A Case of Pediatric Leg-Length Difference After Tibial Fracture Predicted by Bone SPECT/CT

An 11-year-old boy underwent a bone single-photon emission computed tomography/computed tomography (SPECT/CT) scan 3 months after fracturing his right tibia. The standardized uptake values (SUVs) of the growth plates in his right tibia were higher compared to those in the left tibia. One year later, the right leg was 10 mm longer than the left leg with higher SUVs in the right tibial growth plates. After performing epiphysiodesis at the right proximal tibia, the leg-length difference (LLD) decreased from 17 to 12 mm with the decrease of SUVs in the growth plates of the right tibia. This case emphasizes the potential of quantitative analysis using bone SPECT/CT in predicting LLD and determining the necessity of length equalization surgery in pediatric lower limb fractures.

Prediction of leg-length discrepancy in pediatric femoral shaft fracture using bone SPECT/CT: A case report

RATIONALE

Children's bones are in the process of growing in both length and width. Therefore, evaluating whether fractures affect the growth plate or not is very crucial. However, even in cases of lower limb fractures where the growth plate remains unaffected, overgrowth or shortening of the affected limb are encountered.

PATIENT CONCERNS

An 11-year-old boy was admitted to the emergency department after a passenger car accident.

DIAGNOSES

A comminuted fracture of the right femoral shaft was diagnosed by X-ray image.

INTERVENTIONS

Closed reduction and internal fixation were performed using intramedullary titanium elastic nails. Six months after the operation, bone union was achieved and the nails were removed.

OUTCOMES

Nine months after nail removal, the right leg was unexpectedly noticed 5 mm shorter than the left one. On the initial and follow-up bone single-photon emission computed tomography/computed tomography images with a 9-month interval, radioactivity of growth plate in the right proximal femur was much lower than that of the left femur, suggesting a further increasing of leg-length discrepancy (LLD) in the future. As we expected, LLD had progressively increased up to 20 mm. Epiphysiodesis was finally decided for the left distal femur. Twenty-two months after the length equalization operation, LLD decreased to 5 mm.

LESSONS

This case emphasizes that quantitative analysis of growth plate activity using bone single-photon emission computed tomography/computed tomography could predict LLD and help us decide when and which limb should be operated on for pediatric patients with lower limb fractures.

Clinical Outcome after Clavicular Hook Plate Fixation for Displaced Medial-End Clavicle Fractures

Background

Surgery of the medial end of the clavicle remains a challenge for orthopedic surgeons. Moreover, there is no standard surgical procedure for treating displaced fractures or dislocation of the medial clavicle. Thus, the present study aimed to evaluate the safety and efficacy of using a hook plate for treating medial-end clavicular fractures and present functional outcomes.

Methods

We retrospectively investigated 18 patients who underwent surgery with a hook plate from July 2016 to December 2021. There were 14 men and 4 women with a mean age of 57.4 years. Fracture union was assessed at follow-up by computed tomography (CT). Other outcome parameters were complications, including implant failure, infection, nonunion, osteolysis of sternal manubrium, and migration of the hook portion. Range of motion (ROM), visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH), and American Shoulder and Elbow Society (ASES) scores were evaluated 6 months postoperatively and at the last follow-up.

Results

The mean operation time was 43.8 minutes (range, 35-50 minutes) and the mean follow-up was 22.8 months (range, 12-42 months). Bone union was confirmed in all cases. The mean union time was 6.2 months (range, 6-7 months). Implant removal was performed routinely according to the clinical course in 17 cases. The mean implant removal time was 10.0 months (range, 6-14 months). Clinical and functional outcomes measured at the last follow-up were significantly improved compared to those at 6 months postoperatively (p < 0.05). Regarding complications, there were 6 cases (33.3%) of osteolysis of the sternal manubrium. Although the anteroposterior length of the manubrium and hook depth showed significant differences between the non-osteolysis group and the osteolysis group (p = 0.024), ROM, VAS, Quick DASH, and ASES scores were not significantly different between the two groups (all p > 0.05).

Conclusions

Clavicle hook plating can be a safe and effective method that can be easily applied with good outcomes if it is used with appropriate surgical planning and technique for medial-end clavicle fracture. CT scans are useful for preoperative planning and postoperative evaluation of bone union or complications.

Sirtuin 6 Overexpression Improves Rotator Cuff Tendon-to-Bone Healing in the Aged

Aging is an independent risk factor for recurrent tearing after surgical repair of rotator cuff ruptures around the tendon-to-bone area. However, aging signature factors and related mechanisms involved in the healing of the rotator cuff are still unknown. We hypothesized that differences in proteins involved in the rotator cuff according to age may affect tendon-to-bone healing. The proteome analysis performed to identify the signature aging proteins of the rotator cuff confirmed the sirtuin signal as an age-specific protein. In particular, the expression of SIRT6 was markedly down-regulated with age. Ingenuity pathway analysis of omics data from age-dependent rat rotator cuffs and linear regression from human rotator cuffs showed SIRT6 to be closely related to the Wnt/β-catenin signal. We confirmed that overexpression of SIRT6 in the rotator cuff and primary tenocyte regulated canonical Wnt signaling by inhibiting the transcriptional expression of sclerostin, a Wnt antagonist. Finally, SIRT6 overexpression promoted tendon-to-bone healing after tenotomy with reconstruction in elderly rats. This approach is considered an effective treatment method for recovery from recurrent rotator cuff tears, which frequently occur in the elderly.

Comparison of Functional and Cosmetic Outcomes According to Fracture Level in Gartland Type III Pediatric Supracondylar Humerus Fractures

Background

Supracondylar humerus (SCH) fractures in children have been traditionally categorized according to the Wilkins-modified Gartland classification scheme, which is solely based on the degree of displacement. As this classification does not consider fracture patterns in the coronal or sagittal plane, the relationship between the fracture pattern and prognosis in SCH fractures remains unclear. Therefore, the purpose of this study was to evaluate the relationship between the fracture level and prognosis of pediatric SCH fractures.

