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Ind. J. Tub., 1993, 40,109
TUBERCULOSIS OF BONES & JOINTS*
I am grateful to the Tuberculosis Association of India and Lupin Laboratories for giving me an opportunity to give this oration. I would like to dedicate this oration to persons in the field of orthopaedic surgery who were responsible for the modern concepts of treatment of tuberculosis of bones & joints and to my teachers and colleagues in the profession : Prof. Russel Hibbs & Prof. Alan de Forest Smith of New York Orthopaedic Hospital; Prof. John Charnley of Manchester; Prof. Girdlestone of Oxford & Mr. J.C. Wilkinson of Wrightington (U.K.); Prof. Hodgson & Prof. Stock of Hongkong; My teacher and mentor. Prof. M.G. Kini of Madras and my senior colleague, Prof. P.K. Duraiswami. This oration would have been impossible without the support of Prof. S.M. Tuli's classic “Tuberculosis of Bones & Joints”. To him I owe a deep debt of gratitude.
History The tubercle bacillus has co-existed with Homo sapiens since time immemorial. The Rig Veda, Atharva Veda (3000 - 1800 BC) and Samhita of Charaka & Sushruta (1000 & 600 BC) recognized the disease as “Yakshma” in humans, which by its symptoms and signs could only be tuberculosis of the lungs.1 Tuberculous lesions have been found in Egyptian mummies and the Greco Roman civilisation recognised phthisis or consumption as a problemof the lungs.
lion globally and approximately 30% or 10 million cases exist in India,21-3% of the 10 million have involvement of bones & joints. The predisposing factors are malnutrition of the protein calorie type, environmental conditions and living standards such as poor sanitation, over crowded housing and slum dwelling. Trauma as a causative factor is debatable, but cases following trauma have been reported.3 Repeated pregnancies and lactation in women is also a factor. A diabetic status is an important pre-disposing factor. Acquired immuno deficiency syndrome has certainly led to a resurgence of tuberculosis. Osteo-articular disease is always secondary to a primary lesion in the lung. Lymph node involvement (mediastinal, mesenteric or cervical) and visceral lesions, like renal and hepatic tuberculosis, could also be concomitant forms, particularly in diabetics.
The prevalence of the disease is around 30 mil*
Tubercle bacilli are mainly of two types : human & bovine. According to Western reports, bovine tubercle bacilli are responsible for 80% of osteo-articular lesions below the age of 10 years. The human bacillus is responsible for almost all the cases of osteo-articular tuberculosis in India. Bacteriological confirmation by identification of the bacillus in cold abscess aspirate or biopsy taken from the site of the lesion (bone soft or granulation tissue) or culture of bacilli on Lowenstein Jensen medium would be necessary in certain cases. This may not, however, be positive in all the cases 4'5. In the Indian scenario, various studies have shown varying rates of confirmation : 40-80% by Dahl,6 60.5% by Tuli7 and 87% by Lakhanpal* after culture and guinea pig
TAI-Lupin Oration, 1992 prepared in collaboration with Dr S.M. Tuli and delivered at the 47th National Conference on Tuberculosis & Chest Diseases, Bombay, 26th to 28th November, 1992. 1. Director General of Health Services, Government of India (Retired) and Director, WHO Headquarters Office, Geneva (Retd.). Correspondece: Dr. B. Sankaran, Sitaram Bhartia Institute of Science and Research Centre, B-16, Mehrauli Institutional Area, New Delhi-110 016
In the cervical spine. Mandible and temporomandibular joint lesions have not been reported. a cold abscess occurs in the soft tissues.42%. (3) in the supraclavicular area and. (2) local steroidal injection. The average number of vertebrae that are seen to be destroyed radiologically has been shown to be about 3. cervical -12%.19. the lesion is insidious in onset and only rarely is there an acute manifestation. It can also be limited to the centrum of the vertebrae resulting in concentric collapse and should be differentiated from compression of the vertebrae secondary to primary or metastatic malignant disease of the vertebal body. cervico-dorsal .21. The transmission of atypical mycobacteria cannot be by contact. but could also be anatomically located in the following sites : (1) behind the prevertebral fascia.18 The disease can involve vertebral bodies at two or three different sites and these are referred to as “skipped lesions”. and veins as a result of back flow. Aetio-pathogenesis Osteo-articular tuberculosis can occur in the spine. The most common general symptoms are weight loss.3%. reduction of the disc space and concomitant destruction of the vertebral bodies. The disease occurs with equal frequency in both the sexes. The most common method of spread to the vertebral body is through Batson's prevertebral venous plexus.110 B. In most cases.22.0 in children and 2. (3) surgical trauma. shoulder and as diaphysial foci. painful restricted joint movements in all die planes and severe spasm of the surrounding muscles. para discal in location with destruction of the disc.26%. thoraco-lumbar . on either side of the disc. (5) in the back of the neck. Dobson et al9 have confirmed Dahl's findings of 19516 and 1973. rarely.8 in adults. (2) along the posterior border of sternomastoid muscle.5% and lumbo-sacral . The lesion in the spine is. The estimated number of spinal tuberculosis cases in India is between 30. (4) diabetic status. it presents as a retropharyngeal or prevertebral shadow. tracing