We compared the radiological and functional outcomes in patients with radial longitudinal deficiency treated surgically with those managed nonoperatively and correlated the ease of performance of activities with radiological and functional parameters in the two groups. A retrospective analysis was done in 446 type 3 and 4 hands (modified Bayne classification) over 20 years comparing the subjective assessment, objective and functional scores in nonoperatively managed hands (Group 1; n = 137) to hands managed with centralization or radialization (Group 2; n = 309). The subjective, objective and functional measures were significantly better in Group 2. Improved alignment, finger and wrist range of motion and grip strength were related to improvement in functional score. Surgical treatment of radial longitudinal deficiency provides improvement in cosmesis, function and ease of performance of activities when compared with nonoperatively managed hands.

To report unusual occurrence of angiomyolipoma at intraarticular location with another lesion in the same side foot. A 12-year-old girl was referred to us after initial inconclusive work-up done elsewhere for swelling of left knee joint. There was a 15×12cm swelling in the knee joint partially encasing patella while also a similar hourglass shaped swelling measuring 9×4cm was noted in the same side foot. After clinical and radiological evaluation an excision biopsy was planned for both sites. The specimen sent for histopathological evaluation revealed angiomyolipoma with identical characteristics in the two locations and was HMB45 immunostain negative. Patient was evaluated for possibility of tuberous sclerosis but there was no contributory evidence. Angiomyolipoma is typically a solitary renal tumor with rare occurrence at musculoskeletal sites. Multicentric variety is still infrequent. Intraarticular occurrence of angiomyolipoma presents a diagnostic challenge not only in terms of unfamiliarity but also unusual presentation with absence of characteristic immunostaining and multicentricity requiring careful exclusion of other lesions that may require a more radical approach for treatment.

L’objectif de ce travail était de décrire l’apparition inhabituelle d’un angiomyolipome de localisation intra-articulaire avec une autre lésion du pied homolatérale. Une jeune fille de 12 ans nous a été adressée après exploration initiale non concluante faite dans un autre hôpital, pour gonflement de l’articulation du genou gauche. La taille de ce gonflement était de 15×12cm, l’œdème encastrait partiellement la rotule, tandis qu’un gonflement similaire en forme de sablier mesurant 9×4cm était observé du même côté du pied. Après une évaluation clinique et radiologique, une biopsie avec exérèse chirurgicale a été réalisée aux deux sites. Les prélèvements envoyés pour examen anatomopathologique ont montré un angiomyolipome avec des caractéristiques identiques aux deux localisations et un marquage négatif à la coloration HMB45. Le diagnostic de sclérose tubéreuse de Bourneville a été évoqué mais sans preuve formelle. L’angiomyolipome est typiquement une tumeur rénale isolée. Elle peut rarement s’observer aux sites musculosquelettiques. Il existe une variété multicentrique peu fréquente. La survenue intra-articulaire d’un angiomyolipome est un défi diagnostique non seulement en termes de rareté mais également en raison de sa présentation inhabituelle avec l’absence d’immunomarquage caractéristique et son caractère multicentrique, nécessitant une recherche soigneuse d’autres lésions associées. Une approche thérapeutique plus radicale est nécessaire.

Painless osteoid osteoma is an uncommon entity. We report a unique painless osteoid osteoma of proximal tibia in a 15-month-old child. Patient had atypical painless osteolytic lesion with minimal periosteal reaction for which he was initially treated as chronic osteomyelitis at a secondary care hospital. A correct diagnosis could be made on the basis of characteristics of CT scan and bone scan features. Wide excision of tumor was done, and patient had complete recovery with no recurrence during last 2 years of follow-up. To our knowledge, painless osteoid osteoma at an age of 15 months (lowest in literature) affecting metadiaphyseal portion of long bone (very rare) with atypical radiological (radiographs) features has not been reported previously in the world literature. Both bone scan and CT scan play an important role in early diagnosis and treatment to minimize the morbidity particularly in the presence of subtle or atypical radiological feature of osteoid osteoma. But bone scan may be preferred over CT scan for diagnosis particularly in young patients to avoid radiation exposure of CT scan.

