Refractory CSF leakage following untethering surgery performed 10 months after birth for enlarging terminal myelocystocele associated with OEIS complex

Background: Terminal myelocystocele (TMC) is an occult spinal dysraphism characterized by cystic dilatation of the terminal spinal cord in the shape of a trumpet (myelocystocele) filled with cerebrospinal fluid (CSF), which herniates into the extraspinal subcutaneous region. The extraspinal CSF-filled portion of the TMC, consisting of the myelocystocele and the surrounding subarachnoid space, may progressively enlarge, leading to neurological deterioration, and early untethering surgery is recommended. Case Description: We report a case of a patient with TMC associated with OEIS complex consisting of omphalocele (O), exstrophy of the cloaca (E), imperforate anus (I), and spinal deformity (S). The untethering surgery for TMC had to be deferred until 10 months after birth because of the delayed healing of the giant omphalocele and the respiration instability due to hypoplastic thorax and increased intra-abdominal pressure. The TMC, predominantly the surrounding subarachnoid space, enlarged during the waiting period, resulting in the expansion of the caudal part of the dural sac. Although untethering surgery for the TMC was uneventfully performed with conventional duraplasty, postoperative CSF leakage occurred, and it took three surgical interventions to repair it. External CSF drainage, reduction of the size of the caudal part of the dural sac and use of gluteus muscle flaps and collagen matrix worked together for the CSF leakage. Conclusion: Preoperative enlargement of the TMC, together with the surrounding subarachnoid space, can cause the refractory CSF leakage after untethering surgery because the expanded dural sac possibly increases its own tensile strength and impedes healing of the duraplasty. Early untethering surgery is recommended after recovery from the life-threatening conditions associated with OEIS complex.

Multifocal Epithelioid Hemangioendothelioma – A Case Report

Epithelioid hemangioendotheliomas are rare neoplasms involving any sites including soft tissue, lung, liver, kidney, etc. and many more. A multifocal hemangioendothelioma is extremely rare, and it can very well be mistaken as angiosarcoma with metastasis. Here, we describe a case of multifocal hemangioendothelioma which radiologically appeared like multiple metastatic lesions in paraspinal muscle, liver, kidney, adrenal, lung and gluteus muscle arising from renal cell carcinoma, lung carcinoma, or renal angiosarcoma. But histologically the picture is characteristic of epithelioid hemangioendothelioma. Morphological differentiation between an epithelioid hemangioendothelioma and epithelioid angiosarcoma is more helpful than the immunohistochemical markers.

Relief of Sitting Pain by Resecting Posterior Femoral Cutaneous Nerve, and Elucidation of Its Anatomical Branching Pattern

Background Injury to the posterior femoral cutaneous nerve (PFCN) produces sitting pain in the buttock, posterior thigh, and/or the ischial tuberosity. The anatomy of the PFCN has not been well described, and just one small cohort of patients has been reported to have resection of the PFCN. Methods Retrospective review of all patients undergoing resection of the PFCN for sitting pain by the senior author between 2012 and 2019 was performed. Evaluation was done by chart review, intraoperative description of the anatomy of the PFCN, and the outcome of resection of the PFCN with implantation of the proximal nerve into the gluteus muscle. Outcome was determined by direct patient examination, email reports, and telephonic interview. Results Fifty-two patients were included in this study, of which nine were bilateral operative procedures. Thirty-four patients had sufficient follow-up data at a mean of 23 months (3–85 months, range). MRI evidence of hamstring injury was present in 50% of the patients. The classic PFCN anatomy was present in 44% of limbs with the other 56% having a high division permitting branches to the lateral buttock and posterior thigh to be preserved. In patients with bilateral anatomy observations, symmetry was present in 67%. An excellent result (absence of sitting pain, normal activities of daily living [ADL]) was obtained in 53%, a good result (some residual sitting pain with some reduction in ADL), was obtained in 26% and no improvement was observed in 21% of patients. Conclusion Sitting pain due to injury to the PFCN can be relieved by the resection of the PFCN with implantation of the proximal end into muscle. Presence of an anatomical variation, a high division of the PFCN, can permit preservation of sensation in the lateral buttock and posterior thigh in the patient whose symptoms involve just the perineum and ischial tuberosity.

