Dealing with sub-trochanteric fracture in a child with osteopetrosis : A case report.

Osteopetrosis is a rare hereditary condition which may have autosomal recessive or autosomal dominant inheritance. Patients tend to present most commonly with fractures but involvement of cranial nerves and hematopoetic system is not uncommon. Patients with infantile and intermediate type tend to present more often with problems other than orthopaedic problems. While diagnosis can be made on the basis of radiographs, management needs to be customized for every patient. Non operative and operative management both have their advantages and disadvantages. We are here reporting a case of sub-trochanteric fracture in an eight-year-old child which was managed successfully with a dynamic hip screw (DHS). Surgery could be performed successfully by taking precautions during reduction, drilling and screw placement. At the latest follow up, which was after one and half years of surgery, the fracture had united well and the child faced no limitations of activities. Thus, open reduction and fixation with DHS can be considered as an effective management modality for pediatric sub-trochanteric fractures in osteopetrosis.

Calcified giant thoracic disc herniations: considerations and treatment strategies.

INTRODUCTION: Giant herniated thoracic discs (GHTD) remain a surgical challenge. When combined with calcification, these discs require altered surgical strategies and have only been infrequently described. Our objective was to describe our surgical approaches in the management of calcified GHTD. METHODS: This was a retrospective cohort study of all patients with calcified GHTD operated between 2004 and 2012. Data were collected from review of patients' notes and radiographs and included basic demographic and radiological data, clinical presentation and outcome, operative procedure and complications. RESULTS: During the study period, there were 13 patients with calcified GHTD, including 6 males and 7 females (mean age 55 years, range 31-83 years). The average canal encroachment was 62% (range 40-90%); mean follow-up 37 months (12-98). All patients were treated with anterior thoracotomy, varying degrees of vertebral resection, removal of calcified disc and with or without reconstruction. The average time for surgery was 344 min (range 212-601 min) and estimated blood loss 1,230 ml (range 350-3,000 ml). Post-operatively, 8 patients improved by 1 Frankel grade (62%), 2 improved by 2 grades (15%) and 3 did not change their grade (23%). The complication rate was 4/13 (31%; 3 patients with durotomies (2 incidental, 1 intentional) and 1 with recurrence). DISCUSSION: Calcified GHTD remain a surgical challenge. Anterior decompression through a thoracotomy approach, and varying degrees of vertebral resection with or without reconstruction allowed us to safely remove the calcified fragment. All patients remained the same (23%) or improved by at least 1 grade (77%) neurologically, without radiographic failure at final follow-up.

Intracranial hypotension with a sixth cranial nerve palsy subsequent to massive thoracic CSF hygroma: a rare complication of thoracic disc excision.

BACKGROUND: Thoracic cerebrospinal fluid (CSF) hygroma is a rare and potentially devastating complication of the anterior thoracic approach to the spine. We present two cases in which this complication resulted in acute cranial nerve palsy and discuss the pathoanatomy and management options in this scenario. CASE REPORTS: Two male patients presented to our department with neurological deterioration due to a giant herniated thoracic disc. The extruded disc fragment was noted pre-operatively to be calcified in both patients. A durotomy was performed at primary disc prolapse resection in the first patient, whereas an incidental durotomy during the procedure caused complication in the second patient. These were repaired primarily or sealed with Tachosil(®). Both patients re-presented with acute diplopia. Imaging of both patients confirmed a massive thoracic cerebrospinal fluid hygroma and evidence of intracranial changes in keeping with intracranial hypotension, but no obvious brain stem shift. The hemithorax was re-explored and the dural repair was revised. The first patient made a full recovery within 3 months. The second patient was managed conservatively and took 5 months for improvement in his ophthalmic symptoms. CONCLUSIONS: The risk of CSF leakage post-dural repair into the thoracic cavity is raised due to local factors related to the chest cavity. Dural repairs can fail in the presence of an acute increase in CSF pressure, for example whilst sneezing. Intracranial hypotension can result in subsequent hygroma and possibly haematoma formation. The resultant cranial nerve palsy may be managed expectantly except in the setting of symptomatic subdural haematoma or compressive pneumocephaly.

Accuracy of the revised Tokuhashi score in predicting survival in patients with metastatic spinal cord compression (MSCC).

