Total knee arthroplasty is done to reduce pain and disability in elderly individuals with conditions like osteoarthritis and rheumatoid arthritis. One of the dreaded complications of TKR is infection which causes surgery a total failure and furthermore the subsequent treatment becomes more complicated and causes more morbidity and financial expenditure to the patient. TKR to treat active joint tuberculosis remains controversial and most authors advice not to do joint replacements in cases with active discharging sinuses 1, 4, 9 -11 . As a precaution it is always necessary to rule out infection pre operatively by thoroughly investigating the patient. But sometimes we can encounter unexpected things.A 55 year old female who was apparently normal two years back developed right knee pain. Pain is insidious, continuous, not associated with fever or any trauma. She is not a known case of TB of any other organ. But she is a known case of rheumatoid arthritis and epilepsy, on treatment. On investigating she had increased ESR of 56 for one hour, CRP is elevated to 2.4 and serum alkaline phosphatase elevated to 155.As there were no signs to suspect active TB in any of the systems or organs both clinically and radiologically, we proceeded with the total knee replacement. But on opening the joint synovium looked inflamed and hence it was sent for biopsy and TKR was completed with Genesis II (Smith and Nephew). The biopsy report came as granulomatous lesion consistent with tuberculosis. Synovium specimen showed epithelioid granuloma with Langhans Giant cells. But AFB and fungal staining came as negative. Post operatively patient was started on Anti TB treatment. Patient was mobilized next day of surgery with active knee bending exercises and after one week patient was made to walk full weight bearing and patient had no pain. Sutures were removed fifteenth post op day and discharged. Patient had been followed up for six months so far without any reactivation of tuberculosis. Six months follow up post op x-ray did not show any osteolysis of both femoral and tibial components. Skeletal tuberculosis is a common infection in India which is around 2% of all musculo skeletal tuberculosis. In the musculo skeletal system it affects most commonly the spine and next in order is hips and knees. When literature was reviewed TKR has been advised for subclinical TB and there are reports that TKR reduces pain, restores excellent range of motion and even TB gets cured and reactivation of TB is less. But in

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Tuberculosis [TB] usually has prolonged course and not identified before it becomes a full blown disease. TB scaphoid is very rare accounting for less than 1% of all musculo skeletal TB.Scaphoid has a precarious vascularity in which the proximal pole receives the blood supply from the distal pole through the waist of scaphoid which is the narrowest and weakest part of scaphoid; hence fracture is very commonly suspected and most commonly occurs in waist causing proximal pole prone for avascular necrosis and bone resorption. TB scaphoid has been commonly reported due to dog bite or IV canulation 12 but not otherwise. Our patient is a 79 years old male patient with no history of any injury, presented to us with wrist pain and difficulty in using the wrist. On examination he had swelling over dorsal aspect, anatomical snuffbox tenderness with range of movements restricted due to pain but no localized warmth or erythema. There was no neuro vascular deficit. We took an X-ray and found that there ismore than three fourths resorption of proximal pole of scaphoid.We investigated the patient. He had elevated polymorphs 72% (normal 45 -70%) in total blood count, C -Reactive Protein(CRP) is 2.4 mg/dl (normal is 0 -0.6), fasting sugars (FBS) 130 (normal 70 -110mg/dl ), post prandial sugars (PPBS)142 mg/dl (normal 80 -140), erythrocyte sedimentation rate (ESR) 42 mm/hr(normal 4 -30), calcium 10.4 mg/dl (normal 8.5 -10.1), globulin 3.9 g/dl (normal 2 -3.5). He had decreased lymphocytes 22.5% (normal 25 -40) and monocytes 1.4% (normal 2 -10) in total count, Hb 12.6 gms/dl (normal 13 -17), PCV 37.3 (normal 40-50%).We did a magnetic resonance imaging (MRI) of the scaphoid done. It showed resorption of proximal three fourths of scaphoid, except pisiform all other carpals are involved, small erosion in lateral aspect of distal radius, synovial thickening with effusion in lateral aspect of wrist, around scaphoid and along abductor pollicis longus and extensor pollicis brevis tendons. Nextdirect smear for AFB, Gram Staining, Fungal Stain and Tissue Culture all came as negative. ELISA screening for HIV for type 1 and 2 came negative.Biopsy of the scaphoid bone done and it came as tuberculous infection with granulomatous lesion.Under higher resolution it showed slipper shaped epithelioid cells with Langhans Giant Cells surrounded by lymphocytes. Post operatively we started on anti tuberculous treatment. The limb was immobilized in plaster of paris posterior slab for eight weeks. After two months there was excellent range of movements in the wrist with no pain.Chronic wrist pain is among the most difficult to diagnose 3 .The most common non traumatic causes of wrist pain are tendinitis and nerve problems. Causes of symptomatic inflammation of upper extremity tendons and peritendons are poorly understood 4 .Tuberculosis of wrist is very rare 5 .Foci of infection is usually distal radius and primarily in synovium. From there it permeates into carpals and flexor and extensor tendons. In patients with normal immunity tuberculous infection ...