BACKGROUND:Minimally invasive approaches such as sclerotherapy have been introduced to treat aneurysmal bone cysts. Sclerotherapy has been associated with reasonable healing rates during the past two decades. However, it is unclear whether sclerotherapy compares with the more traditional extended curettage and bone grafting.QUESTIONS/PURPOSES:We therefore compared the healing rates and functional scores in patients having percutaneous repetitive sclerotherapy using polidocanol (Group 1) with those with intralesional excision (extended curettage with a high-speed burr) and bone grafting (Group 2) for treatment of aneurysmal bone cyst.PATIENTS AND METHODS:We randomly divided 94 patients into two treatment groups. We assessed healing rates (primary outcome measure), pain relief, time to healing and recurrence, hospital stay, and the Enneking functional score. Forty-five patients from Group 1 and 46 from Group 2 were available for study. The minimum followup was 3.2 years (mean, 4.4 years; range, 3.2-6.1 years).RESULTS:At last followup, 93.3% in Group 1 and 84.8% in Group 2 had achieved healing. Complications in Group 1 were minor and resolved. In Group 2, three patients had deep infections and five had superficial infections, and two had growth disturbances. Although the healing rates were similar, we found higher rates of clinically important complications, worse functional outcomes, and higher hospital burden associated with intralesional excision.CONCLUSIONS:Repetitive sclerotherapy using polidocanol is a minimally invasive, safer method of treatment for aneurysmal bone cysts compared with intralesional excision and bone grafting. In this preliminary study, we found similar recurrence rates for the two treatment methods, however, this will require confirmation in larger studies.LEVEL OF EVIDENCE:Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Complications that develop after femoral neck fracture in children-especially osteonecrosis-have been retrospectively attributed to inadvertent delayed fixation and fracture type. Prospective evaluation of results after delayed fixation of femoral neck fractures in children beyond the first 24 h is not reported in the literature and requires evaluation to increase our understanding of the procedure and improve fixation methods. Also, the role of capsular decompression in initial management needs to be elucidated.Materials and methods Radiological and functional evaluation was done for delayed fixation ([24 h) of displaced fractures in the femoral neck in 21 children (21 hips) treated over 11 years. Mean patient age was 11.8 (median 12, range 5-15) years. Extraphyseal fixation was done using partially threaded cannulated cancellous screws after closed or open reduction. Patients were allowed full weight bearing after 12-18 weeks.Results were assessed on the basis of modified Ratliff criteria. Patients were followed for a mean of 81 (range 66-129) months. Results All fractures united at a mean duration of 12 (range 10.6-14) weeks. Three (14.3%) patients had osteonecrosis of the hip, which was significantly related to poor outcome (r = 0.495; P = 0.022). There was a significant correlation (r = 0.52) between development of osteonecrosis and delayed fracture fixation of [10 days (P = 0.016) and open reduction (P = 0.016).Conclusions Outcome following temporal delay in fracture fixation of the femoral neck is primarily affected by osteonecrosis of the femoral head, whereas restriction of movements, shortening, and premature physeal closure has no significant influence. Osteonecrosis is primarily linked to delay and open reduction, whereas fracture type, age, and sex seem insignificant factors. Capsular decompression does not seem to affect the outcome in delayed presentations and may hinder definitive treatment.

BACKGROUND:Isolated actinomycosis of the humerus is a very rare entity.METHOD:A 30-year-old male had an erythematous plaque with a pus-(minimal) discharging sinus over left lower arm. The patient had no discharge of sulphur granules from the sinus. The patient had raised ESR with a single lytic lesion with minimal sclerosis and inconspicuous periosteal reaction on radiographs. Such atypical clinical and radiological features lead to initial wrong diagnosis of tuberculosis. A diagnosis of Actinomycosis of humerus became possible after demonstration of filamentous bacilli in culture and on histopathology from the sulphur grains obtained by open biopsy.RESULT:The patient recovered completely after administering PenicillinG 24 million units intravenous for 7 days followed by 1.2 g of oral amoxicillin in three divided doses for 3 months and did not show any recurrence during last 2 years of follow up.CONCLUSION:Surgeons should be aware of this rare entity and difficulty in its diagnosis due to its variable manifestations, including confusion with highly endemic tuberculous infection. Awareness of full spectrum of the diseases and careful evaluation in individual cases will expedite diagnosis and avoid unnecessary surgical interventions.

Kimura's disease is a rare, chronic inflammatory disorder, presenting usually as head and neck swellings and regional cervical lymphadenopathy. The disease is more often described from oriental literature but the osseous manifestations and involvement of extremity are rare and unidentified in literature. We present an unusual case of long bone periosteal reaction in a patient of Kimura's disease of extremity. This potentially innocuous disorder must be kept in mind as a radiological differential of periosteal reaction.

