Tuberculosis of the foot and ankle

Extrapulmonary, Chronic Septic Arthritis From Mycobacterium tuberculosis in the Ankle and Subtalar Joints

In the United States, rates of Mycobacterium tuberculosis infection have been declining for decades. Osteoarticular tuberculosis of the ankle is rarely observed. We present the case of a 65-year-old man who immigrated to the United States from India 24 years before the onset of symptoms. The patient initially reported atraumatic swelling and pain of the left ankle and foot and was treated for venous insufficiency. Later, the patient was referred to a nonsurgical orthopaedic clinic for additional workup and was found to have elevated inflammatory markers. MRI showed septic arthritis and osteomyelitis of the talus, distal tibia, and calcaneus. Joint aspiration revealed elevated white blood cell counts with predominately PMNs. The patient was then referred to an orthopaedic foot and ankle surgeon and underwent extensive irrigation and débridement. The patient was discharged on empiric antibiotics. Culture results from the original joint aspirate returned 14 days after surgery as positive for acid-fast bacillus, later identified as M tuberculosis by sequencing. Empiric antibiotics were discontinued, and the patient was started on appropriate antituberculotic therapy. This case report illustrates the challenge in the diagnosis of skeletal tuberculosis and the importance of including this condition on the differential for patients with atypical foot and ankle presentations.

Minimally invasive endoscopic management of tubercular tenosynovitis of the anterior tibial tendon

The incidence of tubercular tenosynovitis around the foot and ankle is rare even in endemic areas. We present an unusual case involving the isolated tubercular tenosynovitis of the Anterior Tibial tendon, which was successfully managed through a combination of medical treatment and endoscopic intervention. Our patient, a 30-year-old female, sought medical attention due to a gradually worsening painful swelling localized to the anterior aspect of her left ankle. Diagnostic imaging, specifically Magnetic Resonance Imaging (MRI), revealed alterations in signal intensity within the Anterior Tibial tendon. Importantly, the infection had not spread to involve the ankle joint. We performed both diagnostic and therapeutic tenosynovectomy endoscopically and subsequently sent the tissue for histopathological examination. The histopathological findings revealed the presence of histiocytic granulomas containing Langhans' giant cells, which strongly suggested a tuberculosis infection. Consequently, we initiated anti-tubercular chemotherapy as the treatment approach. Our patient exhibited a positive response to the treatment, and after one year, she experienced complete resolution of the disease. This case underscores the importance of maintaining a high level of clinical suspicion for tuberculosis, especially in endemic areas, when encountering unusual presentations.

Level of evidence

V.

Unveiling foot tuberculosis as an under-recognized source of foot pain

PURPOSE

Foot tuberculosis is a rare form of osteoarticular tuberculosis, accounting for less than 1% of cases. It presents unique diagnostic challenges due to its nonspecific clinical features and overlapping symptoms with other conditions. This study aimed to investigate the clinical presentation, radiographic findings, and prognosis of foot tuberculosis, with the goal of improving early recognition and appropriate intervention.

METHODS

A prospective study was conducted between November 2016 and July 2021, involving 39 patients diagnosed with foot tuberculosis. Clinical examinations, laboratory tests, X-rays, and MRI evaluations were performed to aid in the diagnosis. Biopsy was conducted on patients with radiological lesions. Patients were treated with an 18-month course of antitubercular therapy (ATT). Foot Function Index (FFI) scores were recorded before and after treatment. Statistical analysis was conducted to assess factors impacting prognosis.

RESULTS

Unilateral foot involvement was observed in all patients, with a male predominance (61.5%) and a mean age of 31.3 years. The most common symptoms were pain and edema, with sinus tracts present in 17.9% of patients. Radiographic findings showed cystic and sclerotic lesions, with the "spina ventosa" appearance primarily affecting the metatarsal bones. MRI played a valuable role in early detection. Histopathological examination confirmed tuberculosis in all cases, and acid-fast bacilli were found in 23% of patients. Most patients (79.4%) responded well to ATT without requiring surgery. Factors such as high initial ESR, delayed ATT initiation, multiple lesions, and tarsal involvement were associated with unfavourable outcomes.

CONCLUSION

Foot tuberculosis presents with nonspecific symptoms, leading to misdiagnosis and delays in appropriate treatment. Clinical examination, radiographic evaluation, and biopsy are essential for accurate diagnosis. Early initiation of ATT is crucial for favourable outcomes. Factors such as high initial ESR, delayed treatment initiation, multiple lesions, and tarsal involvement negatively impact prognosis. This study highlights the importance of recognizing foot tuberculosis and provides insights into its clinical presentation, radiographic features, and treatment outcomes, facilitating timely intervention and improved patient management.

Sarcoidosis with Severe Bone Involvement: A Case Report and Literature Review

Sarcoidosis is a systemic granulomatous disease of the lungs that commonly involves intrathoracic lymph nodes. Here, we report the case of a 68-year-old woman who complained of shortness of breath and had suffered from the enlargement of intrathoracic lymph nodes for 12 years, swelling of the right middle finger for 7 years, and nasal obstruction for 2 years. The damage to the phalange was aggravated continuously and a malignant lesion could not be excluded, thus leading to amputation of the right middle finger. Pathological data indicated chronic inflammatory granulomatous disease and anti-acid staining was negative. Examination of the paranasal sinuses indicated destruction of the sinonasal bone and the swollen mucosa. Combined with the elevated ratio of CD4+/CD8+ T cells in bronchoalveolar lavage fluid and other results, the patient was finally diagnosed with sarcoidosis and received corticosteroid therapy. The shortness of breath and abnormality of the nose were significantly improved after treatment. Our case demonstrated the process of differential diagnosis for systemic granulomatous diseases, indicating the necessity of corticosteroid therapy for systematic sarcoidosis.

Tuberculous arthritis of native joints - a systematic review and European Bone and Joint Infection Society workgroup report

Introduction: The aim of this systematic review was to assess the existing published data on the diagnosis and management of tuberculosis (TB) arthritis involving native joints in adults aged 18 years and older. Methods: This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). Results: The systematic review of the literature yielded 20 data sources involving 573 patients from nine countries. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The diagnosis was mostly made by microbiological tissue culture. Medical management involved a median of 12 months of anti-tubercular treatment (interquartile range, IQR, of 8-16; range of 4-18 months). The duration of preoperative treatment ranged from 2 to 12 weeks. Surgery was performed on 87 % of patients and varied from arthroscopic debridement to complete synovectomies combined with total joint arthroplasty. The mean follow-up time of all studies was 26 months (range of 3-112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of approximately 7.4 % (35 of 475 cases). Conclusions: The current literature on TB arthritis highlights the need for the establishment of standardized guidelines for the confirmation of the diagnosis. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active TB arthritis needs to be explored further. Specifically, comparative studies are required to address questions around the use of medical treatment alone vs. in combination with surgical intervention.

