Sternal cleft and pectus excavatum: an overlooked congenital association?

BACKGROUND

Sternal cleft (SC), a rare thoracic malformation, is associated with pectus excavatum (PE) in 2.6-5% of cases. It remains unclear if these conditions are congenitally linked or if SC repair triggers PE. To investigate the potential higher frequency of PE in SC cases, we conducted a retrospective study of our SC patients.

METHODS

We assessed PE incidence, progression, and management in SC patients treated at our institute from 2006 to 2022. When available, we collected pre-SC repair CT scan data, calculating the Haller Index (HI) and Correction Index (CI) and compared them to a selected control group.

RESULTS

Among 8 SC patients, 7 had concomitant PE (87.5%), varying in severity. PE management ranged from observation to thoracoplasty, depending on its degree. We observed a significant pre-operative CI difference between SC and control group patients (p < 0.00001). In the last two SC repair cases, we attempted concurrent PE prevention or treatment.

CONCLUSION

Our findings suggest an underestimated association between PE and SC in the existing literature. SC patients may exhibit a predisposition to PE from birth, which may become more apparent with growth after SC repair. Consequently, PE prevention or treatment should be considered during SC repair procedures.

The Radiological and Histological Phenotype of Skeletal Abnormalities in Fetal ARCN1-Related Syndrome

Mutations in ARCN1 give rise to a syndromic disorder with rhizomelic short stature with microretrognathia and developmental delay. ARCN1 encodes the delta subunit of the coat protein I complex, which is required for intracellular trafficking of collagen 1 and which may also be involved in the endoplasmic reticulum (ER) stress response. In this paper we describe for the first time the skeletal histological abnormalities in an 18-week-old fetus with an ARCN1 mutation, and we suggest that the skeletal phenotype in ARCN1-related syndrome has more resemblance with ER stress than with a defect in collagen 1 metabolism.

Pectus Arcuatum: A Pectus Unlike Any Other

BACKGROUND

Pectus arcuatum is often mistaken for a type of pectus carinatum. However, pectus arcuatum is a unique clinical form of pectus caused by premature obliteration of the sternal sutures (manubrial sternum, four sternebrae and xiphoïd process), whereas pectus carinatum is due to abnormal growth of the costal cartilage. In order to better describe pectus arcuatum, we analysed the files of patients with pectus arcuatum followed in our centers.

METHODS

Multicenter retrospective study of young patients' files diagnosed with pectus arcuatum.

RESULTS

The clinical diagnosis of pectus arcuatum was made in 34 patients with a mean age at diagnosis of 10.3 years (4-23 years). A chest profile X-ray or a CT scan was performed in 16 patients (47%) and confirmed the diagnosis of PA by the presence of a sternal fusion. It was complete in 12 patients. A malformation was associated in 35% of cases (Noonan syndrome 33%, scoliosis 25% or cardiopathy 16%). 11 patients (32%) had a family history of skeletal malformation. Orthopedic treatment was initiated in 3 patients without any success. 11 patients underwent surgical correction, which was completed in 7 of them.

CONCLUSION

The diagnosis of pectus arcuatum is based on clinical experience and if necessary, on a profile chest X-ray showing the fusion of the sternal pieces. It implies the search for any associated malformations (musculoskeletal, cardiac, syndromic). Bracing treatment is useless for pectus arcuatum. Corrective surgery, based on a sternotomy associated with a partial chondro-costal resection, can be performed at the end of growth.

LEVEL OF EVIDENCE

IV.

Evaluation of congenital rib anomalies with multi-detector computed tomography in the Turkish population

BACKGROUND

This study aimed to evaluate the congenital anomalies of ribs in the Turkish population using multi-detector computed tomography (CT) and to reveal the prevalence and distribution of these anomalies according to sexes and body sides.

MATERIALS AND METHODS

This study included 1120 individuals (592 male, 528 female) over 18 who presented to our hospital with a suspicion of COVID-19 and who had thoracic CT. Anomalies such as a bifid rib, cervical rib, fused rib, Srb anomaly, foramen rib, hypoplastic rib, absent rib, supernumerary rib, pectus carinatum, and pectus excavatum, which were previously defined in the literature, were examined. Descriptive statistics were performed with the distribution of anomalies. Comparisons were made between the sexes and body sides.

RESULTS

A prevalence of 18.57% rib variation was observed. Females had 1.3 times more variation than males. Although there was a significant difference in the distribution of anomalies by sex (p = 0.000), there was no difference in terms of body side of anomaly (p > 0.05). The most common anomaly was the hypoplastic rib, followed by the absence of a rib. While the incidence of the hypoplastic rib was similar in females and males, 79.07% of the absent ribs was seen in females (p < 0.05). The study also includes a rare case of bilateral first rib foramen. At the same time, this study includes a rare case of rib spurs extending from the left 11th rib to the 11th intercostal space.

CONCLUSIONS

This study demonstrates detailed information about congenital rib anomalies in the Turkish population, which may vary between people. Knowing these anomalies is essential for anatomy, radiology, anthropology, and forensic sciences.

A case report of surgical repair of cleft sternum in a child

BACKGROUND

Sternal cleft is a rare congenital chest wall defect, occurring in only 1 in 100,000 live births, and very few cases have been described in the literature. Surgery is indicated to protect the heart and major vessels. This study provides a clinical case presentation and literature review of sternal cleft.

METHODS

This is a review of a case presenting with chest wall defects. The patient underwent a primary cleft closure at Children's Hospital No. 2. All perioperative data were collected and presented.

CASE PRESENTATION

A healthy 3-year-old girl was admitted to Children's Hospital No. 2 with an abnormal chest shape, observed by her mother. An inverted "U"-shaped defect of the sternum was visible, and the extent of the defect could be observed by chest X-ray and spiral computed tomography (CT) imaging of the chest. After the diagnosis was confirmed, the patient was prepared for primary closure surgery. We achieved primary closure, the patient discontinued oxygen 5 days after surgery, and the patient was discharged 14 days after surgery.

