Osteosynthesis of Common Acetabular Fractures Operated on Through a Single Posterior (Kocher-Langenbeck) Approach with or without Trochanteric Flip Osteotomy. A Case Series.

BACKGROUND: The Kocher-Langenbeck approach is recommended in the majority of common posterior acetabular injuries. Trochanteric osteotomy can be used to extend the exposure of the Kocher-Langenbeck approach superiorly and anteriorly. We evaluated the functional outcome of common acetabular fractures operated on through the Kocher-Langenbeck approach with or without trochanteric flip osteotomy. MATERIAL AND METHODS: This prospective study enrolled 42 patients with posterior wall, posterior column, transverse, posterior wall with posterior column, transverse with posterior wall and both column acetabular fractures. The Kocher-Langenbeck approach was used in 35 patients and trochanteric flip osteotomy was done in 7 patients. The radiological outcome was evaluated by Matta's criteria and the functional outcome was evaluated using modified Merle d'Aubigné and Postel criteria. RESULTS: D'Aubigne Postel scores at the final follow-up were excellent in 12 patients, good in 18, fair in 8 and poor in 4. Thirty-seven patients had congruent reduction (anatomical in 29, imperfect in 8) and 5 patients had non-congruent reduction on radiographs as per Matta's criteria. Radiographic congruity (88.09%, 37 out of 42 cases) correlated fairly well with the functional outcome (excellent or good functional outcome in 71.4%, 30 out of 42 cases). The complications included traumatic nerve palsy (3 cases), iatrogenic nerve palsy (2 cases), deep venous thrombosis (2 cases), wound infection (3 cases), non-congruent reduction (5 cases), 8 cases of osteoarthritis of hip, 2 cases of avascular necrosis of femoral head and 3 cases of heterotrophic ossification. CONCLUSIONS: 1. Surgical treatment of common acetabular fractures with major posterior involvement can be attempted via a single posterior approach (Kocher-Langen-beck with or without trochanteric flip osteo-tomy) and leads to good-to-excellent results in a majority of the cases. 2. It is superior to conservative management, which has been found to be accompanied by a much higher rate of complications. 3. A thorough study of the pre-opera-tive radiographs, Judet's views and 3D-reconstructed CT images helps in classifying the fracture and thereby assigning or not assigning it for the posterior approach.

A High-Grade Chondrosarcoma of Calcaneum Mimicking as a Benign Pathology: Delayed Diagnosis and Management.

UNLABELLED: This case is presented to highlight a rare case of chondrosarcoma of calcaneum in a young adult mimicking as a benign pathology and to highlight the diagnosis and early management of such cases to prevent complications and even death. Chondrosarcoma constitutes less than 10% of all primary malignancies of bone and occurs mostly in proximal locations such as pelvis, proximal femur, and proximal humerus. We present a case of high-grade chondrosarcoma at a very rare site, calcaneum of a 40-year-old male that was mimicking as a benign pathology. This case report highlights the importance of proper clinical examination, evaluation, and suspicion for benign occurring lesions to prevent complications related to a delay in diagnosis. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.

Production of ELOVL4 transgenic pigs: a large animal model for Stargardt-like macular degeneration.

BACKGROUND: Truncation mutations in the elongation of very long chain fatty acids-4 (AF277094, MIM #605512) (ELOVL4) gene cause Stargardt-like macular dystrophy type 3 (STGD3). Mice expressing truncated ELOVL4 develop rapid retinal degeneration, but are poor STGD3 models since mice lack a macula. Photoreceptor topography in the pig retina is more similar to that in humans as it includes the cone rich, macula-like area centralis. The authors generated transgenic pigs expressing human disease-causing ELOVL4 mutations to better model the pathobiology of this macular disease. METHODS: Pronuclear DNA microinjection and somatic cell nuclear transfer were used to produce transgenic pigs for two different ELOVL4 mutations: the 5 base pair deletion (5 bpdel) and the 270 stop mutation (Y270terEYFP). Retinal transgene expression, morphology and electrophysiology were examined. RESULTS: The authors obtained four lines of Y270terEYFP and one line of 5 bpdel transgenic animals. Direct fluorescence microscopy indicated that the Y270terEYFP protein is expressed in photoreceptors and mislocalised within the cell. Immunohistochemical examination of transgenic pigs showed photoreceptor loss and disorganised inner and outer segments. Electroretinography demonstrated diminished responses in both transgenic models. CONCLUSIONS: These transgenic pigs provide unique animal models for examining macular degeneration and STGD3 pathogenesis.

