Metaphyseal Region Research Articles

Solitary Peritoneal Metastasis in Case of Osteosarcoma Detected by FDG PET/CT.

Primary osteosarcomas predominantly originate in the metaphyseal region of long bones. The introduction of 18F-FDG PET/CT imaging has revealed unusual and often rare sites of metastatic spread. Peritoneal deposits in osteosarcoma are not a commonly reported finding in the literature. The present case highlights the 18F-FDG PET/CT findings in a case of osteosarcoma of the left fibula with isolated peritoneal metastasis with no regional or distant metastases.

Mid-term Survivorship and Functional Outcomes of Metaphyseal Sleeves for Addressing Anderson Orthopaedic Research Institute (AORI) Type 2 and 3 Bone Defects in Revision Total Knee Arthroplasty.

Introduction Revision Total Knee Arthroplasty (RTKA) is a complex procedure challenged by significant bone loss, necessitating effective restoration techniques. This study investigates the clinical outcomes and complications of metaphyseal sleeves in RTKA with severe metaphyseal bone loss, aiming to evaluate their efficacy over a minimum four-year follow-up. Methods This was a retrospective observational study on 29 patients who underwent RTKA with Anderson Orthopaedic Research Institute (AORI) type II or III bone defects using porous coated tibial and/or femoral metaphyseal sleeves from December 2016 and January 2019. Data collection included demographic information, etiology for revision, and functional outcomes assessed by the Knee Society Score (KSS) and Oxford Knee Score (OKS). Statistical analysis and Kaplan-Meier survival analysis were performed. Results The cohort comprised patients with a mean age of 62.6 years (SD=7.8), predominantly female (N=21, 71.4%). The primary indication for RTKA was aseptic loosening (N=18, 62.1%) followed by Prosthetic Joint Infection (PJI). Significant improvements were noted in the range of motion. Both KSS (Pre-op:57.97 vs. Post-op:73.59) and OKS (Pre-op:15.86 vs. Post-op:30.66) showed highly significant improvement (p<0.0001). Radiographic assessments indicated stable component position and signs of osseous integration without any osteolysis. No sleeve-related complications were observed. Survival analysis demonstrated a high cumulative survival probability over the study period. Conclusion Metaphyseal sleeves offer a viable solution for managing severe bone loss in RTKA, providing stable fixation, restoring joint line kinematics, and facilitating stress distribution to the metaphyseal region. This study corroborates the effectiveness of metaphyseal sleeves in challenging revision scenarios, aligning with previous research.

Case Report : Brucella infection of total knee arthroplasty - The first case report in an endemic country!

Prosthetic joint loosening due to Brucella spp. is a rare event. In this report, we describe a rare case of prosthetic infection caused by brucella. A 71-year-old woman reported a six-month history of progressing pain in the right prosthetic knee, which had been implanted for arthrosis four years prior to admission, associated with fever. No night sweats were noted. On examination, the right knee appeared slightly swollen and painful on mobilization, and the surgical wound was normal. Blood tests showed increased C-Reactive Protein (CRP) (34mg/L) and erythrocyte sedimentation rate (ESR) (34mm/hr). A CT scan of her right knee was performed, showing loosening of the prosthesis, joint effusion, and osteolysis in contact with the internal tibial component measuring 16mm maximum with bone remodeling of the epiphysis and metaphysis regions. Rose Bengal test was positive for brucellosis, a standard brucella tube agglutination test was positive at a titer of 1/80, blood cultures for brucella were negative and a PCR for detection of Mycobacterium tuberculosis was negative. The patient was diagnosed as having Brucella infection of his total knee arthroplasty. Favorable outcome was observed after medical and surgical treatment. We believe this is the first detailed report of Brucella prosthetic infection in the country despite the endemicity of this type of zoonosis.

Bone Mineral Density and Clinical Outcome after Ankle Fracture.

