Os supratrochleare anterius: a very rare clinical case and review of literature

Os supratrochleare anterius: a very rare clinical case and review of literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Os supratrochleare anterius: a very rare clinical case and review of literature David Kachlik, Vojtech Kunc, Sarka Salavova, Lubomir Kopp This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3948540/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose: The accessory ossicles around the elbow are very rare variant structures, present in approximately 0.7% of cases. They can cause diagnostic problems and can be mistaken for pathological structures, especially when pain and limitation of elbow movements are present and a trauma can be traced in the patient’s history. They are of different nature, either presenting within muscle tendons as sesamoids (brachialis and triceps brachii muscles) or presenting intra-articularly probably as separated or accessory ossification centres. The least common is the os supratrochleare anterius . Methods: We present a case of a young male, presenting with chronic blocking and 20° limited flexion of his right elbow, which bothered him during his occupation as a locksmith. In history, he suffered minor trauma to the elbow 20 years ago. X-ray and CT showed a large ossicle in the coronoid fossa of the humerus. Results: The ossicle was surgically extracted in small pieces. The patient left satisfied with no mention of complaints. Conclusion: The os supratrochleare anterius is a very rare accessory osssicle of the elbow, located in the coronoid fossa of the humerus which can mimic many pathological states, and limit movements and causing pain around the elbow. os supratrochleare anterius accessory bone accessory ossicle elbow Figures Figure 1 Figure 2 Introduction The accessory ossicles around the elbow are very rare variant structures, present in approximately 0.7% of cases [ 1 ]. They can cause diagnostic problems and can be mistaken for pathological structures, such as acquired ossification after due to various reasons (injury of central nervous system, burns), separated part of the bone or separated ossification centre in children, a nidus of osteoid osteoma, result of arthritic changes, especially when pain and limitation of elbow movements are present and mainly after any trauma to this specific region. They are of different nature, either presenting within muscle tendons as sesamoids (brachialis and triceps brachii muscles) or presenting intra-articularly probably as separated or accessory ossification centres [ 2 ]. Three accessory bones present themselves intra-articularly – os supratrochleare anterius , os supratrochleare posterius and patella cubiti . Those are also the least common and may produce symptoms such as pain and limitation of the movement [ 3 ]. The least common is the os supratrochleare anterius that is why we present following case encountered in our hospital. Case report A 36-years-old male of Central European origin presented at our clinic with chronic blocking and 20° limited flexion of his right elbow (non-dominant extremity), which bothered him during his occupation as a locksmith. He stated that he had some problems since childhood and mentioned a minor trauma when he was fourteen. During last four years his clinical symptoms gradually worsened. He was a smoker, otherwise his medical history was insignificant. Any pathological structure was found by neither aspection nor palpation. On the radiograph an ossicle in the coronoid fossa of the humerus was present, which we identified as the os supratrochleare anterius (Fig. 1 a). CT showed slight degenerative changes of the ossicle (Fig. 1 b, 2 ). The bone was of approximately pyramidal shape with apex heading proximally, 14 mm long (proximal-distal), 17 mm wide (medial-lateral) and 14 mm thick (anterior-posterior). As this was the probable source of his complaints an arthroscopic extraction was scheduled. Combined anaesthesia and preoperative administration of antibiotic prophylaxis (cephasoline) were used during the surgery. Ventral joint chamber was accessed by standard anterolateral and anteromedial portals, followed by revision of the dorsal joint chamber using transtricipital and dorsoradial (soft-spot) portals. A large ossicle was identified in the coronoid fossa of the humerus and it was extracted in small pieces. The joint was then shaved and limited capsulotomy with extended synovectomy were performed, accompanied by bony coronoid and olecranon resections. Following several cycles of the forced range of motion, the flexion and extension were measured to be 140° and − 5°, respectively. Patient was dismissed after two days without any postoperative complications. Flexion of the forearm was still limited. Postoperative radiographs showed complete removal of the ossicle. Sutures were removed second week postoperatively elsewhere and during a three-month-follow up the forearm flexion resolved to nearly normal values of 140°. Radiograph did not show any pathological changes. Patient did not mention any clinical complaints within one year follow-up period. We have not heard about him since. