Multifocal bilateral metatarsal tuberculosis: a rare presentation.

Tuberculosis, or phthisis (consumption) as it was popularly known in the Greek era, has been endemic in Southeast Asia and Sub-Saharan Africa; however, the human immunodeficiency virus epidemic has seen the re-emergence of this disease in the areas in which it was not very commonly reported. With this, the need for understanding and treatment of rare presentations of tuberculosis has become of paramount importance to achieve the World Health Organization millennium goal of a "reversal of incidence by 2015." Foot involvement has been reported in 0.1% to 0.3% of extrapulmonary cases. Multifocal lesions have an incidence of <10% in osteoarticular tuberculosis. Bilateral feet involvement in multifocal tuberculosis has not yet been reported in either children or adults in published studies. We report a case of tuberculosis with lesions in the bilateral metatarsals, the occurrence of which is very rare. The diagnosis was mainly histopathologic owing to the paucibacillary nature of the disease. Early identification and treatment with antitubercular drugs will normally result in a good cosmetic and functional result.

Can Below-Knee Casts be Effective for Clubfoot Management in Walking-Age Children? A Prospective Cohort Study.

Purpose: Above-knee casts pose a major challenge in the day-to-day activities among walking age clubfoot patients due to complete restriction of knee movement. This current study investigates the effectiveness of below-knee casts compared to above-knee casts for managing walking age clubfoot deformity. Methods: After approval from the institutional ethical committee, we enrolled walking age clubfoot patients for deformity correction through corrective manipulation and casting through below-knee casts over 2 years. The corrective manipulation was performed using the Ponseti technique. The patients were followed for a minimum of 2 years period. To compare the effectiveness of below-knee casts over above-knee casts, we enrolled equal numbers of walking age clubfeet matched for age and gender. We compared the two groups in terms of initial and post-correction Dimeglio scores, individual deformities corrections (maximum ankle dorsiflexion, heel varus correction, foot abduction), failure rates, relapses, and complication rates. Results: 56 patients with 80 clubfeet with a mean follow-up of 39.98 months were considered for the final analysis. There were 29 patients in the below-knee cast group and 27 in the above-knee cast group, with 40 clubfeet each. The patients in the above-knee casting group had significantly better post-correction Dimeglio scores and individual deformity components corrections than the below-knee cast group. There were nil failures in the above-knee casting group and 7.5% in the below-knee cast group. The relapse rate was 15% in both groups, with none requiring any extensive soft tissue procedure. We did not encounter any major complications during the treatment and follow-up. Conclusion: The deformity correction and maintenance are suboptimal with the below-knee casts. Therefore, above-knee casts should be the preferred management modality for correction of walking age clubfoot deformities.

Changes in the Foot After Two Years of Deformity Correction in Neglected Clubfeet Treated With Modified Ponseti Technique.

Introduction Neglected clubfoot comprises clubfoot deformities with late presentation and weight-bearing on the affected foot. These deformities are stiff and need an aggressive approach for cast-based management. The modified versions of the Ponseti technique have been found effective in treating these deformities. However, these techniques' long-term outcomes in neglected clubfoot and related correction maintenance with time progression have not been investigated. The current study aims to analyze the changes in deformity correction after a minimum of two years of follow-up in neglected clubfeet treated with a modified Ponseti method of corrective casting. Methods We retrospectively analyzed the clinical records of 25 patients with 38 neglected clubfeet with a mean follow-up of 37.9±4.1 months after the initial correction of the deformity. These patients were managed with a modified Ponseti technique. The modified technique incorporated simultaneous deformity manipulation before equinus correction and additional dorsiflexion manipulation after two weeks of tendo-achilles tenotomy. The Pirani and Dimeglio scores and individual deformity corrections at the final follow-up were compared with those at final cast removal. Results No significant differences were observed between the initial and the final follow-up Pirani and Dimeglio scores. Concerning the deformity correction parameters, there was a significant loss in heel varus and foot abduction correction. However, the change in these parameters was small (less than 3 degrees). Conclusion The neglected clubfoot deformity can be satisfactorily corrected with an aggressive Ponseti based corrective manipulation and casting at a low relapse rate. However, minor loss of deformity correction is noticed after two years of treatment which is not reflected in clinical scores. Therefore, a strict long-term follow-up and careful deformity assessment are required to predict the recurrence in these cases.