Giant osteochondroma of proximal fibula in a skeletally mature patient.

Osteochondroma are believed to be most common benign tumors. The growth of osteochondroma usually ceases when skeletal maturity is reached but becomes a matter of concern to the attending doctor if the lesion becomes painful and shows evidence of increased growth even after physeal closure, which may be an indication of sarcomatous change in the lesion. We present a case with substantial growth of an osteochondroma after attainment of skeletal maturity. The tumor turned out to be histologically benign, and patient had an uneventful recovery with no recurrence.

Transmalleolar approach to a tubercular lytic lesion of the talar body: a case report.

Tuberculosis of the talus is a rare condition, and the diagnosis can be difficult to make because of inconclusive laboratory and ancillary testing. In such cases, accurate diagnosis and appropriate treatment may require the use of a transmalleolar osteotomy to gain access to the involved portion of the talar body. In the case described in this article, a transmalleolar approach was used to gain access to a lytic lesion of the talar body so as to obtain microbiological and histopathological specimens for diagnostic purposes, and to thoroughly debride the lesion. After 6 years of postsurgical follow-up, the patient was leading a normal life with a full range of ankle and subtalar motion. The rarity of the diagnosis, and the use of the transmalleolar approach to a lytic and likely infected lesion in the body of the talus, makes this case worthy of public discussion.

Isolation, characterization, and nuclear reprogramming of cell lines derived from porcine adult liver and fat.

Genetic manipulation of porcine genome to produce genetically modified pigs with high efficiency has been hampered by the unavailability of an ideal cell type. The cell type currently used for various genetic manipulations is fetal fibroblasts. These cells have very limited life span in culture, and efficiency of gene targeting is very low. In this study, we developed a simple but novel strategy to derive cell lines from adult porcine liver and adipose tissues with long life span. Small colonies with few cells became visible as early as 2 to 3 days on collagen-coated plates, and a full-grown colony took 10 to 14 days to form. These cells maintained a steady growth up to 80 population doublings with normal karyotype. Transfection of these cells with a plasmid containing a neomycin resistance gene and selected under G418 yielded clones with stable genetic modifications and extended expression of the transgene. Further, these cells were used as nuclear donors to produce somatic cell nuclear transfer (SCNT) embryos. The average fusion rates were 86.8, 80.5, and 90.4% for liver-derived cell lines (LDCs), fat-derived cell lines (FDCs), and fetal fibroblasts (FFs), respectively. We achieved a pregnancy rate of 50% with both LDCs and FDCs at day 30 and the efficiencies of generating fetuses from cloned embryos were 3.5, 2.1, and 4.0% for LDCs, FDCs and FFs, respectively.

Outcome of olecranon osteotomy in the trans-olecranon approach of intra-articular fractures of the distal humerus.

BACKGROUND: The trans-olecranon approach has been suggested to improve the visualization of complex intra-articular distal humerus fractures. Significant osteotomy complications have prompted a search for alternative approaches. The purpose of this series was to study the outcome of the olecranon osteotomy in terms of union and complications and the ultimate outcome of the fracture. METHODS: Ninety-four patients with intra-articular fractures of the distal humerus (type C3) were treated by open reduction and internal fixation using the trans-olecranon approach. The patients were followed from 6 to 48 months, with an average follow-up of 24 months. RESULTS: All osteotomies united in an average of 11 weeks (range, 8-20 weeks). There was no non-union, although union was delayed in four osteotomies, which all healed by 20 weeks without any intervention. The most frequent complication in this study was symptomatic osteotomy fixation in 19% of patients, all of whom underwent a secondary procedure for the removal of the implant after the osteotomy had united. Seventy-one percent of the unsatisfactory results were seen in those patients who had symptomatic olecranon fixation. CONCLUSION: Despite a few manageable complications, the trans-olecranon approach is essential for the adequate visualization and fixation of the complex fracture of the distal humerus. Adequate fixation of the osteotomy is essential to prevent complications and achieve a satisfactory outcome.

Ewing's sarcoma of the ilium mimicking inflammatory arthritis of the hip: a case report.

INTRODUCTION: Ewing's sarcoma is second most common primary malignant bone neoplasm in children and adolescents. We report a case of Ewing's sarcoma of ilium in an 18-year-old female mimicking clinically and radiologically inflammatory arthritis of hip joint, a rare entity not mentioned in literature. CASE PRESENTATION: An 18-year-old girl presented with pain hip, limp and fever off and on. Patient had restricted range of motion, raised erythrocyte sedimentation rate, leucocytosis and radiograph showed reduced joint space. Magnetic resonance imaging pelvis revealed an altered marrow signal of acetabulum with a large soft tissue component. Histopathology revealed a malignant round cell tumor consistent with Ewing's sarcoma. CONCLUSION: Classical clinical and radiological presentation of Ewing's sarcoma of ilium may not be the rule. One should be highly suspicious of the disease even if there is no direct pointer to the disease as was encountered in our case.