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Discussion In our previous large study performed on anteroposterior and lateral X-ray images of 2413 elbows of the Central European population there was no os supratrochelare anterius found unlike all other types of the accessory ossicle around the elbow joint [ 1 ], which make this accessory ossicle very rare and interesting when observed. Simril and Trotter in 1949 presented probably the first well documented case of the os supratrochleare anterius in a dissected cadaver, seen in the both upper limbs of an Afroamerican male, in front of the coronoid and radial fossae of the humerus, approximately 24 mm wide (transverse plane) and 6 mm thick (sagittal plane) on the left (oblong shape), and 14 mm wide (transverse plane) and 8 mm thick (sagittal plane) on the right (nearly round shape), visible on the lateral radiographs and also confirmed by dissection. They used the term “os cubiti anterius”. Histological examinations revealed true, mature and viable bone, arthritic changes (frayed articular cartilage) and extension of subchondral bone into the cartilaginous matrix (no resemblance to either loose bodies of osteochondritis dissecans or other clinical entities resulting in a joint mouse were noted). Moreover, bilaterally there were arthritic changes in the whole elbow, long and narrow olecranon and the olecranon fossa of the humerus presented a transverse bony ridge [ 4 ]. In an appended note, they offered a personal communication of Edward A. Holyoke (Nebraska) who definitely encountered such case in an Afroamerican male in his laboratory in 1947 [ 4 ]. Schwarz in 1957 reported probably the first case of the os supratrochleare anterius diagnosed in a life patient, present in the both upper limbs of an American white female, within the coronoid fossa of the humerus, approximately 6 x 11 mm large, visible on the radiographs [ 5 ]. He used the term “antecubital bone/ossicle” but proposed a new term for this variant – “fabella cubiti“– based on the opinion that it is most likely a sesamoid bone within the brachialis muscle tendon and thus analogous to the fabella. In the Introduction, Schwarz offered a personal communication of Birkner who “possibly encountered similar two cases“ but no further data are available and we were unfortunately not able to find closer information [ 5 ]. Ochsenschläger in 1959 described a case of an aseptic necrosis of the bony septum between the coronoid and olecranon fossae of the humerus (supratrochlear septum) in the left upper limb of a German female. The original X-rays are neither of good contrast nor performed in standard projections. After application of previously defined three radiographic criteria for accessory bones it fulfils two out of three: ovoid and regular shape, and smooth margins. The third criterion of regular cortical-to-medullary ratio cannot be assessed duo to the low quality of radiographs. Nevertheless, it is probably a case of the os supratrochleare anterius , although this conclusion is not fully certain [ 6 ]. Gudmundsen and Østsensen in 1987 reported three cases (collected in previous years) which they considered to be the potential os supratrochleare anterius . Unfortunately, their conclusions are based on low quality or even missing radiographs. The first case (male) featured three additional bony particles in the coronoid fossa of the right humerus (no X-ray available) after 7-years-period of increasing pain and limitation of motion and then a suffered minor trauma. The second case (male) one year after minor trauma presented with increasing pain and limitations of motion and small oval ossicles were removed from both the coronoid and olecranon fossae of the humerus (X-ray of low quality do not allow us to decide whether the ossicle is pathological or accessory). Third case (male) after 20-years-period of pain and disturbed motion with no history of trauma (no X-ray available) featured a large ossicle with clear bony structure in the coronoid fossa and two small ossicles in the olecranon fossa of the right humerus. Unfortunately, this last case which is probably an example of the os supratrochleare anterius but it cannot be verified on the X-ray image [ 2 ]. We stated in our previous article [ 1 ] that “three cases of os supratrochleare anterius are described in the literature” [ 3 ] but this information was based on a wrong translation of the original Spanish text and no such is reported in their work. After recent deeper analysis we can in total present two well documented bilateral cases [ 4 , 5 ], one probable unilateral case [ 6 ], one unilateral case with scarce data and no image [ 2 ] and three potentially bilateral cases reported by personal communication with neither evidence nor image [ 4 , 5 ]. There have been no recent reports from 1987 to 2022 which makes this anatomical unit very rare (see Table 1) – 13 bones in 8 individuals (including ours) – and thus important to point at to get larger medical public acquainted with such existing anatomical variant. All three well described cases ([ 4 , 5 ]; ours) were intra-articular which was observed directly. The joint capsule inserts onto the humerus above the coronoid fossa that is why the