No gold standard exists for bone mineral density (BMD) measurement of the ankle. This study aimed to determine the correlation between bone density using Hounsfield units (HU) based on computed tomography (CT) and BMD using dual energy X-ray absorptiometry (DXA) as well as to evaluate the correlation between HU and clinical outcome of ankle fracture. Fifty-one patients aged ≥65 years who underwent surgical treatment for trimalleolus or bimalleolus ankle fractures were included. The HU were measured at the distal tibia metaphyseal region approximately 1 cm proximal to the plafond on the axial images of preoperative CT. BMD was measured using DXA within one year before the injury. The clinical outcome was evaluated according to the Foot and Ankle Outcome Score (FAOS). Although the HU of an osteoporosis group was lower than that of a non-osteoporosis group, we observed no significant difference between the two groups. The mean HU significantly correlated with the lumbar and total lumbar spine BMD using DXA. Increased HU significantly correlated with improved clinical outcomes in three of five FAOS subscales: symptoms, pain, activity of daily living (ADL), and quality of life (QOL). In a linear regression analysis adjusted for age and body mass index, increased HU significantly correlated with improved clinical outcomes in three of five FAOS subscales: symptoms, pain, ADL, and QOL. The correlations between bone density using HU and BMD and those between HU and the clinical outcome were confirmed in ankle fractures. The HU of preoperative CT might provide valuable information for predicting postoperative clinical outcomes.

Assessment of Functional Outcomes of Femur Treatment Using Modified Thoresen’s Criteria in Terms of Malalignment, Knee Motion, and Associated Symptoms

Comminuted fracture shaft of femur is increasing day by day due to Severe violence by road traffic accident and fall from height in modern civilization and intramedullary nailing sometimes technically not feasible in this type of fracture (AO type-32B3, 32C). Reaming may aggravate the comminution and displaced the comminuted fragments and sometimes difficult in segmental fracture involving metaphyseal region. To assessment of functional outcomes of femur treatment using modified Thoresen’s Criteria in terms of malalignment, knee motion, and associated symptoms. The study was carried out at the Dhaka medical college Hospital over a period of one and half year from September, 2016 to February, 2018. The total number of patients were 24. The mean age of the patients was 33.1±9.9 and the lowest and highest ages were 20-60 years respectively. Age of most (58%) of the patients were below 30 years. Three quarter of the patients (75%) were male and 37.5% were day labourer. Most of the patients (81%) were presented with right sided comminuted femoral shaft fracture. All of the injuries were closed type. In terms of type of fracture, AO type 32C2 were predominant (50%).AO type 32B3, 32C1,32C3 were 12.5%, 12.5% and 25%. Associated injury was found 6 patients that was 25% among 24 patients. Total duration of surgery &lt;90 minute was taken in 41.5% and &gt;90 minutes taken in 58.5% with mean deviation was 105 minutes and standard deviation was 19 minutes. 16 patients (67%) exhibited wide range of knee motion (&gt;120), four (17%) patients slightly restricted knee motion (110-120), two patients (8%) moderately restricted knee motion (90-110) and two patients (8%) extremely restricted knee motion (&lt;90). Evaluation of outcome by The Modified Thoresen’s criteria (1985) 6 months after intervention demonstrated that 29% of the patients had excellent outcome, 57% good outcome, 9.5% fair and 4.5% poor outcome. Assessment of Functional Outcomes of Femur Treatment Using Modified Thoresen’s Criter

The Effects of Unitizing Nail-Plate Constructs in Distal Femur Fractures: A Biomechanical Study.

