Shah Alam Khan

Treatment of aneurysmal bone cysts with percutaneous sclerotherapy using polidocanol: A REVIEW OF 72 CASES WITH LONG-TERM FOLLOW-UP

Aneurysmal bone cyst is a rare tumour-like lesion which develops during growth. Our aim was to determine the efficacy of the administration of percutaneous intralesional 3% polidocanol (hydroxypolyaethoxydodecan) as sclerotherapy. Between July 1997 and December 2004 we treated 72 patients (46 males, 26 females) with a histologically-proven diagnosis of aneurysmal bone cyst, at various skeletal sites using this method. The sclerotherapy was performed under fluoroscopic guidance and general anaesthesia or sedation and local anaesthesia. The mean follow-up period was 34 months (26.5 to 80). The patients were evaluated using the Enneking system for functional assessment and all the lesions were radiologically quantified into four grades. The mean age of patients was 15.6 years (3 to 38) and the mean number of injections was three (1 to 5). Ten patients were cured by a single injection. The mean reduction in size of the lesion (radiological healing) was found to be 76.6% (61.9% to 93.2%) with a mean clinical response of 84.5% (73.4% to 100%). Recurrence was seen in two patients (2.8%) within two years of treatment and both were treated successfully by further sclerotherapy. Percutaneous sclerotherapy with polidocanol is a safe alternative to conventional surgery for the treatment of an aneurysmal bone cyst. It can be used at surgically-inaccessible sites and treatment can be performed on an out-patient basis.

Dextrose prolotherapy for recalcitrant coccygodynia

Purpose. To present the results of dextrose prolotherapy undertaken for chronic non-responding coccygodynia in 37 patients. Methods. 14 men and 23 women (mean age, 36 years) with chronic coccygodynia not responding to conservative treatment for more than 6 months were included. 27 of them had received local steroid injections. A visual analogue score (VAS) was recorded for all patients before and after injection of 8 ml of 25% dextrose and 2 ml of 2% lignocaine into the coccyx. In 8 patients with a VAS of more than 4 after the second injection, a third injection was given 4 weeks later. Results. The mean VAS before prolotherapy was 8.5. It was 3.4 after the first injection and 2.5 after the second injection. Minimal or no improvement was noted in 7 patients; the remaining 30 patients had good pain relief. Conclusion. Dextrose prolothearpy is an effective treatment option in patients with chronic, recalcitrant coccygodynia and should be used before undergoing coccygectomy. Randomised studies are needed to compare prolotherapy with local steroid injections or coccygectomies.

Role of MRI in osteosarcoma for evaluation and prediction of chemotherapy response: correlation with histological necrosis

BackgroundHistological necrosis, the current standard for response evaluation in osteosarcoma, is attainable after neoadjuvant chemotherapy.ObjectiveTo establish the role of surrogate markers of response prediction and evaluation using MRI in the early phases of the disease.Materials and methodsThirty-one treatment-naïve osteosarcoma patients received three cycles of neoadjuvant chemotherapy followed by surgery during 2006–2008. All patients underwent baseline and post-chemotherapy conventional, diffusion-weighted and dynamic contrast-enhanced MRI. Taking histological response (good response ≥90% necrosis) as the reference standard, various parameters of MRI were compared to it. A tumor was considered ellipsoidal; volume, average tumor plane and its relative value (average tumor plane relative/body surface area) was calculated using the standard formula for ellipse. Receiver operating characteristic curves were generated to assess best threshold and predictability. After deriving thresholds for each parameter in univariable analysis, multivariable analysis was carried out.ResultsBoth pre-and post-chemotherapy absolute and relative-size parameters correlated well with necrosis. Apparent diffusion coefficient did not correlate with necrosis; however, on adjusting for volume, significant correlation was found. Thus, we could derive a new parameter: diffusion per unit volume.ConclusionIn osteosarcoma, chemotherapy response can be predicted and evaluated by conventional and diffusion-weighted MRI early in the disease course and it correlates well with necrosis. Further, newly derived parameter diffusion per unit volume appears to be a sensitive substitute for response evaluation in osteosarcoma.

VEGF expression as a prognostic marker in osteosarcoma.

