Tuberculosis Tuberculosis Of Bone And Of Bone And

JointJoint

Tuberculosis Tuberculosis Of Bone And Of Bone And

JointJoint presenter

Dr. Sanjeev Kumar Singh

M.S Ortho (PGT)

KMCH, Katihar

presenter

Dr. Sanjeev Kumar Singh

M.S Ortho (PGT)

KMCH, Katihar

HistoryHistoryHistoryHistory

Hippocrates (460-360 BC) – relation between

pulmonary disease & spinal deformity

Percival Pott (1779) described Spinal TB

Lennac (1781-1826) described tubercle

Tubercle bacillus discovered in 1882

Described in Rigveda & Athurveda

Charak Samhita, Shushruta - Yakshma

Hippocrates (460-360 BC) – relation between

pulmonary disease & spinal deformity

Percival Pott (1779) described Spinal TB

Lennac (1781-1826) described tubercle

Tubercle bacillus discovered in 1882

Described in Rigveda & Athurveda

Charak Samhita, Shushruta - Yakshma

Epidemiology & PrevalenceEpidemiology & PrevalenceEpidemiology & PrevalenceEpidemiology & Prevalence

World - 30 million

WHO data- 3 million mortality / yr

India- 1/5th of total TB population

2-3% - skeletal involvement

World - 30 million

WHO data- 3 million mortality / yr

India- 1/5th of total TB population

2-3% - skeletal involvement

General ideasGeneral ideasGeneral ideasGeneral 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.

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 factorsPredisposing factorsPredisposing factorsPredisposing factors

Malnutrition

Poor sanitation

Overcrowding

Immunodeficiency

imunosupressive

drug

Malnutrition

Poor sanitation

Overcrowding

Immunodeficiency

imunosupressive

drug

Diabetes

Alcohol abuse

Old age

Drug abuse

trauma

Diabetes

Alcohol abuse

Old age

Drug abuse

trauma

Pathogenic organism Pathogenic organism tubercle bacillustubercle bacillus

Pathogenic organism Pathogenic organism tubercle bacillustubercle bacillus

tubercle bacillus may be either

the human type or bovine type

human type----involves lung,

transmission airborne by droplet

bovine type----involve the

intestine or alimentary tract ,non-

pasteurized/unboiled milk;

tubercle bacillus may be either

the human type or bovine type

human type----involves lung,

transmission airborne by droplet

bovine type----involve the

intestine or alimentary tract ,non-

pasteurized/unboiled milk;

PredilectionPredilectionPredilectionPredilection

Spine : thoracic , thoraco-lumbar, lumbar,

cervical, cervico-dorsal and

L/S

Hip

Knee

Ankle

Elbow

Hand

Shoulder

Spine : thoracic , thoraco-lumbar, lumbar,

cervical, cervico-dorsal and

L/S

Hip

Knee

Ankle

Elbow

Hand

Shoulder

LocationLocationLocationLocation

Bone: growing age - metaphysis

adults - end of bone

Joint: Synovial membrane

Spine: Paradiscal

Anterior

Central

Appendeges(posterior)

Bone: growing age - metaphysis

adults - end of bone

Joint: Synovial membrane

Spine: Paradiscal

Anterior

Central

Appendeges(posterior)

PathogenesisPathogenesis PathogenesisPathogenesis

spread mainly haematogenous

most common route to the vertebral body is through

Batson's venous plexus

Osteoarteoarticular lesion occcurs 2-3yrs after primary

focus

spread mainly haematogenous

most common route to the vertebral body is through

Batson's venous plexus

Osteoarteoarticular lesion occcurs 2-3yrs after primary

focus

PathologyPathologyPathologyPathologySynovium – swollen & congested,

synovial effusion

Inflammation – epitheloid cells, langhans

giant cells, tubercle (soft/hard), caseation

Pannus, Rice bodie, Kissing Lesion

Cold abcess, TB Sequestra

Intervertebral disc and cartilage not

involved

Synovium – swollen & congested,

synovial effusion

Inflammation – epitheloid cells, langhans

giant cells, tubercle (soft/hard), caseation

Pannus, Rice bodie, Kissing Lesion

Cold abcess, TB Sequestra

Intervertebral disc and cartilage not

involved

Disease typeDisease typeDisease typeDisease type

Pathological:

- Caseous Exudative type (severe)

- Granular type

Pathological:

- Caseous Exudative type (severe)

- Granular type

Clssification of articular T.BClssification of articular T.BClssification of articular T.BClssification of articular T.B

Clinical featuresClinical featuresClinical featuresClinical features

Age- 1rst three decade

Insidious onset

Monoarticular / monosseous

Constitutional sign and symptom

(wt. loss, lassitude, low grade pyrexia,

anorexia, night sweat, tachycardia,

tachypnoea, anemia)

Age- 1rst three decade

Insidious onset

Monoarticular / monosseous

Constitutional sign and symptom

(wt. loss, lassitude, low grade pyrexia,

anorexia, night sweat, tachycardia,

tachypnoea, anemia)

Local symptoms and signsLocal symptoms and signsLocal symptoms and signsLocal symptoms and signs

Monoarticular or mono-osseous involvement

Limp, joint movement restricted

Stiffness

Early stage: limitation of motion;

