Aggarwal and Saibaba
management includes oral or intravenous atropine sul-
phate and has been described in the literature.6–11
Regenbaum et al. reported the first case of IHPS in a
premature infant with TNMG.12 The occurrence of
TNMG with IHPS was explained on the use of antic-
holinesterase therapy, which may potentiate a vagal
response, leading secondarily to smooth muscle pyloric
hypertrophy. This association warrants further investi-
gation, but remains intriguing in view of the possibility
of medical treatment of IHPS.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Papazian O. Transient neonatal myasthenia gravis. J
Child Neurol 1992; 7: 135.
2. To T, Wajja A, Wales PW, et al. Population demographic
indicators associated with incidence of pyloric stenosis.
Arch Pediatr Adolesc Med 2005; 159: 520.
3. Sommerfield T, Chalmers J, Youngson G, et al. The
changing epidemiology of infantile hypertrophic pyloric
stenosis in Scotland. Arch Dis Child 2008; 93: 1007.
Case report of a patient with
tuberculosis of the femur after
osteosynthesis with review of literature
Aditya Aggarwal1 and Balaji Saibaba2
Introduction
Tuberculosis (TB) is a disease of myriad manifest-
ations. Decreased immunity can lead to reactivation
of a previously established yet dormant mycobacterial
infection. There is paucity of literature regarding the
occurrence of osteo-articular TB after osteosynthesis
in an immunocompetent patient. We report a case of
hip TB secondary to screw fixation for traumatic fem-
oral neck fracture in a healthy adult who was neither
immunocompromised nor exhibited any clinical fea-
tures of TB. This report highlights the atypical mani-
festations of an easily treatable disease and the lack of
165
4. Sivitz AB, Tejani C and Cohen SG. Evaluation of hyper-
trophic pyloric stenosis by pediatric emergency physician
sonography. Acad Emerg Med 2013; 20: 646.
5. Macdessi J and Oates RK. Clinical diagnosis of pyloric
stenosis: a declining art. BMJ 1993; 306: 553.
6. Theobald I, Rohrschneider WK, Meissner PE, et al.
[Hypertrophic pyloric stenosis: sonographic monitoring
of conservative therapy with intravenous atropine sul-
fate]. Ultraschall Med 2000; 21: 170.
7. Singh UK, Kumar R and Prasad R. Oral atropine sulfate
for infantile hypertrophic pyloric stenosis. Indian Pediatr
2005; 42: 473.
8. Kawahara H, Takama Y, Yoshida H, et al. Medical
treatment of infantile hypertrophic pyloric stenosis:
should we always slice the ‘‘olive’’? J Pediatr Surg 2005;
40: 1848.
9. Lukac M, Antunovic SS, Vujovic D, et al. Is abandon-
ment of nonoperative management of hypertrophic pyl-
oric stenosis warranted? Eur J Pediatr Surg 2013; 23: 80.
10. Mercer AE and Phillips R. Question 2: can a conservative
approach to the treatment of hypertrophic pyloric sten-
osis with atropine be considered a real alternative to sur-
gical pyloromyotomy? Arch Dis Child 2013; 98: 474.
11. Wu SF, Lin HY, Huang FK, et al. Efficacy of medical
treatment for infantile hypertrophic pyloric stenosis: a
meta-analysis. Pediatr Neonatol 2016; 57: 515.
12. Regenbaum S, Sidhu K and Smith CE. Transient neo-
natal myasthenia gravis and pyloric stenosis. J Clin
Anesth 1995; 7: 515–518.
Tropical Doctor
2018, Vol. 48(2) 165–168
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awareness of which can cause considerable delay not
only in the establishment of an accurate diagnosis but
also in the institution of prompt treatment.
1
Professor, Department of Orthopaedics, Post Graduate Institute of
Medical Education and Research, Chandigarh, India
2