Methods

Medical records and radiographs of 786 patients with SCH fractures who underwent surgical treatment between March 2004 and December 2017 were reviewed. A total of 192 patients were included in this study. Anteroposterior elbow radiographs taken at the time of injury were evaluated to obtain the level of fracture. Functional outcomes were evaluated based on modified Flynn grading at the last follow-up.

Results

Of 192 patients included in this study, 24 (12.1%), 148 (74.8%), and 20 (10.1%) had fractures in zone 1 (metaphyseal-diaphyseal area), zone 2 (between zones 1 and 3), and zone 3 (metaphyseal-epiphyseal area), respectively. There were significant differences in age at the time of injury (p = 0.011), direction of fracture displacement (p = 0.014), and loss of carrying angle (p < 0.001) between fractures in zone 3 and those in zone 1 or zone 2. Zone 3 fractures and classic zone 2 fractures also showed significant difference in outcomes, with zone 3 fractures having more unsatisfactory outcome than classic zone 2 fractures (p = 0.049).

Conclusions

For SCH fractures, varus deformity of the elbow was more common in zone 3 (metaphyseal-epiphyseal area) than in the other zones. Thus, pediatric orthopedic surgeons should be mindful of the possibility of cubitus varus deformity when treating SCH fractures in zone 3. A thorough postoperative follow-up is required.

Delayed dislocation of the radial head associated with malunion of distal radial fracture: A case report

BACKGROUND

Traumatic radial head dislocation (RHD) is a well-described injury in the pediatric population. It is usually associated with an injury to the ulna in Monteggia fracture-dislocation, although it can occur as an isolated injury. Traumatic RHD with ipsilateral radial shaft fracture has rarely been reported. Delayed RHD secondary to the malunion of an isolated radial shaft fracture is extremely rare.

CASE SUMMARY

We report a 9-year-old boy with limited pronation of the right elbow. The patient was diagnosed with delayed RHD associated with the malunion of a distal radial fracture. Since the annular ligament was disrupted with forearm rotation causing subluxation of the radial head, a modified double-strip Bell Tawse procedure was performed to reconstruct the annular ligament without corrective osteotomy for the malunited site. Four years after surgery, the angulation deformity of the distal radius was corrected with the restoration of the normal curvature of the radius. There was no recurrence of RHD.

CONCLUSION

Annular ligament reconstruction without corrective osteotomy could reduce RHD and restore the normal curve of the radial shaft in children with delayed dislocation of the radial head associated with malunion of the radial shaft. Annular reconstruction using double triceps tendon strips might be useful for maintaining a more stable reduction by augmenting anterolateral parts.

Delayed anterolateral radial head dislocation secondary to radial shaft fracture malunion: A case report

RATIONALE

Traumatic radial head dislocation (RHD) can occur due to hyperpronation injury with sequential disruption of the annular ligament, quadrate ligament, and the interosseous membrane. Although studies have shown that traumatic RHD is generally associated with Monteggia fracture-dislocation, traumatic RHD occurring with ipsilateral radial shaft fractures has rarely been reported. Delayed RHD secondary to the malunion of isolated radial shaft fractures is extremely rare.

PATIENT CONCERNS

We report the case of a 12-year-old right-handed boy with progressive pain and limited range of motion in the right elbow.

DIAGNOSIS

The patient was diagnosed with delayed RHD associated with radial shaft fracture malunion.

INTERVENTIONS AND OUTCOMES

A corrective osteotomy was performed at the site of malunion with open reduction of the radial head using an extensile lateral approach. The annular ligament was disrupted. Forearm rotation causes radial head subluxation Therefore, the Bell Tawse procedure was additionally performed to reconstruct the annular ligament by turning down a strip of triceps tendon and anchoring it around the radial neck.

LESSONS

Malunion of the radial shaft can cause delayed RHD with a limited elbow range of motion. Annular reconstruction using a strip of the triceps tendon and corrective osteotomy of the radial shaft with an extensile lateral approach may be useful for treating this rare entity or situation.

Osteoblasts/Osteocytes sirtuin6 Is Vital to Preventing Ischemic Osteonecrosis Through Targeting VDR-RANKL Signaling

Ischemic osteonecrosis (ION) can produce permanent deformity and osteoarthritis in the femoral head and other joints. No biologic treatment has been established, and the molecular mechanisms involved in the pathogenesis of ION have not been elucidated. In this work, we found that treatment with sirtuin6 (Sirt6) suppressed inflammatory cytokines, bone resorption, progression of osteoarthritis, and reduced bone deformity in an ION mouse model. We used a deacetylase mutant adenovirus to confirm that those effects were caused by the deacetylase function of Sirt6. Among the osteoclastogenic factors of osteoblasts, only the receptor activator of NF-κb ligand (RANKL) level changed in response to Sirt6 knockout in primary osteoblasts. In particular, the vitamin D receptor physically interacted with Sirt6 and induced recruitment of Sirt6 around RANKL promoters. Finally, Tg mice overexpressing Sirt6 resisted osteocyte death, bone resorption, and progression of osteoarthritis after ischemic surgery, whereas osteoblast/osteocyte-specific Sirt6 knockout mice showed aggravated bone loss and severe deformity. Our findings demonstrate that administration of Sirt6 prevents bone loss and osteoarthritis in ischemic conditions. Activation of Sirt6 in osteoblasts/osteocytes could be a new therapeutic approach to treating ION of the femoral head and other bone regions. © 2020 American Society for Bone and Mineral Research (ASBMR).