its way through the inter muscular Abscess Pathways Since the cold abscess is the most common and important criterion for establishing the diagnosis of tuberculosis of the spine. tuberculosis fiumanis or bovis have been reported in lesions of the synovial sheath. lateral to the posterior spinal muscles and (6) tracking down the brachial plexus to present in the axilla or even at the elbow joint. there is stiffness. The following factors would have to be considered in this regard : (1) trauma.20 in the body. The destruction could also be on the anterior aspects of the vertebral body extending behind the anterior longitudinal ligament to the sequential vertebrae. A deformity.23. wrist. along one of the main nerves of the upper extremity. prevertebral accumulation of pus is a very noticeable feature.5 to 3. The major method of spread is haematogenous through arteries. The lesion in the spine is almost always secondary to a demonstrable primary focus elsewhere15. A number of authors have confirmed the high occurrence. A thoracic cold abscess is quite frequently .10'17 The commonest age of occurrence is the first three decades of life but it can occur at any age and has been reported from the first year of life to among those 80 years old. posterior element disease can occur behind the anatomical neuro-central-synchondrosis in 6% of cases. Clinical Aspects I shall now discuss the various clinical aspects according to the site of the lesion. SANKARAN inoculation.12%. Locally. elbow. in the spine can be present as kyphosis along with local tenderness and proximal lymphadenopathy. knee. hip. Tuberculosis of the spine has the following distribution : thoracic . If the lesion has been present for a sufficiently long time. Lastly.000 cases. lumbar . foot. lassitude and evening rise of temperature.24 The commonest skeletal lesion is the vertebral lesion which is responsible for 50% of all bone & joint tuberculosis. the anatomical path of the cold abscess is of great importance. (4) down the mediastinum to become an upper mediastinal mass visible on X-ray. most often. hand. (5) use of chemical immunosuppressive drugs like cyclosporin in organ transplantation and (6) acquired immuno-deficiency syndrome. Atypical myco-bacteria. In any region.000 and 90. other than M. (A) Tuberculosis of Spine planes.
Specific radiological appearances in the spine may include. Lesions can now be picked up much earlier. Abscess can sometimes be globular in shape which indicates accumulation of pus under tension.e. One of the most important diagnostic radiological criteria is the delineation and study of para vertebral shadows. an aneurysmal type scalloping (concave erosion) along die anterior margin of the vertebral body. excellent quality X-rays are vital otherwise lesions in this area are frequently missed. if it traverses below the inguinal ligament. (c) along the psoas sheath or (d) in the lumbo-dorsal (Petit's) triangle. under the gluteus maximus. popliteal fossa or on the medial side of the tendo-achilles. Thus. a psoas abscess can be picked up on antero-posterior X-ray by enlargement seen in the psoas shadow. (b) behind the medial lumbo-costal arch of the origin of the diaphragm and enter the psoas sheath and present as a psoas cold abscess. the anatomical presentations of a cold abscess can be far away from the site of the lesion. In the lumbar region. (2) in the buttock. the cold abscess might take various routes. Any increase beyond this should make one suspect the possibility of an increase in the retropharyngeal shadow. diabetes status and X-ray or CAT controlled needle aspiration biopsy. mostly as a result of cold abscess present under the anterior longitudinal ligament. In the cervical region. as the lumbar cold abscess does. This anterior type of lesion is more common in children. It can also track down along the femoral or abturator artery and present on the medial side of the thigh. Spectacular advances in modern imaging technology. (b) abdominal wall behind the rectus sheath (c) midaxillary line and (d) along the posterior division of the intercostal nerve. Retro-peritoneal accumulation of pus may extend downwards to the presacral region and is seen behind the rectum. and in a situation where CAT and MRJ are not available. Radiological Appearances The para discal lesion shows a reduction in disc space before osseous destruction occurs. besides the types described above. & JOINTS 111 prevertebral or posterior mediastinal in location. A very large abscess on both the sides of the aorta. like computerized axial tomography and magnetic resonance imaging have made diagnosis of tuberculosis of the spine much easier. or where there is post element disease. such far away presentations are becoming rarer because of early diagnosis and early clinical suspicion of the disease. below the 4th dorsal vertebra. The abscess can track along (a) behind the lateral lumbo-costal arch of the origin of the diaphragm and present in the retronephritic space or in the layers of the anterior abdominal wall. typical fusiform “Bird Nest” abscess is commonly seen.TUBERCULOSIS OF BONES. lateral to the sacro-spinalis muscle mass. below D10. palpable above the inguinal ligament or on the medial aspect of the thigh. A lumbar cold abscess can spread along the aorta and its branches to present at the (1) ischiorectal fossa. In the dorsal region. (c) it can go behind the median arcuate ligament of the origin of the diaphragm along the aorta and its branches and can. the normal retropharyngeal space is 1. lateral curvature