Megaprosthesis Total Knee Replacement Following Resection of Extensive Osteoblastic Osteosarcoma in the Distal Femur: A Case Report

Osteosarcoma is the most common type of primary bone cancer, which usually appears in the distal femur. The diagnosis of this condition typically involves advanced imaging and tissue biopsy, as well as taking into account characteristic clinical and radiographic indicators. The treatment approach for distal femoral osteosarcoma is multidisciplinary and involves initial chemotherapy, followed by limb-sparing surgery, reconstruction of bone and soft tissue, and subsequent adjuvant chemotherapy. We present a case study of a 25-year-old male admitted with a blastic lesion in the distal femur, confirmed via open biopsy to be osteoblastic osteosarcoma. Further evaluation revealed multiple pulmonary nodular lesions, managed with chemotherapy. After four months, regression of the lesion was observed. Due to malignant clinical and imaging features, excision of the lesion and subsequent reconstruction were performed, utilizing a custom-made total knee arthroplasty. The excision encompassed the removal of the distal 14 cm of the femur, with histological examination confirming central osteoblastic osteosarcoma. Satisfactory outcomes were observed during a one-year follow-up, indicating promising results. Vigilance is crucial, especially in young patients with surface-type bone tumors, as this neoplasm requires consideration.

Traumatic avulsion of the anterior superior and inferior iliac spines in adult: A case report

Introduction

Avulsion fractures of the anterior superior and inferior iliac spines are rare fractures. They are mostly observed in adolescents during sports accidents, traumatic forms are even more exceptional.

Case report

Here we report a case of simultaneous and homolateral avulsion fractures of both anterior superior and anterior inferior iliac spines in a 35-year-old male adult after a motorcycle accident. Surgical treatment using an open reduction and fixation of the two spines was performed with very good functional outcomes. Surgical management of iliac spine avulsion fractures allows recovery of the subsequent level of sports activity in most cases.

Conclusion

Avulsion fractures of the anterior superior and inferior iliac spines are rare fractures. Surgical management of iliac spine avulsion fractures allows recovery of the subsequent level of sports activity in most cases. Orthopedic treatment is still used for the management of this type of injury, thus comparative studies are needed to refine the criteria for surgery.

Terrible triad injury of the elbow: A PROCESS-compliant surgical case series from Eastern Morocco

Introduction

The terrible triad of the elbow (TTE) is a lesion associating a dislocation of the elbow, a fracture of the radial head, and a fracture of the coronoid process, with a high potential of complication. The treatment is based on the restoration of bone lesions and external capsular ligament repair. The systematic repair of the medial collateral ligament (MCL) is still debated in the literature. The aim of this study is to evaluate the clinical and functional results of the surgical treatment in a real-world series from Easter Morocco.

Patients and methods

This was a retrospective study of 6 cases of TTE operated by isolated external approach or combined approach (internal or anterior) of the elbow in the department of Traumatology-Orthopedics of the Mohammed VI University Hospital (Oujda Morocco), over a period of 7 years from 2013 to 2020. Radial head and coronoid process fractures were classified according to the Mason and Morrey-Regan classifications, respectively. The following clinical parameters were evaluated: Mayo Clinic Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (DASH), Visual Analog Scale (VAS), and arc of mobility in flexion-extension and prono-supination.

Results

6 male patients treated between May 2013 and December 2020 were included. The median follow-up was 48 months. All patients had frontal and lateral standard X-ray of over and under joints, and computed tomography (CT)-scan was delivered for 5 cases. The elbow dislocation was posterolateral in five cases, and posteromedial in only one patient. Radial head fractures were classified as type I in one case, type II in two cases, and type III in three cases. Coronoid fractures were type I in three cases, type II in one case, and type III in two cases. At the last follow up, the mean MEPS, Quick DASH, and VAS was 81, 28, 0.8, respectively. The mean arc of mobility in flexion was 120° and it was deficient by 20° in extension. In addition, the mean arc of mobility in protonation was 80°, while in supination it was 75°. Regarding complications, we noticed an instability of the elbow on valgus in a single case, elbow stiffness with heterotopic ossification in a single case, ulnar nerve damage in a single case during medial collateral ligament anchoring, and elbow hygroma in one single case.

Conclusion

The surgical management of TTE can provide good and long-term functional results after restoration of the stabilization of bone structures and the lateral ligament complex, without the need to repair the medial collateral ligament.

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The terrible triad of the elbow is a complex injury affecting both the bone and ligaments.

