Fail-safe nano-formulation of prodrug of sulfapyridine: Preparation and evaluation for treatment of rheumatoid arthritis.

Aim of the present study was to give a second life to the long-abandoned drug, sulfapyridine (SP) for its anti-arthritic potential by design of nano-vesicular delivery system. For this, intra-articular delivery of its liposomal formulation was tried. As the prepared formulation exhibited rapid drug leakage, an arthritis responsive prodrug of SP showing lability towards synovial enzymes was synthesized to exploit the over-expression of arthritis specific enzymes. Prodrug (SP-PD) exhibited better retention in liposomes as compared to the drug, preventing its escape from synovium. Hydrolysis of SP-PD in human plasma and synovial fluid indicated its high susceptibility to enzymes. The liposomes of SP-PD exhibited larger mean size, less PDI and higher zeta potential as compared to those for SP liposomes. In arthritic rats, prodrug liposomes were found to reverse the symptoms of inflammation, including the levels of biochemical markers. Liposomes of bio-responsive prodrug, therefore, offer a revolutionary approach in the treatment of rheumatoid arthritis.

Curettage with cement augmentation of large bone defects in giant cell tumors with pathological fractures in lower-extremity long bones.

BACKGROUND: Thorough curettage and cement augmentation is the procedure of choice for treating giant cell tumor lesions, particularly those associated with large defects. Its association with pathological fractures has not been studied to a great extent, although a pathological fracture following a giant cell tumor is not a contraindication to treatment by curettage and cementation. We present our experience of bone cementation following intralesional curettage for treatment of giant cell tumors of the long bones of lower limbs with associated pathological fractures. MATERIALS AND METHODS: A total of 38 patients who had undergone a procedure in the weight-bearing long bones of lower limbs were included in the study. The age of the patients ranged from 18-79 years with a mean age of 38.57 years. The average follow-up was 102.42 months (8.5 years) ranging from 60-186 months (5-15.5 years). Results were based on serial radiographs showing consolidation of the lesion along with a subjective clinical examination and Enneking functional evaluation noted in the patient's records. RESULTS: Approximately 76 % of the lesions occurred around the knee. The results were graded as excellent (72 %), good (12.82 %) fair (10.25 %) and poor (5.12 %). Four cases developed a recurrence. Apart from a few documented complications, the lesions showed good consolidation and healed well. CONCLUSION: Giant cell tumors of the long bones of lower limbs with an associated pathological fracture at diagnosis can be managed with thorough curettage and cement augmentation of the bone defect with a satisfactory outcome. LEVEL OF EVIDENCE: Level IV.

Role of Joshi's external stabilization system with percutaneous screw fixation in high-energy tibial condylar fractures associated with severe soft tissue injuries.

PURPOSE: The treatment of high-energy tibial condylar fractures which are associated with severe soft tissue injuries remains contentious and challenging. In this study, we assessed the results of Joshi's external stabilization system (JESS) by using the principle of ligamentotaxis and percutaneous screw fixation for managing high-energy tibial condylar fractures associated with severe soft tissue injuries. METHODS: Between June 2008 and June 2010, 25 consecutive patients who were 17e71 years (mean, 39.7), underwent the JESS fixation for high-energy tibial condylar fractures associated with severe soft tissue injuries. Out of 25 patients, 2 were lost during follow-up and in 1 case early removal of frame was done, leaving 22 cases for final follow-up. Among them, 11 had poor skin condition with abrasions and blisters and 2 were open injuries (Gustilo-Anderson grade I&II). The injury mechanisms were motor vehicle accidents (n=19), fall from a height (n=2) and assault (n=1). The fractures were classified according to Schatzker classification system. RESULTS: There were 7 type-V, 14 type-VI and 1 type-lV Schatzker's tibial plateau fractures. The average interval between the injury and surgery was 6.8 days (range 2-13). The average hospital stay was 13 days (range, 7-22). The average interval between the surgery and full weight bearing was 13.6 weeks (range 11-20). The average range of knee flexion was 121°(range 105°-135°). The normal extension of the knee was observed in 20 patients, and an extensor lag of 5°-8° was noted in 2 patients. The complications included superficial pin tract infections (n=4) with no knee stiffness. CONCLUSION: JESS with lag screw fixation combines the benefit of traction, external fixation, and limited internal fixation, at the same time as allowing the ease of access to the soft tissue for wound checks, pin care, dressing changes, measurement of compartment pressure, and the monitoring of the neurovascular status. In a nutshell, JESS along with screw fixation offers a promising alternative treatment for high- energy tibial condylar fractures associated with severe soft tissue injuries.

