Aditya Krishna Mootha

En bloc excision and autogenous fibular reconstruction for aggressive giant cell tumor of distal radius: a report of 12 cases and review of literature

IntroductionGiant cell tumor (GCT) of distal radius follows a comparatively aggressive behaviour. Wide excision is the management of choice, but this creates a defect at the distal end of radius. The preffered modalities for reconstruction of such a defect include vascularized/non-vascularized bone graft, osteoarticular allografts and custom-made prosthesis. We here present our experience with wide resection and non-vascularised autogenous fibula grafting for GCT of distal radius.Materials and methodsTwelve patients with a mean age of 34.7 years (21-43 years) with Campanacci Grade II/III GCT of distal radius were managed with wide excision of tumor and reconstruction with ipsilateral nonvascularised fibula, fixed with small fragment plate to the remnant of the radius. Primary autogenous iliac crest grafting was done at the fibuloradial junction in all the patients.ResultsMean follow up period was 5.8 years (8.2-3.7 years). Average time for union at fibuloradial junction was 33 weeks (14-69 weeks). Mean grip strength of involved side was 71% (42-86%). The average range of movements were 52° forearm supination, 37° forearm pronation, 42° of wrist palmerflexion and 31° of wrist dorsiflexion with combined movements of 162°. Overall revised musculoskeletal tumor society (MSTS) score averaged 91.38% (76.67-93.33%) with five excellent, four good and three satisfactory results. There were no cases with graft related complications or deep infections, 3 cases with wrist subluxation, 2 cases with non union (which subsequently united with bone grafting) and 1 case of tumor recurrence.ConclusionAlthough complication rate is high, autogenous non-vascularised fibular autograft reconstruction of distal radius can be considered as a reasonable option after en bloc excision of Grade II/III GCT.

Displaced proximal humeral fractures: an Indian experience with locking plates

BackgroundThe treatment of displaced proximal humerus fractures, especially in elderly, remains controversial. The objective of this study was to evaluate functional outcome of locking plate used for fixation of these fractures after open reduction. We also attempted to evaluate the complications and predictors of loss of fixation for such an implant.MethodsOver two and a half years, 56 patients with an acute proximal humerus fracture were managed with locking plate osteosynthesis. 47 of these patients who completed a minimum follow up of 1 year were evaluated using Constant score calculation. Statistical analysis was done using SPSS 16 and a p value of less than 0.05 was taken as statistically significant.ResultsThe average follow up period was around 21.5 months. Outcomes were excellent in 17%, good in 38.5%, moderate in 34% while poor in 10.5%. The Constant score was poorer for AO-OTA type 3 fractures as compared to other types. The scores were also inferior for older patients (> 65 years old). Complications included screw perforation of head, AVN, subacromial impingement, loss of fixation, axillary nerve palsy and infection. A varus malalignment was found to be a strong predictor of loss of fixation.ConclusionLocking plate osteosynthesis leads to satisfactory functional outcomes in all the patients. Results are better than non locking plates in osteoporotic fractures of the elderly. However the surgery has steep learning curve and various complications could be associated with its use. Nevertheless we believe that a strict adherence to the principles of locking plate use can ensure good result in such challenging fractures.

Application of the Ponseti principle for deformity correction in neglected and relapsed clubfoot using the Ilizarov fixator

We treated 15 cases of neglected and relapsed clubfeet by the Ilizarov distraction method using the Ponseti principle in 12 children (mean age 7.3 years). The deformities were corrected around the talar head in the sequence of the cavus, adduction, varus and finally equinus (as per the Ponseti principle). Clinical and functional outcome after 2.5 years was significant (P<0.05) with a mean reduction of 11.7 in Dimeglios score and an average Laaveg and Ponseti functional score of 75.47. The average time taken for correction was 4.2 weeks. Differential distraction according to the Ponseti principle leads to early correction with minimal number of residual deformities and complications.

