There has been a major resurgence of tuberculosis (TB) and drug-resistant tuberculosis in the last few decades. Although it has been brought under control in most Western countries, it is still a major cause of death in endemic regions like India. Osteoarticular tuberculosis (OA TB) forms a small proportion of the total cases of tuberculosis. Perceptions and practices of orthopedic surgeons are entirely different in endemic and non-endemic regions around the world, due to the vast difference in exposure. Literature from endemic areas puts stress on clinico-radiological diagnosis and empirical anti-tubercular treatment (ATT). Such practices, although non-invasive, simple to implement, and economical, carry a significant risk of missing TB mimics and developing drug resistance. However, OA TB is still perceived as a “diagnostic enigma” in non-endemic regions, leading to a delay in diagnosis. Hence, a high index of suspicion, especially in a high-risk population, is needed to improve the diagnosis. Evolving drug resistance continues to thwart efforts to control the disease globally. This review article discusses the perceptions and practices in different parts of the world, with India as an example of the endemic world, and lays down priorities for overcoming the challenges of diagnosing osteoarticular TB.

Background: Proximal femoral valgus osteotomy is a recognized salvage procedure for managing hinge abduction in Perthes disease. Although proximal femoral valgus osteotomy aims to improve joint congruency, previous studies have been limited by heterogeneous methodologies and concomitant procedures, making it difficult to determine its isolated effect. Furthermore, no study of which we are aware has specifically examined how proximal femoral valgus osteotomy influences acetabular development or lower limb alignment over time. Questions/purposes: (1) Is isolated proximal femoral valgus osteotomy associated with improvements in femoral sphericity and proximal femur development at skeletal maturity? (2) Is it associated with promotion of acetabular development? (3) Is it associated with changes in the lower limb mechanical axis? Methods: Between November 2000 and December 2020, we treated 33 patients using proximal femoral valgus osteotomy for painful hinge abduction deformity associated with Perthes disease, which was initially suspected through serial clinical examinations and confirmed during examination under anesthesia combined with arthrographic findings. All 33 patients who met diagnostic criteria during the study period were treated with the same operation (except as specified below), and all were accounted for at a minimum of 5 years of follow-up and considered potentially eligible for study here. Of these, eight patients were excluded for prespecified reasons (bilateral surgery, use of shelf procedure or limb lengthening procedure, or skeletal immaturity at the most recent follow-up), leaving 25 patients, with a mean ± SD follow-up of 13 ± 5 years; two of those patients had not been evaluated within the past 5 years, although both had achieved skeletal maturity at their most recent follow-up (19 and 20 years of age, respectively). The mean ± SD age was 9 ± 2 years at the time of surgery and 22 ± 5 years at the most recent follow-up. Femoral head morphology was assessed using the sphericity deviation score, a continuous measure that quantifies the shape of the femoral head, with values < 10 considered spherical. Proximal femoral alignment was evaluated using the neck-shaft angle and the articulotrochanteric distance, with higher neck-shaft angles indicating coxa valga, lower angles indicating coxa vara, and reduced articulotrochanteric distances indicating relative overgrowth or proximal migration of the greater trochanter. Acetabular development was assessed using the center-edge angle and the Sharp angle, with lower center-edge angles and higher Sharp angles associated with acetabular dysplasia. The alignment of the lower limb was assessed at the most recent follow-up. The hip shape at the most recent follow-up was assessed using both the Stulberg classification and the head-acetabulum-trochanter (HAT) system. The Stulberg classification categorizes hips at skeletal maturity as from Class I (a normal hip) to Class V (a flattened femoral head with a normal neck and acetabulum). The HAT classification assesses the femoral head, acetabulum, and greater trochanter, with higher scores indicating greater residual deformity (≤ 3 is considered a “good” outcome). Pain was assessed using the VAS during activities of daily living. Hip ROM was measured at the most recent follow-up. Results: Proximal femoral valgus osteotomy was associated with improvement in femoral head sphericity, as the mean ± SD sphericity deviation score improved from 62 ± 19 before surgery to 34 ± 22 at the most recent follow-up (mean difference 28 [95% confidence interval (CI) 16 to 41]; p < 0.001). The neck-shaft angle increased postoperatively but partially remodeled, while the articulotrochanteric distance returned toward preoperative levels. Proximal femoral valgus osteotomy was also associated with improvements in acetabular development, as the center-edge angle progressively increased and the Sharp angle decreased. The Stulberg classification was Class II in three hips, Class III in 15, Class IV in three, and Class V in four, while 13 hips had a HAT score of ≤ 3, representing a good outcome on that parameter. The mechanical lateral distal femoral angle was 84° ± 2° on the affected side and 86° ± 2° on the contralateral side (mean difference -2° [95% CI -3° to -1°]; p = 0.001), whereas no differences were observed in the other mechanical angles. On the VAS, preoperative scores ranged from 6 to 10, whereas scores at the most recent follow-up ranged from 0 to 2. The overall hip ROM was within normal limits, with internal rotation demonstrating a slight reduction. Conclusion: Isolated proximal femoral valgus osteotomy for hinge abduction deformities was associated with improvements in femoral head sphericity and acetabular development in patients with Perthes disease. We recommend a paradigm shift in which proximal femoral valgus osteotomy may be regarded more as a joint preservation procedure than as a salvage operation. Future research is warranted to evaluate the potential influence of patient age and disease stage on outcomes and to further define the indications for additional acetabular procedures in hinge abduction deformities. Level of Evidence: Level IV, therapeutic study.

Concomitant talocalcaneal coalition (TCC) in idiopathic clubfeet is not well documented in the literature. The purpose of this study was to describe our experience with very early relapsing idiopathic clubfeet associated with TCC. Although cases have been successfully treated with the Ponseti casting method, all recurred within 2 months of removing the final cast. A single-centre cohort of twelve feet in eight patients treated by a single surgeon between 2006 and 2020 was investigated retrospectively. Recurred cavus with variable degrees of equinus was the earliest findings noted. TCC was incidentally detected during the open reduction of the earliest three feet in our series. Afterwards, ultrasonography was advised as a screening tool for detecting an associated anomaly; however, only the use of magnetic resonance imaging (MRI) was 100% accurate in diagnosing concurrent TCC. All coalitions were cartilaginous and the posterior facet was most commonly involved facet. The average age was 18 months for the coalition resection and open reduction of a dislocated talonavicular joint, and the average duration of follow-up was 52 months. None of the patients showed clinical signs of relapse at the latest follow-up. We recommend that an associated TCC should be considered in very early relapsing idiopathic clubfoot cases.