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Introduction: Giant cell tumor of bone (GCTB) is a rare yet locally aggressive neoplasm primarily affecting young adults. Its hallmark features include multinucleated osteoclast-type giant cells and mononuclear tumor cells. Treatment with denosumab, an anti-RANK ligand antibody, has shown efficacy, but it alters histomorphology, posing diagnostic challenges. Co-occurrence with achondroplasia, though rare, warrants consideration in bone lesion evaluations. Case Report: A 30-year-old male with achondroplasia presented with a proximal femur GCT, a rare association. Neoadjuvant denosumab was administered due to thin tumor cortex and cortical breech. Surgical excision with bone cement filling and Philo's plate supplementation was performed. Histopathological examination post-treatment revealed the absence of osteoclast-type giant cells, extensive necrosis, hyalinization, and mononuclear infiltrates. Discussion: Denosumab induces a reduction in osteoclast numbers, causing tumor shrinkage and sclerosis, while altering typical GCT histology. Similar findings were noted in the literature, including stromal changes like spindle-shaped cells, inflammation, vascular proliferation, and hemosiderin-laden foamy macrophages. Recognition of these alterations is crucial for accurate diagnosis. Conclusion: GCT, though rare, presents distinct histopathological features aiding diagnosis. Denosumab treatment modifies tumor morphology, necessitating thorough clinical evaluation for accurate diagnosis post-treatment. Understanding, these challenges is essential for optimal management of GCT cases.

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PURPOSE: To assess the Xpert MTB/XDR assay's efficiency in promptly detecting resistance to isoniazid, fluoroquinolones, ethionamide, and second-line injectable drugs among tuberculosis (TB) patients. METHODS: From August 2020 to July 2021, TB suspected patient samples were enrolled at a tertiary care center for our study. We conducted mycobacterial culture, phenotypic DST using proportion method in liquid culture at WHO-recommended concentrations, and the line probe assay (LPA). Simultaneously, the Index test, Xpert MTB/XDR, was performed following the manufacturer's instructions. RESULTS: Among 360 samples, 107 were excluded due to incomplete information. Resistance to isoniazid, levofloxacin and moxifloxacin was found in 45/251, 21/251 and 20/251 samples, respectively by phenotypic DST. The diagnostic accuracy of Index test, taking phenotypic DST as a reference standard, was 95.8%, 99.04%, and 99.05% for isoniazid, levofloxacin, and moxifloxacin, respectively. The Index test assay demonstrated a specificity of 99.1% for detecting SLID resistance, yielding a diagnostic accuracy of 99.2. Comparing the Index test with LPA revealed a significant enhancement in sensitivity for detecting isoniazid resistance (86.7% vs. 82.2%). CONCLUSIONS: The Index test exhibited promising outcomes in identifying resistance to isoniazid and fluoroquinolones, surpassing the performance of the LPA. This could be valuable for promptly initiating treatment in cases of drug-resistant tuberculosis.

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Pierre Robin sequence is a rare congenital disorder with variable associations. A two-year-old female child was brought in with complaints of an abnormal gait and right lower limb shortening. A comprehensive clinical evaluation unveiled facial characteristics resembling those of Pierre Robin Sequence, including micrognathia, a cleft palate, and glossoptosis. The child also exhibited retrognathia, a low posterior hairline, bilateral developmental dysplasia of the hips, right foot syndactyly, and a left ectopic kidney as confirmed by ultrasonography. Radiological examination showed bilateral developmental dysplastic hips. The connection between Pierre Robin sequence and the presence of bilateral dysplastic hips and an ectopic kidney is an unusual and rare combination.

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Septic arthritis of the hip in late childhood leads to different sequelae. These cases are often missed and lead to various disabilities like hip subluxation, limb length discrepancy, and limping. The primary goal is always to reproduce a concentrically reduced stable hip. We are presenting a 13-year child with sequelae of septic arthritis of the hip with dislocation. The child had septic arthritis of the hip two years back. The patient had a superolateral acetabular defect and was treated with triple innominate steel osteotomy. The osteotomy increased the acetabular head coverage and gave a stable congruent hip to the child. Late childhood septic arthritis cases can produce acetabular defects without involving the femoral head leading to dislocation. Such cases can be effectively treated with triple innominate pelvic osteotomy, giving good head coverage with stable congruent hips.

