Drug resistance patterns in 111 cases of drug-resistant tuberculosis spine

Purpose

We report the largest study conducted till date of drug resistant tuberculosis in spine analyzing the drug susceptibility patterns in 111 cases of proven drug resistance.

Methods

An observed cross-sectional study was conducted. Six-hundred and eighty-six patients with positive cultures underwent sensitivity testing to 13 commonly used anti-tubercular drugs using BACTEC MGIT-960 system.

Results

Females (60.3%) outnumbered males (39.6%). Only three patients (2.7%) were found HIV positive, and none of these had AIDS. Forty-four (39.6%) patients had taken AKT in the past for some form of tuberculosis. Eight (7.2%) patients had history of treatment default. The drug sensitivity testing revealed 87 (78.3%) cases of multi drug resistance (resistance to both isoniazid and rifampicin) and 3 (2.7%) cases of XDR-TB spine. Of the individual drugs, widespread resistance was present to both isoniazid (92.7%) and rifampicin (81.9%), followed by streptomycin (69.3%). Least resistance was found to kanamycin, amikacin and capreomycin.

Conclusion

It is recommended to do routine biopsy, culture and drug sensitivity testing in all patients of tuberculosis spine to guide selection of appropriate second-line drugs when required. In cases of non availability of drug susceptibility testing despite repeated attempts, it is suggested to use data from large series such as this to plan best empirical chemotherapy protocol.

     

A rare case of metaphyseodiaphyseal chondroblastoma of proximal femur presenting with constitutional symptoms in a six-year-old child

Primary metaphyseodiaphyseal chondroblastoma is rare. To our knowledge, very few such cases have been reported in the English literature. Insidious onset of pain is the most common complaint in patients with chondroblastoma. A clinical presentation of constitutional symptoms along with a metaphyseodiaphyseal lesion on radiographs in a young child usually points toward a diagnosis of Ewing's sarcoma or infection. Here, we document a case of metaphyseodiaphyseal chondroblastoma of femur in a 6-year-old child presenting with chief local complaints of an intermediate onset pain and swelling along with systemic complaints of fever and malaise. The patient was operated by excision of the tumor and reconstruction using autogenous-free fibular graft.     

Postvertebroplasty instability

Vertebroplasty provides excellent pain relief and functional restoration for osteoporotic fractures. Short-term complications such as cement leak and embolism are well described. Incident fractures are the only well-reported long-term complications. The authors describe the cases of 5 patients who presented with back pain caused by instability or worsening neurological status 13 months (range 8-17 months) after vertebroplasty. They further classify this postvertebroplasty instability into intervertebral instability and intravertebral instability, depending on the apex of abnormal mobility. One patient presented with cement migration and progressive collapse of the augmented vertebral body. Another patient presented with an additional fracture. Both cases were classified as intravertebral instability. The cases of 3 other patients presenting with adjacent endplate erosion, vacuum disc phenomenon, and bridging osteophyte formation were classified as having intervertebral instability. Long-term effect of cements on the augmented vertebral body and adjacent endplates and discs is a cause for concern. Vertebroplasty acts as a mechanical stabilizer and provides structural support but does not bring about union. Micromotion has been shown to persist for years after vertebroplasty. This study describes persistent instability after vertebroplasty in a series of 5 cases. The authors propose that postvertebroplasty instability occurs due to collapse of soft osteoporotic bone and endplates around cement. All 3 cases of intervertebral instability were associated with an intradiscal cement leak. With increased longevity and higher functional demands of the geriatric population, the durability of this "rock (cement) between cushions (of osteoporotic bone)" arrangement (as seen in vertebroplasty) will be increasingly challenged.     

Displaced femoral neck fractures in the young: significance of posterior comminution and raised intracapsular pressure

Background  

Osteosynthesis in fracture neck of femur (NOF) in young is a universally acceptable procedure. Various factors affect the outcome; with AVN (avascular necrosis) and non-union primarily contributing to adverse results in such patients. To identify factors affecting outcome of displaced fracture NOF, a prospective cohort study was carried out in the setting of a tertiary care centre in developing country.     

Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases

(1) To present the indications of single stage all posterior surgery in thoracic and lumbar tuberculosis. (2) To evaluate the results of single stage all posterior surgery. We analysed 67 patients who underwent single stage all posterior surgery with follow-up of 31.37 months. We performed the following operative procedures depending upon level and case requirements. (Group A) Instrumentation alone for instability. (Group B) Transpedicular decompression and instrumentation for neurological compression in thoracic and thoracolumbar spine. (Group C) Transforaminal approach for access to anterior column in lumbar spine in addition to posterior instrumentation. (Group D) Pedicle subtraction osteotomy and instrumentation for deformity correction. (Group E) Posterior decompression alone for isolated posterior epidural compression. (Group F) Reconstruction of anterior column by all posterior approach. Thirty-eight had neurological deficit whereas 29 were Frankel E. In 12 cases, anterior reconstruction was done. In the remaining 55 cases, we relied on vertebral reconstitution under chemotherapy. Operative time was 150.5 min and blood loss was 514.18 ml. Of 38 patients with deficit, 34 improved. There was radiological fusion in all patients. Pre- and post-operative Cobb’s measurements were 9.95 and 8.1, respectively, in thoracic and thoracolumbar spine and ?9.39 and ?11.42, respectively, in lumbar spine. Of 55 cases where anterior reconstruction was not done, only 3 had progression of Cobb’s >10°. Posterior approach can achieve adequate decompression of offending middle column and if required, even anterior reconstruction. Posterior approach is versatile, with many surgical options depending on the level and case requirements.     

Closed posterior subtalar dislocation without any associated fracture: A case report and review of the literature

Pure posterior subtalar dislocation without any medial or lateral displacement of foot is extremely rare and hardly reported in the literature. Such an injury is more likely to be open and associated with fractures of the surrounding bones of the foot. Here we report a rare case of closed pure posterior subtalar dislocation without any associated fracture. We discuss in detail the mechanism of such an injury and highlight the importance of prompt closed reduction and early mobilization to ensure a satisfactory long term outcome.     

Role of ��low cost Indian implants�� in our practice: our experience with 1,572 pedicle screws

Purpose  

As Indian spine surgeons, we have to choose between ‘foreign implants’ and ‘Indian implants’. An Indian four pedicle screw rod construct costs 330 US dollars (one-third that of a similar foreign construct). About 60% of patients cannot afford expensive foreign implants. There is little written data evaluating how these Indian implants fare. The purpose of our study was to evaluate implant failure rate with Indian implants and compare it to foreign implants.     

A rare case of bicondylar Hoffa fracture associated with ipsilateral tibial spine avulsion and extensor mechanism disruption

Intra-articular coronal fractures (Hoffas fractures) of distal femur are rare. Although bicondylar involvement in these fractures has been reported in the literature in association with high velocity traumata, the occurrence of these fractures involving extensor mechanism rupture and avulsion of ipsilateral tibial spine is extremely rare. To our acquaintance, such a fracture pattern has not yet been reported in the literature so far. In this article, we report one such case and discuss the importance of early diagnosis and prompt internal fixation in the management of such cases. We believe that these rare combinations of injuries should be treated aggressively by early open reduction and anatomic rigid internal fixation in order toachieve good recovery of function.     

Reconstruction of medial epicondyle with an ILIAC crest strut bone graft in a 74-year-old lady with an open type c fracture of distal humerus

Open intraarticular fractures of the distal humerus are frequently associated with severe bone and articular cartilage fragmentation, extensive soft tissue damage and bone loss. Management is controversial, and results are poor especially in old osteoporotic patients. We here present a case of open fracture of distal humerus with extensive bone loss of medial column. The patient was operated with internal fixation and reconstruction of the medial column with strut iliac crest grafting and had an excellent outcome.