TUBERCULOUS OSTEOMYELITIS
RAJEEV VOHRA, HARINDER S. KANG, SAMEER DOGRA,
From Mohan Dai Oswal Cancer Treatment and Research Foundation, Ludhiana, India
Tuberculous osteomyelitis which does not involve a joint
is uncommon and may fail to be diagnosed by an
orthopaedic surgeon. We treated 28 lesions of
tuberculous osteomyelitis in 25 patients between 1988
and 1995. The duration of symptoms was from two to 39
months, and most of our patients had been treated
initially with non-steroidal anti-inflammatory drugs
which failed to provide relief. Bone pain which does not
promptly respond to analgesic medication is often due
to infection or neoplasia.
In the early stages, when plain radiographs are
normal, MRI or CT may help to localise lesions. On
plain radiographs, more advanced lesions may mimic
chronic pyogenic osteomyelitis, Brodie’s abscess,
tumours or granulomatous lesions. Biopsy is mandatory
to confirm the diagnosis, and antituberculous drugs are
the mainstay of treatment. When operative findings at
biopsy have the features of skeletal tuberculosis
curettage of the affected bone may promote earlier
healing.
J Bone Joint Surg [Br] 1997;79-B:562-6.
Received 21 January 1997; Accepted after revision 11 April 1997
Tuberculosis remains a major international problem despite
advances in radiological diagnosis and antituberculous ther-
apy. It affects approximately one-third of the world’s popu-
lation; each year there are about 20 million prevalent cases
1
and 8 million new cases. Some developed countries have
now recorded a resurgence in the incidence of tuberculosis,
attributed, particularly in the USA, to a rise in the number
of people with immunosuppression, the development of
R. Vohra, MS Orth, DNB Orth, MNAMS, Consultant
H. S. Kang, MS Orth, Former Senior Consultant
S. Dogra, MS Orth, Senior Consultant
R. R. Saggar, MS Orth, Junior Consultant
R. Sharma, MS Orth, Senior Resident
Mohan Dai Oswal Cancer Treatment and Research Foundation, G. T.
Road, Sherpur Bye Pass, Ludhiana -141 009, India.
Correspondence should be sent to Dr R. Vohra.
©1997 British Editorial Society of Bone and Joint Surgery
0301-620X/97/47618 $2.00
562
RADHA R. SAGGAR, RAJAN SHARMA
drug-resistant strains of Mycobacterium, an ageing popu-
lation, and an increase in the number of health-care workers
2
exposed to the disease.
The human immunodeficiency virus (HIV) remains an
important risk factor for the reactivation of latent tubercu-
3,4
lous infection. Presentation of skeletal tuberculosis in an
immunocompromised patient may be atypical and reach an
advanced stage by the time of diagnosis.
Isolated involvement of bone by tuberculous infection is
uncommon, and the variable clinical and radiological pic-
tures may mimic chronic pyogenic osteomyelitis, Brodie’s
5-7
abscess, tumours or granulomatous lesions. We have
reviewed our experience in the hope of stimulating a high
index of suspicion for early diagnosis.
PATIENTS AND METHODS
Between 1988 and 1995 we treated 28 sites of tuberculous
osteomyelitis in 25 patients. There were 20 males and 5
females with an average age of 26 years (18 months to 47
years). In the upper limbs, the 12 bones affected were the
phalanges (4), metacarpals (2), humeral shaft (2), medial
condyle of the humerus, olecranon, ulnar shaft, and lower
end of the radius. In the lower limbs ten lesions involved
the metatarsals (4), greater trochanter (2), talus, cuboid,
medial cuneiform, and a phalanx. In the girdle bones the six
affected sites were the ischial tuberosity (2), ischium,
ischium-ilium junction, clavicle, and scapula. Six of our
patients had skeletal tuberculosis at seven other sites
including the dorsal spine (3), cervical spine, elbow, wrist
and the foot. Six patients had associated pulmonary
tuberculosis.
