Efficacy and Safety of Stempeucel in Osteoarthritis of the Knee: A Phase 3 Randomized, Double-Blind, Multicenter, Placebo-Controlled Study.

BACKGROUND: Osteoarthritis is a chronic, progressive, and degenerative condition with limited therapy options. Recently, biologic therapies have been an evolving option for the management of osteoarthritis. PURPOSE: To assess whether allogenic mesenchymal stromal cells (MSCs) have the potential to improve functional parameters and induce cartilage regeneration in patients with osteoarthritis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 146 patients with grade 2 and 3 osteoarthritis were randomized to either an MSC group or placebo group with a ratio of 1:1. There were 73 patients per group who received either a single intra-articular injection of bone marrow-derived MSCs (BMMSCs; 25 million cells) or placebo, followed by 20 mg per 2 mL of hyaluronic acid under ultrasound guidance. The primary endpoint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score. The secondary endpoints were WOMAC subscores for pain, stiffness, and physical function; the visual analog scale score for pain; and magnetic resonance imaging findings using T2 mapping and cartilage volume. RESULTS: Overall, 65 patients from the BMMSC group and 68 patients from the placebo group completed 12-month follow-up. The BMMSC group showed significant improvements in the WOMAC total score compared with the placebo group at 6 and 12 months (percentage change: -23.64% [95% CI, -32.88 to -14.40] at 6 months and -45.60% [95% CI, -55.97 to -35.23] at 12 months P < .001; percentage change, -44.3%). BMMSCs significantly improved WOMAC pain, stiffness, and physical function subscores as well as visual analog scale scores at 6 and 12 months (P < .001). T2 mapping showed that there was no worsening of deep cartilage in the medial femorotibial compartment of the knee in the BMMSC group at 12-month follow-up, whereas in the placebo group, there was significant and gradual worsening of cartilage (P < .001). Cartilage volume did not change significantly in the BMMSC group. There were 5 adverse events that were possibly/probably related to the study drug and consisted of injection-site swelling and pain, which improved within a few days. CONCLUSION: In this small randomized trial, BMMSCs proved to be safe and effective for the treatment of grade 2 and 3 osteoarthritis. The intervention was simple and easy to administer, provided sustained relief of pain and stiffness, improved physical function, and prevented worsening of cartilage quality for ≥12 months. REGISTRATION: CTRI/2018/09/015785 (National Institutes of Health and Clinical Trials Registry-India).

Hereditary Sensory and Autonomic Neuropathy Type II in a Female Child with Multiple Orthopaedic Ailments: Diagnosis and Operative Management.

Hereditary Sensory and Autonomic Neuropathy (HSAN) Type II is an autosomal recessive genetic disease which presents predominantly with sensory neuropathy and neuropathic ulcers. HSAN Type II is a rare disease, and in the few cases that have been reported, the focus has been on identifying genetic markers of the disease. Orthopaedic conditions may be a major presentation of the disease, and the prevention of superficial trauma and foot care is the only definitive management.

Incidence and factors influencing tourniquet pain.

PURPOSE: The use of tourniquet in orthopedic surgery facilitates operation by establishing a bloodless surgical field. However, many complications following the use of tourniquets have been reported. Tourniquet pain is the most common complication. This study aimed to find the actual incidence of pain associated with tourniquet use in orthopedic surgery and the various factors. METHODS: It is a prospective observational study conducted on 132 consecutive cases. Patients aged 18-70 years with musculoskeletal problems of the forearm and leg requiring surgery were included in the study. Patients with open injuries or contraindications such as diabetes mellitus, compromised circulatory states, neurological deficit, compartment syndrome and unable to give informed consent were excluded. The parameters assessed included duration of tourniquet use, tourniquet pressure, type of anesthesia, any interval release of the tourniquet and reapplication after a reperfusion period, whether upper or lower limb surgery, severity of tourniquet pain, timing of tourniquet release and complications. Chi-square and non-parametric Mann-Whitney U test were used for data analysis. RESULTS: In upper limb surgeries, if duration of surgery was less than 60 min, 14 (51.8%) cases experienced tourniquet pain and 13 (48.1%) had no pain, and if duration of surgery was more than 60 min, 24 (60.0%) had pain and 16 (40.0%) experienced no pain. In lower limb surgeries if duration of surgery was less than 60 min, 2 (7.7%) experienced pain and 24 (92.3%) had no pain, and if duration of surgery was more than 60 min, 14 (35.8%) experienced pain and 25 (64.8%) had no pain. Degree of tourniquet pain increases with the duration of surgery. Statistically, there was significant association between tourniquet inflation time and tourniquet pain in both upper and lower limbs (p = 0.034 and 0.024, respectively) CONCLUSION: Incidence of tourniquet pain was in direct proportion to the duration of tourniquet use and was higher in cases with regional anesthesia. Other risk factors assessed including tourniquet pressure, upper or lower limb surgery, tourniquet release time and interval had no significant contribution to the incidence or severity of tourniquet pain.

