A Modified 4-in-1 Stanisavljevic Procedure for Treating Obligatory or Congenital Patellar Dislocations in Children: A Surgical Technique.

Introduction: Patellar instability and dislocation pose complex clinical and surgical challenges, especially in children. Congenital (fixed) and obligatory (habitual) dislocations present significant anatomical and etiological complexity, frequently leading to deformities and functional impairments, which can range from walking difficulties to sports limitations. Conservative treatment is often inadequate. Technique: We describe a surgical technique for treating congenital or obligatory patellar dislocations in patients with various underlying diagnoses-including Down syndrome, nail-patella syndrome, and skeletal dysplasia-that involves extensive subperiosteal quadriceps realignment, distal realignment (Roux-Goldthwait or tibial tuberosity transfer), and optional medial plication. This modified 4-in-1 technique follows the principles described in 1976 by Stanisavljevic, which involves subperiosteal quadriceps mobilization, thus minimizing muscle damage, bleeding, and postoperative muscular adherences. Results: In 24 patients treated at our institution between 2002 and 2021 (35 knees; age range = 5.5-16.8 years; 13 girls, 11 boys), with a mean follow-up of 8.2 years (2.4-20 years), we achieved satisfactory improvements in patellar stability, range of motion, and quality of life with a modified 4-in-1 Stanisavljevic technique. A total of 9 patients (7 with obligatory dislocations and 2 with congenital dislocations) could engage in recreational or competitive sports. The average postoperative pediatric International Knee Documentation Committee (pedi-IKDC) score was 78.45 ± 22.3 (range = 0-100); a patient with DiGeorge syndrome and 1 with multiple epiphyseal dysplasia had scores of 35 and 48, respectively. Discussion: We found at our institution that a modified 4-in-1 Stanisavljevic technique produced favorable outcomes in patellar stability, range of motion, and quality of life in pediatric patients with congenital or obligatory patellar dislocation. More study is warranted to determine the procedure's overall benefits for children with obligatory or congenital dislocations of complex etiology.

Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents.

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

François Gros: from antibiotics to messenger RNA.

François Gros was a prominent French Molecular Biologist who made a major contribution to the discovery of messenger RNA in 1961. He pursued outstanding research on bacterial mRNA and its translation into proteins followed by pioneering work on muscle differentiation. I was lucky to be among his graduate students and owe much of my success in science to him. In this short text I will describe how the initial post-war studies of François guided him to discover the existence of short-lived RNA in bacteria, the messenger RNA containing the information for protein synthesis. I will also recount the influence he had on his students and their carrier in science.

François Gros était un éminent biologiste moléculaire français qui a contribué de manière décisive à la découverte de l'ARN messager en 1961. Il a poursuivi des recherches remarquables sur l'ARNm bactérien et sa traduction en protéines, suivies de travaux pionniers sur la différenciation musculaire. J'ai eu la chance d'être l'un de ses étudiants de thèse d'État et je lui dois une grande partie de ma réussite scientifique. Dans ce court texte, je décrirai comment les études initiales d'après-guerre de François l'ont amené à découvrir l'existence d'un ARN à courte durée de vie dans les bactéries, l'ARN messager, qui contient l'information nécessaire à la synthèse des protéines. Je raconterai également l'influence qu'il a eue sur ses étudiants et leur carrière scientifique.

Translation, cross-cultural adaptation and reliability of the International Knee Documentation Committee (IKDC) subjective knee form and the tampa scale for kinesiophobia (TSK) into Hebrew.

INTRODUCTION: The International Knee Documentation Committee-Subjective Form (IKDC-SF) is one of the most used measures for evaluating the quality of life among people experiencing knee pain but is not yet available in Hebrew. Similarly, the Tampa Scale for Kinesiophobia (TSK), used to evaluate fear of movement, is not available in Hebrew. This study aimed to determine the reliability and construct validity of the Hebrew IKDC-SF and TSK among people experiencing chronic knee pain. MATERIALS AND METHODS: Translation and cultural adaptation of the IKDC-SF and TSK questionnaires, followed by test-retest reliability within a two-week interval. We report on internal consistency, construct validity, and the psychometric properties of both questionnaires. RESULTS: Both questionnaires showed high internal consistency (Cronbach's α = 0.85 and 0.89, respectively) and test-retest reliability, expressed by the Intra-Class Correlation Coefficient (ICC = 0.89 and 0.80 respectively). The standard error of measurement, group smallest real difference and minimal detectable change for the IKDC-SF were 4.66, 9.13, and 12.91 points, and 3.64, 7.13, and 10.08 points for the TSK, respectively. CONCLUSION: We demonstrated that the Hebrew version of the IKDC-SF and TSK is reliable and valid for assessing QoL, function, and kinesiophobia among people experiencing chronic knee pain.

