Intraoperative Diagnosis of a Rare Case of Arthropathy - A Case Report and Review of Literature.

INTRODUCTION: Alkaptonuria is a rare metabolic disorder of autosomal recessive pattern of inheritance caused due to homogentisic acid oxidase enzyme deficiency. As a result, polymers of homogentisic acid get deposited in excessive amounts in the connective tissues, leading to brownish-black pigmentation termed as ochronosis. As the disease progresses, chronic inflammation results in arthritis of large weight-bearing joints. CASE REPORT: A 70-year-old female patient presented with complaints of being non-ambulatory since the past 10 days. She gave a history of difficulty in walking for the past 10-15 years associated with pain in the right hip which did not respond to analgesics and physiotherapy. The radiological assessment revealed severe joint destruction of the right hip. The patient underwent a total hip arthroplasty. A provisional diagnosis of ochronosis was made intraoperatively which was later confirmed on histopathological examination of the tissue. CONCLUSION: At present, there is still no known effective medical treatment to halt alkaptonuria entirely. Ochronotic arthropathy is usually managed conservatively. However, for severely involved hip joints, arthroplasty can provide extremely good results.

Small Cell Prostate Cancer with Atypical Presentation -A Case Report and Review of Literature.

INTRODUCTION: Prostate cancer is one of the leading causes of death due to carcinoma in developed countries due to metastasis. Most of the patient at the time of diagnosis has shown metastasis. Metastasis to bone leads to various skeletal-related events such as fracture and neural compression leading to increase morbidity in such patients. An early diagnosis leads to favorable outcomes. Skeletal metastasis is usually presented as osteoblastic localized lesion in the spine or pelvis. Here, we like to present a case of prostatic metastasis in a patient with widespread metastasis making the diagnosis in such condition a challenging issue. CASE REPORT: A 61-year-old male comes with a complaint of right hip pain who has been diagnosed in some other clinic as a case of osteopoikilosis after an X-ray of the pelvis with both hips. However, on the further skeletal analysis found to involve most of the skeletal system with the diffuse osteolytic lesion. A bone scan, lab investigations helped in the arrival of diagnosis of atypical prostatic metastasis. CONCLUSION: Prostate cancer is less likely to present as widespread osteolytic lesions. A very few case reports have been found in the literature regarding such presentation. This case demonstrates how to differentiate between metastasis and other common condition showing such presentation leading to an early diagnosis and thus improving the overall mortality and morbidity of the patients.

A rare case of posterior interosseous nerve palsy due to ganglion cyst arising from supinator muscle.

Here we present a rare case of ganglion cyst of the elbow joint arising from supinator muscle causing posterior interosseous nerve (PIN) palsy in a 40-year-old female who presented with weakness in finger extension and carrying out routine activities with right hand since 2 weeks. Patient had pain over the right forearm radiating to the right hand since 3 months. She also noted a swelling in the right forearm, which was gradually increasing in size since last 1 month. Atraumatic PIN compression is uncommon and is usually caused by compression of PIN in the arcade of Frohse, by radial recurrent artery, and fibrous band around the radiocapitellar joint. Reports of PIN palsy caused by ganglionic cyst in the elbow joint are rare and case reports regarding the same are sparingly reported. Here we report a case of PIN palsy secondary to ganglion cyst arising from supinator muscle, which recovered completely after excision of the ganglion cyst.

A Rare Case Report of Tuberculous Infection in a Previously Neglected Dysplastic Hip of a Young Woman.

A 14-year-old girl presented with an insidious onset of left hip pain, limp, and intermittent fever for a 3-month duration. Patient had a history of toe walking since childhood which continued into adolescence. On radiographic investigations, she was found to have a dysplastic hip with fluid collection around the hip which was surgically drained. The microbiological investigations proved the presence of Mycobacterium tuberculosis (TB). Accordingly, she was started on anti-TB chemotherapy as per drug sensitivity. TB infection in a previously neglected dysplastic hip is not reported as per our knowledge and poses unique diagnostic and management difficulties.

Does kyphosis in healed subaxial cervical spine tuberculosis equate to a poor functional outcome?