Cross-sectional assessment of cardiovascular risk factors in patients with knee osteoarthritis.

Background: Osteoarthritis (OA) and cardiovascular disease (CVD) are prevalent in India. However, there is dearth of literature among Indians studying the relationship between the two. This study was carried out to assess various cardiovascular (CV) risk factors in patients with knee OA with an objective to investigate their association, screening and management.  Methods: In total, 225 patients were included in this cross-sectional study. Participants were diagnosed with knee OA on the basis of the Kellgren and Lawrence (K-L) classification of their radiograph. Participants were also assessed for CV risk factors; age, body mass index, systolic blood pressure, diabetes mellitus, total cholesterol, high-density lipoprotein, smoking. Joint British Society QRisk3 calculator (JBS3) a comprehensive risk score calculator as well as a screening tool, which produces three more variables, namely 10-years risk of developing CVD, physiological heart age and life expectancy, was used. Chi Square, Fishers exact test and one-way ANOVA tests were used to compare the categorical and quantitative variables, respectively.. Multiple regression analysis was done to adjust the multiple con-founders and determine their significance. Results: Patients with severe knee OA had a statistically significantly higher prevalence of CV risk factors (p<0.05). Grade 4 knee OA patients were found to have a mean JBS3 risk of 38%, heart age of 82 years and life expectancy of 77 years as compared to grade 2 patients who had a mean JBS3 risk of 11%, heart age of 63 years and life expectancy of 82 years.  Conclusions: Our study concluded that there is a strong relation between knee OA and CVD, with CV risk score being positively correlated to the severity of OA.

The Results of Unstable Intertrochanteric Femur Fracture Treated with Proximal Femoral Nail Antirotation-2 with respect to Different Greater Trochanteric Entry Points.

BACKGROUND: Proximal femoral nail antirotation-2 (PFNA-2) has been widely used to treat intertrochanteric fractures with varied outcomes in the previous studies. The entry point of the nail plays an important role in achieving acceptable reduction, stable fixation, and avoiding implant related complications. This study was proposed to determine the optimal greater trochanteric entry point for PFNA-2 in unstable intertrochanteric femur fractures. METHODS: We conducted an observational study on 40 patients with unstable intertrochanteric fracture treated with PFNA-2 implant in a tertiary care hospital. The patients were grouped into two based on the entry point: group L for lateral and group M for medial entry. Randomization was carried out by assigning the patients to the group by alternate allocation. The quality of reduction, tip apex distance, Cleveland index, and all the complications were noted. The final follow-up was conducted at six months. The functional outcome was evaluated using modified Harris hip score. The data analysis was performed using Student's t-test, chi square test, and Mann-Whitney test. A P value below 0.05 was considered significant. RESULTS: Forty patients with 20 patients treated with medial entry point were included in group M and 20 patients in group L with lateral entry point. The group L had an average tip apex distance of 20.53 and group M had 20.02 (P=0.8). The complication of screw back out was seen in 3 out of 4 patients with poor reduction in group L. As per the Cleveland index, 6 patients in each group had suboptimal position and 4 out of 6 patients in group L with suboptimal position had screw back out. The lateral cortex impingement was seen in 14 patients of group L and 6 patients in group M with significant comparison (P=0.01). Three patients in group L had varus collapse with screw back out. Also, none in group M (0.05). The average modified Harris hip score in group L at six months follow-up was 71.94 and 76.8 in group M (P=0.84). CONCLUSION: Overall, to achieve good quality of fixation and reducing damage to gluteus medius entry point for PFNA-2 should be 5 mm medial to the greater trochanter tip.