Injuries from bear (Ursus thibetanus) attacks in Kashmir.

BACKGROUND: Strict conservation of wildlife and encroachment into its habitat have led to an increase in the number of wild animal-inflicted injuries and fatalities in Kashmir. The aim of this study was to report injuries inflicted during bear attacks and discuss their management and sequelae. METHODS: A retrospective study was conducted in the Department of Orthopedics Government Medical College Srinagar, University of Kashmir, from January 2003 to June 2007. A total of 254 cases (186 males, 68 females) with history of bear attacks were recorded over a period of 54 months. RESULTS: Eighty percent of victims were attacked in the maize fields and apple orchards and 20% in the dense forests while collecting firewood or tending to the cattle. Lacerations of the head and neck and fractures of the upper limbs and facial and skull bones were the striking observations. Permanent facial disfigurement, hearing loss, loss of digits, residual neurodeficit, and persistent psychological morbidity were the long-term sequelae in most of the patients. CONCLUSION: Wild animal-inflicted injuries are a neglected part of trauma. There should be a high index of suspicion when treating these injuries, as serious underlying bone or soft-tissue damage can be overlooked. Management of these injuries involves all subspecialties of trauma to achieve the best functional outcome.

Humeral biepicondylar fracture dislocation in a child: A case report and review of the literature.

INTRODUCTION: Humeral biepicondylar fracture dislocation is a very rare injury reported only once in English literature by G R Taylor et al. We report a case of humeral biepicondylar fracture dislocation in a 13-year-old girl with a unique mechanism of injury. CASE PRESENTATION: A 13-year-old girl presented with trauma elbow. Radiographs showed biepicondylar fracture of humerus with dislocation of elbow. CONCLUSION: In humeral biepicondylar fracture dislocation, reduction is always unstable. So treatment is open reduction and internal fixation.

Open reduction and internal fixation in a case with transscaphoid perilunate dislocation 8 months after the injury: a patient with a 5-year follow-up.

The management of perilunate dislocations diagnosed later than three months continue to elicit debate with literature being scarce. We report a 22-year-old male with transscaphoid perilunate dislocation who reported to our hospital 8 months after sustaining the injury. Open reduction was done along with bone grafting. Five years after the surgery the patient is symptom-free with an excellent range of motion.

Enhancement of extra chromosomal recombination in somatic cells by affecting the ratio of homologous recombination (HR) to non-homologous end joining (NHEJ).

Advancements in somatic cell gene targeting have been slow due to the finite lifespan of somatic cells and the overall inefficiency of homologous recombination. The rate of homologous recombination is determined by mechanisms of DNA repair, and by the balance between homologous recombination (HR) and non-homologous end joining (NHEJ). A plasmid-to-plasmid, extra chromosomal recombination system was used to study the effects of the manipulation of molecules involved in NHEJ (Mre11, Ku70/80, and p53) on HR/NHEJ ratios. In addition, the effect of telomerase expression, cell synchrony, and DNA nuclear delivery was examined. While a mutant Mre11 and an anti-Ku aptamer did not significantly affect the rate of NHEJ or HR, transient expression of a p53 mutant increased overall HR/NHEJ by 2.5 fold. However, expression of the mutant p53 resulted in increased aneuploidy of the cultured cells. Additionally, we found no relationship between telomerase expression and changes in HR/NHEJ. In contrast, cell synchrony by thymidine incorporation did not induce chromosomal abnormalities, and increased the ratio of HR/NHEJ 5-fold by reducing the overall rate of NHEJ. Overall our results show that attempts at reducing NHEJ by use of Mre11 or anti-Ku aptamers were unsuccessful. Cell synchrony via thymidine incorporation, however, does increase the ratio of HR/NHEJ and this indicates that this approach may be of use to facilitate targeting in somatic cells by reducing the numbers of colonies that need to be analyzed before a HR is identified.

Neurological outcome following delayed fixation of unstable thoracolumbar spinal injuries with short segment posterior fixation.

