Sachin Upadhyay

Chloroma (Granulocytic sarcoma): An unusual cause of shoulder pain in chronic myeloid leukemia; a diagnostic dilemma

At one point or another in their lives, most people will experience some degree of shoulder pain. It may be secondary to a variety of underlying pathology. We report a case of shoulder pain caused by a granulocytic sarcoma (chloroma) in chronic myeloid leukemia (CML) patient misdiagnosed initially as synovitis. Although granulocytic sarcoma has many classic musculoskeletal manifestations, to our knowledge, a case of CML concurrent with chloroma of the shoulder joint has not been reported in the literature. We must not forget that the shoulder pain arising from granulocytic sarcoma may be the initial presenting feature of underlying hematological malignancy such as CML.

Letter to the Editor Proximal femoral locking plate versus dynamic hip screw for unstable intertrochanteric femoral fractures

To the Editor: We read with interest the article by Dhamangaonkar et al.1 May the authors clarify the following points. 1. A dynamic hip screw (DHS) with fixed angle locking screws reduces the risk of implant failure, particularly for patients with osteoporotic bone or less stable fracture configurations.2 Why did the authors compare a proximal femoral locking plate with a non-locking 135o DHS? Comparison of the DHS locking plate with a proximal femoral locking plate would have been more realistic and generalisable. 2. Filling all screw holes may lead to stress concentration and high strain, which can lead to implant failure after cyclic loading.3 The working length has no effect on stiffness, gap motion, and resistance to fatigue.4 What is the authors’ opinion regarding this issue? We believe that in cases of comminution, increasing working length at the level of the fracture enables a larger area of stress distribution on the plate and reduces the strain at the fracture site. 3. Correct placement of screws is of crucial importance and should be ensured in both anteroposterior and lateral planes. Convergence/ divergence of the locking head screws in the anteroposterior/lateral planes enables an angular stable buttress that increases the stability of fracture fixation.3 Did the authors check the screw placement in both planes? 4. The ‘kickstand’ screw has greater axial stiffness and lesser torsional stiffness,5 but its use to reduce the risk for mechanical failure cannot be established.6 What is the authors’ opinion regarding this? 5. Regarding a large posteromedial void, what were the factors that impeded the locking of screws besides osteoporosis? Did the authors attempt bone grafting for the void? 6. The authors stated that “All patients in the DHS group were operated on with a short barrel plate, which increased the risk of jamming of the lag screw.” The lag screw length during the procedure determines the barrel plate sizes, i.e. standard (38 mm) or short (25 mm).7,8 Please comment.

Commentary: Posterior tension band wiring and instrumentation for thoracolumbar flexion-distraction injuries

Tension band wiring has been used to re-appose bone fragments, secure ligaments or tendon to bone, and improve stability in weakened constructs. 1–5 The spinous ligaments, ligamentum flavum, facet capsular ligament, and posterior longitudinal ligaments collectively form the natural posterior spinal tension band. The integrity of the posterior spinal ligamentous structures is critical, as they function to limit translation (anterior and posterior), flexion, and rotation of the spine. Flexiondistraction injuries (FDIs) lead to posterior disruption and elongation, and hyperextension with or without shear causing anterior disruption and elongation. 6 Proper evaluation of the posterior elements is important for the diagnosis of FDIs. Magnetic resonance imaging has high diagnostic accuracy and inter-observer reliability. 7 Reconstruction of the posterior tension band combined with spinal instrumentation for FDIs improves stability and aids early rehabilitation. 8 Cables, wires, and other strands have been used to re-establish posterior tension band stability. 9–13 In this issue, Hasankhani and Omidi-Kashani 8

Percutaneous autologous stem cell enriched marrow concentrate injection for treatment of cases of impaired fracture healing with implant in situ: A cost-effective approach in present Indian scenario

Background: The objective of present study is to investigate the feasibility of proposed methodology in present Indian scenario, to enhance fracture repair in cases of impaired healing with the implant in situ using autologous bone marrow concentrate. During critical analysis, the existing study also aimed to assess the outcome (both objective and subjective) as well as to document complications specific to the proposed therapy if any. Materials and Methods: First the marrow is aspirated from posterior iliac crests. After that Ficoll-Paque technique of density gradient separation for the isolation of mononuclear cell populations enriched with stem cells is employed. Later, the concentrate is injected into critical-sized defects of eight patients with stable fracture delayed/nonunion via fluoroscopic guidance. New bone formation was evaluated by X-rays in two standard planes (anteroposterior (AP)/lateral). Level of statistical significance was set at a P < 0.05. Result: The critical osseous defect reached radiographic observable union by a mean of 12.28 ± 1.38 weeks. A distance of 5 mm or less between the fractures′ ends resulted in healing in seven cases (87.5%). The results of the Likert four-point scale showed that majority were very satisfied with the outcome of the procedure (Cronbach′s alpha coefficient (follow-up): 0.93 (6 week); 1.0 (1 year)). There were no adverse events reported during the procedure. Conclusion: Our preliminary results indicate that the approach proposed is feasible and effective in the management of stable (implant in situ) fracture with impaired healing. In context of its cost-effectiveness, we recommend to follow proposed methodology in present Indian scenario.

