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Tuberculosis Of Appendicular Skeleton
Dr. Apoorv JainDOrtho, DNB [email protected]+91-9845669975
INTRODUCTION Tuberculosis is a chronic granulomatous infectious disease caused by Mycobacterium Tuberculosis (a gram positive acid fast bacilli).
Transmitted through the air borne spread of droplet nuclei produced by patients with infectious pulmonary tuberculosis.
Problem StatementIndia: highest TB burden in world (accounts for 1/5 (20%) of global burden) Every year 1.8 millions develops TBEvery day about 5000 people develop disease. 2 persons die of TB every 3 min. More than 1000 people die every day.
Increased incidence has been noted with prevalence of AIDS.In India EPTB (extra pulmonary tuberculosis) form 10-15% of all types of TB. Amongst EPTB, Lymph node TB is the commonest. TB of bone and joints constitutes 1-3% of Extra-pulmonary TB of which the most commonly involved is the Spine constituting 50% of all Skeletal Tuberculosis.
Skeletal tuberculosis (TB) refers to TB involvement of the bones and/or joints. It is an ancient disease; features of spinal TB have been identified in Egyptian mummies dating back to 9000 BC
TB Of Appendicular SkeletonTubercular affection of joints:Hip JointKnee joint and Triple deformityShoulder joint and Caries SiccaElbow joint, Wrist and Carpus, Sacroiliac jointsTubercular Osteomyelitis (Long and Flat Bones)Tubercular dactylitis (Spina Ventosa)Tuberculosis of tendon sheath and bursae
Insidious onset (c/w pyogenic infections)Low grade feverWeight loss Night sweatMovement restriction, muscle wasting, regional lymph node involvement and neurologic symptomsWeight bearing joints like hip, knee and ankle are commonly involved, though any part of the skeleton can get involved
Clinical features in General
Tuberculosis Of Hip Joint
Relevant Surgical Anatomy Of Hip Ball and socket type of synovial joint. Fibrocartilaginous labrum attached to acetabulum, makes the socket deeper. Considerable part of articular surface of spherical femoral head remains uncovered. Opening of acetabulum directed laterally, downwards (300) and forward (300).Femoral neck directed medially, upward and anteriorly. Angle of anteversion in adult 10-300, neck shaft angle around 1250.
Ligaments around hip joint
Tuberculosis Of Hip Joint2nd most common osteoarticular TB (next only to spinal TB) Commoner in malesINTRODUCTION: PATHOGENESIS:Invariably secondary to primary site elsewhere (lungs, LNs of mediastinum,mesentry or cervical,kidney etc) The tubercle is the microscopic pathological lesion with central necrosis surrounded by epitheloid cells, giant cells and mononuclear cell.
Two types of lesions Caseating exudative type: when caseating necrosis and cold abscess formation predominates Proliferating type: where cellular proliferation predominates with minimal caseation, tuberculosis granuloma is the extreme form of this type (Former is common in children & latter in adults)
Location of osseous origin of tuberculosis of left hip joint; (1) acetabulum (2) femoral head/epiphysis (3) femoral neck/metaphysic (4) greater trochanter
Babcock's triangle :A relatively radiolucent seen on an anteroposterior radiograph of the hip in the subcapital region of the fermoral head. It is an area of loosely arranged trabeculae noted between the more radiodense lines of the normal bony trabeculae groups. Tuberculosis of hip joint The disease may start in epiphysis, Babcocks Triangle, acetabular roof or in synovium.
Lesions of upper end femur
Involves joint rapidly
Destruction of articular surface of head & acetabulum Lesions of acetabululum(roof)
Jnt involvement is late & by the time patient presents
Extensive bone destruction already present
Tracking Of Cold abscess (within the joint)
Inferior part of Capsule(weak)
Femoral triangle, medial ,lateral & posterior aspect of thigh Pelvis
Above levator ani
Inguinal regionBelow levator ani
Tracking of abcess away from the joint is usually along the Neuro-vascular bundle
Stages Of TB Hip
Stage I: Stage Of Synovitis
Stage II: Stage Of Early Arthritis
Plain X-ray showing "stage of arthritis;" pathology involving articular surface. Irregular and hazy joint margins with diminished joint space on left side
Stage III: Stage Of Advanced Arthritis
Stage IV: Advanced Arthritis with Hip Subluxation / Dislocation
As the disease progress,Head of femur partly absorbed & gets dislocated from acetabulum onto iliumWANDERING ACETABULUM
If left untreated,Healing by absorption & connective tissue encapsulation occurs. Leading to distortion, deformity and fibrous ankylosis of joint
Clinical featuresSymptoms: (when disease is active)Constitutional symptoms
Pain (absent in early stage, night cries/starting pain)
Limp (earliest, commonest, antalgic gait, asso. stiffness)
Deformity of limb (stage of involvement)
Fullness around hip (site of cold abcess)
Physical signsGeneral: pallor, emaciation, LNs, signs of pulm TBGait: antalgic, trendelenburgInspection: deformity of limb, wasting of thigh & gluteal muscles, swelling around hipPalpation: confirmation of above findings, muscle spasm of lower abdomen & adductors of thigh, joint line tenderness, shift of GTMovements: fixed deformities, painful ROMMeasurements: Apparent lengthening/shortening, true shortening (Due to fixed deformities secondary changes in spine (lordosis, scoliosis etc))
Functional Assesment Group 1 Painless ROM in all directions Group 2 Painless range of flexion 35-900 Group 3 Flexion