Abhay Elhence

An interactive medical image segmentation framework using iterative refinement

Segmentation is often performed on medical images for identifying diseases in clinical evaluation. Hence it has become one of the major research areas. Conventional image segmentation techniques are unable to provide satisfactory segmentation results for medical images as they contain irregularities. They need to be pre-processed before segmentation. In order to obtain the most suitable method for medical image segmentation, we propose MIST (Medical Image Segmentation Tool), a two stage algorithm. The first stage automatically generates a binary marker image of the region of interest using mathematical morphology. This marker serves as the mask image for the second stage which uses GrabCut to yield an efficient segmented result. The obtained result can be further refined by user interaction, which can be done using the proposed Graphical User Interface (GUI). Experimental results show that the proposed method is accurate and provides satisfactory segmentation results with minimum user interaction on medical as well as natural images.

Measurement of Ulnar Variance in a Regional Subset of Indian Population-A Pilot Study of 30 Subjects.

BACKGROUND The variation of level of distal articulating surface of ulna with respect to distal articulating surface of radius is known as ulnar variance (UV). Positive and negative UV has been implicated in various wrist and hand pathologies. AIM To measure ulnar variance in a regional subset of Indian population and to compare two techniques of measurement of ulnar variance viz. method of perpendiculars and modification of the concentric circles method. MATERIALS AND METHODS UV was measured in a regional subset of Indian population comprising of 30 subjects. The mean age of patients was 35.9 years. There were 16 males and 14 females in the study group. Antero-posterior (AP) X-rays of wrist in neutral position were taken and UV was measured using method of perpendiculars and the modified circle method. RESULTS The mean UV using method of perpendiculars (UVA) was 0.387 mm and using modified circle method (UVB) was 0.507mm. A higher predominance of positive UV in this regional subset of Indian population was observed. There was no correlation between UV with respect to age and sex. No statistically significant difference was observed between the two methods of measurement utilized in the study. CONCLUSION The documentation of a negative and positive ulnar variance will help in prophylactic and timely intervention for various wrist pathologies, if required. However, a larger sample size with a longer follow up is required to suggest a correlation of ulnar variance with clinically symptomatic disease.

A case of acute septic arthritis hip caused by Brucella melitensis in an adolescent child

Brucella is among the most common zoonotic diseases affecting humans. Although musculoskeletal involvement is seen in a large proportion of patients, the disease is often diagnosed late or misdiagnosed due to its subtle nature and rarity, and lack of awareness among clinicians. In this report, a 12-year-old girl was diagnosed with acute septic arthritis of the hip based on clinico-radiological features, and managed with standard treatment, including arthrotomy. However, the child did not respond to the treatment. Based on the histopathology and local endemicity, Brucella was suspected, and confirmed after serological testing. The child subsequently responded to treatment and, at latest follow-up at 1 year, had a full painless range of motion, with no relapse.

A recurred subungual glomus tumour of the thumb.

Glomus tumours are rare benign neoplasms arising from the glomus body, accounting for 1–5% of all soft-tissue tumours of the hand. The diagnosis of glomus tumour is frequently delayed, varying from 3 to 15 years. We present a case of a recurred glomus tumour of the thumb where symptoms persisted for a period of 6 years after an attempted surgical excision. The patient presented with classical symptoms of localised tenderness, cold sensitivity and excruciating pain on touch. Findings on radiograph, ultrasonography and contrast-enhanced MRI further supported the diagnosis. Complete surgical excision, the only recommended treatment, resulted in complete symptomatic relief to the patient. This case report highlights the importance of meticulous complete excision and clinical awareness of the disease among primary care physicians.

Comment on Madelaine et al.: Results and complications of single-stage total knee arthroplasty and high tibial osteotomy

1. The authors mention measurement of the femoral mechanical axis (mFA), tibial mechanical axis (mTA) and femorotibial mechanical axis (mFTA) on weight-bearing long-leg films to determine the magnitude and location of the extra-articular deformity. However, it is not clear from the study as to how the authors have arrived at these angles and how they have concluded that the deformity measured is an extra-articular deformity. 2. The authors recommend grafting the osteotomy defect with autograft bone from the bony cuts. It is, however, not clear from the article whether the same technique had been used in their study. 3. We would be curious to know whether the autograft introduced into the valgising osteotomy had been placed before or after the introduction of the tibial stem. It is our understanding that both of the above clinical scenarios would lead to damage to the autograft, as is evident from all the postoperative X-rays published in the article which show a valgus tibial stem abutting on to the lateral tibial cortex, which indicates either inadequate correction or loss of correction of the deformity. 4. It is our opinion that single-stage correction for a severe extra-articular deformity entails a significantly higher r isk of nonunion , infec t ion and periprosthetic fracture with increased duration of immobilisation, as has also been reported by the authors in this study. It is only prudent to consider a two-stage surgery, thereby minimising the risk of complications and justifying the need for total knee replacement (TKR) which is to provide early, painless mobilisation in a well-balanced stable knee. 5. It is our submission that conversion to a TKR after high tibial osteotomy (HTO) is a difficult surgery with its antecedent problems, viz. offset stem and alteration of posterior slope: does performing two difficult operations in a single stage compromise the long-term survivorship of a TKR? 6. The authors have concluded that the combination of TKR and HTO is a valid option for treating arthrosis with large extra-articular frontal plane deformity. However, recent studies [2, 3] have concluded that good pre-operative planning, intra-articular bone resection and soft tissue balancing (both in flexion and extension) would be able to correct the majority of the extra-articular deformities.

