Muscle Herniation Research Articles

8658 Role of Progesterone Receptor in Skeletal Muscle Fibrosis and Hernia Formation in Mouse Models and Men with Inguinal Hernias

8658 Role of Progesterone Receptor in Skeletal Muscle Fibrosis and Hernia Formation in Mouse Models and Men with Inguinal Hernias

Computer Hexapod-assisted Orthopaedic Surgery for the Correction of Multiplanar Deformities throughout the Lower Limb.

Computerised hexapod-assisted orthopaedic surgery (CHAOS) is a method by which complex multiplanar, multilevel deformity can be corrected with a high degree of accuracy utilising minimally invasive techniques within a single operative event. This study's aim was to report the reliability, accuracy and magnitude of correction achieved, alongside patient-reported outcomes and risk factors for complications when using the CHAOS technique throughout the lower limb. Retrospective review of medical records and radiographs for consecutive patients who underwent CHAOS for lower limb deformity correction at a tertiary centre between 2012 and 2020. There were 70 cases in 56 patients, with the site of surgery being the femur in 48 cases, proximal tibia in 17 and distal tibia in 5 cases. Multiplanar correction was performed in 43 cases, and multilevel osteotomy was undertaken in 23 cases. Fixation was undertaken with intramedullary nailing (IMN) in 49 cases and locked plates in 21.The maximum corrections were 40° rotation, 20° coronal angulation, 51° sagittal angulation and 62-mm mechanical axis deviation (MAD). Deformity correction was mechanically satisfactory in all patients bar one who was undercorrected requiring revision. The mean patient global impression of change (PGIC) score was 6.2 out of 7.Overall complication rate was 12/70 (17%). Complications from femoral surgery included two nonunions, one case of undercorrection, one case of stiffness, one muscle hernia and one pulmonary embolism. Complications from tibial surgery were one compartment syndrome, one pseudoaneurysm of the anterior tibial artery requiring stenting, one transient neurapraxia of the common peroneal nerve, one locking plate fatigue failure, one seroma and one superficial wound infection. Computerised hexapod-assisted orthopaedic surgery can be used for accurate correction of complex multilevel and multiplanar deformities of both the femur and tibia. The risk profile appears to differ between femoral and tibial surgeries, and also to that of traditional circular frame correction. Patients remain highly satisfied with both the functional and symptomatic outcomes. French JMR, Filer J, Hogan K, et al. Computer Hexapod-assisted Orthopaedic Surgery for the Correction of Multiplanar Deformities throughout the Lower Limb. Strategies Trauma Limb Reconstr 2024;19(1):9-14.

Evaluation of lamina papyracea dehiscence with paranasal computed tomography

IntroductionThe lamina papyracea is the thin line between the ethmoid sinus and the medial orbital wall. Knowledge of the presence of the lamina papyracea dehiscence (LPD) bears critical importance to prevent misdiagnosis of fractures at this level and to define the anatomy before sinonasal surgery, including Functional Endoscopic Sinus Surgery (FESS). The present study is therefore intended to determine the incidence of LPD in paranasal computed tomography, to identify its imaging characteristics in CT, and to compare with the literature.Materials and methodsThe current study included patients who underwent paranasal CT scanning for any reason in our clinic between January 2018 and January 2022. Patients were evaluated in terms of age, gender, and presence of LPD. Patients with dehiscence were evaluated in terms of age, gender, dehiscence localization (right, left), tissue at the level of dehiscence, dehiscence size, and dehiscence grade.Results1000 patients with a mean age of 32. ± 16.3 (min = 18-max = 79) were included in the study. 20 patients (2%) were found to have LPD. Of those with LPD, 14 (70%) were grade 1, 4 (20%) were grade 2 and 2 (10%) were grade 3. Again of those with LPD, 14 (70%) had LPD localized on the right and 6 (30%) had LPD on the left. In 12 (60%) of the patients with LPD, herniated tissue was detected. Among these patients with herniation, fatty tissue herniation was observed in 10 (83.3%) and medial rectus muscle herniation was observed in 2 (16.7%).Discussion and ConclusionComprehensive evaluation for and identification of LPD are very important before possible sinus surgery.