Translation step-cut osteotomy for posttraumatic Cubitus Varus in adults: a retrospective study

BACKGROUND

Cubitus varus is a complex three-dimensional deformity. Various osteotomies have been introduced to correct this complex deformity. The objective of the present study was to evaluate clinical and functional outcomes of adult cubitus varus deformity treated with translation step-cut osteotomy.

METHODS

Seventeen consecutive patients with a mean age of 25 years (range, 19-50 years) who underwent translation step-cut osteotomy were enrolled in this study. Their average follow-up period was 28.2 months. Radiographic measurements preoperatively, 3-month postoperatively, and at the last follow-up were compared. Functional outcomes were assessed using Disabilities of the Arm, Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and Oppenheim criteria.

RESULTS

The mean humerus-elbow-wrist angle improved from 14.7° ± 6.4° (range, 6°-23°) varus preoperatively to 12.1° ± 6.6° (range, 5°-20°) valgus postoperatively (p <  0.001). The lateral prominence index improved 9.6% from its preoperative value, showing no significant difference from that of a normal elbow. Osseous union was radiographically demonstrated in 16 patients (except one out of 17 patients) within a mean of 12.7 weeks (range, 8-18 weeks). The motion arc of the elbow at the last follow-up was not significantly (p > 0.05) different from that at the initial presentation. Based on Oppenheim criteria, results were excellent for 7, good for 8, and poor for 2 patients. Mean final DASH value and MEPS were 2.5 ± 3.8 points (range, 0-15 points) and 97.0 ± 5.8 points (range, 85-100 points), respectively. With regard to complications, one case had delayed union and one case had transient radial nerve injury.

CONCLUSION

Translation step-cut osteotomy using Y plate is an efficient procedure to correct varus alignment and flexion-extension deformities so that they are within normal limits of adults with post-traumatic cubitus varus deformity.

TRIAL REGISTRATION

Institutional Review Board of Jeonbuk National University Hospital (IRB No. 2020-01-020 ).

Myositis ossificans of the thigh causing external compression of the superficial femoral artery and vein: A case report

RATIONALE

Myositis ossificans (MO) is a benign condition characterized by heterotopic bone formation in the skeletal muscle of extremities. Marked variation can occur in the incidence and location of the bone formed as well as resulting complications. Femoral vessel obstruction caused by MO is an extremely rare but disabling complication. Arterial occlusion may aggravate ischemic conditions, resulting in necrosis in the lower extremity.

PATIENT CONCERNS

We report a 41-year-old female with progressive pain and swelling of the right thigh region for 1 year.

DIAGNOSES

We diagnosed it as obstruction of the superficial femoral artery and vein caused by external compression of the MO between the sartorius and vastus medialis of the thigh.

INTERVENTIONS AND OUTCOMES

Adherent tissues and mass were excised with care without damaging the femoral artery or the vein. However, normal morphology did not recover due to loss of elasticity of femoral vessels. Therefore, after resection of the narrowed region of the femoral artery, a femoral-to-femoral graft interposition using the greater saphenous vein was performed. At 12 months after the surgery, vessel reconstruction computed tomography images confirmed normal continuous flow of the femoral artery.

LESSONS

Vascular compression and peripheral inflammatory response due to MO can cause loss of normal vascular morphology. Surgical excision of the mass and the involved femoral artery segment followed by femoral arterial reconstruction should be considered for lesions that do not spontaneously regress to prevent functional impairment and secondary complications in extremities.

Treatment Outcomes at Skeletal Maturity after Calcaneo-Cuboid-Cuneiform Osteotomy for Symptomatic Flatfoot Deformity in Children

Background

The purpose of this study was to evaluate clinical and radiological outcomes at skeletal maturity after a calcaneo-cuboid-cuneiform osteotomy (triple C osteotomy) for symptomatic flatfoot deformity compared with healthy young adult controls.

Methods

Nineteen patients (30 feet) who undergone a triple C osteotomy for idiopathic symptomatic flatfeet from July 2006 to April 2013 were compared with 19 controls (38 feet). Radiographic measurements at preoperative examination, 1-year postoperative follow-up, and follow-up at skeletal maturity were evaluated. Functional outcomes were assessed by using the validated visual analog scale foot and ankle (VAS-FA) and the modified American Orthopaedic Foot and Ankle Surgery (AOFAS) score.

Results

In the triple C osteotomy group, 11 of 12 radiographic measurements were significantly improved at 1 year postoperatively and the last follow-up (p < 0.001). There was no recurrence at skeletal maturity (p > 0.05). There were no significant differences in nine of 12 radiographic measurements between the triple C osteotomy group at maturity and the control group (p > 0.05). Average VAS-FA and AOFAS scores were significantly improved at the time of skeletal maturity (p < 0.001).

Conclusions

Surgical correction of symptomatic flatfoot deformity in childhood resulted in favorable outcomes after the triple C osteotomy. Deformity correction was also maintained during follow-up at skeletal maturity.

Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank: A case report

RATIONALE

Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown.

PATIENT CONCERNS

We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank.

DIAGNOSES

The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy.

INTERVENTIONS

The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap.

OUTCOMES

No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively.

LESSONS

In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.

Management of the First-time Traumatic Anterior Shoulder Dislocation

Traumatic anterior dislocation of the shoulder is one of the most common directions of instability following a traumatic event. Although the incidence of shoulder dislocation is similar between young and elderly patients, most studies have traditionally focused on young patients due to relatively high rates of recurrent dislocations in this population. However, shoulder dislocations in older patients also require careful evaluation and treatment selection because they can lead to persistent pain and disability due to rotator cuff tears and nerve injuries. This article provides an overview of the nature and pathology of acute primary anterior shoulder dislocation, widely accepted management modalities, and differences in treatment for young and elderly patients.

