Perfusion Changes in Acute Septic Arthritis of the Hip Joint During Infancy Using Doppler USG.

Objectives: To quantitatively assess vascularity changes of acute septic hips in infants using Doppler ultrasonography. To compare these findings with asymptomatic hips, and establish a correlation for accurate diagnosis between these findings. Methods: In this prospective case-control study, we included all children under 1 year of age with a diagnosis of acute septic arthritis of the hip in the case group. For the control group, we enrolled apparently healthy, full-term neonates and infants not affected with any hip pathology. Doppler ultrasound of the medial femoral circumflex artery of the hip joint was done using a single Phillips HDI 5000 sonography machine. Following parameters were studied: peak systolic velocity (PSV), resistive index (RI), pulsatility index (PI), and systolic to diastolic ratio (SD ratio). Results: Doppler signals and spectral waveforms were obtainable in 100% of hips in both groups. A statistically significant difference was found between the cases and controls with respect to their PSVs, RIs, PIs and SD ratios. The most striking difference was found between the PSVs of the two groups, whose mean was 6.18 in the control group and 11.8 in the case group. No significant correlation between age/gender and any of the 4 parameters was found. Conclusion: Doppler parameters are useful in raising suspicion of onset in the diagnosis of septic arthritis. No correlation was found between age or gender and any parameter in control group. These baseline values can be held valid for all children below the age of 7 months.

Long-Term Follow-Up of Ulnar Growth in Radial Dysplasia Treated by a Combination of Distraction and Radialization.

PURPOSE: To study the long-term results of radial club hand, regarding ulna growth, radial angulation, and volar subluxation using a 2-stage treatment protocol. METHODS: From 1998 to 2009, 39 radial club hands (32 patients) were treated with distraction, radialization, and a bilobed flap. Long-term follow-up was available in 13 patients (17 hands; average 12.6 years, range 9-16 years). All 17 hands were classified as Bayne and Klug grade 3 or 4. RESULTS: The average age at distraction was 12 months (SD 5.3). The average age at radialization was 14 months (SD 5.8). At final follow-up, the average ulna length on the involved side was 69.3% of the uninvolved contralateral side in the unilateral cases. In the 4 bilateral cases, the average ulna length was 62% of the ulna length of a cohort of normal children. The transverse diameter of the ulna in the posteroanterior view was 79%, and in the lateral view 99%, of the radius on the contralateral side in the unilateral cases. The average radial deviation improved from 82° to 8° and the average volar subluxation improved from 20° to 12°. However, in 4 hands recurrent volar subluxation and required revision surgery. CONCLUSIONS: This approach to treatment was associated with consistent results in the correction of the radial angulation, volar subluxation, and ulna growth in long-term follow-up. Volar subluxation may result in a requirement for revision. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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.

Tuberculosis of the spine in children - does drug resistance affect surgical outcomes?

BACKGROUND CONTEXT: The emergence of drug resistance has complicated the management of spinal tuberculosis (TB). While it is well known that the medical management of drug-resistant spinal TB is more difficult, the surgical outcomes of the same have not been studied sufficiently, particularly in children. PURPOSE: To analyze the surgical outcomes in a cohort of children treated for spinal TB, and to thus assess whether drug resistant (DR) disease is associated with poorer surgical outcomes. STUDY DESIGN/SETTING: Retrospective observational study. PATIENT SAMPLE: All children diagnosed and treated for tuberculous spondylodiscitis at a single center between January 2014 and June 2017. OUTCOME MEASURES: Surgical outcomes in terms of neurological status and kyphosis angle at final follow-up, and complication rates. METHODS: Radiographic and clinical data of children treated for spinal TB with minimum two-year follow-up were retrospectively analyzed. Data gathered included age, gender, level of spine affected, number of vertebrae involved, neurology (Frankel grade), microbiological reports, duration and type of anti-tuberculous therapy (ATT), details of Orthopaedic management and complications during treatment. In DR cases, the time from presentation to starting of second-line ATT was also assessed. Radiographs were reviewed to note the pre- and post-operative degree of kyphosis as well as the angle at final follow-up. Patients that developed major complications were compared statistically with those that did not. RESULTS: Forty-one consecutive children (mean age 8.5 ± 4.2 years, 20 boys, 21 girls) were treated for spinal TB with a mean follow-up of 31.2 ± 6.4 months. Fifteen were managed conservatively, of which only one had DR-TB. Of the 26 managed surgically, 13 were managed with first-line ATT and 13 required second-line ATT. Of this latter group, eight had microbiologically proven drug resistance, whereas five were switched to second-line therapy presumptively because of failure to show an adequate response to first-line regimen. At last follow-up, all children had completed the prescribed course of ATT and had been declared cured. Neurological improvement was seen in all but one patient; and at last follow-up, 18 children were Frankel E, seven were Frankel D, and one was Frankel B. 1The immediate post-operative Kyphosis angle averaged 24.38° ± 15.21°. However, six children showed a subsequent worsening of kyphosis, and the Kyphosis angle at last follow-up averaged 30.96° ± 23.92°. Five children had major complications requiring revision surgery; complications included wound dehiscence, vertebral collapse, screw pull-out and implant breakage. Significantly higher number of patients in the group with complications had required second-line ATT (p < .05). CONCLUSIONS: In a cohort of children treated surgically for spinal tuberculosis, a higher complication rate, and thus poor surgical outcomes, were found to be associated with drug resistant disease.

