Ajay Pal Singh

Total hip replacement in active advanced tuberculous arthritis

We describe the results of cemented total hip replacement in 23 patients (23 hips) with active tuberculous arthritis of the hip with a mean follow-up of 4.7 years (4 to 7). In two patients the diagnosis was proved by pre-operative biopsy, whereas all others were diagnosed on a clinicoradiological basis with confirmation obtained by histopathological examination and polymerase chain reaction of tissue samples taken at the time of surgery. All patients received chemotherapy for at least three months before surgery and treatment was continued for a total of 18 months. Post-operative dislocation occurred in one patient and was managed successfully by closed reduction. No reactivation of the infection or loosening of the implant was recorded and function of the hip improved in all patients. Total hip replacement in the presence of active tuberculous arthritis of the hip is a safe procedure when pre-operative chemotherapy is commenced and continued for an extended period after operation.

Autogenous non-vascularized fibula for treatment of giant cell tumor of distal end radius

AbstractIntroductionGiant cell tumor of distal end of radius is treated by wide resection and intralesional procedures with former having better results. The various modalities for the defect created are vascularized/non-vascularized bone graft, osteoarticular allografts and custom-made prosthesis. We report outcome of wide resection and non-vascularized fibular grafting in biopsy-proven giant cell tumors.Patients and methodsNine patients with mean age of 40 years with Campanacci grade II giant cell tumor of distal radius were managed with radical excision of the tumor and reconstruction with ipsilateral free fibular graft.ResultsMean follow-up time was 56 months. One patient developed recurrence and was treated by amputation. All other patients showed a good union at fibular graft–radius junction. In wrist, average range of motion achieved at last follow-up was 40° of dorsiflexion, 30° of palmar flexion, 45° each of supination and pronation. Major complications encountered included graft fracture (2), wrist subluxation (2), tourniquet palsy (1), aseptic graft resorption (1) and tumor recurrence (1).ConclusionReconstruction after wide excision by non-vascularized fibular graft is a viable alternative for giant cell tumors of the lower end of radius though it is a challenging procedure and may be accompanied by major complications.

Neglected traumatic dislocation of the subaxial cervical spine

The optimal method for the management of neglected traumatic bifacetal dislocation of the subaxial cervical spine has not been established. We treated four patients in whom the mean delay between injury and presentation was four months (1 to 5). There were two dislocations at the C5-6 level and one each at C4-5 and C3-4. The mean age of the patients was 48.2 years (27 to 60). Each patient presented with neck pain and restricted movement of the cervical spine. Three of the four had a myelopathy. We carried out a two-stage procedure under the same anaesthetic. First, a posterior soft-tissue release and partial facetectomy were undertaken. This allowed partial reduction of the dislocation which was then supplemented by interspinous wiring and corticocancellous graft. Next, through an anterior approach, discectomy, tricortical bone grafting and anterior cervical plating were carried out. All the patients achieved a nearly anatomical reduction and sagittal alignment. The mean follow-up was 2.6 years (1 to 4). The myelopathy settled completely in the three patients who had a pre-operative neurological deficit. There was no graft dislodgement or graft-related problems. Bony fusion occurred in all patients and a satisfactory reduction was maintained. The posteroanterior procedure for neglected traumatic bifacetal dislocation of the subaxial cervical spine is a good method of achieving sagittal alignment with less risk of iatrogenic neurological injury, a reduced operating time, decreased blood loss, and a shorter hospital stay compared with other procedures.

Isolated tuberculous biceps tenosynovitis bicipitoradial bursitis: A case report

Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, IndiaTubercular soft tissue infection can involve the tenosy-novium, bursa, muscle, or deep fascia. An uncommon form,it is usually associated with an immunocompromised state.Most cases of tuberculous synovitis have an associatedlesion elsewhere in the body, and very few patients withisolated tuberculous synovitis have been reported.

Primary nonunion of intertrochanteric fractures of femur: An analysis of results of valgization and bone grafting

Background: Nonunion of intertrochanteric fractures is uncommon because there is excellent blood supply and good cancellous bone in the intertrochanteric region of the femur. A diagnosis of primary intertrochanteric nonunion is made when at least 15 weeks after the fracture there is radiological evidence of a fracture line, with either no callus (atrophic) or with callus that does not bridge the fracture site (hypertrophic). There is only one published series that exclusively describes seven primary nonunions of intertrochanteric fractures. The aim of the present study was to analyze the results of internal fixation, valgization with 135° dynamic hip screw (DHS), and bone grafting in patients with primary nonunion of intertrochanteric fractures. Materials and Methods: Eighteen patients with primary intertrochanteric nonunion were included in the study; 16 were male and 2 were female. The age range was 30–70 years (mean: 46.9 years). The mean duration since index injury was 8.5 months (range: 4–18 months). As per the AO classification, the fractures were 31A 1.1 (n=1), 1.2 (n=1), 2.2 (n=3), 2.3 (n=9), and 3.3 (n=4). Three patients had hypermobile nonunion and 15 had stiff nonunion. The surgical principle was excision of pseudarthrosis, if present (n=3); freshening of the bone ends; stable fixation with 135° DHS, with good proximal purchase; bone grafting; and valgization. Results: Union was achieved in all patients at an average of 5.62 months (range: 4–7 months). The Harris hip score improved from 38 points preoperatively to 86 postoperatively at healing. The average limb shortening improved by 2 cm (range: 1.5 cm–3 cm). There was no infection and pain at the hip at final follow-up in any of the cases. All patients were subjectively satisfied with the outcome. All were capable of full weight bearing on their affected limb. Conclusion: Union in primary nonunion of intertrochanteric fractures in physiologically young patients with a well-preserved femoral head and good bone stock can be achieved with internal fixation, valgization, and grafting procedures.