entire fossa is intra-articular. However, the accessory ossicle may be imbedded within the capsule or rests on the external surface of the capsule and still may produce similar picture on X-ray [ 5 ]. Based on this opinion, the imaging method of choice to visualize and differentiate this accessory bone is definitively the magnetic resonance. Differential diagnosis It is necessary to thoroughly consider each case of bony fragment found around the elbow. Either it is an accessory bone/ossicle (typical ovoid shape, smooth margins, cortex ratio) or a pathological structure (quite irregular shape and size, calcifications, can be multiple). The closest accessory bones are the os supratrochleare posterius , much more common, located within the olecranon fossa of the humerus and first described by Pfitzner in 1892 as “sesamum cubiti”, and the os sesamoideum brachiale within the insertional tendon of the brachialis muscle, also considered a separated/persistent ossification centre of the coronoid process of the ulna by some authors [ 5 , 7 , 8 ] and called “accessory coronoid ossicle” [ 9 ]. These three bones located very close to each other can be mistaken in the anteroposterior projection of the X-ray examination and they can also cause similar symptoms such as limitation of elbow range of motion and pain, and often have to be surgically removed [ 9 ]. Both the ossa supratrochlearia have been postulated to arise from separate ossification centres [ 9 ]. Another theory is that the os supratrochleare is as an accessory “bone nucleus” separated from the olecranon [ 10 ]. The pathological situations comprise cases of the osteochondritis dissecans of the supratrochlear septum of the humerus but also other pathological processes (degenerative changes, occult and avulsion fractures, gout, Panner's disease, synovial chondromatosis, primary tumours – chondrom, nidus of an osteoid osteoma – or metastatic tumours) which may feature similar clinical symptoms (pain, limited movements). Entrapment neuropathy concerning the ulnar nerve around the elbow, bursitis, tendinitis, epicondylitis, entesopathy may also coexist with the bone. All these situations can mimic an accessory ossicle and it is necessary to thoroughly judge each case. For critical and uniform decision process we have created a three-step-protocol. Morphological features of a true accessory bone were defined as: 1) regular ovoid shape; 2) smooth margins; and 3) regular cortical to medullar ratio throughout the circumference [ 1 ]. Limitations First limitation is done by the terminological inconsistence in existing literature concerning both the accessory ossicles and pathological structures which may cause that some relevant article have been skipped. Second limitation is the low quality of X-rays in older articles which did not allow us to clearly differentiate between the accessory and pathological structures. Third limitation is the difficult application of our three criteria as there often appear degenerative and traumatic changes influenced by avulsion of the coronoid process of the ulna as well as the olecranon. Fractures of the os supratrochelare posterius have been described [ 10 ]. Conclusion The os supratrochleare anterius is a very rare accessory osssicle, located in the coronoid fossa of the humerus which can mimic many pathological states, and limit movements and causing pain around the elbow. Declarations Conflict of interest The authors declare that they have no conflict of interest. Acknowledgements The authors would like to thank the anonymous patient who gave a written consent with publication of his case-report and and Miroslava Plecitá for help with obtaining the literature. Ethical Approval The patient gave a written consent with publication of his case-report. Funding No funding has been received. Availability of data and materials All other data including X-rays after the surgery are available at the corresponding author upon reasonable request. CrediT author statement David Kachlik: Methodology, Investigation, Data Curation, Visualization, Writing – Original Draft. Vojtech Kunc : Formal Analysis, Surgery, Visualization, Writing – Review & Editing Sarka Salavova: Validation, Writing – Review & Editing Lubomir Kopp : Supervision, Surgery, Resources, Visualization, Writing – Review & Editing. References Kunc V, Kunc V, Černý V, Polovinčák M, Kachlík D (2020) Accessory bones of the elbow: Prevalence, localization and modified classification. J Anat 237(4):618–622. 10.1111/joa.13233 Gudmundsen TE, Østensen H (1987) Accessory ossicles in the elbow. Acta Orthop Scan 58:130–132. 10.3109/17453678709146457 Cañamero B, Ángeles M, Giraldo S, Alberto W, Rivera G, Ignacio J, Javier BC (2014) Os supratrochleare dorsale del codo. Acta Rheuma 1(5):25–27. 10.3823/1304 Simril WA, Trotter M (1949) An accessory bone and other bilateral skeletal anomalies of the elbow. Radiology 53(1):97–100. 10.1148/53.1.97 Schwarz GS (1957) Bilateral antecubital ossicles (fabellae cubiti) and other rare accessory bones of the elbow. Radiology 69(5):730–734. 