Isolated Tuberculosis of the First Metatarsal of the Right Foot Without Pulmonary Involvement: A Rare Case

Tuberculosis of the small bones of the foot is a rare clinical condition. Oftentimes, there is a delay in diagnosis, which could adversely affect the results. Isolated cases of tuberculosis of the first metatarsal of the right foot without pulmonary involvement are seldom reported. Herein, a case of a 13-year-old Indian female who presented with complaints of pain, swelling, and discharge from her right foot is presented. A diagnostic workup led to a definite diagnosis of isolated tuberculosis of the first metatarsal of the right foot without pulmonary involvement, and she was put on anti-tubercular treatment.

Isolated Tuberculosis of the First Metatarsal of the Left Foot With Congenital Hallux Valgus Without Pulmonary Involvement: A First of Its Type Case

Osteomyelitis caused by Mycobacterium tuberculosis is a rare entity. This clinical condition is even rarer when the bones of extremities like the foot are involved. There is a paucity of literature on the isolated tubercular involvement of the bones of the foot. Further, congenital hallux valgus is an infrequently reported condition. A case of tuberculosis of the first metatarsal of the left foot with congenital hallux valgus without pulmonary involvement is never reported in the literature. We herein present a first of its type case where tuberculous osteomyelitis of the first metatarsal of the left foot with congenital hallux valgus was diagnosed with the help of radiology, cartridge-based nucleic acid amplification test, and pus culture. The patient was initiated on anti-tubercular treatment but was ultimately lost to follow-up.

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.

Foot and ankle tuberculosis: A case report and review of the literature

Key clinical message

It is important to consider foot and ankle tuberculosis (TB) as a potential cause of cystic lesion around the ankle, especially in patients with a history of TB. Early diagnosis and treatment with a rifampin-based regimen for a duration of 12 months can lead to good functional and clinical outcomes.

Abstract

Skeletal TB is an uncommon accounting for 10% of extra-pulmonary TB may present slowly over an extended period of time, making a diagnosis difficult and time-consuming (Microbiology Spectr. 2017;5:5). For the best possible outcome and to reduce the risk of deformity diagnosis must be early (Foot (Edinb). 2018;37:105). For the treatment of drug-susceptible musculoskeletal illness, a rifampin-based regimen lasting 12 months is advised (Clin Infect Dis. 2016;63:e147; J Bone Joint Surg Br. 1993;75:240; Tubercle. 1986;67:243). A 33-year-old female who are working as nurse with diffuse, persistent and low in intensity ankle pain not aggravated relieved by analgesia and swelling over a period of 2 months, static not related to activity. With past medical history of partially treated pulmonary TB 1 year ago. She reported night sweats and low-grade fever during this period, and she denied any history of trauma. The right ankle was globally swollen and tender anteriorly and on the lateral malleolus. The skin over the ankle showed dark discoloration with cautery marks with no discharging sinuses. The range of motion of the right ankle was decreased. The plain x-ray of the right ankle showed three cystic lesion at the distal tibia, one cyst at the lateral malleolus and another one at the calcaneum. Surgical biopsy and expert gene test confirmed the diagnosis of tuberculous osteomyelitis. The patient was planned for surgical curettage of the lesion. After the confirmation of the diagnosis of TB with the biopsy and gene expert test, with consultation of senior chest physician the patient fitted to anti-tuberculous regimen. The patient had good functional and clinical outcome. This case report highlights the importance of considering skeletal TB as a potential cause of musculoskeletal symptoms, especially in patients with a history of TB. Early diagnosis and treatment with a rifampin-based regimen for a duration of 12 months can lead to good functional and clinical outcomes. Further research on the management and prevention of musculoskeletal TB is warranted to improve patient outcomes. The lesson behind this case is that the diagnosis TB osteomyelitis should be on the top of differential diagnosis of multiple cystic lesions around the foot and ankle especially in area where TB is endemic. Early diagnosis and early start of anti-tuberculous therapy can lead to full cure of the patient and in bad situation can minimize the complications.

Tuberculosis of the Navicular Bone of the Left Foot Without Pulmonary Involvement in a Fifteen-Year-Old Indian Boy: A Rare Case Report

Tuberculosis of the bones and joints is a relatively rare entity, even in endemic countries. The disease is an outcome of a Mycobacterium tuberculosis infection. Tuberculosis of the small bones of the foot is extremely rare, requires a high index of suspicion for establishing the diagnosis, and is often associated with delayed diagnosis, ultimately affecting the treatment outcomes. Globally, tuberculosis of the navicular bone of the foot is an infrequently reported condition. We herein present a case of isolated tuberculosis of the navicular bone without pulmonary involvement. The patient reported complaints of pain and swelling in his left foot and underwent a detailed diagnostic workup. A final diagnosis was made with fine needle aspiration cytology, biopsy, culture, radiography, and magnetic resonance imaging (MRI). He was initiated on anti-tubercular chemotherapy for twelve months, with a substantial improvement in his symptoms. This case is very rare, as no such case with similar clinical features in this age group has ever been reported in the world.

Tuberculosis of Talonavicular Joint Without Pulmonary Involvement in an Indian Child: A Report of a Rare Case

Osteoarticular tuberculosis is a rare entity, even in endemic countries. Isolated cases of tuberculosis of the talonavicular joint are sparse. Primary involvement of the talonavicular joint without pulmonary infection with Mycobacterium tuberculosis is rarest of rare. Here, we report a case of primary talonavicular joint tuberculosis without pulmonary involvement in an Indian child. To the best knowledge of the authors, it is the third such case ever reported in a child in the world. The patient presented with complaints of pain and swelling of the right foot. Detailed laboratory work-up backed by radiological investigations helped in establishing the diagnosis. He was managed conservatively with antitubercular chemotherapy with improvement in his symptoms and was transferred out to his native village.

