Sripathi Rao

The role of polymerase chain reaction in the management of osteoarticular tuberculosis

A dependable method for the rapid diagnosis of osteoarticular tuberculosis has become increasingly important, as routine methods are neither very sensitive nor very specific. The objective of this study is to verify the reliability of polymerase chain reaction (PCR) in the diagnosis and management of osteoarticular tuberculosis. This investigation was a prospective study conducted at the Kasturba Medical College, Manipal, India. Tissue samples of 74 patients suspected of osteoarticular tuberculosis were sent for PCR and histopathologic examination. Taking histopathology as the gold standard, PCR has a sensitivity of 73.07% and a specificity of 93.75% (with 95% confidence interval [CI] 62.97; 83.17).The positive agreement between histology and PCR was 0.693, indicating good agreement. PCR showed a sensitivity of 90% with spinal samples. It has a low false positivity of 13.63%. We conclude that conventional methods are neither sensitive nor specific enough and are also time consuming. PCR is an effective method for diagnosing tuberculosis and antitubercular treatment can be started if PCR is positive, since false-positive rates are very low.RésuméUne méthode pour le diagnostic rapide des tuberculoses osseuses articulaires voit sont importance augmenter par rapport aux méthodes de routine cependant très sensitives mais peu spécifiques. L’objectif de cette étude est de vérifier la fiabilité de la PCR (polymérase réaction en chaêne) diagnostic dans la conduite et le traitement des tuberculoses ostéo articulaires. Matériel et méthode: au cours d’une étude prospective conduite au Collège Médical Kasturba de Manipal Indes, les fragments tissulaires de 74 patients suspects de tuberculose ostéo articulaire ont été adressés, pour examen histopathologique et dosage PCR. Résultats: l’histopathologie reste le « gold standard », la PCR a une sensitivité de 73.07% et une spécificité de 93.75% (avec 95% d’intervalle de confiance CI 62.97; 83.17). La compatibilité entre histologie et la PCR est de 0.693, la PCR montre une sensitivité de 90% avec du tissu rachidien. Il existe des faux positifs (13.63%). Conclusion: les méthodes conventionnelles ne semblent ni sensitives ni spécifiques et demandent beaucoup de temps. La PCR est une méthode diagnostique de la tuberculose fiable et permet de suivre et de démarrer le traitement anti tuberculeux si la PCR est positive, les taux de faux positifs étant très bas.

Burkholderia pseudomallei musculoskeletal infections (melioidosis) in India

Melioidosis, an infection due to gram negative Burkholderia pseudomallei, is an important cause of sepsis in east Asia especially Thailand and northern Australia. It usually causes abscesses in lung, liver, spleen, skeletal muscle and parotids especially in patients with diabetes, chronic renal failure and thalassemia. Musculoskeletal melioidosis is not common in India even though sporadic cases have been reported mostly involving soft tissues. During a two-year-period, we had five patients with musculoskeletal melioidosis. All patients presented with multifocal osteomyelitis, recurrent osteomyelitis or septic arthritis. One patient died early because of septicemia and multi-organ failure. All patients were diagnosed on the basis of positive pus culture. All patients were treated by surgical debridement followed by a combination of antibiotics; (ceftazidime, amoxy-clavulanic acid, co-trimoxazole and doxycycline) for six months except for one who died due to fulminant septicemia. All other patients recovered completely with no recurrences. With increasing awareness and better diagnostic facilities, probably musculoskeletal melioidosis will be increasingly diagnosed in future.

Staged Arthroscopic Reconstructive Surgery for Multiple Ligament Injuries of the Knee

Purpose. To review treatment outcome of our staged protocol for multiple ligament injuries of the knee. Methods. 21 men who were treated for multiple ligament injuries of the knee and had completed at least one year of rehabilitation were evaluated. Patients were examined under anaesthesia and then by diagnostic arthroscopy. Arthroscopic reconstructive procedures for injured cruciate ligaments were performed after a minimum 110° flexion and full extension were regained. Collateral ligaments injuries were treated first, followed by posterior cruciate ligament (PCL) and then anterior cruciate ligament (ACL) tears. Outcome was evaluated using the Lysholm knee score and International Knee Documentation Committee (IKDC) knee ligament evaluation form. Results. 19 patients aged 24 to 55 (mean, 36) years were followed up for a mean of 22 (range, 14–33) months. The mean Lysholm score was 92. The mean scores for patients treated within and after 3 weeks were 93 and 90, respectively. The overall IKDC grading was B in 15 knees and C and D each in 2 knees. For the 2 patients with grade D, one presented 19 months after the injury and had persistent posterior sag (secondary to capsular contracture). His Lysholm score was 82. The second patient developed a deep infection and endured a flexion loss of 30° but had a satisfactory Lysholm score of 94. There was no significant difference between early and delayed treatments and between low- and high-velocity injuries in terms of the Lysholm score, the IKDC grade, the range of movement, and the functional outcome. Conclusion. Staged management of multiple ligament injuries of the knee enabled satisfactory restoration of function, stability, and range of movement in most of our patients. By staging the procedures, the need for subsequent ACL reconstruction can be better evaluated, as ACL reconstruction is not necessary in patients not undertaking strenuous activities.