in the spine (scoliosis) may be seen but the most common is the kyphotic deformity. and the lower margin extending to the level of the medial arcuate ligaments is a common finding. such as single . thus. In lower thoracic lesions. Fortunately. have wider sites of presentation. a contrast medium study is indicated. Intra spinal spread of abscess into extra dural space cannot normally be detected on routine radiograms. In respect of the lower cervical 6th and 7th vertebrae and lst-4th dorsal vertebrae. however. Diagnosis The investigations to establish the diagnosis are primarily X-ray examination and imaging techniques such as computerized axial tomography (CAT) and magnetic resonance imaging (MRI). Other investigations including a blood profile with erythrocyte sedimentation rate. with broadening of die mediastinum.5 cms below the cricoid cartilage. femoral triangle. In cases with paraplegia but without radiological evidence of skeletal lesion. It could. but focal osteoporosis is seen even earlier than disc space reduction. increase in the antero-posterior curvature. i. The spread of cold abscess has been extensively discussed by Lee Macgregor in his book 'Synopsis of Surgical Anatomy'. track along the intercostal nerves to present at the following sites : (a) anterior end of intercostal space. Rarely.
Histocytosis like eosinophilic granuloma in children might need a fine needle aspiration biopsy under computerized axial tomography scan control. The same is true of cortisone induced osteoporosis. Myotoma actinomycosis : It is a rare condition and difficult to differentiate. 3. 9. In all these problems. facetal joint lesion and post element disease. Multiple compression fractures of vertebral bodies can be noticed. Radio1 logical destruction is limited to one or two vertebrae and the abscess is limited to just one area. Primary malignant bone lesion could be a chondro-sarcoma of the vertebral body. The other possible pathological lesions that might simulate tuberculosis of the spine are osteochondritis of the Scheurmann type and hemivertebrae. SANKARAN localized centrum lesion. severe anaemia. Ewing's sarcoma of the spine is rare but must be thought of. These fractures can be of multiple vertebrae and no abscess shadow or para-vertebral mass is visualized on X-ray examination. the anterior wedging of vertebra and no involvement of the disc space help. 6. loss of osseous trabecule is noted. tract tumours. Secondary metastatic deposits can occur in adrenal medulloblastoma in children. Metabolic skeletal osteoporosis : Senile. Most present as paraplegia or quadriplegia depending on the site of the lesion. These are rare lesions and have specific radiological appearances that help diagnosis. In a patient with paraplegia. multiple myeloma or solitary plasmo-cytoma and lymphoma of bone. 8. Occurrence of paraple- . Chronic infection : Rheumatoid (Seronegative) involvement and ankylosing spondylitis can be differentiated with haematological investigations. prostate and G. no abscess shadow is seen radiologically. Traumatic compression fracture : Normally. Salmonella osteomyelitis : This can be easily missed. soft tissue extension and hepatic involvement are present. Giant cell tumour and aneurysmal bone cyst show multiple vertebral destruction with total destruction of the entire body including posterior elements. osteoblastoma and osteoid osteoma should be thought of when the lesion is restricted to a single vertebra. 10. become more scientific. Clinical presentation is with weight loss. No paravertebral mass or abscess shadow is noted. Sickle cell disease individuals are more prone to get it. the nature of the pressure and the possible functional restoration of the cord after decompression of the abscess. Fine needle aspiration biopsy under X-ray control is necessary to establish a diagnosis. and very high ESR. Benign lesion such as haemangioma. Tumour of the vertebral column : Either benign or malignant may have to be differentiated from skeletal tuberculosis. Complications The most single important complication is paraplegia or quadriplegia. It is important to exclude hyperthyroidism and hyperparathyroidism (primary or secondary) as cause of compression fractures of vertebrae. breast. therefore. The diagnosis and specific method of management. 4. Brucellosis : Drainage and culture of bacilli are needed. All malignant tumours have a characteristic bone destruction pattern but the intervertebral disc space is well preserved.I. Pyogenic osteomyelitis : The clinical presentation is acute with high rise of temperature. the density of bones is decreased. the value of CAT scan and MRI is that it shows the extent of extra dural pressure on the spinal cord. thyroid. Luetic : A rare condition confirmed by blood examination for syphilis. Drainage of abscess and culture of organism helps to establish a diagnosis. Differential Diagnosis Following conditions have to be considered for differential diagnosis: 1. The exact rib that has to be excised and the extent of calcification of the abscess or granulation tissue can also be demonstrated.112 B. post menopausal. Malignant lesions may either be primary or secondary. The diagnosis needs a radial laminectomy and biopsy examination. lung. 7. 5. 2. the inter-vertebral disc space is well preserved. The ESR is well above 100 mm/hr. Other tumours that can metastasize in bones are renal. Echinococcus : The type of destruction in vertebral body is as if punched out with concomitant destruction of the disc space. There is a possibility of septicemia.
