Ewing's Sarcoma of the Talus in an Adolescent Female: An Unusual Case Presentation With Review of Literature.

Ewing's sarcoma is an aggressive primary malignant bone tumor that affects long and flat bones and is commonly seen in children and adolescents. The involvement of the foot especially the talus is an extremely rare entity with less than 15 cases reported in the literature. The rarity and atypical symptoms often lead to delays in diagnosis affecting the prognosis and survival. We present a 14-year-old female with pain and swelling of the left ankle for 18 months. She was being treated previously for an ankle sprain and was later suspected of avascular necrosis of the talus, before presenting to us. Clinicoradiology-pathological workup confirmed the diagnosis of Ewing sarcoma of the talus. Further, the metastatic workup revealed multiple skeletal metastases at the time of diagnosis. The metastatic lesion of the right femur required prophylactic fixation, otherwise, the patient was treated with palliative chemotherapy and radiotherapy. Ewing's sarcoma of the foot involving the talus is extremely rare and is a commonly misdiagnosed entity, affecting the overall prognosis of the patient. A high index of suspicion and a multidisciplinary approach is imperative for its early diagnosis and definitive management.

Concomitant spine and calcaneum fractures: a possible indication of less extensive injury.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To study the incidence of concomitant calcaneum fractures in participants with traumatic spine fractures and to study the association of calcaneum injury with the mode of trauma, morphology and level of vertebral fracture and neurological status in participants with concomitant spine and calcaneum fracture. SETTING: Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India. METHODS: Records of participants with traumatic spine fractures were analyzed. Participants who had calcaneum fracture confirmed on radiographs were considered to have concomitant spine and calcaneum fracture. In these participants, variables noted were age, gender, mode of trauma, level and morphology of vertebral fracture and neurological status. RESULTS: Concomitant calcaneum fracture was present in 43 participants out of a total of 358. The lumbar spine was involved in 72.09% of participants. 46.51% of participants had complete burst type of vertebral fractures. Neurology was found to be intact in 58.13% of participants. The association of concomitant calcaneum injury with the level of spine fracture and type of fracture were found to be statistically significant (p < 0.05). In particular, the association of concomitant calcaneal fracture with intact neurology and incomplete paraplegia (ASIA B, C or D) as compared to spinal injury cases without calcaneal fractures was statistically significant (p < 0.001). CONCLUSION: Calcaneum fractures co-exist with spine fractures in 12.01% participants. Concomitant calcaneal fracture(s) with spine trauma indicate a greater chance of incomplete injury or intact neurology possibly due to dispersion of force vectors.

Cervical Split Cord Malformations: A Systematic Review.

Cervical split cord malformations are extremely rare with less than 75 cases reported in the literature worldwide. The widely different terminologies used to describe the same pathoanatomy make the documentation of all reported cases a difficult task. We conducted a systematic review of 71 cases documented over 38 reports from 1889 to 2016. The controversy regarding prophylactic surgery in asymptomatic individuals remains. We advocate prophylactic surgery in all asymptomatic individuals to preclude severe neurological deficit following trivial trauma in future. The results of surgery in asymptomatic individuals are excellent while those in symptomatic individuals are good as well.

Cervical rotation before and after hinge-door cervical laminoplasty for cervical spondylotic myelopathy.

BACKGROUND: Hinge-Door Cervical laminoplasty is commonly performed procedure in patients with cervical spondylotic myelopathy. Most available studies have established restriction of flexion and extension motion post laminoplasty but the literature on post-laminoplasty axial rotation is sparse. OBJECTIVE: To study the axial neck rotation on either side following hinge door cervical laminoplasty. MATERIALS AND METHODS: Twenty consecutive patients of cervical spondylotic myelopathy planned for cervical laminoplasty were included in the study. Preoperative and postoperative radiological data was recorded for each patient and analysed by an experienced neuroradiologist. The clinical and radiological follow-up was recorded at 6 months post surgery. All patients underwent standard hinge door C3-C6 laminoplasty preserving the muscle attachments to C2 and C7 vertebra. RESULTS: There were 13 men and 7 women with a mean age of 60.5 years, age range 58-70 years. The mean preop C1 C2 rotation was 46.5 degrees and mean post-operative C1-C2 rotation was 44.3 degrees. The average subaxial cervical spine rotation was 11.66 degrees preoperatively and 12.47 degrees postoperatively. The global cervical spine rotation was 80.95 degrees preoperatively and 76.82 degrees postoperatively. There is no significant change in segmental, subaxial and global cervical spine rotation following hinge door C3-C6 laminoplasty preserving the muscle attachments to C2 and C7 vertebra. CONCLUSION: Cervical laminoplasty preserves cervical ROM and is a motion-preserving surgery as far as axial rotation is concerned.