Patellar Instability in Young Athletes.

This article summarizes the latest research related to pediatric patellar instability. The epidemiology, patterns of patellar instability, and underlying pathoanatomy are unique in children and adolescents. Information related to the natural history and predictive factors of patellar instability in young patients would allow for better patient counseling and management decisions. The components of nonoperative treatment for first patellar dislocation are outlined. Physeal-respecting surgical techniques, including medial patellofemoral ligament reconstruction in skeletally immature patients, are discussed. The indications and outcomes for quadricepsplasty to address more complex instability patterns are presented. Evaluation and management strategies for specific anatomic risk factors is provided.

SWI/SNF chromatin remodeler complex within the reward pathway is required for behavioral adaptations to stress.

Enduring behavioral changes upon stress exposure involve changes in gene expression sustained by epigenetic modifications in brain circuits, including the mesocorticolimbic pathway. Brahma (BRM) and Brahma Related Gene 1 (BRG1) are ATPase subunits of the SWI/SNF complexes involved in chromatin remodeling, a process essential to enduring plastic changes in gene expression. Here, we show that in mice, social defeat induces changes in BRG1 nuclear distribution. The inactivation of the Brg1/Smarca4 gene within dopamine-innervated regions or the constitutive inactivation of the Brm/Smarca2 gene leads to resilience to repeated social defeat and decreases the behavioral responses to cocaine without impacting midbrain dopamine neurons activity. Within striatal medium spiny neurons, Brg1 gene inactivation reduces the expression of stress- and cocaine-induced immediate early genes, increases levels of heterochromatin and at a global scale decreases chromatin accessibility. Altogether these data demonstrate the pivotal function of SWI/SNF complexes in behavioral and transcriptional adaptations to salient environmental challenges.

3D-printed Cutting Guides for Lower Limb Deformity Correction in the Young Population.

BACKGROUND: Three-dimensional (3D) virtual surgical planning technology has advanced applications in the correction of deformities of long bones by enabling the production of 3D stereolithographic models, patient-specific instruments and surgical-guiding templates. Herein, we describe the implementation of this technology in young patients who required a corrective osteotomy for a complex 3-plane (oblique plane) lower-limb deformity. PATIENTS AND METHODS: A total of 17 patients (9 males, average age 14.7 y) participated in this retrospective study. As part of preoperative planning, the patients' computerized tomographic images were imported into a post-processing software, and virtual 3D models were created by a segmentation process. Femoral and tibial models and cutting guides with locking points were designed according to the deformity correction plan. They were used for both planning and as intraoperative guides. Clinical parameters, such as blood loss and operative time were compared with a traditional surgical approach group. RESULTS: All osteotomies in the 3D group were executed with the use intraoperative customized cutting guides which matched the preoperative planning simulation and allowed easy fixation with prechosen plates. Surgical time was 101±6.2 minutes for the 3D group and 126.4±16.1 minutes for the control group. The respective intraoperative hemoglobin blood loss was 2.1±0.2 and 2.5+0.3 g/dL.Clinical and radiographic follow-up findings showed highly satisfactory alignment of the treated extremities in all 3D intervention cases, with an average time-to-bone union (excluding 2 neurofibromatosis 1 patients) of 10.3 weeks (range 6 to 20 wk). CONCLUSION: The use of 3D-printed models and patient-specific cutting guides with locking points improves the clinical outcomes of osteotomies in young patients with complex bone deformities of the lower limbs. LEVEL OF EVIDENCE: Level III.

Surgical Treatment of Congenital and Obligatory Dislocation of the Patella in Children.

