Skeletal tuberculosis by Dr Bipul Borthakur

1. DR. BIPUL BORTHAKUR
PROFESSOR & HOD
DEPARTMENT OF ORTHOPAEDICS
SILCHAR MEDICAL COLLEGE

2. BONE TUBERCULOSIS
• Spine – Pott’s spine (50% of all cases of skeletal
Tuberculosis)
• Joints - Tubercular arthritis:
 Hip Joint
 Knee joint and Triple deformity
 Shoulder joint and Caries Sicca
 Elbow joint
 Wrist and Carpus
 Sacroiliac joints
• Long and flat bones - Tubercular osteomyelitis
• Short bones – Tubercular dactylitis (spina ventosa)

3. PRINCIPLES OF MANAGEMENT
• General and systemic treatment is like that of
TB in general
• Any concomitant disease must be treated
• Hospitalization required only for-
 Complications
 Deformity correction under supervision

4. SURGERY IN BONE AND JOINT
TUBERCULOSIS
• Exploration and appropriate operation
mandatory when-
 Lesion not responding favorably to drugs
 Doubt in diagnosis
 Refractory recrudescence of infection
 Juxta-articular osseous focus threatening the joint

5. TUBERCULOSIS OF SPINE
• first described by Sir Percival Pott in 1779, hence the
name Potts disease
• Usually two continuous vertebrae involved but
several vertebrae maybe affected, skip lesions and
solitary vertebral involvement may occur
• skip lesions -- 4 -10 % of cases.
• 12% cases - has associated other osteo-articular
tuberculous involvement

6. CLINICAL FEATURES
• any age group; majority <30 years
• Male=female
• Rare in the 1st year of life but when it occurs, tends
to be more severe
• Constitutional symptoms:
 Malaise
 Loss of weight/appetite
 Night sweats
 Evening rise of temperature

7. CLINICAL FEATURES
• Specific Symptoms:
 Pain/Night cries
 Stiffness/spasm of vertebral muscles
 Localized/Persistent backache
 Deformity
 Restricted ROM
 Enlarged lymph nodes
 Abscess and sinuses
 Neurological deficit

8. NEUROLOGICAL COMPLICATIONS
• 10-30% cases – Neurological deficit
• Age: 1st 3 decades
• Disease below L1 vertebrae rarely causes Paraplegia
• Highest incidence of paraplegia: TB of lower thoracic
vertebrae
• Commonest pathology for non traumatic paraplegia in
developing countries still remains Tuberculosis

9. Staging of Neurological Deficit Goel
1967, Tuli 1985, Kumar 1988, Jain 2002
Stage Severity Clinical Features
I Negligible unaware of neurodeficit
plantar extensors or ankle clonus +
II Mild aware of deficit
walks with support
III Moderate Non ambulatory due to spastic paralysis (in
extension)
sensory deficit <50 %
IV Severe III + Flexor spasm / Paralysis in flexion /
Flaccid/ Sensory deficit >50 % / Sphincter
Involved

10. CLINICAL FEATURES OF POTT’S
PARAPLEGIA
• Paraplegia itself – Rare
• Spontaneous muscle twitching in lower limbs
• Clumsiness while walking
• Extensor plantar response
• Exagerrated reflexes – Sustained patellar and ankle clonus
• Motor affected first – then Sensory
• Sense of position and vibration – last to disappear

11. Regional distribution of Spine TB
(in pre-MRI era)
• Cervical – 12%
• Cervicodorsal – 5%
• Dorsal – 42%
• Dorsolumbar – 12%
• Lumbar – 26%
• Lumbosacral (including sacrum) – 3%

12. Types of vertebral lesions
5 types:
1. Paradiscal- Arterial spread
2. Central – Venous spread
3. Anterior- Subperiosteal spread
4. Appendiceal/ neural arch
5. Synovial

13. LABORATORY INVESTIGATIONS
• CBC:
– Hb% ↓
– ESR:
• Raised:active stage of disease
• Normal ESR over period of 3 months : stage of repair
• CRP
• Biopsy
– In case of doubt, mandatory to prove the diagnosis by
obtaining the diseased tissues

