficult. We present a novel radiodensity based coloring technique, termed the True-Blue technique, to manipulate 3D CT imaging and more accurately diagnose costochondral injuries.

Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma.

BACKGROUND: Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists. METHODS: The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation. RESULTS: No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection. CONCLUSION: This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Open Reduction and Internal Fixation of a Chronic Precordial Flail Chest Segment: A Case Report.

CASE: We report on a 35-year-old man presenting with disabling pain secondary to multiple rib nonunions and a costochondral dislocation 5 months after sustaining a chest wall crush injury. He underwent surgical reconstruction of the chest and was followed for 2 years. Surgical exposure to the heart was necessary during open reduction of the flail segment, followed by costochondral joint fixation with plates and screws. Although he was a workers' compensation patient, he returned to full gainful employment. CONCLUSION: Open reduction and internal fixation of a symptomatic, chronically displaced, precordial, flail segment can relieve pain and promote return to baseline function.

Surgical management of traumatic sternal body nonunions: Technical tricks and clinical experience.

BACKGROUND: Rarely, traumatic sternum fractures may result in nonunion, which can have drastic, negative implications. Literature on traumatic sternal nonunion reconstruction outcomes is limited to case reports. We present the surgical principles and report clinical outcomes for seven patients following surgical reconstruction of a traumatic sternal body nonunion. METHODS: Consecutive adult patients with a nonunion after a traumatic sternum fracture who underwent reconstruction using locking plate technology and iliac crest bone graft at a Level I trauma center from 2013 to 2021 were identified. Demographic, injury, and surgery data was collected, and postoperative patient-reported outcome (PRO) scores were obtained. Patient-reported outcome scores included the one-question single assessment numeric evaluation (SANE), and the combined 10-question global physical health and global mental health values. Injuries were classified and all fractures were mapped onto a sternum template. Postoperative radiographs were reviewed for union. RESULTS: Of the study's seven patients, five were female, and the mean age was 58 years. Mechanism of injury included motor vehicle collision (5) and blunt object chest trauma (2). The mean time from initial fracture to nonunion fixation was 9 months. Four of the seven patients achieved in-clinic follow-up at ≥12 months (mean = 14.3 months), while the other three achieved ≥6 months of in-clinic follow-up. Six patients completed outcomes surveys ≥12 months after surgery (mean = 28.9 months). Mean PRO scores at final follow-up included: SANE of 75 (out of 100), and global physical health and global mental health of 44 and 47, respectively (US population mean = 50).Six of seven patients achieved known radiographic union. CONCLUSION: We describe an effective and practical method of achieving stable fixation in traumatic sternal body nonunions as evidenced by the positive clinical outcomes of a seven-patient series. Despite the variation in presentation and fracture morphology of this rare injury, the surgical technique and principles outlined can serve as a useful tool for chest wall surgeons. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Deltoid-Sparing Modified Judet Approach: Technique and Clinical Series.

SUMMARY: Posterior approaches provide the mainstay for treatment in most of the scapula body and neck fractures, even those associated with many intraarticular variants. Several posterior approach modifications for minimizing soft-tissue damage and limiting muscular detachment, have previously been described in the literature; however, little or no clinical evidence is available specifically applied to the various approaches.In this study, we describe complete sparing of the deltoid muscle origin during the "modified Judet" approach. The modified approach as previously described detaches the deltoid origin. Deltoid sparing allows for satisfactory visualization and fixation of extra-articular scapula fractures and even some intraarticular variants. The purpose of this article was to describe the deltoid-sparing modified Judet approach and report clinical outcomes for 23 patients after surgical treatment.

Mapping of Pelvic Ring Injuries From High-Energy Trauma Using Unfolded CT Image Technology.

OBJECTIVES: High-energy pelvic ring injuries are associated with significant morbidity and mortality, elevating the importance of injury pattern identification. The purpose of this study was to use a novel 3D computed tomography (CT) unfolding process to both evaluate high-energy pelvic ring injures and to produce injury frequency maps based on injury patterns. METHODS: Patients 18-65 years of age presenting to a level 1 trauma center with pelvic ring injuries between 2016 and 2020 were identified. Of the 482 patients reviewed, 355 were excluded primarily due to having a low energy mechanism, inadequate radiographs, or an isolated fracture. Unfolded pelvic CT images were created using syngo.via CT Bone Reading software. Pelvic ring injury frequency maps were created using the unfolded pelvic CT images and a previously described mapping technique. RESULTS: One hundred twenty-seven patients analyzed had a mean age of 32.7 years. The most common mechanisms of injury (MOI) were motor vehicle collision (30.7%) and fall from height (23.6%). The breakdown of pelvic ring injuries included LC1 = 44.1%, LC2 = 7.1%, LC3 = 14.2%, APC1 = 2.4%, APC2 = 15.0%, APC3 = 5.5%, and VS = 11.8%, with OTA/AO-61B = 74.0% and OTA/AO-61C = 26.0%. Pelvic ring mapping revealed that articular and bony injuries varied markedly between the different types of pelvic ring disruptions, both in type and location. CONCLUSIONS: Pelvic ring injury frequency maps created from unfolded CT images reflect consistent injury patterns providing distinctive information based on force vector mechanisms. Unfolded CT images allow for a novel way to visualize pelvic ring injuries which yield greater comprehension of failure patterns with implications for treatment.

