Arun Pal Singh

Craniovertebral tuberculosis: a retrospective review of 13 cases managed conservatively.

Study Design. Retrospective review of 13 cases with craniovertebral tuberculosis treated conservatively. Objective. To evaluate the results of conservative treatment of craniovertebral tuberculosis and compare with the literature. Summary of Background Data. Craniovertebral tuberculosis is a rare entity even in endemic countries, and there is no consensus in the literature regarding conservative or surgical management for the same. Reports range from radical surgery to totally conservative approach. We report our experience in treating such patients conservatively. Methods. A retrospective review of 13 patients diagnosed with craniovertebral tuberculosis was performed. All patients were treated conservatively with cervical traction for initial 3 months followed by a brace along with multidrug antitubercular drugs for 18 months. Results. All patients responded favorably to conservative treatment. Follow-up averaged 43 months (range, 16–65 months). No patient deteriorated neurologically. All patients had symptomatic improvement. Failure to reduce atlantoaxial dislocation/lateral subluxation of the dens completely was seen in 2 cases. Conclusions. We think that all patients with craniovertebral junction tuberculosis can be managed adequately using conservative means regardless of the extent of bony destruction with a good patient outcome. Surgery should be reserved for only a selective few where diagnosis is in doubt and there is initial severe or progressive neural deficit with/without respiratory distress in presence of documented mechanical compression and documented dynamic instability following conservative treatment.

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.

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.

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.

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.

Reverse floating first metatarsal and floating third metatarsal with Lisfranc fracture dislocation: an unusual injury

A 25-year-old man complained of severe pain in the right foot after a traffic accident. There was a wound on the medial aspect of the foot extending over the length of the first metatarsal. There was no sign of vascular compromise and sensations were intact. Radiographs showed dislocation of the first tarsometatarsal (Lisfranc) and metatarsophalangeal joints with the head of the first metatarsal facing proximally and plantarward (reverse floating first metatarsal), a segmental fracture of the second metatarsal, fracture dislocation of the third metatarsal from the metatarsophalangeal and tarsometatarsal joints (floating third metatarsal), and fractures at the base of the fourth and fifth metatarsals and of cuneiforms. Open reduction and internal fixation were performed. The metatarsal head was buttonholed through the capsule and muscles and was released and reduced. The fractured second metatarsal was reduced and stabilized with a K-wire. The third floating metatarsal was aligned and fixed with a K-wire. A below-knee posterior plaster splint was applied for six weeks. Full weight bearing was started at 10 weeks. The patient returned to his activities with only minimal discomfort. This is the first reported case of plantar Lisfranc dislocation and reverse floating first metatarsal.

Coronal shear fractures of distal humerus: Diagnostic and treatment protocols

Coronal shear fractures of distal humerus involving the capitellum and the trochlea are rare injuries with articular complexity, and are technically challenging for management. With better understanding of the anatomy and imaging advancements, the complex nature of these fractures is well appreciated now. These fractures involve metaphysealcomminution of lateral column and associated intraarticular injuries are common. Previously, closed reduction and excision were the accepted treatment but now preference is for open reduction and internal fixation with an aim to provide stable and congruent joint with early range of motion of joint. Various approaches including extensile lateral, anterolateral and posterior approaches have been described depending on the fracture pattern and complexity. Good to excellent outcome have been reported with internal fixations and poor results are noted in articular comminution with associated articular injuries. Various implants including headleass compression screws, minifragment screws, bioabsorbable implants and column plating are advocated for reconstruction of these complex fractures. Inspite of articular fragments being free of soft tissue attachments the rate of osteonecrosis and osteoarthritis is reported very less after internal fixation. This article summarizes the diagnostic and treatment strategies for these rare fractures and recommendations for management.

Comments on Li et al.: Bilateral plate fixation for type C distal humerus fractures: experience at a single institution

Dear Sir, We read with interest the article entitled “Bilateral plate fixation for type C distal humerus fractures: experience at a single institution” by Shao-hua Li et al. and congratulate the authors for their work [1]. In the surgical technique, the authors converted type C fractures into type A fractures after passing intercondylar K-wire, but the authors did not mention how the compression between the fragments was achieved. We could determine from the X-ray that compression screws were passed through the plate holes but are curious as to whether the same technique was followed in all the patients [2]. The authors used 90-90 plating for fixation of type C distal humeral fractures. However, principle-based parallel plating for intercondylar fractures enhances fixation in the distal fragments with structural stability at the supracondylar level [2, 3]. The 90-90 plate fixation is not a good option for type C fractures, especially in the presence of comminution, osteoporosis and bone loss [2–4]. If the authors had compared the two techniques it would be a significant addition to the literature. Also, the authors did not mention the management of concomitant fractures of the distal end radius (three cases in their study). We would like to know if they were fixed or treated conservatively. The authors did not discuss the postoperative mobilisation protocol they followed. These complex fractures require early joint mobilisation. At one point the authors did mention a long period of immobilisation with the TRAP (triceps reflecting anconeus pedicle) approach. We would like to disagree because, on the contrary, it has been repeatedly published that the TRAP approach allows early mobilisation [3, 4]. There was a 13% incidence of heterotopic ossification in this study. How were these patients treated and what were the long term outcomes? The authors used tension band wiring with K-wires to fix olecronon osteotomy, but have attributed the delayed healing of the olecranon osteotomy site to early mobilisation. This is contrary to the principle of tension band wiring and articular reconstructions [5].

Total hip replacement of recurrent monostotic fibrous dysplasia of proximal hip

Correspondence: Dr. Ajay Pal Singh, Department of Joint Replacement Surgery, Inderprastha Apollo Hospital, Sarita Vihar, Delhi. E-mail: docajaypal@boneandspine.com and lytic lesions of the neck of the femur and trochanteric area extending distally along with secondary osteoarthritis (Figure 1). We planned a biopsy to rule out malignancy. A biopsy was taken from three sites under fluoroscopic control. Histology revealed delicate trabeculae of immature bone with no osteoblastic rimming, enmeshed within a bland fibrous stroma of dysplastic spindle shaped cells without any cellular features of malignancy (Figure 2). We planned eradication of the diseased tissue and total hip replacement with customized implants. First, bone graft was harvested from the contralateral iliac crest and then the patient was repositioned and lateral approach was used utilizing the previous incision. Removal of plate and screws were done. Thorough curettage of the lesion was performed using the help of fiber-optic light cable, dental mirror, and high speed burr to remove all the pathological tissue. Femoral head and acetabulum had osteoarthritic changes. Corrective closed wedge valgus osteotomy of proximal femur was made and impaction bone grafting using femoral head bone & harvested grafts was done. We used Total hip replacement of recurrent monostotic fibrous dysplasia of proximal hip