Factors Responsible for Redisplacement of Pediatric Forearm Fractures Treated by Closed Reduction and Cast: Role of casting indices and three point index.

BACKGROUND: Pediatric forearm fractures are still considered an enigma in view of their propensity to redisplace in cast. The redisplacement may be a potential cause for malalignment. We prospectively analyzed the role of risk factors and above casting indices in predicting significant redisplacement of pediatric forearm fractures treated by closed reduction and cast. MATERIALS AND METHODS: 113 patients of age range 2-13 years with displaced forearm fractures, treated by closed reduction and cast were included in this prospective study. Prereduction and postreduction angulation, translation, and shortening were noted. In addition, for distal metaphyseal fractures, obliquity angle was noted. In postreduction X-ray, apart from fracture variables, casting indices were also noted (cast index [CI] for all patients with three-point index [TPI] and second metacarpal radius angle in addition for distal metaphyseal fractures). In 2nd week, X-rays were again obtained to check for significant redisplacement. These patients were managed with remanipulation and casting or were operated if remanipulation failed. Comparison of various risk factors was made between patients with significant redisplacement and those which were acceptably reduced. A subgroup analysis of patients with distal metaphyseal fractures was done. RESULTS: Thirteen (11.5%) patients had significant redisplacement; all of them required remanipulation. No association with respect to age, sex, level of fracture, side of injury, surgeon's experience, number of bones fractured, and injury to definitive cast interval was seen. The presence of complete displacement in any of the plane in either of the bones was seen to be highly significant predictor of redisplacement (P < 0.001). Postreduction angulation more than 10° in any plane in either of the bone and fracture obliquity angle in distal metaphyseal fracture also had a highly significant association with redisplacement. There was a significant difference in the mean values of all three casting indices assessed. TPI was the most sensitive casting index (87.5%). CONCLUSIONS: Conservative management with aim of anatomical reduction, especially in patients with complete displacement, should be the approach of choice in closed pediatric forearm fractures. Casting indices are good markers of quality of cast.

A muscle sparing posterior approach to the elbow joint for total elbow arthroplasty.

We describe a muscle sparing approach in which the triceps is elevated without injuring the muscle or disturbing its insertion. The entire extensor mechanism is preserved in continuity, thus preventing any extensor weakness. This can be used preferentially in cases of non-union intraarticular distal humerus fractures planned for Total Elbow Arthroplasty.

Bilateral patellar tuberculosis masquerading as infected infrapatellar bursitis.

A 30-year-old woman presented to our outpatient department with complaints of pain and swelling in bilateral infrapatellar regions and a discharging sinus in the right knee over the duration of one year. Radiographs showed lytic regions in bilateral patellae. Samples sent from material curetted from sinus yielded no organism but histopathology reported granulomatous inflammation. Following a fresh magnetic resonance imaging (MRI) scan that revealed the infrapatellar pad of fat communicating with the patellar lesions, an exploration and evacuation was done. Material sent revealed epithelioid cell granulomas with caseous necrosis consistent with tuberculosis (TB). The patient was put on first line anti-tubercular treatment (ATT) and has responded favourably with healing of sinus and patellar lesions. Bilateral infrapatellar bursitis is not rare. However patellar TB as a cause for OMIT is not a common diagnosis. A bilateral patellar involvement has not been reported in literature to the best of our knowledge.

Recurrent anterior instability of the shoulder associated with coracoid fracture - An unusual presentation.

Recurrent anterior shoulder instability following shoulder dislocation has an incidence as high as 68% among the younger population, however its association with coracoid fracture is extremely rare. Majority of coracoid fractures reported earlier have been shown to be associated with seizure disorder. We report a case of displaced coracoid fracture associated with recurrent anterior instability in a patient with no history of seizure disorder and its implications in causation as well as management are discussed. A 28 year old male, paramedic by profession, presented with complaints of multiple episodes of shoulder dislocation of right dominant extremity for last ten months. Pre-operative CT scan showed Hill-Sach's lesion associated with coracoid process fracture. In view of significant engaging Hill-Sach's lesion, bony reconstruction of glenoid to increase the articular arc was planned. However in view of the small coracoid fragment occurred due to fracture, Latarjet's procedure could not be planned and iliac crest bone graft (ICBG) was planned instead. Till date only 10 cases of coracoid fracture with anterior shoulder instability have been reported in English literature. Of the ten cases, six cases had history of seizure disorder while four cases had only traumatic association. In our case as coracoid fragment was small, it could not be used for Latarjet's procedure and instead was fixed to its proximal stump with suture anchors. This case highlight's rare injury pattern and emphasises on good clinico-radiological examination supplemented by high index of suspicion needed to diagnose this unusual presentation.

