Vk Gautam

Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis: clinical and ultrasonographic evaluation

Purpose. To evaluate the clinical and ultrasonographic changes in the morphology and vascularity of the common extensor tendon after injecting platelet-rich plasma (PRP) or corticosteroid (CS) for recalcitrant lateral epicondylitis (LE). Methods. 30 patients aged 18 to 60 years with recalcitrant (>6 months) LE not responsive to oral medication or non-invasive treatment were randomised to receive PRP (n=15) or CS (n=15) injection. Patients were assessed using the visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand Scale (DASH) score, Oxford Elbow Score, modified Mayo Clinic performance index for the elbow (modified Mayo score), and hand grip strength. Ultrasonography was performed by a musculoskeletal ultrasonologist to evaluate for tear at the common extensor origin, oedema at the common extensor origin, cortical erosion, probe-induced tenderness, and thickness of the tendon. Results. The VAS for pain, DASH score, Oxford Elbow Score, modified Mayo score, and hand grip strength all improved significantly from pre-injection to the 6-month follow-up in the PRP and CS groups. However, in the CS group, the scores generally peaked at 3 months and then deteriorated slightly at 6 months indicating recurrence of symptoms, which involved 46.7% of the CS patients. At 6 months, the number of patients positive for various ulrasonographic findings generally decreased. However, in the CS group, the number of patients with reduced thickness of the common extensor tendon increased from 2 to 12, and the number of patients with cortical erosion at the lateral epicondyle increased from 9 to 11. Conclusion. PRP appeared to enable biological healing of the lesion, whereas CS appeared to provide short-term, symptomatic relief but resulted in tendon degeneration.

Management of idiopathic clubfoot in toddlers by Ponseti's method.

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10–15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.

Intrapelvic protrusion of guide wire during fixation of fracture neck of femur

Internal fixation is a common modality of treatment for fractures around the hip. In various kinds of osteosynthesis, guide wires are used for localizing the site of entry and to determine the final position of the screws or fixation devices. We report two instances of intrapelvic protrusion of a guide wire during internal fixation of a fractured neck of femur. Though there are several reports of post-operative k-wire migration around the hip [5] and shoulder girdle [2,3,6,7,10] (occurring as early as 7 days) [9] the aforesaid complication has not been reported in the literature, to our knowledge.

The Results of Nonoperative Treatment of Craniovertebral Junction Tuberculosis: A Review of Twenty-six Cases

BACKGROUND There is scarce information on craniovertebral junction tuberculosis even in developing countries. The pendulum of treatment in craniovertebral junction tuberculosis has periodically vacillated between nonoperative management and radical surgery. METHODS We performed a retrospective review of prospectively collected clinical and radiographic data on twenty-six consecutive patients with craniovertebral junction tuberculosis who were treated nonoperatively in our institution. The patients who had weakness of the limbs, pyramidal signs, or evidence of atlantoaxial dislocation and/or basilar invagination were immediately managed with immobilization with Crutchfield tongs traction (Group A), followed by halo-vest application. Patients without a neurological deficit, pyramidal signs, or atlantoaxial dislocation or basilar invagination were treated with cervical immobilization with early application of a halo vest (Group B). RESULTS The common presenting features were neck pain, restriction of neck movement, and spastic weakness of limbs. A retropharyngeal purulent fluid collection and osseous involvement of the dens and lateral mass of the atlas were the common radiographic findings. Twelve patients were partially or completely dependent on others for activities of daily living, and marked ligamentous and bone destruction with displacement at the atlantoaxial level was seen in eight patients at the time of presentation. The twenty patients in group A had cervical traction for a mean of 5.9 weeks, and a halo vest was applied for a mean of 6.9 months with antitubercular therapy for eighteen months. The mean follow-up period was 25.2 months (range, eighteen to forty-two months). All of the patients were independent in activities of daily living at the time of the last follow-up. CONCLUSIONS In the Indian subcontinent, the disease process of craniovertebral junction tuberculosis is usually quite advanced at the time of presentation. On the basis of our study, patients with craniovertebral junction tuberculosis can be managed successfully with nonoperative treatment even with advanced involvement of bone or soft tissues at this spinal level. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Isolated involvement of the posterior elements in spinal tuberculosis: a review of twenty-four cases.