To assess the biomechanical differences between linked and unlinked constructs in young and osteoporotic cadavers in addition to osteoporotic sawbones. Intraarticular distal femur fractures with comminuted metaphyseal regions were created in three young matched pair cadavers, three osteoporotic matched pair cadavers, and six osteoporotic sawbones. Precontoured distal femur locking plates were placed in addition to a standardized retrograde nail, with unitized constructs having one 4.5 mm locking screw placed distally through the nail. Nonunitized constructs had seven 4.5 mm locking screws placed through the plate around the nail, with one 5 mm distal interlock placed through the nail alone. Cadaveric specimens were subjected to axial fatigue loads between 150 and 1500 N (R Ratio = 10) with 1 Hx frequency for 10,000 cycles. Sawbones were axially loaded at 50% of the ultimate load for fatigue testing to achieve runout, with testing performed with 30 and 300 N (R Ratio = 10) loads with 1 Hz frequency for 10,000 cycles. In young cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (1.51 ± 0.62mm) compared to the non-unitized constructs (1.34 ± 0.47mm) (Figure 4A), (p = 0.722). In osteoporotic cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (2.46 ± 0.47mm) compared to the non-unitized constructs (2.91 ± 1.49mm) (p =0.639). There was statistically no significant difference in cyclic displacement between the unitized and non-unitized groups in osteoporotic sawbones(p = 0.181). Linked constructs did not demonstrate increased axial stiffness or decreased cyclical displacement in comparison to unlinked constructs in young cadaveric specimens, osteoporotic cadaveric specimens, or osteoporotic sawbones.

Advancing pediatric bone sarcoma care: navigating complications and innovating solutions in limb salvage and reconstruction-why, when, and how to treat limb length inequalities.

Pediatric bone sarcomas, particularly osteosarcomas, present unique challenges in the realm of orthopedic oncology, given their predilection for the metaphyseal regions of long bones and the intricate balance required between achieving oncologic control and preserving limb function. This abstract encapsulates findings from a comprehensive review aimed at advancing pediatric bone sarcoma care, focusing on navigating the complications and innovating solutions for complications of limb salvage and reconstruction focusing on limb length inequalities and accompanying bone defects. Advancements in imaging, surgical techniques, and adjuvant therapies have shifted the paradigm from amputation to limb-sparing surgeries, albeit with significant challenges, especially in young patients where growth potential complicates reconstructive outcomes. The series highlights the complexity of managing limb length discrepancies (LLD), the cornerstone of limb salvage challenges, and the innovative approaches to address them, including modular endoprosthetic reconstruction with expandable prostheses, magnetic lengthening nails and biological reconstruction strategies like vascularized fibula grafts. This review underlines the importance of a multidisciplinary approach in managing pediatric bone sarcomas, where the aim extends beyond mere survival to ensuring quality of life through functional limb preservation. It highlights the need for ongoing innovation in surgical and reconstructive techniques tailored to the pediatric population's unique needs, emphasizing the potential of emerging technologies and methodologies to improve outcomes. Future research should aim to fill the existing knowledge gaps, particularly in comparing pediatric and adult surgical outcomes, to refine treatment protocols and improve patient care in this challenging domain.

Aging decreases osteocyte peri-lacunar-canalicular system turnover in female C57BL/6JN mice

Osteocytes engage in bone resorption and mineralization surrounding their expansive lacunar-canalicular system (LCS) through peri-LCS turnover. However, fundamental questions persist about where, when, and how often osteocytes engage in peri-LCS turnover and how these processes change with aging. Furthermore, whether peri-LCS turnover is associated with natural variation in cortical tissue strain remains unexplored. To address these questions, we utilized confocal scanning microscopy, immunohistochemistry, and scanning electron microscopy to characterize osteocyte peri-LCS turnover in the cortical (mid-diaphysis) and cancellous (metaphysis) regions of femurs from young adult (5 mo) and early-old-age (22 mo) female C57BL/6JN mice. LCS bone mineralization was measured by the presence of perilacunar fluorochrome labels. LCS bone resorption was measured by immunohistochemical marker of bone resorption. The dynamics of peri-LCS turnover were estimated from serial fluorochrome labeling, where each mouse was administered two labels between 2 and 16 days before euthanasia. Osteocyte participation in mineralizing their surroundings is highly abundant in both cortical and cancellous bone of young adult mice but significantly decreases with aging. LCS bone resorption also decreases with aging. Aging has a greater impact on peri-LCS turnover dynamics in cancellous bone than in cortical bone. Lacunae with recent peri-LCS turnover are larger in both age groups. While peri-LCS turnover is associated with variation in tissue strain between cortical quadrants and intracortical location for 22 mo mice, these associations were not seen for 5 mo mice. The impact of aging on decreasing peri-LCS turnover may have significant implications for bone quality and mechanosensation.

