Tuberculosis Of Appendicular Skeleton Dr. Apoorv Jain D’Ortho, DNB Ortho [email protected] +91-9845669975

Tb appendicular skeleton

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Tuberculosis Of Appendicular Skeleton

Dr. Apoorv JainD’Ortho, DNB Ortho

[email protected]+91-9845669975

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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.

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Problem Statement India: highest TB burden in world (accounts

for 1/5 (20%) of global burden) Every year 1.8 millions develops TB Every day about 5000 people develop

disease. 2 persons die of TB every 3 min. More than 1000 people die every day.

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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.

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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

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Pulmonary(85-90 %)

Extra-Pulmonary(10-15 %)

Lymph nodes (m/c),

Abdominal etc.Skeletal (1-3 %)

TB Spine (Pott’s)50%

TB Hip, Knee, Shoulder etc.

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TB Of Appendicular Skeleton Tubercular affection of joints:

Hip JointKnee joint and Triple deformityShoulder joint and Caries SiccaElbow joint, Wrist and Carpus, Sacroiliac joints

Tubercular Osteomyelitis (Long and Flat Bones)

Tubercular dactylitis (Spina Ventosa) Tuberculosis of tendon sheath and bursae

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Insidious onset (c/w pyogenic infections) Low grade fever Weight loss Night sweat Movement restriction, muscle wasting, regional

lymph node involvement and neurologic symptoms Weight bearing joints like hip, knee and ankle are

commonly involved, though any part of the skeleton can get involved

Clinical features in General

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Tuberculosis Of Hip Joint

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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.

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Ligaments around hip joint

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Tuberculosis Of Hip Joint 2nd most common osteoarticular TB

(next only to spinal TB) Commoner in males


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.

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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)

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Location of osseous origin of tuberculosis of left hip joint; (1) acetabulum (2) femoral head/epiphysis (3)

femoral neck/metaphysic (4) greater trochanter

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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, Babcock’s Triangle, acetabular roof or in synovium.

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Lesions of upper end femur

Involves joint rapidly

Destruction of articular surface of head &


Lesions of acetabululum(roof)

Jnt involvement is late & by the time patient presents

Extensive bone destruction already


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Tracking Of Cold abscess (within the joint)

Inferior part of Capsule(weak)

Femoral triangle, medial ,lateral & posterior aspect of thigh


Above levator ani

Inguinal region

Below levator ani

Ischiorectal fossa

Tracking of abcess away from the joint is usually along the Neuro-vascular bundle

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Stages Of TB Hip

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Stage I: Stage Of Synovitis

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Stage II: Stage Of Early Arthritis

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Plain X-ray showing "stage of arthritis;" pathology involving articular surface. Irregular and hazy joint margins with

diminished joint space on left side

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Stage III: Stage Of Advanced Arthritis

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Stage IV: Advanced Arthritis with Hip Subluxation / Dislocation

As the disease progress,

Head of femur partly absorbed & gets dislocated from

acetabulum onto ilium



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If left untreated,Healing by absorption & connective tissue

encapsulation occurs. Leading to distortion, deformity and fibrous

ankylosis of joint

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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)

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Physical signs General: pallor, emaciation, LNs, signs of pulm TB Gait: antalgic, trendelenburg Inspection: deformity of limb, wasting of thigh &

gluteal muscles, swelling around hip Palpation: confirmation of above findings, muscle

spasm of lower abdomen & adductors of thigh, joint line tenderness, shift of GT

Movements: fixed deformities, painful ROM Measurements: Apparent lengthening/shortening,

true shortening (Due to fixed deformities secondary changes in spine (lordosis, scoliosis etc))

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Functional Assesment

Group 1

Painless ROM in all directions

Group 2 Painless range of flexion 35-900

Group 3

Flexion <35 0 with fibrous ankylosis

Group 4

Bony fusion

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Shanmugasundaram Radiological Classification

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X-ray pelvis with both hip joints showing the "Perthes type" of appearance on left side

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ManagementInvestigations: Hb% (anaemia) TC: increased lymphocytes DC: lymphocytes – monocyte ratio (5:1) normal. ESR raised in active stage Mantaux test (in children) TB Elisa (usually IgM. Titre is active) : sensitive in

60-80%, but may be negative in patient with advanced disease.

RNA and DNA based PCR studies X-ray hip, AP and lateral and X-ray chest PA view.

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Biopsy and histopathological examination : smear, culture and guinea pig inoculation. Culture – 8 wks and only positive in 30-60% case. Likelihood of identifying organism on a smear is 10-30%.