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.

Swaddling Practices in an Indian Institution: Are they Hip-Safe? A Survey of Paediatricians, Nurses and Caregivers.

PURPOSE: Traditional infant swaddling or binding with hips and knees extended is a known risk factor for Developmental Dysplasia of the Hip (DDH), while 'hip-safe swaddling' with hips and knees flexed is believed to eliminate this risk. We conducted a survey to determine the prevalent practices for infant swaddling in India; why mothers practice swaddling and who teaches them; and whether Paediatricians, nurses and caregivers are aware of hip-safe swaddling. METHODS: Anonymous one-time surveys were conducted in three groups-Paediatricians, Nurses and caregivers - at a tertiary-care, urban based, paediatric and maternity hospital. RESULTS: Forty-five paediatricians, 219 nurses and 100 caregivers were surveyed. Ninety percent caregivers practiced traditional swaddling, for on average 10.2 hours a day, starting soon after birth, up to 4.2 months of life. Traditional swaddling was advocated by 99% nurses and 53% Paediatricians. Reasons for swaddling included sleep, warmth and the misbelief that the child's legs would remain bowed if not bound straight; contrarily few mothers (8%) avoided swaddling out of superstition. Mothers learnt swaddling mainly from relatives (94%) and nurses (64%). Most nurses (70%) had learnt the practice during nursing training. Only 6.6% Paediatricians, 4% caregivers and 0% nurses were aware of 'hip-safe swaddling'. CONCLUSION: Traditional swaddling of infants is a practice deeply rooted in India, born out of misbeliefs, and propagated by lack of awareness. Training in hip-safe swaddling targeted at nurses and Paediatricians would be an effective initial step in creating awareness among mothers and changing their practices.

Bilateral traumatic distal femoral transphyseal fracture in a 9-year-old male.

A case of bilateral traumatic distal femoral Salter-Harris Type I fracture presented to our emergency department. History was of a 9-year-old male playing at a building site when a concrete block fell from height on to his knees, which were extended in a sitting position. Management was with analgesia and transfer to theatre followed by closed reduction and internal fixation-position was assessed under mobile X-ray. The patient made a full clinical recovery within 18 weeks and was followed-up over 5 years. There was no clinical effect on final adult length of femur and no deficit in range of movement. The foot-drop observed at presentation resolved over a period of 12 weeks. This case highlights the importance of performing a thorough neurovascular examination of the patient at presentation, followed by a careful closed reduction and internal fixation under anaesthesia, being careful not to damage the distal femoral growth plates.

Developmental Dysplasia of Hip and Post-natal Positioning: Role of Swaddling and Baby-Wearing.

