Does surgical technique influence the burden of lung metastases in patients with pathologic long bone fractures?

BACKGROUND: The aims of this study are to (1) determine whether fixation of metastatic long bone fractures with an intramedullary nail (IMN) influences the incidence of lung metastasis in comparison to arthroplasty or ORIF (Arthro/ORIF); and (2) assess this relationship in primary tumor types; and (3) to assess survival implications of lung metastasis after surgery. METHODS: Retrospective cohort study investigating 184 patients (107 IMN, and 77 Arthro/ORIF) surgically treated for metastatic long bone fractures. Patients were required to have a single surgically treated impending or established pathologic fracture of a long bone, pre-operative lung imaging (lung radiograph or computed tomography) and post-operative lung imaging within 6 months of surgery. Primary cancer types included were breast (n = 70), lung (n = 43), prostate (n = 34), renal cell (n = 37). Statistical analyses were conducted using two-tailed Fisher's exact tests, and Kaplan-Meier survival analyses. RESULTS: Patients treated with IMN and Arthro/ORIF developed new or progressive lung metastases following surgery at an incidence of 34 and 26%, respectively. Surgical method did not significantly influence lung metastasis (p = 0.33). Furthermore, an analysis of primary cancer subgroups did not yield any differences between IMN vs Arthro/ORIF. Median survival for the entire cohort was 11 months and 1-year overall survival was 42.7% (95% CI: 35.4-49.8). Regardless of fixation method, the presence of new or progressive lung metastatic disease at follow up imaging study was found to have a negative impact on patient survival (p < 0.001). CONCLUSIONS: In this study, development or progression of metastatic lung disease was not affected by long bone stabilization strategy. IM manipulation of metastatic long bone fractures therefore may not result in a clinically relevant increase in metastatic lung burden. The results of this study also suggest that lung metastasis within 6 months of surgery for metastatic long bone lesions is negatively associated with patient survival. LEVEL OF EVIDENCE: III, therapeutic study.

One-stage versus 2-stage bilateral total joint arthroplasty: a matched cohort study.

Background: Patients with bilateral end-stage hip or knee arthritis want to know if it is safe to have bilateral surgery under a single anesthetic, to restore their quality of life as quickly as possible. The purpose of this study was to assess if there is an increase in the rate of postoperative medical adverse events, length of stay (LOS), blood transfusion rate and 30-day readmission rate among patients who undergo 1-stage bilateral total hip arthroplasty (BTHA) and 1-stage bilateral total knee arthroplasty (BTKA) compared with patients who undergo 2-stage BTHA and BTKA. Methods: Our study cohorts included patients who underwent BTHA and BTKA between Apr. 1, 2009, and Jan. 31, 2016, in Alberta, Canada. To minimize selection bias associated with our retrospective study design, we matched patients who underwent 1-stage BTHA and BTKA with patients with patients who underwent 2-stage BTHA and BTKA, respectively, for age, sex and number of presurgical risk factors using propensity score in a matching ratio of 1:1. Results: Our study included 1645 patients who underwent BTHA and 4125 patients who underwent BTKA. We matched 195 patients who underwent 1-stage BTHA and 302 patients who underwent 1-stage BTKA with patients who underwent 2-stage BTHA and BTKA, respectively. There was no significant difference in postoperative medical adverse events between the 1-stage and 2-stage matched cohort groups for both BTHA (adjusted odds ratio [OR] 1.3, 95% confidence interval [CI] 0.3-4.9) and BTKA (adjusted OR 0.9, 95% CI 0.3-2.6). There was no difference in inpatient, 30- or 90-day mortality between the 2 groups for BTHA or BTKA. Patients who underwent 1-stage BTHA and BTKA had a shorter acute length of stay but increased total length of stay (acute care and rehabilitation unit) and were less likely to be discharged home postoperatively. One-stage BTHA and BTKA were associated with higher odds of blood transfusion than 2-stage BTHA and BTKA. The 30-day readmission rate was significantly lower for 1-stage BTHA than for the 2-stage BTHA matched cohort (adjusted OR 0.3, 95% CI 0.1-0.8), whereas there was no difference in the 30-day readmission rate (adjusted OR 0.6, 95% CI 0.2-1.7) between the 1-stage and 2-stage BTKA matched cohorts. Finally, operating room time was significantly lower for 1-stage BTHA (49.6 min less) and 1-stage BTKA (66.7 min less) than for the 2-stage arthroplasty procedures. Conclusion: Healthy patients who undergo 1-stage BTHA and BTKA have postoperative medical complication rates comparable to those of patients who undergo 2-stage procedures with the additional benefits of a shorter acute length of stay, but they do have a higher risk of blood transfusion and are less likely to be discharged directly home from the acute care hospital. A multicentre randomized controlled trial on this topic is currently being condcuted by the Canadian Arthroplasty Society.

