Samarth Mittal

Giant cell tumour of tendon sheath with simultaneous two tendon involvement of the foot treated with excision of the tumour and reconstruction of the flexor retinaculum using tibialis posterior tendon in a paediatric patient: A rare case report

Giant cell tumour of tendon sheath is a benign soft tissue tumour arising from the tendon sheath. The involvement of foot and ankle by such tumours is relatively rare. Children are not commonly afflicted by this condition. All such tumours are reported to arise either from a single tendon sheath or one joint. We report a case of giant cell tumour of tendon sheath in a 12-year-old child, arising simultaneously from the tendon sheaths of tibialis posterior and flexor digitorum longus tendons, as well as extending into the ankle joint. It was treated by complete excision of the mass along with the tendon sheaths with reconstruction of the flexor retinaculum. The location of the tumour, age of the patient, diffuse nature of the tumour and novel technique of reconstruction of the flexor retinaculum make this case extremely rare and the first to be reported in literature.

Spinal Tuberculosis: Which Is the Best Surgical Approach?

cral TB were subjected to anterior radical debridement and strut grafting and instrumentation, while cases with a large paraspinal abscess, especially lumbar TB, were given the surgical treatment of posterior instrumentation. The differential selection of the patients in each group may itself have influenced the results. In group B (posterior approach), either a titanium cage filled with morcelized rib bone or large autoilliac or costal grafting were used. What were the criteria for choosing either of them? One hundred and eighty-one patients with spinal TB were included in the study. Of these, only 25 patients had a neurological deficit. What was the indication for surgery in the other patients? They could very well have been managed conservatively or with a middle-path regimen [5] . The development of anti-TB drugs has revolutionized the treatment of patients with spinal TB, as most patients do not have extensive destruction of bone, and sequestration can be successfully treated conservatively with chemotherapy, external bracing and prolonged rest [6] . Spinal TB with the lesion situated in the thoracic spine is more prone to develop kyphosis. In their study [1] , the majority of patients in group A had TB in the dorsal spine while those in group B mostly had lesions in the lumbar spine. The poor results in group A cannot be attributed to instrumentation alone. The surgical time and blood loss which are critically important parameters for the choice of approach were not mentioned. Although the mean age was mentioned, the age range in each group was not. In children and young adults, vertebral destruction is more severe because most bone is cartilaginous. In addition, angulation is more significant due to the growth retardation of the anterior column and unrestricted growth of the posterior column. We read the article entitled ‘Outcomes of different surgical procedures in the treatment of spinal tuberculosis in adults’ by Cui et al. [1] with great interest. Despite being an age old disease debate still surrounds the choice of approach. The authors concluded that posterior approach was superior to anterior approach for correcting deformity and maintaining correction. However, this conclusion is drawn from study groups that were not comparable from the beginning. There were statistically significant differences in the preoperative kyphosis angle in the anterior and posterior groups. Hence, the conclusion may not be appropriate. The anterior approach popularized by Hodgson et al. [2] in 1960 is currently considered the gold standard for debridement and decompression in Pott’s spine [3] . Advocates of the traditional anterior approach cite the ability to directly access the disease pathology and perform decompression, the fact that there is less muscle dissection and the ability to place a large graft under compressive load for fusion [2, 4] . In the study of Cui et al. [1] , anterior instrumentation was found to be inferior to posterior instrumentation. One of the reasons given by the authors was that the screws in the vertebral body cannot provide the same strength as the pedicle screws due to osteoporosis of the vertebral body caused by spinal TB. We disagree with the authors, as the screws were put into the normal healthy vertebral body and the affected vertebrae were removed. If there were osteoporosis of the vertebral body, then the hold of the posterior screw would also be poor. The vertebra level operated on and the range of kyphosis angle in each group have not been mentioned. The anterior approach should be avoided in patients with lesions above T5 (as instrumentation above T4 body is difficult), in patients with kyphosis of more than 60° (anterior-only correction causes spinal lengthening), in patients with disease involving the posterior elements and in patients with a bad preoperative chest condition. It would be interesting to know how the authors managed the 28 patients with a kyphosis angle of between 61 and 70°. The size of paraspinal abscess decided the choice of approach. The cases lacking a large paraspinal abscess and without lumbosaPublished online: August 21, 2013

Uncoiling of reamer during intramedullary nailing for fracture shaft of femur

Intramedullary nailing is considered the standard of care for closed femoral shaft fractures. Several studies have shown that reamed intramedullary nailing is a safe procedure in fracture shaft femur with lower nonunion rates than unreamed nailing. Reamed intramedullary nailing provides better stability because of increased contact between the nail and medullary canal. However, careful attention to reaming techniques as well good instrumentation is necessary while undertaking such a procedure. We report what is, to the best of our knowledge, the first case of uncoiling of reamer while reaming the medullary canal. Possible causes and measures to avoid such a complication are discussed.