INTRODUCTION:The association of fibular duplication with metatarsal diplopodia is extremely rare with only a few cases reported in the medical literature.CASE PRESENTATION:We present a 4-month-old girl with left tibial agenesis with fibular duplication (mirror foot) and metatarsal diplopodia.CONCLUSION:The case report highlights the need for an understanding of this rare congenital anomaly which may be seen only once in the working lifetime of an orthopaedic surgeon.

BACKGROUNDAim of our study was to evaluate the use of Locking Compression Plate (LCP) in patients with long standing nonunions of the clavicle with osteoporotic bones.MATERIAL AND METHODSThere were a total of 11 patients. Surgery was performed for painful nonunion with shoulder dysfunction. Average time since injury was 6.9 months (3-39 months). Nonunions were stabilized by a 3.5-mm LCP, applied on the antero-inferior surface of the clavicular shaft. A six-hole LCP was used in eight cases. In three patients seven-hole LCP and in one patient eight-hole LCP was used. The fixation was supplemented by autogenous cancellous bone graft (except in hypertrophic nonunions). Patients were followed for a mean of 2.8 (1-3) years.RESULTSThe average time of radiologic union was 5.3 months (3-9 months). Union was achieved in all patients. Subjective clinical assessment was performed using the Disabilities of the Arm, Shoulder, and Hand functional score (DASH). The mean DASH score preoperatively was 42 (25-52) and postoperatively was 24 (11-34). Superficial infection and features of reflex sympathetic dystrophy were seen in one patient each.CONCLUSIONLong standing clavicular nonunion with osteopenic bone is a difficult problem to treat. Our study shows that LCPs can be an improved implant option with good fracture healing.

Spinal tuberculosis constitutes 50% of all musculoskeletal tuberculosis. However, literature regarding congenital spinal tuberculosis is very scanty. Congenital spinal tuberculosis was diagnosed in a two-month-old child on the basis of age at presentation (gibbus since three weeks of age), hepatomegaly, raised ESR, radiological destruction of D10–D11 vertebrae, asymptomatic maternal endometrial tuberculosis and tuberculous histopathology from CT guided biopsy specimen from D10 vertebra. Both child and mother were treated by antitubercular treatment. Child improved symptomatically, gibbus became less prominent and ESR became normal at the end of one year of treatment. Patient had no recurrence during last two years of follow-up. This is the first case of congenital tuberculosis of spine with a documented source of infection from asymptomatic maternal endometrial tuberculosis. CT guided core biopsy from vertebra/aspiration from the paravertebral abscess help in early diagnosis and treatment to reduce neurological morbidity and mortality. Endometrial biopsy help in establishing the diagnosis of congenital tuberculosis and adequate antitubercular treatment in such cases may provide protection to fetus in subsequent pregnancy.

L’ostéosarcome central de faible malignité est une tumeur osseuse primitive rare. En raison de certaines caractéristiques radiographiques et histologiques communes, cette tumeur fibro-osseuse peut être confondue avec la dysplasie fibreuse (lésion osseuse bénigne plus fréquente) et entraîner un traitement inadapté, à l’origine d’une récidive tumorale osseuse de malignité plus élevée. Nous présentons le cas d’un ostéosarcome central de faible malignité du tibia droit, initialement traité comme une dysplasie fibreuse par curetage et greffe osseuse. Trois ans plus tard, la tumeur a récidivé avec un envahissement plus important des parties molles et de l’os, mais sans dissémination métastatique. Le patient a été traité par une amputation au-dessus du genou. Il est resté asymptomatique au cours des deux dernières années.

Le fibrome desmoplastique de l’os est une tumeur osseuse primaire, extrêmement rare et agressive localement. Le diagnostic en est difficile et l’expérience thérapeutique limitée pour les chirurgiens spécialistes dans l’excision des tumeurs. Nous avons étudié trois cas rares de fibromes desmoplastiques survenant au niveau de l’os à des localisations inhabituelles. Le diagnostic a été établi grâce à la radiographie et à l’histopathologie. Les patients ont subi une intervention chirurgicale selon diverses modalités. Les résultats ont été évalués sur une longue période de suivi (six à neuf ans). La pathologie a été éradiquée dans les trois cas et aucune récidive n’a été observée pendant la longue période de suivi. L’évolution fonctionnelle a été bonne et aucune complication n’a été observée. Une résection large de la tumeur est préconisée, car sinon, le taux de récidive après la chirurgie est élevé.