Contexte: Les patients atteints d'arthrite bilatérale de la hanche ou du genou au stade terminal veulent savoir s'il est sécuritaire de subir une chirurgie bilatérale avec une seule anesthésie pour retrouver leur qualité de vie le plus rapidement possible. Le but de cette étude était de comparer le taux de complications postopératoires de nature médicale, la durée du séjour hospitalier, le taux de transfusions sanguines et le taux de réadmissions à 30 jours chez les patients selon que les arthroplasties totales de la hanche bilatérales (ATHB) et les arthroplasties totales du genou bilatérales (ATGB) se font en 1 étape ou en 2 étapes. Méthodes: Les cohortes de notre étude incluaient des patients qui ont subi des ATHB et des ATGB entre le 1er avril 2009 et le 31 janvier 2016 en Alberta, au Canada. Pour réduire le biais de sélection associé à notre protocole d'étude rétrospective, nous avons assorti les patients soumis aux ATHB et aux ATGB en 1 étape à ceux qui les ont subies en 2 étapes, respectivement, selon l'âge, le sexe et le nombre de facteurs de risque préopératoires, avec score de propension et rapport 1:1. Résultats: Notre étude a regroupé 1645 patients soumis à des ATHB et 4125 patients soumis à des ATGB. Nous avons assortis 195 patients soumis aux ATHB en 1 étape et 302 patients soumis aux ATGB en 1 étape avec des patients soumis à des ATHB et des ATGB en 2 étapes, respectivement. On n'a noté aucune différence significative quant aux complications postopératoires de nature médicale entre les groupes des cohortes assorties pour les interventions en 1 et en 2 étapes, tant avec les ATHB (rapport des cotes [RC] ajusté 1,3, intervalle de confiance [IC] de 95% 0,3­4,9), qu'avec les ATGB (RC ajusté 0,9, IC de 95% 0,3­2,6). Il n'y a pas eu de différences au plan de la mortalité à 30 jours ou à 90 jours chez les patients hospitalisés des 2 groupes avec les ATHB ou les ATGB. Les patients soumis aux ATHB et aux ATGB en 1 étape ont séjourné moins longtemps en soins actifs, mais la durée totale de leur séjour a été plus longue (soins actifs et réadaptation) et ils étaient moins susceptibles de retourner à la maison au moment de leur congé hospitalier après l'intervention. Les ATHB et les ATGB en 1 étape ont été associées à un risque plus grand de transfusions sanguines que les ATHB et les ATGB en 2 étapes. Le taux de réadmission à 30 jours a été significativement plus faible avec les ATHB en 1 étape que dans la cohorte assortie soumise aux ATHB en 2 étapes (RC ajusté 0,3, IC de 95% 0,1­0,8), tandis qu'il n'y a eu aucune différence au plan des taux de réadmission à 30 jours (RC ajusté 0,6, IC de 95% 0,2­1,7) entre les cohortes assorties soumises aux ATGB en 1 et 2 étapes. En terminant, le temps opératoire a été significativement plus bref avec les ATHB et les ATGB en 1 étape (respectivement 49,6 minutes et 66,7 minutes de moins) comparativement aux arthroplasties en 2 étapes. Conclusion: Les patients en bonne santé qui subissent des ATHB et des ATGB en 1 étape ont des taux de complications postopératoires de nature médicale comparables à ceux qui les subissent en 2 étapes, avec l'avantage additionnel d'un séjour hospitalier plus bref en soins actifs; mais ils sont exposés à un risque plus grand de transfusions sanguines et sont moins susceptibles de retourner directement à la maison en quittant l'hôpital de soins actifs. La Société canadienne d'arthroplastie procède actuellement à un essai randomisé et contrôlé multicentrique à ce sujet.

Concordance between laboratories in metal ion testing in patients with metal-on-metal hip implants.