INTRODUCTION: Traditional swaddling, which implies restrictive immobilisation of the infant's lower limbs with the hips in forced extension and adduction, has been shown to be a risk factor for Developmental Dysplasia of Hip (DDH). METHODS: We reviewed the literature regarding the correlation between DDH and post-natal positioning by swaddling and baby-wearing, to draw awareness of healthcare professionals towards an important risk factor for DDH that has often been overlooked. RESULTS: There is overwhelming evidence in the literature, by both experimental and clinical studies, that proves the close association between improper post-natal positioning of the baby's hips in extension-adduction and an increased incidence of DDH. On the other hand, "hip safe" swaddling which allows unrestricted flexion-abduction movements of the infants' hips, and the use of baby-wearing devices which keep the lower limbs in an attitude of hip flexion-abduction and knee flexion, is optimal for hip development. Populations which practice these "hip-safe" techniques of infant immobilisation have a lower incidence of DDH as compared to those which practice restrictive immobilisation. Furthermore, populations which have adopted "hip-safe" positioning have demonstrated a significant decrease in the incidence of DDH. Understanding this association is vital, since this is a modifiable risk factor, rectification of which can decrease the incidence of DDH. CONCLUSION: Policy makers and governments must design educational campaigns tailored to their respective populations to increase awareness regarding the benefits of "hip-safe" techniques of infant positioning, since this simple intervention has the potential of decreasing the incidence of DDH.

Assessment of pedicle screw malposition in uniplanar versus multiplanar spinal deformities in children.

BACKGROUND: Spinal deformities can either be uniplanar or multiplanar. The current study aims to compare mal-positioned pedicle screw assessment on radiographs versus CT in children <12 years with multiplanar and uniplanar spinal deformities. METHODS: A cohort of 15 children, mean age 10.1 years, who underwent posterior spinal fusion using free-hand pedicle screw insertion for multiplanar (M) or uniplanar (U) deformities with post-operative radiograph and CT evaluation of 154 screws. The outcome measures included the assessment of malpositions detected on plain radiographs versus CT scans in U and M deformities. The overall breaches in post-operative plain radiographs and CT in each group were compared and analyzed by two independent observers.The mal-positioned screws were graded on extent of cortical breach on CT. Inter and intra-observer variability was calculated with Kappa(k) method. Sensitivity, Specificity and Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated by comparing breaches on radiographs versus CT considered the gold standard. RESULTS: In total,154 pedicle screws were analyzed, 65 in U group and 89 in M group. There were 23 (14.9%) malpositioned screws identified on plain radiographs and 43 (27.9%) on CT (p = 0.008). There were 17/154 (11.03%) Grade 1 breaches, 16/154 (10.38%) Grade 2 breaches and 10/154(6.49%) Grade III breaches.Among the 43 CT breaches, 12/65 (18.46%) were in U group, 31/89 (34.83%) were in M group (p = 0.013).The overall Sensitivity, Specificity and PPV of plain radiographs compared to CT in detecting malpositions were 32.56%, 91.89% and 60.87% respectively. CONCLUSIONS: There was a significant discrepancy in identification of pedicle screw malposition based on plain radiographic versus CT based assessment, more so in multiplanar deformities. The ability to detect a breach on plain radiographs is lesser in multiplanar versus uniplanar deformities.

Changes in the Management of Clubfoot Cases During COVID-19 Pandemic-A Survey Among Orthopaedic Specialists.

PURPOSE: The on-going COVID-19 pandemic has curtailed the established practice norms of many ailments including clubfoot. We conducted a survey to study the changes in the clubfoot treatment practices, Achilles tenotomy methods, and the role along with the possible impact of teleconsultation during this pandemic. METHODS: A web-based survey was conducted using a questionnaire prepared on Google forms. The link for this questionnaire was sent to Indian Orthopaedic specialists with a special interest in clubfoot management via a social messaging platform. RESULTS: 127 eligible responses were analysed. Of them, 67% respondents were in practice for more than 10 years. During the study period, 30.7% of doctors did not perform any casting; 66.9% performed casting in 1-5 cases per week and only 2.4% performed casting in more than five cases per week. A statistically significant difference was noted in the number of doctors who performed casting in less than five cases per week and the doctors who performed casting in more than five cases per week, before and during the COVID-19 pandemic. 30.7% of doctors deferred doing Achilles tenotomy during the study period, and among those who performed one, a significant number of them avoided tenotomy under general anaesthesia. CONCLUSION: The COVID-19 pandemic has significantly impacted clubfoot treatment practices during the lockdown period in India. Significant reductions in the number of cases, and a reduction with changes in Achilles tenotomy practices were noted too. However, whether this had any adverse influence on the eventual outcome in these feet is yet to be determined.