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A complete and accurate management of this entity during any trauma of the elbow is required.

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A careful clinical and radiological assessments must be performed during complex elbow trauma.

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The main objective of any treatment is to provide a stable elbow and avoid early arthrosis.

Giant squamous cell carcinomas of the shoulder

Giant squamous cell carcinomas (SCC) larger than 5 cm in diameter are uncommon; there is no guideline on the size of an SCC that is considered giant. Treatment may be difficult with the need for large tissue resections and complex surgical reconstruction. We report a rare case of giant squamous cell carcinoma of the shoulder attached to deep anatomic planes. The entire mass was removed, resulting in a large defect that was repaired with myocutaneous flap rotation of the latissimus dorsi. Three courses of radiotherapy were performed after surgery. Fifteen months after the operation, the patient is well and working without any local recurrence and metastasis.

[Gauthier's osteotomy and fixation using osteosuture in the treatment of Freiberg's disease]

La maladie de Freiberg est une ostéochondrose des têtes métatarsiennes, touchant le plus fréquemment la deuxième tête. Les auteurs rapportent à travers une étude rétrospective étalée sur trois ans, une série de 06 patientes, dont l’âge moyen est de 19,8 ans, opérées par une ostéotomie de soustraction dorsale selon Gauthier avec une fixation par des ostéosutures. Les résultats de cette technique sont satisfaisants vue que la majorité de nos patientes ont retrouvé l’indolence et ont récupéré une activité quotidienne habituelle. Les auteurs ont conclu que la fixation par des ostéosutures est une méthode fiable et peu coûteuse.

[Simultaneous bilateral rupture in both cruciate knee ligaments (about a case)]

Bilateral cruciate ligament rupture is rare while simultaneous rupture in both anterior cruciate ligaments (ACL) is exceptional; that's why post-traumatic simultaneous bilateral cruciate ligament rupture has never been described in the literature making this case study based on patient's observation, follow-up and therapeutic discussion very interesting. The procedure was performed in two surgical steps spaced in time and results were very satisfactory for both us and patient.

[Osteosynthesis of fractures of the metacarpals and phalanges of the hand with mini plate: about 12 cases]

Le traitement des fractures instables des métacarpes et des phalanges reste un objet de controverse. Peu de séries ont été rapportées dans la littérature, rendant leur analyse difficile. Nous rapportons une étude rétrospective comportant 12 patients, opérés par cette technique, ayant eu des fractures déplacées des métacarpes ou des phalanges, sur une période de deux ans. Les résultats globaux ont été bons dans 75% des cas, moyenne dans 16,5% des cas et mauvais dans 8,5% des cas. La stabilité du montage par mini plaques des fractures instables des métacarpiens et des phalanges ont permis une mobilisation précoce des articulations de la main, évitant ainsi la raideur.

[Osteoid osteoma in the lower extremity of the radius: about a case, rare location and review of the literature]

L'ostéome ostéoïde est une tumeur osseuse bénigne, mais douloureuse et dont le traitement consiste en l'exérèse chirurgicale totale. Nous rapportons, dans ce travail le cas d'une jeune patiente présentant un ostéome ostéoïde de l'extrémité inférieur du radius.

[An exceptional form of perilunar carpal dislocation]

Les luxations périlunaires (LPL) du carpe sont des lésions extrêmement rares, qui peuvent passer inaperçue en raison d'un tableau clinique souvent trompeur, des radiographies en profil non strict ou d'interprétation difficile. Nous rapportons l'observation d'une luxation périlunaire stade III selon la classification de Witvoët et Allieu chez un patient de 32 ans, il s'agit d'une forme encore plus rare voire exceptionnelle et qui peut induire de sérieux problèmes en raison de la sévérité des dommages ligamentaires et du risque de nécrose du semilunaire plus important dans ce type de lésions. Le traitement est toujours chirurgical et doit être réalisé dans les plus brefs délais afin d’éviter les complications.

Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul

PURPOSE

Management practices associated with war-related amputations in countries at war may be different from the recommendations of occidental Health Force Services due to the high numbers of wounded persons to treat in precarious conditions. This observational retrospective study documents the current management of local lower extremity amputees in Afghanistan. Surgical practices, with or without delayed primary closure (DPC), and prosthetic rehabilitation issues are analyzed.

METHODS

This retrospective study was conducted in the National Military Hospital (NMH) of Kabul from May 2011 to November 2011. Fifty-four Afghan patients who underwent a lower extremity combat-related amputation were included. Ten of them sustained a bilateral amputation.

