Unifocal Tubercular Osteomyelitis of Ulna Diaphysis in a Child: A Case Report.

Introduction: Osteoarticular tuberculosis (OATB) contributes to around 10% of extrapulmonary tuberculosis of which the spine is the most common site. Isolated involvement of ulna diaphysis is extremely rare. We present a case of unifocal tuberculous osteomyelitis of ulna diaphysis in a 3 -year-old male child and highlight its resemblance with musculoskeletal tumors and stress the importance of GeneXpert mycobacterium tuberculosis (MTB)/resistance to rifampicin (RIF) in the diagnosis of OATB. Case Report: A mother of a 2-year-old male child incidentally noticed that her son complained of left forearm pain. She was not sure of any fall or trauma to the forearm. No history of fever or other constitutional symptoms was present. Clinical examination was uneventful except for local tenderness in over the dorsomedial aspect of the left mid forearm. A plain radiograph revealed an oval solitary lytic lesion over distal one-third ulna diaphysis. A needle biopsy was done after clinical, hematological, and radiological evaluation, and finally, GeneXpert detected tuberculosis without RIF. No further tests were required and the child was started on antitubercular therapy (ATT) which resulted in complete healing without any symptoms. Conclusion: The authors conclude that it is therefore essential to consider tuberculosis in the differential diagnosis while evaluating a lytic bone lesion. Where possible, all patients should have a biopsy of the lesion and provide a specimen for GeneXpert MTB/RIF to confirm the diagnosis and drug susceptibility testing.

Diagnosis of Intraosseous Hibernoma of an Appendicular Skeleton in an Adult - A Rare Case Report.

Introduction: Hibernoma is an uncommon benign tumor composed of multivacuolated brown adipocytes described in the literature a decade back. Intraosseous hibernomas are extremely rare with propensity to affect axial skeleton. Involvement of appendicular skeleton has been reported only twice in the literature till date. Case Report: We present a case of solitary, painless mass in the left proximal tibia mimicking neoplasm in a 35-year-old male. The plain radiographs revealed a lytic lesion with well-defined margin at the junction of metaphyseal-diaphyseal region of the left proximal tibia. The lesion was hyperintense on T2 and hypointense on T1 with heterogenous enhancement on contrast imaging. FDG-PET showed high uptake of fluorodeoxyglucose. Histopathological examination revealed the presence of multivacuolated cytoplasm with abundant mitochondria suggestive of hibernoma. On immunohistochemistry, the cells were positive for S-100. Conclusion: The findings of imaging modalities are non-specific and histopathological examination is required to confirm the diagnosis of hibernoma. Intraosseous hibernoma needs to be considered as a differential diagnosis of sclerotic bone lesion. Further, evaluation with regular follow-up with imaging will be required if the mass undergoes any clinical changes. Both radiologists and pathologists, need to be aware of this rare entity to avoid misdiagnosis of the uncommon lesion.

Proximal Thoracic Kyphoscoliosis with Dorsal Myelopathy in a Case of Congenital Absence of Thoracic Pedicles: A Case Report.

CASE: A 14-year-old boy with proximal thoracic kyphoscoliosis associated with the bilateral absence of thoracic pedicles presented with progressive deformity, paraparesis, and difficulty in ambulation. The case was managed by preoperative halo traction, single-stage 2-level vertebral column resection, decompression, and arthrodesis of thoracic vertebrae. Two years postoperatively, the patient showed neurological improvement, leading to unassisted ambulation and fusion at the corpectomy site. CONCLUSION: Preoperative halo-gravity traction restores the sagittal and coronal balance, improves the functional status of the patient, and corrects the deformity to some extent. 3D printed models help in better understanding of osseous anatomy and minimizing intraoperative time.

Clinicoradiological outcome of percutaneous intralesional polidocanol in Aneurysmal Bone Cysts: A prospective study of 43 patients in a single tertiary care centre.

Objective: The study reports the efficacy of sequential instillations of intralesional percutaneous polidocanol in the treatment of skeletal ABC. The study also analyses the pain relief, recurrence, radiological outcome and complications after percutaneous sclerotherapy. Materials and methods: A total of 43 patients with ABC were managed by fluoroscopy assisted percutaneous intralesional sclerotherapy with 3% Injection Polidocanol under suitable anaesthesia. The pain relief was assessed by Visual Analog Scale (VAS) and the progressive healing of the lesion by Rastogi Classification. Patients were evaluated clinico-radiologically, pre-operatively and at monthly interval for the first three months and then at 6 months, one year and two years follow up. Result: The VAS score decreased significantly at six months follow up and was zero (No pain) at one year follow up. Out of 43 patients, 37 patients had Degree I (excellent) residual lesion and 6 patients had degree II (good) lesion at one year follow-up as per Rastogi classification. The lesions resolved completely by two-year follow-up with all 43 patients having Degree (excellent) I resolution. Conclusion: Our study highlights the efficacy of percutaneous intralesional polidocanol in the treatment of ABC's. The procedure is safe, simple and effective with excellent outcome. Sclerotherapy is highly beneficial for deep lesions which are difficult to assess and for comorbid patients who are medically unfit for surgery. Our study strongly advocates the use of sclerotherapy as the first line treatment for ABC, considering its clinical and radiological efficacy.

