Mid-term follow-up of superior pubic ramus osteotomy in locked symphysis pubis with urethral injury: A case report.

A locked pubic ramus body is an unusual variant of lateral compression injury. Till date, there have been only 25 cases reported in the published literature. We herein described a case where the right pubic ramus was entrapped within the opposite obturator foramen with an overlap of greater than 4 cm, with associated urethral injury. When all maneuvers of closed and instrumented reduction failed, we performed a superior pubic ramus osteotomy on the left side and unlocked the incarcerated right pubic ramus. The osteotomy site was stabilized with a 6-hole recon plate. The patient underwent delayed urethral repair 10 weeks after the index surgery. At 3-year follow-up, the patient has sexual dysfunction especially difficulty in maintaining erection, secondary urethral stricture, heterotopic ossification, and breakage of implants.

Pigmented Villonodular Synovitis of Flexor Hallusis Longus, Flexor Digitorum Longus, Tibialis Posterior: A Rare Case Report.

Pigmented villonodular synovitis (PVNS) is a locally aggressive benign tumour of the synovial membrane and tendon sheath. The unique presentation of this tumour is hemosiderin deposition with synovial proliferation. Depending on the situation, surgical excision is always the first line of treatment with adjuvant radiotherapy. Arthroscopic excision is preferred in some intraarticular nodular PVNS cases. This is a rare pigmented villonodular synovitis involving flexor hallusis longus, flexor digitorum longus, and tibialis posterior (TP). The tumour was entirely extra-articular without any joint involvement. The tumour was the diffuse type of PVNS and was treated by excision followed by radiotherapy. There is no recurrence till nine months of follow-up.

Giant Cell Tumor of Talus - A Case Report.

Introduction: A giant cell tumor (GCT) is a benign tumor of bones which commonly arises from epiphysis of long bones. The tumor is locally aggressive and rarely metastasizes to the lungs. GCT of small bones of the foot and ankle is very rare. The GCT of the talus is very rare, and only a few case reports and series are described in the literature. In general, the GCT is monostotic, and few incidences of multicentricity have been described in the foot and ankle bones literature. Here are the findings of our case GCT of talus and reviews of earlier literature. Case Report: We present a case of a GCT of the talus in a 22-year-old female. Patient presented with pain in ankle with mild swelling and tenderness at ankle. Radiograph and Computer tomography scan conformed an eccentric osteolytic lesion on anterolateral part of talus body. Magnetic resonance imaging showed no extra osseous extension or articular surface breach. Biopsy conformed the lesion to be giant cell tumor. The tumor was reated with curettage and bone cement filling. Conclusion: Giant cell tumor of talus is extremely rare and presentation of these tumor may change. Curettage and bone cementing are an effective method of treatment. It gives early weight bearing and rehabilitation.

Outcomes of Ipsilateral Femoral Neck and Shaft Fractures Treated With Proximal Femoral Nail Antirotation 2.

Ipsilateral femoral neck and shaft fractures are relatively rare fractures, which most commonly occur in young adults following high-energy trauma. In most cases of such fractures, neck fracture is undisplaced and often of basicervical type. Many treatment methods have been described, but there is still no generalized consensus on the same. Cephalomedullary nails are one of the preferred modalities of treatment. A cephalomedullary nail-like proximal femoral nail antirotation 2 (PFNA 2) of recent design is being widely used currently. In this study, we present 13 cases of ipsilateral femoral neck and shaft fractures treated with PFNA 2 implants. The advantages of the PFNA 2 system include reduced blood loss, reduced operative time, and fewer fluoroscopy shots. PFNA 2 is a biomechanically better implant than many cephalomedullary implants. It provides satisfactory results in ipsilateral femoral neck and shaft fractures, especially where neck fracture is of a basicervical type. Some aspects have to be taken care of when employing PFNA 2, such as anatomical reduction, and length, angulation, and rotation of both neck and shaft.

Functional outcome of gastrocnemius advancement flap augmented with short flexor hallucis longus tendon transfer in chronic Achilles tear.

