Xanthogranulomatous Osteomyelitis of Proximal Femur Masquerading as Benign Bone Tumor

We describe a case of xanthogranulomatous osteomyelitis (XO) of the proximal femur in a 65-year-old woman who presented with pain of 6 months' duration in the right hip. Plain radiographs showed a lytic well-defined lesion in the right peritrochanteric region suggestive of a benign neoplastic etiology. The gross and histopathologic examination of the curettage specimen was consistent with XO. Xanthogranulomatous osteomyelitis is a rare chronic inflammatory process that is characterized by the presence of a large number of lipid-containing macrophages with an admixture of lymphocytes, plasma cells, and neutrophils. Gross and radiologic examination of this entity can mimic malignancy, and differentiation should be confirmed by histopathologic evaluation. To the best of our knowledge, XO of the femur has not been reported in the English-language literature. The rarity of this condition and its resemblance to bone tumors form the basis of this case report.

Dual luminescence in solid CuI(piperazine): hypothesis of an emissive 1-D delocalized excited state

Dual luminescence in crystals of [CuI(piperazine)_0.5]_∞ has been photophysically characterized and discussed on the basis of TD-DFT theoretical calculations.

"A 40-year-old female with painless, slow growing prepatellar mass"

A 40-year-old woman from India presented with a mass in the front of her left knee which had been present for 8 months. Local examination revealed a globular mass of approximate size 5 cm × 4 cm × 4 cm in front of the lower pole of left patella. The patient was investigated with imaging studies and laboratory tests. Plain radiograph of the chest was normal. In addition, contrast enhanced Magnetic Resonance Imaging (MRI) of the left knee was performed. Based on the history, physical examination, laboratory and imaging studies, what is the differential diagnosis?

Limb Salvage in Secondary Chondrosarcoma of the Metatarsus

Malignant transformation of metatarsal osteochondroma into chondrosarcoma is a rare entity. The most optimal line of treatment, salvage procedure or amputation, continues to be debated. Both of these treatments have varied in popularity. We report the case of a 24-year-old male with chondrosarcoma secondary to differentiation of an osteochondroma in the second and third metatarsals. Wide resection of the tumor mass and reconstruction of the second and third metatarsals was performed using a simple and biologic approach. This was accomplished with an autologous nonvascularized fibular graft to reconstruct the longitudinal arch of the foot. The foot was successfully salvaged, with good anatomic, functional, and aesthetic results. At 1 year postoperatively, the patient was able to walk without any orthotic devices and had returned to his routine work. No evidence of local recurrence or metastasis was observed.

Fracture of distal end clavicle: A review

Management of fracture distal end clavicle has always puzzled the orthopaedic surgeons. Now-a-days with a relatively active lifestyle, patients want better results both cosmetically and functionally. Despite so much literature available for the management of this common fracture, there is no consensus regarding the gold standard treatment for this fracture. In this article, we reviewed the literature on various techniques of management for this fracture, both conservative as well as surgical, and their merits and demerits.

Functional anthropometric measurements of Indian pelvis

PURPOSE

To determine the normal values of several radiographic measurements of hip and pelvis in individuals of Indian population.

MATERIAL AND METHODS

We conducted a cross-sectional study of Indian population and calculated mean and variation seen in different parameters in Indian pelvis. We took the plain X-ray of randomly selected hundred patients in identical position with 20% magnification factor. Different parameters including acetabular inclination angle, cup size, tear drop position, neck shaft angle, neck offset, abductor lever arm and head size were drawn on the X-rays and values measured.

RESULTS

100 subjects were taken (63 male and 37 female). The mean of acetabular inclination angle was 37.70 ± 3.82° (30-47°). The mean neck shaft angle was131.53 ± 7.70° (114-158) the most commonly occurring value was 131°. The mean abductor lever arm was 38.48 mm ± 5.77 (23-54) with the mode of 40. The mean cup size was 48.9 ± 3.67 mm (34-58) with the most commonly occurring value as 50. The mean angle from tip of trochanter to center of head was 80.2 ± 9.1 (62-110). Among all the seven parameters correlations were drawn. There were in all 22 correlations out of which 14 were statistically significant.

CONCLUSION

Since there is significant difference between the neck shaft angles and other measurements of Indian population than to the European population, an evaluation in the design of the implant by the Indian manufacturers is recommended. Also this study proposes that the normal values of our own population be used as reference values in interpreting standard radiographs of pelvis with both hips.

Surgical dislocation of the hip for reduction of acetabular fracture and evaluation of chondral damage

PURPOSE

To assess the outcome of open reduction and internal fixation combined with surgical dislocation of the hip for displaced acetabular fractures.

