Prakash P. Kotwal

Giant-cell tumour of the tendon sheath: IS RADIOTHERAPY INDICATED TO PREVENT RECURRENCE AFTER SURGERY?

Giant-cell tumour of the tendon sheath, also called pigmented villonodular synovitis, is a benign tumour with a high incidence of recurrence. We have tried to identify risk factors for recurrence. Of the 48 patients included in the study, 14 received radiotherapy after surgery. Only two (4%) had a recurrence. This compares favourably with previously reported incidences of between 25% and 45%.

Outcome of short proximal femoral nail antirotation and dynamic hip screw for fixation of unstable trochanteric fractures. A randomised prospective comparative trial

A prospective, randomised, controlled trial was performed to compare the outcome of treatment of unstable trochanteric fractures with either a short proximal femoral nail antirotation (PFNA) or dynamic hip screw (DHS). Eighty one patients with unstable fracture of the proximal part of the femur were randomised, at the time of admission, for fixation with either a short PFNA (n=42) or DHS (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Clinical and radiological follow-up was undertaken for a minimum of 36 months. Any changes in the position of the implant or fixation failure were recorded. Hip range of motion, pain in the hip or thigh and return to work were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. The mean operative time was significantly less in PFNA group (25 min) than in the DHS group (38 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. Six patients in DHS group had implant failure while none experienced this in PFNA group. The PFNA group had a better functional outcome than the DHS group.

Prospective randomized trial comparing open reduction and internal fixation with minimally invasive reduction and percutaneous fixation in managing displaced intra-articular calcaneal fractures

PurposeManaging displaced intra-articular calcaneal fractures remains controversial. A prospective randomised trial was undertaken to compare open reduction and internal fixation (ORIF) with minimally invasive reduction and percutaneous fixation (MIRPF).MethodsForty-five displaced intra-articular calcaneal fractures were randomised to undergo either ORIF (n = 23) or MIRPF (n = 22). Patients were followed up clinically and radiologically for a minimum of one year postoperatively. The primary outcome measure was wound-healing complication. Functional outcome was assessed using Creighton Nebraska Health Foundation (CNF) scale, and radiological outcome was assessed using plain radiographs and computed tomography (CT) scans.ResultsOf the 23 heels in the ORIF group, seven (30%) had wound-healing problems, compared with none in the MIRPF group (p = 0.005). There was no statistically significant difference in radiological outcomes between groups, as measured by Böhler’s angle, Gissane’s angle and Score Analysis of Verona (SAVE). Median time to return to work was two weeks earlier (p = 0.004), and the functional outcome score (CNF scale) at one year of follow-up was better (p = 0.013) following MIRPF compared with ORIF.ConclusionMIRPF is associated with fewer wound-healing problems, better functional outcome and earlier return to work compared with ORIF.

Comparison of surgical treatment and nonoperative management for radial longitudinal deficiency

We compared the radiological and functional outcomes in patients with radial longitudinal deficiency treated surgically with those managed nonoperatively and correlated the ease of performance of activities with radiological and functional parameters in the two groups. A retrospective analysis was done in 446 type 3 and 4 hands (modified Bayne classification) over 20 years comparing the subjective assessment, objective and functional scores in nonoperatively managed hands (Group 1; n = 137) to hands managed with centralization or radialization (Group 2; n = 309). The subjective, objective and functional measures were significantly better in Group 2. Improved alignment, finger and wrist range of motion and grip strength were related to improvement in functional score. Surgical treatment of radial longitudinal deficiency provides improvement in cosmesis, function and ease of performance of activities when compared with nonoperatively managed hands.

Giant cell tumour of the tendon sheath of the hand

Purpose. To review outcomes of 106 patients after complete excision of the giant cell tumour of the tendon sheath of the hand, with or without postoperative radiotherapy. Methods. Records of 77 women and 29 men aged 11 to 61 (mean, 31) years who underwent excision of giant cell tumours of the tendon sheath of the hand were reviewed. All patients presented with gradually progressive swelling; only 3 of them also presented with pain. The lesions were located on the dorsal aspect (n=11), the palmar aspect (n=66), both aspects (n=10), or circumferentially (n=14). No patient had multiple lesions. Five patients had bony erosion and 3 had neurovascular bundle involvement. Results. The mean follow-up period was 12 (range, 4–22) years. 56 patients with well-encapsulated giant cell tumour in the palmer and/or dorsal aspects were classified as at low risk of recurrence. The remaining 50 patients were classified as at high risk of recurrence and underwent postoperative radiotherapy. None of the patients at low risk had any recurrence; 4 of those at high risk had recurrence despite radiotherapy. No complication was attributable to the irradiation, except that 3 patients had some dark pigmentation around the wound scar. Conclusion. Postoperative radiotherapy may have a role in reducing recurrence of the giant cell tumour of the tendon sheath of the hand.