C-reactive protein – prognosis factor MRI : effusion, periarticular osteoporosis,

thickening of synovial membrane. PCR : DNA based PCR can be quite sensitive, it

may not distinguish between viable and non-viable bacilli. Messenger RNA based reversed transcription PCR may be more specific

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Aim Of Management To obtain a:

Painless, symptom freeStableFreely mobile jointwith the patient having a normal gait

without limp, deformity or shortening.

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Prognosis With the advent of modern

chemotherapeutic agents the intervention at early stages with combination of surgical

management determines the prognosis

Before irreversible change have taken place in cartilage a good result can be expected from conservative management.

When head is affected the result is always doubtful and if there is much bone destruction ankylosis in a good position is the limit of cure.

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Treatment (General, Local And Chemotherapy)

General treatment : Liberal diet, fresh air, sunshine, education and

occupation. Chemotherapy (ATT) : Chemotherapy forms the basis of treatment in all cases

and must be started immediately once the diagnosis is made.

The problem lies in deciding upon appropriate duration of chemotherapy.

Prevailing practice of extending treatment till radiological evidence of healing in complete, may be unnecessary

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Minimum of 6 months is a must but some prefer 9 months regime.

Both 6 and 9 months regime appear to give acceptable relapse rates of within 2%.

Except in pediatric cases, relapses are not drastically improved by extending treatment to 12 months.

Prolonged treatment is indicated:• If surgical debridement is indicated but cannot

be done.• Co-existent HIV/AIDS also necessitate

prolonged treatment. (Interaction between 1st line ATT and antiretroviral therapy can result in complications)

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Drugs First line essential drugs (most effective and necessary

component of therapeutic regimen) : Rifampicin, Isoniazid and Pyrazinamide

First line supplemental drugs (highly effective and infrequently toxic) : Ethambutol, Streptomycin, Fluoroquinolines – Cipro and Levofloxacin.

Second line (less effective and elicit severe reaction more frequently) : PAS, Ethionamide, Cycloserine, Amikacin and Capreomycin.

Newer drugs: Rifapentine, Gatifloxacin and Moxifloxacin

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Drug Side effects ManagementRifampin Rash Observe patient / stop drug if significant

Liver dysfunction Monitor AST / limit alcohol consumption / monitor for hepatitis symptoms

Flulike syndrome Administer at least twice weekly / limit dose to 10 mg/kg (adults)

Red-orange urine Reassure patient

Drug interactions Consider monitoring levels of other drugs affected by rifampin, especially with contraceptives, anticoagulants, and digoxin/avoid use the protease inhibitors.

Isoniazid Fever, chills Stop drug

Hepatitis Monitor AST/limit alcohol consumption/monitor for hepatitis symptoms/educate patient / stop drug at first symptoms of hepatitis (nausea, vomiting, anorexia, flulike syndrome)

Peripheral neuritis Aminister vitamin B6

Optic neuritis Administer vitamin B6/ stop drug

Seizures Administer vitamin B6

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Pyrazinamide Hepatitis Monitor AST/limit daily dosage to 15-30mg/kg/discontinue with signs or symptoms of hepatitis


Monitor uric acid level only in cases of gout or renal failure.

Ethambutol Optic neuritis Use lower doses when possible. Monitor visual acuity (eye chart) and red-green colour vision (Ishihara chart). With any visual complaint stop drug and get ophthalmologic evaluation.

Streptomycin, Amikacin, Capreomycin

Ototoxicity, Renal toxicity

Limit dose and duration of therapy as much as possible. Monitor BUN and serum creatinine levels and conduct audiometry as needed

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Treatment of MDR-TB Definition: Resistance to both INH and Rifampicin, with

or without resistance to any other AT drugs. Suspect MDR-TB if disease activity does not show signs

of subsiding after 4-6 months of uninterrupted multidrug therapy.

No standard regimes or guidelines. A regimen of 4 or 5 second line drugs including flouroquinolones is advised & if needed, these drugs should be changed at sometime.

Treatment, with these drugs takes 2 yr or longer, as opposed to 6-9 months with INH rifampicin containing regimen. 2nd line drugs more expensive & toxic initial part of the treatment should be supervised in hospital.

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Local Treatment a) Stages of synovitis and early arthritis ATT (multidrug therapy) Traction Palpable cold abscess may be aspirated with

instillation of streptomycin with or without isoniazid.

Active assisted movements of hip started as soon as pain has subsided.

Hip mobilization exercises every hour (when patient is awake) within limits of tolerable pain.