The Ponseti method of treatment for neuromuscular and syndromic (non-idiopathic) clubfeet: evaluation of a programme-based approach at a mean follow-up of 5.8 years.

PURPOSE: To analyse the results of the Ponseti method in the treatment of non-idiopathic clubfeet and compare them with idiopathic clubfeet in a programme-based setting using a standardized protocol METHODS: We reviewed two groups of 782 children treated prospectively in our programme-based Clubfoot Clinic: group I comprised of 89 patients (146 feet) with non-idiopathic clubfoot and group II comprised of 693 patients (1032 feet) with idiopathic clubfoot. Both groups were compared on the basis of patient demographics, number of casts, tenotomy rate, success rate, rate of recurrences, and the need for additional secondary procedures. RESULTS: Non-idiopathic clubfeet had a higher incidence of bilateral involvement (p = 0.0093) and affected both males and females equally (p = 0.002) as compared with idiopathic clubfeet. Non-idiopathic clubfeet (group I) required significantly more casts (6.75 ± 4.2) compared with idiopathic clubfeet (4.23 ± 4.14), had a higher rate of Achilles tenotomy (90.4% vs 75%, p < 0.0001), and had a lower initial correction rate compared with idiopathic clubfeet (92.5% vs 100%, p < 0.0001). There was a significant difference in the recurrence rates between the two groups, as 42.5% of non-idiopathic feet (38 patients) relapsed compared with 10.2% (71 patients) in the idiopathic group (p < 0.0001). Most recurrences in group I were amenable to re-casting, with only nine patients (14 non-idiopathic clubfeet) requiring extensive soft tissue releases. The final success rate in the non-idiopathic group at a mean follow-up of 5.8 years (2-8 years) was 87.7%. CONCLUSIONS: We recommend the use of the Ponseti method as an effective treatment for non-idiopathic clubfeet associated with neuromuscular and syndromic conditions.

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.

Tibial-tubercle avulsion and patellar-tendon rupture in pre-pubertal child with osteogenesis imperfecta(OI): Case report and review of current treatment in OI.

Very few cases of simultaneous occurrence of tibial tuberosity fracture with lower pole patella and distal patellar tendon rupture type injuries have been reported in adolescent athletic age group, but its occurrence in osteogenesis imperfecta (OI)* has not been reported to the best of our knowledge in a literature search of last 5 years in the English Language. The mechanism of avulsion injury after low-velocity trauma and the underlying pathology is a unique combination in our patient and a note on updates in general management of osteogenesis imperfecta is discussed.

Widely Divergent Congenital Inferior Tibiofibular Diastasis with Separate Soft-Tissue Cover and Persistent Sciatic Artery: A Previously Unreported Combination: A Case Report.

CASE: We report a case of a child with widely divergent congenital inferior tibiofibular diastasis with persistent sciatic artery (PSA). The dysplastic tibia and fibula were widely divergent, and the fibula was displaced proximally and medially with the foot alongside the thigh between the 2 legs, with PSA diagnosed on computed tomography angiogram. The child was treated with fibula-foot complex excision and below-knee prosthesis and was ambulating independently at 1-year follow-up. CONCLUSIONS: The combination of a major structural anomaly (tibiofibular diastasis with a separate soft-tissue cover) and an unusual vascular malformation (PSA) has not been reported previously and made surgical reconstruction challenging.

Short Term Results of a New Comprehensive Protocol for the Management of Congenital Pseudarthrosis of the Tibia.

