Azal Jalgaonkar

Bizarre parosteal osteochondromatous proliferation of bone: CLINICAL MANAGEMENT OF A SERIES OF 22 CASES

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Noras lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.

Intra-neural Ewing’s sarcoma of the upper limb mimicking a peripheral nerve tumour. A report of 2 cases

Ewings sarcoma is a malignant round cell tumour of bone commonly affecting children and young adults. Intra-neural Ewings is very rare form of extraosseous Ewings sarcoma (EES), posing diagnostic and therapeutic challenges. We report two cases of intra-neural EES presenting with elbow pain and swelling, mimicking an upper limb peripheral nerve sheath tumour. Following a CT guided biopsy to confirm diagnosis, the patients were treated with a combination of surgical resection, chemotherapy and radiotherapy. These cases highlight the potential diagnostic challenges as their presentation can be misleading due to the non-specificity of symptoms. These are highly aggressive tumours with the propensity to metastasize. We review importance of collective radiological and immunohistochemical analysis followed by early, aggressive multimodal treatment within a multidisciplinary setting. This provides the best prognosis in the context of upper limb peripheral nerve tumours.

Prospective Study of Posterior Lumbar Interbody Fusion With Either Interbody Graft or Interbody Cage in the Treatment of Degenerative Spondylolisthesis.

Study Design: A prospective study of 2 different fusion techniques for the treatment of single-level degenerative spondylolisthesis. Objective: To determine whether the addition of an intervertebral cage improves the clinical outcome and fusion rate of patients undergoing posterior lumbar interbody fusion (PLIF) after decompression for degenerative spondylolisthesis. Summary of Background Data: The surgical approach that should be used for degenerative spondylolisthesis is a controversial issue. Decompression and PLIF with an interbody cage is widely used. Theoretical advantages in favor of PLIF include anterior column support, indirect foraminal decompression, restoration of lordosis, and reduction of the slip via ligamentotaxis. Despite numerous publications, the scientific support for the PLIF method is, however, weak. Materials and Methods: A prospective study was carried out including 59 patients with degenerative spondylolisthesis. Average age of patients was 66 years: 34 males and 25 females. Patients were divided into 2 treatment groups: group 1—32 patients with PLIF with interbody graft and group 2—27 patients with PLIF with cage. Minimum 2-year follow-up. Outcomes were assessed by measuring preoperative and postoperative lordotic angles. SF-12 physical and mental health scores were recorded along with visual analogue scores for pain. Complications were also recorded. Results: No significant difference in the postoperative lordotic angles was achieved between the 2 techniques. Nonsignificant difference in the clinical outcomes between both the techniques. Conclusions: We have found the use of a cage to achieve lumbar interbody fusion in the treatment of degenerative lumbar spondylolisthesis does not confer any significant advantages in terms of restoration of lumbar lordosis, improvement in clinical symptoms, or relief of pain postoperatively.

Identification of the biopsy track in musculoskeletal tumour surgery: A novel technique using India ink

Local recurrence along the biopsy track is a known complication of percutaneous needle biopsy of malignant musculoskeletal tumours. In order to completely excise the track with the tumour its identification is essential, but this becomes increasingly difficult over time. In an initial prospective study, 22 of 45 patients (48.8%) identified over a three-month period, treated by resection of a musculoskeletal tumour, had an unidentifiable biopsy site at operation, with identification statistically more difficult after 50 days. We therefore introduced the practice of marking the biopsy site with India ink. In all 55 patients undergoing this procedure, the biopsy track was identified pre-operatively (100%); this difference was statistically significant. We recommend this technique as a safe, easy and accurate means of ensuring adequate excision of the biopsy track.

Deep Soft Tissue Leiomyoma Mimicking Fibromatosis in a 5-year-old Male

Leiomyomas of the deep soft tissue in the extremities of children are very rare. These benign soft tissue tumors occur more frequently in adults between the fourth and sixth decades of age. Women are more commonly affected than men, with the uterus the most common location. We present a rare case of deep soft tissue leiomyoma in the foot of a 5-year-old male. The tumor was misdiagnosed as a desmoid-type fibromatosis from the findings of both magnetic resonance imaging and needle biopsy. The unusual age of presentation, atypical location, and failure of magnetic resonance imaging and ultrasound-guided needle biopsy in diagnosing the lesion make the case interesting. The case also highlights the importance of treating such patients at specialist tertiary centers with a multidisciplinary setting.

Free fibular graft reconstruction following resection of chondrosarcoma in the first metacarpal.

Chondrosarcoma is most frequently present in the pelvis and long bones and rarely seen in the bones of the hand. Traditionally the treatment of choice for involvment of the hand is ray amputation, however this causes significant functional deficit if there is thumb involvement. There are limited cases in literature of resection of thumb chondrosarcoma with restoration of function. We present a case of high grade chondrosarcoma of the first metacarpal treated with resection and free fibular graft reconstruction. We report excellent functional outcome with this procedure.