BACKGROUND The literature on tuberculosis of the posterior spinal elements without involvement of the vertebral body is scarce. In this study we report our experience with twenty-four cases of neural arch tuberculosis that were treated at our center. METHODS We performed a retrospective review of the clinical and radiographic data of twenty-four consecutive patients who had tuberculosis of the posterior spinal elements with total sparing of the vertebral bodies and intervertebral disc space. We categorized the patients into two groups on the basis of the clinical and radiographic evaluation. The patients who had rapid onset weakness of the lower limbs or pyramidal signs or who showed evidence of epidural abscess underwent emergency decompressive laminectomy (Group A). Patients who had pyomyositis of the posterior spinal muscles without any neurological deficit, pyramidal signs, or epidural abscess were managed with antitubercular therapy alone (Group B). RESULTS The common presenting features were spastic limb weakness and back pain. The majority of the patients had involvement of the thoracic spine. Epidural abscess, erosion of lamina, and pyomyositis of posterior spinal muscles were common imaging findings. Group A consisted of nineteen patients and Group B consisted of five patients. The mean period of follow-up was 16.9 months (range, nine to sixty months). Patients in Group A had a poorer outcome than those in Group B. Thirteen of the nineteen patients in Group A improved to become independent in the activities of daily living, with complete neurological recovery in eight patients and partial recovery in five patients. Six of the nineteen patients continued to have spastic paraplegia and were wheelchair-dependent. All of the patients in Group B remained neurologically intact during the follow-up period. None of the patients had recurrence of the disease or developed anterior element involvement or kyphotic deformity during the follow-up period. CONCLUSIONS Neural arch tuberculosis is often missed at the time of initial presentation. In association with epidural abscess, it leads to rapid neurological deterioration. This atypical picture of spinal tuberculosis showed a high rate of neurological deficit at the time of initial presentation for medical care.

Neonatal separation of distal humeral epiphysis during Caesarean section: a case report

We report a rare injury of distal humeral epiphyseal separation in a newborn during a Caesarean section. The diagnosis was made using magnetic resonance imaging. Emergency Caesarean deliveries with considerable traction applied to extract the baby can be the risk factor of such an injury.

Intraosseous glomus tumor in acromion process of scapula.

A 25-year-old woman presented with a 5-year history of left shoulder pain, which was constant dull aching in nature, non-radiating with no relieving or aggravating factors and no seasonal variation, gradually increasing in intensity over years. There was no history of trauma or constitutional symptoms. the patient had taken anti-tubercular drugs for 6 months for this pain with no relief. There was point tenderness over the left acromion process. Local temperature was not raised. Movements of the left shoulder were not effected. All routine hematological investigations were normal. Surgical exploration of the lesion revealed a normal soft tissue periosteum and cortex. On removing the cortical bone a red colored jellified tissue was isolated and thoroughly curetted. Histopathology revealed intraosseous glomus tumor. The patient became pain free immediately postoperatively and continued to be symptom free at 24-month follow-up. Glomus tumor located within bone is rare. Only 22 cases of primary intraosseous glomus tumor have been reported in world literature. Glomus tumors are generally treated by meticulously shelling out the entire lesion. Recurrence of symptoms and the need for reoperation have been reported between 12% and 24%. Most authors assume the recurrence is due to inadequate excision, prompting some to recommend more extensive en bloc excision. Tuberculosis being endemic in this region, antituberculer chemotherapy is generally started on clinical suspicion and tissue diagnosis is only attempted in nonresponders. This case however re-emphasizes the value of tissue diagnosis especially when a lesion is at an unusual site like the acromion process.