Modified step-cut osteotomy for post-traumatic cubitus varus: Our experience with 14 children

BACKGROUND Lateral closing wedge osteotomy is a commonly described procedure for correcting cosmetically unacceptable post-traumatic cubitus varus deformity in children. However, complications like residual deformity, lateral prominence, loss of fixation and ulnar nerve palsies commonly contribute to poor outcomes with such an osteotomy. PATIENTS AND METHODS Fourteen children (11 boys and three girls) presenting a mal-united extension type supracondylar fracture of the humerus with an average age of 9.07 years (6-14 years) were operated around 3.6 years (1.5-7 years) after the injury using a modified step-cut osteotomy. The average follow-up period was 2.1 years (1-4 years). Objective assessment included measurement of preoperative and postoperative lateral prominence index, carrying angle and range of elbow motion. Results were graded excellent, good or poor as per the Oppenheim criteria. RESULTS There were eight excellent, five good and one poor result. A residual varus of more than 10° was seen in the single patient with poor result. None of the patients showed a prominent lateral humeral condyle or formation of hypertrophic scar. Our results were comparable to the published results of the classical lateral closing wedge osteotomy in terms of elbow motion and correction of deformity. CONCLUSION A modified step-cut osteotomy is a safe and simple procedure which prevents lateral prominence and leads to good or excellent outcomes in most of the patients. The step-cut osteotomy procedure, mentioned here, might be beneficial over the conventional lateral closing wedge osteotomy in certain aspects like the lateral humeral condyle prominence, scar acceptibility and cosmesis. However, the apparent aforementioned advantages of this osteotomy over the conventional lateral closing wedge osteotomy needs to be further evaluated and confirmed on the basis of large, prospective randomised controlled trials.

Tuberculosis of symphysis pubis in a 17 year old male: a rare case presentation and review of literature.

Tuberculosis of symphysis pubis is a rare condition with hardly any report of such cases in the last decade. It is necessary to distinguish the entity from more common ones like Osteitis pubis and Osteomyelitis of pubis symphysis by urgent means in order to start the treatment early and thereby minimize morbidity and prevent complications. A rare case of tuberculosis of symphysis pubis in a 17 year old male is described. A high index of suspicion along with an extensive workup including 3-phase bone scan and fine needle aspiration led to the diagnosis. The patient had an excellent outcome following a complete course of multidrug chemotherapy for tuberculosis.

Neglected irreducible posterolateral knee dislocation

Knee dislocations are rare injuries. Posterolateral knee dislocations are only a small subset of them. There is a paucity of literature regarding the management of such neglected cases. We report here, a case of neglected irreducible posterolateral knee dislocation treated with open reduction and isolated posterior cruciate ligament reconstruction followed by gradual rehabilitation with good outcome at 3 years followup.

Modified resection technique for proximal fibular osteochondromas

Osteochondroma is one of the most common tumors arising from the proximal fibula. Surgical treatment of proximal fibula osteochondromas may vary from debulking to resection of proximal fibula. We describe a modified surgical technique for excision of proximal fibular osteochondromas which preserves the proximal tibio-fibular joint (PTFJ). We present a series of six cases of symptomatic proximal fibular osteochondroma. Four cases were solitary osteochondromas while two were a manifestation of a hereditary multiple exostoses. Indication for surgery was peroneal nerve symptoms in three, cosmesis in one, restricted knee motion in one, and pain in one case. All these cases were operated by a modified resection technique where the head of fibula was preserved. The PTFJ was preserved. Lateral stabilizing structures of the knee were left undisturbed, and hence did not need repair. Complications occurred in two patients, one had marginal wound necrosis and one had persistent weakness of extensor haullicis longus. At a minimum follow-up of 2 years, none had recurrence or late disruption of PTFJ.

Salvage of infected total knee arthroplasty with Ilizarov external fixator.