RESULTS

Injuries were caused by improvised explosive devices (IEDs) or mines in 48 cases, bullets in three cases, and exploding shell fragments in three cases. Of the 64 amputations studied, 46 were open length preserving amputations and primary closure (PC) was applied in 18 cases. Patients were reviewed with a mean follow-up of 5.4 months (range 1-28 months). In the DPC group, secondary closure was performed with a mean time of 18.7 days (range 4-45 days) from injury. The proportion of infectious complications seemed to be higher in the PC group (5/18) than in the DPC group (3/46), but it was only a statistical trend (p = 0.1). Forty-three patients were not prosthetic fitted at the last follow-up.

CONCLUSION

This study supports the surgical strategy of a two-stage procedure for lower limb amputations in countries at war, but underlines the problems of late secondary closure and prosthetic fitting related to decreased sanitary conditions.

Hydatidosis of the pelvic bone: case report and review of the literature

The authors report three cases of pelvic bone hydatidosis: two men and a woman aged from 25 to 42 years. The lesions were extensive: In two cases, they extended to the entire hemipelvis, and in one case, the extension was to the sacrum, which makes it difficult to carry out a radical surgery. In two cases, computed tomography was evocative and allowed for the completion of a local and precise checkup for a patient through MRI. At the therapeutic level, the first patient was treated by curettage and sterilization with oxygenated water followed by medical treatment, but with recurrence few months later. The second patient was put only under medical treatment because of the extent of the lesions, allowing therefore for clinical and radiological stabilization. Concerning the last patient, she benefitted from the resection of the femoral head and the right iliac wing followed by a medical treatment. The evolution was favorable with a three-year recession. The actual treatment of the osseous echinococcosis would be a combination of albendazole and surgery.

[Permanent abduction of the little finger without ulnar nerve palsy: a case report]

Wartenberg's sign, or permanent abduction of the little finger, occurs in the context of sequelae of ulnar nerve palsy. Its presence alone is rarely reported in the literature and is due to avulsion of the insertion of the third volar interosseous muscle. Several surgical techniques to correct this sign are reported in the literature. The authors report the case of a Wartenberg's sign without ulnar nerve palsy due to traumatic avulsion of the third volar interosseous muscle that was treated by a transfer of the extensor digiti minimi onto the radial side of the extensor digitorium communis according to technique of Bellan et al. After 1-year follow-up, result was good with no recurrence of any deformities and a normal active extension.

Gender specific correlations of adrenal gland size and body fat distribution: a whole body MRI study

OBJECTIVE

The aim of this study was to investigate the gender specific correlations of stress related tissues [adrenal gland volume (AV), visceral fat] and alimentary dependent fat compartments with cortisol concentrations in healthy male and female subjects.

METHODS

Fourteen men and 13 women were examined. Fat compartments [whole body fat, visceral adipose tissue (VAT) and subcutaneous adipose tissue (SCAT)] were determined using whole body MRI. Adrenal gland volume was assessed by a 3D MR data set. The salivary cortisol was determined at 9 AM and 4 PM.

RESULTS

Men had significantly more visceral fat and less subcutaneous fat than women. Adrenal gland size correlated significantly with the visceral and subcutaneous fat in women (r=0.7, p=0.008), but not in men (r=0.2, p=0.4). There was a negative correlation between the decrease of cortisol between 9 AM and 4 PM with VAT (r=-0.451, p=0.027) in the whole group.

DISCUSSION

The high correlation between the adrenal gland volume and VAT in women underlines the link between hypothalamic-pituitary-adrenal (HPA) axis, stress, and circadian cortisol rhythm, respectively, and an increased abdominal fat volume. The lack of correlation between visceral fat and adrenal volume in men points to an additional influence of sex hormones.

Moderate therapeutic efficacy of positron emission tomography-navigated repetitive transcranial magnetic stimulation for chronic tinnitus: a randomised, controlled pilot study

BACKGROUND

Tinnitus has been shown to respond to modulations of cortical activity by high-frequency and low-frequency repetitive transcranial magnetic stimulation (rTMS).

OBJECTIVE

To determine the tinnitus-attenuating effects of a 2-week daily regimen of rTMS, navigated to the maximum of tinnitus-related increase in regional cerebral blood flow.

