Divesh Jalan

Management of nonunion of lower-extremity long bones using mono-lateral external fixator – Report of 37 cases

INTRODUCTION The management of nonunion has remained a constant challenge. The associated bone defect, shortening, deformity and infection complicate the management. A mono-lateral external fixator may minimise some of the problems frequently encountered in these patients. We report our results of prospectively evaluated 37 consecutive patients regarding nonunion of lower-extremity long bones managed using a mono-lateral external fixator. PATIENTS AND METHODS A total of 37 patients (7 femurs and 30 tibias), mean age 36 years, were stabilised using a mono-lateral fixator for nonunion of long bones. The mean time since injury was 8 months. Fifteen cases were infected and they received debridement and antibiotic treatment as per culture and sensitivity reports. In cases where the bone gap or shortening was >3 cm in the tibia and >5 cm in the femur, corticotomy and bone transport (bifocal procedure) was done and in the remaining cases, only compression-distraction (monofocal procedure) was done. The bone and functional results were assessed at the end of treatment according to the criteria described by Paley et al. RESULTS Union was achieved in 34 cases (91.9%). The average time for union was 5 months. Five cases were treated with the bifocal method and 32 cases were treated with the monofocal method. The average length gain in the bifocal method was 5.7 cm, mean duration of treatment was 8.2 months and bone healing index (BHI) was 1.44 months cm(-1). In six cases, the monofocal treatment was used for limb lengthening. The average length gain was 1.9 cm, mean duration of treatment was 4.83 months and BHI was 2.5 months cm(-1). Bone grafting was required in two cases at the docking site. The bone results were excellent in 24 cases, good in nine cases, fair in one case and poor in three cases. The functional results were excellent in 27 cases, good in six cases, fair in one case and poor in three cases. The most common complication in this series was pin-tract infection (11.5%). CONCLUSIONS A mono-lateral external fixator is an effective method for treating nonunion in the lower extremity with or without bone loss. The nonunion site can be carefully controlled with simultaneous correction of angulation and length.

Role of vascular endothelial growth factor as a tumour marker in osteosarcoma: a prospective study

PurposeA prospective study was undertaken to evaluate the diagnostic and prognostic significance of serum levels of vascular endothelial growth factor (VEGF) in patients with primary localised osteosarcoma.MethodsSerum VEGF levels were measured by an enzyme-linked immunosorbent assay (ELISA) in blood samples collected prechemotherapy, postchemotherapy, and postsurgery in 40 patients with histologically proven primary osteosarcoma. Comparison was made between serum VEGF level of healthy controls (n = 10) and prechemotherapy patient sera to evaluate its diagnostic potential. Serum VEGF levels of patients with and without metastasis were compared. Immunohistochemical staining was done to establish the correlation between serum and tissue VEGF expression. The Kaplan–Meier curve was used for survival analysisResultsNo significant relationship was observed between serum VEGF levels and age, gender, tumour size, local recurrence or histopathological subtypes of osteosarcoma. We observed significantly raised mean serum VEGF in patient sera compared with healthy controls (p = 0.001). Significant fall in mean serum VEGF level was observed following chemotherapy (p = 0.001). Patients who developed metastases had significantly higher serum VEGF levels compared with the nonmetastatic group (P = 0.001). Serum VEGF levels correlated well with VEGF expression in tissues.ConclusionSerum VEGF levels might prove to be of diagnostic, predictive and prognostic value in patients with primary osteosarcoma, although further studies with larger sample size and longer follow-up is needed to support the hypothesis.

Results of titanium elastic nailing in paediatric femoral diaphyseal fractures----report of 30 cases.