10.1148/69.5.730 Ochsenschläger A (1959) Zum Krankheitsbild der aseptischen Knochennekkrose des Septum supratrochleare. Z Orthop 91:441–444 Köhler A, Zimmer EA (1956) Grenzen des Normalen und Anfänge des Pathologischen im Röntgenbilde des Skelettes. Georg Thieme, Stuttgart Rumpold HJ (1964) Die Persistenz des Verkoecherungszentrums im proximalen Gelenkabschnitt der Ulna. (Beitrag zur Abgrenzung gegen dortige Frakturen). Fortschr Geb Rontgenstr Nuklearmed 100:651–654 Wood VE, Campbell GS (1994) The supratrochleare dorsale accessory ossicle in the elbow. J Shoulder Elb Surg 3(6):395–398. 10.1016/S1058-2746(09)80026-8 Obermann WR, Loose HW (1983) The os supratrochleare dorsale: A normal variant that may cause symptoms. AJR Am J Roentgenol 141(1):123–127. 10.2214/ajr.141.1.123 Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.xlsx Table1 Overview of collected case reports Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Feb, 2024 Reviews received at journal 27 Feb, 2024 Reviews received at journal 27 Feb, 2024 Reviewers agreed at journal 22 Feb, 2024 Reviewers agreed at journal 21 Feb, 2024 Reviewers invited by journal 20 Feb, 2024 Editor assigned by journal 14 Feb, 2024 Submission checks completed at journal 14 Feb, 2024 First submitted to journal 11 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3948540","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":272820567,"identity":"76add119-f1d5-4499-b8d1-d1aafa524f4e","order_by":0,"name":"David Kachlik","email":"data:image/png;base64,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","orcid":"","institution":"Charles University","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"","lastName":"Kachlik","suffix":""},{"id":272820568,"identity":"f2e90a37-5c10-459e-882a-71f2acaeb2d3","order_by":1,"name":"Vojtech Kunc","email":"","orcid":"","institution":"Charles University","correspondingAuthor":false,"prefix":"","firstName":"Vojtech","middleName":"","lastName":"Kunc","suffix":""},{"id":272820569,"identity":"0800d249-5afa-40bd-951e-fec5d16ee2b6","order_by":2,"name":"Sarka Salavova","email":"","orcid":"","institution":"Charles University","correspondingAuthor":false,"prefix":"","firstName":"Sarka","middleName":"","lastName":"Salavova","suffix":""},{"id":272820570,"identity":"30d35294-7a8f-4d8b-8913-da57399f7022","order_by":3,"name":"Lubomir Kopp","email":"","orcid":"","institution":"Charles University","correspondingAuthor":false,"prefix":"","firstName":"Lubomir","middleName":"","lastName":"Kopp","suffix":""}],"badges":[],"createdAt":"2024-02-11 13:20:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3948540/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3948540/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51186381,"identity":"cefdbde0-c06b-4131-994e-f5d5126b15ab","added_by":"auto","created_at":"2024-02-15 15:58:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4203544,"visible":true,"origin":"","legend":"\u003cp\u003eRight elbow and the \u003cem\u003eos supratrochleare anterius \u003c/em\u003ewith the coronoid fossa of the humerus before the surgery\u003c/p\u003e\n\u003cp\u003ea – Lateral X-ray; b – CT sagittal section.\u003c/p\u003e","description":"","filename":"OnlineFig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-3948540/v1/186690462a6a11dd8890921b.png"},{"id":51186498,"identity":"8d7487a2-78dd-497e-b293-3336d5527b5d","added_by":"auto","created_at":"2024-02-15 15:58:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4739287,"visible":true,"origin":"","legend":"\u003cp\u003eRight elbow and the \u003cem\u003eos supratrochleare anterius \u003c/em\u003ewith the coronoid fossa of the humerus\u003c/p\u003e\n\u003cp\u003ea – CT axial section; b – CT 3D reconstruction\u003c/p\u003e","description":"","filename":"OnlineFig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-3948540/v1/1de695eaff6b27ee1a0a2988.png"},{"id":51187152,"identity":"52766a17-46d4-4cf9-a482-5adca1ef7b8a","added_by":"auto","created_at":"2024-02-15 16:06:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1213558,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3948540/v1/8bfbbdf3-b5ce-42a4-a81a-d1919bbb6eec.pdf"},{"id":51186372,"identity":"82639841-4845-44a1-a3a4-c0b004fdb95e","added_by":"auto","created_at":"2024-02-15 15:58:56","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12546,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable1 \u003c/strong\u003eOverview of collected case reports\u003c/p\u003e","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3948540/v1/22c9e5228b530f974734b6d8.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Os supratrochleare anterius: a very rare clinical case and review of literature","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe accessory ossicles around the elbow are very rare variant structures, present in approximately 0.7% of cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. They can cause diagnostic problems and can be mistaken for pathological structures, such as acquired ossification after due to various reasons (injury of central nervous system, burns), separated part of the bone or separated ossification centre in children, a nidus of osteoid osteoma, result of arthritic changes, especially when pain and limitation of elbow movements are present and mainly after any trauma to this specific region. They are of different nature, either presenting within muscle tendons as sesamoids (brachialis and triceps brachii muscles) or presenting intra-articularly probably as separated or accessory ossification centres [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Three accessory bones present themselves intra-articularly \u0026ndash; \u003cem\u003eos supratrochleare anterius\u003c/em\u003e, \u003cem\u003eos supratrochleare posterius\u003c/em\u003e and \u003cem\u003epatella cubiti\u003c/em\u003e. Those are also the least common and may produce symptoms such as pain and limitation of the movement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The least common is the \u003cem\u003eos supratrochleare anterius\u003c/em\u003e that is why we present following case encountered in our hospital.