000 to 45. Grade B. out of a total of 15. The addition of steroid might prove crucial. Isoniazid. Rifampicin.TUBERCULOSIS OF BONES & JOINTS 113 gia is 10-30%. both Streptomycin and Rifampicin are advocated by paediatricians. both sensory and motor. If toxicity develops. inadequate blood supply to the spinal cord as a result of slow exsanguination resulting in a fibrous cord. and grade B with late onset. it is continued for a minimum of 18 months. There is bladder and bowel involvement and total sensory and motor loss. The drugs of choice are Rifampicin. Grade B paraplegia might be due to recrudescence of disease. It is important. Ethambutol can produce depressed thyroid function. cervical. Treatment Antituberculosis drug regimens : The Medical Research Council of the United Kingdom carried out a series of trials in the late 60's and early 70's to establish the antituberculosis regimens necessary for treatment of tuberculous lesions of bones and joints. Ethambutol and Pyrazinamide. drugs. the offending drug is changed. The vertebral regions commonly involved in paraplegia of tuberculosis origin are thoracic. I personally advise surgery in all cases of tuberculous quadriplegia. careful attention must be paid to toxicity. and patchy meningitis. therefore. lumbar and cauda equina. Allergic reaction can occur to any drug. Briefly.500. Rifampicin can produce hepatotoxicity and hence SCOT & SGPT levels must be monitored. A careful detailed neurological examination every 3 or 4 days is mandatory. i. Rifampicin. Thus. usually exhibited by long tract involvement signs or segmental paresis. thoraco-lumbar. Short term steroid therapy can be given in patients who are in a moribund state. in that order. mechanical pressure as a result of severe kyphosis. paraplegia due to upper dorsal tuberculous lesion. In children below the age of 12 years. Streptomycin can effect the VIII nerve resulting in deafness or vestibular functional derangement. till anti-tuberculosis treatment starts acting or when patchy meningitis is present.000 to 90. Seddon & Roaf25 classified tuberculous paraplegia in two grades. On clinical examination. there is a four drug regimen for the first three months with dosages of the drugs based on age and body weight of the patient.e. there are signs of compression.e. Though the emphasis in the trials was primarily on tuberculous spine. if there is improvement. Grade II: There is evident spasticity but the patient is able to walk. One half of all reported paraplegias are due to tuberculosis of thoracic and thoracolumbar regions. i. If there is an increase in neurological deficit. Nobody has studied this aspect in our country till today and the numbers given are pure guesstimates. Isoniazid and Ethambutol for 16 to 24 months. Grade A paraplegias (Pott's paraplegia) have also been described26-27 as: Grade I : The patient is not aware of the problem. has a poor prognosis which must be explained to the patient. often with “jumpiness” in the gait. Short term therapy with anabolic steroids in debilitated malnourished patients enhances the protein intake but .000 paraplegics in the country. after more than 2 years. within 2 years after onset of symptoms of tuberculosis. The major aim of treatment is to prevent paraplegia. The drugs used are Streptomycin. The patient is able to walk.500 and 22. Most authors have adopted the use of 4 anti-tuberculosis drugs for a period of three months initially followed by three drugs for 18 to 24 months. Griffiths. when there is grade IV type paralysis. If there are 30. Grade A and Grade B : Grade A with early onset. Isoniazid. Grade IV : Paraplegia occurs with flexor spasm. that some body should take up the study of this important problem since the entire sequence of disease leading to complication is preventable.000 cases of tuberculosis of the spine. Auxiliary Treatment : Steroids are not recommended to be given routinely.e. surgical intervention becomes desirable. i. However. in general. periodic review of progress by X-ray and ESR done every 4 weeks. Grade III : The patient is bed-ridden and has spastic paraplegia in extension with demonstrable neurological deficits. patients with paraplegia would be between 7. The commonly followed treatment modality is the middle path. bed rest. on conservative treatment. the recommendations are for all types of musculo-skeletal lesions. Ethambutol and Pyrazinamide. Long tract involvement signs are significantly present. The prognosis is poor. and where investigations have indicated extradural spread of the cold abscess or granulation tissue. followed by three drugs.