Surgical outcome of delayed presentation of congenital proximal radioulnar synostosis.

BACKGROUND: Presentation of proximal radioulnar synostosis varies from cosmetic concerns with no functional limitations to significant pronation deformity which hampers activities of daily living. Surgical management must be considered based on the position of the forearm and functional limitations. We describe the surgical technique, results, and complications of excision of the radial head along with the proximal radius up to the distal extent of the synostosis site and securing the osteotomized radial shaft with a tensor fascia lata graft. MATERIALS AND METHODS: Four patients having six affected elbows with delayed presentation of congenital proximal radioulnar synostosis with dislocated radial head managed surgically were included in the study. There were three males and one female with an average age of 20.25 years (ranging from 16 to 25 years). Preoperatively wrists were locked in the mean pronation position of 51.6° (ranging from 30° to 70°). The indications for surgery were limitation in activities of daily living and an obvious cosmetic deformity. RESULTS: All patients were satisfied with the surgery and showed significant improvement in functional status. Mean active supination was 15° (ranging from 5 to 32°) with passive supination was a mean of 24.8° (ranging from 11° to 44°). Similarly, mean active pronation was 58.5° (ranging from 50° to 71°) with further passive correction up to a mean of 64.16° (ranging from 57° to 87°) at last follow up. CONCLUSIONS: This procedure is simple, cost effective, and a reasonable option for treatment of proximal radioulnar synostosis with a dislocated radial head in adult patients. The operation does not require any specialized team or implants, and can be performed in a moderately equipped hospital.

The Huntington procedure: still a reasonable option for large tibial defects in paediatric patients.

BACKGROUND: Management of gap nonunion of tibia is technically difficult, time consuming, physically and psychologically demanding for the patient with unpredictable results. Various techniques have been described in literature for the treatment of gap nonunions, but each one has its own limitations. PURPOSE: This study reports the outcomes of ipsilateral fibular transposition for reconstruction of tibial defects in paediatric age group. METHODS: We retrospectively reviewed records of 14 patients who underwent surgery for gap nonunion tibia with ipsilateral tibialization of fibula. Fibula is transferred to tibia as pedicle graft in two-staged procedure. Due to retained blood supply to one end of the transplant, the graft easily takes up and hypertrophies upon weight bearing over a period of time. RESULTS: Average time of radiographic union was 13.35 weeks. Guarded partial weight bearing was started at an average of 16.5 weeks with gradual progression to full weight bearing. The leg length discrepancy at final follow-up ranged from 0 to 7 cms with an average of 2.60 cms. Hypertrophy of tibialized fibula was observed in all patients, with 8 patients showed grafted fibula reaching the diameter of opposite tibia. On subjective assessment, 9 patients were highly satisfied, 4 patients were satisfied and one patient was dissatisfied with the procedure. CONCLUSIONS: Huntington procedure is a simple, cost-effective and easy procedure for large tibial defects in paediatric patients which does not require any specialized team and implants, and can be performed in moderately equipped hospital. Leg length discrepancy may be addressed, after the transferred fibula is well developed.

Concomitant double epiphyseal injuries of the tibia with vascular compromise: a case report.

A rare case of double epiphyseal injuries in the same tibia is reported. A 4-year-old child was struck by a vehicle and presented with the above fractures and vascular compromise to the extremity. Following localization of the vascular occlusion level by arteriography, popliteal vessel anastomosis was attempted. The vascular repair failed, resulting in disarticulation through the knee. Simultaneous displaced proximal and distal epiphyseal injury in the same tibia has not been previously reported in the literature. The most serious complication of injury to the proximal tibia is vascular compromise. A delay in recognition or intervention in such cases can be devastating.