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 36-years-old male of Central European origin presented at our clinic with chronic blocking and 20\u0026deg; limited flexion of his right elbow (non-dominant extremity), which bothered him during his occupation as a locksmith. He stated that he had some problems since childhood and mentioned a minor trauma when he was fourteen. During last four years his clinical symptoms gradually worsened. He was a smoker, otherwise his medical history was insignificant. Any pathological structure was found by neither aspection nor palpation. On the radiograph an ossicle in the coronoid fossa of the humerus was present, which we identified as the \u003cem\u003eos supratrochleare anterius\u003c/em\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). CT showed slight degenerative changes of the ossicle (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The bone was of approximately pyramidal shape with apex heading proximally, 14 mm long (proximal-distal), 17 mm wide (medial-lateral) and 14 mm thick (anterior-posterior). As this was the probable source of his complaints an arthroscopic extraction was scheduled. Combined anaesthesia and preoperative administration of antibiotic prophylaxis (cephasoline) were used during the surgery. Ventral joint chamber was accessed by standard anterolateral and anteromedial portals, followed by revision of the dorsal joint chamber using transtricipital and dorsoradial (soft-spot) portals. A large ossicle was identified in the coronoid fossa of the humerus and it was extracted in small pieces. The joint was then shaved and limited capsulotomy with extended synovectomy were performed, accompanied by bony coronoid and olecranon resections. Following several cycles of the forced range of motion, the flexion and extension were measured to be 140\u0026deg; and \u0026minus;\u0026thinsp;5\u0026deg;, respectively. Patient was dismissed after two days without any postoperative complications. Flexion of the forearm was still limited. Postoperative radiographs showed complete removal of the ossicle. Sutures were removed second week postoperatively elsewhere and during a three-month-follow up the forearm flexion resolved to nearly normal values of 140\u0026deg;. Radiograph did not show any pathological changes. Patient did not mention any clinical complaints within one year follow-up period. We have not heard about him since.\u003c/p\u003e \u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our previous large study performed on anteroposterior and lateral X-ray images of 2413 elbows of the Central European population there was no \u003cem\u003eos supratrochelare anterius\u003c/em\u003e found unlike all other types of the accessory ossicle around the elbow joint [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], which make this accessory ossicle very rare and interesting when observed.\u003c/p\u003e \u003cp\u003eSimril and Trotter in 1949 presented probably the first well documented case of the \u003cem\u003eos supratrochleare anterius\u003c/em\u003e in a dissected cadaver, seen in the both upper limbs of an Afroamerican male, in front of the coronoid and radial fossae of the humerus, approximately 24 mm wide (transverse plane) and 6 mm thick (sagittal plane) on the left (oblong shape), and 14 mm wide (transverse plane) and 8 mm thick (sagittal plane) on the right (nearly round shape), visible on the lateral radiographs and also confirmed by dissection. They used the term \u0026ldquo;os cubiti anterius\u0026rdquo;. Histological examinations revealed true, mature and viable bone, arthritic changes (frayed articular cartilage) and extension of subchondral bone into the cartilaginous matrix (no resemblance to either loose bodies of osteochondritis dissecans or other clinical entities resulting in a joint mouse were noted). Moreover, bilaterally there were arthritic changes in the whole elbow, long and narrow olecranon and the olecranon fossa of the humerus presented a transverse bony ridge [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In an appended note, they offered a personal communication of Edward A. Holyoke (Nebraska) who definitely encountered such case in an Afroamerican male in his laboratory in 1947 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSchwarz in 1957 reported probably the first case of the \u003cem\u003eos supratrochleare anterius\u003c/em\u003e diagnosed in a life