Spontaneous migration of bullet from arm to forearm and its ultrasound guided removal

Spontaneous migration of a retained bullet is rare. We are presenting here a case of a 24-year-old male with spontaneous migration of bullet from arm to forearm. At the time of initial injury, bullet was left inside the arm as it was deep and patient had no complaints. Three months after injury, he started complaining of pain over forearm and tingling sensations in the forearm and hand over median nerve distribution. Radiographs showed bullet in the proximal forearm. The bullet was than precisely localized and removed under ultrasound guidance. This case report emphasizes the fact that spontaneous migration of bullet in extremities may occur and have the potential to cause neurovascular damage. Removal under ultrasound guidance is a viable option in such locations.SommarioLa migrazione spontanea di un proiettile trattenuto è rara. Presentiamo il caso di un paziente maschio, di 24 anni di età, con migrazione spontanea di una pallottola dal braccio all’avambraccio. Al momento iniziale, il proiettile era stato lasciato all’interno del braccio perchè in sede profonda in paziente con scarsa resistenza al dolore. Tre mesi dopo, questi ha iniziato a lamentare dolore al l’avambraccio e sensazioni di formicolio a braccio e mano, nelle aree innervate del nervo mediano. Le radiografie hanno mostrato il proiettile nell’avambraccio prossimale. Il proiettile veniva localizzato con più precisione e rimosso sotto guida ecografica. Questo caso sottolinea il fatto che la migrazione spontanea di un proiettile nelle estremità può verificarsi ed è potenzialmente causa di danni neurovascolari. In tale situazione la rimozione sotto guida ecografica è una valida opzione.

Effectiveness of arthroscopic elbow synovectomy in rheumatoid arthritis patients: Long-term follow-up of clinical and functional outcomes

OBJECTIVE To determine the long-term clinical and functional results of arthroscopic elbow synovectomy in rheumatoid arthritis patients with refractory elbow synovitis in terms of improvement in pain, function, and active range of motion (AROM) or arc of motion. METHOD Fifteen rheumatoid elbows in 13 patients, not responding to DMARD therapy and with radiological changes not more than Larsen grade 3 were taken, who underwent arthroscopic elbow synovectomy. The main outcome measured in forms of Mayo Elbow Performance Scale (MEPS) score, measurement of pain using a Visual Analogue Scale (VAS), radiological angles of elbow, disease activity score (DAS-28), arc of motions (AOM) and complications, which were assessed at follow-up periods of 6 months, 24 months, and 30 months. Statistical analysis was done both qualitatively and quantitatively. Mann-Whitney U test, chi-square test, and Student t test were used as the statistical test for determining significance. RESULTS In the study group, the improvement was sustained and significant as compared to baseline (VAS 1.28, MEPS 81.07 and mean flexion range 85°) (p value <0.001). No significant complications were encountered postoperatively after elbow synovectomy. CONCLUSION The study assesses the long-term results of arthroscopic synovectomy in elbow synovitis secondary to rheumatoid arthritis with significant results favoring arthroscopic synovectomy.

Safe corridor for iliosacral and trans-sacral screw placement in Indian population: A preliminary CT based anatomical study

Objectives Nonsurgical management of unstable pelvic ring injuries is associated with poor outcomes. Posterior pelvic ring injuries include sacroiliac joint disruption and sacral fractures or a combination of the two. Morbidity is high in non-operatively managed patients. Screw fixation is being increasingly used to manage unstable posterior pelvic injuries. Limitations include a steep learning curve and potential for neurovascular injury. This is the first study in Indian population to describe the safe corridor for screw placement and check the feasibility of screw in both upper and lower sacral segments. Methods This study involved retrospective analysis of 105 pelvic CT scans of patients admitted to the emergency department of a Level 1 trauma centre. Vertical height at the level of constriction (vestibule) of S1 and S2 was measured in coronal sections and anteroposterior width of constrictions was measured in axial sections. We created a trajectory for 7.3 mm cylinder keeping additional 2 mm free bony corridor around it and confirmed that bony limits were not breached in axial, coronal and sagittal sections. Whenever there was breach in bony limit we checked applicability of 6.5 mm screw. Results The vertical height and anteroposterior width of vestibule/constriction of S1 was significantly higher in males, whereas S2 vestibule height and width were similar in males and females. Both male and female pelves were amenable to S1 Trans-sacral and S1 Iliosacral screw fixation with a 7.3 mm screw when a safe corridor of 2 mm was kept on all sides. However, when S2 segment was analysed, only 42.9% of male pelves and 25.7% of female pelves were amenable to insertion of trans-sacral 7.3 mm screw. Conclusion An individualized approach is necessary and each patients CT must be carefully studied before embarking on sacroiliac screw fixation in Indian population.

