Shivinder Singh Gill

Tuberculosis of Bones and Joints of the Foot: An Analysis of 22 Cases

Skeletal tuberculosis constitutes 1% to 3% of extrapulmonary cases and involvement of foot bones is rare. Lack of awareness and a confusing clinical and radiological picture often lead to a delay in diagnosis. We reviewed 23 feet seen over a 3.5-year period. Most cases were children or young adults less than 40 years of age; isolated bony involvement was seen in 10 feet, with the calcaneus being involved in five cases. Articular involvement at presentation was seen in 13 cases and these cases had significantly higher delays in diagnosis. Twenty cases responded to antitubercular therapy alone while one case had to be operated (there was one fatal outcome). Complete resolution of sequestra was seen with antitubercular therapy alone. The results were better in cases with isolated bony involvement, while cases with joint involvement had residual sequelae in the form of stiffness or pain. Two patients were advised arthrodesis. Early diagnosis and antitubercular therapy is essential to prevent joint involvement from periarticular bony lesions; surgical intervention is rarely needed. A high index of suspicion has to be maintained in high risk groups like Asian immigrants. Concomitant extraskeletal lesions may not always be present.

En bloc excision and autogenous fibular reconstruction for aggressive giant cell tumor of distal radius: a report of 12 cases and review of literature

IntroductionGiant cell tumor (GCT) of distal radius follows a comparatively aggressive behaviour. Wide excision is the management of choice, but this creates a defect at the distal end of radius. The preffered modalities for reconstruction of such a defect include vascularized/non-vascularized bone graft, osteoarticular allografts and custom-made prosthesis. We here present our experience with wide resection and non-vascularised autogenous fibula grafting for GCT of distal radius.Materials and methodsTwelve patients with a mean age of 34.7 years (21-43 years) with Campanacci Grade II/III GCT of distal radius were managed with wide excision of tumor and reconstruction with ipsilateral nonvascularised fibula, fixed with small fragment plate to the remnant of the radius. Primary autogenous iliac crest grafting was done at the fibuloradial junction in all the patients.ResultsMean follow up period was 5.8 years (8.2-3.7 years). Average time for union at fibuloradial junction was 33 weeks (14-69 weeks). Mean grip strength of involved side was 71% (42-86%). The average range of movements were 52° forearm supination, 37° forearm pronation, 42° of wrist palmerflexion and 31° of wrist dorsiflexion with combined movements of 162°. Overall revised musculoskeletal tumor society (MSTS) score averaged 91.38% (76.67-93.33%) with five excellent, four good and three satisfactory results. There were no cases with graft related complications or deep infections, 3 cases with wrist subluxation, 2 cases with non union (which subsequently united with bone grafting) and 1 case of tumor recurrence.ConclusionAlthough complication rate is high, autogenous non-vascularised fibular autograft reconstruction of distal radius can be considered as a reasonable option after en bloc excision of Grade II/III GCT.

Tuberculous osteomyelitis of the cuboid: a report of four cases.

Osteoarticular tuberculosis, although rare, has shown a resurgence in recent times, especially in immunocompromised patients. Involvement of the foot is infrequent, and the differential diagnosis is confusing, leading to diagnostic delays. We reviewed four cases of tuberculosis of the cuboid where the infection was limited to the bone without articular involvement. All four cases were adults and diagnostic delays were observed in all. Three of the cases had an osteolytic lesion on radiographs resembling a space-occupying lesion. Magnetic resonance imaging (MRI) or Computed tomography (CT) scans were helpful in three cases, and post-treatment MRI helped in evaluating outcome in one case. Antitubercular chemotherapy was sufficient to cause resolution of the lesion in three cases, while in one case surgical intervention was necessary. Since isolated osteomyelitis is usually seen only in the early stages of the disease process, early diagnosis and appropriate therapy are imperative to get good long-term results. Concomitant extraskeletal lesions are not always seen, nor is the organism cultured in a majority of the cases. Thus a high index of suspicion is mandatory in high-risk groups (immigrants, immunocompromised cases or those with history of contact); clinical and radiologic features, along with histopathologic evidence of granulomatous pathology should be sufficient to initiate therapy.

Management of giant cell tumor of the tarsal bones: a report of nine cases and a review of the literature.

