We studied 51 patients with osteo-articular tuberculosis who were divided into two groups. Group I comprised 31 newly-diagnosed patients who were given first-line antituberculous treatment consisting of isoniazid, rifampicin, ethambutol and pyrazinamide. Group II (non-responders) consisted of 20 patients with a history of clinical non-responsiveness to supervised uninterrupted antituberculous treatment for a minimum of three months or a recurrence of a previous lesion which on clinical observation had healed. No patient in either group was HIV-positive. Group II were treated with an immunomodulation regime of intradermal BCG, oral levamisole and intramuscular diphtheria and tetanus vaccines as an adjunct for eight weeks in addition to antituberculous treatment. We gave antituberculous treatment for a total of 12 to 18 months in both groups and they were followed up for a mean of 30.2 months (24 to 49). A series of 20 healthy blood donors served as a control group.

Twenty-nine (93.6%) of the 31 patients in group I and 14 of the 20 (70%) in group II had a clinicoradiological healing response to treatment by five months.

The CD4 cell count in both groups was depressed at the time of enrolment, with a greater degree of depression in the group-II patients (686 cells/mm³ (sd 261) and 545 cells/mm³ (sd 137), respectively; p < 0.05). After treatment for three months both groups showed significant elevation of the CD4 cell count, reaching a level comparable with the control group. However, the mean CD4 cell count of group II (945 cells/mm³ (sd 343)) still remained lower than that of group I (1071 cells/mm³ (sd 290)), but the difference was not significant. Our study has shown encouraging results after immunomodulation and antituberculous treatment in non-responsive patients. The pattern of change in the CD4 cell count in response to treatment may be a reliable clinical indicator.

Tuberculosis of short tubular bones is uncommon after childhood. “Spina Ventosa” is considered the classical radiological presentation and hallmark of this disease. The short tubular bones are uncommon loci for the manifestation of adult skeletal TB. We report our experience with 31 cases of tuberculosis of hand (excluding wrist) with the intention to call attention to its occurrence in infrequently documented areas, to stress upon its morphologic variability and to illustrate little emphasized radiological signs.

Material & Methods: (n=31) Age range 1–68 years; M:F – 11:20; duration of symptoms-3 weeks to 2 years; history of Incision and Drainage before presentation −12 (38%) cases; Epitrochlear lymph node enlargement seen in 22 (71%) cases. Radiologically-classical spina ventosa seen in 5 cases; primarily diaphyseal involvement of metacarpal in 9, lesion in metacarpal head in 4, juxtraarticular metacarpal head erosion in 3, metacarpal base lesion in 3, phalangeal involvement in 2, carpometacarpal joint involvement in 2 and primarily small joint involvement in 3 cases. Majority of them were treated conservatively. Follow up is 1–5 years.

Discussion: Tuberculosis of hand might mimic several other inflammatory or neoplastic diseases. Disease might be initially painless and constitutional symptoms may be absent. Rapid collection because of lax skin on the dorsum of hand might tempt the surgeon for incision and drainage. FNAC of Epitrochlear lymph nodes may be diagnostic which may be enlarged in 60–70% cases. The clinicoradiological presentation, differential diagnosis and treatment with special reference to dynamic finger traction will be discussed.

The diagnosis of painful heel syndrome is quite common in any busy orthopaedics OPD. Though neoplasm and infections are not uncommon in calcaneum, the surgeon does not suspect infection unless there is an obvious history of punctured wound or constitutional symptoms. As such till date there is no series of large number of cases of calcaneal tuberculosis. We present our experience with 39 cases of calcaneal tuberculosis which include 2 cases of simultaneous bilateral symmetric involvement and 13 cases of tubercular lesion at the site of the attachment of Tendoachilles and Plantar Fascia. A classification of calcaneal tuberculosis is proposed.

Material & Methods: (n=39) age 6–60 years; male: female – 20:19; duration of symptoms – 2 weeks to 8 years; “Heel up” sign present in 19 cases; X-ray showed erosive lesion at the site of Tendoachilles attachment (enthesitic type lesion) – 8 cases; erosive lesion at the site of Plantar Fascia attachment – 5 cases; Intraosseous lytic lesion(s) without subtalar joint involvment – 23 cases; subtalar joint involvemnet – 3 cases. FNAC was positive in 17 cases and core biopsy revealed tubercular material in 12 cases. All cases except one were treated conservatively.

Discussion: The diagnosis and treatment of calcaneal tuberculosis are often delayed because the surgeon is unaware and signs and symptoms of calcaneal osteomyelitis are less dramatic than seen in osteomyelitis of long bones. The diagnostic and radiological features will be discussed.