Osteoarticular tuberculosis – diagnostic solutions in a disease endemic region

Background: We conducted a study of osteoarticular tuberculosis in patients from private and public settings in a disease endemic area. Our objective was to assess the role of mycobacterial culture and polymerase chain reaction (PCR) in the diagnosis of osteoarticular tuberculosis (TB) in settings where only clinical and imaging diagnosis form the basis for treatment. Methodology: Ninety-three consecutive specimens collected from clinically suspected patients of osteoarticular TB were screened for bacterial culture, mycobacterial culture and in-house nested PCR. In addition, specimens were examined by imaging and histopathology. Ten specimens collected from patients suffering from other bone diseases were included as negative controls. Results: Of the 93 clinically suspected TB patients, mycobacterial culture was positive for Mycobacterium tuberculosis (MTB) in 47 (51%) patients who were confirmed as definite TB cases. Of the remaining patients, 16 (17%) were diagnosed as probable, 19 (20%) as possible, and 11 (12%) as only clinically suspected TB cases. In-house nested PCR was positive in 65 (70%) cases. Fifteen patients were resistant to one or more anti-tuberculous drugs; twelve patients were multi-drug resistant, two of whom were extensively drug resistant. Conclusion: Mycobacterial cultures using liquid media with susceptibility should form the backbone of management of osteoarticular TB. Nested PCR enhances the sensitivity if performed in addition to culture.

Tumor-induced osteomalacia: experience from three tertiary care centers in India

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by recalcitrant hypophosphatemia. Reports from the Indian subcontinent are scarce, with most being single center experiences involving few patients. Herein, we conducted a retrospective analysis of 30 patients of TIO diagnosed at three tertiary care hospitals in India. Patients with persistent hypophosphatemia (despite correction of hypovitaminosis D), normocalcemia, elevated alkaline phosphatase, low TmP/GFR and elevated or 'inappropriately normal' FGF23 levels were labeled as having TIO. They were sequentially subjected to functional followed by anatomical imaging. Patients with a well-localized tumor underwent excision; others were put on phosphorous and calcitriol supplementation. The mean age at presentation was 39.6 years with female:male ratio of 3:2. Bone pain (83.3%) and proximal myopathy (70%) were the chief complaints; 40% of cases had fractures. The mean delay in diagnosis was 3.8 years. Tumors were clinically detectable in four patients (13.3%). The mean serum phosphate was 0.50 mmol/L with a median serum FGF23 level of 518 RU/mL. Somatostatin receptor-based scintigraphy was found to be superior to FDG-PET in tumor localization. Lower extremities were the most common site of the tumor (72%). Tumor size was positively correlated with serum FGF23 levels. Twenty-two patients underwent tumor resection and 16 of them had phosphaturic mesenchymal tumors. Surgical excision led to cure in 72.7% of patients whereas disease persistence and disease recurrence were seen in 18.2% and 9.1% of cases, respectively. At the last follow-up, serum phosphate in the surgically treated group was significantly higher than in the medically managed group.

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.

"Floating knee," an Uncommon Injury: Analysis of 12 Cases

Objective

Floating knee injuries are complex injuries and are usually caused by high-velocity trauma. These injuries are often associated with life treating injuries, which should take precedent over extremity injuries. The authors reviewed the outcomes of floating knee injuries managed in this institute from 2003 to 2015.

Method

A retrospective study was conducted of all patients with floating knee injuries from2003 to 2015. Twelve patients were included in the study. Data related to fracture type, associated injuries, treatment modalities, and complications were noted. Functional assessment was performed using the modified Karlstrom and Olerud criteria after complete bony union.

Result

The mechanism of injury was motor vehicle accident in all patients. The mean follow up was four years. The mean age of patients was 34.75 year. The mean union time was 6.5 months in femurs and 6.7 month in tibias. The complications were knee stiffness, delayed union, and infection. According to modified Karlstrom criteria, there were three - excellent, five - good, three - fair, and one poor result.

Conclusion

Floating knee injuries are severe injuries and are usually associated with multi-organ injuries. Early detection and appropriate management of associated injuries, early fixation of fractures, and postoperative rehabilitation are needed for good outcome. Complications are frequent, in the form of delayed union, knee stiffness, and infection.

CT-guided percutaneous sacroiliac stabilization in unstable pelvic fractures: a safe and accurate technique

OBJECTIVE

The use of open reduction and internal fixation (ORIF) for unstable pelvic injuries is associated with extensive blood loss, iatrogenic neurovascular injury, and infection. Moreover, the placement of sacroiliac (SI) screws is a blinded procedure, guided primarily by palpation and two-dimensional radiological screening, which demands expertise. The complex three-dimensional anatomy of SI joint and its proximity to neurovascular structure require a safe and precise technique. Computed tomography (CT)-guided SI joint stabilization allows an accurate intra-operative assessment of screw placement. This study demonstrated a technique of CT-guided closed reduction and screw fixation of the SI joint in unstable pelvic fractures.