OBJECTIVE: To evaluate the improvement in neurological deficit following late decompression and stabilization of the fractured thoracolumbar spine. METHODS: Between January 2001 and August 2004 neurological recovery in 120 thoracolumbar fractures was studied after posterior stabilization at the Hospital for Bone & Joint Surgery, Srinagar, India. There were 88 male and 32 female patients. Fall from a height, usually a tree, was the most common (90%) cause of injury. Seventy-six patients (63%) had neurologic deficit at the time of presentation. The unstable spine was fixed, between 4-18 days after trauma, by posterior short segment instrumentation (Steffee). Neurological recovery for the patients was recorded in the follow-up period. Frankel grade was used to assess the neurological status. The average follow-up period was 25 months (range 8-44 months), and average age was 34 years (18-54). RESULTS: There were 40 patients (30%) with an incomplete neurological deficit, namely, patients with Frankel grade B, C, and D. Two grades of improvement were found in 8 patients, and one grade improvement in 32 patients with incomplete lesion. Only one third of the patients with complete neuro deficit improved at the final follow-up. The overall result of the surgery for partial lesions was an improvement of at least one Frankel grade in all cases, but no improvement in most of the cases with complete lesion. CONCLUSION: This study demonstrates a clear relationship between the level of injury and Frankel grades, translational injuries are associated with a more severe neurologic grade, and surgical intervention appears to improve the neurological outcome, even when the intervention is inadvertently delayed (average 7.9 days).

Retrospective analysis of the occurrence of radiologically detectable surgical error in cases of failed pedicle screw implants.

Pedicle screw instrumentation is an important tool in an orthopaedic surgeon's armamentarium in the management of spinal fractures. Complications with this system have been studied extensively. Due to the exacting technique the possibility of surgical error exists while using this modality. We studied a series of 216 cases where pedicular screws had been used and isolated 34 cases of implant failure. Retrospective analyses of their radiographs showed that surgical error does contribute to the implant failure in a statistically significant manner.

Swine generated by somatic cell nuclear transfer have increased incidence of intrauterine growth restriction (IUGR).

While somatic cell nuclear transfer (SCNT) has been successful in several species, many pregnancies are lost and anomalies are found in fetal and perinatal stages. In this study SCNT and artificial inseminations (AI) populations were compared for litter size, average birth weight, piglets alive at birth, stillborn, mummies, dead at the first week, intrauterine growth restriction (IUGR) and large for gestational age (LGA). Twenty-three SCNT litters (143 individuals) were compared to 112 AI litters (1300 individuals). Litter size average was 11.5 for AI and 6.2 for SCNT. Litter weight and average birth weight adjusted by litter size were significantly (p < 0.05) higher in AI than in SCNT litters. The SCNT population had a significant (p < 0.01) increase in the number of IUGRs per litter with LSmeans 7.2 +/- 1.4 versus 19.4 +/- 3.5 and means 8.0 +/- 10.8 versus 15.5 +/- 24.5 for AI and SCNT, respectively. Additionally, there was a trend for higher postnatal mortality and stillbirths in the SCNT population. These findings demonstrate that there are some differences between SCNT-derived and AI litters. SCNT-derived pigs are excellent models to study epigenetic factors and genes involved in IUGRs, and to develop effective means to improve fetal growth in humans and animals.

Management of unstable thoracolumbar spinal injuries by posterior short segment spinal fixation.

Fifty patients with thoracolumbar fractures were treated operatively between July 2000 and December 2001. The average age of the patients was 33.6 years (range: 20-50 years), 36 were males and 14 were females and the follow-up averaged 59 months (range: 49-68 months). A fall from a height, usually a tree, was the most common cause of injury. Twenty six patients had unstable burst fractures and 13 had translational injury. There were 15 patients with complete neurological deficit, 17 had partial neurological lesions, while 18 had no neurological deficit. All patients were treated by posterior short segment fixation (Steffee VSP). The average pre-operative kyphotic angle was 21.48 degrees , which improved to 12.86 degrees in the immediate post-operative period. The loss of kyphosis averaged 3.46 degrees (0-26 degrees ) at the final follow-up. The average pre-operative anterior vertebral body height was 44.7% (range: 36-90%), which improved to 72.0% (range: 55-97%) in the immediate post-operative period. The loss of body height averaged 3.0% (range: 1-15%) at the final follow-up. No neurological deterioration was seen, and in 24 cases a one grade or better improvement was observed. The mean pain score was 1.6, and the mean functional score was 2.8. We found that the application of posterior instrumentation resulted in a reasonable correction of the deformity with a significant reduction in recumbency-associated complications; there were, however, significant other complications.