Odd presentations of skeletal tuberculosis: A case series

Tuberculosis has been afflicting mankind since times immemorial and yet can still present itself in such a disguised manner that even the bests of experts may be duped. Any site from head to toe can be affected but certain sites are far less common than the others. We came across three inconspicuous manifestations at atypical sites-parapharyngeal abscess, wrist joint and foot ulcer. No other primary site could be identified in any case. Two cases were diagnosed microbiologically and one with radiological evidence. All the three cases were medically managed and depicted positive response.

Midfoot tuberculosis: Clinical suspicion and early investigation is the key

BACKGROUND

Tuberculosis affecting midfoot is not common, leading to delay in diagnosis further leading to deformity and difficult management. Tissue diagnosis is always not possible at such sites. MRI is the better imaging modality to diagnose earlier than conventional radiographs. The aim of the study is to have a clinical suspicion of tuberculosis in midfoot pain and a low threshold to perform MRI in these patients.

METHODS

The data of 7 patients were collected prospectively over 3 years. Inclusion criteria included midfoot pain for more than 4 weeks in a skeletally mature patient with no radiographic findings. MRI and laboratory investigations were done in all the patients. All the patients were given Anti-tubercular therapy and followed up for 12 months. The patients were assessed at 3, 6- and 12-months duration with ESR, CRP, MRI, VAS and AOFAS Midfoot scores.

RESULTS

There were 3 males and 4 females included in the study with a mean age of 55.5 years. The mean duration of symptoms was 5.2 weeks. The mean ESR and CRP at presentation were 46 and 12 respectively which progressively decreased over 12 months. The mean VAS and AOFAS midfoot score at presentation were 4 and 70 respectively. None of the patients had any complication from ATT drugs. Residual pain was present in 4 patients with no functional limitation of the foot. The follow-up MRI showed healed tuberculosis in all the patients.

CONCLUSIONS

Tuberculosis can be a cause of vague midfoot pain in tuberculosis endemic countries. The MRI in such patients along with laboratory findings can lead to early diagnosis and the empirical institution of the ATT. The tissue diagnosis is not always possible in the early stages of the disease as there is no radiographic lesion or collection in the midfoot.

Osteoarticular tuberculous infection of the first tarsometatarsal joint - a case report

Introduction

The prevalence of osteoarticular tuberculosis is increasing. Tuberculous infection in midfoot is rare. Establishing the diagnosis is difficult, leading to delay in management and leave many complications.

Case presentation

An 18-year-old man presents to our clinic with pain on his foot for the last 1 year. No other remarkable signs and symptoms. X-ray of his foot shown destruction of the 1st tarsometatarsal joint, later confirmed with MRI that shown synovitis and bone edema. Mantoux test and biopsy were done and established the diagnosis of tuberculous infection.

Clinical discussion

Intensive phase of anti-tuberculosis chemotherapy was given for 2 months, followed by continuation phase for 7 months. Surgical management of debridement and arthrodesis were performed as adjunctive treatment. At 10 months follow-up patient was pain free, fully weight-bearing and no signs of further destruction.

Conclusion

Osteoarticular tuberculosis is difficult to diagnose, a high index of suspicion is required to avoid delay treatment and complications. Anti-TB chemotherapy is still the treatment of choice, with surgical management is reserved for advance case.

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Tuberculous infection in midfoot is rare, especially in young healthy patient

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Establishing the diagnosis is difficult, since laboratory and radiological findings often give non-spesific results

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Surgeon who works in endemic area has to have a High suspicion to the disease

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Conservative treatment with anti-TB chemotherapy is still the first-line treatment, with surgical management is reserved for late and advance presentation

Tuberculosis of talus: A case report

Introduction

Osteoarticular tuberculosis represents 1 to 3% of all tuberculosis cases, the tuberculosis of the talus is a very rare form of osteoarticular tuberculosis. Its clinical and radiological features are not specific.

In this study, we report a case of ankle tuberculosis involving the talus in a 5-year-old girl.

Case report

A 5 years old girl, was admitted for pain, swelling, and functional impairment of the left ankle, on the clinical examination, the patient manifested a painful oedematous ankle. The biological examination revealed a slight inflammatory syndrome, The X-ray of the ankle showed a lytic image of the posterior part of the talus with a cortical involvement.

The biopsy revealed an epithelioid cell granuloma without any caseous necrosis.

The medical management consisted of anti-tuberculosis multi-drug.

Discussion

The tuberculosis of the talus is a very rare form of osteoarticular tuberculosis. In this study, we report a rare case of this localization of a 5-year-old girl.

The non-specificity of symptoms is the main difficulty that causes a delay in diagnosis.

Standard radiology, MRI, and biology were non-contributory. Bone biopsy and anatomopathological study led to the diagnosis of tuberculosis of the talus.

The main aims of the surgical treatment are to take some sample for histological study, and to curette the diseased part in the bone followed by 6 to 9 months of anti-tuberculosis chemotherapy.

Conclusion

Tuberculosis of the talus is extremely rare, it deserves special attention especially in endemic areas.

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Talus localization of tuberculosis is rare and represents less than 1-3 % of skeletal locations.

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In front of any suspicious bone lesion or atypical clinical picture, the diagnosis of TB must be invoked in order to avoid a diagnostic delay

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Treatment is medical, but surgery is required for some cases.

Postpartum Ankle Pain: A Suspected Complex Regional Pain Syndrome or a Rare Cause of Septic Arthritis?

Ankle tuberculosis is a relatively rare condition and may develop after hematogenous dissemination from the pulmonary origin, particularly in cases of immunosuppression. Both pregnancy and delivery are relatively immunosuppressive states, and immune modulations during these periods can contribute to the pathogenesis of disseminated tuberculosis. A 26-year-old mother presented with severe, continuous, and debilitating pain in the left ankle, lasting for three months after delivery and associated with fever. Inspection demonstrated ankle swelling and redness, with a cold and cyanotic forefoot. Ankle radiograph and musculoskeletal ultrasound evaluation were obtained. Tibiotalar joint arthrocentesis revealed purulent liquid suggestive of septic arthritis and an emergent arthroscopic washout of the ankle was performed. The synovial mycobacterial culture was posteriorly positive and the diagnosis established was both pulmonary and osteoarticular tuberculosis. A comprehensive rehabilitation program was then implemented to achieve maximum functional gains. This report presents a rare case of ankle tuberculosis diagnosed in the postpartum period. Early evaluation, treatment, and adequate rehabilitation interventions can be crucial to promote functionality and enhance the quality of life.

