Ravi Mittal

Tuberculosis of the foot

In 44 patients with tuberculosis of the foot we identified five radiological patterns of lesions; cystic, rheumatoid, subperiosteal, kissing and spina ventosa. Cystic destruction had the best outcome and rheumatoid the poorest. All the patients were cured after antituberculous treatment for 18 months, and none required surgery.

Pattern of osteophyte distribution in primary osteoarthritis of the elbow

The goal of this study was to look at the pattern of osteophyte distribution on a 3-dimensional computed tomography scan of patients with symptomatic osteoarthritis in the elbow. We recruited 22 consecutive patients with symptomatic osteoarthritis of the elbow for the study. Three-dimensional reconstructed anterior, posterior, medial, and lateral views of the elbow were reviewed. Ulnohumeral osteophytes were found in 21 patients (95%), and radiohumeral osteophytes were found in 13 (59%). Cadaveric and biomechanical studies suggest that the radiohumeral joint appears to be more prone to wear and stress than the ulnohumeral joint. Our study showed that the percentage of patients with ulnohumeral joint osteophytes (95%) was higher than that of radiohumeral joint (59%). Therefore, this study challenges the conventional belief that osteoarthritis starts from the radiohumeral joint and progress toward the ulnohumeral joint.

Trapezius transfer for deltoid paralysis

We have reviewed 26 patients treated by trapezius transfer for deltoid paralysis due to brachial plexus injury or old poliomyelitis. We assessed the power of shoulder abduction and the tendency for subluxation. There were good results in 16 patients (60%); five were fair and five poor. Trapezius transfer appears to give reasonable results in the salvage of abductor paralysis of the shoulder.

Giant cell tumor of rib – rare location on the anterior aspect

Abstract Giant cell tumor rarely occurs in ribs, where it presents posteriorly. We present a report of a giant cell tumor of bone occurring anteriorly in the rib with a review of the literature.

The role of Tc-99m bone imaging in the management of pain after complicated total hip replacement.

A case of reflex sympathetic dystrophy (RSD) after total hip replacement (THR) is reported. It is a very unusual cause of pain after any arthroplasty procedure. Three-phase bone imaging diagnosed the condition and sympathetic blockade was used for confirming and treating the condition. The role of the bone scan in differentiating RSD from other causes of pain after THR is highlighted.

Diagnosis of post-traumatic complex regional pain syndrome of the hand: current role of sympathetic skin response and three-phase bone scintigraphy.

Purpose. To evaluate the role of sympathetic skin response (SSR) and three-phase bone scintigraphy (TPBS) in the diagnosis of complex regional pain syndrome (CRPS). Methods. 60 patients with CRPS of the hand were recruited. TPBS was performed using a bolus injection of 20 mCi of Tc-99m methylene diphosphonate in an antecubital vein and blood flow (first phase) image, blood pool (second phase) image, and delayed (third phase) image obtained. Patients were considered to have CRPS when the blood pool and blood flow images showed diffuse asymmetric uptake, or when the delayed image indicated increased asymmetric periarticular uptake. SSR was measured simultaneously in the affected and unaffected hands. Standard surface electromyogram disc electrodes were applied to the palm and dorsum of both hands. Electrical stimuli were applied to the skin at the base of little and ring fingers of the unaffected hand. Patients were considered abnormal when response was absent or the peak-to-peak amplitude was <50% of the contralateral hand in at least 2 readings. Results. The delayed phase of TPBS tested positive in all; the first and second phases tested positive in 54 (90%) and 56 (93%) of the patients, respectively. Four of the 6 patients with a negative first phase had had symptoms persisting for more than 6 months, and the other 2 for about 3 to 6 months. No patient presenting within 3 months had a negative scan. SSR was absent in 16 (27%) patients and normal in 44 (73%). 11 (79%) of 14 patients who presented more than 6 months after symptom onset displayed an abnormal SSR, while only 10% of those presenting within 3 to 6 months and 11% of those presenting within 3 months had an abnormal SSR. 12 (75%) of the 16 patients with abnormal SSR had associated decreased sweating, compared with 2 (4.5%) of the 44 patients with a normal SSR. Conclusion. TPBS is a very sensitive corroborative test to confirm the clinical suspicion of CRPS during the initial stages, but not in late cases. SSR can be used to document the sympathetic dysfunction in cases having an associated sweating abnormality and may have some diagnostic value in late cases of CRPS, when TPBS is less reliable.