Ipsilateral hip and knee dislocation: Case report and review of literature.

Hip and knee dislocations are not uncommon but simultaneous ipsilateral dislocation of the hip and knee joint is rare; consequently, there is an inadequate amount of literature on the subject. We identified only 11 such cases reported in English literature. In the present report, we describe the case of a 23-year-old male patient who presented with ipsilateral hip and knee dislocation on the right side after being involved in a road traffic accident. The hip dislocation was associated with a posterior wall acetabular fracture. The hip as well as the knee joints was reduced in the emergency bay. The patient underwent an urgent fixation of the posterior wall acetabular fracture with delayed ligament reconstruction for the knee dislocation. At one-year follow-up, he had no pain in the hip or knee. There was grade 1 posterior sag but no symptoms of knee instability. Radiographs revealed no evidence of avascular necrosis or arthritis of the femoral head. The normal treatment protocol for individual injury is affected by the simultaneous occurrence of hip and knee dislocation.

Tubercular spondylitis in children.

Spine of the child has unique anatomy and growth potential to grow to adult size. Tuberculosis (TB) spine results in bone loss as well as disturbed growth potential, hence spinal deformities may progress as the child grows. The growth potential is also disturbed when the disease focus is surgically intervened. Surgery is indicated for complications such as deformity, neurological deficit, instability, huge abscess, diagnostic dilemma and in suspected drug resistance to mycobacterium tuberculosis. The child on antitubercular treatment needs to be periodically evaluated for weight gain and drug dosages need to be adjusted accordingly. The severe progressive kyphotic deformity should be surgically corrected. Mild to moderate cases should be followed up until maturity to observe progression/improvement of spinal deformity. The surgical correction of kyphotic deformity in active disease is less hazardous than in a healed kyphosis. The internal kyphectomy by extra pleural approach allows adequate removal of internal salient in paraplegic patients with healed kyphotic deformity.

Tuberculosis spine: Therapeutically refractory disease.

BACKGROUND: India ranks second amongst the high-burden multi drug resistant tuberculosis (MDR-TB) countries, with an estimated incidence of 2.3% MDR-TB cases amongst the new cases and 17.2% amongst the previously treated cases. The diagnosis and treatment protocol for MDR-TB of the spine are not clearly established. We report outcome of a series of 15 cases of TB spine who were suspected to be therapeutically refractory cases (MDR-TB) on the basis of clinicoradiological failures of initial treatment. MATERIALS AND METHODS: Fifteen cases of TB spine from C2 to L5 spine were suspected to be the cases of MDR-TB (therapeutically refractory cases) on the basis of failures of adequate clinicoradiological healing response at 5 months or more on antitubercular treatment (ATT). None of the patient was immunocompromised. Thirteen out of 15 patients had tissue samples sent for histopathology, culture and sensitivity, smear, BACTEC, and polymerase chain reaction (PCR). All patients were put on second line ATT and followed up fortnightly with regular liver and kidney function tests, erythrocyte sedimentation rate (ESR), and plain X-ray. Healing was documented as subjective improvement of symptoms, reduction in ESR, and observations on contrast enhanced magnetic resonance imaging (MRI) such as resolution of marrow edema, fatty replacement of bone marrow and resolution of abscesses. Ambiguous MRI observations in a few patients were resolved on positron emission tomography (PET) scan. Patients were monitored continuously for 2 years after stopping ATT. RESULTS: We could demonstrate a positive culture in three cases. Two of them had multi drug resistance. We could achieve healing status in 13 out of 14 patients after starting second line drugs, one patient is still on treatment while other patient with no drug resistance is responding well on ATT. CONCLUSIONS: The suspicion of therapeutically refractory case is of paramount importance. Once suspected, surgery to procure tissue for diagnosis and culture is to be undertaken. The demonstration of drug resistance on culture may not be achieved in all TB spine cases and empiric drug regimen for MDR-TB is to be started. We have achieved the healed status with immunomodulation and second line ATT. The length of treatment needs to be monitored with MRI and PET scan.