Response to Chouhan DK, regarding: “Retrospective analysis of proximal humeral fracture-dislocations managed with locked plates”

In reply: We appreciate the effort of the authors in reading our article with interest and providing insightful comments to our article titled “Retrospective analysis of proximal humeral fracturedislocations managed with locked plates.” We would like to address the raised queries in the following manner. In our series, we did not encounter recurrent instability after osteosynthesis of fracture-dislocations of the proximal humerus. The presence of a bony Bankart lesion or anterior glenoid rim fracture was specifically looked for before embarking on surgery with computed tomography scans. Labral tears were ruled out intraoperatively in all cases having separate lesser tuberosity fractures. An attempt to look for the same was not made in fractures with intact lesser tuberosity fractures. Capsular tears were present, whereas significant labral tears were not found in our series. At the end of every fixation, intraoperative fluoroscopy was also used to rule out any residual instability. In our experience, unlike simple dislocations, fracturedislocations have different pathoanatomy. Given the lack of observation of labral tears in our series and absence or lack of mention of the same in other such series, it may be possible that fracture-dislocations do have much lower incidence of labral tears and much higher incidence of capsular tears compared with simple dislocations. Robinson et al in their series of 58 patients with a mean age of 66 years had 20 soft tissue Bankart lesions, 3 bony Bankart lesions, and 2 cases with partial inferior soft tissue labral attachment. However, their publication, of a different cohort, does not elaborate on any repair of these lesions and does not mention any complication related to instability. Lahav et al also mentioned 2 cases of fracture-dislocation with anterior glenoid rim fractures in which they fixed the glenoid rim along with performing an arthroplasty for proximal humerus fracture in their patients of old age. The use of an anterior approach to fix these fracturedislocations may cause fibrosis of the anterior structures, which may in turn prevent instability. In spite of early physiotherapy, some stiffness may persist that may also contribute to decreased chances of instability. Soliman and Koptan reported no case of redislocation after fixation in a series of 39 patients with 4-part fracture-dislocation of the proximal humerus in young adults. They remarked that this intriguing fact might be because all the patients in their study were on the stiff side. We feel that if labral tears are evident in such fractures, they should be fixed in the same setting to prevent any unnecessary future procedures. However, additional dissection just to look for the same should be avoided to preserve vascularity of fragments to a maximum, especially in cases in which osteosynthesis is contemplated, looking at the low possibility of instability after such procedures on the basis of both our experience and published literature. To the best of our knowledge, no such reports of recurrent dislocation of the shoulder after fixation have been mentioned in the literature, Hence, very little is known about the frequency of such a complication; neither any comprehensive pathoanatomy of soft tissue injury pattern of the capsulolabral complex nor any standard treatment rationale has been detailed. Going by the available evidence and the standard practice in patients of our tertiary care trauma center, we can speculate that labral injury might not be necessary to repair in this complex injury, and only open reduction– internal fixation might be sufficient to produce satisfactory results. We once again thank the authors for bringing the issue to the fore and letting us explain our point.

Multidrug resistant Elizabethkingia meningoseptica bacteremia – Experience from a level 1 trauma centre in India

Elizabethkingia meningoseptica (E. meningoseptica) is a non-fermenting gram negative organism that is commonly detected in the soil and water but is rarely reported to cause human infection. However it is emerging as a nosocomial pathogen in patients admitted in intensive care units (ICUs). Infections caused by this organism have a high mortality rate due to lack of effective therapeutic regimens and its intrinsic resistance to multiple antibiotics. We report our experience in managing Elizabethkingia meningoseptica (E. meningoseptica) septicemia in our ICU patients with septic shock during prolonged intensive care management. Over a two year period four cases were admitted into the polytrauma ICU developed sepsis due to E. meningoseptica. All these patients were on mechanical ventilation, had central venous catheter (CVC) and were exposed to various broad spectrum antibiotics. Of the four patients, three died and one recovered. E. meningoseptica infection should be considered as a possible etiological agent of sepsis in patients who do not respond to empirical therapy, as this results in an inappropriate choice of antimicrobial therapy, leading to increased morbidity and mortality of patients. Its unusual resistance pattern along with inherent resistance to colistin makes this organism difficult to treat unless susceptibility patterns are available.

Dual ACL Ganglion Cysts: Significance of Detailed Arthroscopy

Intra-articular ganglion cysts of the knee joint are rare and most frequently are an incidental finding on MRI and arthroscopy. Most of the previous studies have reported a single ganglion cyst in the knee. There have been previous reports of more than one cyst in the same knee but not in the same structure within the knee. We are reporting a case of dual ACL (anterior cruciate ligament) ganglion cysts one of which was missed on radiological examination but later detected during arthroscopy. To the best of our knowledge, no such case has been reported in the indexed English literature till date.

Weismann-Netter-Stuhl syndrome: report of two cases and treatment

Weismann-Netter-Stuhl syndrome is a rarely reported cause of bowed legs; hence a thorough clinical and radiological examination is needed for its diagnosis. In view of the paucity of reports guiding the treatment of the deformity, we propose a one-level/two-level osteotomy with intramedullary nail fixation as a treatment modality for the tibial bowing.