CONCLUSION

Chest wall malformations can present with various phenotypes, although congenital sternal cleft is a rare anomaly. This defect is often asymptomatic. Depending on the size of the defect, a sternal cleft may be treated or monitored. The optimal treatment during early life is surgical repair to achieve primary closure.

A calibrated deep learning ensemble for abnormality detection in musculoskeletal radiographs

Musculoskeletal disorders affect the locomotor system and are the leading contributor to disability worldwide. Patients suffer chronic pain and limitations in mobility, dexterity, and functional ability. Musculoskeletal (bone) X-ray is an essential tool in diagnosing the abnormalities. In recent years, deep learning algorithms have increasingly been applied in musculoskeletal radiology and have produced remarkable results. In our study, we introduce a new calibrated ensemble of deep learners for the task of identifying abnormal musculoskeletal radiographs. Our model leverages the strengths of three baseline deep neural networks (ConvNet, ResNet, and DenseNet), which are typically employed either directly or as the backbone architecture in the existing deep learning-based approaches in this domain. Experimental results based on the public MURA dataset demonstrate that our proposed model outperforms three individual models and a traditional ensemble learner, achieving an overall performance of (AUC: 0.93, Accuracy: 0.87, Precision: 0.93, Recall: 0.81, Cohen's kappa: 0.74). The model also outperforms expert radiologists in three out of the seven upper extremity anatomical regions with a leading performance of (AUC: 0.97, Accuracy: 0.93, Precision: 0.90, Recall:0.97, Cohen's kappa: 0.85) in the humerus region. We further apply the class activation map technique to highlight the areas essential to our model's decision-making process. Given that the best radiologist performance is between 0.73 and 0.78 in Cohen's kappa statistic, our study provides convincing results supporting the utility of a calibrated ensemble approach for assessing abnormalities in musculoskeletal X-rays.

Advanced MRI Techniques for Assessing Marrow Abnormalities of the Spine

It is important to review the physics of current MRI developments in nontraumatic spinal imaging and their specific applications for assessing the bone marrow. Techniques include chemical shift imaging and its use in differentiating aggressive from benign lesions and in confirming the presence of diffuse red marrow conversion, which may mimic diffuse marrow infiltration in metastatic disease. The principles of dynamic contrast MRI and its uses in multiple myeloma and discriminating between postoperative change/scarring versus recurrence in soft-tissue tumors warrant discussion. The basic physics of diffusion-weighted imaging (DWI) in bone marrow pathologies are distinguished from the principles of DWI as applied to solid organs, and DWI is used in the staging of multiple myeloma and in differentiating between benign versus malignant compressive vertebral fractures. The orthopaedic surgeon should be knowledgeable about whole-body MRI principles and its uses in staging multiple myeloma and sarcoma. Knowledge about PET-MRI principles and its limitations as well as its potential use in assessing the subchondral bone plate and bony remodeling is also important. This technique may play a role in the future for predicting progression to osteoarthritis.

Cervical digit in a child: A case report

BACKGROUND

A "digit-like" bone is a rare developmental anomaly that is usually seen in the pelvic or thoracic regions. Such an anomaly in the cervical spine is extremely rare and few cases have been reported. We present a patient with an anomalous bone posterior to a cervical vertebra. The patient was admitted to our hospital with a gradually growing hard neck mass and esthetic complaints. Physical examination, radiographs, reconstructed computed tomography, and magnetic resonance imaging revealed a digit-like bone posterior to the cervical spine. The patient was diagnosed with a "cervical digit." Through a posterior midline approach, the anomalous bone was excised because of its gradually increasing size and esthetic complaints.

RESULTS

Intraoperatively, the bony mass was found to have a pseudoarticulation with the spinous process of C5 (the fifth cervical vertebra). The specimen consisted of normal bone and cartilage. The child returned to a normal life postoperatively with no symptoms. There was no recurrence at the 2-year follow-up.

CONCLUSION

A congenital cervical digit is a rare deformity. A detailed clinical workup and advanced imaging examinations are useful for diagnosing such conditions. Esthetic complaints contribute to surgical indications. This is the first cervical digit managed with surgical excision of the anomalous bone and had a favorable outcome.

Complex Truncal Masses in the Setting of CLOVES Syndrome: Aesthetic and Functional Implications

BACKGROUND

Congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal abnormalities (CLOVES) is a complex overgrowth syndrome with dramatic aesthetic and functional implications. The truncal masses characteristic of CLOVES syndrome are described as vascular malformations or lipomatous lesions with variable vascular components. Herein, we describe our single-institution experience with surgical excision of CLOVES-related truncal masses and discuss future directions in treatment of these complex anomalies.

METHODS

A single-institution retrospective review was performed for patients diagnosed with CLOVES syndrome. Patients undergoing excision of truncal vascular malformations were included. Outcome measures included perioperative characteristics [estimated blood loss (EBL), specimen size/anatomic location, blood-product requirement], as well as length-of-stay [LOS], and complication profile. Mean follow-up was 23.4 months (range 4.2-44).

RESULTS

Three consecutive patients were reviewed, accounting for 4 surgical operations. One patient underwent two operations for two distinct masses. All lesions were located on the upper back or flank with various degrees of muscular involvement. One patient required no transfusions with an uneventful 2-day hospitalization. The remaining three patients had an EBL ranging from 1500 to 6450 mL, requiring 9-13 units of packed red blood cells and 5-8 units of fresh frozen plasma during LOS (averaging 5 days). Mean weight of resected masses was 6.26 lbs (range 2.04-12 lbs) and mass dimensions ranged between 1778.9 and 15,680 cm³. One patient with recurrence was subsequently treated with a combination of sclerotherapy and rapamycin, leading to significant mass reduction.