METHODS

20 men and 2 women aged 20 to 55 (mean, 28) years underwent open reduction and internal fixation combined with surgical dislocation of the hip for displaced acetabular fracture. The most common fracture pattern was bicolumnar (n=12), followed by transverse (n=6) and T-type (n=4). Femoral head chondral lesions were classified as grade 0 (no defect) to grade 4 (osteochondral defect). Fracture fragments were fixed with titanium plates and screws, and the femoral head was redislocated to inspect for intraarticular screws. The association between functional status and acetabular fracture pattern and femoral head chondral lesions was explored.

RESULTS

Nine patients had chondral lesions in the femoral head (mostly in the anterosuperior zone), but none in the acetabulum. All femoral heads were viable. Reduction was anatomic in 6 patients and satisfactory in 16. Functional outcome was very good in 6 patients, good in 13, medium in 2, and fair in one. No patient developed avascular necrosis of the femoral head. Four patients had iatrogenic sciatic nerve palsy. One patient developed early degenerative hip arthritis and underwent total hip arthroplasty 14 months later.

CONCLUSION

Surgical dislocation of the hip facilitated anatomic reduction and inspection of any chondral lesions. It did not result in avascular necrosis of the femoral head.

Neurilemmoma of median nerve

Neurilemmomas constitute one of the most common tumors of peripheral nerves. Rarer amongst them is their occurrence in median nerve in the region of arm. A sixteen-year-old female presented with painless mass in right arm which was non-tender on palpation with positive Tinel's sign and no motor or sensory deficit in the affected arm. Ultrasound examination revealed an eccentrically arising mass of size 19 × 11 mm along median nerve. MRI study revealed a mass homogenously isointense on T1 weighted images and hyperintense in T2 weighted images placed eccentrically in relation to median nerve in arm. Excisional biopsy under loupe magnification was carried out which revealed the mass to be neurilemmoma. This slowly growing benign tumor of peripheral nerves with an incidence of 5% with 14% involvement of Median nerve can be enucleated from the nerve with little or no damage. In spite of advanced imaging studies the mass cannot be differentiated preoperatively from another peripheral nerve sheath tumor neurofibroma. Both these tumors although bearing some clinical and imaging resemblance carry different intraoperative findings, histopathological features and post-operative results.

The role of tranexamic acid in reducing blood loss in total knee replacement

BACKGROUND

Total knee arthroplasty is associated with significant perioperative blood loss which may necessitate blood transfusion. In this prospective randomised case control study we analysed the efficacy and safety of tranexamic acid in reducing perioperative blood loss and requirement of blood transfusion in total knee arthroplasty.

METHODS

Fourteen patients (group A) undergoing total knee replacement were given intravenous tranexamic acid twice, once ten minutes before tourniquet deflation and once after four hours. Thirteen patients (group B) were observed as a separate group without the administration of the drug. Total perioperative blood loss, need of blood transfusion and D-dimer assay were analysed subsequently.

RESULTS

The average blood loss in the first group was 266.2 ml and in the second group was 667.5 ml (p < 0.001). average requirement of transfusion in both the groups were 0.54 and 1.6 units of blood respectively (p < 0.001). There was no case of deep vein thrombosis or any other untoward effects.

CONCLUSION

Hence from these evidences it was concluded that administration of tranexamic acid during total knee replacement helps to reduce blood loss without increasing the risk of deep vein thrombosis.

Bilateral Traumatic Anterior Dislocation of Shoulder - A Rare Entity

INTRODUCTION

Bilateral shoulder dislocation are most commonly posterior type. These are most commonly due to seizure disorder and electrocution. Anterior shoulder dislocations occurring bilaterally without any predisposing factors are very rare. These types of injuries are due to trauma with a unique mechanism of injury. To best of our knowledge there are only few cases of similar kind are reported in literature. We hereby report a interesting case of posttraumatic, bilateral anterior dislocation of shoulder without associated fracture in a 45 old women without any predisposing pathoanatomy.

CASE REPORT

A 45-year-old women presented to casualty with sudden onset of pain and restriction of movement in both shoulders fallowing trauma. Immediately post trauma she had severe pain and restriction of both shoulders. On examination arms were abducted and externally rotated. Bilateral shoulder movements were painful and restricted. There was loss of round contour of shoulder with increased vertical diameter of axilla anteriorly. Radiological examination revealed bilateral anterior dislocation of the shoulders without any associated fractures. Closed reduction done by Milch technique after intraraticular lignocaine injection. MRI of bilateral shoulder showed no pathological lesion. Both shoulders were immobilized with a shoulder immobilizer for three weeks.