BACKGROUND: There are various techniques of Achilles tendon (TA) repair and reconstruction in chronic Achilles tear. However, there is no clear consensus on the relevance of one method over the other. The short flexor hallucis longus tendon (FHL) transfer has recently gained popularity because of its same phasic action, ease of harvesting and tensile strength. METHODOLOGY: Fifteen chronic Achilles tear (>6 weeks) were treated with tendon repair using gastrocnemius advancement flap augmented with FHL transfer. The patients were followed-up at 1.5, 3, 6, 12 and 24 months. The clinical outcome at latest follow-up was evaluated using the American Orthopedic Foot and Ankle Score (AOFAS) and the Achilles Tendon Rupture Score (ATRS). RESULTS: The mean age was 43.5 ± 12.4 years and the median time from injury to surgery was 17.13 ± 9.64 weeks. The mean gap between the retracted ends of the ruptured tendon was 5.67 ± 1.63 cm (range 4-10 cm). The mean follow-up was 19.07 ± 3.15 months (range, 13-24 months). The mean AOFAS and ATRS improved from 72.07 ± 8.29 (62-83) to 98.4 ± 2.03 (94-100) and 61.73 ± 8.16 (52-70) to 98 ± 1.85 (94-100) respectively (paired t-test, p-value 0.0001). All patients resumed their pre-injury daily activities, and there was no donor site morbidity. Two patients had sterile serous discharge, and one patient had a staphylococcus infection. These patients responded to debridement with prolonged antibiotic therapy. There were no nerve injuries or re-rupture. CONCLUSION: The functional outcome of chronic Achilles tear treated with gastrocnemius advancement flap augmented with short FHL transfer is rewarding.

Tibial Plateau Fracture with Avulsion Fracture of Tibial Tuberosity: A Case Report and Review of Literature.

Tibial tuberosity fractures are usually seen in the adolescent age group and are very rare in adults. Here we describe a case of knee injury following a road traffic accident. The patient had tibial tuberosity avulsion along with tibial plateau fracture. He was treated with open surgical reduction and internal fixation. His rehabilitation was quite successful, resulting in a good range of motion and functional outcome. This study aims to present this unusual case of tibial tuberosity avulsion fracture associated with tibial plateau fracture and its appropriate management.

Clinico-radiological Outcomes of Using Modified Stoppa Approach for Treating Acetabular Fractures: An Institutional Review.

Introduction Acetabular fractures are complex intra-articular fractures. The extra-pelvic ilioinguinal (IL) has been the workhorse for the anterior approach and remains the gold standard. The major difference between the IL and the Stoppa approaches is that Stoppa allows for the avoidance of the middle window of the IL approach. Hence, the modified Stoppa approach (MSA) can be adopted by a comparatively less experienced surgeon with minimal complications. The purpose of this study is to evaluate the radiological and functional outcomes of patients operated on using the MSA. Materials and methods Patients operated on by the MSA for acetabular fractures with a minimum of one year of clinical and radiographic follow-ups were reviewed. CT scans and radiographs were evaluated for the fracture pattern, time to surgery, operative time, blood loss, quality of reduction (Matta criterion), FO [Harris hip score (HHS) and Nach Merle d'Aubigné and Postel score (NMAPS)] and complications (perioperative and follow-up). Twenty-three of 26 patients with 45 acetabular fractures operated between January 2016 and November 2018 were included. Descriptive statistics were used for demographic data, and Pearson's chi-squared statistic was calculated for the association between radiological and functional outcomes. Results  Among the 23 patients, the mean age was 38.5 years (range: 15-65) with a male-to-female ratio of 18:5. The average time to surgery was 11.5 days (range: 2-32), operating time was 155 minutes (range: 90-243), and average blood loss was 650 ml (range: 500-1,250). A supplemental lateral window was used in 20 patients (87%), and three underwent the combined anterior and posterior [Kocher Langenbacks (KL)] approach. All cases were unilateral. The transverse fracture was the most common pattern (eight patients) followed by the associated both-column fracture in six and T-type, isolated anterior column fracture, and anterior column and posterior hemi-transverse fractures seen in three patients each. Iliac blade (high anterior column) fracture was seen in 14 cases and one patient had associated sacral type II fracture. Road traffic accidents accounted for 61% of the injuries and injury severity score (ISS) of >15 (polytrauma) was seen in more than 50% of the cases (associated with other organ injuries). The radiological outcome was anatomical in 52% of the cases, imperfect in 39%, and poor in 9%. The functional outcomes were good to excellent in 74% (HHS) and 79% (NMAPS) of the cases. The association and correlation between them were nonsignificant (p-value: >0.5). Two patients developed a superficial infection and three had iatrogenic obturator nerve palsy. One patient had a direct inguinal hernia, one had grade 3 bedsores, and two patients developed grade 2 arthritic changes during the follow-up. No case of vessel injury was encountered. Conclusion Adoption of the MSA for the treatment of acetabular fractures leads to a good-to-excellent anatomical reduction in most cases while providing direct visualization of the quadrilateral plate and posterior column. The learning curve is smaller for less-experienced surgeons in terms of complications and results. We recommend this technique as a viable alternative to the IL approach for anterior acetabular fixation.

