Severe life-threatening hypersensitivity reaction to polidocanol in a case of recurrent aneurysmal bone cyst.

Aneurysmal bone cysts (ABC) are expansile lytic lesions constituting around 1% of all benign bone tumors with an annual incidence of 1.4/100000. A variety of treatments are available ranging from curettage with or without bone grafting (autologous or allogeneic), curettage with use of adjuvants [Polymethylmethacrylate (PMMA) bone cement, high speed burr, phenol, liquid nitrogen], wide en-block excision with or without reconstruction, selective arterial embolization of the feeding vessels, radiation therapy, high precision megavoltage radiotherapy and percutaneous radio-nuclide ablation, sclerotherapy (ethibloc, aetoxisclerol, alcohol gel, polidocanol). The optimal treatment is debatable due to various indications and contraindications of different modalities of treatment. Recent data suggest that percutaneous sclerotherapy with polidocanol is safe and effective alternative to surgery for treatment of ABCs as it has minimal side effects. We are reporting the first case of life-threatening adverse reaction to intra-lesional polidocanol in a three-year-old boy with a proximal femoral aneurysmal bone cyst. The importance of reporting this case is to make people aware regarding the adverse reaction of polidocanol and to highlight the precautions one should follow while using polidocanol for aneurysmal bone cysts.

Mega Prosthetic Replacement of Elbow for Resistant Nonunion of Distal Humerus.

INTRODUCTION: Fractures of the distal humerus are a rare entity accounting for approximately 2% of the humeral fractures. Non union of the distal humerus is further rare and poses a major challenge. These fractures usually respond to open reduction and bone grafting but some may fail multiple surgical attempts at union and hence are labelled as "resistant" non union. We report a case of resistant non union of the distal humerus which was managed by total elbow arthroplasty. CASE PRESENTATION: A 49-year-old male presented to the out patient department with history of a compound comminuted fracture of the distal end of the humerus approximately 25 years back. The fracture was treated with multiple debridements and plaster cast application. There was involvement of the radial and the ulnar nerves as well. The patient continued to use the disabled upper limb with severe difficulties in activities of daily living (ADL). The patient finally presented to us for regaining some range of motion and improvement in his ADL. In view of the grossly distorted anatomy, bone loss and chronic nature of the problem, patient was offered total elbow arthroplasty. The Wadsworth extensile posterior approach was used for exposure of the non union site. The fragments were found to be small, osteoporotic and deformed. In view of the distorted anatomy, the elbow was finally salvaged with mega-prosthetic replacement of the elbow. Posterior elbow splint was used for 2 weeks and active as well as passive range of motion was started after that. The post-operative Mayo elbow score improved from 50 to 80 and the patient was able to achieve a range of motion from 10 degrees to 110 degrees. CONCLUSION: Total elbow arthroplasty can be used as a salvage procedure for resistant non union of the elbow with failed multiple failed attempts at union. It can also be used as a definitive procedure for severely distorted non union with massive bone loss with satisfactory functional results.