Metaphyseal trauma of the lower extremities in major orthopedic surgery as an independent risk factor for deep vein thrombosis

PurposeMajor orthopedic surgeries of the lower extremities, which heavily injure the metaphyseal region, are strongly associated with the risk of developing deep vein thrombosis (DVT). This study aims to investigate the role of metaphyseal trauma as an independent risk factor for DVT.MethodsPatients undergoing major orthopedic surgery of the hip and knee had their existing DVT risk factors recorded. Metaphyseal trauma was defined by the extent of bone injury during these surgeries. The samples were categorized into three surgery groups: total arthroplasty group (TA), hemiarthroplasty group (HA), and the open reduction internal fixation group (ORIF). Logistic regression test between significant existing risk factors and surgery groups determines the independent association between risk factors and DVT.ResultThe study found a 24.8% incidence of asymptomatic DVT in patients undergoing major orthopedic surgeries, with the highest prevalence (37.2%) in TA, which had the largest extent of metaphyseal trauma and the least existing DVT risk factors. TA showed 6.2 OR and 95% CI (p = 0.036) compared to the other existing risk factor in relation to DVT incidence.ConclusionMetaphyseal bone trauma in the hip and knee major orthopedic surgery is an independent risk factor for deep vein thrombosis.

Immunohistochemical and Morphometric Assessment on the Biological Function and Vascular Endothelial Cells in the Initial Process of Cortical Porosity in Mice With PTH Administration.

To clarify the cellular mechanism of cortical porosity induced by intermittent parathyroid hormone (PTH) administration, we examined the femoral cortical bone of mice that received 40 µg/kg/day (four times a day) human PTH (hPTH) (1-34). The PTH-driven cortical porosity initiated from the metaphyseal region and chronologically expanded toward the diaphysis. Alkaline phosphatase (ALP)-positive osteoblasts in the control mice covered the cortical surface, and endomucin-positive blood vessels were distant from these osteoblasts. In PTH-administered mice, endomucin-reactive blood vessels with TRAP-positive penetrated the ALP-positive osteoblast layer, invading the cortical bone. Statistically, the distance between endomucin-positive blood vessels and the cortical bone surface abated after PTH administration. Transmission electron microscopic observation demonstrated that vascular endothelial cells often pass through the flattened osteoblast layer and accompanied osteoclasts in the deep region of the cortical bone. The cell layers covering mature osteoblasts thickened with PTH administration and exhibited ALP, α-smooth muscle actin (αSMA), vascular cell adhesion molecule-1 (VCAM1), and receptor activator of NF-κB ligand (RANKL). Within these cell layers, osteoclasts were found near endomucin-reactive blood vessels. In PTH-administered femora, osteocytes secreted Dkk1, a Wnt inhibitor that affects angiogenesis, and blood vessels exhibited plasmalemma vesicle-associated protein, an angiogenic molecule. In summary, endomucin-positive blood vessels, when accompanied by osteoclasts in the ALP/αSMA/VCAM1/RANKL-reactive osteoblastic cell layers, invade the cortical bone, potentially due to the action of osteocyte-derived molecules such as DKK1.

Variability of the proximal phalanx in warmblood and coldblood horses – morphological and structural analyses

Anatomical shape as well as bone geometry are important factors for the mechanical properties of stiffness and strength in bones. In the light of this statement, the primary aim of the study was to evaluate the variable forms of the proximal phalanx in different types of horses. Multivariate analyses of data from 81 horses revealed that the proximal phalanx has diverse spatial forms. Differences were observed particularly in the length of the bone and the breadth of its diaphysis. In horses with lighter morphotype, the phalanx is significantly narrower in its middle section. In the second stage of the study, geometrical parameters of the phalanx were analysed with the use of peripheral quantitative computed tomography (pQCT). Tomographic analysis was conducted at three levels: at 15%, 50% and 85% of the bone length. Based on the analysis, we concluded that most of the geometric parameters have higher values in coldbloods but only at the mid-diaphysis (50%) and at 85% of the bone length. Moreover, in coldblood horses, higher strength of the phalanx at these levels, expressed by Strength Strain Index, was observed. We did not observe any significant differences between warmblood and coldblood horses in the metaphyseal proximal region which is located at 15 % of the bone length.