Internal fixation of pelvic injuries

The essence of management of pelvic fractures, a high energy injury, is multidisciplinary approach, wherein, the primary goal of treatment is hemodynamic stability. Restoration of a stable pelvic ring which allows optimum weight transmission to the limbs is the ultimate aim of any surgical procedure. Contradicting schools of thought exist between whether to fix the anterior pelvic ring first vis-a-vis the posterior ring. To some extent, the decision is guided by the operating surgeon′s preference for percutaneous fixation as opposed to conventional open surgery. Anatomic reduction of the fracture remains an important goal, whether performed open or closed, as residual displacement is associated with poorer outcomes. A comprehensive literature search was conducted using the Ovid interface; 1232 English language citations relating to management of pelvic fractures were screened, out of which 34 articles were perused for surgical treatment of pelvic fractures and 21 of the above, specifically dealing with the principles and techniques and biomechanics of internal fixation of the disrupted pelvic ring, formed the basis of the present narrative.

Comment on Lan et al.: S-osteotomy with lengthening and then nailing compared with traditional Ilizarov method

1. The authors have used very small incisions (0.8–1 cm) to perform longitudinal osteotomy of sizes 8–15 cm for lengthening of 6–13 cm; however, it is difficult to understand such long osteotomies with a mini-incision [2]. We would appreciate if the authors could explain the details of the procedure as well as provide some clinical photographs to show the mini-incision approach. 2. The authors have mentioned that they have introduced an intramedullary nail without removing the external fixator to avoid destabilizing the fixation. We would be keen to know how a size 9 intramedullary nail could be introduced into the medullary canal of a constitutionally short stature patient after over-reaming by 2 mm with the external fixator frame in-situ. 3. We agree with the authors that the procedure has the advantages of decreased consolidation time, pin tract problems and axial deviation. However, this procedure would require three surgical interventions viz. osteotomy and ring fixation, insertion of nail and removal of ring fixator and finally removal of nail, instead of two in the conventional method. Also, the intramedullary nailing poses a great risk for deep infection and complications related to nail and screw breakage [3], even though the authors did not encounter any in their case series. 4. The authors did not find any limb-length discrepancy in the present series. As all the lengthenings were bilateral, we would be interested to know how the authors managed to achieve perfect limb-length equalization in such a large cohort of patients. Also, as the authors have used joint spanning fixators, we would like to know whether any special post-operative protocol was followed to prevent residual ankle stiffness.

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg.

1. Authors have grouped the patients into two groups according to whether fibula was fixed or not. However, there would be variations in the discussed group with respect to the age, degree of soft tissue injury, fracture geometry and fixation method of the tibial fracture which would influence the fracture management, healing and the outcome with respect to the time to union and complications [1–3]. In such a situation, it is difficult to relate fracture healing of the tibial fracture with the level of the ipsilateral fibular fracture and its fixation alone. We would like to know from authors if any criterion was used to decide the method of fixation. 2. The authors have mentioned in their description of the methodology, that in patients treated with interlocking nail for fracture of the tibia, if no sign of union was apparent at 12 weeks, dynamisation was performed. In the same section, the authors have also mentioned that ORIF of the fibula was always performed first. This seems to be a biomechanical contradiction as pre-fixation of the fibula would not allow the tibial fracture to collapse and thereby does not justify the dynamisation procedure in the first place; also a pre-fixed fibula would also put the tibial fracture at risk of non-union. 3. The authors have reported five cases of non-union in the result section of the study. Among these, four non-union were in cases with open fractures. In the given scenario, open fracture seems to be the major factor contributing to non-union. Also, the authors have not mentioned the degree of soft tissue injury which also affects rate of union in a fracture [3,4]. 4. The authors have concluded that in cases with fibular fracture at different level than tibia fracture and tibia fracture stabilized with nail, there is higher tendency to unite when fibular fixation