after allowing the lung to collapse. granulations tissue and vertebral body excised till a pulsating cord is demonstrated. This is the commonest procedure used in this country. (5) Mechanical instability after healing. an abscess of the cervical spine is evacuated through an approach centred on the posterior margin of the sternomastoid muscle. where there is a large abscess in the thoracic region. (2) Paraplegia of the flexor spasm type. is done in children to prevent excessive kyphosis. The cold abscess can be either intra pelvic or under the gluteus maximus muscle. The ribs are separated. besides the above given criteria: (1) Neurological complications which fail to respond to conservative care. Where . A psoas abscess is evacuated through the external abdominal muscle parallel to the hypogastric or ilio-inguinal nerves. evacuation of the lumbar abscess is done through Petit's triangle or by means of renal approach or through a retroperitoneal sympathectomy approach. 2 or 3 ribs are removed for about 2 to 3 inches at their vertebral end. Antituberculosis therapy and protective bracing are the treatment of choice. and partial excision of the vertebral body so that the pressure on the cord is relieved. No instrumentation should be done in such cases. Post operative care in all the cases should be a protective plaster jacket or a moulded orthoplast brace for about 4 weeks. Diagnosis is established by aspiration of pus or a fine needle aspiration biopsy. in which the rib is excised at the maximum diameter of the abscess below the 5th dorsal vertebra on the left side. The abscess is located intrapleurally and confirmed first by aspiration of its content. SANKARAN it should be avoided in women and children. exposure of . There could be either sacral or iliac lesion. Post spinal fusion. The vertebral bodies are then fused with the excised ribs.there is extensive obstruction. (B). the pulsations of the cord are confirmed. The cord with its covering membranes should be exposed anteriorly and laterally so that pulsation of the cord commences after the decompression. Diseased vertebral body is excised to normal bone. an abscess in the C. The trachea and oropharynx are identified. as recommended by Hibbs28. and (7) Multiple vertebral involvement in children with severe kyphosis. either an abscess or granulation tissue. the abscess evacuated. and above the 5th dorsal vertebra on the right side. The intercostal artery is ligated beyond the origin of retrograde spinal arterial branches. Normally. I have always practised the following. Laminectomy is indicated only if there is post element disease with cord compression. as indications for surgery. An adequate supportive brace is necessary till bony fusion has occurred. with bladder and bowel involvement and sensory deficit. (3) Neurological status remaining static. In the cervical spine. (2) Antero-lateral decompression for a paravertebral mass.and where there is multiple segmental vertebral involvement.-C2 region is normally retropharyngeal and a transoral evacuation is necessary. Anterior spinal fusion is done in all cases where an anterio-lateral or a trans-thoracic decompression has been done.114 B. Ligation of the branches of the external carotid artery may be necessary. The intercostal artery and nerve are identified and ligated. taking particular care to preserve the 9th left intercostal artery. Tuberculosis of Sacro-iliac Joint Tuberculosis at this uncommon site is frequently missed. The technique is primarily an extra-pleural exposure of the abscess/granulation tissue and the vertebral lesion. The abscess cavity is then opened by a cruciate incision. (3) Transthoracic anterior decompression. retracted medially. Below the C2 level. The vertebrae are then fused with the resected ribs. the longus colli and anterior vertebral muscles identified after longitudinal division of the prevertebral layer of the deep cervical fascia and the abscess evacuted. and then fusion is done using an iliac graft. . The various techniques of surgical treatment are: (1) Costo-transversectomy. or (4) Where the diagnosis remains doubtful. Pleura is then opened. (6) Recurrence of the disease. Tenderness over the sacroiliac joint and compression and distraction tests are painful. In the lumbar spine.
