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This simulation study on MRI of the knee was performed to assess the risk of injury to the popliteal artery (PA) and common peroneal nerve (CPN) during all-inside meniscal repairs in adults.We simulated repair of the posterior horn of both medial (PHMM) and lateral menisci (PHLM) through anteromedial (AM) and anterolateral (AL) portals, using straight and curved devices, on 200 magnetic resonance imaging (MRI) scans taken with the knee in extension. For simulation using straight devices, the shortest distance from the menisco-capsular junction (MCJ) and the free edge of the meniscus to PA and CPN in vectors of AM and AL portals was measured. In curved devices, the closest extracapsular distance from the device tip to PA was measured.With a straight device through AM portal, the mean distance from the MCJ of PHMM to the PA was 20.7 ± 3.15 mm (13.5-27.4). In PHMM repair through AM portal using a curved device, the mean extracapsular distance from the device tip to PA was 18.8 ± 4 mm (7.7-27.2) while pointing toward and 26 ± 4.5 mm (15.5-35.6) while pointing away from the midline. When using straight devices, the average distance from free edge of LM to PA was 18.5 ± 3.3 mm (9.6-31.2) and from MCJ to PA was 8.9 ± 2.4 mm (3.5-18.8). The average distance measured from the MCJ to CPN through AM and AL portals using straight devices was 19.4 ± 2.8 mm (10.2-32.5) and 22 ± 2.8 mm (10.4-36.7) respectively.In adults, PA is safe in PHMM repairs using both straight and curved devices irrespective of depth and direction of insertion. In PHLM repairs, the PA is at risk with both straight and curved devices. We recommend adjusting the depth of insertion to as minimum as possible to just penetrate the capsule. The CPN is safe in LM repairs using all-inside devices.Level IV.

Hyperostosis of the ischiopubic synchondrosis, van Neck disease, is a rare skeletal abnormality in children. Asymmetric and delayed closure of this cartilaginous joint is considered as a normal phenomenon. The symptomatic presentation of this pathology often mimics other closely related conditions like stress fracture, infection, or tumor. We are presenting a case of van Neck disease in the nondominant limb of an eleven-year-old boy.

A 15 years old boy presented with an atypical osteoid osteoma (OO) in distal femur. He underwent radiofrequency ablation (RFA) elsewhere. He presented to our centre a year later with persisting pain. MR scan showed incomplete ablation of the nidus as there was only a single pass of the RF probe for a 14 mm long linear lesion. We also found penumbra sign and wall enhancement on contrast MRI suggestive of a Brodie’s abscess (BA). Under CT guidance the OO was drilled and BA was saucerised. Following this he was treated with culture sensitive antibiotics and his symptoms resolved. BA and OO are common differential diagnoses. RFA of OO leading to BA has not been reported in literature. Atypical linear OO requires multiple probe placements to ablate the long nidus. Diligent care should be taken to avoid intraoperative contamination in CT room which could lead to infection.

Background Recreation of the normal proximal femoral anatomy is paramount for a successful total hip arthroplasty. The study aims to look at whether the range of offset options available in the femoral stems available locally, would be adequate to restore the native femoral horizontal offset (FHO) of the South Indian population. Method This is a prospective single-center study of 1-year duration, where we study the FHO on radiographs and CT scans in 100 patients. We then look at the femoral stems available in the Indian market and see if the offset may be restored with the available stems. Result The FHO ranged from 23.3 to 46.9 mm with a mean of 35.7 ± 5.3 mm. The females in the group (33.86 ± 4.71 mm) had a lower FHO compared to males (37.78 ± 5. 21 mm). We found that 50% of the South Indian population and 62% of the females have an offset less than 35 mm. Among the 18 stems that we studied, four out of nine cemented and two out of nine uncemented stems did not offer an offset below 35 mm. Conclusion The native FHO in the South Indian population is significantly less than that of Caucasians. The surgeon should be aware that many implant systems available in India do not offer offset options in this range. In this group, even when a stem with smallest offset is used, there is a risk of increasing the FHO with a potential for intraoperative fractures due to difficult reduction and leg-lengthening. Hence, the surgeon should template carefully and choose only those implant systems which can offer an offset similar to the native offset to restore the anatomy accurately. We recommend that all manufacturers consider offering implants with smaller offset (25–35 mm).

Case We report a patient with a long-standing post-traumatic pubic diastasis along with acetabular nonunion who developed painful hip arthritis that needed a total hip arthroplasty. We discuss the unique challenges in the acetabular component positioning. Conclusion In patients with symphysis pubis diastasis, the surgeon should be prepared to place the cup in less than normal anteversion. This relative retroversion, which is an unusual position, is due to the external rotation of the whole hemipelvis including the femur. The degree of version of the cup should be guided by intraoperative stability checks and to ensure an impingement free range of motion.

Juvenile recurrent parotitis (JRP) is defined as recurrent inflammatory parotitis in children of unknown etiology. It is described as recurrent parotid inflammation, usually associated with non-obstructive sialectasis of peripheral ducts of the parotids with periductal lymphocytic infiltration of the parotid gland. It is characterized by multiple episodes of parotid swelling and/or pain associated with fever or malaise over a period of years. Symptoms resolve spontaneously after puberty. All children with recurrent parotitis should be screened to exclude Sjögren's syndrome, lymphoma, and immunodeficiency including human immunodeficiency virus. We present the case of a 4-year-old boy who had four episodes of recurrent parotid swelling over a period of 6 months.

