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   2010| October-December  | Volume 44 | Issue 4  
    Online since September 14, 2010

 
 
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CASE REPORTS
Subchondral stress fracture of femoral head in a healthy adult
Ashish Anand, A RaviRaj, Gautam Kodikal
October-December 2010, 44(4):458-460
DOI:10.4103/0019-5413.67125  PMID:20924491
Subchondral fracture of the femoral head is an uncommon entity and usually occurs as an insufficiency fracture associated with poor bone quality or as a fatigue fracture in young military recruits. This condition should be considered in the differential diagnosis of acute hip pain in young patients along with transient osteoporosis and avascular necrosis of the hip. We report a case of acute onset hip pain in an asymptomatic healthy adult in which the diagnosis was made by magnetic resonance imaging and the patient responded well to conservative treatment.
  24,244 181 1
ORIGINAL ARTICLES
Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions
Anil K Jain, Ish Kumar Dhammi, Saurabh Jain, Jaswant Kumar
October-December 2010, 44(4):409-416
DOI:10.4103/0019-5413.69315  PMID:20924482
Background: Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single "T" incision outcome in thoracolumbar spinal trauma and tuberculosis. Patients and Methods: Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single "T" incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height. Results: In traumatic spine group the mean duration of surgery was 269 minutes (range 215-315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550-1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750-2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care. Conclusions: Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by "T" incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.
  16,917 398 13
Dislocation following total knee arthroplasty: A report of six cases
Manuel Villanueva, Antonio Ríos-Luna, Javier Pereiro, Homid Fahandez-Saddi, Antonio Pérez-Caballer
October-December 2010, 44(4):438-443
DOI:10.4103/0019-5413.69318  PMID:20924487
Background: Dislocation following total knee arthroplasty (TKA) is the worst form of instability. The incidence is from 0.15 to 0.5%. We report six cases of TKA dislocation and analyze the patterns of dislocation and the factors related to each of them. Materials and Methods: Six patients with dislocation of knee following TKA are reported. The causes for the dislocations were an imbalance of the flexion gap (n=4), an inadequate selection of implants (n=1), malrotation of components (n=1) leading to incompetence of the extensor mechanism, or rupture of the medial collateral ligament (MCC). The patients presented complained of pain, giving way episodes, joint effusion and difficulty in climbing stairs. Five patients suffered posterior dislocation while one anterior dislocation. An urgent closed reduction of dislocation was performed under general anaesthesia in all patients. All patients were operated for residual instability by revision arthroplasty after a period of conservative treatment. Results: One patient had deep infection and knee was arthrodesed. Two patients have a minimal residual lag for active extension, including a patient with a previous patellectomy. Result was considered excellent or good in four cases and fair in one, without residual instability. Five out of six patients in our series had a cruciate retaining (CR) TKA designs: four were revised to a posterior stabilized (PS) TKA and one to a rotating hinge design because of the presence of a ruptured MCL. Conclusion: Further episodes of dislocation or instability will be prevented by identifying and treating major causes of instability. The increase in the level of constraint and correction of previous technical mistakes is mandatory.
  14,304 144 16
Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: A retrospective case series
KH Sancheti, PK Sancheti, AK Shyam, S Patil, Q Dhariwal, R Joshi
October-December 2010, 44(4):428-434
DOI:10.4103/0019-5413.67122  PMID:20924485
Background: The management of unstable osteoporotic intertrochantric fractures in elderly is challenging because of difficult anatomical reduction, poor bone quality, and sometimes a need to protect the fracture from stresses of weight bearing. Internal fixation in these cases usually involves prolonged bed rest or limited ambulation, to prevent implant failure secondary to osteoporosis. This might result in higher chances of complications like pulmonary embolism, deep vein thrombosis, pneumonia, and decubitus ulcer. The purpose of this study is to analyze the role of primary hemiarthroplasty in cases of unstable osteoporotic intertrochanteric femur fractures. Materials and Methods: We retrospectively analyzed 37 cases of primary hemiarthroplasty performed for osteoporotic unstable intertrochanteric fractures (AO/OTA type 31-A2.2 and 31-A2.3 and Evans type III or IV fractures). There were 27 females and 10 males with a mean age of 77.1 years (range, 62-89 years). Results: Two patients died due to unrelated cause (myocardial infarction) within 6 months of surgery and remaining 35 patients were followed up to an average of 24.5 months (range,18-39 months). The average surgery time was 71 min (range, 55-88 min) with an average intraoperative blood loss of 350 ml (range, 175-500 ml). Six patients needed blood transfusion postoperatively. The patients walked on an average 3.2 days after surgery (range, 2-8 days). One patient had superficial skin infection and one had bed sore with no other significant postoperative complications. One patient of Alzheimer's disease refused to walk and had a poor result. A total of 32 out of 35 patients (91%) had excellent to fair functional results and 2 had poor result with respect to the Harris hip score (mean 84.8΁9.72, range 58-97). One patient who had neurological comorbidity refused to walk post operatively and was labeled as failed result. Conclusion: Hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in elderly results in early ambulation and good functional results although further prospective randomized trials are required before reaching to conclusion.