BACKGROUND: Testing of whole blood or serum metal ion levels has become an important part of assessing and monitoring the performance of metal-on-metal bearings, both in hip resurfacing arthroplasty and in total hip replacement. The aim of this study was to determine the concordance between 2 laboratories testing cobalt and chromium ion levels in patients with metal-on-metal bearings. METHODS: Serum and whole blood samples from patients who had undergone metal-on-metal resurfacing or large-diameter total hip arthroplasty were tested for cobalt and chromium ions in laboratory A (a recognized laboratory) and laboratory B (tasked with testing clinical specimens). Laboratory A performed cobalt and chromium testing on whole blood, and laboratory B performed cobalt testing on whole blood and chromium testing on serum. RESULTS: Samples from 104 patients were tested. Laboratory B reported lower whole blood cobalt levels than laboratory A. Furthermore, laboratory A reported that all patients had elevated whole blood cobalt ion levels compared to the normal reference values for the laboratory, whereas laboratory B reported that 46 patients (44.2%) had whole blood cobalt ion levels within the normal reference range for the laboratory. CONCLUSION: This comparative study highlights the importance of using a single laboratory for metal ion testing, as values generated from different laboratories may not be directly comparable. With recent literature suggesting that whole blood cobalt levels as low as 1 ppb may be a predictor of adverse reactions to metal debris, accurate clinical measurement needs to be increasingly exact.

CONTEXTE: Le dosage sanguin ou sérique d'ions métalliques est devenu une étape importante de l'évaluation et du suivi des prothèses à couple de frottement métal-métal utilisées en arthroplastie de resurfaçage ou totale de la hanche. La présente étude visait à évaluer la concordance entre les résultats de 2 laboratoires pour le dosage du cobalt et du chrome chez des patients porteurs de ces prothèses. MÉTHODES: Des prélèvements de sérum et de sang entier de patients porteurs d'une prothèse de resurfaçage ou d'une prothèse totale à grand diamètre de hanche à couple métal-métal ont été expédiés au laboratoire A (un laboratoire reconnu) et au laboratoire B (spécialisé en analyse d'échantillons cliniques) pour le dosage des ions cobalt et chrome. Le laboratoire A a effectué toutes ses analyses sur des prélèvements de sang entier, et le laboratoire B a utilisé le sang entier pour le dosage du cobalt et le sérum pour le dosage du chrome. RÉSULTATS: Les prélèvements de 104 patients ont été analysés. Le laboratoire B a détecté des taux sanguins de cobalt inférieurs à ceux du laboratoire A. De plus, le laboratoire A a indiqué que tous les patients présentaient des taux de cobalt sanguins élevés par rapport à ses valeurs de référence, alors que le laboratoire B a déterminé que le taux de cobalt sanguin de 46 patients (44,2 %) se trouvait dans sa fourchette de valeurs de référence normales. CONCLUSION: Cette étude comparative vient souligner l'importance de choisir un seul laboratoire pour le dosage des ions métalliques, car les valeurs générées par des établissements différents pourraient ne pas être directement comparables. Comme des études récentes semblent indiquer que des taux de cobalt sanguins aussi faibles que 1 p. p. milliard pourraient être des prédicteurs de réaction indésirable aux débris métalliques, la précision et l'exactitude des mesures cliniques revêtent une importance croissante.

Comparison between intravenous and intra-articular regimens of tranexamic acid in reducing blood loss during total knee arthroplasty.

Tranexamic acid is an antifibrinolytic drug used widely to prevent bleeding. Its use in reducing bleeding during total knee arthroplasty surgery is well proven but there is no final consensus regarding the regimen. The purpose of our study was to compare the effectiveness of intravenous and intra-articular regimen of tranexamic acid during the total knee arthroplasty surgery. A total of 40 patients were received three doses of intravenous tranexamic acid during total knee arthroplasty surgery. Intra-articular tranexamic acid was used in 40 patients during the surgery. We concluded that intra-articular tranexamic acid is equally effective as three dose intravenous regimen in reducing blood loss during total knee arthroplasty surgery.

Primary malignant melanoma of proximal tibia.

Primary malignant melanoma (clear cell sarcoma) of bone is a very rare neoplasm. Although metastatic melanoma to bone is not uncommon, primary malignant melanoma of bone is extremely uncommon. To date, only nine cases have been reported in the English literature. In this report, we present a case of primary malignant melanoma arising from the medial aspect of the proximal tibia in a 26-year-old woman. We treated the patient with above-knee amputation without any chemotherapy or radiotherapy. At final follow-up of 18 months, the patient was free of disease.

Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre.