Tubercular Osteomyelitis of Cuboid

INTRODUCTION

Tuberculosis (TB) affection of foot appears to be a rare clinical entity and accounts for <10% and 0.1-0.3% of osteoarticular and extrapulmonary TB, respectively. In TB foot, tarsal joints and calcaneum are more commonly affected followed by talus, distal end of first metatarsal, navicular, cuneiforms, and cuboid bones.

CASE REPORT

A 24-year-old female presented with pain and swelling over dorsum of the left foot from the past 8 months. On examination, there was a diffuse round shaped, solitary swelling measuring about 3.5 cm × 2.5 cm (approx.) with its surface smooth, non-pulsatile, non-fluctuant, non-transilluminant, non-compressible, and non-reducible present over dorsum of the left foot. Radiographic investigations revealed osteolytic lesion over the base of 3rd, 4th, and 5th metatarsals, middle and lateral cuneiforms and cuboid bones along with soft tissue swelling and diffuse transient osteopenia. Under spinal anesthesia, trucut biopsy of the mass revealed paucibacillary type of TB in histopathological examination. The patient was provided with ATT drugs in the form of intensive phase drugs (HRZE) daily for 4 months and continuation phase drugs (HRE) daily for 10 months according to the weight of the patient. The patient was followed up with erythrocyte sedimentation rate and C-reactive protein every 2 months once. The patient achieved a normal range of movements in the midtarsal joints except for the painful terminal range of movements. The patient was still under our follow-up.

CONCLUSION

The cuboid is the second most involved tarsal bone. The diagnosis is not always frankly evident, and a high index of suspicion has to be maintained. Surgical intervention should be limited to biopsy only as multidrug chemotherapy alone is sufficient to achieve complete healing.

Tuberculosis of the Cuboid in a 16-Month-Old Child: A Case Report

CASE

A 16-month-old male child presented with swelling over the dorsolateral aspect of the right foot associated with limp and no other constitutional symptoms. Tenderness and swelling were noted over the dorsolateral aspect, and radiographs revealed an eccentric lytic expansile lesion in the right cuboid. Biopsy of the lesion revealed necrotizing granulomas, and molecular testing later documented tuberculosis. The child received antitubercular medications and was relieved of symptoms in 6 weeks. Complete healing was observed after 12 months.

CONCLUSION

In developing countries, a high index of suspicion helps in the early diagnosis and appropriate management of tubercular osteomyelitis in children.

A Rare Case of Tuberculosis as a Cause of Lytic Lesion of Talus Without Adjacent Bone Involvement in a Four-Year-Old Child

Extra-pulmonary tuberculosis still remains an important differential diagnosis for chronic musculoskeletal ailments in developing countries like India and may involve any part of the body without characteristic systemic features. We are presenting a rare case of a four-year-old female child, who came to our tertiary-care hospital with chief complaints of pain in the left foot along with a gradually increasing swelling over the dorsum of the foot for the past five months. There was no history of trauma or constitutional symptoms. The serum inflammatory markers were found raised, and X-ray and magnetic resonance imaging revealed an isolated lytic lesion in the talus bone. Debridement, as well as curettage of the lesion, was done, both as a diagnostic and therapeutic procedure. A caseous cheesy material was evacuated and sent for microbiological and histopathological evaluation, which revealed the presence of acid-fast bacilli and granulomatous lesion confirming the diagnosis of tuberculosis. The patient was started with anti-tubercular chemotherapy, which continued for a total duration of 14 months, along with foot and ankle immobilization in a below-knee cast for three months. After completion of therapy, there was complete resolution of the lytic lesion on x-ray, with full symptom relief, and a full range of movement of the ankle was obtained. In cases with longstanding pain and swelling of the foot, with or without associated systemic symptoms, tuberculosis should be considered as a strong differential diagnosis even in young children, especially in developing countries. Diagnostic and therapeutic curettage along with anti-tubercular chemotherapy can result in a good functional outcome in such patients.

Tuberculosis presenting as arthritis of the ankle: A case report

Tuberculosis presenting as monoarticular involvement in immunocompetent patients is rare. Here, we report a Sri Lankan patient presenting with ankle swelling due to tuberculosis with no other extrapulmonary or pulmonary involvement. Magnetic resonance imaging showed destruction of articular cartilage of the ankle joint with chronic inflammation of the subtalar joint. The diagnosis was confirmed by synovial tissue culture which was positive for Mycobacterium tuberculosis. The patient recovered uneventfully with anti-tuberculosis treatment. Therefore, a high degree of suspicion is necessary to diagnose extrapulmonary tuberculosis when patients are presenting with atypical monoarthritis.

Ankle arthritis - an important signpost in rheumatologic practice

Ankle arthritis is a useful clinical signpost to differential diagnosis in rheumatic disease. Biomechanical features and differences in cartilage physiology compared with the knee may confer protection of the ankle joint from factors predisposing to certain arthritides. The prevalence of ankle OA is low, and usually secondary to trauma. Primary OA of the ankle should be investigated for underlying causes, especially haemochromatosis. New presentations of inflammatory mono/oligo arthritis involving the ankle are more likely due to undifferentiated arthritis or spondyloarthritis than RA, and gout over CPPD. The ankle is often involved in bacterial and viral causes of septic arthritis, especially bacterial, chikungunya and HIV infection, but rarely tuberculosis. Periarticular hind foot swelling can be confused with ankle arthritis, exemplified by Lofgren’s syndrome and hypertrophic osteoarthropathy where swelling is due to subcutaneous oedema and osteitis respectively, and the ankle joint is rarely involved.

Tuberculous Arthritis of the Ankle Joint Mimicking Pigmented Villonodular Synovitis

Osteoarticular tuberculosis (TB) of the ankle joint is rare, and there is a delay in diagnosis in most cases. All patients with the disease complained of swelling and pain in the affected ankle. Ankle TB is a disorder that can be simply misdiagnosed. The delay in diagnosis may range from months up to years. All patients in this series had already been diagnosed with ankle TB by the time they visited our hospital. The current case was reported in a middle-aged male nurse with ankle pain, ulcer, and limited range of movement. The classical clinical manifestations of TB were absent on free chest radiography. Ulcer biopsy showed TB infection with no lymph nodes. Nonspecific inflammation was initially treated, but, subsequently, anti-TB treatment was useful.