INTRODUCTION: Tuberculosis (TB) of the subaxial cervical spine has a high percentage of morbidity. It accounts for about 10% of cases with the major concerns being quadriparesis and localized kyphosis. AIM: The study aims to provide an insight in the management of subaxial cervical spine TB treated by multiple modalities. MATERIALS AND METHODS: A retrospective analysis of 91 patients with subaxial cervical (C3-C7) TB was performed. Neurology was assessed by Nurick's grading and pain using the visual analog scale (VAS) (in mm). Radiological evaluation was done with standard anteroposterior and lateral view of the cervical spine at presentation and 3 monthly intervals after intervention. Magnetic resonance imaging was done in all patients. Angle of kyphosis (K angle) was calculated from plain radiographs. RESULTS: Mean age of the patients was 31.5 years. Neurological status was Nurick's Grade 5 in 8, Grade 4 in 15, Grade 3 in 28, Grade 2 in 22, Grade 1 in 7, and further 11 had Nurick's Grade 0. Operative intervention was either anterior, or posterior, or a combination of both depending on extent of vertebral destruction. All patients with Nurick's 5 and 4 improved to 3 or less at final follow-up. The kyphosis angle at presentation ranged from 2° to 58° of with an average kyphosis of 16.05°. The postoperative kyphosis was graded as mild (loss of lordosis to 10° kyphosis), moderate (10°-30°), and severe (>30°). Ten patients had mild kyphosis and 6 patients had moderate kyphosis. Mean VAS score at presentation was 45.5 mm which improved to 14.48 mm at follow-up. Patients with mild and moderate kyphosis remained asymptomatic till the last follow-up. CONCLUSION: Healing of subaxial cervical TB in kyphosis does not necessitate a poor clinical outcome as most patients remain asymptomatic.

Bilateral Spontaneous Osteonecrosis of Knee with Concomitant Medial Femoral and Tibial Condyle Involvement - A Rare Presentation and Short Review.

INTRODUCTION: Osteonecrosis of knee is classified as primary spontaneous osteonecrosis of knee (SPONK) and secondary osteonecrosis of knee. Primary SPONK usually involves medial femoral condyle (MFC). Incidence of medial tibial plateau (MTP) is only 2% among the patients with SPONK and simultaneous involvement of MFC and MTP is very rare. CASE REPORT: We report a very rare case of 45-year-old female with SPONK affecting both MFC and MTP simultaneously with subchondral insufficiency fractures. She presented with pain in both the knees and difficulty in walking since 1 year. Physical examination revealed decreased range of motion and local tenderness over MFC and medial tibial condyle. Subchondral fracture with articular surface collapse of MFC with joint space narrowing and varus deformity was seen on X-ray in both the knees. Sclerosis was seen in the medial tibial condyle bilaterally. Magnetic resonance imaging showed characteristic focal hyperintense areas surrounded by band like hypointense areas in both MFC and MTP which was suggestive of subchondral collapse with ill-defined bone marrow changes. X-ray of both knees revealed SPONK in Koshino's Stage IV and Carpintero's Stage IV. Bilateral total knee replacement (TKR) was planned. First left knee was operated. A cruciate retaining type of TKR was done. Two weeks, later right side TKR was operated. MFC of right side also had a large osteochondral fragment which was excised to leave defect with depth more than 2 cm. Defect was reconstructed with bone graft obtained from posterior condylar cuts. Posterior stabilized type of knee replacement component was used along with femoral extender stem. Histopathological examination revealed necrotic bone surrounded by an area of fibrovascular granulation tissue on both the femoral and tibial sides. Patient has good functional outcome at 2 years follow-up. CONCLUSION: Concomitant SPONK of MFC and MTP in bilateral knee is very rare and in advanced stages TKR can provide good radiological and functional outcome. Furthermore, pre-operative assessment of bone defects is necessary and appropriate use of augments (extender stem or metal wedges) is crucial.

A Rare Anatomical Variation in the Origin of the Tendon of Long Head of Biceps in a 30-Year-Old Male: A Case Report and Review of Literature.