The dynamic condylar screw in the management of subtrochanteric fractures: does judicious use of biological fixation enhance overall results?

Subtrochanteric fractures are fraught with certain anatomic, biologic and biomechanical challenges. Evolution of implants like the Gamma nail, fixed-angle nail plates, compression hip screws and dynamic hip screws with trochanteric stabilization plates underlines a persistent quest for a better implant. We studied the dynamic condylar screw DCS as an implant on a series of 30 consecutive patients with subtrochanteric fractures. Our purpose was to assess this implant as a panacea for subtrochanteric fractures. All cases of AO type A and B were anatomically fixed, whereas type C was biologically plated. The idea was to assess the applicability and adaptability of the DCS. Fractures in 29 cases united, with one patient suffering from an implant failure. There were 17 excellent, 5 good, 5 fair and 3 poor results. The DCS is a definite advance over previous methods of treatment; when combined with the utilization of biological fixation techniques for comminuted fractures, can be relied upon to treat all types of subtrochanteric fractures.

Detection of transcriptional difference of porcine imprinted genes using different microarray platforms.

BACKGROUND: Presently, multiple options exist for conducting gene expression profiling studies in swine. In order to determine the performance of some of the existing microarrays, Affymetrix Porcine, Affymetrix Human U133+2.0, and the U.S. Pig Genome Coordination Program spotted glass oligonucleotide microarrays were compared for their reproducibility, coverage, platform independent and dependent sensitivity using fibroblast cell lines derived from control and parthenogenic porcine embryos. RESULTS: Array group correlations between technical replicates demonstrated comparable reproducibility in both Affymetrix arrays. Glass oligonucleotide arrays showed greater variability and, in addition, approximately 10% of probes had to be discarded due to slide printing defects. Probe level analysis of Affymetrix Human arrays revealed significant variability within probe sets due to the effects of cross-species hybridization. Affymetrix Porcine arrays identified the greatest number of differentially expressed genes amongst probes common to all arrays, a measure of platform sensitivity. Affymetrix Porcine arrays also identified the greatest number of differentially expressed known imprinted genes using all probes on each array, an ad hoc measure of realistic performance for this particular experiment. CONCLUSION: We conclude that of the platforms currently available and tested, the Affymetrix Porcine array is the most sensitive and reproducible microarray for swine genomic studies.

Progeny of somatic cell nuclear transfer (SCNT) pig clones are phenotypically similar to non-cloned pigs.

Systematic studies of cloned animals generated from adult somatic cell nuclei are critical in assessing the utility of somatic cell cloning in various applications, including the safety of food products from cloned animals and their offspring. Previously, we compared somatic cell derived cloned pigs with naturally bred control pigs on a series of physiological and genetic parameters. We have extended our studies to the F1 progeny of these clones to see whether these phenotypic differences are transmitted to the next generation. There were no differences in the average litter size between litters from cloned gilts and naturally bred controls (7.78 +/- 2.6 and 7.40 +/- 3.0, respectively; mean +/- SD) or in the degree of litter size variation (coefficients of variation of 33.4% and 40.5% for litters of clones and controls, respectively). Similarly there were no statistical differences between sex ratios of cloned litters (51-49%, M:F) and control litters (59-41%, M:F). Blood profiles between cloned pigs, control pigs, and their progeny were compared at two time points (i.e., 15 and 27 weeks) to quantify the effect of cloning on various blood parameters and their transmission to the next generation. Although the range of values for all traits overlapped between different classes, the variability between all the traits in F1 progeny of clones and the control pigs was similar at 15 and 27 weeks, with one exception. Combined, our data and previous results in mice strongly support the hypothesis that offspring of clones are similar to offspring of naturally bred animals, and as such there should not be any increased risks associated with consumption of products from these animals.

Somatic cell cloning: the ultimate form of nuclear reprogramming?

With the increasing difficulties associated with meeting the required needs for organs used in transplantation, alternative approaches need to be considered. These include the use of stem cells as potential sources of specialized cells, the ability to transdifferentiate cell types in culture, and the development of complete organs that can be used in humans. All of the above goals will require a complete understanding of the factors affecting cell differentiation and nuclear reprogramming. To make this a reality, however, techniques associated with cloning and genetic modifications in somatic cells need to be continued to be developed and optimized. This includes not only an enhancement of the rate of homologous recombination in somatic cells, but also a thorough understanding of the nuclear reprogramming process taking place during nuclear transfer. The understanding of this process is likely to have an effect beyond the area of nuclear transfer and assist with better methods for transdifferentiation of mammalian cells.