14. • Smear and culture
– Culture: gold standard
– Staining: Zeill- Neilson stain - sensitivity 25 to 75
%
– Culture: Lowenstein jensen- median incubation
period: 4 to 6weeks
• Bactec For faster culture of Mycobacterium
tuberculosis(Bactec radiometric culture)
– takes < 2 weeks (7-14 days)

15. PCR
• Ideal for detection of paucibacillary TB case
• ADVANTAGES
– Highly efficient, sensetive & rapid method for Dx –
3days
– Can differentiate typical mycobacteria from atypical
mycobacteria
• DISADVANTAGES
– Not able to differentiate live from dead organism
– Does not tell about the activity of the disease
• PCR – not a substitute for culture

16. IMAGING MODALITIES
• Conventional Radiographs –
 often negative in early disease
 >30 to 50 % of mineral must be lost before a
radiolucent lesion becomes conspicuous; takes
about 2 to 5 months

17. Computed tomography
 early detection of bone and soft tissue changes
 better anatomic localization and evaluation of difficult
areas such as cranio-vertebral junction, cervico-dorsal
junction, sacrum
 guidance for biopsy, surgical approach
• Disadvantages-
– Early signs (inflammatory marrow changes) in
vertebral body not well depicted
– Effect on the thecal sac and spinal cord and neural
elements: difficult to evaluate properly

18. Magnetic resonance imaging
• modality of choice
• MRI Scores over CT in
 Detection of early disease (marrow edema)
 Skip lesions more easily and more often detected
 Detection of epidural, meningeal and cord involvement
 Planning the surgical approach
• Diffusion weighted MR imaging: distinguish between
tubercular and neoplastic vertebral disease (metastasis ,
myeloma)

19. PET CT
• high sensitivity: chronic osteomyelitis
• determine multiple occult foci of involvement in
single scan
• Baseline for monitoring response to treatment and
information on disease spread
• Guide the site of biopsy or other interventional
procedures
• Limitations–
 uptake patterns are indistinguishable from malignant
processes

20. USG
• to find out primary in abdomen
• Detect cold abscess
• Guided aspiration
Radionucleotide Scan T 99m
• ↑uptake in up to 60% patients with active tuberculosis
• >= 5mm lesion size can be detected
• Aid to
– localize the site of active disease
– detect multilevel involvement

21. BASIC PRINCIPLES OF MANAGEMENT
• Early Diagnosis
• Expeditious medical treatment with ATT DOTS
daily regimen
• Aggressive surgical approach
• Prevent Deformity

22. Present management
• Conservative treatment with ATT
• Radical surgery
• Monitoring
– Radiographs and ESR at 3-6 months interval
– MRI at 6 months interval for 2 years
• Gradual mobilization
– Encouraged in absence of neurological deficit with
support of spinal braces
– As soon as the diseased part permits

23. • Absolute Indications of surgery
1. No progressive recovery after fair trial of conservative
treatment
2. Neurological complications develops during
conservative treatment
3. Worsening of neurological deficit during t/t
4. Recurrence of neurological complications
5. Pressure effects (deglutition/respiration)
6. Advanced cases of neurological involvement(Sphincter
disturbances, flaccid paralysis or severe flexor spasm)

24. FOLLOW UP
• evaluated at 3 months interval upto 2 years
• Evaluation
• Clinical:
o Weight gain
o Pain relief
o Free ROM
o Resolution of abscesses
o Neurological recovery
• Radiological:
o Decreased soft tissue
shadow
o Disappearance of
erosions
o Return of mineralization
o Graft incorporation
o Bony ankylosis

25. TB HIP
• 2nd only to spine
• Spine: Hip ratio – 10:7
• Hematogenous dissemination
• Articular cartilage destruction begins peripherally
• TB Arthritis- does not form proteolytic enzymes in joint
space.
• Hence central areas of articular cartilage preserved for long
time.