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Introduction: Avascular necrosis (AVN) of patella is a very rare condition and occurs in very few case. Although underlying etiology is still unknown, some expert suggest that its due to interruption of blood supply to patella which may be due to high velocity trauma or may be due to long term history of steroid intake. Here are the findings of our case AVN patella and reviews of earlier literature. Case Report: We present a case of a AVN patella in a 31-year-old male. The patient presented with pain in knee with stiffness and tenderness at knee followed by decrease range of movement of knee. Magnetic resonance imaging showed irregular cortical outline of patella with degenerative osteophytes-suggestive of osteonecrosis of patella. It was treated conservatively with physiotherapy for range of movement of knee. Conclusion: ORIF with extensive exploration and infection may compromise that the vascularity of patella may lead to AVN of patella. As the disease is non-progressive, it is better to manage such patients conservatively with range of movement brace so as to decrease the chance of complication associated with surgical intervention.

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Introduction: Chronic radial head dislocation in old standing or neglected Monteggia fracture is a devastating complication. We present our case regarding managing such a case using plating and fascial slip annular ligament reconstruction (ALR). Case Report: A 40-year-old male patient, farmer by profession presented with a 4-month-old neglected Monteggia fracture. He was treated with open reduction and internal fixation of fracture ulna with ALR using forearm deep fascial slip. The patient underwent regular physiotherapy post-operatively after 2 weeks of surgery. The patient was followed for 6 months, and DASH score was used to evaluate functional outcome. Conclusion: Excellent results were obtained as regards to pain, wrist range of motion, fracture union, and resuming routine activities at the follow-ups.

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Pigmented villonodular synovitis (PVNS) is a locally aggressive benign tumour of the synovial membrane and tendon sheath. The unique presentation of this tumour is hemosiderin deposition with synovial proliferation. Depending on the situation, surgical excision is always the first line of treatment with adjuvant radiotherapy. Arthroscopic excision is preferred in some intraarticular nodular PVNS cases. This is a rare pigmented villonodular synovitis involving flexor hallusis longus, flexor digitorum longus, and tibialis posterior (TP). The tumour was entirely extra-articular without any joint involvement. The tumour was the diffuse type of PVNS and was treated by excision followed by radiotherapy. There is no recurrence till nine months of follow-up.

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Introduction: A giant cell tumor (GCT) is a benign tumor of bones which commonly arises from epiphysis of long bones. The tumor is locally aggressive and rarely metastasizes to the lungs. GCT of small bones of the foot and ankle is very rare. The GCT of the talus is very rare, and only a few case reports and series are described in the literature. In general, the GCT is monostotic, and few incidences of multicentricity have been described in the foot and ankle bones literature. Here are the findings of our case GCT of talus and reviews of earlier literature. Case Report: We present a case of a GCT of the talus in a 22-year-old female. Patient presented with pain in ankle with mild swelling and tenderness at ankle. Radiograph and Computer tomography scan conformed an eccentric osteolytic lesion on anterolateral part of talus body. Magnetic resonance imaging showed no extra osseous extension or articular surface breach. Biopsy conformed the lesion to be giant cell tumor. The tumor was reated with curettage and bone cement filling. Conclusion: Giant cell tumor of talus is extremely rare and presentation of these tumor may change. Curettage and bone cementing are an effective method of treatment. It gives early weight bearing and rehabilitation.

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Ipsilateral femoral neck and shaft fractures are relatively rare fractures, which most commonly occur in young adults following high-energy trauma. In most cases of such fractures, neck fracture is undisplaced and often of basicervical type. Many treatment methods have been described, but there is still no generalized consensus on the same. Cephalomedullary nails are one of the preferred modalities of treatment. A cephalomedullary nail-like proximal femoral nail antirotation 2 (PFNA 2) of recent design is being widely used currently. In this study, we present 13 cases of ipsilateral femoral neck and shaft fractures treated with PFNA 2 implants. The advantages of the PFNA 2 system include reduced blood loss, reduced operative time, and fewer fluoroscopy shots. PFNA 2 is a biomechanically better implant than many cephalomedullary implants. It provides satisfactory results in ipsilateral femoral neck and shaft fractures, especially where neck fracture is of a basicervical type. Some aspects have to be taken care of when employing PFNA 2, such as anatomical reduction, and length, angulation, and rotation of both neck and shaft.

