Sarvdeep Dhatt

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.

Proximal femoral medullary canal diameters in Indians: correlation between anatomic, radiographic, and computed tomographic measurements

Purpose. To compare anatomic, radiographic, and computed tomographic (CT) measurements of the proximal femur in an Indian population. Methods. 26 left and 24 right dried cadaveric femurs were obtained. Each femur was divided into segments at 10 cross-sectional levels from proximal to distal. At each level, anteroposterior (AP), lateral, 45° internal oblique, and 45° external oblique diameters of the medullary canal weremeasured using radiography and CT. To minimise magnification, the femur was placed over the film/board. The neck shaft angle, femoral head offset, neck length, and femoral head diameter were also measured. For anatomic measurements, the cross-sections of the medullary canal at levels 3 to 10 were measured using a calliper. Anatomic measurements were compared with radiographic and CT measurements, and the distortion calculated. Correlation between the 3 modalities was calculated using the Pearson correlation coefficient. Accuracy index of the 2 diagnostic modalities was measured, based on the differences between anatomic and radiographic/CT measurements. Lower accuracy indices indicated higher accuracy. Results. On AP radiographs of all femurs, the mean femoral head diameter was 45 mm, the mean neck shaft angle was 132°, the mean femoral head offset was 42 mm, and the mean neck length was 63 mm. With regard to medullary canal diameters, the radiographic and CT measurements were smaller than anatomic measurements at proximal levels, but similar at distal levels. Variations between femurs and between the 4 diameters at the same level were greater at proximal levels. Conclusions. Combined use of radiography and CT is recommended for preoperative assessment of implant size, particularly in uncemented arthroplasty where an optimal fit is essential for biological fixation.

The influence of foot and ankle injury patterns and treatment delays on outcomes in a tertiary hospital; a one-year prospective observation.

BACKGROUND Ankle and foot fractures are amongst the most common injuries, and patterns may vary from primary care set up to tertiary hospitals. Severe foot injuries are projected to have significantly worse outcomes and surgical delays are thought to alter prognosis. METHODS All patients with foot and ankle trauma were prospectively evaluated at a Tertiary trauma centre over one year. The incidence, fracture patterns, risk factors, and outcomes were evaluated, and cases were divided into simple foot injuries (FASS ≤ 3) and severe foot injuries (FASS>3). Injury mechanisms, associated injuries, and delays in treatment were evaluated, and outcomes were analyzed using Visual-Analogue Scale Foot and Ankle (VASFA), Maryland Foot Score (MFS) and Foot and ankle disability index (FADI). RESULTS 294 Foot and Ankle injuries (51 females, 243 males) were encountered in 2919 trauma cases (incidence of 10%). 80 patients (27.2%) had simple foot injuries and 214 (72.8%) had severe foot injuries. 29 patients (9.9%) were below 18 years; most (65.3%) patients were between 18 and 45 years age. Road traffic accident was most commonest mode of injury, with ankle fractures (30.6%) the most common. Metatarsal fractures (27.9%) and calcaneal fractures (21.4%) were 2nd and 3rd most common injuries in the foot. Surgical delay averaged 1 day in both severe and simple injuries. Injury led to 32 (10.9%) below knee amputations. Outcome evaluation in 127 (91 severe, 36 simple injuries) patients showed mean Maryland foot score of 89.30 in simple injury group and 84.87 in severe injury group. Mean VASFA score was 82.87 (simple) and 81.87 in severe injury, and mean FADI score was 93.13 (simple) and 91.05 (severe injury). More detailed analysis revealed that more good scores (64.4%) were documented in severe injuries group, and more excellent scores (52.8%) in simple injuries group. CONCLUSION Foot injuries constitute 10% of all orthopaedic trauma at tertiary hospitals; Majority of them are severe foot injuries, with 68.7% being open injuries. Surgical delay was similar in simple and severe foot and ankle injuries. Outcomes of severe injuries were similar to simple foot and ankle injuries, reflecting on the quality of care that could be administered to them when they present to tertiary hospitals.

Migration of anterior spinal rod from the dorsolumbar spine to the knee: an unusual complication of spinal instrumentation.

Study Design. A retrospective case report. Objective. The objective of the present article is to report an unusual complication of spinal instrumentation. Summary of Background Data. Migration of spinal implants to distant site is quite unusual, and literature till date has only 2 case reports. For the first time, we are reporting a case of anterior spinal rod migration from the dorsolumbar spine to the knee joint in a young male patient after 4 years of its fixation following spinal injury. Methods. A 38-year-old man presented with pain, swelling, and restriction of movement of left knee joint. On clinical examination, a hard movable rod was palpable which was suspected to be a metallic foreign body initially. The detailed history of the patient revealed anterior spinal fixation following posttraumatic injury of L1 vertebra 4 years back. Radiograph showed a metallic rod lying around the knee joint with absence of anterior rod of dorsolumbar spine. The suspicion of migration of the rod was confirmed by surgical exploration. Results. After 1 week of removal of the rod, patient became totally asymptomatic with normal full range of movement of the knee joint. Conclusion. Though rare, migration of implants from the spine to the distant sites is always a possibility and may have severe complications too. We stress the need of long-term follow-up with clinical examination and radiographs to prevent missing such a complication.

