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Editorial Bone tumour management : a success story

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he history of cancer therapy is a long and arduous story of human effort in the face of death. Valiant patients and relentless and at times remorseless physicians have together charted this journey through mostly uncharted territory and have shown oncologists of the present time roads which lead to benefit. In some instances, this foray has resulted in unprecedented success, much to the relief of the scientific community. The treatment of skeletal malignancies, especially primary bone tumours reflects one such story in medical science. The management of malignant bone and soft tissue tumours was, until the middle of the 20th century, a very discouraging area. Benign tumours were managed well without major problems aside from a high local recurrence rate for tumours such as giant cell tumour or osteoblastoma. The malignant tumours such as Ewings sarcoma or osteosarcoma had very high local recurrence, metastasis and death rates. The great changes that occurred arose principally because of the use of chemotherapeutic agents, better radiotherapy techniques and improved imaging technology. In 1973, Norman Jaffe and coworkers introduced high-dose methotrexate with leukovorin rescue for the treatment osteosarcoma. At almost the same time, Cortes and Holland and others reported the effect of doxorubicin on osteosarcoma and found that they could bring the survival rate to greater than 40%. Cis-platinum was introduced in 1979 by Baum and shortly thereafter, Marti introduced ifosfamide, thus establishing the four principal players in the chemotherapeutic regimen for this and other malignant connective tissue neoplasms. In the 1970s Rosen introduced the concept of neoadjuvant therapy, which allowed the treating physicians to assess the impact of the drugs chosen on the tumour prior to resective surgery, and thus allow possible changes in protocol. This improved the cure rates further and also made limb sparing resective surgery considerably safer. These drugs and the neoadjuvant approach have shifted the curve for all the high grade tumours such that the average long term survival rate for osteosarcoma and other tumours is as much as 50% to 60%. These scientific advancements need to be put into perspective of the real world situation of these patients. There was a time when oncologists used to dread seeing patients with bone tumors, especially osteosarcomas. The patients were usually children or young adults with their entire lives before them who faced the prospect of losing an entire limb, and, more importantly, their future due to mutilating surgeries. Despite such tremendously brave decisions, most of these patients subsequently went on to develop metastatic disease and subsequently succumbed to the tumours, death usually being from respiratory failure arising from lung metastases. The more than seven-fold improvement in outcome for these patients is a blessing that has transformed lives of both the patients as well as oncologists treating the disease! The spectre of loss of limb remained a major drawback for bone tumour therapy. With the neoadjuvant and adjuvant radiation and chemotherapy and improved surgical technology, orthopaedicians developed a series of systems for surgical eradication of the lesions and replacement with autograft, allograft, plastic materials and metallic implants. These systems are in many cases quite successful in maintaining a functional limb and have greatly decreased the disability of the affected patients and allowed the patient to maintain a functional limb. To put things in a different perspective, the history of therapy for bone and soft tissue sarcomas provides an excellent example of how multidisciplinary approach and interdisciplinary exchange of pertinent information can help improve outcomes in cancer. In early days, virtually everyone with high grade sarcomas succumbed and if they had a surgical solution to their problem, it was an amputation. Over the decades that followed these dreadful early days, the pathologists contributed knowledge about the tumours and identified their features and the radiologists their cardinal findings on radiological imaging. The medical oncologists provided drugs in adjuvant and neoadjuvant protocols and the radiation oncologists offered better means of safely radiating the lesional area, both of 770


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which vastly enhanced the patients survival rate. The orthopaedician provided a means of staging the patient and developing a protocol for assessing the patients degree of disease and stage and at least in part predicting the outcome. In addition based on the modern technology of surgery and the information gained as a result of the staging studies, the treating team developed protocols for the resection of the bone and soft tissue tumours which were safe and caused the least damage to adjacent muscular, vascular and neurological structures. Finally the orthopaedicians and their engineering and tissue banking colleagues developed methods of safely and functionally replacing a part of the skeleton after resection of the tumours.

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The paucity of success stories in the specialty of oncology makes this one special. This success story has inspired a generation of oncologists to formulate similar systematic approaches in other cancers. One can only hope that one day this success story will be one of the many such stories in oncology. Professor and Head of the Department SUBIR GANGULY1 of Radiotherapy, RG Kar Medical College AMITABH RAY2 and Hospital, Kolkata 700004 and Hony Editor, JIMA, Kolkata 700014 2 Assistant Professor, NRS Medical College and Hospital, Kolkata 700014 1

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Disclaimer

JIMA assumes no responsibility for the authenticity or reliability of any product, equipment, gadget or any claim by medical establishments/institutions/manufacturers or any training programme in the form of advertisements appearing in JIMA and also does not endorse or give any guarantee to such products or training programme or promote any such thing or claims made so after. Hony Editor