Giant cell tumor of the tarsal bones is uncommon and therapeutic options are ill defined. We report on nine cases of giant cell tumors of the tarsal bones treated by excision of the complete bone in 6 cases, partial excision in 1 case, and curettage and bone grafting in two cases. There was no recurrence at an average 25.8-month follow-up. Function after calcanectomy was satisfactory. Excision of the talus may or may not be followed by arthrodesis, but arthrodesis is essential after excision of all the other tarsal bones except the calcaneus. We advocate aggressive surgical measures in these cases; amputation should be reserved for recurrences only. Satisfactory function may be expected after excision of tarsal bones.

Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children

Summary Seventeen transcervical/basal femoral neck fractures in children were treated by free fibular graft and cancellous lag screw. Two cases were failures of a previous surgery, and 15 had been untreated for 3 weeks or more. Four cases had radiological evidence of avascular necrosis of the head and one of the neck preoperatively; five cases had neck resorption. At an average of 48.1 months postsurgery all fractures had united and there was only one new case of avascular necrosis. Four cases had coxa vara, and four cases had premature epiphyseal closure. There were 13 good, three fair, and one poor result(s) using Ratliffs criteria. We recommend this procedure in cases with delayed initial appearance or failed previous surgery. Complications of the procedure such as long screw/graft and fibular fracture are preventable. The incidence of coxa vara in cases with neck resorption may be reduced by adding subtrochanteric osteotomy to the procedure.

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.

Primary malignant and potentially malignant tumours of the foot

Abstract Primary malignant soft tissue and bony tumours of the foot are rare; these are usually misdiagnosed, leading to either a delay in appropriate treatment or improper surgical excision. We reviewed 20 cases of foot tumours, 5 of which were malignant soft tissue tumours, all of which were treated by wide excision or amputation. Six cases of giant cell tumour were seen; the calcaneum was the most frequently involved bone (3 giant cell tumour, 3 malignant cases). All giant cell tumours were treated by wide excision with or without bone grafting. Treatment protocols for 9 malignant bony tumours included amputation/wide excision and/or chemotherapy/radiotherapy and only irradiation for the lymphomas. Only 3 malignant cases (1 Ewings sarcoma, 1 chondrosarcoma and 1 neurofibrosarcoma) developed metastatic lesions. All 3 could probably have been prevented by early radical surgery. It is recommended that all malignant tumours of the foot (except lymphomas) be subjected to early radical excision with or without chemotherapy. Giant cell tumours can be treated by excision of the involved bone, with surprisingly little disability.

Regeneration of the Achilles tendon after percutaneous tenotomy in infants: a clinical and MRI study.

We aimed to study the regeneration potential of tendo-achilles after percutaneous tenotomy in 34 clubfeet treated by Ponsetis technique. Clinical and MRI evaluation was done after 6 weeks and 6 months of tenotomy to assess the regeneration of the tendon. At the follow-up, Achilles tendon was palpated like a cord in all the feet. MRI study revealed continuity of the tendon in all cases at the end of 6 weeks and 6 months of the tenotomy. Thus, it could be concluded that tendo-achilles does regenerate following percutaneous tenotomy, used in the correction of clubfoot using Ponsetis technique.

Results of dorsal approach in surgical correction of congenital vertical talus: an Indian experience.

We present our experience in the correction of congenital vertical talus deformity in a single stage using dorsal approach. We operated on 20 feet using the dorsal approach and the average age of patients at the time of surgery was 16 months. Talonavicular reduction was achieved in all the feet and there was significant improvement in postoperative talo-calcaneal and talo-first metatarsal angles, which were well maintained at a follow-up of 4 years. In conclusion, the dorsal approach efficiently manages the deformities of a congenital vertical talus foot and provides consistent radiological and clinical outcome with minimal complications such as revision surgeries and osteonecrosis of the talus.

Bacterial load in tissues and its predictive value for infection in open fractures

The role of quantitative bacteriology is considered controversial for the prediction of infection in open fractures. A study was done in 20 patients with open fractures. Post debridement pieces of skin, muscle and periosteal tissue were obtained for quantitative bacterial counts. Among a total of 50 samples from all of the tissues, 29 showed positive bacterial counts (16 of 20 skin, 11 of 20 muscle and 2 of 10 periosteum samples). By quantitative estimation, the bacterial load was >105 per gram in 10 skin and 3 muscle tissue samples. Infection developed in 9 of the 20 cases within one month, and eight of these patients had contamination of >105 per gram in 8 of the skin but only 3 muscle samples. It was concluded that with tissue specific bacterial load estimation, prediction of subsequent infection can be made if skin tissue contains >105 per gram, or if muscle tissue carries any level of bacterial presence.