  11,040 828 16
REVIEW ARTICLES
Pathology of Ewing's sarcoma/PNET: Current opinion and emerging concepts
Saral S Desai, Nirmala A Jambhekar
October-December 2010, 44(4):363-368
DOI:10.4103/0019-5413.69304  PMID:20924475
Ewing's sarcoma/PNET are small round cell tumors showing a varying degree of neuroectodermal differentiation. They are one of the commonest tumors of childhood and occur in bone and within soft tissues. Traditionally, light microscopy with the aid of immunohistochemical stains was suitable for diagnosis. But now translocation analyses are being used not only for the diagnosis and classification of small round cell tumors, but to ascertain their prognostic significance, detect micrometastasis, and monitor minimal residual disease, with potential for targeted therapy. This article analyzes the pathology, biology, and molecular aspects of Ewing's sarcoma/PNET and discusses their clinical and therapeutic implications.
  9,300 470 10
CASE REPORTS
Neglected irreducible posterolateral knee dislocation
Raghav Saini, Aditya Krishna Mootha, Vijay G Goni, Mandeep Singh Dhillon
October-December 2010, 44(4):468-470
DOI:10.4103/0019-5413.69323  PMID:20924494
Knee dislocations are rare injuries. Posterolateral knee dislocations are only a small subset of them. There is a paucity of literature regarding the management of such neglected cases. We report here, a case of neglected irreducible posterolateral knee dislocation treated with open reduction and isolated posterior cruciate ligament reconstruction followed by gradual rehabilitation with good outcome at 3 years followup.
  8,724 133 2
REVIEW ARTICLES
Chemotherapy in Ewing's sarcoma
Sandeep Jain, Gauri Kapoor
October-December 2010, 44(4):369-377
DOI:10.4103/0019-5413.69305  PMID:20924476
Ewing's sarcoma constitutes three per cent of all pediatric malignancies. Ewing's sarcoma has generally been more responsive to chemotherapy than adult-type sarcomas, and chemotherapy is now recommended for all patients with this disease. It is essential to integrate local control measures in the form of surgery and/or radiotherapy at the appropriate time, along with chemotherapy to eradicate the disease. This approach has improved the survival substantially to the tune of 70% in localized disease, although outcome for metastatic disease remains dismal. Newer therapeutic approaches are required to improve outcome for metastatic and recurrent or refractory Ewing's sarcoma in organized co-operative group trials.