Irreducible Femur Head Fracture-Dislocation Treatment With Kocher-Langenbeck Approach With Flip Trochanteric Osteotomy: A Novel Approach.

Femoral head fracture-dislocations are rare, and irreducible cases are even less frequent. Truly irreducible fracture-dislocations must be differentiated from incomplete reduction due to incarcerated bone or soft tissue interposition. The Pipkin classification is commonly used to classify femoral head fractures. An urgent reduction is required in traumatic hip dislocations to reduce the risk of avascular necrosis (AVN) of the femoral head. However, in femoral head fractures, the dislocated hip cannot be reduced easily due to incarcerated bone or soft tissue. In an irreducible fracture hip dislocation, It is not advisable to attempt to reduce it repeatedly because sometimes femoral head fracture-dislocation is associated with the impacted fracture of the femoral neck. It may lead to iatrogenic femoral neck fracture. Hence, in such cases, immediate open reduction and internal fixation are recommended. The Kocher-Langenbeck approach can be used for reduction and safe surgical dislocation with flip trochanteric osteotomy for fixation as a novel approach.

Complete Agenesis of Dorsal Wall of Sacral Canal: A Case Report.

The sacral canal is the continuation of the vertebral canal in the sacrum. The sacral canal contains spinal meninges, lumbar and sacral part of spinal nerves and filum terminale. So sacral canal has been used for the caudal epidural block. During routine osteology demonstration classes for undergraduate students, we observed a dry human sacrum with complete agenesis of the dorsal wall of the sacral canal. Knowledge of these variations is important to diagnose lower back pain, sciatica, caudal regression syndrome and to avoid complications related to caudal epidural block and other spinal surgeries like in placement of screw for spinal fusion.

Arthroscopic ankle fusion to manage sequel of loss of lateral malleoli in compound crushed ankle injury.

Defect in the lateral malleolus along with lateral ligamentous injury of ankle is rare. It occurs mainly due to resection of distal fibula tumors and severe trauma leading to loss of lateral malleolus. Lateral malleoli has the major contribution in weight transmission to foot and ankle stability. To avoid persistent pain and gait abnormality due to ankle instability, reconstruction of bony defect is inevitable. Methods to address these defects are iliac crest bone grafting, vascular and nonvascular proximal fibula transfer, patella tendon bone graft and allograft. Donor site morbidity, allograft related problems are not rare. Arthrodesis of ankle gives painless stable joint. Arthrodesis can be performed by open and arthroscopic methods. Open method has more soft tissue dissection and too difficult in scenario with previous skin grafting with adherent skin to bone. We managed a case of compound ankle injury with loss of lateral malleolus with loss of lateral ligament in stages, first management of compound crushed ankle followed by arthroscopic ankle arthrodesis. Even after 6 year of follow patient has stable pain less ankle with satisfactory gait.

Intra-tendinous Patellar Ganglion Cyst Maybe the Unusual Cause of Knee Pain: A Case Report.

Cystic lesion around knee usually presents as painless swelling and diagnosed incidentally by imaging for any internal derangement of the knee. Few cases presented with pain. Intra-tendinous patellar ganglion is very rare in location for the disease. Ganglionic cyst usually treated by aspiration followed by steroid and surgical excision in some cases. We reported a case with anterior knee pain due to patellar intra-tendinous ganglion cyst which treated conservatively with no recurrence even after one year.

