Justin Arockiaraj

The use of titanium mesh cages in the reconstruction of anterior column defects in active spinal infections: can we rest the crest?

Study Design Retrospective clinical series. Purpose To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis. Overview of Literature The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy. Methods Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnabs criteria. Results Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnabs criteria 61 (95.3%) patients reported a good to excellent outcome. Conclusions Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.

Amphotericin B cement beads: A good adjunctive treatment for musculoskeletal mucormycosis

Mucormycosis is one among the aggressive, invasive fungal infections usually seen in immunocompromised patients. Mucormycosis osteomyelitis is very rare. We present a patient with acute myeloid leukemia who complained of pain over the right proximal thigh. Plain radiograph revealed ill defined osteolytic lesion of proximal femur. MRI showed altered signal in proximal femur with focal collection and cortical breach. Biopsy and tissue culture diagnosed mucormycosis both histologically and microbiologically. He was treated with aggressive debridement, skeletal stabilization, and amphotericin antifungal cement beads. He recovered with no residual pain, minimal limb shortening, and no clinical or radiological evidence of recurrence at 3 years followup. The high index of suspicion, early diagnosis, aggressive surgical debridement, and adequate antifungal therapy play a significant role in the treatment of musculoskeletal mucormycosis.

Bilateral talus fracture dislocation: is avascular necrosis inevitable?

Bilateral simultaneous fracture dislocation of the talus is a very rare injury. It occurs usually following high-velocity injuries. We report a 45-year-old man who presented with bilateral talar fracture dislocation following a heavy stone falling on him. On his right side, he had open talus dislocation with lateral process fracture and on his left side he had closed talar neck fracture dislocation. He underwent immediate debridement and external fixator application for his right side and open reduction and internal fixation for his left talus. At the end of 34 months’ follow-up, he was able to walk up to 2 km without pain. His ankle range of movements were restricted bilaterally. Radiographs revealed bilateral avascular necrosis with right side showing complete collapse. We present this case for its rare presentation of bilateral talar fracture dislocation with bilateral avascular necrosis with sequential radiographs.

Gorham's Disease of Spine

Gorhams disease is a rare disorder characterized by clinical and radiological disappearance of bone by proliferation of non-neoplastic vascular tissue. The disease was first reported by Jackson in 1838 in a boneless arm. The disease was then described in detail in 1955 by Gorham and Stout. Since then, about 200 cases have been reported in the literature, with only about 28 cases involving the spine. We report 2 cases of Gorhams disease involving the spine and review related literature to gain more understanding about this rare disease.

Osteoblastoma of the coracoid process: an unusual location

Bone tumours arising from the coracoid process of the scapula are very rare. We present a case of a 19-year-old man with left shoulder pain for 1 year, with associated infraclavicular swelling for 8 months. Examination revealed a tender, bony, hard swelling measuring 3×4 cm. Imaging revealed an expansile osteolytic lesion arising from the coracoid process with loss of corticomedullary differentiation. MRI showed altered signal in the adjacent soft tissues. The patient underwent en bloc resection of the lesion. Histology was suggestive of osteoblastoma. At the end of 2 years follow-up, the patient had no pain or recurrence of the lesion. We present this case for its rare location and have briefly discussed the difficulties in diagnosis of this condition.

Chondrosarcoma of the Spinous Process: A Rare Presentation

Chondrosarcomas are malignant cartilage forming tumours. They form the second most common primary malignant tumour involving the vertebral axis. We present a rare presentation of a secondary chondrosarcoma from the spinous process of lumbar vertebra and discussed its management. The main emphasis is on the rare presentation and the need for awareness and suspicion of the pathology.

Non-Caseating Granulomatous Infective Spondylitis: Melioidotic Spondylitis

Study Design Retrospective clinical analysis. Purpose To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. Overview of Literature Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei, has been labeled as a bio-terrorism agent. Methods We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels. Results Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up. Conclusions Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.

