Anurag Tiwari

Early reimplantation for open total talar extrusion

Purpose. To review outcome of early reimplantation for open total talar extrusion in 7 patients. Methods. Medical records of 5 men and 2 women aged 19 to 53 years who underwent reimplantation for open total talar extrusion within 6 hours after road traffic accident (n= 6) or industrial injury (n=1) were reviewed. The talus was first irrigated with 9 to 10 litres of saline solution, followed by 10% povidone iodine. It was then reduced after thorough debridement and fixed with tension band wiring or external fixation. Ankle mobilisation exercises were started at week 6 and full weight bearing at week 14. Outcome was assessed using the American Foot And Ankle Society score. Results. After a mean follow-up of 31.9 (range, 24–46) months, the mean American Foot and Ankle Society score was 81, and the mean dorsiflexion-plantar flexion arc was 36.9° (range, 25°–45°). All patients were able to walk with a balanced, unaided gait with mild-to-moderate pain (n=3) or pain-free (n=4). No patient developed deep infection or instability. Three patients developed avascular necrosis of the talus; restriction of motion was moderate at the ankle joint and severe at the subtalar joint. None of these 3 patients opted for revision surgery, as the pain was tolerable and did not limit their daily activities, but their condition was expected to deteriorate with time. Conclusion. Early reimplantation is recommended for open total talar extrusion, as it restores (to some extent) hind foot mechanics, heel height, and bone stock for activities of daily living and future reconstructive options.

Subungual osteochondroma: Nail sparing excision

Subungual osteochondroma is a relatively uncommon benign bone tumor affecting mostly children and young adults, and is a major source of pain and nail deformity. Treatment consists of marginal excision and meticulous wound closure. In this report, we present three cases of subungual osteochondroma arising from the dorsal aspect of distal phalanx of the great toe, which were managed by marginal excision with preservation of nail apparatus under digital block anesthesia with the use of a ring tourniquet. We emphasize on the use of ring tourniquet made by gloves finger and the technique of preserving the nail apparatus to prevent nail deformity. At final follow-up, there is no evidence of recurrence or nail deformity with good functional and cosmetic result.

Non-union fracture neck femur in a toddler: Reconstructed by valgus osteotomy – A minimally invasive approach

BACKGROUND Non-union is one of the devastating complications of fracture neck of femur. Though a very rarely encountered entity in a toddler (1-3 years paediatric age group), non-united femoral neck fractures are reported in developing countries because of mismanagement by quacks and delay in referrals. For operative treatment, many different procedures have been described, including close/open reduction and internal fixation using K-wires, cannulated screws, fibula or nails. There is no evidence in the literature that one or other implant influences the rate of postoperative complications, such as avascular femoral head necrosis or coxa vara. But, still the choice of fixation implant is debatable. CASE REPORT We present a case of 3-year-old child of non-union femoral neck fracture treated with valgus osteotomy. Choice of implant was kept to bare minimum to reduce the cost of implant and magnitude of surgery, which made the surgery minimally invasive, which is not the case in other studies. Two solid cancellous screws and a Kirschner wire (K-wire) were used to acheive fixation. Implant was removed after one year. The patient was followed up for 2 years and was found to be asymptomatic clinically with restoration of neck shaft angle and no signs of AVN. CONCLUSION Our method of intertrochanteric valgus osteotomy and internal fixation stabilized using K-wire and screws is a technically simple yet effective method of treating difficult fracture neck femur. Although a larger series and multicentric trails are needed, yet we would safely recommend extension of this technique to unstable fractures, to minimize the incidence of complications, cost and magnitude of surgery.

Radiological evaluation of pelvic inlet and outlet radiographic view in Indian population

Background Pelvic fractures represent one of the most challenging clinical problems in which an urgent multidisciplinary approach is required. The early management in a suspected pelvic fracture starts with the good radiological evaluation. The standard radiographic view includes the anteroposterior, inlet and outlet views. The inlet and outlet views are taken with 45° tilt from anteroposterior plane. However, recent studies have shown that there is significant individual variation within the population and these values should be redefined. Material and Methods This is a retrospective study carried out in a tertiary care teaching institute. Total 110 patients (including 42 female and 68 male patients) of age older than 18 years, who had a routine pelvic Computed Tomography (CT) scan performed for any indications unrelated to pelvic pathologies were included. Statistical analysis Mean and standard deviation were calculated. For each angle measured, the effect of age was determined and a comparison was made between male and female patients, p value <0.05 is considered significant. Results The mean angle of caudal tilt for the ideal screening inlet view was 33° +/-8 (16.3-31.3) and the mean angle of cephalic tilt for the ideal screening outlet view was 56° +/-9 (51.6-81.8). Conclusion This study re-evaluated the optimal inlet and outlet angles in Indians and demonstrated that the mean angles needed to create an ideal pelvic inlet and outlet views are 33° and 56° respectively.