Consultant Orthopaedic Surgeon, Billroth Hospitals, Shenoy Nagar,
Chennai, Tamil Nadu, India
Corresponding author:
Balaji Saibaba, Consultant Orthopaedic Surgeon, Billroth Hospitals,
Shenoy Nagar, Chennai 600030, Tamil Nadu, India.
Email: balajijipmer@gmail.com
166
Figure 1. (a) Preoperative radiograph of pelvis with bilateral hip showing sub-capital fracture of the right neck of femur. (b)
Postoperative radiograph – two years after PTCS fixation showing screw back-out, articular penetration and head collapse. (c)
Anteroposterior and lateral radiographs of the right hip after PTCS removal, showing nonunion of femoral neck fracture. The fracture
lines are ill-defined. There is resorption of femoral head and neck. Prominent screw tracts are visible. (d) Postoperative radiograph
after cementless THR at 3.5-year follow-up.
Figure 2. Intraoperative photograph showing the cut section of
the resected femoral head. Black arrow mark shows granulation
tissue filling the previous screw tracts.
Case report
A 45-year-old healthy woman of poor socioeconomic
background sustained an injury to her right hip follow-
ing a fall from a two-wheeler after skidding on a
slippery road on a rainy day. Radiographs showed a
sub-capital femoral neck fracture (Figure 1a). Open
reduction and internal fixation with partially threaded
cancellous screw fixation (PTCS) (four in number) was
performed on the same day at a private hospital. The
early postoperative period was uneventful. The wound
completely healed and sutures were removed on the
14th day. Progressive gradual weight-bearing was
started from six weeks. After an apparently
Tropical Doctor 48(2)
asymptomatic period of two years, she developed dull
aching pain on the right hip which was of insidious
onset and gradually progressive. The pain was aggra-
vated on walking and partially relieved with rest. All
hip movements were painful. There was no history of
fever or any constitutional symptoms. Radiographs
showed coxa breva with collapse of the femoral head,
penetration of a single screw supero-medially into the
joint and slipping out of all four screws infero-laterally
(Figure 1b). A diagnosis of nonunion was made and all
the four screws were removed in a second intervention
at a different hospital. The postoperative period was
uneventful. Three months later, she presented with a
painful hip with radiological evidence of nonunion
(Figure 1c).
The clinical evaluation of hip function and disability
was done using the Harris Hip Score.1 The preoperative
score was 44. The patient had no history of fever, cough
or expectoration. There was no history of contact with
patients with TB, nor were any constitutional symp-
toms present. Poor housing conditions with inadequate
ventilation, overcrowding and inadequate exposure to
sunlight were noted. There were no local signs of infec-
tion apart from painful hip movements. Blood investi-
gations revealed a total leucocyte count of 9600 cells/mL
with a differential leucocyte count of 55% neutophils,
35% lymphocytes, 7% monocytes and 3% eosinophils.
Erythrocyte sedimentation rate, C-reactive protein
level, liver function tests were all normal. HIV testing
was negative. A cementless total hip replacement
(THR) (TridentÕ Acetabular Cup and AccoladeÕ Hip
Stem with modular metallic 36 mm head, Stryker,
Kalamazoo, MI, USA) was inserted (Figure 1d).
There were no gross signs of infection intraopera-
tively. The previous screw tracts were filled with
Table 1. Review of literature of cases with TB occurring after osteosynthesis.

