Yasir S. Siddiqui

Fixation using cannulated screws and fibular strut grafts for fresh femoral neck fractures with posterior comminution

Purpose. To evaluate the use of fibular grafting for fresh femoral neck fractures with posterior comminution. Methods. 18 women and 15 men aged 20 to 60 years underwent osteosynthesis and fibular strut grafting supplemented with 7.0-mm cannulated hip screws for Garden grades III (n=21) and IV (n=12) femoral neck fractures associated with posterior comminution. All fractures were reduced by closed methods, and no hip was aspirated. Clinical and radiological outcomes were evaluated. Results. The mean delay in presentation after injury was 3.2 (range, 1–12) days. The mean delay in operation was 8.8 (range, 5–21) days. The mean follow-up period was 2 (range, 1–4) years. According to the Harris hip score, outcome was good to excellent in 20 patients, fair in 7, and poor in 6. 27 of the 33 patients achieved bone union after a mean of 4.7 (range, 4.2–7) months. In 5 patients, the bone was united with a mean of 10° of varus collapse and a mean of 1 cm of shortening. Six patients had nonunion. Other complications included screw migration in the joint space (n=1), graft migration into the joint space (n=3), and screw pullout (n=5). No patient had avascular necrosis of the femoral head. Conclusion. Osteosynthesis and fibular grafting for freshly displaced femoral neck fractures with posterior comminution is an inexpensive and technically less demanding procedure for retaining a stable, painless, mobile, and functional hip.

Pathological Fractures in Primary Non-Hodgkin's Lymphoma of the Bone: A Case Series with Review of the Literature.

Primary non-Hodgkins lymphoma of bone (PLB) is a rare entity. Patients generally present with localized bone pain and, less frequently, soft-tissue swelling or a palpable mass. Pathological fracture of the proximal femur and proximal humerus secondary to soft-tissue tumours is well documented in the literature; however, lymphomas presenting primarily at these sites with pathological fracture is unusual. A review of the world literature shows that the incidence of skeletal manifestation from NHL is less than 5%, and in all these cases, bony involvement was reported many years after presentation of the primary cancer. Histopathologically, PLB usually represents diffuse large B-cell lymphoma. We report our experience with two cases of Primary non-Hodgkins lymphoma of proximal femur and proximal humerus with pathological fracture and their management.

Metastasis from scapular Ewing's sarcoma presenting as sutural diastasis: An unusual presentation

Ewing’s sarcoma is a malignant non-osteogenic primary tumor of the bone. It is one of the most common primary malignant tumors of bone. Peak incidence is noticed in second decade of life with male preponderance of 1.6:1. It occurs most frequently in long bones and flat bones of pelvic girdles. In 30% cases, Ewing’s sarcoma is multicentric in origin. In 14-50%, multiple metastases are present at the time of diagnosis. CNS spread is rare and isolated CNS involvement is not seen. Skull metastasis of Ewing’s sarcoma is not rare compared to primary Ewing’s sarcoma of the skull, but the actual frequency is unknown. We wish to report a case of “Primary Ewing’s sarcoma of scapula with metastasis to Skull Vault in a Child resulting in sutural diastasis” diagnosed by clinicoradiological examination and confirmed by histopathology.

Chondroblastic Osteosarcoma of Proximal Fibula

Osteosarcoma is the most common form of primary malignant bone tumour that occurs during childhood and adolescence. The incidence of new diagnoses peaks in the second decade of life. The metaphysis of the long bones is the site of predilection, and, in declining order, it commonly involves distal femur, proximal tibia, and proximal humerus. The proximal fibula is a relatively rare site for osteosarcoma. We are reporting a case of osteosarcoma of proximal fibula in a 17-year-old male child and discuss the difficult aspects of diagnosis and management.

Giant cell tumor of the first metatarsal

Giant cell tumor (GCT) is a benign locally aggressive tumor with a tendency for local recurrence. GCT of metatarsal is of rare occurrence with very few cases reported so far. GCT in this location is rare and should be considered in the differential diagnosis of a destructive bony lesion in both skeletally immature and mature patients. We report the case of GCT of 1 st metatarsal in a 28-year-old female and discuss the difficult aspects of diagnosis.

Neglected orthopedic oncology--Causes, epidemiology and challenges for management in developing countries.