Pain and swelling were the most common symptoms
with a duration ranging from two to 39 months. Eight
patients had sinuses, three of which developed after the
surgical drainage of abscesses. Six patients had palpable
abscesses. The draining lymph nodes were considerably
enlarged in seven patients, and loss of weight and appetite
with low-grade fever were seen in four.
The ESR was significantly raised in 22 patients, ranging
from 31 to 83 mm/hour. A positive tuberculin skin test was
found in 21. In ten patients serological testing for tubercu-
losis by the enzyme-linked immunosorbent assay was pos-
itive in six. We performed serological testing for HIV in
seven young or middle-aged patients with either multiple
THE JOURNAL OF BONE AND JOINT SURGERY
 TUBERCULOUS OSTEOMYELITIS
Fig. 1
MRI of a foot in which the plain radiographs were normal.
There is an altered signal from the cuboid which confirmed
tuberculosis (arrow).
lesions or with a history of multiple sexual contacts: in all
it was negative.
All patients had plain radiographs of the affected area. In
one, these were normal but MRI located an abnormality.
Only eight lesions showed the characteristic radiological
findings of tuberculosis; six had the appearance of chronic
pyogenic osteomyelitis or a Brodie’s abscess, and nine
were cystic. One patient presented with features of a neo-
plasm and three lesions of tubercular dactylitis had a coarse
trabecular pattern.
In 22 patients the diagnosis was confirmed by histo-
logical examination of the material obtained from the
lesions and in the remaining three by histopathological
examination of the material obtained from associated
osteoarticular lesions. In 19 patients the macroscopic
appearance at biopsy was suggestive of tuberculosis with
soft friable whitish-grey debris resembling clumped cheesy
Fig. 2a
VOL. 79-B, NO. 4, JULY 1997
563
material typical of caseous necrosis. In these we also
performed curettage of the affected bone and the excision
of a sinus, if present. In three patients in whom the
diagnosis had been doubtful during surgery only biopsy
was performed. Mycobacterium tuberculosis was cultured
in nine cases, and culture for pyogenic organisms was
positive in five lesions with sinuses.
Antituberculous drugs used for medical treatment includ-
ed rifampicin (10 mg/kg in adults and 10 to 20 mg/kg in
children), isoniazid (5 to 10 mg/kg in adults and 10 to
20 mg/kg in children), pyrazinamide (20 to 40 mg/kg),
ethambutol (15 to 25 mg/kg), and streptomycin (15 mg/kg).
Treatment for 18 months was used in five patients, for 12
months in nine and for nine months in 11. There was no
recurrence of disease after any of these durations of
treatment.
RESULTS
The mean follow-up was 41 months (13 to 96). All patients
were relieved of pain within six months of the initiation of
treatment and sinuses healed within 14 weeks. In 20
patients the ESR returned to normal within six months of
the beginning of treatment. Demineralisation of the affected
region persisted for a maximum of five months. During
healing, we noticed increased radiodensity in all cases. By
the end of treatment for nine months 23 patients had
regained full range of painless movements of the adjacent
joints; only two had slight limitation.
Imaging appearances. In the early stage plain radiography
may not show any abnormality. If the clinical features
favour skeletal tuberculosis MRI may be useful (Fig. 1), but
the diagnosis is confirmed by biopsy. Subtle radiological
changes may be missed (Fig. 2), but clinical progression, or
the formation of a sinus with obvious involvement of the
bone, reinforces our view that the radiologist must be told
the precise site of pain initially. A small focal area of
osteolysis located eccentrically with little or no surrounding
reactive bone is characteristic, and the presence of local
Figure 2a – Radiograph of the right foot of a
20-year-old woman. The abnormality (arrow) in
the fourth metatarsal bone was missed when the
first examination was done. Figure 2b – Plain
radiograph taken three months later, shows
obvious signs of bone loss, and bone production
(arrow).
Fig. 2b
564 R. VOHRA, H. S. KANG,
Fig. 4
Radiographs of a 23-year-old man show a distal radial abnormality which
is characteristic of chronic pyogenic osteomyelitis.
osteopenia helps to diagnose tuberculosis. In our series only
eight lesions had such radiological findings. In one patient
(Fig. 3) a pathological fracture was seen.