Role of arthroscopy and endoscopy in management of tuberculosis of the foot and ankle

Tuberculosis of the foot and ankle is rare but destructive. It can affect bones, joints and soft tissue and can mimic a wide range of acute and chronic infections or tumorous conditions. The primary treatment objectives for osteoarticular TB include curing the infection, limiting deformity, maintaining mobility, and reducing discomfort. Chemotherapy remains the mainstay of treatment in acute stage. Indications of surgery include biopsy and debridement in early stages to reduce the tuberculosis load and enable better penetration of anti-tuberculous drugs. Other reported indications for surgery in early stage of TB foot and ankle include resection of lesion not responding to chemotherapy and debridement of lesions close to the articular surface, as surgical debridement might halt progression and joint invasion, avoiding worsening of the prognosis. The success of arthroscopic treatment for infectious arthritis with decreased morbidity and postoperative pain makes arthroscopy an excellent alternative to open surgery. The advantages such as minor trauma, short hospitalization time and short post operative rehabilitation period as well as good cosmetic and therapeutic results should lead to a more frequent use of arthroscopy as early as possible as an adjuvant for the tuberculous joint. However, tuberculosis can involve any joints, bone and soft tissue (tendon) of the foot and ankle and surgeons should equip with various arthroscopic and endoscopic techniques in order to deal with the various situations of tuberculosis of the foot and ankle.

Rare Coexistence of Giant Cell Tumor and Tuberculosis of the Metatarsal

The coexistence of giant cell tumor (GCT) and metatarsal bone tuberculosis (TB) of the foot has not been reported in the literature so far. We report a case of a 25-year-old male who presented with severe pain and swelling of his left foot for two months, which was aggravated on walking. A plain radiograph of the left foot showed an expansile eccentric lytic lesion of the base of the second metatarsal. He underwent extended curettage and antibiotic cement spacer insertion. Biopsy of the lesion revealed the presence of GCT, while tissue cultures were positive for Mycobacterium tuberculosis. He was treated with standard anti-tubercular treatment (ATT), four drug regimens for twelve months. He then underwent reconstruction of the second metatarsal with cement spacer exit and iliac crest bone grafting, following which the cultures were negative for TB. The diagnosis of this unexpected and unique combination of pathologies (GCT and TB) depends on a high index of clinical suspicion, relevant investigations, and accurate histological diagnosis.

Tuberculosis of Calcaneus - A Case Report and Review of Literature

Introduction

Osteoarticular tuberculosis (TB) constitutes 1-3 % of cases and about 10% of osteoarticular TB affects the foot and ankle. In foot, TB calcaneus is the most commonly affected bone.

Case Report

A 21-year-old male presented with pain, swelling in the right heel for 5 months and difficulty in walking for 2 months. Plain X-ray (axial) view of calcaneus showed a lytic lesion in calcaneus. Biopsy was done under local anaesthesia and histologic examination revealed a characteristic granuloma, caseous necrosis, and Langhans giant cells which confirmed our diagnosis. The patient was treated with anti-TB chemotherapy for 12 months. Radiographs at 18 months follow-up showed a healed lesion. At present, the patient is comfortable with no complaints.

Discussion and Conclusion

TB calcaneus is rare condition and a high index of clinical suspicion along with imaging studies helps in diagnosis. Conservative management with anti-TB chemotherapy for adequate duration helps in complete resolution of the infection with good functional results.

Paediatric osteoarticular tuberculosis: A review

OBJECTIVE

Tuberculosis (TB) is endemic in Indian subcontinent. The paediatric osteoarticular (OA) TB is frequently confused with suppurative etiology as both can have similar clinical, radiological and laboratory presentation. It has become a health hazard due to its association with immunosuppression diseases such as HIV, chronic renal and liver diseases and use of immunosuppressive drugs. Furthermore, there is much dilemma regarding the drug choice and duration of anti tubercular treatment among practicing clinicians. This mini review briefs the reader to the classical regional and atypical tubercular clinical presentations, imaging and laboratory investigations and management for bone and joint TB.

METHODS

The article details both common and atypical clinical tubercular presentations, the approach to diagnosis, drug treatment and surgical indications in paediatric OA TB.

RESULTS

OA TB in the paediatric age group is uncommon. Diagnosis is often delayed because of diseases' nonspecific symptoms, non-characteristic imaging findings and lack of awareness of the condition. Multidrug antitubercular chemotherapy remains the anchor sheet of tubercular treatment in children. Surgery is needed in select cases to obtain tissue, to ensure better joint movement, prevent deformities and restore neurological function.

CONCLUSIONS

TB can have varied presentation and therefore it is essential to keep tubercular infection in differential diagnosis while working up for any infective pathology. Conservative treatment produces good results in vast majority of cases. Surgery is reserved for select indications.

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.

Arthroscopic management for early-stage tuberculosis of the ankle

Background

Due to atypical clinical presentation, wide use of antibiotics, and lack of specificity in diagnosis, diagnosis of tubercular (TB) infection in joints is increasingly difficult, and misdiagnosis is common. The use of arthroscopy for the diagnosis and treatment of early-stage ankle TB has rarely been reported. This case series intended to present the clinical outcomes of arthroscopic management for early-stage ankle TB.

Methods

Fifteen patients with chronic synovitis of the ankle and suspicious cause of early-stage ankle TB underwent arthroscopic treatment from April 1, 2010, to March 31, 2016. These cases all failed to confirm diagnosis of TB by ankle arthrocentesis. They included seven males and eight females with an average age of 37.5 (8 to 70) in the study. Among them, five cases had history of pulmonary tuberculosis, and six had history of trauma. The procedure included synovial membrane biopsy and debridement. The diagnosis was confirmed by pathologic examination and culture. The treatment was combined with systemic anti-tuberculous drugs. Follow-up measurements included VAS score, AOFAS score, ESR, CRP, and MRI.

Results

After arthroscopic management, 13 cases confirmed TB by pathologic examination and culture, and two cases still remained clinically suspected TB; the rate of confirmed case was 87%. The incision healed well in all cases, and no serious complications were observed. There were significant differences in VAS scores, AOFAS scores, ESR, and CRP between before and after treatment (P < 0.01). Joint swelling disappeared or was relieved after 2 months in most patients. Ankle swelling and pain in one patient was improved after changing anti-tuberculous drugs. MRI suggested that all patients had effusion in the articular cavity, accompanied by bone edema of the distal tibia and talus before the treatment. After the surgery, the effusion was significantly reduced, and the signal of bone edema almost disappeared. No recurrent TB was found during the follow-ups.

