Surgical treatment of an old avulsion fracture of the ischial tuberosity and ischial ramus: A case report

BACKGROUND Avulsion fracture of the ischial tuberosity is a relatively clinically rare type of trauma that is mainly incurred by adolescents during competitive sports activities.According to previous literature,the most commonly involved sports are soccer,sprinting,and gymnastics,in descending order.Dance-induced avulsion fracture of the ischial tuberosity and ischial ramus is extremely clinically rare.CASE SUMMARY A case of a neglected avulsion fracture of the ischial tuberosity and ischial ramus was diagnosed in a young female dancer who complained of pain and restricted movement of her right hip.She stated that she had suffered the injury while performing a split leap during a dance performance 9 mo prior.Eventually,she underwent surgery and obtained satisfactory treatment results.CONCLUSION Early diagnosis of these fractures is important to ensuring early proper treatment towards a quicker recovery.For old fractures with nonunion and chronic buttock pain,surgery is a preferred therapeutic choice with good treatment outcomes.

TSC2 Deletions and Duplications: A Descriptive Study in Iranian Patients Affected with Tuberous Sclerosis

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by formation of benign tumors called hamartomas. Although the TSC is diagnosed based on clinical findings but approximately 85% of individuals who meet diagnostic criteria for TSC a mutation can be identified in TSC2 (69%) and TSC1 (31%). A review of mutation type in TSC1 & TSC2 genes reveals that deletion/duplication assay could be a good screening strategy as a first step in TSC molecular diagnosis. All 41 exons and 5’ untranslated region of TSC2 gene in addition to adjacent PKD1 gene were screened for deletion/duplication in 81 patients DNA samples using multiplex ligation dependent probe amplification (MLPA) method. Deletion/duplication was found in 29 (35.8%) patients, including deletions in 26 (32.0%) patients and duplication in 3 (3.8%). Genotype/phenotype analysis, showed five patients with renal function impairment who have large deletions including PKD gene area. Approximately 65% of cases were sporadic, while the remaining have familial positive history. Deletions/duplications of TSC2 gene were seen in 35.8% of patients with TSC. So it could be concluded that MLPA is a useful testing strategy for molecular screening in sporadic forms of TSC patients. MLPA increased the detection of TSC mutations. MLPA is less expensive, quicker and more precise than direct sequencing and southern blot in the characterization of TSC deletions. This technique is recommended as a standard part of TSC clinical molecular diagnosis.

Minimally invasive open reduction of greater tuberosity fractures by a modified suture bridge procedure

BACKGROUND Most greater tuberosity fractures can be treated without surgery but some have a poor prognosis.The surgical procedures for avulsion fractures of the humeral greater tuberosity include screw fixation,suture anchor fixation,and plate fixation,all of which have treatment-associated complications.To decrease surgical complications,we used a modified suture bridge procedure under direct vision and a minimally invasive small incision to fix fractures of the greater tuberosity of the humerus.AIM To investigate the clinical efficacy and outcomes of minimally invasive modified suture bridge open reduction of greater tuberosity evulsion fractures.METHODS Sixteen patients diagnosed between January 2016 and January 2019 with an avulsion-type greater tuberosity fracture of the proximal humerus and treated by minimally invasive open reduction and modified suture bridges with anchors were studied retrospectively.All were followed up by clinical examination and radiographs at 3 and 6 wk,3,6 and 12 mo after surgery,and thereafter every 6 mo.Outcomes were assessed preoperatively and postoperatively by a visual analog scale(VAS),the University of California Los Angeles(UCLA)shoulder score,the American Shoulder and Elbow Surgeon score(ASES),and range of motion(ROM)for shoulders.RESULTS Seven men and nine women,with an average age of 44.94 years,were evaluated.The time between injury and surgery was 1-2 d,with an average of 1.75 d.The mean operation time was 103.1±7.23 min.All patients achieved bone union within 3 mo after surgery.VAS scores were significantly decreased(P=0.002),and the mean degrees of forward elevation(P=0.047),mean degrees of abduction(P=0.035),ASES score(P=0.092)were increased at 3 wk.The UCLA score was increased at 6 wk(P=0.029)after surgery.The average degrees of external rotation and internal rotation both improved at 3 mo after surgery(P=0.012 and P=0.007,respectively).No procedure-related deaths or incision-related superficial or deep tissue infections occurred.CONCLUSION Modified suture bridge was effective for the treatment of greater tuberosity evulsion fractures,was easier to perform,and had fewer implants than other procedures.