Traumatic Bifocal whereas and Ipsilateral Posterior Knee Dislocation: A Case Report.

CASE: A 19-year-old man sustained combined, ipsilateral inferior hip and posterior knee fracture-dislocations secondary to a motor vehicle collision. He underwent immediate closed reduction of the knee and delayed open reduction internal fixation but required emergent open hip reduction for an irreducible femoral head incarcerated on a pubic root fracture. At the 1-year follow-up, he demonstrated excellent functional outcome with painless and full hip and knee range of motion. CONCLUSION: Irreducible inferior femoral head dislocation in combination with a knee dislocation requires thoughtful staging and treatment but can result in satisfactory outcomes.

Does the Option to Keep Explanted Orthopaedic Trauma Implants Influence Patient Satisfaction and Perception of Care? Results of a Survey Study.

OBJECTIVE: Orthopaedic trauma implants may be electively explanted after fracture healing; reasons include symptomatic implants, cosmetic/functional concerns, or personal expectations. Certain institutions provide the option to keep implants after removal, although this has been retracted in others. This study examines patients' desire for return of implants, reasons for desiring return, and influence of return on perceptions of care. METHODS: A cohort of adult patients who underwent elective orthopaedic implant removal by a single surgeon at a Level I trauma center between 2008 and 2019, with the option to keep their removed implants, was identified. Surveys were sent to patients with contact information. Demographics, reasons for removal, satisfaction, and perceptions of care were studied. RESULTS: The overall response rate was 47.4% (117 of 247). Respondents' mean age was 46.9 years, and 50% were female. Ninety-one percent kept their implants. Eighty-nine percent of patients felt that removal achieved their desired outcome, with decreasing pain cited as primary motivation for explantation (62%). Forty-five percent reported a strong desire to keep their implants, most commonly to show to family (49%). Seventy-four percent were happy to have this option. Thirty-seven percent of patients reported respecting their provider more for having this option, and 27% reported that this positively impacted their satisfaction. CONCLUSIONS: Patients perceive elective implant removal as highly effective. A majority were pleased to have the option to keep their implants, and many reported increased respect and satisfaction. Thus, providing patients with this option should be strongly considered to honor patient choice and optimize outcomes when feasible.

Fully desktop fabricated flexible graphene electrocorticography (ECoG) arrays.

Objective:Flexible Electrocorticography (ECoG) electrode arrays that conform to the cortical surface and record surface field potentials from multiple brain regions provide unique insights into how computations occurring in distributed brain regions mediate behavior. Specialized microfabrication methods are required to produce flexible ECoG devices with high-density electrode arrays. However, these fabrication methods are challenging for scientists without access to cleanroom fabrication equipment.Results:Here we present a fully desktop fabricated flexible graphene ECoG array. First, we synthesized a stable, conductive ink via liquid exfoliation of Graphene in Cyrene. Next, we established a stencil-printing process for patterning the graphene ink via laser-cut stencils on flexible polyimide substrates. Benchtop tests indicate that the graphene electrodes have good conductivity of ∼1.1 × 103S cm-1, flexibility to maintain their electrical connection under static bending, and electrochemical stability in a 15 d accelerated corrosion test. Chronically implanted graphene ECoG devices remain fully functional for up to 180 d, with averagein vivoimpedances of 24.72 ± 95.23 kΩ at 1 kHz. The ECoG device can measure spontaneous surface field potentials from mice under awake and anesthetized states and sensory stimulus-evoked responses.Significance:The stencil-printing fabrication process can be used to create Graphene ECoG devices with customized electrode layouts within 24 h using commonly available laboratory equipment.

Resection of Posttraumatic Rib Synostoses Resolves Pulmonary Insufficiency: A Case Report.

CASE: A 30-year-old woman underwent open reduction and internal fixation for multiple segmental rib fractures status post a motor vehicle collision. A year later, the patient presented with extensive intercostal heterotopic ossification associated with multilevel, hemithoracic, rib synostoses compromising her ventilation. The patient subsequently underwent synostoses excision and hardware removal. Pulmonary function tests (PFT), imaging, and patient-reported outcome scores demonstrate resolution of impairment. CONCLUSION: Resection of multilevel, intercostal, rib synostoses provided an effective treatment for pulmonary restrictive disorder secondary to traumatic rib synostosis. This is the first patient with documentation of prereconstructive and postreconstructive PFTs for chest wall synostosis excision.

Three-dimensional mapping of sternum fractures from high-energy trauma.