If there is sequestration. with skin traction to ease the spasm in the initial stages followed by hip spica to prevent mobility of the joint. or posteriorly under the gluteus maximus muscle. In early stages. in the greater trochanter. palpable synovial thickening and restriction of mobility. early and advanced tuberculous arthritis with involvement of the articular cartilage and bone. In India. In late stages. If there is marked synovial thickening. or doubt in the diagnosis. with villi formation. acute infective arthritis of infancy and childhood osteoid osteoma of the neck of the femur with synovial involvement. Legg Berthes Halve disease. when there is an effusion in the joint. the lesion could be purely synovial in location. and ultimate pathological dislocation. osteomyelitis of upper end of femur. Skeletal lesion can occur in the head and neck of femur. a malignant synoviona of the hip joint can be mistaken for tuberculosis of the hip. The anatomical sites of the lesions could be (a) the superior rim of the acetabulam. Abscesses in the hip joint normally present themselves in the femoral triangle. The clinical stages of the disease can be synovitis. as discussed. Laterally. Rarely. in men. it can take the course of the femoral nerve. open biopsy and sequestrectomy is desirable. a hip intraarticular arthrodesis with total excision of the focus and articular cartilage may be necessary. synovial effusion. both in femur and tibia. sometime with caseating lymphnodes. rheumatoid arthritis. It can occur in any age group but is more common in children. Tuberculosis of Hip Joint Involvement of the hip joint is the second commonest skeletal lesion. the limb goes into flexion. which is drained by the communicating venous channels of the Batson's prevertebral venous plexus and (b) Babcock's triangle limited by the inferior neck of femur.TUBERCULOSIS OF BONES & JOINTS 115 the sacro-iliac joint. as a result of gross destruction of the femoral head or the superior acetabular margin. In advanced cases. Treatment Treament of hip joint comprises : (1) Rest in the acute phase. but can present on the medial aspect of the thigh. the most useful method of treatment is Mac Murray's defunctioning inter-trochanter medial displacement osteotomy. Tuberculosis of Knee Joint Tuberculosis of knee joint can occur in any age group. Differential Diagnosis Tuberculosis of hip has to be differentiated from transient synovitis of the hip. The most common symptoms are : pain on movement of the knee joint. because of the deformity that is frequently present. medially by the epiphysial line or equivalent stress lines in adults and laterally by the stress trabeculae of the neck of the femur which is intraarticular in location. (C). next to that of spine. as evidenced by radiological finding. (D). as advocated by Smith Patersen is done followed by fusion of the joint after curettage of all infected bone and cartilage. there is triple dislocation of the knee : lateral. abduction and internal rotation. Rarely. with an apparent lengthening of the extremity. In selected cases. External iliac lymphadenopathy is normally present. the affected limb is flexed. The femoral triangle can be full and an abscess may be palpable. the hip is dislocated posteriorly and superiorly with true shortening of the involved limb. The diagnosis is best established by aspiration of the joint for a cold abscess or needle aspiration biopsy of synovial membrane. posterior. Diagnosis is established by radiological examination which can show destructive lesions in the . when destruction has been progressive. a synovectomy of the hip joints is of value. The clinical presentation is primarily a painful hip limp. destruction of articular cartilage secondary to the synovitis and metaphysial and subarticular lesions can occur. If a pathological dislocation occurs. The lesion is quite frequently synovial in location. with an apparent limb shortening. and superior displacement of tibia on femur. (2) Anti-tuberculosis treatment. Purulent material can accumulate in the joint space. abducted and externally rotated. avascular necrosis of the head of the femur secondary to coronary disease or cortisone induced avascular necrosis. Tenderness may be present in the medial or lateral joint line and patello-femoral segment of the joint.
coracoid process and synovial lesion. Synovial thickening of the radio-humeral segment of the articulation can be normally felt. synovial thickening and pain on movement. and arthrodesis at 95° planter flexion after debridement in adults are ideal. spine of the scapula. Clinical symptoms are the same as for other joint lesions : swelling. The clinical presentation is with severe painful restriction of the shoulder movements. Biopsy of the synovial membrane and aspiration of the joint fluid followed by smear. There is an atrophic type of tuberculosis of the shoulder. (E). Post-operative immobilization. rigidity of foot and swelling of the metatarsus. lesions very similar to tuberculous lesions can occur in Madurella madurella infection. A pathological dislocation of elbow is very rare. SANKARAN femoral or tibial condyles. X-ray examination is highly suggestive. osteo-arthritis of the knee joint and synovial sarcoma. Tuberculosis of Upper Extremity The shoulder involvement is rare. rheumatoid arthritis of the knee joint. particularly in diabetics. A triple arthrodesis is the ideal procedure for lesions of the talo-navicular. calcaneo-cuboid or talo-calcaneal lesions. Treatment: Comprises anti-tuberculosis regimens as given for other tuberculous lesions of bones and joints combined with postoperative immobilization. glenoid. swelling. Synovectomy and joint debridement. pigmented or apigmented villio-nodular synovitis. It can also be iatrogenic : steroid injection given for a stiff shoulder with the mistaken diagnosis of frozen shoulder. (F). Tuberculosis of Foot The foot bones can have isolated tuberculous lesions as in the os calcis or as diaphysial foci in metatarsal bones (tuberculous dactylitis). The diagnosis can be con- . Signs and symptoms are pain. Foot (H). give good results. The classical sites could be head of humerus. culture and guinea pig inoculation can confirm the diagnosis. Differential Diagnosis : Comprises peri-arthritis of the shoulder. A subchondral lesion in the os calcis leading to talocalcaneal