Onkar N. Nagi

Tuberculosis of the foot and ankle.

Tuberculosis of the foot and ankle is an uncommon presentation of skeletal tuberculosis. The uncommon site, lack of awareness, and ability to mimic other disorders clinically and on radiographs, leads to diagnostic and therapeutic delays. In the early stages and when the disease is limited to bone, medical treatment leads to excellent healing and limited residual disabilities. Joint involvement occurs because of spread from a periarticular bony focus, and in the midfoot, the disease may spread to involve all the interconnected joints, leading to a stiff foot and residual deformities. Of 74 cases reviewed, the calcaneus was involved most commonly, followed by infection of the midtarsal, Lisfranc joints, and ankle. The most common radiologic finding is that of osteoporosis, which may be intense: cancellous bone involvement may present as a cystic lesion with or without sequestrum. Computed tomography scans and magnetic resonance imaging are helpful examinations. Because the disease is paucibacillary, a positive acid fast bacilli culture is rare and the diagnosis usually is confirmed by obtaining granulomatous tissue on biopsy. The treatment basically is medical, with surgical intervention being reserved for patients with intractable disease or as a salvage procedure for patients with deformed hindfoot joints.

Tuberculosis of Bones and Joints of the Foot: An Analysis of 22 Cases

Skeletal tuberculosis constitutes 1% to 3% of extrapulmonary cases and involvement of foot bones is rare. Lack of awareness and a confusing clinical and radiological picture often lead to a delay in diagnosis. We reviewed 23 feet seen over a 3.5-year period. Most cases were children or young adults less than 40 years of age; isolated bony involvement was seen in 10 feet, with the calcaneus being involved in five cases. Articular involvement at presentation was seen in 13 cases and these cases had significantly higher delays in diagnosis. Twenty cases responded to antitubercular therapy alone while one case had to be operated (there was one fatal outcome). Complete resolution of sequestra was seen with antitubercular therapy alone. The results were better in cases with isolated bony involvement, while cases with joint involvement had residual sequelae in the form of stiffness or pain. Two patients were advised arthrodesis. Early diagnosis and antitubercular therapy is essential to prevent joint involvement from periarticular bony lesions; surgical intervention is rarely needed. A high index of suspicion has to be maintained in high risk groups like Asian immigrants. Concomitant extraskeletal lesions may not always be present.

Open reduction, internal fixation and fibular autografting for neglected fracture of the femoral neck

Neglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or avascular necrosis (AVN). We treated 52 cases by open reduction, fixation by compression screw and a free fibular graft. The mean delay between injury and operation was 5.1 months. Of 40 fractures assessed at a mean of 58.8 months (24 to 153), 38 were found to be united and two, owing to surgical errors, were not. Seven of eight heads which were avascular before operation revascularised without collapse, while seven others developed AVN after the procedure. At the last follow-up considerable collapse was apparent in five femoral heads, and 11 hips had developed coxa vara. The fibular graft had fractured in four cases. The hip had been penetrated by the screw in six cases and by the graft in three. Hip function was excellent in seven patients, good in 21 and fair in seven. Five patients had poor results. Incorporation of the fibular graft was seen after four years: in many cases the graft had been almost completely resorbed. We recommend this procedure for the treatment of neglected fractures of the neck of the femur in young adults to reduce resorption of the neck, AVN and nonunion.

Tuberculosis of the sternoclavicular joints

From May 1991 to December 1997, we treated 9 patients with tubercular arthritis in 10 sternoclavicular joints. The patients presented with a painful swelling (7 joints), painless swelling (2 joints) and a painless (?) discharging sinus (1 joint) having a mean duration of symptoms of 13 (6-32) months. The diagnosis was made with fine-needle aspiration or open biopsy. In 1 patient debridement of the joint was combined with open biopsy. All patients were initially put on a 4-drug regimen of antitubercular therapy (ATT). 2 joints not responding to closed treatment were surgically debrided after 2-3 months of ATT. Total duration of ATT was 14-18 months. At final follow-up after average 4.5 (1.5-7.5) years, all lesions had healed. 3 patients had mild limitation of shoulder motion, with no pain, and 2 patients had a cosmetically ugly scar at the site of the sinus or biopsy

Tuberculous osteomyelitis of the cuboid: a report of four cases.

Osteoarticular tuberculosis, although rare, has shown a resurgence in recent times, especially in immunocompromised patients. Involvement of the foot is infrequent, and the differential diagnosis is confusing, leading to diagnostic delays. We reviewed four cases of tuberculosis of the cuboid where the infection was limited to the bone without articular involvement. All four cases were adults and diagnostic delays were observed in all. Three of the cases had an osteolytic lesion on radiographs resembling a space-occupying lesion. Magnetic resonance imaging (MRI) or Computed tomography (CT) scans were helpful in three cases, and post-treatment MRI helped in evaluating outcome in one case. Antitubercular chemotherapy was sufficient to cause resolution of the lesion in three cases, while in one case surgical intervention was necessary. Since isolated osteomyelitis is usually seen only in the early stages of the disease process, early diagnosis and appropriate therapy are imperative to get good long-term results. Concomitant extraskeletal lesions are not always seen, nor is the organism cultured in a majority of the cases. Thus a high index of suspicion is mandatory in high-risk groups (immigrants, immunocompromised cases or those with history of contact); clinical and radiologic features, along with histopathologic evidence of granulomatous pathology should be sufficient to initiate therapy.