Estimation of Femoral Neck Anteversion in Adults: A Comparison Between Clinical Method, Radiography, and Computed Tomography at a Tertiary-care Center in Eastern India.

Introduction Femoral anteversion is the anterior inclination of the femoral neck and head in relation to the shaft of the femur. Femoral anteversion provides torsional stability of the hip - an important clinical factor for conditions such as trauma, arthroplasty, developmental dysplasia of the hip, and Legg-Calve Perthes disease. Precise measurement is important to avoid instability in pathological conditions of the hip. Computed tomography (CT) measures the angle more accurately as compared to plain radiography and is considered the gold standard procedure for measurement. Patients are exposed to significantly more ionizing radiation in CT, especially the pediatric population, which is more susceptible. Material and methods A prospective study of 25 individuals was undertaken wherein the femoral anteversion angle was comparatively measured by clinical, radiographic, and CT methods. Results The radiological evaluation depicted mean values that were far from those of the CT evaluation as compared to the clinical evaluation. Conclusion The clinical method (trochanter prominence angle test) can be used to measure femoral anteversion to avoid exposure to ionizing radiation and cases where CT is unavailable.

Spinal Epidural Abscess in Melioidosis: A Rare Case Report from Eastern India.

A spinal epidural abscess (SEA) is a rare condition that has a devastating impact on the patient's health. It is difficult to diagnose and can present with a myriad of symptoms with or without the involvement of a neurological deficit. The conditions that lead to immunocompromised status, such as malnutrition, diabetes, intravenous drug abuse, previous surgical intervention, and human immunodeficiency virus (HIV) infection/acquired immune deficiency syndrome (AIDS) can predispose a patient to SEA. The most common organisms isolated from the affected patient include Staphylococcus aureus and Streptococcus species while an abscess in some cases can be caused by tuberculosis and fungal and parasitic infections. Among the other causative organisms is Burkholderia pseudomallei (B. pseudomallei), also known as Pseudomonas pseudomallei, which is a Gram-negative, bipolar, aerobic, motile, and rod-shaped bacterium. It is a soil-dwelling bacterium, which is endemic in tropical and subtropical regions worldwide, particularly in Thailand and northern Australia, and causes melioidosis. To our knowledge, SEA caused by B. pseudomallei from the Indian subcontinent has not been reported in the literature. In this case report, we present the case of a patient with SEA caused by B. pseudomallei.

Standalone Instrumented Posterior Approach Used as Universal Approach for Tuberculosis Spondylodiscitis.

BACKGROUND: Surgical management of spinal tuberculosis (TB) has been classically the anterior, then combined, and of late increasingly by the posterior approach. The posterior approach has been successful in early disease. There has been a paradigm shift and inquisitive to explore this approach in the more advanced and even long-segment disease. Our study is a retrospective analysis by authors in variable disease pattern of TB Spine operated at an institute using a single posterior approach. SETTINGS AND DESIGN: A retrospective case study series in a tertiary level hospital. AIMS: The aim of this study is to evaluate the functional and radiological results of an all posterior instrumented approach used as a "universal approach" in tubercular spondylodiscitis of variable presentation. MATERIALS AND METHODS: The study is from January 2015 to May 2018. Twenty-four of 38 patients met the inclusion criterion with a male: female = 8:16, and mean age 44.26 years. The initial diagnosis of TB was based on clinic-radiologic basis. Their level of affection, number of vertebrae affected, and vertebral body collapse, the kyphosis (preoperative, predicted, postoperative, and final residual) and bony fusion were measured in the preoperative, postoperative, and final X rays. Functional scoring regarding visual analog scale and Frankel neurology grading was done at presentation and follow-up of patients. Histopathological data of all patients were collected and anti-tubercular therapy completed for a period of 1 year with 4 drugs (HRZE) for 2 months and 2 drugs (HR) for rest of period. STATISTICAL ANALYSIS USED: The descriptive data were analyzed by descriptive statistics, and other parameters were calculated using the appropriate statistical tests such as the Student paired t-test for erythrocyte sedimentation rate, visual analog scale score, and kyphosis. RESULTS: The mean number of vertebrae involved was 3.29 ± 0.86 (2-6) with mean vertebral body destruction was 0.616. Preoperatively, the mean kyphosis angle was 22.42° ± 12.56° and was corrected postoperatively to 13.08° ± 11.34° with an average correction of 9.34° (41.66%). At the latest follow-up, there was mean loss of correction of 0.80° resulting in 13.88° of final correction. Bony fusion was achieved in 20 patients (83.33%) cases. Neurological recovery occurred in all patients (100%), and 92% could be ambulatory at 1 year follow-up. There was improvement of visual analog scale from 6.33 ± 1.05 preoperatively to 1.042 ± 0.75 at 3 months of postoperative period. Two patients had bed sore, two had urinary infection, and one had neurological worsening requiring re exploration and cage removal eventually recovering to Frankel E. Two patients died due to unrelated cause. CONCLUSIONS: The procedure in safe and has satisfactory results in variable group affection of Pott's spine including early and late disease, multisegment involvement using pedicle screw fixation with/without cage support.