BACKGROUND: Congenital (fixed) dislocations and obligatory (habitual) patellar dislocations represent a complex clinical and surgical challenge. Numerous treatment options, offering different perspectives, and surgical solutions are reported in the literature.We implemented the surgical technique principles, originally described by Stanisavljevic, for congenital (fixed) and obligatory (habitual) patellar dislocations, with slight modifications. METHODS: We retrospectively evaluated the results of group of 12 patients (15 knees), operated between the years 2002 and 2013. The procedure includes extensive subperiosteal quadriceps realignment and soft tissue medial plication, followed by distal realignment through patellar tendon splitting. The outcome measures were patellar stability, knee range of motion, Pedi-IKDC knee function score, and the PODCI global function score. RESULTS: The study group included 12 patients, 9 females and 3 males (15 knees) whose mean age was 5 years 2 months at diagnosis and 7 years 5 months at surgery. Nine patients had an underlying diagnosed genetic background [Down syndrome (n=6), Larsen syndrome (n=2), nail-patella syndrome (n=1)]. The mean follow-up was 46.2 months. Eleven patients, gained stable patella with no recurrence of dislocation. Postoperative knee active extension was improved significantly (P<0.0001) for all patients. The average postoperative Pedi-IKDC and PODCI scores were significantly higher (P<0.001) among the idiopathic group. CONCLUSIONS: These results suggest that the Stanisavljevic procedure principles with modifications, provides an efficient method for treatment of fixed and obligatory patellar dislocation. In our opinion, young age at surgery played an important role in the surgical outcome. LEVEL OF EVIDENCE: Level IV-therapeutic.

Chromatin remodeling: from transcription to cancer.

In this short review article, I have tried to trace the path that led my laboratory from the early studies of the structure of papova minichromosomes and transcription control to the investigation of chromatin remodeling complexes of the SWI/SNF family. I discuss briefly the genetic and biochemical studies that lead to the discovery of the SWI/SNF complex in yeast and drosophila and summarize some of the studies on the developmental role of the murine complex. The discovery of the tumor suppressor function of the SNF5/INI1/SMARCB1 gene in humans and the identification of frequent mutations in other subunits of this complex in different human tumors opened a fascinating field of research on this epigenetic regulator. The hope is to better understand tumor development and to develop novel treatments.

The transcription factor JunD mediates transforming growth factor {beta}-induced fibroblast activation and fibrosis in systemic sclerosis.

OBJECTIVES: Transforming growth factor ß (TGFß) has been identified as a key player in fibrotic diseases. However, the molecular mechanisms by which TGFß activates fibroblasts are incompletely understood. Here, the role of JunD, a member of the activator protein 1 (AP-1) family of transcription factors, as a downstream mediator of TGFß signalling in systemic sclerosis (SSc), was investigated. METHODS: The expression of JunD was analysed by real-time PCR, immunofluorescence, western blotting and immunohistochemistry. The canonical Smad pathway was specifically targeted by small interfering (si)RNA. The expression of extracellular matrix proteins in JunD deficient (JunD(-/-)) fibroblasts was analysed by real-time PCR and hydroxyproline assays. The mouse model of bleomycin-induced dermal fibrosis was used to assess the role of JunD in experimental fibrosis. RESULTS: JunD was overexpressed in SSc skin and in cultured fibroblasts in a TGFß dependent manner. The expression of JunD colocalised with pSmad 3 in fibrotic skin and silencing of Smad 3 or Smad 4 by siRNA prevented the induction of JunD by TGFß. JunD(-/-) fibroblasts were less responsive to TGFß and released less collagen upon stimulation with TGFß. Moreover, JunD(-/-) mice were protected from bleomycin-induced fibrosis with reduced dermal thickening, decreased myofibroblast counts and lower collagen content of lesional skin. CONCLUSIONS: These data demonstrate that JunD is overexpressed in SSc and that JunD is a mediator of the profibrotic effects of TGFß. Considering that inhibitors of AP-1 signalling have recently been developed and are available for clinical trials in SSc, these findings may have translational implications.

The 50th anniversary of the publication of the operon theory in the Journal of Molecular Biology: past, present and future.

A series of eight review articles that appear in the present issue of the Journal of Molecular Biology celebrates the 50th anniversary for the landmark publication of François Jacob and Jacques Monod entitled "Genetic Regulatory Mechanisms in the Synthesis of Proteins". In this publication, the authors presented a model for the regulation of gene expression deduced from genetic and biochemical studies. They proposed that a new class of genes, regulatory genes, would code for repressors that bind to operator sequences upstream of operons consisting of a group of catabolic or biosynthetic genes with related functions. Binding is controlled by small metabolites, substrates or end products. The repressors control the transmission of information from genes to mRNA that is translated into proteins. The present review articles demonstrate how this publication influenced our thinking and how it stimulated the studies on the regulation of gene expression all the way to present day epigenetics and systems biology.

