Diagnostic role of Xpert-MTB RIF assay in osteoarticular tuberculosis:A retrospective study

BACKGROUND Osteoarticular tuberculosis(OATB) is a severe form of extrapulmonary TB, which causes notable morbidity and warrants a high index of suspicion for prompt management. The diagnosis of OATB poses a challenge, because of the difficulty of collecting the samples and, secondarily, the paucibacillary nature of lesion, which gives poor sensitivity and reproducibility, with long turnaround time of routine/conventional laboratory tests and the requirement for invasive procedures and expertise. The Xpert MTB/RIF assay has been approved by the World Health Organization as a rapid diagnostic tool for diagnosing pulmonary and extrapulmonary TB.AIM To emphasize the diagnostic efficiency of gene Xpert for OATB in suspected patients in a tertiary care hospital of Eastern India.METHODS This retrospective study was conducted in the Department of Microbiology and Orthopaedics by analyzing the data of the gene Xpert assay over a 3-year duration from January 2018 to February 2021. Demographic and clinical data were recorded. The diagnostic efficiency of gene Xpert was evaluated against the composite reference standard(CRS).RESULTS A total of 37 cases fell into positive, probable, and possible categories of osteoarticular TB out of 112 patients included in the study by CRS;gene Xpert result was positive in 35 out of the 37 different CRS categorized cases. Of the 112 cases, culture was put in 40 cases, and, of these cultures, 5 cases showed the growth of MTB. Of these, 4 cases were included in the 35 cases diagnosed by gene Xpert.Smear microscopy was positive in 6 out of 37 CRS categorized cases. When compared with CRS, the sensitivity of gene Xpert assay, culture, and smear was found to be 94.6%, 13.5%, and 16.2%, respectively, while specificity in all the three types of tests was 100%. When kappa statistics were applied, the percentage of agreement gene Xpert, culture, and microscopy with CRS was found to be 95%, 20%, and 22.6%, respectively. Follow-up of the gene Xpert positive patients after getting anti-tubercular treatment revealed improved conditions.CONCLUSION Gene Xpert could detect 31 extra cases with a low and very low mycobacterial load that were missed by the routine culture methods. Hence, more samples should be processed for molecular diagnostic methods like gene Xpert along with other conventional methods for the validation of the molecular test prospectively for the timely diagnosis of osteoarticular TB.

Effect of osteoarthritic knee flexion deformity correction by total knee arthroplasty on sagittal spinopelvic alignment in Indian population

BACKGROUND Sagittal alignment of the spine,pelvis,and lower extremities is essential for maintaining a stable and efficient posture and ambulation.Imbalance in any element can result in compensatory changes in the other elements.Knee flexion is a compensatory mechanism for spinopelvic sagittal alignment and is markedly affected in severe knee osteoarthritis(OA).The correction of knee flexion deformity(KFD)by total knee arthroplasty(TKA)can lead to complementary changes in the sagittal spinopelvic parameters(SSPs).AIM To determine the SSP changes in patients with knee OA,with or without KFD undergoing TKA.METHODS The study was conducted in 32 patients who underwent TKA.A neutral standing whole-spine lateral radiograph was performed before surgery and 3 mo after surgery in these patients.Subjects were divided into two groups(Group 1 obtained>10°corrections in KFD;group B obtained<10°correction).The pelvic tilt(PT),pelvic incidence(PI),sacral slope(SS),lumbar lordosis(LL),and sagittal vertical axis(SVA)were measured.RESULTS The median of change in PT,PI,SS,LL,and SVA was 0.20 mm,1.00 mm,2.20 mm,−0.40 mm,and 6.8 mm,respectively.The difference in the change in SSPs between the two groups was statistically non-significant.CONCLUSION SSPs,such as PI,PT,SS,LL,and SVA,do not change significantly following TKA in end-stage knee OA despite a significant correction(>10°)in KFD.

Histological difference in ligament flavum between degenerative lumbar canal stenosis and non-stenotic group:A prospective,comparative study

BACKGROUND Ligament flavum(LF)hypertropy is the main etiopathogenesis of lumbar canal stenosis(LCS).The purely elastic LF undergoes a morphological adaptation including a reduction in the elastic fibers and a consequent increase in the collagen content,fibrosis,cicatrization,and calcification.However,the morphometric analysis can delineate the LF in patients with LCS from those without LCS,which would help in better understanding LCS pathogenesis.AIM To compare the histopathological changes in LF between the degenerative LCS and non-stenotic(non-LCS)group.METHODS The present prospective study was conducted in 82 patients who were divided into two groups,namely LCS and non-LCS.Demographic details of the patients such as duration of symptoms,level of involvement,and number of segments were recorded.The LF obtained from both groups was histopathologically examined for the fibrosis score,elastic fiber degeneration,calcification,and chondroid metaplasia.Morphometrical details included a change in elastin and collagen percentages,elastin/collagen ratio,elastic fiber fragmentation,and ligamentocyte numbers.All parameters were compared between the two groups by using the independent t test,Chi-square test,and Pearson’s correlation test.RESULTS Out of 82 cases,74 were analysed,34 in LCS and 40 in non-LCS group.The mean±SD age of presentation in LCS and non-LCS group was 49.2±8.9 and 43.1±14.3 respectively.The LCS group(n=34)exhibited significant differences in fibrosis(P=0.002),elastic fiber degeneration(P=0.01),%elastic fragmentation(66.5±16.3 vs 29.5±16.9),%elastic,content(26.9±6.7 vs 34.7±8.4),%collagen content(63.6±10.4 vs 54.9±6.4),reduction of elastic/collagen(0.4±0.1 vs 0.6±0.1),and ligamentocyte number(39.1±19.1 vs 53.5±26.9)as compared to non-LCS group(n=40).The calcification(P=0.08)and Pearson’s correlation between duration and loss of elastin was not significant.The difference in LF morphology is consistent in patient’s≥40 years of age among the groups as found in subgroup analysis.Similarly in the patents<40 and>40 in the non-LCS group.CONCLUSION LF is vital in the pathogenesis of LCS.The purely elastic LF undergoes a morphological adaptation that includes a reduction in the elastic fibers with a consequent increase in the collagen content,fibrosis,cicatrization,and calcification.The present study provides a detailed morphometric analysis to semiquantitatively delineate the LF changes in patients with LCS from those in patients without LCS.