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BACKGROUND: There are various techniques of Achilles tendon (TA) repair and reconstruction in chronic Achilles tear. However, there is no clear consensus on the relevance of one method over the other. The short flexor hallucis longus tendon (FHL) transfer has recently gained popularity because of its same phasic action, ease of harvesting and tensile strength. METHODOLOGY: Fifteen chronic Achilles tear (>6 weeks) were treated with tendon repair using gastrocnemius advancement flap augmented with FHL transfer. The patients were followed-up at 1.5, 3, 6, 12 and 24 months. The clinical outcome at latest follow-up was evaluated using the American Orthopedic Foot and Ankle Score (AOFAS) and the Achilles Tendon Rupture Score (ATRS). RESULTS: The mean age was 43.5 ± 12.4 years and the median time from injury to surgery was 17.13 ± 9.64 weeks. The mean gap between the retracted ends of the ruptured tendon was 5.67 ± 1.63 cm (range 4-10 cm). The mean follow-up was 19.07 ± 3.15 months (range, 13-24 months). The mean AOFAS and ATRS improved from 72.07 ± 8.29 (62-83) to 98.4 ± 2.03 (94-100) and 61.73 ± 8.16 (52-70) to 98 ± 1.85 (94-100) respectively (paired t-test, p-value 0.0001). All patients resumed their pre-injury daily activities, and there was no donor site morbidity. Two patients had sterile serous discharge, and one patient had a staphylococcus infection. These patients responded to debridement with prolonged antibiotic therapy. There were no nerve injuries or re-rupture. CONCLUSION: The functional outcome of chronic Achilles tear treated with gastrocnemius advancement flap augmented with short FHL transfer is rewarding.

Asunto(s)

Tendón Calcáneo/lesiones , Colgajos Quirúrgicos , Traumatismos de los Tendones/cirugía , Transferencia Tendinosa , Adolescente , Adulto , Enfermedad Crónica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Músculo Esquelético , Recuperación de la Función , Estudios Retrospectivos , Rotura , Resultado del Tratamiento , Adulto Joven

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A 23-year old male with bilateral hip dislocations and associated femur head fractures (Pipkin type-II) presented with pain and flexion deformity of both hips after 9 days. After imaging, closed reduction was attempted but failed. Open reduction through Kocher-Langenbeck approach was performed and the femoral head fracture was accessed through Ganz's safe surgical dislocation. The fracture was reduced anatomically and fixed with headless Herbert screws. After two years, the patient was walking without pain or limp and there was no evidence of osteonecrosis. Simultaneous sequential Ganz's safe surgical dislocation can be performed in bilateral Pipkin's fracture dislocation with excellent short term outcome.