  8,045 432 3
ORIGINAL ARTICLES
Percutaneous osteosynthesis of Galeazzi fracture-dislocation
Wasudeo M Gadegone, Yogesh Salphale, DS Magarkar
October-December 2010, 44(4):448-452
DOI:10.4103/0019-5413.67121  PMID:20924489
Background: A Galeazzi fracture is defined as a fracture of the radius associated with dislocation of the distal radio-ulnar joint (DRUJ). The conventional surgical technique of nailing does not give enough stability and open reduction, internal fixation with the plate is associated with numerous complications. The stacked nailing for the management of these injuries provides adequate stability, maintains the relationship of the DRUJ and promotes uneventful union by closed technique. The purpose of this study is to evaluate the results of simple, user-friendly, low cost elastic stacked nailing for the management of Galeazzi fracture dislocation. Materials and Methods: We treated 22 young adults with fresh Galeazzi fracture-dislocation of the forearm, from January 2004 to January 2008, by percutaneous fixation of fracture by stacked elastic nailing at our institute. There were 19 males and three females and the age group ranged from 20-56 years (average 35 years). Surgery was performed within 48 to 72 hours under the guidance of image intensifier. Medullary cavity was filled with two elastic titanium nails having unequal lengths and diameter. One nail acts as a reduction nail and the other acts as a stabilizing nail. The results were evaluated using Mikic criteria based on union, alignment, relationship of the DRUJ, and movements at the inferior radio ulnar joint, elbow and wrist. Results: In six cases, following radiological union, nails in the radius were extracted between six to nine months after operation because of discomfort complained by the patient at site of insertion. After one year follow-up, 18 patients had excellent, four had fair results. Conclusion: Closed reduction and internal fixation of Galeazzi fracture by two elastic rods re-establishes the normal relationship of the fractured fragments and the DRUJ without repair of the ligaments. The stability is achieved by the flexibility and elasticity of the nails, crowding of the medullary canal and anchorage they gain in the radial diaphysis. Elastic nailing can produce excellent clinical results for Galeazzi fracture-dislocation. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.
  7,927 338 5
Extracorporeal irradiated tumor bone: A reconstruction option in diaphyseal Ewing's sarcomas
Ajay Puri, Ashish Gulia, MG Agarwal, NA Jambhekar, S Laskar
October-December 2010, 44(4):390-396
DOI:10.4103/0019-5413.69310  PMID:20924479
Background: Limb salvage in extremity tumors is now established as an oncologically safe option without compromising long-term survival. En bloc resection followed by extracorporeal radiation and reimplantation is a biological reconstruction option in diaphyseal Ewing's sarcomas. We analyzed the results of 12 cases of diaphyseal Ewing's sarcomas treated using this modality. Materials and Methods: Between March 2006 and March 2008, 12 patients with Ewing's sarcoma underwent enbloc resection and reconstruction, with reimplantation of the sterilized tumor bone, after extracorporeal irradiation. There were eight males and four females, with a mean age of 14 years (range 2 to 22 years). The femur was the most common bone involved (n=8) followed by the tibia and the humerus (two cases each). All these patients were non-metastatic at presentation and received chemotherapy as per the existing hospital protocol. The mean length of the bone resected was 20 cm (range 11 to 25 cm). The specimen was irradiated with 50 Gy prior to reimplantation and stabilized with the host bone, using suitable internal fixation. Standard biplanar radiographs were assessed for evidence of union on the follow-up visits. The functional status was assessed using the Musculoskeletal Tumor Society Scoring system at the time of the last follow up. The mean follow up duration was 29 months (range 12 to 57 months). Results: Two patients (17%) had early infection with graft removal, hence are excluded from any analysis of union, however they are included when analysing complications such as infection. Rest 10 cases were analyzed for bony union at the osteotomy sites. Sixteen (84%) of the 19 osteotomy sites united primarily, without any intervention. Implant failure and non-union was seen at three diaphyseal osteotomy sites. The average time for union of all osteotomy sites was 7.2 months (range 3 to 13 months).The average time for union of the metaphyseal osteotomy sites was 5.9 months (range 3 to 12 months) and of diaphyseal osteotomy sites was 8.3 months (range 4 to 13 months). The mean Musculoskeletal Tumor Society Score was 27 (range 19 to 30) with a mean of 27. Nine of the ten patients with lower limb involvement were independent ambulators without additional aids. At the time of the last review, six patients were free of disease and six patients had died from the disease. There were two recurrences around the operative site. Both were associated with disseminated disease and in both the recurrences were in the soft tissue, away from the irradiated graft. Conclusion: Extracorporeal irradiation is a useful, convenient technique for limb salvage in diaphyseal Ewing's sarcomas when there is reasonable residual bone stock. It is oncologically safe and has good functional results. A radiation dose of 50 Gy for sterilizing the bone ensures adequate tumor kill, while minimizing the deleterious effects on the biomechanical and biological properties of the bone. The use of appropriate implants for adequate internal fixation and supplementary bone grafting at the index surgery may help reduce the need for subsequent additional interventions to achieve union. The limitations of this procedure are that it is not applicable in tumor bones that are structurally weak and in bones with pathological fractures.