Objective: Fractures of the femur are the most incapacitating fractures. For children aged 6‐14 years, there is no clear consensus as to the preferred treatment. The conventional treatment of traction and casting is no longer recommended. We report our experience in titanium elastic nailing for treatment of paediatric femoral diaphyseal fractures. Methods: Thirty patients in the age group of 6‐16 years with displaced diaphyseal femoral fractures were stabilized with titanium elastic nails. Patients were followed up clinically and radiologically for a minimum period of 1 year. The final results were evaluated using Flynns criteria. Technical difficulties and complications associated with the procedure were also analysed. Results: Overall results were excellent in 20 cases and satisfactory in 10 cases. No patient had poor result. The average hospital stay was 9 days. All the fractures healed with an average time to union of 6.86 weeks. The most common complication encountered was soft tissue irritation at the nail entry site seen in 6 cases. Clinically, lengthening was noticed in 4 cases, while no patient had shortening. Malalignment was seen in only 6 cases. Perioperative difficulties encountered were failure of closed reduction seen in 6 cases and corkscrewing of nails in one case. Conclusion: Titanium elastic nails are a relatively easy to use, minimally invasive, physeal‐protective implant system with high rate of good and excellent outcomes in children aged 6‐16 years. Technical pitfalls can be eliminated by adhering to the basic principles.

Transient patellar dislocation resulting in simultaneous osteochondral fractures of patella and lateral femoral condyle - a case report.

Transient Patellar dislocations are commonly associated with bony contusions or osteochondral fractures involving the medial facet of patella or lateral femoral condyle. Simultaneous osteochondral fractures are rare and have not been reported in the adult. The authors report a case of combined osteochondral fracture of patella and lateral femoral condyle following acute patellar dislocation in an adult, which was misdiagnosed as meniscal injury. Both the osteochondral fracture fragments were rigidly fixed with headless compression screws and repair of the medial retinaculum was done. At latest follow up after two years, patient had regained full range of motion with no further episodes of patellar dislocation. The rarity of this combination of injury along with difficulty in interpreting radiographs makes this case interesting.

Measurement of Ulnar Variance in a Regional Subset of Indian Population-A Pilot Study of 30 Subjects.

BACKGROUND The variation of level of distal articulating surface of ulna with respect to distal articulating surface of radius is known as ulnar variance (UV). Positive and negative UV has been implicated in various wrist and hand pathologies. AIM To measure ulnar variance in a regional subset of Indian population and to compare two techniques of measurement of ulnar variance viz. method of perpendiculars and modification of the concentric circles method. MATERIALS AND METHODS UV was measured in a regional subset of Indian population comprising of 30 subjects. The mean age of patients was 35.9 years. There were 16 males and 14 females in the study group. Antero-posterior (AP) X-rays of wrist in neutral position were taken and UV was measured using method of perpendiculars and the modified circle method. RESULTS The mean UV using method of perpendiculars (UVA) was 0.387 mm and using modified circle method (UVB) was 0.507mm. A higher predominance of positive UV in this regional subset of Indian population was observed. There was no correlation between UV with respect to age and sex. No statistically significant difference was observed between the two methods of measurement utilized in the study. CONCLUSION The documentation of a negative and positive ulnar variance will help in prophylactic and timely intervention for various wrist pathologies, if required. However, a larger sample size with a longer follow up is required to suggest a correlation of ulnar variance with clinically symptomatic disease.

A case of acute septic arthritis hip caused by Brucella melitensis in an adolescent child

Brucella is among the most common zoonotic diseases affecting humans. Although musculoskeletal involvement is seen in a large proportion of patients, the disease is often diagnosed late or misdiagnosed due to its subtle nature and rarity, and lack of awareness among clinicians. In this report, a 12-year-old girl was diagnosed with acute septic arthritis of the hip based on clinico-radiological features, and managed with standard treatment, including arthrotomy. However, the child did not respond to the treatment. Based on the histopathology and local endemicity, Brucella was suspected, and confirmed after serological testing. The child subsequently responded to treatment and, at latest follow-up at 1 year, had a full painless range of motion, with no relapse.

Aneurysmal bone cyst of medial cuneiform and a novel surgical technique for mid-foot reconstruction.

Aneurysmal bone cyst of the foot is extremely rare and the involvement of medial cuneiform has never been reported in the literature. In this report, we describe a 15-year-old boy who presented with a 6-month history of pain and swelling in his left foot. Radiograph demonstrated a lytic lesion in the medial cuneiform extending on to the middle cuneiform, the navicular bone and the base of the first metatarsal. En bloc resection of the lesion was performed using a dorsal longitudinal incision along the first ray. Tricortical iliac crest graft was harvested and shaped to fill the defect. Two drill holes were made and the tibialis anterior tendon was attached to the graft. Prepared, morcellised allograft was placed along the junction of autograft and host bone. At 1-year follow-up, the patient was pain free, the medial arch of the foot was maintained and the graft had united with the host bone.