Editorial Orthopaedic surgery advancement in modern era Medical science is an observed science and thats why it is ever changing rapidly, what we learn today might not be appropiate tomorrow. To stay updated, publication of research papers and information of latest technoloPROF BIPLAB gies and gadgets in standard journals are necessary as well as everyone DR KIRAN KUMAR ACHARYYA should have a habit of going through the same regularly. MUKHOPADHYAY MS (Orth), For proper development of orthopaedic surgery in our country, the socioMS (Orth), Joint Guest Editor Joint Guest Editor economical condition is to be considered and application is to be done accordingly, keeping in mind the progress of medical science. Medical Council of India, Indian Orthopaedic Association, orthopaedic association of all states, universities, Government of India, all state governments, senior teachers and senior orthopaedic surgeons should come to the forefront for proper development of orthopaedic surgery for better management of the patients in our country. For this orthopaedic surgery should be a complete separate discipline in the MBBS curriculum and not to be kept as a part of general surgery. Medical Council of India should consider the curriculum and syllabus with proper training programme for the PG course. There is an uneven development of medical colleges in our country. After consultation with the Indian Orthopaedic Association and orthopaedic associations of states, Government of India should take proper policy decision for the benefit of orthopaedic surgery in our country as early as possible. For updating knowledge with hightech skill in orthopaedic surgery the teachers and orthopaedic surgeons should be trained in proper training and research centres in the government and private institutions. Proper understanding of mechanical and biological aspect of fracture healing is necessary for management of fracture. Understanding of pathogenesis of diseases is also necessary for its management. Biological fixation in fracture a new philosophy is coming out which is to be taken for consideration. In this issue, wide range of interesting topics has been included. Even with a dramatic advancement of medical science, also in the field of orthopaedic surgery in recent years, fracture neck femur still remains an unsolved problem. Valgus ostetomy may be an effective alternative to manage fracture neck femur particularly in younger patients. Primary total hip arthroplasty in proximal femoral deficiency is another difficult and challenging area to arthroplasty surgeons also which had been dealt in this issue very nicely. The advancement in the field of spine surgery is remarkable in recent years which includes trauma, deformity, degenerative diseases and so on.Cervical spine trauma is an area of major concern in this part of world. A study on operative management of cervical spine trauma has been discussed in this issue which would be helpful to orthopaedic surgeons. Like spine surgery, there is recent advance in arthroscopic surgery which can be used in other various joint surgeries. Anterior cruciate ligament reconstruction still remains on the top of arthroscopic surgery and the results are very encouraging. Difficult areas of trauma surgery have been covered, particularly high energy femoral trauma ,locking plate fixation in volar Barton's fracture which usually requires a rigid fixation, tendo-achilles injury which is not so uncommon in our country, osteomyelitis of calcaneum which is a little bit difficult to manage had been well represented in this issue. Monteggia fracture in children which is very often missed and creates a problem in management later on and relatively common but not so much discussed topic like peri-arthritis shoulder has also been discussed in this issue. We hope that this issue will be attractive, useful and interesting to everybody. Department of Orthopaedics, NRS Medical College and Hospital, Kolkata 700014 and Joint Guest Editor, JIMA, Kolkata 700014 1 Professor and Head of the Department 2 Associate Professor

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Originals and Papers Transportal versus transtibial drilling technique of creating femoral tunnel in arthroscopic anterior cruciate ligament reconstruction using hamstring tendon autograft Ananda Mandal1, Ranjit Kumar Shaw1, Debasis Biswas2, Anindya Basu2 Drilling of femoral tunnel by transtibial technique is widely used in arthroscopic anterior cruciate ligament (ACL) reconstruction. Recent studies suggest in this technique graft is placed in non-anatomical position leading to instability. If the femoral tunnel is drilled through an anteromedial portal (transportal technique), graft can be placed more anatomically leading to better knee stability theoratically. The purpose of this study is to compare the clinical outcome of transtibial technique and transportal technique for drilling of femoral tunnel in arthroscopic ACL reconstruction using hamstring tendon autograft. All patients operated between January 2009 and September 2011 were approached for eligibility. Blinded assessment of IKDC score, Lachman test, pivot shift test, time of recovery from surgery were obtained from both the transtibial and transportal groups. The transportal group shows significantly better IKDC score, higher anteroposterior knee stability by Lachman test and lower recovery time from surgery. [J Indian Med Assoc 2012; 110: 773-5]

Key words : Arthroscopic ACL reconstruction, trastibial, transportal, hamstring graft.

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n arthroscopic ACL reconstruction drilling of femoral tunnel by transtibial technique is widely used. But studies1,2 suggest that in this technique the position of femoral tunnel is directed by the tibial tunnel, so placement of the graft becomes anterior to native ACL and more vertical which may lead to instability. The technique of drilling the femoral tunnel by an anteromedial portal was suggested to place the graft in anatomical position3. Another aspect of arthroscpic ACL reconstruction is the choice of graft. Use of hamstring tendon autograft (preferably semitendinosus) reduces the morbidity compared to the use of patellar bone-tendon-bone graft. Better outcome has been found with transportal technique compared to transtibial technique using single bundle patellar-bone-tendon-bone graft4. The purpose of this study is to compare the clinical outcome of ACL reconstruction by transportal technique and transtibial technique using hamstring tendon autograft. MATERIAL AND METHOD This was an observational cross -sectional study. ACL reconstruction was done between January 2009 and September 2011. All patients were operated arthroscopically and surgical technique was differred only by the method Department of Orthopaedics, RG Kar Medical College, Kolkata 700004 1 MS (Orth), Assistant Professor 2 MBBS, Postgraduate Trainee Accepted November 1, 2012 773

