Ish Kumar Dhammi

Extrapleural anterolateral decompression in tuberculosis of the dorsal spine

We reviewed 64 anterolateral decompressions performed on 63 patients with tuberculosis of the dorsal spine (D1 to L1). The mean age of the patients was 35 years (9 to 73) with no gender preponderance. All patients had severe paraplegia (two cases grade III, 61 cases grade IV). The mean number of vertebral bodies affected was 2.6; the mean pre-treatment kyphosis was 24.8 degrees (7 to 84). An average of 2.9 ribs were removed in the course of 64 procedures. The mean time taken at surgery was 2.45 hours when two ribs were removed and 3.15 hours when three ribs were removed. Twelve patients (19%) showed signs of neurological recovery within seven days, 33 patients (52%) within one month and 12 patients (19%) after two months; but six patients (10%) showed no neurological recovery. Forty patients were followed up for more than two years. In 34 (85%) of these patients there was no significant change in the kyphotic deformity; two patients (5%) showed an increase of more than 20 degrees.

Kyphosis in spinal tuberculosis - Prevention and correction

Spinal deformity and paraplegia/quadriplegia are the most common complications of tuberculosis (TB) of spine. TB of dorsal spine almost always produces kyphosis while cervical and lumbar spine shows reversal of lordosis to begin with followed by kyphosis. kyphosis continues to increase in adults when patients are treated nonoperatively or by surgical decompression. In children, kyphosis continues to increase even after healing of the tubercular disease. The residual, healed kyphosis on a long follow-up produces painful costopelvic impingement, reduced vital capacity and eventually respiratory complications; spinal canal stenosis proximal to the kyphosis and paraplegia with healed disease, thus affecting the quality and span of life. These complications can be avoided by early diagnosis of tubercular spine lesion to heal with minimal or no kyphosis. When tubercular lesion reports with kyphosis of more than 50° or is likely to progress further, they should be undertaken for kyphus correction. The sequential steps of kyphosis correction include anterior decompression and corpectomy, posterior column shortening, posterior instrumentation, anterior bone grafting and posterior fusion. During the procedure, the spinal cord should be kept under vision so that it should not elongate. Internal kyphectomy (gibbectomy) is a preferred treatment for late onset paraplegia with severe healed kyphosis.

Magnetic Resonance evaluation of tubercular lesion in spine

PurposeInformation on Magnetic Resonance (MR) features of active and healed lesions in tuberculosis (TB) spine are lacking. We evaluated MRI findings in active and healed proven TB spine to establish the diagnostic features.Materials and methodForty-nine consecutive spinal TB patients (20 male; 29 female) diagnosed clinicoradiologically and/or on histopathology, Fine Needle Aspiration Cytology (FNAC), bacteriology, or Polymerase Chain Reaction (PCR) were enrolled. Pretreatment MR scans were reviewed for diagnostic features, and eight-month follow-up MR scans were reviewed for healing changes.ResultsCervical spine (n = 6), dorsal spine (n = 14), and lumbar spine (n = 29) were affected. Fourteen had paraplegia. Mean vertebrae involved were 2.61 on X-ray with a total of 128 vertebrae (VB) and 3.2 on MRI (range, 2–15) with 161 VB. The lesions were more extensive on MRI (34.7%) than appreciated on X-ray. The disc was preserved partially or fully in 88.2% of instances. End plate erosions (159/161 VB), lost VB height (94/161), exudative lesion (158/161), granular lesion (3/161), pre and paravertebral collections (49/49 cases), marrow oedema (161/161), discitis (98%), epidural involvement (107/161), epidural spread (100/161), and subligamentous spread (156/161) were observed. Canal encroachment (10–90%) was seen in 37 cases. Mean motor and sensory scores with greater than 50% canal encroachment were 87/100 and 156/168, respectively. Cord oedema was observed in 11 cases (eight with neural deficit and three cases without). Cord atrophy was seen in one case each before and after treatment. A total of 83% of patients had a combination of paravertebral collections, marrow oedema, subligamentous and epidural extension, endplate erosions and discitis. On healing (n = 20), complete resolution of marrow oedema and collections, fatty replacement of bone marrow and resolution of cord signal intensity were observed.ConclusionThe marrow oedema, preservation of disc space, subligamentous extension of abscess, septate paravertebral abscess, epidural extension, endplate erosions and discitis were consistently observed in 83% cases of TB spine on MRI.