CONCLUSIONS

Management of CLOVES syndrome requires a collaborative and multimodal approach. Although surgical debulking is one treatment option, non-invasive medical modalities and sclerotherapy should be considered prior to surgical resection.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Broadening the phenotypic spectrum of POP1-skeletal dysplasias: identification of POP1 mutations in a mild and severe skeletal dysplasia

Processing of Precursor 1 (POP1) is a large protein common to the ribonuclease-mitochondrial RNA processing (RNase-MRP) and RNase-P (RMRP) endoribonucleoprotein complexes. Although its precise function is unknown, it appears to participate in the assembly or stability of both complexes. Numerous RMRP mutations have been reported in individuals with cartilage-hair hypoplasia (CHH) but, to date, only three POP1 mutations have been described in two families with features similar to anauxetic dysplasia (AD). We present two further individuals, one with severe short stature and a relatively mild skeletal dysplasia and another in whom AD was suspected. Biallelic POP1 mutations were identified in both. A missense mutation and a novel single base deletion were detected in proband 1, p.[Pro582Ser]:[Glu870fs*5]. Markedly reduced abundance of RMRP and elevated levels of pre5.8s rRNA was observed. In proband 2, a homozygous novel POP1 mutation was identified, p.[(Asp511Tyr)];[(Asp511Tyr)]. These two individuals show the phenotypic extremes in the clinical presentation of POP1-dysplasias. Although CHH and other skeletal dysplasias caused by mutations in RMRP or POP1 are commonly cited as ribosomal biogenesis disorders, recent studies question this assumption. We discuss the past and present knowledge about the function of the RMRP complex in skeletal development.

Congenital abnormalities of the ribs: evaluation with multidetector computed tomography

OBJECTIVE

To evaluate congenital abnormalities of ribs using multidetector computed tomography.

METHODS

The retrospective study was conducted at Mustafa Kemal University Research Hospital, Hatay, Turkey and comprised data of patients aged 1-45 years who attended the Radiology Department for computed tomography of the thorax between January 2010 and July 2013. Multiplanar reconstructions, maximum intensity projections, and 3-dimensional images were acquired to investigate numerical and structural abnormalities of the ribs of the patients who underwent multidetector computed tomography for a variety of indications.

RESULTS

The study comprised 650 patients. Of them, 231(35.5%) were female and 419(64.5%) male. The overall mean age was 20.9± 5.1years. However, data of 90(13.8%) patients was excluded from cervical rib evaluation and of 120(18.5%) from lumbar rib evaluation as these regions were out of the section because of the positioning. Finally, 560(86.5%) patients were included in the cervical rib evaluations, and 530(81.5%) in the lumbar rib evaluations. All the 650(100%) patients were included in the thoracic rib evaluations. Numerical abnormalities were observed in cervical ribs in 19(3.6%), in thoracic ribs in 1(0.15%) and in lumbar ribs in 7(1.3%) cases. The structural abnormalities were bifid rib in 44(6.7%) and fused type in 17(2.6%) cases.

CONCLUSIONS

Multidetector computed tomography enabled evaluation of the thoracic cage as a whole.

Loss of Type I Collagen Telopeptide Lysyl Hydroxylation Causes Musculoskeletal Abnormalities in a Zebrafish Model of Bruck Syndrome

Bruck syndrome (BS) is a disorder characterized by joint flexion contractures and skeletal dysplasia that shows strong clinical overlap with the brittle bone disease osteogenesis imperfecta (OI). BS is caused by biallelic mutations in either the FKBP10 or the PLOD2 gene. PLOD2 encodes the lysyl hydroxylase 2 (LH2) enzyme, which is responsible for the hydroxylation of lysine residues in fibrillar collagen telopeptides. This hydroxylation directs crosslinking of collagen fibrils in the extracellular matrix, which is necessary to provide stability and tensile integrity to the collagen fibrils. To further elucidate the function of LH2 in vertebrate skeletal development, we created a zebrafish model harboring a homozygous plod2 nonsense mutation resulting in reduced telopeptide hydroxylation and crosslinking of bone type I collagen. Adult plod2 mutants present with a shortened body axis and severe skeletal abnormalities with evidence of bone fragility and fractures. The vertebral column of plod2 mutants is short and scoliotic with compressed vertebrae that show excessive bone formation at the vertebral end plates, and increased tissue mineral density in the vertebral centra. The muscle fibers of mutant zebrafish have a reduced diameter near the horizontal myoseptum. The endomysium, a layer of connective tissue ensheathing the individual muscle fibers, is enlarged. Transmission electron microscopy of mutant vertebral bone shows type I collagen fibrils that are less organized with loss of the typical plywood-like structure. In conclusion, plod2 mutant zebrafish show molecular and tissue abnormalities in the musculoskeletal system that are concordant with clinical findings in BS patients. Therefore, the plod2 zebrafish mutant is a promising model for the elucidation of the underlying pathogenetic mechanisms leading to BS and the development of novel therapeutic avenues in this syndrome. © 2016 American Society for Bone and Mineral Research.

Restrictive Dermopathy: A Rare Disease with Unusual Radiographic Findings

The patient is a unique case presenting with presumed Restrictive Dermopathy (RD) and intracranial and adrenal calcifications, an association not previously described in the literature. This case postulates the possibility of additional radiographic features that can be included in the spectrum of RD or as secondary events from the underlying pathophysiology of RD.

The Chondroepitrochlearis Muscle: A Rare Cause of Axillary Vein Thrombosis and Lymphedema

The chondroepitrochlearis muscle is a rare anomaly of the pectoralis major crossing over the neurovascular bundle in the axilla. Often associated with other supernumerary muscles like the arch of Langer, it has been reported in the past as a cause of restriction of arm abduction, cosmetic defects and compression of the ulnary nerve. This case report describes the first known vascular complication due to a chondroepitrochlearis muscle, causing intermittent compression of the axillary vein and thrombosis, associated with pain, upper limb lymphedema, and impaired movements. The diagnosis was suspected from the medical history and confirmed by palpation and dynamic ultrasonography. Surgery was performed to divide the muscle slip with the help of lymphofluoroscopy to prevent damage to the lymphatic structures. Pain and impairment of movement disappeared within a few days after surgery and lymphedema decreased significantly.