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Introduction Acetabular fractures are complex intra-articular fractures. The extra-pelvic ilioinguinal (IL) has been the workhorse for the anterior approach and remains the gold standard. The major difference between the IL and the Stoppa approaches is that Stoppa allows for the avoidance of the middle window of the IL approach. Hence, the modified Stoppa approach (MSA) can be adopted by a comparatively less experienced surgeon with minimal complications. The purpose of this study is to evaluate the radiological and functional outcomes of patients operated on using the MSA. Materials and methods Patients operated on by the MSA for acetabular fractures with a minimum of one year of clinical and radiographic follow-ups were reviewed. CT scans and radiographs were evaluated for the fracture pattern, time to surgery, operative time, blood loss, quality of reduction (Matta criterion), FO [Harris hip score (HHS) and Nach Merle d'Aubigné and Postel score (NMAPS)] and complications (perioperative and follow-up). Twenty-three of 26 patients with 45 acetabular fractures operated between January 2016 and November 2018 were included. Descriptive statistics were used for demographic data, and Pearson's chi-squared statistic was calculated for the association between radiological and functional outcomes. Results  Among the 23 patients, the mean age was 38.5 years (range: 15-65) with a male-to-female ratio of 18:5. The average time to surgery was 11.5 days (range: 2-32), operating time was 155 minutes (range: 90-243), and average blood loss was 650 ml (range: 500-1,250). A supplemental lateral window was used in 20 patients (87%), and three underwent the combined anterior and posterior [Kocher Langenbacks (KL)] approach. All cases were unilateral. The transverse fracture was the most common pattern (eight patients) followed by the associated both-column fracture in six and T-type, isolated anterior column fracture, and anterior column and posterior hemi-transverse fractures seen in three patients each. Iliac blade (high anterior column) fracture was seen in 14 cases and one patient had associated sacral type II fracture. Road traffic accidents accounted for 61% of the injuries and injury severity score (ISS) of >15 (polytrauma) was seen in more than 50% of the cases (associated with other organ injuries). The radiological outcome was anatomical in 52% of the cases, imperfect in 39%, and poor in 9%. The functional outcomes were good to excellent in 74% (HHS) and 79% (NMAPS) of the cases. The association and correlation between them were nonsignificant (p-value: >0.5). Two patients developed a superficial infection and three had iatrogenic obturator nerve palsy. One patient had a direct inguinal hernia, one had grade 3 bedsores, and two patients developed grade 2 arthritic changes during the follow-up. No case of vessel injury was encountered. Conclusion Adoption of the MSA for the treatment of acetabular fractures leads to a good-to-excellent anatomical reduction in most cases while providing direct visualization of the quadrilateral plate and posterior column. The learning curve is smaller for less-experienced surgeons in terms of complications and results. We recommend this technique as a viable alternative to the IL approach for anterior acetabular fixation.

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Tibial tuberosity fractures are usually seen in the adolescent age group and are very rare in adults. Here we describe a case of knee injury following a road traffic accident. The patient had tibial tuberosity avulsion along with tibial plateau fracture. He was treated with open surgical reduction and internal fixation. His rehabilitation was quite successful, resulting in a good range of motion and functional outcome. This study aims to present this unusual case of tibial tuberosity avulsion fracture associated with tibial plateau fracture and its appropriate management.

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Femoral head fracture-dislocations are rare, and irreducible cases are even less frequent. Truly irreducible fracture-dislocations must be differentiated from incomplete reduction due to incarcerated bone or soft tissue interposition. The Pipkin classification is commonly used to classify femoral head fractures. An urgent reduction is required in traumatic hip dislocations to reduce the risk of avascular necrosis (AVN) of the femoral head. However, in femoral head fractures, the dislocated hip cannot be reduced easily due to incarcerated bone or soft tissue. In an irreducible fracture hip dislocation, It is not advisable to attempt to reduce it repeatedly because sometimes femoral head fracture-dislocation is associated with the impacted fracture of the femoral neck. It may lead to iatrogenic femoral neck fracture. Hence, in such cases, immediate open reduction and internal fixation are recommended. The Kocher-Langenbeck approach can be used for reduction and safe surgical dislocation with flip trochanteric osteotomy for fixation as a novel approach.

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Cystic lesion around knee usually presents as painless swelling and diagnosed incidentally by imaging for any internal derangement of the knee. Few cases presented with pain. Intra-tendinous patellar ganglion is very rare in location for the disease. Ganglionic cyst usually treated by aspiration followed by steroid and surgical excision in some cases. We reported a case with anterior knee pain due to patellar intra-tendinous ganglion cyst which treated conservatively with no recurrence even after one year.

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Ipsilateral fracture of the shaft of femur and dislocation of the hip are very rare injuries. There always exists a dilemma regarding the treatment to reduce hip and choosing the appropriate method of fixation for a femur fracture, and a clear consensus is yet to be reached. A number of treatment methods such as the open reduction of femur and fixation followed by hip reduction have been tried so far. Ipsilateral fractures and dislocation occur due to high-energy trauma, and reduction of hip dislocation is considered as an orthopedic emergency. Here, we report a case in which we tried a novel approach by temporarily fixing the femur with an external fixator and reducing the hip dislocation. In the next sitting, we performed femur fixation in a closed manner with an interlocking intramedullary nail. We recommend that this novel method of treatment can be used for such types of injuries.

