MRI in patients with tuberculous spondylitis presenting as vertebra plana: a retrospective analysis and review of literature.

AIM: To present the magnetic resonance imaging (MRI) findings of 10 patients with histopathologically proven tuberculous spondylitis (TS) presenting as vertebra plana (VP) on radiographs. MATERIAL AND METHODS: Radiographs of 451 adult TS patients were reviewed. In this consecutive series, there were 11 patients who presented as VP. MRI of 10 of these patients was available for review. RESULTS: VP-like collapse of a single vertebral body of the dorsal spine with preserved endplates and disc was seen in all cases. Epidural, pre- and para-vertebral soft tissue was found in all patients. Epidural soft tissue presenting on sagittal images as a convexity of the posterior longitudinal ligament was also found in all the signal of which was different from the involved vertebra on axial images. All patients showed posterior element involvement, which was characterized by preserved cortical outline without expansion. CONCLUSION: TS presenting with VP-like collapse of the bone is rare, accounting for 2.4% of the cases in the present series. MRI may show a collapsed vertebra with preserved endplates and disc. MRI findings that are suggestive of TS include: (1) signal intensity of the epidural soft-tissue mass on axial images, which is different from the vertebral body; (2) presence of a thin, T2-weighted hypointense capsule of the para-vertebral soft tissue; (3) posterior element involvement characterized by intact hypointense cortical outline without expansion; and (4) involvement of the costovertebral joint.

Preoperative embolisation in benign bone tumour excision.

PURPOSE: To assess the role of preoperative embolisation in benign bone tumour excision. METHODS: 3 men and 3 women aged 19 to 35 (mean 23) years with either a giant cell tumour or an aneurysmal bone cyst in limb girdle sites underwent preoperative embolisation a day prior to wide local excision by the same surgeon. Tumour size, blood loss, wound healing, infection, and tumour recurrence were assessed. RESULTS: The mean total blood loss was 391 (range, 100-980) ml. No blood transfusion was needed. No patient had any surgery- or embolisation-associated complication. No tumour recurred within a minimum 5-year follow-up. All patients had satisfactory limb function. CONCLUSION: Preoperative embolisation is useful in the management of vascular and aggressive bone tumours located at limb girdle sites where a tourniquet cannot be used.

Telangiectatic osteosarcoma of the spine: a case report.

Telangiectatic osteosarcoma (TOS) of the spine is rare accounting for only 0.08% of all primary osteosarcomas. Though a well described radio-pathological entity it is not often thought of as a cause of paraplegia. We describe the clinical, radiological and pathological features and discuss the treatment options of telangiectatic osteosarcoma of the dorsal spine presenting in a young man. The diagnostic pitfalls are discussed emphasising the fact that the diagnosis of TOS of the spine requires not only a multi modal approach of appropriate radiological and pathological tests but also an awareness of this condition.

Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation.

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab's criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

Fracture neck of femur in haemophilia A - experience from a cohort of 11 patients from a tertiary centre in India.

We describe here the management of eleven patients with fracture neck of femur. Excepting one patient all had severe haemophilia A. Nine patients were less than 50 years of age. Eight out of eleven patients had fracture after trivial trauma. Nine patients had closed reduction and one patient open reduction. The patient with non union had a Valgus osteotomy. All fractures united. The average time to union was 11 weeks (range:8-16). We followed either a low dose intermittent or a low dose continuous infusion factor support protocol for the management of these patients. The median dose of factor support was 252 u/kg (range: 136-580). The average duration of factor support was 9 days (range: 7-10). Two patients had aggravation of pre existing knee stiffness following post operative immobilisation. No other major complication was observed in this cohort of patients. To conclude, management of fracture neck of femur in patients with haemophilia is no different from general population if an adequate haemostasis is achieved.

External fixators in haemophilia.

External fixators (EF) are not commonly used for patients with haemophilia. We describe the use of EF (Ilizarov, AO- uni- and bi-planar fixators and Charnley clamp) in nine patients (mean age: 19.2 years; range: 9-37) with haemophilia for the following indications - arthrodesis of infected joints, treatment of open fractures and osteoclasis. EF required an average of nine skin punctures [range: 4-17 were maintained for a period of 15 weeks (range: 8-29.5), without regular factor replacement, till bone healing was adequate and were removed with a single dose of factor infusion]. The mean preoperative factor level achieved was 85% (range: 64-102%). Much lower levels were subsequently maintained till wound healing. The average total factor consumption was 430 IU kg(-1) (range: 240-870), administered over a period of 17 days (range: 9-44). There were no major complications related to EF except in a patient who developed inhibitors. In conclusion, EF can be used safely in haemophilic patients who do not have inhibitors and does not require prolonged factor replacement.

Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine.

