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
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