Sweet's syndrome: a clinical entity need to discriminate against acute haematogenous periprosthetic joint infection

Sweet's syndrome (SS) or acute febrile neutrophilic dermatosis is an uncommon condition. It is characterized by fever, polymorphonuclear leukocytosis, painful erythematous cutaneous plaques, and dense dermal infiltrate of neutrophils without vasculitis at the site of skin lesions. Lesions in SS might enlarge and coalesce with increasing dermal oedema, resulting in pseudo-vesicular appearance mimicking joint infections. Here, a rare case of SS mimicking acute haematogenous periprosthetic infection in a 74-year-old woman with a history of total knee arthroplasty is reported. This report aims to elaborate clinical various manifestations of SS in a patient with a history of total knee arthroplasty. In addition, this report describes how to discriminate inflammation between SS and periprosthetic joint infection. Level of evidence V.

An unusual mechanism of coracoid fracture in a beginner golfer

Golfers may injure themselves as a result of repetitive asymmetrical loads exerted on the body by poor swing mechanics. If the repetitive sub-maximal loading is not removed, this repetitive loading will exceed the adaptive capacity of bone, eventually resulting in a stress fracture. Stress fracture of the scapula due to golfing is extremely rare. Only two cases of acromion fracture have been reported. A rare case of nontraumatic coracoid fracture in a 50-year-old female beginner golfer is reported here. The mechanism of injury is also discussed. Level of evidence Level IV.

Interferon β protects against avascular osteonecrosis through interleukin 6 inhibition and silent information regulator transcript-1 upregulation

Synovitis of the affected joint is a common in avascular osteonecrosis (AVN). Increased levels of pro-inflammatory cytokine interleukin-6 (IL-6) have been reported in AVN, but the mechanism of this increase remains unclear. Silent information regulator transcript-1 (SIRT1), an NAD-dependent deacetylase, inhibits the release of inflammatory cytokines. Interferon β (IFN-β) has clear anti-inflammatory properties. We sought to investigate the effects of IFN-β treatment on AVN and to evaluate the specific signal pathway relating to IL-6 and SIRT1 affected during AVN. Using a dissection microscope, AVN was surgically induced in the distal femurs of mice. Exogenous IFN-β was administered to the model mice. The effects of exogenous IFN-β on AVN model mice were assessed using hematoxylin eosin and safranin-O staining, and bone resorption activity was measured using tartrate-resistant acid phosphatase (TRAP) and CD68 staining. Western blots, real-time RT-PCR, and immunohistochemical staining were performed to evaluate the production of SIRT1 and IL-6 in tissues. The RAW 264.7 cell line and bone marrow derived osteoclasts treated with exogenous IFN-β. Histological findings indicated well preserved trabecular bone and decreased osteoclast bone resorption activity in IFN-β treated mice compared with mice in the AVN group. Treatment with IFN-β increased SIRT1 expression and inhibited secretion of IL-6 in this AVN mouse model. IFN-β decreased IL-6 secretion by activating SIRT1 in the RAW 264.7 cell and bone marrow derived osteoclasts. Our work suggests that IFN-β could be used to treat AVN and that both SIRT1 and IL-6 are useful targets for treating patients with AVN.

Intra-articular osteochondroma of the posteroinferior femoral neck associated with hip joint osteochondromatosis: A case report

Osteochondromas are usually extra-articular lesions originating from the metaphysis of long bones. Intra-articular osteochondromas may also occur, causing pain and discomfort and restricting the range of motion. Osteochondromas of the femoral neck are intra-articular lesions that are difficult to access for surgical resection, particularly when located posteriorly. We herein present a rare case of an intra-articular osteochondroma involving the posteroinferior aspect of the femoral neck associated with secondary synovial osteochondromatosis (SOC) of the hip joint in a 25-year-old woman. Determining the optimal treatment was difficult due to the high risk of avascular necrosis (AVN) following surgical excision. The patient was successfully treated with arthroscopic surgery and she remained in good condition at 2 years postoperatively, with a full range of motion of the hip joint, and without signs of limping, recurrence of the SOC, or AVN of the femoral head.

Effect of greater trochanteric epiphysiodesis after femoral varus osteotomy for lateral pillar classification B and B/C border Legg-Calvé-Perthes disease: A retrospective observational study

This is a retrospective observational study. Greater trochanteric epiphysiodesis (GTE) has been recommended to prevent Trendelenburg gait and limitation of the hip joint motion due to trochanteric overgrowth after femoral varus osteotomy (FVO) in Legg-Calvé-Perthes disease (LCPD). However, capital femoral physeal arrest frequently occurs in patients with severe disease (lateral pillar C), so GTE might not be as effective in these patients. The aim of this study was to compare trochanteric growth inhibition due to GTE after FVO between 2 age groups (<8 or >8 years) in patients with lateral pillar B and B/C border LCPD and evaluate the effectiveness of GTE compared with the normal, unaffected hip.This study included 19 children with lateral pillar B and B/C border LCPD in 1 leg who underwent FVO followed by GTE. Of the 19 children, 9 underwent GTE before the age of 8 years and 10 underwent GTE after 8 years of age. On radiographs taken at the immediate postoperative period and at skeletal maturity, the articulo-trochanteric distance (ATD), center-trochanteric distance (CTD), and neck-shaft angle (NSA) were compared between the 2 age groups. The amount of correction was compared between groups. The contralateral, unaffected hip was used as a control for trochanteric growth. The patients were clinically evaluated with Iowa hip score at the final follow-up.There was no significant difference between the 2 age groups in terms of time to GTE, length of follow-up, or lateral pillar classification. In the affected hip, the amount of correction of the ATD, CTD, and NSA was significantly greater in patients < 8 years than in patients > 8 years. However, in the unaffected hip, the change in the ATD, CTD, and NSA did not differ significantly between the 2 groups.We suggest that FVO followed by GTE for lateral pillar B and B/C border LCPD in patients under the age of 8 years can affect growth of the greater trochanter. However, effective growth inhibition due to GTE was not achieved after 8 years of age.