Presenting features Treatment

Aggarwal and Saibaba

Study Cases Fracture Diagnostic

no. Study, year (n) Age, Sex site, type Implant used Clinical Radiological method Medical Surgical

1 Sennoune 1 72, F Trochanter, DHS Pain Implant loosening, HPE ATT Implant removal þ THA
et al., 20033 closed femoral head
necrosis
2 Kumar 5 25, F Ulna, closed DCP Induration, dischar- Screw loosening, lytic HPE ATT Debridement þ implant
et al., 20064 ging sinus lesions removal
51, M Trochanter, External fixator Pin tract discharge Cutting through of HPE ATT Debridement þ Excision
closed pins, lytic lesions, arthroplasty
femoral head
necrosis, acetabular
erosions
65, M Trochanter, CBP (initial), Pain, induration, Implant loosening, HPE, PCR ATT Debridement þ implant
closed DHS (later) wound dehis- screw cut-through, removal þ fibular
cence, discharge nonunion autograft
35, F Intercondylar DCS – Implant loosening, HPE, PCR ATT Debridement þ implant
femur, open collapse removal (initial) þ
fixation (later)
35, M Intercondylar Buttress plate Pain, induration Implant loosening, loss PCR ATT Implant removal
tibia, closed of reduction
3 Habib et al., 1 48, F Olecranon, TBW Discharge, wound Nonunion, osteolysis, HPE, ATT Implant removal þ
20135 closed dehiscence articular destruc- ZN stain repeated
tion, radial head debridements
dislocation
4 Current 1 45, F Neck of femur, PTCS Pain Implant loosening, HPE, PCR ATT Implant removal (initial)
study closed nonunion, femoral þ cementless THA
head collapse
DHS, dynamic hip screw; HPE, histopathological examination; ATT, anti-tubercular treatment; THA, total hip arthroplasty; DCP, dynamic compression plate; CBP, condylar blade plate; PCR, polymerase chain
reaction; DCS, dynamic condylar screw; TBW, tension band wiring; ZN, Ziel Nielson; PTCS, partially threaded cancellous screws.
167
168
unhealthy granulation tissue (Figure 2). The resected
femoral head and curettings from the screw tracts
were sent for microbiological and histopathological
analysis. Biopsy of the femoral head showed numerous
granulomata in the intertrabecular spaces, predomin-
antly composed of epithelioid histiocytes and
Langhans type of giant cells. The granulomata
showed characteristic lymphocytic cuffing. A histo-
logical diagnosis of TB was made.
Polymerase chain reaction (PCR) of the tissue
sample was also positive for TB. PCR analysis for
detection of Mycobacterium tuberculosis DNA was
done using M. tuberculosis-specific gene primers
namely insertion sequence 6110 (IS6110). However,
acid fast bacilli (AFB) could not be detected by AFB
stain or culture. Standard anti-tubercular treatment
(ATT) was commenced postoperatively. There were
no problems of wound discharge or delayed wound
healing. Weight-bearing was started six weeks post-
operatively. ATT was given for a total duration of 18
months and was well tolerated. At final follow-up of 3.5
years, the patient was pain-free and independently
ambulant. There was no clinical or radiological evi-
dence of infection. The final Harris Hip Score was 98.
Discussion
The incidence of skeletal TB in Asians is estimated
to be 15–20%. It has a bi-modal age distribution –
more commonly affecting the younger age group
(20–35 years) and less commonly the older individuals
(>55 years).2 The occurrence of TB infection of the
skeletal system after osteosynthesis for traumatic
closed fractures in immunocompetent individuals is
rare. We found only three studies (a total of seven
cases) reported in the literature (Table 1).3–5
India is an endemic for TB and thus previous expos-
ure to M. tuberculosis was highly likely, especially con-
sidering the patient’s social circumstances, but the
organism must have remained dormant. The most
common occult sites for latent tubercular infection
are the lung, kidney and mesenteric lymph nodes.6
The most likely pathogenesis for skeletal TB
after osteosynthesis in our case is either local reactiva-
tion of a dormant infection or haematogenous
seeding from reactivation of a distant foci. Such reacti-
vation may be secondary to a fall in either local
or systemic immunity following trauma and/or surgical
intervention.3,4,7 Major trauma has been documented
to precipitate a fall in both cell-mediated and
antibody-mediated immunity, with elevation of anti-
Tropical Doctor 48(2)
inflammatory mediators such as IL-10 and TGF-beta,
both of which are potential deactivators of an immune
response in TB.5,7
In our patient, there were no local signs of infection
such as induration, wound dehiscence or discharging
sinus as described by Kumar et al. (four cases) and
Habib et al. (one case).4,5 The disease activity might
have been responsible for the pain which the patient
had, even at rest. Pain which was aggravated on walk-
ing may be attributable to articular screw penetration.
Lack of clinical suspicion coupled with an atypical
presentation of the disease led to considerable diagnos-
tic delay. Nonetheless, ATT for 18 months is effective
in curing the disease. Nonunion following osteosynth-
esis was secondary to TB infection. Early detection and
prompt and adequate treatment could have prevented
the need for prosthetic replacement.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Harris WH. Traumatic arthritis of the hip after disloca-
tion and acetabular fractures: treatment by mold arthro-
plasty. An end-result study using a new method of result
evaluation. J Bone Joint Surg Am 1969; 51: 737–755.
2. Pigrau-Serrallach C and Rodrı́guez-Pardo D. Bone and
joint tuberculosis. Eur Spine J 2013; 22(Suppl. 4):
556–566.
3. Sennoune B, Koulali KI, Fnini S, et al. Tuberculous
infection after dynamic-hip screw osteosynthesis: a case
report. Rev Chir Orthop Reparatrice Appar Mot 2003; 8:
257–260.
4. Kumar S, Agarwal A and Arora A. Skeletal tuberculosis
following fracture fixation - a report of five cases. J Bone
Joint Surg Am 2006; 88: 1101–1116.
5. Habib M, Tanwar YS, Jaiswal A, et al. Tubercular arth-
ritis of the elbow joint following olecranon fracture fix-
ation and the role of TGF-beta in its pathogenesis. Chin J
Traumatol 2013; 16: 288–291.
6. Harries A and Maher D. TB: A clinical manual for South
East Asia. Geneva: World Health Organization, 1997.
7. Rodrick ML, Wood JJ, O’Mahony JB, et al. Mechanisms
of immunosuppression associated with severe nonthermal
traumatic injuries in man: production of interleukin 1 and
2. J Clin Imunol 1986; 6: 310–318.