Indian Academy of Pediatrics Consensus Statement on Diagnosis and Management of Bone and Joint Infections in Children.

JUSTIFICATION: Osteoarticular infections are fairly common in children but often these are associated with underdiagnosis, delayed diagnosis and improper management. This leads to an increased incidence of complications and poor outcomes. Given the paucity of standard protocols for the management of these children in the Indian context, Indian Academy of Pediatrics (IAP) has taken the initiative to formulate guidelines for the early diagnosis and rational management of bone and joint infections (BJIs). OBJECTIVES: To critically evaluate the current evidence and formulate consensus guidelines for the diagnosis and management of BJIs in children. PROCESS: A committee comprising of eminent national faculty from different parts of the country who are experts in the field of Pediatric Infectious Diseases, Pediatric Orthopedics and Musculoskeletal Radiology was constituted and duly approved by the IAP. On Jan 16, 2021, a virtual meeting was held and a detailed discussions were carried out regarding the need to formulate these guidelines. Subsequently, the expert group defined the key questions in the first stage followed by collection and review of scientific evidences including available national and international recommendations or guidelines. This was followed by detailed deliberation among group members and presentation of their recommendations. The same were finalized in an online meeting on Aug 01, 2021, and a consensus statement was developed and adopted by the group. STATEMENT: BJIs are medical emergencies that need early diagnosis and appropriate therapy to prevent long term sequelae like limb deformities. Bacterial infections like Staphylococcus aureus is the most common etiological agent. Nonspecific and subtle clinical manifestations make the diagnosis of pediatric BJIs more challenging. Diagnosis of BJIs is primarily clinical, supplemented by laboratory and radiological investigations. The choice of antibiotic(s), mode of administration and duration of therapy requires individualization depending upon the severity of infection, causative organism, regional sensitivity patterns, time elapsed between onset of symptoms and the child's presentation, age, risk factors and the clinical and laboratory response to treatment. There is paucity of appropriate guidelines regarding the diagnosis and management of BJIs in children in Indian context. Hence, the need for this expert consensus guidelines in Indian settings.

Reliability of overcoverage parameters with varying morphologic pincer features: comparison of EOS® and radiography.

BACKGROUND: Multiple radiographic parameters used for diagnosis and quantification of morphologic pincer features have emerged, but the degree to which pelvic tilt or rotation affects conventional radiography and EOS(®) is unknown. QUESTION/PURPOSES: We asked: (1) What is the reliability of EOS(®) and conventional radiography at increasing sizes of morphologic pincer features with varying degrees of tilt and rotation? (2) What is the effect of tilt and rotation on acetabular overcoverage measurements? METHODS: Using a dry cadaveric pelvis, AP conventional radiographs and EOS(®) images were taken at intervals of increasing modeled pincer size with 0° to 15° varying tilt and rotation. Lateral center-edge angle, Sharp angle, Tönnis angle, crossover sign, and retroversion index were measured on all images. Statistical analysis was conducted. RESULTS: The intermodality intraclass correlation coefficients for conventional radiography and EOS(®) radiography across all pincer sizes, rotations, and tilts were excellent (0.93-0.98). Crossover sign was in perfect agreement in conventional radiography and EOS(®). Rotation of the hip away from the beam source and/or increased anterior tilt falsely increased all overcoverage parameters except for Tönnis angle. Rotation away from the beam of 10° or greater or anterior tilt of 5° or greater produced a false-positive crossover sign. CONCLUSIONS: EOS(®) radiography maintained excellent reliability in comparison to conventional radiography but both were equally vulnerable to the effects of tilt and rotation for quantification of hip parameters used in acetabular overcoverage assessment. A standardized pelvic radiograph ensuring that the pelvis is not excessively tilted or rotated should be used for assessing acetabular overcoverage parameters.

Does femoral rotation influence anteroposterior alpha angle, lateral center-edge angle, and medial proximal femoral angle? A pilot study.