of drilling the femoral tunnel. Previously transtibial technique was used for drilling of the femoral tunnel. From March 2010 transportal technique was adopted. After that all patients were operated by transportal ie, anteromedial portal (AMP) technique. Eligible patients were appointed for single follow-up visit in which subjective and objective clinical and functional outcome were assessed. Pre-operative and postoperative data were taken from medical records. Informed consent was taken from all the patients. Inclusion criteria were : (1) Young active patients between 16 and 39 years. (2) Patients with unilateral, isolated, primary ACL tear whose arthroscopic reconstruction was done using autologous hamstring tendon graft. (3) Patients should having healthy contralateral knee. Inclusion criteria was strictly applied to minimise the confounding. Surgical techniques : In all patients surgery was done in supine positon after spinal or epidural anesthesia. Standard one incision arthroscopic reconstruction procedure with autologous hamstring graft was used in all patients. In transtibial technique knee was flexed to 90o. For drilling of ideal tibial tunnel entry point of the guide pin should be 1 cm proximal to pes anserinus and 1.5 cm medial to tibial tuberosity5. Guide pin was advanced with the help of a tibial guide frame. Tibial guide frame was set at an angle 50o in sagittal plane and 20o in frontal plane. The intra-articular reference point should be 7mm anterior to posterior cruciate ligament (PCL) and 2-3mm anterior to

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the peak of medial tibial spine, just posterior to ACL footprint5. Guide pin was overdrilled incrementally with cannulated reamer up to 9mm diameter depending on the graft size. A standard femoral jig with 7mm offset was placed through the tibial tunnel at a desirable position.The guide pin was advanced into the femoral ACL footprint under arthroscopic view. Now it was reamed incrementally up to 8 to 9mm depending on the graft size to a depth of 30mm. Transportal technique places the posterior tibial landmark to a more anterior and medial location in comparision to that of transtibial technique. The tibial tunnel exit position should be in the posteromedial portion of ACL footprint.The tibial tunnel should be inclined posteriorly towards Blumensaats line in full extension to prevent graftnotch impingement.The tibial guide was set at an angle of 55o and placed medial to centre of remaining tibial stump of native ACL through an accessory anteromedial portal. Accessory AMP was created 1.5cm medial to patellar tendon.The knee was then hyperflexed to 110o before drilling the lateral femoral condyle. The femoral tunnel is positioned with the 7-8mm femoral guide. A guide wire with eyelet was passed through the accessory anteromedial portal. The centre of the tunnel was marked depending on the graft size and a remaining posterior wall of 2-3mm was recommended5. This femoral insertion site represented a 2 O clock position on a left knee and a 10 Oclock position in right knee. After graft placement, graft impingement and tension was checked. OBSERVSATIONS Medical records of 43 patients were reviewed. Out of them 35 met the inclusion criteria. Reasons for exclusion were 3 (6.97%) had associated PCL injury, 2 (4.65%) had associated meniscal injury and in 3 patients (6.97%) bonepatellar-tendon-bone graft was used. Out of these 35 patients, 4 could not be followed up as they didnt respond. So clinical outcome of 31 patients were reviewed at minimum 1 year after surgery. Objective IKDC scores (Table 1)6, Lachman test (Table 2), pivot shift test, maximum range of movements were assessed and time from surgery to return to jogging (Table 3) was also noted in all the patients. Principal finding of this study is use of transportal technique for drilling of femoral tunnel which has significantly improved the overall IKDC score, anteroposterior stability and recovery time from surgery compared to the use of transtibial technique (Tables 1 & 3). DISCUSSION Success in arthroscopic ACL reconstruction surgery is determined by similarity between graft morphology, tension, position, orientation compared to native ACL 7. An anteriorly placed graft in femur results in anteroposterior knee stability8, whereas a vertically oriented graft in coro-