RETROPERITONEAL FIBROSIS: A RARE COMPLICATION OF POTT’S DISEASE

A 45-year-old man presented with general malaise, anorexia, nausea and backache 6 months in duration. Medical history was significant for Pott’s disease 3 years earlier for which he had undergone antituberculous treatment for 1 year. Physical examination was unremarkable. Laboratory evaluation revealed increased creatinine and blood urea nitrogen (5.4 and 70 mg./dl., respectively). Ultrasonography of the abdomen showed bilateral moderate hydronephrosis. Computerized tomography (CT) of the abdomen revealed a soft tissue density mass in the retroperitoneum along L3 to L4 vertebra involving the inferior vena cava and both ureters (fig. 1). Bilateral ureteropyelogram demonstrated medial displacement of both ureters at L3 to L4 along with hydronephrosis on both sides. At surgery a glistening, whitish firm mass was found in the retroperitoneum encasing the ureters and inferior vena cava, extending from L2 to L4 vertebra. Bilateral ureterolysis with omental wrapping was done. Bilateral Double J (Medical Engineering Corp., New York, New York) stents were placed. At 6-week followup hydronephrosis had improved on both sides and serum creatinine decreased to 2.2 mg./dl. Magnetic resonance imaging from 3 years ago was reviewed and findings correlated with the present CT (fig. 2). Urine polymerase chain reaction and culture for Mycobacterium tuberculosis were negative. Histological examination of the specimen re- vealed chronic inflammatory cells with fibrotic collagenous tissue. At 3-month followup creatinine was 1.8 mg./dl. and bilateral hydronephrosis had subsided. DISCUSSION

Proximal femoral fractures: Principles of management and review of literature

UNLABELLED The purpose of this study was to review the principles involved in the management of proximal femoral fractures as reported in the literature. METHODS A medical literature search in the MEDLINE (PubMed) and Cochrane database was undertaken to review strategies and principles in proximal femoral fracture treatment. Randomized control trials and meta analysis were given preference while case reports/small series were rejected. RESULTS AND CONCLUSIONS Early anatomical reduction and surgical fixation remains the best option to reduce the risk of complications like non-union and avascular necrosis in treating fracture neck femurs. Cancellous screws continue to be the preferred treatment for fixation of neck femur fractures in younger population until the benefit of using sliding hip screws is validated by large multicentric studies. In the geriatric age group, early prosthetic replacement brings down the mortality and morbidity associated with neck femur fractures. Sliding hip screw (DHS) is the best available option for stable inter trochanteric fractures. The use of intramedullary nails e.g. PFN is beneficial in treating inter trochanteric fractures with comminution and loss of lateral buttress. Intramedullary implants have been proven to have increased success rates in subtrochanteric fractures and should be preferred over extramedullary plate fixation systems.

Giant cell tumor of bone: Is curettage the answer?

Background: Giant cell tumors (GCT) are neoplasms of mesenchymal stromal cells with varied manifestations. There is no uniform accepted treatment protocol for these tumors, Materials and Methods: 49 cases of proven giant cell tumors of appendicular skeleton, 27 prospective and 22 retrospective constituteed this study. The retrospective cases were collected by using computerized data base collection method. The patients were evaluated clinically, radiologically and by histology. Companacci grading and Enneking staging was used in the study. Two treatment modalities were used a) extended curettage (with/ without bone grafting/ cementation) or b) wide excision and reconstruction with a prosthesis or arthrodesis. Functional evaluation was done by Ennekings system. Chi square tests, mann-whitney test and ANOVA were used for statistical analysis. Results: The average age was 26.82 years (16-50 years). 25 patients (51%) were recurrent GCT at presentation. The commonest site was lower end of femur (16 cases, 32.65%) and upper end of tibia (13 cases, 26.53%). 40 (81.63%) tumors had less than 5 mm of subchondral bone free of tumor. 35 (71.43%) tumors were Ennekings surgical stage III and companacci grade III. Pathological fractures were seen in 12 (24.49%) cases. Intra-lesional currettage was used in 28 and enbloc excision in 19 patients and 2 (4.08%) underwent amputation. The average follow up period was 18.6 months (range 2-84). One recurrence was seen in a grade III recurrent distal radial lesion in the intralesional curettage group (3.57%) Ennekings functional score with intralesional curettage (25.41) was better than enbloc excision (21.37). Enbloc excision had higher rates of infections (36.84 % Vs 25%) and soft tissue coverage problems (21.05% Vs 0). Conclusion: Intralesional therapy has a better functional outcome and less complications than enbloc excision, albeit with a high recurrence rate which can however be effectively treated with repeat extended curettage.

Magnetic Resonance Arthrography for Assessing Severity of Glenohumeral Labroligamentous Lesions

Purpose. To compare magnetic resonance (MR) arthrography and arthroscopy as a means of assessing the severity of labral tear in anterior glenohumeral instability. Methods. 52 patients presenting with traumatic recurrent anterior shoulder instability were evaluated using MR arthrography; 30 shoulders with a labroligamentous lesion were treated with arthroscopic Bankart repair. Their MR arthrographic images were interpreted by 3 senior musculoskeletal radiologists, and a radiological diagnosis was reached by consensus. The sensitivity and positive predictive values of MR arthrography for detecting a labral tear were determined. Agreement between MR arthrography and arthroscopy in terms of the width and depth of the labral tear was analysed. Results. On arthroscopy, a labroligamentous lesion (Bankart lesion and its variants) was present in all the 30 shoulders. Agreement between the MR arthrography and arthroscopy in terms of the width and depth of the labral tears was good. Conclusion. MR arthrography is an accurate means of assessing the severity of anterior labroligamentous lesions and yields a good correlation with arthroscopy.