Chondroblastoma in a Metatarsal Treated with Autogenous Fibular Graft: A Case Report

Chondroblastoma is a relatively rare tumor that mimics giant cell tumor and displays a predilection for long bones. In the present report, we describe the case of a benign chondroblastoma localized to the second metatarsal in a 20-year-old male who presented with a 2-year history of painless left foot swelling. Treatment of the tumor involved excision of the second metatarsal with use of an autologous structural fibular bone graft to stabilize the metatarsus and second toe. After 27 months of follow-up, the patient was ambulating well in regular shoes, with no clinical or radiographic evidence of tumor recurrence.

Metaphyseo-diaphyseal junction fracture of distal humerus in children.

Six metaphyseo-diaphyseal junction fractures of distal humerus and 182 supracondylar fractures of humerus treated in our institute over a period of 5 years were retrospectively analyzed. Clinical data regarding child’s age, neurovascular status, mechanism of injury, mode of treatment, and ultimate clinical outcome were collected for both these fractures and a comparison was made. Oblique (n=2), comminuted (n=3), and transverse types (n=1) of fracture patterns were identified at distal humeral metaphyseo-diaphyseal junction. The oblique and comminuted fractures were managed by closed reduction and plaster of Paris cast, whereas the only transverse fracture was treated by closed reduction and Kirschner wire fixation. In contrast, 125 patients of supracondylar fractures were treated by closed reduction and plaster of Paris cast and the remaining 57 fractures needed Kirschner wire fixation after closed reduction. Assessment by Flynn criteria after 1 year after of injury revealed better functional outcome in metaphyseo-diaphyseal junction fractures. Although transverse fractures are unstable and may require surgical fixation; oblique and comminuted fractures at the metaphyseo-diaphyseal junction of distal humerus can be managed conservatively.

Peripheral primitive neuroectodermal tumor causing cauda equina syndrome with destruction of L5 vertebra

A 24-year-old male patient presented with cauda equina lesion symptoms. His clinicoradiological examination including X-rays, CT scan and MRI revealed destruction of L5 vertebral body, pedicle and a mass extending to lateral recess and left intervertebral foramina causing pressure over the thecal sac. A CT guided FNAC was inconclusive. Open biopsy and hemilaminectomy of L5 vertebra was performed. Histopathology and immunocytochemical analysis revealed it to be primitive neuroectodermal tumor. Patient was given chemotherapy and radiation therapy. His lower limb power improved by grade I post operatively and at 2 years follow-up bowel/bladder recovery was noticed. Patient died after 2.5 years of surgery because of pulmonary metastasis.

Morphometric Analysis of Cervical Spine Pedicles in an Indian Population.

Introduction: The quantitative understanding of cervical pedicle morphology minimizes the injury to the neurovascular structure and improves the surgical outcome. The aim of this study was to investigate the morphometry of the cervical pedicle using computed tomography (CT) scans. Materials and methods: The CT scan was performed in eleven cervical spine injury patients and the axial and sagittal images were used to calculate the four linear parameters—outer pedicle width (OPW), inner pedicle width (IPW), pedicle height (PH), pedicle axis length (PAL), and the pedicle transverse angle (PTA). Results: A total of 110 pedicles were measured and studied. The mean OPW, IPW, and PH showed gradual increase of the value from C3 to C7. The PTA showed maximum value at C4 vertebra and minimum value at C7 vertebra. Conclusion: The study demonstrated that pedicle dimensions were small in comparison to European and other Asian populations. To enhance the safety of cervical pedicle screw insertion, the pedicle dimensions and trajectories should be determined individually. The screw diameter should also be optimal to avoid pedicle violations because of narrow OPW in our study population.

A Modified Anterior Approach to L 1 Vertebra: An Early Clinical Experience

Purpose: To study the results of a new surgical approach to the L1 vertebra which is a modified anterior approach and is extrapleural and retroperitoneal in nature. Materials and Methods: Five patients with fracture L1 vertebra underwent surgical decompression and stabilization via this modified anterior approach. In this approach, the L1 vertebra is approached anteriorly without invading the pleural cavity or the peritoneal cavity by gentle, blunt dissection (extrapleural and retroperitoneal approach) Results: No significant complications, especially pulmonary complications, were noted in any of the 5 cases. Conclusions: This modified anterior approach to L1 vertebra allows effective, circumferential decompression of the thoracolumbar spinal canal without the associated morbidity of the traditional anterior approach. However, comparative studies between the 2 approaches will be needed in the future to more accurately ascertain benefits of this approach.

Spontaneous spinal epidural abscess in a normoglycemic diabetic patient – Keep it as a differential

Spinal epidural abscess (SEA) is a rare and serious condition which can lead to permanent neurological deficit. Spontaneous SEA is even rarer condition with an incidence of less than 1 per 10,000 person-year. Being spontaneous, it has high chances of being misdiagnosed, more so when the risk factors are not clearly explainable for the condition. This is a case report of such a case in a middle aged normoglycemic recently diagnosed diabetic man with atypical presentation. The diagnosis was made after magnetic resonance imaging and confirmed after surgical intervention in form of spinal decompression and patient recovered after appropriate antibiotics. This article also sums up the risk factors of spontaneous SEA.