Ischiadic Nerve Lesion Due to Metastasis of a Non-Differentiated Urethra Carcinoma: Case Report and Review of the Literature

In clinical practice, we encounter mechanical lesions of the ischiadic nerve most frequently with a trauma of the pelvis circle or because of surgical injury in the alloplastic treatment of the hip joint. Other causes for nerve lesions are sporadic or even rare. To such ones also belongs compression of the nerve by metastasis of a urethra carcinoma to the gluteus maximus muscle. A typical manifestation of this nerve injury is a tibioperoneal paresis with a preponderance in its peroneal component. The diagnostic process can be additionally complicated by a contemporal vertebrogenic syndrome with radiculopathy, the more so, when an intervertebral disc protrusion on imaging would be discovered. We present a case of a woman with a two-year history of an undifferentiated urethra carcinoma which has metastasized into the gluteus muscle and has produced a compression of the ischiadic nerve.

Occurrence of asymmetries of lower limbs in basic futsal athletes

Futsal is a sport on the rise worldwide, attracting more and more new practitioners and as well as in field soccer, it has undergone changes in recent years, increasingly demanding athletes, becoming a high impact sport, promoting overload, in the short, medium and long term, predisposing to injury to different degrees of the locomotor apparatus. The aim of this study was to analyze lower limbs asymmetries in futsal-based athletes, as well as their relationship to the incidence of injuries. The study was developed with 47 athletes of the basic category, futsal, from a city in the interior of the state of São Paulo, where functional tests were performed with the help of the PHAST application. A pattern of similarity was identified between the muscle groups tested, except for the gluteus muscle, presenting a significant difference. According to the indicators found, the patterns of strength deficit of the middle glutes may trigger, or predispose to, some types of biomechanical lesions whether proximal, in the hip region, or distal, as dysfunctions in the knee joint. When an athlete presents with a weakness of this muscle, ipsilateral femur adduction, increased medial rotation and fall of the pelvis against lateral, promoting increased dynamic angle of the knee, increasing the overload in this joint. Thus, it is concluded that pre-season evaluation is important to identify possible asymmetries, implementing preventive work to correct them, in order to minimize the risks of injuries.

Lytic parasitic: a case of bone destructing echinococcosis

Pelvic hydatid bone disease is a rare and debilitating condition. Patients often present with symptoms and signs when the disease process is advanced and curative resection is not possible. We present a case of destructive bone hydatid disease affecting the left iliac bone. A 45-year-old woman presented initially 5 years ago with a left pelvic mass to the gynaecology department. Computed tomography (CT) scan done at that time showed a large pelvic, left iliac fossa cystic mass with the destruction of the left iliac bone. Extension of the cystic mass transversed the iliac bone into the posterior soft tissue. Percutaneous biopsy taken showed hydatid cystic disease. The patient was planned for surgery and, however, was lost to follow-up. Four years later, she presented with a history of worsening left pelvic pain with an enlarging, left pelvic mass, and another mass in the posterior gluteal area. In addition, CT imaging showed extensive left iliac bone destruction with posterior soft tissue extension to the gluteus muscle. A multidisciplinary team concluded that complete excision would not result in cure. Thus, complete iliac wing bone reconstruction was not an option in this patient. Instead, palliative measures were deemed in the patient’s best interest to control disease progression and relieve painful pressure-related symptoms from the hydatid cystic mass. The patient received preoperative albendazole and underwent an extraperitoneal debulking of the soft tissue hydatid infiltration and debridement of bony fragments from left iliac bone destruction. Postoperatively, the patient did well, and her main complaint of pain related to the cystic mass pressure had improved significantly.