Late stage: fibrous ankylosis

Deformity: bone destruction, gibbus result

from the lesion of thoracolumbar spine,

Monoarticular or mono-osseous involvement

Limp, 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 signsLocal symptoms and signsLocal symptoms and signsLocal symptoms and signs Muscle atrophy

Muscle spasm

Night cry

Doughy swelling

Fluctuated swelling-cold abscess formed

Sinus or fistula

Muscle atrophy

Muscle spasm

Night cry

Doughy swelling

Fluctuated swelling-cold abscess formed

Sinus or fistula

investigationinvestigationinvestigationinvestigation

CBC

ESR

CXR

X-Ray of joint / bone

Tuberculin test

Biopsy

Smear and culture

CBC

ESR

CXR

X-Ray of joint / bone

Tuberculin test

Biopsy

Smear and culture

Guinea pig inoculation

PCR

ELISA

Isotopes scintigraphy

CT scan

MRI

Guinea pig inoculation

PCR

ELISA

Isotopes scintigraphy

CT scan

MRI

X-RAYX-RAYX-RAYX-RAY

XRAY HIP XRAY HIP XRAY HIP XRAY HIP

Treatment:Treatment: general caregeneral careTreatment:Treatment: general caregeneral care

Nutritional support

Fresh air, warm dry climate ,sanatorium life, hygienic and nursing care.

T/t of concomittant disz

Immunomodulation drugs

Nutritional support

Fresh air, warm dry climate ,sanatorium life, hygienic and nursing care.

T/t of concomittant disz

Immunomodulation drugs

local treatmentlocal treatmentlocal treatmentlocal treatment

Immobilization

Traction

Active gaurded intermittent mobilization of joint

Ambulation

Immobilization

Traction

Active gaurded intermittent mobilization of joint

Ambulation

ATTATTATTATT

1st line drugs:

- Isoniazid (INH)

- Rifampicin (R)

- Pyrizinamide (Z)

- Ethambutol (E)

- Streptomycin (S)

1st line drugs:

- Isoniazid (INH)

- Rifampicin (R)

- Pyrizinamide (Z)

- Ethambutol (E)

- Streptomycin (S)

ATT…ATT…ATT…ATT…2nd line drugs:

- Thiacetazone

(TZN)

- PAS

- Amikacin

- Kanamycin

- Capreomycin

- Ethionamide

- Cyclocerine

2nd line drugs:

- Thiacetazone

(TZN)

- PAS

- Amikacin

- Kanamycin

- Capreomycin

- Ethionamide

- Cyclocerine

Newer drugs:

- Ciprofloxacin

- Ofloxacin

- Clarithromycin

- Azithromycin

- Rifabutin

Immunomodulators:

- Levamisole

Newer drugs:

- Ciprofloxacin

- Ofloxacin

- Clarithromycin

- Azithromycin

- Rifabutin

Immunomodulators:

- Levamisole

Middle Path RegimeMiddle Path RegimeMiddle Path RegimeMiddle Path RegimeIntensive phase (5-6 mth):INH+R+Ofloxacin

Continuation phase (7-8 mth) :

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

Intensive phase (5-6 mth):INH+R+Ofloxacin

Continuation phase (7-8 mth) :

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

DOTsDOTsDOTsDOTsIt is strategy to ensure cure by providing the most effective

medicine and confirming that it is taken.

Two Phase t/t:

1. Intensive phase (2-3 mth)

2. Continuation phase (5-6 mth)

Category-1

IP -- 2(HRZE)3

CP -- 4(HR)3

It is strategy to ensure cure by providing the most effective

medicine and confirming that it is taken.

Two Phase t/t:

1. Intensive phase (2-3 mth)

2. Continuation phase (5-6 mth)

Category-1

IP -- 2(HRZE)3

CP -- 4(HR)3

DOTs……DOTs……DOTs……DOTs……

Category-2

IP -- 2(HRZES)3 + 1(HRZE)3

CP – 5(HRE)3

Category-3

IP – 2(HRZ)3

CP – 4(HR)3

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….Surgical Treatment….Surgical Treatment….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.

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 OperationIndications of OperationIndications of OperationIndications of Operationlarge sequestrum

big abscess which can not be absorped

sinus

when TB osteitis or synovitis is uncontrolled and

has a progress to true arthritis

spinal TB with paraplagia

early TB arthritis(1/3 destruction of joint surface)

large sequestrum

big abscess which can not be absorped

sinus

when TB osteitis or synovitis is uncontrolled and

has a progress to true arthritis

spinal TB with paraplagia

early TB arthritis(1/3 destruction of joint surface)

ContraindicationsContraindicationsContraindicationsContraindications

General condition is not good and low resistance condition, such as too young or old

The patient with other vital visceral diseases can not bear the operation

Another foci of active TB is present

Tubercle bacilli are resistant.

General condition is not good and low resistance condition, such as too young or old

The patient with other vital visceral diseases can not bear the operation

Another foci of active TB is present

Tubercle bacilli are resistant.

Surgical TreatmentSurgical TreatmentSurgical TreatmentSurgical Treatment

When abscess formation threatens the

integrity of neighboring structure,

Removal of the infected foci is indicated,

including curettage, debridement,

synovectomy, arthrodesis, Osteotomy.

When abscess formation threatens the

integrity of neighboring structure,

Removal of the infected foci is indicated,

including curettage, debridement,

synovectomy, arthrodesis, Osteotomy.

Thankyou;;Thankyou;;Thankyou;;Thankyou;;