Arthrodesis in a neuropathic elbow after posttubercular spine syrinx

A 46-year-old man, who was left-hand dominant with knownparaplegia due to tuberculosis spondylitis, presented withcomplaints of progressively increasing weakness and instability ofthe left upper limb for the past 2 years. The patient had difficultyusing his left upper limb for activities of daily living such aseating, combing his hair, and maneuvering his wheelchair. Onexamination, the left elbow was swollen, but not warm, and wasnot tender. Range of motion was 25 to 100 , with palpable andaudible crepitation. There was grade 3 weakness of the inteross-eous muscles and digital flexors of the ipsilateral hand. A sensoryexamination revealed sensory loss in the ulnar nerve distribution.Examination showed the median, radial, and musculocutaneousnerves were normal.Radiographs of the left elbow showed severe destruction of thedistal humerus and proximal radioulnar joint with dislocation, andsevere erosion into the intercondylar area left both condyles in aninverted U-shape. The proximal radioulnar joint was dislocatedposterolaterally but no dissociation was noted in the proximalradioulnar bones. Diffuse soft-tissue swelling, especially in theposterior elbow and heterotopic ossification, was noted in theadjacent soft tissue (Figure 1).The patient gave a history of tuberculosis of the thoracic spineinvolving the second, third, and fourth thoracic vertebrae, whichwas treated with anterolateral decompression and antituberculardrugs 4 years previously. He remained paraplegic and wheelchair-bound, but bladder and bowel functions were spared. Previousmagnetic resonance imaging of his cervicothoracic spine revealeda cervicodorsal syrinx extending from C6 to T4, which wasdiagnosed 3 years previously (Figure 2). The patient had refusedany surgical intervention for syrinx at that time.Results of blood investigations of patient were within normallimits. Computed tomography (CT)-guided aspiration of fluidfrom the elbow joint was investigated for gram stain and acid-fastbacilli stain as well as culture and polymerase chain reaction testfor tuberculosis. All the results were negative. We discussed thetreatment options, both conservative and surgical, including thehigh risks of failure in the latter with patient. Our patient insistedon having a stable elbow.Through a posterior approach, we performed ulnar nervedecompression and anterior transposition with arthrodesis of theelbow joint. Intraoperatively, the ulnar nerve was markedly dis-placed to the radial side (Figure 3). The radial head was excised.The articular margins of the humerus and ulna were freshened,and a prebent 12-hole locking plate (AO, Synthes Inc, WestChester, PA) was applied with the elbow in a functional position at70 flexion. An anterior submuscular transposition of the ulnarnerve was performed. Results of gram stains, acid-fast bacillistain, and culture of removed tissue were negative.Postoperatively, the limb was supported in an above elbowsplint for 4 weeks. The patient was followed up at monthly

Upper extremity deep vein thrombosis following soft tissue trauma

A 27-year-old man sustained soft tissue injury to the left shoulder following a fall. Three days later, a diagnosis of left proximal subclavian vein thrombosis was made. The patient was given intravenous urokinase for 24 hours, followed by intravenous unfractionated heparin and oral warfarin. Oral anticoagulant treatment was continued for 12 months. His symptoms completely disappeared after three months of treatment. It is important to be aware of this unusual but potentially serious complication, as early diagnosis and treatment may limit morbidity and mortality.

Unusual knee swelling: a diagnostic dilemma

Haemangioma is a common benign soft tissue tumour. Intramuscular haemangiomas are rare but pose quite a diagnostic challenge. An intramuscular haemangioma can be confused with other soft tissue swellings including abscess. We present a case report of swelling around the knee in an adolescent patient, which was ultimately diagnosed and treated as intramuscular haemangioma of the quadriceps muscle.

Extraskeletal juxtaarticular chondroma of the knee.

Extraskeletal chondromas are atypical lesions and their recognition is important to avoid invasive treatment methods like marginal excision. The diagnosis must be confirmed with correlating clinical, radiological and histopathological examination. We report a 40-year-old woman with an extraskeletal chondroma around the knee joint. The radiological and histopathological aspects of the patient are presented along with a review of the literature.

Oncogenic osteomalacia: Problems in diagnosis and long-term management

Oncogenic osteomalacia is a rare association between mesenchymal tumors and hypophosphatemic rickets. It is more of a biochemical entity than a clinical one. The pathophysiology of the tumor is not clear. However, it has been seen that the clinical and biochemical parameters become normal if the lesion responsible for producing the osteomalacia is excised. For a clinical diagnosis a high index of suspicion is necessary. We present three such cases where in one the oncogenic osteomalacia reversed while in rest it did not. We present this case report to sensitize about the entity.