Professional Documents
Culture Documents
OF KNEE
Presented by:
Dr Dipendra Maharjan
2nd yr Resident, MS Orthopaedics
NAMS, Bir Hospital
Introduction
• Skeletal Tuberculosis
– Ancient disease
– 2% of all Tuberculosis cases
– The most common form of skeletal TB is Pott’s
disease
– The next most common form of musculoskeletal
TB is tuberculous arthritis
• The knee joint
– the largest joint
– the largest intra-articular space
– third common site for osteoarticular tuberculosis
– accounts for nearly 10% of all skeletal tuberculous
lesions
Pathology
• Initial focus
– hematogenous dissemination in the synovium
– in the subchondral bone
– juxta-articular osseous focus.
• The synovial lesion may for many months
remain purely as tubercular synovitis.
• The synovial membrane gets congested,
edematous and studded with tubercles.
• The naked eye examination
– pinkish-blue or pinkish-gray appearance.
• In long case
– Posterior capsule of the knee joint gets contracted
Roentgonograms
• synovial stage
– Generalized osteoporosis and
– increased soft tissue swelling caused by
• synovial effusion,
• thickened synovium and capsule.
• As the arthritis sets
– loss of definition of articular surfaces,
– marginal erosions,
– diminution of the joint space and
– destruction of the bones forming the joint.
• In advance stage,
– gross destruction and deformation of bone ends,
– osteolytic cavities,
– tubercular sequestra and
– triple deformity may be seen
right knee demonstrating
extreme valgus deformity
and joint destruction.
Differential Diagnosis
• Monoarticular affections
– rheumatic arthritis (in children)
– chronic traumatic synovitis due to chronic internal derangement of knee
(e.g.
• meniscal tears, loose bodies,
• osteochondritis dissecans,
• chondromalaciapatellae,
• discoid semilunar cartilage etc)
• Rheumatoid arthritis (in adults),
• subacute pyogenic arthritis/synovitis,
• hemarthrosis,
• dysenteric arthritis,
• villonodular synovitis,
• synovial chondromatosus,
• synovioma,
• foreign body granuloma.
Prognosis
• lee et al 1995, Hoffman et al 2002
– With the modern methods of management the
functional results are directly related to the extent
of disease at the onset of antitubercular drugs
• In the stage of synovitis,
– non operative or operative
– complete healing
– excellent range of movements.
In advance arthritis with subluxation
severe restriction of motion is
inevitable,
arthrodesis (in adults) in functioning
position (5 to 10 degree of flexion) is
one of the option of treatment.
Treatment
• Non operative treatment with antitubercular drugs
is employed in
– tubercular synovitis
– children.
• Traction is applied to
– prevent (for correct) flexion and subluxation deformity
and to
– keep the joint surfaces distracted.
• In addition to the systemic drugs, the joint may
be aspirated
• With the quiescence of acute local signs, gently active
and assisted knee bending should be.
•
• Usually after 12 weeks of treatment the patient may be
permitted ambulation with suitable orthosis and
crutches.
• In early arthritis,
– synovectomy,
– removal of loose/rice bodies, debris, pannus, loose articular
cartilage and
– careful curettage of osseous juxtaarticular foci