A"messenger zone hypothesis"based on the visual three-dimensional spatial distribution of motoneurons innervating deep limb muscles

Coordinated contraction of skeletal muscles relies on selective connections between the muscles and multiple classes of the spinal motoneuro ns.Howeve r,current research on the spatial location of the spinal motoneurons innervating differe nt muscles is limited.In this study,we investigated the spatial distribution and relative position of different motoneurons that control the deep muscles of the mouse hindlimbs,which were innervated by the obturator nerve,femoral nerve,inferior gluteal nerve,deep pe roneal nerve,and tibial nerve.Locations were visualized by combining a multiplex retrograde tracking technique compatible with three-dimensional imaging of solvent-cleared o rgans(3DISCO)and 3-D imaging technology based on lightsheet fluorescence microscopy(LSFM).Additionally,we propose the hypothesis that"messenger zones"exist as interlaced areas between the motoneuron pools that dominate the synergistic or antagonist muscle groups.We hypothesize that these interlaced neurons may participate in muscle coordination as messenger neurons.Analysis revealed the precise mutual positional relationships among the many motoneurons that innervate different deep muscles of the mouse.Not only do these findings update and supplement our knowledge regarding the overall spatial layout of spinal motoneurons that control mouse limb muscles,but they also provide insights into the mechanisms through which muscle activity is coordinated and the architecture of motor circuits.

Silk-based nerve guidance conduits with macroscopic holes modulate the vascularization of regenerating rat sciatic nerve

Peripheral nerve injuries induce a severe motor and sensory deficit. Since the availability of autologous nerve transplants for nerve repair is very limited, alternative treatment strategies are sought, including the use of tubular nerve guidance conduits(tNGCs). However, the use of tNGCs results in poor functional recovery and central necrosis of the regenerating tissue, which limits their application to short nerve lesion defects(typically shorter than 3 cm). Given the importance of vascularization in nerve regeneration, we hypothesized that enabling the growth of blood vessels from the surrounding tissue into the regenerating nerve within the tNGC would help eliminate necrotic processes and lead to improved regeneration. In this study, we reported the application of macroscopic holes into the tubular walls of silk-based tNGCs and compared the various features of these improved silk^(+) tNGCs with the tubes without holes(silk^(–) tNGCs) and autologous nerve transplants in an 8-mm sciatic nerve defect in rats. Using a combination of micro-computed tomography and histological analyses, we were able to prove that the use of silk^(+) tNGCs induced the growth of blood vessels from the adjacent tissue to the intraluminal neovascular formation. A significantly higher number of blood vessels in the silk^(+) group was found compared with autologous nerve transplants and silk^(–), accompanied by improved axon regeneration at the distal coaptation point compared with the silk^(–) tNGCs at 7 weeks postoperatively. In the 15-mm(critical size) sciatic nerve defect model, we again observed a distinct ingrowth of blood vessels through the tubular walls of silk^(+) tNGCs, but without improved functional recovery at 12 weeks postoperatively. Our data proves that macroporous tNGCs increase the vascular supply of regenerating nerves and facilitate improved axonal regeneration in a short-defect model but not in a critical-size defect model. This study suggests that further optimization of the macroscopic holes silk^(+) tNGC approach containing macroscopic holes might result in improved grafting technology suitable for future clinical use.

Efficacy of the femoral neck system in femoral neck fracture treatment in adults: A systematic review and meta-analysis