A diagnostic dilema in benign lytic lesions of clavicle - our experience of 37 patients.

INTRODUCTION: The studies on benign lytic lesion of clavicle are sparse. Asymptomatic nature of lesions, rare occurrence, the difficulty in interpretation of the X-rays because of the surrounding structures and striking similarities in various lesions further make the diagnosis of such atraumatic lytic lesions difficult. MATERIAL AND METHODS: Prompted by the rarity of lesion and scarcity of data regarding presentation and management, we performed a prospective study of benign lytic lesions of clavicle. The results of the lesions are categorised in infective, metabolic and neoplastic conditions. RESULTS: Infective lesions were most common cause of symptomatic painful benign lytic lesions. Metabolic lesions, like rickets, were the most common cause of painless swelling in clavicle. Neoplastic conditions although rare were an important differential. CONCLUSION: It is important to differentiate and diagnose lytic lesions of clavicle. Early MRI and Biopsy of the lesion helps in preventing an undue delay in diagnosis. Most lesions when diagnosed in time have excellent results.

Open reduction versus in-situ fixation of neglected lateral condyle fractures: a comparative study.

The management of neglected fracture of the lateral condyle of the humerus is controversial. Careful neglect and conservative management with early ulnar nerve transposition and ostetomy, in-situ surgical fixation and accurate open reduction and internal fixation are all recommended as treatment options. However, an overgrowth of fractured condyle, highly distorted anatomy, contracted soft tissue and almost unrecognizable fracture ends make open reduction a challenging task. As the functional loss is not severe, in-situ fixation of the fragment provides a good alternative. There have been proponents of both surgeries with very limited data on comparison on both procedures. Here, we present our experience of 45 patients, 22 treated with anatomical reduction and 23 treated with in-situ fixation with no attempts of anatomical restoration, and attempted to evaluate the results of two surgeries with a follow-up of at least 2 years. Neglected fractures of the lateral condyle were surgically treated with two different techniques. In all, 22 patients were treated with open reduction and fixation whereas 23 patients were treated with in-situ fixation to render the elbow stable. Patients were followed for a minimum of 2 years. These patients were studied in terms of functional scores and radiological union. Radiological union was better in the anatomical reduction group with one nonunion compared with five in the in-situ group. However, functional results and elbow range were better in the in-situ fixation group. The surgical time was 57 min in in-situ fixation compared with 73 min in the anatomical reduction group. Complication rates were found to be high in the open reduction group. In-situ fixation of neglected lateral condyle fractures is an effective technique for the treatment of these difficult fractures presenting late compared with anatomical fixation. Radiological union, although less successful compared with open anatomical reduction, leads to better functional outcome, with decreased surgical time and postoperative complications.

Modified Ponseti technique for management of neglected clubfeet.

Achieving adequate dorsiflexion in neglected clubfoot cases remains challenging. On a close observation of the Ponseti method, we have now made certain modifications from the standard Ponseti protocol. This has helped us improve functional results, as well as reduce the number of casts in this walking-age group. From March 2011 onward, we managed 62 neglected clubfeet in 41 patients with the modified protocol. All these patients were treated with serial weekly above-knee casts. The feet were assessed by Dimeglio and Pirani scorings, which were done every week. These children were closely monitored and followed up at regular intervals for any signs of relapses. The mean age group was 3.1 years (1.1-12 years). The mean follow-up period for these feet was 3 years (1.2-4 years). Mean Dimeglio score before treatment was 15.9, and after treatment it was 0.52. Mean Pirani score before treatment was 4.21 and after treatment it was 0.03. The average number of casts before tenotomy with our modified method was 6.9. Percutaneous tenotomy was done in all the cases. The mean dorsiflexion achieved at the end of treatment was 21.3° (15°-40°). Our modified Ponseti technique is a very effective and reproducible method for correction of neglected clubfeet. We feel that an extensive soft tissue surgery may not be required for neglected clubfeet even up to the age of 10 years.

Hand and wrist tuberculosis in paediatric patients - our experience in 44 patients.