Letter to the Editor Clavicular hook plate for grade-III acromioclavicular dislocation

To the Editor: In the article by Steinbacher et al.,1 could the authors clarify the following: 1. Transfer of the acromiocoracoid ligament to repair the coracoclavicular ligament and the acromioclavicular ligament after implantation of a clavicular hook plate is advocated to improve stability of the acromioclavicular joint and prevent recurrent dislocation.2,3 Nonetheless, the authors did not attempt to reconstruct the ligaments. 2. The time from injury to surgery may have affected outcome. Functional outcome was significantly better in patients with early than with delayed acromioclavicular reconstruction.4 The authors did not mention the time from injury to surgery. 3. For grade-III acromioclavicular dislocations, operative treatment results in a better cosmetic outcome (p<0.0001) but a greater duration of sick leave (p<0.001), compared with non-operative treatment.5 The difference is insignificant in terms of strength, pain, and throwing ability.5 What is the authors’ opinion? 4. In the method section, the authors state that “All patients could resume their sporting activities at month 3”. Yet in the result section, the authors stat that “Sports activities were resumed by month 6 at the latest.” Please explain the discrepancy. 5. The authors state that the clavicular hook plate achieved good-to-excellent results. However, it was considered not to be an ideal implant owing to various complications and need for second surgery to remove the plate.6 What is the authors’ opinion? 6. The authors did not report any complications. Did the authors use some precautions to prevent complications? 7. The study sample size was not based on power calculation. Type-II error owing to an insufficient sample size may prevent the generalisability of the findings.7 In addition, there was no control group to decrease the risk of assessment bias.

A preliminary study of a novel technique of suprascapular nerve block in treating chronic shoulder pain

Objective: The objective was to evaluate efficacy of a novel landmark-based technique of suprascapular nerve block (SSNB) in the treatment of shoulder pain and disability. Study Design: Prospective, observational study. Materials and Methods: Forty patients with chronic shoulder pain were treated with a new technique of SSNB. Visual analog scale for pain (VAS) and shoulder pain disability index (SPADI) were assessed before giving the block and at both the follow-up visits at the end of 1 st and 4 th week. Pain relief was also assessed on Likert scale in both the follow-up visits. Results: The baseline VAS of 8.45 ± 0.87 was significantly improved to 2.80 ± 0.70 and 5.02 ± 1.02 after 1 st and 4 th week of SSNB, respectively (P = 0.000). Similarly, the baseline total SPADI was of 71.15 ± 4.96, was significantly improved to 55.22 ± 1.32 and 57.61 ± 3.50 after 1 st and 4 th week of follow-up, respectively (P = 0.000). The mean Likert scale score after 1 week was 3.68 ± 0.656 and after 4 weeks was 4.00 ± 0.679. Conclusion: This new technique of SSNB is safe, effective, and well-tolerated in treating chronic shoulder pain and disability.

Repair of Achilles tendon ruptures with peroneus brevis tendon augmentation

To the Editor: In the article by Singh et al,1 may the authors clarify: 1. Records of 6 women and 19 men (25 patients) who underwent repair of Achilles tendon ruptures with peroneus brevis tendon augmentation were reviewed, but the outcomes of only 22 patients were reported. 2. Selection of treatment method for Achilles tendon repair depends on the type and size of the defect. What were the authors’ criteria for this? 3. Reconstruction of chronic Achilles tendon rupture with transfer of the peroneus brevis tendon is suitable in patients with a gap of <6.5 cm between ruptured ends.2,3 The gap is usually larger in chronic and neglected patients who have a habit of squatting that widens the defect. Was peroneus brevis augmentation alone sufficient? We usually augment the repair with gastrocnemius aponeurotic reverse flap and/ or tensor fascia graft. What was the authors’ experience in repairing larger defects? 4. The flexor hallucis longus (FHL) tendon is a plantar flexor and is stronger than peroneus brevis and flexor digitorum longus tendons.4 Its axis of contractility resembles that of the Achilles tendon, and it works in phase with the gastrocnemiussoleus complex and thus can maintain the normal muscle balance of the ankle. It can be transferred without neurovascular interference. A complete integration of the FHL tendon is reported in 60% of the patients,5 and the tendon increases blood supply to the repaired tendon.6 Modified FHL transfer with fibrous Achilles tendon stump reinforcement has demonstrated excellent outcome.6 Morbidity associated with FHL transfer is clinically insignificant, even for good push-off or balance in running sports.7,8 What led the authors to choose peroneus brevis as their first choice for augmentation? 5. Turco and Spinella modification9 can be beneficial if a long distal stump is present. Did the authors use the same modification? During negotiation of peroneus brevis through a mid-coronal slit in the distal stump of the Achilles tendon, the stump might split. Did the authors experience this? What are the key factors to prevent this? 6. The authors evaluated patients at 3, 9, and 12 months using the Foot and Ankle Outcome Score (FAOS). At 3 and 9 months, the cohort was small. What were the causes for these dropouts? Were the patients lost to follow-up? 7. The small cohort prevents generalisation of the findings and leads to type-II errors.10 We appreciate the authors’ comment on this concern. 8. Were there any contraindications and/or limitations of peroneus brevis augmentation in terms of aetiology and/or critical size defect? We appreciate the authors’ comments on this concern.