Functional outcomes of Gartland III supracondylar humerus fractures with early neurovascular complications in children: A retrospective observational study

This was a retrospective observational study. The aim of this study was to evaluate functional outcomes in children treated for Gartland III supracondylar humerus (SCH) fracture with neurovascular (NV) injuries using validated outcome measures. A secondary goal was to determine whether clinical parameters such as age at injury, sex, weight, fracture site, and/or direction of displacement could predict NV injury at the time of fracture or long-term functional outcomes in these patients.One hundred fifty-four patients of Gartland III SCH fractures between March 2004 and May 2013 were studied retrospectively. The patients were divided into 2 groups according to the presence of NV injury. Medical records and radiographs were reviewed to assess several parameters, including age, sex, weight, treatment intervention, the extremity involved, direction of fracture displacement, and NV injury. Functional outcome was assessed on final follow-up using the Pediatric Outcomes Data Collection Instrument (PODCI) and Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) outcome measures. Statistical analysis was used to determine the relationship between NV injury and functional outcomes.There were 33 cases with Gartland III SCH fracture associated with NV injuries (10 cases of vascular compromise, 14 cases of neural injury, and 9 cases involving both vascular compromise and neural injury). There were significant differences between the 2 groups in age (P  =  .048), weight (P  =  .009), and direction of displacement (P  =  .004). Vascular compromise and median nerve injury were most common in fractures with posterolateral displacement, and radial nerve injuries were common in fractures with posteromedial displacement. The mean global function score in the PODCI was 91.4 points, and the mean Quick DASH score was 11.7 points, with excellent functional outcomes. No differences in outcomes were identified based upon age, fracture site, sex, weight, direction of displacement, or operative technique in NV injury patients (P > .05).The majority of patients with Gartland III SCH fractures associated with NV injuries returned to a high functioning level after treatment of their injuries. NV injury does not appear to influence functional outcomes. Good functional results can be expected regardless of age, fracture site, sex, weight, direction of displacement, and operative technique.

Suprascapular nerve entrapment caused by an intraosseous ganglion of the scapula: A case report

RATIONALE

Suprascapular nerve compression is a rare but important entity that is often missed in clinical practice. Nerve dysfunction caused by an intraosseous ganglion of the glenoid is extremely rare, to the best of our knowledge, only 1 case of suprascapular nerve entrapment due to an intraosseous ganglion cyst has been reported previously in the published literature.

PATIENT CONCERNS

We report a 61-year-old woman who had complained right shoulder pain that lasted over 3 years which was exacerbated by overhead activities.

DIAGNOSES

We diagnosed it as suprascapular nerve entrapment at the spinoglenoid notch caused by an intraosseous ganglion of the scapula.

INTERVENTIONS

Plain X-ray, computed tomography, magnetic resonance imaging (MRI), and electromyography (EMG) of the shoulder.

OUTCOMES

She undertook surgical excision with curettage of the cyst. The infraspinatus fossa dull pain subsided immediately after surgery. No recurrence of the cystic lesion was noted on follow-up plain radiograph and MRI performed 18 months postoperatively. Shoulder external rotation strength was graded as 5 of 5.

LESSIONS

Intraosseous ganglion of the glenoid can cause compression of the suprascapular nerve when the lesion is expanded toward the spinoglenoid notch. The EMG study confirmed compression of the suprascapular nerve. The patient showed clinical and radiologic improvement after surgical decompression with no recurrence.

The role of arthroscopy in the dysplastic hip-a systematic review of the intra-articular findings, and the outcomes utilizing hip arthroscopic surgery

Acetabular dysplasia is one of the most common sources of hip arthritis. With the recent innovation in hip arthroscopy, the question has been raised whether arthroscopy can be used to treat dysplastic hip conditions. The purposes of this systematic review are (i) describe the prevalence of intra-articular pathologies and (ii) report the outcomes of dysplastic hip treatment with hip arthroscopy as a sole treatment. Medical databases were searched for articles including arthroscopic findings and treatment of dysplastic hip with predetermined criteria. PubMed, Ovid database and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched up until 7 January 2015. Two reviewers independently assess the eligibility of retrieved studies using titles, abstracts and full-text articles. Thirteen studies were eligible to be included for the systematic review. Overall, labral tear was the most common pathology with a prevalence rate of 77.3%. All of the four studies describing arthroscopic treatment for only borderline dysplasia reported favorable outcome. With regard to more severely dysplastic hips, two out of three studies reported acceptable outcomes while one study reported negative results. This review indicates that intra-articular pathology is commonly observed in symptomatic dysplastic hips with a labral tear being the most common pathology. Arthroscopic treatment of borderline dysplasia could provide benefits whereas treatment of more dysplastic hips is controversial. Nevertheless, there is a lack of evidence for using arthroscopy alone in hips with a center edge angle <20°. Level IV, systematic review of Level IV studies.

Concomitant calcaneo-cuboid-cuneiform osteotomies and the modified Kidner procedure for severe flatfoot associated with symptomatic accessory navicular in children and adolescents

BACKGROUND

Accessory navicular can become symptomatic in childhood, and in some cases, the condition is associated with progressive flattening of the longitudinal arch. Moreover, some severe, rigid flatfoot deformities are associated with an accessory navicular. We investigated the results of concomitant calcaneo-cuboid-cuneiform osteotomies (triple C) and the modified Kidner procedure for severe flatfoot associated with a symptomatic accessory navicular in children and adolescents.

METHODS

Twenty-one feet of 13 patients (nine boys, four girls; mean age 12.7 years) with severe flatfoot associated with a symptomatic accessory navicular who were treated with concomitant triple C and the modified Kidner procedure were evaluated based on clinical and radiographic examinations preoperatively and at a mean follow-up of 22.4 months (range, 12-36 months). We measured 12 variables on the anteroposterior (AP) and lateral weight-bearing radiographs, and we used the American College of Foot and Ankle Surgeons (ACFAS) score for clinical assessment.