A 15-year-old boy presented with insidious onset bilateral thigh pain for 6 months. Examination of hips showed restricted internal rotation. Pelvis radiograph (figure 1) showed bilateral slipped capital femoral epiphysis (SCFE) with subchondral bone resorption in right inferior pubic rami and ilium . Hand radiograph (figure 2) showed subperiosteal bone resorption along the radial aspect of middle phalanges. Figure 1 Anteroposterior view of pelvis shows whole epiphysis lying inferior to the line (Klein’s line) suggestive of SCFE. In normal hip, one-third of physis should be above the line. Subperiosteal resorption along the ilium (black arrow) …

Background Primary hemochromatosis is unusual in India. The homeostatic iron regulator (HFE) gene C282Y mutation, a common cause for hemochromatosis in Europe, is considered almost nonexistent in India. We are reporting a case of hemochromatosis with the HFE gene C282Y mutation and two other adult cases with a novel hemojuvelin (HJV) mutation from Kerala. Methods Of 434 cases with chronic liver disease, 3 cases were identified with the serum ferritin level of more than 1000 ng/mL and primary hemochromatosis after excluding secondary causes. Whole exome sequencing, including genes HFE, HJV, SLC40A1, TFR2, FTH1, HAMP, SKIV2L, TTC37, and BMP2, was performed for blood samples in all 3 cases. Results One patient with hemochromatosis had a homozygous HFE gene C282Y mutation, and two other adult cases had a novel homozygous HJV D355Y mutation. This is the first report of hemochromatosis associated with the HFE C282Y mutation from Kerala and the second report in India. This is the second report of hemochromatosis associated with an HJV mutation from India. Conclusion HJV mutations may explain some of the adult onset primary hemochromatosis in India.

Introduction Mucormycosis is a rare opportunistic invasive fungal infection. The most commonly reported form of the disease is rhinocerebral mucormycosis. Early diagnosis of the disease and aggressive medical and surgical intervention prevent the high morbidity and mortality associated with mucormycosis. Case report A 54-year-old diabetic and hypertensive male presented with severe frontal headache and retro-orbital pain of 4 days duration with high-grade fever. On examination, the patient was conscious and oriented with a blood pressure of 210/100 mm Hg. The pupils were anisocoric. Frontal sinus tenderness was present. Anterior rhinoscopy showed deviation of nasal septum to left without edema and nasal mucosal congestion. Eye examination revealed normal vision without any periorbital swelling and normal fundus. Plain axial computed tomography showed soft-tissue density material in sphenoid sinus with focal hyperdense component anteriorly. Cerebrospinal fluid study was negative for meningitis with a normal cerebrospinal fluid pressure. Axial T1-weighted image showed T1 intermediate to high signal soft tissue occluding the sphenoid sinus. Axial T2-weighted image showed T2 high signal soft tissue occluding the sphenoid sinus. Similar signal tissue was seen in the middle and posterior ethmoid air cells on both sides. Axial and coronal postcontrast T1-weighted fat-saturated images showed heterogeneously enhancing soft tissue in sphenoid and ethmoid sinuses. The patient underwent functional endoscopic sinus surgery and tissue sampling, following which antifungal therapy with posaconazole was initiated since biopsy from sinus mucosa was consistent with mucormycosis. The patient responded well to functional endoscopic sinus surgical evacuation of the fungal debris and posaconazole and is doing well on follow-up. Conclusion This report highlights the possibility of occurrence of this rapidly fatal condition even with normal-looking nasal mucosa. High index of suspicion is required to prevent the complications as the course of the disease is very rapid. This case report emphasizes the fact that posaconazole is the only available oral antifungal that can be used as a first-line agent in the management of mucormycosis, even in immunocompromised individuals. How to cite this article Jalal MJA, Fernandez SJ, Thomas RM, Kandathil JC, Menon MK, Kuruttukulam G. Posaconazole: An Only Oral First-line Antifungal for Rhinocerebral Mucormycosis. Clin Rhinol An Int J 2016;9(1):46-49.

Tuberculosis of the central nervous system accounts for approximately 1% of all cases of tuberculosis and 50% of these involve the spine. Intramedullary involvement is rare in tuberculosis. Clinical presentation of spinal intramedullary tuberculosis (SIMT) is similar to intramedullary spinal cord tumor. Here, we report the case of a 49-year-old female with dull aching pain of both upper limbs of 1-week duration. On examination, she had no motor deficits. All the deep tendon reflexes were normal. The plantar responses were flexor bilaterally. Cervical spine imaging favored intramedullary tumor. She had partial relief of symptoms with steroid treatment. Repeat imaging done 1 month later revealed mild interval enlargement of the intramedullary lesions and multiple enlarged mediastinal and hilar nodes. Endoscopic ultrasound-guided fine-needle aspiration cytology of mediastinal nodes was suggestive of granulomatous inflammation. Hence, SIMT was considered as the probable diagnosis. The patient was started on antituberculosis therapy.