Comparison of exposure of the radius afforded by the craniomedial and craniolateral open surgical approaches in dog cadavers.

Management of antebrachial fractures in dogs typically involves open reduction and bone plate stabilisation of the radius performed using either a craniomedial approach (CMA) or craniolateral approach (CLA). The aim of this cadaveric study was to compare radial exposure afforded via the craniomedial and craniolateral approaches, without and with releasing the abductor digiti I longus (ADIL) muscle. The CMA and CLA were performed on alternate paired cadaver forelimbs with the subsequent release (CMA) or elevation (CLA) of the ADIL muscle (n = 12). The percent area of exposure was calculated in defined longitudinal radial segments (LRSs) and hemi-circumferential radial segments (HRSs) using digitally uploaded images. A non-parametric rank sum test was used for statistical analysis (p < 0.05). While both the CMA and CLA provided sufficient exposure for radial cranial plate placement in the mid-to-distal diaphyseal region (50-80% LRSs), the CMA afforded greater exposure to the distal metaphysis (80-90% LRS). The CLA was advantageous in exposing the proximal diaphysis (20-50% LRSs) and distal epiphysis (90-100% LRS). Exposure of the distal diaphyseal, metaphyseal, and epiphyseal regions (80-100% LRSs) was impeded by the ADIL muscle. A tenotomy of the tendon of insertion of the ADIL muscle increased exposure afforded by the CMA in the distal metaphyseal and epiphyseal regions. The exposure afforded by the CLA in the distal diaphyseal and metaphyseal regions was significantly improved by elevating the origin of the ADIL muscle. The results of this study provide useful clinical information when surgeons are deciding which approach to use for cranial radial plating.

Pubic Tubercle Osteochondroma

Background: The commonest benign bone tumors, osteochondromas, which can be solitary or multiple involving the metaphyseal region of long bones, rarely present in the axial skeleton, such as pelvic girdle, which warrants surgical excision in case of symptoms arising out of pressure effects.&#x0D; Case Report: In this study, we are herewith reporting an unusual case of pubic tubercle osteochondroma, which is solitary and pedunculated in a 37-year-old woman. She has had the swelling for the past 15 years, which was asymptomatic except for mild hydroureteronephrosis, which was an incidental diagnosis; however, we managed the patient with surgical excision of the tumor with elaborate preoperative radiological imaging using both X-ray and computed tomography (CT) scan. Histopathological examination confirmed the diagnosis of osteochondroma.&#x0D; Conclusion: Asymptomatic pelvic osteochondroma should be considered in patients with incidental swelling in the groin region, especially women who may be reluctant to seek medical attention due to social stigma.

Diagnosis and Current Treatment of Aneurysmal Bone Cysts.

The purpose of this review is to increase awareness about the evolution and development of current trends in the diagnosis and treatment of aneurysmal bone cysts (ABCs). ABCs are benign, but locally aggressive bone tumors that mainly affect children. ABCs comprise 1% of all primary bone tumors and occur most frequently during the first two decades of life. The diagnosis is made using a variety of imaging modalities and has the characteristic features of an expansile, radiolucent lesion that is often seen in the metaphyseal region of the bone and has fluid-fluid levels that are apparent on MRI. In the pediatric population, telangiectatic osteosarcoma and unicameral bone cyst (UBC) are the main differential diagnoses of an ABC. Giant cell tumors (GCTs) also include in differential diagnosis, which often manifest in patients older than 15 and do not penetrate the open physis although they develop after the physeal closure. Imaging alone cannot rule out telangiectatic osteosarcoma; therefore, a biopsy is recommended. A variety of treatment options have been described; traditionally, most patients are treated with curettage and bone grafting. Curettage alone, however, usually results in tumor recurrence following excision. A variety of adjuvants have been utilized with varying degrees of effectiveness to reduce the risk of local recurrence. When a cyst is in the pelvis, its location and size are such that surgery is a very risky option. Selective arterial embolization has significantly contributed to the development of effective treatments for these situations. Embolization or radiation, as well as denosumab therapy, are widely used as therapies for ABCs in anatomic locations where surgery would significantly increase morbidity.