RESULTS

We found significant improvements (p < 0.001) in eight of the 12 radiographic measurements: the AP talo-first metatarsal (MTT) angle, AP talo-navicular coverage angle, AP talo-calcaneal angle, lateral talo-first MTT angle, calcaneal pitch, lateral talo-calcaneal angle, lateral talo-horizontal angle, and naviculo-cuboid overlap. Average ACFAS scores were significantly improved at the time of the last follow-up (p < 0.001). The only complication was overcorrection of the hindfoot in one patient.

CONCLUSIONS

Concomitant triple C and the modified Kidner procedure result in favorable radiographic and clinical outcomes in the treatment of severe flatfoot associated with a symptomatic accessory navicular in children and adolescents.

Differential glucocorticoid responses of CYP3A23 and CYP3A2 are mediated by selective binding of orphan nuclear receptors

CYP3A2 and CYP3A23 are two cytochrome P450 genes in rat that are differentially regulated in both their constitutive activities and their responsiveness to glucocorticoids, the prototypic CYP3A inducers. CYP3A2 displays 20-25% of the response to glucocorticoids as CYP3A23 despite extensive sequence homology in their 5'-regulatory regions. Promoter deletion analyses revealed that the CYP3A2 -57 to -168 region, homologous to the CYP3A23 dexamethasone-responsive region, mediated its low level activation. When this region was analyzed by DNase I footprinting, three binding sites were shown to correspond to the functional elements described for CYP3A23: DexRE-1, DexRE-2, and Site A (J. M. Huss and C. B. Kasper (1998) J. Biol. Chem. 273: 16155-16162). The CYP3A2 DexRE-2 and Site A elements bear two mismatches each from the CYP3A23 elements but displayed similar binding patterns in footprinting and gel-shift analyses as their CYP3A23 counterparts. The region containing 3A2DexRE-1 has six mismatches and displayed unique footprinting and gel-shift patterns compared to 3A23DexRE-1. Functional assays revealed that four mismatches within the DexRE-1 and DexRE-2 elements accounted for the differential inducibility of the two isoforms. We propose that the reduced responsiveness of CYP3A2 is the result of preferential binding of COUP-TF at the CYP3A2 DexRE-1 site. In contrast, CYP3A23 DexRE-1 associates with an accessory factor(s) that acts in concert with downstream sites to mediate the strong glucocorticoid induction response observed for CYP3A23. Site A mismatches did not influence induction magnitude but were responsible for basal activity differences. Higher CYP3A23 basal activity appears to be due to an E-box in 3A23SiteA that interacts with USF1, a ubiquitous bHLH/leucine zipper transcription factor. This site is disrupted in the corresponding 3A2SiteA. Hence, 4 nucleotide mismatches within two elements account for the difference in glucocorticoid induction, and a single mismatch is responsible for the fivefold difference in the basal activities of CYP3A2 and CYP3A23.

Analysis of PTEN mutations and deletions in B-cell non-Hodgkin's lymphomas

The PTEN gene is involved in 10q23 deletions in several types of cancer, including glioma, melanoma, endometrial and prostate carcinomas. The PTEN gene product is a dual-specificity phosphatase with putative tumor suppressor function. Deletions and rearrangements of 10q22-25 have been reported in approximately 5%-10% of non-Hodgkin's lymphomas (NHLs), raising the possibility of PTEN involvement in these tumors. In order to address this question, we analyzed a panel of NHLs (n = 74) representative of the main histologic subtypes for mutations and homozygous deletions of PTEN. We report somatic coding/splice site mutations in 20% (2 of 10) of Burkitt's lymphoma cell lines and in 3% (2 of 64) of primary NHL cases analyzed. No homozygous deletions were found in these tumors. Interestingly, this study showed that cytogenetically characterized NHL cases (n = 6) with 10q22-q25 abnormalities displayed neither biallelic deletions nor mutations of PTEN. These results suggest that a tumor suppressor gene distinct from PTEN may be involved in 10q deletions in this subgroup of NHL cases.

Allelic loss of chromosome 10q23 is associated with tumor progression in breast carcinomas

To determine the status of chromosome 10q23 in primary breast carcinomas, in situ and invasive carcinomas were analysed for allelic loss using microsatellite markers spanning the 10q23 region. No LOH was seen in pure intraductal carcinomas (0/20 cases). On the other hand, LOH was observed in 40% (17/42) of invasive carcinomas (P = 0.0005). Interestingly, in situ lesions found in invasive tumors displayed LOH. Allelic loss was also significantly associated with loss of the estrogen receptor (P = 0.011). Thus, loss of the 10q23 is strongly associated with tumor progression.

Point mutation and homozygous deletion of PTEN/MMAC1 in primary bladder cancers

A new tumor suppressor gene PTEN/MMAC1 was recently isolated at chromosome 10q23 and found to be inactivated by point mutation or homozygous deletion in glioma, prostate and breast cancer. PTEN/MMAC1 was also identified as the gene predisposing to Cowden disease, an autosomal dominant cancer predisposition syndrome associated with an increased risk of breast, skin and thyroid tumors and occasional cases of other cancers including bladder and renal cell carcinoma. We screened 345 urinary tract cancers by microsatellite analysis and found chromosome 10q to be deleted in 65 of 285 (23%) bladder and 15 of 60 (25%) renal cell cancers. We then screened the entire PTEN/MMAC1 coding region for mutation in 25 bladder and 15 renal cell primary tumors with deletion of chromosome 10q. Two somatic point mutations, a frameshift and a splicing variant, were found in the panel of bladder tumors while no mutation was observed in the renal cell carcinomas. To screen for homozygous deletion, we isolated two polymorphic microsatellite repeats from genomic BAC clones containing the PTEN/MMAC1 gene. Using these new informative markers, we identified apparent retention at the gene locus indicative of homozygous deletion of PTEN/MMAC1 in four of 65 bladder and 0 of 15 renal cell tumors with LOH through chromosome 10q. Identification of the second inactivation event in six bladder tumors with LOH of 10q implies that the PTEN/MMAC1 gene is occasionally involved in bladder tumorigenesis. However, the low frequency of biallelic inactivation suggests that either PTEN/MMAC1 is inactivated by other mechanisms or it is not the only target of chromosome 10q deletion in primary bladder and renal cell cancer.