BACKGROUND Controversy remains around the available choices for the internal fixation of a femoral neck fracture.The femoral neck system(FNS)was developed in 2018 and has been widely applied since then as it can provide rigid fixation stability with less damage to the bone mass around the fracture.However,no systematic reviews and meta-analyses have investigated the efficacy of the FNS in comparison with that of traditional internal fixation in the treatment of femoral fractures.AIM To assess the efficacy of the FNS in comparison with that of cannulated compression screws(CCS)in the treatment of femoral fractures through systematic review and meta-analysis.METHODS Five electronic databases(PubMed,Embase,Cochrane Central Register of Controlled Trials,China National Knowledge Infrastructure,and Wanfang)were searched from the earliest publication date to December 31,2021.Reference Citation Analysis(https://www.referencecitationanalysis.com/)was used to check the results and further analyze the related articles.Controlled trials were included if the FNS was applied for the femoral neck fracture in adults and if it was compared with CCS for the achievement of internal fixation.The measurement outcomes included the required operation time,observed patient’s blood loss,extent of fracture healing,patient’s Harris Hip score(HHS)at the last follow-up,and records of any complications(such as failure of internal fixation,femoral neck shortness,avascular necrosis of the femoral head,and delayed union or nonunion).RESULTS Ten retrospective controlled studies(involving 711 participants)were included in this metaanalysis.The meta-analysis showed that compared with CCS,use of the FNS could not decrease the operation time[standardized mean difference(SMD):-0.38,95%confidence interval(CI):-0.98 to 0.22,P=0.21,I2=93%),but it could increase the intraoperative blood loss(SMD:0.59,95%CI:0.15 to 1.03,P=0.009,I2=81%).The pooled results also showed that compared with CCS,the FNS could better promote fracture healing(SMD:-0.97,95%CI:-1.65 to-0.30,P=0.005,I2=91%),improve the HHS at the last follow-up(SMD:0.76,95%CI:0.31 to 1.21,P=0.0009,I2=84%),and reduce the chances of developing femoral neck shortness(OR:0.29,95%CI:0.14 to 0.61,P=0.001,I2=0%)and delayed union or nonunion(OR:0.47,95%CI:0.30 to 0.73,P=0.001;I2=0%)in adult patients with femoral neck fractures.However,there was no statistically significant difference between the FNS and CCS in terms of failure of internal fixation(OR:0.49,95%CI:0.23 to 1.06,P=0.07,I2=0%)and avascular necrosis of the femoral head(OR:0.46,95%CI:0.20 to 1.10,P=0.08,I2=0%).CONCLUSION Compared with CCS,the FNS could decrease the chances of developing femoral neck shortness and delayed union or nonunion in adults with femoral neck fractures.Simultaneously,it could accelerate fracture healing and improve the HHS in these patients.

Major Limb Amputations: Etiological and Clinical Profile in a Hospital in Sub-Saharan Africa

Introduction: During the 19th and 20th centuries, the Wars were the cause of many amputations among military and civilians. Despite the absence of armed conflict in our country, we notice a high frequency of major amputations in our activity. Objective: The aim of this work was to study the causes of major amputations observed in our practice in order to develop preventive measures. Materials and Method: This was a descriptive retrospective study over a 6-year period, from January 1, 2008 to December 31, 2014. The following parameters were studied: epidemiological aspects (age according to WHO age groups and gender of patients), type of amputation, level of amputation and causes. Results: Two hundred and fifty-two patients were included. The distribution of amputations by cause and age group showed two distinct entities: The forms of the young subject where there was a predominance of tumour and traumatic causes;and the forms of the elderly person caused by vascular infections and conditions. Infections were the main cause of amputation in both sexes. Conclusion: The causes of major limb amputations vary according to age and limb: tumor and trauma in young people and for the upper limb, infectious and vascular in the elderly and for the lower limb.

Vascular Trauma Registry Analysis in Sulaimani Province of Southern Kurdistan

Background: Vascular injury presents a great challenge to the trauma and vascular surgeons because it needs urgent diagnosis and intervention. Aims: Prospective cohort study is to determine management and outcome of peripheral vascular injuries in a tertiary centre with very poor facilities. Methods: Analysis of peripheral vascular injuries during August 2013 to August 2014. Results: Total of 47 patients (3.4%) from 1377 total trauma admissions had vascular injuries. Penetrating trauma was present in 93.6% of cases. Brachial artery injury was the highest (31.9%), followed by superficial femoral and popliteal arteries (each with 17% incidence). Vein injury occurred in 61.7% of cases. End-to-end anastomosis performed in 76.6% of cases;arterial ligation was done in 14.9% of cases;venous graft was harvested in 6.4% of cases;and arterial wall was repaired in 2.1% of cases. Conclusions: Early intervention is the most important determinant factor of outcome.