Tibial tuberosity avulsion-fracture associated with complete distal rupture of the patellar tendon:A case report and review of literature

BACKGROUND Few cases of avulsion fractures of the tibial tuberosity with simultaneous rupture of the patellar tendon have been reported in the literature.Therefore,its mechanism and incidence have not been determined conclusively.This type of fracture is considered a serious injury that requires prompt diagnosis and early surgical repair.There is no therapeutic algorithm or standard method of treatment due to the infrequency of the injury.In this case report,we conducted an exhaustive review and synthesis of the existing literature including all previously reported cases.CASE SUMMARY We present a 16-year-old male soccer player with a case of a tibial tuberosity fracture with distal avulsion of the patellar tendon 5 d prior to surgical treatment.The patient presented with a loss of the extensor mechanism of the knee,edema,the inability to walk,and pain.X-rays showed a high patella and a 180-degree avulsion of the tibial tuberosity.The diagnosis was confirmed by magnetic resonance imaging and computed tomography.The patient underwent open reduction and internal fixation of the fracture with a cannulated screw and washer as well as patellar tendon repair with two metallic anchors.The rehabilitation protocol consisted of initial immobilization in extension followed by passive mobility and muscle strengthening exercises.The patient demonstrated excellent postoperative outcomes and returned to regular activity without complications.CONCLUSION This case presentation and literature review comprise the most relevant clinical,radiographic,and treatment details described in the international literature to date,providing the reader with an overview of this rare condition.

Two-level reconstruction of isolated fracture of the lesser tuberosity of the humerus

Fractures of the lesser tuberosity of the humerus are typically met in combination with other injuries of the shoulder. Case reports of isolated lesser tuberosity fractures are particularly rare and, consequently,therapeutic protocols have not yet been completely clarified. Conservative as well as surgical treatment has been recommended, while several operative techniques have been applied. We present a case of a 39-yearold man with an isolated lesser tuberosity fracture who was treated surgically in our institution. Due to fracture comminution, a two-level reconstruction technique with headless screws and buttress plate was applied. As far as we know, this method of fixation of this type of fracture has not been previously described in the literature.The patient tolerated the procedure well and excellent results were obtained at the latest follow-up.

Natural Postoperative Bone Metabolic Changes after Total Knee Arthroplasty Determined by Positron Emission Tomography Scans

Artificial joint replacement surgery is the orthopedic procedure of choice to relieve pain, correct joint deformities, and help patients resume everyday activities. However, the detailed mechanisms regulating peri-implant bone remodeling at the bone-prosthesis interface remain elusive. To address this gap in knowledge, we evaluated the natural postoperative course of bone metabolism by using [18F] NaF positron emission tomography (PET)/computed tomography in 57 patients (104 joints) who underwent asymptomatic total knee arthroplasty (TKA). First, we measured total tracer uptake around TKA to determine the total bone metabolism (TBM) and used the ischial tuberosity as the reference tissue for normalization of PET images. Second, we calculated the TBM ratio (TBMR) by dividing the TBM by tracer uptake in the reference tissue. A moderate increase in TBMR was observed 4 - 5 days after implantation, and its intensity reached the maximum on the seventh postoperative day. The TBMR showed no differences until 12 weeks, after which it decreased slowly and returned to the basal levels. The new parameter TBMR and the unique pattern of postoperative metabolic changes in the bone around the prosthesis may help set accurate interpretation criteria to diagnose complications such as loosening or infections.

Imaging Review of Adolescent Tibial Tuberosity Fractures

Adolescent tibial tuberosity injuries are infrequent fractures usually seen in physically active adolescent males. Powerful contraction of the knee extensors by sudden acceleration or deceleration of the quadriceps muscle can result in avulsion fractures of the tibial tuberosity apophysis. In late puberty, as the growth plate closes, it is transiently replaced by fibrocartilaginous elements. This transition causes a period of weakened tensile strength, which predisposes the tibial tuberosity to traction injury. Classification of tibial tuberosity fractures includes types I-V with added A and B subsets to types I, II and III. Multidetector computed tomography (MDCT) is a useful tool to more accurately classify complex, higher grade adolescent tibial tuberosity avulsion fractures when compared to plain film. This aids in preoperative planning and, therefore, results in improved treatment and management.

Description of the technique of bone marrow harvesting in the coxal tuberosity for isolation and culture of mesenchymal stem cells of buffaloes(Bubalus bubalis)

Several studies with mesenchymal stem cells (MSCs) have been developed in many species because of its ability to differentiate into other mesoderm lineages, capacity of self-regeneration, low immunogenicity, paracrine, anti-inflammatory, immunomodulatory and antiapoptotic effects which make them a promissory source to be used in therapeutic strategies. The aim of this study is to report the technique of harvest of bone marrow (BM) in the coxal tuberosity (CT) of buffaloes and its processing and cultivation. For this, after anesthetic block from the region corresponding to the CT, bone marrow harvesting was performed with a myelogram’s needle. The samples collected showed plastic adherence with 96 hours and took approximately 32 days to reach 80% confluence. And then differentiation into adipogenic and osteogenic lineages was performed. Samples showed morphological changes during differentiation protocol, but not all presented production of extracellular deposits of calcium or intracellular fat droplets. The anatomical site tested showed to be an alternative site of harvest of BM once provided with the appropriate isolation and culture of the mononuclear fraction. Moreover, the procedure was performed without difficulty and with great security. Based on this, it can be concluded that CT is an excellent anatomical site for isolation and culture of MSCs and the proposed technique is viable and feasible to be held in buffaloes.