nal plane results in roTable 1 Distribution of Cases tational instability9. In according to IKDC Score in Both Groups trastibial technique the IKDC Transtibial Transportal femoral tunnel is placed score (n=13) (n=18) anteriorly and higher in A 5 10 intercondyiar notch B 7 8 compared to the native C 1 0 0 0 ACL insertion site in fe- D mur10. An anatomical Table 2 Distribution of Cases femoral tunnel is pos- according to Lachman Test in Both sible by transtibial drillthe Groups ing which would re- Lachman Transtibial Transportal quire a starting point test (n=13) (n=18) too close to tibial joint 0 3 12 10 6 line resulting in a rela- 1+ 2+ 0 0 tively short medial tibial 3+ 0 0 tunnel and a tunnel p=0.042, significant length-graft length mismatch. This Table 3 Showing the Time (in Weeks) might also compro- Taken after Surgery when the Patient Can Perform Jogging mise the medial colGroup Time (in weeks) lateral ligament Transtibial 30 weeks (SD=2.198) (MCL), graft fixation Transportal 24.72 weeks (SD=1.406) and graft incorporaNo significant difference was found on tion11,12. pivot shift test A radiological study shows transportal drilling of femoral tunnel resulted graft position more posterior in sagittal plane and more oblique (towards lateral cortex of lateral femoral condyle) compared to transtibial drilling of femoral tunnel13. Higher anteroposterior and rotational stability explains faster recovery time from surgery. Greater activity level after ACL reconstruction with an oblique femoral tunnel also have been found in a randomised controlled trial comparing high femoral (1 O'clock) and low femoral (2 O' clock) ACL reconstruction14. Low femoral group showed greater activity level, ability to jump and land. Therefore advantages of transportal technique over transtibial technique are: (1) The femoral and tibial tunnel can be placed independently of each other; (2)femoral tunnel can be placed more anatomically on ACL femoral insertion site; (3)femoral tunnel can be drilled with knee hyperflexion reducing the risk of posterior wall blow out; (4) tunnel placement is independent of graft type or tunnel guide. There are several limitations in this study. First, cases of transtibial technique have longer follow-up. But we are confident that it has limited impact on this study because minimum one year follow-up has been taken and all have returned to their normal activity before examination. In addition longer follow-up do not necessarily imply worse result15.Causal effect relationship between the surgical technique and main outcome of this study may be ques-


TRANSPORTAL VERSUS TRANSTIBIAL DRILLING TECHNIQUE OF CREATING FEMORAL TUNNEL MANDAL ET AL

tioned given observational cross-sectional nature of this study. Prospective randomised controlled study is warranted to better elucidate the clinical implication of different methods of drilling of femoral tunnel. REFERRENCES 1 Bottoni CR, Rooney RC, Harpstrite JK, Kan DM — Ensuring accurate femoral guide pin placement in anterior cruciate ligament reconstruction. Am J Orthop 1998; 27: 764-6. 2 Harner CD, Honkamp NJ, Ranawat AS — Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 2008; 24: 113-5. 3 Basdekis G, Abisafi C, Christel P — Influence of knee flexion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy 2008; 24: 459-64. 4 Alentorn-Geli E, Samitier G, Alvarez P, Steinbacher G, Cuqat R — Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up. Int Orthop 2010; 34: 122-6. 5 Crenshaw AH Jr — Campbell’s Operative Orthopedics.11th ed. Philadelphia: Mosby Elsevier Co, 2008: 2862-3. 6 Hefti F, Muller W, Jakob RP, Staubli HU — Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthroscopy 1993; 1: 226-34. doi: 10.1007/ BF01560215. 7 Scopp JM, Jasper LE, Belkoff SM, Moorman CT — The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004; 20: 294-9. 8 Markolf KL, Hame SL, Hunter DM, Oakes DA, Zoric B, Gause P, et al — Effects of femoral tunnel placement on knee laxity

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and forces in an anterior cruciate ligament graft. J Orhop Res 2002; 20: 1016-24. doi: 10.1016/S0736-0266(02)00035-9. Lee MC, Seong SC, Lee S, Chang CB, Park YK, Jo H, et al — Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 2007; 23: 771-8. Arnold MP, Kooloos J, Kampen A — Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthroscopy 2001; 9: 194-9. Heming JF, Rand J, Steiner ME — Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 2007; 35: 1708-15. doi: 10.1177/ 0363546507304137. Steiner ME, Murray MM, Rodeo SA — Strategies to improve anterior cruciate ligament healing and graft placement. Am J Sports Med 2008; 36: 176-89. Dargel J, Schmidt-Wiethoff R, Mader K, Koebke J, Schneider T — Femoral bone tunnel placement using the transtibial tunnel for the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthroscopy 2009; 17: 220-7. doi: 10.1007/s00167-008-06392. Jepsen CF, Lundberg-Jensen AK, Faunoe P — Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? A clinical, prospective, randomized, double-blind study. Arthroscopy 2007; 23: 1326-33. Aune AK, Holm I, Risberg MA, Jensen HK, Steen H — Fourstrand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction: a randomized study with two-year follow-up. Am J Sports Med 2001; 29: 722-8.