CONCLUSION

Most of the bilateral shoulder dislocations are posterior type seen in seizure disorders. Bilateral traumatic anterior shoulder dislocations are rare and are seen as a result of unique mechanism of injury. In our case patient had a fall on her elbows causing forced extension. If diagnosed and treated promptly completely normal function of the shoulders can be restored.

Stopping light in two dimensional quasicrystalline waveguides

The introduction of defects in photonic lattices generally allows to control the localization and the propagation of light. While point defects are conventionally used in order to obtain localized photonic states, linear defects are introduced for waveguiding EM waves. In this work we demonstrate the possibility of obtaining localized states also in a waveguiding configuration, by using quasicrystalline lattices. This result opens a new range of possibilities in designing optical circuits, in which the localization-propagation switch is easly obtainable by mechanical or opto-electric methods.

Isolated involvement of the posterior elements in spinal tuberculosis: a review of twenty-four cases

BACKGROUND

The literature on tuberculosis of the posterior spinal elements without involvement of the vertebral body is scarce. In this study we report our experience with twenty-four cases of neural arch tuberculosis that were treated at our center.

METHODS

We performed a retrospective review of the clinical and radiographic data of twenty-four consecutive patients who had tuberculosis of the posterior spinal elements with total sparing of the vertebral bodies and intervertebral disc space. We categorized the patients into two groups on the basis of the clinical and radiographic evaluation. The patients who had rapid onset weakness of the lower limbs or pyramidal signs or who showed evidence of epidural abscess underwent emergency decompressive laminectomy (Group A). Patients who had pyomyositis of the posterior spinal muscles without any neurological deficit, pyramidal signs, or epidural abscess were managed with antitubercular therapy alone (Group B).

RESULTS

The common presenting features were spastic limb weakness and back pain. The majority of the patients had involvement of the thoracic spine. Epidural abscess, erosion of lamina, and pyomyositis of posterior spinal muscles were common imaging findings. Group A consisted of nineteen patients and Group B consisted of five patients. The mean period of follow-up was 16.9 months (range, nine to sixty months). Patients in Group A had a poorer outcome than those in Group B. Thirteen of the nineteen patients in Group A improved to become independent in the activities of daily living, with complete neurological recovery in eight patients and partial recovery in five patients. Six of the nineteen patients continued to have spastic paraplegia and were wheelchair-dependent. All of the patients in Group B remained neurologically intact during the follow-up period. None of the patients had recurrence of the disease or developed anterior element involvement or kyphotic deformity during the follow-up period.

CONCLUSIONS

Neural arch tuberculosis is often missed at the time of initial presentation. In association with epidural abscess, it leads to rapid neurological deterioration. This atypical picture of spinal tuberculosis showed a high rate of neurological deficit at the time of initial presentation for medical care.

Broken guidewire protruding into the hip joint: A bone endoscopic-assisted retrieval method

Broken implants, especially broken wires at difficult sites, may pose a challenge for the treating orthopedic surgeon. We describe a method for extraction of a broken guidewire that was, protruding into the hip joint following the insertion of a proximal femoral nail. A 35-year-old man with displaced femoral neck fracture with ipsilateral fracture shaft of femur was operated and fixed with long proximal femoral nail. The guidewire of proximal screw broke during the process of drilling. The tip of the 2-cm-long broken guidewire was touching the articular surface. The guidewire was misdirected posteroinferiorly from its path for the insertion of the proximal screw (6.8 mm), this screw was removed and bone endoscopy was performed with a 30° arthroscope. The broken end of the guidewire was located under direct vision. The grasper was introduced with its jaws at the 8 O'clock position and its position was confirmed under a C-arm image intensifier in both anteroposterior and lateral views. The broken end of the guidewire was grasped and it was retrieved. The screw was replaced in its original track to complete the procedure. The fractures united and patient was asymptomatic when last followed-up at 12 months.

Neonatal separation of distal humeral epiphysis during Caesarean section: a case report

We report a rare injury of distal humeral epiphyseal separation in a newborn during a Caesarean section. The diagnosis was made using magnetic resonance imaging. Emergency Caesarean deliveries with considerable traction applied to extract the baby can be the risk factor of such an injury.

A method to localize the radial nerve using the 'apex of triceps aponeurosis' as a landmark

BACKGROUND

The relationship of the radial nerve is described with various osseous landmarks, but such relationships may be disturbed in the setting of humerus shaft fractures. Alternative landmarks would be helpful to more consistently and reliably allow the surgeon to locate the radial nerve during the posterior approach to the arm.