Effect of 4 Weeks of Anti-Gravity Treadmill Training on Isokinetic Muscle Strength and Muscle Activity in Adults Patients with a Femoral Fracture: A Randomized Controlled Trial

This study aimed to identify the effect of anti-gravity treadmill training on isokinetic lower-limb muscle strength and muscle activities in patients surgically treated for a hip fracture. A total of 34 participants were randomly assigned into two groups: anti-gravity treadmill training group (n = 17) and control group (n = 17). The isokinetic muscle strength and endurance of hip flexor and extensor and the activities of the vastus lateralis (VL), vastus medialis (VM), gluteus maximus (GM), and gluteus medialis (Gm) muscles were measured before and after 4 weeks of the interventions. Significant improvements were observed in isokinetic muscle strength and endurance of hip flexors and extensors in both groups (p < 0.05); however, no significant differences were observed between the groups (p > 0.05) except for muscle strength of the hip extensor (d = 0.78, p = 0029). Statistically significant increases in the muscle activity of VL, VM, GM, and Gm were found before and after the intervention (p < 0.05), and significant differences in muscle activities of GM (d = 2.64, p < 0.001) and Gm (d = 2.59, p < 0.001) were observed between the groups. Our results indicate that both groups showed improvement in muscle strength, endurance, and activities after the intervention. Additionally, anti-gravity treadmill training improved significantly more muscle strength at 60°/s of the hip extensor and gluteus muscle activities than conventional therapy, which may be appropriate for patients with hip fracture surgery.

Hatchet Thigh Flap with Hemi-gluteus Flap for Recurrent Ischial Sore Reconstruction

Background: Ischial pressure sores are the most challenging sores to treat because of associated bursa and high rate of recurrence. Reconstruction flaps originating in the thigh have a disadvantage as movement may increase shear forces, and tension during closure may lead to wound dehiscence. To circumvent these problems, we hereby present a hatchet thigh flap with good mobility, which can be used for recurrent cases as well.Methods: All patients treated at our hospital in the last 5 years for ischial pressure sores were included in the study. The flap is elevated in the subfascial plane from lateral to medial until the medial circumflex artery perforators are revealed. In recurrent cases the lower half of the gluteus maximus muscle is used to fill in the cavity while the flap from the previous surgery is re-advanced.Results: Sixteen patients (11 males and five females) were in the study. The median age of the patient was 54 years (range, 25–82 years). All the flaps survived fully. Two patients had recurrence at three sites, which were successfully reconstructed by advancing the same flap and hemi-gluteus muscle. An average of 6 months follow-up after surgery for recurrence showed stable reconstruction.Conclusion: The hatchet thigh flap is easy to dissect and reliable for ischial pressure sores. It can be used effectively in recurrent cases when combined with hemi-gluteus flaps.

Abundance of the skeletal muscle Glut-4 glucose transport protein in Standardbred foals during development and exercise

The objective of this study was to investigate the changes in Glut-4 expression in gluteus muscle, and in the plasma concentrations of hormones and metabolites during the suckling period, after weaning, and after exercise training in foals. Our hypotheses were Glut-4 abundance will decrease following metabolite and hormonal concentration between neonatal period and late development but will increase with exercise training. Eight clinically normal Standardbred foals were used in this study, and they stayed with their mothers from birth until weaning at 6 months. After weaning, the foals were randomly divided in two groups: an exercise group (EX) (n=4; ~282 kg) which trained 3 d/wk for 12 wks and a control group (n=4; ~271 kg) without structured exercise. Venous blood samples were obtained immediately after birth (<30 min), at 24 h, at day 7 and day 14, and at 1, 3, 6, 9 and 12 months after parturition. Results were analysed using one-way ANOVA for repeated measures. Post-hoc differences were identified using the Tukey test and correlations were obtained using Pearson product moment analysis. The abundance of Glut-4 in skeletal muscle was highest immediately after birth and with growth and development (P<0.05). Exercise training did not change Glut-4 abundance (P>0.05). Plasma lactate, insulin and cortisol concentrations decreased during the first three months of lactation while glucose and leptin concentrations increased (P<0.05). There were no effects of exercise training on any of the above plasma parameters (P>0.05). In conclusion, Glut-4 abundance in gluteus muscle was highest at the birth and decreased during development and exercise training for 12 weeks did not change its’ abundance.