PURPOSE: The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our aim was to analyse the actual survival time of patients treated for metastatic spinal cord compression (MSCC) in comparison with the predicted survival based on the revised Tokuhashi score. This would thereby allow us to determine the overall predictive value of this scoring system. METHODS: This study was a semi-prospective clinical study of all patients with MSCC presenting to our unit over 8 years-data from October 2003 to December 2009 were collected retrospectively and from December 2009, all data collected prospectively to October 2011. Patients were divided into three groups--Group 1 (Tokuhashi score 0-8, n = 84), Group 2 (Tokuhashi score 9-11, n = 83) and Group 3 (Tokuhashi score 12-15, n = 34). Data collected included demographic data, primary tumour histology, surgery type and complications, neurological outcome (Frankel grade) and survival. RESULTS: A total of 233 patients with MSCC were managed surgically in our unit during this time. Out of these complete data were available on 201 patients for analysis. Mean age of patients was 61 years (range 18-86; 127 M, 74 F). The primary tumour type was Breast (n = 29, 15 %), Haematological (n = 28, 14 %), Renal (n = 26, 13 %), Prostate (n = 26, 13 %), Lung (n = 23, 11 %), Gastro-intestinal (n = 11, 5 %), Sarcoma (n = 9, 4 %) and others (n = 49, 24 %). All patients included in the study had surgical intervention in the form of decompression and stabilisation. Posterior decompression and stabilisation was performed in 171 patients (with vertebrectomy in 31), combined anterior and posterior approaches were used in 18 patients and 12 had an anterior approach only. The overall complication rate was 19 % (39/201)--the most common being wound infection (n = 15, 8 %). There was no difference in the neurological outcome (Frankel grade) between Groups 1 and 2 (p = 0.34) or Groups 2 and 3 (p = 0.70). However, there was a significant difference between Groups 1 and 3 (p = 0.001), with Group 3 having a significantly better neurological outcome. Median survival was 93 days in Group 1, 229 days in Group 2 and 875 days in Group 3 (p = 0.001). The predictive value between the actual and predicted survival was 64 % (Group 1), 64 % (Group 2) and 69 % (Group 3). The overall predictive value of the revised Tokuhashi score using Cox regression for all groups was 66 %. CONCLUSION: We would conclude that although the predictive value of the Tokuhashi score in terms of survival time is at best modest (66 %), the fact that there were statistically significant differences in survival between the groups looked at in this paper indicates that the scoring system, and the components which it consists of, are important in the evaluation of these patients when considering surgery.

Tuberculosis lymphadenitis in a well managed case of sarcoidosis.

Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young man, with a proven diagnosis of sarcoidosis who later developed TB after completion of treatment for sarcoidosis. A 32-year-old male patient presented with low-grade fever since two months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation; the chest radiograph was normal. Repeat FNAC from the same lymph node was suggestive of reactive lymphoid hyperplasia. The patient was treated with antibiotics and followed-up. He again presented with persistence of fever and lymphadenopathy and blurring of vision. Ophthalmological examination revealed uveitis, possibly due to a granulomatous cause. His repeat Mantoux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. This time an excision biopsy of the lymph node was done which revealed discrete, non-caseating, reticulin rich granulomatous inflammation suggestive of sarcoidosis. The patient was treated with oral prednisolone and imporved symptomatically. Subsequently, nearly nine months after completion of corticosteroid treatment, he presented with low-grade, intermittent fever and a lymph node enlargement in the right parotid region. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. He was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.

Tractor nail as impacted foreign body: rare case scenario.

A patient presented with a metallic nail impacted in the right orbital floor after being hit by a projectile. The nail was disimpacted and removed as guided by the radiograph image. Radiography proved helpful in forming a coherent scheme for case management.

'Mind if I record this?' Patients making audio-visual recordings of consultations: a survey of surgeons' experiences.

INTRODUCTION: Audio-visual recordings made by patients of their clinical encounters are increasingly common. This may be done with or without their doctors' knowledge or consent and is considered admissible legal evidence. Many surgeons may feel uncomfortable with being recorded and lack knowledge regarding the legal implications. The aim of this study was to gauge how surgeons react to being recorded, and what specific medico-legal insight they have regarding these matters. METHODS: In total, 150 surveys were distributed to surgeons in two hospitals in South Wales by email, Survey Monkey and paper copy between 28 October 2019 and 9 March 2020. The survey was anonymous and recorded level of training, as well as four simple questions regarding how surgeons may react to being recorded and what they felt their legal rights were. RESULTS: There were 91 respondents: 28 consultants, 36 registrars and 27 junior surgical trainees. Of the respondents, 56% were uncomfortable with being recorded and 23% would stop a consultation if their patient insisted on recording it. These issues were most marked for junior surgical trainees. Sixty-two per cent of respondents were unaware of their legal rights and 21% believed they were legally able to refuse to continue a consultation. This belief was particularly marked among consultants. CONCLUSION: Many surgeons are uncomfortable with being recorded and lack knowledge regarding their medico-legal standing. Education and guidance from the Royal Colleges would help address this issue and avoid misunderstanding when surgeons are faced with these potentially difficult scenarios.

Evaluation of scleral incisions and their effects on corneal curvature in manual small-incision cataract surgery.