Muscle Hernia of the Leg

Muscle herniation is defined as a myofascial defect resulting in protruding of the muscle through the fascia covering it (3). It can present anywhere in the body, the most common is the lower limbs (3). Tibialis muscle herniation is considered a rare entity with few reported cases. Here, we present the case of a 24-year-old athlete male patient who complained of swelling and pain in the anterior aspect of the left leg for three months. He underwent fasciotomy with a good outcome. Keywords: Muscle hernia, tibialis anterior muscle, fasciotomy, trauma, athlete, myofascial

Investigation of the Relationship Between Multifidus Muscle and Lumbar Disc Herniation Through Magnetic Resonance Imaging

Investigation of the Relationship Between Multifidus Muscle and Lumbar Disc Herniation Through Magnetic Resonance Imaging

Lower Leg Muscle Hernia: A Systematic Review

Lower Leg Muscle Hernia: A Systematic Review

THU571 Mechanisms Of Estrogen-induced Skeletal Muscle Fibrosis In An Inguinal Hernia Humanized Aromatase Mouse Model

Abstract Disclosure: T. Potluri: None. H. Zhao: None. P. Yin: None. J.J. Stulberg: None. R.L. Lieber: None. S.E. Bulun: None. Mechanisms of Estrogen-Induced Skeletal Muscle Fibrosis in an Inguinal Hernia Humanized Aromatase Mouse Model Abdominal skeletal muscle weakening via fibrosis and atrophy leads to inguinal herniation. Despite the high prevalence and morbidity of inguinal herniation, the mechanisms and etiology are largely unknown. We developed a transgenic mouse model with the human aromatase gene (Aromhum), where all male mice develop spontaneous scrotal hernias at puberty. The lower abdominal muscles (LAM) in these mice can synthesize estradiol (E2), which activates the stromal fibroblasts, leading to fibrosis and herniation. Remarkably, the administration of Estrogen Receptor Alpha (ERα) antagonist Fulvestrant to the herniated mice reverses fibrosis and herniation. We use this novel model to uncover mechanisms of E2-induced skeletal muscle fibrosis and its subsequent reversal. Hernia-Associated Fibroblasts (HAFs) were isolated from LAM tissues and cultured under estrogen-replete (10nM E2) and deplete (10nM E2 + 100nM Fulvestrant) conditions. The cells were analyzed using ERα ChIP-seq, ATAC-seq, and RNA-seq to observe genetic, epigenetic, and transcriptomic changes (n = 10-15 mice/group in 3 technical replicates).Via RNA-seq, we identified 853 differentially expressed genes between E2 and E2+Fulvestrant treated fibroblasts. These genes were associated with the extracellular matrix, WNT signaling, TGFβ, and focal adhesions were enriched in our study. We further identified 657 E2-upregulated annotated genes common between ATAC-seq and ChIP-seq. Overall, 58 genes were identified across all three datasets, including known E2-responsive genes such as Pgr, as well as extracellular modulators such as Adamts3, Adamts6, Pcdh7, Ltbp1, Fbln5, and Fbln7. Furthermore, E2-ERα activation also directly induced the expression of other transcription regulators, such as Pbx1, Id2, Hlf, Zfp521, and Zfp618. Together, we identified the core E2-modulated genes in HAFs that lead to skeletal muscle fibrosis and reversal. To validate these findings, we performed RNAscope on human inguinal hernia tissues. We detected PBX1, PIEZO2, NRP2, LTBP1, NCAM1, and ADAMTS6 expression in the herniated fibrotic regions of the samples. In contrast, there is no expression of these genes in corresponding healthy muscle fibers.Using this Aromhum mouse model, we characterized, for the first time, characterize E2 mechanisms in skeletal muscle fibrosis and herniation. In addition, we provide an insight into the specific disease-causing fibroblast populations and markers that can form the source for future therapeutics to treat hernias and other fibrotic disorders. Presentation Date: Thursday, June 15, 2023

