Aditya N. Aggarwal

Extrapleural anterolateral decompression in tuberculosis of the dorsal spine

We reviewed 64 anterolateral decompressions performed on 63 patients with tuberculosis of the dorsal spine (D1 to L1). The mean age of the patients was 35 years (9 to 73) with no gender preponderance. All patients had severe paraplegia (two cases grade III, 61 cases grade IV). The mean number of vertebral bodies affected was 2.6; the mean pre-treatment kyphosis was 24.8 degrees (7 to 84). An average of 2.9 ribs were removed in the course of 64 procedures. The mean time taken at surgery was 2.45 hours when two ribs were removed and 3.15 hours when three ribs were removed. Twelve patients (19%) showed signs of neurological recovery within seven days, 33 patients (52%) within one month and 12 patients (19%) after two months; but six patients (10%) showed no neurological recovery. Forty patients were followed up for more than two years. In 34 (85%) of these patients there was no significant change in the kyphotic deformity; two patients (5%) showed an increase of more than 20 degrees.

Correlation of canal encroachment with neurological deficit in tuberculosis of the spine

Abstract CT scans of fifteen patients with tuberculosis of the spine without neurological deficit were analysed for canal encroachment. We calculated that up to 76% encroachment of the spinal canal by tubercular pathological tissue is compatible with undisturbed neural status.Résumé Quinze malades atteints de tuberculose de 1a colonne vertébrale sans insuffisance neurologique (quadriplégie ou paraplégie) on été examinés par scanner pour 1e pourcentage de l’empiètement du canal. D’après cette étude, soixante seize pourcent de l’empiètement du canal vertébral par le tissu pathologique tuberculeux est compatible avec l’état neurologique non derangé ou intact.

Multifocal skeletal tuberculosis in children: a retrospective study of 18 cases.

Multifocal skeletal tuberculosis is an uncommonly reported entity. Unanimity on terminology is lacking in the literature. The article presents a series of 18 such patients encountered in our institution. All the patients were below 15 y of age. Male to female ratio was 13:5. Most of the cases presented with swellings, discharging sinuses and/or ulcers. Appendicular involvement was seen in 17 of these cases. All the cases were diagnosed histopathologically as tuberculosis. All the cases were treated with multi-drug anti-tubercular therapy with additional procedures such as incision and drainage or sinus tract curettage performed in 9 of the patients. All the lesions healed. Their clinical behaviour, result and outcome are analysed with available international literature.

Normal range of motion of hip and ankle in Indian population

OBJECTIVE Most studies that determine the range of motion of joints of the lower limbs study the Western population. The Asian population differs significantly, as daily activities demand different sitting positions. Our study aimed to establish the normal values of hip and ankle range of motion in various age groups in the Indian population and the effect of various functional positions of the hip on range of motion. METHODS Three hundred and twenty-six Indian subjects, between the ages of 1 month to 75 years, were randomly selected for measurement of the range of motion of the hip and ankle joint. Exclusion criteria included history of injury or disease related to the lower extremities. Changes with age in the arc of joint motion were studied. The influence of various functional positions of the lower limb on the range of motion of the hip and the effect of weight-bearing on the ankle joint range of motion were also analyzed. RESULTS Hip range of motion differed in various positions. Hip rotations were significantly greater when measured with the knee in flexion in both the sitting and prone positions than in the supine position. The arc of hip rotation was highest in the prone position. A significant increase in the arc of ankle dorsiflexion was found in a weight-bearing (squatting) position. Age related reduction in movement was found mainly in the rotations of the hip and dorsiflexion of the ankle. CONCLUSION The data compiled in this study on the range of motion in the hip and ankle joint of the Indian population will be useful in the evaluation of patients with disorders of these joints, especially in the Indian and Asian population.

Treatment of intraspinal tuberculoma.

Neurological manifestations in spinal tuberculosis often occur secondary to vertebral involvement. However, tuberculoma of the spinal cord or extradural granuloma without radiological evidence of vertebral involvement may be responsible for neurological complications. We report 22 patients with intraspinal tuberculoma (19 extradural, three intramedullary) ranging in age from 17 to 70 years. Three patients had a history of paraplegia of acute onset (within 12 hours of the appearance of neural deficit). Only four patients had spinal tenderness, and bone involvement could be seen on plain radiographs in only three patients. Extradural tubercular granuloma without vertebral involvement is uncommon. Of the 15 extradural tuberculoma patients who had a CT scan and/or MRI, only five had no osseous involvement. Laminectomy and surgical decompression was performed in all 19 patients with extradural granuloma. Thirteen patients showed complete neural recovery within 2 years. Of the three patients with intramedullary involvement, one underwent myelotomy and decompression and died within 2 months of surgery. The other two patients were treated nonoperatively with antitubercular therapy and showed complete neural recovery. All patients received antitubercular therapy for a minimum of 1 year. Intraspinal tubercular granuloma should be considered in the differential diagnosis when a case of spinal tumor syndrome is encountered in an endemic zone of tuberculosis.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Rubber band syndrome--high accuracy of clinical diagnosis.