METHODS

Six patients with chronic tinnitus were enrolled in this sham-controlled crossover study and treated with 2x2 weeks of suprathreshold 1 Hz rTMS (30 min) applied to the region with maximal tinnitus-related increase in regional cerebral blood flow delineated by functional imaging with [15O]H2O positron emission tomography and a control area. Tinnitus-related distress was assessed before and after each treatment and 2 weeks after the end of the 4-week course of stimulation using a validated tinnitus questionnaire. Additional self-assessment scores of tinnitus change, loudness and annoyance were obtained.

RESULTS

In five of six patients, rTMS induced greater reduction of the tinnitus questionnaire score than sham stimulation. In two patients, all parameters measured (tinnitus change score, tinnitus loudness, tinnitus annoyance) showed unequivocal improvement. At the group level, the degree of response in the tinnitus questionnaire score was correlated with tinnitus-associated activation of the anterior cingulate cortex. Two weeks after the final stimulation, tinnitus had returned to baseline in all patients but one.

CONCLUSION

Tinnitus can be attenuated by low-frequency rTMS navigated to each person's maximum tinnitus-related cortical hyperactivity. The effects are only moderate; interindividual responsiveness varies and the attenuation seems to wear off within 2 weeks after the last stimulation session. Notably, tinnitus-related anterior cingulate cortex activation seems to predict the response to rTMS treatment.

Doping strategies to optimise the oxide ion conductivity in apatite-type ionic conductors

The apatite-type phases, La(9.33+x)(Si/Ge)(6)O(26+3x/2), have recently been attracting considerable interest as potential electrolytes for solid oxide fuel cells. In this paper we report results from a range of doping studies in the Si based systems, aimed at determining the key features required for the optimisation of the conductivities. Systems examined have included alkaline earth doping on the rare earth site, and P, B, Ga, V doping on the Si site. By suitable doping strategies, factors such as the level of cation vacancies and oxygen excess have been investigated. The results show that the oxide ion conductivities of these apatite systems are maximised by the incorporation of either oxygen excess or cation vacancies, with the former producing the best oxide ion conductors. In terms of samples containing cation vacancies, conductivities are enhanced by doping lower valent ions, Ga, B, on the Si site. The presence of higher valent ions on these sites, e.g. P, appears to inhibit the incorporation of excess oxygen within the channels, and so limits the maximum conductivity that can be obtained. Overall the results suggest that the tetrahedral sites play a key role in the conduction properties of these materials, supporting recent modelling studies, which have suggested that these tetrahedra aid in the motion of the oxide ions down the conduction channels by co-operative displacements.

Tetanus toxin modulates serotonin transport in rat-brain neuronal cultures

As has been previously described, tetanus toxin (TeTx) and its H(C) fragment inhibit the sodium-dependent 5-hydroxytryptamine (5-HT) uptake in rat-brain synaptosomes, probably through a kinase mechanism affecting the 5-HT transporter. Now, the inhibition of 5-HT uptake in neurons in primary culture by TeTx in a dose-dependent manner is described in this work. This effect is also produced by the nontoxic C-terminal fragment of the TeTx heavy chain (H(C)-fragment), indicating that 5-HT uptake inhibition is a consequence of the toxin binding to the plasmatic membrane and not to its catalytic activity. This conclusion is supported by the fact that the 5-HT accumulation was not inhibited by the light chain of TeTx or the toxoid, and was even potentiated by botulinum neurotoxin A. These results correlate with the activation of phosphoinositide-phospholipase C activity in the cultures used in this study, this activity only being enhanced by TeTx and by its Hc-fragment. On the other hand, the use of tyrosine phosphorylation modulators indicates that both Na3VO4 and basic fibroblast growth factor (bFGF) produce an enhancement of 5-HT uptake in this system, which is also sensitive to TeTx inhibition. On the other hand, genistein alone is able to reduce the 5-HT transport in cultured neurons, and this effect did not appear to be additive to that elicited by TeTx. This result suggests that TeTx and genistein may share some events in their respective mechanisms of action. Furthermore, the incubation at different concentrations of 12-O-tetradecanoylphorbol 13-acetate (TPA) confirms the involvement of protein kinase C (PKC) in 5-HT transport modulation in rat-brain neuronal primary cultures. In summary, we shall demonstrate in this work that TeTx induces, through its Hc fragment, an inhibition of both basal and stimulated serotonin uptakes in primary neuronal cultures, in parallel to the activation of phosphoinositide-phospholipase C activity and PKC activation.