Herniación muscular – reporte de caso diagnosticado por ultrasonografía

Muscular hernia in extremities is an uncommon and underdiagnosed condition. Most masses are painless and asymptomatic. However, in some cases, muscle hernia can become painful after prolonged physical exercise. In this case report, we present an 18-year-old patient complaining of bulging in the left leg after physical activity, with initial suspicion of lipoma of the extremity. Ultrasonography identified a muscle hernia, highlighting the importance of early detection and leading adequate treatment without complications, unnecessary expenses, and misdiagnoses.

Primary Repair of Peroneus Longus Myofascial Herniation With Symptomatic Superficial Peroneal Nerve Compression

Symptomatic myofascial herniations of the extremities occur infrequently; however, they can contribute to significant pain, weakness, and neuropathy with activity. Muscle herniation typically occurs through either a traumatic or congenital focal defect in the deep overlying fascia. Patients may present with an intermittently palpable subcutaneous mass and may have neuropathic symptoms, depending on the degree of nerve involvement. Patients are initially treated with conservative modalities, whereas surgery is reserved for patients who demonstrate persistent functional limitations and neurologic symptoms. Here, we demonstrate a technique for primary repair of a symptomatic lower-leg fascial defect.

A Traumatic Neuroma Formation Following Fasciotomy for the Treatment of Tibialis Anterior Muscle Herniation: A Case Report

Muscle herniation of the lower extremity, such as tibialis anterior muscle herniation (TAMH), is not a rare cause of leg pain in athletes. However, a few studies have reported surgical treatment for TAMH, and the optimal surgical procedure remains controversial. Fasciotomy was reported to be effective for patients with TAMH. However, this procedure would be associated with a risk of intraoperative injury to the superficial peroneal nerve (SPN), although no previous literature has reported this complication. This case report aimed to report a case of bilateral TAMHs in which a traumatic neuroma of the SPN developed after fasciotomy. A 16-year-old baseball player presented with painful swelling lesions of the bilateral lower extremities (1 lesion on the right, 3 lesions on the left) after sports activities. An ultrasonographic evaluation showed swelling lesions of the anterolateral parts of the bilateral lower extremities in the standing position after dashing, while these lesions were not detected in the supine position. A fasciotomy of the crural fascia was performed after conservative treatment failed. Several days after surgery, the patient presented with weakened touch sensation over the dorsal area of the left foot. At the three-month follow-up examination, a swelling lesion with hard elasticity was identified. The palpation of this lesion caused a radiating sensation in the area supplied by the SPN. He was able to return to playing baseball six months after surgery. The patient was asymptomatic without palpation of the traumatic neuroma of the SPN at the latest follow-up examination. In conclusion, the present case report suggests that orthopedic surgeons need to consider the risk of iatrogenic injury to the SPN during fasciotomy for the treatment of TAMHs. However, there may be a risk of injuring the SPN because of the many variants of the course of the SPN within the compartment of the lower extremities.

Hip resurfacing for small-sized osteonecrosis: 73 cases at a median 8 years’ follow-up