BACKGROUND: Clubfoot or congenital talipes equinovarus is a common congenital abnormality of uncertain etiology. The purpose of this study was to assess the results of the Ponseti method in India and to investigate the demography of relapse and resistant cases. METHODS: A total of 86 children (146 feet) below 1 year of age who had presented to the paediatric orthopedic outpatient department of our institution between June 2003 and January 2007 with unilateral or bilateral idiopathic clubfoot deformity were included in our study and treated conservatively by use of the Ponseti technique. RESULTS: 128 feet responded to the Ponseti casting technique initially and 18 feet were resistant to the conservative treatment. Of the responsive feet, for 20 feet there was a relapse of the deformity. Evaluation of the results showed that poor compliance with splintage was the most common cause of relapse; delayed presentation and atypical clubfeet resulted in high resistance to this technique. Correction achieved at our centre was 82.18%. This is less than in many recent studies and could be attributed to increased incidence of delayed presentation, poorer compliance, and atypical feet in our population. CONCLUSION: We conclude that the Ponseti technique is recommended for management of clubfoot and strict compliance with splintage is essential to prevent relapses. People of lower socioeconomic status are at high risk of relapse and must be targeted to create awareness among them about the importance of compliance with splintage.

Do we need femoral derotation osteotomy in DDH of early walking age group? A clinico-radiological correlation study.

INTRODUCTION: The occurrence of exaggerated femoral anteversion and the role of femoral derotation osteotomy in developmental dysplasia of hip, especially early walking age group are controversial. METHOD: We evaluated femoral anteversion, acetabular anteversion, acetabular index in 15 dislocated hips and 11 normal hips in cases of unilateral dislocation of hip in DDH of age group 12-48 months. We correlated this femoral anteversion with the intra operative "test of stability" which is described by Zadeh et al. We found that there was no statistically significant difference in femoral anteversion between dislocated and normal hips. In all the 15 cases we did open reduction by anterior approach (Somerville approach) and evaluated the position for maximum stability. In 3 cases we were unable to perform test of stability as they needed femoral shortening for reduction of joint. RESULTS: In the rest 12 hips, 10 were stable in flexion and abduction while 2 were stable in flexion. None of the hips required internal rotation for stability. Hence we did salters osteotomy in all the hips and femoral shortening through lateral approach in 3 cases. At a minimum follow up of 18 months all the hips were clinically stable and none of them dislocated till final follow up. The mean correction of acetabular index was 15.4 degrees and the outcome was excellent in 8 hips and good in 7 hips as per modified McKay's criteria. Hence we recommend that femoral derotation osteotomy is not needed in DDH of early walking age group. CONCLUSION: As the surgical treatment of DDH involves complex osteotomies around the hip and these surgeries have effect on long term outcome, MRI evaluation of femoral anteversion as a part of pre operative evaluation is advised. Also, as the intra operative evaluation needs enough clinical experience and it can not be performed in cases requiring femoral shortening for reduction, we consider pre operative evaluation of femoral anteversion by MRI as essential rather than adjunctive.

Low-grade fibromyxoid sarcoma of the talus: a case report.

Low-grade fibromyxoid sarcoma is a rare tumor, which most commonly arises from the deep soft tissues of the lower extremities in young men. Diagnosis of this tumor can be difficult because of its deceptively benign histopathologic appearance. Specifically, the lesion is characterized by alternating fibrous and myxoid areas with variable cellularity and a whorled growth pattern. Like many soft tissue tumors, low-grade fibromyxoid sarcoma is also characterized by strong immunoreactivity to the human proto-oncogene BCL-2. Cytogenetically, the lesion has also been associated with the t (7,16) (q33;p11) translocation, with the characteristic resultant FUS and CREB3L2 fusion gene. In this report, we describe the rare case of a low-grade fibromyxoid sarcoma that appeared to develop as a primary malignancy in the neck of the talus of a young man who presented with recurrent ankle pain after a previous surgery for a cystic lesion at the same site.

Is there a need for reconstruction after excision of the distal ulna for giant-cell tumour?

Giant cell tumour rarely involves the distal ulna; the literature has sporadic cases reported, and the need for reconstruction after distal ulnar resection remains controversial. The uncommon presentation often leads to diagnostic delays, and some of the cases reported have attained large sizes prior to diagnosis, leading' to procedures which range from soft tissue stabilization to bone graft reconstruction of the surgical defect. We analyzed our cases with specific reference to the need for additional reconstruction; the radiological and functional outcome of extraperiosteal distal ulna resection without reconstruction in 4 patients with giant cell tumour of the distal ulna was assessed at a mean follow-up of 9 years post surgical excision. In our experience there was no radiological evidence of recurrence, radioulnar convergence and ulnar translocation of the carpus. Functional outcome was graded as excellent in 3 and good in one patient. In conclusion, it could be suggested that there is no need for reconstruction after distal ulna resection for GCT as an adequate functional outcome is seen even in late diagnosed cases. Reconstructive procedures, which come at the cost of additional morbidity and complications, and requires special technical skills, are not routinely justified for this rare condition.