INTRODUCTION: Early studies on human embryology reveal a migration of the tendon of long head of biceps from the synovium and fibrous capsule to an intra-articular position [1, 2, 3]. Any hindrance in the normal course of events of development, pathological or otherwise, may result in variations from the normal anatomy. CASE REPORT: Here, we discuss a case of a rare anatomical variant of the origin of long head of biceps tendon discovered incidentally in a 30-year-old manual laborer. The patient had an insidious onset and gradually progressive right shoulder pain, especially in initiating abduction, with a feeling of instability for 5 months. On examination, apprehension test and anterior drawer test were present and sulcus sign was positive. Partial-thickness supraspinatus tear and fraying of the anteroinferior glenoid labrum were noted in the imaging. After giving a fair trial of conservative management, the patient was posted for an arthroscopic repair of the supraspinatus tear and the anteroinferior glenoid labrum when the anomalous origin of the tendon of long head of biceps was discovered incidentally. This origin was from the inferior surface of the supraspinatus muscle outside the capsule. The tendon was left intact as it was not found to be inflamed or degenerated and was not the source of instability. CONCLUSION: Due to the rarity of this anatomical variant, definite conclusions cannot be drawn currently regarding its pathological nature. Shoulder arthroscopists should be aware of its potential to become abnormally thickened and causing shoulder dysfunction.

High tibial osteotomy in a lax knee: A review of current concepts.

The technique of high tibial osteotomy (HTO) was traditionally documented for symptomatic medial tibiofemoral arthrosis associated with coronal plane malalignment in a stable knee., recently, more attention has been given to the treatment of coronal malalignment in lax knees with HTO with or without ligament reconstruction. Patients with overwhelming pain, chronic ligament deficiency and coronal or sagittal deformity are generally easier to treat with HTO as compared to those who have mild pain and a proximal tibial deformity. The instability at the knee joint can be either in the coronal or sagittal plane or in both planes. Younger patients with chronic ACL deficiency, varus malalignment and advanced medial compartment arthritis, who present with pain and slight instability show satisfactory results with HTO. Double-limb weight bearing anteroposterior view radiographs are used to plot mechanical leg axis (from the centre of the femoral head to the centre of the knee), anatomical axis (a line from the centre of the piriformis fossa to the centre of the knee joint and a line through the long axis of tibia) and weight bearing axis (line drawn from the centre of the femoral head to the centre of the ankle joint) and are used to plan HTO. A 3-dimensional pre-operative plan using CT and MRI is recently studied. The decision to perform HTO alone or in combination with ligament reconstruction involves consideration of patient demographics, symptoms and ligaments involved. The most commonly used surgical techniques for high tibial osteotomy include lateral close wedge osteotomy, medial open wedge osteotomy and dome osteotomy. The post-operative rehabilitation depends on the rigidity of fixation.

Alleviating head and neck pain.

Pain in patients who have cancer can be caused by direct effects of the tumor or by complications of treatment, or it can be unrelated to the disease or its treatment. This article discusses interventional pain procedures in the treatment of head and neck pain as they relate to malignancies and cervicogenic headache and neck pain.

Complete Extra-articular Ankylosis of Hip and Stiff Elbow in a Case of Extensive Myositis Ossificans: A Rare Presentation.

INTRODUCTION: Myositis ossificans (MO) is a benign ossifying lesion. It is also known as heterotopic ossification of muscle, in which lamellar bone is formed in the muscle most commonly due to trauma or neurological injury. Complete extra-articular ankylosis due to extensive MO is rare. CASE REPORT: We report a case of 22-year-old female with post-traumatic MO following head injury. The patient developed extensive MO in iliopsoas and brachialis muscle leading to complete extra-articular ankylosis of hip and stiffness of elbow which lead to severe functional disability to the patient. Hematological parameters were normal. Surgical excision of the bony mass was done in two stages- hip followed by an elbow. The patient had marked functional improvement in hip and elbow. CONCLUSION: Complete extra-articular ankylosis of hip is rare in the case of MO. The massive size of bony mass connecting the femur to pubis is not common and computed tomography angiography is beneficial if bony mass is in the vicinity of neurovascular bundle. Good functional results can be obtained with excision of bony mass after ruling out bony malignancy.

Evaluation of anatomic risk factors using magnetic resonance imaging in non-contact anterior cruciate ligament injury.

BACKGROUND: The purpose of our study was to compare the significance of the tibio-femoral morphological variables (notch width index, notch shape index, intercondylar notch angle, medial and lateral tibial slopes) in predicting non-contact ACL (anterior cruciate ligament) injuries and to compare these factors between genders in South Asian population. The author hopes to provide a comprehensive analysis on the risk factors which would help in betterment of the patients at danger for anterior cruciate ligament injury. MATERIALS AND METHODS: A total of 110 MRI knees of patients with 55 subjects of noncontact ACL injury and 55 age and sex matched controls were included in a retrospective study. Notch width index, notch shape index, intercondylar notch angle were assessed in axial and coronal MR imaging along with medial and lateral posterior tibial slopes. Morphology of the notch was also assessed. RESULTS: ACL injured group were found to have a statistically significant narrow notch width index and decreased intercondylar notch angle with increased lateral posterior tibial slope. Type-A notches were found to have increased risk of having ACL injuries. Gender comparative results showed no statistically significant differences. CONCLUSION: ACL tears are associated with decreased notch width index, intercondylar notch angle and increased lateral posterior tibial slope. Type-A notches are seen to have increased risk for ACL injuries.