BACKGROUND: Treatment of Congenital Psuedarthrosis of Tibia (CPT) often poses significant challenges due to difficulty in achieving union and subsequent complications like refractures, implant failures, etc. Our new comprehensive protocol is aimed at achieving crossunion between the tibia and fibula. AIMS AND OBJECTIVES: The aim of the present study is to evaluate the short-term results of our new protocol and to compare the results with our previously used techniques. MATERIALS AND METHODS: 10 patients with mean age 2.35 years (1 to 6.5 years) who were treated by our new comprehensive protocol were included in Group A, and 11 patients with mean age 2 years (1 to 5.5 years) who primarily underwent intramedullary rodding with bone graft were included in Group B. The new comprehensive protocol consisted of pre-operative Zolendronate infusion, surgery consisting of intramedullary fixation of tibia supplemented with Ilizarov ring fixator and bone grafting aimed at achieving tibia-fibula cross-union. Retrospective evaluation of serial radiographs was performed and outcomes with respect to union and subsequent complications were analysed. RESULTS: 10/10 (100%) patients in Group A united, whereas union was achieved in only 8/11 (72%) patients in Group B. The index surgery was successful in achieving union in all 10 patients in Group A, whereas in Group B 2.25 (1 to 4) surgeries were needed to achieve union. The time to union was significantly shorter in Group A (4.68 months) as compared to Group B (30.88 months). The cross sectional area of union was significantly greater in Group A (3.82 cm2) as compared to Group B (1.18 cm2). One patient in Group A needed a subsequent corrective osteotomy for tibial valgus, and one patient underwent tibia lengthening; whereas in Group B, two patients needed corrective osteotomes for residual malaligments. CONCLUSION: Our study demonstrates that the new comprehensive protocol is extremely effective for achieving sound union in Congenital Pseudarthrosis of Tibia.

Distal Femoral Extension Osteotomy with 90° Pediatric Condylar Locking Compression Plate and Patellar Tendon Advancement for the Correction of Crouch Gait in Cerebral Palsy.

BACKGROUND: Various treatment modalities are available for the correction of crouch gait, ranging from hamstring lengthening to a combination of soft-tissue and bony procedures. We report the results of distal femoral extension osteotomy (DFEO) fixed with 90° pediatric condylar locking compression plate (LCP) and patellar tendon advancement (PTA) for crouch gait in children with cerebral palsy. MATERIALS AND METHODS: A total of 26 patients (52 knees) with a mean age of 14.36 years (range 11.6-20 years) who presented with crouch gait were treated with DFEO and PTA. Patients were analyzed prospectively using clinical (knee flexion deformity, knee range of motion, extensor lag), functional (modified Ashworth, Tardieu scores, muscle strength, gross motor functional classification system [GMFCS], functional mobility scale [FMS], gross motor functional measure [GMFM]) and radiological (Koshino Index) outcome measures and followed up at a mean of 22 months (range 12-53 months). RESULTS: There was an improvement in all outcome measures postoperatively, with improved function and independence. The mean knee flexion deformity improved significantly from 20.7° ± 6.59 to 0.67° ± 2.62, mean muscle strength of quadriceps improved from 3.01 ± 0.5 to 3.5 ± 0.54 and mean extensor lag improved from 20° ± 7.14 to 4.13° ± 4.16. The mean Koshino Index improved from 1.4 ± 0.16 to 1.0 ± 0.08. The mean GMFM-D improved from 15.58 ± 6.2 to 26.31 ± 5.8 and mean FMS for 5 m improved from 2.9 ± 1.09 to 3.6 ± 0.84, indicating significant improvement in household ambulation. There were four complications; transient peroneal nerve palsy in 3 patients, which recovered completely and 1 superficial wound dehiscence. There was no loss of fixation, tendon pull-out or deep infection. CONCLUSION: The combined procedure of DFEO and PTA can correct knee flexion deformity, restore knee extensor strength, and improve function in patients with crouch gait. The pediatric condylar LCP provides stable fixation to allow early mobilization and faster rehabilitation.

The Ponseti method of clubfoot treatment in walking age children: is it effective? A study of 56 children from 1 to 10 years of age.