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With traction : patient progressively encouraged to sit, touch his forehead, sitting in squatting position and putting thigh in abduction and external rotation.

After 4-6 months patient is permitted for ambulation with suitable caliper and crutches. 12 wk non weight bearing, followed by 12 wk partial weight bearing

Nearly 12 months after onset of treatment – crutches / caliper discarded.

Unprotected weight bearing – usually 18-24 months later.

If response to conservative treatment is unfavourable, synovectomy and debridement of joint performed.

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B) Advanced Arthritis : Usual outcome is gross fibrosis ankylosis. Traction and exercises help to overcome the

deformities. Once gross ankylosis is anticipated of accepted limb

should be immobilized with help of plaster hip spica for about 6-9 months.

Ideal position in adults is neutral between abduction and adduction; 5-10 degree of external rotation and flexion depending upon age (between 10 degree in children and 30 degree in adult).

After 6 month partial weight bearing is started and later with crutches / with caliper for 2 years.

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Role Of Surgery Indications

To establish diagnosis by obtaining tissue culture Surgery as a therapeutic measure

Joint debridement and clearance in moderately involved cases.

Excision arthroplasty or arthrodesis Very rarely total hip replacement.

If response to non-operative treatment is unfavourable, then go for synovectomy or debridement.

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In Children The deformity and subluxation / dislocation is

corrected or minimized by employing traction or with plaster under G.A. with or without adductor tenotomy.

Failure to achieve correction of gross deformities and minimization of subluxation / dislocation warrants open arthrotomy, synovectomy and debridement of the joint.

Arthrodesis / excisional arthroplasty differed till completion of growth potential. Disease with gross deformity require an extra articular corrective osteotomy to make them walk better till skeletal maturity

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Synovectomy Hypertropied synovium from inner surface of

capsule and from synovial reflections near the acetabular rim and femoral neck are separated.

Diseased and thickened capsule is excised. Diseased synovium from the retinacular

relfextions on femoral head gently curreted. Appropriate rotations of hip joint permit

adequate synovectomy from deeper parts of hip joint without deliberately dislocating hip joint.

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Joint Debridement / Joint Clearance In addition to synovectomy, Remove the destroyed areas of femoral head & neck and

in the acetabulum. Loosened pieces of articular cartilage, sequestra,

granulation tissue and loose bodies / debris within the joint

The diseased thickened capsule (Synovectomy and joint debridement can be

satisfactorily carried out without dislocating the hip joint. IR and ER provide access to deeper

parts of joint cavity)

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1) Avascular Necrosis

2) Slippage of proximal femoral epiphysis in


3) Fracture of femoral neck or acetabulum.

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Osteotomy Sound ankylosis in bad position requires upper

femoral corrective osteotomy. Sometimes unsound (fibrous painful) ankylosis

in bad position becomes an osseous fusion (sound painless) by a high femoral corrective osteotomy.

This extra articular procedure can be done at any age.

Ideal site for corrective osteotomy is as near the deformed joint as possible.

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Arthrodesis Success of chemotherapy has almost eliminated the

absolute indications for surgical fusion of hip joint. Surgery deferred till the growth potential of proximal

femur has been completed. Consider in cases of

Failure of conservative treatment (after 1 year) Relapse, especially recurrence of pain and deformity after

conservative treatment. Certain destruction lesions. Ex : formation of sequestra in

head or neck of femur or acetabulum.

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Problems encountered : Early development of degenerative osteoarthritis

in lumbosacral spine, ipsilateral knee and contralateral hip.

Compensatory mechanisms for fused hip Increased rotation of pelvis (during sitting and walking)

Activities affected – bending, sitting on floor, cross legged sitting, squattering, kneeling, sports, sexual mechanisms (in women) and bicycling.

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Types : • Intraarticular

• Extraarticular (ischio-femoral and


• Combined (pan articular)


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Best position of Arthrodesis: 300of flexion (depending upon age) No abduction or adduction (in adults) 5 to 100 of external rotation (the position of flexion – 10 for each year of

life upto 200 then, a little more is suggested)

Extended hip – comfortable for walking Flexed hip – comfortable for sitting This surgery best suited for young active people and for

manual labourer

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Intra Articular Arthrodesis

Performed if disease is active, painful fibrous ankylosis is present

Permits - To obtain tissue for HPE - Exploration of joint - Excision of diseased tissues - Curettage of juxta articular infected cavities - Supplementation of bone grafts to obtain


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Procedure : Standard anterolateral approach, dislocate joint carefully, Excise cartilage and subchondral bone from femoral head

and acetabulum,curet juxta articular cavities, large ones fill up with cancellous bone grafts repose head into acetabulum, place cancellous bone graft around joint line.