Avaliação rápida do membro superior (RULA) na investigação ergonômica: uma revisão abrangente / Rapid upper limb assessment (RULA) in ergonomic assessment: A comprehensive review

INTRODUÇÃO: A avaliação rápida de membro superior (RULA) é um método de pesquisa desenvolvido para uso em investigações ergonômicas em postos de trabalho onde distúrbios de membros superiores relacionados ao trabalho são relatados. Existem diversas pesquisas disponíveis sobre o uso de RULA na avaliação distúrbio osteomuscular relacionado ao trabalho (DORTs). Porém, até o momento não há nenhuma revisão compilada disponível sobre a pesquisa abrangendo os usos de RULA em avaliações ergonômicas. OBJETIVO: Compilar artigos relacionados com o uso de RULA na avaliação de DORTs entre trabalhadores de diversas áreas. MATERIAIS E MÉTODOS: A busca por artigos relacionados ao tema foi realizada nas bases de dados acadêmicas PubMed, Medline, CINAHL, PsycINFO e EBSCO. A coleta foi realizada até 22 de julho de 2019 usando as cinco palavras-chave, "ergonomia" "Musculoesquelético", "local de trabalho" e "avaliação rápida de membros superiores". Essas palavras-chave foram combinadas usando os operadores booleanos "AND", "OR" e "NOT". Adotou-se as recomendações do checklist PRISMA. RESULTADOS: Foram identificados 263 artigos. Após a remoção de 161 artigos duplicados, sobraram 102 artigos para as análises. Destes, 21 artigos foram excluídos pelo título e resumo e 81 artigos completos foram avaliados. Novamente, 68 artigos foram excluídos por não atenderem aos critérios de inclusão e, finalmente, 13 artigos foram incluídos na análise qualitativa abrangente. CONCLUSÃO: A aplicação mais ampla do RULA foi confirmada a partir desta revisão abrangente.

INTRODUCTION: RULA (rapid upper limb assessment) is a survey method developed for use in ergonomics investigations of workplaces where workrelated upper limb disorders are reported. There are various researches available regarding the use of RULA in assessing work-related musculoskeletal disorders (WRMSDs). But till date, there is no compiled review available regarding the comprehensive research on the uses of RULA in various ergonomic assessment. OBJECTIVE: To compile the availability of article related to the uses of RULA in assessing WRMSDs among workers from various fields. MATERIALS AND METHODS: The articles related to RULA in ergonomic assessment were searched using the reputed academic databases, including PubMed, Medline, CINAHL, PsycINFO, and EBSCO from inception to July 22, 2019 using the five keywords, "ergonomics," "musculoskeletal," "workplace," and "rapid upper limb assessment." These keywords were combined using the Boolean operators "AND," "OR," and "NOT." RESULTS: A total of 263 articles (n=263) were identified. After the removal of 161 duplicate articles, 102 articles were screened for the analysis. Among then, 21 articles were excluded and 81 fulltext articles were assessed for eligibility. Again 68 articles were excluded due to not meeting the inclusion criteria and finally 13 articles were included in the qualitative comprehensive analysis. CONCLUSION: The wider application of RULA has been confirmed from this comprehensive review.

Percutaneous technique for fluoroscopy-guided biopsy in the supra-acetabular region.

The peri-acetabular area of the pelvis is a common site for a variety of lesions including neoplasia, histiocytosis or infective-like tuberculosis. A biopsy is necessary before planning treatment for these patients. Access to these lesions requires extensive dissection of soft tissues and is associated with blood loss and prolonged operative time. A percutaneous fluoroscopy-guided technique can be used to perform biopsy of lesions in the roof of the acetabulum through a minimally invasive approach. We have described a simple technique for biopsy of lesions in the acetabular roof using a percutaneous fluoroscopy-guided approach.