BACKGROUND: Femoral rotation on AP radiographs affects several parameters used to assess morphologic features of the proximal femur but its effect on femoroacetabular impingement parameters remains unknown. QUESTION/PURPOSES: We therefore evaluated and characterized the potential effect of femoral rotation on (1) AP alpha angle, (2) lateral-center edge angle (LCEA), and (3) medial proximal femoral angle (MPFA) on AP hip radiographs. METHODS: We took seven AP hip radiographs at intervals of successive femoral rotation on a single dry, cadaveric specimen: 60°, 40°, and 20° internal rotation; 0° neutral/anatomic rotation; and 20°, 40°, and 50° external rotation. The AP alpha angle, LCEA, and MPFA were measured on all radiographs by two independent evaluators. RESULTS: Within the range of femoral rotation studied, the AP alpha angle ranged from 39° to 62°, the LCEA from 25° to 35°, and the MPFA from 70° to 115°. MPFA and AP alpha angle showed a linear relationship with femoral rotation. Each additional degree of internal rotation produced a reciprocal reduction of the MPFA by 0.36° and the AP alpha angle by 0.18° and vice versa in external rotation. The LCEA, especially within the internal rotation range, showed minimal variation. CONCLUSIONS: These changes in radiographic parameters emphasize the importance of femoral rotation and patient positioning. We recommend radiographs be evaluated for excessive femoral rotation or nonstandardized positioning before interpretation for diagnostic and treatment implications. It may be prudent to repeat radiographs in these circumstances or, when standardized positioning is not feasible, proceed toward advance imaging.

Labral Support Shelf Acetabuloplasty for Late Presenting Perthes Disease: Outcomes in Indian Patients.

Introduction: The treatment of late-presenting Perthes disease with extrusion is controversial and debatable. One of the options available is the labral shelf acetabuloplasty (LSA). Aim: The aim of the study was to evaluate the results of LSA in late-presenting Perthes disease in terms of clinic-radiological outcome measures. Materials and Methods: A retrospective analysis of prospectively collected data of patients with late presenting Perthes disease (Elizabethtown stage 2B onwards) treated by LSA by 2 experienced paediatric orthopaedic surgeons was performed. Data was collected of clinical parameters such as hip range of motion(ROM) and Harris Hip score and radiological parameters such as acetabular height, width and volume, shelf width, Centre Edge angle(CEA) and the lateral extrusion. Results: Thirty-five patients (28 males and 7 females) treated between 2012 to 2019 were analyzed. Majority were in Elizabethtown stage 3A (23) followed by 2B and 3B (12 each). At a mean follow up of 36 months, the hip ROM and the Harris Hip Score (from 65 ± 3.5 to 81.33 ± 7.12) improved significantly and there was a statistically significant improvement in terms of all radiological parameters. Majority of the hips were in Stulberg grade 3 (20) followed by grade 1 and 2 (7 each) and Stulberg 4 (1). There were no major complications in any of the patients of the series. Conclusion: Labral support shelf acetabuloplasty is a valuable surgery for late presenting Perthes disease and helps in maintenance of good coverage and allows restoration of range of motion over time.

One-Bone Forearm Procedure for Severe Recalcitrant Forearm Deformities in Masada IIb Hereditary Multiple Exostoses.

