Tuberculosis Of Bone And Joint

presenter Dr. Sanjeev Kumar Singh M.S Ortho (PGT) KMCH, Katihar

History
 Hippocrates (460-360

BC) relation between pulmonary disease & spinal deformity Pott (1779) described Spinal TB

 Percival  Lennac

(1781-1826) described tubercle bacillus discovered in 1882 in Rigveda & Athurveda

 Tubercle

 Described  Charak

Samhita, Shushruta - Yakshma

Epidemiology & Prevalence

 World  WHO  India-

30 million

data- 3 million mortality / yr 1/5th of total TB population 2-3% - skeletal involvement

General ideas


Tuberculosis is a chronic infectious disease caused by the tubercle bacilli. Insidious in onset. TB of bone and joint is merely local manifestation of a general disease. Most TB lesion of bone and joint appear at least 2to3 years of the onset of the primary lesion, Commonest age - first three decades ,can occur at any age . Equally both the sexes.

Predisposing factors
 Malnutrition  Poor sanitation  Overcrowding  Immunodeficiency  imunosupressive  Diabetes  Alcohol  Old age  Drug

abuse

abuse

 trauma

drug

Pathogenic organism tubercle bacillus

 tubercle

bacillus may be either the human type or bovine type type----involves lung, transmission airborne by droplet type----involve the intestine or alimentary tract ,nonpasteurized/unboiled milk;

 human

 bovine

Predilection
 Spine :

thoracic , thoraco-lumbar, lumbar, cervical, cervico-dorsal and L/S

 Hip  Knee  Ankle  Elbow  Hand  Shoulder

Location
 Bone:

growing age - metaphysis adults - end of bone

 Joint: Synovial membrane  Spine: Paradiscal

Anterior Central Appendeges(posterior)

Pathogenesis


spread mainly haematogenous

 most

common route to the vertebral body is through Batson's venous plexus

 Osteoarteoarticular lesion

occcurs 2-3yrs after

primary focus

Pathology
 Synovium

swollen & congested, synovial effusion epitheloid cells, langhans giant cells, tubercle (soft/hard), caseation bodie, Kissing Lesion

 Inflammation

 Pannus, Rice  Cold

abcess, TB Sequestra disc and cartilage not

 Intervertebral

involved

Disease type
 Pathological:

- Caseous Exudative type (severe) - Granular type

Clssification of articular T.B

Clinical features
 Age-

1rst three decade onset monosseous and symptom

 Insidious

 Monoarticular /

 Constitutional sign

(wt. loss, lassitude, low grade pyrexia, anorexia, night sweat, tachycardia, tachypnoea, anemia)

Local symptoms and signs

 Monoarticular or  Limp,

mono-osseous involvement

joint movement restricted

 Stiffness

Early stage: limitation of motion; Late stage: fibrous ankylosis

 Deformity:

bone destruction, gibbus result from the lesion of thoracolumbar spine,

Local symptoms and signs

    

Muscle atrophy Muscle spasm Night cry Doughy swelling Fluctuated swellingcold abscess formed Sinus or fistula

investigation
      

CBC ESR CXR X-Ray of joint / bone Tuberculin test Biopsy Smear and culture
     

Guinea pig inoculation PCR ELISA Isotopes scintigraphy CT scan MRI

X-RAY

XRAY HIP

Treatment: general care

 Nutritional support  Fresh

air, warm dry climate ,sanatorium life, hygienic and nursing care. of concomittant disz drugs

 T/t

 Immunomodulation

local treatment
 Immobilization  Traction  Active

gaurded intermittent mobilization of

joint
 Ambulation

ATT
 1st

line drugs:

- Isoniazid (INH) - Rifampicin (R) - Pyrizinamide (Z) - Ethambutol (E) - Streptomycin (S)

ATT
 2nd

line drugs:

 Newer drugs:

Thiacetazone (TZN) PAS Amikacin Kanamycin Capreomycin Ethionamide Cyclocerine -

Ciprofloxacin Ofloxacin Clarithromycin Azithromycin Rifabutin

Immunomodulators: Levamisole

Middle Path Regime

 Intensive

phase (5-6 mth): INH+R+Ofloxacin (7-8 mth) :

 Continuation phase

INH+Z (3-4 mth), then INH+R (4-5 mth)

 Prophylactic phase(4-5

mth):

INH+E (4-5 mth)

This regime is for OPD patients For Indoor pts, any of above drugs is replaced by Streptomycin except INH

DOTs
It is strategy to ensure cure by providing the most effective medicine and confirming that it is taken.

Two Phase t/t:

1. 2.

Intensive phase (2-3 mth) Continuation phase (5-6 mth)

Category-1 IP -- 2(HRZE)3 CP -- 4(HR)3

DOTs
Category-2 IP -- 2(HRZES)3 + 1(HRZE)3 CP 5(HRE)3 Category-3 IP 2(HRZ)3 CP 4(HR)3

Surgical Treatment.


Miliary disseminations of the disease has been reported when surgery was carried out without adequate chemotherapy coverage. Before operation, at least general supportive nutrition and anti-microbial agents were performed for 2-4 weeks, and satisfied following index: ESR: show the normal General condition improved-good appetite, body weight grow etc.

 

Indications of Operation
 large

sequestrum which can not be absorped

 big abscess  sinus  when

TB osteitis or synovitis is uncontrolled and has a progress to true arthritis TB with paraplagia

 spinal  early

TB arthritis(1/3 destruction of joint surface)

Contraindications
 General

condition is not good and low resistance condition, such as too young or old patient with other vital visceral diseases can not bear the operation of active TB is present bacilli are resistant.

 The

 Another foci  Tubercle

Surgical Treatment
 When

abscess formation threatens the integrity of neighboring structure, of the infected foci is indicated, including curettage, debridement, synovectomy, arthrodesis, Osteotomy.

 Removal

Thankyou;; Thankyou;;