Intra- and Periarticular Ganglia (Synovial Cysts) of the Hip with Compression of the Obturator Nerve, Concomitant with Lesions of the Ligamentum Teres—A Report of 3 Cases

Background: Synovial cysts of the hip are commonly found in patients with intra- or extraarticular pathologies of the joint. Symptoms are mostly unspecific. To date there are no guidelines for a gold standard of treatment. Aim of this article is to show up how lesions of the ligamentum teres (LT) might possibly lead to a specific formation of synovial cysts of the hip joint and how this can be treated arthroscopically. Methods: This case series included 3 patients with ganglia of the hip. All patients had impingement symptoms, combined with untypical location of pain. All patients qualified for joint preserving surgery and underwent hip arthroscopy with pre- and postoperative MRI imaging. The mean follow-up time was 22 months. Results: MRI imaging showed extensive ganglia, presumably originating from the pelvic root of LT, extending to the obturator lodge. In 2 of 3 cases MRI showed lesions of the LT. Hip arthroscopy revealed damage of the LT in all cases, caused by chronic instability of the joint. The postoperative MRI showed a complete regression of the ganglia in all patients after offset correction. After follow-up, 2 of 3 patients were mostly symptom free. One patient was still suffering from a chronic weakness of the gluteus medius muscle. Conclusion: Whenever unspecific radiating pain of surrounding areas of the hip is encountered and cannot be explained by common pathologies of the hip, possible compression of nerves by ganglion cysts should be excluded. This should be done by MRI arthrography. A partial rupture of the LT can occur during FAI with consecutive formation of ganglia in the obturator canal, compressing the obturator nerve. Primarily the articular pathology needs to be repaired. In our cases, this was feasible by hip arthroscopy, as a minimally invasive and safe technique.

Thymic lipofibroadenomas:Three case reports

BACKGROUND Thymic lipofibroadenomas are extremely rare.In this study,we investigated the clinicopathological characteristics of thymic lipofibroadenomas.CASE SUMMARY This study included three patients with thymic lipofibroadenomas.We retrospectively analyzed the patient data to determine the clinicopathological characteristics of thymic lipofibroadenomas.The study included one man and two women[mean age,43(33–59)years].All patients were non-smokers and presented with well-defined anterior mediastinal tumors.The cut surfaces of the tumors were solid,with a mixture of yellow and white areas.Microscopic evaluation of resected specimens showed scattered cord-like structures of epithelial cells embedded within abundant fibrotic and hyaline stroma admixed with variable quantities of adipose tissue.One patient showed hyperplastic thymic tissue in a part of the tumor.CONCLUSION Thymic lipofibroadenomas are an extremely rare type of benign thymic tumor.Surgical removal of lipofibroadenomas is usually curative.

Cortical plasticity and nerve regeneration after peripheral nerve injury

With the development of neuroscience, substantial advances have been achieved in peripheral nerve regeneration over the past decades. However, peripheral nerve injury remains a critical public health problem because of the subsequent impairment or absence of sensorimotor function. Uncomfortable complications of peripheral nerve injury, such as chronic pain, can also cause problems for families and society. A number of studies have demonstrated that the proper functioning of the nervous system depends not only on a complete connection from the central nervous system to the surrounding targets at an anatomical level, but also on the continuous bilateral communication between the two. After peripheral nerve injury, the interruption of afferent and efferent signals can cause complex pathophysiological changes, including neurochemical alterations, modifications in the adaptability of excitatory and inhibitory neurons, and the reorganization of somatosensory and motor regions. This review discusses the close relationship between the cerebral cortex and peripheral nerves. We also focus on common therapies for peripheral nerve injury and summarize their potential mechanisms in relation to cortical plasticity. It has been suggested that cortical plasticity may be important for improving functional recovery after peripheral nerve damage. Further understanding of the potential common mechanisms between cortical reorganization and nerve injury will help to elucidate the pathophysiological processes of nerve injury, and may allow for the reduction of adverse consequences during peripheral nerve injury recovery. We also review the role that regulating reorganization mechanisms plays in functional recovery, and conclude with a suggestion to target cortical plasticity along with therapeutic interventions to promote peripheral nerve injury recovery.