Compartment syndrome as a late presentation of brachial artery pseudoaneurysm following shaft of humerus fracture.

Peripheral artery pseudoaneurysm is rare in upper extremities compared with lower extremities. Early diagnosis and prompt management are two cornerstones of successful outcomes in these cases. Delay can lead to limb and life-threatening complications. We present a case of compartment syndrome of upper limb as a sequel to pseudoaneurysm of brachial artery for which we had to do shoulder disarticulation. The patient recovered uneventfully.

Non-compressive postoperative cauda equina syndrome following decompression and transforaminal interbody fusion surgery.

Postoperative cauda equina syndrome (CES) is a known rare complication following lumbar disc surgery. Seldom are they seen following decompression for spinal stenosis and may be actually more frequent and under-reported? Emergent surgical exploration remains the mainstay of management as the factors responsible for postop CES remains a variety of compressive forces. Yet many a time postoperative imaging or surgical exploration fails to identify a pathology and this leads to an ischaemic theory responsible for CES. Our article highlights conservative management in these selective group. We share our experience in two cases of incomplete CES during our routine transforaminal interbody fusion which we followed closely without re-exploration eventually ending in a favourable outcome. Key messages: The factors responsible for postop CES remains mostly a variety of compressive forces though in some instances postoperative imaging or surgical exploration fails to identify such in some cases. This leads to an ischaemic theory responsible for CES. The role of conservative management of postoperative CES in certain selective cases has a favourable outcome as illustrated in our cases.

A Rare Case of Extra-abdominal Desmoid-type Fibromatosis Arising from the Popliteal Fossa.

Desmoids are rare soft-tissue tumors of the abdominal wall that may sporadically occur extra-abdominally. It manifests as clonal fibroblastic proliferation with an infiltrative tendency and capacity to recur without metastasizing. An adolescent male presented with a gradually increasing globular, non-tender, firm, non-pulsatile swelling (8 × 5 × 3 cm3) in the left popliteal fossa that had been present for five months. Following thorough investigation with imaging and Tru-cut biopsy, finally, an excisional biopsy was done. Histopathological examination confirmed a desmoid tumor, and the patient received adjuvant radiotherapy. At the one-year postoperative follow-up, there was no recurrence; the patient had been explained the prognosis. This case highlights a rare site of an extra-abdominal desmoid but with classical clinical presentation, imaging, intraoperative, and histopathological findings. Awareness and knowledge of this entity are of paramount importance for clinical practitioners.

Non-concentric Reduction Due to Entrapped Loose Bone Piece During a Single-stage Bilateral Total Hip Arthroplasty.

Total hip arthroplasty (THA) is the treatment of choice for Grade IV avascular necrosis of the femoral head. Dislocation following THA, although rare, is a known complication. Common causes of unsuccessful reduction include interposition of soft tissue, component loosening, malalignment, and inadequate muscle relaxation following anaesthesia. Here, we encountered a rare complication during a single-stage bilateral THA that resulted in a non-concentric reduction on the left side. The pathology was a loose bone piece, which possibly was an osteophyte that was broken.