  7,055 382 12
Short-term followup after surgical treatment of Ewing's sarcoma
Shishir Rastogi, Ashok Kumar, Himanshu Gupta, Shah Alam Khan, Sameer Bakhshi
October-December 2010, 44(4):384-389
DOI:10.4103/0019-5413.69308  PMID:20924478
Background: Results of surgical treatment in Indian patients of Ewing's sarcoma managed with multimodality treatment with chemotherapy and/or radiotherapy are insufficient. We report a retrospective evaluation of a series of cases of Ewing's sarcoma managed with chemotherapy, surgery with or without radiotherapy. Materials and Methods: 54 patients of biopsy-proven Ewing's sarcoma of the bone, except craniofacial and vertebral bones were included. The patients having recurrence or having previous treatment were excluded from the study. Local and systemic extent of the sarcoma was defined, staged, and patients were subjected to the chemotherapy, surgery, and in some cases radiotherapy. Patients were evaluated for results of surgery with respect to complications, recurrence, and metastases at 3, 6, 9, 12, 18 and 24 months of follow-up Results: Average age of patients was 15.6 years (range 7-26 years); average delay in treatment was 4.1 months (1-7 months); follow-up ranged from 2 to 5 years (median 3.1 years); 14 patients (25.9%) had pulmonary metastases at their initial presentation. Twenty-one patients (38.9%) underwent resection and intercalary reconstruction with bone grafting, fixed with locking plates. Allograft was also used in 11 of these. Sixteen patients underwent resection and reconstruction with endoprosthesis, while seven patients (13.0%) underwent resection and arthrodesis. An above-knee amputation was required in 7.4% (four patients). Mesh was used for containing the graft longitudinally in five patients (femoral and tibial intercalary reconstructions) and for soft tissue attachment in two patients (hip and shoulder endoprostheses). Two patients had deep wound infection. One patient presented 1 year later with implant failure. The disease-free survival at 2 years from the time of diagnosis was 57.5% (23 out of 40) for patients without preoperative metastases and 42.9% (6 out of 14) for those with preoperative metastases. Overall, the disease-free survival at 2 years was 53.7% (29 out of 54 patients). Overall survival rate at 2 years was 61.1% (33 out of 54 patients). Conclusion: Results of surgical treatment in this study are comparable with the current literature in spite of involvement of long bony segment and large soft tissue component. Intramedullary fibular autograft with morcellized cancellous autograft and allograft contained longitudinally in a mesh appears to be a good alternative with such large bone tumors.
  6,371 116 2
CASE REPORTS
Internal jugular phlebectasia as an incidental finding in cervical spine surgery
V Thulasiraman, TR Ramesh Pandian, S Cheralathan, S Ashok
October-December 2010, 44(4):471-473
DOI:10.4103/0019-5413.69324  PMID:20924495
Idiopathic internal jugular phlebectasia, occurs either unilaterally or bilaterally affecting the internal jugular vein is a rare congenital variation often diagnosed during childhood. It usually presents with a benign swelling over the lateral side of neck on the affected side, seen on exertion. A-30-year old male was operated for anterior cervical dissectomy from right lateral approach and was diagnosed per-operatively as internal jugular phlebectasia.The surgery was abandoned at this stage on the advice of cardiothoracic surgeon to investigate the patient for the secondary etiological factors for internal jugular vein dilatation. The patient was reassured without any active intervention for the phlebectasia and cervical dissectomy was performed in the second surgery through the lateral approach from left side. This case is presented in view of rarity and suggested that during preoperative workup the nearby structures like carotid sheath should be evaluated by magnetic resonance imaging to avoid such per-operative surprises.