Evaluation of clinico-radiological, bacteriological, serological, molecular and histological diagnosis of osteoarticular tuberculosis

Background: The diagnosis of osteoarticular tuberculosis is clinico-radiological in endemic areas. However every patient does not have the classical picture. Osteoarticular tuberculosis is a paucibacillary disease hence bacteriological diagnosis is possible in 10-30% of the cases. The present study is undertaken to correlate clinico-radiological, bacteriological, serological, molecular and histological diagnosis. Materials and Methods: Fifty clinico-radiologically diagnosed patients of osteoarticular tuberculosis with involvement of dorsal spine (n = 35), knee (n = 8), shoulder (n = 1), elbow (n = 2) and lumbar spine lesion (n = 4), were analyzed. Tissue was obtained after decompression in 35 cases of dorsal spine and fine needle aspiration in the remaining 15 cases. Tissue obtained was subjected to AFB staining, AFB culture sensitivity, aerobic/anaerobic culture sensitivity histopathological examination and polymerase chain reaction (PCR) using 16srRNA as primer. Serology was performed by ELISA in 27 cases of dorsal spine at admission and one and three months postoperatively. Results: AFB staining (direct) and AFB culture sensitivity was positive in six (12%) cases. Aerobic/anaerobic culture sensitivity was negative in all cases. Histology was positive for TB in all the cases. The PCR was positive in 49 (98%) cases. All dorsal spine tuberculosis cases showed fall of IgM titer and rise of IgG titer at three months as compared to values at admission. Conclusion: Histopathology and PCR was diagnostic in all cases of osteoarticular tuberculosis. The serology alone is not diagnostic.

Cubitus varus: problem and solution

Abstract A lateral closing wedge osteotomy was performed in 39 children with cubitus varus deformity resulting from a supracondylar fracture. All had a deformity of 15° or more, with 5 having more than 30° of varus. The osteotomy was fixed by three different methods. In 8 cases the osteotomy was fixed with 2 parallel Kirschner wies (group K). A modified French technique (group TBW) was used in 25 cases and held with a figure-of-8 wire loop tightened over the screw heads. In the last 6 cases the osteotomy was fixed with an external fixator (group EF). The only poor result (i.e. loss of carrying angle of more than 10° and loss of flexion and extension of 20° or more) was in group K due to pin tract infection and loosening of the K-wires. In the TBW group 5 patients lost some degree of correction, and none became infected. In the EF group no patient suffered pin tract infection or loss of correction. Based on our experience and results, we feel that the best age at which to correct cubitus varus deformity was 6–11 years and that the external fixator is a safe, effective and reliable method to fix the osteotomy. We propose this method of fixation as a good alternative method to the modified French technique, especially in cases of severe cubitus varus deformity, where removal of a large wedge can produce a big step at the osteotomy site, increasing the possibility of disengagement of the stainless steel wire from the screw head. In addition, minor postoperative modifications of correction, if required, can also be performed. It also avoids a second operation for implant removal.

Multifocal skeletal tuberculosis in children: a retrospective study of 18 cases.

Multifocal skeletal tuberculosis is an uncommonly reported entity. Unanimity on terminology is lacking in the literature. The article presents a series of 18 such patients encountered in our institution. All the patients were below 15 y of age. Male to female ratio was 13:5. Most of the cases presented with swellings, discharging sinuses and/or ulcers. Appendicular involvement was seen in 17 of these cases. All the cases were diagnosed histopathologically as tuberculosis. All the cases were treated with multi-drug anti-tubercular therapy with additional procedures such as incision and drainage or sinus tract curettage performed in 9 of the patients. All the lesions healed. Their clinical behaviour, result and outcome are analysed with available international literature.

Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions

Background: Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single “T” incision outcome in thoracolumbar spinal trauma and tuberculosis. Patients and Methods: Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single “T” incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height. Results: In traumatic spine group the mean duration of surgery was 269 minutes (range 215–315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550–1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750–2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care. Conclusions: Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by “T” incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.

Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial

PurposeThere is no consensus about the best option of internal fixation for unstable intertrochanteric fractures. The aim of the present study was to compare proximal femoral nail (PFN) with contralateral reverse distal femoral locking compression plate (reverse-DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall.MethodIn a randomized controlled study, from November 2011 to October 2012, 40 patients with unstable intertrochanteric fractures with compromised lateral wall (AO 31A 2.2 to 3.3) had osteosynthesis by PFN (n = 20) or reverse-DFLCP (n = 20). Intra-operative variables compared were duration of surgery, blood loss during surgery, fluoroscopy time and surgeons perception of the surgery. Patients were followed up clinically for a minimum of one year. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12. Failure was defined as any condition which would necessitate revision surgery with change of implant.ResultsDuration of surgery (p = 0.022), blood loss during surgery (p = 0.008) and fluoroscopy time (p = 0.0001) were significantly less in the PFN group than in the reverse-DFLCP group. No significant difference was found in type of reduction, difficulty in reduction and surgeon’s perception of surgery. The PFN group had better functional outcome than the reverse-DFLCP group. HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 (p = 0.018). SF-12 physical (p = 0.002) and mental component (p = 0.007) scores in the PFN group was significantly better than in the reverse-DFLCP group. There was one failure in the PFN group as compared to six in the reverse-DFLCP group (p = 0.036).ConclusionDue to favourable intra-operative variables, better functional outcome and lower failure rates, we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall.

Tubercular spondylitis in children

Spine of the child has unique anatomy and growth potential to grow to adult size. Tuberculosis (TB) spine results in bone loss as well as disturbed growth potential, hence spinal deformities may progress as the child grows. The growth potential is also disturbed when the disease focus is surgically intervened. Surgery is indicated for complications such as deformity, neurological deficit, instability, huge abscess, diagnostic dilemma and in suspected drug resistance to mycobacterium tuberculosis. The child on antitubercular treatment needs to be periodically evaluated for weight gain and drug dosages need to be adjusted accordingly. The severe progressive kyphotic deformity should be surgically corrected. Mild to moderate cases should be followed up until maturity to observe progression/improvement of spinal deformity. The surgical correction of kyphotic deformity in active disease is less hazardous than in a healed kyphosis. The internal kyphectomy by extra pleural approach allows adequate removal of internal salient in paraplegic patients with healed kyphotic deformity.

Normal range of motion of hip and ankle in Indian population

OBJECTIVE Most studies that determine the range of motion of joints of the lower limbs study the Western population. The Asian population differs significantly, as daily activities demand different sitting positions. Our study aimed to establish the normal values of hip and ankle range of motion in various age groups in the Indian population and the effect of various functional positions of the hip on range of motion. METHODS Three hundred and twenty-six Indian subjects, between the ages of 1 month to 75 years, were randomly selected for measurement of the range of motion of the hip and ankle joint. Exclusion criteria included history of injury or disease related to the lower extremities. Changes with age in the arc of joint motion were studied. The influence of various functional positions of the lower limb on the range of motion of the hip and the effect of weight-bearing on the ankle joint range of motion were also analyzed. RESULTS Hip range of motion differed in various positions. Hip rotations were significantly greater when measured with the knee in flexion in both the sitting and prone positions than in the supine position. The arc of hip rotation was highest in the prone position. A significant increase in the arc of ankle dorsiflexion was found in a weight-bearing (squatting) position. Age related reduction in movement was found mainly in the rotations of the hip and dorsiflexion of the ankle. CONCLUSION The data compiled in this study on the range of motion in the hip and ankle joint of the Indian population will be useful in the evaluation of patients with disorders of these joints, especially in the Indian and Asian population.