Background: Back pain in adult patients with a pars-interarticularis defect may be due to movement at the defect or abnormal inter-segmental movement at the adjacent degenerate disc. The suggested treatment of segmental fusion may not be necessary, if the defect alone was source of pain. We hypothesize that the defect may be the only source of pain in certain adults, even if the MRI scan shows an abnormal disc.

Objective: To form a protocol of management in adults with pars defect and adjacent level disc degeneration. To study the results of primary lysis repair using ‘AO Morscher clamp’ in patients with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’.

Methods: This is a prospective study involving adults with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’ not responding to conservative management and requiring interventional treatment. We investigated this subgroup of patients with lysis block and discography. On this basis, of a total of ten patients, seven were offered lysis repair and bone grafting using ‘Morscher’s clamp’; three were offered spinal fusion. Outcome was assessed using Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) done pre-operatively and six months post-op.

Results: Out of ten patients (28 to 45 years; 4males and 6 females), seven patients underwent primary lysis repair using ‘AO Morscher clamp’. Union of pars achieved in all the patients by 4 months (Follow-up 4 months to 2 years). Three underwent fusion. Mean VAS improved from 7.2 to 1.2 in lysis repair group. Mean ODI improved from 68 % to 24%. All patients had full range of spinal movement postop.

Conclusion: A thorough pre-operative workup of patients with pars defect and adjacent level disc degeneration showed that pain is due to the pars defect in 70% of our cohort. This subgroup of patients could successfully be treated with ‘lysis repair’ rather than a more morbid procedure of ‘spinal fusion’.

We evaluated the effectiveness of local and free flap cover done at revision surgery for infected endoprosthetic replacement (EPR) in achieving ultimate control of infection.

Methods: Ten patients needed plastic surgical input in the form of flap cover at the time of revision surgery for infective endoprosthetic failure between March 1999 and March 2005. The revision of EPR itself was undertaken in 2 stages. The 1st stage involved removal of the endoprosthesis, insertion of antibiotic spacer and flap cover. After achieving adequate control of infection, 2nd stage revision was carried out, in which the spacer was exchanged for an endoprosthesis.

Results: Average age at time of flap surgery was 29 years (range 14 – 58 years). Average follow up was 23 months (3 to 72 months) for patients who remained free of infection and 19 months (5 to 52 months) for those who underwent amputation. 9 out of 10 patients underwent some form of muscle flap (6 free LD flaps, 2 gastrocnemius flaps and 1 pedicled LD flap). Infection was adequately controlled in 5 out of 6 patients in free flap group. Out of 4 patients who underwent local flaps, 2 ended up having amputation.

Conclusion: Reconstructive surgery in the form of flap cover has an important role in limb salvage in patients with endoprosthetic failure due to infection. The aim of such surgery should be to provide as much new vascularized tissue over the dependent portions with sinuses and areas of radiotherapy with scarring. Results of cover by a broad flat musculocutaneous flaps seem to be better in comparison to local flaps.

Metachronous multifocal osteosarcoma (MFOS) is a rare form of osteosarcoma manifested by one or more new tumors developing after the initial treatment of primary osteosarcoma. We present a 61 year old Asian male who was referred with 10 week history of pain and discomfort around his left shoulder and low back pain. In 1968, he received radiotherapy followed by disarticulation of left hip for an osteosarcoma of lower end of left femur complicated with pathological fracture. He did not show any clinical features suggestive of recurrence of disease since then until he presented again in February 2005. CT scan of left scapula has revealed extensive osteosarcoma of lower part of scapula, involving subscapularis and infraspinatus muscles. An MRI scan of whole spine has shown evidence of multiple lesions in sacrum, ilium and acetabulum. A core biopsy from scapula has confirmed the histological diagnosis as high grade osteoblastic osteosarcoma. Slides from 1968 were reviewed in the context of recent recurrence and were consistent with features of intermediate grade fibroblastic osteosarcoma. He is currently undergoing chemotherapy prior to planning definitive treatment as there is evidence in the literature that MFOS is a potentially curable condition.