Human papillomavirus type 8 E2 protein unravels JunB/Fra-1 as an activator of the beta4-integrin gene in human keratinocytes.

The papillomavirus life cycle parallels keratinocyte differentiation in stratifying epithelia. We have previously shown that the human papillomavirus type 8 (HPV8) E2 protein downregulates beta4-integrin expression in normal human keratinocytes, which may trigger subsequent differentiation steps. Here, we demonstrate that the DNA binding domain of HPV8 E2 is sufficient to displace a cellular factor from the beta4-integrin promoter. We identified the E2-displaceable factor as activator protein 1 (AP-1), a heteromeric transcription factor with differentiation-specific expression in the epithelium. beta4-Integrin-positive epithelial cells displayed strong AP-1 binding activity. Both AP-1 binding activity and beta4-integrin expression were coregulated during keratinocyte differentiation suggesting the involvement of AP-1 in beta4-integrin expression. In normal human keratinocytes the AP-1 complex was composed of JunB and Fra-1 subunits. Chromatin immunoprecipitation assays confirmed that JunB/Fra-1 proteins interact in vivo with the beta4-integrin promoter and that JunB/Fra-1 promoter occupancy is reduced during keratinocyte differentiation as well as in HPV8 E2 positive keratinocytes. Ectopic expression of the tethered JunB/Fra-1 heterodimer in normal human keratinocytes activated the beta4-integrin promoter, while coexpression of HPV8 E2 reverted the JunB/Fra-1 effect. In summary, we identified a novel mechanism of human beta4-integrin regulation that is specifically targeted by the HPV8 E2 protein mimicking transcriptional conditions of differentiation. This may explain the early steps of how HPV8 commits its host cells to the differentiation process required for the viral life cycle.

SWI/SNF deficiency results in aberrant chromatin organization, mitotic failure, and diminished proliferative capacity.

Switch (SWI)/sucrose nonfermentable (SNF) is an evolutionarily conserved complex with ATPase function, capable of regulating nucleosome position to alter transcriptional programs within the cell. It is known that the SWI/SNF complex is responsible for regulation of many genes involved in cell cycle control and proliferation, and it has recently been implicated in cancer development. The ATPase action of SWI/SNF is conferred through either the brahma-related gene 1 (Brg1) or brahma (Brm) subunit of the complex, and it is of central importance to the modification of nucleosome position. In this study, the role of the Brg1 and Brm subunits were examined as they relate to chromatin structure and organization. Deletion of the Brg1 ATPase results in dissolution of pericentromeric heterochromatin domains and a redistribution of histone modifications associated with these structures. This effect was highly specific to Brg1 and is not reproduced by the loss of Brm or SNF5/BAF47/INI1. Brg1 deficiency is associated with the appearance of micronuclei and aberrant mitoses that are a by-product of dissociated chromatin structure. Thus, Brg1 plays a critical role in maintaining chromatin structural integrity.

Mitochondrial dysfunction contributes to impaired insulin secretion in INS-1 cells with dominant-negative mutations of HNF-1alpha and in HNF-1alpha-deficient islets.

Maturity Onset Diabetes of the Young-type 3 (MODY-3) has been linked to mutations in the transcription factor hepatic nuclear factor (HNF)-1alpha, resulting in deficiency in glucose-stimulated insulin secretion. In INS-1 cells overexpressing doxycycline-inducible HNF-1alpha dominant-negative (DN-) gene mutations, and islets from Hnf-1alpha knock-out mice, insulin secretion was impaired in response to glucose (15 mm) and other nutrient secretagogues. Decreased rates of insulin secretion in response to glutamine plus leucine and to methyl pyruvate, but not potassium depolarization, indicate defects specific to mitochondrial metabolism. To identify the biochemical mechanisms responsible for impaired insulin secretion, we used (31)P NMR measured mitochondrial ATP synthesis (distinct from glycolytic ATP synthesis) together with oxygen consumption measurements to determine the efficiency of mitochondrial oxidative phosphorylation. Mitochondrial uncoupling was significantly higher in DN-HNF-1alpha cells, such that rates of ATP synthesis were decreased by approximately one-half in response to the secretagogues glucose, glutamine plus leucine, or pyruvate. In addition to closure of the ATP-sensitive K(+) channels with mitochondrial ATP synthesis, mitochondrial production of second messengers through increased anaplerotic flux has been shown to be critical for coupling metabolism to insulin secretion. (13)C-Isotopomer analysis and tandem mass spectrometry measurement of Krebs cycle intermediates revealed a negative impact of DN-HNF-1alpha and Hnf-1alpha knock-out on mitochondrial second messenger production with glucose but not amino acids. Taken together, these results indicate that, in addition to reduced glycolytic flux, uncoupling of mitochondrial oxidative phosphorylation contributes to impaired nutrient-stimulated insulin secretion with either mutations or loss of HNF-1alpha.