Serotonin transporter phosphorylation modulated by tetanus toxin

Tetanus toxin (TeTx) modifies Na(+)-dependent, high-affinity 5-hydroxytryptamine (5-HT, serotonin) uptake in a synaptosomal-enriched P(2) fraction from rat brain. The effect corresponds to a rapid and non-competitive uptake inhibition, and it is preceded by induction of phospholipase C (PLC) activity and translocation and down-regulation of the classical protein kinase C (PKC-alpha, -beta and -gamma) isoforms. The effects on serotonin transport and on cPKC activation were similar to the effects exhibited by phorbol ester 12-O-tetradecanoylphorbol 13-acetate (TPA). Moreover, after treatment with TeTx, an increase in Ser- and Tyr-specific phosphorylation was found. Activation of PKC by both TeTx and TPA results in a loss of transport capacity and serotonin transporter (SERT) phosphorylation, which are abolished by coapplication of the specific PKC inhibitor bisindolylmaleimide-1. Since a specific PLCgamma1 phosphorylation prior to TeTx's inducing SERT phosphorylation was found, the studies suggest that part of the action of TeTx consists of modifying the signal cascade initiated in tyrosine kinase receptors on nerve tissue previous to its cellular internalization, resulting in transporter phosphorylation.

Clostridium neurotoxins influence serotonin uptake and release differently in rat brain synaptosomes

Clostridium neurotoxins produce inhibition of both basal and K(+)-evoked serotonin release in rat brain synaptosomes. To produce these effects, tetanus toxin (TeTx), as well as botulinum neurotoxin type A (BoNT/A), added to brain synaptosomes, must be incubated at 37 degrees C over a long interval (hours). This serotonin exocytosis inhibition was abolished with previous treatment with specific Zn2(+)-metalloprotease inhibitors. Nevertheless, a short incubation time produces different behavior of the indicated neurotoxins: TeTx significantly blocks the sodium-dependent, high-affinity serotonin uptake, whereas a small increase of this uptake was found with BoNT/A. Both Zn2(+)-metalloprotease active fragments, light chains of TeTx and BoNT/A, are unable to reproduce the block of the serotonin uptake, whereas the C-terminal portion of the TeTx heavy chain (Hc-TeTx), which binds specifically to the target tissue, inhibited the serotonin uptake in a dose-dependent manner. The IC50 of Hc-TeTx ranges from 0.62 to 2.08 nM. Binding of [3H]imipramine and [3H]serotonin did not change after toxin treatments, which indicates that these clostridium neurotoxins do not act on the serotonin high-affinity site at the serotonin transporter or at other serotonin high-affinity sites. These results could indicate that TeTx and Hc-TeTx bind to different targets than BoNT/A in the plasma membrane.

Inhibition by tetanus toxin of sodium-dependent, high-affinity [3H]5-hydroxytryptamine uptake in rat synaptosomes

Tetanus toxin (TeTx) is a powerful clostridial neurotoxin that inhibits Ca2+-dependent neurotransmitter secretion as do the botulinum neurotoxins (BoNTs). We found that TeTx (but not BoNT/A) produced a specific time- and dose-dependent inhibition of Na+-dependent [3H]5-hydroxytryptamine (serotonin, 5-HT) uptake in rat CNS synaptosomes. This effect was found in all CNS tryptaminergic areas, being maximal in the hippocampus and occipital cortex. TeTx produced the maximum reduction in [3H]5-HT uptake after 30 min of preincubation, being significant also at lower doses (10(-12) M) or shorter incubation times (10 min). Serotonin transport inhibitors such as fenfluramine (IC50, 11.0 +/- 0.9 microM), paroxetine (IC50, 33.5 +/- 0.1 microM), and imipramine (IC50, 89.9 +/- 5.7 microM) were 3 or 4 orders of magnitude less potent than TeTx (IC50, 8.7 +/- 1.0 nM). Of the two fragments of TeTx, (the C-terminal portion of the neurotoxin heavy chain, which is responsible for the binding to the nerve tissue) was consistently more effective than the L-H(N) fragment (the light neurotoxin chain disulfide linked to the N-terminal portion of the heavy chain, which is responsible for the toxic metalloprotease action) as inhibitor of [3H]5-HT uptake in synaptosomal preparations (56 +/- 5% and 95 +/- 3% with respect to control, respectively). Antagonism of the toxin-induced [3H]5-HT uptake blockade could not be reversed by zinc chelators but did have the ability to antagonize the TeTx inhibition of basal and K+-evoked [3H]5-HT release in rat synaptosomes. The reduction in serotonin accumulation induced by TeTx could be responsible for some tetanic symptoms that have been related to the serotonergic system.

Phlegmasia cerulea dolens: an experimental study

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