Conclusion

Arthroscopic management for early-stage ankle TB is minimally invasive, safe, and reliable. It can easily obtain samples from specific area of TB for further confirmation of the diagnosis, while the debridement can also assist in local disease control. For cases of highly suspicious joint TB, arthroscopic biopsy and debridement after transient anti-TB treatment is recommended.

Level of evidence

Level IV, therapeutic case series

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1048-y) contains supplementary material, which is available to authorized users.

Diagnosis and treatment of tuberculosis of the foot and ankle-A literature review

Foot osteoarticular tuberculosis is uncommon. Late diagnosis and sub-optimal management can lead to significant morbidity, deformity and even death. Preservation of life, limb and function can be achieved with prompt diagnosis and treatment. In 1882, Robert Koch published his discovery of mycobacterium tuberculosis as the causative agent of tuberculosis (TB), and showed the disease was infectious rather than inherited. Over two centuries later, TB remains one of the top 10 causes of death worldwide. Whilst in 90% of cases TB infects the respiratory system, in 10% it is extrapulmonary and can infect the skeletal, nervous, lymphatic and genitourinary systems. The spine is the most frequently affected site in the musculoskeletal system and this is known as Pott's disease. The foot and ankle is affected in only 0.13% cases of extrapulmonary TB. A high index of suspicion is thus required. This infrequency in incidence, heterogeneity of its presentation along with the difficulty in early diagnosis often causes significant delays in its treatment and hence results in a considerable disability. The medical treatment is well established but the role of surgery, its usefulness and its correct timing remain controversial. The main diagnostic issues include imaging being non-specific. Plain radiographs remain the first line imaging modality. MRI and CT scans provide greater detail and capture the disease at an earlier stage. Microbiological testing has low sensitivity and specificity becasue TB lesions are paucibacillary. Bone biopsy is of significant diagnostic value as it not only allows histological examination to detect granulomas but enables sensitivity and resistance testing of anti-tuberculous therapy (ATT). Issues relating to treatment include timing, duration, combination of chemotherapy and the challenge of multi drug resistant tuberculosis MDR-TB. The selection and timing of appropriate surgical techniques and optimal duration of follow-up are further points to consider. In this article we aim to review the literature on diagnosis and treatment of foot and ankle TB.

Unusual Presentation of Tuberculosis of Subtalar Joint

Introduction:

A case of seronegative variety of subtalar joint arthritis was treated with subtalar joint fusion surgery. In spite of perfect execution of surgery, fusion did not occur. It was only at a revision surgery that case could be diagnosed as a case of tuberculosis of subtalar joint.

Case Report:

Elderly female was operated for seronegative subtalar joint arthritis with fusion plus primary bone grafting. Fusion did not progress in spite of every added efforts such as extended immobilization, calcium supplements, and antibiotic therapy. Revision surgery was undertaken considering the reason of failure being a low-grade infection. At a revision surgery, case was diagnosed as a case of tuberculosis of subtalar joint, a very rare presentation. Fusion succeeded just with addition of antituberculous therapy supported with short-term immobilization.

Conclusion:

Tuberculosis of the foot and ankle joints, though are rare, they can mimic like many other disorders. In developing countries, a high index of suspicion is warranted to early diagnose it.

Ankle tuberculosis. A case in childhood

Articular tuberculosis of the ankle joint is a rare presentation of skeletal tuberculosis (10% of cases). This unusual location and the low index of clinical suspicion leads to delays in diagnosis and treatment. Radiographic and analytic studies are unspecific in the first stage. CAT and MRI are useful in diagnosis. Chemotherapy is the mainstay of treatment and surgery is often required to establish the diagnosis and in the treatment. We report a case of ankle tuberculosis in a 22 month-old child. The diagnosis was confirmed by synovial biopsy. There was no patient or family contact with tuberculosis patients. There was no risk factor. There was no lung disease. Diagnosis was made 1 year after onset of symptoms. The treatment was with chemotherapy and surgery was performed as preventive treatment of equinus deformity and osteoarthritis. Good clinical and functional outcome was achieved after 20 years of follow up.

Role of Surgery in Management of Osteo-Articular Tuberculosis of the Foot and Ankle

Background:

Tuberculosis of the foot and ankle still remains to be a significant problem, especially in the developing countries, and with an increase in incidence in immunosuppressed patients. Treatment is mainly medical using multidrug chemotherapy; surgical interventions range from biopsy, synovectomy and debridement, to joint preserving procedures like distraction in early cases, and arthrodesis of hindfoot joints and the ankle in advanced disease with joint destruction.

Surgical Options: All procedures should be done after initiating appropriate medical management. The ankle is the commonest joint needing intervention, followed by the subtalar and talo-navicular joint. Forefoot TB limited to the bone rarely needs surgical intervention except when the infective focus is threatening to invade a joint. Articular disease can spread rapidly, so early diagnosis and treatment can influence the outcome. Surgical interventions may need to be modified in the presence of sinuses and active disease; fusions need compression, and implants have to be chosen wisely. External fixators are the commonest devices used for compression in active disease, but intramedullary nails better stabilize pantalar arthrodesis. Arthroscopy has become a valuable tool for visualizing the ankle and hindfoot joints, and is an excellent adjunct for arthrodesis by minimally invasive methods.

Conclusion:

Although Osteoarticular Tb involving the foot and ankle is largely managed with chemotherapy, specific indications for surgical intervention exist. Timely done procedures could limit joint destruction, or prevent spread to adjacent joints. Fusions are the commonest procedure for sequelae of disease or for correcting residual deformity.

Two-stage operation to treat destructive midfoot tuberculosis: 14 cases experience

INTRODUCTION

Tuberculosis (TB) in midfoot is often secondary to tuberculosis elsewhere in the body. The experience and literatures to treat midfoot tuberculosis are rare. Up until now, no successful method is reported to treat midfoot tuberculosis.

HYPOTHESIS

Stage surgery is an effective method to treat midfoot bone TB.