IntroductionTotal hip resurfacing arthroplasty (THRA) is an alternative to conventional total hip replacement (THR) in young patients with osteonecrosis of the femoral head. Series have been small, without criteria regarding extent of necrosis, thus vitiating results. We therefore conducted a retrospective assessment of THRA for small necrosis, to determine (1) implant survival, (2) functional scores, and (3) systemic chromium, cobalt and titanium ion concentrations. HypothesisThe study hypothesis was that the revision rate is low, meeting the National Institute for Health and Care Excellence (NICE) criterion of<0.5% revision per year. Material and methodA single-center single-surgeon retrospective study included 62 patients, for 73 RTHAs, with a mean age of 45.6years (range: 23–68years) presenting Ficat stage 3 or 4 osteonecrosis of the femoral head with<330° total Kerboul angle (frontal+lateral angles) on simple preoperative X-ray. Study data comprised implant survival and preoperative and last follow-up functional scores (Postel–Merle–d’Aubigné, Oxford-12, Harris, and Devane) and titanium, chromium and cobalt blood concentrations. Necrosis size was assessed on preoperative Kerboul angle. ResultsAt a median 8years’ follow-up (IQR: 5.9–9.3years), implant survival was 98.6% (95% CI: 97.22–99.98%). Only 1 implant was exchanged, for femoral loosening. Three other patients underwent revision surgery: 2 cases of lavage for infection, and 1 muscle hernia repair. Postel–Merle–d’Aubigné, Oxford-12 and Harris functional scores and Devane activity scores were significantly improved at follow-up, by a median +5 (IQR: 5 to 7), −26 (IQR: −29 to −23), +55 (IQR: 49 to 61) and +1 (IQR: 1 to 2), respectively (all p<0.001). Ion concentrations at last follow-up for titanium, chromium and cobalt were respectively 4.0μg/L (range: 3.6–4.1), 1.1μg/L (range: 0.8–1.9) and 1.1μg/L (range: 0.6–1.8). ConclusionTHRA is a useful option in the long-term for young patients with osteonecrosis with Kerboul angle<330°. Level of evidenceIV, retrospective study.

Anterior cruciate ligament arthroscopic reconstruction and lateral tenodesis with iliotibial band and gracilis tendon: Technical note

While anterior cruciate ligament reconstruction using the iliotibial band is not a new technique, it still remains underdeveloped. The iliotibial band has historically been described as a thin and less resistant structure. Its harvesting has been associated with a risk of complications (hematoma, muscle hernia) and its small graft diameter increases the risk of rerupture. The addition of the gracilis tendon could potentially produce a graft with an increased diameter. In this technical note, we present a modification to the traditional technique performed on 50 patients, describing the surgical steps, graft diameter, clinical outcomes and complications at the 2-year follow-up. The mean graft diameter was 8.9±0.9 mm at the femur and 7.7±0.7 mm at the tibia. No rerupture was reported at the 2-year follow-up. Level of evidenceIV.

Dynamic and interactive ultrasound examination for muscle hernia: 'Here it comes again !'

Dynamic and interactive ultrasound examination for muscle hernia: 'Here it comes again !'

Use of polypropylene mesh in orthopedic surgery – literature review and report of three cases

In this article we describe three applications of polypropylene mesh in orthopedic surgery, where the synthetic material was used in challenging scenarios: (1) quadriceps tendon, (2) shoulder and (3) muscle hernia repair. All cases were followed-up for at least two years and there were no complications related to the procedure. Polypropylene mesh is a safe synthetic material widely used in general surgery, however, its use in orthopedic procedures is uncommon. We reported three different applications for polypropylene mesh in complex orthopedic cases. Further studies are necessary to understand the biomechanical behavior of such materials under the tensile load of each tendon; functional results and long term complications associated to this material.

Magnetic Resonance Imaging of Gluteus Medius Muscle Hernia.

Resident, Department of Physical Medicine and Rehabilitation, University of Michigan Assistant Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Michigan. Correspondence: Reina Nakamura, 325 East Eisenhower Pkwy, Ann Arbor, MI 48108. Phone: (734) 936-7175 Fax: (734) 615-6713. Email: [email protected] Author Disclosures: no competing interests, funding or grants provided for the project from any source or financial benefits to the authors. Deanna Brinks and Reina Nakamura. There are no previous presentations of this manuscript. Patient Consent: patient consent via electronic signature was obtained on Michigan Medicine Authorization for Publication of Case Study form. Author Contributions: DB and RN contributed to the writing of the manuscript. RN supervised the project. Data Access statement: Not applicable Ethics Statement: Not applicable

Multimodality evaluation of transfascial muscle and other soft tissue herniations of the extremities.