Contribution of fracture healing in paediatric DMP zone fracture patients using the pry lever technique.

This study describes the efficacy of applying the prying lever technique to distal radial metaphyseal symphysis diaphysis joining region (DMP) fractures in children, and reports that the technique has an ameliorative effect on the phenomenon of delayed healing and non-union that occurs after surgery for fractures in the DMP region. The medical records of 72 children with fractures in the DMP region, treated between December 2017 and December 2023, were retrospectively analyzed. The patients were randomly assigned to either the cut-and-displace group (n = 36) or the pry-and-lever group (n = 36). Both groups were monitored for time to fracture healing, incidence of delayed or non-union, radiologic outcomes, complications, and functional assessments using the EQ-5D, DASH, and VAS scales. The follow-up period ranged from 3 to 5 years, with a mean of 26.5 months. After 6 months of follow-up, the incidence of delayed/non-union of fractures was 2.7% and 16.6% in the study and control groups, respectively, and the incidence of delayed healing was significant (P < 0.05) in both groups. Additional manipulations or complications caused by delayed healing or non-union were also significantly less in the study group than in the control group. The EQ-5D scale was used to compare the level of surgical satisfaction between the two groups, and the study group had a higher level of satisfaction. Carpal function was significantly improved in both groups compared to the preoperative period, scored using the DASH scale (P > 0.05). Postoperative pain level was scored using VAS (P < 0.05). The prying lever technique has the advantages of low impact on periosteal blood supply, simple operation, and fast recovery, which makes it a worthwhile attempt of minimally invasive reduction of fractures in the DMP region in children.

Non-ossifying fibroma of distal tibia: case report

Non-ossifying fibroma is a benign fibrohistiocytic lesion most commonly seen in the metaphyseal region in children. It usually doesn’t present with any symptoms. As the bone grows and undergoes remodeling, the lesion tends to vanish and get substituted with healthy bone. Nonetheless, the lesion can debilitate the affected bone, leading to a potential fracture. Here, we report a case of non-ossifying fibroma in the metaphyseal region of the tibia in a 13-year female. The patient presented with complaints of pain in the left leg for 5 months and underwent radiological investigation showing a well-defined, multi-loculated, expansile, radiolucent, lytic lesion with a thin sclerotic margin in the meta-diaphyseal region of the distal tibia, for which extended bone curettage with bone grafting was performed. The sample was sent for histopathological examination, which showed bony trabeculae with bits of tumor composed of spindle cells with elongated nuclei and scant cytoplasm, arranged in a storiform pattern along with many scattered multinucleate giant cells and foamy histiocytes suggestive of non-ossifying fibroma. Post operatively, non-weight bearing mobilization was advised for 4 weeks. Most non-ossifying fibromas were diagnosed in childhood to late adolescence, found incidentally, and clinically asymptomatic. Most distal tibial non-ossifying fibromas (NOFs) tend to transpire at a specific anatomical site located at the far end of the interosseous membrane. The prognosis for NOFs is typically excellent with a low risk of recurrence.

Fixed and Relative Positioning of Scans for High Resolution Peripheral Quantitative Computed Tomography