Comparison of conventional MRI and MR arthrography in the evaluation of wrist ligament tears: A preliminary experience

Aims: To compare conventional magnetic resonance imaging (MRI) and direct magnetic resonance (MR) arthrography in the evaluation of triangular fibrocartilage complex (TFCC) and intrinsic wrist ligament tears. Materials and Methods: T1-weighted, fat suppressed (FS) proton density plus T2-weighted (FS PD/T2), 3D multiple-echo data image combination (MEDIC) sequences and direct MR arthrography were performed in 53 patients with wrist pain. Images were evaluated for the presence and location of TFCC, scapholunate ligament (SLL) and lunatotriquetral ligament (LTL) tears, and imaging findings were compared with operative findings in 16 patients who underwent arthroscopy or open surgery (gold standard). Results: Sixteen patients underwent arthroscopy/open surgery: 12 TFCC tears were detected arthroscopically out of which 9 were detected on FS PD/T2 sequence, 10 on MEDIC sequence, and all 12 were detected on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in the detection of TFCC tears were 75%, 83.3%, and 100%, respectively. Out of the eight arthroscopically confirmed SLL tears, three tears were detected on FS PD/T2 sequence, five on MEDIC sequence, and all eight were visualized on MR arthrography. The sensitivities of FS PD/T2, MEDIC sequences, and MR arthrography in detecting SLL tears were 37.5%, 62.5%, and 100%, respectively. One arthroscopically confirmed LTL tear was diagnosed on FS PD/T2 sequence, three on MEDIC sequence, and all five arthroscopically confirmed LTL tears were detected with MR arthrography. The sensitivities of PD, MEDIC sequences, and MR arthrography in detecting LTL tears were 20%, 40%, and 100%, respectively. Conclusions: MR arthrography is the most sensitive and specific imaging modality for the evaluation of wrist ligament tears.

Aneurysmal bone cyst in the metacarpal of a child: A case report

An unusual case of aneurysmal bone cyst in the metacarpal of a five-year-old girl is described. The lesion was initially diagnosed and treated as a simple bone cyst. Subsequently the affected metacarpal was excised and replaced by an autogenous fibular graft, with good results. A discussion of the pathogenesis of the lesion is given, with a review of the literature.

Staged reduction of neglected transscaphoid perilunate fracture dislocation: A report of 16 cases

BackgroundTransscaphoid perilunate fracture dislocation is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is not possible and needs extensive dissection. An alternative treatment such as proximal row carpectomy may be required for neglected injuries, but surgical outcome is not as good as that of an early reduction. We aim to present an alternative technique of staged reduction and fixation in patients of neglected transscaphoid perilunate dislocations and study its outcome.Material & Methods16 cases (14 males & 2 females) with neglected transscaphoid perilunate fracture dislocation (> 3 month old) were treated with staged reduction. Mean duration between injury and surgery was 4.5 months. In first stage an external fixator was applied across the wrist and distraction was done at 1 mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation.ResultsThe mean duration between two surgeries was 2.4 weeks (range 2–4 weeks). 9 cases had excellent results, 5 had good result. Two patients developed reflex sympathetic dystrophy and had fair results.ConclusionStaged reduction should be considered for neglected transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome.

Clinical Comparative Study: Efficacy and Tolerability of Tolperisone and Thiocolchicoside in Acute Low Back Pain and Spinal Muscle Spasticity

Study Design We performed a multicentric, randomized, comparative clinical trial. Eligible patients were randomly assigned to receive 150 mg of Tolperisone thrice daily or 8 mg of Thiocolchicoside twice daily for 7 days. Purpose To assess the efficacy and tolerability of Tolperisone in comparison with Thiocolchicoside in the treatment of acute low back pain with spasm of spinal muscles. Overview of Literature No head on clinical trial of Tolperisone with Thiocolchicoside is available and so this study is done. Methods The assessment of muscle spasm was made by measuring the finger-to-floor distance (FFD), articular excursion in degrees on performing Lasegues maneuver and modified Schobers test. Assessment of pain on movement and spontaneous pain (pain at rest) of the lumbar spine was made with the help of visual analogue scale score. Results The improvement in articular excursion on Lasegues maneuver was significantly greater on day 3 (p = 0.017) and day 7 (p = 0.0001) with Tolperisone as compared to Thiocolchicoside. The reduction in FFD score was greater on day 7 (p = 0.0001) with Tolperisone. However there was no significant difference in improvement in Schobers test score on day 3 (p = 0.664) and day 7 (p = 0.192). The improvement in pain score at rest and on movement was significantly greater with Tolperisone (p = 0.0001). Conclusions Tolperisone is an effective and well tolerated option for treatment of patients with skeletal muscle spasm associated with pain.

Vascularised Joint Transfer in the Management of Recurrent Giant Cell Tumour of the Second Metacarpal

This paper presents the medium-term follow-up results (34 and 40 months, respectively) of two cases of recurrent giant cell tumour of the head of the second metacarpal, treated by marginal excision and reconstruction with a vascularised toe joint transfer. Both patients had painless, stable joints with excellent ranges of motion at the metacarpophalangeal joint of 80° and 70°, respectively, no degenerative changes and no recurrence of the tumours.