Characterization of an acromesomelic dysplasia, Grebe type case: novel mutation affecting the recognition motif at the processing site of GDF5

Acromesomelic dysplasia, Grebe type is a very rare skeletal dysplasia characterized by severe dwarfism with marked micromelia and deformation of the upper and lower limbs, with a proximodistal gradient of severity. CDMP1 gene mutations have been associated with Grebe syndrome, Hunter-Thompson syndrome, Du Pan syndrome and brachydactyly type C. The proband is a 4-year-old boy, born of consanguineous Pakistani parents. Radiographic imaging revealed features typical of Grebe syndrome: severe shortening of the forearms with an acromesomelic pattern following a proximodistal gradient, with distal parts more severely affected than medial parts; hypoplastic hands, with the phalangeal zone more affected than the metacarpal zone; and severe hypoplastic tibial/femoral zones in both limbs. After molecular analyses, the p.Arg377Trp variant in a homozygous pattern was identified in the CDMP1 gene in the affected child. In silico and structural analyses predicted the p.Arg377Trp amino acid change to be pathogenic. Of the 34 mutations described in the CDMP1 gene, four different missense mutations have been associated with Grebe syndrome. The CDMP1 gene encodes growth differentiation factor 5 (GDF5), which plays a role in regulation of limb patterning, joint formation and distal bone growth. Homozygous mutations in the mature domain of GDF5 result in severe limb malformations such as the Grebe type or the Hunter-Thompson type of acromesomelic chondrodysplasia. The p.Arg377Trp mutation is located within the recognition motif at the processing site of GDF5 where the sequence RRKRR changes to WRKRR. The genotype-phenotype correlation allowed not only confirmation of the clinical diagnosis but also appropriate genetic counselling to be offered to this family.

[STERNAL CLEFT – REPORT OF THREE CASES]

During the last 25 years we surgically treated three patients with sternal cleft anomaly, aged from 6 weeks to 2 years. The aim of this case series is to present this extremely rare congenital anomaly and differences in the operative treatment of sternal cleft (SC) depending on patients age due to flexibility of the chest wall. Patients presented to us with signs of sternal cleft; displaced sternoclavicular articulations and paradoxical motion of the skin over the defect. Preoperatively we performed X-ray and computed tomography of the chest which revealed displaced sternoclavicular articulations with superior incomplete sternal cleft and echocardiography which showed orthotopic heart without malformations of the great vessels. Surgical treatment included primary closure in two infants and Sabiston’s technique in a two-year-old girl. All three patients were successfully operated without complications.

Validation of an Objective Assessment Instrument for Non-Surgical Treatments of Chest Wall Deformities

Depending on the severity of the condition and associated risk, surgical intervention may not always be the first choice. This is true for treating chest wall deformities such as pectus excavatum and pectus carinatum. For both conditions, novel non-surgical treatments have been developed to gradually alleviate the malformation making use of the elastic nature of the costal cartilages at an early age of the patient. To quantify the performance of such treatments, this paper introduces and discusses the development of a software-based instrument that utilizes 3D chest optical images (surface scans) as input and uses registration techniques to produce an objective gauge of a patient's physical improvement after undergoing treatments. Further discussed is an experiment designed to investigate the construct validity of the developed instrument.

Beyond osteogenesis imperfecta: Causes of fractures during infancy and childhood

Fractures in infancy or early childhood require prompt evaluation with consideration of accidental or non-accidental trauma as well as a large number of genetic disorders that predispose to fractures. Bone fragility has been reported in more than 100 genetic disorders, including skeletal dysplasias, inborn errors of metabolism and congenital insensitivity to pain. Most of these disorders are rare but often have distinctive clinical or radiographic findings to assist in the diagnosis. Gene sequencing is available, albeit connective tissue and skeletal dysplasia panels and biochemical studies are only helpful in a minority of cases. This article presents the clinical, radiographic, and molecular profiles of the most common heritable disorders other than osteogenesis imperfecta with increased bone fragility. In addition, the clinicians must consider non-heritable influences such as extreme prematurity, prenatal viral infection and neoplasia in the diagnostic process.

Feasibility of C2 Vertebra Screws Placement in Patient With Occipitalization of Atlas: A Tomographic Study

Occipitalization of atlas (OA) is a congenital disease with the possibility of anomalous bony anatomies and the C2 pedicle screw insertion is technically challenging. However, there are no existing literatures clarified the dimensions and angulations of the C2 pedicles, lamina and lateral masses for screw insertion in patients with OA. Therefore, the aim of this study was to assess the morphometric features of C2 for screw placement in OA to guide the use of surgical screws. Measurements of the OA patients on the computer tomography (CT) images including lamina angle, length and thickness, pedicle angle, length and thickness, and lateral mass thickness and length of the axis vertebra. The OA patients data were compared with age and gender matched cohort of randomly selected patients in a control group without OA. The picture archiving and communication system was used for all patients who had received cervical CT scanning between January 2001 and January 2015. Measurements were performed independently by 2 experienced observers who reviewed the CT scans and recorded the patients with OA. Statistical analysis was performed at a level of significance P < 0.05. A total of 73 patients (29 males and 44 females) were eligible to be included in the OA group. In most of the measurements the pathological cohort had significantly smaller values compared to the control group (P < 0.05). In the OA group, only 45% of the pedicles and 88% of the lamina had thicknesses bigger than 3.5 mm. Both groups had all pedicle and lamina lengths bigger than 12 mm. Regarding the length of the lateral mass, no value was bigger than 12 mm in the OA group, whereas 40% of the values in the control group were bigger than 12 mm. The average pedicle and laminar angles were 37° and 49° in the patients with OA, respectively. The variable anatomy in patients with OA needs to be taken into account when performing spinal stabilization as the C2 bony architectures are significantly smaller than normal. Anatomically, translaminar screw is a more viable option in comparison with pedicle screw for C2 fixation in OA. Nevertheless, the suitability should be fully assessed prior to surgery.