patient, present in the both upper limbs of an American white female, within the coronoid fossa of the humerus, approximately 6 x 11 mm large, visible on the radiographs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. He used the term \u0026ldquo;antecubital bone/ossicle\u0026rdquo; but proposed a new term for this variant \u0026ndash; \u0026ldquo;fabella cubiti\u0026ldquo;\u0026ndash; based on the opinion that it is most likely a sesamoid bone within the brachialis muscle tendon and thus analogous to the fabella. In the Introduction, Schwarz offered a personal communication of Birkner who \u0026ldquo;possibly encountered similar two cases\u0026ldquo; but no further data are available and we were unfortunately not able to find closer information [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOchsenschl\u0026auml;ger in 1959 described a case of an aseptic necrosis of the bony septum between the coronoid and olecranon fossae of the humerus (supratrochlear septum) in the left upper limb of a German female. The original X-rays are neither of good contrast nor performed in standard\u003c/p\u003e \u003cp\u003eprojections. After application of previously defined three radiographic criteria for accessory bones it fulfils two out of three: ovoid and regular shape, and smooth margins. The third criterion of regular cortical-to-medullary ratio cannot be assessed duo to the low quality of radiographs. Nevertheless,\u003c/p\u003e \u003cp\u003eit is probably a case of the \u003cem\u003eos supratrochleare anterius\u003c/em\u003e, although this conclusion is not fully certain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Gudmundsen and \u0026Oslash;stsensen in 1987 reported three cases (collected in previous years) which they considered to be the potential \u003cem\u003eos supratrochleare anterius\u003c/em\u003e. Unfortunately, their conclusions are based on low quality or even missing radiographs. The first case (male) featured three additional bony particles in the coronoid fossa of the right humerus (no X-ray available) after 7-years-period of increasing pain and limitation of motion and then a suffered minor trauma. The second case (male) one year after minor trauma presented with increasing pain and limitations of motion and small oval ossicles were removed from both the coronoid and olecranon fossae of the humerus (X-ray of low quality do not allow us to decide whether the ossicle is pathological or accessory). Third case (male) after 20-years-period of pain and disturbed motion with no history of trauma (no X-ray available) featured a large ossicle with clear bony structure in the coronoid fossa and two small ossicles in the olecranon fossa of the right humerus. Unfortunately, this last case which is probably an example of the \u003cem\u003eos supratrochleare anterius\u003c/em\u003e but it cannot be verified on the X-ray image [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe stated in our previous article [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] that \u0026ldquo;three cases of \u003cem\u003eos supratrochleare anterius\u003c/em\u003e are described in the literature\u0026rdquo; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] but this information was based on a wrong translation of the original Spanish text and no such is reported in their work. After recent deeper analysis we can in total present two well documented bilateral cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], one probable unilateral case [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], one unilateral case with scarce data and no image [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and three potentially bilateral cases reported by personal communication with neither evidence nor image [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. There have been no recent reports from 1987 to 2022 which makes this anatomical unit very rare (see Table\u0026nbsp;1) \u0026ndash; 13 bones in 8 individuals (including ours) \u0026ndash; and thus important to point at to get larger medical public acquainted with such existing anatomical variant. All three well described cases ([\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; ours) were intra-articular which was observed directly. The joint capsule inserts onto the humerus above the coronoid fossa that is why the entire fossa is intra-articular. However, the accessory ossicle may be imbedded within the capsule or rests on the external surface of the capsule and still may produce similar picture on X-ray [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Based on this opinion, the imaging method of choice to visualize and differentiate this accessory bone is definitively the magnetic resonance.