Homozygous deletion of the PTEN tumor suppressor gene in a subset of prostate adenocarcinomas

A novel tumor suppressor gene, PTEN, which encodes a dual-specificity protein phosphatase, has recently been identified on chromosome 10q23. We have previously shown that both alleles of this gene are inactivated in three of four prostate cancer cell lines tested. To evaluate the role of inactivation of this gene in primary stage B prostate cancers, 60 cases were analyzed using Southern blotting with PTEN probes and microsatellites on 10q23. Eight of 60 cases had homozygous deletions by Southern blotting. In three of these cases, homozygous deletion was confirmed by apparent retention of heterozygosity at PTEN with loss of heterozygosity at telomeric and centromeric loci. In the remaining five cases, microsatellite analysis was consistent with homozygous deletion. Loss of heterozygosity at PTEN was found in only two cases both by microsatellite analysis and quantitative Southern blotting. No small mutations within PTEN exons were found in any tumors exhibiting alterations on 10q23. Thus, inactivation of the PTEN gene by homozygous deletion occurs in approximately 10-15% of primary stage B prostate carcinomas.

Somatic mutations of PTEN in glioblastoma multiforme

Alterations of the PTEN gene occur in glioblastoma multiforme. To determine the frequency of PTEN alteration, 34 consecutive glioblastomas were studied in detail. Sequencing each of the nine exons amplified from tumor DNA revealed 11 mutations. Analysis of polymorphic markers within and surrounding the PTEN gene identified an additional four homozygous deletion mutations. Loss of heterozygosity (LOH) was observed in 25 of 34 (74%) cases. All mutations occurred in the presence of LOH. PTEN was mutated in 44% (15 of 34) of all glioblastomas studied and 60% (15 of 25) of tumors with LOH on 10q. Thus, PTEN appears to be the major target of inactivation on chromosome 10q in glioblastoma multiforme.

Mutations in PTEN are frequent in endometrial carcinoma but rare in other common gynecological malignancies

Loss of heterozygosity of chromosome 10q has been reported in approximately 40% of endometrial carcinomas. PTEN, a candidate tumor suppressor gene located at chromosome 10q23.3, was recently identified and found to be homozygously deleted or mutated in several different types of human tumors. To determine if PTEN is a target of 10q loss of heterozygosity in carcinomas of the endometrium, we examined 32 primary endometrial carcinomas for mutations in PTEN. The tumors included the two major histopathological types of endometrial carcinoma: endometrioid (n = 26; 14 microsatellite instability (MI)-positive and 12 MI-negative) and serous (n = 6). Overall, mutations were detected in 50% of the endometrial carcinomas we analyzed. Mutations were present in 12 of 14 (86%) MI-positive and 4 of 12 (33%) MI-negative endometrioid tumors. Furthermore, mutations were found in all three histological grades of MI-positive endometrioid carcinoma. All six serous endometrial carcinomas lacked detectable mutations. To evaluate the role of PTEN in other common malignancies of the female genital tract, 12 serous ovarian carcinomas and 10 squamous cervical carcinomas were analyzed and were negative for mutations. Our results support PTEN as a tumor suppressor gene and suggest that mutations in PTEN play a significant role in the pathogenesis of the endometrioid type of endometrial carcinoma.

P-TEN, the tumor suppressor from human chromosome 10q23, is a dual-specificity phosphatase

Protein tyrosine phosphatases (PTPs) have long been thought to play a role in tumor suppression due to their ability to antagonize the growth promoting protein tyrosine kinases. Recently, a candidate tumor suppressor from 10q23, termed P-TEN, was isolated, and sequence homology was demonstrated with members of the PTP family, as well as the cytoskeletal protein tensin. Here we show that recombinant P-TEN dephosphorylated protein and peptide substrates phosphorylated on serine, threonine, and tyrosine residues, indicating that P-TEN is a dual-specificity phosphatase. In addition, P-TEN exhibited a high degree of substrate specificity, showing selectivity for extremely acidic substrates in vitro. Furthermore, we demonstrate that mutations in P-TEN, identified from primary tumors, tumor cells lines, and a patient with Bannayan-Zonana syndrome, resulted in the ablation of phosphatase activity, demonstrating that enzymatic activity of P-TEN is necessary for its ability to function as a tumor suppressor.

Germline mutations of the PTEN gene in Cowden disease, an inherited breast and thyroid cancer syndrome

Cowden disease (CD) is an autosomal dominant cancer predisposition syndrome associated with an elevated risk for tumours of the breast, thyroid and skin. Lhermitte-Duclos disease (LDD) cosegregates with a subset of CD families and is associated with macrocephaly, ataxia and dysplastic cerebellar gangliocytomatosis. The common feature of these diseases is a predisposition to hamartomas, benign tumours containing differentiated but disorganized cells indigenous to the tissue of origin. Linkage analysis has determined that a single locus within chromosome 10q23 is likely to be responsible for both of these diseases. A candidate tumour suppressor gene (PTEN) within this region is mutated in sporadic brain, breast and prostate cancer. Another group has independently isolated the same gene, termed MMAC1, and also found somatic mutations throughout the gene in advanced sporadic cancers. Mutational analysis of PTEN in CD kindreds has identified germline mutations in four of five families. We found nonsense and missense mutations that are predicted to disrupt the protein tyrosine/dual-specificity phosphatase domain of this gene. Thus, PTEN appears to behave as a tumour suppressor gene in the germline. Our data also imply that PTEN may play a role in organizing the relationship of different cell types within an organ during development.