En bloc resection of osteosarcoma of the proximal fibula. An analysis of 8 cases.

Osteosarcoma of the proximal fibula is a rare entity that poses a surgical challenge. Limb salvage is the goal of treatment, and this entails sacrifice of the common peroneal nerve as well as the anterior tibial artery. Also the loss of the lateral collateral ligament and biceps attachment leads to unavoidable knee instability which requires special reconstructive procedures. From 2002 to 2008, eight patients with osteosarcoma of the fibular head were treated in our institution with Malawer type II resection. Seven of these patients are still alive without evidence of disease. Our results indicate that the sacrifice of the common peroneal nerve ensures a wide margin of resection which in turn correlates with long-term survival. Furthermore, our technique of reconstruction of lateral knee structures has produced good functional outcome without significant postoperative knee instability.

Arthrodiastasis and surgical containment in severe late-onset Perthes disease: an analysis of 14 patients.

Late-onset Perthes disease usually carries a poor prognosis. In severe cases there may be increasing pain, decreased range of motion and hinge abduction which forms a contraindication for surgical containment. We have managed 14 such patients in a two-stage procedure. Arthrodiastasis done as a first stage dramatically reduced pain and Trendelenburg limp while at the same time leading to a substantial improvement in range of motion and hinged abduction. Once the contraindications to surgical containment were overcome by arthrodiastasis, we proceeded with a varus osteotomy of the femur in a second stage in the hope that the femoral head would remodel to some extent with time and would improve the final functional outcome.

MRI evaluation of femoral and acetabular anteversion in developmental dysplasia of the hip. A study in an early walking age group.

MRI assessment of acetabular and femoral anteversion was done in 45 children with developmental dysplasia of the hip in an early walking age group of 12 to 48 months. Femoral anteversion, acetabular anteversion, acetabular anteversion of the cartilage anlage and acetabular index were measured by MRI in 45 dislocated hips and in a control group of 37 normal contralateral hips of index cases. We found that there was no statistically significant difference between these two groups for femoral anteversion. The acetabular anteversion was found to be significantly increased in the dislocated group compared to the normal group. Similar results were obtained for the cartilage anlage of the acetabulum. There was a positive correlation between acetabular anteversion and acetabular index, while there was no correlation between femoral anteversion and other parameters. We conclude that femoral anteversion is not increased, while the acetabulum is excessively anteverted on the dislocated side in developmental dysplasia of the hip in an early walking age group. Analysis of femoral and acetabular anteversion is an essential part of pre operative planning in developmental dysplasia of hip, and for this MRI is a good modality as it is radiation free.

Clinico-radiological assessment and their correlation in clubfeet treated with postero-medial soft-tissue release.

The controversy regarding the radiographic parameter which best represents the various deformities of clubfoot continues. The aim of our study was to clear up this controversy. Fifty surgically treated (soft-tissue release) congenital clubfeet were studied clinically using Laaveg and Ponseti score and radiologically using twelve different radiographic parameters in weight-bearing AP and lateral views. The talo-calcaneal angle (TCA) in AP and lateral view showed statistically significant correlation with the functional rating, but significant variation in the dimension of the angles among the different functional groups was found with AP angle only. The talo-first metatarsal angle in AP and lateral view averaged 10 degrees and 19 degrees respectively, and showed significant correlation with the functional rating. The talo-navicular subluxation in AP, the calcaneo-fifth metatarsal angle and the first-fifth metatarsal angle in lateral view did not show any significant correlation with function. Talo-calcaneal index averaged 44 degrees in the clubfeet and showed significant correlation. The wide range of parameters representing each of the deformities gives a better radiological assessment of the clubfoot than any single parameter.

Role of MRI in detecting early physeal changes due to acute osteoarticular infection around the knee joint: a pilot study.

Physeal changes of any aetiology in children are usually diagnosed once the deformity is clinically evident. Between January 2006 and June 2007, 15 children who suffered from acute osteoarticular infection around the knee joint were studied. They were called up for follow-up six months after the onset of infection. All patients were evaluated by clinical and roentgenographic examination before undergoing magnetic resonance imaging (MRI) study of both knees "with the unaffected knee serving as control". Abnormal findings in the physis, metaphysis and/or epiphysis on MRI were observed in five children. This group of five children was compared with the other ten children for clinical presentation and course of disease. We believe that MRI is a useful tool in the evaluation of growth plate insult in the early period following acute osteoarticular infection, and we can diagnose and prevent the catastrophic complications of the same.