A recurred subungual glomus tumour of the thumb.

Glomus tumours are rare benign neoplasms arising from the glomus body, accounting for 1–5% of all soft-tissue tumours of the hand. The diagnosis of glomus tumour is frequently delayed, varying from 3 to 15 years. We present a case of a recurred glomus tumour of the thumb where symptoms persisted for a period of 6 years after an attempted surgical excision. The patient presented with classical symptoms of localised tenderness, cold sensitivity and excruciating pain on touch. Findings on radiograph, ultrasonography and contrast-enhanced MRI further supported the diagnosis. Complete surgical excision, the only recommended treatment, resulted in complete symptomatic relief to the patient. This case report highlights the importance of meticulous complete excision and clinical awareness of the disease among primary care physicians.

Evaluation of Aspartate Aminotransferase-to-Platelet Ratio Index as a Non-Invasive Marker for Liver Cirrhosis.

INTRODUCTION Liver biopsy is considered as a gold standard for the diagnosis of cirrhosis. Till date there is no non-invasive marker to replace it. AIM To investigate the effectiveness of Aspartate aminotransferase-to-platelet ratio index (APRI) as a non-invasive marker for liver cirrhosis. MATERIALS AND METHODS Fifty-one patients with cirrhosis, identified on USG abdomen were included in study. Platelet count and Aspartate aminotransferase (AST) were done using haematology automatic analyser and automatic HITACHI-912 Auto Analyser respectively. APRI was calculated for every patient using the formula {(AST / ULN) x 100}/platelet count (10(9)/L). Predictive accuracy was evaluated with a receiver-operating characteristics (ROC) curve. RESULTS APRI correctly classified 49 (96.1%) patients of cirrhosis with area under the ROC curve of 0.973 (95% CI) at cut-off 0.65 with negative predictive value (NPV) and Positive predictive value (PPV) of 96% and 96.1% respectively. The sensitivity and specificity of the test was found to be 96% and 96.1% respectively. CONCLUSION APRI could identify cirrhosis with high degree of accuracy in the studied patients.

Comment on Madelaine et al.: Results and complications of single-stage total knee arthroplasty and high tibial osteotomy

1. The authors mention measurement of the femoral mechanical axis (mFA), tibial mechanical axis (mTA) and femorotibial mechanical axis (mFTA) on weight-bearing long-leg films to determine the magnitude and location of the extra-articular deformity. However, it is not clear from the study as to how the authors have arrived at these angles and how they have concluded that the deformity measured is an extra-articular deformity. 2. The authors recommend grafting the osteotomy defect with autograft bone from the bony cuts. It is, however, not clear from the article whether the same technique had been used in their study. 3. We would be curious to know whether the autograft introduced into the valgising osteotomy had been placed before or after the introduction of the tibial stem. It is our understanding that both of the above clinical scenarios would lead to damage to the autograft, as is evident from all the postoperative X-rays published in the article which show a valgus tibial stem abutting on to the lateral tibial cortex, which indicates either inadequate correction or loss of correction of the deformity. 4. It is our opinion that single-stage correction for a severe extra-articular deformity entails a significantly higher r isk of nonunion , infec t ion and periprosthetic fracture with increased duration of immobilisation, as has also been reported by the authors in this study. It is only prudent to consider a two-stage surgery, thereby minimising the risk of complications and justifying the need for total knee replacement (TKR) which is to provide early, painless mobilisation in a well-balanced stable knee. 5. It is our submission that conversion to a TKR after high tibial osteotomy (HTO) is a difficult surgery with its antecedent problems, viz. offset stem and alteration of posterior slope: does performing two difficult operations in a single stage compromise the long-term survivorship of a TKR? 6. The authors have concluded that the combination of TKR and HTO is a valid option for treating arthrosis with large extra-articular frontal plane deformity. However, recent studies [2, 3] have concluded that good pre-operative planning, intra-articular bone resection and soft tissue balancing (both in flexion and extension) would be able to correct the majority of the extra-articular deformities.