Mutations in DDX58, which encodes RIG-I, cause atypical Singleton-Merten syndrome

Singleton-Merten syndrome (SMS) is an autosomal-dominant multi-system disorder characterized by dental dysplasia, aortic calcification, skeletal abnormalities, glaucoma, psoriasis, and other conditions. Despite an apparent autosomal-dominant pattern of inheritance, the genetic background of SMS and information about its phenotypic heterogeneity remain unknown. Recently, we found a family affected by glaucoma, aortic calcification, and skeletal abnormalities. Unlike subjects with classic SMS, affected individuals showed normal dentition, suggesting atypical SMS. To identify genetic causes of the disease, we performed exome sequencing in this family and identified a variant (c.1118A>C [p.Glu373Ala]) of DDX58, whose protein product is also known as RIG-I. Further analysis of DDX58 in 100 individuals with congenital glaucoma identified another variant (c.803G>T [p.Cys268Phe]) in a family who harbored neither dental anomalies nor aortic calcification but who suffered from glaucoma and skeletal abnormalities. Cys268 and Glu373 residues of DDX58 belong to ATP-binding motifs I and II, respectively, and these residues are predicted to be located closer to the ADP and RNA molecules than other nonpathogenic missense variants by protein structure analysis. Functional assays revealed that DDX58 alterations confer constitutive activation and thus lead to increased interferon (IFN) activity and IFN-stimulated gene expression. In addition, when we transduced primary human trabecular meshwork cells with c.803G>T (p.Cys268Phe) and c.1118A>C (p.Glu373Ala) mutants, cytopathic effects and a significant decrease in cell number were observed. Taken together, our results demonstrate that DDX58 mutations cause atypical SMS manifesting with variable expression of glaucoma, aortic calcification, and skeletal abnormalities without dental anomalies.

Discordant Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome in identical twins - a case report and implications for reproduction in MRKH women

Infertility has previously been considered as an inevitable consequence of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. With modern assisted reproductive technology (ART) techniques becoming increasingly accessible, MRKH women have the opportunity for their own genetic offspring. The availability of such technology, however, increases the importance of understanding the aetiology of this complex condition. The literature debating the relevance of genetic versus post-zygotic events in the aetiology of MRKH syndrome is reviewed in the context of this report of monozygotic twins discordant for MRKH syndrome.

AN ISOLATED SUPERIOR STERNAL CLEFT IN A NEONATE IN WESTERN KENYA: CASE REPORT

Sternal cleft is a rare congenital anomaly and very few cases have been described especially in Africa. This is a case of an isolated superior sternal cleft in a term neonate in Western Kenya.

Cono-spondylar dysplasia: clinical, radiographic, and molecular findings of a previously unreported disorder

We report on a consanguineous Arab family in which three sibs had an unusual skeletal dysplasia characterized by anterior defects of the spine leading to severe lumbar kyphosis and marked brachydactyly with cone epiphyses. The clinical phenotype also included dysmorphic facial features, epilepsy, and developmental delay. This constellation likely represents a previously undescribed skeletal dysplasia, most probably inherited in an autosomal recessive pattern. A homozygosity mapping approach has thus far failed to unearth the responsible gene as the region shared by these three sibs is 27.7 Mb in size and contains over 200 genes with no obvious candidate.

Treatment of congenital thoracic scoliosis with associated rib fusions using VEPTR expansion thoracostomy: a surgical technique

INTRODUCTION

Untreated growing patients with congenital scoliosis and fused ribs will develop finally thoracic insufficiency syndrome. The technique of expansion thoracoplasty with implantation of a vertical expandable prosthetic titanium rib (VEPTR) was introduced initially to treat these children.

METHODS

This article attempts to provide an overview of the surgical technique of opening-wedge thoracostomy and VEPTR instrumentation in children with congenital thoracic scoliosis and fused ribs.

RESULTS

Our modification of the surgical approach using a posterior midline incision rather than the modified thoracotomy incision initially described could potentially help to diminish wound dehiscence and secondary infection, while preserving a more acceptable esthetic appearance of the back.

CONCLUSIONS

Vertical expandable prosthetic titanium rib-based treatments should be undertaken only with a good knowledge of its numerous specific complications. Every aspect of the treatment should be oriented to minimize these complications. At the same time it should be kept in mind that the ultimate step of this long-term fusionless treatment strategy will be a technically demanding spine fusion.

Developmental malformations in the area of the lumbosacral transitional vertebrae and sacrum: differences in gender and left/right distribution

PURPOSE

The aim of this study was to determine the incidence of congenital malformations of the lumbosacral transitional vertebrae in the general population, and the differences in their gender and left/right distributions.

METHODS

The examined group comprised of all patients who underwent a pelvic X-ray during 2010 for any reason. The observed parameters included the following malformations: the presence of megatransversus at L5; sacralization of L5 or L6; a S1 lumbarization; the presence of six sacral vertebrae; or spina bifida at the level of L5, S1 or S2. In cases of megatransversus at L5, the lateral distribution was recorded. A total of 1,513 images were evaluated. Sex and lateral differences were evaluated using the Pearson's (χ (2)) test with a significance level of 5 %.

RESULTS AND CONCLUSIONS

A total of 478 malformations were found in 417 patients, which constituted 27.6 % of the entire group. Malformations occurred in 250 women (25.4 % of all women) and 167 men (31.6 % of all men) and the female to male ratio in affected individuals was 1.5:1. The predominance of the occurrence of malformations observed in men was statistically significant (p = 0.009). The most frequently occurring malformations were the presence of six sacral vertebrae (179 patients) and megatransversus at L5 (150 patients). The study confirmed a high incidence of congenital malformations in the area of the lumbosacral transitional vertebrae and demonstrated a higher incidence in males. Unilaterally occurring megatransversus at L5 was significantly more common on the left side.

