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

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

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.nonpasteurized/unboiled milk. transmission airborne by droplet type----involve the intestine or alimentary tract .  human  bovine .

cervical. thoraco-lumbar. cervico-dorsal and L/S  Hip  Knee  Ankle  Elbow  Hand  Shoulder . lumbar.Predilection  Spine : thoracic .

end of bone  Joint: Synovial membrane  Spine: Paradiscal Anterior Central Appendeges(posterior) .metaphysis adults .Location  Bone: growing age .

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 .

TB Sequestra disc and cartilage not  Intervertebral involved . caseation bodie. Rice  Cold abcess. tubercle (soft/hard). synovial effusion ± epitheloid cells.Pathology  Synovium ± swollen & congested. Kissing Lesion  Inflammation  Pannus. langhans giant cells.

Granular type .Disease type  Pathological: .Caseous Exudative type (severe) .

Clssification of articular T.B .

Clinical features  Age- 1rst three decade onset monosseous and symptom  Insidious  Monoarticular /  Constitutional sign (wt. loss. low grade pyrexia. night sweat. anemia) . tachycardia. anorexia. lassitude. tachypnoea.

mono-osseous involvement joint movement restricted  Stiffness Early stage: limitation of motion. Late stage: fibrous ankylosis  Deformity: bone destruction.Local symptoms and signs  Monoarticular or  Limp. . 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. hygienic and nursing care. of concomittant disz drugs  T/t  Immunomodulation . warm dry climate .sanatorium life.

local treatment  Immobilization  Traction  Active gaurded intermittent mobilization of joint  Ambulation .

ATT  1st line drugs: .Streptomycin (S) .Pyrizinamide (Z) .Ethambutol (E) .Isoniazid (INH) .Rifampicin (R) .

ATT«  2nd line drugs:  Newer drugs: - Thiacetazone (TZN) PAS Amikacin Kanamycin Capreomycin Ethionamide Cyclocerine - Ciprofloxacin Ofloxacin Clarithromycin Azithromycin Rifabutin Immunomodulators: Levamisole .

any of above drugs is replaced by Streptomycin except INH . 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.Middle Path Regime  Intensive phase (5-6 mth): INH+R+Ofloxacin (7-8 mth) :  Continuation phase INH+Z (3-4 mth).

Two Phase t/t: 1.2(HRZE)3 CP -. 2. Intensive phase (2-3 mth) Continuation phase (5-6 mth) Category-1 IP -.DOTs It is strategy to ensure cure by providing the most effective medicine and confirming that it is taken.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 .

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

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) .

 The  Another foci  Tubercle . 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.Contraindications  General condition is not good and low resistance condition.

including curettage.  Removal . arthrodesis. synovectomy. debridement. of the infected foci is indicated. Osteotomy.Surgical Treatment  When abscess formation threatens the integrity of neighboring structure.

.Thankyou.. Thankyou..