Free Osteoarticular Metatarsal Transfer for Giant Cell Tumor of Metacarpal—a Surgical Technique

BackgroundGiant cell tumor is a relatively uncommon tumor of bonesaccountingfor5%ofalltheprimarybonetumors.Inthesmallbones of hands it occurs even more rarely. Only 2–5% of allthegiantcelltumorshavebeenreportedtoaffectthehandandmetacarpal involvement is much less common than aphalangeal one [1–4]. The tumor occurring at this sitecommonly presents at an advanced stage and is associatedwith more bony destruction thereby complicating treatment[5–8]. Also these are associated with higher rate ofrecurrence [2]. The various treatment modalities describedare curettage with or without bone grafting, en bloc resectionand reconstruction and ray amputations [2] . We heredescribe a case of successful transplantation of 4th metatarsalalong with its osteo-articular ligamentous complex to replacethe 5th metacarpal bone which was the site of tumor. Thisenabled us to preserve the full function of the metacarpo-phalangeal joint by a relatively simple technique.Case PresentationA 25 year old female patient presented to us with a 8-monthhistory of pain and progressive swelling of the right littlefinger metacarpal. She did not sustain any kind of trauma orsuffer any febrile illness during this period. The patient wasin good general condition with normal systemic examina-tion. Local examination revealed a fusiform, non tenderswelling in the area of 5th metacarpal (Fig. 1).Theoverlying skin was free without any sign of inflammation.Movements of the adjoining joint were full in range andwere painless. A radiograph of the hand showed anexpansile, lytic lesion in the diaphyseal region with paperthin cortex of right 5th metacarpal extending up to thesubchondral bone. There was breach in the ulnar side ofcortex. (Figure 2). A radiograph survey of the skeletonshowed no other lesions. Provisional diagnosis of giant celltumour was made and diagnosis confirmed with corebiopsy.Surgical TechniqueEnbloc resection of tumor was done by dorsal approach(Fig. 3a). Whole of the capsule and collateral ligaments ofmetacarpo-phalangeal joint were preserved while excisingthe tumor (Fig. 3b). Disarticulation was done at the level ofcarpo-metacarpal joint. 4th metatarsal was harvested fromthe foot along with capsule and collateral ligaments of itsmetatarso-phalangeal joint. Metatarsal was osteotomisedproximally at a level, according to the pre-operativeplanned length, desired at the recipient site. The capsuleand ligaments of the transferred metatarsal were sutured tothe corresponding capsule and ligaments at the recipientsite, to reconstruct metacrpo-phalangeal joint (Fig. 3c, d).

Surgical dislocation of the hip for reduction of acetabular fracture and evaluation of chondral damage.

Purpose. To assess the outcome of open reduction and internal fixation combined with surgical dislocation of the hip for displaced acetabular fractures. Methods. 20 men and 2 women aged 20 to 55 (mean, 28) years underwent open reduction and internal fixation combined with surgical dislocation of the hip for displaced acetabular fracture. The most common fracture pattern was bicolumnar (n=12), followed by transverse (n=6) and T-type (n=4). Femoral head chondral lesions were classified as grade 0 (no defect) to grade 4 (osteochondral defect). Fracture fragments were fixed with titanium plates and screws, and the femoral head was redislocated to inspect for intra-articular screws. The association between functional status and acetabular fracture pattern and femoral head chondral lesions was explored. Results. Nine patients had chondral lesions in the femoral head (mostly in the anterosuperior zone), but none in the acetabulum. All femoral heads were viable. Reduction was anatomic in 6 patients and satisfactory in 16. Functional outcome was very good in 6 patients, good in 13, medium in 2, and fair in one. No patient developed avascular necrosis of the femoral head. Four patients had iatrogenic sciatic nerve palsy. One patient developed early degenerative hip arthritis and underwent total hip arthroplasty 14 months later. Conclusion. Surgical dislocation of the hip facilitated anatomic reduction and inspection of any chondral lesions. It did not result in avascular necrosis of the femoral head.

Cowherd's injury: Traumatic retrospondyloptosis of L1 over L2 in a 7-year-old child

Traumatic retrolisthesis of the first lumbar vertebra is a rare injury and only one case has been documented in the literature. We report a case of traumatic retrolisthesis of the first lumbar vertebra in a 7-year old child. He was injured after being dragged by a cow and presented with Frenkel grade A paraplegia. His plain radiographs revealed complete retrolisthesis of the first lumbar vertebra over the second. The patient was treated surgically with open reduction and sublaminar wire loop rectangle fixation. The patient showed Frankle grade D (Frankle grade) neurological recovery in the postoperative period over a period of 15 months. This case is reported in view of rarity and mechanism of injury is described.