Chondro-manubrial deformity and bifid rib, rare variations seen in pectus carinatum: a radiological finding

Pectus carinatum or protrusion deformity of chest wall is less frequently occurring anterior chest wall deformity when compared to pectus excavatum. It may be classified as type 1 or chondro-gladiolar and type 2 or chondro-manubrial deformity. Other variations seen are symmetrical and asymmetrical pectus carinatum. Here we present two unique case reports, one with chondro-manubrial deformity (Currarino-Silverman syndrome) and other with asymmetrical pectus carinatum having bifid rib which are some of the rare variations seen in pectus carinatum found during Computerized tomographic examination. Currarino-Silverman syndrome is a type 2 pectus carinatum, a rare deformity with chondro-manubrial involvement and usually associated congenital heart diseases. Early fusion of sternal plates is one of the known theories in producing this deformity. On the other hand, asymmetrical pectus deformity are usually seen due to imbalance or abnormality in growth plates of costal cartilages leading to forked rib or bifid rib, which are accidently seen on radiological examination. To conclude, our reports would help in differential diagnosis from frequently occurring conditions affecting chest like chondro-gladiolar deformity, pectus excavatum, chest wall tumours, rib fractures and intra thoracic ribs.

Prenatal prevalence of skeletal dysplasias and a proposal ultrasonographic diagnosis approach

OBJECTIVE

To determine the prevalence of fetal bone dysplasias diagnosed at the Department of Maternal Fetal Medicine (UNIMEF) of the Instituto Nacional de Perinatologia (INPer); and to describe the most frequent skeletal dysplasias and to propose a diagnostic flow chart.

MATERIALS AND METHODS

This is a case series study including skeletal dysplasias cases from January 1995 until December 2009 at the UNIMEF Statistical analysis was performed using SPSS 12 statistical software.

RESULTS

A total of 81,892 births were registered at the institution during the study period. The prevalence of bone dysplasia was 8.1 per 10,000 births. We used a diagnostic flow chart that was developed at our institution to diagnose skeletal dysplasias. Micromelia (n = 40, 59.7%) and both rhizomelia and mesomelia (n = 17, 25.3%) were highly prevalent. We found other structural anomalies in 40 cases (61.1%), which were associated with different skeletal dysplasias; these other anomalies were mainly congenital heart diseases (12 cases) with a predominance of ventricular septal defects. There was polyhydramnios in 43.2% of cases. The mean of the gestational age at diagnosis was 24.5 weeks (SD 5.66). The karyotype was obtained in 11.9% (8/67) of cases. A total of 7 stillbirths and 11 neonatal deaths were registered, of which only 10 cases received a necropsy. Births occurred in the third trimester for 88% of cases, of which 85% were born via Cesarean section, whereas in the second trimester, the vaginal approach was chosen in 100% of cases.

CONCLUSIONS

The prenatal diagnosis of bone dysplasias is challenging due to the late development of the diagnostic features. Nevertheless, using ultrasonography in a systematic approach, in conjunction with a multidisciplinary approach, is a key factor in the diagnosis of this disease during the fetal period.

[Roles of computed tomography in the diagnosis and treatment of complex atlas pillow deformity]

OBJECTIVE

To explore the roles of computed tomography (CT) in the diagnosis and treatment of complex atlas pillow deformity.

METHODS

From January 2010 to February 2012, the preoperative and postoperative CT imaging findings were collected from 32 cases of complicated atlas pillow deformity undergoing surgical treatment at Henan Provincial People's Hospital. There were 18 males and 14 females with a mean age of 36.8 years (range: 23 - 65). The average duration of disease was 4.5 years (range: 0.25 - 10).

RESULTS

In 32 cases, a definite diagnosis was established preoperatively by coronary sagittal CT scans and 3-dimensional reconstruction. And CT re-examinations were performed to review the postoperative curative efficacies.

CONCLUSION

CT imaging examination is of vital importance in the diagnosis, personalized surgical procedures and prognostic evaluation of complex craniocervical junction deformity.

Ulnocarpal epiphyseal arthrodesis for recurrent deformity after centralization for radial longitudinal deficiency

PURPOSE

To report our results for ulnocarpal epiphyseal arthrodesis for recurrent or late-presenting wrist deformity in patients with radial longitudinal deficiency, using both objective data and long-term subjective follow-up evaluation.

METHODS

A retrospective review of our surgical logs between 1970 and 2007 identified 12 postcentralization patients treated with ulnocarpal epiphyseal arthrodesis, and 1 patient (who had reached skeletal maturity) treated with traditional ulnocarpal arthrodesis. Indications for the arthrodesis included postcentralization recurrence of radial angulation to greater than 45°, an inability to actively extend the wrist to within 25° of neutral (ie, 25° of flexion), or both. We collected objective and radiographic data on all 12 patients by chart review at a mean of 89 months (range, 2-472 mo) after arthrodesis. We collected subjective data from 9 patients at a mean of 160 months (range, 14-602 mo) after arthrodesis.

RESULTS

Ulnocarpal union was obtained in 11 wrists at an average of 4 months (range, 2-6 mo); the 1 case of nonunion was treated successfully with revision arthrodesis. The mean radial angulation position was 20° after arthrodesis (range, 0° to 35°), an average improvement of 42°. The mean position of wrist fusion was 11° of flexion (range, 0° to 35° of flexion), an average improvement of 7°. The mean postoperative Disabilities of the Arm, Shoulder, and Hand score was 24.5 (SD, 12.3; range, 6.8-36.4). Final postoperative Visual Analog Score rating for function averaged 8 (range, 4-10); for appearance, it averaged 7 (range, 5-10), and for pain, it averaged 1 (range, 0-5).