Intra-Articular Injection of Tranexamic Acid to Reduce Blood Loss after Total Knee Arthroplasty

To the Editor: In the article by Jang et al.,1 could the authors please clarify the following: 1. A high-dose local tranexamic acid (TXA) was used in total knee arthroplasty (TKA) for postoperative blood loss reduction. What was the systemic absorption and were there any side-effects? It has been reported that a plasma concentration of TXA of only 10 mg/l is adequate for anti-fibrinolytic action2; this correlates to a concentration of 10 to 20 mg/ml for the topical TXA solution.3–5 The success rate is similar when lowor high-dose local TXA is used.6,7 Why did the authors use high-dose (1500 or 3000 mg) TXA? What are the advantages of using TXA in high concentrations? 2. The authors used high-dose intra-articular TXA, and thus the chances of systemic effects cannot be overlooked. Did the authors measure the serum TXA? 3. The authors did not use a surgical drain. In view of potential complications, such as infection, limb swelling, and joint pain, most surgeons advocate placing a drainage tube at the joint. In an emergency situation with immediate brisk blood loss, drains can be clamped without any excess morbidity.8 Please comment. 4. ‘Tissue contact time’ is the time that the TXA solution is applied to the surgical bed. This can enhance (with clamped drain) or lessen (without surgical drain) the effect. What is the authors’ opinion regarding this? 5. When high-dose TXA is used, Doppler ultrasonography should be used and plasma levels of TXA measured one hour after release of the tourniquet. 6. Randomised controlled trials are preferred for studying the effects of topical TXA to avoid bias. 7. Although the study supports the use of topical TXA for decreasing blood loss following TKA, the conclusion is perplexing regarding the dosage of TXA? What is the authors’ comment about a dosage of 1500 mg versus 3000 mg?

Outcome of Locking Compression Plating for Proximal Humeral Fractures: A Prospective Study

To the Editor: In the article by Chowdary et al,1 may the authors clarify: 1. The PHILOS construct is very rigid if locked both proximally and distally. This produces stress concentration at the humeral neck.2,3 The rigidity can be reduced by using standard screws in the humeral shaft. What is the authors’ opinion and protocol on this? 2. In patients with poor bone stock, did the authors pack the humeral head and shaft with bone grafts or substitutes? In elderly osteoporotic patients, bicortical self-tapping locking screws should be used to avoid screw pullout or secondary displacement at the bone-screw interface.4 What are the key components when fixing osteoporotic bones? 3. The authors stated that “the plate span ratio, number of screws, and working length were based on the protocol”. Would the authors explain this? Both a high plate span ratio (that decreases the load onto the plate) and a low plate screw density produce a sound fixation. 4. During the procedure, the biceps tendon may be interposed in the fracture fragments requiring mobilisation. Did the authors experience the same problem? How would they manage it? 5. In the postoperative radiographs, the plate seems to be at a higher level that could result in symptomatic impingement and/or restricted range of motion. Ideally, the plate should be placed 1 to 2 cm distal to the upper end of the greater tuberosity.5 Please comment on the positioning of the plate. 6. Did the authors find any significant difference in functional outcomes between different fracture types or age groups? 7. It would be better if the authors present their results with meta-analysis and advocate how to improve the drawing of future trials.

Costal exostosis with fungation: A rare presentation

Costal exostosis occurs either sporadically or as a manifestation of hereditary multiple osteochondromas (HMOs), a disorder that is inherited in an autosomal dominant manner. Costal exostosis may cause chest pain and, on rare occasions, result in intra-thoracic complications. We report a case of a 15-year-old boy with exostosis in the right anterior fifth rib, who presented with protruded painful skin lesions that had ulcerated over the last one month. He previously received a diagnosis of multiple exostoses. There was no evidence of a malignant change on histopathological analysis. Enbloc excision was done and there has been no recurrence to date. To the best of our knowledge, the present case is the only report of costal exostosis presenting as an extrathoracic chest wall ulcerating mass. The present report illustrates this rare clinical scenario and reviews the relevant literature.