Raghav Saini

En bloc excision and autogenous fibular reconstruction for aggressive giant cell tumor of distal radius: a report of 12 cases and review of literature

IntroductionGiant cell tumor (GCT) of distal radius follows a comparatively aggressive behaviour. Wide excision is the management of choice, but this creates a defect at the distal end of radius. The preffered modalities for reconstruction of such a defect include vascularized/non-vascularized bone graft, osteoarticular allografts and custom-made prosthesis. We here present our experience with wide resection and non-vascularised autogenous fibula grafting for GCT of distal radius.Materials and methodsTwelve patients with a mean age of 34.7 years (21-43 years) with Campanacci Grade II/III GCT of distal radius were managed with wide excision of tumor and reconstruction with ipsilateral nonvascularised fibula, fixed with small fragment plate to the remnant of the radius. Primary autogenous iliac crest grafting was done at the fibuloradial junction in all the patients.ResultsMean follow up period was 5.8 years (8.2-3.7 years). Average time for union at fibuloradial junction was 33 weeks (14-69 weeks). Mean grip strength of involved side was 71% (42-86%). The average range of movements were 52° forearm supination, 37° forearm pronation, 42° of wrist palmerflexion and 31° of wrist dorsiflexion with combined movements of 162°. Overall revised musculoskeletal tumor society (MSTS) score averaged 91.38% (76.67-93.33%) with five excellent, four good and three satisfactory results. There were no cases with graft related complications or deep infections, 3 cases with wrist subluxation, 2 cases with non union (which subsequently united with bone grafting) and 1 case of tumor recurrence.ConclusionAlthough complication rate is high, autogenous non-vascularised fibular autograft reconstruction of distal radius can be considered as a reasonable option after en bloc excision of Grade II/III GCT.

Application of the Ponseti principle for deformity correction in neglected and relapsed clubfoot using the Ilizarov fixator

We treated 15 cases of neglected and relapsed clubfeet by the Ilizarov distraction method using the Ponseti principle in 12 children (mean age 7.3 years). The deformities were corrected around the talar head in the sequence of the cavus, adduction, varus and finally equinus (as per the Ponseti principle). Clinical and functional outcome after 2.5 years was significant (P<0.05) with a mean reduction of 11.7 in Dimeglios score and an average Laaveg and Ponseti functional score of 75.47. The average time taken for correction was 4.2 weeks. Differential distraction according to the Ponseti principle leads to early correction with minimal number of residual deformities and complications.

Clinico-radiological assessment and their correlation in clubfeet treated with postero-medial soft-tissue release

The controversy regarding the radiographic parameter which best represents the various deformities of clubfoot continues. The aim of our study was to clear up this controversy. Fifty surgically treated (soft-tissue release) congenital clubfeet were studied clinically using Laaveg and Ponseti score and radiologically using twelve different radiographic parameters in weight-bearing AP and lateral views. The talo-calcaneal angle (TCA) in AP and lateral view showed statistically significant correlation with the functional rating, but significant variation in the dimension of the angles among the different functional groups was found with AP angle only. The talo-first metatarsal angle in AP and lateral view averaged 10° and 19° respectively, and showed significant correlation with the functional rating. The talo-navicular subluxation in AP, the calcaneo–fifth metatarsal angle and the first–fifth metatarsal angle in lateral view did not show any significant correlation with function. Talo-calcaneal index averaged 44° in the clubfeet and showed significant correlation. The wide range of parameters representing each of the deformities gives a better radiological assessment of the clubfoot than any single parameter.RésuméLes paramètres radiographiques des pieds bots sont toujours très discutés. Le but de cette étude est de clarifier les controverses à ce propos. Matériel et méthode : 50 pieds bots opérés (libération interne) ont été étudiés sur le plan clinique en utilisant le score de Laaveg et Ponseti et sur le plan radiographique avec douze paramètres différents, les radiographies étant effectuées en charge de face et de profil. Résultat : l’angle Talo-calcanéen (TCA) de face et de profil est de façon significative associée aux résultats fonctionnels, l’angle talo-métatarsien (du premier métatarsien varie de 10 à 19°) et est également corrélé, de façon significative avec le score fonctionnel. La subluxation talo-naviculaire de face, l’angle calcaneo-métatarsien avec le 5ème méta et le premier méta ainsi que l’angle 1er et 5ème méta de profil ne sont pas corrélés avec le score fonctionnel. L’index talo-calcanéen est en moyenne de 44° et a une importante signification. En conclusion : l’association de ces différents paramètres permet d’avoir une meilleure appréciation radiologique du pied bot bien plus que l’utilisation d’un paramètre isolé.