CONCLUSIONS

Ulnocarpal and epiphyseal arthrodesis are appropriate surgical procedures to stabilize the carpus in postcentralization patients with recurrent or late-presenting wrist deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Congenital musculoskeletal abnormalities associated with aortic, pulmonary and iliac aneurysms

We present the case of a young patient with severe congenital musculoskeletal abnormalities. associated with different pathologies, with involvement of the arterial tree on both the systemic and pulmonary circulation, and involvement of the lungs due to thoracic hypoplasia. The presence of such extensive pathology raises the question of the suitability of such patients to undergo major corrective cardiac surgery procedures.

Prenatal sonographic diagnosis of skeletal dysplasias

OBJECTIVE

To assess the types and numbers of cases, gestational age at specific prenatal diagnosis and diagnostic accuracy of the diagnosis of skeletal dysplasias in a prenatal population from a single tertiary center.

METHODS

This was a retrospective database review of type, prenatal and definitive postnatal diagnoses and gestational age at specific prenatal diagnosis of all cases of skeletal dysplasias from a mixed referral and screening population between 1985 and 2007. Prenatal diagnoses were grouped into 'correct ultrasound diagnosis' (complete concordance with postnatal pediatric or pathological findings) or 'partially correct ultrasound diagnosis' (skeletal dysplasias found postnatally to be a different one from that diagnosed prenatally).

RESULTS

We included 178 fetuses in this study, of which 176 had a prenatal ultrasound diagnosis of 'skeletal dysplasia'. In 160 cases the prenatal diagnosis of a skeletal dysplasia was confirmed; two cases with skeletal dysplasias identified postnatally had not been diagnosed prenatally, giving 162 fetuses with skeletal dysplasias in total. There were 23 different classifiable types of skeletal dysplasia. The specific diagnoses based on prenatal ultrasound examination alone were correct in 110/162 (67.9%) cases and partially correct in 50/162 (30.9%) cases, (160/162 overall, 98.8%). In 16 cases, skeletal dysplasia was diagnosed prenatally, but was not confirmed postnatally (n = 12 false positives) or the case was lost to follow-up (n = 4). The following skeletal dysplasias were recorded: thanatophoric dysplasia (35 diagnosed correctly prenatally of 40 overall), osteogenesis imperfecta (lethal and non-lethal, 31/35), short-rib dysplasias (5/10), chondroectodermal dysplasia Ellis-van Creveld (4/9), achondroplasia (7/9), achondrogenesis (7/8), campomelic dysplasia (6/8), asphyxiating thoracic dysplasia Jeune (3/7), hypochondrogenesis (1/6), diastrophic dysplasia (2/5), chondrodysplasia punctata (2/2), hypophosphatasia (0/2) as well as a further 7/21 cases with rare or unclassifiable skeletal dysplasias.

CONCLUSION

Prenatal diagnosis of skeletal dysplasias can present a considerable diagnostic challenge. However, a meticulous sonographic examination yields high overall detection. In the two most common disorders, thanatophoric dysplasia and osteogenesis imperfecta (25% and 22% of all cases, respectively), typical sonomorphology accounts for the high rates of completely correct prenatal diagnosis (88% and 89%, respectively) at the first diagnostic examination.

Radiological analysis of ponticulus posticus in Koreans

PURPOSE

Since there has been little reporting on the prevalence or morphologic characteristics of ponticulus posticus in Asians, we retrospectively reviewed cervical 3-dimensional CT scan images and plain radiographs which had been ordered by neurosurgeons or orthopaedic surgeons for evaluation of cervical spine problems to investigate the prevalence and morphologic features of the ponticulus posticus in Koreans.

PATIENTS AND METHODS

The presence and types of ponticulus posticus were investigated on 200 consecutive cervical 3-D CT scans.

RESULTS

Thirty-one patients, 48 ponticulus posticus, complete or partial, bilateral or unilateral, were identified on the 200 cervical 3-D CT scans; therefore, the prevalence was 15.5% in our patient population. In plain radiographs analysis, the prevalence was 6.95%.

CONCLUSION

The ponticulus posticus is a relatively common anomaly in Koreans. Therefore, proper identification of this anomaly on preoperative lateral radiographs should alert surgeons to avoid using the ponticulus posticus as a starting point for a lateral mass screw. Because of its size and shape have wide variation, 3-D CT scanning should be considered before lateral mass screw placement into the posterior arch if its presence is suspected or confirmed on radiographs.

Genetic counseling in a case of congenital hemivertebrae

A case of in utero spondylothoracic dysostoses is diagnosed during a routine third trimester ultrasound scan in a low-risk patient. Ultrasound showed spine deformation, hemivertebrae and crab-like ribs. The newborn had no other associated anomalies except inguinal hernia, and karyotype was normal. Bidimensional and 3-4D ultrasound imaging as well as radiograph of the fetus and photos of the newborn are presented and discussed. Sporadic cases are difficult to diagnose and classify, as they are probably due to genetic heterogenicity. Sporadic cases of hemivertebrae are rare and not always lethal. Fetal ultrasound scan findings can help predict prognosis, enabling the parents' informed decision making.

First-trimester ultrasound diagnosis of skeletal dysplasia associated with increased nuchal translucency thickness

A series of five cases of skeletal dysplasia is reported in which the diagnosis was reached at the 11-14-week routine ultrasound examination in our referral center. All five cases had increased nuchal translucency thickness (NT) associated with bone abnormalities. We review the current literature on skeletal dysplasia in the first trimester of pregnancy associated with increased NT.

Jarcho-Levin syndrome presenting as neural tube defect: report of four cases and pitfalls of diagnosis

Jarcho-Levin syndrome (JLS) causes severe vertebral and thoracic deformity and has an autosomal-recessive mode of inheritance. Prenatal diagnosis may be difficult in some cases without the history of an affected baby. We present 4 cases of JLS with neural tube defects as the prominent finding. In 2 of them the deformity of the thorax was minimal and was not detected by ultrasonography. Rib anomalies were revealed with radiological and pathological examinations after the termination. The location of the vertebral defect may be the determinant factor for the severity of the thoracic deformity. The real recurrence risk could only be found out after postnatal examinations in cases with neural tube defects.

