Extrapulmonary, extraspinal tuberculosis is underreported despite being a common presentation of tuberculosis in the Philippines. The ankle and the smaller joints of the foot are infrequent locations of tuberculosis. A 41-year-old female presented with a six-year history of left midfoot swelling, pain, and limited ankle dorsiflexion following trauma. She underwent several wound debridements, with inconclusive biopsy findings. Radiographs showed cortical irregularities with sclerotic changes of the talus and navicular bones, and MRI revealed synovitis with associated bony erosive changes and marrow edema. Debridement, sequestrectomy, and application of antibiotic-laden cement were done. Histopathology revealed caseating necrosis, confirming the diagnosis of tuberculosis. She underwent eight months of antituberculosis therapy. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) remained normal postoperatively. After two months, the patient underwent removal of antibiotic cement and talonavicular arthrodesis with iliac bone grafting. Follow-up radiographs showed incorporation of the graft with no implant loosening. Patient eventually recovered full weight bearing of the left foot with minimal pain. Diagnosis was difficult due to the insidious onset and non-specific symptoms, delaying treatment and allowing progression of the disease. Antituberculosis therapy (ATT) is the mainstay of treatment of bone tuberculosis, and should be initiated upon diagnosis. Surgical intervention depends on the extent of bony destruction and joint instability.
Severe kyphotic deformity is one of the sequelae of tuberculosis of the spine. When left untreated, patients may develop restrictive lung and heart disease and even neurologic deficits. Surgery is complex and risky, especially in young children. Halo-pelvic traction is a technique reported to decrease complexity, blood loss, operative times, and complication rates of definitive fixation of severe deformities; however, the technique has not been used locally. This is a case report on a 6-year-old with severe kyphotic deformity secondary to tuberculosis of the spine. The aim was to provide novel insights into the design and application of the halo-pelvic traction construct, combined with an all-posterior surgical technique to achieve deformity correction. The halo-pelvic traction was able to achieve 26 degrees (35.13%) correction over 35 days with an average daily angular correction of 0.72 degrees per day and daily lengthening at 1.52 mm per day. The patient was able to ambulate with assistance at two weeks and ambulate without assistance at three weeks on the traction construct. At six weeks, vertebral column resection and definitive fixation through an all-posterior approach were done with final angular correction of 49 deg (66.21%). The halo-pelvic construct was maintained as an adjunct to fixation and will be maintained until fusion. The combined two-staged approach of halo-pelvic traction and vertebral column resection through an all-posterior approach has proven to be effective in this pediatric patient with severe kyphotic deformity.
Slipped capital femoral epiphysis (SCFE) is typically a chronic condition associated with metabolic and biomechanical factors, whereas acute traumatic SCFE in a previously asymptomatic adolescent is uncommon and carries a higher risk of avascular necrosis (AVN). We report the case of a 15-year-old male who presented with acute right hip pain and inability to bear weight following high-energy trauma. Radiographs demonstrated an unstable SCFE with severe displacement and no radiographic features of chronicity. The patient underwent urgent closed reduction and percutaneous fixation using two 4.0 mm cannulated screws, consisting of one partially threaded and one fully threaded screw. Postoperatively, he was managed with staged non-weight-bearing followed by gradual return to full weight-bearing. At 12 months, the patient was asymptomatic with no radiological evidence of AVN or loss of reduction. Functional outcome assessment demonstrated excellent recovery, with a Non-Arthritic Hip Score of 97.5% and high Hip disability and Osteoarthritis Outcome Score values across domains, including pain (98.6), symptoms (98.5), activities of daily living (100), sports and recreation (93.75), and quality of life (100). This case shows a favorable short-term outcome following dual small-diameter screw fixation; however, given the single-case design and limited follow-up, no conclusions regarding implant superiority or reduction in AVN risk can be drawn. Further studies are required to evaluate this technique in unstable SCFE.
Humeral shaft fractures may progress to nonunion despite operative management. We report a 50-year-old male with repeated surgical failure of a left humeral shaft fracture, found intraoperatively to have uric acid crystal deposition within the pseudoarthrosis site. The patient underwent implant removal, excision of the pseudoarthrosis, and rigid plate fixation augmented with an intramedullary fibular strut graft. At six months postoperatively, clinical evaluation demonstrated mechanical stability and satisfactory functional recovery. Although fibular strut grafting is not universally considered standard treatment for humeral nonunion, this case highlights its potential role in complex, biologically compromised nonunions associated with gout.
Nonunion occurs when a fracture fails to heal within the anticipated time, which varies depending on the location and degree of related soft-tissue injury. Pain, poor quality of life, and psychological, social, and economic consequences greatly impact these orthopedic patients. Recent studies have proposed percutaneous injection of platelet-rich plasma (PRP) to treat nonunion. Platelets are present in the early inflammatory stages of fracture healing, in theory enhancing angiogenesis and the recruitment of mesenchymal cells. This study aimed to determine if percutaneous administration of a single 5 mL dose of platelet-rich plasma for long bone nonunion would result in bone union within a span of 3 months of follow-up. We present seven patients diagnosed with nonunion of long bones of the upper extremity. PRP was administered into the nonunion site percutaneously via imaging guidance. Improvements in pain scale and function were monitored using VAS and DASH scores. Radiographic union was assessed using the Modified Lane Radiographic Scoring System. The initial mean VAS score was 4.29 (SD = 2.56), decreasing to 2.71 (SD = 1.38) on the first follow-up, and 0.71 (SD = 0.76) on the third and last follow-up. Functional scores also improved, with a mean DASH score of 28.74 (SD = 4.06) on the last follow-up. The mean MLSRS score was 1.98 (MLSRS 1) and increased to 7.10 (SD = 1.59, MLSRS 3). Platelet-rich plasma (PRP) can be used to treat upper extremity long bone nonunion. The study showed improvements in pain, clinical, and radiographic union.