  6,404 64 3
Oncogenic osteomalacia: Problems in diagnosis and long-term management
Ish K Dhammi, Anil K Jain, Ajay Pal Singh, Puneet Mishra, Saurabh Jain
October-December 2010, 44(4):453-457
DOI:10.4103/0019-5413.69320  PMID:20924490
Oncogenic osteomalacia is a rare association between mesenchymal tumors and hypophosphatemic rickets. It is more of a biochemical entity than a clinical one. The pathophysiology of the tumor is not clear. However, it has been seen that the clinical and biochemical parameters become normal if the lesion responsible for producing the osteomalacia is excised. For a clinical diagnosis a high index of suspicion is necessary. We present three such cases where in one the oncogenic osteomalacia reversed while in rest it did not. We present this case report to sensitize about the entity.
  6,039 166 3
ORIGINAL ARTICLES
Os odontoideum with "free-floating" atlantal arch causing C1-2 anterolisthesis and retrolisthesis with cervicomedullary compression
Sanjay Behari, Awadhesh Jaiswal, Arun Srivastava, Dinesh Rajput, Vijendra K Jain
October-December 2010, 44(4):417-423
DOI:10.4103/0019-5413.69316  PMID:20924483
Background: Os odontoideum (OO) with C1-2 anterolisthesis and retrolisthesis may cause cervicomedullary injury both from anterior and posterior aspects. We analyzed fourteen such patients for biomechanical issues, radiological features and management of OO with free-floating atlantal arch and review pertinent literature. Materials and Methods: Fourteen patients having nonsyndromic, reducible atlantoaxial dislocation (AAD) with orthotopic OO were analyzed. During neck flexion, their C1 anterior arch-os complex displaced anteriorly relative to remnant odontoid-C2 body. The posteriorly directed hypoplastic remnant odontoid sliding below the atlas and forward translation of the C1 posterior arch caused concomitant cervicomedullary compression. During neck extension, there was retrolisthesis of the "free-floating" C1 arch-os complex into spinal canal. Spinal stenosis and lateral C1-2 facet dislocation; Klippel-Feil anomaly; and posterior circulation infarcts were also present in one patient each, respectively. Posterior C1-2 (n=10) or occipitocervical fusion (n=3) was performed in neutral position to stabilize atlantoaxial movements. Results: Follow-up (mean, 3.9 years) assessment revealed improvement in spasticity and weakness in 13 patients. One patient had neurological deterioration following C1-2 posterior sublaminar fusion, requiring its conversion to occipitocervical contoured rod fusion. One patient with posterior circulation stroke died prior to any operative intervention. Follow-up lateral view radiographs showed a bony union or a stable construct in these 13 patients. Conclusions: OO with free-floating atlantal arch may precipitate cord injury both during neck flexion and extension. This condition may be overlooked unless lateral radiographs of craniovertebral junction are undertaken in neck extension, along with the usual ones in neutral and flexed positions. Etiological factors include C1 ring-OO unrestrained movements above the hypoplastic odontoid; upward pull on OO by alar and apical ligaments; lax C1-2 facet joint ligaments; and congenital presence of horizontal facet joint surfaces that facilitates C1-2 translation.
  5,942 133 1
Clinical signs and anatomical correlation of patellar tendinitis
Ehud Rath, Ran Schwarzkopf, John C Richmond
October-December 2010, 44(4):435-437
DOI:10.4103/0019-5413.69317  PMID:20924486
Background: Patellar tendinitis is one of the several differential diagnosis of anterior knee pain. The clinical diagnosis of patellar tendinitis is based on tenderness to palpation at the inferior pole of the patella. The tenderness has been noted to be maximal when the knee is extended and the quadriceps relaxed, but a definite clinical sign for diagnosis is lacking. The accuracy of two clinical signs was assesed by a two-stage study which included physical examination, MRI and a cadaveric study. Materials and Methods: Two clinical signs, the "passive flexion-extension sign" and the "standing active quadriceps sign" were assessed in 10 consecutive patients with presumed patellar tendinitis. Five patients had an MRI, showed focal abnormality in the tendon. The location of the MRI finding corresponded, to the region of maximal tenderness. A cadaveric dissection was undertaken to describe the anatomy of the patella and the patellar tendon during these tests. Results: Both tests showed a significant decrease in tenderness at the area of inflammation when the patellar tendon was under tension. The cadaveric dissection showed that when the knee is flexed to 90΀ or when the quadriceps is tensioned the deep fibers of the tendon do not deform to anteriorly applied pressure. Conclusion: We suggest using these studies routinely in the evaluation of patients with anterior knee pain.