Efficacy of extended DOTS category I chemotherapy in spinal tuberculosis based on MRI-based healed status.

BACKGROUND: Duration of treatment in tuberculosis of spine has always been debatable in the absence of marker of healing. The objective of the study was to evaluate the efficacy of extended DOTS regimen (2 months of intensive phase and 6 months of continuation phase) as recommended by WHO, by using MRI observations as the healing marker. MATERIALS AND METHODS: 51 (Group A -28 prospective and Group B- 23 retrospective) patients of spine TB with mean age of 26.8 years (range 15-54 years) diagnosed clinico radiologically/imaging (n=36), histopathology or by PCR (n=15) were enrolled for the study. They were treated by extended DOTS regimen (2 months of HRZE and 6 months of HR) administered alternate day. The serial blood investigations and X-rays were done every 2 months. Contrast MRI was done at the end of 8 months and healing changes were recorded. Criteria of healing on the basis of MRI being: complete resolution of pre and paravertebral collections, resolution of marrow edema of vertebral body (VB), replacement of marrow edema by fat or by calcification suggested by iso- intense T1 and T2 weighted images in contrast enhanced MRI. Patients with non healed status, but, responding lesion on MRI after 8 months of treatment were continued on INH and rifampicin alternate day and contrast MRI was done subsequently at 12 months and 18 months till the healed status was achieved . RESULTS: 9 patients had paraplegia and required surgical intervention out of which 1 did not recover neurologically. All patients have completed 8 months of extended DOTS regimen, n=18 achieved healed status and duration of treatment was extended in rest (n=33) 5 were declared healed after 12 months, 8 after 18 months and one after 36 months of treatment, thus 32 were declared healed at varying periods. CONCLUSION: 35.2% patients demonstrate MRI based healed vertebral lesion at the end of 8 months of extended category 1 DOTS regimen. It is unscientific to stop the ATT by fixed time frame and MRI evaluation of the patients is required after 8 months of ATT and subsequently to decide for the continuation stoppage of treatment.

Magnetic resonance evaluation of tubercular lesion in spine.

PURPOSE: Information on Magnetic Resonance (MR) features of active and healed lesions in tuberculosis (TB) spine are lacking. We evaluated MRI findings in active and healed proven TB spine to establish the diagnostic features. MATERIALS AND METHOD: Forty-nine consecutive spinal TB patients (20 male; 29 female) diagnosed clinicoradiologically and/or on histopathology, Fine Needle Aspiration Cytology (FNAC), bacteriology, or Polymerase Chain Reaction (PCR) were enrolled. Pretreatment MR scans were reviewed for diagnostic features, and eight-month follow-up MR scans were reviewed for healing changes. RESULTS: Cervical spine (n = 6), dorsal spine (n = 14), and lumbar spine (n = 29) were affected. Fourteen had paraplegia. Mean vertebrae involved were 2.61 on X-ray with a total of 128 vertebrae (VB) and 3.2 on MRI (range, 2-15) with 161 VB. The lesions were more extensive on MRI (34.7%) than appreciated on X-ray. The disc was preserved partially or fully in 88.2% of instances. End plate erosions (159/161 VB), lost VB height (94/161), exudative lesion (158/161), granular lesion (3/161), pre and paravertebral collections (49/49 cases), marrow oedema (161/161), discitis (98%), epidural involvement (107/161), epidural spread (100/161), and subligamentous spread (156/161) were observed. Canal encroachment (10-90%) was seen in 37 cases. Mean motor and sensory scores with greater than 50% canal encroachment were 87/100 and 156/168, respectively. Cord oedema was observed in 11 cases (eight with neural deficit and three cases without). Cord atrophy was seen in one case each before and after treatment. A total of 83% of patients had a combination of paravertebral collections, marrow oedema, subligamentous and epidural extension, endplate erosions and discitis. On healing (n = 20), complete resolution of marrow oedema and collections, fatty replacement of bone marrow and resolution of cord signal intensity were observed. CONCLUSION: The marrow oedema, preservation of disc space, subligamentous extension of abscess, septate paravertebral abscess, epidural extension, endplate erosions and discitis were consistently observed in 83% cases of TB spine on MRI.