Outcome of varus derotation closed wedge osteotomy in Perthes disease.

The aim of this study is to evaluate the clinical and radiological outcome of varus derotation osteotomy in Perthes disease. We studied 45 children with a mean age of 9.2 years, belonging to Herring's lateral pillar group B and C treated with varus derotation osteotomy. Containment was achieved in all patients on postoperative radiographs. At a mean follow-up of 6.4 years, good results were obtained in 23, fair in 20, and poor in 2 patients using Catterall's postoperative classification. Radiological evaluation was done using Mose's index and the epiphyseal quotient. Statistical analysis has concluded that better outcome was achieved in patients younger than 10 years of age as compared to those older than 10 years. Our study suggests that varus derotation osteotomy is an effective and easy surgical containment method for children with severe Perthes disease, especially who are younger than 10 years of age.

Management of a neglected femoral neck fracture in a limb affected by poliomyelitis - a case report.

Neglected femoral neck fractures are difficult to treat successfully without resorting to total hip arthroplasty. Baksi described a tensor fascia lata muscle pedicle bone graft procedure for such cases. Management of such fractures following poliomyelitis presents additional challenges. We present a case of a neglected femoral neck fracture in a young adult with late sequelae of poliomyelitis managed by Baksi's procedure. At final follow up at 2 years the patient was able to walk without aids and had returned to his job.

En bloc excision and autogenous fibular reconstruction for aggressive giant cell tumor of distal radius: a report of 12 cases and review of literature.

INTRODUCTION: Giant cell tumor (GCT) of distal radius follows a comparatively aggressive behaviour. Wide excision is the management of choice, but this creates a defect at the distal end of radius. The preffered modalities for reconstruction of such a defect include vascularized/non-vascularized bone graft, osteoarticular allografts and custom-made prosthesis. We here present our experience with wide resection and non-vascularised autogenous fibula grafting for GCT of distal radius. MATERIALS AND METHODS: Twelve patients with a mean age of 34.7 years (21-43 years) with Campanacci Grade II/III GCT of distal radius were managed with wide excision of tumor and reconstruction with ipsilateral nonvascularised fibula, fixed with small fragment plate to the remnant of the radius. Primary autogenous iliac crest grafting was done at the fibuloradial junction in all the patients. RESULTS: Mean follow up period was 5.8 years (8.2-3.7 years). Average time for union at fibuloradial junction was 33 weeks (14-69 weeks). Mean grip strength of involved side was 71% (42-86%). The average range of movements were 52° forearm supination, 37° forearm pronation, 42° of wrist palmerflexion and 31° of wrist dorsiflexion with combined movements of 162°. Overall revised musculoskeletal tumor society (MSTS) score averaged 91.38% (76.67-93.33%) with five excellent, four good and three satisfactory results. There were no cases with graft related complications or deep infections, 3 cases with wrist subluxation, 2 cases with non union (which subsequently united with bone grafting) and 1 case of tumor recurrence. CONCLUSION: Although complication rate is high, autogenous non-vascularised fibular autograft reconstruction of distal radius can be considered as a reasonable option after en bloc excision of Grade II/III GCT.

Application of the Ponseti principle for deformity correction in neglected and relapsed clubfoot using the Ilizarov fixator.

We treated 15 cases of neglected and relapsed clubfeet by the Ilizarov distraction method using the Ponseti principle in 12 children (mean age 7.3 years). The deformities were corrected around the talar head in the sequence of the cavus, adduction, varus and finally equinus (as per the Ponseti principle). Clinical and functional outcome after 2.5 years was significant (P<0.05) with a mean reduction of 11.7 in Dimeglio's score and an average Laaveg and Ponseti functional score of 75.47. The average time taken for correction was 4.2 weeks. Differential distraction according to the Ponseti principle leads to early correction with minimal number of residual deformities and complications.

Neglected irreducible posterolateral knee dislocation.

Knee dislocations are rare injuries. Posterolateral knee dislocations are only a small subset of them. There is a paucity of literature regarding the management of such neglected cases. We report here, a case of neglected irreducible posterolateral knee dislocation treated with open reduction and isolated posterior cruciate ligament reconstruction followed by gradual rehabilitation with good outcome at 3 years followup.