Skeletal tuberculosis (TB) of the hand and wrist is rare, accounting for less than 1% of all osteoarticular TB. Although rare, TB of the hand and wrist is a cause of major morbidity. A common feature among all available reports on TB of the hand and wrist was a delay in diagnosis, causing residual stiffness and pain after treatment. Minimal initial symptoms, rarity of the lesion and ability of wrist TB to mimic more common pathologies account for the delay. Skeletal TB may behave differently in this age compared with the adult population. Further, the disease may affect the growing bone, causing residual deformities. The paucity of studies from different countries, coupled with a difficulty in diagnosis resulting in major morbidity, led us to carry out a study on this topic. A total of 44 patients with skeletal lesions in the hand and wrist were studied. The diagnosis was confirmed by biopsy. Patients were started on multidrug antitubercular treatment (ATT). Those not responding were scheduled for debridement. All patients were assessed using the Green O'Brian scoring system. All these patients were studied separately for clinical presentation, nutritional status (Rainey-Mcdonald nutritional index), time from onset of symptoms to presentation, treatment required, prognosis and complications. The proximal phalanx of the fourth digit and the metacarpal of the fifth digit were the most commonly involved bones in our series, with five cases of each. The capitate was the most common carpal bone, followed by the lunate. The duration of symptoms ranged from 5 weeks to 24 weeks (mean: 7.6 weeks). Most of these patients presented with complaints of pain, followed by swelling. 13 patients did not respond favourably to ATT over an 8-week period and were scheduled for surgery. Three of these patients had multidrug resistance. There was one case of a pathological fracture in our series and seven cases of arthritis/residual significant pain at the end of follow-up. For all the other patients, the results were excellent. A very high index of suspicion, MRI and early biopsy are required for a timely diagnosis of skeletal TB of the hand and wrist. Early commencement of ATT was the most important factor for good results. The possibility of multidrug resistance should be kept in mind for patients not responding to treatment.

Is surgery always indicated in rachitic coronal knee deformities? Our experience in 198 knees.

INTRODUCTION: Defective mineralization of osteoid matrix prior to physeal closure causes rickets. Poor calcification of the cartilage matrix in the zone of provisional calcification causes flattened skull, rachitic rosary, bowed legs, coxa vara and brittle bones. The recent literature has seen an increase in the incidence of the disease in both developing and developed nations. We evaluated behaviour of lower limb deformities due to nutritional rickets in 117 patients. MATERIALS AND METHODS: A prospective study was conducted from January 2009 to December 2011 for clinical and radiological evaluation of knee deformities in nutritional rickets. A total of 117 patients with 198 coronal plane knee deformities between 2 years and 12 years age of rickets were enrolled in this study. RESULTS: In our study, there were 65 genu varum and 133 genu valgum deformities. Seven genu varum (10.7%) and 37 genu valgum (28%) deformities were regarded as failure. Fifty eight genu varum got corrected completely obtaining an average of 5° of valgum in an average of 6.3 months. The average rate of spontaneous correction was 1.9° a month. Ninety six valgum got corrected obtaining an average of 4.7 valgum in an average of 13.3 months. The average rate of spontaneous correction was 0.92° a month. CONCLUSION: Most of the rachitic deformities get corrected with age. Genu varum is having better chances and a faster rate of correction as compared with genu valgum. Early surgery may be indicated in late presenting cases. We believe varum above 4 years and 18° of valgum above 9 years usually do not correct and may require surgical intervention.

Experience of supracondylar cheveron osteotomy for genu valgum in 115 adolescent knees.

PURPOSE: Medial close wedge Coventry type osteotomy is commonly performed procedure for adoloscent Genu valgum. However this osteotomy has some inherent problems, a wedge resection causes shortening of affected site. An additional plate for stabilization causes increase in soft tissue dissection and surgical time. A cheveron osteotomy is an alternative procedure, not requiring any internal fixation due to its inherent stability. We started this study with aim to analyze the results of Cheveron osteotomy, to see if the osteotomy was stable enough without implants, time required for healing of osteotomy, post-operative range of motion, limb length discrepancy and to evaluate any other complication. METHODS: This study was conducted to evaluate the efficacy of cheveron osteotomy in cases with genu valgum in our department from 2005 to 2012. 75 children with 115 knee deformities were included in the study. Patients were followed upto minimum 3 years post surgery. Clinical and radiological assessment was done on all subsequent visits. RESULTS: Preoperative mean valgus angle was 21° (12-30°) and mean inter malleolar distance was 12.3 cm(11-21 cm). The mean post-operative angle was 6.5° and mean intermalleolar distance was 5.6 cm. The difference was statistically significant. The mean tourniquet time was 26 min and mean surgical time including plaster cast application was 38 min. Mean blood loss was 75 ml. The mean time to union was 10.3 weeks. CONCLUSION: Supracondylar cheveron osteotomy is simple, stable, low cost osteotomy for surgical correction of genu valgum. The osteotomy provides excellent clinical, radiological and functional results in short surgical time and has an added advantage of omitting the need of second surgery.

