Tubercular osteomyelitis of calcaneum bone: A rare occurrence

Clinical characteristics, treatment and efficacy of calcaneal osteomyelitis: A systematic review with synthesis analysis 1118 reported cases

BACKGROUND

Calcaneal osteomyelitis (CO) still poses great challenges to orthopaedic surgeons due to unique anatomic and functional features of the calcaneus. This study summarized the current data regarding clinical characteristics, treatment and efficacy of CO, based on an analysis of literature-reported cases.

MATERIALS AND METHODS

We searched the PubMed, Embase, and Cochrane Library databases to find English and Chinese studies reporting on CO patients between 2000 and 2021, with available data for synthesis analysis. The quality of the included studies was evaluated by the National Institutes of Health (NIH) assessment scale. Effective data were extracted and pooled for analysis.

RESULTS

Altogether 198 studies involving 1118 patients were included, with a male-to-female ratio of 2.3 (724 males and 310 females). The median age at CO diagnosis was 46 years, with a median symptom duration of 3 months. Injury-related infections (524 cases) and diabetic foot infections (336 cases) were the two most common causes, with ulcer (468 cases) and wound sinus or exudation (209 cases) being the predominant symptoms. The overall positive culture rate was 80.2%, with polymicrobial infections accounting for 18.1%. Staphylococcus aureus was the most frequently detected pathogen (42.7%), with fungal-related infections isolated in 17 cases. Although most patients received surgical interventions (96.9%), the recurrence rate was 20.1%. The incidence of infection relapse following partial calcanectomy, total calcanectomy, debridement with implantation of local antibiotics, and debridement with or without flap or skin coverage were 31.7%, 45.0%, 16.8%, and 15.1%, respectively. The overall incidence of limb amputation was 12.4%, with all-cause and CO-related mortalities of 2.8% and 0.2%, separately.

CONCLUSIONS

CO shared similar characteristics with extremity chronic osteomyelitis, primarily affecting young males, with trauma and diabetic foot as the leading causes and Staphylococcus aureus as the most frequently detected pathogen. Despite surgery being the primary treatment modality, clinical outcomes remained unsatisfactory, marked by high rates of infection recurrence and limb amputation.

Tuberculosis of the Right Fifth Metatarsal and Fourth Web Space Without Pulmonary Involvement: A Rare Case

Tuberculosis of the bones and joints is an uncommon entity. The bacterial infection of small bones of the foot, like the metatarsals, is extremely rare. Such cases are often detected late, and as a result, there is delayed management. The present case is that of a 12-year-old Indian boy who came with complaints of pain and swelling below his right foot. In the absence of pulmonary involvement, a definite diagnosis of tuberculosis of the fifth metatarsal with fourth web space was established using histopathology, a cartridge-based nucleic acid amplification test, magnetic resonance imaging, and culture of the pus. He was prescribed first-line anti-tubercular treatment for 12 months.

Tuberculous Osteomyelitis of the Left Fifth Metatarsal and Phalanx Without Pulmonary Involvement: A First-of-Its-Type Report

Tuberculosis manifesting at extrapulmonary sites is relatively rare. Isolated cases involving small bones of the foot are the rarest of the rare. We herein present the case of a 30-year-old Indian female who presented with pain and a wound with a discharging sinus over her left foot. In the absence of constitutional symptoms of tuberculosis, this case was diagnosed as isolated tuberculous osteomyelitis of the left fifth metatarsal and phalanx with the help of radiography, a cartridge-based nucleic acid amplification test, a line probe assay, a culture of the biopsy specimen, and magnetic resonance imaging. She was initiated on anti-tubercular treatment per national guidelines.

Osteoarticular tuberculosis: A series of six cases diagnosed on fine-needle aspiration cytology

A few studies are dealing with the role of fine-needle aspiration cytology in diagnosing osteoarticular tuberculosis (TB). The present study was undertaken to study the cytomorphological features of six cases of osteoarticular TB throughout 1 year, diagnosed by fine-needle aspiration cytology. The Papanicolaou, Giemsa, Ziehl–Neelsen, and periodic acid–Schiff stains were used in each case. The sampled material was also cultured in Lowenstein– Jensen media for Mycobacterium species and polymerase chain reaction assay for Mycobacterium tuberculosis. Histopathological findings were correlated whenever available. There were four male and two female patients. The age of the patients ranged from 15 to 53 years, with a mean age of 37 years. Most cases involved small bones (4/6) and long bones of upper and lower limbs (2/6). Radiologically, the suspected lesions presented as osteolytic lesions, fractures, and joint destruction. The smears showed epithelioid cell granulomas in 5 out of 6 cases (83.3%), multinucleate and Langhans’ giant cells in 3 out of 6 cases (50%), and only necrosis in 1 case (16.7%). Inflammatory cells were seen in the background in 5 out of 6 cases (83.3%). AFB was positive in 3 cases (50%). Culture in Löwenstein–Jensen media, done in three cases, showed growth of M. tuberculosis. PCR showed positivity for M. tuberculosis in all six cases. Fine-needle aspiration cytology is an easy procedure that can be used for the diagnosis of osteoarticular tuberculosis. Cytomorphologically, smears show epithelioid cell granulomas, multinucleated and Langhan’s’ giant cells, and necrosis.

Tubercular involvement of the lateral malleolus and adjacent calcaneus: presentation of a rare case and review of the literature

Osteoarticular tuberculosis (TB), despite being on the wane in the developed world, stays a problem of significance in the developing world. The issue is compounded by unusual presentations, inadequate diagnostic skills and limited understanding of its management. For foot infections, despite an increased awareness, many patients may be misdiagnosed, with associated treatment delays. A 19-year-old man presented with pain and swelling on lateral aspect of right ankle for 2 months. The patient had an undermined discharging sinus with surrounding induration and the skin adherent to the underlying bone. Patient was diagnosed as a case of ipsilateral TB lateral malleolus and calcaneus, managed with antitubercular drugs with complete resolution at 3 years of follow up. Foot and ankle TB can have atypical presentations causing delay in diagnosis. Contiguous spread of infection occurs through the synovium or the joint; however, extra-articular spread along the tendon sheaths or other soft tissues is possible, which is highlighted by the present case.