MATERIAL AND METHODS

Between January 2008 to January 2011, 14 patients who were diagnosed midfoot tuberculosis and suffered stage operation were enrolled. All the patients had been diagnosed definitely relying on imaging examination and laboratory tests preoperatively. Two-stage operation was performed to all patients. At the first stage, TB tissue and infective tissue were completely removed and replaced by antibiotic bone cement. Normal foot length and arch would be restored and maintained by K-wires and external fixators. At the second stage, autologous iliac and allogeneic bone graft were used to replace bone cement and by fixed by locking plates. American Orthopaedic Foot and Ankle Society (AOFAS), SF-36 and visual analogue scale (VAS) pain score were recorded at the last follow-up.

RESULTS

The average bone union time was 3.8 (range 3-6) months. There is no case of local recurrence or skin sinus. Neither implant broken nor screw loosen was present in this study. The AOFAS score was increased from 51.7±6.8 (range 43-61) preoperatively to 82.9±3.9 (range 76-90) postoperatively (P<0.001). The SF-36 score increased from 46.1±6.1 preoperatively to 83.1±5.4 postoperatively (P<0.001). The VAS score decreased from 6.1±1.1 preoperatively to 1.4±0.9 points postoperatively (P<0.001).

DISCUSSION

Stage operation is an effective treatment to stage III, IV midfoot tuberculosis.

LEVELS OF EVIDENCE

Level IV, retrospective.

An exceptional location of tuberculous arthritis: The metatarsal phalangeal joint

Osteoarticular tuberculosis is a rare type of tuberculosis. The spine is the most frequent location, while peripheral locations in the limbs are rare. We report a case of tuberculous osteoarthritis of the metatarsophalangeal joint of the first ray of the foot in a 48-year-old woman. The patient presented with painful swelling of the dorsum of the big toe, insidiously evolving for 6months. Diagnosis was obtained with histological study after surgical biopsy. Antitubercular chemotherapy for 12months promoted healing. Through this clinical case the authors describe the epidemiological, diagnostic features, and treatment of osteoarticular tuberculosis and discuss the causes of delayed diagnosis often encountered in these exceptional locations and differential diagnoses, gout in particular, for this particular case.

Poncet's disease (tubercular rheumatism) with primary involvement of the foot - A case report

We present a rare case with primary tubercular involvement of the foot, accomapanied by a reactionary (aseptic) effusion in the knee. The diagnosis was delayed due to unusual presentation and also because of failure to elicit a detailed history. Incision and drainage of the foot abscess and antitubercular drug therapy resulted in satisfactory control of tubercular infection. Polyarticular presentation may not always signify active tubercular focus in every joint; it may reflect reactive synovitis known as Poncet's disease, which resolves with multidrug antitubercular therapy.A multidispilinary approach should be adopted and chest physicians, rheumatologists and orthopaedic surgeons should work in close association to correctly diagnose and treatthis condition.

Tuberculosis of Calcaneum - A Rare presentation

Introduction:

Tuberculosis of calcaneum is a rare entity. Osteoarticular tuberculosis of foot is uncommon and that of calcaneum is very rare. In children, diagnosis is often delayed as clinical presentation is non-specific and awareness is low due to its rare presentation. Also pediatric tuberculosis has traditionally received a lower priority than adult TB in National TB programmes.

Case presentation:

8 yr old girl presented to OPD with swelling and dull aching pain over left heel. Radiograph of calcaneum showed small lytic puctate lesions in the calcaneum. Further investigations showed presence of multiple tuberculous bacilli. Anti-Kochs treatment was started immediately and patient was treated conservatively. Four drugs (HRZE) were prescribed for a period of 12 months. Radiographs at 2 years follow-up showed a healed lesion.

Conclusion:

Rare and unusual locations of osteoarticular TB often pose a problem of differential diagnosis. Meticulous history and clinical examination helps in reaching the diagnosis. Start of AKT drugs as soon as reports show presence of tubercular bacilli plays a vital role in treatment as well as functional outcome of the patient.

An Isolated Displaced Fracture of the Coracoid Process Treated with Open reduction and internal fixation - A Case Report and Review of Literature

INTRODUCTION

Isolated coracoid fractures are rare and few scattered cases are reported in literature. Coracoid fractures can be missed and the treatment for coracoid process fractures is still controversial. The case presented here is of an isolated coracoid process fracture which was treated surgically.

CASE REPORT

A 15-years old male presented after 4 days of injury complaining of persistent pain in the right shoulder following a jerk during bowling. Physical examination revealed tenderness in the left shoulder. There was pain on abduction and external rotation. The neurovascular examination was normal. Osseous avulsion of the distal tip of the coracoid process was confirmed by CT and MRI. The short head of the biceps and coracobrachialis was attached to the avulsed tip, while the pectoralis minor was attached to the coracoid base. The case was managed by open reduction and fixation with a 3.5mm cannulated screw and washer.

CONCLUSION

Isolated coracoid fracture is a rare entity causing impairment of upper limb movement. It can be diagnosed more accurately by MRI scan and CT scan. In case of young highly demanding individuals like athletes surgical management may be a better option as compared to conservative treatment to achieve early use of the extremity, good radiological union and clinical function.

Magnetic resonance imaging evaluation of tubercular arthritis of the ankle and foot

BACKGROUND

Ankle and foot tuberculosis is relatively uncommon. Magnetic resonance imaging (MRI) is highly sensitive in detecting the changes but there is limited experience with MRI evaluation and differentiation from other mono-articular arthritis, particularly pyogenic arthritis, is a challenge.

PURPOSE

To report MRI findings in ankle and foot tuberculosis.

MATERIAL AND METHODS

MRI was performed in 17 selected patients with ankle and foot tuberculosis. T1-weighted, proton density (PD) weighted, T2-weighted, and postcontrast sequences were performed in multiple imaging planes. Recorded findings included: number of bones involved; specific bones involved; extent of involvement; erosions; joint effusion, synovial thickening, tenosynovitis; joint effusion; adjacent soft-tissue changes; and involvement of sinus tarsi. Clinical data of all patients were also reviewed. Radiographic correlation at the time of MRI was available in selected patients.

RESULTS

The most common abnormality was synovial thickening. Signal abnormality was noted most frequently in the talus (n = 14). Erosions and intra-osseous abscesses were noted in 10 (58%) and eight (47%) patients, respectively. Tenosynovitis was present in eight (47%) patients. Soft tissue changes were noted in all patients, including abscesses in 13 patients (76%).

CONCLUSION

A multiplicity of findings (both osseous and extra-osseous) on MRI favors the diagnosis of tuberculosis. Three findings (intra-osseous abscess, soft tissue abscess, tenosynovitis), when present together, have a high sensitivity and specificity.