Low grade central osteosarcoma is a rare primary bone tumor. This fibro-osseous lesion shares some radiological and histopathological resemblance with fibrous dysplasia, which is a more common entity. Thus it may be mistaken as fibrous dysplasia and may receive inadequate treatment resulting in a more malignant recurrent bone tumor. We present a case of low grade central osteosarcoma of the right tibia, which was initially treated as fibrous dysplasia with curettage and bone grafting. Three years later the tumor recurred with greater soft tissue and bony involvement but without metastasis. The patient was treated with above knee amputation and has been asymptomatic for the last two years.

Clubfoot is the commonest congenital deformity in babies. More than 100,000 babies are born worldwide each year with congenital clubfoot. Around 80% of the cases occur in developing nations. We treated 154 feet [mean Pirani score (total) 5.57] in 96 children (78 males, 18 females) by the Ponseti method from January 2003 to December 2005. A prospective follow-up for a mean duration of 19.5 months (range 6–32 months) was undertaken. After six months of treatment the Pirani score was reduced to zero for all patients. The results show that corrective surgery, sometimes multiple, can be avoided in most cases which are usually associated with the development of a stiff, painful foot. Low socio-economic status and illiteracy prevailing in developing nations increases the prevalence of neglected clubfoot that is still harder to correct. Integration into various programs and proper use of available resources can decrease neglected clubfoot and improve chances of successful and timely correction of deformity. Bracing constitutes an important part of treatment and proper motivation and education of the parents mitigates the chances of losing correction. The Ponseti method of correcting clubfoot is especially important in developing countries, where operative facilities are not available in the remote areas and well-trained physicians and personnel can manage the cases effectively with cast treatment only.

La maladie de Kimura est une affection chronique inflammatoire rare qui se traduit habituellement par des masses sous-cutanées à la tête et au cou, accompagnées d’adénopathies cervicales. La plupart des cas décrits à ce jour ont été observés en Asie. L’atteinte des membres et les lésions osseuses sont rares. Nous décrivons une observation inhabituelle de maladie de Kimura responsable d’une réaction périostée le long du fémur gauche. Cette maladie bénigne doit faire partie des diagnostics évoqués devant une réaction périostée radiologique.

La tuberculose vertébrale représente la moitié des cas de tuberculose de l’appareil locomoteur. Toutefois, les publications sur la tuberculose vertébrale congénitale sont très rares. Une tuberculose vertébrale congénitale a été diagnostiquée chez un enfant de deux mois en se basant sur l’âge à la présentation d’une bosse (depuis l’âge de trois semaines), la présence d’une hépatomégalie, une vitesse de sédimentation (VS) élevée, l’observation radiographique de la destruction des vertèbres D10–D11, une tuberculose de l’endomètre asymptomatique chez la mère et des résultats anatomopathologiques en faveur de la tuberculose sur les échantillons prélevés par une biopsie scanoguidée au niveau de la vertèbre D10. L’enfant et la mère ont été traités avec un traitement antituberculeux. Les symptômes de l’enfant se sont améliorés, la bosse est devenue moins saillante et la VS s’est normalisée après un an de traitement. Il n’y a eu aucune récidive pendant la période de suivi de deux ans. Il s’agit du premier cas de tuberculose vertébrale congénitale avec comme source infectieuse documentée une tuberculose de l’endomètre asymptomatique maternelle. Le cylindre osseux prélevé par biopsie scanoguidée et l’aspiration de l’abcès paravertébral aident à poser un diagnostic précoce et à traiter rapidement pour réduire la morbidité et la mortalité neurologiques. La biopsie de l’endomètre aide à établir le diagnostic de tuberculose congénitale et l’institution d’un traitement antituberculeux adéquat assure la protection du fœtus pendant les grossesses ultérieures.

To the EditorA 42 year old female presented to the OPD withcomplaints of swelling and pain for past 4 months onthe left clavicular region. It progressed in size rapidlywith early rise in pain. Pain was continuous andincreased with movements, partially remitting withanalgesics. There was no history of trauma orfever. On examination a bony hard swelling arisingfrom medial two-thirds of clavicle measuring 8 cm

La tumeur osseuse à cellules géantes est agressive mais histologiquement bénigne. Dans les rares cas d'atteinte costale, la tumeur siège habituellement à l'extrémité postérieure d'une côte. Il existe peu de données sur l'atteinte de l'extrémité antérieure. Nous décrivons une observation de tumeur à cellules géantes de l'extrémité antérieure d'une côte qui simulait un abcès sous-mammaire chez une femme en période d'allaitement.