Introduction: Hereditary multiple exostoses (HME) Masada IIB has traditionally been treated by gradual ulnar lengthening with questionable efficacy in reducing the dislocated head. One-bone forearm (OBF) has been used as a reconstructive procedure in forearm deformities with very scarce literature for HME. The study aims to report short-term results of OBF as a definitive procedure for severe forearm deformities in Masada IIB patients with respect to clinical and radiological parameters. Materials and Methods: Four patients with HME Masada IIb were included in this retrospective study. All patients complained of forearm and wrist deformity with an abnormal bony protrusion restricting elbow motion. Indications for OBF were ulnar shortening > 3 cm, dysplastic proximal radius with convex radial head and restricted prono-supination. All patients were examined pre-operatively and post-operatively clinically and radiographically using the Peterson's outcome score. Results: The average age was 13 years (12-14 years). Pre-operative ulnar shortening, carpal slip percentage, and radial articular angle was 3.4 cm, 79.5%, and 47.5°, respectively. All radial heads were dislocated with convex articular surface restricting elbow extension and forearm prono-supination. At the latest follow-up, the mean elbow flexion was 110° with forearm in 10° supination. The mean carpal slip percentage, radial articular angle, and Peterson functional grade was 15%, 22.5°, and 8 points, respectively. The mean follow-up period was 30.25 months with no recurrence. Conclusion: We recommend one bone forearm as a definitive procedure in HME Masada IIB patients with severe forearm deformities with ulnar shortening > 3 cm and dysplastic proximal radius with a dislocated radial head, for faster return to function.

New proposed clinico-radiologic and molecular criteria in hypochondroplasia: FGFR 3 gene mutations are not the only cause of hypochondroplasia.

We applied a comprehensive set of clinical and radiological criteria for the diagnosis of hypochondroplasia (HCH) in 160 patients with short stature 58 of whom were diagnosed to have HCH. Taking into account the genotypic and phenotypic variations in HCH, we conducted a study with these 58 patients and tested them for mutations in the fibroblast growth factor receptor 3 (FGFR3) and the short stature homeobox (SHOX) gene. We characterized the phenotypes by clinical and radiologic findings. In the patients with HCH, 19 were included in Group I (FGFR3 mutations-mutations of definite significance), and 39 were in Group II (6 SHOX mutations and 33 negative for disease-causing FGFR3 mutations). The clinical findings were similar in two groups regardless of the presence or absence of mutations. More than 95% of the patients had mesomelic proportions. In Group I, the radiological findings of mesomelia of upper and lower limbs and, L1/L4 ratio in anterior-posterior and lateral view were more typical than in Group II. This study proposes comprehensive clinico-radiological criteria for the diagnosis of HCH, which would help in detecting the true incidence of this underdiagnosed condition. The presence of SHOX mutations suggest genotypic-phenotypic overlap between HCH and Leri-Weill dyschondrosteosis, though further investigation is needed to effectively elucidate the importance of these mutations. Also, the 56.9% of HCH patients with negative mutations for FGFR3 suggests that there are other undiscovered gene mutations associated with this phenotypic entity.

Is bilateral lower limb lengthening appropriate for achondroplasia?: midterm analysis of the complications and quality of life.

BACKGROUND: Use of the Ilizarov technique for limb lengthening in patients with achondroplasia is controversial, with a high risk of complications balancing cosmetic gains. Although several articles have described the complications of this procedure and satisfaction of patients after surgery, it remains unclear whether lengthening improves the quality of life (QOL) of these patients. QUESTIONS/PURPOSES: We asked whether bilateral lower limb lengthenings with deformity correction in patients with achondroplasia would improve QOL and investigated the correlation between complication rate and QOL. PATIENTS AND METHODS: We retrospectively reviewed 22 patients (average age, 12.7 years) diagnosed with achondroplasia who underwent bilateral lower limb lengthenings between 2002 and 2005. These patients were compared with 22 patients with achondroplasia for whom limb lengthening was not performed. The two groups were assessed using the American Academy of Orthopaedic Surgeons (AAOS) lower limb, SF-36, and Rosenberg self-esteem scores. Minimum followup was 4.5 years (range, 4.5-6.9 years). RESULTS: Among the lengthening group, the average gain in length was 10.21 ± 2.39 cm for the femur and 9.13 ± 2.12 cm for the tibia. A total of 123 complications occurred in these 88 segments. The surgical group had higher Rosenberg self-esteem scores than the nonsurgical group although there were no differences in the AAOS and the SF-36 scores. The self-esteem scores decreased with the increase in the number of complications. CONCLUSIONS: Our data suggest that despite frequent complications, bilateral lower limb lengthening increases patients' QOL. We believe lengthening is a reasonable option in selected patients. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Fibula-related complications during bilateral tibial lengthening: 60 patients followed for mean 5 years.