Isolated L5 nerve root injury without osseous disruption in a case of gunshot injury to the paediatric spine-A case report.

INTRODUCTION: There exists sparse literature on Gunshot injuries (GSI) to the pediatric spine, its natural course, management protocols and outcomes following surgical intervention. Here, we present a projectile injury to the paediatric lumbar spine without any osseous disruption in a 5-year-old child requiring surgical management. CASE PRESENTATION: A 5-year-old child presented with a gunshot injury to the pediatric lumbar spine. On radiological imaging, there was no osseous disruption and an intraspinal canal projectile was embedded in an organised infected complex, compressing onto the left-sided L5 traversing nerve root with resultant grade 4 motor power of the left Extensor Hallucis Longus (EHL). Under fluoroscopic guidance using two separate mini-open incisions, the pellets were extracted. One from the spinal canal through left-sided L4 laminotomy and the other from the right paraspinal region. Post-surgical decompression and pellet retrieval there was gradual recovery to grade 5 motor power of Left EHL and improvement in the general condition of the child. CONCLUSION: The absence of osseous disruption can be attributed to the size of the projectile, widely spaced interlaminar spaces in the lumbar spine due to the absence of lumbar lordosis in the pediatric group and flexibility of the pediatric spine owing to its ligamentous laxity.

Evaluation of functional outcome and neurological recovery pattern in patients with retro-thecal tubercular epidural abscess managed at a tertiary center.

We performed a retrospective observational study to analyze the neurological recovery pattern in patients with a sub-laminar retro-thecal epidural abscess managed at our tertiary apex center from 2014 to 2020. We evaluated the Maximal Spinal Cord Compression (MSCC) ratio on Magnetic Resonance Imaging (MRI), the time interval between the appearance of neurological deficit and the initiation of management, spasticity as per Modified Ashworth Scale, presence of drug resistance, and the Lower Extremity Motor Score (LEMS). All patients were given anti-tubercular chemotherapy. We surgically managed 8 patients of which 6 required decompression alone, while 2 patients required additional instrumentation. 2 patients were managed conservatively of which 1 responded favorably to conservative treatment while the other patient showed a worsening of neurology following the detection of drug resistance and abrupt discontinuation of chemotherapy. The mean LEMS on admission was 20.2, which improved to 38.5 at the end of 1 year (p-value <0.05). The patients in whom the time interval between the onset of neurological deficit and the initiation of management was fewer than 6 weeks showed better LEMS and milder or absent spasticity at follow-up (p-value <0.05). The MSCC ratio did not have a significant correlation with the LEMS (p-value >0.05).

Extensive Synovial Chondromatosis of the Knee Managed by open radical synovectomy: A Case Report with review of literature.

Introduction: Synovial chondromatosis of the knee is an unusual, rare, benign metaplastic neoplasm of the synovium, characterized by the formation of focal cartilaginous nodules in the synovium. It predominantly involves the anterior compartment of knee and extensive, disseminated involvement is rarely reported. Diagnosis is usually established with clinicoradiological imaging and confirmed by histology. The paucity of literature on the management of synovial chondromatosis puts an orthopedician in dilemma regarding the optimal surgical intervention. Case Report: We report a case of 50-year-old male who presented with severe pain and swelling in his left knee associated with functional incapacitation. Magnetic resonance imaging demonstrated diffuse proliferation of synovium with mild effusion displaying multiple, disseminated calcific nodules. We managed the case by open removal of loose bodies and radical synovectomy through combined anterior and posterior approach. At 4 years follow-up, there are no clinical or radiological signs of recurrence. Conclusion: Extensive involvement of the knee with calcific nodules is extremely rare. Treatment is controversial which usually includes removal of loose bodies combined with an open or arthroscopic synovectomy. Our case report recommends single stage, open retrieval of loose bodies combined with radical synovectomy to decrease the incidence of recurrence in extensive synovial chondromatosis. To the best of our knowledge, disseminated synovial chondromatosis of the knee, managed by open, combined approach, has been reported only once in the literature.