Neglected irreducible posterolateral knee dislocation

Knee dislocations are rare injuries. Posterolateral knee dislocations are only a small subset of them. There is a paucity of literature regarding the management of such neglected cases. We report here, a case of neglected irreducible posterolateral knee dislocation treated with open reduction and isolated posterior cruciate ligament reconstruction followed by gradual rehabilitation with good outcome at 3 years followup.

Regeneration of the Achilles tendon after percutaneous tenotomy in infants: a clinical and MRI study.

We aimed to study the regeneration potential of tendo-achilles after percutaneous tenotomy in 34 clubfeet treated by Ponsetis technique. Clinical and MRI evaluation was done after 6 weeks and 6 months of tenotomy to assess the regeneration of the tendon. At the follow-up, Achilles tendon was palpated like a cord in all the feet. MRI study revealed continuity of the tendon in all cases at the end of 6 weeks and 6 months of the tenotomy. Thus, it could be concluded that tendo-achilles does regenerate following percutaneous tenotomy, used in the correction of clubfoot using Ponsetis technique.

Low-grade fibromyxoid sarcoma of the talus: a case report.

Low-grade fibromyxoid sarcoma is a rare tumor, which most commonly arises from the deep soft tissues of the lower extremities in young men. Diagnosis of this tumor can be difficult because of its deceptively benign histopathologic appearance. Specifically, the lesion is characterized by alternating fibrous and myxoid areas with variable cellularity and a whorled growth pattern. Like many soft tissue tumors, low-grade fibromyxoid sarcoma is also characterized by strong immunoreactivity to the human proto-oncogene BCL-2. Cytogenetically, the lesion has also been associated with the t (7,16) (q33;p11) translocation, with the characteristic resultant FUS and CREB3L2 fusion gene. In this report, we describe the rare case of a low-grade fibromyxoid sarcoma that appeared to develop as a primary malignancy in the neck of the talus of a young man who presented with recurrent ankle pain after a previous surgery for a cystic lesion at the same site.

Results of dorsal approach in surgical correction of congenital vertical talus: an Indian experience.

We present our experience in the correction of congenital vertical talus deformity in a single stage using dorsal approach. We operated on 20 feet using the dorsal approach and the average age of patients at the time of surgery was 16 months. Talonavicular reduction was achieved in all the feet and there was significant improvement in postoperative talo-calcaneal and talo-first metatarsal angles, which were well maintained at a follow-up of 4 years. In conclusion, the dorsal approach efficiently manages the deformities of a congenital vertical talus foot and provides consistent radiological and clinical outcome with minimal complications such as revision surgeries and osteonecrosis of the talus.

Rapidly progressive ochronotic destructive hip arthropathy misdiagnosed as tuberculosis

Rapidly progressive destructive hip arthropathy due to ochronosis is a rare entity about which most of the average orthopaedic surgeons are unaware of. In a developing country like India, such rapidly progressive hip destruction is seen in the far more commonly in tuberculosis of the hip. We present one such case which was misdiagnosed and treated as tuberculosis in an attempt to increase the awareness of ochronosis amongst the orthopaedic surgeons. We also briefly review the literature and discuss the management principles in such a rare diagnosis.

Outcome of one-stage treatment of developmental dysplasia of hip in older children

Sir, We read the article1 entitled “Outcome of one-stage treatment of developmental dysplasia of hip in older children” with great interest. We would like to congratulate the author for his excellent work. However, we have a few concerns. The author performed derotational osteotomy (DRO) along with femoral shortening in all the cases (30 hips).1 We would like to know whether any radiographic analysis was done preoperatively to assess the femoral anteversion. In our experience, we found that femoral anteversion is rarely exaggerated in DDH of the early walking age group,2 and this is in coordinance with other radiographic studies.3,4 Secondly, the author’s method of assessing the need for derotation seems a little unclear. As the author performed femoral shortening in all cases, it means the hip cannot be reduced before shortening; then, how could they hold the limb in full internal rotation after reduction. Zadeh et al.5 recommended a test of stability to determine the need for DRO and, based on this test as well as the preoperative radiological assessment, we found that derotation is not essential in DDH of the early walking age group.6 Hence, we would like to clarify from the author regarding the assessment of anteversion and need of derotation, especially in those cases where the reduction of hip cannot be achieved before performing a shortening osteotomy. Thirdly, we would like to ask whether we need shortening in all cases as the data show that five out of 25 cases were less than 2 years of age. In such young children, can the reduction be achieved without femoral shortening; if so, we can get away with only open reduction and Salter’s osteotomy. In our experience, we needed femoral shortening osteotomy in only three out of 15 cases.6