arthritis and peroneal spastic flat foot is a definite clinical entity.dle aspiration biopsy might be necessary to establish the diagnosis. particularly if the synovium is involved. Tuberculous dactylitis can be curetted out with adequate sequestrectomy. secondary to diabetes or leprosy. The patient responds well to anti-tuberculosis regimens. Foot lesions are most amenable to curettage and immobilization. particularly abduction and external rotation. osteo-chondritis desicans of the articular surface of femur. fibula and talus. haemophilic arthropathy of the knee. and gross wasting of shoulder muscles. occuring mostly in adults. Osteochondritis desicans of talus can simulate a tuberculous lesion of the ankle. as for the other forms. Plaster of Paris immobilization.116 B. Aspiration of the shoulder and fine nee. Rigid peroneal spastic flat foot has to be excluded. (G). The treatment of choice is antituberculosis drugs. A shoulder spica in the position of function is necessary in the younger age groups. Treatment : Anti-tuberculosis regimens. Differential diagnosis should include a neuropathic change in the foot. The tarso metatarsal articulation at Lisfranc's level and the metatarso phalangeal joint of the great toe can be other foci of involvement. Talo-navicular and naviculo-cuneiform lesions and calcaneocuboid joint involvement can also occur. An isolated navicular lesion can be treated by excision of the navicular bone. Though total knee replacements have been done for tuberculosis of the knee. When extensive articular destruction is present. Charnley's29 compression arthrodesis of the knee is the treatment of choice. with foot in the plantigrade position is essential in all cases. Shoulder arthrodesis is rarely necessary and if one is done. long term follow ups have not been reported. called caries sicca. articular surface of olecranon-intra articular (but occasionally extra articular) and head of radius. acromio-clavicular joint. if done early. particularly in diabetes mellitus. it is restricted to the right shoulder only. Tuberculosis of Elbow The most frequent sites of involvement are medial and lateral condyles of the humerus. Differential Diagnosis : Comprises internal derangement of the knee. rheumatoid arthritis and post traumatic shoulder stiffness. Tuberculosis of Ankle Joint The most common sites of lesions are tibia.
269. sternum and isolated spinous processes. Editorial : Tuberculosis . Tuberculosis of Short Bones Tuberculosis of the metacarpus. (L). Simple excision of the elbow gives satisfactory results though there is lack of stability of the elbow. leutic osteitis and mycotic lesions in the foot bones have to be differentiated.: Tuberculosis of Bones' & Joints. I owe a deep debt of gratitude for providing me with clinical photographs and clinical slides for presentation. Concomitant involvement of the sheaths of volar or dorsal tendons might occur. being mistaken for tuberculosis of the elbow joint. It can also occur from gravitational spread of the disease from the diseased area. 75. A firm diagnosis can only be established by biopsy of the lesion. Clin. intra-articular in location. Tubercu- Antituberculosis regimes coupled with excision of the synovial sheath and bursae are the treatment of choice. metatarsus. (K). Tuberculosis of Tendon Sheaths & Bursae The anatomical sites of the lesions may be in the radius or proximal row of carpal bonesscaphoid. References 1. They quite frequently present as marked swelling on die dorsum of the hand and soft tissue abscess is normally a common feature. but the diagnosis is frequently missed. as prescribed for musculo-skeletal lesions and immobilization in a functional position during early treatment. E. (I).W. 3. 4. Clinician.retrospect and prospect. (J). the skeletal site of lesion is multiple. and phalanges is common. S. ischium and fibula. G. subacromial bursa. Orthop. Modern Trends in Orthopaedics. 2. joint debridement. Synovectomy. The most significant clinical feature is crepitus due to melon seed bodies which are agglutinated protein nodules nurtured by the synovial fluid. spine of the scapula. Tuberculous Osteomyelitis Tuberculous ostemomyelitis occurs in about 3% of patients with bone and joint tuberculosis. P. London.TUBERCULOSIS OF BONES & JOINTS 117 finned by aspiration or biopsy of synovium from the lateral side. and Somerville. 1. In the volar aspect of the wrist. excisional arthroplasty of elbow with distraction of the excised surface using an external fixateur (Ognasian) has been advocated. 32. The commonest sites are flexor tendon sheaths of hand. Disseminated lesions may also present as bone cysts. Chronic pyogenic osteomyelitis. Butterworth & Co. In 7% of them. olecranon bursa and bursae under the medial head of gastrocnemius. An arthrodesis of the wrist in 10° dorsiflexion gives very good result. : Five thousand years of Orthopaedics in India. Biopsy of the wrist can be easily done from the dorsal route. the classical presentation is a dumb-bell shaped swelling giving cross fluctuation and crepitus. 1971.R. B.M. Dhaon of the Lok Nayak Jai Prakash Narain Hospital who gave me his invaluable time and material for making the entire package. Acknowledgements Any tendon sheath or bursa can be involved in tuberculosis. : The rapid diagnosis of pauciba- . and Tuli. Antituberculosis regimens with curettage of the lesion are the treatment of choice.K. I have seen a case of osteochondritis desicans of the humeral condyle and an osteoid-osteoma of the lateral condyle of the humerus. In differential diagnosis. Tuberculosis of Wrist lous osteomyelitis can also occur in odontoid process. Debridement and antituberculosis regimen result in complete subsidence of the lesion. To Dr Mathew Varghese of St. Duraiswamy. The spread to these sites is normally from the neighbouring bone or joint but it could be due to haematogenous spread. This oration would have been impossible to give without the help of Prof. 1950. The most frequent sites are : manubrium sterni.. J. 1968. Girdlestone. Treatment : Anti-tuberculosis regimes. lunate and capitate. Anti-tuberculosis regimens along with plaster of Paris immobilization (a scaphoid type of plaster) in position of function are recommended till the acute episode subsides. Stephens Hospital.M.K. Grange. The differential diagnosis is rheumatoid arthritis of the wrist.. Series I.