Originals and Papers Augmented versus non-augmented open surgical repair of fresh tendo-achilles injury : a prospective randomised study Sabyasachi Santra1, Partha Sarathi Sarkar1, Abdul Latif2, Arunangsu Bhattacharyya3 Injuries to the tendo-achilles in our country are mostly open injuries due to fall or slippage into the Indian type of lavatory pan. After thorough debridement open repair of the tendoachilles is done by nonaugmented or augmented method. We studied about the augmented versus non-augmented open surgical repair of fresh tendo-achilles injuries. This was a prospective randomised study. It is evaluated from the study that the mean operative time was about 29 minutes longer (p30 years, attending general ophthalmic clinic in a tertiary eye hospital. Demographics, detailed history and 6-items McMonnies’ dry eye questionnaire were asked. Tear film break-up time (TBUT), Schirmer-I test, Rose Bengal (RB) staining, slit lamp examination and Meibomian gland dysfunction (MGD) were studied. Dry eye diseases were significantly higher in women than in men ie, 51.9% versus 48.1% (p0.05 1.485 95% CI- (1.5614-4.2406)], Female 35 (28.2%) 65 (52.4%) 24 (19.4%) 124 (41.4%) caste [OR=2.531 ,95% CIReligion : (1.5156-4.1945)] and educaHindu 90 (35.2%) 130 (50.8%) 36 (14.0%) 256 (85.3%) 5mm induration) but have no active TB disease. (c) All TST positive children who are receiving immunosuppressive therapy (eg, children with nephrotic syndrome, acute leukemia, etc.). (d) A child born to a mother who was diagnosed to have TB in pregnancy should receive prophylaxis for 6 months, provided congenital TB has been ruled out. BCG vaccination can be given at birth even if INH chemoprophylaxis is planned.

The Way Forward :

These consensus national guidelines on paediatric tuberculosis was jointly developed in consultation with Indian Academy of Paediatrics and TB experts from various premier institutions in India. Keeping the interests of the nation at large, it is urged that all the clinicians, teachers, academicians, researchers or any other person dealing with paediatric tuberculosis within the Government or private or non-governmental sector should adopt these guidelines for the diagnosis and treatment of paediatric tuberculosis in India.

Acknowledgement : We are extremely grateful to Indian Academy of Paediatrics (IAP) for the valuable contributions made in revising and updating the guidelines. We also duly acknowledge the experts opinions from various institutions like AIIMS (New Delhi), National Institute for Research in Tuberculosis (earlier TB Research Centre) (Chennai), National TB Institute (Bangalore), LRS Institute of TB and Respiratory Diseases (New Delhi), National AIDS Control Organisation (New Delhi),World Health Organisation (New Delhi),Lady Hardinge Medical College (New Delhi), (Continued on page 845)

Case Note Oral hyaline ring granuloma : a case report Veena V Naik1, Mithelesh Mishra2, Ganga S Pilli3 An unusual granulomatous inflammatory lesion characterised by the presence of ring shaped hyaline bodies accompanied by foreign body giant cell reaction has been mentioned in the literature. A lack of agreement exists on the nature of these hyaline rings. Opinions ranging from their being hyaline degenerative blood vessels to remains of leguminous cells have been postulated. Although the nature and origin of these bodies is uncertain, there is now considerable evidence that they represent, at least in part, vegetable material, especially pulses, that have been implanted in the tissues. An inflammatory oral lesion in a 17-years-old male patient caused due to traumatic implantation of the vegetable matter (sugar cane) has been reported in this paper. Based on the histological finding of a granulation tissue surrounding a hyaline ring the lesion was diagnosed as hyaline ring granuloma. [J Indian Med Assoc 2012; 110: 844-5]

Key words : Oral vegetable granuloma, pulse granuloma, vegetable cell granuloma, chronic peri-ostitis, giant cell reaction, hyaline granuloma, hyaline bodies, hyaline ring, foreign body reaction, granuloma.

H

yaline ring granuloma (HRG) has been described in the literature under a variety of names. The terms most commonly used are chronic peri-ostitis1, granuloma in edentulous jaws2, giant cell hyaline angiopathy3 and oral vegetable granuloma4. The aetiology of this condition is controversial, but evidence present negates that these lesions either arise by hyaline degenerative change in the walls of blood vessels or are a foreign body reaction to pulses or vegetable matter. The purpose of this paper is to add a new case which favours an aetiology of remains of vegetable matter. CASE REPORT A 17-year-old male patient reported to this institution, with the chief complaint of pain and swelling in the lower left vestibule for the past four days. Past history revealed that the patient had a fall from 30 feet height on a heap of sugar cane when he was working in a sugar factory a month ago, due to which he had several contused lacerated wounds in the region of left cheek and lower left border of body of mandible. An orthopantomogram radiograph (OPG) was taken but did not reveal any abnormality. The wounds were sutured and the patient discharged. Patient failed to report for follow-up only to return after a month with swelling and pus discharge. Examination The patient had a non-healing wound in the left lower vestibular region. Intra-oral examination revealed ulcerated lesion covered with pseudomembrane and slough extending from premolar to molar region, measuring about 3cm x 1cm. Patient complained of pain in the affected area. Teeth in that area were periodontally compromised. Extra-orally, the wound appeared to be infested with some unusual particles. These particles appeared Department of Oral Pathology, KLE VK Institute of Dental Sciences, Belgaum 590010 1 MDS, Associate Professor 2 MDS, Lecturer of Oral Pathology, ITS Dental College and Hospital, Noida 201308 3 MD, Professor of Pathology, JN Medical College, Belgaum 590010 844