Purpose: Incisions in cataract surgery can be modified in various ways in terms of size, shape, and axis to reduce or tailor astigmatism. This study was conducted to examine the effect of site (superior vs, temporal) and shape (frown vs. V-shaped, chevron) of scleral incisions for cataract surgery on corneal curvature. Methods: The prospective study was carried out on 200 consecutive patients with senile cataract and who were planned for surgery at a tertiary eye hospital in north India. The placement of the incision was decided by the steeper corneal meridian-whether superior or temporal-and then patients of these two groups were randomized for frown and V-shaped incision; in this way, four groups of 50 patients each were formed. Follow-up was done on day 1, at 2 weeks, 4 weeks, 8 weeks, and 12 weeks. At each follow-up, post-operative keratometry with routine postoperative examination was done. The results were statistically analyzed by using student's t-test, Chi-squared test, and the Pearson correlation coefficient. Results: In all the four groups, the difference of preoperative astigmatism and surgically-induced astigmatism was statistically highly significant. The analysis of uncorrected visual acuity (UCVA) was statistically significant (P < 0.05) on postoperative day 1 and at 2, 4, and 12 postoperative weeks; it was statistically insignificant (P > 0.05) at postoperative week 8. Conclusion: Temporal incisions result in lesser postoperative surgically induced astigmatism (SIA) than superior incisions. Chevron incisions result in minimal change in corneal curvature. This effect can be utilized to tailor the postoperative astigmatism.

Weil osteotomy: assessment of medium term results and predictive factors in recurrent metatarsalgia.

BACKGROUND: The angle of the Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of the metatarsal. This study aims to analyse the long term results following the Weil osteotomy and identify the cause of poor outcome. METHODS: This study presents a retrospective review of 61 patients (86 feet), with mean follow-up of 31 months. Each patient underwent clinical, pedobarographic and radiological examination. The radiographs obtained included 'Metatarsal Skyline Views' (MSV), to assess the plantar declination of the metatarsal heads following the osteotomy. The functional scoring was performed using AOFAS and Foot Function Index. RESULTS: Fifty-five patients (80 feet) showed good to excellent results clinically. Six patients had persistent metatarsalgia. All these 6 patients had callosities beneath metatarsal heads. Pedobarography showed peak pressures in the same distribution as callosities and the MSV showed increased plantar declination of the metatarsal heads. This correlation was found to be significant (p<0.05). CONCLUSION: The Weil osteotomy is a safe and effective treatment for metatarsalgia. An MSV radiograph is helpful to identify the plantar prominence of metatarsal which can be associated with poor clinical outcomes.

Symphytum officinale augments osteogenesis in human bone marrow-derived mesenchymal stem cells in vitro as they differentiate into osteoblasts.

ETHNOPHARMACOLOGICAL RELEVANCE: Mesenchymal stem cells (MSCs) are multipotent stem cells possessing regenerative potential. Symphytum officinale (SO) is a medicinal plant and in homoeopathic literature, believed to accelerate bone healing. AIM OF THE STUDY: This study aimed to determine if homoeopathic doses of SO could augment osteogenesis in MSCs as they differentiate into osteoblasts in vitro. MATERIALS AND METHODS: Bone marrow samples were obtained from patients who underwent bone grafting procedures (n = 15). MSCs were isolated, expanded and characterized by flow cytometry (CD90, CD105). Cytotoxicity of SO was evaluated by MTT assay. Osteogenic differentiation was induced in MSCs with ß-glycerophosphate, ascorbic acid and dexamethasone over 2 weeks. Different homoeopathic doses of SO (MT, 3C, 6C, 12C and 30C) were added to the basic differentiation medium (BDM) and efficiency of MSCs differentiating into osteoblasts were measured by evaluating expression of Osteocalcin using flow cytometry, and alkaline phosphatase activity using ELISA. Gene expression analyses for osteoblast markers (Runx-2, Osteopontin and Osteocalcin) were evaluated in differentiated osteoblasts using qPCR. RESULTS: Flow cytometry (CD90, CD105) detected MSCs isolated from bone marrow (93-98%). MTT assay showed that the selected doses of SO did not induce any cytotoxicity in MSCs (24 hours). The efficiency of osteogenic differentiation (2 weeks) for different doses of Symphytum officinale was determined by flow cytometry (n = 10) for osteoblast marker, Osteocalcin, and most doses of Symphytum officinale enhanced osteogenesis. Interestingly, gene expression analysis for Runx-2 (n = 10), Osteopontin (n = 10), Osteocalcin (n = 10) and alkaline phosphatase activity (n = 8) also showed increased osteogenesis with the addition of Symphytum officinale to BDM, specially mother tincture. CONCLUSIONS: Our findings suggest that homoeopathic dose (specially mother tincture) of Symphytum officinale has the potential to enhance osteogenesis.

Glycolipid antigen processing for presentation by CD1d molecules.

The requirement for processing glycolipid antigens in T cell recognition was examined with mouse CD1d-mediated responses to glycosphingolipids (GSLs). Although some disaccharide GSL antigens can be recognized without processing, the responses to three other antigens, including the disaccharide GSL Gal(alpha1-->2)GalCer (Gal, galactose; GalCer, galactosylceramide), required removal of the terminal sugars to permit interaction with the T cell receptor. A lysosomal enzyme, alpha-galactosidase A, was responsible for the processing of Gal(alpha1-->2)GalCer to generate the antigenic monosaccharide epitope. These data demonstrate a carbohydrate antigen processing system analogous to that used for peptides and an ability of T cells to recognize processed fragments of complex glycolipids.