26. COMMON SITES
• Initial focus may start in
1. Acetabular roof –most
common
2. Epiphysis/Femur Head-joint
involved rapidly
3. Metaphyseal region/ Femur
neck
4. Greater trochanter- least
common; may involve the
overlying trochanteric bursa

27. CLINICAL FEATURES
• Commonest age : 1st three decades
• Limping – earliest, commonest symptom
• Antalgic gait
• Pain – referred to medial aspect of knee - max
towards end of the day
• Deformity

28. DIAGNOSIS
• Clinico-radiological- X-Rays, CT Scan, MRI and
USG
• Synovial fluid aspiration
– AFB positive in 10 – 20% of cases
– Cultures positive in 50% of cases
• Aspiration of cold abscess
• Synovial Biopsy
– Cultures positive in 80% cases
• HPE & PCR –diagnostic

29. MANAGEMENT
• Early diagnosis , effective chemotherapy – vital to
save the joint
• Depends upon the stage of clinical presentation
• Rx includes :
– ATT
– Absolute bed rest
– Traction
– Arthroplasty
– Arthrodesis
– THA

30. • After 4-6 months of Rx – Ambulation with
crutches / orthosis
• Ambulation :
– 1st 12 weeks :non weight bearing
– 2nd 12 weeks :partial weight bearing
– Unprotected weight bearing :18 -24 months after
onset of Rx

31. TB KNEE
• 10 % of osteo-articular tuberculosis
• Any age group
• Symptoms
– Pain
– palpable synovial thickening
– Tenderness in the medial or lateral joint line and
patello-femoral segment of the joint
• Initial focus: synovium or subchondral bone of
distal femur, proximal tibia or patella

32. TB ANKLE AND FOOT
ANKLE
• Swelling - front of joint, around the
malleoli and tendoachilles insertion
• Marked osteoporosis with/ without
erosion, unsharpness of articular
surfaces with reduction joint space
FOOT
• Common: calcaneum, subtalar and
midtarsal joints
• Radiograph: osteolytic lesion with or
without coke-like sequestrum

33. TB SHOULDER
• Rare; more frequent in adults
• The classical sites could be –
 head of humerus
 Glenoid
 spine of the scapula
• Classical dry type: more
common- adults
• fulminating variety with cold
abscess/sinus formation: more
common- children

34. TB ELBOW• 2-5 % cases
• Most frequent sites
 medial and lateral condyles of humerus
 articular surface of olecranon
 head of radius
• Rarely synovial in origin, Infants and children: sequestra
may be present
• Radiographic features
 Osteoporosis
 blurring of articular cortex and early diminution of joint space
 Periostitis

35. TB WRIST AND CARPUS
• rare
• Adults; more localized lesions in
children
• Radiographic features
– intense osteoporosis
– erosions of articular margins and
cartilage destructions
– periosteal reaction
• Biopsy, when in doubt.

36. TB SACROILIAC JOINTS
• frequently missed
• Young adults > children
• usually unilateral
• Clinically: Tenderness over sacroiliac joint
• MRI ideal
• Radiographic features –
– Irregularity, fuzziness of articular surfaces
– Both sclerosis and erosions predominate on
the iliac side while punched out lesions may
be seen in ilium or sacrum

37. Long and flat bones- TB osteomyelitis
• TB osteomyelitis: 3 % of MSK tuberculosis
• In 7 % of them, multiple skeletal site of lesions
• Earliest lesion: eccentric osteolytic lesion in the
shaft near the epiphysis or metaphysis
• Solitary involvement predominant
• Multiple sites of involvement are seen in children,
while in adults, involvement is more often
confined to a single bone

38. Tuberculosis of short bones(TB Dactylitis)
• primarily childhood; hands > feet
• affects short tubular bones distal to wrist;
Monostotic and diaphyseal involvement
• Clinically
– marked swelling on the dorsum of the hand
– soft tissue abscess
– Often follows a benign course, as opposed to
acute osteomyelitis
• Radiography
– Cystic expansion of short tubular bones have
led to the name of "spina ventosa”

39. Atypical Mycobacterial Infection
• immunocompromised patients ,renal transplants
or those receiving cortico-steroids
• Infection can lead to osteomyelitis, septic
arthritis, tenosynovitis and bursitis
• Radiologically –
– multiple lesions may be seen
– metaphysis and diaphysis of long bones usually
affected
– osteoporosis is NOT marked