Background Rubber band syndrome is a rare condition seen in younger children in communities where rubber bands are worn around the wrist for decorative purposes. When the band is worn for a long duration, it burrows through the skin and soft tissues resulting in distal edema, loss of function, and even damage to the neurovascular structures. Recognition of this syndrome at the earliest can prevent catastrophic events. Methods We report 3 cases of rubber band syndrome. Three children presented with a discharging sinus at the wrist. There was a linear circumferential scar at the wrist in all cases. Plain radiographs showed a circumferential constriction in the soft tissue shadow in all the cases. There was a history of a band tied around the wrist, which had been forgotten by the parents and eventually became embedded in the soft tissues of the wrist. Results Surgical removal of the buried rubber band was successful in all the cases. Postoperative follow-up over a mean period of 13 months have shown a surprisingly good outcome of hand function in all our patients. Conclusions The cardinal features of a linear constricting scar around the wrist in the presence of a discharging sinus should always alert the clinician to the possibility of a forgotten band around the wrist, which might have burrowed into the soft tissues over a period of time. A radiograph of the affected wrist shows a soft tissue constriction at the wrist. A high index of clinical suspicion and the uniformity of symptoms and clinico-radiologic signs enabled us to make a clinical diagnosis of a constriction band (rubber band syndrome), which was proved after a surgical exploration. Study Design Case series. Level of Evidence-—Level IV.

Multifocal skeletal tuberculosis.

Multifocal skeletal tuberculosis is an uncommonly reported entity. The article presents a series of 18 cases encountered in our institution. There clinical characteristics are analysed and compared with available international literature.

Bone and Joint Infections in Children: Septic Arthritis

The pathological invasion of a joint and subsequent inflammation is known as septic arthritis. The knee and hip are the most frequently involved joints. Staphylococcus aureus is the most common cause of septic arthritis in children. An acute onset of illness with an inflamed painful joint and restricted movements and inability to use joint (pseudoparalysis) clinically indicates septic arthritis. The diagnosis is difficult in a neonate or young child where refusal to feed, crying, discomfort during change of diaper (if hip is involved) or attempted joint movement may be the only findings. Fever and other systemic signs may also be absent in neonates. Septic arthritis is diagnosed clinically, supported by appropriate radiological and laboratory investigations. The peripheral blood white cell count is frequently raised with a predominance of polymorphonuclear cells. The acute phase reactants such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are often markedly raised. Ultrasonography and MRI are preferred investigations in pediatric septic arthritis. Determination of infecting organism in septic arthritis is the key to the correct antibiotic choice, treatment duration and overall management. Joint aspirate and/or blood culture should be obtained before starting antibiotic treatment. Several effective antibiotic regimes are available for managing septic arthritis in children. Presence of large collections, thick pus, joint loculations and pus evacuating into surrounding soft tissues are main indications for surgical drainage. Joint aspiration can be a practical alternative in case the lesion is diagnosed early, with uncomplicated presentations and superficial joints.

Unstable recent intracapsular femoral neck fractures in young adults: osteosynthesis and primary valgus osteotomy using broad dynamic compression plate.

Background: Displaced intracapsular femoral neck fractures continue to be a difficult problem to treat. Various treatment modalities and their modifications have been proposed to improve the outcome. Osteosynthesis and primary valgus angulation osteotomy is one of them. Technique and outcome in a consecutive series of recent intracapsular femoral neck fractures in young adults, from a single center, is presented. Materials and Methods: Fifty-five patients of recent (<3 weeks old) displaced intracapsular fracture neck femur (Garden III and IV, Pauwels III, with or without comminution) in the age group 20-50 years (mean 35.4±10.4 years) were subjected to osteosynthesis and primary valgus intertrochanteric osteotomy using contoured broad dynamic compression plate (DCP). The patients were followed up from two to six years (mean 4.6 years). Results: Fifty-one fractures united by six months of the index procedure (92.7% union range). Avascular necrosis (AVN) developed in six patients (11%). The other complications were shortening (six), coxa vara (two), infection (two) and delayed union at osteotomy site (one). Excellent results were achieved in 48, good/fair in four and poor in three patients. Conclusion: Osteosynthesis with cancellous screw and primary valgus intertrochanteric osteotomy stabilized by a contoured broad DCP is a simple, easy to perform, biological treatment. Failure in a particular case can be treated with any appropriate second procedure. Level of Evidence: IV

Augmentation of bone healing in delayed and atrophic nonunion of fractures of long bones by partially decalcified bone allograft (decal bone)

Background: Autograft from iliac crest is considered as gold standard for augmentation of bone healing in delayed and nonunion of fractures. Bone demineralized with 0.6N hydrochloric acid has shown to retain its osteoinductive capacity. We report the outcome of partially decalcified bone allograft (decal bone) in the treatment of delayed union and atrophic nonunions of bones. Materials and Methods: Twenty patients with clinicoradiological diagnosis of delayed union or atrophic nonunion of long bone fractures were included in this retrospective study. Patients at extreme of ages (<18 years and >60 years), pathological fractures, metabolic bone diseases, infected nonunion, hypertrophic nonunion and those having systemic illness like diabetes mellitus and on drugs that impair fracture healing were excluded from the study. Decal bone was prepared in the bone bank and maintained in department of orthopedics. Allografting was done in 20 patients of delayed union (9/20) and atrophic nonunion (11/20) of long bone fractures with mean age of 34 years (range 18–55 years). The bones involved were humerus (8/20), tibia (7/20) and femur (5/20). Fourteen patients underwent treatment in the form of internal fixation and allografting and six patients were operated with osteoperiosteal allografting. Results: Nineteen patients achieved union in mean time of 14.9 weeks range (range 8–20 weeks). Eight patients had serous discharge from the operative site that subsided in 11 days (range 4–21 days). One patient had pus discharge that required repeat debridement and antibiotics for 6 weeks. The fracture healed in 16 weeks. Conclusion: The partially decalcified bone allograft is an effective modality for augmentation of bone healing without complication associated with autograft like donor site morbidity, increased blood loss and increase in the surgical time.