Ann. Girdlestone. 1960. : Tuberculosis of the Skeletal System.. Hodgson. Kumar. Seddon..1. Cheke. 24.M. Amerind Publishing Co.. G. Srivastava. 394.. Oxford University.M. Oxford University Press.176. R. & Wilkinson.L. P. Tuli. B. : Skeletal Tuberculosis. : Treatment of vertebral tuberculosis by the spine fusion operation. 517. Tuli. Dobson. : Broth culture. Martini. Orthop. 33B. N.. 25. and Sen. Scand. 1973. 3rd Ed.... : Compression arthrodesis. 1974. B. Ind. Jour. I. Ltd. 1989. Sprintger-Varlat. (Revised by Somerville.N. B. 5. Surg. and Mishra. 1991. 135.M. 53. 42A. : Tuberculosis of the spine. 9. London. 70. Jl. J. A preliminary communication on the radical treatment of Pott's disease and Pott's paraplegia. : Tuberculosis of Spine. Bone & Joint Surg. 19. 1958. 23.L. J. : Multiple Osteoarticular tuberculosis. 18. S. D. 17. 49B. M.K. 13. Konstam. Heidelberg. Ofthop. 21. P. Tub. Freidman.R.: Chemotherapy of Tuberculosis of the Spine. V. Sinha. Hibbs. 1948.. Jaypee Brothers Publishers. : Tuberculosis of Bone & Joint. J. H. : Role of excisional surgery in bone and joint tuberculosis . Jaypee Brothers Publishers. Coll. the modern guinea pig for isolation of mycobacteria. 19.. 16. 1991. : Tuberculosis of spine. Surg. Dahl. Br. Baltimore. E & S Livingstone. A. H. Engl. K.12. 28. 1956. V. 4. : The ambulant treatment of spinal tuberculosis. J.). and Saxena. Surg. Singh. Bone & Joint Surg. E. 5.R. 1988. : Examination of pH in tuberculous pus. London. 1949. : Tuberculosis of spine. 1967. London. Coll.Hunterian Lecture.O. 26.. and Stock F. 8. Tubercle. 1928.B. H. J. Ind.P. Charnley.. Verma. Acta. 1956. Int.M... J. Orthop. 20. 1951. J. and Sinha. T... : Tuberculosis of the Spine. Bone Joint Surg. and Blesovsy. : Pott's paraplegia 1956. 45. Surg. 20. 1953. 10. R.C. 26. 1967. 674.K. Bone & Joint Surg..A. Mukhopadhya. Anterior spinal fusion for the treatment of tuberculosis of the spine. 12. Hodgson.C. Griffiths.445. 59.L. 1988. Williams & Wilkins Co. 27. 1989. J. K. 1975. : The value of histology culture and guinea pig inoculation examination in osteo-articular tuberculosis. 22. T. A. : Ed: Tuberculosis of the Bones & Joints. 1952. M. J. 29.C. Tuli.: Tuberculosis of the Skeletal System.P. 36. Bone & Joint Surg. Ind. Br..18. Tuli S. Sanchez-Olmos. (SICOT). R. S. Engl.K. 1956. Ortho. Surg. D and Natyashak.E. B. Ann. 38. Goel. Wilkinson. S. 288. 1962.118 B. A. Tuli. 44.R. 266. Surg. 805. . 295. 70. R. 1957. and Risser.V. Martin. Scand. and Stock F. 10. B. Pvt.E.M. Lakhanpal. ciliary tuberculosis. 5. 50. : Observations on the pathogenesis and treatment of skeletal tuberculosis. Scand. M. Mukhopadhya. 134. and' Singh. 6. M. M. S.P. 7. Tubercle. Jour. G. 15. : Osteo-articular tuberculosis. M. J. Grewal.. 11. Acta. SANKARAN 18.P.C. Acta. and Roaf.S.. 1951. Press. 168.. : Treatment of Pott's paraplegia by operation. 14. : Anterior spinal fusion.
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