BACKGROUND AND PURPOSE: Complications related to the fibula during distraction osteogenesis could cause malalignment. Most published studies have analyzed only migration of the fibula during lengthening, with few studies examining the effects of fibular complications. PATIENTS AND METHODS: We retrospectively reviewed 120 segments (in 60 patients) between 2002 and 2009. All patients underwent bilateral tibial lengthening of more than 5 cm. The mean follow-up time was 4.9 (2.5-6.9) years. RESULTS: The average lengthening percentage was 34% (21-65). The ratio of mean fibular length to tibial length was 1.05 (0.91-1.11) preoperatively and 0.83 (0.65-0.95) postoperatively. The mean proximal fibular migration (PFM) was 15 (4-31) mm and mean distal fibular migration (DFM) was 9.7 (0-24) mm. Premature consolidation occurred in 10 segments, nonunion occurred in 12, and angulation of fibula occurred in 8 segments after lengthening. Valgus deformities of the knee occurred in 10 segments. INTERPRETATION: PFM induced valgus deformity of the knee, and premature consolidation of the fibula was associated with the distal migration of the proximal fibula. These mechanical malalignments could sometimes be serious enough to warrant surgical correction. Thus, during lengthening repeated radiographic examinations of the fibula are necessary to avoid complications.

Physeal growth arrest after tibial lengthening in achondroplasia: 23 children followed to skeletal maturity.

BACKGROUND AND PURPOSE: Bilateral tibial lengthening has become one of the standard treatments for upper segment-lower segment disproportion and to improve quality of life in achondroplasia. We determined the effect of tibial lengthening on the tibial physis and compared tibial growth that occurred at the physis with that in non-operated patients with achondroplasia. METHODS: We performed a retrospective analysis of serial radiographs until skeletal maturity in 23 achondroplasia patients who underwent bilateral tibial lengthening before skeletal maturity (lengthening group L) and 12 achondroplasia patients of similar height and age who did not undergo tibial lengthening (control group C). The mean amount of lengthening of tibia in group L was 9.2 cm (lengthening percentage: 60%) and the mean age at the time of lengthening was 8.2 years. The mean duration of follow-up was 9.8 years. RESULTS: Skeletal maturity (fusion of physis) occurred at 15.2 years in group L and at 16.0 years in group C. The actual length of tibia (without distraction) at skeletal maturity was 238 mm in group L and 277 mm in group C (p = 0.03). The mean growth rates showed a decrease in group L relative to group C from about 2 years after surgery. Physeal closure was most pronounced on the anterolateral proximal tibial physis, with relative preservation of the distal physis. INTERPRETATION: Our findings indicate that physeal growth rate can be disturbed after tibial lengthening in achondroplasia, and a close watch should be kept for such an occurrence-especially when lengthening of more than 50% is attempted.

Congenital pseudarthrosis of the tibia treated with a combination of Ilizarov's technique and intramedullary rodding.

BACKGROUND AND PURPOSE: Ilizarov's technique and intramedullary rodding have often been used individually in congenital pseudarthrosis of the tibia. In this series, we attempted to combine the advantages of both methods while minimizing the complications. METHODS: We reviewed 15 cases of congenital pseudoarthrosis of the tibia (CPT) who were treated with a combination of Ilizarov's apparatus and antegrade intramedullary nailing between 2003 and 2008. The mean age at surgery was 7.5 (3-12) years and the mean limb length discrepancy was 2.5 (1.5-5) cm. At a mean follow-up time of 4.5 (1.6-7.2) years after the index surgery, the patients were evaluated clinically and radiographically for ankle function (AOFAS score) and for malalignment, signs of union, limb length discrepancy, and complications. RESULTS: 14 patients achieved union, in 6 patients primary union and in 8 patients after secondary procedures. The AOFAS score improved from a preoperative mean of 40 (20-57) to 64 (47-75). The main complication was refracture in 1 patient, and non-union in 1 patient. INTERPRETATION: The combination of the Ilizarov technique and conventional antegrade intramedullary nailing was successful in achieving union with few complications, though this should be shown in long-term studies lasting until skeletal maturity.