Avaliação rápida de membros superiores (RULA): evidências de validade e confiabilidade na identificação da ergonomia do local de trabalho entre funcionários de bancos que usam computadores / Rapid upper limb assessment (RULA): validity and reliability evidences in identifying workplace ergonomics among bank employee's using computers

INTRODUÇÃO: Distúrbios musculoesqueléticos (DME) representam uma das principais causas de lesões e incapacidades ocupacionais. Postura corporal inadequada durante a digitação é associada com DME entre os usuários de computador. O RULA (rapid upper limb assessment) é um método subjetivo de observação da postura para utilização em investigações ergonômicas de postos de trabalho. OBJETIVO: Examinar a validade e confiabilidade do RULA aplicado a usuários de computadores do setor bancário. MATERIAIS E MÉTODOS: Amostra aleatória simples de bancários com medidas antropométricas (idade, altura e peso). A validade concorrente do RULA foi estabelecida na comparação com o instrumento validado de Avaliação Rápida do Corpo Inteiro (REBA). A confiabilidade intraexaminador do RULA foi estabelecida pelo investigador principal em dois ensaios no mesmo grupo de participantes, na mesma condição ambiental e nos mesmos tempos, com um intervalo de 2 dias. A confiabilidade interavaliadores foi estabelecida pelo investigador principal e outro pesquisador no mesmo grupo de participantes com as mesmas condições ambientais e com um intervalo de 2 minutos. RESULTADO: Total 301 participantes foram recrutados, sendo 170 participantes do sexo masculino e 131 do sexo feminino. O RULA apresentou alta correlação com o REBA (ρ = 0,91; p <0,001). A confiabilidade intra e interobservador do RULA foi excelente com ICC = 0,92 (0,90-0,94) e 0,91 (0,89-0,93), respectivamente. CONCLUSÃO: A validade e a confiabilidade do RULA foram estabelecidas entre bancários no uso de computadores, com excelente correlação e concordância interexaminadores.

BACKGROUND: Musculoskeletal disorders (MSDs) represent one of the leading causes of occupational injury and disability. Awkward body posture while typing is associated with MSDs among the computer users. RULA (rapid upper limb assessment) is a subjective observation method of posture analysis for use in ergonomics investigations of workplaces where work-related upper limb disorders are reported. To date, no data available on reliability and validity of RULA among the bank employee's using computers. OBJECTIVE: To examine the validity and reliability of RULA among the bank employees' using computers. MATERIALS AND METHODS: A sample of bank employee were recruited by simple random sampling technique to take part in this validity and reliability study. All anthropometric measurement was taken before the beginning of the study including age, height and weight. The concurrent validity of RULA was established with the criterion referenced, Rapid Entire Body Assessment (REBA). Principal investigator recorded both the scores of RULA and REBA to estimate the concurrent validity. Intra-rater reliability of RULA was established by the principal investigator across two trials on the same group of participants in the same environmental condition and same timings with a gap of 2 days. Inter­rater reliability of RULA was established by the principal investigator and another researcher on the same group of participants with in the same environmental conditions and same with a gap of 2 minutes. RESULT: Total 301 Participants were recruited in this study, in which 170 participants were males, and other 131 were females. Concurrent validity of RULA with the criterion measure REBA is found to be good as measured by spearman's rank correlation test, ρ=0.91 (p<0.001). Intra-and inter-rater reliability of RULA is found to excellent with ICC=0.92 (0.90-0.94) and 0.91 (0.89-0.93) respectively. CONCLUSION: Validity and reliability of RULA have been established among the bank employees' using computers. There exists good validity and excellent reliability among them.

Comparison of radiological and functional outcome of unstable intertrochanteric femur fractures treated using PFN and PFNA-2 in patients with osteoporosis.