BACKGROUND Management of malignant bone and soft tissue tumors remains an overwhelming confront to orthopedic surgeons. The challenge is discriminating in developing countries due to inadequate diagnostic and therapeutic amenities and unawareness. A lot has been discussed about the neglected orthopedic trauma, but the published literature on the causes and management of neglected bone and soft tissue tumors is sparse. Hence, current study was undertaken to highlight the causes of neglect and therapeutic challenges for managing these neglected tumors in developing countries. AIMS AND OBJECTIVES To determine the causes of neglect of malignant bone and soft tissue tumors, their epidemiology (including their relative frequencies, age, gender discrimination, anatomical sites of occurrence and histological characteristics) and difficult aspect of management due to neglect or delayed presentation. MATERIALS AND METHODS This was an appraisal of the neglected malignant bone and soft tissue tumors presented to J. N. Medical College and Hospital from June 2008 to May 2013. Criteria for labeling the tumor as neglected malignant bone and soft tissue tumor was delayed presentation (>3 months), locally advanced disease, ulceration, sepsis, fungating mass or metastasis at the time of presentation. All the cases were reviewed and analyzed for age, gender, histological types, educational status and socioeconomic status of the family, any prior treatment by traditional bone setters or registered medical practitioner, cause of delay for seeking medical advice. We have also analyzed the treatment given at our institute and the outcome of the tumor. OBSERVATIONS AND RESULTS Eighteen patients fulfilled the criteria for neglected malignant bone and soft tissue tumors, hence were included in study. Eight cases were of osteosarcoma, five cases were of Ewings sarcoma, three cases were of chondrosarcoma and 1 case each was of pleomorphic liposarcoma and primary lymphoma of bone. According to Enneking staging system 11 cases were of stage III (distant metastasis) and 7 were stage II-B. Seven were females, and 11 were males. Age range was 5-68 years. 15 patients (83.3%) belonged to low socioeconomic status with 17 patients (94.4%) belonged to uneducated background. Cause of delay in seeking medical advice was neglect by the patient and family due to financial constraints, cultural and religious believes, lack of access to health care facilities, consultation with traditional bone setters and even misdiagnosis by qualified orthopedic surgeons. The tumors included were all unresectable and of huge sizes, hence were managed with amputation/dis-articulation, chemotherapy or radiation. CONCLUSION The current study tries to highlight the causes and quantity of neglect of malignant bone and soft tissue tumors prevalent in our country, which poses a therapeutic challenge for management and consequent mutilating surgeries with poor outcome resulting in loss of extremity and existence.

Minimally Invasive Percutaneous Plate Osteosynthesis (Mippo) in DistalTibial Fractures â A Prospective Study from Developing Nation

Background: The management of distal tibial fractures can be challenging because of scarcity of soft tissues, their subcutaneous nature and poor vascularity. Consequently, operative treatment can lead to complications. The surgical treatment of fractures has evolved a great deal since the development of the original “open reduction and internal fixation” technique by the AO group. A mechanically stable fracture-bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues by minimally invasive percutaneous plate osteosynthesis (MIPPO). This technique utilizes indirect reduction and internal fixation with locking compression plates. Our aim was to observe the outcome of the distal tibial fracture fixation (extra-articular and intra-articular) with locking compression plate (LCP) using MIPPO technique. Material and Methods: 26 consecutive patients were prospectively underwent minimally invasive percutaneous plate osteosynthesis for distal tibial fractures between January 2010 and December 2011. Patients were aged between 20 to 65 years with seventeen males and nine females. Both open and closed AO types 43A, 43B and 43C fractures were included. Patients were managed with LCP using MIPPO technique. Postoperative regimen consisted of knee and ankle bending exercises starting on 1st postoperative day. Non weight bearing ambulation started on 3rd post-operative day, progressing to partial weight bearing at 6 to 8 weeks. Full weight bearing ambulation was allowed after clinico radiological union at 12 to 14 weeks. Observation and Results: RTA was the commonest cause of injury. All fractures healed with good functional outcome. Mean union time was 4.5 months (range 3.5–8 months). Mean follow-up was 14.3 months. For all fractures acceptable active range of ankle movement was achieved. Mean AOFAS score was 88. There were 2 cases of superficial infection, treated successfully with antibiotics. No deep infection, wound dehiscence and hardware failure was noted. Conclusion: MIPPO is a well-documented technique that offers biological advantages and appears to be a reasonable treatment option for complex unstable distal tibial or pilon fractures that are not suited for intramedullary nailing. The literature is full of studies from developed nations, but studies from developing nations are lacking. Nevertheless small numbers of patients were involved in our study to draw any definitive conclusions, but our encouraging results will motivate the trauma surgeons from the developing nations to use MIPPO technique in managing distal tibial fractures, in an endeavor to reduce morbidity and associated complications, especially of the soft tissues.