The vascular endothelial growth factor (VEGF) pathway is the key regulator of angiogenesis. In osteosarcoma baseline VEGF is of proven prognostic value but prognostic potential of post‐NACT VEGF expression is largely unexplored.

Ponseti's manipulation in neglected clubfoot in children more than 7 years of age: a prospective evaluation of 25 feet with long-term follow-up.

We wanted to evaluate the efficacy of Ponsetis technique in neglected clubfoot in children more than 7 years of age. The results of Ponsetis method were evaluated in 21 children (25 feet) with neglected club feet. Patients were evaluated using the Dimeglio scoring system. All patients underwent percutaneous tenotomy of the Achilles tendon. The mean age at the time of treatment was 8.9 years. The mean follow-up period was 4.7 years. The average Dimeglio score at the start of the treatment was 14.2 compared with an average score of 0.95 at the end of the treatment at 1-year follow-up. Eighteen feet (85.7%) had full correction. Recurrence was seen in six feet (24%). At 4-year follow-up, the average Dimeglio score for 19 feet was 0.18. We recommend that Ponsetis method should be the preferred initial treatment modality for neglected clubfeet.

Locking Compression Plate in Long Standing Clavicular Nonunions With Poor Bone Stock

BACKGROUND Aim of our study was to evaluate the use of Locking Compression Plate (LCP) in patients with long standing nonunions of the clavicle with osteoporotic bones. MATERIAL AND METHODS There were a total of 11 patients. Surgery was performed for painful nonunion with shoulder dysfunction. Average time since injury was 6.9 months (3-39 months). Nonunions were stabilized by a 3.5-mm LCP, applied on the antero-inferior surface of the clavicular shaft. A six-hole LCP was used in eight cases. In three patients seven-hole LCP and in one patient eight-hole LCP was used. The fixation was supplemented by autogenous cancellous bone graft (except in hypertrophic nonunions). Patients were followed for a mean of 2.8 (1-3) years. RESULTS The average time of radiologic union was 5.3 months (3-9 months). Union was achieved in all patients. Subjective clinical assessment was performed using the Disabilities of the Arm, Shoulder, and Hand functional score (DASH). The mean DASH score preoperatively was 42 (25-52) and postoperatively was 24 (11-34). Superficial infection and features of reflex sympathetic dystrophy were seen in one patient each. CONCLUSION Long standing clavicular nonunion with osteopenic bone is a difficult problem to treat. Our study shows that LCPs can be an improved implant option with good fracture healing.

Tuberculosis of the sternum: a clinical study.

A series of 14 patients suffering from tuberculosis of the sternum with a mean follow-up of 2.8 years (2 to 3.6) is presented. All were treated with antitubercular therapy: ten with primary therapy, two needed second-line therapy, and two required surgery (debridement). All showed complete healing and no evidence of recurrence at the last follow-up. MRI was useful in making the diagnosis at an early stage because atypical presentations resulting from HIV have become more common. Early adequate treatment with multidrug antitubercular therapy avoided the need for surgery in 12 of our 14 patients.

Autism Speaks: meeting on folate metabolism and Autism spectrum disorders, March 19-20, 2009, Washington, DC.

