Devdatta Suhas Neogi

Tubercular infection after arthroscopic anterior cruciate ligament reconstruction.

PURPOSE Tubercular infection has not been described, to our knowledge, in the literature after anterior cruciate ligament (ACL) reconstruction, and, hence, the purpose of our case series was to describe our experience, evaluate the clinical and laboratory findings, and assess the treatment outcome. METHODS We performed a retrospective analysis of 1,152 cases of arthroscopic ACL reconstruction with autografts performed at our institution between January 1998 and May 2007. Tubercular infection was considered to be present in the setting of recurrent negative bacterial cultures but a positive result on microscopy, culture, histopathology, or polymerase chain reaction (PCR). All patients underwent arthroscopic lavage and synovectomy, followed by antitubercular therapy for 12 months. RESULTS We identified 8 patients (0.69%) with infection. Bone-patellar tendon-bone graft was used in 1 and hamstring graft in 7. All patients were immunocompetent. The mean time from surgery to presentation was 64.4 days (range, 23 to 152 days). Aspirate fluid staining and culture for acid-fast bacilli was negative in all cases, synovial tissue culture was positive in 3, characteristic histopathology was positive in 7, and PCR was positive in 6. A mean of 1.25 surgeries (range, 1 to 2) were performed. The mean length of follow-up in our series was 43.6 months (range, 25 to 73 months), with no reinfections. The mean postoperative Lysholm knee score was 80. CONCLUSIONS Tubercular infection as a complication after arthroscopic ACL reconstruction, though rare, should be kept in mind as a possible cause of infection in immunocompetent patients in zones endemic for tuberculosis. It should also be kept in mind in nonendemic areas, among immigrants from endemic areas, and in cases with persistent swelling and discharge, effusion with minimal inflammatory signs, and negative cultures. We recommend deoxyribonucleic acid-PCR testing for early diagnosis of tuberculosis. Arthroscopic debridement and antitubercular chemotherapy together are the mainstay of treatment.

Comparative study of single lateral locked plating versus double plating in type C bicondylar tibial plateau fractures.

Background: Bicondylar tibial plateau fractures are complex injuries and treatment is challenging. Ideal method is still controversial with risk of unsatisfactory results if not treated properly. Many different techniques of internal and external fixation are used. This study compares the clinical results in single locked plating versus dual plating (DP) using two incision approaches. Our hypothesis was that DP leads to less collapse and change in alignment at final followup compared with single plating. Materials and Methods: 61 cases of Type C tibial plateau fractures operated between January 2007 and June 2011 were included in this prospective study. All cases were operated either by single lateral locked plate by anterolateral approach or double plating through double incision. All cases were followed for a minimum of 24 months radiologically and clinically. The statistical analysis was performed using software SPSS 10.0 to analyze the data. Results: Twenty nine patients in a single lateral locked plate and 32 patients in a double plating group were followed for minimum 2 years. All fractures healed, however there was a significant incidence of malalignment in the single lateral plating group. Though there was a significant increase in soft tissue issues with the double plating group; however, there was only 3.12% incidence of deep infection. There was no significant difference in Hospital for special surgery score at 2 years followup. Conclusion: Double plating through two incisions resulted in a better limb alignment and joint reduction with an acceptable soft tissue complication rate.

Skeletal muscle tuberculosis simultaneously involving multiple sites.

Tuberculosis (TB) continues to be a public health problem in both developing and industrialized countries. TB of the skeletal muscle is very rare. We present a case of the simultaneous involvement of skeletal muscles in multiple sites in an 11-year-old immune-competent female patient. All physicians should have adequate knowledge of TB and awareness of its atypical presentations to ensure the proper management of such patients.

An unusual cause of Wartenberg’s syndrome: tuberculosis of brachioradialis muscle

World wide there has been an increase in incidence of tuberculosis with unusual site of infections being reported in increasing number more so in association with HIV/AIDS. Isolated neuropathy of superficial branch of radial nerve or Wartenberg’s syndrome is a rarely recognized pathology. We report one such case in association with tubercular infection of brachioradialis muscle without underlying bony involvement. All physicians should have adequate knowledge of tuberculosis and awareness of its atypical presentations to ensure proper management of such patients.

Rifampicin use in MRSA infections: will it add to the emergence of multidrug-resistant tuberculosis in developing countries?

disease may develop at any time later, depending on his or her immune status. Trials have shown that the use of rifampicin as monotherapy in latent TB prophylaxis may not lead to the emergence of resistance, whereas in active disease such therapy may do so. The presence of MRSA, as with any infection, may decrease the immune status and may cause a fl are up of a latent disease. The clinical impact of multidrug-resistant (MDR) TB is enormous: the rate of treatment failure with standard regimens is high, and treatment with second-line regimens is toxic, is expensive, and is associated with a substantial incidence of treatment failure and death. For this reason, efforts to “protect” rifampicin have been promulgated by organizations such as the World Health Organization and the International Union Against Tuberculosis and Lung Disease. These measures include restriction of rifampicin use to the treatment of active TB, promotion of the use of fi xed-dose combinations to prevent monotherapy, the use of non-rifampicin-containing regimens during the continuation phase of TB treatment, and supervision of the administration of all rifampicin-based regimens. The use of rifampicin for indications other than active TB, and the self-administration of rifampicin are strongly discouraged by these organizations. An important, unresolved question regarding the use of rifampicin regimens for indications other than TB is whether their use will result in the development of rifampicinresistant TB. However, what is very well known is that rifampicin is the cornerstone of modern therapy for TB. The effective prevention and control of infections caused by MRSA depends on the practice of infection-control measures such as hand-washing, theater discipline, and respect for soft tissues during surgery. Minimizing risk factors and paying attention to alternative cost-effective therapies, as per guidelines, may ease the problem of the management of MRSA infections and at the same time not add to the emergence of MDR TB. Received: April 11, 2008 / Accepted: September 2, 2008

Fat emboli syndrome in a nondisplaced tibia fracture.

To the Editor: We read with interest the case report ‘‘Fat Emboli Syndrome in a Nondisplaced Tibia Fracture’’ by Sara et al. It is essential for the residents to keep fat embolism in mind and to periodically read something about it because eyes cannot see what the mind does not know. We would like to highlight an important association that is missing in this case report, ie, the association of ‘‘football and fat embolism.’’ Young amateur soccer players sustaining tibial shaft fractures are in a state of dehydration at the time of fracture. The postinjury order of ‘‘nothing by mouth’’ often without the orders of ‘‘intravenous fluids’’ deteriorates the hydration. The importance of proper preoperative rehydration in prevention of ‘‘fat embolism syndrome (FES),’’ particularly when injury was sustained during heavy exercise, has been emphasized by McDermott et al. Correction of hypovolemic shock has long been considered as a preventive measure of FES. Animal studies have revealed the mortality increasing relationship between dehydration and FES. Dehydration increases blood viscosity, decreases the suspension ability of the blood, and impedes microcirculation. Adequate volume supplementation decreases this ‘‘sludging’’ effect. So, we agree that an eye should be kept on FES after any long bone fracture; we add that an eagle’s eye is required if that fracture has happened during contact/ high-impact sport in a young medically fit adult.