Botulinum toxin type A for treating chronic low back pain:A double blinded randomized control study

BACKGROUND Low back pain(LBP)is a prevalent issue that orthopedic surgeons frequently address in the outpatient setting.LBP can arise from various causes,with stiffness in the paraspinal muscles being a notable contributor.The administration of Botulinum toxin type A(BoNT-A)has been found to alleviate back pain by relaxing these stiff muscles.While BoNT-A is approved for use in numerous conditions,a limited number of randomized clinical trials(RCTs)validate its efficacy specifically for treating LBP.AIM To study the safety and the efficacy of BoNT-A in minimizing pain and improving functional outcomes in patients of chronic LBP(CLBP).METHODS In this RCT,adults aged 18-60 years with mechanical LBP persisting for at least six months were enrolled.Participants were allocated to either the Drug group,receiving 200 Ipsen Units(2 mL)of BoNT-A,or the Control group,which received a 2 mL placebo.Over a 2-month follow-up period,both groups were assessed using the Visual Analog Scale(VAS)for pain intensity and the Oswestry Disability Index(ODI)for disability at the start and conclusion of the study.A decrease in pain by 50%was deemed clinically significant.RESULTS The study followed 40 patients for two months,with 20 in each group.A clinically significant reduction in pain was observed in 36 participants.There was a statistically significant decrease in both VAS and ODI scores in the groups at the end of two months.Nonetheless,when comparing the mean score changes,only the reduction in ODI scores(15 in the placebo group vs 16.5 in the drug group,clinically insignificant)was statistically significant(P=0.012),whereas the change in mean VAS scores was not significant(P=0.45).CONCLUSION The study concludes that BoNT-A does not offer a short-term advantage over placebo in reducing pain or improving LBP scores in CLBP patients.

Valgus osteotomy in delayed presentation of femoral neck fractures using fixed angle simple dynamic hip screw and plate

Purpose: Reduction and fixation in femoral neck fracture in young patients have a problem of nonunion, requiring additional procedures like valgus osteotomy;but fixation devices are technically difficult for in experienced surgeons. We aims to assess the results of valgus osteotomy in femoral neck fracture in our setup. Methods: We reported a series of 20 patients of higher Pauwel's angled fracture of femoral neck fracture presenting late wherein valgus osteotomy was added to reduction fixation which was secured with a commonly available 135 dynamic hip screw and plate. Results: Femoral neck fractures united in 16 patients (80%). Excellent to good results (Harris hip score >80) were seen in 70% patients. Angle of correction of preoperative Pauwels has been changed from 68.3 to 34.3. Conclusion: The 135 dynamic hip screw and plate provides rigid internal fixation after valgus osteotomy and being a more familiar fixation device simplifies the procedure with good results.

Tropical cyclone Fani-perspective from the trauma and emergency department of an affected tertiary hospital

Purpose:To explore the epidemiological and clinical profile of patients admitted to the trauma and emergency department(TED)of a tertiary care hospital due to tropical cyclone Fani and highlight the challenges faced by the hospital in this natural disaster.Methods:A retrospective study was conducted in the TED in the affected zone.Data of all victims affected by the cyclone Fani on May 3,2019 were obtained from disaster records and medical case sheets.All patients except death on admission were included.Clinical variables included anatomical sites and severity of injuries which was assessed by revised trauma score(RTS)and injury severity score(ISS).Trauma injury severity score(TRISS)was also calculated.Results:Of 75 patients,74 were included and the other one was brought dead and thus excluded.The age,median±interquartile range(IQ),was 41.0(27.7-53.0)years.The male to female ratio was 2:1.Most of the wounded were transported by the police control room vans on day 1:first 10 h,50.0%;10-24 h,20.3%.The median±IQ range of RTS,ISS and TRISS were 20(14-28),7.84(7.841-7.841),and 97.4(91.6-98.9),respectively.Simple external injury was the dominant injury type.Polytrauma(ISS>15)was seen in 67%cases and spine injury in 14%cases(7%cervical and 7%thoracolumbar).Injury causes included sharp flying objects(broken pieces of glasses and asbestos)in 31%cases,followed by fall of trees in 20.3%.Twenty-four patients were discharged after primary treatment,30 admitted to the indoor-trauma ward or intensive care unit and 20 deferred or transferred to another center.There was no in-house mortality.Challenges were related to electricity failure,mobile network breakdown,infrastructure collapse,and delay in expertise repair from outside due to airport/railway closure.Conclusion:In cyclonic storm like Fani,sharp flying objects,fall of trees/poles and collapsing walls constitute the common mode of injuries causing harm to more than one body regions.Polytrauma was seen in the majority of patients though external injury was the commonest.The affected hospital had the uphill task of treating hospitalized patients as well as disaster victims.