Introduction: High resolution peripheral quantitative computed tomography (HR-pQCT) imaging protocol requires defining where to position the ∼1 cm thick scan along the bone length. Discrepancies between the use of two positioning methods, the relative and fixed offset, may be problematic in the comparison between studies and participants. This study investigated how bone landmarks scale linearly with length and how this scaling affects both positioning methods aimed at providing a consistent anatomical location for scan acquisition.Methods: Using CT images of the radius (N = 25) and tibia (N = 42), 10 anatomical landmarks were selected along the bone length. The location of these landmarks was converted to a percent length along the bone, and the variation in their location was evaluated across the dataset. The absolute location of the HR-pQCT scan position using both offset methods was identified for all bones and converted to a percent length position relative to the HR-pQCT reference line for comparison. A secondary analysis of the location of the scan region specifically within the metaphysis was explored at the tibia.Results: The location of landmarks deviated from a linear relationship across the dataset, with a range of 3.6 % at the radius sites, and 4.5 % at the tibia sites. The consequent variation of the position of the scan at the radius was 0.6 % and 0.3 %, and at the tibia 2.4 % and 0.5 %, for the fixed and relative offset, respectively. The position of the metaphyseal junction with the epiphysis relative to the scan position was poorly correlated to bone length, with R2 = 0.06 and 0.37, for the fixed and relative offset respectively.Conclusion: The variation of the scan position by either method is negated by the intrinsic variation of the bone anatomy with respect both to total bone length as well as the metaphyseal region. Therefore, there is no clear benefit of either offset method. However, the lack of difference due to the inherent variation in the underlying anatomy implies that it is reasonable to compare studies even if they are using different positioning methods.

SOLITARY DIAPHYSEAL OSTEOCHONDROMA OF DISTAL FEMUR - A CASE REPORT

Osteochondromas are among the most common benign bone tumours with a male predilection which are usually incidentally detected. They are usually found in the metaphyseal region of long bones.This case is reported in view of the unique origin of the tumour in the diaphyseal region in a female. A woman came to the outpatient department with complaints of a painless, non mobile swelling over left distal femur for past 4 years.The swelling initially small gradually increased in size over 4 years but was not associated with pain or restriction of movements. Clinical examination revealed bony hard swelling in the anteromedial aspect of left distal femur not involving the knee joint. X ray showed a cauliflower shaped, pedunculated bony mass arising from the diaphyseal region of distal femur. MRI done was suggestive of osteochondroma. In order to confirm the diagnosis and to rule out malignant transformation,surgical excision and biopsy of the bony mass was performed. Histopathological reports confirmed the diagnosis of osteochondroma.

Case Report: Effectiveness of physiotherapy rehabilitation in a patient with compound grade IIIC proximal third tibia fracture along with vascular injury

The proximal metaphyseal region of the bone is thought to be the location of fractures of the proximal tibia. The surgical management of proximal tibial shaft fractures and high-energy bicondylar tibial plateau fractures is still challenging . Supra-cutaneous plating, also known as a locking compression plate, has been promoted as a crucial technique in the management of challenging reconstructive scenarios since it has shown to be adjustable, concealed, and well-accepted by patients. Physical therapy rehabilitation is critically necessary for a full recovery from a range of orthopaedic issues. Physical therapy rehabilitation is a vital step in the healing process for patients with lower limb fractures. In our study , we rehabilitated a patient with Compound grade IIIC proximal third tibia fracture right side managed with Closed reduction external fixator application and vascular repair along with proximal fibula fracture. Through this study, we developed a physiotherapy rehabilitation protocol that was very helpful for these patients, produced positive results, and served to enhance the patient's quality of life.

A rare case of acute osteomyelitis in a 13-year-old with physeal involvement

Osteomyelitis of epiphyses in adolescents is a rare finding. We evaluate one such case in which high degree of clinical suspicion and prompt surgical intervention yielded good functional results. This is a case report of 13-year-old girl diagnosed with osteomyelitis of right knee. MRI is suggestive of physeal involvement. Physeal involvement makes the management very challenging. Surgical intervention was planned to reduce bacterial load and minimize possibility of damage to knee joint (articular cartilage and joint capsule). Lateral and posterior compartment of leg was decompressed, fibular osteotomy done, drilling in tibial epiphyseal and metaphyseal region of tibia done avoiding any injury to growth plate. Pus for culture and sensitivity and specific antibiotics started with monitoring of blood parameters for infection like ESR, CRP, TLC. Patient taken up for second debridement after one week of index surgery. After 6 weeks of intravenous antibiotic patient discharged in afebrile state with reduced values of blood parameters and acceptable range of knee movement. Lower extremity functional scoring (LEFS) of 45/80 i. e., 56.83 % at the end of 4 months. Good functional outcome at the end of 1 year. Early clinical suspicion with prompt investigation, surgical and medical management gives promising result.