Supracondylar Humerus Fractures: Classification Based Treatment Algorithms.

Supracondylar humerus fractures are the most common fractures around the elbow in children between 4 and 10 years of age. The treatment of supracondylar humerus fractures can vary from conservative treatment to operative treatment depending on the fracture type. All around the world, the most commonly used classification system is the Wilkins-modified Gartland classification of supracondylar humerus fractures. Currently, the decision to operate or conserve the fracture is taken on basis of this classification system. Non-operative treatment for type I fractures and operative treatment for type III fractures have been well-established in literature. The management of type II supracondylar humerus fracture creates confusion in the minds of numerous orthopaedic surgeons around the world. We have tried addressing this using a classification-based treatment algorithm. Other classification systems like the AO classification, Lagrange and Rigault classification and Bahk classification with special reference to special fracture patterns that require attention and pre-op planning have also been mentioned. It is important to understand that operative management of each supracondylar humerus fracture is unique as regards fixation method and it is important to consider the fracture pattern before internal fixation.

Modified Dunn Osteotomy for Moderate and Severe Slipped Capital Femoral Epiphysis - A retrospective study of thirty hips.

BACKGROUND: Modified Dunn procedure has become popular for the treatment of severe cases of slipped capital femoral epiphysis (SCFE). We assessed the outcomes in a consecutive series of thirty Indian adolescents treated by the modified Dunn procedure. MATERIALS AND METHODS: All patients treated by the modified Dunn procedure by a single senior Paediatric Orthopaedic surgeon over six years were retrospectively reviewed. Only moderate and severe slips undergoing modified Dunn procedure were included. Clinical records and radiographs were reviewed to obtain demographic information; to classify the slips by duration of symptoms, severity and physeal stability; and to assess the outcomes by Harris Hip Score, radiological changes and rate of complications. RESULTS: Thirty consecutive hips with 19 stable and 11 unstable slips were included. Mean age was 13.05 years, 25 boys and 5 girls; six were acute slips, six chronic and eighteen acute-on-chronic. There were 20 moderate and 10 severe slips. Slip angle correction was on average 43.63° ± 8.42° (p < 0.001). At a mean follow-up of 25.36 months, the slip angle averaged 9.9° ± 3.78°, and alpha angle was 33.63° ± 4.14. The average Harris Hip Score was 81.833 ± 7.12 points, with six excellent, 17 good, six fair and one poor result. Osteonecrosis occurred in two hips (6.6%). One hip had post-operative subluxation which was corrected. CONCLUSION: This study adds to the evidence that the modified Dunn procedure is safe, reliable and reproducible. It should be the first choice for the treatment of moderate and severe SCFE.

Technique and Interpretation of Arthrogram for Developmental Dysplasia of the Hip.

Closed reduction, arthrography and hip spica application is the treatment of choice for DDH between 6 and 18 months. There is a lot of controversy about what exactly constitutes an "acceptable" closed reduction and arthrogram and the arthrography findings are often difficult to interpret. In this video, the authors describe the technique to perform the arthrogram as well as the interpretation of the same. Various static parameters such as the femoral head coverage, the medial dye pool and the hourglass constriction are shown. In addition, the validity of the safe zone is discussed. With this video technique article, the authors hope that it becomes easy for the budding paediatric orthopaedic surgeon to perform and interpret the DDH arthrogram with ease. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00493-4.