Approximate capsule and soft tissue over the site of fusion Hold hip in functional position, 2-3 Steinmen’s pins passed from base of greater trochanter to neck, head and into the acetabulum.

Close wound over suction drain, single hip spica applied.

Post op regime : Steinmen pin removal after 6 to 8 wksSingle hip spica applied in desired position Gradual weight bearing with crutches for 4 to 6 months until radiologicalE/o bone fusion.

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Indications : Extensive destruction of head and neck of femur. Deficient bone stock due to prior arthroplasty. Patients life style prefers a strong, fused and

painless hip joint. Can be done in the presence of active infection or

draining sinuses.

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Excision Arthroplasty Of Hip (Girdle Stone)

Involves excision of femoral head, neck, proximal part of trochanter and acetabular rim.

Best suited for Indian subcontinent people, whose essential activities are squatting, sitting crosslegged and kneeling.

Safely done in healed / active disease after completion of growth potential.

Provides painless, mobile hip joint with control of infection and correction of deformity.

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Procedure: Upper tibial skeletal traction, mounted in 300-500

abduction for 3 months. Encouraged to sit soon after surgery and active

assisted movements of hip and knee started during first week.

Encouraged to place limb in tailor’s position and squatting posture.

After 3 months – mobilization with caliper / crutches. After 6-9 months – they are discarded and to use

walking stick on the contralateral hand.

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Soon after surgery 5 years later

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X-ray of right hip joint anteroposterior view showing (a) active tubercular arthritis of right hip. (b) After Girdlestone excision


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Instability after excision arthroplasty Excision arthroplasty can rarely have a very

unstable hip joint. If happen in young patient, it need supplementary operation.

Hip stabilization procedure Pelvic support osteotomy (Milch- Bacheolar type) at

the level of ischeal tuberosity. Supra acetabular shelf : full thickness iliac crest is used

to provide shelf at upper margin of acetabulum, to minimize upward excursion of femur on weight bearing.

An interesting technique of interposition arthroplasty employing multilayered amniotic membrane – reported by Vishwakarma (1986).

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Replacement Arthroplasty Low friction arthroplasty. Role of THR is being debated and

performed in highly selected cases. Most authors suggest this operation at

least 10 yrs after last E/o active infection / drainage and under cover of ATT. Despite precaution, reactivation rate is 10-30%

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X-ray pelvis with both hip joints anteroposterior view showing (a) tubercular arthritis of left hip. (b) After

uncemented total hip arthroplasty

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Tuberculosis Of Knee Joint

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Largest intra-articular space Involved in about 10 % of osteo-articular

tuberculosis Any age group Symptoms - pain, swelling, palpable synovial

thickening and restriction of mobility. Tenderness in the medial or lateral joint line and patello-femoral segment of the joint

The initial focus may be in synovium or subchondral bone of distal femora, proximal tibia or patella.


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Osteoporosis, soft tissue swelling, joint / bursa effusion.

Distension of supra-patellar bursa on lateral radiograph of knee

Infection in childhood can lead to accelerated growth and maturation resulting in big bulbous squared epiphysis

Widening of the inter-condylar notch (synovitis)

Stage of synovitis

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Periarticular osteopenia

Erosions Symmetric reduction

of joint space

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Loss of definition of articular surfaces Marginal erosions Decreased joint space Osteoporosis

Stage of arthritis:

Stage of advanced arthritisOsteolytic cavities with or without sequestra

formationMarked reduction of joint spaceDestruction and deformity of jointsIn advanced cases, there is triple deformity of the

knee may occur

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• Peripherally enhancing joint collection

• Marginal erosion

T1 PC non fat sat

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• Marrow edema• Synovial



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Differential diagnosis – Juvenile rheumatoid arthritis Villonodular synovitis Osteochondritis dissecans Hemophilia

Biopsy of the synovial membrane and aspiration of the joint fluid followed by smear & culture can confirm the diagnosis

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Triple Deformity Components:

FlexionExternal rotation

and valgus at kneeAssociated with

posterior subluxation of tibia

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Triple Deformity of knee is seen in : "TRIPLE“:


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Can be prevented by adequate posturing and Bracing in initial affection of joint

Treatment of Triple Deformity of Knee in TB: Double Traction (90-90): For Supple

deformities Anti- tubercular Therapy

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Surgical options include:

Debridement and SynovectomyArthrodesisTotal Knee Replacement

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Tuberculosis Of Shoulder Joint

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Rare entity More frequent in adults Incidence of concomitant pulmonary

tuberculosis is high

The classical sites are: head of humerus, glenoid, spine of the scapula, acromio- clavicular joint, coracoid process and rarely synovial lesion.