This review illustrates the multimodality assessment of transfascial muscle and other soft tissue herniations of the extremities. Transfascial herniations of the extremities can develop from congenital or acquired disruptions of the deep fascia, resulting in herniation of the underlying muscle, nerve, or soft tissue tumor into the subcutaneous tissues. While most patients present with a painless subcutaneous nodule that may change in size with muscle activation, some may experience focal or diffuse extremity symptoms such as pain and paresthesias. Although the diagnosis may be clinically suspected, radiologic evaluation is useful for definitive diagnosis and characterization. Ultrasound is the preferred modality for initial workup through a focused and dynamic examination. Magnetic resonance imaging can be utilized for equivocal, complicated, and preoperative cases. Computed tomography is less useful in the evaluation of transfascial herniations in the extremities due to similarities in the attenuation between muscle and fascia, which can decrease the conspicuity of small defects.

Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study

PurposeElbow dislocations are at risk for persistent instability and stiffness of the joint. Treatment with a hinged external fixation provides elbow joint stability, and allows early mobilization to prevent stiffness. Mounting a hinged elbow fixator correctly, however, is technically challenging. The low incidence rate of elbow dislocations with persistent instability suggests that centralization would result in higher surgeon exposure and consequently in less complications. This study aimed to investigate the results of treatment of elbow dislocations with a hinged elbow fixator on the rate of complications, range of motion, level of pain and restrictions in activities of daily living.MethodsA retrospective observational cohort study in a level I trauma center, in which the majority of patients was treated by a dedicated elbow surgeon, was performed. All patients of 16 years or older treated with a hinged external elbow fixator between January 1, 2006 and December 31, 2017 were included. The fixator could be used (1) for the treatment of persistent instability in acute/residual simple and complex dislocations or (2) as revision surgery to treat joint incongruency or a stiff elbow. Patient and injury characteristics, details on treatment, complications, secondary interventions, and range of motion were extracted from the patients’ medical files.ResultsThe results of treatment of 34 patients were analyzed with a median follow-up of 13 months. The fixator was removed after a median period of 48 days. Fixator-related complications encountered were six pintract infections, one redisclocation, one joint incongruency, one muscle hernia, and one hardware failure. The median range of motion at the end of follow-up was 140° flexion, 15° constraint in extension, 90° pronation, and 80° supination.ConclusionA hinged elbow fixator applied by a dedicated elbow surgeon in cases of elbow instability after elbow dislocations can result in excellent joint function. Fixator-related complications are mostly mild and only temporary.

Minimally invasive fasciotomy for symptomatic tibialis anterior muscle hernia

BackgroundSymptomatic muscle herniae are an uncommon cause of chronic exercise induced leg pain. The most common site for muscle hernia is the tibialis anterior muscle. This study evaluates the outcome of a minimal incision fasciotomy in patients with a symptomatic muscle hernia of the tibialis anterior muscle, and their return to normal daily activities including sport. MethodsThe study reports mid-term results in a series of 22 consecutive patients (17 males and 5 females, median age: 22 years) with a unilateral tibialis anterior MH who had undergone minimally invasive fasciotomy between 2008 and 2019. Clinical outcomes were assessed with SF-36 and European Quality of Life-5 Dimensions scale (EQ-5D). The ability to participate in sport before and after surgery, and the time to return to training (RTT) and to sport (RTS) were recorded. ResultsAt a median follow up after surgery of 23 months, both questionnaires showed a statistically significant improvement (P < 0.005). At the latest follow up, 16 of patients (73%) had returned to pre-injury or higher levels of sport/activity. The median time to return to training and to return to sport was 7 and 11 weeks respectively. No severe complications and no recurrence of symptoms were recorded. ConclusionMinimally invasive fasciotomy is effective and safe for patients suffering from muscle hernia of the tibialis anterior muscle with good results in the mid-term. Level of EvidenceIV.