Lengthening After Nonvascularized Fibula Grafting for Large Postinfective Bone Defect: A Case Report with Long Follow-up.

CASE: We describe a case of lengthening of the tibial regenerate after nonvascularized fibula grafting, for postinfective tibial gap nonunion in a child. A large tibial defect secondary to osteomyelitis in a 10-month-old boy was reconstructed using a 5-cm fibula autograft. Concomitant distal tibial physeal arrest led to progressive shortening. Distraction osteogenesis was performed, through the grafted segment, on 2 occasions-at the ages of 3.5 and 8 years-to achieve total lengthening of 9 cm and good functional recovery at 11.5 years of age. CONCLUSION: The tibial regenerate after nonvascularized fibula grafting in children has good potential for distraction osteogenesis.

Functional and Radiological Outcomes Following Calcaneo-Cuboid-Cuneiform Osteotomy for the Treatment of Planovalgus Feet: A Short-Term Analysis.

INTRODUCTION: Flexible flatfoot refers to the loss of the medial longitudinal arch of the foot on weight bearing and is associated with excessive heel eversion or forefoot abduction. Unless symptomatic, flexible flatfeet are best managed non-operatively. The calcaneo-cuboid-cuneiform osteotomy is a procedure that restores the anatomical shape of the foot without arthrodesis of the joints. Our study aims to evaluate the functional and radiological outcomes of patients treated with calcaneo-cuboid-cuneiform osteotomy in patients with planovalgus feet. METHODOLOGY: A retrospective review of records and radiographs of patients with symptomatic flexible planovalgus feet, who were operated with the calcaneo-cuboid-cuneiform osteotomy by a single senior surgeon in a time period between April 2016 and July 2017 was done. The clinical and radiological outcomes were evaluated in 12 feet in 8 children. RESULTS: A total of 12 feet in 8 children were operated (6 males and 2 females). Average age of patients was 11 ± 1.27 years; average follow up was 14.7 months ± 2.7 months. Two patients had planovalgus feet secondary to spastic diplegia and 6 had idiopathic planovalgus feet. There was a statistically significant improvement in the pain score as well as the radiographic parameters in all the operated patients. CONCLUSION: The calcaneo-cuboid-cuneiform osteotomy has potential to give good results for symptomatic planovalgus feet with minimal complications.

Preparation of cement spacer in treatment of segmental bone defects in children by the induced membrane technique: A technical note.

The Masquelet Induced Membrane Technique (IMT) is one of the tools in the surgeon's armamentarium for the management of segmental bone defects. The first stage of the IMT includes the insertion of a cement spacer, which is typically fashioned by the free-hand technique. We propose a novel technique for preparation of the cement spacer using a split syringe barrel as a mould. This technique produces a uniformly cylindrical spacer with minimum cement spillage, while also minimizing thermal damage to the surrounding soft tissues. It is a simple and cost-effective method that can be adapted for use in any long bone in children.

Lower-Limb Ischemia at Birth Because of Spontaneous Arterial Thrombosis: A Case Report.

CASE: A full-term neonate presented with right lower extremity ischemia at birth because of spontaneous thrombosis of the right common iliac artery. He was initially managed with supportive treatment, anticoagulation, and dressings; however, advanced gangrenous changes precluded salvage of the ischemic limb. A guillotine amputation was performed at day 15 of life, and the stump went on to heal well by secondary intention. CONCLUSION: Thromboembolic events occurring in infancy are well-recognized phenomena; however, it is far rarer to encounter a neonate born with "congenital gangrene". We discuss the etiology, approach to diagnosis, and treatment of this rare but devastating condition.

Unusual Combination of a Fracture Monteggia Equivalent With Post-traumatic Radial Artery Pseudoaneurysm in a Child: A Case Report and Review of Literature.