BACKGROUND: Sternum fractures are relatively uncommon injuries, which generally occur as a result of a high-energy mechanism and are often associated with significant concomitant injuries. These injuries may result in decreased quality of life if not properly addressed and yet are rarely operated on. The purpose of this project is to evaluate high-energy sternum fracture patterns using a previously published three-dimensional (3D) computed tomography (CT) reconstruction process to produce fracture frequency maps. METHODS: Patients 18 years and older presenting to a Level I trauma center with sternum fractures due to high-energy trauma between October 2013 and January 2022 were included. A 3D reconstruction and reduction was performed for each sternum using medical image processing software (Materialize NV, Leuven, Belgium). The reconstructions were subsequently overlaid onto a template sternum and normalized using bony landmarks. Fracture lines for each injured sternum were transferred onto the template, creating 3D frequency maps. RESULTS: A total of 120 patients met inclusion criteria. The study population had a uniform age distribution and 57.5% were male. The most common mechanism of injury was motor vehicle collision (64.2%). The breakdown of sternum fractures were isolated sternal body (55.8%), isolated manubrium (31.7%), and combined sternal body and manubrium fractures (12.5%). No xiphoid fractures were observed. Sternal body fractures were a near even mix of transverse (31.7%), oblique (32.9%), and comminuted (35.4%), while 75.5% of manubrium fractures were oblique. The most common associated injuries included rib fractures (80.8%) and traumatic brain injury (61.7%). CONCLUSION: This study presents the fractures from sternum injuries in 3D, and provides insight into reproducible sternum injury patterns that have not previously been analyzed in this format. This fracture mapping technique presents numerous injury patterns simultaneously, such that more frequent morphologies can be appreciated for different patient groups. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level V.

Bony Decompression of a Chronically Painful Intercostal Nerve Yields Immediate and Long-Lasting Pain Relief: A Case Report.

CASE: The case of an active 16-year-old adolescent girl who presented with rib malunion and 1 year of unremitting intercostal nerve pain after sustaining multiple rib fractures is presented. She underwent successful bony and soft-tissue decompression of her eighth and ninth intercostal nerves to relieve neurogenic symptoms. CONCLUSION: When conservative treatment fails, chronic intercostal nerve pain due to chest wall trauma may be effectively managed with surgical bony decompression of the offending intercostal bundle(s). Anatomic knowledge of the intercostal nerve and a critical history and physical examination were critical for accurate diagnosis and surgical decompression of the patient's intercostal nerve.

Miniaturized head-mounted microscope for whole-cortex mesoscale imaging in freely behaving mice.

The advent of genetically encoded calcium indicators, along with surgical preparations such as thinned skulls or refractive-index-matched skulls, has enabled mesoscale cortical activity imaging in head-fixed mice. However, neural activity during unrestrained behavior substantially differs from neural activity in head-fixed animals. For whole-cortex imaging in freely behaving mice, we present the 'mini-mScope', a widefield, miniaturized, head-mounted fluorescence microscope that is compatible with transparent polymer skull preparations. With a field of view of 8 × 10 mm2 and weighing less than 4 g, the mini-mScope can image most of the mouse dorsal cortex with resolutions ranging from 39 to 56 µm. We used the mini-mScope to record mesoscale calcium activity across the dorsal cortex during sensory-evoked stimuli, open field behaviors, social interactions and transitions from wakefulness to sleep.

Assembly and operation of an open-source, computer numerical controlled (CNC) robot for performing cranial microsurgical procedures.

Cranial microsurgery is an essential procedure for accessing the brain through the skull that can be used to introduce neural probes that measure and manipulate neural activity. Neuroscientists have typically used tools such as high-speed drills adapted from dentistry to perform these procedures. As the number of technologies available for neuroscientists has increased, the corresponding cranial microsurgery procedures to deploy them have become more complex. Using a robotic tool that automatically performs these procedures could standardize cranial microsurgeries across neuroscience laboratories and democratize the more challenging procedures. We have recently engineered a robotic surgery platform that utilizes principles of computer numerical control (CNC) machining to perform a wide variety of automated cranial procedures. Here, we describe how to adapt, configure and use an inexpensive desktop CNC mill equipped with a custom-built surface profiler for performing CNC-guided microsurgery on mice. Detailed instructions are provided to utilize this 'Craniobot' for performing circular craniotomies for coverslip implantation, large craniotomies for implanting transparent polymer skulls for cortex-wide imaging access and skull thinning for intact skull imaging. The Craniobot can be set up in <2 weeks using parts that cost <$1,500, and we anticipate that the Craniobot could be easily adapted for use in other small animals.

Craniobot: A computer numerical controlled robot for cranial microsurgeries.

Over the last few decades, a plethora of tools has been developed for neuroscientists to interface with the brain. Implementing these tools requires precisely removing sections of the skull to access the brain. These delicate cranial microsurgical procedures need to be performed on the sub-millimeter thick bone without damaging the underlying tissue and therefore, require significant training. Automating some of these procedures would not only enable more precise microsurgical operations, but also facilitate widespread use of advanced neurotechnologies. Here, we introduce the "Craniobot", a cranial microsurgery platform that combines automated skull surface profiling with a computer numerical controlled (CNC) milling machine to perform a variety of cranial microsurgical procedures on mice. The Craniobot utilizes a low-force contact sensor to profile the skull surface and uses this information to perform precise milling operations within minutes. We have used the Craniobot to perform intact skull thinning and open small to large craniotomies over the dorsal cortex.