Isolated Tubercular Osteomyelitis of Scapula - A Report of Two Cases and Review of Literature.

Introduction: Isolated tuberculosis of the scapula is rare. The presentation mimics the tumors of scapula. Hence it is important to know the clinical presentation and when to suspect tubercular osteomyelitis of scapula. Few cases have been described before. We have analyzed all reports with isolated scapular tuberculosis so far and described the varied presentations. Case Report: We report two cases of isolated scapular tuberculosis. One patient underwent aspiration and was started on antituberculous drugs (ATT) and the other underwent debridement, drainage of abscess and then was started on ATT. Both had excellent outcomes at the end of one year follow up. We reviewed previous published literature of isolated scapular tuberculosis. The most common presentation of scapular tuberculosis is as follows: age less than 30 years and there is no difference with respect to gender. Swelling and pain are the commonest symptoms. Lytic areas with surrounding sclerosis is the commonest radiological finding. Body of the scapula is affected most commonly. Prognosis is excellent with adequate treatment. Conclusion: To conclude, clinicians should have high index of suspicion for diagnosing this condition as it mimics tumors. Pain and swelling is the most common presentation of scapular tuberculosis. Radiography shows lytic lesion with marginal sclerosis. The prognosis is excellent with appropriate treatment.

A Rare Case of Cryptococcal Infection of Talus with Pathological Fracture That Healed with Medical Management

Skeletal involvement occurs in 5% to 10% of reported cases of disseminated cryptococcal infection. We are reporting a very rare presentation of cryptococcal infection of the talus with pathological fracture, which healed with medical management. Our patient had pain and swelling around the ankle associated with fever. Radiologically, he had a lytic lesion of the talus with fracture of the talar neck. Biopsy and cultures revealed cryptococcal infection. He was treated with surgical debridement combined with antifungal therapy, and the fracture healed well by 5 months. At the end of the 1-year follow-up, he had painless ankle movement and there was no evidence of recurrence. He was able to walk without support or limp, and he could wear normal footwear.

Treatment Strategy and Outcomes in Patients with Hematogenous Culture-Negative Pyogenic Vertebral Osteomyelitis

Study Design Retrospective case series. Purpose The aim of this study was to analyze functional and radiological outcomes in patients with culture-negative pyogenic vertebral osteomyelitis (PVO). Overview of Literature There were only few literature available for these group of patients. Methods Patients with biopsy-positive but culture-negative PVO were included. We analyzed records for data on demography, comorbidities, coexisting infections, neurological status, prior antibiotic therapy, pre- and postoperative erythrocyte sedimentation rate, C-reactive protein levels, and Oswestry Disability Index, and Japanese Orthopedics Association scores. Results Sixty-one patients were included, of which data of 45 patients were available for follow-up. The patients were predominantly males (71%), with a mean age of 53.2 years. Seventy-seven percent patients had comorbidities. Echocardiography, blood culture, and urine culture were performed on 8%, 24%, and 18% of patients, respectively. Thirty-one percent patients had neurological deficits. Computed tomography-guided biopsy was performed on 67% patients. Fifty-two percent patients were treated surgically, and 48% were treated non-surgically. Nineteen percent patients were treated according to the results of cultures from other foci, and the rest were treated empirically. For the initial 2 weeks, all patients were treated with intravenous antibiotics empirically or based on culture from other foci. This treatment was followed by 10 weeks of oral cloxacillin/cephalexin for gram-positive organisms or ciprofloxacin for gram-negative organisms. The mean follow-up time was 18 months (range, 12–120 months). All patients had improvement in Japanese Orthopedics Association, Oswestry Disability Index, and Visual Analog Scale scores (p<0.001). Conclusions Treatment with empirical antibiotics for 12 weeks with watchful clinical and radiological follow-up yields good resolution of the disease. Further multicenter clinical research needs to be performed for obtaining an algorithmic treatment plan for these patients.