CASE: We report a unique case of a combination of forearm fracture and traumatic radial artery pseudoaneurysm in an 8-year-old child. The fracture pattern was a Monteggia equivalent with a mid-diaphyseal ulnar fracture and a radial neck fracture with displacement of the distal radial diaphyseal fracture fragment. The pseudoaneurysm, which probably developed after vigorous manipulation by a bonesetter, thrombosed spontaneously, and the fracture was managed nonoperatively with a good outcome. CONCLUSION: Pseudoaneurysm of the radial artery is a rare phenomenon associated with fracture in a child. A history of vigorous manipulation of displaced fracture fragments in the vicinity of a major vessel should raise suspicion of this possible complication.

CT-Guided Percutaneous Drilling of Osteoid Osteoma: A Safe, Minimally Invasive and Cost-Effective Method.

BACKGROUND: CT-guided percutaneous drill resection (PDR) for osteoid osteoma fell out of vogue with the advent of radiofrequency ablation (RFA). However, the routine use of RFA is offset by its high cost and need for specialized instrumentation. AIMS AND OBJECTIVES: This study is an analysis of our series of patients treated with PDR, to know its efficacy, safety and cost-effectiveness. MATERIALS AND METHODS: This study is a retrospective analysis of prospectively collected data of 33 patients with a mean age of 10.03 years (2-21 years 13:10 M:F). The proximal femur was the commonest location, followed by shaft femur, tibial shaft, pubic ramus and lateral humeral condyle. Three were recurrences. The procedures were performed by one of four fellowship-trained paediatric orthopaedic surgeons, using a standard protocol with the help of a radiologist. CT-guided drilling was performed under sedation/short general anaesthesia using a guidewire for identification, followed by sequential drilling using a 6.5 mm cannulated drill or a triple ream drill. Patients were hospitalized overnight for pain relief and allowed protected weight bearing as per pain tolerance. They were evaluated weekly for 2 weeks and 3 monthly thereafter. RESULTS: The mean final follow-up was 19.72 months (6 months to 58 months). All patients had complete resolution of symptoms within 3 days of the procedure. There were no major complications and there were two minor complications (haematoma and cutaneous hypoaesthesia). There were no recurrences till the last follow-up. CONCLUSION: This study, one of the first and largest from India about CT-guided PDR, shows that this method can still be safely and effectively used as a primary treatment modality in OO, especially in economically challenged population. It is much more cost-effective than RFA, can be used even for recurrent tumours and can be safely be performed by a general orthopaedic surgeon without any special instrumentation.

Diagnosis and Management of Osteoarticular Tuberculosis: A Drastic Change in Mind Set Needed-It is Not Enough to Simply Diagnose TB.

BACKGROUND: In the era of increasing drug resistance in pulmonary tuberculosis (TB), it is prudent to assess causes of poor response to anti tubercular therapy (ATT) and drug sensitivity pattern (DSP) in osteoarticular TB. MATERIALS AND METHODS: As a part of Bombay Orthopaedic society's research project, members were asked to refer non responders to ATT to our institute. Cases were enrolled from October 2010 to March 2014. Deep tissue samples were obtained in all but five cases and subjected to a battery of tests including histopathology (HPE) and TB culture and sensitivity. The DSP was compared with the study performed by the principle author from 2004 to 2007 and published in 2009. RESULTS: 39 male and 50 female patients with a mean age of 24.85 years (2-66) were included and classified in four groups after results. (1) Culture and HPE positive-36. 24 had MDR and three XDR TB. Primary resistance to even second line drugs and deterioration of DSP since last study was noted, (2) culture negative and HPE positive-21. The cause of poor response was surgical in more than half cases, (3) non representative samples or lost to follow-up-15, (4) TB mimics-16. CONCLUSION: There is increasing incidence of primary resistance to second line drugs, primary resistance in children and worsening of resistance patterns as compared to older studies. ATT initiation is a fateful decision and every attempt should be made to rule out TB mimics and establish DSP before initiation.