PTEN, a putative protein tyrosine phosphatase gene mutated in human brain, breast, and prostate cancer

Mapping of homozygous deletions on human chromosome 10q23 has led to the isolation of a candidate tumor suppressor gene, PTEN, that appears to be mutated at considerable frequency in human cancers. In preliminary screens, mutations of PTEN were detected in 31% (13/42) of glioblastoma cell lines and xenografts, 100% (4/4) of prostate cancer cell lines, 6% (4/65) of breast cancer cell lines and xenografts, and 17% (3/18) of primary glioblastomas. The predicted PTEN product has a protein tyrosine phosphatase domain and extensive homology to tensin, a protein that interacts with actin filaments at focal adhesions. These homologies suggest that PTEN may suppress tumor cell growth by antagonizing protein tyrosine kinases and may regulate tumor cell invasion and metastasis through interactions at focal adhesions.

Dexamethasone responsiveness of a major glucocorticoid-inducible CYP3A gene is mediated by elements unrelated to a glucocorticoid receptor binding motif

Elements responsible for dexamethasone responsiveness of CYP3A23, a major glucocorticoid-inducible member of the CYP3A gene family, have been identified. DNase I footprint analysis of the proximal promoter region revealed three protected sites (sites A, B, and C) within the sequence defined by -167 to -60. Mutational analysis demonstrated that both sites B and C were necessary for maximum glucocorticoid responsiveness and functioned in a cooperative manner. Interestingly, neither site contained a glucocorticoid responsive element. Embedded in site C was an imperfect direct repeat (5'-AACTCAAAGGAGGTCA-3'), showing homology to an AGGTCA steroid receptor motif, typically recognized by the estrogen receptor family, while site B contained an ATGAACT direct repeat; these core sequences were designated dexamethasone response elements 1 and 2 (DexRE-1 and -2), respectively. Neither element has previously been associated with a glucocorticoid-activated transcriptional response. Conversion of the DexRE-1 to either a perfect thyroid hormone or vitamin D3 responsive element further enhanced induction by dexamethasone. Gel-shift analysis demonstrated that glucocorticoid receptor did not associate with either DexRE-1 or -2; hence, glucocorticoid receptor does not directly mediate glucocorticoid induction of CYP3A23. These unusual features suggest an alternate pathway through which glucocorticoids exert their effects.

Effects of third-order spherical aberration on the 3-D incoherent optical transfer function

We derive the expression for the 3-D incoherent optical transfer function when third-order spherical aberration is present. The normalized verision of the transfer function is numerically calculated for various amounts of spherical aberration. We find the effects of the aberration to be highly dependent on the spatial frequency in the longitudinal direction. We also calculate a structure content parameter, as a quality criterion, from the normalized transfer function. The structure content parameter dependence on spherical aberration is well-fit by a simply Cauchy curve for aberrations out to two waves at the margin.

The hepatotoxicity of valproic acid and its metabolites in rats. II. Intermediary and valproic acid metabolism

The role of metabolites in valproic acid (VPA)-associated hepatotoxicity was studied in rats. The most steatogenic mono-unsaturated metabolite, 4-en-VPA, caused the greatest changes in indicators of beta-oxidation inhibition (dicarboxylic aciduria, beta-hydroxybutyrate reduction); however, the biochemical effects were much less pronounced than those reported for hypoglycin. Steatosis in VPA-treated rats occurred only at nearly lethal doses. Phenobarbital induction was confirmed as a predisposing factor; however, it appeared not to greatly enhance production of 4-en-VPA or its recognized metabolites, which collectively comprised only 0.5% of the dose. Elevated oxo-VPA metabolites in serum and 2-propylglutarate in liver were associated with toxicity. Among the newly discovered minor metabolites with possible biologic effects were diols (suggesting epoxide precursors) and a series of dienes and trienes. The rarity of severe human hepatotoxicity indicates that, normally, beta-oxidation inhibition is compensated, and cellular defense mechanisms prevail over reactive metabolites. This requires adequate nutrition; on the other hand, severe glycogen depletion may promote toxicity by compromising glucuronidation, the major clearance route. Other literature comments are also supported: (i) caution is indicated for patients with various unusual congenital disorders (e.g., organic acidurias or other mitochondrial defects), and (ii) monotherapy obviates both the predisposition to toxicity and the requirement of large doses to produce therapeutic levels.

Aspects of the metabolism of valproic acid

The metabolic routes of valproic acid (VPA) were studied by i.p. administration of the mono-unsaturated and hydroxylated metabolites to rats. Conjugation with glucuronic acid was a major metabolic route for VPA and its metabolites. Conjugation with glycine was a minor route for VPA, but was of more importance with the unsaturated metabolites. The hydroxylated metabolites, which were further oxidized to oxo-derivatives and subsequently to the dicarboxylic acids, were not metabolically dehydrated to form unsaturated metabolites. Multiple metabolic pathways, including dehydrogenation, isomerization, hydration, hydroxylation, reduction and epoxidation were inferred from the metabolites obtained after dosage of the unsaturated metabolites. Six dien-VPA metabolites were detected in VPA-treated rats, four of which are present in patients. It was concluded that 3-en-VPA and 4-en-VPA pathways, originating through dehydrogenation, are distinct from the omega- and omega-1-hydroxylation pathways. Enzyme induction from co-administration of phenobarbital caused enhancement of the minor omega-1-oxidation pathway, yet the largest effect on clearance came from increases in glucuronidation. Mitochondrial processes were unaffected, resulting in decreased contribution to the total clearance.