Involvement of SMARCA2/BRM in the SWI/SNF chromatin-remodeling complex in schizophrenia.

Chromatin remodeling may play a role in the neurobiology of schizophrenia and the process, therefore, may be considered as a therapeutic target. The SMARCA2 gene encodes BRM in the SWI/SNF chromatin-remodeling complex, and associations of single nucleotide polymorphisms (SNPs) to schizophrenia were found in two linkage disequilibrium blocks in the SMARCA2 gene after screening of 11 883 SNPs (rs2296212; overall allelic P = 5.8 x 10(-5)) and subsequent screening of 22 genes involved in chromatin remodeling (rs3793490; overall allelic P = 2.0 x 10(-6)) in a Japanese population. A risk allele of a missense polymorphism (rs2296212) induced a lower nuclear localization efficiency of BRM, and risk alleles of intronic polymorphisms (rs3763627 and rs3793490) were associated with low SMARCA2 expression levels in the postmortem prefrontal cortex. A significant correlation in the fold changes of gene expression from schizophrenic prefrontal cortex (from the Stanley Medical Research Institute online genomics database) was seen with suppression of SMARCA2 in transfected human cells by specific siRNA, and of orthologous genes in the prefrontal cortex of Smarca2 knockout mice. Smarca2 knockout mice showed impaired social interaction and prepulse inhibition. Psychotogenic drugs lowered Smarca2 expression while antipsychotic drugs increased it in the mouse brain. These findings support the existence of a role for BRM in the pathophysiology of schizophrenia.

Small DNA tumour viruses and their contributions to our understanding of transcription control.

The study of small DNA tumour viruses like SV40 and polyoma was one of the major entry points for the study of eukaryotes. It opened fields like gene structure, transcription or replication control, chromatin structure and cell transformation. This review outlines the breakthroughs that occurred at the end of the 1970s and during the 1980s in our understanding of gene structure and the basic processes involved in control of gene expression starting with DNA tumour viruses and reaching their cellular hosts. These developments were made possible by concomitant advances in the isolation of restriction enzymes, developing DNA sequencing protocols, DNA cloning, DNA transfections, in vitro transcription systems and isolation of sequence specific DNA binding protein among others. The conceptual and methodological advances that resulted from the studies of small DNA tumour viruses opened the era for the study of host genomes far more complex, culminating with the establishment of the sequence and a functional map of the human genome.

The SWI/SNF ATPase Brm is a gatekeeper of proliferative control in prostate cancer.

Factors that drive prostate cancer progression remain poorly defined, thus hindering the development of new therapeutic strategies. Disseminated tumors are treated through regimens that ablate androgen signaling, as prostate cancer cells require androgen for growth and survival. However, recurrent, incurable tumors that have bypassed the androgen requirement ultimately arise. This study reveals that the Brm ATPase, a component of selected SWI/SNF complexes, has significant antiproliferative functions in the prostate that protect against these transitions. First, we show that targeted ablation of Brm is causative for the development of prostatic hyperplasia in mice. Second, in vivo challenge revealed that Brm-/- epithelia acquire the capacity for lobe-specific, castration-resistant cellular proliferation. Third, investigation of human specimens revealed that Brm mRNA and protein levels are attenuated in prostate cancer. Fourth, Brm down-regulation was associated with an increased proliferative index, consistent with the mouse model. Lastly, gene expression profiling showed that Brm loss alters factors upstream of E2F1; this was confirmed in murine models, wherein Brm loss induced E2F1 deregulation in a tissue-specific manner. Combined, these data identify Brm as a major effector of serum androgen-induced proliferation in the prostate that is disrupted in human disease, and indicate that loss of Brm confers a proliferative advantage in prostate cancer.