Effects of clinical application of free anterolateral thigh perforator lobulated flap in repair of electrical burn wounds on head based on the concept of donor site protection

Objective: To explore the effects of clinical application of free anterolateral thigh perforator lobulated flap in repair of electrical burn wounds on head based on the concept of donor site protection. Methods: A retrospective observational study was conducted. Eight patients with electrical burns with huge scalp defects and exposed skulls were admitted to the First Affiliated Hospital of Zhengzhou University, from May 2017 to December 2019, who were all males, aged 21-57 (39±13) years, sustaining multiple deep partial thickness to full-thickness electrical burns to 5%-14% total body surface area. Among the scalp burn sites of the patients, 1 case was posterior occipital, 2 cases were parietal occipital, 4 cases were parietal temporal, and 1 case was frontotemporal. After debridement, the defect area was 10 cm×9 cm-16 cm×14 cm. The incision area of the free anterolateral thigh perforator lobulated flap was 22 cm×6 cm-30 cm×9 cm. The artery and vein of flap were anastomosed with superficial temporal artery and vein or facial artery and vein, and the other vein of skin flap was anastomosed with superficial vein of recipient area. The donor site of skin flap was closed by layer interrupted tension-reducing suture. After the operation, the survival of flop, donor site wound healing and complications were observed. The flap appearance, wound healing of donor sites, long-term complications and functional recovery of donor sites were observed on follow-up. Results: After the operation, the flaps of 8 patients survived completely without vascular crisis. The donor sites of flaps in all the patients healed well with no osteofascial compartment syndrome. Seven patients were followed up for 3 to 12 months, and 1 case was lost to follow up. During follow-up, the flaps of the patients' heads were in good appearance but with alopecia. The donor sites showed linear scars, which were well hidden. There were no significant differences in sensory and motor functions between the two sides, and no complications were found such as muscle hernia. Conclusions: Free anterolateral thigh perforator lobulated flap has a good clinical effect in the early repair of electrical burn wounds with huge scalp defect and skull exposure on head, and the donor wounds can be directly closed and sutured, greatly reducing the damage to the donor area.

Missing the Bull’s Eye: A Case Report of Tibialis Anterior Hernia

Objectives: Shin pain is a broad term used to describe lower leg pain. It is commonly seen in the athletic/sports population. Various conditions have been claimed to produce leg pain, and muscle herniation is one of these conditions. Muscle herniation is the protrusion of muscle through a defect in the overlying fascia. Although such herniation is common, it is often an underdiagnosed condition in the lower extremity. It usually occurs in athletes, especially in the anterior compartment of the leg, as a result of trauma or due to muscle hypertrophy secondary to strenuous exercise. Herniation diagnosis depends on its clinical presentation as it appears as a palpable soft tissue bulge through a fascia defect; radiological findings are used to confirm the diagnosis. Conservative treatment should be the initial approach, and surgery can be performed if conservative treatment fails. Methods: We present a case of symptomatic anterior lower leg pain, initially diagnosed as a psychosomatic disorder by two orthopedic physicians. However, tibialis anterior hernia in this patient was confirmed after physical examination by a physiotherapist and subsequent referral for ultrasonographic evaluation to a radiologist. The patient underwent an 8-week course of conservative treatment under the supervision of a physiotherapist. This treatment significantly improved the patient’s pain and function. Results: After eight weeks of conservative treatment using Minhaj protocol for Tibialis Anterior hernia, the patient has reported improvement in pain (reduction of score from eight to two on the NPRS scale) and function. The patient returned to his previous level of physical activity following eight weeks of rehabilitation. Discussion: Tibialis anterior hernia should be considered a differential diagnosis in chronic leg pain with palpable soft tissue protrusion. Conservative treatment can be chosen as the primary approach.