OBJECTIVES Some children treated for acute lymphoblastic leukemia (ALL) experience delayed neurocognitive effects similar to autism, which we hypothesize to at least in part be a result of a disruption of folate metabolism due to treatment with an antifolate such as methotrexate. The objectives of this meeting are to review research on the neurocognitive effects of disruption of folate metabolism, to explore the possible role of folate metabolism in autism, and to propose potential avenues of research for further elucidating this role. This meeting was graciously hosted by Autism Speaks and organized by Dr Barton Kamen who at the time was the Chief Medical Officer of the Leukemia & Lymphoma Society and Dr Leanne Chukoskie. Notes from the meeting were recorded by Marcy Ray. The summary of the talks presented here was edited by Drs Kamen and Chukoskie with the help of some of the participants.BACKGROUND The current standard for neoadjuvant chemotherapy (NACT) response evaluation in osteosarcoma is histopathologic necrosis (HN). However, it is accessible only after NACT completion and may get affected by confounding factors. Thus, noninvasive surrogate such as (18)Fluorine-Fluorodeoxyglucose-positron emission tomography-computerized tomography (PET-CT) scan would be useful to individualize therapy. METHODS Thirty-one treatment naive osteosarcoma patients evaluated prospectively by PET-CT scan preceding and after 3 cycles of NACT and surgery during 2006 to 2008. Various anatomic and metabolic parameters of PET-CT scan were compared with HN (good response ≥90% HN) as reference standard. Receiver operating characteristic curves were generated to assess the best threshold and predictability. RESULTS Median age was 17 years; 25 were male patients and 23 were nonmetastatic. Ten cases were good, whereas 21 cases were poor histologic responders. PET-CT parameters including post-NACT (2) and pre-NACT (1) standard uptake value (SUV)max ratio (SUV2:SUV1), SUV2, pre-NACT and post-NACT volumes (V1and V2), change in V after NACT, pre-NACT and post-NACT metabolic burden (MB) and change in MB after NACT correlated with HN. Two independent predictors were identified in stepwise multivariable analysis; if V1 ≤300 mL and SUV2:SUV1 ≤0.48, observed good histologic response proportions was 83%, whereas if V1 >300 mL and SUV2:SUV1 >0.48, it was 0%. CONCLUSIONS NACT response can be predicted reliably by PET-CT scan early in disease course (even at baseline) and PET-CT parameters correlate well with HN. MB seems to be sensitive substitute for response evaluation. Independent predictors may have wider clinical applications if further validation can be done.

Calcaneal osteomyelitis caused by exophiala jeanselmei in an immunocompetent child. A case report.

Fungal osteomyelitis of the calcaneus is very rare and has been reported in immunocompromised children1,2. We present the case of an eight-year-old immunocompetent child with fungal osteomyelitis of the calcaneus from the fungus Exophiala jeanselmei, which has been reported to be a very rare cause of mycetoma pedis. To our knowledge, isolated involvement of the calcaneus with fungal osteomyelitis has not been reported previously. The family of our patient was informed that data concerning the case would be submitted for publication. Fig. 1 Clinical photograph showing multiple sinuses and granulation tissue involving the left heel. An eight-year-old boy presented with a six-month history of pain, swelling, and multiple discharging sinuses over the heel of the left foot. There was no history of trauma or skin puncture, but there had been intermittent discharge of black-colored granules from the sinuses along with an associated occasional low-grade fever. There were no systemic or constitutional symptoms otherwise. He had received treatment in the form of local dressings and broad-spectrum antibiotics from his primary care physician, but these treatments had had no appreciable effect. Fig. 2 Radiograph of the left heel, showing the honeycomb appearance of the extensive loculated lytic areas of destruction within the body of the calcaneus. Clinical examination of the left heel revealed discharging sinuses with black, soft, …

Role of vascular endothelial growth factor as a tumour marker in osteosarcoma: a prospective study

PurposeA prospective study was undertaken to evaluate the diagnostic and prognostic significance of serum levels of vascular endothelial growth factor (VEGF) in patients with primary localised osteosarcoma.MethodsSerum VEGF levels were measured by an enzyme-linked immunosorbent assay (ELISA) in blood samples collected prechemotherapy, postchemotherapy, and postsurgery in 40 patients with histologically proven primary osteosarcoma. Comparison was made between serum VEGF level of healthy controls (n = 10) and prechemotherapy patient sera to evaluate its diagnostic potential. Serum VEGF levels of patients with and without metastasis were compared. Immunohistochemical staining was done to establish the correlation between serum and tissue VEGF expression. The Kaplan–Meier curve was used for survival analysisResultsNo significant relationship was observed between serum VEGF levels and age, gender, tumour size, local recurrence or histopathological subtypes of osteosarcoma. We observed significantly raised mean serum VEGF in patient sera compared with healthy controls (p = 0.001). Significant fall in mean serum VEGF level was observed following chemotherapy (p = 0.001). Patients who developed metastases had significantly higher serum VEGF levels compared with the nonmetastatic group (P = 0.001). Serum VEGF levels correlated well with VEGF expression in tissues.ConclusionSerum VEGF levels might prove to be of diagnostic, predictive and prognostic value in patients with primary osteosarcoma, although further studies with larger sample size and longer follow-up is needed to support the hypothesis.