Unusual presentation of chondroblastoma mimicking Trevor's disease

Chondroblastoma is a benign bone tumor, represents 1%–2% of all primary bone tumors, typically seen in patients 10–25-year-old and more common in males. It occurs most frequently in the distal femur, proximal tibia, and proximal humerus. Soft tissue extension is extremely rare. Adjacent joints may develop effusions, but the tumor mass protruding into the joint has never been seen in case of chondroblastoma. We report a rare case of intra-articular chondroblastoma arising from proximal tibia in a 16-year-old boy and growing into the knee joint mimicking an intra-articular osteochondroma.

Approach to Total Knee Replacement: A Randomized Double Blind Study between Medial Parapatellar and Midvastus Approach in the Early Postoperative Period in Asian Population

&NA; The purpose of this randomized study was to compare clinical and surgical outcomes of total knee replacements (TKRs) in the early postoperative period using midvastus approach versus medial parapatellar approach in Asian population in a double blind manner. Forty‐two knees each were operated using midvastus approach and the medial parapatellar approach. Clinical parameters that were evaluated included Knee Society score (KSS); knee pain using visual analogue scale (VAS) on day 1, 1 week, and 1 month; time required to straight leg raise (SLR); patellar tracking; mean extensor lag at 1 week and 1 month; and time of discharge from the hospital. Surgical parameters that were evaluated included tourniquet time, incidence of lateral retinacular release, estimated blood loss, and any complications during the surgery. KSS at 1 week and 1 month postoperatively were significantly higher in the midvastus group as compared with medial parapatellar group; though similar at 3 months, 6 months, and 1 year. The patients in midvastus group required fewer number of lateral retinacular releases; achieved SLR earlier; had less mean extensor lag at 1 week; had less mean VAS score at day 1, 1 week, and 1 month; and had shorter hospital stay. There was no significant difference in the mean tourniquet time and estimated blood loss. One patient had patellar maltracking in the medial parapatellar group as compared with none in midvastus group. Midvastus approach to TKR results in quicker functional recovery with early discharge and rehabilitation in the Asian population as compared with medial parapatellar approach.

Astragalus Tuberculosis: A Case Report and Review of the Literature

Osteo-articular tuberculosis continues to be a major global pandemic, with its greatest impact in the third-world countries. Among osteo-articular tuberculosis, plantar localisation, particularly isolated involvement of the talus is an extremely rare event. We discuss the case of a 20-year-old male diagnosed with isolated tuberculosis of right talus without the radiological involvement of the distal tibia, fibula or calcaneum. The diagnosis was made with the help of magnetic resonance imaging and confirmed through core biopsy of the talus. He was treated with multi-drug antitubercular chemotherapy and ankle immobilization with protected weight bearing with good results.

Isolated tubercular osteomyelitis of acromion: A case report and review of literature

Tuberculosis is an infectious disease of public health interest, infecting one-third of the world population. Up to 3% of all Tubercular cases have musculoskeletal involvement with less than 1% involving the scapular. To the best of our knowledge, we present the third case of acromion involvement in reported literature. An adolescent female with complains of shoulder pain with no restriction of movements, no local symptoms, no fever, no history of tuberculosis was being treated on analgesics for three months at a primary health centre. With a provisional diagnosis of Chondroblastoma, surgical exploration was done, but pus was drained. It was realized in retrospect that tuberculosis needs to be considered as a differential diagnosis for any undefined bony pain, however uncommon the site of involvement may be, especially in Indian subcontinent.

Finger trapped in door latch removed using an electric saw. A new technique and review of other techniques

Trapping of fingers in metallic bands is a commonly encountered situation. The children, elderly people, and psychiatric patients are the usual victims. The constricting object in the digit causes obstruction to lymphatic and venous drainage leading to oedema distal to the constriction, which leads to further neurovascular compromise and presents as a surgical emergency. A 7-year-old boy presented to us with his right middle finger being stuck in a steel door latch. Multiple attempts were made to remove the trapped finger with conventional methods, and subsequently, it was removed by electric-driven metal cutting saw, which was not previously described in medical literature to the best of our knowledge.

Primary leiomyosarcoma of femur

Primary leiomyosarcoma of the bone is exceedingly rare. In this case, we describe a middle-aged female with a primary leiomyosarcoma of the distal femur. The patient was treated by hip disarticulation. The patient continues to be disease-free at one-year follow-up.