Tuberculous arthritis revisited as a forgotten cause of monoarticular arthritis

Tuberculosis [TB] continues to be a major concern for health care workers. The number of reported cases of extrapulmonary tuberculosis, particularly osteoarticular tuberculosis, is increasing. This fact is attributed to different factors such as underestimating the disease and difficulty in diagnosis, which requires tissue sampling and can lead to a delay in the diagnosis, and can result in significant morbidity and mortality. The aim of this study was to highlight the difficulties and delay in diagnosis of articular tuberculosis, raising the need to create awareness about the importance of early diagnosis to avoid major complications of joint destruction. Retrospective review of patients presenting to a tertiary care center between 2003 and 2009. We reviewed cases who presented with monoarticular joint pain and swelling that failed to respond to treatment elsewhere and were eventually diagnosed as having articular tuberculosis. We collected the demographic data, history, data on clinical examination and the relevant laboratory investigations, in addition to the data on radiological studies. All patients were treated medically with antituberculosis chemotherapy and surgically according to the severity of joint destruction. Thirteen patients had a mean age was 40 years [range, 17-70 years]. The average delay in diagnosis was 2 years. Only 1 patient had pulmonary TB. The hip, knee and elbow were the most common joints involved. Bacteriology was positive in 69% of the cases; and histopathology, in 92%. Fifteen percent of the patients had arthrodesis. None showed recurrence after follow-up of 4 years. A high level of clinical suspicion is essential for early diagnosis and treatment of osteoarticular TB to reduce its significant morbidity

Results of primary total hip replacement with special attention to technical difficulties encountered in a cohort of Saudi patients

To illustrate our experience and the difficulty faced in primary total hip replacement [THR] in Saudi patient population. We retrospectively reviewed our database between February 2002 to December 2007 for primary THR cases at King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia and identified 58 hips [54 patients]. Patients data were collected from patient's medical records, clinical examination, and x-ray films. Operative reports were examined for the difficulty encountered during surgery and was classified into femoral, acetabular, soft tissue and combined difficulties. Patients follow up was a minimum of 2 years. The indication of surgery was posttraumatic arthritis in 50%, sickle cell anemia related avascular necrosis in 16.6%, primary osteoarthritis in 9.2%, idiopathic avascular necrosis in 9.2%, rheumatoid arthritis in 7.4%, and other indications were 14.7%. The femoral obstacles included narrow femoral canal in 27.7% and proximally migrated femur in 5.5%. Acetabular obstacles included protrusio acetabuli in 14.8% and structural posterior acetabular bone defect in 5.5%. Soft tissue obstacles included tight capsule in 14.8% and muscle contracture in 11.1%.Our Saudi patient population has shown different pathology of their hip disease in which most of the hips being posttraumatic as compared to series published in the west. We advised those who intend to tackle THR in this population to perform extensive preoperative planning in order to be able to anticipate the difficulty demonstrated by our experience

Ultrastructural changes of compressed lumbar ventral nerve roots following decompression

To study whether there will be a permanent lumbar nerve root scarring or degeneration secondary to continuous compression followed by decompression on the nerve roots, which can account for postlaminectomy leg weakness or back pain. The study was performed at the Department of Anatomy, Faculty of Medicine, King Abdul-Aziz University, Jeddah, Kingdom of Saudi Arabia during 2003-2005. Twenty-six adult male New Zealand rabbits were used in the present study. The ventral roots of the left fourth lumbar nerve were clamped for 2 weeks then decompression was allowed by removal of the clips. The left ventral roots of the fourth lumbar nerve were excised for electron microscopic study. One week after nerve root decompression, the ventral root peripheral to the site of compression showed signs of Wallerian degeneration together with signs of regeneration. Schwann cells and myelinated nerve fibers showed severe degenerative changes. Two weeks after decompression, the endoneurium of the ventral root showed extensive edema with an increase in the regenerating myelinated and unmyelinated nerve fibers, and fibroblasts proliferation. Three weeks after decompression, the endoneurium showed an increase in the regenerating myelinated and unmyelinated nerve fibers with diminution of the endoneurial edema, and number of macrophages and an increase in collagen fibrils. Five and 6 weeks after decompression, the endoneurium showed marked diminution of the edema, macrophages, mast cells and fibroblasts. The endoneurium was filled of myelinated and unmyelinated nerve fibers and collagen fibrils. Decompression of the compressed roots of a spinal nerve is followed by regeneration of the nerve fibers and nerve recovery without endoneurial scarring

Functional outcome following cementless total hip arthroplasty in patients with steroid induced avascular necrosis

Twenty six consecutive total hip arthroplasties performed for steroid induced avascular necrosis of the femoral head were identified in our prospective total hip arthroplasty [THA] database with 5 years minimum follow-up. These 26 hips [group one] were randomly matched in a blinded fashion to 26 total hip arthroplasties done for nonsteroid induced avascular necrosis of the femoral head. Functional data and Saint Michael's Hip Score were collected prospectively. Short form 36 [SF-36] health status survey and Western Ontario McMaster Osteoarthritis Index [WOMAC] were utilized. Radiographic assessment was performed. A cement less prosthesis was inserted in all patients. Statistically significant improvement in function was documented postoperatively in both groups. There was no significant difference between both groups with regards to the post operative Saint Michael's Hip Score, estimated blood loss, complications, and bony ingrowth. SF-36 survey did not show a significant difference in both groups except in social functioning where group one scored better than group two. There was no statistically significant difference in the WOMAC score between both groups. Definite bone ingrowth was seen in 84% of the hips. Cementless THA provides satisfactory outcome despite long term immunosuppression and a significant history of steroid use