  5,178 155 3
Surgical management of pelvic Ewing's sarcoma
Mayil Vahanan Natarajan, M Mohamed Sameer, Jagdish Chandra Bose, Kunal Dheep
October-December 2010, 44(4):397-401
DOI:10.4103/0019-5413.69312  PMID:20924480
Background: Despite advances in adjuvant therapy, Ewing's sarcoma of the pelvis remains an anatomic site with a poor prognosis due to its relative inaccessibility, complex anatomy, and limited reconstructive options available. This study evaluates the role of surgery in the management of patients with pelvic Ewing's sarcoma who also have received conventional radiation therapy and chemotherapy. Materials and Methods: From July 1990 to July 2006, we received 10 patients with Ewing's sarcoma of pelvis at our center. Nine patients were in stage II B and one in Stage III at the time of presentation to us. All patients underwent surgical resection after preoperative chemotherapy with or without radiotherapy, which was given at the discretion of the referral center. Reconstruction was attempted using plate osteosynthesis in four patients, SS wires and screws in three patients, free fibular strut graft in one patient, and none was done in two patients. Results: Functional outcome assessed by Enneking's criteria revealed excellent outcome in two patients, good outcome in five patients, and poor outcome in two patients. At a mean followup of 10.3 years, seven patients remained free from the disease, and three patients died. The 5- and 10-year cumulative survival (Kaplan Meier method) was 63% and 34%, respectively. Conclusion: This study demonstrates that surgery plus chemotherapy and radiation therapy is helpful for treating patients with pelvic Ewing's sarcoma, particularly in achieving local control.
  4,211 131 7
Outcome of multimodality treatment of Ewing's sarcoma of the extremities
Akshay Tiwari, Himesh Gupta, Sandeep Jain, Gauri Kapoor
October-December 2010, 44(4):378-383
DOI:10.4103/0019-5413.69307  PMID:20924477
Background: The management of Ewing's sarcoma family of tumors (ESFT, Ewing's sarcoma/primitive neuroectodermal tumor) has been established as a multimodality treatment. Advances in imaging and diagnostics, chemotherapy, surgical techniques, radiotherapy and prosthetic technology have resulted in drastic changes in the outcome of this disease, with most of the recent studies having 5-year survival rates of more than 60%. The Indian patients present at a more advanced stage and the compliance of treatment is suboptimal. While there is plenty of data in the world literature on the outcome of Ewing's sarcoma, there is paucity of data in Indian patients. Therefore, we conducted the present study to analyze the outcome of multimodality treatment of ESFT of the extremities at a tertiary nonprofit institute over a decade. Materials and Methods: 34 patients who had histopathologically proven diagnosis of Ewing's sarcoma of the extremities and had received treatment at our institute from 1997 through 2007 were included for analysis. The majority of patients had involvement of the femur (35%), followed by tibia (17%), fibula and foot (15% each), humerus (12%) and soft tissue of thigh (6%). Twenty-nine patients presented with localized disease (Enneking stage II B) while five patients presented with metastases (Enneking stage III). All patients received Vincristine, Actinomycine D, Cyclofosfamide + Ifosfamide and Etoposide (VAC+IE)-based chemotherapy and local treatment was offered to all but three patients having multicentric disease. The local treatment offered were, radiation (n= 15), surgery (n= 12) both surgery and radiation (n=4). All patients were analyzed for oncological outcome (event-free and overall survival, local and systemic relapses) by clinical and imaging evaluation and functional outcome by using the musculoskeletal tumor society (MSTS) score. These outcomes were correlated with age, sex, size of tumor, stage at presentation, modality of local treatment and site of relapse. Results: At the final follow-up (mean, 26 months; median, 17 months; range, 3-97 months), the overall and event-free survivals were 47 ± 12% and 34 ± 9%, respectively. Sixty-two percent of the patients presented with a tumor size more than 8 cm. On correlation with age, sex, size of tumor, stage at presentation, modality of local treatment and site of relapse, no correlation of survival was seen with any of the variables except event-free survival with size of the tumor. The functional outcome of all the patients was satisfactory (MSTS score >16 out of 30). No patient underwent amputation. Conclusion: Although the demographic profile, stage at presentation and the local and systemic treatment regimen followed in our study was similar to the world literature, the outcome of Ewing's sarcoma in Indian patients were found to be inferior to that reported in the western literature. Larger multicentric studies with longer follow-up are required to exactly determine the key areas crucial in improving this outcome.
