Varatharaj Mounasamy

Salvage of failed massive allograft reconstruction with endoprosthesis.

A subset of osteoarticular allograft reconstructions after tumor resection ultimately will fail in patients achieving long-term survival. There are several alternative surgical approaches to revising these reconstructions. We retrospectively evaluated the outcome of 20 patients who had allograft reconstruction with a modular endoprosthesis. All patients had a failed massive allograft (average length, 15.7 cm) after tumor resection about the shoulder and knee. The reasons for original allograft failure were fracture (14 patients), infection (five patients), and both (one patient). Followup of the patients averaged 159.7 months (range, 63-293 months) after allograft reconstruction and 77 months (range, 24-234 months) after endoprosthetic revision. The average number of operative procedures each patient had was 4.1 (range, 2-15 procedures). Two patients had amputations for resistant periprosthetic infections. A successful revision procedure was accomplished in 80% of the patients, and 90% of the patients retained functional limbs at recent followup. The predicted 5-, 10-, and 15-year survivals were 92%, 55% and 28% respectively. Musculoskeletal Tumor Society scores averaged 76% (range, 60-93.3%). When used to salvage massive allograft failure from infection and fractures, endoprosthetic revision preserves limb function with minimal complications. Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Rotator cuff tears: An evidence based approach

Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, cost-effective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

Ganglioneuromas of the sacrum–a report of two cases with radiologic–pathologic correlation

Ganglioneuromas are rare, benign, well-differentiated, slow-growing tumors, composed of ganglion cells and Schwann cells. Ganglioneuromas are derived from the neural crest cells and can arise anywhere from the base of the skull to the pelvis. We present and discuss the clinicopathologic and radiographic features of two patients with ganglioneuroma arising from the sacrum, a rare anatomic location.

The successful use of vancomycin-impregnated cement beads in a patient with vancomycin systemic toxicity: a case report with review of literature

We report the use of vancomycin laden antibiotic cement beads in a patient with calcaneal osteomyelitis who had prior acute kidney injury (AKI). The patient experienced non-oliguric renal failure after exposure to intravenous vancomycin and recovered well after antibiotic discontinuation and adequate hydration. We are not aware of any similar case report where vancomycin laden antibiotic cement has been used in a patient with AKI to vancomycin.

Stiffness following total knee arthroplasty : evaluation and treatment

Total knee arthroplasty (TKA) for advanced arthritis of the knee is one of the most successful orthopaedic reconstructive procedures performed with excellent patient satisfaction and functional outcomes. Stiffness following total knee arthroplasty is relatively common and has a multifactorial etiology with associated pain and decreased range of motion. Preoperative flexion is found to be an important variable of post-operative range of motion and hence, the patients should be well informed of the outcomes, activity restrictions and questioned as to their expectations before surgery to achieve an optimum result. Detailed analysis of the etiology of stiffness with specific reference to patient factors, technical errors and others factors during the course of operative treatment and rehabilitation need to be assessed after ruling out infection. Treatment methods for stiffness following TKA include non-operative management, extensive physiotherapy, manipulation under anesthesia, arthroscopic arthrolysis, open arthrolysis with or without component exchange and revision arthroplasty. Treatment should be directed towards the specific cause, and poor results are likely for revision TKA surgery without identifying the specific etiology.RésuméL’arthroplastie totale du genou (PTG) pour arthrose évoluée du genou est l’une des plus belles réussite de l’orthopédie, avec une grande satisfaction du patient t et un bon résultat fonctionnel. L’enraidissement du genou après arthroplastie est par contre une complication relativement banale avec une étiologie multifactorielle, associant douleur et diminution de l’amplitude de mobilité. L’angle de flexion pré-opératoire conditionne nettement l’amplitude postopératoire et par conséquent le patient doit être bien informé sur le résultat final, sur l’éventuelle restriction des activités et doit être interrogé avant l’intervention sur ses attentes, afin d’avoir un résultat optimal. Une analyse détaillée de l’étiologie de l’enraidissement avec une attention particulière portée sur les facteurs inhérents au patient lui-même, aux erreurs techniques et autres acteurs pouvant intervenir pendant le déroulement de la chirurgie et de la rééducation, doit être menée après avoir exclu les causes infectieuses. Les méthodes thérapeutiques de la raideur après PTG comprennent des traitements non opératoires, de la physiothérapie intensive, de la mobilisation sous anesthésie générale, de l’arthrolyse arthroscopique et enfin de l’arthrolyse à ciel ouvert avec ou sans changement des pièces prothétiques et arthroplastie de reprise. Le traitement doit être correctement ciblé car sinon les arthroplasties de reprises n’ont que des résultats médiocres.

