OSTEOARTICULAR TUBERCULOSIS

Dr.E.Kaizar Ennis

Introduction
1 3 % involves skeletal system. 50% vertebral involvement. Organism M.Tuberculosis M.Bovis M.kansasii

Prophylaxis
Vaccination-Bacille Calmette Guerin -80%protection Chemoprophylaxis -Isoniazid 5mg/kg body wt daily -6 months.

Pathology & pathogenesis

Haematogenous dissemination Disease may start in bone/synovial mem. Initial focus -metaphysis in growing age -end of bone in adults Cartilage tissue is resistant Metaphyseal lesion may infect neighbouring jt. through subperiosteal space / capsule or by destruction of epiphyseal cartilage.

Cont
Tubercle -soft tubercle-diagnostic (with caseation necrosis) -hard tubercle Cold abscess -Serum,leukocytes,caseous material,bone debris,tubercle bacilli.

Types of the disease

Caseous exudative type(children) -destruction,exudation & abscess formation. Granular type(adult) -dry lesion.

Stages
i) Inflammatory edema & exudate (predestructive phase) ii)Necrosis & Cavitation iii)Destruction & Deformation iv)Healing & Repair

Clinical features
Insidiousonset, monoarticular/mono-osseous involvement, fever, lassitude, anorexia, loss of wt, night cries, tachycardia,anemia. local signs/symptoms-pain,painful limitation of movements,muscle wasting,regional lymphnode enlargement. protective muscle spasm.

Diagnosis
Clinical & Radiological examn.

Investigations
Roentgenogram -localised osteoporosis -washed-out appearance -soft tissue swelling -jt. Space diminution If destruction continues -collapse of bone,sequestrum -subluxation/dislocation -migration & deformity of jt.

Blood parameters
Lymphocytosis,anemia,raised ESR Mantoux(heaf)test

Biopsy Synovial fluid examnleucocytosis,decrease glucose,elevated protein content. Guinea pig inoculation Smear & culture Isotope scintigraphy

Serological investigations CT-scans MRI Ultrasonography

Antitubercular Drugs
Streptomycin bacteriostatic & bactericidal 20mg/kg (max.1gm) vestibular damage deafness(decreased by adminis. Of ca.pantothenate daily) Paraaminosalicylic acid(PAS) bacteriostatic 12 gm OD/2 div doses GIT irritation lymphadenopathy

25mg

Cont
Isoniazid(INH)-isonicotinic acid hydrazide) bactericidal 300-400mg OD/2 div.doses peripheral neuropathy hepatitis Thioacetazone 150mg OD liver damage skin rashes

Cont
Ethambutol 15-25mg/kg OD/ 2 div.doses retrobulbar neuritis optic neuritis Rifampicin 450-600 mg OD/ 2 div. doses red-brown colorn of body fluids Pyrazinamide bactericidal 40mg/kg OD/ 2 div. doses

Newer drugs
cycloserine ,capreomycin,kanamycin & fluoroquinolones. Corticosteriods

Classification of Articular Tuberculosis

Stage I : Synovitis Clinical : ROM > 75% Radiology :soft tissue swelling osteoporosis Treatment :synovectomy chemotherapy movements Expectation:retention to near full movement

Cont
Stage II : Early Arthritis ROM : 50-75 % Radiology :diminution of jt. Space marginal erosions Treatment :chemotherapy rarely synovectomy & debridement. Expectation:restoration of 50-75% mobility

Cont
Stage III : Advanced arthritis ROM : >75% movements lost Radiology :jt. Space diminution destruction of jt. Surface Treatment :chemotherapy & surgery Arthrodesis in lower limb Expectation :Ankylosis

Cont
Stage IV:Advanced arthritis ROM : >75% movements lost Radiology:jt shows dislocation/subluxn
Treatment :chemotherapy & surgery Expectation :Ankylosis

Cont
Stage V : Terminal or aftermath of arthritis Clinical :Deformity & ankylosis Radiology :deformed articilar margins degenerative osteoarthrosis Treatment: Chemotherapy & surgery Expectation: Ankylosis

Principles of Management
General treatment Rest Mobilization Brace Traction Ambulation

Anti tubercular drugs-Regime

Phase I(intensive) :IRF for 5 months Phase II(continuation) :IP for 5 months Phase III(continuation) :IR for 5 months Phase IV(prophylaxis) :IE for 3 months

Surgery in TB of bone & jt.

Adjunct to sys.chemotherapy

Extent & Type of Surgery

Arthrodesis Excision arthroplasty Juxta-articular corrective osteotomy

Prognosis
At the stage of tubercular arthritis if the disease remains closed, the natural outcome is generally a fibrous ankylosis.If an abscess discharges & sinuses with sec. infection developes,the outcome may be a bony ankylosis.The position of ankylosis on healing is determined by the presence /absence of effective splintage.prognosis regarding movements in TB of jts depends upon the stage /extent of the disease when the specific treatment was started.

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