INTRODUCTION: Presently, unstable intertrochanteric femur fractures are treated commonly with intramedullary nailing devices. Various designs of intramedullary nail are introduced. The conventional Proximal Femoral Nail has given diverse outcome. Complications have also been noted with this implant. Newer designs like Proximal Femoral Nail Antirotation-2 have been introduced for Asian population. The aim of our study was to compare the radiological and functional outcome of unstable intertrochanteric femur fracture treated with conventional Proximal Femoral Nail and Proximal Femoral Nail Antirotation-2 in osteoporotic patients. MATERIALS AND METHODS: Patients presenting with unstable intertrochanteric femur fracture (AO classification) and Singh's index ≤ 3 were included. Patients were assigned to the groups based on the implant used for treatment (PFN and PFNA2 group). Post-operative radiographs were used to assess the quality of reduction, by calculating neck shaft angle. The quality of fixation was assessed, by calculating tip apex distance and Cleveland index. The duration of surgery, blood loss, number of fluoroscopic images taken and length of hospital stay were noted. Patients were followed up for 6 months, and complications were noted. The functional outcome was compared using modified Harris hip score. The data analysis was done using Student's unpaired t test/Mann-Whitney U test and Chi-square test/Fisher's exact test. A p value less than 0.05 was considered significant. RESULTS: Seventy-eight patients with unstable intertrochanteric fractures and Singh's index < 3 were included. Thirty-seven were treated with PFNA2 and 41 with PFN. The average age in PFNA2 group was 69.51, and PFN group was 70.804. Nine patients in PFNA2 group and 10 patients in PFN group had tip apex distance more than 25 mm. Twelve patients in PFNA2 group and 14 Patients in PFN group had sub-optimal implant position as per Cleveland index. The difference in neck shaft angle between uninjured and operated side was more than 10° in four patients of PFNA2 group and seven patients of PFN group. The average Harris hip score was 74.55 for PFNA2 group and 69.88 for PFN group. Four complications were seen in PFNA2 group and 5 in PFN group. CONCLUSION: The functional outcome (p = 0.102) achieved with both the implants was similar. Good functional outcome can be achieved, when the radiological parameters are restored, i.e. TAD < 25 mm, Cleveland index in centre-centre position and neck shaft angle difference < 5°. The overall complications, in the set-up of osteoporosis, seen with both the implants were similar (p = 0.44). PFNA2 group showed better results in terms of perioperative morbidity.

A Case Report of Isolated Cysticercosis of Biceps Muscle.

INTRODUCTION: Cysticercosis is more commonly seen in developing countries like India caused by larval stage of Taenia solium. Neurocysticercosis is more commonly seen than isolated muscle involvement. There are very few sporadic cases of isolated biceps muscle involvement, but most of them are managed medically. We are reporting an isolated case of cysticercosis of biceps muscle managed surgically. CASE REPORT: A 32-year-old male, security personnel by occupation, comes with complaints of painful swelling of the right arm for past 1 week. There was no trauma to the limb and no similar swellings elsewhere in the body. On examination, there was an anteromedial tender swelling of mid-third of arm. X-ray was normal with soft tissue shadow on the anterior aspect. Ultrasound showed cystic lesion with central hyperechoic lesion. Magnetic resonance imaging of arm showed 7.7 mm × 4.8 mm lesion in anteromedial aspect of arm with surrounding edema s/o granuloma. The patient underwent excision of the cyst and biopsy was suggestive of cysticercosis and surrounding granuloma. CONCLUSION: Isolated cysticercosis of muscle is very rare, but when it is symptomatic and hindering in daily activities, surgical excision can be done for faster relief and early return to normal day-to-day activities.

Radiological assessment of congenital talipes equinovarus (clubfoot): Is it worthwhile?

The lack in consensus with regard to qualitative use of standard radiographs and their predictive value in evaluating congenital talipes equinovarus among infants continues to be apparent in clinical practice. Since standard radiographs continue to play a role in the assessment of clubfoot it is essential to ensure that the values measured are reliable and reproducible keeping in mind acceptable tolerances for clinical application. This study was undertaken to assess the inter-observer and the intra-observer reliability in estimation of talocalcaneal and talo-first metatarsal angles on standard radiographs done according to Simon's method. The study was conducted by consecutively selecting eleven children with unilateral idiopathic congenital clubfoot who presented to our tertiary care hospital with a paediatric orthopaedic service unit. Only those with unilateral idiopathic clubfoot with persistent deformity at the age of 3 months were included. The data obtained from three observers on two separate occasions was analysed by the method proposed by Bland and Altman to assess intra and inter observer variability in the measurements. The results of the present study suggest a significant difference between the measurements on two occasions by the same observer. The difference was constant and the level of experience of the observer had no significance. Also, there was a marked inter observer variability as evident from the calculation of limit of agreement. Therefore, radiological assessment of the type and degree of malalignment in these cases is insufficient as it does not possess the accuracy required in evaluation and further management.