Osteoporosis, bone lysis, sclerosis and periostitis are
seen in both tuberculous osteomyelitis and chronic pyo-
genic osteomyelitis and it is often difficult to differentiate
the two conditions. Six of our 28 lesions had radiological
findings similar to those of chronic pyogenic osteomyelitis
or a Brodie’s abscess; histopathological examination was
required for diagnosis (Figs 4 and 5).
One type of tuberculous osteomyelitis is cystic tubercu-
losis, which is more commonly encountered in children
8
than in adults. The multifocal form is more common than
9
solitary lesions and, in a series of 13 children with histo-
logically confirmed tuberculosis of bone, solitary cystic
10
lesions were found in ten. We detected nine solitary cystic
lesions in six adults and three children (Figs 6 and 7). In
S. DOGRA, R. R. SAGGAR, R. SHARMA
Fig. 3
Radiographs of the hand of a nine-year-old boy show a
pathological fracture of the proximal phalanx of the
middle finger (arrow).
Fig. 5
Radiograph of the pelvis of an 18-year-old woman. The abnormality
(arrow) in the ischium had been described as a Brodie’s abscess.
four the lesions were expansile with underlying bone
destruction and periosteal thickening giving the appearance
that has previously been termed spina ventosa. Although
11
this is more common in the metacarpals and metatarsals
we found this appearance in the ulna in one of our patients
(Fig. 8).
In three cases of tuberculous dactylitis the radiological
finding was diffuse bone infiltration with a coarse tra-
becular pattern (Fig. 9). One patient appeared to have a
neoplasm of the ischium (Fig. 10), but the appearances at
biopsy and the subsequent histology showed it to be
tuberculosis.
DISCUSSION
Our aim was to draw attention to tuberculous osteomyelitis
which is rare compared with skeletal tuberculosis involv-
THE JOURNAL OF BONE AND JOINT SURGERY
 TUBERCULOUS OSTEOMYELITIS
Fig. 6
Radiographs of the foot of an 18-year-old man show a cystic lesion in
the first metatarsal.
Fig. 8
Radiographs of a 15-year-old boy show the appearance of spina ventosa in
the diaphysis of the ulna.
ing the spine or a joint. Because of that, and a low index of
suspicion for its diagnosis, early lesions may be neglected.
Osteoarticular tuberculosis is a major problem in many
parts of the world. The spine is the site of bone tubercu-
12-14
losis in about half the cases, and isolated bone involve-
ment without spread to a joint often fails to attract atten-
tion. Because of the subtle nature of the symptoms, the
diagnosis is not made until the process is well advanced.
VOL. 79-B, NO. 4, JULY 1997
565
Fig. 7
Radiographs showing cystic tuberculosis in the proximal phalanx of
the thumb of a six-year-old boy. There is a large soft-tissue swelling
overlying the bone.
Fig. 9
Radiograph showing tuberculous dactylitis in the
first metacarpal of a 30-year-old woman. There is
soft-tissue swelling.
Nearly all of our patients had initial treatment with non-
steroidal anti-inflammatory drugs which offered some
relief of pain or swelling or both. The repeated use of these
drugs created a false sense of security until it became
566 R. VOHRA, H. S. KANG, S. DOGRA,
apparent that their continued use had failed to provide
complete relief. Mild pain and swelling of bone, with slight
warmth and tenderness, and overlying boggy swelling of
the soft tissues should alert clinicians to the possibility of
skeletal tuberculosis. Enlargement of regional lymph nodes
and the presence of an abscess or sinus are also of great
significance.
Bone pain which does not respond to analgesic medica-
tion may be due to infection or neoplasia. If plain radio-
graphs are normal more sensitive investigations such as
MRI and CT are required to detect and localise lesions. The
presence of a sinus from which pyogenic organisms are
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We wish to thank Mr Ramakrishnan and Mrs Paramjit Kaler for their help
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No benefits in any form have been received or will be received from a
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