GSK3β inhibitor promotes myelination and mitigates muscle atrophy after peripheral nerve injury

Delay of axon regeneration after peripheral nerve injury usually leads to progressive muscle atrophy and poor functional recovery. The Wnt/β-catenin signaling pathway is considered to be one of the main molecular mechanisms that lead to skeletal muscle atrophy in the elderly. We hold the hypothesis that the innervation of target muscle can be promoted by accelerating axon regeneration and decelerating muscle cell degeneration so as to improve functional recovery of skeletal muscle following peripheral nerve injury. This process may be associated with the Wnt/β-catenin signaling pathway. Our study designed in vitro cell models to simulate myelin regeneration and muscle atrophy. We investigated the effects of SB216763, a glycogen synthase kinase 3 beta inhibitor, on the two major murine cell lines RSC96 and C2C12 derived from Schwann cells and muscle satellite cells. The results showed that SB216763 stimulated the Schwann cell migra- tion and myotube contraction. Quantitative polymerase chain reaction results demonstrated that myelin related genes, myelin associated glycoprotein and cyclin-D1, muscle related gene myogenin and endplate-associated gene nicotinic acetylcholine receptors levels were stimulated by SB216763. Immunocytochemical staining revealed that the expressions of ^-catenin in the RSC96 and C2C12 cytosolic and nuclear compartments were increased in the SB216763-treated cells. These findings confirm that the glycogen synthase kinase 3 beta in- hibitor, SB216763, promoted the myelination and myotube differentiation through the Wnt/β-catenin signaling pathway and contributed to nerve remyelination and reduced denervated muscle atrophy after peripheral nerve injury.

Sustained release of exosomes loaded into polydopamine-modified chitin conduits promotes peripheral nerve regeneration in rats

Exosomes derived from mesenchymal stem cells are of therapeutic interest because of their important role in intracellular communication and biological regulation.On the basis of previously studied nerve conduits,we designed a polydopamine-modified chitin conduit loaded with mesenchymal stem cell-derived exosomes that release the exosomes in a sustained and stable manner.In vitro experiments revealed that rat mesenchymal stem cell-derived exosomes enhanced Schwann cell proliferation and secretion of neurotrophic and growth factors,increased the expression of Jun and Sox2 genes,decreased the expression of Mbp and Krox20 genes in Schwann cells,and reprogrammed Schwann cells to a repair phenotype.Furthermore,mesenchymal stem cell-derived exosomes promoted neurite growth of dorsal root ganglia.The polydopamine-modified chitin conduits loaded with mesenchymal stem cell-derived exosomes were used to bridge 2 mm rat sciatic nerve defects.Sustained release of exosomes greatly accelerated nerve healing and improved nerve function.These findings confirm that sustained release of mesenchymal stem cell-derived exosomes loaded into polydopamine-modified chitin conduits promotes the functional recovery of injured peripheral nerves.

Polydopamine-modified chitin conduits with sustained release of bioactive peptides enhance peripheral nerve regeneration in rats

The introduction of neurotrophic factors into injured peripheral nerve sites is beneficial to peripheral nerve regeneration.However,neurotrophic facto rs are rapidly degraded in vivo and obstruct axonal regeneration when used at a supraphysiological dose,which limits their clinical benefits.Bioactive mimetic peptides have been developed to be used in place of neurotrophic factors because they have a similar mode of action to the original growth fa ctors and can activate the equivalent receptors but have simplified sequences and structures.In this study,we created polydopamine-modified chitin conduits loaded with brain-derived neurotrophic factor mimetic peptides and vascular endothelial growth fa ctor mimetic peptides(Chi/PDA-Ps).We found that the Chi/PDA-Ps conduits were less cytotoxic in vitro than chitin conduits alone and provided sustained release of functional peptides.In this study,we evaluated the biocompatibility of the Chi/P DA-Ps conduits.Brain-derived neurotrophic factor mimetic peptide and vascular endothelial growth fa ctor mimetic peptide synergistically promoted prolife ration of Schwann cells and secretion of neurotrophic factors by Schwann cells and attachment and migration of endothelial cells in vitro.The Chi/P DA-Ps conduits were used to bridge a 2 mm gap between the nerve stumps in rat models of sciatic nerve injury.We found that the application of Chi/PDA-Ps conduits could improve the motor function of rats and reduce gastrocnemius atrophy.The electrophysiological results and the microstructure of regenerative nerves showed that the nerve conduction function and re myelination was further resto red.These findings suggest that the Chi/PDA-Ps conduits have great potential in peripheral nerve injury repair.