QUESTIONS/PURPOSES

We investigated the relationship of the radial nerve with the apex of triceps aponeurosis, and describe a technique to locate the nerve.

MATERIALS AND METHODS

We performed dissections of 10 cadavers and gathered surgical details of 60 patients (30 patients and 30 control patients) during the posterior approach of the humerus. We measured the distance of the radial nerve from the apex of the triceps aponeurosis along the long axis of the humerus in cadaveric dissections and patients. This distance was correlated with the height and arm length. For all patients, we recorded time until first observation of the radial nerve, blood loss, and postoperative radial nerve function.

RESULTS

The mean distance of the radial nerve from the apex of the triceps aponeurosis was 2.5 cm, which correlated with the patients' height and arm length. The mean time until the first observation of the radial nerve from beginning the skin incision was 6 minutes, as compared with 16 minutes in the control group. Mean blood loss was 188 mL and 237 mL, respectively. With the numbers available, we observed no difference in the incidence of patients with postoperative nerve palsy: none in the study group and three in the control group.

CONCLUSION

The apex of the triceps aponeurosis appears to be a useful anatomic landmark for localization of the radial nerve during the posterior approach to the humerus.

An unusual presentation of hemophilia B: pseudotumor of proximal tibia

Hemophilia is one of the most common genetically inherited causes of bleeding disorders. The usual presentation is continuous bleeding from a wound. Very seldom, it presents as a pseudotumor of bone. When left untreated, it may induce compression and pressure necrosis of adjacent structures. Careful evaluation and a high index of suspicion are usually required to arrive at the correct diagnosis. In this article, we report the case of a 10-year-old boy with hemophilia B (Christmas disease) that presented as a pseudotumor producing a large defect in the proximal tibia.

Neglected femoral neck fractures in adults

PURPOSE

To assess treatment outcomes in adults with neglected femoral neck fractures, and propose a treatment protocol based on bone quality measured by the Singh index.

METHODS

16 men and 6 women aged 18 to 48 (mean, 33) years presented with neglected (>3 weeks old) femoral neck fractures. Those with good bone quality (Singh index, >3) underwent closed reduction and valgus osteotomy and fixation with 120º double angle blade plates (group 1, n=8), whereas those with poor bone quality (Singh index, >3) and/or communition of the posterior femoral neck underwent fibular grafting and internal fixation with one or two 7-mm cannulated cancellous screws (group 2, n=14). Functional outcome was assessed at the 6-month follow-up, according to modified Askin and Bryan criteria.

RESULTS

The mean delay in surgery was 12 (range, 4-21) weeks. Patients were followed up for a mean of 19 (range, 12-24) months. The mean time to union was 20 (range, 12-52) weeks. The mean time to full weight bearing was 18 (range, 12-40) weeks. All patients achieved bone union except one in group 1 who had non-union and breakage of the blade plate at week 20 and underwent total hip arthroplasty. Other complications included slippage of fibular graft (n=1), delayed union (n=1), avascular necrosis of the femoral head (n=2), limb length discrepancy (n=3), and superficial infection (n=1). Functional outcome was excellent in 2 patients, good in 17, and poor in 3.

CONCLUSION

Valgus osteotomy and double angle blade plate fixation, and fibular grafting and cancellous screw fixation appeared to be appropriate treatments for neglected femoral neck fractures in adults.

Open wedge osteotomy of the proximal medial tibia for malunited tibial plateau fractures

PURPOSE

To review outcomes of open wedge osteotomy of the proximal medial tibia for malunited tibial plateau fractures.

METHODS

Seven men (mean age, 36 years) underwent open wedge osteotomy of the proximal medial tibia for instability secondary to malunited tibial plateau fractures of Schatzker types IV (n=3), V (n=1), and VI (n=3). Five patients had been treated conservatively and 2 surgically.

RESULTS

Patients were followed up for 12 to 30 months. Five patients achieved complete correction of the deformity, whereas 2 had residual articular surface depression of <2 mm. All patients were satisfied with their improvement in stability and knee function. One patient developed anterior cruciate ligament deficiency and instability and underwent anterior cruciate ligament reconstruction. No patient developed any complication related to wound healing. No delayed loss of correction was observed.

CONCLUSION

Open wedge osteotomy of the proximal medial tibia is recommended for young adults with instability of the knee joint secondary to malunited proximal tibial plateau fractures. The technique is simple and does not require specialised training or any specific instrumentation.