Isolated Tuberculous Peroneal Tenosynovitis: A Case Report

Tuberculosis (TB) of osteoarticular sites constitutes less than 3% of total patients with tuberculosis. Involvement of the foot and ankle is less than 0.3% of total disease. Even in a country like India, where the incidence of TB is not uncommon, we do not encounter isolated tenosynovitis. We present a young man with bilateral tubercular peroneal tenosynovitis who was evaluated with relevant investigations and operated upon and started on antitubercular treatment (ATT) in consultation with the pulmonologist. After tenosynovectomy and commencement of ATT, the patient's symptoms improved.

Isolated C-C joint tuberculosis - A diagnostic dilemma

Painful lytic lesions of the foot raise a diagnostic dilemma for the foot surgeon. The localization of the lytic lesion in the mid foot is rare and isolated involvement of the calcaneo-cuboid (C-C) joint is even rarer. Early diagnosis is imperative in the mid foot to avoid rapid disease spread due to multiple venous interconnections. The diagnostic possibilities include infection, tumor (primary and metastasis), inflammatory arthritis, foreign body prick among others. The clues to rule out other differential diagnoses of lytic lesions can be history and examination, both clinical and radiographic but the gold standard for final diagnosis remains biopsy and histo-pathological examination. We describe two cases of lytic lesion around the calcaneo-cuboid joint and discuss the diagnostic dilemma. The lesions were diagnosed as tubercular in nature after histo-pathological examination of open biopsy. Both cases had complete resolution of lytic lesions and had fair functional outcome after completing the course of anti-tubercular therapy. Tuberculosis (TB) is making a worldwide resurgence due to the epidemic of HIV. In order to control this global epidemic of TB, it is important to know about all the possible presentations of the disease, including rare ones. Tuberculosis if diagnosed early in the disease course, when the pathology is localized, can result in good to fair results in the foot if adequately managed by anti-tubercular therapy.

LEVEL OF EVIDENCE

V.

Treatment and outcome of destructive tuberculosis of the talus

We describe a case of isolated destructive talar tuberculosis that is, to the best of our knowledge, the first reported case in Germany. Caseous talar necrosis was finally detected after repeated surgical debridements of an infection eight months after subtalar screw arthrodesis. Following the diagnosis of TB, we performed a total of three additional surgical revisions within a three-month period; these revisions included a talectomy and an induction of a septic tibiocalcaneal arthrodesis with an external fixator that was removed after solid fusion six months later. Following this treatment regime, which included pharmaceutical anti-tuberculosis therapy, the 50-year-old male patient was fitted with orthopaedic shoes. He resumed work as a professional farmer with a number of restrictions 12 months after the diagnosis and treatment of destructive talar tuberculosis.

Tuberculosis of the calcaneus in children

PURPOSE

To review 10 children with calcaneal tuberculosis in terms of presentation, healing, and functional outcome.

METHODS

Medical records of 7 boys and 3 girls aged 7 to 12 (mean, 9.8) years who presented with calcaneal tuberculosis were reviewed. The erythrocyte sedimentation rate of all patients was elevated. All patients presented with pain and swelling around the lateral malleolus and a 'heal-up' sign; 7 of them presented with an additional discharging sinus. Three patients had palpable lymph nodes in the right inguinal or left popliteal region. Symptoms had lasted for one month to 1.5 years. Two patients had healed tuberculosis in the lungs; 8 patients had no pulmonary involvement. Seven patients had a single lytic lesion in the calcaneal body (n=1), tuberosity (n=3), and extension to anterior process (n=3). Three patients had multiple lytic lesions in the calcaneum; one of them had bilateral involvement who had lesions in the phalanges, lumbar spine, and ulna. Two patients had subtalar joint involvement.

RESULTS

The mean follow-up period was 17 (range, 8-60) months. The erythrocyte sedimentation rate returned to normal after 3 months in 7 patients and after >6 months in 3 patients. The subtalar range of movement was normal in all except for 2 patients. One patient developed subtalar ankylosis. Sinuses healed in a mean of 10 (range, 2-16) weeks. No patient had pain on level walking after treatment. At 3 months, remineralisation of bone was evident in all patients. Sclerosis of cavity margins and sequestra resorption was noted from 6 to 9 months. No patient experienced recurrence.

CONCLUSION

The 'heel up' sign was common in children with calcaneal tuberculosis in this endemic region. The central granuloma-type presentation was the most common. Pathological fractures and involvement of the subtalar joint were not common. Subtalar joint involvement was a poor prognostic factor.

Isolated tuberculous osteomyelitis of the talonavicular joint without pulmonary involvement-a rare case report

Tuberculosis is one of the leading causes of death worldwide amongst curable diseases. It is estimated that one-third of the world's population has been diagnosed with tuberculosis infection [1]. The prevalence is on the rise with an estimated 9.4 million new cases per year worldwide [1]. Tuberculosis most commonly presents with pulmonary involvement. However, approximately 23-30% of patients found to be infected with tuberculosis have extrapulmonary symptoms [2]. Of those, only 1-3% have been found to have osseous disease. Skeletal involvement with a primary focus of tuberculosis usually affects major weight-bearing joints such as the hip and knee. Tuberculosis infections of the foot and ankle are very rare, accounting for 1% of all tuberculosis infections [2-4]. Difficulties arise in the timing of diagnosis, patient compliance of therapy and awareness of the less obvious presenting symptoms. Musculoskeletal tuberculosis, although rare, can be a problem. Its uncommon site, non-specific presenting symptoms and its ability to mimic numerous disorders make it more difficult to formulate a definitive diagnosis and, in turn, leads to therapeutic delays [5-7]. It is for this reason that we report this case in an effort to promote awareness.

Foot and ankle tuberculosis: case series and literature review

Foot and ankle tuberculosis (TB) is a rare presentation of skeletal TB. The uncommon site along with low index of clinical suspicion in the western world leads to delays in the diagnosis and treatment. This can make joint sparing procedures less successful, especially in the midfoot where the joints can often be interconnected. Plain radiographs have low sensitivity and specificity and cross sectional imaging in the form of MRI or CT is more reliable. Treatment involves the use of multiple anti-tuberculous drugs in the first instance, followed by surgery to address any symptomatic deformity and/or secondary degenerative changes. We present our experience on the management of this rare problem and review the literature on the clinical presentation, diagnosis, imaging modalities and treatment.