RANK-ligand and osteoprotegerin as biomarkers in the differentiation between periprosthetic joint infection and aseptic prosthesis loosening

AIM To assess serum levels of RANK-ligand(RANKL) and osteoprotegerin(OPG) as biomarkers for periprosthetic joint infection(PJI) and compare their accuracy with standard tests.METHODS One hundred and twenty patients presenting with a painful total knee or hip arthroplasty with indication for surgical revision were included in this prospective clinical trial. Based on standard diagnostics(joint aspirate, microbiological, and histological samples) and Musculoskeletal Infection Society consensus classification,patients were categorized into PJI, aseptic loosening,and control groups. Implant loosening was assessed radiographically and intraoperatively. Preoperative serum samples were collected and analyzed for RANKL, OPG, calcium, phosphate, alkaline phosphatase(AP), and the bone-specific subform of AP(b AP). Statistical analysis was carried out, testing for significant differences between the three groups and between stable and loose implants. RESULTS All three groups were identical in regards to age, gender, and joint distribution. No statistically significant differences in the serum concentration of RANKL(P = 0.16) and OPG(P = 0.45) were found between aseptic loosening and PJI, with a trend towards lower RANKL concentrations and higher OPG concentrations in the PJI group. The RANKL/OPG ratio was significant for the comparison between PJI and non-PJI(P = 0.005). A ratio > 60 ruled out PJI in all cases(specificity: 100%, 95%CI: 89, 11% to 100.0%) but only 30% of non-PJI patients crossed this threshold. The positive predictive value remained poor at any cut-off. In the differentiation between stable and loose implants, none of the parameters measured(calcium, phosphate, AP, and b AP) showed a significant difference, and only AP and b AP measurements showed a tendency towards higher values in the loosened group(with P = 0.09 for AP and P = 0.19 for b AP). CONCLUSION Lower RANKL and higher OPG concentrations could be detected in PJI, without statistical significance.

Long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome:a 15-year follow-up from a prospective cohort study

The most severe sequelae after rehabilitation from SARS are femoral head necrosis and pulmonary fibrosis. We performed a 15-year follow-up on the lung and bone conditions of SARS patients. We evaluated the recovery from lung damage and femoral head necrosis in an observational cohort study of SARS patients using pulmonary CT scans, hip joint MRI examinations, pulmonary function tests and hip joint function questionnaires. Eighty medical staff contracted SARS in 2003. Two patients died of SARS, and78 were enrolled in this study from August 2003 to March 2018. Seventy-one patients completed the 15-year follow-up. The percentage of pulmonary lesions on CT scans diminished from 2003(9.40 ± 7.83)% to 2004(3.20 ± 4.78)%(P < 0.001) and remained stable thereafter until 2018(4.60 ± 6.37)%. Between 2006 and 2018, the proportion of patients with interstitial changes who had improved pulmonary function was lower than that of patients without lesions, as demonstrated by the one-second ratio(FEV1/FVC%, t = 2.21, P = 0.04) and mid-flow of maximum expiration(FEF25%–75%, t = 2.76, P = 0.01). The volume of femoral head necrosis decreased significantly from 2003(38.83 ± 21.01)% to 2005(30.38 ± 20.23)%(P = 0.000 2), then declined slowly from 2005 to 2013(28.99 ± 20.59)% and plateaued until 2018(25.52 ± 15.51)%. Pulmonary interstitial damage and functional decline caused by SARS mostly recovered, with a greater extent of recovery within 2 years after rehabilitation. Femoral head necrosis induced by large doses of steroid pulse therapy in SARS patients was not progressive and was partially reversible.

Short-term observations of the regenerative potential of injured proximal sensory nerves crossed with distal motor nerves

Motor nerves and sensory nerves conduct signals in different directions and function in different ways.In the surgical treatment of peripheral nerve injuries,the best prognosis is obtained by keeping the motor and sensory nerves separated and repairing the nerves using the suture method.However,the clinical consequences of connections between sensory and motor nerves currently remain unknown.In this study,we analyzed the anatomical structure of the rat femoral nerve,and observed the motor and sensory branches of the femoral nerve in the quadriceps femoris.After ligation of the nerves,the proximal end of the sensory nerve was connected with the distal end of the motor nerve,followed by observation of the changes in the newly-formed regenerated nerve fibers.Acetylcholinesterase staining was used to distinguish between the myelinated and unmyelinated motor and sensory nerves.Denervated muscle and newly formed nerves were compared in terms of morphology,electrophysiology and histochemistry.At 8 weeks after connection,no motor nerve fibers were observed on either side of the nerve conduit and the number of nerve fibers increased at the proximal end.The proportion of newly-formed motor and sensory fibers was different on both sides of the conduit.The area occupied by autonomic nerves in the proximal regenerative nerve was limited,but no distinct myelin sheath was visible in the distal nerve.These results confirm that sensory and motor nerves cannot be effectively connected.Moreover,the change of target organ at the distal end affects the type of nerves at the proximal end.