We present a prospective study of patients with tuberculosis of the dorsal, dorsolumbar and lumbar spine after combined anterior (radical debridement and anterior fusion) and posterior (instrumentation and fusion) surgery. The object was to study the progress of interbody union, the extent of correction of the kyphosis and its maintenance with early mobilisation, and the incidence of graft and implant-related problems. The American Spinal Injury Association (ASIA) score was used to assess the neurological status. The mean preoperative vertebral loss was highest (0.96) in the dorsal spine. The maximum correction of the kyphosis in the dorsolumbar spine was 17.8 degrees. Loss of correction was maximal in the lumbosacral spine at 13.7 degrees. All patients had firm anterior fusion at a mean of five months. The incidence of infection was 3.9% and of graft-related problems 6.5%. We conclude that adjuvant posterior stabilisation allows early mobilisation and rehabilitation. Graft-related problems were fewer and the progression and maintenance of correction of the kyphosis were better than with anterior surgery alone. There is no additional risk relating to the use of an implant either posteriorly or anteriorly even when large quantities of pus are present.

Desmoplastic fibroma of the proximal ulna.

A young man presented with desmoplastic fibroma in the proximal ulna. This rare tumour was treated by curettage and bone grafting.

Total innominatectomy for chondrosarcoma innominate.

Internal hemipelvectomy or innominatectomy is a preferred alternative to hindquarter amputation for malignant tumours of the pelvis. Various segments of the pelvis have been removed surgically leaving the lower limb with residual segments of the pelvis in treatment of such tumours. We herewith present a case of total innominatectomy, i.e. dis-articulation at the pubic symphysis and sacroiliac joint for surgical clearance and treatment of a chondrosarcoma of the Innominate bone. The tumour extended from just in front of the sacroiliac joint to the ischium and warranted such a complete resection.

Multicentric giant cell tumour of bone--a report of two cases.

Two cases of metachronous multicentric giant cell tumour of bone are reported. One patient had tumours in the tibia and the femur, the second tumour appearing five years after the first. The other patient developed tumours in the tibia and the radius, the second tumour appearing two years and nine months after the first. The metachronous tumours, in both cases, were clinically and radiologically more aggressive than the initial tumours. Treatment with curettage and bone grafting proved to be ineffective for these tumours and en-bloc excision was required for cure.

Opponensplasty by extensor indicis and flexor digitorum superficialis tendon transfer.

From 1977 to 1988, 166 patients with median nerve paralysis of varied aetiology underwent opponensplasty. In 50 of these the extensor indicis was used, and in 116 the flexor digitorum superficialis of the ring finger. An analysis of these hands showed that the EI opponensplasty was best in supple hands and FDS opponensplasty was more suitable for less pliable hands. There were fewer complications seen after FDS opponensplasty if the detachment of the donor tendon was done through a volar oblique incision rather than the conventional lateral incision.

Opponensplasty by extensor indicis and flexor digitorium superficialis tendon transfer

From 1977 to 1988, 166 patients with median nerve paralysis of varied aetiology underwent opponensplasty. In 50 of these the extensor indicis was used, and in 116 the flexor digitorum superficialis of the ring finger. An analysis of these hands showed that the EI opponensplasty was best in supple hands and FDS opponensplasty was more suitable for less pliable hands. There were fewer complications seen after FDS opponensplasty if the detachment of the donor tendon was done through a volar oblique incision rather than the conventional lateral incision.

Extensor indicis proprius opponensplasty.

An analysis of 39 patients (40 hands) who underwent an extensor indicis proprius opponensplasty was carried out. Of these, 29 hands had simultaneous adjuvant surgery to correct other deformities. The mean follow-up period was 33.8 months. Excellent or good results were seen in 87.5%, fair in 10% and poor in 2.4% hands.

Management of Volkmann's ischaemic contracture of the upper limb.

One hundred and ninety six cases of Volkmann's ischaemic contracture in the upper limb were studied for their pattern of contracture and recovery (Sundararaj and Mani 1985). Mild, moderate and severe forms of contracture have been described (Tsuge 1975; Sundararaj and Mani 1985). The management of 102 of these cases has been studied and discussed here.

Pattern of contracture and recovery following ischaemia of the upper limb.

196 cases of Volkmann's Ischaemic Contracture of the upper limb with well-established ischaemia are presented. In all cases tight external circumferential splintage was the primary factor. 59.2% of these patients had been initially treated by "bone setters". 54.6% had fractures of the forearm; supracondylar fracture of the humerus was seen in 10.7% and 17.9% had no evidence of bone or joint injury. Different patterns of ischaemic contractures are recognised and the severity of the contracture is found to be related to the extent of paralysis. Sensory recovery occurs in a proximodistal direction even following total ischaemia and degeneration of the nerve. Motor recovery, however, does not seem to take place. Sensory recovery in the forearm proceeds rapidly in the first six months; thereafter it is less significant. However, the sensory recovery in the hand is significant only after more than twelve months. Since sensory recovery occurs even after total ischaemic degeneration of the nerve it is postulated that such nerves recover and regenerate in course of time.