\u003c/p\u003e\n\u003ch3\u003eDifferential diagnosis\u003c/h3\u003e\n\u003cp\u003eIt is necessary to thoroughly consider each case of bony fragment found around the elbow. Either it is an accessory bone/ossicle (typical ovoid shape, smooth margins, cortex ratio) or a pathological structure (quite irregular shape and size, calcifications, can be multiple). The closest accessory bones are the \u003cem\u003eos supratrochleare posterius\u003c/em\u003e, much more common, located within the olecranon fossa of the humerus and first described by Pfitzner in 1892 as \u0026ldquo;sesamum cubiti\u0026rdquo;, and the \u003cem\u003eos sesamoideum brachiale\u003c/em\u003e within the insertional tendon of the brachialis muscle, also considered a separated/persistent ossification centre of the coronoid process of the ulna by some authors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and called \u0026ldquo;accessory coronoid ossicle\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese three bones located very close to each other can be mistaken in the anteroposterior projection of the X-ray examination and they can also cause similar symptoms such as limitation of elbow range of motion and pain, and often have to be surgically removed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth the \u003cem\u003eossa supratrochlearia\u003c/em\u003e have been postulated to arise from separate ossification centres [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Another theory is that the \u003cem\u003eos supratrochleare\u003c/em\u003e is as an accessory \u0026ldquo;bone nucleus\u0026rdquo; separated from the olecranon [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathological situations comprise cases of the osteochondritis dissecans of the supratrochlear septum of the humerus but also other pathological processes (degenerative changes, occult and avulsion fractures, gout, Panner's disease, synovial chondromatosis, primary tumours \u0026ndash; chondrom, nidus of an osteoid osteoma \u0026ndash; or metastatic tumours) which may feature similar clinical symptoms (pain, limited movements). Entrapment neuropathy concerning the ulnar nerve around the elbow, bursitis, tendinitis, epicondylitis, entesopathy may also coexist with the bone. All these situations can mimic an accessory ossicle and it is necessary to thoroughly judge each case. For critical and uniform decision process we have created a three-step-protocol. Morphological features of a true accessory bone were defined as: 1) regular ovoid shape; 2) smooth margins; and 3) regular cortical to medullar ratio throughout the circumference [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eFirst limitation is done by the terminological inconsistence in existing literature concerning both the accessory ossicles and pathological structures which may cause that some relevant article have been skipped. Second limitation is the low quality of X-rays in older articles which did not allow us to clearly differentiate between the accessory and pathological structures. Third limitation is the difficult application of our three criteria as there often appear degenerative and traumatic changes influenced by avulsion of the coronoid process of the ulna as well as the olecranon. Fractures of the \u003cem\u003eos supratrochelare posterius\u003c/em\u003e have been described [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe \u003cem\u003eos supratrochleare anterius\u003c/em\u003e is a very rare accessory osssicle, located in the coronoid fossa of the humerus which can mimic many pathological states, and limit movements and causing pain around the elbow.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the anonymous patient who gave a written consent with publication of his case-report and and Miroslava Plecit\u0026aacute; for help with obtaining the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe patient gave a written consent with publication of his case-report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding has been received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll other data including X-rays after the surgery are available at the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCrediT author statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDavid Kachlik:\u0026nbsp;\u003c/strong\u003eMethodology, Investigation, Data Curation, Visualization, Writing \u0026ndash; Original Draft.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVojtech Kunc\u003c/strong\u003e: Formal Analysis, Surgery, Visualization, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSarka Salavova:\u0026nbsp;\u003c/strong\u003eValidation, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLubomir Kopp\u003c/strong\u003e: Supervision, Surgery, Resources, Visualization, Writing \u0026ndash; Review \u0026amp; Editing.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKunc V, Kunc V, Čern\u0026yacute; V, Polovinč\u0026aacute;k M, Kachl\u0026iacute;k D (2020) Accessory bones of the elbow: Prevalence, localization and modified classification. J Anat 237(4):618\u0026ndash;622. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/joa.13233\u003c/span\u003e\u003cspan address=\"10.1111/joa.13233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGudmundsen TE, \u0026Oslash;stensen H (1987) Accessory ossicles in the elbow. Acta Orthop Scan 58:130\u0026ndash;132. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/17453678709146457\u003c/span\u003e\u003cspan address=\"10.3109/17453678709146457\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCa\u0026ntilde;amero B, \u0026Aacute;ngeles M, Giraldo S, Alberto W, Rivera G, Ignacio J, Javier BC (2014) Os supratrochleare dorsale del codo. Acta Rheuma 1(5):25\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3823/1304\u003c/span\u003e\u003cspan address=\"10.3823/1304\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimril WA, Trotter M (1949) An accessory bone and other bilateral skeletal anomalies of the elbow. Radiology 53(1):97\u0026ndash;100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/53.1.97\u003c/span\u003e\u003cspan address=\"10.1148/53.1.97\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwarz GS (1957) Bilateral antecubital ossicles (fabellae cubiti) and other rare accessory bones of the elbow. Radiology 69(5):730\u0026ndash;734. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/69.5.730\u003c/span\u003e\u003cspan address=\"10.1148/69.5.730\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchsenschl\u0026auml;ger A (1959) Zum Krankheitsbild der aseptischen Knochennekkrose des Septum supratrochleare. Z Orthop 91:441\u0026ndash;444\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026ouml;hler A, Zimmer EA (1956) Grenzen des Normalen und Anf\u0026auml;nge des Pathologischen im R\u0026ouml;ntgenbilde des Skelettes. Georg Thieme, Stuttgart\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRumpold HJ (1964) Die Persistenz des Verkoecherungszentrums im proximalen Gelenkabschnitt der Ulna. (Beitrag zur Abgrenzung gegen dortige Frakturen). Fortschr Geb Rontgenstr Nuklearmed 100:651\u0026ndash;654\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWood VE, Campbell GS (1994) The supratrochleare dorsale accessory ossicle in the elbow. J Shoulder Elb Surg 3(6):395\u0026ndash;398. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S1058-2746(09)80026-8\u003c/span\u003e\u003cspan address=\"10.1016/S1058-2746(09)80026-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObermann WR, Loose HW (1983) The os supratrochleare dorsale: A normal variant that may cause symptoms. AJR Am J Roentgenol 141(1):123\u0026ndash;127. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2214/ajr.141.1.123\u003c/span\u003e\u003cspan address=\"10.2214/ajr.141.1.123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"os supratrochleare anterius, accessory bone, accessory ossicle, elbow","lastPublishedDoi":"10.21203/rs.3.rs-3948540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3948540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eThe accessory ossicles around the elbow are very rare variant structures, present in approximately 0.7% of cases. They can cause diagnostic problems and can be mistaken for pathological structures, especially when pain and limitation of elbow movements are present and a trauma can be traced in the patient\u0026rsquo;s history. They are of different nature, either presenting within muscle tendons as sesamoids (brachialis and triceps brachii muscles) or presenting intra-articularly probably as separated or accessory ossification centres. The least common is the \u003cem\u003eos supratrochleare anterius\u003c/em\u003e.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe present a case of a young male, presenting with chronic blocking and 20\u0026deg; limited flexion of his right elbow, which bothered him during his occupation as a locksmith. In history, he suffered minor trauma to the elbow 20 years ago. X-ray and CT showed a large ossicle in the coronoid fossa of the humerus.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe ossicle was surgically extracted in small pieces. The patient left satisfied with no mention of complaints.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe \u003cem\u003eos supratrochleare anterius\u003c/em\u003e is a very rare accessory osssicle of the elbow, located in the coronoid fossa of the humerus which can mimic many pathological states, and limit movements and causing pain around the elbow.\u003c/p\u003e","manuscriptTitle":"Os supratrochleare anterius: a very rare clinical case and review of literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-15 15:58:20","doi":"10.21203/rs.3.rs-3948540/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-02-27T16:36:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-27T15:41:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-27T15:23:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4cf1c1ac-2011-40ed-9f62-8d9098054ba5","date":"2024-02-22T08:42:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74c76035-4a73-4f8f-ae8c-640bf92b3499","date":"2024-02-21T09:11:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-20T10:21:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-14T11:39:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-14T06:07:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Surgical and Radiologic Anatomy","date":"2024-02-11T13:05:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"321b965b-00d1-486b-abb0-c92b96e21f8a","owner":[],"postedDate":"February 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-12T16:04:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-15 15:58:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3948540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3948540","identity":"rs-3948540","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}