whitish in colour, soft and slimy in consistency resembling sago seeds measuring about 3mm to 4mm in diameter. Provisional clinical diagnosis of infected lacerated wound was made. Investigation An OPG taken for the second time did not reveal any abnormality. Management Debridement and curettage of the wound was done and specimen sent for histopathological examination. Pathology Gross specimen consisted of multiple pieces of soft tissue measuring 0.5cm x 0.5cm in size and reddish brown in colour. Histopathology The tissues were routinely processed and stained. The haematoxylin and eosin (H&E) stained sections showed granulation tissue surrounding a large spherical structure, a hyaline ring resembling vegetable matter. The hyaline ring consisted of double layer capsule, which was showing epidermis, hypodermis and endodermis. The capsule was representing cortex of the plant cell. Faint eosinophilic ground substance was seen within the capsule. The ground substance showed dark and light stained areas, which were similar to xylem and phloem of plant cell (Fig 1, H&E x 100). The surrounding granulation tissue showed inflamed stroma with foreign body type of giant cell reaction. Granulation tissue also showed proliferating blood vessels and inflammatory cell infiltration. Periodic acid Schiff (PAS) stained section showed positive for hyaline ring consisting of pale homogeneous eosinophilic ground substance, indicating presence of carbohydrates in the hyaline ring and eosinophilic mass, suggestive of plant cell (Fig 2, PAS x 40). Based on these features, diagnosis of hyaline ring granuloma was made. Follow-up Healing was uneventful with no recurrence after a follow-up of 3 months. DISCUSSION HRG is an unusual chronic inflammatory oral lesion containing hyaline rings with associated multinucleated giant cells. The lesions could be classified as central HRG and peripheral HRG. Radiographically, a radiolucent area irregularly outlined by well formed


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trabeculae of bone is found in central HRG, and poorly defined erosion at the crest of alveolar ridge is often seen in peripheral HRG5. Dunlap and Barker labeled this condition as giant cell hyaline angiopathy because they believed that it is due to a localised hyaline degenerative change in the wall of the blood vessels3. Adkins considered the lesion to be a foreign body granuloma. He suggested that the rings were foreign bodies that might be the unresorbed residue of therapeutic agents inserted into extraction sockets. Some investigators considered the lesion to be a foreign body reaction to legume cells, and referred to this condition as a pulse granuloma6-7. Harrison and Martin4 supported the vegetable nature of the hyaline rings on the basis of their ultrastructural study. They stated that the hyaline rings were mainly composed of vegetable cell walls. The cellulose and other mucosubstances in vegetable cell walls are stained by PAS stain on account of the presence of vicglycols. The vegetable material gains access to the tissue via a tooth socket, a surgical flap, open root canal or through some other breach in the mucosa such as trauma or ulceration associated with ill Fig 1 Numerous Multinucleated Giant Cells Associated with the Hyaline Ring, fitting dentures. Pale Staining Hyaline Material and Typical Vegetable Cell with Distinct Layers Hyaline ring granuloma is treated by curettage or of Xylem and Phloem surgical excision. Care should be taken to remove the entire lesion in order to avoid recurrence5. In the present case, based on the history and the histopathological findings it may be concluded that the HRG was due to a foreign body reaction to impacted vegetable matter. REFERENCES 1 2 3 4

5

6 7 Fig 2 Hyaline Ring Enclosing Vegetable Matter and Surrounded by Inflamed Stroma

Lewars PHD — Chronic periostitis in the mandible underneath artificial dentures. Br J Oral Surg 1971; 8: 264-9. Adkins KF — Granulomas in edentulous jaws. NZ Dent J 1972; 68: 209-12. Dunlap CL, Barker BF — Giant cell hyaline angiopathy. Oral Surg 1977; 44: 587-91. Harrison JD, Martin IC — Oral vegetable granuloma: ultrastructural and histological study. J Oral Pathol 1986; 15: 322-6. Chou L, Ficarra G, Hansen LS — Hyaline ring granuloma: a distinct entity. Oral Surg Oral Med Oral Path 1990; 70: 318-24. Rannie I — Chronic mandibular periostitis associated with ‘vasculitis’. Path Microbiol 1975; 43:199-203. Mincer HH, Mc Coy JM, Turner JE — Pulse granuloma of alveolar ridge. Oral Surg 1979; 48: 126-30.

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Maulana Azad Medical College (New Delhi), Manipal Hospitals (Bangalore),PGIMER (Chandigarh), TB Association of India (New Delhi), Empowered Procurement Wing (EPW), Ministry of Health and Family Welfare (New Delhi), SN Medical College (Agra) and Central TB Division, Ministry of Health and Family Welfare (New Delhi) who have immensely contributed in framing the guidelines. REFERENCES 1 Ministry of Home Affairs, Government of India — Broad age groups, India at a glance, census data 2001. http:// w w w . c e n s u s i n d i a . g o v. i n / C e n s u s _ D a t a _ 2 0 0 1 /