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Iatrogenic due to steroid injection given for a stiff shoulder with the mistaken diagnosis of frozen shoulder, particularly in diabetics.

Initial tubercular destruction is typically widespread (because of the small surface contact area of articular cartilage)

Symptoms – severe painful movement restriction

particularly abduction and external rotation gross wasting of shoulder muscles

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Radiologically, osteoporosis erosion of articular margins (fuzzy) osteolytic lesion involving head of humerus,

glenoid or both The lesion may mimic giant cell tumor.

The joint space involvement and capsular contracture are seen early in the disease.

Sinus formation Inferior subluxation of the humeral head Fibrous ankylosis

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Deformity Erosions Osteopenia Peri-articular


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• Erosion• Synovial proliferation• Subdeltoid collection

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Caries sicca:

Atrophic type of tuberculosis of the shoulder Benign course Without pus formation Small pitted erosions on the humeral head

Classical dry type is more common in adults fulminating variety with cold abscess or sinus

formation is more common in children

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Caries sicca: there is erosion and destruction of humoral head and glenoid cavity with soft

tissue swelling, along with fibrotic opacites in the right upper and middle lobe.

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Differential diagnosis - Peri-arthritis of the shoulder Rheumatoid arthritis Post-traumatic shoulder stiffness

Aspiration of the shoulder and FNAC might be necessary to establish the diagnosis.

The patients usually respond well to anti-tubercular drugs.

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Tubercular Dactylitis

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Tubercular dactylitis

primarily a disease of childhood affects short tubular bones distal to tarsus and

wrist bones of the hands are more frequently affected

than bones of the feet proximal phalanx of the index and middle fingers

and metacarpals of the middle and ring fingers being the most frequent locations

Frequently present as marked swelling on the dorsum of the hand and soft tissue abscess is normally a common feature

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Monostotic involvement is common Often follows a benign course without pyrexia and

acute inflammatory signs, as opposed to acute osteomyelitis.

Plain radiography is the modality of choice for evaluation and follow-up.

The radiographic features – Cystic expansion of the short tubular bones have

led to the name of "spina ventosa" being given to tubercular dactylitis of the short bones of the hand. spina - short bone and ventosa - expanded with air

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Bone destruction and fusiform expansion of the bone

It is most marked in diaphysis of metacarpals and metatarsals in children

Periosteal reaction and sequestra are uncommon. Healing is gradual by sclerosis.

Differential diagnosis – Syphilitic dactylitis – bilateral and symmetric

involvement, more periostitis, less soft tissue swelling.

Chronic pyogenic osteomyelitis and mycotic lesions in the foot

Debridement and antitubercular regimen result in complete subsidence of the lesion

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Tuberculous dactylitis

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Spina ventosa

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• Rare entity• May be localized and well defined • Or may be more diffuse• Associated with cold abscess

Calvarial tuberculosis

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1)Lateral radiograph shows large circumscribed lytic lesion in frontal bone2) AP radiograph demonstrates a large frontoparietal lytic lesion suggestive of diffuse spreading type3) Frontal radiograph shows a lytic lesion with a sclerotic margin

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Skull - Frontal bone most common site Ill-defined lytic lesion may be the only radiological

feature seen with overlying cold abscess (Potts' Puffy tumor)

Button sequestrum sometimes seen Facial bones and mandibular involvement is

extremely rare

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Pott’s puffy tumour – TB osteomyelitis of skull with overlying abscess

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Button sequestrum

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Other Important Topics: Tubercular affection of tendons and Bursae Tubercular Osteomyelitis Tuberculosis of Ribs and Flat bones Tubercular infection of Sacroiliac joints

and Pelvis (also read Weaver’s Bottom) BCG Osteomyelitis/ Arthritis Atypical Mycobacterial infection

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Poncet’s Disease Also k/as Tubercular Rheumatism It is a form of Polyarthriris

occuring in patients suffering from Tuberculosis, commonly affecting the Knee and Ankle joints

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Tuberculosis is a major public health problem in most of the world.

“Before the disease can be treated, it must be recognized and before it can be recognized, it must be considered a

diagnostic possibility”.

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Thank You!