Anaplastic large cell lymphoma presenting as an epiphyseal lytic lesion—a case report with clinico-pathologic correlation

Anaplastic large cell lymphoma (ALCL) is predominantly a systemic disease with nodal involvement, but extranodal involvement can occur either as the primary presentation or during the disease course. Primary epiphyseal involvement is extremely rare with lymphomas. This case report illustrates an 8-year old boy who first presented with pain over the right upper extremity, which was initially treated as epiphyseal osteomyelitis. A few weeks later, he presented with abdominal pain and an abdominal wall mass, which on biopsy proved to be an anaplastic large-cell lymphoma.

Bilateral synchronous quadriceps tendon rupture: a case report

Bilateral spontaneous rupture of quadriceps tendons is rare and is usually associated with predisposing comorbid conditions. We report an uncommon case of bilateral synchronous rupture of the quadriceps tendon after a ground level fall in a 51-year-old male, 8 years after renal transplant.RésuméLa rupture spontanée du tendon quadricipital est rare, elle est habituellement liée à une comorbidité. Nous rapportons un cas inhabituel de rupture bilatérale synchrone après chute au sol d’un patient de 51 ans, huit ans après greffe de rein.

Peri-implant fracture of the distal tibia after intra-medullary nailing of a tibial fracture: a report of two cases

Fracture of the tibia in the area of a pre-existing implant is not common. We report two cases of a fracture of the distal tibia at the distal interlocking screw site. We are not aware of any similar reports in the literature.

Primary total knee arthroplasty for a complex distal femur fracture in the elderly: a case report

Fractures of the distal femur in the elderly account for 4–5% of fractures in the geriatric population and are usually due to low energy ground level fall onto a flexed knee. A high incidence of postoperative complications and poor results are secondary to associated co-morbidities and osteopenia in this age group resulting in high levels of comminution and articular damage at the time of injury. Preservation of knee function and early weight bearing should be the objectives of management in the geriatric population. We present in this case report of an elderly patient with comminuted distal femoral fracture who had Primary total knee arthroplasty as an alternative to internal fixation.RésuméLes fractures du fémur distal du vieillard représentent entre 4–5% des fractures des personnes âgées et surviennent habituellement par une chute sur le sol à basse énergie et le genou étant fléchi. Une haute fréquence de complications post-opératoires et des résultats médiocres sont de règle, associés à des co-morbidités, à l’ostéoporose fréquente à cet âge et responsable de lésions articulaires au moment du traumatisme.. La préservation de la fonction du genou et la mise en charge précoce doivent être les objectifs du traitement de la population âgée. Nous présentons un cas chez une personne âgée avec une fracture comminutive du fémur distal, traitée par une arthroplastie totale de première intention du genou, comme alternative à l’ostéosynthèse interne.

Acute sciatic neuritis following total hip arthroplasty: a case report

Nerve injuries after total hip arthroplasty are relatively uncommon, but a higher prevalence has been reported in revision arthroplasties, in women and in patients with dysplastic hips. We report a case of a patient who had a painful neuritis of the sciatic nerve after primary arthroplasty, without any objective evidence of motor or sensory deficit and had complete relief of pain after the limb lengths were matched to the contra-lateral side after revision arthroplasty.