India_at_Glance/broad.aspx (accessed October 15, 2012) 2 Nelson LJ, Wells CD — Global epidemiology of childhood tuberculosis. Int J Tuber Lung Dis 2004; 8: 636-47. 3 WHO — Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children. Geneva: WHO, 2006. 4 Central TB Division — Tuberculosis India 2012: annual Report of the Revised National Tuberculosis Control Programme. New Delhi: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, 2012. 5 Government of India — National Guidelines on Diagnosis and Treatment of Pediatric Tuberculosis. New Delhi : Government of India, 2012. http://www.tbcindia.nic.in/Paediatric guidelines_New.pdf

Case Note Bleeding diathesis as a cause of menorrhagia : a report of 3 cases Jyotsna Suri1, Bharti Minocha2, Anjali Dabral3 Bleeding diathesis as a cause of menorrhagia should not be overlooked at any age even in the perimenopausal woman. Three cases have been presented, wherein bleeding diathesis was the cause of menorrhagia. Two of these patients had acute myeloid leukaemia and the third had immunothrombocytopaenic purpura. A noteworthy point of this series is that one patient was in her teens, the second in the peak reproductive age group and the third in the perimenopausal age. [J Indian Med Assoc 2012; 110: 846-7]

Key words : Menorrhagia, bleeding diathesis, perimenopausal.

M

enorrhagia affects about 20% of women during their reproductive years1. It causes considerable physical and mental discomfort to the patient and at times can lead to life threatening situations. Most often abnormal uterine bleeding is attributed to a reproductive tract disorder or a hormonal problem and an underlying bleeding disorder is rarely considered during the diagnostic workup, especially in the perimenopausal age. Three cases have been presented wherein bleeding diathesis lead to menorrhagia. A noteworthy point of this series is that one patient was in her teens, the second in the perimenopausal age and the third in the prime of her youth. Case 1 : Miss A, 18-year-old, unmarried girl presented to the emergency with complaints of bleeding per vaginum since 20 days along with fever for one month. She was referred from a nursing home in Bareily, where she had been transfused 5 units of blood. The patient had attained menarche at 16 years age and her cycles since then were regular, lasting for 4 days with normal blood loss. Examination Patient was severely anaemic with a pulse rate of 120/min and BP of 100/60 mmHg. Investigation She had a Hb of 3gm/dl, TC of 4000 cells/cmm and a platelet count of 16,000/cmm. Peripheral smear showed normocytic normochromic red blood cells and reduced platelets and lymphocytes. Liver, kidney and thyroid functions were within normal limits. On USG pelvis the uterus and adnexa were normal and endometrial thickness was 6 mm. Management and follow-up Patient was transfused 4 units of blood and started on high doses of norethisterone acetate which controlled the bleeding within 24 hours. Consultation was done with the haematologist and a decision for bone marrow aspiration was arrived at in view of abnormal peripheral smear, which was carried out after the patient's general condition improved. Bone marrow aspiration reported peroxidase +ve, PAS-ve, acute myeloid leukaemia (M2). Department of Obstetrics and Gynaecology, Safdarjang Hospital, New Delhi 110029 1 MD, Specialist 2 MD, Consultant 3 MD, Chief Medical Officer 846

The patient and her parents were counselled regarding the prognosis and treatment of AML. Subsequently she was referred to the haematology department for chemotherapy. Case 2 : Mrs S, 25-year-old nulliparous woman, married for 8 years presented with menorrhagia for last 6 months. Cycles were regular but flow was heavy, lasting for 7-8 days, with history of passage of clots. Patient gave history of being operated for an ovarian cyst 2 years ago at which time she was diagnosed as a case of idiopathic thrombocytopaenic purpura (ITP). Examination Vital parameters of the patient were normal but she had marked pallor. Per abdomen there was no organomegaly. The cervix was healthy on per speculum examination and on per vaginal examination the findings were unremarkable. Investigation The patient had a Hb of 4.5gm/dl, TC of 10,000 cells/cmm, DC P60L30E2M1 and platelet count 10 x 109/l. Kidney, liver and thyroid function tests were normal. Coagulation profile was within normal limits, USG showed normal uterus and adnexa with endometrial thickness of 6 mm. Management As the patient was already on high doses of steroid (40 mg/day of prednisolone), she was referred to haematologist for review of treatment in view of menorrhagia. Splenectomy was decided upon as further increase in dose of steroids was not safe. Pre-operatively she was transfused 4 units of blood and 10 units of platelet rich plasma. Post splenectomy her daily dose of steroid was reduced to 15 mg on which her platelet count stabilised to about 30 x 109/l and she was relieved of her menorrhagia. Follow-up Subsequently the patient conceived in December 2006. She had a closely supervised pregnancy. Her platelet count dipped to 8000/ cumm in the late 3rd trimester for which the dose of prednisolone was increased to 60 mg/day. She had a lower seqment caesarean section (LSCS), at term for pre-eclampsia with failed induction. Both mother and baby are doing well. Case 3 : Mrs K, 45-years-old resident of Muzzafarnagar presented with history of continuous bleeding per vaginum since 1 month. There was no history of preceeding amenorrhoea. Her previous cycles were regular though there was history of heavy flow lasting for 7 days since last 6 months. Patient had been transfused 10 units