variation in expression of small ubiquitin-like modifiers in injured sciatic nerve of mice

Small ubiquitin-like modifiers (SUMOs) have been shown to regulate axonal regeneration, signal transduction, neuronal migration, and myelination, by covalently and reversibly attaching to the protein substrates during neuronal cell growth, development, and differentiation. It has not been reported whether SUMOs play a role in peripheral nerve injury and regeneration. To investigate any association between SUMOylation and potential neuroprotective effects during peripheral nerve injury and regeneration, C57/BL mice were randomly divided into sham and experimental groups. The sciatic nerve was exposed only in the sham group. The experimental group underwent neurotomy and epineurial neurorrhaphy. Real-time quantitative polymerase chain reaction and western blot assay results revealed different mRNA and protein expression levels of SUMO1, SUMO2, SUM03 and UBC9 in sciatic nerve tissue (containing both 5 mm of proximal and distal stumps at the injury site) at various time points after injury. Compared with the sham group, protein levels of SUM01 and SUMO2/3 increased in both their covalent and free states after sciatic nerve injury in the experimental group, especially in the covalent state. UBC9 protein levels showed similar changes to those of SUMO1 and SUMO2/3 in the covalent states. Immunohistochemical staining demonstrated that SUMO1 and SUMO2/3 immunopositivities were higher in the experimental group than in the sham group. Our results verified that during the repair of sciatic nerve injury, the mRNA and protein expression of SUMO1, SUMO2, SUMO3 and UBC9 in injured nerve tissues changed in varying patterns and there were clear changes in the expression of SUMO-related proteins. These findings reveal that SUMOs possibly play an important role in the repair of peripheral nerve injury. All animal protocols were approved by the Institutional Animal Care and Use Committee of Tianjin Fifth Central Hospital, China (approval No. TJWZXLL2018041) on November & 2018.

An electroencephalography-based human-machine interface combined with contralateral C7 transfer in the treatment of brachial plexus injury

Transferring the contralateral C7 nerve root to the median or radial nerve has become an important means of repairing brachial plexus nerve injury.However,outcomes have been disappointing.Electroencephalography(EEG)-based human-machine interfaces have achieved promising results in promoting neurological recovery by controlling a distal exoskeleton to perform functional limb exercises early after nerve injury,which maintains target muscle activity and promotes the neurological rehabilitation effect.This review summarizes the progress of research in EEG-based human-machine interface combined with contralateral C7 transfer repair of brachial plexus nerve injury.Nerve transfer may result in loss of nerve function in the donor area,so only nerves with minimal impact on the donor area,such as the C7 nerve,should be selected as the donor.Single tendon transfer does not fully restore optimal joint function,so multiple functions often need to be reestablished simultaneously.Compared with traditional manual rehabilitation,EEG-based human-machine interfaces have the potential to maximize patient initiative and promote nerve regeneration and cortical remodeling,which facilitates neurological recovery.In the early stages of brachial plexus injury treatment,the use of an EEG-based human-machine interface combined with contralateral C7 transfer can facilitate postoperative neurological recovery by making full use of the brain’s computational capabilities and actively controlling functional exercise with the aid of external machinery.It can also prevent disuse atrophy of muscles and target organs and maintain neuromuscular junction effectiveness.Promoting cortical remodeling is also particularly important for neurological recovery after contralateral C7 transfer.Future studies are needed to investigate the mechanism by which early movement delays neuromuscular junction damage and promotes cortical remodeling.Understanding this mechanism should help guide the development of neurological rehabilitation strategies for patients with brachial plexus injury.