The Ponseti method is well-established for the treatment of clubfoot in younger babies; however, its effectiveness in older children is still unclear. The aim of our study was to report our results of the 'traditional' Ponseti method in the management of clubfoot in children of walking age. A total of 56 (81 clubfeet) children with a mean age of 3.16±2.35 years (1-10 years) were divided into two groups: group I consisted of 12 (18 clubfeet) patients with a mean age of 3.36±2.7 years (range: 1-8.4 years) who presented with an untreated clubfoot whereas group II consisted of 44 (63 clubfeet) patients with a mean age of 3.19±2.34 years (range: 1-10 years) who presented with a recurrent clubfoot. All children underwent the standard manipulation and casting technique described by Ponseti, including a percutaneous tenotomy of the Tendo Achilles. The bracing protocol was modified appropriately. All feet corrected with a mean of 7.36 (3-17) casts in group I and 4.49 (1-12) casts in group II. All children in group I and 70.45% in group II underwent a percutaneous Tendo Achilles tenotomy. There was a statistically significant change between the pretreatment and post-treatment Pirani scores in both groups. Nineteen (30.86%) patients underwent relapse at a mean follow-up of 2.84±1.25 years (1.2-5.4 years), who were treated by re-casting, bracing and tibialis anterior tendon transfer. The Ponseti method is effective even in walking age children upto the age of 10 years with a good success rate, although approximately one-third of the clubfeet relapsed and needed further treatment. No modifications to the standard casting protocol are required. Despite a high relapse rate, a supple, plantigrade and pain-free foot is achievable without the need for extensive soft-tissue surgeries or bony procedures. The Ponseti method lends itself well to developing a nation-wide program for clubfoot treatment in countries with limited resources. Level of Evidence: Level III.

Current trends of microorganisms and their sensitivity pattern in paediatric septic arthritis: A prospective study from tertiary care level hospital.

PURPOSE: Early treatment of septic arthritis is essential before irreversible damage to the articular cartilage occurs. Clinicians often start empirical antibiotic therapy for symptomatic relief while awaiting a definitive culture report. In present day parlance with variations in different centres in the private and public sector and rampant antibiotic abuse, a lot of resistance is being seen in the flora and their sensitivity patterns. Hence it is imperative to document and analyze these changing trends. METHODS: The authors conducted a retrospective analysis of prospectively gathered data of 60 patients under 14 years of age. Joint arthrotomy was performed as a standard therapeutic protocol and the drained pus or synovial fluid was sent for gram stain and culture by 2 different methods: conventional agar plate method and BACTEC Peds Plus/F bottle method. Antibiotic susceptibility tests were done by the disc diffusion method of Clinical Laboratory Standards Institute (CLSI). RESULTS: The commonest presenting age group was below 1 year (80% patients) including 24 neonates. There were 19 hospital and 41 community acquired cases of septic arthritis. The hip (56%) was the commonest affected joint followed by knee (28%), shoulder joint (11%) and elbow (5%). Microorganism was isolated in 53% isolates of joint fluid only (36 culture positive patients). Conventional agar methods of culture showed positive report in only 42% patients (15/36 patients) while with the BACTEC method the yield was 71%. In the Community acquired septic arthritis, methicillin sensitive Staphylococcus aureus was isolated as commonest microbe while resistant variety of gram negative bacilli including E. coli and Klebsiella were found as predominant organism causing hospital acquired nosocomial infection of joints. The results strikingly differ in terms of response to treatment as most patients (11/19 patients) showed significant resistance to the most commonly practiced empirical antibiotic regimen of ampicillin-cloxacillin group in routine practice. When cefazolin was used as empirical antibiotic, it has shown good response and better sensitivity in 82% patients (27/33 patients). CONCLUSION: S. aureus is still the most common organism in septic arthritis. The BACTEC system was found to improve the yield of clinically significant isolates. Though a significant resistance to common antibiotic regimen is noticed, the strain is susceptible to cephalosporin group of antibiotics. We recommend the use of cephalosporine antibiotics as an empirical therapy till culture and sensitivity report are available.

Isolated scapular involvement: uncommon presentation of childhood tuberculosis.

Scapular involvement in childhood tuberculosis (TB) is rare. To date, only eight cases are reported in the literature in children aged <18 years. We report a case of isolated scapular TB in a 7-year-old boy who presented with swelling and pain over right shoulder and was suspected to have malignancy based on the X-ray findings. Magnetic resonance imaging was suggestive of erosive lesion of whole scapula with normal shoulder joint, humerus and spine and conglomerate axillary lymph nodes. Histopathology and TB culture were diagnostics of TB. Patient was started on anti-TB treatment and doing well on follow-up.