Mucoid degeneration of the anterior cruciate ligament: Management and outcome.

Background: Mucoid degeneration (MD) is a rare pathological affection of the anterior cruciate ligament (ACL). Mucinous material within the substance of ACL produces pain and limited motion in the knee. This series describes the clinicoradiological presentation of patients with mucoid ACL, partial arthroscopic debridement of ACL and outcomes. Materials and Methods: During a period of 3 years, 11 patients were included based upon the clinical suspicion, magnetic resonance imaging (MRI) findings, arthroscopic features and histopathologic confirmation of MD of ACL. Result: Six patients were male and five were female with median age of 40 years (range 21-59 years). All patients complained of knee pain with median duration of 5 months (range 1-24 months). All patients had painful deep flexion with 63.6% (N = 7) reporting trivial trauma before the onset of symptoms. MRI revealed MD of ACL in all with associated cyst in three patients. Partial debridement of ACL was done in ten and complete in one patient. None of them required notchplasty. Histopathology confirmed the diagnosis in all of them. At the mean followup of 13.81 months (range 6-28 months), all patients regained complete flexion and none complained of instability. Conclusion: Prior knowledge of condition with high index of suspicion and careful interpretation of MRI can establish the diagnosis preoperatively. It responds well to partial debridement of ACL and mucinous material without development of instability.

Femoral tunnel-interference screw divergence in anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft: A comparison of two techniques

Background: Interference screw is a popular fixation device used to rigidly fix bone-patellar tendon-bone (B-PT-B) graft both in femoral and tibial tunnels in anterior cruciate ligament (ACL) reconstruction. Parallel placement of screw is difficult in transtibially drilled femoral tunnel but always desired as it affects pullout strength of the graft. Commonly, interference screw into the femoral tunnel is inserted through the anteromedial (AM) or accessory AM portal. These portals are not-in-line with the transtibially drilled femoral tunnel. Furthermore, these portals increase the divergence of the interference screw in the femoral tunnel. We hypothesized that interference screw placement through patellar tendon (PT) portal (through donor defect) in transtibially drilled femoral tunnel can be less divergent. We report the prospective randomized study to investigate the difference of divergence of interference screw placed through PT portal and AM portal and its clinical relevance. Materials and Methods: Forty-one patients underwent femoral tunnel B-PT-B graft fixation through AM portal (group 1) and other 41 (group 2) through PT portal. Femoral tunnel-interference screw divergence was measured on postoperative digital lateral X-rays. Ha’s method was used to grade divergence. The clinical outcome was assessed by postoperative intervention knee documentation committee grading (IKDC) and Lysholm score at 2 years followup. Results: Mean tunnel-screw divergence in sagittal plane through AM portal was 13.38° (95% CI: 12.34-14.41) and through PT portal was 7.20° (95% CI: 6.25-8.16) (P<0.0001). In AM portal group, 82.9% patients had divergence in either grade 3 or 4 category, whereas in PT portal group, 82.9% patients were in grade 1 or 2 category (P<0.0001). Mean Lysholm score were 92.8 and 94.5 at two-year follow-up in both groups which were statistically not significant. The International knee documentation committee grades of patients in both groups were similar and had no statistical significance. Conclusion: Femoral interference screw placement through the PT portal leads to significantly less screw divergence as compared with screw placement through the AM portal. However, this difference in divergence is not reflected in clinical outcome.

Bifurcated intraarticular long head of biceps tendon

Though rare, many anomalous origins of long head of the biceps tendon (LHBT) have been reported in the literature. Anatomic variations commonly explained are a third humeral head, anomalous insertion, congenital absence and adherence to the rotator cuff. We report a rare case who underwent shoulder arthroscopy with impingement symptoms where in LHBT was found to be bifurcated with a part attached to superior labrum and the other part to the posterior capsule of joint. Furthermore, intraarticular portion of LHBT was adherent to the undersurface of the supraspinatus tendon. Awareness of such an anatomical aberration during the shoulder arthroscopy is of great importance as it can potentially avoid unnecessary confusion and surgery.

MENISCAL ABNORMALITIES: DISCOID MENISCUS

The discoid meniscus is the most common meniscal variant. The likely etiology being congenital, the condition usually affects the lateral meniscus. Poorly vascularized, thicker and unstable, the discoid lateral meniscus (DLM) is more prone to tears due to abnormal shearing forces. Watanabe et al. (1979) classified the discoid lateral meniscus into three types: Complete, incomplete and Wrisberg type; Monllau et al. (1998) added the ring type as the fourth variant. Pain and clicks/thud are the most common presentations. Plain radiograph and magnetic resonance imaging are helpful in confirming the diagnosis. Asymptomatic DLM is best left alone. For symptomatic complete and incomplete types, partial arthroscopic saucerization is the treatment of choice leaving behind a stable rim. The Wrisberg type needs peripheral stabilization with resection of excess rim, if any. Total meniscectomy should be avoided unless inevitable. Short term results after partial meniscectomy are good.