Vivek Trikha

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.

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.

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, …

A study of vascular injuries in pediatric supracondylar humeral fractures.

194 children with supracondylar fractures of the humerus were reviewed. Of the 49 children with Gartland grade III displacement, signs of vascular compromise were clinically suspected in 5 cases. Immediate open reduction, internal fixation and exploration were performed. Four children had a satisfactory outcome. One child required amputation. A careful clinical evaluation for vascular injury and an aggressive surgical approach is suggested, when indicated.

RETROPERITONEAL FIBROSIS: A RARE COMPLICATION OF POTT’S DISEASE

A 45-year-old man presented with general malaise, anorexia, nausea and backache 6 months in duration. Medical history was significant for Pott’s disease 3 years earlier for which he had undergone antituberculous treatment for 1 year. Physical examination was unremarkable. Laboratory evaluation revealed increased creatinine and blood urea nitrogen (5.4 and 70 mg./dl., respectively). Ultrasonography of the abdomen showed bilateral moderate hydronephrosis. Computerized tomography (CT) of the abdomen revealed a soft tissue density mass in the retroperitoneum along L3 to L4 vertebra involving the inferior vena cava and both ureters (fig. 1). Bilateral ureteropyelogram demonstrated medial displacement of both ureters at L3 to L4 along with hydronephrosis on both sides. At surgery a glistening, whitish firm mass was found in the retroperitoneum encasing the ureters and inferior vena cava, extending from L2 to L4 vertebra. Bilateral ureterolysis with omental wrapping was done. Bilateral Double J (Medical Engineering Corp., New York, New York) stents were placed. At 6-week followup hydronephrosis had improved on both sides and serum creatinine decreased to 2.2 mg./dl. Magnetic resonance imaging from 3 years ago was reviewed and findings correlated with the present CT (fig. 2). Urine polymerase chain reaction and culture for Mycobacterium tuberculosis were negative. Histological examination of the specimen re- vealed chronic inflammatory cells with fibrotic collagenous tissue. At 3-month followup creatinine was 1.8 mg./dl. and bilateral hydronephrosis had subsided. DISCUSSION

Giant cell tumor of bone: Is curettage the answer?

Background: Giant cell tumors (GCT) are neoplasms of mesenchymal stromal cells with varied manifestations. There is no uniform accepted treatment protocol for these tumors, Materials and Methods: 49 cases of proven giant cell tumors of appendicular skeleton, 27 prospective and 22 retrospective constituteed this study. The retrospective cases were collected by using computerized data base collection method. The patients were evaluated clinically, radiologically and by histology. Companacci grading and Enneking staging was used in the study. Two treatment modalities were used a) extended curettage (with/ without bone grafting/ cementation) or b) wide excision and reconstruction with a prosthesis or arthrodesis. Functional evaluation was done by Ennekings system. Chi square tests, mann-whitney test and ANOVA were used for statistical analysis. Results: The average age was 26.82 years (16-50 years). 25 patients (51%) were recurrent GCT at presentation. The commonest site was lower end of femur (16 cases, 32.65%) and upper end of tibia (13 cases, 26.53%). 40 (81.63%) tumors had less than 5 mm of subchondral bone free of tumor. 35 (71.43%) tumors were Ennekings surgical stage III and companacci grade III. Pathological fractures were seen in 12 (24.49%) cases. Intra-lesional currettage was used in 28 and enbloc excision in 19 patients and 2 (4.08%) underwent amputation. The average follow up period was 18.6 months (range 2-84). One recurrence was seen in a grade III recurrent distal radial lesion in the intralesional curettage group (3.57%) Ennekings functional score with intralesional curettage (25.41) was better than enbloc excision (21.37). Enbloc excision had higher rates of infections (36.84 % Vs 25%) and soft tissue coverage problems (21.05% Vs 0). Conclusion: Intralesional therapy has a better functional outcome and less complications than enbloc excision, albeit with a high recurrence rate which can however be effectively treated with repeat extended curettage.

Isolated tuberculosis of the coccyx

Vertebral disease constitutes approximately 50% of all skeletal tuberculosis. We describe a patient who developed a discharging sinus at the tip of the coccyx. Extensive examination revealed isolated tuberculosis of the coccyx. Although rare, the condition should be suspected in patients presenting with a chronic sinus in the sacrococcygeal area and a lytic lesion in the coccyx on CT or MRI, particularly in the developing world.

Role of rhenium-188 tin colloid radiosynovectomy in patients with inflammatory knee joint conditions refractory to conventional therapy

AimTo evaluate the treatment response of rhenium-188 (188Re) tin colloid radiosynovectomy (188Re-RSV) in patients with inflammatory knee joint conditions refractory to conventional treatment. Materials and methodsSixty-one knee joints in 48 patients with chronic synovitis caused by various inflammatory knee joint diseases refractory to conventional therapy were included in this prospective study. All patients were assessed clinically for pain, tenderness, joint swelling, mobility, analgesic intake, and blood pool activity on bone scan. Different scores were assigned to all these parameters. RSV of knee joint was done using intra-articular injection of 555 MBq of 188Re tin colloid. Response was assessed at 3, 6, and 12 months using various clinical parameter scores and blood pool bone scan mentioned above and categorized as responders and nonresponders on the basis of change in percentage of cumulative scores. ResultsOf the 61 joints, 57 were responder and four were nonresponder at 3-month post-RSV. Out of 57 responders, seven had recurrence on further follow-up (three at 6 months and four at 12 months). There was a statistically significant reduction in clinical parameters cumulative scores at 3, 6, and 12 months when compared with baseline (P<0.0001) in responder group. Blood pool scinitgraphy also showed decrease in blood pool activity compared with the baseline. There was statistically significant association between the responder group and shorter duration of disease (P=0.011). Patients having normal or minor X-ray changes, little or no swelling, mild tenderness, and better mobility were independently associated with good response. Conclusion188Re tin colloid synovectomy is a useful treatment modality in patients with chronic inflammatory knee joint conditions refractory to conventional treatment. Patients with shorter duration of disease, normal or minor X-ray findings, little or no swelling, mild tenderness, and better mobility are better candidates for RSV.