  4,146 181 2
Ilizarov's method for treatment of nonunion of diaphyseal fractures of the humerus
Manish Kiran, Rabi Jee
October-December 2010, 44(4):444-447
DOI:10.4103/0019-5413.69319  PMID:20924488
Background: Nonunion in diaphyseal fractures of the humerus can be treated by various modalities like plating and bone grafting, exchange nailing, fibular strut grafting and Ilizarov's method of ring fixation. To achieve union in infected nonunion in which multiple surgeries have already been done is further challenging. We conducted a prospective study wherein the outcome of the treatment of nonunion of diaphyseal fractures of the humerus by Ilizarov's method was analyzed. Materials and Methods: Nineteen patients with diaphyseal nonunion of the humerus were treated by Ilizarov's external fixator. These included nonunion after plating (n=11), intramedullary nailing (n=1) or conservative methods (n=7). In post-surgical infected nonunion (n=6), the implants were removed, debridement done, bone fragments were docked followed by application of ring fixator and compression. In aseptic nonunion (n=13), distraction for three weeks followed by compression was the protocol. Early shoulder and elbow physiotherapy was instituted. The apparatus was removed after clinical and radiological union and the results were assessed for bone healing and functional status. Results: Fracture union was achieved in all the 19 cases. Pin site infection was seen in 2 cases (10.52%). The bone healing results were excellent in eighteen cases (94.73%) and good in one case (5.26%).The functional results were found to be excellent in fourteen cases (73.68%), good in four (21.05%) and fair in one case (5.26%). Conclusion: Ilizarov's method is an excellent option for treatment of septic and aseptic non union of diaphyseal fractures of the humerus as it addresses all the problems associated with non union of the humerus like infection, deformity and joint stiffness.
  3,821 247 5
Experimental posterolateral spinal fusion with beta tricalcium phosphate ceramic and bone marrow aspirate composite graft
Ankit Gupta, Vijendra Chauhan, Neena Chauhan, Sansar Sharma, Rajesh Maheshwari, Atul Agarwal
October-December 2010, 44(4):402-408
DOI:10.4103/0019-5413.67118  PMID:20924481
Background: Beta tricalcium phosphate is commonly used in metaphyseal defects but its use in posterolateral spinal fusion remains controversial. There are very few published animal studies in which use of beta tricalcium phosphate has been evaluated in the posterolateral lumbar arthrodesis model. Hence we conducted a study to evaluate the potential of composite graft of beta tricalcium phosphate and bone marrow aspirate in comparison to autologous bone graft, when used for posterolateral spinal fusion. Materials and Methods: Single level posterolateral lumbar fusion was performed in 40 adult male Indian rabbits, which were assigned randomly into one of the four groups based on graft materials implanted; a) 3 gm beta tricalcium phosphate plus 3 ml bone marrow aspirate (Group I); b) 3 ml bone marrow aspirate alone (Group II); c) 3 gm beta tricalcium phosphate (Group III) and d) 3 gm autologous bone graft (Group IV). Each group had 10 rabbits. Half of the rabbits were sacrificed by injecting Phenobarbitone intraperitoneally after eight weeks and the remaining after 24 weeks, and were evaluated for fusion by X-rays, computed tomography (CT) scans, manual palpation test and histology. Results: Beta tricalcium phosphate used with bone marrow aspirate produced best results when compared to other groups (P =.0001). When beta tricalcium phosphate was used alone, fusion rates were better as compared to fusion achieved with autologous iliac crest bone graft though statistically not significant (P =0.07). Autologous bone graft showed signs of new bone formation. However, the rate of new bone formation was comparatively slow. Conclusion: Composite graft of beta tricalcium phosphate and bone marrow aspirate can be used as an alternative to autologous iliac crest bone graft.