Background: Knee arthrodesis may be the only option of treatment in cases of chronic infected total knee arthroplasty (TKA) with concomitant irreparable extensor mechanism disruption, extensive bone loss or severe systemic morbidities. Circular external fixation offers possible progressive adjustment to stimulate the bony fusion and to make corrections in alignment. We evaluated the results of knee arthrodesis with one or two stage circular external fixator for infected TKA. Materials and Methods: 16 cases of femoro-tibial fusion were retrospectively evaluated. Male-to-female ratio was 10:6. Mean age of the patients was 62.2 years. Cierney-Mader classification was used for anatomical and physiological evaluation while the bone stock deficiency was classified into mild, moderate and severe. Surgical technique involved either single or two stage arthrodesis using circular external fixator. Results: Union was achieved in 15 patients (93.75%). The mean duration for union (frame application time) in these patients was 28.33 weeks (range 22 to 36 weeks). Analysis showed that in the group with frame application time of less than 28 weeks, the incidence of mild to moderate bone deficiency was 83.33%, while in the frame application time more than 28 weeks group the incidence was 20% (P-value 0.034). Similarly the incidence of Cierney-Mader 4B (Bl, Bs, Bls) was found to be 33.33% in the group of frame application time of less than 28 weeks, while it was 90% in the group with frame application time more than 28 weeks (P-value 0.035). Conclusion: Circular external fixator is a safe and reliable method to achieve knee arthrodesis in cases of deep infection following TKA. Severe bone stock deficiency and Cierney- Mader type B host are likely risk factors for prolonged frame application time. We recommend a two-stage procedure especially when there is compromised host or severe bone loss.

Low-grade fibromyxoid sarcoma of the talus: a case report.

Low-grade fibromyxoid sarcoma is a rare tumor, which most commonly arises from the deep soft tissues of the lower extremities in young men. Diagnosis of this tumor can be difficult because of its deceptively benign histopathologic appearance. Specifically, the lesion is characterized by alternating fibrous and myxoid areas with variable cellularity and a whorled growth pattern. Like many soft tissue tumors, low-grade fibromyxoid sarcoma is also characterized by strong immunoreactivity to the human proto-oncogene BCL-2. Cytogenetically, the lesion has also been associated with the t (7,16) (q33;p11) translocation, with the characteristic resultant FUS and CREB3L2 fusion gene. In this report, we describe the rare case of a low-grade fibromyxoid sarcoma that appeared to develop as a primary malignancy in the neck of the talus of a young man who presented with recurrent ankle pain after a previous surgery for a cystic lesion at the same site.

Concomitant laparoscopy: An effective technique for successful retrieval of intra pelvic migrated broken guide pin

Many devices are used for fixation of fractures around hip need guide pins for accurate positioning of the final implants. Breakage of these guide pins during surgery is one of the most dreaded complications of such surgeries. The true incidence of this complication is not known and remains under-reported. The most common causes of breakage of guide pins are re-use of the guide pins, blockade of the cannulated drills, and mismatch between the guide pins and cannulated drills. Most commonly, the guide pin breaks either during drilling over the guide pin or during manoeuvring the hip. Such broken guide pins can migrate into pelvis and can cause a variety of complications. At the same time retrieval of such broken guide pins can be a challenge to the treating surgeon, especially if they are found transfixing the hip joint. Techniques described for retrieval of migrated and broken guide pins vary from exploration of the fracture site, creating a window in the femoral neck, hip arthroscopy, extra peritoneal exploration by ilio-inguinal approach to laparotomy. In this report, we document a novel technique for retrieving a broken guide pin that was transfixing the hip joint and protruding in to the pelvis. We retrieved the guide pin from the abdomen via laparoscopy after laparoscopic-guided pushing from the neck of femur. Whilst laparoscopic retrieval of freely migrating k-wires from the pelvis has been documented in the past, this is the first ever documentation of a novel technique used to retrieve intra pelvic migrated broken guide pin.