Treatment of Chronic Simple Elbow Dislocation by Two Separate Incisions - A Case Report.

INTRODUCTION: Chronic elbow dislocation is a highly disabling condition to be treated and to provide a successful functional outcome. Surgical treatment of such conditions might result in persisting instability or stiffness of the elbow joint due to associated shortening and contracture of the soft tissues and articular incongruity. Most of the described open reduction techniques are through an extensile posterior approach which might result in increased post-operative stiffness. We report the treatment of such a case with separate medial and lateral incisions with the excellent functional outcome at 1-year follow-up. CASE REPORT: A 45-year-old lady with 2-month-old elbow dislocation was planned for open reduction of the joint through two separate incisions, medial and lateral. Surgical details and difficulties faced will be analyzed in this paper. The patient currently has 30-140°flexion with complete pronation-supination movements at 1-year follow-up. CONCLUSION: Chronic dislocation of the elbow is a highly disabling condition and has a very unpredictable outcome. By combining an understanding in the anatomy and biomechanics of the elbow with a proper surgical technique tailored to the individual patient, it is possible to achieve a functional and painless elbow in the majority of cases. By accessing medial and lateral elbow separately, the morbidity and wound complications of an extensile posterior approach can be reduced and also it has similar, if not better, functional results.

X-ray and Computed Tomography Scan-Based Morphometric Analysis of Skull Baselines in Indian Population.

INTRODUCTION: The study aims at providing an overview of morphometric measurements of the skull baselines in normal Indian population and compares these dimensions with those of other races and ethnicities. This study will help in defining "normal" baseline values for Indian population. It will also compare dimensions as measured on X-ray and computed tomography (CT) scan to assess the reliability of X-ray as a diagnostic modality for the assessment of the skull baselines in Indian population. MATERIALS AND METHODS: Retrospective study with a sample size of 116 patients and duration of 30 months. RESULTS: The mean value for distance between dens tip and Chamberlain line on CT was 0.498 mm and on X-ray was 0.528 mm and for the distance between dens tip and McGregor line on CT was 0.213 mm and on X-ray was 0.228 mm. The mean distance between the dens tip and McRae line was 4.67 1.69 mm on CT scan and 4.7 1.76 mm on X-ray. CONCLUSION: There was not a single patient in whom the dens tip crossed the McRae line. Any protrusion of the dens tip beyond the foramen magnum is abnormal. Hence, the McRae line is easiest to understand and remember. Furthermore, the Chamberlain and McGregor lines rely on identifying the hard palate, which may not be included in routine X-ray, CT, and magnetic resonance imaging studies depend on the field of view. Hence, we recommend the use of McRae line for screening purposes while evaluating pathologies of the craniovertebral junction. X-ray is a reliable diagnostic technique for assessing morphometry of the skull baselines in an emergency or rural setting if facility for CT scan is not available.

A case report of Poland Syndrome with Absent Limb Anomalies.

INTRODUCTION: Poland Syndrome(PS) is a rare congenital condition associated with the absence of unilateral chest wall muscles and sometimes ipsilateral symbrachydactyly (abnormally short and webbed fingers). The condition typically presents with unilateral absence of the sternal portion of the pectoralis major muscle which may or may not be associated with a hypoplasia of the breast, an ipsilateral webbing of the fingers (cutaneous syndactyly) and agenesis of 2, 3, 4, and 5 ipsilateral costal cartilages, and athelia. CASE REPORT: We report a 13-year-old patient with an atypical variant of PS without any limb anomalies. In view of the good function of the upper limb, no surgical treatment was offered, and the patient and his family were counseled regarding the condition. A follow-up of the patient at 2 years revealed that the patient is still asymptomatic with good functional status of the upper limb. CONCLUSION: It is hoped that this paper will further improve our understanding of this rare syndrome and its atypical presentations.