  3,887 118 2
GUEST EDITORIAL
Oncogenic osteomalacia: A reversible metabolic bone disorder
Dinesh Kumar Dhanwal
October-December 2010, 44(4):361-362
DOI:10.4103/0019-5413.67124  PMID:20924474
  3,705 271 1
CASE REPORTS
A new mode of clinical failure of porous tantalum rod
Kwang-Jun Oh, Dilbans Singh Pandher
October-December 2010, 44(4):464-467
DOI:10.4103/0019-5413.69322  PMID:20924493
The area of osteonecrosis of the head of femur affected by the disease process varies from a small localized lesion to a global lesion. Without specific treatment 80% of the clinically diagnosed cases will progress, and most will eventually require arthroplasty. Therefore the goal is to diagnose and treat the condition in the earliest stage. A number of surgical procedures have been described to retard or prevent progression of the disease and to preserve the femoral head. An implant made of porous tantalum has been developed to function as a structural graft to provide mechanical support to the subchondral plate of the necrotic femoral head, and possibly allow bone growth into the avascular region. Porous tantalum implant failure with associated radiological progression of the disease is reported in the literature; however, there is no report of clinical failure of the implant without radiological progression of the disease. We report a case of clinical failure of porous tantalum implant, seven months after surgery without any radiological progression of the disease, and with histopathological evidence of new bone formation around the porous tantalum implant. The patient was succesfully treated by total hip arthroplasty.
  3,533 79 1
ORIGINAL ARTICLES
The impact of chronic obstructive pulmonary disease and obesity on length of stay and cost of spine surgery
M Sami Walid, Nadezhda V Zaytseva
October-December 2010, 44(4):424-427
DOI:10.4103/0019-5413.67120  PMID:20924484
Background: Chronic obstructive pulmonary disease (COPD) and obesity may be more common among spine surgery patients than in the general population and may affect hospital cost. Materials and Methods: We retrospectively studied the prevalence of COPD and obesity among 605 randomly selected spine surgery inpatients operated between 2005 and 2008, including lumbar microdiskectomy, anterior cervical decompression and fusion and lumbar decompression and fusion patients. The length of hospital stay and hospital charges for patients with and without COPD and obesity (body mass index [BMI]≥30 kg/m 2 ) were compared. Results: Among 605 spine surgery patients, 9.6% had a history of COPD. There were no statistical difference in the prevalence of COPD between the three spine surgery groups. Obesity was common, with 47.4% of the patients having a BMI≥30 kg/m 2 . There were no significant differences in obesity rates or BMI values between the three types of spine surgery patients. Obesity rates between patients with and without COPD were 62.1% vs. 45.9%, and were statistically different (P<0.05). Similarly, significant difference (P<0.01) in BMI values between COPD and non-COPD groups, 32.66±7.19 vs. 29.57±6.048 (mean ± std. deviation), was noted. There was significant difference (P<0.01) in cost between nonobese female patients without COPD and those with obesity and COPD in the anterior cervical decompression and fusion (ACDF) group. No association with increased hospital length of stay or cost was found in the other two types of spine surgery or in male ACDF patients. Conclusion: COPD and obesity seem to additively increase the length of hospital stay and hospital charges in ACDF female patients, an important finding that requires further investigation.
  3,284 71 5
CASE REPORTS
Early lateral migration of head after bipolar hemiarthoplasty in a cerebral palsy patient
Ken Hiragami, Arata Mukohyama, Yoshiyuki Maruyama
October-December 2010, 44(4):461-463
DOI:10.4103/0019-5413.69321  PMID:20924492
Migration of the outer head after bipolar hemiarthroplasty within several years after surgery is not a rare complication. We present a patient with cerebral palsy who showed lateral migration of the outer head seven months after bipolar hemiarthroplasty for femoral neck fracture. The patient had no acetabular pathology prior to the fracture, and lacked ambulatory ability in a community setting. She underwent conversion to a total hip arthroplasty and returned to her previous lifestyle.
  2,733 65 -
EDITORIAL
Better patient care: Need of the hour
Ashok N Johari
October-December 2010, 44(4):359-360
DOI:10.4103/0019-5413.70779  PMID:20924473
  2,013 128 -
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