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A spinal epidural abscess (SEA) is a rare condition that has a devastating impact on the patient's health. It is difficult to diagnose and can present with a myriad of symptoms with or without the involvement of a neurological deficit. The conditions that lead to immunocompromised status, such as malnutrition, diabetes, intravenous drug abuse, previous surgical intervention, and human immunodeficiency virus (HIV) infection/acquired immune deficiency syndrome (AIDS) can predispose a patient to SEA. The most common organisms isolated from the affected patient include Staphylococcus aureus and Streptococcus species while an abscess in some cases can be caused by tuberculosis and fungal and parasitic infections. Among the other causative organisms is Burkholderia pseudomallei (B. pseudomallei), also known as Pseudomonas pseudomallei, which is a Gram-negative, bipolar, aerobic, motile, and rod-shaped bacterium. It is a soil-dwelling bacterium, which is endemic in tropical and subtropical regions worldwide, particularly in Thailand and northern Australia, and causes melioidosis. To our knowledge, SEA caused by B. pseudomallei from the Indian subcontinent has not been reported in the literature. In this case report, we present the case of a patient with SEA caused by B. pseudomallei.

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BACKGROUND: Surgical management of spinal tuberculosis (TB) has been classically the anterior, then combined, and of late increasingly by the posterior approach. The posterior approach has been successful in early disease. There has been a paradigm shift and inquisitive to explore this approach in the more advanced and even long-segment disease. Our study is a retrospective analysis by authors in variable disease pattern of TB Spine operated at an institute using a single posterior approach. SETTINGS AND DESIGN: A retrospective case study series in a tertiary level hospital. AIMS: The aim of this study is to evaluate the functional and radiological results of an all posterior instrumented approach used as a "universal approach" in tubercular spondylodiscitis of variable presentation. MATERIALS AND METHODS: The study is from January 2015 to May 2018. Twenty-four of 38 patients met the inclusion criterion with a male: female = 8:16, and mean age 44.26 years. The initial diagnosis of TB was based on clinic-radiologic basis. Their level of affection, number of vertebrae affected, and vertebral body collapse, the kyphosis (preoperative, predicted, postoperative, and final residual) and bony fusion were measured in the preoperative, postoperative, and final X rays. Functional scoring regarding visual analog scale and Frankel neurology grading was done at presentation and follow-up of patients. Histopathological data of all patients were collected and anti-tubercular therapy completed for a period of 1 year with 4 drugs (HRZE) for 2 months and 2 drugs (HR) for rest of period. STATISTICAL ANALYSIS USED: The descriptive data were analyzed by descriptive statistics, and other parameters were calculated using the appropriate statistical tests such as the Student paired t-test for erythrocyte sedimentation rate, visual analog scale score, and kyphosis. RESULTS: The mean number of vertebrae involved was 3.29 ± 0.86 (2-6) with mean vertebral body destruction was 0.616. Preoperatively, the mean kyphosis angle was 22.42° ± 12.56° and was corrected postoperatively to 13.08° ± 11.34° with an average correction of 9.34° (41.66%). At the latest follow-up, there was mean loss of correction of 0.80° resulting in 13.88° of final correction. Bony fusion was achieved in 20 patients (83.33%) cases. Neurological recovery occurred in all patients (100%), and 92% could be ambulatory at 1 year follow-up. There was improvement of visual analog scale from 6.33 ± 1.05 preoperatively to 1.042 ± 0.75 at 3 months of postoperative period. Two patients had bed sore, two had urinary infection, and one had neurological worsening requiring re exploration and cage removal eventually recovering to Frankel E. Two patients died due to unrelated cause. CONCLUSIONS: The procedure in safe and has satisfactory results in variable group affection of Pott's spine including early and late disease, multisegment involvement using pedicle screw fixation with/without cage support.

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Total hip arthroplasty (THA) is the treatment of choice for Grade IV avascular necrosis of the femoral head. Dislocation following THA, although rare, is a known complication. Common causes of unsuccessful reduction include interposition of soft tissue, component loosening, malalignment, and inadequate muscle relaxation following anaesthesia. Here, we encountered a rare complication during a single-stage bilateral THA that resulted in a non-concentric reduction on the left side. The pathology was a loose bone piece, which possibly was an osteophyte that was broken.