METHODS

This was a retrospective non-randomized cohort study conducted at a tertiary care hospital. Six patients with unstable pelvic fractures were operated; the anterior rim was stabilized first by ORIF with plate on the superior and anterior aspects of the pubic symphysis. Subsequently, the posterior stabilization was made percutaneously under CT guidance with a 7-mm cannulated cancellous screw.

RESULTS

The mean operative time was 48 min (35-90 min), the mean effective radiation dose was 9.32 (4.97-13.27), and the mean follow-up was 26 months (6-72 months). All patients had satisfactory healing, with near-anatomic reduction and no complications, except in one case where the plate broke at 61 months post surgery, but no intervention was required. The mean VAS score at the final follow-up was 1.8, and all patients returned to their original occupation without any limitations.

CONCLUSION

CT-guided SI joint stabilization offers many advantages, including safe and accurate screw placement, reduced operating time, decreased blood loss, early definitive fixation, immediate mobilization, and fewer infections and wound complications.

Radiation mapping inside the bunkers of medium energy accelerators using a robotic carrier

The knowledge of ambient and peak radiation levels prevailing inside the bunkers of the accelerator facilities is essential in assessing the accidental human exposure inside the bunkers and in protecting sensitive electronic equipments by minimizing the exposure to high intensity mixed radiation fields. Radiation field mapping dynamically, inside bunkers are rare, though generally dose-rate data are available in every particle accelerator facilities at specific locations. Taking into account of the fact that the existing neutron fields with a spread of energy from thermal up to the energy of the accelerated charged projectiles, prompt photons and other particles prevailing during cyclotron operation inside the bunkers, neutron and gamma survey meters with extended energy ranges attached to a robotic carrier have been used. The robotic carrier movement was controlled remotely from the control room with the help of multiple visible range optical cameras provided inside the bunkers and the wireless and wired protocols of communication helped its movement and data acquisition from the survey meters. Variable Energy Cyclotron Centre, Kolkata has positive ion accelerating facilities such as K-130 room Temperature Cyclotron, K-500 Super Conducting Cyclotron and a forthcoming 30 MeV Proton Medical Cyclotron with high beam current. The dose rates data for K-130 Room Temperature Cyclotron, VECC were collected for various energies of alpha and proton beams losing their total energy at different stages on different materials at various strategic locations of radiological importance inside the bunkers. The measurements established that radiation levels inside the machine bunker dynamically change depending upon the beam type, beam energy, machine operation parameters, deflector condition, slit placement and central region beam tuning. The obtained inference from the association of dose rates with the parameters like beam intensity, type and energy of projectiles, helped in improving the primary beam transmission and minimizing the ambient radiation fields inside the bunkers.

Second Ray Amputation in Diabetic Foot – Functionally Better than Proximal Foot Amputations, but Beware of Charcot Arthropathy: A Case Report and Review of Literature

Introduction:

Lower limb amputations secondary to diabetic foot infection/osteomyelitis (OM) are the most common cause for non-traumatic amputations of the lower extremity. Hind/midfoot amputations are commonly done for metatarsal (MT) OM. They are, however, associated with higher complication and revision rates and often lead to below knee amputation. In comparison, distal/forefoot toe disarticulation/ray amputation (R amp) have lesser revision rates/complications and give better functional outcome. Here, we report a case of 2nd R amp with an uncommon complication.

Case Report:

A 42-year-old male with uncontrolled diabetes and bilateral diabetic neuropathy presented with discharging sinus over plantar aspect of the left foot since 1 week. There was no evidence of underlying OM on MRI. Wound healed with soft-tissue debridement and empirical antibiotics (culture negative) for 2 weeks. Re-debridement was done for a wound gape 6 weeks later. Infection resolved with targeted antibiotics (oral ciprofloxacin and doxycycline) for Enterobacter cloacae given for 1 month. Six months later, he developed pain and swelling in the left foot following prolonged barefoot walking and possible injury with a stone. There was local redness, swelling, and a plantar sinus. MRI revealed septic arthritis of the left 2nd metatarsophalangeal (MTP) joint, OM of the 2nd MT head, and an encapsulated soft-tissue abscess. Aggressive debridement with 2nd R amp and careful separation of encapsulated abscess was done leaving behind base of 2nd MT to maintain stability of the Lisfranc joint. Wound healed primarily. Targeted antibiotics for Methicillin Susceptible Staphylococcus aureus were given for 6 weeks. Good diabetic control and avoiding bare foot walking were advised and he is infection free, fully functional, and asymptomatic at 36 months. However, he was noted to have developed valgus deformity of the midfoot secondary to Charcot osteoarthropathy of the Lisfranc joints at 36 months follow-up, involving 1st, 3rd, and 4th TMT joints. The other foot did not show any evidence of Charcot arthropathy.

Conclusion:

Recurrent wound infections with subsequent OM are a common feature of diabetic foot. R amps have better functional outcomes with preserved foot stability, shorter length of hospitalization, and associated costs as compared to hind/midfoot amputations. They may, however, develop Charcot osteoarthropathy due to the void between adjoining MTs resulting in altered forces across the Lisfranc joints. Surgeons must beware of this complication, especially following R amps and monitor these patients with serial clinical and radiographic examination.