Lasègue's Sign.

Lasègue's sign is an interesting and important clinical sign in medicine for the last 150 years. The Lasègue test is commonly used in the physical examination of patients with low back pain. It is a test for lower lumbosacral nerve root irritation for example, due to disc prolapse. It is evident that the method of performance of this diagnostic sign varies with the physician. This article reviews the historical background and method of eliciting the sign.

Thromboprophylaxis with dabigatran after total hip arthroplasty in Indian patients: A subanalysis of a double-blind, double-dummy, randomized RE-NOVATE II study.

OBJECTIVE: In the Re-NOVATE II study, oral dabigatran provided thromboprophylaxis after total hip arthroplasty and improved compliance postdischarge in a global population. This article aims to identify trends (if any) in the Indian population. METHODS: In this prospective, double-blind, double-dummy study, patients scheduled for primary, unilateral, elective total hip arthroplasty were randomized to 220 mg oral dabigatran once daily, starting with a 110 mg half-dose, 1-4 hours after surgery, or subcutaneous enoxaparin 40 mg once daily, starting the evening before surgery. Each group received a placebo of the other study drug. The primary efficacy outcome was the composite of total venous thromboembolism (VTE) and all-cause mortality. Secondary outcome measures were composite of major VTE and VTE-related mortality during the treatment period. The major safety outcome was incidence of bleeding events. RESULTS: Of the 179 Indian patients randomized, 91 received oral dabigatran and 88 received subcutaneous enoxaparin for 28-35 days. Total VTE and all-cause mortality occurred in 18.7% of patients in the dabigatran group and 13.7% in the enoxaparin group [odds ratio = 1.4 (95% confidence interval 0.6, 3.5)]. Major VTE and VTE-related mortality was numerically lower in the dabigatran group (7.9%) compared with the enoxaparin group (9.9%). Safety outcomes were comparable between both groups. CONCLUSION: Dabigatran is an effective oral alternative to enoxaparin for thromboprophylaxis as demonstrated by the RE-NOVATE II study global results. Data analyzed in Indian patients indicate comparable effects of dabigatran etexilate for major efficacy and safety outcomes.

Accuracy of Needle Placement into the Intra-Articular Space of the Knee in Osteoarthritis Patients for Viscosupplementation.

INTRODUCTION: Knee osteoarthritis is characterized by inflammation in the intra-articular space or synovial membrane, breakdown of articular cartilage, and sclerosis of the subchondral bone. Intra-articular injections of Sodium hyaluronate which have viscoelastic and protective effect on articular cartilage and restores normal articular homeostasis. The efficacy of these injections is diminished when they are placed inadvertently outside the joint. For the maximum benefit, injection of hyaluronic acid derivatives needs to be placed accurately into the knee joint. AIM: The study was performed to know the correct placement of needle inside the knee joint prior to Viscosupplementation by fluoroscopy using a contrast material. MATERIALS AND METHODS: The accurate placement of needle was evaluated in a prospective series of 94 consecutive injections in patients without clinical knee effusion. All the injections were performed by single orthopaedic surgeon using a 5 cm 21-gauge needle through anterolateral, and lateral midpatellar portals. The needle placement in the knee joint was confirmed with fluoroscopy using the contrast material. RESULTS: The accuracy rates through Lateral midpatellar and Anterolateral portals were lower than expected rate (100%). A total of 43 out of 47 injections were intra-articular, indicating accuracy of 91.5% through lateral midpatellar portal, 41 out of 47 injections were intra-articular through anterolateral portal with accuracy of 87.4%. CONCLUSION: Study showed that the accuracy of needle placement was higher through Lateral midpatellar than the Anterolateral portal.

A Rare Cause of Postoperative Bleeding from A Lytic Lesion of Calcaneum.