Evaluation of Ponseti method in neglected clubfoot.

BACKGROUND: Gentle passive manipulation and casting by the Ponseti method have become the preferred method of treatment of clubfoot presenting at an early age. However, very few studies are available in literature on the use of Ponseti method in older children. We conducted this study to find the efficacy of Ponseti method in treating neglected clubfoot, which is a major disabler of children in developing countries. MATERIALS AND METHODS: 41 clubfeet in 30 patients, presenting after the walking age were evaluated to determine whether the Ponseti method is effective in treating neglected clubfoot. This is a prospective study. Pirani and Dimeglio scoring were done for all the feet before each casting to monitor the correction of deformity. Quantitative variables were expressed as mean ± standard deviation and compared between preoperative and postoperative followup using the paired t-test. Also, the relation between the Pirani and Dimeglio score, and age at presentation with the number of casts required was evaluated using Pearson's correlation coefficient. No improvement in Dimeglio or Ponseti score after 3 successive cast was regarded as failure of conservative management in our study. RESULTS: The mean age at presentation was 3.02 years (range 1.1 - 10.3 years). The mean followup was 2.6 years (range 2-3.9 years). The mean number of casts applied to achieve final correction were 12.8 casts (range 8 - 18 casts). The mean time of immobilization in cast was 3.6 months. The mean Dimeglio score before treatment was 15.9 and after treatment were 2.07. The mean Pirani score was 5.41 before treatment and 0.12 after treatment. All feet (100%) achieved painless plantigrade feet without any extensive soft tissue surgery. 7 feet (17%) recurred in our average followup of 2.6 years. CONCLUSIONS: Painless, supple, plantigrade, and cosmetically acceptable feet were achieved in neglected clubfeet without any extensive surgery. A fair trial of conservative Ponseti method should be tried before resorting to extensive soft tissue procedure.

Ganglion cysts of the wrist : a prospective study of a simple outpatient management.

We present the results of a modified minimally invasive surgical technique in the management of ganglia of the wrist. Twenty six ganglia have been treated by this method. The patient satisfaction for the procedure was 92.3%. An average of 2 days were lost off work consequent to the procedure. The use of this technique has resulted in a 77.9% mean resolution in size with 50% of the patients showing complete resolution. There were no recurrences noted in the 2 year follow-up.

Isolated tuberculosis of scaphoid in the skeletally immature: a rare cause of chronic wrist pain.

The hand and wrist are rare sites for tuberculosis and account for less than 1% of all skeletal tuberculosis. Though rare, tuberculosis of the wrist is a cause of major morbidity. A common feature in the available reports on hand and wrist tuberculosis was a delay in diagnosis causing residual stiffness and pain after treatment. Minimal initial symptoms, rarity of the lesion and ability of wrist tuberculosis to mimic more common pathologies account for the delay. No report of isolated scaphoid lesion in the paediatric age group has ever been reported. We present one such case, which was treated with multidrug chemotherapy. At the end of treatment the patient regained complete range of motion was completely pain free. No reactivation of disease was seen over 2-year follow-up.

Giant cell tumour--a very rare differential for a lytic lesion of the medial condyle of the humerous.

Tumours are rare around the elbow joint, and giant cell tumours are especially rare in this region. A single case report of a giant cell involving the distal humerous was found in the literature and none were found involving the isolated medial condyle. We present a rare case of a 22-year-old woman with progressively increasing painful swelling in her left elbow over a period of 6 months. A plain radiograph revealed an expansile epiphyseometaphyseal, radiolucent lesion in the medial end of the distal humerous, with the rim being thin but still intact. The MRI of the elbow revealed a solid lesion in the medial aspect of the elbow with no breach of cortex. Biopsy of the lesion revealed multinucleated giant cells along with mononuclear cells consistent with a diagnosis of giant cell tumour. Extended curettage with bone cement was performed through an anterior approach. There has been no recurrence of the tumour in 2 years of follow-up; the patient has a good range of elbow movements of 20-110°.