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BLEEDING DIATHESIS AS A CAUSE OF MENORRHAGIA : A REPORT OF 3 CASES SURI ET AL 847

blood in the last month and had undergone a dilatation and curettage (D and C) in Muzzafarnagar. Examination The patient was severely anaemic. Her pulse rate was 120/min and BP 90/60 mmHg. Per abdomen examination revealed an enlarged liver which was one finger below costal margin. Spleen was not palpable. Per speculum and per vaginum examination were unremarkable. Investigations She had a Hb of 2.4 gm/dl, platelet count 50,000/ cmm, TC 1,500 cells/cmm, DC P12L88E0. Peripheral smear revealed a microcytic hypochromic picture with reduced platelets. Her bleeding time, clotting time and coagulation profile were normal. Kidney function test, liver function test and thyroid function were within normal limits. The D and C report showed secretory endometrium with decidualisation of stroma. USG pelvis was normal. Management and follow-up Patient was transfused 5 units blood. She was started on high doses of norethisterone acetate. The bleeding was controlled after 48 hours. On 2nd day of admission, purpuric rashes were noted. In view of leucopaenia and lymphocytosis and overall clinical picture, patient was referred to haematologist. Bone marrow biopsy was done which diagnosed her as a case of acute myeloid leukemia. The patient and her relatives were counselled about prognosis and treatment of AML. Subsequently, they were registered in haematology department for chemotherapy. DISCUSSION Value of menorrhagia as a predictor of bleeding disorders has been very little studied and reported. Oral et al2 have reported bleeding diathesis as a cause of menorrhagia in 28% of cases admitted for puberty menorrhagia of which more than 50% were due to idiopathic thrombocytopaenic purpura (ITP) and 15% due to acute promyelocytic leukaemia. Another case of acute myelocytic leukaemia presenting as menorrhagia in a 22-year-old has been reported3. The main reason of abnormal bleeding in cases of leukaemia is attributed to the associated thrombocytopaenia in these patients. However acute promyelocytic leukaemia (APL) is peculiar in that it often presents as disseminated intravascular coagulation (DIC) and about 10% of patients die of bleeding diathesis in the presentation period. The cause of coagulopathy in APL is complex, resulting from a combination of tissue factor and cancer procoagulant induced DIC4. In the 2 cases of leukaemia reported, the cause of bleeding was thrombocytopaenia. Both patients had been bleeding continuously for few months and had undergone several investigations but had not been diagnosed. On the basis of strong clinical suspicion and abnormal blood picture, they were referred to haematologist who made the diagnosis after bone marrow biopsy. The third case was a diagnosed case of ITP on treatment. Splenectomy cured her menorrhagia and reduced the dose of prednisolone required to maintain her platelet count above the critical level. ITP is a disorder in which antiplatelet antibodies cause accelerated destruction of platelets resulting in thombocytopaenia and propensity for bleeding. Bleeding symptoms are typically mucocutaneous and life threatening bleeding is rare. The goal of management is to increase the platelet count and prevent serious haemorrhage, keeping treatment related toxicity to the minimum. Treatment is advised if platelets are less than 20 x 109/l in the presence of moderate symptoms or if the count is less than 10 x 109/l even in the

absence of symptoms5. Splenectomy is done in cases refractory to medical management and it is seen that it restores normal platelet count in twothirds of the patients for about 5-10 years6. The gynaecologist must screen all cases of unexplained menorrhagia irrespective of age group for any underlying bleeding disorder especially before any operative intervention. A screening protocol consisting of a complete blood count, bleeding time and coagulation profile practically rules out most of the bleeding diathesis including ITP, leukaemias, inherited factor deficiency and Von Willebrands disease7. REFERENCES 1 Stabinsley SA, Einstein M, Breen JL — Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding. Obstet Gynaecol Surv 1999; 54: 61-72. 2 Oral E, Cagdas A, Gezer A, Kaleli S, Aydin Y, Ocer F — Haematological abnormalities in adolescent menorrhagia. Arch Gynaecol Obstet 2002; 266: 72-4. 3 Swamy ACV — Leukemia presenting as menorrhagia. J Obstet Gynaecol India 2002; 52: 108. 4 Arbuthnol C — Hemostatic problems in acute promyelocytic leukemia. Blood Rev 2006; 20: 289-97. 5 British Committee for Standards in Hematology : General Hematology Task Force — Guidelines for the investigations and management of idiopathic thrombocytopenic purpura in adults, children & in pregnancy. Br J Haematol 2003; 120: 574-96. 6 Vianelli N, Galli M, de VivoA — Efficacy and safety of splenectomy in immune thrombocytopenic purpura: long term results of 402 cases. Haematologica 2005; 90: 72-7. 7 American College of Obstetricians and Gynaecologists — Von Willebrand’s disease in gynaecologic practice: committee opinion no 263. Obstet Gynaecol 2001; 98: 1185-6.


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