Bupivacaine/ketamine is superior to intra-articular ketamine analgesia following arthroscopic knee surgery

PurposeCentroneuraxial and parenteral administration of ketamine has been shown to produce analgesia. However, this analgesia is limited by adverse effects. The purpose of this study was to determine whether ketamine alone or in combination with bupivacaine provides superior pain relief after surgery in patients undergoing knee arthroscopy.MethodsSixty patients (classified as ASA status I or II) undergoing arthroscopic meniscus repair during general anesthesia were randomized to receive 1.0 mg·kg-1 ketamine (Group K), 0.25% bupivacaine (Group B) or a combination of 1.0 mg·kg-1 ketamine and 0.25% bupivacaine (Group BK) to a total volume of 20 mL by intra-articular route following surgery. Visual analogue score in the postanesthesia care unit at 0.5, 1, 2, 4, 6, 8, 12 and 24 hr after surgery, duration of analgesia and subsequent 24 hr consumption of rescue analgesic (dextroproxyphene/ acetaminophen) were evaluated.ResultsThe results showed significantly higher pain scores in Group K as compared to Group B and Group BK. The duration of analgesia was significantly shorter in Group K as compared to the other two groups (Group B = 5.7 ± 0.8; Group BK = 5.1 ± 1.1 vs Group K = 1.7 ± 0.9 hr; P < 0.05). However, 24 hr consumption of analgesic was similar in the three groups.ConclusionWe conclude that intra-articular bupivacaine-ket-amine combination provides better pain relief than intra-articu-lar ketamine after day care arthroscopic knee surgery.RésuméObjectifĽadministration centro-neuraxiale et parentérale de kétamine peut produire une analgésie, limitée toutefois par des effets indésirables. Nous avons voulu vérifier la qualité de ľanalgésie selon ľutilisation de kétamine seule ou en combinaison avec de la bupivacaïne à la suite ďune arthroscopie du genou.MéthodeSoixante patients, ďétat physique ASA I ou II, devant subir la réparation arthroscopique ďun ménisque sous anesthésie générale, ont été répartis au hasard pour recevoir 1,0 mg·kg-1 de kétamine (Groupe K), de la bupivacaïne à 0,25 % (Groupe B) ou une combinaison de 1,0 mg·kg-1 de kétamine et de bupivacaïne à 0,25 % (Groupe BK) dans un volume total de 20 mL administré par voie intra-articulaire après ľopération. Les scores de ľéchelle visuelle analogique 0,5, 1, 2, 4, 6, 8, 12 et 24 h après ľopération, la durée de ľanalgésie et les analgésiques supplémentaires pendant 24 h de plus (dextroproxyphène/acétaminophène) ont été enregistrés.RésultatsLes scores de douleur ont été significativement plus élevés chez les patients du Groupe K, comparé aux Groupes B et BK. La durée de ľanalgésie a été plus courte aussi dans le Groupe K (Groupe B = 5,7 ± 0,8 ; Groupe BK = 5,1 ± 1,1 vs GroupeK = 1,7 ± 0,9 h ; P < 0,05).La consommation ďanalgésique supplémentaire a toutefois été similaire dans les trois groupes.ConclusionĽadministration intra-articulaire ďune combinaison de bupivacaïne et de kétamine fournit une meilleure analgésie que la kétamine seule après une arthroscopie du genou en chirurgie ďun jour.Objectif Ľadministration centro-neuraxiale et parenterale de ketamine peut produire une analgesie, limitee toutefois par des effets indesirables. Nous avons voulu verifier la qualite de ľanalgesie selon ľutilisation de ketamine seule ou en combinaison avec de la bupivacaine a la suite ďune arthroscopie du genou.

Management of giant cell tumor of the tarsal bones: a report of nine cases and a review of the literature.

Giant cell tumor of the tarsal bones is uncommon and therapeutic options are ill defined. We report on nine cases of giant cell tumors of the tarsal bones treated by excision of the complete bone in 6 cases, partial excision in 1 case, and curettage and bone grafting in two cases. There was no recurrence at an average 25.8-month follow-up. Function after calcanectomy was satisfactory. Excision of the talus may or may not be followed by arthrodesis, but arthrodesis is essential after excision of all the other tarsal bones except the calcaneus. We advocate aggressive surgical measures in these cases; amputation should be reserved for recurrences only. Satisfactory function may be expected after excision of tarsal bones.

Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children

Summary Seventeen transcervical/basal femoral neck fractures in children were treated by free fibular graft and cancellous lag screw. Two cases were failures of a previous surgery, and 15 had been untreated for 3 weeks or more. Four cases had radiological evidence of avascular necrosis of the head and one of the neck preoperatively; five cases had neck resorption. At an average of 48.1 months postsurgery all fractures had united and there was only one new case of avascular necrosis. Four cases had coxa vara, and four cases had premature epiphyseal closure. There were 13 good, three fair, and one poor result(s) using Ratliffs criteria. We recommend this procedure in cases with delayed initial appearance or failed previous surgery. Complications of the procedure such as long screw/graft and fibular fracture are preventable. The incidence of coxa vara in cases with neck resorption may be reduced by adding subtrochanteric osteotomy to the procedure.

Un mélange de bupivacaïne et de kétamine est supérieur à la kétamine seule pour ľanalgésie intra-articulaire à la suite ďune arthroscopie du genou

PurposeCentroneuraxial and parenteral administration of ketamine has been shown to produce analgesia. However, this analgesia is limited by adverse effects. The purpose of this study was to determine whether ketamine alone or in combination with bupivacaine provides superior pain relief after surgery in patients undergoing knee arthroscopy.MethodsSixty patients (classified as ASA status I or II) undergoing arthroscopic meniscus repair during general anesthesia were randomized to receive 1.0 mg·kg-1 ketamine (Group K), 0.25% bupivacaine (Group B) or a combination of 1.0 mg·kg-1 ketamine and 0.25% bupivacaine (Group BK) to a total volume of 20 mL by intra-articular route following surgery. Visual analogue score in the postanesthesia care unit at 0.5, 1, 2, 4, 6, 8, 12 and 24 hr after surgery, duration of analgesia and subsequent 24 hr consumption of rescue analgesic (dextroproxyphene/ acetaminophen) were evaluated.ResultsThe results showed significantly higher pain scores in Group K as compared to Group B and Group BK. The duration of analgesia was significantly shorter in Group K as compared to the other two groups (Group B = 5.7 ± 0.8; Group BK = 5.1 ± 1.1 vs Group K = 1.7 ± 0.9 hr; P < 0.05). However, 24 hr consumption of analgesic was similar in the three groups.ConclusionWe conclude that intra-articular bupivacaine-ket-amine combination provides better pain relief than intra-articu-lar ketamine after day care arthroscopic knee surgery.RésuméObjectifĽadministration centro-neuraxiale et parentérale de kétamine peut produire une analgésie, limitée toutefois par des effets indésirables. Nous avons voulu vérifier la qualité de ľanalgésie selon ľutilisation de kétamine seule ou en combinaison avec de la bupivacaïne à la suite ďune arthroscopie du genou.MéthodeSoixante patients, ďétat physique ASA I ou II, devant subir la réparation arthroscopique ďun ménisque sous anesthésie générale, ont été répartis au hasard pour recevoir 1,0 mg·kg-1 de kétamine (Groupe K), de la bupivacaïne à 0,25 % (Groupe B) ou une combinaison de 1,0 mg·kg-1 de kétamine et de bupivacaïne à 0,25 % (Groupe BK) dans un volume total de 20 mL administré par voie intra-articulaire après ľopération. Les scores de ľéchelle visuelle analogique 0,5, 1, 2, 4, 6, 8, 12 et 24 h après ľopération, la durée de ľanalgésie et les analgésiques supplémentaires pendant 24 h de plus (dextroproxyphène/acétaminophène) ont été enregistrés.RésultatsLes scores de douleur ont été significativement plus élevés chez les patients du Groupe K, comparé aux Groupes B et BK. La durée de ľanalgésie a été plus courte aussi dans le Groupe K (Groupe B = 5,7 ± 0,8 ; Groupe BK = 5,1 ± 1,1 vs GroupeK = 1,7 ± 0,9 h ; P < 0,05).La consommation ďanalgésique supplémentaire a toutefois été similaire dans les trois groupes.ConclusionĽadministration intra-articulaire ďune combinaison de bupivacaïne et de kétamine fournit une meilleure analgésie que la kétamine seule après une arthroscopie du genou en chirurgie ďun jour.Objectif Ľadministration centro-neuraxiale et parenterale de ketamine peut produire une analgesie, limitee toutefois par des effets indesirables. Nous avons voulu verifier la qualite de ľanalgesie selon ľutilisation de ketamine seule ou en combinaison avec de la bupivacaine a la suite ďune arthroscopie du genou.

Bilateral sternoclavicular joint tuberculosis.

Abstract A unique case of bilateral sternoclavicular tuberculosis is presented, with discussion of the possible mechanism of infection. Early diagnosis is mandatory for good results, and with a world-wide resurgence of this disease, a high index of suspicion is mandatory (especially in immunocompromised patients and migrant populations). Computed tomography and magnetic resonance imaging are helpful for defining the exact extent of the disease.