OSTEO ARTICULAR TUBERCULOSIS

2.  Discovered that anthrax was caused by bacteria
 Discovered how to grow bacteria in cultures for study
and how to add stain in order to see them
 Proved that most diseases are caused by a particular
type bacteria
 Discovered the tubercle bacillus in 1882 where one in
seven deaths in Europe was due to TB

3.  Samhitha of Charaka and Susrutha ( 1000- 600BC) called
this disease as YAKSHAMA
 Greek- roman
PHTHISIS or CONSUMPTION
 Egyptian mummied – lesions were recorded
 Laennec (1781-1826)
French physician described the TUBERCLE

4.  20 % of AIDS patients have TB
 50 % of young adults with TB
have AIDS

8.  Skeletal tuberculosis is a chronic infectious
disease caused by Mycobacterium
tuberculosis.

9.  Predisposing factors
 Poor diet and sanitation
 Direct injury
 Reactive disease
 Measles and chicken pox

10.  Skeletal TB always secondary
 Hematogenous spread

11.  Initial response
in reticulo-endothelial skeletal tissue
polymorphs replaced by mononuclear cells
highly phagocytic – bacilli phagocytosed and broken down
lipid dispersed in cytoplasm of mononuclear cells – EPITHELIOD CELLS

12.  EPITHELOID CELLS
characteristic of TB
large and pale with large vesicular nucleus
abundant cytoplasm, indistinct margins

13.  LANGHAN’S GIANT CELLS
fusion of many epithelioid cells
peripheral nuclei
often contains TB bacilli
seen only in caseation necrosis
digest and remove dead tissue

14.  After 1 week
lymphocytes appear
form a ring around the lesion
mass of newly fromed cells
translucent nodule- TUBERCLE
several tubercles fuse to a larger one

15.  During 2 week
caseating necrosis
liberation of protein fraction of bacilli
caseation is diagnostic

16.  Local destruction of the joint, marked demineralization with surrounding lytic
areas (PHEMISTER TRIAD)
 Extension of the granulation tissue from the synovium on to the bone , at the
periphery of the articular cartilage the granulation tissue forms a ring (PANNUS)
which grows ion the subchondral region

17.  RICE BODIES: flakes of loose sheets of necrotized articular cartilage and
fibrinous material in the synovial fluid

18.  Cold abscess is formed by a collection of products of liquefaction and t reactive
exudation.
 Mostly composed of serum, leukocytes, caseous material, bone debris and tubercle
bacilli
 Penetrates the ligaments and migrates in various direction following the fascial
planes and along the vessels and nerves
 Feels warm
 May burst into form a sinus or ulcer
 Walls of abscess , sinus or ulcer are covered with tuberculous granulation

20.  Cord compression
quadri/paraplegia
 Tense paravertebral abscess with or without neurological symptoms

21.  Pus produced at the site of pathology may stay at
the same vertebral level
 May track down the paths of least resistance
along the fascial planes , vessels or nerves
 Present as a cold abscess in different regions far
away from the site of pathology

22.  Cervical and upper dorsal abscess track
down upto D4
retropharyngeal abscess
posterior mediastinal mass

23.  From D4 – D10 lesions present on either side of the
vertebral body contained in a thick walled sac leading to a
bird’s nest abscess
 May track along the
intercostal nerves
midaxillary
parsternal

24.  Below D11 lesions
 May present as late as then psoas
sheath can accommodate lot of pus
 May track behind the medial arcuate
ligament of the diaphragm along the
sheath up to its insertion into LT
 Present as groin swelling pushing
forward the femoral artery

25.  May track down behind lateral arcuate ligament between lumbodorsal fascia and
quadratus lumborum
 May remain kidney
 May track along three nerves
subcostal
ilioinguinal
iliohypogastric

26.  May present in
anterior abdominal wall
petit’s triangle
ischiorectal fossa
femoral canal
gluteal region
popliteal fossa

28.  Osseous destruction by lysis of bone
 Necrosis- ischemic infarction of a segment due to endarteritis
 Softening leads to yielding – gravity and muscle action
 Bone compression, collapse and deformity
 Sequestration – coarse sand
 Rarely large sequestrum

30.  Granular
synovial
osseous
 Exudative
synovial
osseous

31. Constitutional
 Low grade fever
 Anorexia
 Loss of weight
 Lassitude
 Night sweats
 Tachycardia


32.  Local symptoms
 Pain
 Night cries
 limitation of movements
 Effusion and swelling
 Muscle wasting
 Regional lymphadenitis

33. Xray
 localized osteoporosis – first sign
 Art margin and cortex – haziness
 Osteolysis
 Soft tissue swelling
 Narrowing of joint space
 Collapse of bone , subluxation , dislocation
 Irregular growth – premature fusion of epiphysis
 Increased longitudinal growth- hyperemia

39.  Leukocytosis
 Relative lymphocytosis
 Low HB
 Raised ESR

40.  Positive – present or past infection
 Negative – generally rules out disease
 False negative
severe and disseminated diseas3e
high fever
exanthemata
post viral vaccination
steroid treatment
immune incompentent

42. Microscopic examination of tubercle
 Granulation tissue
 Synovium
 Bone
 Lymph node

43.  Leukocytosis
 Glucose decreased
 Protein elevated

44.  Positive scan localizes suspicious lesions
 Technicium-99
 Gallium 67
 indium 111

45.  Picks up early lesions
 Difficult area
CV junction
cervico-dorsal
LS region
ribs, sternum

46.  Confirms plain Xray/ CT finding
 Pre destructive lesions
 Encroachment of vertebral canal
 Displacement of Dural sheath
 Localised tuberculoma

47.  Detection of soft tissue abscess
 Behaviour to treatment

48.  Pyogenic spinal osteomyelitis: severe pain, spasm, hyperextension, early disc
destruction
 Typhoid spine: follows enteric fever
 Brucellosis: undulant fever
 Mycotic infection: sinuses and typical discharge

49.  Benign
hemangioma: coarse vertical trabeculae
giant cell and ABD
 PRIMARY MALIGNANT: Ewings’s sarcoma, lymphoma, chordoma,
chondrosarcoma, fibrosarcoma, multiple myeloma
 secondaries

51.  General rest
 Anti anemic drugs
 Multivitamins
 High protein diet

52.  TRACTION:
 Relieves spasm
 Prevents deformity
 Maintains joint space and avoids subluxation and minimizes migrating acetabulum
 Active and assited movements at hip and knee are started after pain and muscel
spasm comes down

60.  Gamma interferons
 Alpha TNF
 IL -2, 12

61.  If response to conservative treatment is not favorable
 Failure to achieve acceptable outcome

62.  SYNOVECTOMY and joint debridement
 Osteotomy
 Arthrodesis
 Girdlestone excision arthroplasty
fibrous ankkylosis
 Total hip replacement

63.  Pott’s spine indications for surgery
 Quadriplegia/ paraplegia
 Active disease with severe pain
 Progression of kyphotic deformity
 Impairment of pulmonary function
 Resistance to chemotherapy

64.  Drainage of cold abscess
 Costotransversectromy
 Anterolateral decompresiion
 Laminectomy
 Posterior spinal fusion