Recalcitrant distal humeral non-union following previous Leiomyosarcoma excision treated with retainment of a radiated non-angiogenic segment augmented with 20 cm free fibula composite graft: A case report

BACKGROUND Leiomyosacromas in the Extremities are rare malignant smooth muscle tumors.Adjuvant radiation therapy, in combination with wide surgical excision allows the best chance of treatment. During the follow up pathological fractures are common complications that can be accompanied by Implant failure and defect situations that are most challenging in their management.CASE SUMMARY We present a case of a 52-year-old female suffering from a pathological fracture of the humeral shaft 10 yr after resection of a Leiomyosarcoma and postoperative radiotherapy. She developed implant failure after retrograde nailing and another failure after revision to double plate fixation. In a two-stage revision, the implants were removed and the huge segmental defect created after debridement was bridged by a compound osteosynthesis with nancy nails and bone cement for formation of the induced membrane. Due to the previous radiotherapy treatment,20 cm of the humeral shaft were declared devascularized but were left in situ as a scaffold. In the second stage, a vascularized fibula graft was used in combination with a double plate fixation and autologous spongiosa grafts for final reconstruction.CONCLUSION This combinatory treatment approach led to a successful clinical outcome and can be considered in similar challenging cases.

Soft tissue coverage using pedicled flap in combat zone: A case series

Background:Soft tissue reconstruction is typically conducted after evacuation from theater of operations.If circumstances do not allow timely evacuation,however,defect site may need to be reconstructed in the combat zone.Case presentation:A total of 41 patients with extremity soft tissue defect were treated using pedicled flaps by a single orthopedic surgeon during four deployments in Chad,Afghanistan and Mali between 2010 and 2017.The mean age was 25.6 years.A total of 46 injury sites in extremities required flap coverage:19 combat-related injuries(CRIs)and 27 non-combat related injuries(NCRIs).Twenty of the injury sites were infected.Overall,63 pedicled flap transfers were carried out:15 muscle flaps,35 local fasciocutaneous flaps and 13 distant fasciocutaneous flaps.The flap types used did not differ for CRIs or NCRIs.Mean follow-up was 71 days.Complications included deep infection(n=6),flap failure(n=1)and partial flap necrosis(n=1).Limb salvage rate was 92.7%(38/41).Conclusions:Soft tissue defect can be managed with simple pedicled flaps in theatre of operations if needed.Basic reconstructive procedures should be part of the training for military orthopedic surgeons.Trial registration:Retrospectively registered in January 2019(2019-0901-001).

Spinal Cord Injuries without Visible Bone Lesions: Analysis of Four Consecutive Cases

Objectives: Interest of this study is to report four cases of spinal cord injuries without bone lesion. Evolution of the injured patients according to the initial clinic assessment at admission and the treatment performed are discussed. Materials and Methods: From January to December 2016, we performed a retrospective study at the Neurosurgery Department of Hospital General Grand Yoff of Dakar. Four patients were followed for spinal cord injury without visible bone lesions. We analyzed the clinical, radiological, therapeutic and evolutionary data. Trauma caused by stabbing was excluded. Results: In a year, 83 cases of spinal trauma with neurological deficit were hospitalized in the department. Among them, 4 had spinal cord injuries without visible bone lesions. The average age was 31.7 years with extremes ranging from 14 to 47 years. The sex ratio of male/female was 3. We have recorded 2 cases of road traffic accidents, 1 case of fall from height and 1 case of sports accident. On the neurological level, we found 3 cases of tetraplegia, and 1 brachial monoplegia. Computed tomography in all patients was normal. All of them benefited from magnetic resonance imaging that showed spinal cord injury. All patients were under conservative treatment. One patient fully recovered, two partially and one passed away. Conclusion: In presence of any post traumatic myelopathy case, the absence of disco-vertebral lesions should bring to mind the SCIWORA as well as indicate the realization of magnetic resonance imaging.

Case of Unusual Abscess Localization in Lumbar Pott’s Disease

In Pott’s disease, cold abscesses usually sit and spread along the psoas muscle. This case concerned a 60 years old man who came to us with bilateral lomboradicular pain and a swelling of inguinal area and the anterior part of the left thigh. We found a 2 years long lasting story of low back pain complaint. Physical examination showed good general health status, stiffness of lumber spine, a left psoitis and no neurological deficit. CT scan going downward from the lumbar spine to the pelvic region and femoral limb with coronal reconstruction demonstrated a huge disco-vertebral destruction of L2-L3 with translation, and bilateral paramedian psoas abscess migrating subfascially toward Scarpa triangle and cleaving anteriorly mainly muscles of the left thigh. After 12 months medical treatment, the evolution has been favorable with clinical cure. The localization of the cold abscess in the left thigh anterior muscles compatment is uncommon. It is why we report this case.