Osteocraniostenosis: a further case report documenting the antenatal findings

Osteocraniostenosis is a rare, lethal skeletal dysplasia with a distinctive phenotype and diagnostic X-ray findings. We present a case of an infant who was antenatally detected to have dysmorphic facial features as early as 22 weeks of gestation. Subsequent postnatal investigations confirmed the diagnosis of osteocraniostenosis. These antenatal findings have not been documented previously. We discuss both the antenatal and postnatal findings of this condition.

Prenatal diagnosis of Jarcho-Levin syndrome in the first trimester

INTRODUCTION

Jarcho-Levin syndrome is a congenital segmental costo-vertebral deformation with multiple vertebral and numerical or structural rib abnormalities resulting in the 'crab-like' aspect of the chest. We describe an ultrasound antenatal diagnosis of the Jarcho-Levin syndrome with spina bifida during the first trimester of pregnancy.

CASE REPORT

Prenatal ultrasonography showed shortened spine with marked kyphoscoliosis and spina bifida.

CONCLUSION

If a prenatal diagnosis of Jarcho-Levin syndrome is made before viability, the choice of pregnancy termination should be offered to the parents.

Epiphyseal dysplasia and other skeletal anomalies in a patient with the 6p25 microdeletion syndrome

The 6p25 microdeletion syndrome comprises the Axenfeld-Rieger eye anomaly in association with a characteristic facies, developmental delay, hearing loss, and organ malformations. Skeletal anomalies in the form of hemivertebrae, clubfeet, and other positional joint anomalies have also been described in some patients. We report on a patient with a 2.2-2.4 Mb terminal microdeletion of the short arm of chromosome 6 who in addition had abnormalities of the proximal femoral and humeral epiphyses. We suggest that an epiphyseal dysplasia may be an additional clinical component of the 6p25 microdeletion syndrome.

Abnormal spicules on the inferior aspect of anterior arch of atlas vertebra

Anterior arch of the atlas vertebra is known to exhibit various developmental anomalies. Bony outgrowths, osteophytes, clefts and aplasia of the anterior and posterior arches of the atlas have received special attention by research workers. To the best of our knowledge, not many osteological studies have defined the spicules on the anterior arch of the atlas. The present study describes an abnormal atlas vertebra with 2 spicules on the inferior aspect, 2 additional facets inferior to the superior articular facets and a peculiar facet to the left of the posterior tubercle. These abnormal spicules may cause dysphagia or involve atlanto-occipital movements. Such anomalies may be misinterpreted in routine X rays as a degenerative disease. However, asymptomatic cases remain undetected throughout life. Such anomalies may be important in radiological, clinical, forensic and anthropological studies.

Craniovertebral malformation complex in a child with Weismann-Netter-Stuhl syndrome

OBJECTIVE

Bowing of the legs is usually thrown into the basket of vitamin D deficiency rickets; therefore, a significant number of affected children can be misdiagnosed and improperly managed. This case illustrates how the careful clinical and radiological assessment of such a case can lead to the adequate understanding of its etiology.

DESCRIPTION

We report a sporadic case of a 2-year-old male child who presented with radiological features that were compatible with Weismann-Netter-Stuhl syndrome. In addition, we observed craniovertebral malformation complex. He was of normal intelligence. To our knowledge, the combination of Weismann-Netter-Stuhl syndrome and presence of a hypoplastic occipitalized atlas and further C2-C3 fusion has not been reported before. The diagnosis of Weismann-Netter-Stuhl is discussed. Classically, Weismann-Netter-Stuhl syndrome is characterized by short stature, mental retardation (in some individuals), dural calcification, and anterior bowing of the tibiae. However, we believe that careful clinical and radiological examinations can reveal more striking data which might positively reflect on the whole process of management.

COMMENTS

We postulate that the congenital limitations in neck movements in our patient developed because of the marked fusion of the hypoplastic and occipitalized atlas and simultaneous C2-C3 fusion. Therefore, if this form of malformation is disregarded, there may be involvement of the atlantoaxial structure, and this can possibly lead to serious neurological and even life-threatening complications. The use of CT scanning for the detection of such abnormalities can be remarkably important.

Use of the elbow compass universal hinge in pediatric patients

The purpose of this study was to review the Compass Universal Hinge dynamic elbow external fixator in pediatric conditions. Eight patients with diagnoses of ulnar club hand (n = 2), proximal radial synostosis with hypoplastic coronoid (n = 1), pterygium cubitale (n = 2), and elbow arthrofibrosis (n = 3) were identified. Indications for fixator placement were to maintain elbow stability during forearm lengthening (two cases), protect a coronoid reconstruction (one case), increase range of motion via the fixator (two cases), and maintain stability and increase range of motion after open release (three cases). There were five boys and three girls with an average age at surgery of 11.5 (range 3-19) years. In each case, the goal for fixator use was achieved: both forearm lengthenings were completed without elbow instability, the coronoid reconstruction healed in good position, and four of five patients obtained increased range of motion via the fixator (average improved arc of motion of 31 degrees), with all elbows remaining reduced and stable. Complications included four pin tract infections, one of which became osteomyelitis; two broken/loose pins; and two cases of decreased elbow range of motion. Average follow-up was 29 (range 3-62) months. Use of the Compass Universal Hinge dynamic external fixator can be adapted to children and has proven useful in managing certain difficult conditions.

Skeletal dysplasia and myelopathy in congenital disorder of glycosylation type IA

We report on a boy with a congenital disorder of glycosylation (CDG) Ia and a severe narrowing of the spinal canal caused by atlantoaxial subluxation with anterior displacement of C1. C1-laminectomy improved the progressive paresis. Progressive paresis caused by spinal cord compression is a hitherto unrecognized complication in patients with CDG-Ia.