INTRODUCTION: Post-operative excessive bleeding can be due to various causes, which may platelet deficiency, both quantitative and qualitative, vascular disorder, clotting factor defects and excessive fibrinolysis. Rarely can be due to some undiagnosed malignant tumours. Angiosarcoma of bone is an exceedingly rare primary bone malignancy. We report an interesting and rare case of an intraosseous angiosarcoma that presented as an excessive postoperative bleeding with diagnostic dilemma. CASE REPORT: A twenty eight year old gentleman admitted to our hospital with history of continuous bleeding from surgical site over left heel since three months. About six months ago he was evaluated elsewhere for a painful progressive lesion in the left calcaneum. Following which he underwent curettage of lesion with bone grafting. One month after this he was re-operated for recurrence with curettage with bone cementing. Curetted material on both occasions was reported as aneurysmal bone cyst. One month following the second surgery, surgical scar over the outer aspect of left heel opened out and started to bleed continuously. X rays and MRI done before surgical treatment were suggestive of aneurysmal bone cyst Investigations for clotting and bleeding disorders were normal. The granulation tissue from the floor of the cavity was curetted and sent for histopathology, which was reported as angiosarcoma. CONCLUSION: Intraosseous angiosarcoma is a rare primary bone tumour. The diagnosis is often delayed because of the non-specific clinical presentation and radiological features. Clinicopathological correlation is very important to differentiate aneurysmal bone cyst from the aggressive type of vascular malignancies. The clinical course of disease is aggressive, as demonstrated by this current case. The initial biopsies done twice at curettage were not diagnostic and suggested the presence of a benign aneurysmal bone cyst. Due to the excessive postoperative bleeding, repeat biopsy performed which diagnosed angiosarcoma.

Musculoskeletal and joint manifestations in human immunodeficiency virus positive patients.

With the increase in the number of human immunodeficiency virus positive patients, more and more patients are referred with musculoskeletal or joint manifestations. It is important to differentiate between various causes resulting in musculoskeletal or joint manifestations. In this prospective study 30 patients out of 569 human immune deficiency virus positive patients presented with musculoskeletal or joint manifestations (incidence being 5.27%), simple arthralgia was the most common manifestation in 16 patients. Reactive arthritis was diagnosed in 6 patients and infective arthritis in 5 patients. After the treatment 16 patients had complete recovery, 9 patients had partial recovery and 3 patients had no recovery of joint manifestation. One patient expired due to septicaemia and another lost to follow-up.

Tuberculous retropharyngeal abscess.

Chronic retropharyngeal abscess caused by tuberculosis is rare. It should be suspected in a person who presents with a destructive lesion of the vertebra and a retropharyngeal mass. Early diagnosis and treatment are necessary to prevent the serious complications of the disease. We present the case of a patient who came to our clinic with collapse of the C5-C6 vertebrae and retropharyngeal abscess. We were able to avoid any complications by initiating early surgical drainage and antituberculous therapy.

Re-dislocation following open reduction for developmental dysplasia of the hip.

We have reviewed 17 patients (18 hips) who required repeat open reduction for recurrent or persistent dislocation after a previous attempt at open reduction for developmental dysplasia of the hip (DDH). The mean follow-up was 5.5 (3-15) years. At the review, five patients were limping and had limited hip motion but no pain. Six hips were classified as Severin class III or more, and avascular necrosis was evident in 11. We suggest that technical failure is usually the cause for re-dislocation in unilateral cases, as we discovered at repeat open reduction in five of six patients with unilateral dislocation. The biological behaviour of bilateral dislocations may in some way be different since in nine of 11 patients with bilateral dislocations, no obvious cause could be attributed. The outcome is usually poor.

Does developmental dysplasia of the hip cause a delay in walking?

Developmental dysplasia of the hip (DDH) is commonly supposed to lead to a delay in walking. The authors present a retrospective review of the age of walking in 86 children with established DDH and compare them with an age- and sex-matched group of controls. While the median age of walking was 1 month later than in the control group, this was clinically insignificant, as all walked within the normal time limits. The authors conclude that children with DDH do not present as late walkers.