Postinfective skin contracture: a rare cause of fifth metatarsophalangeal joint subluxation.

Dislocation or subluxation of the metatarsophalangeal joint (MTP) is common and usually follows a traumatic event. Non-traumatic causes usually include inflammatory arthritis (rheumatoid arthritis), connective tissue disorders, crowded shoewear or flexor digitorum longus tendon contracture. We present a very unusual case of subluxation of the fifth MTP joint following a postboil skin contracture. The case was treated with the release of contracture by Z-plasty. It resulted in concentric reduction of the joint and normal skin healing.

Primary tuberculosis of the clavicle.

Tuberculosis of the clavicle is a rare lesion, accounting for less than 1% of all osteoarticular tuberculosis. The lesion has been described in a few case reports. The lesion can have a varied presentation, ranging from dull, aching pain to bony swelling and a draining sinus. The rarity of the lesion, its nonspecific symptoms, and its striking resemblance to common cystic conditions such as bone tumors and metabolic conditions such as rickets make diagnosis difficult. The authors describe a series of 17 patients with primary tuberculosis of the clavicle. Radiographs and magnetic resonance images were obtained for all patients, and a preliminary diagnosis was made on the basis of clinical features and the results of erythrocyte sedimentation rate, C-reactive protein, and Mantoux tests. Erythrocyte sedimentation rate was uniformly elevated. Radiographs showed diffused thickening and honeycombing, eccentric expansile lytic lesions with surrounding osteopenia, or sequestration not unlike pyogenic infection. Magnetic resonance imaging is useful for determining the extent of the lesion and soft tissue involvement. The radiological and laboratory findings provided complementary information. The diagnosis was confirmed on biopsy material that was analyzed with histopathology, pus culture and sensitivities, gram stain, acid-fast stain, and cultures on Löwenstein-Jensen medium. Patients were treated with multidrug antitubercular chemotherapy for 18 months and were assessed on pre- and posttreatment radiology, erythrocyte sedimentation rate, and University of California, Los Angeles (UCLA) shoulder rating scale. The results of conservative management of tubercular osteomyelitis were uniformly good, and all patients recovered well.

A very rare cause of chronic foot pain in a child: metatarsal tubercular osteomyelitis.

Pure tubercular osteomyelitis without joint involvement is rare and easily missed. Moreover the lesion is common in spine and large joints like hip and knee. The involvement of isolated metatarsal has been described rarely, only as few sporadic case reports. We present one such case of isolated first metatarsal involvement in an 8-year-old child who presented with chronic pain in left foot for over 6 months. The X-rays suggested a lytic lesion and lesion was confirmed on histopathology and acid-fast bacteria staining. The patient was treated with multidrug antitubercular chemotherapy. The results were excellent with complete healing of the lesion.

Femoral shortening in the congenital dislocation of the knee joint: results of mid-term follow-up.

Femoral shortening has an advantage of gaining reduction in severe grades of congenital dislocation of the knee joint without release or lengthening of the quadriceps tendon, thereby reducing the incidence of extensor lag. We report our mid-term functional results in six patients (10 knees) with grade III congenital dislocation of the knee joint who were treated with femoral shortening. At an average follow-up of 4.1 years, the mean active range of motion was -0.5 to 107° and none of the patients had extensor lag. The results in arthrogryposis multiplex congenita were noteworthy for the absence of extensor weakness, postoperative deformity, or recurrence.

Pediatric cervical disc calcification simulating tubercular spondylitis - A case report.

Calcification of intervertebral disc in children is rare. It mostly affect lower cervical region and present with acute neck pain, torticolis, restriction of range of motion. Neurological deficit or dyspahagia are rare features. The presence of fever, leukocytosis and elevated erythrocyte sedimentation rate, gives impression of tuberculosis or other infections. This differentiation is important as the management of pediatric disc calcification is mostly conservative and prognosis is good.