Is tuberous sclerosis complex-associated autism a preventable andtreatabledisorder?

Background Tuberous sclerosis complex(TSC)is a genetic disorder caused by inactivating mutations in the TSCl and TSC2 genes,causing overactivation of the mechanistic(previously referred to as mammalian)target of rapamycin(mTOR)signaling pathway in fetal life.The mTOR pathway plays a crucial role in several brain processes leading to TSC-related epilepsy,intellectual disability,and autism spectrum disorder(ASD).Pre-natal or early post-natal diagnosis of TSC is now possible in a growing number of pre-symptomatic infants.Data sources We searched PubMed for peer-reviewed publications published between January 2010 and April 2023 with the terms“tuberous sclerosis",“autism",or“autism spectrum disorder""animal models",“preclinical studies",“neurobiology",and“treatment".Results Prospective studies have highlighted that developmental trajectories in TSC infants who were later diagnosed with ASD already show motor,visual and social communication skills in the first year of life delays.Reliable genetic,cellular,electroencephalography and magnetic resonance imaging biomarkers can identify pre-symptomatic TSC infants at high risk for having autism and epilepsy.Conclusions Preventing epilepsy or improving therapy for seizures associated with prompt and tailored treatment strategies for autism in a sensitive developmental time window could have the potential to mitigate autistic symptoms in infants with TSC.

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

Purpose:Unsatisfactory results of hemiarthroplasty in Neer’’s 3- and 4-part proximal humerus fractures in elderly,have led to the shift towards reverse shoulder arthroplasty (RSA).The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.Methods:We include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head.Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded.According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month,the patients were divided into 2 groups,as the group with successful tuberosity repair and the other with failed tuberosity repair.Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independentt-test for normally distributed parameters and Mann-Whitney test for the parameters,where data was not normally distributed.Results:Of 41 patients,tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases.Lysis of the tuberosity occurred in 5 patients,tuberosity displacement in 2,and nonunion in 2.Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months).There were no major complications.Group with successful tuberosity repair showed improvement in mean active range of movements,like anterior elevation (165.1°± 4.9°vs.144.6°± 9.4°,p < 0.000),lateral elevation (158.9°± 7.2°vs.138.4°± 9.6°,p < 0.000),external rotation (30.5°± 6.9°vs.35.0°± 6.3°,p = 0.367),internal rotation (33.7°± 7.5°vs.32.6°± 6.9°,p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1vs.55.5 ± 5.7,p < 0.000),American shoulder and elbow surgeons score (90.3 ± 2.4vs.69.0 ± 5.7,p < 0.000),disability of arm shoulder and hand score (22.1 ± 2.3vs.37.6 ± 2.6,p < 0.000).Conclusion:Successful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion,strength and shoulder scores.Standardized repair technique and interposition of cancellous bone grafts,harvested from the humeral head can improve the rate of tuberosity healing.

Arthroscopic reduction and fixation for isolated greater tuberosity fractures

Background Traditionally, displaced greater tuberosity fractures are treated with open reduction and internal fixation. Arthroscopic treatment and outcome of greater tuberosity fractures is far from comprehensive. The objective of the current study was to assess the surgical procedure and outcome of an arthroscopic method in the treatment of isolated greater tuberosity fractures. Methods From January 2006 to December 2009, 23 patients with isolated greater tuberosity fractures were treated with an arthroscopic procedure using three cannulated screws combined with washers. During follow-up, radiographs and the constant shoulder score （CSS） were used to evaluate the outcome. Results Three cannulated screws with washers were used to fix the fractured fragment of the greater tuberosity under an arthroscope. All incisions healed at primary intention without infection. The mean duration of follow-up was 20 months （range 18-36 months）. Fracture fixation was excellent, and fractures healed 2-6 months （mean 3.8 months） after surgery. At final follow-up, the CSS was 92 （range 86-100）. Conclusions The described arthroscopic procedure provides anatomical reduction and firm fixation for isolated greater tuberosity fractures. It is a successful and minimally invasive procedure with satisfying therapeutic effects as well as excellent functional recovery.

3D optical measurement of relative displacement for the tuberosities in the shoulder prosthesis

In this paper,a binocular 3-D computer vision measurement system is used to measure the relative displacement for the greater and lesser tuberosities in the shoulder prosthesis.The basic principles of binocular optical measurement are introduced in detail,and the loading apparatus is designed for external rotation and anteflexion of the shoulder prosthesis.Both the motion of external rotation and anteflexion of the shoulder are measured,and the corresponding displacement values for the greater and lesser tuberosities are extracted.These results will play an important role in evaluating the stability of humeral tuberosity in the shoulder prosthesis.