[Pitfalls in the diagnosis of tuberculous arthritis].

Jewish immigrants from Russia, and Arabs added to the population register since 1967, have a relatively high incidence of bone and joint tuberculosis. These patients now account for most of this disease in Israel. Skeletal tuberculosis imitates various joint conditions, most commonly, rheumatoid arthritis, and therefore presents a diagnostic problem. Injections of corticosteroids and/or immunosuppressive therapy can reactivate quiescent tuberculous lesions. During a 12-year period 14 patients with tuberculous arthritis involving 16 joints were seen in this hospital. They included 9 males and 5 females, 14-70 years old, 4 of whom were known to have had previous skeletal tuberculosis: 3 had spinal and 1 had hip involvement. None of the other 10 had a clinical history of tuberculosis, nor X-ray evidence of active pulmonary disease. 7 patients were diagnosed postoperatively as having joint tuberculosis on histopathological and bacteriological examination; 3 had positive cultures from joint aspirations. Most commonly involved were the spine and knee--4 cases of each. The wrist and acromioclavicular joint were affected in 2 cases each, and the hip, sacroiliac joint, ankle and elbow joints in 1 case each. The youngest patient, 14 years old, had triple-joint involvement of the wrist and the acromioclavicular and sacroiliac joints; the others had single-joint disease. In 1 patient the disease was reactivated after 36 years by surgical conversion of a fused hip to a mobile artificial joint. 3, whose joints were injected with corticosteroids, developed active, destructive tuberculous arthritis. A patient with rheumatoid arthritis who underwent total knee replacement was found to have active tuberculous arthritis.(ABSTRACT TRUNCATED AT 250 WORDS)

Joint surgery in severe ankylosing spondylitis.

Twenty-three patients with ankylosing spondylitis with severe deformities of hips, knees, and ankles were treated by a variety of surgical procedures followed by a comprehensive rehabilitation program. The surgery included 35 total hip replacements, six knee arthroplasties, and seven femoral osteotomies. Elongation of the Achilles tendon (eight procedures) was done on 6 patients. Shortening of the femur was performed in patients with long-standing flexion contractures when straightening of the limb during the operation caused traction on the vessels and the nerves. When there was both hip and knee involvement, hip arthroplasty was performed first. Preoperative planning aimed at obtaining plantigrade position of the feet and lower limb-length equality. Availability of custom-made and miniaturized components was essential. Positioning of patients on the operating table necessitated special supports. Six patients were completely bedridden before surgery and 17 were severely disabled or deformed. All the patients but 2 improved markedly, became mobile, independent, and self-supporting. Revision arthroplasty was performed in 4 patients; 3 others deteriorated functionally, but refused further treatment. Heterotopic bone formation was observed after operation in 6 patients. Surgery for severe ankylosing spondyloarthritis requires highly specialized and well-equipped centers.

An unusually high incidence of homozygous MM in ankylosing spondylitis.

Blood types of patients admitted to the Hadassah University Hospital with ankylosing spondylitis did not differ significantly from the expected percentages among the Israeli population, except for a very high incidence (92% to 100%) of homozygous MM. Among healthy controls the incidence of homozygous MM was found to be in line with accepted values.

The pulseless club foot.

Previous reports have suggested that the blood supply derived from the anterior tibial artery is absent or markedly diminished in 85% of severe, untreated club feet. To investigate these claims, we used a Doppler technique to study the arterial pulses in 40 children with 63 club feet. In feet with mild or moderate deformities the anterior tibial pulse was always present; in feet with severe deformities it was absent in two out of 30 feet in children under three years and in seven out of 18 feet in children over three years. These results confirm that the incidence of pulselessness increases with the severity and duration of deformity, but not to the extent previously suggested by angiographic studies. The significance of these findings is discussed.

Hypernatremic dehydration complicated by peripheral gangrene in infancy.

Two infants with hypernatremic dehydration (HD) who developed peripheral gangrene are described. A review of the literature revealed 10 infants who had HD and gangrene of the extremities. This combination could occur because of hypoperfusion and sluggish blood movement due to hyperviscosity, which coexist in HD, resulting in a disturbed microcirculation. We feel that the association of peripheral gangrene with HD may be a more frequent phenomenon than previously believed.

The cleavage intercondylar fracture of the femur.

The mechanism of injury and long-term effects in three cases suggest that a specific type of intercondylar injury of the femur, i.e., cleavage fracture, is caused by force transmitted through the patella. Treatment is conservative. The fracture does not appear to have been mentioned previously in the English literature.

Infantile cortical hyperostosis with unusual clinical manifestations.

Infantile cortical hyperostosis may mimic a variety of serious conditions in early infancy, such as trauma, vitamin deficiencies, infection, or tumors, In a patient in good general condition there are typical roentgenological features often with involvement of the mandible that are diagnostic of the condition. In 3 cases of infantile cortical hyperostosis (Caffey's disease), one had the clinical picture of Erb's palsy and subsequently developed hyperostosis of the scapula. The second, had a "pulled elbow" and radial nerve palsy and later developed hyperostotic changes in the humerus and radius on the same side. The third was referred for treatment of congenital torticollis and found to develop hyperostosis of the clavicle on the same side. The recognition of this condition obviates unnecessary prolonged investigation and treatment.